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
2
Q
when is the NDI used
A
acute and chronic conditions of neck pain associated with:
- MSK dysfunction
- WAD
- cervical radiculopathy
3
Q
for patients on either end of the spectrum w their NDI score, what is suggested
A
supplement NDI w PSFS
4
Q
those who recovered from WAD have a NDI score of
A
=/< 8
5
Q
those w mild disability from a WAD have a NDI score of
A
10-28
6
Q
those w mod to severe disability from a WAD have a NDI score of
A
> 30
7
Q
when is the PSFS used
A
back, neck, knee, and UE problems
8
Q
how are NDI scores interpreted
A
higher = worse disability
9
Q
how are PSFS score interpreted
A
low score is worse
high score is better
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
11
Q
why is the PSFS a helpful tool to use
A
specific to pts
helps to develop long term functional goal
12
Q
what does the GROC measrure
A
measures change in health status
- pt rate degree of improvement compared retrospectively
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
14
Q
what is the MCID for the NRPS
A
2pts
15
Q
what is the NPRS
A
rate pain 1-10 current, best, worst in the last 24hrs
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
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
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
19
Q
what are 7 questions to ask in the pt interview that are cervical spine mandatory questions
A
- dizziness
- drop attack
- gait disturbance
- meds (steroids, anticoag)
- bilateral/quad neuro s/sx
- respiratory hx
- imaging
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
21
Q
what is the significance of a traumatic vs atraumatic MOI for the cspine
A
traumatic injuries have different trajectory than non traumatic
22
Q
how will a c-spine disc herniation pain present
A
worse in morning
23
Q
what are the 3 underlying pain mechansims
A
nociceptive
nociplastic
neuropathic
24
Q
what is nociceptive pain and what causes it
A
d/t activation of nociceptors
- inflammation
- mechanical irritant
- injury
localized to area
25
what will nociceptive pain feel like
throbbing, aching pain
26
what is neuropathic pain and what causes it
d/t lesion or dz of somatosensory system
nerve pain
27
what will neuropathic pain feel like
burning, shooting, electric, tingling
28
what are examples of neuropathic pain
sciatica
TOS
peripheral nerve compression
diabetic neuropathies
29
what are examples of nociceptive pain
ankle sprain
OA
RA
30
what is nociplastic pain
d/t disturbance in central pain processing
- inc excitability
- dec inhibition
lower pain threshold, high pain levels
31
what are examples of nociplastic pain
fibromyalgia
TMJ disorder
nonspecific LBP
CRPS possibly
32
what is an important component to include when treating someone w nociplastic pain
patient ed
- telling them that moving is important and that it is okay if it hurts
33
what are factors which contribute to nociplastic pain to consider
psychosocial impacts
- depression
- anxiety
- catastrophizing
34
SINSS: what does it stand for, how are results interpreted, why is it used
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
35
how do you prioritize the exam after pt interview
based on most likely hypotheses and SINSS
36
what outcome tool should you use if picking up a lot of yellow flags in interview
OSPRO-YF
37
what outcome tool should you use if you note the patient avoiding movement
FABQ
38
at what point should you have a good hypothesis list
after pt interview
39
what systems review is done in the exam for someone w neck pain
testing for nerve palsy
- spinal accessory
- long thoracic
- axillary
40
what is the order of clinical examination (tests and measures) for neck pain
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
41
what are components of posture analysis
quantify findings
- objective, not min/mod/severe
standing
sitting
dynamic
42
what is an important thing to consider w posture during the exam
posture is dynamic
- movement is more important than having perfect posture all the time
43
what is the relationship posture analysis has to injury
if someone injured, posture will be more important
44
what is upper crossed syndrome
postural dysfunction
tight pecs, upper traps, and levator scapula
inhibited (d/t lengthened position) neck flexors, rhomboids, serratus anterior
45
what is included in the shoulder screen
shoulder functional movement screen:
- active elevation, ABD, ABD/ER, ADD/IR
- observe scapular motion
- passive ROM testing/overpressure
- resisted movements
46
what does it mean to look at the quality of ROM
smooth motion throughout
any deviations
is it slow
47
what is a way to quantify your visual estimation of ROM
look at in cardinal planes and divide into quadrants
- can determine if someone is having trouble in a specific quadrant
48
when is overpressure is important
almost never
won't need to do if have pain w movement
might do w flex to be provocative
49
what motions do you do use a visual estimation of ROM
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
what is a combined movement that is part of visual estimation of ROM
lower cspine - flex, SB, and rotation occur in same direction
- on diagonal in quadrant
51
how can upper cspine movements be isolated
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
how can soft tissue/ ms length be differentiated with dec SB
shrug shoulders then SB
- more ROM: tight SCM contra
- same ROM: limitation isn't ms or soft tissue
53
how can soft tissue/ms length be differentiated with dec extension
open mouth, then ext
- more ROM: tight hyoid ms
- same ROM: limitation isn't ms or soft tissue
54
what angle to cspine facets sit on
45deg
55
flex vs ext cspine arthrokinematics
flex:
- upglide bilat and ant
ext:
- downglide bilat and post
56
R SB cspine arthrokinematics
downglide R
upglide L
57
R rotation cspine arthrokinematics
separation on R
compression on L
+ SB arthrokinematics (R down, L up)
d/t transverse plane motion
58
cspine flex norm
45deg
59
cspine ext norm
45deg
60
cspine SB norm
45-60deg
61
what position should cspine rotation be measured in and why
supine
- get more motion than in sitting bc tissues more relaxed
- more consistent measurements
62
cspine rotation norm
75deg
63
what repeated motions do you have pts demonstrate and what do you ask
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
what is the purpose of the cervical torsion test
differentiate cervical dizziness from BPPV (benign paroxysmal positional vertigo)
65
how are results of the cervical torsion test interpreted
dizziness with only moving head on trunk = vestibular (BPPV)
dizziness with both moving head on trunk and trunk on head = cervical
66
how is the vestibular system eliminated in the cervical torsion test
head is still, and move the trunk
67
how can the vestibular system be isolated in the cervical torsion test
head and trunk are rotated together
68
what are possible cervical dizziness dx that could possibly be r/i or r/o by the cervical torsion test
VBI
cervicogenic dizziness
69
what are tests for upper cervical instability
alar ligament
modified sharp purser
70
what are indications for upper cervical stability testing
trauma
inflammatory arthritis
report of instability ("head feels heavy")
screening for upper cspine manual therapy
certain s/sx
71
what s/sx are indications for upper cspine stability testing
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
what type of test is the alar ligament test
test of immediacy
73
what is a (+) alar ligament test
SP of C2 doesn't start to move as soon as head is SB
74
what is the function of alar ligament and how is this tested in the alar ligament test
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
what does (+) alar ligament test mean
further dx testing may be indicated
upper cervical joint mob or ROM exercises contraindicated
76
what can AA instability be caused by
transverse ligament insufficiency/laxity d/t:
- downs
- RA
- ankylosing spondylitis
- trauma -> fx dens
77
what are (+) modified sharp purser test findings
(+ 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
what is indicated if (+) modified sharp purser test
joint mob and ROM exs contraindicated
hard c collar
immediate referral to MD for imaging
79
why is a (+) modified sharp purser test an immediate referral
can have serious consequence as can get cord compression if thrown into extreme flex (ie if in MVA)
80
what population are and are not appropriate for a sharp purser test
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
what are components of a neurological exam specific to cspine
myotomes
sensory dermatomes
DTRs
test for cervical radiculopathy
test for path UMN relex or SC compression
82
what are tests for cervical radiculopathy
neurodynamic testing
spurling's test
cervical distraction test
cervical compression test
83
what are commonly seen cervical radiculopathies
C6 and C7
84
sensory testing C5-T1 dermatomes
C5 - delt
C6 - lateral forearm and hand
C7 - middle finger
C8 - medial hand and forearm
T1 - medial upper arm
85
motor testing C5-T1
C5 - delt, bicep
C6 - bicep, wrist ext
C7 - tricep, wrist flex, finger ext
C8 - finger flexors; ABD/ADD fingers
T1 - ABD/ADD fingers
86
what are upper limb neurodynamic tests
upper limb tension tests
- put stress on neurological structures of upper limb
87
how can upper limb neurodynamic tests be sensitized
neck and arm movements
88
what is ULTT 1
median nerve
shld girdle depression
shld ABD 110, ER 80
forearm sup
wrist and finger ext
elbow ext
sensitize - SB head away
89
what does a (+) ULTT test mean
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
what is ULTT 2
radial n.
shld depression, ABD, IR
forearm pron
wrist flex
ulnar dev
wrist and thumb flex
sensitize - SB head away
91
what is ULTT 3
ulnar n.
shld depression, ABD
elbow flex
forearm pron
wrist ext
radial dev
sensitize - SB head away
92
what are (+) findings on ULTTs
reproduction of sx
>10deg diff in elbow ext side-side
symptomatic side:
- inc sx w SB away
- dec sx w SB toward
93
what is the cervical distraction test used for
to identify cervical radiculopathy
94
what is a (+) cervical distraction test
dec or elimination of pt sx
95
what is the cervical compression test used for
cervical radiculopathy
- tells you less info than distraction test
96
what is a (+) cervical compression test
reproduction of sx
97
what is the quadrant/spurling test doing
maximally downgliding the facet in one quadrant (on sx side) and compressing to see if reproduction
- for cervical radiculopathy
98
what is a (+) quadrant/spurling test
reproduction of pt sx
99
what are tests for pathological UMN reflex or spinal cord compression
hoffman's reflex
lhermittes sign
babinski sign
inverted supinator sign
clonus
100
how is radiculopathy r/i or r/o ultimately
pt hx + several tests
101
what is a (+) hoffman's sign
flex of IP joint of thumb and index finger
102
what is a (+) lhermitte's sign
"electric type" shocks into spine and possibly extremities
103
what is a (+) babinski sign
great toe ext/DF and fanning of digits 2-5
104
what is a (+) inverted supinator sign
finger flex and slight elbow ext
105
what is (+) clonus
3+ beats of hand or foot
106
what are PPVIMS
passive physiological intervertebral motions
assess passive physiological motion at each segment: quantity and end feel in
- flex/ext
- SB
- rotation
107
what are PAIVMS
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
what are the two type of PA glides (PAIVMS)
central
unilateral
109
central vs unilateral PA glides
central - apply pressure to SP
unilateral - pressure to articular facet joint
110
what is translatoric joint play C2-T1 and what pt population is this good for
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
what are your scap stabilizers
mid traps
lower traps
rhomboids
serratus anterior
112
what does the cranial cervical flexion test (CCFT) test for
action of deep cervical flexor ms (longus capitis, colli)
test of neuromotor control
113
what are compensations seen with the cervical extensor endurance test and what do they indicate
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
what are 3 cervical extensor ms movement control tests
a. active c ext in 4pt kneeling
b. active upper c rotation in 4pt
c. active c flex in 4pt
115
what are tests for cervical radiculopathy
cervical distraction, compression
quadrant/spurling test
valsalva test
shoulder ABD test (badoky sign)
arm squeeze test
116
what the valsalva test and what is a positive
pt seated, exhale against closed glottis x10-15sec
inc intraspinal pressure
(+) reproduction sx = c rad
117
what is a Badoky sign and what is a positive
pt seated, arms ADD, hand on head
(+) relief of sx = c rad
- unloads tension on nerve
118
arm squeeze test: purpose, what is it, and what is a positive
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
if you suspect nociplastic pain what should you do
measure using quantitative testing
- thermal pain threshold
- mechanical pressure pain threshold
120
what are differential dx and their tests to think ab with the upper cervical spine
confirm - CN testing
differential:
- TMJ screening
- TOS tests
121
what is the clinical reasoning model basis
hypothesis oriented orthopaedic-focused algorithm (HOO-FA)
