Phục Hồi Chức Năng ĐAU CỘT SỐNG CỔ .Hồ Quang Hưng.Khoa Phục hồi chức năng – BV Chợ Rẫy

Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association..

Các lo ại đau cổ / CSSKBĐ

đau cổ cơ năng) (Non-specific neck pain)

headache)

(Whiplash)

3

Thoái hóa c ột sống cổ

4

Necksolutions.com

Mullin, J., Shedid, D., & Benzel, E (2011) Overview of cervical spondylosis pathophysiology

and biomechanics World Spinal Column J, 2(3), 89-97.

Các lo ại đau cổ / Vật lý trị liệu

ICF ICD Clinical findings

1 Neck pain with

mobility deficits

Cervicalgia or pain in thoracic spine

Cervical active range of motion (ROM) Cervical and thoracic segmental

mobility

2 Neck pain with

headaches

Headaches or cervicocranial syndrome

Cervical active ROM Cervical segmental mobility Cranial cervical flexion test

3 Neck pain with

Upper limb tension test Spurling’s test

Lượng giá đau cổ

6

D ấu hiệu cờ đỏ (Red flag)

• G ợi ý một số bệnh lý: gãy xương, trật khớp, chấn

thương tủy, nhiễm trùng, ung thư, bệnh lý hệ thống

• Tuổi dưới 20 hay trên 55

• Đau liên tục, tăng dần, không có tính cơ học

• Hội chứng chùm đuôi ngựa

• Dấu hiệu Lhermitte dương tính (gấp cổ gây cảm giác như điện

giật lan xuống thân và tay chân)

• Chóng mặt, nhìn mờ

7

Khám th ần kinh

• Ki ểm tra tổn thương nơ-ron vận động trên: tăng

ph ản xạ, dấu đa động, phản xạ lòng bàn chân

• Ki ểm tra tổn thương nơ-ron vận động dưới: mất

c ảm giác, phản xạ, sức mạnh và phản xạ

D ấu hiệu cờ vàng (Yellow flag)

– Ni ềm tin rằng đau và hoạt động thì có hại

– Lo l ắng quá mức về đau cổ

– C ảm xúc tiêu cực

– Mong ch ờ kết quả điều trị không thực tế

– Có nh ững vấn đề trong công việc

– Gia đình bảo bọc quá mức hay hoàn toàn không

h ỗ trợ

– V ấn đề trong trợ cấp hay những quyết định trong công vi ệc liên quan đến đau cổ

9

Y ếu tố nguy cơ của đau cổ

• Hút thu ốc

• Ít v ận động

• Tư thế xấu

• Lo âu và tr ầm cảm

• Y ếu tố tâm lý xã hội

• Y ếu tố nghề nghiệp: đã có bệnh sử đau cơ xương

(đau lưng), cường độ làm việc cao, hỗ trợ xã hội thấp, không th ỏa mãn công việc, thiết kế nơi làm việc máy

tính kém, công vi ệc lập đi lập lại, công việc chính xác cao

• Thoái hóa đĩa đệm không được xác định là yếu tố nguy cơ

Côté P, van der Velde G, Cassidy JD et al The burden and determinants of neck pain in workers: results of the Bone and Joint 2000–2010 Task Force on Neck Pain and Its Associated Disorders Spine 2008;33(4 Suppl):S60-S74.

Hogg-Johnson S, van der Velde G, Carroll LJ et al The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders Spine 2008;33(4 Suppl):S39-S51 10

Tư thế đầu ngả trước

Donatelli RA, Wooden MJ (2010) Orthopaedic physical therapy

Đánh giá vận động cổ

and thoracic segmental mobility)

flexion test)

endurance)

12

T ầm vận động chủ động

Donatelli RA, Wooden MJ (2010)

Orthopaedic physical therapy

Độ di động từng đoạn cổ, ngực

Đánh giá vận động cổ

Jason Craig Examination of the Thoracic Spine Available from: http://www.youtube.com/watch?v=iy7qjHEld_U [last accessed 17/06/16]

Sandmark, H., & Nisell, R (1995) Validity of five common manual neck pain provoking tests Scandinavian journal of

rehabilitation medicine, 27(3), 131-136.

Pain during segmental testing associated with reports of neck pain:

Sensitivity = 0.82, negative likelihood ratio = 0.23 Specificity = 0.79, positive likelihood ratio = 3.9

14

Phép ki ểm gấp đầu – cổ

Đánh giá vận động cổ

Jull, G A., O'Leary, S P., & Falla, D L (2008) Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test

Journal of manipulative and physiological therapeutics, 31(7), 525-533. 15

S ức bền cơ gấp cổ sâu

Đánh giá vận động cổ

Harris, K D., Heer, D M., Roy, T C., Santos, D M., Whitman, J M., & Wainner, R S (2005) Reliability of a

measurement of neck flexor muscle endurance Physical therapy, 85(12), 1349-1355. 16

Đo lường kết quả

17

Cleland, J A., Childs, J D., & Whitman, J M (2008) Psychometric properties of the Neck Disability Index and Numeric

Pain Rating Scale in patients with mechanical neck pain Archives of physical medicine and rehabilitation, 89(1), 69-74.

Minimal clinically important difference / mechanical NP: 9.5/50 points (19%)

Siêu âm tr ị liệu

Laser tr ị liệu

• LLLT (Low Level Laser

Therapy): Laser công

su ất thấp, 50-100 mW,

xuyên sâu 2-3 cm

• HILT (High Intensity

Laser Therapy): Laser

Điều trị bằng tay (Manual therapy)

Kéo n ắn cột sống (chiropractics)

• Không nên dùng khi

đang có bệnh lý rễ,

b ệnh lý tủy rõ ràng

Maple Healthcare Center /Q7, Saigon

Anderson-Peacock, Elizabeth, et al "Chiropractic clinical practice guideline: evidence-based treatment of adult

neck pain not due to whiplash." The Journal of the Canadian Chiropractic Association 49.3 (2005): 158. 26

V ận động trị liệu

L ựa chọn bài tập hợp lý (1)

Bài t ập theo

t ầm vận động Bài tập kéo dãn Bài tập mạnh cơ

28

L ựa chọn bài tập hợp lý (2)

Du ỗi cổ cao G ấp cổ sâu kết hợp duỗi cổ thấp

“Chin tuck” exercise

29

Lao động khoa học (Ergonomics)

• Tư thế tốt

• Ngh ỉ ngơi, thư giãn đều đặn

• Kh ởi động chuẩn bị

30

T ờ bướm dành cho bệnh nhân

31

Y h ọc chứng cứ EBM-Evidence Based Medicine

32

B ệnh lý rễ do thoái

hóa (2010)

• What is the role of manipulation/chiropractics in the treatment of cervical radiculopathy from degenerative disorders?

RECOMMENDATION: As the efficacy of manipulation in the treatment of

cervical radiculopathy from degenerative disorders is unknown,

careful consideration should be given to evidence suggesting that

manipulation may lead to worsened symptoms or significant

complications when considering this therapy Premanipulation

imaging may reduce the risk of complications

Work Group Consensus Statement

33

B ệnh lý rễ do thoái

hóa (2010)

• What is the role of ancillary treatments such as bracing, traction, electrical stimulation, acupuncture and transcutaneous electrical stimulation in the treatment of cervical radiculopathy from

degenerative disorders?

RECOMMENDATION: Ozone injections, cervical halter traction and

combinations of medications, physical therapy, injections and traction have been associated with improvements in patient reported pain in

uncontrolled case series Such modalities may be considered

recognizing that no improvement relative to the natural history of

cervical radiculopathy has been demonstrated

Work Group Consensus Statement

34

The Italian Society of Physical and Rehabilitation

Medicine (SIMFER) recommendations for neck pain.

G Ital Med Lav Erg 2013; 35:1, 36-50

Education There are no indications for educational interventions

(alone or in addition to other conservative techniques) for patients with acute and chronic NP.

B

Exercise It is recommended to use exercise to reduce pain and

disability in patients with chronic NP The best exercises are

those based on strengthening and stabilising the cervical musculature Combined manual therapy and exercise has

led to encouraging results and is a therapeutic option that can be recommended.

A

Manipulation

and

mobilisation

The use of manipulation alone is recommended for patients

with acute non-specific NP A multimodal approach

based on manipulation/mobilization combined with exercise is recommended for those with chronic NP.

A

Massage We recommend the combination of massage with exercise

and manipulation / mobilization in patients with

chronic NP.

B

35

The Italian Society of Physical and Rehabilitation

Medicine (SIMFER) recommendations for neck pain.

G Ital Med Lav Erg 2013; 35:1, 36-50

Traction There are no specific indications for cervical traction. D

TENS There are no indications for the use of TENS alone in

patients with acute and chronic NP.

We recommend using TENS in combination with exercise

and other methods of physical therapy in patients with

chronic NP.

D B

Ultrasound We recommend using ultrasound therapy combined with

exercise and other methods of physical therapy in patients with chronic NP.

B

LLLT We recommend using LLLT to reduce acute and chronic NP

in the short term.

B

Accupuncture We recommend using acupuncture for the short-term relief

of subacute and chronic NP.

A Orthoses There are no indications for the use of cervical orthoses. C

36

The Italian Society of Physical and Rehabilitation

Medicine (SIMFER) recommendations for neck pain.

G Ital Med Lav Erg 2013; 35:1, 36-50

Childs JD, Cleland JA et al (2008) Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the

American Physical Therapy Association J Orthop Sports Phys Ther 2008;38(9):A1-A34

39

INTERVENTIONS – CERVICAL MOBILIZATION/MANIPULATION

Clinicians should consider utilizing cervical manipulation and

mobilization procedures, thrust and non-thrust, to reduce neck pain and headache Combining cervical manipulation and mobilization

with exercise is more effective for reducing neck pain, headache,

and disability than manipulation and mobilization alone

(Recommendation based on strong evidence.)

Childs JD, Cleland JA et al (2008) Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the

American Physical Therapy Association J Orthop Sports Phys Ther 2008;38(9):A1-A34

40

INTERVENTIONS – THORACIC MOBILIZATION/MANIPULATION

Thoracic spine thrust manipulation can be used for patients with

primary complaints of neck pain Thoracic spine thrust manipulation can also be used for reducing pain and disability in patients with

neck and neck-related arm pain (Recommendation based on weak evidence.)

Childs JD, Cleland JA et al (2008) Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the

American Physical Therapy Association J Orthop Sports Phys Ther 2008;38(9):A1-A34

41

INTERVENTIONS – STRETCHING EXERCISES

Flexibility exercises can be used for patients with neck symptoms

Examination and targeted flexibility exercises for the following

muscles are suggested: anterior/medial/posterior scalenes, upper

trapezius, levator scapulae, pectoralis minor, and pectoralis major

(Recommendation based on weak evidence.)

Childs JD, Cleland JA et al (2008) Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the

American Physical Therapy Association J Orthop Sports Phys Ther 2008;38(9):A1-A34

42

INTERVENTIONS – COORDINATION, STRENGTHENING, AND

ENDURANCE EXERCISES

Clinicians should consider the use of coordination, strengthening,

and endurance exercises to reduce neck pain and headache

(Recommendation based on strong evidence.)

Childs JD, Cleland JA et al (2008) Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the

American Physical Therapy Association J Orthop Sports Phys Ther 2008;38(9):A1-A34

43

INTERVENTIONS – CENTRALIZATION PROCEDURES AND

EXERCISES

Specific repeated movements or procedures to promote

centralization are not more beneficial in reducing disability when

compared to other forms of interventions (Recommendation

based on weak evidence.)

Childs JD, Cleland JA et al (2008) Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the

American Physical Therapy Association J Orthop Sports Phys Ther 2008;38(9):A1-A34

44

INTERVENTIONS – UPPER QUARTER AND NERVE

MOBILISATION PROCEDURES

Clinicians should consider the use of upper quarter and nerve

mobilization procedures to reduce pain and disability in patients with neck and arm pain (Recommendation based on moderate

evidence.)

Childs JD, Cleland JA et al (2008) Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the

American Physical Therapy Association J Orthop Sports Phys Ther 2008;38(9):A1-A34

45

INTERVENTIONS – TRACTION

Clinicians should consider the use of mechanical intermittent

cervical traction, combined with other interventions such as manual therapy and strengthening exercises, for reducing pain and disability

in patients with neck and neck-related arm pain (Recommendation based on moderate evidence.)

Childs JD, Cleland JA et al (2008) Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the

American Physical Therapy Association J Orthop Sports Phys Ther 2008;38(9):A1-A34

46

INTERVENTIONS – PATIENT EDUCATION AND COUNSELING

To improve recovery in patients with whiplash-associated disorder,

clinicians should (1) educate the patient that early return to normal, non-provocative pre-accident activities is important, and (2) provide reassurance to the patient that good prognosis and full recovery

commonly occurs (Recommendation based on strong evidence.)

Th ực tế nên làm thế nào?

EBP-Evidence Based Practice

SATTERFIELD ET AL 2009

47

• Quan điểm cá nhân : không có s ự khác biệt

đáng kể, có chăng là xem xét khi nào cần có

can thi ệp ngoại khoa Tránh làm các can

48

Tư vấn bệnh nhân như thế nào?

49

Cám ơn quí vị đã lắng nghe

50

Đau cổ không chuyên biệt

Ch ẩn đoán phân biệt một số bệnh lý

thoracic outlet syndrome)

H ội chứng cơ bậc thang trước

Waldman SD (2008) Atlas of common pain syndromes 53

Ylinen (2007) Physical exercises and

functional rehabilitation for the management of chronic neck pain EURA

MEDICOPHYS;43:119-32

• Ten randomized controlled or comparative high-quality trials were included in a more detailed analysis using patient-oriented primary

outcome measures (e.g., patient’s rated pain and disability) as well

as pressure pain threshold and functional outcomes (neck strength and range of motion)

• Findings revealed moderate evidence supporting the effectiveness

of both long-term dynamic as well as isometric resistance exercises

of the neck and shoulder musculature for chronic or frequent neck disorders

• Findings revealed no evidence supporting the long-term

effectiveness of postural and proprioceptive exercises or other very low intensity exercises

54