Gen Sahr 1 Friday General Session Sahrmann Ortho Sec Cervical Presentation

4/14/2014

1

MovementSystemImpairmentSyndromesoftheCervicalSpine

ShirleySahrmann,PT,PhD,FAPTAProfEmeritaPhysicalTherapy

WashingtonUniversitySchoolofMedicine St.Louis

HumanMovementSystem PhysicalTherapyIdentity DiagnosismadebyPTsareofthemovementsystem

MovementSystemImpairment(MSI)Syndromes SubsetofMovementSystemDiagnoses

MSISyndromes Namedforthealignmentand/ormovementdirectionthatmostconsistentlycausespainandisimpaired

Whentheimpairedmovementiscorrectedthesymptomsdecreaseorareeliminated

MovementSystemImpairmentDiagnosesofCervicalSpine

Extension Rotation* Flexion Rotationextension Rotationflexion

*mostcommoncomponent

ManualSkills Handsonfor Assessingthecervical

rotation Wherethemotionis

occurring Theresistanceofshoulders

andshouldermusculature Correctionofcervical

muscleeffectsandtheeffectonmobility

Treatment: Guidepatientincorrect

motion Alleviatingsymptomswith

correctionofcervicalalignment,

Cervicalmotion Shouldergirdlemuscular

effects Manualassistancefor

correctioninseveralpositions

ContributingFactors Themusculatureoftheshouldergirdleaffects

alignment,movement,stressonthecervicalspine alignmentoftheshouldergirdleisakeytocervicalpain

Thealignmentofthethoraxaffectsthealignmentofthecervicalspine Bothkyphosisandflat

Alterationofintrinsiccervicalmuscleperformance usuallyrelatedtoheadpositioninrelationtogravity

Compensationsbetweenupperandlowercervicalspinemotion

Missing figures because of copyright restrictions

Copyright Program in Physical Therapy Washington University School of Medicine - St. Louis

4/14/2014

2

CommonImpairments Intrinsic neckmusclesbecomeweakorlongcompromisefinecontrolofvertebralmotion

Extrinsic musclesbecomedominantaddingtocompressive,rotational,&shearforcesexertedonthecervicalspine

UpperCervicalRangeofMotion

LowerCervicalRangeofMotion HeadandNeckExtensors Intrinsicmuscles semispinaliscapitis semispinaliscervicis puresagittalrotation

DeRosa & Porterfield

Head&NeckRotators/extensors Intrinsicmuscles semispinaliscervicis superioroblique

inferioroblique rectuscapitis

cervicis

AttachedtoC2DeRosa & Porterfield

AttachmentofCervicoscapular MusclesExtensionwithTranslation

Trapezius Levator Scapulae

DeRosa & Porterfield

Missing figures because of copyright restrictions

Copyright Program in Physical Therapy Washington University School of Medicine - St. Louis

4/14/2014

3

CERVICALEXTENSIONSYNDROMESignsandContributingFactors:Alteredupperandlowercervical

participation;overdevelopedextensors,inadequatedeepneckflexors

Cervical extension with shoulder flexion.

MovementsoftheUpperExtremitiesCervicalmotioninducedbyshouldermotion

ShoulderFlexionwhilecontractingdeepneckflexorsDecreasescervicalextensionandpain

CERVICALROTATIONSYNDROMESignsandContributingFactors:Asymmetricalupperandlowercervicalrotation;Impreciserotation;AlteredactionofCervicoscapularmuscles

Upward rotation of scapula stretches levator scapulae musclecervical vertebrae will rotate to same side if hypermobile

Kendall 1993

Upper trapezius rotates head & neck to opposite side

Kendall 1993

Missing figures because of copyright restrictions

Copyright Program in Physical Therapy Washington University School of Medicine - St. Louis

4/14/2014

4

Cervical rotation to the right during left shoulder flexion

Right shoulderflexion

Left shoulderflexion

Spinous processesto left

Tennisinstructor

AsymmetricalRotation Cervical rotation limited by trapezius and levator scapulae musclesMaximum rotation Shoulders passively elevated

Upperandlowershiftedtoleft

Cervical rotation limited byupper trapezius & levator scapulae muscles

Maximum rotation Rotation with shoulders elevated

Uppercervicalrotationnotlower

CervicalRotation:ImpairedAffectedbyCervicoScapularMuscles

Missing figures because of copyright restrictions

Copyright Program in Physical Therapy Washington University School of Medicine - St. Louis

4/14/2014

5

ImpairedFlexion

Forward head with increase upper thoracic flexion Flexion lower spine remains extended

NeckFlexors Intrinsicmuscles Longuscapitis Longuscolli

Puresagittalrotation

DeRosa & Porterfield

DominantExtrinsicNeckFlexors

Sternocleidomastoid Sternal&clavicularhead>Mastoid significantinfluenceoncervicalspinemotionbutdoesnotdirectly

attachtoCspine Function:

bilateral flexion unilateral rotatetoone side&laterallyflexto oppositeside

Mechanical Neck Pain - Porterfield & DeRosa

SternocleidomastoidMultipleActions

Rotation

FlexionlowerCspine

ExtendupperCspine

ForwardtranslationwithanteriorshearParticularly withweak intrinsics

Mechanical Neck Pain - Porterfield & DeRosa

LengthenIntrinsicNeckFlexors

Longuscapitis TPsC36>Occiput

Longuscolli TPsC3C5>C1arch BodiesofT1,2,3>TPsC5,6 BodiesofC57,T13>Bodies ofC2,3,4

Mechanical Neck Pain -Porterfield & DeRosa

DeepNeckFlexorMuscleWeakness

Missing figures because of copyright restrictions

Copyright Program in Physical Therapy Washington University School of Medicine - St. Louis

4/14/2014

6

WeakDeepNeckFlexorMusclesUnabletoMaintainFlexion

ImpairedPositioning CervicalExtensionwithRocking

UpperCervicalExtension

Upper cervical extension greater than Lower cervical -

Limited cervical flexion

Initial visit 2 weeks later

ShoulderElevationandKyphosisContributingtoCervicalExtension

Initial visit 2 weeks later

ImprovedAlignment DecreasedPainPoor sitting alignment Corrected sitting alignment

Contributing factors: long trunk, short arms, large breasts with bras straps adding to downwardpull on neck

Missing figures because of copyright restrictions

Copyright Program in Physical Therapy Washington University School of Medicine - St. Louis

4/14/2014

7

DominantExtrinsicNeckFlexors

Scaleni:Anterior TPsC36>1stribMiddle TPsC27>1stribPosterior TPsC57>1stribFunction:Flexionwithanteriorshear

Depressedchestaffectscervicalalignment

Mechanical Neck Pain - Porterfield & DeRosa

CERVICALFLEXIONSYNDROMESignsandContributingFactors:Flatcervicalandthoracicspine

Kendall 1993

CervicalFlexionandFlatThoracicSpine

Cervical Lordosis with thoracic kyphosis

Kendall 1993ImpairedCorrection

SCALENEMUSCLERESTRICTIONAnotherformofFlexionSyndrome:Swayback

Missing figures because of copyright restrictions

Copyright Program in Physical Therapy Washington University School of Medicine - St. Louis

4/14/2014

8

Without arm support With arm support

Passive elevation of rib cage

Initial Visit Two Months later

ShoulderDepression CervicalCompression

Cervicalsurgerytwicestillinconstantpain

Initial Visit Two Months Later

ShoulderDepression CervicalExtension

Initial Visit Two Months Later

ImprovedShoulderMotionDecreasedCompression

Missing figures because of copyright restrictions

Copyright Program in Physical Therapy Washington University School of Medicine - St. Louis