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MSK 2 > 1b - Patient Exam > Flashcards

1b - Patient Exam Flashcards

1
Q

what is a limitation of the NDI

A

ceiling and floor effect
- not great for pts on either end of spectrum

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2
Q

when is the NDI used

A

acute and chronic conditions of neck pain associated with:
- MSK dysfunction
- WAD
- cervical radiculopathy

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3
Q

for patients on either end of the spectrum w their NDI score, what is suggested

A

supplement NDI w PSFS

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4
Q

those who recovered from WAD have a NDI score of

A

=/< 8

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5
Q

those w mild disability from a WAD have a NDI score of

A

10-28

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6
Q

those w mod to severe disability from a WAD have a NDI score of

A

> 30

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7
Q

when is the PSFS used

A

back, neck, knee, and UE problems

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8
Q

how are NDI scores interpreted

A

higher = worse disability

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9
Q

how are PSFS score interpreted

A

low score is worse
high score is better

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10
Q

how does the PSFS work

A

pts list 3-5 activities they have difficulty with or are unable to do
- rate from 0-10 the difficulty

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11
Q

why is the PSFS a helpful tool to use

A

specific to pts
helps to develop long term functional goal

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12
Q

what does the GROC measrure

A

measures change in health status
- pt rate degree of improvement compared retrospectively

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13
Q

what is the GROC limited by and how can this be mitigated

A

recall bias

use in combo w NDI or PFPS for objective functional outcomes

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14
Q

what is the MCID for the NRPS

A

2pts

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15
Q

what is the NPRS

A

rate pain 1-10 current, best, worst in the last 24hrs

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16
Q

why is steroid use relevant to ask for a pt w neck pain

A

side effects - prolonged use of steroids weaken tissues and ligaments, osteoporosis/penia
- also longer time to heal

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17
Q

why is anticoagulant use relevant to ask for pt w neck pain

A

risk for bleeding
- important for thrust-joint manip and mobilizations

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18
Q

why is respiratory hx important to ask for pt w neck pain

A

often linked to chronic steroid use to treat respiratory hx
- think steroid SE

if severe URI (more common in peds) -> can cause AA instability

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19
Q

what are 7 questions to ask in the pt interview that are cervical spine mandatory questions

A
  1. dizziness
  2. drop attack
  3. gait disturbance
  4. meds (steroids, anticoag)
  5. bilateral/quad neuro s/sx
  6. respiratory hx
  7. imaging
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20
Q

since asymptomatic abnormalities are commonly found on cspine imaging, what is focus when looking at someone’s imaging and what is imaging useful for

A

looking for a clinical correlation
useful for r/o serious path

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21
Q

what is the significance of a traumatic vs atraumatic MOI for the cspine

A

traumatic injuries have different trajectory than non traumatic

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22
Q

how will a c-spine disc herniation pain present

A

worse in morning

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23
Q

what are the 3 underlying pain mechansims

A

nociceptive
nociplastic
neuropathic

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24
Q

what is nociceptive pain and what causes it

A

d/t activation of nociceptors
- inflammation
- mechanical irritant
- injury

localized to area

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25
Q

what will nociceptive pain feel like

A

throbbing, aching pain

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26
Q

what is neuropathic pain and what causes it

A

d/t lesion or dz of somatosensory system

nerve pain

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27
Q

what will neuropathic pain feel like

A

burning, shooting, electric, tingling

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28
Q

what are examples of neuropathic pain

A

sciatica
TOS
peripheral nerve compression
diabetic neuropathies

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29
Q

what are examples of nociceptive pain

A

ankle sprain
OA
RA

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30
Q

what is nociplastic pain

A

d/t disturbance in central pain processing
- inc excitability
- dec inhibition

lower pain threshold, high pain levels

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31
Q

what are examples of nociplastic pain

A

fibromyalgia
TMJ disorder
nonspecific LBP
CRPS possibly

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32
Q

what is an important component to include when treating someone w nociplastic pain

A

patient ed
- telling them that moving is important and that it is okay if it hurts

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33
Q

what are factors which contribute to nociplastic pain to consider

A

psychosocial impacts
- depression
- anxiety
- catastrophizing

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34
Q

SINSS: what does it stand for, how are results interpreted, why is it used

A

Severity - intensity of pain (VRS)
Irritability
1. vigor of activity needed to sx
2. severity of sx
3. time it takes for sx to then subside
Nature
- type of tissue causing pain
- mechanical, neural, etc.
Stage - acute, chronic, etc.
Stability - of sx

min, mod, max

determines rigor of exam and interventions

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35
Q

how do you prioritize the exam after pt interview

A

based on most likely hypotheses and SINSS

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36
Q

what outcome tool should you use if picking up a lot of yellow flags in interview

A

OSPRO-YF

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37
Q

what outcome tool should you use if you note the patient avoiding movement

A

FABQ

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38
Q

at what point should you have a good hypothesis list

A

after pt interview

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39
Q

what systems review is done in the exam for someone w neck pain

A

testing for nerve palsy
- spinal accessory
- long thoracic
- axillary

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40
Q

what is the order of clinical examination (tests and measures) for neck pain

A
  1. observation/postural assessment/functional testing
  2. gait and balance
  3. shoulder screening
  4. cervical AROM/PROM/combined motions
  5. repeated motions
  6. cervical flex rotation test
  7. special tests
  8. neurological testing
  9. neurodynamic testing
  10. biomechanical exam
  11. cervical/thoracic PPIVMs and PAIVMs
  12. thoracic and first rib screening
  13. ms length assessment
  14. ms performance
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41
Q

what are components of posture analysis

A

quantify findings
- objective, not min/mod/severe
standing
sitting
dynamic

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42
Q

what is an important thing to consider w posture during the exam

A

posture is dynamic
- movement is more important than having perfect posture all the time

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43
Q

what is the relationship posture analysis has to injury

A

if someone injured, posture will be more important

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44
Q

what is upper crossed syndrome

A

postural dysfunction

tight pecs, upper traps, and levator scapula

inhibited (d/t lengthened position) neck flexors, rhomboids, serratus anterior

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45
Q

what is included in the shoulder screen

A

shoulder functional movement screen:
- active elevation, ABD, ABD/ER, ADD/IR
- observe scapular motion
- passive ROM testing/overpressure
- resisted movements

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46
Q

what does it mean to look at the quality of ROM

A

smooth motion throughout
any deviations
is it slow

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47
Q

what is a way to quantify your visual estimation of ROM

A

look at in cardinal planes and divide into quadrants
- can determine if someone is having trouble in a specific quadrant

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48
Q

when is overpressure is important

A

almost never
won’t need to do if have pain w movement

might do w flex to be provocative

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49
Q

what motions do you do use a visual estimation of ROM

A

upper cervical flex/ext (nodding)
SB, rotation
combined movements
isolate C1/2 movement

soft tissue/ms length differentiation
- shrug shoulders - SB
- mouth open - extension

50
Q

what is a combined movement that is part of visual estimation of ROM

A

lower cspine - flex, SB, and rotation occur in same direction
- on diagonal in quadrant

51
Q

how can upper cspine movements be isolated

A

nodding comes from OA joint
- nod in rotated position locks out lower cspine

rotation from AA
- rotate in flex position, locks out lower cspine

52
Q

how can soft tissue/ ms length be differentiated with dec SB

A

shrug shoulders then SB
- more ROM: tight SCM contra
- same ROM: limitation isn’t ms or soft tissue

53
Q

how can soft tissue/ms length be differentiated with dec extension

A

open mouth, then ext
- more ROM: tight hyoid ms
- same ROM: limitation isn’t ms or soft tissue

54
Q

what angle to cspine facets sit on

A

45deg

55
Q

flex vs ext cspine arthrokinematics

A

flex:
- upglide bilat and ant

ext:
- downglide bilat and post

56
Q

R SB cspine arthrokinematics

A

downglide R
upglide L

57
Q

R rotation cspine arthrokinematics

A

separation on R
compression on L
+ SB arthrokinematics (R down, L up)

d/t transverse plane motion

58
Q

cspine flex norm

A

45deg

59
Q

cspine ext norm

A

45deg

60
Q

cspine SB norm

A

45-60deg

61
Q

what position should cspine rotation be measured in and why

A

supine
- get more motion than in sitting bc tissues more relaxed
- more consistent measurements

62
Q

cspine rotation norm

A

75deg

63
Q

what repeated motions do you have pts demonstrate and what do you ask

A

head retraction
head protrusion
head retraction + ext

do sx centralize and move prox or do they peripheralize
does it get worse w repeated movement to end range

64
Q

what is the purpose of the cervical torsion test

A

differentiate cervical dizziness from BPPV (benign paroxysmal positional vertigo)

65
Q

how are results of the cervical torsion test interpreted

A

dizziness with only moving head on trunk = vestibular (BPPV)

dizziness with both moving head on trunk and trunk on head = cervical

66
Q

how is the vestibular system eliminated in the cervical torsion test

A

head is still, and move the trunk

67
Q

how can the vestibular system be isolated in the cervical torsion test

A

head and trunk are rotated together

68
Q

what are possible cervical dizziness dx that could possibly be r/i or r/o by the cervical torsion test

A

VBI
cervicogenic dizziness

69
Q

what are tests for upper cervical instability

A

alar ligament
modified sharp purser

70
Q

what are indications for upper cervical stability testing

A

trauma
inflammatory arthritis
report of instability (“head feels heavy”)
screening for upper cspine manual therapy
certain s/sx

71
Q

what s/sx are indications for upper cspine stability testing

A

lip or tongue parasthesia
n/v
severe HA or ms spasm
dizziness
lump in throat
signs of cord compression (ie bilateral or quadrilateral parasthesia)

72
Q

what type of test is the alar ligament test

A

test of immediacy

73
Q

what is a (+) alar ligament test

A

SP of C2 doesn’t start to move as soon as head is SB

74
Q

what is the function of alar ligament and how is this tested in the alar ligament test

A

ligament limits SB and rotation at C2

should feel the SP move contra of SB direction as the intact ligament pulls C2 into rotation

75
Q

what does (+) alar ligament test mean

A

further dx testing may be indicated

upper cervical joint mob or ROM exercises contraindicated

76
Q

what can AA instability be caused by

A

transverse ligament insufficiency/laxity d/t:
- downs
- RA
- ankylosing spondylitis
- trauma -> fx dens

77
Q

what are (+) modified sharp purser test findings

A

(+ part 1) - ant sublux of atlas
- provocation of s/sx w flexion, ie cord compression (pain down both arms or both legs)

(+ part 2) - relocation of atlas
- clunk/excess motion w post force to head

78
Q

what is indicated if (+) modified sharp purser test

A

joint mob and ROM exs contraindicated

hard c collar
immediate referral to MD for imaging

79
Q

why is a (+) modified sharp purser test an immediate referral

A

can have serious consequence as can get cord compression if thrown into extreme flex (ie if in MVA)

80
Q

what population are and are not appropriate for a sharp purser test

A

studied in RA and downs
- can’t be extrapolated to all pt populations

no appropriate for pts w acute trauma or suspicion of fx

81
Q

what are components of a neurological exam specific to cspine

A

myotomes
sensory dermatomes
DTRs
test for cervical radiculopathy
test for path UMN relex or SC compression

82
Q

what are tests for cervical radiculopathy

A

neurodynamic testing
spurling’s test
cervical distraction test
cervical compression test

83
Q

what are commonly seen cervical radiculopathies

A

C6 and C7

84
Q

sensory testing C5-T1 dermatomes

A

C5 - delt
C6 - lateral forearm and hand
C7 - middle finger
C8 - medial hand and forearm
T1 - medial upper arm

85
Q

motor testing C5-T1

A

C5 - delt, bicep
C6 - bicep, wrist ext
C7 - tricep, wrist flex, finger ext
C8 - finger flexors; ABD/ADD fingers
T1 - ABD/ADD fingers

86
Q

what are upper limb neurodynamic tests

A

upper limb tension tests
- put stress on neurological structures of upper limb

87
Q

how can upper limb neurodynamic tests be sensitized

A

neck and arm movements

88
Q

what is ULTT 1

A

median nerve

shld girdle depression
shld ABD 110, ER 80
forearm sup
wrist and finger ext
elbow ext

sensitize - SB head away

89
Q

what does a (+) ULTT test mean

A

doesn’t tell you where problem in nervous system is
- could be radiculopathy
- could be any impacting the nerve along course

more info if test is neg

90
Q

what is ULTT 2

A

radial n.

shld depression, ABD, IR
forearm pron
wrist flex
ulnar dev
wrist and thumb flex

sensitize - SB head away

91
Q

what is ULTT 3

A

ulnar n.

shld depression, ABD
elbow flex
forearm pron
wrist ext
radial dev

sensitize - SB head away

92
Q

what are (+) findings on ULTTs

A

reproduction of sx
>10deg diff in elbow ext side-side
symptomatic side:
- inc sx w SB away
- dec sx w SB toward

93
Q

what is the cervical distraction test used for

A

to identify cervical radiculopathy

94
Q

what is a (+) cervical distraction test

A

dec or elimination of pt sx

95
Q

what is the cervical compression test used for

A

cervical radiculopathy
- tells you less info than distraction test

96
Q

what is a (+) cervical compression test

A

reproduction of sx

97
Q

what is the quadrant/spurling test doing

A

maximally downgliding the facet in one quadrant (on sx side) and compressing to see if reproduction
- for cervical radiculopathy

98
Q

what is a (+) quadrant/spurling test

A

reproduction of pt sx

99
Q

what are tests for pathological UMN reflex or spinal cord compression

A

hoffman’s reflex
lhermittes sign
babinski sign
inverted supinator sign
clonus

100
Q

how is radiculopathy r/i or r/o ultimately

A

pt hx + several tests

101
Q

what is a (+) hoffman’s sign

A

flex of IP joint of thumb and index finger

102
Q

what is a (+) lhermitte’s sign

A

“electric type” shocks into spine and possibly extremities

103
Q

what is a (+) babinski sign

A

great toe ext/DF and fanning of digits 2-5

104
Q

what is a (+) inverted supinator sign

A

finger flex and slight elbow ext

105
Q

what is (+) clonus

A

3+ beats of hand or foot

106
Q

what are PPVIMS

A

passive physiological intervertebral motions

assess passive physiological motion at each segment: quantity and end feel in
- flex/ext
- SB
- rotation

107
Q

what are PAIVMS

A

passive accessory intervertebral motions

require outside force to produce motion (ie post-ant glide)
- passive motion assess
- end feel (grade 3 mob)
- pain provocation

108
Q

what are the two type of PA glides (PAIVMS)

A

central
unilateral

109
Q

central vs unilateral PA glides

A

central - apply pressure to SP
unilateral - pressure to articular facet joint

110
Q

what is translatoric joint play C2-T1 and what pt population is this good for

A

pt in SL, palpating finger b/w 2 SPs
- head and neck moved in A-P direction, producing small oscillatory movements parallel to disc

good for hypermobile pts

111
Q

what are your scap stabilizers

A

mid traps
lower traps
rhomboids
serratus anterior

112
Q

what does the cranial cervical flexion test (CCFT) test for

A

action of deep cervical flexor ms (longus capitis, colli)
test of neuromotor control

113
Q

what are compensations seen with the cervical extensor endurance test and what do they indicate

A

excessive ext
- weak deep neck ext as the “chin length” is inc w neck ext
- compensating w superficial neck ext ?

excessive flex
- weakness of both deep and superficial neck ext

114
Q

what are 3 cervical extensor ms movement control tests

A

a. active c ext in 4pt kneeling
b. active upper c rotation in 4pt
c. active c flex in 4pt

115
Q

what are tests for cervical radiculopathy

A

cervical distraction, compression
quadrant/spurling test
valsalva test
shoulder ABD test (badoky sign)
arm squeeze test

116
Q

what the valsalva test and what is a positive

A

pt seated, exhale against closed glottis x10-15sec
inc intraspinal pressure

(+) reproduction sx = c rad

117
Q

what is a Badoky sign and what is a positive

A

pt seated, arms ADD, hand on head

(+) relief of sx = c rad
- unloads tension on nerve

118
Q

arm squeeze test: purpose, what is it, and what is a positive

A

differentiate shoulder path from cervical nerve root pain

squeeze upper arm x3, apply pressure to AC joint, apply pressure to ant-lat subacromial area
- compare pain VRS scores

(+) arm pain 3pts higher than other 2 sites
- good to r/o and r/i radiculopathy

119
Q

if you suspect nociplastic pain what should you do

A

measure using quantitative testing
- thermal pain threshold
- mechanical pressure pain threshold

120
Q

what are differential dx and their tests to think ab with the upper cervical spine

A

confirm - CN testing

differential:
- TMJ screening
- TOS tests

121
Q

what is the clinical reasoning model basis

A

hypothesis oriented orthopaedic-focused algorithm (HOO-FA)

MSK 2 (20 decks)

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