“HOLY OW!!! “ Clinical Perils: Chiropalooza!!! Spinal Stenosis … · 2020-07-21 · 7/21/2020 1 “HOLY OW!!! “ Welcome to the Chiropalooza!!! Spinal Stenosis – UPDATE 2020

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“HOLY COW!!! “

Welcome to the Chiropalooza!!!

Spinal Stenosis – UPDATE 2020

Steven G. Yeomans, DC, FACO 404 Eureka Street Ripon, WI 64971-0263 920-748-3644 (Ph) 920-748-3642 (Fax) [email protected] www.yeomansdc.com

Clinical Perils:

What is it??

Narrowing of the canal &/or foramen at any spinal region. Common causes: 1) OA: Spurs (endplates) 2) DDD/Disc derrangement 3) DJD of facets 4) Thickening lig. Flavum 5) Calcification of the PLL 6) Tumors (more rare) 7) Trauma (fracture)

MOST OFTEN, a COMBO!

2 Types: Central & Lateral/Foraminal (often co-exist)

Foramen

What is it??

Symptoms • Many people have evidence of spinal stenosis on an MRI or CT scan but may not have symptoms. • When they do occur, they often start gradually and worsen over time. • Symptoms vary depending on the location of the stenosis and which nerves are affected.

https://www.mayoclinic.org/diseases-conditions/spinal-stenosis/symptoms-causes/syc-20352961

Wolfgang Rauschning, M.D., Ph.D. Professor of Clinical Anatomy Academic University Hospital Department of Orthopaedic Surgery Uppsala, Sweden http://www.akademiska.se/

Wolfgang RAUSCHNING, M.D., Ph.D., born: 4. June 1938, Zinten, Germany Department of Orthopaedic Surgery Academic University Hospital S - 751 85 UPPSALA, Sweden Phone: (+46) 8 - 594 80169 Fax: (+46) 8 - 592 56128 e-mail: [email protected]

Rauschning Wolfgang: "Computed Tomography and Cryomicrotomy of Lumbar Spine Specimens. A New Technique for Multiplanar Anatomic Correlation", Spine 8: 170-180, 1983

http://www.ismissturkey.org/wp-content/uploads/2013/03/Wolfgang-Raushning-CV.pdf

ANATOMY: P: Pedicle; AP: Articular process; DR: Dorsal root; VR: Ventral root; D: Disc; UP: Uncinate process; IF: Inferior facet; SF: Superior facet Wolfgang Rauschning, MD










http://www.akademiska.se/

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P: Pedicle; AP: Articular process; DR: Dorsal root; VR: Ventral root; Wolfgang Rauschning, MD VA: Vertebral artery; PLL: Post. Long. Lig.; VR: Ventral root; DR: Dorsal root; LF: Ligamentum flavum; L: Lamina; DRG: Dorsal root ganglia. Wolfgang Rauschning, MD

C5

What’s New (since 2018)? What’s New (2019)?

https://pubmed.ncbi.nlm.nih.gov/30646197/

Handout 1a


Handout 1a


Handout 1a




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file:///C:/Users/sgyeomans/Downloads/jamanetwopen-2-e186828-s001.pdf https://pubmed.ncbi.nlm.nih.gov/30646197/

Handout 1a

SO WHAT DID THEY DO??? (See Supplement 1. “Trial Protocol” – Handout 1b)

file:///C:/Users/sgyeomans/Downloads/jamanetwopen-2-e186828-s001.pdf

(2 DC’s & 2 PT’s)



(continued)



Handout 1b

(continued)

Protocol



Handout 1b

(continued)


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Handout 1b

Completed: 1) Baseline 2) 2 months 3) 6 months

RESULTS: Manual Therapy + Pt specific exercise = BEST SHORT-TERM OUTCOMES (2- mo. FU)

What’s Else Is New?

• 2018 Study + ADDENDUM (Exercises):

(SEE Handouts 2a & b)

Handout 2a

https://www.bmj.com/content/361/bmj.k1662 or, https://pubmed.ncbi.nlm.nih.gov/30646197/

SGY: MANY SS Pts have multiple co-existing conditions, especially hip pain! This study includes a GREAT, well-laid out exercise program for lateral hip pain/trochanteric bursitis!

Handout 2a


Handout 2a


SGY: This is a GREAT study out of Australia showing superior long-term outcomes for exercise + education compared to corticosteroid injection (CSI) for gluteal tendinopathy / lateral hip pain. NOTE: Spinal Stenosis OFTEN includes lateral hip pain; CURRENT CASE STUDY: RS 74yoM had Short-term 100% relief w/ lateral hip CSI for 6-weeks; Long-term relief w/ CMT (DC) + these exercises (PT) (see addendum/handout 2b)!

Handout 2a


Addendum

Handout 2b

https://www.bmj.com/content/361/bmj.k1662








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Addendum

Handout 2b

Inclusion/Exclusion Criteria: FYI

Addendum/handout 2b

Addendum/handout 2b Addendum/handout 2b


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Addendum/handout 2b


SGY: Note, EDX was obviously superior at EVERY time point after the 1st 4-weeks vs. CSI and, had the least number that worsened.

38

51 44 46 52

Spinal Stenosis – NASS Case

Steven G. Yeomans, DC, FACO 404 Eureka Street Ripon, WI 64971-0263 920-748-3644 (Ph) 920-748-3642 (Fax) [email protected] www.yeomansdc.com

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SGY: Rare case but interesting images!

SGY: Hard to tell where the kyphotic kink is in these axial cuts………. But, the central canal appears fairly patent throughout! Difficult to ID the lateral foraminae (cell phone picture by the treating doc)

SGY: Probably “best” image

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LE Paresthesia w/o paresis!!!

Compare to post-surg/next 4 slides (frontal & sagittal planes)

Compare pre- vs. post- surgical (NEXT 2 slides)

PRE- vs. POST- Surgical

PRE- vs. POST- Surgical

I wonder what chiropractic care “could have” achieved??? Contraindicated???

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SGY: The docs discuss the “best” surgical approach….

Discussion

• Obviously, NOT a typical case but certainly interesting! Personally, chiropractic should be tried prior to surgery on MOST cases (pending “Red Flags” are not present)!

Yogi Berra

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NEW CASE

SGY: We’ve all seen “Failed Back” Pts, right???

1/8/2016

SEE next slide for side by side comparison

2/9/2017

SGY: Axial pain w/ LT radic.

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SGY: Axial pain w/ LT radic.

SGY: Note, there is discussion of long S1 screws & misplaced L5 screws (3, 4, & 5 slides ahead)

SGY: If the Pt can tolerate stress views, that could help assess stability. 3 stress XR options: 1) FL/EXT (Knutson) 2) Hanging/Back PK 3) Side-lying flexion

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SGY: I studied with Eva at the Prague School (& Vladimir Janda in 1995 w/ Craig Liebenson’s LACC rehab group)!!!

SGY: See Donaldson paper in the handouts (dated but good!!!)

See Handout #4

SGY: New Slide - Posted 12/10/18; NOTE: This figure 1 is included in Handout #4

Peripheralization

Centralization

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Loaded

Unloaded

Positive Discograms

This Dr raises concerns of selection bias when commenting that MDT is more useful than MRI for surgical decision-making

SGY: The calculated sensitivity/specificity is interesting as well as this Dr’s concluding statement.

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SGY: With ALL this discussion, isn’t it interesting how many varying opinions about management there are? James Pemberton, Eva Novakova, and Ronald Donaldson support Mechanical Diagnosis & Therapy (MDT) for BOTH diagnosis & treatment, pending the results. I might add, prognostic reasons as well as in my experience when I can’t find ANY position of relief/decreased pain, the prognosis is usually poor. Here’s a GREAT follow-up 2004 article by Long, Donaldson, & Fung:

Handout #5

Handout #5

MDT/DP is a “HOME RUN” winner of a World Series!!!! Do this, it will change your world!!!

Dx & Rx!

Flexion-biased = Facet/Joint Extension-biased = Disc derang.

Pain Scale: -1 0 +1 (-1 = Centralization; 0 = No Change; +1 = Peripheralization) Dx & Treatment focus: Find a position/direction that REDUCES (not reproduces) pain!!!

See Handouts #4-7

BEEP HORN if you feel patients with lumbar spinal stenosis are flexion-biased (or, their Directional Preference is FLEXION).

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Cervical Spinal Stenosis

CASE

THIS PATIENT PRESENTS TO YOUR OFFICE ON A FRIDAY NIGHT AT

CLOSING TIME

Case 1

Patient History The patient is a 45-year-old male. He has a 3-month history of left neck, shoulder, and arm pain. His pain radiates through his left radial forearm to his thumb and first finger.

http://www.spineuniverse.com/professional/case-studies/browse/chiropractic

Case 1 (continued)

Patient History The patient is a 45-year-old male. He has a 3-month history of left neck, shoulder, and arm pain. His pain radiates through his left radial forearm to his thumb and first finger. Examination The patient's neurological examination revealed 4/5 strength in the left bicep, decreased bicep reflex on the left, and decreased pinprick in the LT thumb and first finger. Prior Treatment Previously, the patient tried narcotic analgesics, massage, physical therapy, and chiropractic care. These nonsurgical treatments did not bring pain relief.

What n. root(s) are you MOST suspicious of?


Case 1 (continued)

Hx: LT radial forearm to TH & D2 (radiculopathy) Sensory: TH/D2 hypoesthesia/hypesthesia Motor: 4/5 biceps (WrExt?) / DTR: 1/5 Biceps (Brachioradialis ?)

ANSWER: C5-6 level = C6 n. root)

MEMORIZE (proximal to distal)!

Sensory Motor DTR C5 N. Root Deltoid Delt/shldr abd Biceps (C5-6) C6 N. Root Radial f.a., th, D2 Biceps/elb fl., WrEx Biceps+brachiorad C7 N. Root D3 Wr Fl; FE, triceps Triceps (Wrist) C8 N. Root Ulnar f.a./hand Finger Ext (FE) Wrist (C7-8)/Ulnar (C8-T1)

T1 N. Root Medial antebrach DABs Ulnar (C8/T1) T2 N. Root Medial brach. PADs ???

SGY: • WHAT PE/PROVOCATIVE TESTS WOULD YOU DO BESIDES THE NEUROLOGICAL EXAM DESCRIBED PREVIOUSLY? •WHAT IMAGING (if any) WOULD YOU CONSIDER? WHAT ARE YOU CONSIDERING?

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SGY: • WHAT PE/PROVOCATIVE TESTS WOULD YOU DO BESIDES THE NEUROLOGICAL EXAM DESCRIBED PREVIOUSLY?

1) Max. C. Rot. Compression: Hold / report TIME to numbness/radicular pain location 2) Brachial plexus compression (thumb pressure over ant. Scalene): Report SAME info 3) Static C-Extension: Report SAME info 4) BPTT (Brachial Plexus Tension Test): Contra C-lat. Fl. + supinate UE & Wr DF (elb

extended)

•WHAT IMAGING (if any) WOULD YOU CONSIDER? WHAT ARE YOU CONSIDERING? 1) MRI

Case 1 (continued)

SGY: •What do you see (in spite of the poor quality)? Patient History: 45-year-old male; 3-mo. Hx LT neck, shoulder, arm pain that radiates through his radial forearm to thumb and first finger/D2. Examination: Neurological examination: 4/5 weakness left bicep; +1/5 LT bicep DTR, decreased pinprick in the thumb and first finger/D2.

R L


C5-6

Case 1 (continued)

• Does this confirm your Dx noted on the axial view?


Case 1 (continued)

Suggest Treatment • Treatment options: BEEP HORNS if you would elect to NOT manage this case conservatively (if you’d prefer to refer for surgical consult). NOTE: THERE ARE NO WRONG ANSWERS!!!!

Sidebar: Can SMT be done safely in

C-spine HNP’s?

BEEP HORNS if your answer is “YES”

Sidebar: Can SMT be done safely in C-spine HNP &/or stenosis?

Don Murphy (Rhode Island Spine Center)

• References/Handouts: NEXT SLIDE

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Case Options (Don Murphy Case

Studies)

• 1) C-HNP post-CMT managed non-surgically w/ a LVLA/mm energy CMT approach – Herniated disc w/ radic post-C-manip: non-surg Tx; Spine J (2006) 459-463 [Handout

“#1”]

• 2) C-Myelopathy “Near-Miss” (Natural Hx) [ incl. in a grp of 3 articles Handout “#2 & 2a”]

• 3) Cervical Spondylosis w/ Cord compression – incl. a literature review re: preventative surgery for this condition is NOT recommended [incl. in handout “#2”]

• 4) CMT in presence of C-Spinal Cord compression (a 27 case series treated w/ CMT – great outcomes!) [JMPT 2006;29:236-244] [ #5 & incl. in handout #2]

• 5) Radiculopathy & dermatome inaccuracies in 169 pts – (interesting stats on the relationship between n roots & dermatome) [see handout “3”, 9/2009]

• 6) Non-surgical/Chiropractic treatment of C-radiculopathy (impressive outcomes of 30+ pts) [JMPT 2006;29(4):279-287] [incl. in handout “4”]

• 7) Non-surgical management of L-HNP (Lumbar HNP – 49 Pt Case series using clinical prediction rule) [JMPT 2009;32:723-733] [Incl. in handout “6”]

• 8a) C-Extension & Sp Cord compression (incl. interesting PE tests and treatment) Handout“7”

• 8b) 2011 Murph Dx-based C-sp clin decision guide

SGY: The articles in “RED” support C-HNP chiropractic care SEE Articles in your “Handouts” [#9-20]

Case 1 (continued)

SGY: (These are NOT this author’s options)

SGY: Take a moment and “THINK” about your comfort level in managing this with your non-surgical care… (there are no “right” vs. “wrong” answers here)

SGY: This is what they chose to do: (next slide)

Case 1 Case 1 (continued)

Case 1 (conclusion)

SGY: Discuss Murphy article! Handout #11?

Back to the question Can SMT be done safely in C-

spine HNP’s?

BEEP HORNS if your answer is “YES”

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Handout #9

SUMMARY •38 yo M •CMT (HVLA) at 6th visit = radic •Neurosurg rec surg •Pt went to a dif. DC (DM) •MRI: 3 levels HNP C3-5 •C-SMT = LVLA/mm energy + Exerc •Successful outcome w/ DC#2

CONCLUSION: “This paper reports a case of a patient with radiculopathy secondary to multilevel disc herniations that appeared to be precipitated by cervical manipulation and who was treated nonsurgically with resolution of the problem. It is doubtful that the manipulation actually caused the disc herniations, but it is possible that it caused preexisting asymptomatic disc herniations to become symptomatic. Consideration should be given to nonsurgical referral of patients who have postmanipulative complications but do not need immediate surgery.”

SGY: So what did DM do differently?

SGY: This is a case of a patient with C-HNP (at 3 levels becoming symptomatic after HVLA-CMT & then treated successfully with LVLA-CMT and exercise.

Handout #9

Fig. 2. Cervical manipulation maneuver in the anterior to posterior direction. Reprinted with permission from: Murphy DR, ed. Conservative management of cervical spine syndromes. New York: McGraw-Hill, 2000. SGY: DM describes this as a CSMT or, muscle energy technique (MET)

Handout #9

Fig. 2. Cervical manipulation maneuver in the anterior to posterior direction. Reprinted with permission from: Murphy DR, ed. Conservative management of cervical spine syndromes. New York: McGraw-Hill, 2000.

SGY: DM describes this as a CSMT muscle energy technique (MET)

• (p460-1): “With this method, a contact (RH) was made as close to the anterolateral aspect of the involved segment as possible, and the spine was moved into a direction of combined flexion, lateral flexion away from the side of contact, and rotation toward that RT side (Fig. 2). • The movement was continued until the author felt the onset of the ‘‘barrier of resistance’’ [21], i.e., the point at which resistance to further movement was first perceived. • The patient was then asked to move the eyes away (LT) from the side of contact (in an attempt to

activate the muscles that would resist movement in the direction of manipulation) and take a deep breath (in an attempt to further activate these muscles).

• The patient was then asked to move the eyes toward the side of contact (RT) (in an attempt to

relax the muscles that would resist movement in the direction of manipulation) and breathe out (in an

attempt to further relax these muscles). • On the out breath, the ‘‘barrier’’ was felt to release, allowing for further movement into rotation. NO THRUST! • This was typically repeated two more times. Further information regarding the method of Muscle Energy can be found in the volume by Chaitow and Liebenson [20].”

[20] Chaitow L, Liebenson C. Muscle Energy techniques. 2nd ed. Edinburgh: Churchill Livingstone, 2001.

Handout #9

(p461): “Manual neural mobilization to target the involved nerve roots was performed [22]. • Place the patient in a position that allowed for applying tension to the peripheral nerves (with a median nerve bias [23]), the brachial plexus, and the nerve roots. • The position was the same as that of the BPTT [BPTT: Brachial Plexus Tension Test] which, on examination, had reproduced the patient’s arm pain. • From this position, gentle oscillatory movements were applied, repeatedly moving the hand in an extension [DF] and flexion [PF]direction, away from the barrier and back to the barrier, within the patient’s tolerance. • The mechanism by which this treatment may be beneficial is not known, but it is thought to promote ‘‘neural gliding’’, having a positive impact on freedom of movement, intraneural circulation, and axonal transport [24]. • The patient was given home exercises designed to mobilize the involved nerve roots.

These involved repetitive movements of the head and the upper extremity in a direction that mimicked the BPTT.”

[20] Chaitow L, Liebenson C. Muscle Energy techniques. 2nd ed. Edinburgh: Churchill Livingstone, 2001.

Handout #9 & #16b

Summary: At week 3: Tx 2x/wk x 3wks = 40% improved w/ centralized UE Sx (C-BQ: 29 to 17 or 58% improved) & pain 4/10 ave. & 8/10 max. vs. 6 ave. & 10/10 max. initially); LT deltoid 5/5 (vs. 4/5 initially) & neg. C-compression & Brachial Plexus Tension Test (BPTT) (+ initially); cervical and scapular stabilization exercises were then started (at 3wks).

SGY: Nerve flossing= (left figure 3) C-RLF + WDF/Elb-Ext followed by C-LLF + WPF/Elb-FL (repeat slowly, like flossing your teeth) 1. WrDF & Elb Ext + C-RLF = distal stretch

2. WrPF + Elb FL + C-LLF = prox stretch

A B

BPTT

1

1

2

2

VS

(FLOSS)!

Neuro-glide: add Wr PF/ DF

Handout #9

SGY: At week 7, 70% improved w/ 2/10 ave., 3/10 max. pain; C-BQ: 14% (vs. 29 to 17, now 14). Home exercises continued without passive care (no DC care); FU 4 weeks later (week 11): 80% improved; less frequent/more mild pain 2/10 max. pain; C-BQ: 14%; MET treatment total: 11 visits SGY: Note, in Case 1, surgery was performed – should this type of LVLA CMT & exercise been tried???

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Handout #12

•35 consecutive pts •Treated passively (CSMT) •FU minimum 3mo. • C-BQ & VAS/NRS •RESULTS: •31 of 35 completed treatment •27 long-term FU (mean 8.2 mo. LT FU) •“Excellent”: 17 (49%) •“Good”: 14 (40%) •Mean improvement 88.2% •C-BQ: 78% improvement •NRS: 72% improvement •24/31(77.4%) “significant improvement” at end of treatment •25/27 (96%) “significant improvement” at end of LT FU

“This paper presents a patient with cervical radiculopathy in whom MRI revealed 4 disc protrusions, 2 of which compressed the spinal cord. The symptoms centralized and later abolished with end range extension maneuvers of the cervical spine.”

Handout #18

2008

• 32yo M (police officer) w/ RT scapular pain & RT UE pain & numbness to Th & D2 • 3 wk duration, insidious onset; prior care included SMT & meds w/o change • Pain increases w/ C-extension (COMMON); decreased w/ rest; weakness triceps • PE: C-BQ: 20/70 (29%); pain 5/10; + C-compression (Spurling’s) & + RT BPTT (https://www.youtube.com/watch?v=FqlKnFt_DOM) = Brachial Plexus Tension Test (BPTT)

> SGY sidebar: Compression of brachial plexus (timed) • (PE): C-extension 1 rep symptoms but REPEATED extension centralized UE Symptoms > Discuss “Directional Preference” (DP) (https://www.spine-health.com/wellness/exercise/mckenzie-method-assessment)

> MDT: Mechanical Diagnosis & Therapy (McKenzie Method) • (PE): Neuro: 4/5 wkness RT deltoid (C5), wrist extensors (C6) & triceps (C7); C5 & 6 derms • See pain diagram & MRI (next slide):

Handout #18

2008

• A: Using a Dx-based clinical decision rule (See Handout 8a&b) = C5 & 7 radiculopathy d/t HNP • P: DP = extension end-range loading exercises (McKenzie & May, 2003)

See Handout 19 (2013 DPT + extension strength exercises = best long-term outcomes)

• (P): Supine extension mobilization technique (passive) • (P): C-Brace exercise (for the Deep neck flexors & T’s & C mm): Quadruped “start” position:

Chin poke towards floor; then in a smooth, scooping motion flex the upper C’s (Cr-C flexion or “nod”); lastly, return to a position in which the lower C- / upper T-spine is neutral & upper C’s remain slightly flexed. 10 reps/10sec ea. (see pg 16, Exercise 4.1 “Cervical Brace” in “Cervical spinal stabilization exercises” 2nd ed., OPTP.com; DR Murphy et al): (https://www.amazon.com/Cervical-Spinal-Stabilization-Exercises-8722-2/dp/0990423034)

• (P): Scapular stabilization exercises (See Handouts 26 & 26a)

Handout #18

2008

HANDOUT 16b: Figure 1 Diagnostic algorithm for the application of the DBCDR. Adapted with permission from: Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision rule (DBCDR) for the management of patients with spinal pain. BMC Musculoskelet Disord 2007;8:75. cerv = cervical; thor = thoracic; lumb = lumbar; SI = sacroiliac; TrP = trigger point; CPH = central pain hypersensitivity; dysfx = dysfunction.

DX

R/O Red FLs

ID Pain Gen’s

ID Yellow FLs

2011

HANDOUT 16b: Figure 2 Management algorithm for the application of the DBCDG. Reprinted with permission from: Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskelet Disord 2007;8:75. ER = end range; NSAID = non-steroidal anti-inflammatory drugs; ESI = epidural steroid injection; mob = mobilization; CPH = central pain hypersensitivity.

RX

2011

https://www.youtube.com/watch?v=FqlKnFt_DOM

https://www.spine-health.com/wellness/exercise/mckenzie-method-assessment







https://www.spine-health.com/wellness/exercise/what-mckenzie-method-back-pain-and-neck-pain

https://www.amazon.com/Cervical-Spinal-Stabilization-Exercises-8722-2/dp/0990423034











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“Diagnosis-based Clinical Decision Rule” Similar to C-DBCDR prev rev

HANDOUT 16a

“Diagnosis-based Clinical Decision Rule”

DBCDR Follows the evidence: 1) R/O “Red Flags” 2) ID Yellow Flags & manage 3) DD n. root vs. mech.

R/O Red Flags (#3)

Central Pain Hypersensitivity or, sensitization

ID Yellow Flags & Manage (refer)

DD n root vs. mechanical (i.e., find the pain generator!)

Dx Algorithm

HANDOUT 16a

Rx Algorithm

Ice (PRICE), Laser, deflame diet/vits ???

ER: End-range loading

Transcranial PEMF???

Co-manage vs. refer (CBT &/or ACT (Acceptance & Commitment Therapy)

= DC Scope

HANDOUT 16a SIDEBAR: WORKSHOP

pp 16

continue

SIDEBAR: WORKSHOP

pp 17

SGY MOD: Sitting, do same but use hand resist on forehead (DNF) & back of head

Cervical Spine Exercises • Anterior Head Carriage Series

Effects of a Resistance and Stretching Training Program on Forward Head and Protracted Shoulder Posture in Adolescents

Article (PDF Available) in Journal of manipulative and physiological therapeutics 40(1) · November 2016 DOI: 10.1016/j.jmpt.2016.10.005

https://www.researchgate.net/publication/309956478_Effects_of_a_Resistance_and_Stretching_Training_Program_on_Forward_Head_and_Protracted_Shoulder_Posture_in_Adolescents

Handout #26

SIDEBAR

2016

https://www.researchgate.net/journal/1532-6586_Journal_of_manipulative_and_physiological_therapeutics

https://www.researchgate.net/journal/1532-6586_Journal_of_manipulative_and_physiological_therapeutics





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Exercise Form – see Next 3 slides

Handout #26a 2016


Handout #26a 2016

Slide permission: Courtesy of Tim Bartelsman & Brandon Steele (ChiroUP) https://www.researchgate.net/publication/309956478_Effects_of_a_Resistance_and_Stretching_Training_Program_on_Forward_Head_and_Protracted_Shoulder_Posture_in_Adolescents

Handout #26a

Cervical Spine Exercises • Forward Head & Protracted Shoulder Series • Fiber Stretch (Levator scap & Ant. Scalenes) • Deep Neck Flexors – Gwendolyn Jull

SGY: Alternate DNF Strengthening exercise: Fist under tucked chin; “Nod” head up/down (Cranio-Cervical Flexion) = isotonic exercises (emphasize the eccentric – chin upwards resistance)

[DNF: Deep Neck Flexors (longus capitus & L. colli)]

END of SIDEBAR; Back to the case!











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• FU: 4-wks: 100% pain-free; RTW 2-wks post-initial visit; bench press: pre-injury 60# db’s; post-injury/pre-treatment 25#; 4-wk point 40# dumbbells; BQ 0/70 = 0%; pain 0/10; Neg. BPTT & end-range C-ext. loading; neg. neuro tests • FU: 8-wks: No pain/normal ADLs; bench press 45# dumbbells • FU (telephone) 5-months: No pain/normal ADLs; bench press 50# dumbbells • Discussion: Cord encroachment without myelopathy was present in this case

Handout #18: 32 yo police officer 2008

SUMMARY •Case Study •C5-6 HNP •Referred by an MD to DM •Prior to the 1st visit (d/t a 10-day delay in scheduling), Pt developed acute myelopathy 2ndary to the HNP. •Myelopathy (like CES), is a “red flag” & considered a contraindication for HVLA-CMT. •The progression was d/t the “natural history” of C-HNP. •But, HAD HVLA-CMT been performed, HVLA CMT most likely would have been blamed

Handout #10

Conclusion: “Herniated disk in the cervical spine can progress to myelopathy as part of the natural history of this condition. Because of this, any interpretation of myelopathy that occurs after cervical manipulation, or any other procedure, must be made with caution.”

2008

SGY: NOTE: “Causation” must be made w/ caution! Note, med-legal implications are significant!

Handout #10 2008

SGY: Q: Should preventive surgery be done in this population?

Review Open Access Cervical spondylosis with spinal cord encroachment: should preventive surgery be recommended? Donald R Murphy*1,2,3, Christopher M Coulis4,5 and Jonathan K Gerrard6

Handout #20 2009

HONK HORNS if you feel surgery should be done in this population to prevent cord injury

SGY: Insufficient data to support injury from minor trauma & surgery

2009

SHORT ANSWER: NO!!!

SGY: Still NOT convinced that CAREFULLY applied manual therapies (both HVLA &/or

LVLA/mm energy) is safe for C-HNPs?

Check out the next study!!!

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SUMMARY: Next slide

Handout #13 2006

Cord compression and manipulation

• Murphy & Hurwitz et al., presented a 27 consecutive patient case series

Murphy DR, Hurwitz EL, Gregory AA . Manipulation and the presence of cervical spinal cord compression: A case series. J Manipulative Physiol Ther 2006;29:236-244

Handout #13

2006

Cord compression and manipulation (continued)

• Murphy & Hurwitz et al., presented a 27 consecutive patient case series – Neck &/or arm pain with clear findings of

cervical spinal cord compression on MRI • MRI = disc material, osteophytes, ligamentum

flavum hypertrophy, or some combination distorted the C-spinal cord or obliterated the CSF; no advanced myelomalacia

– Ave. # of treatments: 12 (r. 2-32) • 18 pts had HVLA-CMT, 8 pts had low-velocity mm

energy techniques, and 1 pt had both types

Handout #13

Fig 1 (Tx): HVLA manipulation, neural mobilization, and over-the-door traction = 80% after 3 treatments w/ C-BQ improving from 62 to 7 (88.7% improvement) & pain from 9/10 to 0/10.

2006

Cord compression and manipulation (continued)

• Murphy & Hurwitz et al., presented a 27 consecutive patient case series

– Rate of improvement: 70% (pain & disability: BQ, NDI, NRS)

– 3 pts had transient pain lasting 1-4 days but no major complications or new neuro symptoms/signs

– Care in Dx, CMT set up & careful choice of manual treatments NOT causing peripheralization of pain.

SGY CONCLUSION: MAKE PTs AWARE OF THIS STUDY when

discussing treatment options

Handout #13

2006

Cord compression and manipulation (SIDEBAR!)

Myelomalacia Look for myelopathy! Please BEEP HORNS if you

feel this is a “RED FLAG” for manual therapies.

(SEE HANDOUTS #10A &

21a)

SGY: Updated 1/2020 after DM discussion

Asymptomatic cord compression – contraindication of manual therapy?

• Answer: Not necessarily! • Thorough neuro exam • Assess for risk of progression • Monitor neuro status • Appropriate skills and

comfort level

Murphy DR, Hurwitz EL, Gregory AA. Manipulation in the presence of cervical spinal cord compression: a case

series. Journal of manipulative and physiological therapeutics. 2006;29(3):236-44.

Murphy DR, Beres JL. Is treatment in extension contraindicated in the presence of cervical spinal cord compression

without myelopathy? A case report. Manual therapy. 2008 Oct;13(5):468-72.

Note: DM Slides (1/6)

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25

• Acute myelopathy

• Advanced or progressive myelopathy

• Presence for risk factors for progression: – Unusually large C-ROM

– Segmental kyphosis at level of maximum compression

– Spondylolisthesis at level of compression

– Low signal on T1 (better than bright signal on T2)

– Circumferential compression

Absolute Contraindications to

Manual Therapy to the C Spine


Oshima Y, et al. Natural course and prognostic factors in patients with mild cervical spondylotic myelopathy with increased signal intensity on T2-weighted magnetic resonance imaging. Spine 2012 Oct 15;37(22):1909-13. Avadhani A, et al. Comparison of prognostic value of different MRI classifications of signal intensity change in cervical spondylotic myelopathy. Spine J 2010;10(6):475-85 Shimomura T, et al. Prognostic factors for deterioration of patients with cervical spondylotic myelopathy after nonsurgical treatment. Spine. 2007;32(22):2474-9.

• Prior adverse reaction to manual therapy

• Mild but symptomatic myelopathy

• PSP low self-efficacy (no guilt or feeling of inadequacy!)

– Can refer

Relative Contraindications to Manual

Therapy to the C Spine


• Natural history favorable – only ~20% develop myelopathy1

• A small minority likely to develop myelopathy after minor trauma2

• Risk of surgery outweighs risk of minor trauma3, 4

Asymptomatic cord compression – Is surgery necessary d/t risk of

myelopathy with minor trauma?

1. Bednarik J, et al. Presymptomatic spondylotic cervical myelopathy: an updated predictive model. Eur Spine J.

2008;17(3):421-31.

2. Bednarik J, et al. Are subjects with spondylotic cervical cord encroachment at increased risk of cervical spinal cord injury after minor trauma? J Neurol Neurosurg Psychiatry 2011;82(7):779-81. (Handout 21a)

3. Murphy DR, Coulis CM, Gerrard JK. Cervical spondylosis with spinal cord encroachment: should preventive surgery be

recommended? Chiropractic & osteopathy. 2009;17(8). (Handout 20)

4. Takao T, et al. Clinical relationship between cervical spinal canal stenosis and traumatic cervical spinal cord injury without

major fracture or dislocation. Eur Spine J. 2013 Oct;22(10):2228-31 (Handout 23)


Modified Japanese Orthopedic Association (mJOA) score

• Modified from the original Japanese instrument

• Used to monitor improvement or regression of patients with CSM

• Primarily using by surgeons to assess response to surgery

Kato S, et al. Comparison of the Japanese Orthopaedic

Association (JOA) score and modified JOA (mJOA) score

for the assessment of cervical myelopathy: a multicenter observational study. PloS one. 2015;10(4):e0123022

http://operativeneurosurgery.com/doku.php?id=modified_japanese_orthopaedic_association_scale Note: DM Slides (5/6)

General guideline – no hard data (…as of 2007):

Severe (0–9)

Moderate (10–12)

Mild (13–17)* *Best candidates for non-surg care of symptomatic cervical spine myelopathy (Mild only) (Rhee)

Those w/ moderate to severe CSM had better outcomes w/ surgery (Rhee)

**No hard data to support avoiding specific ADLs or minor trauma as being risk factors for neurological deterioration in those with myelopathy OR asymptomatic cord compression (Rhee & Bednarik)

No hard evidence to support prophylactic surgery to prevent C-sp. cord injury in patients with asymptomatic C-spinal stenosis (Takao)

( Rhee et al. 2013 – Handout #14)

(Bednarik et al, 2011 – Handout #13a)

(Takao et al, 2013 – Handout #15)

How severe is the myelopathy?

Shimomura T, et al. Prognostic factors for deterioration of patients with cervical spondylotic myelopathy after nonsurgical

treatment. Spine. 2007;32(22):2474-9.

Note: DM Slide w/ SGY mods (6/6)

Study Design. Cross-sectional study. Objective. The purpose of this study was to determine the prevalence and distribution of abnormal findings on cervical spine magnetic resonance image (MRI). Summary of Background Data. Neurological symptoms and abnormal findings on MR images are keys to diagnose the spinal diseases. To determine the significance of MRI abnormalities, we must take into account the (1) frequency and (2) spectrum of structural abnormalities, which may be asymptomatic. However, no large-scale study has documented abnormal findings of the cervical spine on MR image in asymptomatic subjects. Methods. MR images were analyzed for the anteroposterior spinal cord diameter, disc bulging diameter, and axial cross-sectional area of the spinal cord in 1211 healthy volunteers. The age of healthy volunteers prospectively enrolled in this study ranged from 20 to 70 years, with approximately 100 individuals per decade, per sex. These data were used to determine the spectrum and degree of disc bulging, spinal cord compression (SCC), and increased signal intensity changes in the spinal cord.

But, ….

https://journals.lww.com/spinejournal/Abstract/2015/03150/Abnormal_Findings_on_Magnetic_Resonance_Images_of.11.aspx

2015

http://operativeneurosurgery.com/doku.php?id=modified_japanese_orthopaedic_association_scale

http://operativeneurosurgery.com/doku.php?id=modified_japanese_orthopaedic_association_scale


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Results.

• Most subjects presented with disc bulging (87.6%), which significantly increased with age in terms

of frequency, severity, and number of levels. • Even most subjects in their 20s had bulging discs, with 73.3% and 78.0% of males and females, respectively. • In contrast, few asymptomatic subjects were diagnosed with SCC (5.3%) or increased signal intensity (2.3%). • These numbers increased with age, particularly after age 50 years. • SCC mainly involved 1 level (58%) or 2 levels (38%), and predominantly occurred at C5–C6 (41%) and C6–C7 (27%). Conclusion. • Disc bulging was frequently observed in asymptomatic subjects, even including those in their 20s. • The number of patients with minor disc bulging increased from age 20 to 50 years. • In contrast, the frequency of SCC and increased signal intensity increased after age 50 years, and this was accompanied by increased severity of disc bulging. Level of Evidence: 2


2015

Can we trust radiologists reading MRI’s???

2017

Handout #27

Can we trust radiologists reading MRI’s???

2017

Handout #27

Low Back Pain Case

History

• 75 yo F, 4’9”, 111#

• Persistent severe LBP for “many years”

• Bilateral leg pain, worse in the last 12 mo.

• All ADLs are limited d/t persistent severe pain

• Does not smoke; drinks alcohol socially

http://www.spineuniverse.com/professional/case-studies/errico/lumbar-spinal-stenosis-grade-spondylolisthesis

Time to Share…

• What are your initial impressions based off of this limited case history?

• What are you looking for in the physical examination?

• What are the important parts of the Hx & Vital Signs (age, Ht/Wt, symptom severity)?

BEEP YOUR HORNS if you feel this patient is at risk for osteoporosis


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History (continued)

• Symptomatic low back pain for > 10 years

• The patient rates her low back and bilateral leg pain as severe; 9 on a 10-point scale

• Bilateral pain radiates downward into the posterior thighs and partially into the knees; left > right

• Paresthesias are greater in the left than right foot

• The patient is unable to walk more than one city block

• The patient trips over her feet

Physical Exam

• Lumbar range of motion is limited in flexion and extension

• Range of motion in her hips is abnormal; pain with internal rotation

• Bilateral muscle strength is 4+/5 in ankle dorsi- and plantar flexors

• Bilateral negative straight leg raise

• Reflexes muted bilaterally

• Sensory diminished to pinprick on the left side; L4-S1

• Baseline Oswestry Disability Index score is 74% (100% scale)

Time to Share…

• Any updated thoughts re: diagnosis?

• Any other information desired?

• What imaging would you order?

BEEP HORN if you would order x-rays with flexion & extension stress views

Prior Treatment

• A trial of epidural steroid injections did not reduce the patient's pain

• A six-week course of physical therapy had a transient benefit

• The patient refuses NSAIDs or narcotics for pain

Imaging- Xray

Neutral AP & LAT

SIDEBAR: Notice the improved view by lowering the CR to the LS junction vs. iliac crest? Do lateral spot views!!!

Imaging- Xray

Flex Ext

Neutral

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Time to Share…

• BEEP HORN if you agree with these Dx’s:

1) Spinal stenosis and Grade I spondylolisthesis at L4-L5

2) Degenerative disc disease at L2-L5 IVDs

SGY: Any other treatment options?

Time to Share…

http://www.spineuniverse.com/professional/case-studies/errico/lumbar-spinal-stenosis-grade-spondylolisthesis

Time to Share… Post-Operative Imaging

AP LAT

Post-Operative Imaging

Flex Ext

Time to Share…

7/21/2020

29

5-yr Post-Operative Imaging

AP

LAT

Post-Op initial vs. 5-yr Imaging

AP Initial AP 5-yr

Post-Op initial vs. 5-yr Imaging

Lat. Initial Lat 5-yr

5-yr Post-Operative Imaging

Flex Ext

Post-Op Initial vs 5-yr Imaging

FL Initial FL 5yr

Post-Op Initial vs 5-yr Imaging

EXT Initial EXT 5-yr

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Time to Share… Time to Share…

https://www.spineuniverse.com/resource-center/lumbar-spinal-stenosis/lumbar-spinal-stenosis-coflex-solution

Time to Share…(1)

One of those ‘‘dynamic’’ devices is the CoflexTM device which has been already implanted worldwide more than 14,000 times. The aim of implanting this interspinous device is to unload the facet joints, restore foraminal height and provide stability in order to improve the clinical outcome of surgery. The purpose of our prospective study is to evaluate the surgical outcome of decompressive surgery in comparison to decompressive surgery and additional implantation of the CoflexTM interspinous Device.

2010: 1-Yr FU

60 patients with one or two level symptomatic LSS were treated with decompressive surgery. Group one (UD) included 30 patients with decompression surgery alone and group two (CO) in 30 patients with decompression surgery AND a CoflexTM device implanted. At 1-year follow up there were no statistical differences between the 2 groups in all studied parameters including patient satisfaction and subjective operation decision. Because there is no current evidence of the efficacy of the CoflexTM device we need further data from randomized controlled studies for defining the indications for theses procedures. To the best of our knowledge this is the first prospective controlled study which compares surgical decompression of lumbar spinal stenosis with additional implanting of an interspinous CoflexTM device in the treatment of symptomatic LSS.

2010: 1-Yr FU

Conclusion: Based on the present study, it showed that Coflex implantation and fusion after spinal decompression had the same clinical outcomes and satisfaction in treatment of symptomatic lumbar spinal stenosis after 7 years follow-up. Nevertheless, Coflex implantation had the advantages of less bleeding loss, less trauma and quick recovery. Compared with fusion surgery, Coflex implantation had also advantages in maintaining intervertebral height and delaying intervertebral disc degeneration of adjacent segments.

2018: 7-Yr FU

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Based on the image below, BEEP YOUR HORN if you feel this IS a chiropractic case?

Excoffon, Gr 4 spondy Pg. 17

Excoffon, Gr 4 spondy Pg. 18 Excoffon, Gr 4 spondy Pg. 1

SGY: Monitor neuro carefully/try DC Rx 1st!!!

Opioid Use Least Likely with Chiropractic > PT > GPs for LBP

https://bmjopen.bmj.com/content/bmjopen/9/9/e028633.full.pdf

Handout 28

Kazis LE, et al. BMJ Open 2019;9:e028633. doi:10.1136/bmjopen-2018-

028633

BONUS STUDY!!! Opioid Use Least Likely with Chiropractic > PT > GPs for LBP


Abstract Objective This study examined the association of initial provider treatment with early and long-term opioid use in a national sample of patients with new-onset low back pain (LBP). Design A retrospective cohort study of patients with new onset LBP from 2008 to 2013. Setting The study evaluated outpatient and inpatient claims from patient visits, pharmacy claims and inpatient and outpatient procedures with initial providers seen for new-onset LBP.

Participants 216 504 individuals aged 18 years or older across the USA who were diagnosed

with new-onset LBP and were opioid-naïve were included. Participants had commercial or Medicare Advantage insurance. Exposures The primary independent variable is type of initial healthcare provider including physicians and conservative therapists (physical therapists, chiropractors, acupuncturists).

Handout 28 2019



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Opioid Use Least Likely with Chiropractic > PT > GPs for LBP


Abstract (continued) Main outcome measures Short-term opioid use (within 30 days of the index visit) following new LBP visit and long-term opioid use (starting within 60 days of the index date and either 120 or more days’ supply of opioids over 12 months, or 90 days or more supply of opioids and 10 or more opioid prescriptions over 12 months). Results Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), DC & PT respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively).

Conclusions Initial visits to chiropractors or physical therapists is associated with

substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

2019 Handout 28

WAIT!!!!

SGY: How do we do that??? Email me: [email protected]

“HOLY COW!!!“ THIS WAS FUN!!!

Chiropalooza!!!

THANK YOU!!!

Please step out of your car and SING ALONG:

Take me out to the ball game Take me out with the crowd Buy me some peanuts and crackerjacks I don't care if I never get back Let me root, root, root For the home team If they don't win it's a shame. For it's one, Two, Three strikes you're out At the old ball game

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“HOLY OW!!! “ Clinical Perils: Chiropalooza!!! Spinal Stenosis … · 2020-07-21 · 7/21/2020 1 “HOLY OW!!! “ Welcome to the Chiropalooza!!! Spinal Stenosis – UPDATE 2020