CD#1302#–#Mod#3/4#Exam#Review#

Informed#Consent!
Health!care!practitioners!required!to!obtain!informed!consent!of!a!patient!before!any!assessment!or!treatment!
•! It’s!a!process,!not!just!signing!a!form!–!explain!your!tests,!exam,!palpation!to!recreate!pain!–!prevents!misunderstanding!
5!steps!to!informed!consent!
1. Recommended!
1.! Explain!recommended!examination/treatment!
2. Why!
2.! Explain!why/rationale!
3. Alternatives!
3.! Discuss!alternatives!–!e.g.!mobs,!acupuncture!
4. SideIeffects!
4.! Discuss!effects,!risks,!sideIeffects!of!examination/treatment!
5. Natural!history!
5.! Explain!what!may!happen!if!pt.!does!NOT!have!examination/treatment!(natural!history)!
Diagnosis!
•! Must!obtain!informed!consent!again!after!arriving!to!a!diagnosis!but!before!treating!for!it!
Elements!of!Consent!
•! Fully!informed!–!must!explain!and!discuss!all!5!steps!
•! Voluntarily!given!–!no!persuasion!that!may!benefit!the!doctor! If!pt.!refuses!to!sign,!document!their!concerns!
•! Related!to!patient’s!condition!and!circumstance!–!risks! and!the!discussion!had.!
•! Not!obtained!via!fraud!of!misrepresentation! Maybe!the!pt.!just!doesn’t!want!SMT!but!is!okay!
•! Can!be!withdrawn!at!any!time!(document!this)! with!everything!else,!document!this.!
Updated!informed!consent!when…! Pt.!can!withdraw!consent!for!SMT!at!ANY!time!
•! Pt.!is!absent!from!care!for!period!of!time!
•! Pt.!presents!with!a!new!condition!
•! Pt.’s!general!health!status!changes!
•! You!decide!to!change!treatment!–!for!various!reasons!
•! After!2!years!have!lapsed!since!existing!pt.!has!signed!most!current!form!(by!CCPA)!
Material!risk!
•! Involves!any!health!care!practitioner’s!knowledge!of!any!possible!adverse!serious!effect!of!a!Tx!for!a!pt.!
o! Includes!anything!–!no!matter!how!rare!it!is!
•! If!pt.!has!adverse!effect!from!assessment!or!treatment!–!doesn’t!matter!how!properly!protocol!was!performed,!
chiropractor!is!liable!for!damages!to!pt.!
•! CCPA!encourages!its!members!to!utilize!their!informed!consent!form!–!to!protect!yourself!
Complications!of!SMT!
•! Evidence!found!primarily!in!case!reports!
•! Most!frequently!reported!complications!–!VBAs!(stroke)!and!CES!(cauda!equina!syndrome)!–!probably!underreported!
•! 295!complications!of!SMT!from!literature!–!165!VBAs,!61!LDH!(led!to!CES),!13!other!cerebral!complications,!56!other!
•! Average!age!of!pt.!with!VBA!is!38!years!old!
•! VBAs!occur!mainly!after!cervical!manipulation!with!a!rotary!component!
Critical!Analysis!–!concerns!about!this!article!on!risks!of!SMT!
•! Assendelft!et!al!–!MD!–!biased!opinion!
•! Two!main!reasons!MDs!avoid!referring!to!chiropractors:!
o! Perceived!lack!of!scientific!evidence!of!efficacy!of!SMT!–!they!just!don’t!know!enough!about!chiropractic!
o! Impression!that!manipulation!is!potentially!dangerous!intervention!
•! Weak!paper!–!relies!on!case!reports!
•! Takeaways!from!the!paper!
o! Most!complications!in!the!lumbar!spine!involved!progression!to!CES!
o! Chances!of!developing!CES!from!SMT!of!HLDH!is!1!in!100!million!(most!of!which!under!anesthesia)!
o! Most!VBAs!from!non!DCs!–!95%!of!SMTs!performed!by!DCs!
Complications!from!Manual!therapies!–!adverse!effects!! Complications!resulting!from!treatments!of!cervical!spine!
•! Dizziness/vertigo,!increased!pain/stiffness! •! VBA!or!other!complication!–!5I10/10,000,000!
•! Strain/sprain,!fracture,!disc!herniation! o! Or!1!in!1.5!million!
•! Vertebral!artery!injury,!carotid!artery!injury! •! Major!impairment!–!3I6/10,000,000!
•! Nerve!root!compression,!SC!injury,!post.!circ.!stroke! •! Death!I!<3/10,000,000!
•! NSAIDS!(Advil)!–!can!give!you!a!GI!event!more!commonly!that!cervical!SMT!can!give!you!an!adverse!event!
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Absolute!contraindications!to!SMT! Relative!contraindications!to!SMT!
•! Acute!arthropathies!(AS,!RA)! •! Note:!all!underlying!systemic!diseases!can!be!screened!by!XIray!
•! Acute!fractures!or!dislocations! or!ESR!
•! Signs!of!ligamentous!rupture/instability! •! Spondylolisthesis!w/!progressive!slippage!articular!hypermobility!
•! Malignancy!or!metastasis! •! PostIsurgical!joints!
•! Infection!or!bones!or!joints! •! Acute!soft!issues!injury!–!Dr.!G!disagrees!with!this!
•! Acute!myelopathy!–!compression!of!SC! •! Osteoporosis!–!important!risk!
•! Cauda!equine!syndrome! •! Benign!bone!tumours!
•! Clinical!manifestations!of!VBI!(vertebrobasilar!infarction)!
•! Aneurysm!
•! Anticoagulant!therapy!(e.g.!heparin,!Coumadin)!
•! Blood!dyscrasias!(e.g.!hemophilia)!
Possible!contraindications!to!SMT!
•! Age!>!50!(controversial)!–!Dr.!G!disagrees!
•! History!of!significant!trauma!–!Dr.!G!disagrees!
•! Fever!greater!than!100!F!
•! History!of!prolonged!corticosteroid!use!(decreased!bone!density)!
•! Unexplained!weight!loss,!history!of!cancer,!adenopathy,!endocrinopathy!(e.g.!calcium!metabolism),!neurological!deficit!
Medical!mistakes!–!death,!brain,!or!spinal!damage,!organ!damage,!internal!bleeding,!operation!on!wrong!limb!–!all!increasing!
Case!studies!–!summarized!
•! DC’s!should!provide!risks!in!written!and!verbal!form!to!be!optimal!–!allow!time!for!questions!and!discussion!
•! Informed!consent!provided!before!assessment/examination!as!well!as!before!treatment!after!arriving!to!diagnosis!
A!consent!is!informed!if,!before!giving!it…!(Glenerin!Guidelines!–!2003)!
•! 5!steps!performed!
•! Health!practitioner!responded!to!person’s!concerns!or!requests!
•! Nature!of!proposed!treatment!is!disclosed!including!all!material!risks!
•! Continuing!obligation!to!keep!patients!informed!–!in!case!of!new!or!changed!material!risk!
•! Orally!or!written!
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Introduction#to#the#Cervical#Spine#
Characteristics!of!Cervical!Spine!
•! Most!complicated!and!mobile!articular!system!–!more!mobility!=!less!stability!=!more!prone!to!injury!
•! Anatomically!–!3!functions:!support!head,!facet!jts!allow!ROM,!housing/transport!of!spinal!cord/arteries!
•! Many!potential!pain!generators!–!muscles,!ligaments,!joints,!larger!arteries,!GI!system!
•! From!clinical!standpoint,!most!cases!of!neck!pain!is!mechanical!including!degenerative!joint!and!disc!
Neck!Pain!Task!Force!–!group!set!up!by!WHO!–!Goals:!
•! Systemic!review!of!neck!pain!(epidemiology,!diagnosis,!prognosis,!economic!costs,!preferences,!treatment)!
•! Original!research!on!risks!associated!with!treatment!
Best!evidence!synthesis!on!neck!pain:!
•! Most!people!experience!nck!pain!in!their!lifetime!–!but!will!NOT!seriously!interfere!with!normal!activities!(LBP!does)!
•! 12!month!prevalence!=!1.7%!to!11.5%!
•! Number!of!people!seeking!health!care!in!emergency!rooms!for!traffic!related!WAS!increasing!over!last!3!decades!
•! Degeneration!is!NOT!risk!factor!for!neck!pain!
NPTF:!Rule!of!Thirds!–!resolution!36.6%,!improvement!32.7%,!persistent!37.3%,!aggravated!9.9%!
NonImodifiable!risk!factors!for!NP!–!age,!gender,!genetics!
Modifiable!risk!factors!for!NP!–!smoking,!some!types!of!physical!activity!(e.g.!cycling!can!make!it!worse)!
Epidemiology!–!women!more!likely!to!develop!NP,!suffer!from!persistent!NP,!les!likely!to!experience!resolution!
Anatomy!–!should!know!this!stuff!already,!not!typing!it!out!
Referred!Pain!
•! When!source!of!pain!is!ligament,!tendon,!capsule,!or!muscle,!pain!may!be!perceived!throughout!somatic!distribution!
o! E.g.!somatic!distribution!of!the!neck!involves!some!of!the!upper!limb!including!scapular!area!and!some!viscera!
o! May!also!skip!certain!structures!
•! Pain!may!also!be!referred!to!proximal!structures!(from!somatic!or!visceral!origin)!
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Course!and!Prognosis!of!NP!
•! Most!neck!pain!sufferers!do!not!experience!complete!resolution!–!50I85%!will!report!reoccurrence!in!1I5!years!
•! Prognosis!depends!on!positive!(optimism,!selfIassurance,!social!activity)!and!negative!factors!(poor!health,!stress)!
NPTF!–!Treatments!for!Neck!Pain!within!chiropractic!care!
•! Educational!videos,!mobilization,!manual!therapy,!exercises,!lowIlevel!laser!therapy,!and!acupuncture!all!have!benefit!
•! Interventions!that!focused!on!regainging!function!and!return!to!work!ASAP!were!more!effective!
o! Encourage!engagement!at!work,!contact!workplaces!to!discuss!job,!don’t!stop!work!completely,!ADLs!
CCO!Guidelines!Initiative!–!acute!nonIspecific!neck!pain!–!tool!to!utilize!for!treatment!advice!
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Torticollis#
•! Contracted!state!of!cervical!muscles!producing!twisting!of!the!neck!and!an!unnatural!position!of!the!head!
o! Typically!from!sleeping!in!an!uncomfortable!position!
o! Can!be!first!sign!of!serious!underlying!musculoskeletal!or!CNS!disorder!
•! Not!a!diagnosis!–!its!an!observation!–!usually!benign!
Etiology!
•! Congenital!–!muscular,!bony!(KF,!or!Sprengel’s),!Ocular!
•! Acquired!–!traumatic!(fracture,!dislocation),!infection/inflammatory,!neoplasm,!neurogenic,!idiopathic,!other!
Congenital!Muscular!Torticollis!
•! Limited!ROM,!associated!with!plagiocephaly!(head/face!asymmetry)!and!dysplasia!of!the!hip!
•! Deformity!slowly!worsens!if!left!untreated!–!scoliosis!may!develop!as!compensation!
•! Treatment!–!conservative!–!90%!resolved!with!stretching!if!early!enough!(taught!to!parents)!
Congenital!Bony!Torticollis!
•! Deformities!of!the!cervical!vertebrae!–!more!tilt!than!turn!(compared!to!CMT)!
•! May!be!associated!with!vertebral!artery!compromise,!KF!
o! Commonly!coIexist!with!other!system!defects!–!genitourinary!anomalies,!hearling!loss,!CNS!problems,!CHD!
•! Treatment!is!limited!with!CBT!
Acquired!Torticollis!
•! Clinical!rotation!of!the!neck!due!to!some!disease!process!–!e.g.!minor!(infection)!or!major!(MVA)!
•! Remember!torticollis!is!an!observation,!not!a!diagnosis!
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Thoracic#Outlet#Syndrome#
•! Associated!with!the!scalenes!and!clavicle!–!a!compression!phenomenon!–!lots!of!things!in!a!tight!space!
o! Nerve!compression!much!more!common!than!vascular!(8:1)!
Etiology!and!Pathogenesis!
•! Compression!of!neurovascular!bundle!–!usually!C8IT1,!subclavian!a./v.!–!between!clavicle/first!rib!or!clavicle/scalenes!
•! Symptoms!not!usually!perceived!at!neck!(lesion),!but!referred!to!distal!upper!extremity!(arm!and!hand)!
o! However,!they!may!be!present!in!some!cases!
•! One!of!two!characteristic!appearances!may!render!someone!prone!to!TOS:!
o! Muscular!individuals!with!short,!thick!necks!(big!traps)!
o! Asthenic!individuals!with!poor!musculature,!long!hypermobile!necks!(swan!necks),!low!riding!shoulder!girdles!
•! Trauma!may!attribute!to!35I50%!of!cases!or!precipitated!symptoms!
Congenital!or!anatomical!abnormalities!associated!with!TOS!
•! Prevalence!of!cervical!ribs!–!present!in!n1%!of!population!–!bilateral!in!80%!of!cases!
•! Fibrous!bands!–!originating!from!cervical!rib!or!elongated!TVP!and!attaching!to!first!thoracic!rib!
Incidence!and!Epidemiology!–!2I4:1!(females:males),!35!years,!working!overhead!often!
Be!wary!of!precipitating!factors!–!working!over!head,!carrying!heavy!loads!over!shoulders,!sleeping!with!arms!above!head!
Signs!and!Symptoms!–!usually!felt!at!most!distal!point!along!nerve!distribution!
•! 100%!I!numbness!and!tingling!in!pinky/ring!finger,!medial!hand!and!even!medial!forearm!(C8IT1!distribution)!
•! 75%!I!aching!pain!in!forearm!and!hand!–!somatic!referral!
•! 38%!I!weakness!and!fatigue!of!arm!–!may!affect!ADLs!a!lot!(clumsiness,!dropping!things)!
Important!points!to!elicit!from!history!–!activities!that!elicit!symptoms,!lost!dexterity,!inability!to!manipulate!objects!over!head!
Physical!Examination!–!weakness!of!shoulder!(drooping),!hand!swelling!and!discolouration,!intrinsic!muscle!atrophy,!palpation!
Orthopaedic!tests!–!Adson’s,!EAST!
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Vascular!examination!
•! Arterial!–!auscultate!subclavian!artery!for!bruits,!measure!BP!in!both!arms!
•! Patients!with!venous!obstruction!–!bluish!colour!of!hand,!swollen!unilaterally,!relieved!by!elevating!arm!
o! Most!infrequently!seen,!easiest!to!diagnose,!
Diagnosis!of!TOS!–!cervical!xIray,!arterial!Doppler,!EMG/NCT!
DDX!–!cervical!disc!disease,!carpal!tunnel!syndrome,!ulnar!n.!entrapment!at!elbow,!Pancoast!tumour,!cardiac!pathology!
Treatment!–!correct!postural!faults!and!poor!body!mechanics,!joint!manipulation,!muscular!relaxation!technique/massage!
•! SelfItreatment!–!postural!exercise,!avoid!painful!positions,!avoid!carrying!heavy!objects,!avoid!sleeping!on!arm!
Operative!indications!–!intolerable!pain/sufficient!loss!of!function/strength,!sleep!disturbance,!threatened/prolonged!disability!
•! 24%!of!pts!with!TOS!require!surgery,!the!rest!can!be!treated!conservatively!(70%)!
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Stroke#
Vertebral!Artery!Syndrome!and!Stroke!(VAS)!–!spontaneous!occlusion!of!a!branch!of!the!vertebral!artery!
•! VAS!associated!with!manipulation!has!been!documented!in!the!literature!since!1934!(Foster!V.!Thornton)!
Incidence!of!VAS!associated!with!manipulation!–!1!in!1I2!million!
•! An!adverse!event!usually!occurs!once!every!400,000!cervical!!
•! Risk!of!death!is!less!than!3!in!10,000,000!
•! Mean!age!=!38!years!–!female:male!=!2:1!or!1:1!
Mechanisms!of!Vascular!Insufficiency!
•! Vertebral!artery!insufficiency!–!result!of!transient!partial/complete!mechanical!occlusion!of!one!or!both!vertebral!
arteries!or!their!branches!(if!one!is!occluded,!you!might!be!okay!due!to!functioning!opposite!artery!
o! Vertebral!aa.!vulnerable!to!mechanical!compression,!shearing,!or!stretching!at!various!sites!during!movement!
•! Arterial!Wall!Trauma!–!mechanism!of!injury!to!the!nervous!system!from!a!VBA!is!brainstem!ischemia!
o! Brainstem!ischemia!due!to!
!! Trauma!to!arterial!wall!producing!vasospasm!
!! Trauma!to!arterial!wall!producing!damage/occlusion!to!arterial!wall!
o! Types!of!arterial!wall!damage:!
!! Intimal!tear!–!clot!formation!(thrombosis)!–!result!is!repair!or!spasm!
!! Intimal!tear!with!embolic!formation!–!if!thrombus!extends!to!lumen,!it!may!detach!forming!embolism!
!! Vessel!wall!dissection!with!subintimal!hematoma!–!thrombosis!partially!occluding!vessel!
!! Perivascular!bleeding!–!blood!may!leak!into!peripheral!tissue!producing!external!compression!
Onset!of!signs!and!symptoms!
•! Temporal!relationship!–!depends!on!mechanism!of!injury!
•! Vasoconstriction/embolism!–!immediate!onset!of!symptoms!(within!first!hour,!suddenly)!
•! Thrombosis!–!onset!within!hours!to!days!(20%!of!symptoms!arise!within!1I48!hours)!
Three!main!potential!sites!of!vertebral!artery!compression!
•! Between!C1IC2!TVPs!–!vertebral!artery!on!contralateral!side!undergoes!stretching!and!possible!kinking!
•! C2IC3!level!(sup.!articular!facet!of!C3)!–!compression!may!occur!during!ipsilateral!rotation!
•! Area!of!posterior!atlantoIoccipital!membrane!–!compression!against!posterior!membrane!
5!Signs!and!symptoms!of!vertebrobasilar!insufficiency/dissection/occlusion!
•! 5!D’s!–!diplopia,!dysphagia,!dysarthria,!dizziness,!drop!attack!
•! 1!A!–!Ataxia!
•! 3!N’s!–!nystagmus,!nausea,!numbness!
Headache!in!Stroke!–!7I65%!
•! Headache!is!common!symptoms!in!acute!ischemic!and!hemorrhagic!stroke,!but!its!association!is!controversial!
•! Women!had!a!higher!probability!of!headache!at!stroke!than!men!
Detection!and!Prevention!of!VAS!–!do!a!good!clinical!examination!(including!cranial!nn.)!
•! Auscultate!for!carotid!bruits!and!take!blood!pressure!
•! May!consider!taking!radiographs!to!rule!out!associated!conditions!
•! Use!proper!manipulative!procedures!(i.e.!avoid!neck!extension)!
4!most!commonly!discussed!risk!factors!for!vertebral!artery!dissection!–!do!good!cardiovascular!exam!with!pts.!w/!these!Sx!
•! Hypertension!
•! Smoking!
•! Oral!contraceptives!
•! Migraines!

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Validity!of!VBI!provocation!test!–!very!poor!–!high!levels!of!false!positives!and!false!negatives!
George’s!4!step!screening!procedure!for!VBI!(American)!
•! Case!history!–!blood!pressure!measurement,!neck!auscultation,!functional!vascular!tests!(Dekleyn’s,!Houles)!
Practitioner!response!to!VAS!in!your!office!–!record!everything!–!take!charge!until!pt.!under!care!of!emergency!medical!staff!
•! Do!NOT!repeat!the!SMT!in!hopes!of!reversing!the!problem!
•! Collar!and!holler!
•! Receive!anticoagulant!therapy!at!hospital!within!3!hours!
•! Monitor!vitals!
•! Perform!CPR!if!pt.!goes!into!arrest!
•! Notify!CCPA!immediately!with!report!
Clinical!note!I!cervicogenic!headache!symptoms!may!in!fact!be!vertebrobasilar!insufficiency!(VBI)!
•! Severe!and!persistent!headache!with!sudden!onset!unlike!any!previously!experienced!headache!–!suspect!VBI!
•! Some!signs/symptoms!may!be!provoked!by!SMT!(especially!if!its!their!first!one)!
Examples!of!stroke!presentation!based!on!location!of!lesion!
•! Posterior!inferior!cerebellar!artery!(PICA)!–!Wallenberg!Syndrome!
•! Pontine!arteries!–!“locked!in”!syndrome!–!can!hear!you,!just!not!move!and!communicate!
3!main!causes!of!vertebrobasilar!aratery!dissection/occlusion!
•! Iatrogenic!(43%,!most!common),!neck!manipulation!(31%),!trauma!(26%)!
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Cervical#Facet#Syndrome#
Epidemiology!
•! Wide!variability!is!reported!and!exact!prevalence!is!difficult!to!establish!
•! In!general,!its!accepted!that!50%!NP!patients!suffer!from!CFJS!–!prof!says!60I75%!will!have!NP!within!their!lives!
Clinical!Anatomy!
•! Diarthrodal!joints!surrounded!by!a!fibrous!capsule!(highly!innervated!and!“looser”!than!capsules!of!thoracic/lumbar)!
•! Angled!at!45!and!gradually!more!vertical!as!they!transition!into!thoracic!spine!
•! Anterior!joint!capsule!–!blends!with!lig.!flavum!which!itself!can!kink!or!hypertrophy!(could!cause!facet!or!n.!irritation)!
•! Posterior!joint!capsule!–!strong!and!fibrous,!sweeps!upward!and!medially,!continuous!with!interspinous!lig!
•! IntraIarticular!inclusions!–!synovial!folds!that!can!be!trapped!causing!mechanical!“lock”!
•! Multifidus!mm.!–!may!affect!joint!capsule!during!extension!(pull!it!out!avoiding!intrapment),!proprioceptive!
CFJS!pathomechanics!–!cIspine!vulnerable!to!a!number!of!mechanisms!of!injury!that!can!lead!to!pain!
•! Functional/postural!
o! Myofascial!–!prolonged!low!level!“tension”!or!contraction!(do!tissue!breaks!and!postural!relief!movements)!
o! Stress!–!anecdotally,!the!cervical!spine!and!shoulders!“hold!stress”!
o! Occupational!–!sustained!positions,!headwear,!repetitive!tasks!
•! Structural!
o! Scoliosis!–!not!common!in!cervical!spine!but!if!present!can!result!in!aberrant!joint!loading/pain!
o! Lack!of!normal!curvature!(lordosis)!–!not!always!associated!
•! Degeneration/pathologic!
o! Osteoarthritis!–!involves!loose!bodies,!surface!erosions,!fibrous!adhesions,!aberrant!loading,!previous!trauma!
•! Trauma/whiplash!
Cervical!facet!pain!patterns!
•! Study!1!–!mapped!out!painful!areas!in!normal!patients!
•! Study!2!–!confirmed!prior!findings!in!neck!pain!patients!(could!predict!which!facet!was!involved!based!on!pain!pattern)!
Cervical!roots!pain!patterns!
•! Note!that!irritation!of!cervical!roots!often!causes!scapular!region!and!interscapular!pain!–!facet!and!root!irritation!mimic!
CFJS!–!4!different!syndromes!–!theories!
•! Facet!synovitis/Hemarthrosis!–!most!common!theory!
o! Irritation!of!synovial!lining!or!bleeding!around!the!area!
o! MOI!–!awkward!movement,!sudden!acute!pain!(crick)!or!stiffness!in!the!neck!–!patient!straightens!immediately!
o! Common!cause!is!stomach!sleeping!–!constant!extension!and!rotation!
o! Presentation!–!normally!one!sided!and!localized!to!one!level!
o! SMT!may!prolong!intraIarticular!bleeding!or!aggravate!hemarthrosis!despite!providing!temporary!relief!
o! Hold!off!on!SMT!for!a!week!or!so!when!bleeding!is!resolved!and!stiffness!remains!
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•! Facet!Restricted!Motion!
o! Identified!during!normal!visit!–!early!moderate!stiffness!without!pain!(yet?)!
!! May!progress!to!disc/synovial!impingement!if!left!untreated!
o! Stiffness!decreases!proprioceptive!output!and!resistance!to!insult,!also!causes!hypermobility!in!adjacent!joints!
o! Treatment!–!SMT,!STT,!electrotherapy!
•! Facet!Mechanical!Lock!
o! Synovial!joints!are!prone!to!locking!due!to!intraIarticular!inclusions/menisci!
o! Cause!–!jamming!of!joint!surfaces!via!motion!(via!sudden!fast!movement)!
o! Presentation!–!pt.!flexes!and!can’t!straighten!up,!no!severe!pain!
o! Treatment!–!SMT!with!distraction!component,!traction,!passive!ROM!
•! Facet!Painful!Block!–!like!3!but!painful!
o! Any!attempt!to!straighten!up!or!extend!is!painful!–!intrapment!of!synovial!fold?!
o! Diagnosis!–!isometric!multifidus!contraction!may!provide!dramatic!relief!(pulls!synovial!fold!out!of!the!way!
o! Treatment!–!isometric!exercise,!SMT!as!tolerated,!traction,!electrotherapy!
Cervical!synovial!folds!
•! Common!yet!inconsistent!in!size!and!shape!–!fatty!in!children,!fibrous!in!adults!
•! Abundant!vascular!network!and!nerve!endings!–!why?!–!maybe!nociceptive,!proprioceptive,!vasomotor?!
•! “Passive!spaceIfillers”!–!unclear!how!this!may!affect!physiological!motion!and!joint!loading!
CFJS!–!Clinical!presentation!
•! Axial!pain,!unilateral!neck!pain,!interscapular!pain,!stiffness,!sometimes!focalized!
•! Researched!referral!patterns!(not!down!the!arm!though),!no!neurological!symptoms!
CFJS!–!diagnosis!
•! The!only!way!to!definitively!diagnose!a!CF!as!a!pain!generator!is!diagnostic!block!–!invasive!
•! Suggested!criteria!–!axial!neck!pain,!pain!with!pressure,!positive!kemps,!absence!of!neurological!symptoms!
Neck!pain!–!diagnostic!considerations!
•! Difficult!to!diagnose!specifically,!however,!specific!diagnosis!has!NOT!been!demonstrated!to!change!prognosis!
•! Signs!and!symptoms!should!assist!in!treatment!selection,!not!specific!diagnosis!
CFJS!–!treatment!
•! SMT/mobs,!ice!(acute),!heat!or!ice!(subacute),!acupuncture,!STT,!antiIinflammatory,!exercise!
Natural!history!–!90%!recovery!in!8!weeks!with!no!treatment!
Prognosis!–!excellent,!persistent!pain!suggests!underlying!pathology!
!
Cervical#Spine:#Disc#Herniation#
•! Similar!to!those!in!other!regions,!but!smaller,!do!not!bear!as!much!weight,!share!load!equally!with!facets!
Cervical!IVD!functions!–!resist!compression,!allow!movement,!largely!responsible!for!spinal!curve,!load!transmission!
Anatomy!–!outer!annulus!fibrosus!(concentric!and!oblique!fibrocartilaginous!rings!+!inner!nucleus!pulposus!(jelly!)!
•! Innervation!via!sinuvertebral!n.!only!to!outer!lamellae!(inner!layer!and!pulposus!has!little!if!any!innervation!
•! Blood!supply!–!healthy!discs!have!few!(if!any)!blood!vessels!(via!pathology,!blood!vessel!concentration!can!increase)!
Changes!with!age!–!annular!lamellae!become!irregular,!fissure!formation!from!inside!to!outside,!decreased!osmotic!pressure!in!
nucleus!causing!reduced!water!content!(dehydration;!thus!DH!more!common!in!younger!individuals),!loss!of!disc!height!
•! All!factors!may!shift!loadIbearing!reasonability!to!adjacent!facets!–!this!can!cause!further!degeneration!on!the!facets!
•! Note,!by!age!45,!chances!of!an!overt!herniation!is!greatly!reduced!
Study!–!suggests!DDD!might!be!a!systemic!issue,!not!local!
Correlation!of!imaging!findings!of!disc!degeneration!with!clinical!symptoms!is!poor!(treat!the!patient,!not!the!pictures)!
Cervical!IVD!–!pathology!
•! IVDs!degenerate!faster!than!any!other!tissue!in!the!body!–!e.g.!20%!of!teens!have!signs!of!disc!degeneration!
o! Two!primary!MOIs:!rotation!and!compression!
•! CDH!can!occur!acutely!during!whiplash!trauma!
•! CDH!(or!any!disc!herniation)!is!an!ongoing!process!(i.e.!degeneration),!rarely!does!a!healthy!disc!herniate!suddenly!
•! 90%!of!CDHs!occur!at!C5IC6!–!rare!to!see!CDH!in!upper!cervical!spine!–!most!are!posterolateral!
•! Neck!pain!+!arm!pain/radiculopathy!is!more!disabling!than!neck!pain!alone!and!has!greater!impact!on!overall!health!
•! Recall!DH!continuum:!Bulge!–!small!focal!protrusion!–!extrusion!–!sequestration!
CDH!–!risk!factors:!male,!frequent!lifting,!smoking,!occupation!(esp.!with!vibration),!driving,!frequent!diving!from!board!
CDH!–!nonIrisk!factors:!wearing!high!heels,!#!pregnancies,!occupational!neck!twisting,!time!spent!sitting,!smoking!pipe/cigars,!
participation!in!sports,!race,!height/weight,!education!

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CDH!–!signs!and!symptoms!
•! Arm!pain!I!#1!symptom!
•! Neck!pain!or!stiffness!–!cervical!facets!and!discs!can!refer!in!between!shoulder!blades!
•! CervicoIbrachial!neuralgia,!cervical!radiculopathy,!weakness!of!upper!extremity,!dysphagia,!headache/dizziness!
•! Decreased!cervical!ROM!(painful!flexion),!dermatomal!arm!pain!or!paresthesia,!diminished!motor!function,!atrophy!
CDH!–!aggravating!factors:!neck!motion,!coughing/sneezing/straining,!sudden!neck/arm!movement,!poor!posture!
CDH!–!clinical!findings!
•! Neurological!abnormalities!
•! +ve!Kemp’s,!SotoIHall,!Valsalva,!Spurling’s,!ULTT!
•! pain!relief!with!axial!distraction,!abducted!arm!
•! Torticollis!look,!joint!fixations/stiffness/rigidity,!gait!disturbance!
CDH!–!diagnosis!
•! Primarily!from!Hx!and!physical!examination!findings!(C5IC6!most!common)!
•! Neurological!findings!may!identify!specific!spinal!level!
•! Use!imaging!(MRI)!to!confirm/expand!diagnosis!–!remember!to!treat!the!patient,!not!the!pictures!
•! Dermatomal!patterns!often!don’t!exist!(70%)!
CDH!–!treatment!
•! Main!objective!is!to!reduce!pain!via!conservative!care!(SMT?,!mobs,!STT,!traction,!acupuncture,!education!on!posture)!
•! Other!methods!include!epidural!injections,!NSAIDs,!surgery!
•! SMT?!–!Dr.!G!believes!it!is!not!a!good!idea!(take!precaution!if!you!are!to;!waitIout!acute!flairIups)!
o! Overall,!may!be!best!to!employ!treatments!other!than!SMT!for!the!timeIbeing!
CDH!–!prognosis:!most!improvement!in!pain/disability!within!4I6!months,!complete!recovery!within!2I3!years!
•! As!always,!worker’s!compensation!and!traumatic!onset!=!poorer!diagnosis!
CDH!–!takeIhome!messages!
•! Be!aware!that!recurrent!neck!pain!patients!may!be!on!their!way!to!a!CDH!
•! We!may!be!blamed!for!causing!CDH!–!follow!protocol!and!be!careful!
•! Prudent!doctoring,!open!communication,!frequen!reIevals!and!common!sense!can!help!medicolegal!concerns!
!
Myofascial#Pain#Syndrome#(MPS)#
•! Usually!relates!to!trigger!points!–!an!area!of!muscle!that!refers!pain!to!another!part!of!the!body!
•! Can!be!caused!by!trauma,!repetitive!strain!injury!(RSI),!
•! When!diagnosing!MPS,!determine!the!muscle!that!is!causing!the!problem!and!include!it!into!the!Dx!of!MPS!
Hypertonicity!–!excessive!muscle!tone,!tension,!or!activity!that!can!be!transient!or!chronic!
•! Ask!the!pt.!if!upon!deep!palpation!if!it!hurts!anywhere!else!(found!a!TP)!
•! Constant!lowIgrade!contraction!can!lead!to!accumulation!of!metabolic!endIproducts!which!can!cause!pain!and!
inflammation,!and!further!”protective”!contraction!
Spasm!–!involuntary!muscle!contraction!of!sudden!onset,!often!caused!by!injury,!inflammatory!products,!neurological!problems!
•! Often!limits!mobility!of!affected!joints!
Common!MPS!of!the!cervical!spine!include”!
•! SCM,!splenius!capitus,!semispinalis!capitus!
•! Trapezeius!–!upper!fibers!–!where!most!people!will!have!tenderness!
•! Levator!scapulae!–!“stiff!neck”!muscle!(travel)!
•! Scalenes!
MPS!–!Scalenes!
•! Common!MPS!of!the!neck!
•! Active!TPs!can!refer!pain!down!arm,!into!chest!and!into!interscapular!area!or!“dorsal!spot”!
•! Prof!says!50%!of!pts!will!have!hypertonic!scalenes!so!you!should!learn!to!properly!isolate!
MPS!–!Levator!Scapulae!
•! Travellers!refer!to!this!as!the!“stiff!neck”!muscle!
•! Painful!passive!ROM!–!opening!windows!causing!a!cold!draft!to!be!present!may!cause!MPS!
Prevalence!of!MPS!after!WAD!
•! In!order!of!most!common:!seminspinalis!capitus,!trapezius,!levator!scapulae,!scalenes!medius,!SCM,!masseter!
!
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Benign#Paroxysmal#Positional#Vertigo#(BPPV)#
Dizziness!and!benign!BPPV!
•! Paroxysmal!–!intermittent!in!nature!(on/off),!lasts!a!few!days,!goes!away,!comes!back!
•! Positional!–!symptoms!change!with!head!position!
•! BPPV!is!the!most!common!cause!of!vertigo!of!peripheral!(vs.!central)!origin!–!30I50%!
•! BPPV!is!a!mechanical!disorder!of!inner!ear!–!characterized!by!brief!epodes!of!severe!vertigo!and!rotary!nystagmus!
o! Precipitated!by!specific!positions!of!the!head!relative!to!gravity!
Vertigo!–!sensation!of!instability,!loss!if!equilibrium!(“spinning”)!
•! Caused!by!a!disturbance!in!the!semicircular!canals!of!the!ear!or!vestibular!nucleus!of!the!brainstem!
•! Two!types:!
o! Subjective!vertigo!–!sensation!of!spinning!
o! Objective!vertigo!–!sensation!of!the!world!spinning!about!one’s!self!
Dizziness!–!nonspecific!term!used!to!describe!unsteadiness,!giddiness,!lightIheadedness,!disequilibrium,!vertigo,!ataxia!
•! Could!be!proprioceptive!problem!of!the!neck!
Causes!of!dizziness!
•! Otologic!(inner!ear)!–!BPPV,!Meniere’s!(hearing!loss,!vertigo,!tinnitus,!the!triad),!vestibular!neuritis,!labyrinthitis!
•! Neurological!–!stroke,!TIA,!migraine,!seizres,!MS,!tumours,!TBI,!CSF!leak!
•! Medical!–!hypotension,!hypoglycemia,!arrhythmia!
•! Psychogenic!–!anxiety,!panic,!depression,!agoraphobia,!hyperventilation!syndrome,!malingering!
•! Undiagnosed!–!postItraumatic!vertigo!
Strokes!and!Dizziness!
•! Carotid!a.!disease!does!not!cause!dizziness,!as!carotids!supply!anterior!brain,!not!vestibular!bit!
•! Common!strokes!and!dizziness!–!PICA!100%,!lateral!medulla!and!cerebellum!
Natural!history!of!BPPV!–!3I9!days!to!recover!typically!
Causes!of!BPPV!
•! Idiopathic!–!50%!
•! TBI!–!head!injury!–!17%!
•! Viral!neurolabyrinthitis!–!15%!
•! Other!
Mechanism!of!BPPV!–!cupulolithiasis!(20%)!or!canalithiasis!(80%!
Assessment!of!Dizziness!–!Romberg!and!tandem!gait,!rotary!chair,!DixIHallpike,!
Treatment!of!BPPV!
•! Epley’s!“canalith!repositioning!procedure”!–!best!for!PC!BPPV!
o! Sit!for!10!minutes,!DixIHallpike!for!2I3!minutes!(bad!ear!down),!rotate!180!(good!ear!down)!for!2I3!mins,!then!
sit!back!up!–!repeat!3!times,!3!times!per!week!–!pt.!must!stay!up!right!unless!sleeping!(45!degrees)!
•! Brandt!Daroff!maneuver!
•! Semont!–!best!for!AC!BPPV!
•! Log!roll!–!best!for!LC!BPPV!
Complication!of!vestibular!rehab!
•! If!you!do!not!pick!the!right!type!of!BPPV!treatment,!you!could!cause!canal!conversion!or!canal!jamming!
•! Nausea!and!vomiting,!generalized!dizziness!

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Cervical#Spondylotic#Myelopathy#(CSM)#
•! Most!common!neurological!spinal!cord!disorder!after!middle!age!
•! Stenosis!of!the!spinal!column!in!the!cervical!spine!which!leads!to!pathology!of!the!spinal!cord!–!usually!C4IC7!
•! Caused!by!cervical!spondylosis!(fixation!or!stiffness!of!a!vertebral!joint!leading!to!degenerative!changes)!
•! Myelopathy!–!implies!spinal!cord!pathology,!possibly!due!to!ischemia!of!the!cord!
•! Normal!canal!width!is!17!mm,!stenosis!is!<12!(at!risk)!
Pathophysiology!of!CSM!
•! Chemical!changes,!derangement!of!disc,!compensatory!hypermobility/segmental!instability,!bony/lig.!reactive!changes!
Diagnosing!CSM!
•! XIray!can!measure!canal!width,!MRI!will!confirm!diagnosis!
•! Hoffman’s!sign!may!be!positive!
Treatment!
•! Limit!flexion!and!extension!of!neck!
•! SMT!–!contraindicated!in!early!stages!–!don’t!adjust!any!hypermobile!necks!or!necks!with!canals!<11mm!
•! Other!treatments!–!immobilization!(limit!flexion/extension)!or!surgery!(decompression!via!laminectomy,!shaving!
osteophytes)!
Note!about!clinical!reflex!presentation!with!lower!cervical!compression:!
•! UMNL!–!in!the!spinal!cord!–!hyperreflexia!
•! LMNL!–!at!nerve!root!–!hyporeflexia!
•! Cord!compression!can!lead!to!ataxic!gait!(impaired!ability!to!coordinate!movement)!–!stiff!lower!limbs!and!wide!gait!
•! E.g.!!pt.!with!cord!compression!at!C5IC6:!exhibit!hyporeflexia!at!that!level!and!hyperreflexia!below!that!level!
!
Cervical#Spine#Fractures!
2!classifications!of!fractures!in!the!CIspine:!stable!and!unstable!
•! Stable!–!NO!surgical!fusion!required!as!there!is!no!direct!danger!to!the!spinal!cord!
•! Unstable!–!may!need!surgical!fusion!due!to!possible!spinal!cord!injury!or!cord!compression!
Canadian!CIspine!rules!–!higher!sensitivity!and!specificity!and!nexus!
•! Age!>!65!years!
•! Paraesthesia!in!extremities!
•! Dangerous!mechanism!of!injury!
•! Immediate!onset!of!pain!
•! Unable!to!rotate!neck!activity!45!degrees!bilaterally!
•! Unsafe!to!do!AROM!–!not!simple!rear!end!collision,!midline!cervical!tenderness,!unable!to!sit!
Cervical!Instability!vs.!Hypermobility!
•! Instability!–!decreased!integrity!of!spine!leading!to!cord!compression,!nerve!root!compression!etc!
o! Determine!radiographically!I!>3.5!mm!of!translation!suggests!clinical!instability!
!
Whiplash#Associated#Disorder#(WAD)#
Incidence!(cases/1000!capita):!USA!(3.8I14.5),!UK!(5),!Australia!(1),!Norway!(2),!Canada!(3),!Quebec!(0.7),!Ontario!(0.6)!
•! Point!prevalence!suggests!1%!of!cases!of!chronic!neck!pain!are!due!to!whiplash!and!0.4%!are!severe!
Motor!Vehicle!Accident!–!most!common!mechanism!for!WAD!
•! Impact!types!–!rear!end!(most!common!and!most!resistant!to!resolution),!frontal,!lateral,!sideswipe,!rollover!
•! 3!types!of!MVA!collisions!–!occupant!of!people!(most!common),!pedestrian,!cyclist!
Pathomechanics/biomechanics!of!WAD!in!a!rearIend!collision!–!hyperextension!injury!followed!by!hyperflexion!
•! Entire!body!constrained!except!head!thus!more!susceptible!to!perturbation!(movement)!
•! Usually!hit!while!stopped!or!slowing!down!–!sudden!acceleration!forward!causes!neck!to!hyperextend!past!normal!
ROM/physiological!limits.!
o! Hyperextension!occurs!within!150I200ms!after!initial!impact,!neck!flexor!reflex!occurs!at!220ms!(late)!
•! Neck!then!hits!head!restraint!and!recoils!forward!from!tissue!elasticity!and!relative!deceleration!of!vehicle!
•! Centre!of!force!for!hyperextension!is!usually!C5IC6!
•! If!head!restraint!is!too!low!–!can!accentuate!hyperextension!(“ramping”)!
•! Modern!cars!have!stiffer!seats!in!order!to!decrease!horizontal!acceleration!of!the!head!by!70%!
•! If!the!head!makes!contact!with!windshield!or!steering!wheel!–!compression!injury!+!concussion!
•! If!driver!is!aware!of!impending!rearIend!collision,!tightening!anterior!neck!musculature!and!keeping!foot!on!the!break!
can!decrease!forward!acceleration!thus!decreasing!degree!of!hyperextension!
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HighIspeed!rearIend!MVA!(rearIend)!
•! Seatback!often!breaks!and!traction!forces!predominate!–!limits!cervical!hyperextension,!but!increases!lower!back!injury!
•! Note!about!velocity!–!it!is!the!best!criteria!to!evaluate!injury!likelihood!
Cervical!Spine!Kinematics!(rearIend)!
•! By!44ms,!CIspine!straightens!and!is!thrust!upwards!from!rising!trunk!
•! By!110ms,!CIspine!undergoes!“sIshaped”!configuration!
o! Lower!cervical!spine!extends!(ant.!elements!separate,!post.!elements!impact)!and!upper!cervical!spine!flexes!
Muscle!activity!(rearIend)!
•! Muscle!recruitment!starts!by!100I125ms,!may!take!another!60ms!to!develop!tension!(more!yet!if!unbraced,!>200ms)!
•! By!this!time,!(200I250ms)!compression!and!abnormal!intersegmental!movements!damaging!to!spine!have!occurred!
!
Clinical!Notes!(rearIend)!
•! Women!at!greater!risk!–!ramp!earlier,!greater!CIspine!displacement,!insufficient!muscle!force,!increased!distraction!
Frontal!(head!on)!Collision!–!hyperflexion!injury!
•! Commonly!occurs!after!making!left!turn!or!when!attempting!to!pass!grandma!
•! Airbags!should!deploy!–!year!and!make!of!the!car!is!relevant!in!this!case!(all!cases!really)!
•! SeatIbelt!provides!support!and!may!prevent!thoracic!and!abdominal!injuries!but!it!can!aggravate!CIspine!injuries!
•! Patient!may!hit!knees!on!dashboard!–!can!cause!serious!lower!extremity!injury!
•! Head!injury!may!occur!–!impact!on!steering!wheel,!dashboard!or!windshield!(ask!if!LOC!occurred)!
•! Chest!will!block!hyperflexion!of!the!neck!(but!then!may!distract!the!neck)!
Lateral/Broadside!Collision!(TIbone)!
•! Broadside!–!body!motion!is!lateral!–!shoulder!will!block!neck!from!lateral!flexion!
•! NearIside!(driver!side)!–!usually!more!severe!–!head,!shoulder!and!rib!injuries!may!occur!if!driver!hits!door/window!
•! FarIside!(passenger!side)!–!occupant!moves!away!from!door!–!injury!of!ribs/back!can!occur!from!hitting!console!
Sideswipe!Collision!–!most!likely!will!not!cause!injury!
•! Vehicles!do!not!reach!common!velocity!
•! Wheel!impact!or!bumper!“catching”!could!cause!some!significant!jolting!
Rollovers!–!really!dangerous!(potential!for!roof!to!collapse)!
•! Multiple!injuries!can!occur!–!head!and!multiple!fractures!
Vehicle!component!damage!resistance!
•! Low!resistance!–!sheet!metal,!grill,!headlamps!
•! High!resistance!–!wheels/axles!(will!absorb!more!force!before!warping)!
•! Variable!resistance!to!damage!–!bumpers!(types:!piston,!honeycomb,!foam,!bracket);!varies!depending!on!type!of!car!
AutoIsafety!features!that!have!a!“Direct!Bearing!on!the!Extent!of!a!Whiplash!Injury”!
•! Firm!seatbelt!(minimize!acceleration!on!occupant),!shoulder!strap,!stiff!headIrestraint,!inflatable!airbags!
Head!Restraints!
•! Decreases!neck!extension!injury!by!24%!I!however,!only!10%!of!head!rests!are!adjusted!to!proper!height!
o! Proper!height!=!top!of!restraint!level!with!top!of!your!head!–!will!prevent!“ramping”!
•! Cannot!prevent!damage!in!vertical!component!(distraction)!
•! Proper!distance!is!as!close!as!possible!to!head!restraint!
Shoulder!straps!–!Ideal!position!is!over!the!clavicle,!NOT!around!neck!–!may!cause!bruising!of!shoulder,!chest!or!breasts!
Seatback!stiffness!and!elasticity!–!just!know!stiffer!is!better!in!most!cases!
Child!safety!–!must!use!booster!seat!(provides!60%)!more!protection!than!seatbelts!alone!unless!the!child!is!able!to!use!seatbelt!
Threshold!for!softItissue!injuries!–!rearIend!impact!with!less!than!8km/h!difference!appears!to!be!within!“tolerance”!
Tissue!pain!threshold!from!lowest!to!highest:!periosteum,!ligament,!fibrous!joint!capsule,!tendon,!fascia,!muscle!
Onset!of!symptoms!–!0I48!hours,!neurological!symptoms!may!occur!months!later!(TOS)!
Symptoms!of!WAD!–!NP!and!stiffness,!headaches,!arm!pain/numbness,!dysphagia,!vertigo,!tinnitus,!extremity!injuries,!LBP,!
interscapular!pain,!upper!back!pain,!chest!pain,!sleep!disturbance/anxiety/fear/depression,!Horner’s!syndrome,!visual!issues!
Diagnostic!Classification!of!Whiplash!Injuries!(Quebec!Task!Force)!
•! Grade!0!–!no!complaint!about!neck!and!no!physical!signs!
•! Grade!I!–!neck!complain!of!pain,!stiffness!or!tenderness!only,!NO!physical!signs!
•! Grade!II!–!neck!complaint!AND!musculoskeletal!sign(s)!–!most!common!
•! Grade!III!–!neck!complain!AND!neurological!sign(s)!
•! Grade!IV!–!neck!complain!AND!fracture!or!dislocation!
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Dr.!G!Rules!–!XIray!neck!when…!
•! Red!flags,!trauma,!WAD!>1,!cervical!radiculopathy,!decrease!in!C/S!ROM,!low!hairline/webIneck,!Torticollis,!age!>55!
Prognosis!for!WAD!
•! Controversy…!NPTF!says!up!to!55%!of!claims!report!persistent!neck!pain!after!1!year!
Symptoms!reported!by!patients!during!first!months!AFTER!cervical!injury:!
•! Neck!ache!(98%),!Neck!stiffness!(95%),!headache!(72%),!Shoulder!pain!(36%),!etc…!
Location!of!lesions!in!WAD!
•! Most!common!tissues!injured!–!ligaments,!muscle,!disc,!facet!joints!
•! Less!common!tissues!injured!–!disc!herniation,!fractures,!tear,!brain!hemorrhage!
Treatment!of!WAD!
•! Acute!phase!(2I4!weeks)!–!pain!control,!education!and!reassurance!
•! SubIacute!phase!(4I8!weeks)!–!easing!of!m.!spasms,!education,!rehab/physio!(recovery!of!function!is!key),!reassurance!
•! Chronic!phase!(12I16!weeks)!–!functional!restoration!(back!to!work),!residual!headaches,!rheumatism!
•! Last!stage!–!full!recovery!(longest!phase),!may!still!have!residual!pain,!encourage!to!pursue!physical!fitness!
•! Recovery!rate!and!extent!of!recovery!really!depends!on!patient!(social!activity,!mood,!attitude,!motivation!to!improve)!
•! Average!=!75%!will!recover!within!6!months!to!2!years!
Important!questions!to!ask!patient!involved!in!MVA!–!too!many!to!list,!most!of!which!are!obvious/common!sense!
Minor!Injury!Definition!–!KNOW!THIS!
•! “Any!one!or!more!sprain,!strain,!WAD,!contusion,!abrasion,!laceration!or!subluxation!and!any!clinically!associated!
sequelae”!
•! Note!–!12!weeks!of!treatment!standard,!can!start!anytime!before!chronic!pain!develops!
!
Thoracic#Spine#Syndromes#
Overview:!
•! Nerve/disc!lesions!and!overt!radicular!problems!are!rare!in!TIspine!due!to!the!inherently!rigid!structure!of!the!rib!cage!
•! Pain!syndromes!are!often!lowIgrade!in!nature!–!usually!originating!from!faulty!respiration!and!postural!adaptations!
•! SMT!to!TIspine!is!potentially!useful!for!mechanical!neck!pain!according!a!number!of!studies!
TIspine/ribcage!anatomy!
•! Inherently!stable!interface!between!cervical!and!lumbar!regions!–!both!of!which!are!more!mobile!
o! Ribs!play!a!major!factor!in!the!structural!stability!–!also!act!to!protect!visceral!organs!
•! Its!kyphotic!curvature!is!primary!(cervical!and!lumbar!lordosis!are!secondary)!
•! Is!a!factor!in!shoulder!girdle!mechanics!–!may!play!into!shoulder!complications!if!abnormal!enough!
•! T10IT12!are!transitional!vertebra!–!sites!of!moreIthanInormal!amounts!of!and!different!stresses!
•! Ribs!partially!govern!breathing!mechanics!and!are!sits!of!global!and!local/instrinsic!muscle!attachments!
Thoracic!IVD!
•! Thinnest!discs!in!the!spine!–!allow!rotation!and!little!other!motion!–!1%!of!all!disc!herniations!occur!in!the!TIspine!
Somatic!pain!referral!–!many!visceral!complications!will!refer!pain!to!the!thoracic!region!–!roughly!based!on!location!of!organ!
Thoracic!coupled!motion!and!motion!palpation!–!doctor!interpretation,!assessment,!and!treatment!differ!greatly!
Rib!Fracture!
•! Generally!associated!with!distinct!trauma!–!if!not,!then!investigate!for!BMD!or!other!pathology!
•! Possible!risk!when!performing!SMT!–!would!require!a!lot!of!force!unless!underlying!pathology!is!present!
•! Pt.!will!have!pain!with!all!motions!–!ADLs!are!difficult!–!gentle!rib!springing!to!locate!fracture!
•! Suspicion!may!warrant!referral!for!imaging!–!if!it!doesn’t!change!your!POM,!then!why!both!radiating!patient?!
Vertebral!compression!fracture!
•! Generally!older!patients!–!most!frequent!cause!is!osteoporosis!and!longIterm!corticosteroid!use!
•! Younger!patients!–!occurs!when!falling!on!buttocks!or!via!hyperIflexion!mechanism!
•! Sudden!onset!of!acute!pain!–!often!after!minor!trauma!should!raise!suspicion!(e.g.!stepping!off!curb,!sneezing)!
•! Most!important!risk!factor!–!previous!fragility!fracture!(RR!>!8)!
•! Diagnosis!–!clinical!suspicion,!possible!decrease!in!height!(2cm),!hyperIkyphosis,!xIray!
•! Prevention!–!exercise!(proper!loadIbearing!will!keep!BMD!from!dropping!rapidly!and!strengthen!intrinsic!musculature)!
o! Daily!standing,!stair!climbing,!and!walking!are!known!to!lower!risk!
•! Clinical!management!–!metastatic!suspicion/cause,!refer!out!–!for!stable!fx,!rest!and!OTC!medication!for!acute!phase!
!
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Fibromyalgia!–!controversial!condition/diagnosis!–!not!going!to!go!over!details!as!we!already!know!it!
•! American!College!of!Rheumatology!(ACR)!Diagnostic!Criteria!(1990)!
o! History!of!widespread!pain!(chronic,!>3!months)!above!and!below!waist,!11/18!tender!points!to!palpation!
•! New!ACR!Diagnostic!Critieria!(2010)!
o! Widespread!pain!index!(WPI)!=!7!and!symptom!severity!(SS)!scale!=!5!or!WPI!=!3I6!and!SS!=!9!
Ankylosing!Spondylitis!
•! Chronic,!systemic,!inflammatory!arthritis!–!affects!primarily!SI!joints,!spine!and!enthuses!(boneItendon!junctions)!
•! Difficult!buy!crucial!to!diagnose!early!–!before!severe!symptoms!arise!–!usually!a!5I12!year!delay!in!diagnosis!
•! Prevalence!=!0.1I2%!in!varying!populations!(European!data)!–!male:female!ratio!is!2:1"5:1!
•! 80%!are!symptomatic!by!30!–!the!younger!someone!is,!the!worse!their!prognosis!(early!onset!is!bad)!
•! New!diagnostic!criteria!–!positive!if!2/4!criteria!are!present!
o! Morning!stiffness!for!>30!minutes!–!very!distinct!and!key!
o! Pain!relieved!with!exercise!but!not!with!rest!
o! Awakening!with!back!pain!but!only!in!the!second!half!of!the!night!
o! Alternating!buttock!pain!
•! Clinical!features!
o! Inflammatory!back!pain!(sacroiliitis!or!other!axial!locations)!–!insidious,!worse!in!the!morning!(>30!minutes)!
!! Sacroiliitis!–!uni/bilateral!SI/buttock!pain!+!posterior!thigh!pain!(may!alternate!sides)!
o! Rib!cage!pain!–!don’t!like!it!when!people!slap!them!on!the!back!
o! Spinal!stiffness!and!decreased!mobility!
o! Peripheral,!monoarticular!arthritis!–!lower!limb!>!upper!limb!
o! Sleep!disturbance/daytime!fatigue!are!nonIspecific!to!AS,!but!common!
o! Enthesiopathy!–!pain!rising!from!boneItendon!junction!(not!muscle!belly)!including!Achilles!and!plantar!fascia!
•! Examination!–!decreased!lumbar!forward!flexion!(Schober’s)!and!side!bending,!decreased!chest!expansion,!SIJ!testing!
•! LabIworkup!–!HLAIB27!–!genetic!component!to!AS!
•! Associated!conditions!–!inflammatory!bowel!symptoms!(Crohn’s/Colitis),!psoriasis,!iritis,!osteoporosis,!fractures!
•! Treatment!–!physiotherapy!is!beneficial,!SMT!if!tolerated!(not!during!acute!flairIups),!STT,!mobs,!general!exercise!
•! Medical!management!–!NSAIDs,!corticosteroids,!antiIrheumatic!drugs,!TNF!inhibitors!(weigh!against!costs)!
•! Prognosis!–!poor!outcome!associated!with!high!level!of!initial!radiographic!damage,!early!onset,!hip!involvement!
o! Similar!for!all!inflammatory!arthritides!
•! Potential!outcomes!–!aggressive!endIstage!disease!can!manifest!with!complete!bony!ankyloses!of!spine!(fused!spine)!
#
Nerve#Lesions#
•! Complete!lesion!–!loss!of!sensory,!motor,!and/or!autonomic!functions!
•! Incomplete!lesion!–!permit!generation!and!transmission!of!pain!–!still!hurts!
Intercostal!Nerve!Lesions!
•! Tends!to!be!sharp,!superficial,!and!often!burning!–!associated!with!hypersensitivity!or!dysesthesia!
•! Sensory!loss!is!rare!in!single!intercostal!nerve!lesions!due!to!overlap!of!adjacent!nerves!–!need!>1!adjacent!intercostal!n.!
•! Muscle!weakness!very!difficult!to!detect!clinically!since!ribcage!moves!together!
Herpes!Zoster!(shingles)!–!infections!of!the!dorsal!root!ganglia!
•! Varicilla!zoster!–!childhood!infection!resulting!in!overt!or!subclinical!chickenpox!–!may!remain!latent!in!DRG!
•! With!age,!antibodies!to!virus!decrease!–!allows!reactivation!(usually!in!relation!to!trauma,!infection,!or!stress)!
•! Characterized!by!rash!occurring!in!a!nerve!root!distribution!–!generally!doesn’t!cross!midline!
•! After!several!days,!vesicles!break,!crust,!and!heal!by!scarring!–!very!contagious!!
o! Pain!precedes!appearance!of!skin!lesions!by!2I5!days!–!may!confuse!with!actual!rib!complication!
Herpes!Zoster!(shingles)!–!postIherpetic!neuralgia!
•! May!involve!C3IC5!nerve!roots!or!phrenic!n.!(which!may!cause!shoulder!pain!or!hemidiaphragmatic!paralysis)!
•! Pain!usually!subsides!after!a!few!weeks!–!however,!25I50%!of!patients!develop!postIherpetic!neuralgia!
o! This!pain!may!persist!for!years!
•! Only!50%!of!patients!will!have!a!rash!in!the!thoracic!region!
•! Both!conditions!are!difficult!to!treatI!usually!managed!with!oral!pain!medication!or!corticosteroids!
•! Study!found!that!severity!of!initial!injury!seems!to!predict!PHN!–!catch!it!early!and!get!it!treated!!
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Traumatic!Intercostal!Neuralgia!
•! Intercostal!nn.!are!vulnerable!to!injury!when!ribs!are!traumatized!–!on!xIray!look!for!fractures/calluses!
o! 30I50%!of!acute!rib!fractures!will!not!be!seen!on!initial!radiographs!
o! With!persistent!pain,!xIrays!should!be!repeated!10I14!days!after!initial!trauma!
•! Pain!is!aggravated!by!respiration!and!other!movement!of!the!ribcage!
Thoracic!Disc!Disease!
•! Ratio!of!disc!to!VB!height!in!the!TIspine!is!1:5!to!1:7!–!restricts!motion!
•! Symptomatic!thoracic!disc!herniation!(TDH)!represents!<!1%!of!symptomatic!spinal!disc!herniations!
o! More!common!in!the!lower!TIspine!(75%!occur!below!T8,!peaking!at!T11IT12!with!28%)!
•! “Critical!zone”!from!T4IT9!(narrow!canal!relative!to!cord)!–!even!small!herniations!can!have!impact!on!spinal!cord!
•! Most!common!cause!for!thoracic!radiculopathy!is!diabetes!mellitus!
o! Other!causes!include!scoliosis,!metastatic!tumour,!Herpes!Zoster,!disc!herniation,!tuberculosis!
•! Signs!and!symptoms!–!typical!disc!herniation!symptoms!including…!
o! “bandIlike”!chest!pain,!vague!“visceral”!pain,!bowel/bladder!dysfunction,!hyperactive!DTF!in!legs,!increased!leg!
motor!tone,!decreased!anal!sphincter!tone!
•! Treatment!–!conservative!–!relatively!few!require!surgery!(progressive!neurological!deterioration,!or!intractable!pain)!
#
Other#MSK#conditions#
Rib!“dysfunction”!
•! Includes!costovertebral!and!costotransverse!joints,!surrounding!soft!tissues!as!pain!generators!
•! May!manifest!as!atypical!interscapular,!chest,!sternum!or!arm!pain!
•! CVJs!supplied!by!sympathetic!nerve!plexi,!free!nerve!endings,!networks!of!axonal!bundles!
•! Dysfunction!of!CVJs!1I2!may!present!as!arm!pain!via!“Kuntz’s!nerve”!(brachial!plexus!linkage!present!in!~60%!of!people)!
o! May!change!circulation!patterns!to!the!arm!thus!causing!patient!to!have!cold!or!discoloured!hands!
•! Can!mimic!more!serious!pathology!–!cardiac,!pulmonary,!subIdiaphragmatic,!cervical!spine!disorders!–!concerning!
•! May!occur!acutely!after!trauma!or!simple!mechanical!stressors!(coughing,!rolling!over)!
•! Chronic!presentations!may!result!from!mechanical!stressors!(desk!job)!
•! Clinical!presentation!–!sharp!pain,!aggravated!by!motion,!increased!pain!with!sneezing/coughing,!paraspinal!tenderness!
•! Treatment!–!respond!well!to!SMT!(should!provide!instant!relief;!confirms!diagnosis),!heat/ice,!mobs,!STT!
o! Evaluate!for!postural!dysfunction!and!secondary!causes!
Thoracic!Facet!Syndrome!
•! Very!common!condition!
•! Pain!arises!fro!inflamed/irritated!facet!joints!(ipsilaterally)!
o! May!refer!pain!along!course!of!corresponding!rib!or!adjacent!segments!(similar!pain!to!impinged!intercostal!n.)!
•! Mechanism!of!injury!similar!to!low!back!condition!(lifting,!twisting,!bending,!or!hyperextension!trauma)!
o! Could!also!be!cumulative!trauma!(postural,!occupation)!
•! Clinical!findings!–!decreased!ROM/joint!play,!pain!
•! Good!prognosis!–!responds!well!to!conservative!treatment!(SMT,!STT,!etc.!+!education!and!exercise)!
#
Muscle/Myofascial#Conditions#
Pectoralis!Major!Syndrome!
•! Caused!by!stress!overload!on!muscle!or!referred!phenomena!(MI,!ischemic!heart!disease!when!on!left)!
•! Short!term!treatment!–!soft!tissue!therapy,!acupuncture,!etc.!
•! Long!term!treatment!–!correct!poor!standing/sitting!posture,!avoid!of!mechanical!overload,!selfImanagement!
Pectoralis!Minor!Syndrome!(more!common!than!major)!
•! Patients!presents!with!roundedIshoulder!posture,!scapular!tilting!or!dyskinesis!
•! May!develop!entrapment!syndromes!due!to!compression!of!brachial!plexus!(medial/lateral!cords!or!axillary!a.)!
•! Treatment!–!pectoralis!major!first,!correct!posture!–!pec!minor!just!requires!adjustment!of!posture!
Rhomboid!Syndrome!
•! Trigger!points!usually!caused!by!poor!posture!–!often!due!to!latent!trigger!points!in!pectoral!muscles!
o! Short/tight!pectoralis!muscles!=!forward!shoulders!=!overloading!rhomboids!
•! Pain!–!medial!border!of!scapula!
•! Treatment!–!correction!of!posture,!inactivation!of!pectdoral!TrPs,!selfIdirected!stretching!exercises!
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Anterior#Chest#Wall#Disorders#
Chest!pain!–!cardiac!or!nonIcardiac!classification!
•! May!originate!from!MSK!structures!–!chiropractic!care!is!helpful!here!
•! MSK!conditions!may!mimic!abdominal,!pulmonary,!cardiac!conditions!–!may!be!alarming!to!patient!
•! If!you!cannot!recreate!the!feeling,!then!it!may!be!serious!
Costochondritis!
•! Relatively!common!as!a!primary!condition!as!well!as!in!combination!with!coronary!heart!disease!
•! Pain!at!costochondral!junctions!(+/I!associated!swelling)!–!induced!by!breathing,!coughing/sneezing,!prone!
nd th
•! Diffuse!tenderness!–!90%!of!cases!involved!multiple!lesions!(most!common!is!2 I5 !costoIcartilages)!
•! Trauma!most!likely!MOI!–!excessive!coughing!from!bad!viral!infection?!
•! SelfIlimiting!and!should!be!treated!conservatively!(pain!relief,!ice,!OTC!pain!meds,!manual!therapy!if!tolerable)!
Sternoclavicular!Joint!Syndrome!
•! Etiology!either!arthritic!or!traumatic!(common!in!contact!sports)!
•! Presents!with!point!tenderness,!swelling,!and!crepitus!–!aggravated!by!shrugging!shoulders!–!conservative!Tx!
Tumours!
•! Produce!pain!via!compression!of!nerve!roots!or!other!painIsensitive!tissue!
•! Screen!for!redIflags!!–!esp.!if!clinical!picture!is!unclear!in!an!older!patient!
•! XIray!is!first!line!of!imaging!–!advanced!diagnostic!imaging!is!usually!required!(e.g.!MRI)!
•! Extradural!metastatic!tumours!such!as!carcinoma,!lymphoma,!and!myeloma!are!most!common!growths!causing!root!
pain!
•! Benign!neoplasms!–!grow!slowly!–!slower!symptoms!onset!
•! Malignant!tumours!–!grow!quickly!–!compression!occurs!sooner!
#
Additional#Consideration#
Pain!from!extraIthoracic!structures!
•! Gas!entrapment!syndromes,!biliary!tract!disease,!peptic!ulcer,!acute!pancreatitis,!disease!of!liver/spleen!
Pain!from!Intrathoracic!structures!
•! Angina!pectoris,!acute!MI,!postIMI!somatic!referral,!acute!pericarditis,!mitral!prolapse!syndrome!
•! Respiratory!–!tracheobronchitis,!chronic!bronchial!disease,!pulmonary!embolism,!pneumothorax,!pleurisy!
•! Acute/chronic!esophageal!conditions!
•! Listen!to!your!patients!!!!–!people!love!DCs!because!we’re!so!soft,!emotional,!and!warm!hearted!(we!listen)!
Pain!in!Special!Circumstances!–!gynecomastia!(male!mammaries),!chest!pain!associated!with!pregnancy!
Emotional!conditions!–!anxiety,!depression,!conversion!disorder,!hypochondriasis,!malingering,!somatization!
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Thoracic#Spine:#Structural#Disorders!–!the!burden!of!adult!spinal!deformity!(ASD)!
Scores!on!all!SFI36!domains!lower!in!ASK!vs.!any!other!chronic!condition!
•! “…global!burden!of!ASD!was!huge!compared!with!other!selfIreported!chronic!conditions!in!the!general!population!of!
eight!industrialized!countries”!
Scoliosis!
•! Majority!of!cases!are!idiopathic!(~80%)!
•! Majority!of!cases!do!not!progress!–!however,!is!the!main!concern!leading!to!cosmetic!deformity!or!visceral!compromise!
•! Adolescent!idiopathic!scoliosis!(AIS)!represents!the!largest!subIgroup!of!human!spinal!curvatures!(>10°!need!for!Dx)!
o! However,!is!technically!present!in!MOST!people!to!some!degree!
•! 3!dimensional!deformity!involving:!
o! Lateral!spinal!curve!
o! Rotation/torsion!about!a!vertical!axis!
o! Change!in!sagittal!plane!dimension!(in!a!lordosis!or!kyphosis)!
Uncertainties/Misinterpretations!
•! Vast!majority!of!research!literature!is!surgical!–!manual!therapy!literature!remains!sparse!
Epidemiology!
•! AIS!(>10°)!affects!~2I3%!of!children!6I10!years!old!(when!spinal!growth!rate!is!most!rapid!–!again!at!puberty)!
•! Only!10%!of!diagnosed!progress!to!require!medical!intervention!
•! Patients!are!generally!unaware!of!curves!<!30°!
•! Curves!10I20°,!girls=boys;!curves!>30°,!ratio!of!girls:boys!increases!to!7I10:1!
•! Treatment!indicated!for!curves!>20°,!“critical!threshold!is!30I50°,!surgery!considered!if!>45°!
•! Prevalence!in!adults!is!~9%!I!correlated!with!increasing!aged!–!unlikely!to!be!aware!of!it!
•! Generally,!males!with!comparable!curves!have!lower!risk!of!progression!vs.!females!
•! Curve!size!is!(logically)!a!reliable!predictor!of!pain!
•! Mortality!rate!in!those!with!scoliosis!is!similar!to!general!population!
•! Psychosocial!effects!rarely!manifest!in!childhood!unless!curve/deformity!is!severe!
•! Fun!fact:!humans!are!the!only!bipedal!vertebrates!(except!chickens!lacking!pineal!glands)!that!display!AIS!
o! Due!to!full!erectile!posture?!
Primary!
Risk!Factors!for!Progression!
• Onset!before!puberty/menarche!
•! Curve!magnitude!at!first!presentation!was!most!important!
• Younger!age!at!Dx/skeletal!maturity!
factor!for!curve!progression!to!>30°!at!skeletal!maturity!
• Curve!severity!at!first!detection!(esp.!if!>!30°)!
•! Initial!age,!gender,!and!pubertal!status!were!less!important!
• Female!gender!
•! Risk!factors!for!altered!lung!development!is!>70°,!7+!
• Double!curve!patterns!
involved!vertebrae,!curve!in!upper!part!of!spine,!decreased!
Secondary!–!Associated!kyphosis!
kyphosis!
•! In!skeletally!mature!individuals…!
o! Thoracic!curve!>!50°!with!apical!rotation!>!30°!
o! Lumbar!curves!>!30°,!right!convex!curves,!translator!shifts!
o! Thoracolumbar!curves!>!30°,!apical!rotation!>!30°,!translator!shifts!
•! Those!with!family!history!might!be!at!risk!for!more!severe!curves!
•! Why!do!females!progress!more?!–!overall!uncertainty!
o! “Slenderness”!of!vertebrae!–!cannot!accommodate!load!like!males!
o! Vertebral!height!increase!50%!in!adolescence!while!width!increases!only!15%!
o! Growth!spurts!generally!occur!when!kyphosis!is!at!a!minimum!(decreased!absorptive!capacity!of!sagittal!curve)!
o! Hormonal!vulnerability?!
Classifications!–!structural!vs.!nonIstructural!
•! Structural:!fixed!curve,!nonIflexible,!normally!correlated!with!ribcage!deformity,!does!not!correct!with!sideIbending!
•! NonIstructural!(or!functional):!flexible!curve!
Structural!Scoliosis!
•! Idiopathic!–!80%!of!cases!–!resolving!or!progressive,!establishes!“vicious!cycle”!of!asymmetrical!loading!of!spinal!tissues!
•! Neuromuscular!–!neuropathic!(UMNL/LMNL)!or!myopathic!(muscular!dystrophy,!congenital!hypotonia)!
•! Congenital!–!failure!of!formation!(wedge,!hemivertebra),!failure!of!segmentation!(“bar”,!“block”)!
o! Check!for!other!defects!
•! Other:!neurofibromatosis,!mesenchymal!disorders!(Marfan’s),!rheumatoid!disease,!trauma,!extraspinal!contractures,!
osteochondystrophies,!infection,!metabolic!disease,!related!to!lumbosacral!region,!tumours!

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NonIstructural!Scoliosis!
•! Postural!–!normally!evident!at!7I10!years!of!age!
•! Compensatory!–!leg!lengths!or!hip!muscle!contracture!
•! Nerve!root!irritation!–!disc,!tumour!(bending!for!relief)!
•! Inflammatory!–!organ!abscesses,!infections,!etc.!
•! Hysterical!(rare)!
Etiological!Theories!–!“Pathogenesis!is!multifactorial”!
•! Genetics!–!connective!tissue!structure,!bone!formation/metabolism,!melatonin!signalling!pathways,!puberty,!growth!
•! Anthropometrics!–!tall!stature,!long!column!lengths!compared!to!people!of!same!age,!slender!vertebrae,!faster!growth!
•! Hormones!–!melatonin!(more!likely!related!to!progression;!prognostic!factor)!
•! Growth!abnormalities!–!AIS!children!are!taller!and!more!slender,!asymmetrical!vertebral!growths,!shorter!SC!tethering!
•! Muscle!imbalances!–!more!likely!a!result!of!scoliosis!than!cause!
•! Bone!density!–!prevalence!of!AIS!with!osteoporosis!is!20I38%,!decreased!BMD!persists!after!curve!progression!ceases!
•! Balance!–!often!worse!in!children!with!AIS!vs.!without,!sensory!integration!deficits,!asymmetrical!cortical!excitability!
•! Vestibular!–!asymmetric!vestibular!input!may!result!in!asymmetric!muscle!activity!(controversial)!
•! Commonality!among!theories!–!aberrant!sensory!information,!interpreted!at!spinal!or!cortical!levels,!results!in!
abnormal!output!information!regarding!body!orientation!in!space,!which!results!in!spinal!deformity!
•! Bottom!line!–!attributed!to!a!number!of!causes!
History!
Clinical!Presentation!
• Acute!or!slowly!progressive!onset!
•! Adult!scoliosis!–!common!concerns!–!progressive!deformity,!pain,!
• Associated!acute!pain!at!apex!(fracture,!
cosmetic,!neural!compression!(9%!increase!with!age)!
tumour,!disc?),!or!chronic!pain!
•! Adult!lumbar!scoliosis!–!associated!with!increased!rates!of!
• Previous!diagnosis!of!scoiosis,!imaging?!
inguinal!pain,!obturator!neuralgia!
• Family!history!
•! Proposed!pain!mechanisms!–!muscular,!asymmetric!facet!
• Growth!spurts,!puberty,!menarche,!etc.!
loading,!disc!degeneration,!discogenic!pain,!aberrant!tissue!
• Cosmetic!concerns!
loading,!contral!sensitization?!
• Organ!malfunction!(severe!cases)!
•! Changes!in!gait!–!shorter!stride!in!AIS!pts,!frontal!shoulder,!hip,!
and!pelvis!motion!decreased,!muscle!activity!increased!for!longer! !
period!during!stride!(analysis!requires!advanced!methods)!
•! Scoliosis!and!Syringomyelia!–!syrinx!(fluid!tumour!in!middle!of!spinal!cord!can!compromise!cord)!can!alter!posture!
o! Typically!left!primary!thoracic!curve,!male,!atypical!upper!extremity!deformity,!spinal!pain,!neuro!abnormalities!
o! concave!rib!deformity!on!lateral!radiograph!
•! Potential!complications!–!cardiopulmonary!compromise,!DJD/arthritis,!curve!progression,!fatigue/jt.!dysfunction,!and!
radiation!exposure!from!xIrays!
Assessment!I!Observation!
•! Head!orientation!(rot./!tilt)! •! Café!au!lait!spots!(neurofibromatosis)! •! Femoral!anteI/retroversion!
•! Shoulder!height! •! Other!skin!lesions! •! Leg!length!inequality!
•! Scapular!winging/protraction/level! •! Hair!patches!(spina!bifida)! •! Foot!pronation!
•! Rib!deformity!(humping)! •! Lower!extremity!asymmetries! •! Other!congenital!anomalies!
•! Pelvic!level/tilt/rot.! •! Tibial!torsion!
!
Congenital!Scoliosis!
•! Block!or!hemiIvertebrae!"!scoliosis!
Screening!
•! SOSORT!Guidelines!recommend!at!minimum…!
o! Forward!bending!(Adam’s!test)!
o! Study!suggest!this!test!is!insufficient!alone!
!
Associated!abnormalities!–!may!warrant!internist!referral!
• 20%!I!genitourinary!abnormalities!
• 15%!I!heart!defects!
• 10%!I!spinal!dysraphism,!anomalous!bands,!tight!fila!terminale!
!
!

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Treatment!
•! In!general:!small!curves!are!observed,!severe!curves!warrant!surgical!referral!
o! In!between!there!is!a!large!variety!of!curves!and!treatment!options!–!none!of!which!are!very!good!
•! Management!hasn’t!changed!much!in!30!years…!
•! Traditional!Tx!include!–!observation,!manual!therapy,!bracing,!surgery!
•! Gaols!of!Tx!–!decrease!spinal!pain,!address!respiratory!dysfunction,!decrease!rate/chance!of!progression!
•! Improve!aesthetics!and!posture!
•! Chiropractic!theory!
o! By!correcting!asymmetry!(or!improper!input)!and!keeping!the!spine!segmentally!and!globally!mobile,!AIS!can!
be!halted!or!reversed!(?)!
o! Cervical!SMT!can!influence!righting!reflexes!thought!to!be!involved!in!AIS!(?)!
o! SMT!may!remove/correct!“aberrant!input”!(?)!
o! Level!pelvis/sacrum!and!correcting!leg!length!inequality!can!decrease!compensation!(?)!
•! Exercise!–!generally!suggested!by!research!to!be!ineffective!(controversial)!–!consider!ScoliosisISpecific!Exercise!!
o! NonIcompliance!is!an!issue!–!“compliers”!have!better!outcomes!generally!
o! Result!vary!individual!to!individual!
o! Rotation!training!–!literature!not!strong!methodologically,!but!promising!results!!
•! Bracing!–!4!types:!night!rigid!bracing!(8I12!hrs),!soft!bracing,!part!time!rigid!(12I20!hrs),!full!time!rigid!(24!hr)!
o! It!can!help!–!but!research!quality!is!low!(general!trend!suggests!high!compliance!produces!positive!results)!
o! Electronic/heat!signature!monitoring!can!increase!compliance!(knows!when!brace!is!worn!and!for!how!long)!
o! Again,!literature!cannot!define!the!effectiveness!of!bracing!for!treatment/prevention!of!progression!
o! Contraindications:!<20°!(not!needed)!or!>45°!(surgery!indicated)!–!patient!has!to!agree!to!it!!
•! Surgery!–!major!intervention!–!large!longIterm!studies!indicate!positive!outcomes!(literature!still!inconclusive)!
o! Each!patient!is!different!–!take!into!account!riskIbenefit!analysis!
Treatment!summary!
•! <!20°!I!if!skeletally!mature!(SM),!observe!and!treat.!If!not!SM,!image!if!suspicion!of!progression!
•! 20I40°!I!if!not!SM!and!<30°,!treat!initially,!monitor!and!refer!if!suspicion!of!progression.!If!SM,!progression!unlikely!
•! >!40°!I!may!require!surgery/bracing!
•! Younger!patients!–!treatment!or!observation!dictated!more!by!degree!of!deformity!
•! Older!patients!–!treatment!dictated!by!more!subjective!measures!(pain,!function,!etc.)!
•! Role!of!exercise!(SSE!or!other)!unclear!
!
Scheuermann’s#Kyphosis#
•! Structural!disorder!of!the!thoracic!and!thoracolumbar!spines!
•! Aka.!Scheuermann’s!disease,!vertebral!epiphysitis,!osteochondrosis!juvenilis!dorsi,!juvenile!kyphosis,!spinal!osteoch.!
Epidemiology!–!more!common!in!children!who!are!athletically!active,!taller!and!heavier!
•! Incidence:!0.4I8%!of!the!population!–!higher!in!elderly!
•! Prevalence:!males!>!or!=!females!(?)!–!true!prevalence!likely!underreported!due!to!misdiagnosis!as!“poor!posture”!
Etiology!–!likely!multifactorial!–!Combination!of…!
o! Genetics!–!dominant!autosomal!inheritance!pattern!with!high!penetrance!and!variable!expressivity!(best)!
o! Biomechanics!–!altered!mechanical!stresses!on!vulnerable!developing!spinal!structures!in!adolescents!(?)!
o! Hormonal!abnormalities!(?)!
•! Onset!is!normally!just!prior!to!puberty,!after!ossification!of!ring!apophyses!
•! Characterized!by!anterior!VB!wedging,!endplate!irregularities,!thick!ALL,!decreased!ant.!VB!growth,!premature!DD!
Classification!–!two!curve!patterns!
1! Thoracic!–!most!common!
2! Thoracolumbar!–!rare!–!thought!to!be!more!likely!to!progress!in!adulthood!
•! Both!can!be!associated!with!nonIstructural!hyperlordosis!in!CIspine/LIspine!
•! 1/3!of!pts!will!have!coexisting!scoliosis!
Clinical!Features!
•! Local!pain!or!discomfort!–!normally!mild,!related!to!postural!strain,!apex!of!deformity!(often!resolves!with!SM)!
•! “Tight”!psoas,!hamstrings,!anterior!shoulder!girdle,!hypertonic!spinal!musculature!
•! Vertebral!and!costovertebral!joint!fixations!
•! Decreased!physical!capacity!+/I!fatigue!
•! Respiratory/visceral!complications!and/or!neurological!compromise/TDH!(rare,!sever!cases)!

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Imaging!–!plain!film!radiographs!are!first!line!modality!
•! Kyphosis!of!at!least!>35°!(some!say!45°)!–!Anterior!wedging!of!3!or!more!contiguous!segments!by!at!least!5°!
•! +/I!endplate!irregularities,!+/I!Schmorl’s!nodes,!disc!space!narrowing!at!affecdted!levels!
Assessment!–!similar!to!scoliosis!
•! Observation,!palpation,!mobility!assessment!combined!with!presenting!history/complaints!
•! Observe!bending!forward!(Adam’s)!–!prone!PA!challenge!(fixed/rigid)!
•! Check!hamstring!flexibility!and/or!hip!mobility!
Management!–!as!usual,!no!high!level!evidence!to!guide!us!–!is!based!on!the!severity!of!the!curve!
•! Those!<60°!managed!with!exercise!and!manual!therapy!(with!periodic!radiographic!monitoring!until!SM)!
•! Patients!should!seek!sports/activities!involving!extension!(?)!and!avoid!jumping!sports!(?)!
Exercise!–!one!study!found!significant!pain!reduction!in!16I32%!with!longIterm!exercise!treatment!plan!
Bracing!–!compliance!is!an!issue!with!all!forms!of!bracing!
•! Milwaukee!brace!(most!common)!–!3!point!pressure!system,!works!best!if!apex!at!T7!or!above!
•! Bracing!generally!thought!to!be!effective!in!SM!patients!
•! Predictors!of!success:!begin!when!<65°!(early),!still!flexible!curve,!15°!of!correction!when!braced,!compliance!
SMT!–!sparse!literature!(what!do!you!know…),!in!theory!is!logical!but!not!supported!by!high!level!evidence!
Surgery!–!considered!in!curves!>75°!that!don’t!respond!to!bracing,!side!effects!more!common!in!adult!pts!as!opposed!to!children!
Treatment!Summary!–!no!firm!guidelines!exist!
•! Surgical!referral!if!progressive!pain/curvature,!neuro!compromise,!not!responding!to!conservative!treatment!or!brace!
!
Back#School#
•! A!back!school!is!a!costIeffective!series!of!classes!designed!to!provide!information!to!back!pain!patients!regarding!
prevention!and!return!to!work!strategies!–!deals!with!anything!from!desk!job!workers!to!weekend!athletes!
o! Controversy!lies!in!the!fact!that!different!patients!require!different!styles/amounts!of!instruction/education!
•! Chiropractors!may!be!asked!by!companies!to!give!presentations!about!back!safety,!prevention,!etc.!(tailor!to!audience)!
History!
•! Swedish!Back!School!(VOLVO!plant)!–!back!school!group!had!fewer!sick!days!than!control!group,!increased!productivity!
•! Canadian!Back!Education!Units!–!dealt!with!chronic!pain!population!with!overlying!psychological!factors!
o! 62%!of!chronic!patients!sought!no!further!treatment;!of!those!that!did!seek!more,!frequency!decreased!
o! Results!–!back!school!can!substantially!decrease!the!cost!of!medical!care!for!chronic!back!pain!patients!
•! California!Back!School!–!dealt!with!LBP!patients;!obstacle!course!to!evaluate!and!train!pts!on!ergonomic!efficiency!
•! Miami!Back!School!–!pathology,!biomechanics,!pain!control,!emotional!aspects,!advice!on!exercise,!and!practice!
•! Canadian!Back!School!–!focused!on!chronic!pain!and!showed!decrease!in!pursuit!of!medical!care!
•! Conclusions:!decreased!pursuit!of!medical!care,!decreased!episodes!of!pain,!faster!return!to!work,!very!costIeffective!
Goal!–!allay!patients!fears,!reduce!reoccurrence,!decrease!medical!costs,!increase!independent!pain!coping!strategies!
Outcomes!–!see#Goals!because!its!soooo!guud!
Indications!–!intermittent!LBP,!acute!LBP,!chronic!LBP,!not!for!“doctor!shoppers”!(pts!that!have!mindset!that!something!is!worse!
than!it!actually!is),!not!for!unremitting!pain!
Content!–!epidemiology/cause,!anatomy,!biomechanics,!pathophys.,!posture,!ergonomics,!pain!coping,!psychosocial!factors!
Evidence!–!found!to!be!effective!at!improving!lifting!and!safety,!cannot!prevent!LBP!(multifactorial),!good!in!occupational!setting!
•! Little!is!actually!known!about!costIeffectiveness!nor!has!recent!research!supported!“return!to!work!faster”!claims!
Outcomes!measures!used:!Tampa!Scale,!Pain!selfIefficacy,!VAS,!pain!catastrophizing!scale!
Positions!of!relief!–!independent!pain!coping!strategies,!assist!to!decrease!postural!fatigue,!physically!active!pain!coping!strategy!
Positions!of!relief!strategies:!e.g.!chin!tuck,!spinal!flossing!
•! Bruegger’s!exercise!–!great!position!of!relief!as!it!opposes!the!position!in!which!most!people!sit!in!most!of!the!time!
o! I.e.!hunched!shoulders,!arms!forward,!feet!crossed!or!close!to!one!another!decreased!lumbar!lordosis!
o! Oppose!this!by!extending!shoulders,!shoulder!blades!together,!abducting!hips!–!literally!the!opposite!of!above!
o! Considered!an!active!coping!strategy!
Repetitive!microIbreaks!–!periodic!breaks!that!can!incorporate!(but!not!limited!to)!–!for!those!that!endure!prolonged!positions!
•! Range!of!motion!exercise!(dynamic!stretching)!
•! Static!stretching!
•! Corrective!posture!exercises!(Bruegger’s)!
•! Walking!around!

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