1f - Upper Cervical Spine Flashcards
what is the structure of C1 and how does this lend to its functions
no real body
giant superior facets
- articulate w occiput
inferior facets flatter but on angle
- orientation allows for rotation
describe the orientation of C2
dens sits ant against C1
SC is posterior
what is the function of the transverse ligament
hold position of C2 forward so that C1 can spin around it
what is a characteristic of the transverse ligament which lends to its primary function
fibers have very low coefficient of friction to allow for a lot of movement as C1 spins around dens
what is the result if the transverse ligament is injured
can’t stop C2 from moving posteriorly against SC
what are 3 major risk factors that can lead to transverse/alar ligament damage/insufficiency
trauma (MVA, trauma, fall)
RA
connective tissue disorder
what is the function of the alar ligament
comes off the head of dens to attach it to occiput
how does the alar ligament’s function influence movement at upper cervical spine
occiput and C2 will have correlation w each other
- see some rotation when SB occiput (getting movement at C2)
in SBing the occiput to the R, the R rotation at C2 is the result of what 2 things:
- tension of alar ligament
- geometry of facet joints
describe the movements happening at the occiput condyles, C1, and C2 during SB R
occiput condyles roll right and glide L on C1 (vex on cave)
alar lig becomes taut and induces R rotation of C2
C1 is shaped like a wedge b/w occiput and C2 + the position of dens + strong transverse ligament = C1 can’t SB & is still
C2 is rotating R under C1 (which is still), C1 rotates L relative to C2
path of vertebral artery and where is it at greatest risk for an injury
travels thru transverse foramen
at C1, there is a hook shape where you can get cervical arterial dissections and need to be careful of any manipulation at this level
what is a (+) alar ligament test
no IMMEDIATE contralateral mvmt of C2 spinous process
what is a (+) modified sharp purser test and what is the indication
dec in myelopathic sx
good specificity, worth taking time to stabilize w hard collar and send to ER
describe the anatomy of what is happening during a (+) modified sharp purser test and why it would mean a dec in sx
when flex forward, occiput falls of edge of cliff and dens moves to posterior portion of arch
- presses SC against dens, resulting in sx down arms, legs, unstable head
when ext head, get a clunk as dens clunks against arch and relocates
- relief in sx
what is the anterior shear transverse ligament safety test
pt supine and PT presses C1 anteriorly hold 10-15sec
(+) reproduction of myelopathic sx (not pain)
what is an alternate method for an anterior shear transverse ligament safety test if pt is already having myelopathic sx lying in supine
in supine, PT presses ant on C2
nose should elevate immediately
(+) some dec in sx as taking pressure off
what is the purpose of a lateral shear test
assess integrity of dens and osseous portion of C1 and its alar ligamentous attachment
what is procedure of a lateral shear test
stabilize occiput and C1
laterally shear C2
pain isn’t necessarily (+)
what is an important consideration when doing a cervical safety test
use in conjunction w clinical hx
- trauma, RA, down syndrome, connective tissue disorder
what is indicated if clinical tests and tests implicate upper cervical instability
immediate referral to MD for further assessment w c-collar
- want orthopedic surgeon to make the decision ab treatment
what are vertebral artery insufficiency sx similar to
myelopathic sx seen w SC
what are clinical s/sx of vertebral artery insufficiency
5Ds
- dizziness
- diplopia
- dysarthria
- dysphagia
- drop attacks
Ataxia of gait
3Ns
- nausea
- nystagmus
- numbness of face
what is a consideration of the ataxia of gait s/sx of vertebral artery insufficiency
might not show up immediately in gait
- might see it as do balance tests
what is the procedure of vertebral artery screening and why
sustained rotation
- puts pressure on hooked part of vertebral artery
don’t let them close eyes and keep them talking so see if vision/speech changes
extension w rotation to be more provocative
what do the results of vertebral artery screening indicate
if (-), not enough to r/o vertebral insufficiency
good (+) test result validity
25yo F exercise physiologist w PMH of lyme dz and neck/back pain and went to chiropractor for 1st time. Onset of dizziness/lightheadedness 1wk ago secondary to chiropractic C and T manip. No immediate sx, but develop the next day. XR, EKG, and CBC all neg in ED. Virtual appt w PCP suggested PT.
What cervical safety tests should be performed?
a. alar lig in supine & sitting
b. transverse lig test
c. lateral shear test
d. sustained rotation
e. all of the above
all of the above
- 5Ds, emphasis on sustained rotation
25yo F exercise physiologist w PMH of lyme dz and neck/back pain and went to chiropractor for 1st time. Onset of dizziness/lightheadedness 1wk ago secondary to chiropractic C and T manip. No immediate sx, but develop the next day. XR, EKG, and CBC all neg in ED. Virtual appt w PCP suggested PT.
cerv ext reproduce sx
L rotation reproduce, worsen in prolonged
(-) alar, transverse, lateral shear
keeping in mind that avery has been to ER and spoken to PCP, is she currently safe to treat?
no
- in ER just did XR and EKG but those wouldn’t tell you anything
wouldn’t have been looking for this before and might have missed it
what are common locations for pain in UCS paths
base of skull
unilateral
ear/jaw/TMJ pain
HA/ram’s horn pattern
what is commonly injured if the UCS is
TMJ
what are common MOI for UCS path
often insidious, long standing
slept funny
MVA (WAD)
what are MAPS to the pt’s pain
Movements
Activities
Positions
Situations
what are 5 common MAPS for UCS path
computer work
sleeping
looking a phone
turning head
driving
what should be observed during a UCS eval
position of head on neck
reposition in neutral as needed
how should you examine UCS ROM in an eval
cardinal planes (bias upper vs lower Cspine)
pre- flex upper w nose nod, assess lower c spine
pre- flex lower to assess C1/C2
- FRT in supine
regionalization
what is a (+) FRT and what does this indicate
(+) ROM dec by 10deg +
- normal ROM is 44deg
indicate cervicogenic headache w C1/C2 restriction
what is FRT assessing
passive full cervical flex then rotation
- how much C1 rotates on C2 (should be ~1/2 of cervical rotation from this segment)
what ms have a large influence on how the upper cspine moves
upper trap
levator scap
SCMS
superficial ms are prime movers
what are the 4 main deep neck flexors
rectus capitis lateralis
rectus capitis anterior
longus capitis
longus colli
what are the functions of deep neck flexors
maintain stability and position
endurance ms
not prime movers
norm for CCFT
24-28mmHg
what compensation do you look for during the neck flexor endurance test
see engaged SCM - extends UCS and flexes lower cspine
- upper cervical flexors fight this
function of rectus capitus posterior major and minor
head ext and ipsilateral rotation
functions of obliquus capitus superior
head ext and side bending
functions of obliquus capitus inferior
ipsilateral head on neck rotation
what was noted in a muscle control assessment for pts w neck pain
inc activation of superficial neck extensors (ie upper traps, levator scap) and delayed activity in deep neck extensors (ie semispinalis cervicis, multifidi)
what was noted in motor control of pts w post-concussional HAs
overactive superficial ms, acting tonically
what was noted in motor control in WAD
dec deep cervical ms tonic hold
- poor patterning, dec kinesthesia, and proprioception
what is a compensation for scapular winging
use upper trap which creates upper cervical extension
what is the significance of extra upper trap activity
impacts c spine bc of attachments
what are (+) findings of scapular dyskinesis
winging
loss/lack of control when lifting
loss/lack of control when lowering
scapular asymmetry
what are the 4 main UCS dx
neck pain w mobility deficits
wry neck (acute facet lock) / torticollis
cervicogenic HA
concussion
what does wry neck deformity describe
posture
what are other terms for wry neck deformity
acute facet joint lock
acquired torticollis
what will the pt complain of if they have a wry neck deformity
neck pain/stiffness w loss of ROM
- often accompanies by spasm of surrounding ms (UT or SCM)
what are the 4 types of acquired torticollis
traumatic micro induced
sudden onset/acute
muscular
post viral
traumatic micro induced acquired torticollis: common pt pop, sx, treatment and resolution
young hypermobile females
motor control deficit
several episodes quickly resolve
restore ROM, address MC
sudden onset/acute acquired torticollis: MOI, treatment and resolution
facet or disc dysfunction that created inflammatory response
facet: restore ROM, address MC
disc: no manip, soft collar 2-3 days
self resolve 1-2 weeks, PT speeds up process
muscular acquired torticollis: MOI, treatment
spasm SCM and stuck is SCM ms action: lat flex and contralateral rotation
STM, ms lengthening, functional adapt, ROM
post viral acquired torticollis: pt pop/MOI, treatment
spontaneous onset in child or adolescent after URI causing temp insufficiency of UCS ligaments
manual therapy contraindicated
what are wry neck deformities that should be referred and what are examples
if no ms involvement, concern for CNS/PNS signs
spasmodic torticollis
drug induced
hysterical
what is spasmodic torticollis
neurological conditions w or w/o a tick, can be transient
what might cause drug induced torticollis
antipsychotics
what is hysterical torticollis
psychological
no objective signs
what are 8 research informed UCS interventions
- modify function at work, ergonomics
- change ROM disturbances
- address motor control deficit (feed forward mech)
- sensory motor function
- change pain processing
- psychosocial distress
- sensory motor processing
- multimodal approach
what are the 3 main ways to change ROM disturbances in UCS
joint mob
traction
ms length
how can you address motor control deficits in UCS
change patterning
how can you intervene on sensory motor function in UCS (3)
joint position sense
balance response
endurance and strength deficits
what intervention is the “low hanging fruit” for UCS
ergonomics
what is the ideal sitting posture and why
hip above knee to get slight lumbar ext and then put thoracic and cervical spines in neutral
if you flex lumbar spine, flexes thoracic and ext cspine
why is thoracic spine an important thing to address when addressing cervical spine
if thoracic segments not moving well, inc work thru cspine
typical initial prescription and the progression for joint mobs in UCS
initial:
5-10 reps, 3-5 hold, grade 2-4
progression:
10-15reps, 3-10hold, grade 4
what are 6 things that the joint mob prescription depends on
pt tolerance in moment
pt tolerance after treatment
chronicity of mobility deficits
hx w manual therapy
grade of mobility deficits
pt psychosocial factors/beliefs
what does a feed forward mechanism have to do with motor control interventions
anticipatory/automatic ms that brace for movement
w pain and loss of activity, motor planning has been altered and changed
- start by doing them in isolation and then function
what are 3 components to interventions to change motor control patterns/progressions
- patterning in isolation then co-contraction
- endurance strength and function
- retrain normal movement patterns (ROM)
as a rule, for pts who sx are more irritated, what type of exercises are good to strengthen DNE or DNF
isometric
what should be integrated w sensory motor function
strength and endurance training
if you at retraining sensory motor function, what feedback to do you give for joint position sense
external cue for cervical position
what type of intervention is used to treat sensory motor function
cervical kineasthetic treatment
what is a common piece of equipment used when improving motor control
laser on head
what is it important to educate the patient on
to change pain processing and psychosocial distress
- address fear avoidance
- desensitize movement
*importance of aerobic exercise
