1b - Patient Exam Flashcards
what is a limitation of the NDI
ceiling and floor effect
- not great for pts on either end of spectrum
when is the NDI used
acute and chronic conditions of neck pain associated with:
- MSK dysfunction
- WAD
- cervical radiculopathy
for patients on either end of the spectrum w their NDI score, what is suggested
supplement NDI w PSFS
those who recovered from WAD have a NDI score of
=/< 8
those w mild disability from a WAD have a NDI score of
10-28
those w mod to severe disability from a WAD have a NDI score of
> 30
when is the PSFS used
back, neck, knee, and UE problems
how are NDI scores interpreted
higher = worse disability
how are PSFS score interpreted
low score is worse
high score is better
how does the PSFS work
pts list 3-5 activities they have difficulty with or are unable to do
- rate from 0-10 the difficulty
why is the PSFS a helpful tool to use
specific to pts
helps to develop long term functional goal
what does the GROC measrure
measures change in health status
- pt rate degree of improvement compared retrospectively
what is the GROC limited by and how can this be mitigated
recall bias
use in combo w NDI or PFPS for objective functional outcomes
what is the MCID for the NRPS
2pts
what is the NPRS
rate pain 1-10 current, best, worst in the last 24hrs
why is steroid use relevant to ask for a pt w neck pain
side effects - prolonged use of steroids weaken tissues and ligaments, osteoporosis/penia
- also longer time to heal
why is anticoagulant use relevant to ask for pt w neck pain
risk for bleeding
- important for thrust-joint manip and mobilizations
why is respiratory hx important to ask for pt w neck pain
often linked to chronic steroid use to treat respiratory hx
- think steroid SE
if severe URI (more common in peds) -> can cause AA instability
what are 7 questions to ask in the pt interview that are cervical spine mandatory questions
- dizziness
- drop attack
- gait disturbance
- meds (steroids, anticoag)
- bilateral/quad neuro s/sx
- respiratory hx
- imaging
since asymptomatic abnormalities are commonly found on cspine imaging, what is focus when looking at someone’s imaging and what is imaging useful for
looking for a clinical correlation
useful for r/o serious path
what is the significance of a traumatic vs atraumatic MOI for the cspine
traumatic injuries have different trajectory than non traumatic
how will a c-spine disc herniation pain present
worse in morning
what are the 3 underlying pain mechansims
nociceptive
nociplastic
neuropathic
what is nociceptive pain and what causes it
d/t activation of nociceptors
- inflammation
- mechanical irritant
- injury
localized to area
what will nociceptive pain feel like
throbbing, aching pain
what is neuropathic pain and what causes it
d/t lesion or dz of somatosensory system
nerve pain
what will neuropathic pain feel like
burning, shooting, electric, tingling
what are examples of neuropathic pain
sciatica
TOS
peripheral nerve compression
diabetic neuropathies
what are examples of nociceptive pain
ankle sprain
OA
RA
what is nociplastic pain
d/t disturbance in central pain processing
- inc excitability
- dec inhibition
lower pain threshold, high pain levels
what are examples of nociplastic pain
fibromyalgia
TMJ disorder
nonspecific LBP
CRPS possibly
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
what are factors which contribute to nociplastic pain to consider
psychosocial impacts
- depression
- anxiety
- catastrophizing
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
how do you prioritize the exam after pt interview
based on most likely hypotheses and SINSS
what outcome tool should you use if picking up a lot of yellow flags in interview
OSPRO-YF
what outcome tool should you use if you note the patient avoiding movement
FABQ
at what point should you have a good hypothesis list
after pt interview
what systems review is done in the exam for someone w neck pain
testing for nerve palsy
- spinal accessory
- long thoracic
- axillary
what is the order of clinical examination (tests and measures) for neck pain
- observation/postural assessment/functional testing
- gait and balance
- shoulder screening
- cervical AROM/PROM/combined motions
- repeated motions
- cervical flex rotation test
- special tests
- neurological testing
- neurodynamic testing
- biomechanical exam
- cervical/thoracic PPIVMs and PAIVMs
- thoracic and first rib screening
- ms length assessment
- ms performance
what are components of posture analysis
quantify findings
- objective, not min/mod/severe
standing
sitting
dynamic
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
what is the relationship posture analysis has to injury
if someone injured, posture will be more important
what is upper crossed syndrome
postural dysfunction
tight pecs, upper traps, and levator scapula
inhibited (d/t lengthened position) neck flexors, rhomboids, serratus anterior
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
what does it mean to look at the quality of ROM
smooth motion throughout
any deviations
is it slow
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
when is overpressure is important
almost never
won’t need to do if have pain w movement
might do w flex to be provocative
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
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
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
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
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
what angle to cspine facets sit on
45deg
flex vs ext cspine arthrokinematics
flex:
- upglide bilat and ant
ext:
- downglide bilat and post
R SB cspine arthrokinematics
downglide R
upglide L
R rotation cspine arthrokinematics
separation on R
compression on L
+ SB arthrokinematics (R down, L up)
d/t transverse plane motion
cspine flex norm
45deg
cspine ext norm
45deg
cspine SB norm
45-60deg
what position should cspine rotation be measured in and why
supine
- get more motion than in sitting bc tissues more relaxed
- more consistent measurements
cspine rotation norm
75deg
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
what is the purpose of the cervical torsion test
differentiate cervical dizziness from BPPV (benign paroxysmal positional vertigo)
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
how is the vestibular system eliminated in the cervical torsion test
head is still, and move the trunk
how can the vestibular system be isolated in the cervical torsion test
head and trunk are rotated together
what are possible cervical dizziness dx that could possibly be r/i or r/o by the cervical torsion test
VBI
cervicogenic dizziness
what are tests for upper cervical instability
alar ligament
modified sharp purser
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
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)
what type of test is the alar ligament test
test of immediacy
what is a (+) alar ligament test
SP of C2 doesn’t start to move as soon as head is SB
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
what does (+) alar ligament test mean
further dx testing may be indicated
upper cervical joint mob or ROM exercises contraindicated
what can AA instability be caused by
transverse ligament insufficiency/laxity d/t:
- downs
- RA
- ankylosing spondylitis
- trauma -> fx dens
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
what is indicated if (+) modified sharp purser test
joint mob and ROM exs contraindicated
hard c collar
immediate referral to MD for imaging
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)
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
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
what are tests for cervical radiculopathy
neurodynamic testing
spurling’s test
cervical distraction test
cervical compression test
what are commonly seen cervical radiculopathies
C6 and C7
sensory testing C5-T1 dermatomes
C5 - delt
C6 - lateral forearm and hand
C7 - middle finger
C8 - medial hand and forearm
T1 - medial upper arm
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
what are upper limb neurodynamic tests
upper limb tension tests
- put stress on neurological structures of upper limb
how can upper limb neurodynamic tests be sensitized
neck and arm movements
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
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
what is ULTT 2
radial n.
shld depression, ABD, IR
forearm pron
wrist flex
ulnar dev
wrist and thumb flex
sensitize - SB head away
what is ULTT 3
ulnar n.
shld depression, ABD
elbow flex
forearm pron
wrist ext
radial dev
sensitize - SB head away
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
what is the cervical distraction test used for
to identify cervical radiculopathy
what is a (+) cervical distraction test
dec or elimination of pt sx
what is the cervical compression test used for
cervical radiculopathy
- tells you less info than distraction test
what is a (+) cervical compression test
reproduction of sx
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
what is a (+) quadrant/spurling test
reproduction of pt sx
what are tests for pathological UMN reflex or spinal cord compression
hoffman’s reflex
lhermittes sign
babinski sign
inverted supinator sign
clonus
how is radiculopathy r/i or r/o ultimately
pt hx + several tests
what is a (+) hoffman’s sign
flex of IP joint of thumb and index finger
what is a (+) lhermitte’s sign
“electric type” shocks into spine and possibly extremities
what is a (+) babinski sign
great toe ext/DF and fanning of digits 2-5
what is a (+) inverted supinator sign
finger flex and slight elbow ext
what is (+) clonus
3+ beats of hand or foot
what are PPVIMS
passive physiological intervertebral motions
assess passive physiological motion at each segment: quantity and end feel in
- flex/ext
- SB
- rotation
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
what are the two type of PA glides (PAIVMS)
central
unilateral
central vs unilateral PA glides
central - apply pressure to SP
unilateral - pressure to articular facet joint
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
what are your scap stabilizers
mid traps
lower traps
rhomboids
serratus anterior
what does the cranial cervical flexion test (CCFT) test for
action of deep cervical flexor ms (longus capitis, colli)
test of neuromotor control
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
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
what are tests for cervical radiculopathy
cervical distraction, compression
quadrant/spurling test
valsalva test
shoulder ABD test (badoky sign)
arm squeeze test
what the valsalva test and what is a positive
pt seated, exhale against closed glottis x10-15sec
inc intraspinal pressure
(+) reproduction sx = c rad
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
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
if you suspect nociplastic pain what should you do
measure using quantitative testing
- thermal pain threshold
- mechanical pressure pain threshold
what are differential dx and their tests to think ab with the upper cervical spine
confirm - CN testing
differential:
- TMJ screening
- TOS tests
what is the clinical reasoning model basis
hypothesis oriented orthopaedic-focused algorithm (HOO-FA)
