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NECK AND SPINE DISEASES

Neck Pain
Cervical Sprain/Strain
Cervical Disc Disease
Spondylosis
Myofacial Pain Syndrome
Fibromyalgia
Low Back Pain
IVD Disease
Abnormal Bony Structure of Back
Spina Bifida
Spondylolisthesis
Spinal Stenosis
Sacralization
Variation in L-S Angle
Neoplastic
Traumatic
Visceral Affectation
Sacroiliac Disease
Coccygodynia


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NECK PAIN

-  Inspite of common condition, in most cases, specific lesions
     can’t be find
-  Neck pain is associated with previous neck, shoulder and back surgery
-  Neck pain is affecting less frequently people engaged with:
-  White-collar jobs
-  Housewives
-  High educational attainment
-  Affected by mental, physical, emotional stress and other psychological
      factors such as occupation (multifactorial)
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CERVICAL SPRAIN/STRAIN

-  Resolve in 4-8 weeks (chronic)
-  Sprain
   -  if there injury to ligaments, supporting structures, posterior
      elements of the spine.
   -  Pain is deep so even palpation will not elicit tenderness

-  Strain
   - if there’s injury in musculotendinous area of the spine

-  (-) Tenderness because it involves stretching of the muscles
     (tenderness due to hemorrhage and spasm to the area)
-  Mechanism of injury: WHIPLASH INJURY (if somebody bumps from behind,
     hyperextension of neck followed by hyperflexion, hitting of object
     resulting to hyperflexion)
-  Post traumatic MPS (injury to muscles wherein there’s shortening of
     muscles due to trauma) 
     – is the cause of chronic cervical sprain and strain.
-  Patient who sustains with acute cervical sprain/strain are prone to
     recurrent

Signs and symptoms:
  1.  Hx of trauma
  2.  Stiff neck
  3.  Inability to look sideward because of severe pain
  4.  Muscles spasm (indicate of absence of lumbar lordosis
       on visual inspection)

PE:
  1.  Palpate paravertebral muscles spasm
  2.  LOM
  3.  Tenderness

Diagnosis:
1. MRI		- normal (visualize disc, muscles, ligament, soft tissue
		of the spine) but may have concomitant disk herniation.
2. X-ray	- normal/negative
3. CT scan	- normal/negative (bony details/narrowing of canal)
4. CT myelogram	- best diagnostic
5. EMG/NCV	- normal/negative for physiologic information

(+) Provocative test:
-  Spurling test
-  Lhermitte’s sign
-  Adson’s test

Tx:
-  To prevent any further injury and to rest the area
1.  Analgesics
2.  Anti-inflammatory
3.  Physical therapy
4.  Soft collar	
   - best tx
   - Provide warmth, limits mov’t (ms become relax), avoids high
       impact activities
   - Immobilize the neck 
   - Used for 2-3 days
   - Slight flexion (widens foramen)
5.  NSAID’s, tricyclic anti-depressants, steroids, muscle relaxant
   - For acute and chronic
6.  Moist heat
   – most beneficial if pain is muscular in origin; short term benefit
7.  Exercise of neck muscle
   – for long term benefit
a. Cervicothoracic stabilization – to prevent poor posture, future
       neck injuries, poor muscle tone
b. Cervical spine flexibility and stretching
c. Cervical spine strengthening (px supine, put towel roll at the
       curvature of neck and ask px to press against it for 10 sec or
       more for several repetition
d. Postural re-education (forward neck/anterior head position)
8. Massage, electrotherapy, IRR
9. Traction
   - make sure neck is flex
   - Trial traction – 3x tx sessions (if pain subsides – continue;
       if pain increases – discontinue)
   - Usually 1/5 of body weight
   - Head (10 lbs); should be >10 lbs of body weight  

CI in traction:
  1.  Fracture
  2.  Instability
  3.  Cancer
  4.  Infection
  5.  Atherosclerosis of carotid and vertebral artery
  6.  If px is unable to relax or in absence of PT supervisor
  7.  Don’t leave px during traction or treatment
  8.  Icing: for ms spasm and neck pain

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CERVICAL DISC DISEASE

-  Can be or without nerve compression
-  Chronic neck pain with repetitive lifting and pain radiating on limbs =
       cervical disc disease with disc herniation and accompanying.
       root compression
-  If disc degenerate, disc protrusion, disc inflammation but without
       nerve root compression = patient experience pure neck pain.
-  When nerve root is compressed = neck pain with radiculopathy

Manifestation:
1. Disc herniation - trauma
		- Young people
		- DJD
		- Older >50 y/o
2. Radiating pain - interscapular area, occiput, shoulder, arm
		- Location: dermatomal/myotomal distribution
		- Sx: hyporeflexia of C5 innervated tendon, muscle
	     	     weakness, reflex changes, and sensory deficit
		- Sensory changes: 1st to be affected 
		– proprioception and vibration; last to be
                     affected-pain
		- Proprioception and vibration are affected =
                     sensory nerve compression
3. Neurological- seizures
		- Blurring of vision
		- Tinnitus
		- Nausea
		- Vomiting
		- Learning impairment
4. Aggravated axial compression	
		- by neck extension and lateral bending

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SPONDYLOSIS

-  OA of the spine
-  Degenerative arthritis of IVD, vertebral body, facet joint, luschka
      joint and zygopophyseal joint

-  Spinal cord: 10 cm in diameter
-  Spinal canal: 12-20 cm
-  Average: 17 cm	

-  If there is arthritis of the spine = spinal canal can narrow which
      could lead to spinal stenosis resulting to spinal cord compression
-  Relative spinal stenosis – spinal canal is <12 cm
-  Absolute spinal stenosis – spinal canal is <10 cm
-  Spinal canal is wider transversely than anteropostero diameter (and
       also spinal canal which is 2x wider transversely
       than anteropostero)
-  If there is narrowing in transverse plane = later manifestation
       of spinal stenosis
-  If there is narrowing in A-P = earlier manifestation of spinal stenosis
	
Signs and symptoms:
-  Neck pain with radiation
-  Can manifest with myelopathy and radiculopathy

* Myelopathy – UMNL, spasticity, hyperreflexia, impotence, bladder
      dysfunction, gait disturbance
* Radiculopathy – if IV foramen narrows; radicular pain, sensory deficits,
      muscle weakness, reflex changes
* In severe cases (for surgery) – spinal cord compression leading to
       incontinence, spasticity, hyperreflexia, weakness and
       incoordination, progressive neurological deficit and relenting
       pain that doesn’t respond to treatment.

-  Common in elderly

Tx:
1. Conservative	- 1st line of tx; (-) surgery (80-90%) gets well in
		     6 months
		- Medication for inflammation of nerves and SC,
		     anti-depressants
2. Collar	- more rigid than soft collar and position the neck in
                  flexion because foramen becomes wider.
3. Cervicothoracic stabilization
		- don’t strengthen the neck in extension.
4. Job modification
5. Surgery	- if neurological deficit is progressive, (+) spur,
		impotence and relenting pain doesn’t respond
		to conservative management
		- Decompress spine by laminectomy with or without
		discotomy, spinal fusion, and faraminotomy

Diagnosis:
1.  CT myelogram – to visualize the spine
2.  MRI – to visualize disc, muscle, ligament
3.  EMG-NCV – physiologic information

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MYOFACIAL PAIN SYNDROME

-  Most common
-  Pain is localized or regional
-  Trigger point – area of hyperirritability wherein if you apply
   pressure there is referred pain pattern and a localized twitch response
-  Taut band - muscle that is shortened so it is weak
-  Has sleep disorder
-  Local treatment:
-  Modalities to relax the muscle
-  Stretching/lengthening
-  Myotherapy

Important protocols:
- Ischemic compression
- Needling of muscles (trigger point therapy) 
- Proprioception therapy
- Vapocoolant spray (as counter-irritant, done before stretching, called
     stretch spray)
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FIBROMYALGIA

-  Generalized pain
-  Tender point (palpated using 4 kg pressure)
-  Tenderness
-  Criteria – generalized pain for at least 3 months
-  11 out of 18 tender points

18 tender points

  -  2 at base of occiput
  -  2 at trapezius
  -  2 at insertion of supraspinatus muscles
  -  2 at 2nd intercostals space (angle of louis)
  -  2 at lateral epicondyle
  -  2 at medial knee fat pad
  -  2 at paralumbars
  -  2 at gluteus maximus
  -  2 at rhomboids

-  Patient doesn’t respond to modalities
-  Best treatment: aerobic, low impact conditioning exercise
-  More pronounced sleep disorder
-  Presence of bilateral pain and tenderness is included in criteria
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LOW BACK PAIN

- Commonest cause of time loss from work
- ETIOLOGY: idiopathic/unknown
- 90% resolve spontaneously with or without treatment in 6 months

- Affected by:
  1.  Psychosocial factors (emotions, physical, mental)
  2.  Smoking – can interfere with nutrient transport in IVD
  3.  Poor job satisfaction
  4.  Poor perception of job security

-  Most common site of pain among gymnast, football player, wrestlers,
     weight lifters, rower (top 3 causes of pain)
-  2nd most common in general dance population
-  Most common cause of disability in people 45 y/o and below
-  3rd most common cause in people of 45 y/o and above
-  Most common chronic pain disability
-  Treatment is empirical, arbitrary and without scientific basis
-  Everybody gets well

A. Acute lumbosacral strain
   - Most common affectation of low back
   - With severe back pain, walks slowly to prevent jarring, stoop posture
       and had lift a heavy objects just a few weeks ago, bending forward
       (usually included in hx)

* If you lift an object = weight is transmitted in spine; the center of
       weight bearing is near the lumbosacral region therefore injury
       to spine is most common in the lumbosacral region (L5-S1)

Signs and symptoms:
  1.  Pain upon movement
  2.  Rigid and spastic paralumbar muscle upon palpation
  3.  Muscle guarding

Diagnosis:
1.  X-ray – negative, unless for back pain, only to R/O fracture
2.  CT scan - negative
3.  MRI - negative
4.  EMG/NCV – negative

Treatment:
1.  Bed rest	- no movement
		- If severe (-) toilet privileges
		- Best position: semi fowler’s (hip, knee, trunk is
                        slightly flex); position where intradiscal
	        pressure is lowest and paralumbar muscles
	        are very relaxed.
2. PT modalities- electrotherapy; moist heat; massage;
                        strengthening of gluteals, abdominal, paralumbars
                        (erector spinae) by aerobic conditioning exercise;
                        stretching of hamstring muscles.

B. Chronic lumbosacral strain
- Same manifestations of acute low back but with less severe and less
     obvious findings
- Acute trauma not relieve
- Recurrent and persistent pain
- With accompanying degenerative disc disease
- In pain but movable
- Provides a back support (corset)
- Look for lumbar lordosis
- Pathology: degenerative disc disease and degenerative facet joint
- Tx: trial traction

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IVD DISEASE

INTERVERTEBRAL DISC DISEASE
-  Most common in L5-S1 (compression of S1)
-  Back pain radiating on dermatome distribution, motor weakness, reflex
     changes, sensory deficits, provocative test, some LOM,
     minimal tenderness

Special test:
1.  Low back maneuver
2.  SLR (at buttocks, if (+) pain before 60° there is radicular electric
     like pain sensation
3.  Bilateral SLR (for large lesion)
4.  Hoovers
5.  Braggards
6.  Sensation of inguinal region
7.  Well leg raise

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SPINA BIFIDA
1.  Spina bifida
-  Failure of closure of spinous process
-  If multiple segment s of spina bifida = instability
-  If portion of spine is absent = biomechanical activity is affected 
-  Can cause back pain; can be incidental finding 

-  Spina bifida occulta
    -  Not obvious
    -  (+) Dimple 
    -  Mole with hair 
    -  Needs x-ray

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SPONDYLOLOSTHESIS
-  Because of lumbosacral angle highest stress in L4S1
-  Articulation of facet & ligaments should be strong to prevent “forward
     slippage of vertebra”
-  A condition where vertebra slip: highest in L5S1: next in L4L5
-  Excess lumbar (up to 1.6) = more motion: less (up to 1.3 only)
     = less motion

Types according to Wiltse
  1.  Dysplastic congenital bony anomaly
  2.  Isthmic most common type [(-) slipping but (+) fracture]
    - Isthmus (narrowest portion of neutral ach also called par
       interarticularis
    - Rapture of isthmus = spondylolysis & if this result to slipping
       forward it becomes spondylolisthesis

    a.  Lytic sliding due to repetitive fatigue fracture 
       (Ballet dancer)
    b.  elongated – if lytic heals with slight elongation of pars inter
     articularis

  3. Degenerative – 2nd most common 
    -  Degeneration of facet & weakness of I

  4.  Isthmus leads to slipping 
  5.  Traumatic bone fracture resulted to slipping of spine 
      except isthmus 
  6.  Pathologic – destruction of bone 2° to weakness
  7.  Latrogenic caused by the doctor
   - Px with back pain, hyperlordosis with pain radiation, on x- ray
      forward slipping of spine/pelvic rotates posteriorly

   Myerdings
   ¼ = grade 1
   ½ = grade 2
   ¾ = grade 3   spinal fusion (1-2 vertebrae to sacrum)
   >¾ = grade 4

-  The higher the grading, the greater the chance of nerve
      compression
-  If vertebra is sliding, forward, increase the LS angle (the 
     increase angle,the increase sliding)
-  To prevent sliding, do exercise that ?angle = William’s exercise
-  If px is very mobile, put a brace in slightly flexed position
     (Chairback brace)
-  Lumber traction

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SPINAL STENOSIS

-  Narrowing of canal due to IVD, spondylosis, tumor, thickening, 
    spondylolisthesis
-  Referring to IV foramen where nerve roots exit
-  TX is aimed at decrease or decompressing hernia, corset, flexion 
   of trunk
-  Dx – CT myelogram – bone

MRI – sc, soft tissue
EMG-NCV – physiologic info

- Claudication – relief of pain at climbing up, flexion of trunk, 
  drugs

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SACRALIZATION

-Sacrum & L5 that forms lumbosacral; region when needed interiorly, 
  transverse process of L5 is close to ileum
-In some px: L5 articulates with ileum &sacrum making it appears that
  L5 and sacrum is one (fused bone) = this is called socialization of 
  L5
-Limit mobility & increase stability = px will complain of back pain 
  stiffness

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VARIATION IN L-S ANGLE

-Obese & pregnancy
-Increase in LS angle can stretch ligaments
    - Infection of spine = Pott’s dse (TB of spine), viral infection, 
     Tb (destroy spine) 
    - Tabes Dorsalis (numbness, absence of proprioception, affects 
     posterior column of respiratory fxn

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NEOPLASTIC

-Pain severe at night
-Cancer of spine is commonly metastatic in 
    female – breast
    male- lungs & prostate & stomach
-Cancer of spinal cord most common is cauda equina

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TRAUMATIC
- Correct injury if muscular rest, PT, massage, an I-inflammatory
- If bone destruction reduction


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VISCERAL AFFECTATION

- Back pain is not always muscular in nature
- Female: to t/o pelvic problems (ectopic pregnancy)
- Male: peptic ulcer, pancreatitis, cancer of colon, dse of prostate, 
    kidney (UTI renal stone, kidney & urethral stone)
    Endometriosis – severe dysmenorrhea	
- Uterine tissue outside uterus, which can cause back pains


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SACROILIAC DISEASE

- malgaigne fracture, reiter’s ankylosing, spondylosis, psoriatic
    dse, inflammatory bowel dse.

    - Pregnant women – temporary relaxation of S1 & symphysis pubis 
      due to hormonal factors (corpus luteum (lining in uterus) 
      secretes relaxin) 
    - Ostetis Condensans - in female 

- Increase density in iliac portion of S1 joint
		-Back pains results
		
Special test:
	-Faber/patrick’s
	-Pelvic drop 
	-Gaenslen


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COCCYGODYNIA

-Trauma to sacrum (inflammatory of low back)
-Sacral pain during bowel movement
-Strain in sacrococcygeal ligament 
-Tenderness on palpation & rectal exam

Tx:
         -Pain meds
	-PT
	-Adhesive strapping buttocks (to stabilize the area)
	-Do not sit on hard surfaces – use donut or cushion ring 
	-Hot sits bath – also done for hemorrhoids


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