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Ortho PT Residency Trimester 1 > Adv Cervical Spine I: Examination and Evaluation > Flashcards

Adv Cervical Spine I: Examination and Evaluation Flashcards

1
Q

What are risk factors for atraumatic neck pain?

A
  • female sex
  • prior hx of neck pain (50-85% experience recurrent neck pain within 1-5 yrs of an episode)
  • potentially: older age, higher job demands, hx of smoking, low social support, prior hx of LBP, stress & anxiety

-older age and hx of other MSK disorders predicted greater chronicity

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2
Q

What’s the prognosis for atraumatic neck pain?

A
  • younger people have better prognosis
  • poorer health with a modest effect on prognosis
  • initial evidence suggests: general exercise at baseline is NOT related to prognosis, but one study suggests regular cycling may WORSEN prognosis
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3
Q

What are WORSE prognoses linked to for for atraumatic neck pain?

A

worse prognosis linked to:

-poor psychological health

-lower social support and passive coping strategies

-low workplace control decision making

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4
Q

What’s the prognosis for cervical radiculopathy?

A

favorable outcome usually regardless of intervention

  • 75-90% good improvement w/o surgery
  • pain, sensory deficit, and OBJECTIVE WEAKNESS used as decision to operate
  • no clear evidence of better long-term outcomes with any intervention though specific populations may benefit from surgery
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5
Q

What’s the prognosis for TRAUMATIC neck pain (WAD/whiplash associated disorder)?

A
  1. 42% mild problems with rapid recovery
  2. 40% moderate problems with incomplete recovery
  3. 17% severe problems without recovery

-trajectory not impacted by collision factors

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6
Q

What’s the prognosis for CHRONICITY of traumatic neck pain?

A

Within 6 weeks of trauma, 5 factors predict chronicity of pain:

  1. Pain intensity >6/10 (pain severity)
  2. NDI >30% (disability/function)
  3. Pain catastrophizing scale >20 (pain catastrophizing)
  4. Impact of Events Scale - Revised > 20 (post-traumatic stress response)
  5. Cold hyperalgesia (multiple ways of assessing)
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7
Q

What’s the prognosis for chronic disability in WAD?

A

Predictors of chronic disability in WAD are:
- high level of baseline disability
- self reported psychological distress
- passive coping strategies
- predicted recovery >6 months
- 6+ physical symptom complaints (e.g. pain, numbness, head feels heavy, dizziness, etc)

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8
Q

What’s the primary movement of the O-C1 joint?

A

craniocervical flexion (nod)

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9
Q

What’s the primary movement of the C1-C2 joint?

A

mainly cervical rotation

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10
Q

What’s the coupled motion in the lower cervical spine?

A

C/S sidebend and ipsilateral rotation
- this closes the intervertebral foramen and extends (closes) the facet joint

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11
Q

How do you test the facet jt?

A

with uncoupled motion- this takes away (opens) the intervertebral foramen. will feel stiff b/c it’s not the normal mechanics
ex: sidebending and contralateral rotation

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12
Q

What anatomical variation of the cervical spine are children born with?

A

Children are born w/o uncinate processes and uncovertebral joints until ~9 years old

uncovertebral jts are distinct by ~33 y/o

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13
Q

What percentage of asymptomatic people age 65+ have cervical DJD?

A

57%
- evidence of DJD on imaging doesn’t equal pain

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14
Q

If imaging shows DJD/OA in people age <20, is this normal, and what would you suspect?

A

Abnormal. Suspect trauma (e.g. sports, child abuse, landing on head [gymnastics], sports that involve falling].
Or there could be hypermobility (EDS, Down Syndrome)

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15
Q

Does pathology on imaging equal presence of pain or pain source?

A

no

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16
Q

what are pathoanatomical diagnoses related to neck pain?

A

-degenerative disc disease (DDD)
-degenerative joint disease (DJD, arthropathy)
-spinal stenosis (Central/foraminal)
-disc disruption/herniation (HNP)
-sprain/strain (WAD)
-spondylolisthesis
-radiculopathy
-myofascial pain
-instability
-fracture
-myelopathy
-infection
-vascular conditions
-malignancy
-inflammatory spondyloarthropathies
-autoimmune conditions
-more…

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17
Q

2017 Neck CPG Revision categories // ICF classifications include:

A
  • neck pain with mobility deficits
  • neck pain with movement coordination impairments (WAD)
  • neck pain with radiating pain
  • neck pain with cervicogenic headache
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18
Q

What are the steps to a PT exam for neck pain?

A
  1. Medical Screening. Treat, Refer & Treat, or Refer?
  2. Classify patient according to ICF model
  3. Determine stage (acute, subacute, chronic)
  4. Select treatment aligned with ICF classification
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19
Q

what are red flags?

A

signs and sxs associated with increased likelihood of serious pathology, MSK or non-MSK

-clusters of red flags are more useful than single red flags

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20
Q

Screening tool for red flag

A

Optimal Screening for Prediction of REferral and Outcome– Review of Systems (OSPRO)

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21
Q

what are yellow flags?

A

psychosocial risk factors for the dvlpmt of chronic pain (related outcome measure if available)

  • Fear avoidance (FABQ)
  • myths about condition or activity
  • Pain catastrophizing (Pain Catastrophizing Scale)
  • Hypervigilance (Impact of Event Scale–Revised)
  • Depression (PHQ-2)
  • Social withdrawal
  • Self-efficacy

yellow flags more strongly assoc. w/ a patient’s outcome than physical factors

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22
Q

validated tool for helping with prognosis of pts with chronic LBP?

A

OSPRO-yellow flag

-helps assess psychosocial factors

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23
Q

what are orange flags?

A

psychosocial sxs that are consistent with psychological or psychiatric condition

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24
Q

what are blue flags?

A

related to those injured on the job- negative perception of work or effect of work on sxs can impair return to work

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25
Q

what are black flags?

A

the context of the person’s condition
- cultural factors
- economic factors
- healthcare policy in the region
- reimbursement
- professional culture

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26
Q

Urgent/ Emergent conditions

A

Can mimic mechanical neck pain or common cervical conditions (many of them affect MSK structures or are affected by activity/position)

-to not miss these, cluster red flag sxs and pay attention when a patient is NOT IMPROVING the way you expect

-REFER OUT

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27
Q

Urgent/Emergent Conditions include:

A

Fracture, vascular pathology, ligamentous instability, malignancy, referred pain from organs, infection

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28
Q

what are screening guidelines for fractures in the neck?

A

Canadian C-Spine Rules (SN: 99.4%, may be better for elderly population)

Nexus Criteria (SN 99.6%): for acute trauma, alert patients, fx, dislocation, ligamentous instability

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29
Q

What X-ray views should be taken for C/S fracture?

A

AP, lateral, odontoid (open mouth) views

Flexion/extension radiographs no longer recommended d/t inadequacy of imaging instability

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30
Q

Canadian C-spine rule

A

know it. can’t get picture on here

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31
Q

Canadian C-spine rule: what are high risk factors? what does it mean if the patient has one?

A

High risk factors: any of the following
- age 65+
- dangerous mechanism
-paresthesias in extremities

if pt has any of the above, this could mean a possible spine injury

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32
Q

what is a dangerous mechanism from the Canadian C-spine rule?

A

Dangerous mechanism:
fall from 3+ feet or 5 stairs
- axial load to head
- MVA high speed (>62mph or >100km/hr) rollover, ejection
- bike struck or collision
-motorized recreational vehicles

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33
Q

What are LOW risk factors of canadian c-spine rule?

A

low risk factors: any of the following
- simple rear-end MVA
-ambulatory at any time
-delayed onset of neck pain
-absence of midline C-spine tenderness

**simple rear-end MVA EXCLUDES:
- pushed into oncoming traffic
-hit by bus/large truck
-rollover
-hit by high speed vehicle

If patient does not have LOW risk factors, this could mean possible spine injury.
If patient DOES have LOW risk factors, move onto C/S rotation AROM

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34
Q

canadian c-spine rule: if patient has low risk factors and cannot rotate their neck actively 45 degrees left or right, what does this mean?

A

possible spine injury

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35
Q

canadian c-spine rule: if pt has low risk factors, and they can rotate neck actively 45 deg to the left and right, what does this mean?

A

no spine injury

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36
Q

you can’t apply the canadian c-spine rule if:

A

-pt is not awake, alert, and reliable
-unstable vital signs
- <16 years old
- acute paralysis
- known vertebral disease
- previous C-spine surgery

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37
Q

Nexus Criteria for Fracture: trauma patients who DON’T require C/S imaging require ALL of the following:

A

-alert and stable
-NO focal neurologic deficit
-no altered level of consciousness
-not intoxicated
-no midline spinal tenderness
-no distracting injury

38
Q

what are some vascular pathologies in the neck?

A

Arterial:
-VBI (vertebrobasilar insufficiency)
-vertebrobasilar artery dissection
- internal carotid artery dissection
- arteritis (inflammation of an artery)

39
Q

how to neck vascular pathologies present?

A

-neck pain, headache, often unilateral and/or suboccipital
- ACUTE ONSET, insidious or traumatic
- distinct pain w/o specific features, NOT EXPERIENCED BEFORE, can be severe/sharp
- complains of stiffness w/o loss of motion
- onset of sxs to ischemia can be hours to 2 wks
- may have neuro involvement depending on the affected artery (–> check cranial nerves)

40
Q

pain presentations associated w/ vertebral artery pathologies:

A

forehead, right cheek, posterolateral left and posterolateral right neck/suboccipital area

41
Q

pain presentation with carotid artery pathologies:

A

forehead, eyes, middle of the cranium (top of head), suboccipital area, posterolateral left and posterolateral right neck

42
Q

other presentations of vascular pathology (5 D’s, 3 N’s, 1A)

A

Dizziness
Drop attacks
Dysarthria
Dysphagia
Diplopia
Nausea (often w/o vomit)
Numbness (facial and less often limbs)
Nystagmus
ATAXIA/unsteadiness (most common!)

-limb weakness: less common

43
Q

Vascular pathology: common neuro features

A

-ipsilateral Horner’s syndrome
-ipsi limb ataxia
-gait ataxia
-ipsi sensory abnormalities (CN V); most commony loss of pain/temp; diminished/absent corneal reflex
-ipsi CN IX-XII abnormalities
-nystagmus (cerebellar/vestibular)
-possible CN VII deficit
-possible pyramidal signs
-most clinical features are related to Wallenberg Syndrome (posterior inferior cerebellar artery)

44
Q

signs of VBA dissection

A

**unsteadiness, ataxia (most frequent)
dysphagia, dysarthria, aphasia
lower limb weakness
upper limb weakness
nausea, vomiting
facial palsy
dizziness, loss of equilibrium
loss of consciousness

45
Q

signs of internal carotid artery dissection

A

**ptosis (eyelid droop)- most common
**upper limb weakness
**facial palsy (entire half of face)
lower limb weakness
dysphagia, dysarthria, aphasia
unsteadiness, ataxia
nausea, vomiting
loss of consciousness

46
Q

individual risk factors for vascular pathology include:

A

HLD, hx of smoking, HTN, recent trauma or infection of the head/neck (including respiratory), CAD/atherosclerosis

look for clusters of these risk factors

47
Q

physical exam components for vascular pathology?

A

-blood pressure
-palpate internal carotid artery
-auscultate ICA
-no longer recommended to do positional/provocative testing (e.g. vertebral artery test) due to poor validity
-neuro screen (CN, gait/balance)

48
Q

causes of C/S Ligamentous Instability

A

-insufficiency or injury to the cervical ligaments, particularly upper cervical
- trauma (collisions, concern for transverse and posterior AO ligaments)
-repetitive microtrauma
-congenital (Down Syndrome, EDS type III)
-related to disease process (RA, SLE, Reiter’s, ankylosing spondylitis, Grisel’s syndrome) or prolonged corticosteroid use

49
Q

Signs/sxs of C/S ligamentous instability

A

-Headaches
-Severe suboccipital or other muscle spasm
-Fear/anxiety/apprehension with head motion
-Neuro signs related to the spinal cord or brain stem. Can be constant, absent, or transient

50
Q

C/S ligamentous instability tests:

A

-sharp-purser
-alar ligament test
-anterior shear test
-distraction test
-neuro screen including UMN testing (Babinski, Hoffman)
- caution w/ segmental mobility assessment and PROM

51
Q

Malignancy screen: another urgent/emergent condition

A

-previous hx of cancer
-unexplained weight loss
-failure to improve after 1 month
- age>50 y/o
- no relief with bed-rest

note: neck pain is the MOST common sx assoc. w/ cancers of the head and neck. can also see sore throat, dysphagia, tinnitus

52
Q

Referred pain from organs to the neck

A

Neck pain referred from: lung, diaphragm, spleen, liver conditions

Lower neck/upper back pain referred from thymus gland issues

neck pain referred from: lymph node inflammation, thyroid, esophageal conditions

Anterior C/S pain are sometimes referred from the heart and ascending aorta

53
Q

Infections causing neck pain include:

A

-Meningitis (septic or aseptic); it presents as neck pain and stiffness [worse w/ flexion and rotation]. assoc w/ signs of infection and neuro involvement
- tests for meningitis: Kernig’s and Brudzinski’s signs

-osteomyelitis
-Abscess
-more. screen for red flags assoc w/ infection + patient not improving

54
Q

Zorse conditions: refer and (maybe) treat

A

Concussion, Myelopathy, Rhematological conditions (RA, SLE, fibromyalgia, polymyalgia rheumatica, more)

55
Q

What’s the most common cause of myelopathy?

A

spondylosis. myelopathy is a spinal cord pathology

56
Q

what are signs and sxs of myelopathy?

A

-bowel /bladder urgency, incontinence
-balance issues/ataxia
-fine motor/coordination deficits
-bilateral presentation in limbs. if cervical, may affect all 4 limbs

57
Q

what’s the recommended diagnostic cluster for myelopathy?

A

-gait deviation
- (+) Hoffman’s sign
- (+) inverted supinator sign
- (+) Babinski’s sign
- Age >45 yrs

having >3/5 variables = 94-99% post-test probability

58
Q

what are red flags for rheumatological conditions?

A

-Insidious onset,
-no relief with rest,
-improvement with
-activity/exercise,
-waking up due to pain -during 2nd half of the night,
-morning stiffness >30 min
-age <40

59
Q

what are common conditions seen in the clinic (horses)?

A

DDD, DJD, Spondylolisthesis, spinal stenosis, disc disruptions and herniations, radiculopathy, TOS, sprain/strain (includes whiplash), myofascial pain, cervical dystonia, referred pain from other joints

60
Q

what is degenerative disc disease (DDD)?

A

-anatomic/structural changes within an intervertebral disc (IVD) causing a loss of function
-occurs naturally with aging, not always assoc. w/ pain

-loss of H2O content in nucleus and decreased disc height –> decreased space at intervertebral foramen + increased stress at facet jts –> higher potential for DJD and radiculopathy

61
Q

what is DJD?

A

facet osteoarthritis (DJD)
-involves facet arthropathy and osteophytosis, can develop due to DDD
-pain is thought to be d/t cartilage destruction and decreased joint space
-pain can be local or referred to the proximal upper quarter

OA pattern: stiff in AM and after a period of immobility; worse pain in AM -> better midday-> worse by end of day

62
Q

what is spondylolisthesis

A

slippage of one vertebra on another
-degenerative: most common type, due to DDD/DJD
-often presents with sxs of spinal stenosis/radicular or myelopathic sxs

-slippage can be anterolisthesis or retrolisthesis

other types: traumatic, iatrogenic, congenital

63
Q

what is the grading for spondylolisthesis?

A

Grade 1: -25% slippage
Grade 2: 25-50%
Grade 3: 50-75%
Grade 4: 75-100%
Over 100% is Spondyloptosis, when the vertebra completely falls off the supporting vertebra

64
Q

what is spinal stenosis? what is it typically caused by?

A

spinal stenosis= clinical diagnosis (Vs. only radiological finding) involving symptomatic narrowing of the spinal canal or intervertebral foramen causing pain and/or neuro sxs in the extremities

-typically caused by spondylosis (DDD/DJD with ligamentum flavum hypertrophy) or spondylolisthesis
-some ppl are born with narrow spinal canals

65
Q

what is the incidence for disc herniations (asymptomatic, protrusion, and extrusion)

A

asymptomatic bulge 61.3%
protrusion 46.3%
extrusion 31/7%

66
Q

imaging evidence of healing from disc disruption and herniation occurs within :

A

2-40 months

67
Q

does a more severe disc injury (sequestration and extrusion vs. protrusion and bulge) have a greater or lesser likelihood of healing?

A

greater likelihood of healing with a more severe injury

68
Q

imaging does or does not always correlate with clinical outcome

A

does not

69
Q

what is radiculopathy?

A

nerve root compression leading to RADICULAR sxs – pain/paresthesia in a dermatomal pattern, myotomal (fatiguable), weakness, hyporeflexia, usually unilateral

70
Q

what are potential causes of radiculopathy?

A

disc herniation, foraminal stenosis

71
Q

what is thoracic outlet syndrome (TOS)?

A

Lateral neck pain radiating into the distal UE particularly medially (C8/T1/ ulnar nerve distribution)

-can be neurogenic TOS or vascular TOS (rare)

72
Q

what can TOS be caused by?

A
  • 1st rib elevation
  • scalene tightness/spasm
  • pec minor tightness
  • anterior shoulder laxity/instability
  • possible weakness in intrinsic hand muscles
73
Q

what is the clinical presentation of a cervical sprain (ligament) or strain (muscle), including whiplash?

A

pain, muscle spasm, edema, increased temperature of local tissue

-can have pain radiating into the proximal upper quarter
-pain increase w/ muscle contraction or stretch of the affected tissue

74
Q

what is cervical myofascial pain?

A

Persistent regional neck pain w/ trigger points.
-think of common muscles w/ trigger points

-often limited in ROM
-trigger pts can refer pain to the upper quarter

75
Q

what is cervical dystonia?

A

SCM causing pain due to spasm or spasticity

-presents as anterior/lateral neck pain, often with rotated/tilted position of the head
-painful form of torticollis

76
Q

what other joints can refer pain into the neck?

A

TMJ, shoulder, thoracic spine

77
Q

what are some recommended patient recorded outcome measures for neck pain?

A

NDI (validated in many languages);
PSFS;
McGill Pain Questionnaire; Oswestry for axial pain;
outcome measures for yellow flags;
consider using Radar plot for pain domains

78
Q

characteristics of Neck Pain with Mobility Deficits

A

-primarily motion limitations in cervicothoracic spine related to joint or muscle stiffness
-NO radiating pain or trauma, likely cntral or unilateral cervical pain that pay or may not refer to shoulder and upper quarter but NOT into the distal UE. should have (-) neuro screen.

-sxs usually elicited by A/PROM and/or segmental testing (PAIVMs, PPIVMs, up/downglides, lateral glides)

-may have weak neck and scapular muscles if condition is subacute or chronic

79
Q

what’s a helpful special test for neck pain with mobility deficits?

A

cervical rotation lateral flexion (CRLF)

(if 1st rib is elevated, it’ll feel stiffer/blocked)

-The test is performed with the patient in a sitting.
-The cervical spine is passively and maximally rotated away from the side being tested.
-While maintaining this position, the spine is gently flexed as far as possible moving the ear toward the chest.
-A test is considered positive when the lateral flexion movement is blocked.

80
Q

what are characeristics of Neck pain with movement coordination impairments?

A

-whiplash or traumatic onset
-pain primarily related to motor control issues

-neck pain, shoulder girdle pain or referred UE pain, dizziness, nausea, concussive sxs, HA, difficulty concentrating, light sensitivity, heightened affective distress, general hypersensitivity to stimuli

-reduced mm recruitment in C/S and shoulder girdle, degeneration of posterior cervical mm; proprioceptive deficits, sensory hypersensitivity or reduced pain thresholds, psychosocial disturbances– depression, anxiety, fear of mvmt

81
Q

What are helpful special tests for neck pain with movement coordination impairments?

A
  1. craniocervical flexion test (the one with the BP cuff),
  2. neck flexor muscle endurance test (chin tuck + lifting head up an inch, then holding),
  3. pressure pain threshold (uses a digital pressure algometer)
    –use for allodynia or hyperalgesia, central sensitization
    –lower thresholds locally -> local mechanical sensitivity
    –widespread lower thresholds -> suggest central nociceptive processing disorder [central sensitization]
82
Q

What is the norm for the neck flexor muscle endurance test for people with neck pain, and people without neck pain?

A

Norm for ppl w/ neck pain: 24.1 sec
Norm for ppl w/o neck pain: 38.95 sec

83
Q

What are characteristics of neck pain with cervicogenic headache?

A

-Intermittent, UNILATERAL “ram’s horn” presentation from occiput to temporal region

-related to changes in mvmt of the neck and jaw
-Present with ROM DEFICITS, painful/ HYPOMOBILE segmental mobility of UPPER 3 cervical segments, weakness or impaired coordination of DNF’s

84
Q

What’s the diagnostic cluster for neck pain with cervicogenic HA?

A

-Decreased cervical AROM
-Impaired craniocervical flexion test
-Provocative and/or hypomobile PAs Occiput-C3

85
Q

What’s a helpful special test for diagnosing neck pain with cervicogenic headache?

A

cervical flexion-rotation test (highest specificity)

-pt is supine
-you flex their neck (hold with your hands & belly)
-rotate to one side, then the other
-inclinometer/goni to measure

86
Q

What’s a positive cervical flexion rotation test?

A

either < 32 deg of rotation, or a 10 degree reduction when comparing side to side

-note: if ROM >45, pt likely came out of flexion or started to sidebend

87
Q

What are characteristics of neck pain with radiating pain?

A

Pain or parethesias that radiate to DISTAL UE or medial scapular border

-neuro screen (DTRs, myotomes, dermatomes C5-T1): not great at determining location of disc herniation, but tells us if there’s generally a nerve root compromise

-Valsalva maneuver (increased sxs with cough/sneeze)

88
Q

what’s the diagnostic cluster for neck pain with radiating pain?

A

-Cervical rotation <60 deg on affected side (specific)
- (+) ULTTa (most sensitive)
- Positive Spurling’s (specific)
- Positive distraction (specific)

  • 4 of 4 = 90% post-test probability
  • 3 of 4 = 65% post-test probability
89
Q

describe/practice the ULTTa. what is a positive test?

A
  1. prevent scapular elevation (block it)
  2. shoulder ABD 90 deg + elbow flexion
  3. forearm supination, wrist and fingers extension
  4. shoulder ER
  5. elbow extension
  6. contralateral and then ipsilateral sidebending of neck

Positive test:
1. reproduce sxs
2. side to side difference >or = 10 deg in elbow or wrist
3. contralateral SBing increases sxs
4. ipsi SBing decreases sxs

90
Q
A

Ortho PT Residency Trimester 1 (3 decks)

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