Supported in part by Arkansas Blue Cross and Blue Shield - PowerPoint Presentation

Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID: 29835-24581

Cervicalgia & Tech-Neck…How a PT can help “Heads up” Reboot your posture Leah Tobey PT, DPT, Cert. DN

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Objectives What is cervicalgia? Treatment options for patients with cervicalgia Tips to reduce improper mechanical load of patients with cervicalgia Review corrective ergonomics

Cervical Functions Supports the skull & protects the spinal cord # 1 Primary purpose of the neck is to optimize the head position & create equal weight distribution of the head to minimize overload to the stabilizing muscles By nature, the C-spine has diverse motion thus is at risk for injury due to the flexibility.

Cervicalgia defined Common medications prescribed: NSAIDs, muscle relaxants, narcotics

Cervicalgia Causes AAOS (American Academy of Orthopaedic Surgeons) reports common causes as: Inflammatory condition (such as RA)Degeneration of cervical spine/disc iAn injury stemming from an incident (such as MVA, sports injury or fall) An infection or tumor Commonly known causes: Poor posture or long periods with neck at awkward angle Long-term stress causing mm guarding of neck & shoulders, leading to a strain on the neck Bone conditions: arthritis, osteoporosis (age is a risk factor)

Tech-Neck (aka Texting Neck): Overuse syndrome involving the head, neck and shoulders A position with rounded shoulders where the neck is strained protracted at an uncomfortable angle Usually results from excessive strain on the spine from looking in a forward & downward position at any hand-held mobile device Examples: cell phone use, laptops, books or e-readers, video games, etc…

Improper loading through spine Tight sub-occipital mm & tight pectorals Neck pain Inability to take deep breathsNeural tension in arms or legs (N&T)

How do I know if I’m suffering from Tech Neck? 4 signs you might be spending too much time staring at your screen: Poor posture Holding your device at chest hip level? Persistent neck pain If it occurs on a daily or even weekly basis N&T in fingersWithout intervention, TOS symptoms can developHeadaches & Migraines For every inch you lean forward, you’re “adding” weight

Lit review estimates neck pain affects 30-50% of adults/year Of those, 50-85% do not have full resolution of symptoms Like LBP, chronic neck pain can be unresponsive to treatment & very costly * Caroll L.J. et al, “Course and prognostic factors for neck pain in the general population.” Spine 2008.

Literature Review “Prevalence, practice patterns, and evidence for chronic neck pain” Adam Goode, et. al (Duke University School of Medicine & University of North Carolina)5,300 households with 9K participants 35 minute phone surveyIndividuals with chronic cervicalgia were middle-aged (mean 48.9 yrs ) 56% womenMean of 5.21 provider types & mean of 21 visits Therapies reported: electrotherapy stimulation (30.3%), corsets or braces (20.9%), massage (28.1%), U/S (27.3%), heat (57.0%) and cold (47.4%).

Saw provider , % (95% CI) Mean visits (95% CI) † Range of visitsProvider type Primary care physician71.9 (62.1–80.0)3.4 (2.4–4.5) 1–30 Orthopedic surgeon31.6 (22.6–42.2)5.2 (1.3–9.3)1–40  Neurosurgeon 29.1 (20.5–39.6) 3.0 (1.88–4.2) 1–12  Neurologist 22.8 (14.9–33.3) 3.1 (1.7–4.5)1–20 Rheumatologist3.2 (1.1–8.9)3.1 (1.2–5.1) 2–5 Anesthesiologist‡13.3 (7.6–22.4)2.9 (1.5–4.4)1–12 Physiatrist13.4 (7.5–22.8) 6.5 (0.3–12.8)1–24 Physical therapist35.2 (25.7–46.0)17.2 (7.7–26.8)1–100 Chiropractor 40.4 (30.3–51.5)16.5 (9.0–23.9)1–150 Psychologist or psychiatrist3.9 (1.3–10.7)4.1 (2.5–8.3)2–5 Acupuncturist‡ 3.9 (1.4–10.3)7.9 (0.18–16.0)2–18 Massage therapist28.1 (19.3–39.0)8.4 (4.7–12.1)1–50 Pain clinic11.4 (6.2–19.9) 3.8 (1.6–6.0) 1–12 Saw medical doctor 91.7 (84.3–95.8) 7.7 (5.3–10.1) 1–52 Saw alternative care provider 41.4 (31.2–52.3) N/A N/A Mean no. of providers seen 5.2 (4.8–5.6) N/A 1–12 Total no. of provider visits N/A 20.8 (14.5–27.0) N/A Saw >3 providers 77.4 (68.3–84.5) N/A N/A * Caroll L.J. et al, “Course and prognostic factors for neck pain in the general population.” Spine 2008.

*77% sought 3 or more providers for pain management

Comparative analysis of common interventions for neck pain compared with the utilization of care seekers (n = 113) in our study Treatment Use, % (95% CI) No. of treatments received, mean (95% CI) Efficacy or effectiveness studies in the BJD (19) CochraneMedications†  NSAIDs (OTC)56.3 (45.7–66.3)N/ANR+/− (33) Weak narcotics 23.1 (15.0–33.7) N/A NR +/− (33)  Strong narcotics 28.8 (20.0–39.5) N/ANR+/− (33) Muscle relaxants31.5 (22.4–42.4) N/A+/−+/− (33)Physical treatments‡ Traction 17.7 (10.7–27.7)Not asked+/−§+/− (34) Corset or brace20.9 (12.7–32.4)Not askedNRNR  Used TENS unit21.8 (13.9–32.6)Not asked+/−§+/− (35) Spinal manipulation36.8 (27.13–47.6)12.7 (6.7–18.7)+/−+ (36)  Injection¶18.6 (11.7–28.2)2.4 (1.5–3.3)NR+ (33) Rehabilitation conditioning/work hardening program2.7 (0.78–8.7)Not askedNR+ (37) Prescribed exercise 52.6 (42.2–62.8) N/A + + (27)  Electrostimulation during visit 30.3 (21.1–41.4) 20.8 (8.8–32.8) NR +/− (35)  Heat 57.0 (46.2–67.1) 23.2 (13.9–32.6) +/− § NR  Cold 47.7 (36.9–58.7) 20.7 (9.6–31.7) +/− § NR  Ultrasound 27.3 (18.6–38.1) 9.2 (4.2–14.3) +/− NR  Acupuncture ¶ 3.9 (1.4–10.4) 7.9 (0.18–16.0) + + (38)  Therapeutic massage 28.1 (19.3–39.0) 8.4 (4.7–12.1) +/− +/− (39) Total no. of treatments, mean # N/A 15.6 (10.9–20.4) N/A N/A No. of different treatment types, mean 3.9 (3.3–4.5) N/A N/A N/A

Results Based on the current evidence for best practice, our findings indicate overutilization of diagnostic testing, narcotics, and modalities, and underutilization of effective treatments such as therapeutic exercise. The use of treatments among subjects with chronic impairing neck pain varied substantially . The most commonly used treatments were superficial heat, cold, exercise, massage, and manipulation. Of these treatments, exercise and manipulation had moderate to good evidence of effectiveness for patients with neck pain according to both of the systematic reviews referenced for this study.*Caroll L.J. et al, “Course and prognostic factors for neck pain in the general population.” Spine 2008.

Take home Tid -Bits Prevention is key How should I sit? Maintain a gentle inward curve to create normal lordosis: helps align the spine when seated and lets your head rest in tall, neutral position Perform gentle exercises: Chin tucks Lay flat on your back with no pillow Place a folded hand towel (lengthwise) (~2-4” diameter roll) under the base of your skull (the bumps). Gently and slightly nod your head yes as you exhale Repeat 10-20 times for up to 3-5 minutes Scapular retraction: Squeeze shoulder blades together, hold 5 seconds, + resistance as tolerated

Keep your upper back (thoracic spine) flexible & strong Manual, orthopedic therapy may be recommended The biggest service you can do to relieve your neck pain is to be mindful of your neck position during the day Rolling on a foam roller or small ball all through your thorax to promote good alignment of your neck from below. Shoulder strengthening exercises include retraction & depression as well as RC strengthening to support your neck.

Kate Kate is a 27 y/o F currently in grad school to become a mental health therapist. PMHx of cervical tightness and pain with c/c of migraines since age 15. She reports HA 2-5 days/ wk and most are severe. Family History: aunt and older brother have migraines. Allergies include NSAIDs & Tylenol (hives, facial & tongue swelling). Referred to PT by her neurologist. Pain localizes to either L or R side of her head, associated with light, sound; odor sensitivity, nausea and occasional vomiting, poor concentration. She may occasionally note blurry spots in her vision as the migraine begins.She has tried: nortrtiptyline, amitriptyline, topamax, Lexapro & robaxin Current medicine regimen: alternates between sumatriptan and rizatriptan and takes 5-6 tabs per day. Neurologist provided education regarding ‘analgesic rebound headaches & the importance in limiting this class of medication.’

Kate’s Diagnosis & PT Eval Tid -Bits Two diagnoses given: Analgesic overuse headache & chronic migraine without aura intractable She was on her new pain medication regimen for about 1 month when I evaluated her in PT; Baclofen had been added C/o migraines & shooting pains along her upper traps, described as "constant right there." She denies N&T.T&Ms: observation-FHRSP with dowager’s hump; palpation- hypertonic B up traps; ROM- 75% B rotation & SB; 50% cervical flexion (greatest pain!)Assessment: Poor postural habits, hypomobility noted: C1-2, C7-T4; DNF endurance was weak <10”; poor study/ergonomic habits: laptop-couchResults: 12 visits over 2 month periodAverage HA (when present) improved from 8/10 to 5/10; improved concentration & no longer had visual changes NDI improved minimally from 15/50 to 13/50 *of note: “belief my pain is improving” WNL mobility through cervical and thoracic spineIndep with gym and home ex programs

Kate’s treatment plan Put your head on your bodyPostural retraining Proprioception retraining Recognition of postural habits Bring your work closer to youErgonomics of work and home environments changedInstruction to keep neutral spine Pain cues, visual/mirror cuesSupport your lower back when sitting Morbidly obese & her chair didn’t fit her wellLumbar support pillow behind her back to achieve neutral pelvis (WB through pelvic floor not her sacrum) Perform gentle neck stretching & exercisesDNF strengtheningCervical retraction/chin tucks in supine *keep pain freeIsometrics: cervical spine all planes, scapular retraction resistance with therabands & pulley systemKeep your upper back flexible & strongManual therapies medically needed (joint mobilization, dry-needling upper traps (endogenous opioid, endorphins)Foam rolling for self-mobilization (daily)

Do ergonomics matter?

Healthy Ergonomics Don’t perch—Sit all the way back in your office chair Bring your work station to you Raise your monitor to face height Rest your forearms on the armrests of your chair Use an ergonomic keyboard & mouse (build-ups with mousepad for example)

5 PT Tips: Put your head on your body Bring your work closer to you Support your lower back when sitting Perform gentle neck stretching & exercises Keep your upper back flexible & strong

Do yourself a service…avoid tech-neck

UAMS Physical Therapy Clinics: 501-296-1500 Spine Center Institute on Aging Autumn Clinic* Colonel Glenn** Free standing Outpatient Clinics

UAMS Occupation Health and Safety department Consultation Request for ergonomic set up 501-686-5536

Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076Event ID: 29835-24581