2. C/S Examination Flashcards
Neck pain may be assoc’d w/….
HAs
LBP
Hx of MVA
*2nd most common reason for referral to PT, w/ neck pain making up 25% of pts seen for tx
Symptoms of CS Dysfunction
- Neck pain
- HAs (cervicogenic)
- Upper thoracic/scap pain
- TMJ/craniofacial pain
- UE pain (separate card)
- radicular vs referred
- UE neurologic sx’s
- parasthesias, numbness, reflex changes, weakness
- Balance, auditory, visual disturbs
- Cervical myelopathy
- Vert aa occlusion
- Vestib dysf
Sx’ of CS Dysf
UE Pain
Elaborate…
- Radicular→ along dermatome; due to compression/irritation of nerve root
-
Referred→ somatic referral into UE from various cervical tissues
- joints, ligs, mm’s
Interventions for CS
- Evidence lacking
- High degree of variation of tx strategies= high degree uncertainty about optimal tx
- Pts w/ neck pain lag behind LBP and knee pain in response to PT
- Pathoanatomic source of neck pain cannot be ID’d in the majority of pts
Basic Exam for Pts w/ Neck Pain
Always what?
ALWAYS take thorough hx
ALWAYS have pt compete SRO tool
Basic Exam for Pts w/ Neck Pain
Do more, less, enough of what?
- LESS→ in pts w/ high irritability/acute inj
- avoid irritating pt or worsening patho or injury
- MORE→ in pts w/ low irritability/subacute/chronic
- ENOUGH→ to make a sound tx decision and classify into subgroup
More on Exam for pts w/ Neck Pain
- Do high lvl functional testing as pts are improving any and may be ready for return to sport or work
- sport specific, work-related functional tasks
- GOAL: By end of exam, be able to classify into subgroup!!
Suggested Order of Examination for Neck Pain
see pics
Exam: Hx
Start by asking Gen questions about injury/problem, then proceed down list
see pics
More questions to ask!!
see pics
Self Reported Outcome tools for CS region
Global Rating of Change Scale
*can be used for any region of body
see pics
More SROs for Neck Pain
PSFS
NDI (see pics)
- NDI
- We want LOW, LOW=LESS disability
- MDC= 5/50 for uncomplicated neck pain; 10/50 for radiculopathy
- NOTE: double value if using % score
- MDC= 5/50 for uncomplicated neck pain; 10/50 for radiculopathy
- We want LOW, LOW=LESS disability
MacDermid et al 2009
NDI
Takeaways
- NDI is reliable, valid and responsive
- Scored out of 50
- 40-50, or 0-10= approaching ceiling/floor effect
- Score outside 10-to-40 range→ supplement w/ PSFS
- 0-4=no disability
- 5-14=mild
- 15-24=moderate
- 25-34=severe
- >35=complete disability
Ex. NDI
Upon initial exam, Sachiko’s NDI score was 20/50 and weeks later is 16/50. Can you confidently say based on this info her disability has lessened?
NO!!!
does NOT meet MDC
UQ Neuro Screen
Myotomes
- C1-2→ cervical flexion
- C3→ cervical LF
- C2-C3-C4→ shoulder elevation
- C5→ shoulder ABD
- C6→ forearm PRO
- C5-C6→ elbow flex
- C6→ wrist ext
- C7→ elbow ext/wrist flex
- C8→ thumb extension (thumb for thumb)
- C8→ gen. grip (mult mm’s/lvls but mostly C8)
- T1→ hand intrinsics→ Abd Digiti Minimi
UQ Neuro Screen
Dermatomes
*pts eyes closed, light brushing over dermatomes B/L
- C2,3→ post neck
- C4→ AC jt
- C5→ lat aspect of upper arm
- C6→ lat aspect forearm, hand; thumb, index finger (D1/D2)
- C7→ middle finger (D3)
- C8→ ring/little finger (D4/D5); medial aspect of hand/wrist
- T1→ medial forearm
- T2→ medial arm, axilla forearm
*NOTE: in general, derms in UE overlap. This is why radiculopathies typ may cause PARTIAL NUMBNESS or PARASTHESIAS, but are unlikely to result in complete anasthesia
UQ Neuro Screen
DTRs
- C5, 6→ Biceps
- C6→ Brachioradialis
- C7→ Triceps
See pics for scoring
Patho Reflexes for Upper Motor Neuron Lesions/Myelopathy
Hoffman’s Sign
see pics
Pathological Reflexes for UMN Lesions/Myelopathy
Babinksi’s
see pics
Peripheral Joint Screening:
Look for symptom repro/aggravation and/or limtd or abnormal motion
- Cursory assess of UE function→ forms, remove shirt/coat, reaching OH
- Cursory observation and inspection of UE jts
- Shoulder/Elbow→ Apley Scratch Tests; reach overhead
- Wrist/Hand→ Grip test; wrist/finger AROM
Observation/Inspection
Posture
- FHP? If yes, can they reverse it?
- Torticollis? Acute wry neck (adult version of torticollis)
- Scapular pos (protracted? elevated?)
- Cervicothoracic junction (C7-T1)→ Dowager’s Hump?
- T-spine
- Kyphosis normal, flattened, excessive?
- scoliosis? rib hump?
Mvmt Patterns & ROM Testing
- Includes:
- Cervical AROM testing
- *Keep order consistent bc any 1 mvmt can influence ROM of mvmt that follows!
see pics for instructions
Mvmt Patterns & ROM Testing
Recommended Order of Testing:
- L. rotation
- R. rotation
- EXT
- FLEX
- L L/F
- R L/F
Passive ROM: 2 options
- Apply manual overpressure to single AROM mvmts
- Perform w/ pt in Supine to eliminate mm tension and assess mobility of spine
Differentiation of “Intrinsic” vs. “Extrinsic” Cervical ROM restrictions
Cross-arm Cervical ROM test
*If no longer restricted w/ arms up= mm tension
*If still restricted w/ arms up= CS issue
Cervical Passive Interverterbral Mvmts (PIVM)
- Record as normal, hypOmobile, hypERmobile
- Record as painful or not
- Perform in following order:
- O-A jt→ lateral glide
- Mid and Lower cervical segment lateral glides
- NOTE the diff in mobility and pain response bw sides
Mid and Lower Cervical Segment Lateral Glides
- PT uses abdomen to exert constant gentle stabilizing pressure against apex of pts head; force applied w/ therapists 2nd MC head to “push” pts articular pillar @ the desired lvl (or you can reach underneath and pull)
- PT glides ea segment starting @ C2 and ending @ C6 L then R
- Diff in mobility and pain response bw sides noted @ ea segment
P-A glide (Spring Tests) on Cervical Spine
- Pressure applied B/L (P-A) glide
- Pressure applied U/L (just off side to SP) to assess segmental rotation
- Push down on Rt Side of SP== L rotation
- Push down on L Side of SP== R rotation
- uncomfortable
- More comfortable if P-A force directed slighly SUP towards pts eyeballs (along plane of facets jts)
- CS spring tests (P-A) not as commonly used today as in past
These tend to shut down w/ chronic neck pain or inflammatory CS neck pain
DCFM’s!!!!
Testing of the DCFM’s:
Craniocervical Flexion Test
CCFT
- Tests neuromsk control and endurance of the Longus capitis and Longus colli
- Primary functional action is to sustain low int contraction to support Cervical jts during functional acts
- Primary anatomical action is to flex the head on a stable C/S
Craniocervical Flexion Test
- Test Motion: Pt asked to gently and slowly perform head nodding motion as if saying “yes”. If pt able to demonstrate this w/out compensatory mvmts: proceed to steps below
- air filled cuff placed bw occiput and C7 w/ pt in hooklying
- Pts face must be horiz.
Stage 1 vs Stage 2 see pics
Assess of Atlanto-Axial Jt Rotation
w/ pts neck in full passive flexion→ PT rotates pts head L THEN R
*diff in mobility and pain response bw sides noted
Special Tests
Atlanto-Occipital Joint
Alar Lig Stress Test
see pics for description
-
Normal Findings→ Normally, there should be minimal mvmt of the head and C1 into LF
-
When head LF to Right→ C2 rotates to the Right.
- PT will feel SP of C2 move toward Left (R rotation of C2 causes its SP to move to L)
-
When head LF to Left→ C2 rotates to the Left
- PT will feel SP of C2 move to R (L rotation of C2 causes its SP to move to R)
- If you DO NOT feel mvmt of C2 SP→ this suggests instability of the alar lig, very serious (Red Flag) problem
-
When head LF to Right→ C2 rotates to the Right.
- ** You are feeling for ipsilateral rotation of C2— that is what you are palpating w/ this test!!!
Transverse Lig Tests OR Anterior Sheer Test
* RED FLAG if POSITIVE!!!
- INCd parasthesias of B/L upper or lower extrems==> cervical myelopathy and instability of Transverse Lig
Sharp-Purser Test
The “clunk” one
- NOTE: if this test is Positive→ pt likely had an upper CS subluxation of C1 (Atlas) on C2 (Axis) @ rest, i.e. before doing test. Test maneuver actually reduces the subluxation, and thus a “clunk” and/or reduction in sxs is noted. If this test is (+), there is clearly instability/hypERmobility at C1/C2. Referral to spine surgeon or neurosurgeon is indicated, as this is a very serious problem!!!
Vertebral Artery Test → purported to test for vertebrobasilar artery insufficiency (VBI)
*ALWAYS DO THIS TEST JUST TO BE SAFE!!!
Supine or Seated
- VBI: occlusion of blood flow during cervical rotation or extension in the area of junction for vertebral and basilar arteries
- controversy as to if this test is effective in determining VBI
- Although true cases of VBI are rare, ignoring suspicion that a pt has VBI risks causing a catastrophic injury****
Best special tests to detect Cervical Radiculopathy
ALL of them:
- Shoulder ABD test
- Spurling’s Test
- Traction/neck distraction
- ULTT
Best Special Tests to detect Cervical Radiculopathy
HIGH SPECIFICITY/Low to Mod sensitivity: 3
*good for Ruling IN
- Shoulder ABD test
- Spurling’s Test
- Traction/Neck distraction
Best special tests to detect cervical radiculopathy
MOD-HIGH Sensitivity
*good for Ruling OUT
Upper limb tension test (ULTT)
When pts hx and other phys findings indicate possible cervical radiculopathy
These tests Rule IN cervical radiculopathy
*think SpPIN
POSITIVE:
Spurlings
Neck distraction
Shoulder ABD test
When pts hx and other phys findings indicate possible cervical radiculopathy:
This test Rules OUT cervical radiculopathy: 1
*think SnNOUT
NEGATIVE
ULTT
Shoulder ABD test
*cervical radiculopathy test
NOTE: If this test INCs sx’s→ could be brachial plexopathy
- We are looking for RELIEF OF SX’S W/ THIS TEST!!! → puts nerves slack
Spurling’s Test
*cervical radiculopathy
Provocation test ***
can add EXT and Rot towards symptomatic side***
Neck Distraction Test
*cervical radiculopathy
NOTE: if this test INCs sx’s→ could be brachial plexopathy
*We are looking for RELIEF OF Sx’s w/ this test
Upper Limb Neural Tension Test
ULTT
*cervical radiculopathy
Rules OUT (SnNOUT)
Provocation test
We are looking for repro or inc in neck/arm sx’s for this test***
Valsalva’s Maneuver
pt instructed to take a deep breath and hold it while attempting to exhale for 2-3s
*Reproduction or an INC in sx’s==> POSITIVE TEST
Palpation
*soft tissues are palpated for tenderness, repro of sx’s, and/or fibrosis or tightness
- SCM (avoid direct downward pressure)
- Scalenes
- Semispinalis cervicis/capitis
- Splenius capitis (splays)
- Upper traps
- Mid traps
- Lower traps
- Lev scap
- Suboccipitals w/ pt in supine
