Cervical Segmental Dysfunction

Synonyms

Definition

Abnormal or altered functional relationship between contiguous cervical vertebrae.

Patient History

Patient history may include:

Patient Data

Specific Considerations

The following table presents common red flags for this diagnosis and their possible causes.

Red Flag

Possible Consequence or Cause

Severe trauma

Fracture

Direct trauma to the head with loss of consciousness (LOC)

Subdural hematoma; epidural hematoma; fracture

Nuchal rigidity, and/or positive Brudzinskis, or Kernigs sign

Subarachnoid hemorrhage; meningitis

Bladder dysfunction associated with onset of neck pain

Myelopathy; spinal cord injury

Associated dysphasia

Cerebrovascular accident

Associated cranial nerve, or central nervous system (CNS) signs/symptoms

Tumor; intracranial hematoma

Onset of a new headache

Tumor; infection; vascular cause (older patients, also consider temporal arteritis; glaucoma)

Co-morbidities of rheumatoid arthritis, seronegative arthritides, Down syndrome

Atlantoaxial instability due to associated transverse ligament laxity

Exertional pain, history of CAD

CAD

Pleuritic pain, chronic cough, dyspnea

Pulmonary diseases

Cancer

Cause of symptoms (metastatic or primary)

Alcoholism, drug abuse

Side effect, or withdrawal phenomenon

Immune-compromised state

Infection

Presentation

Acute or chronic localized pain and stiffness with or without a history of trauma.

Subjective Findings

Objective Findings

Objective findings may include:

Scope of Examination

Examine the musculoskeletal system for possible causes, or contributing factors to the complaint.

Specific Examination Considerations

The following standardized tests may be used to assess functional limitations:

Results if Cervical Segmental Dysfunction

Differential Diagnoses

Physical/Occupational Therapy Management

Therapy must show measurable functional progress.

Requirements for Physical/Occupational Therapy Visits

Two or more of the following findings must be present to establish medical necessity. At least one of the findings must address functional limitation.  Degree of abnormality should be specified at initiation of therapy, and periodically, to establish an objective response to therapy:

  1. Significant Functional Limitations (i.e. social, recreational, vocational activities) - Practitioners are strongly encouraged to utilize peer reviewed, standardized tools to quantify Functional Limitations.

  2. Strength: <4/good (5 = normal; 4 = good; 3 = fair; 2 = poor; 1 = trace)

  3. Cervical ROM: limited >30% (norms: cervical flexion = 60; extension = 70; rotation = 80; lateral flexion = 45)

  4. Pain: limiting function and at least 3/10

  5. Neurological signs: altered reflexes and/or sensations

Treatment frequency and duration must be based on:

Treatment Methods

Use the following modalities to reduce pain and inflammation:

Discharge Criteria

Referral Guidelines

Refer patient to their primary care provider for evaluation of alternative treatment options if:

Appropriate Procedures/Modalities

Use of modalities and/or passive treatments should be limited. The goal is to transition the patient as quickly as possible to active, self-management and functional independence.

The following table lists the procedures for Early Phase presentation:

Expected Outcome

Procedures/Modalities Such As

Decrease pain/inflammation

  • Modalities i.e. Ultrasound, phonophoresis, interferential current, electrical muscle stimulation, functional electrical stimulation, transcutaneous electrical nerve stimulation

  • Cryotherapy

Improve cervical range of motion

  • Mobilization of adjacent segments

  • Active movements in pain-free range

Patient education and home exercise program

  • Rest, reduction of strenuous activity/causative factors

  • Home exercise program-pain-free range of motion

The following table lists the procedures for Mid Phase presentation:

Expected Outcome

Procedures/Modalities Such As

Decrease pain

  • Modalities i.e. Ultrasound, phonophoresis, interferential current, electrical muscle stimulation, functional electrical stimulation, transcutaneous electrical nerve stimulation

  • Cryotherapy

  • Thermotherapy (superficial/deep heat)      

Restore flexibility of the cervical musculature and facet joints

  • Segmental joint mobilization

  •  Stretching of neck musculature

Increase strength/power of cervical spine

  • Resisted Isometric Exercises

  • Isotonic exercises

  • Functional training

Improvement in body mechanics and postural stabilization

  • Body mechanics training

  • Postural stabilization activities

  • Postural Control

Gradual return to normal functional activity and fitness

  • Gradual tolerance of activities and positions

  • Self-management of symptoms

  • Functional training

  • Home exercise program (ROM, strengthening and postural exercises)

  • Aerobic Conditioning

The following table lists the procedures for Final Phase presentation:

Expected Outcome

Procedures/Modalities Such As

Restore flexibility of the cervical musculature and facet joints

  • Segmental joint mobilization

  •  Stretching of neck musculature

Increase strength/power of cervical spine

  • Resisted Isometric Exercises

  • Isotonic exercises

  • Functional training

Improvement in body mechanics and postural stabilization

  • Body mechanics training

  • Postural stabilization activities

  • Postural Control

Gradual return to normal functional activity and fitness

  • Gradual tolerance of activities and positions

  • Self-management of symptoms

  • Functional training

  • Home exercise program-ROM, strengthening and postural exercises

  • Aerobic Conditioning

Note

Not all of the above modalities are appropriate for each individual case; they require the skill and judgment of persons properly trained and licensed for safe use. Use of diathermies, including microwave, shortwave, and ultrasound, is controversial and may be contraindicated in the presence of metals, and prior to neurological, and/or orthopedic maturity. Landmark recommends following all manufacturer and educational guidelines in the use of electrotherapeutic modalities.

Home and Self-Care Techniques

The patient can be taught to use medical equipment and administer self care at his residence.

Home Medical Equipment

Self-Care Techniques

Alternatives/Adjuncts to Physical/Occupational Therapy Management

References

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