C-spine APTA Flashcards
(109 cards)
1
Q
What % of outpatient practice pts are neck pain patients?
A
- ~25%
2
Q
Neck pain occurs at the highest rates in what decade of life?
A
- 5th decade
3
Q
What % of people will have neck pain in their lives?
A
- 22-70%….that’s a stupid range
4
Q
T or F
Men have neck pain more commonly than women.
A
- F
5
Q
What is more common; acute or chronic neck pain?
A
- acute. Chronic is much lower in prevalence (2-11% over a 12 month period, compared to 30-50%)
6
Q
A pt comes in with neck pain. It’s been getting better, but they’re worried that it could come back later. Is this a valid concern?
A
- yes. ~26% will experience recurrence within one year.
7
Q
A pt comes in with neck pain. It’s been taking a while to improve and they still have symptoms after 3 months. Is this expected?
A
- ~30% of neck pain patients will have ongoing symptoms with pain that lasts longer than 6 months
8
Q
T or F;
Economic cost associated with neck pain is 2nd only to low back pain.
A
- T
9
Q
What articulations make up the upper and lower cervical spine?
A
- upper: C0-1, C1-2
- lower: C3-7
10
Q
Which vertebra is the “atlas” and which is the “axis”? Which has the dens?
A
- C1 is atlas
- C2 is axis, and has the dens
11
Q
The vertebral artery branches from the ________ artery, and then becomes the _______ artery after passing through the foramen magnum.
A
- vertebral a. branches from the subclavian a., becoming the basilar a.
12
Q
The alar ligaments connect what to what?
A
- the dens of C2 to the occipital condyles of the cranium
13
Q
What ligaments make up the cruciform ligament? What is its function?
A
- the transverse and longitudinal ligaments
- they cover the dens, attaching C1 and C2, keeping the two vertebrae closely approximated and away from the spinal canal during motion
14
Q
What are the articulations that occur between vertebrae of the lower C-spine?
A
- vertebral bodies
- zygopophyseal joints
- uncovertebral joints
15
Q
What articulations may play a role with degenerative changes in cervical spondylosis?
A
- the uncovertebral joints
16
Q
What does the ligamentum nuchae span?
A
- spinous px of C7 through the occipital protuberance
17
Q
What are 2 functions of the ligamentum nuchae?
A
- limits cervical flexion
- deepens cervical spinous pxs allowing for more muscle attachment
18
Q
What are the 4 short suboccipital muscles of the upper C-spine?
A
- rectus capitus posterior major
- rectus capitus posterior minor
- obliquus capitus inferior
- obliquus capitus superior
19
Q
Where are the attachments of the rectus capitus posterior major and minor? What do they do?
A
- major: spinous px of C2 and lateral portion of nuchal line of occipital bone. It extends and rotates ipsilaterally
- minor: posterior tubercle of atlas and medial inferior nuchal line of occipital bone. Extends the head at the C0-1 joint.
20
Q
What are the attachments of the obliquus capitis inferior and superior? What do they do?
A
- inferior: C2 spinous px to C1 transverse px. Rotates ipsilaterally
- superior: transverse px of C1 and in between the inferior and superior nuchal lines. Ipsilateral extension and rotation.
21
Q
What are the 3-ish small anterior muscles of the upper c-spine?
A
- rectus capitus anterior
- rectus captius lateralis
- some fibers of the longus colli cervicis
22
Q
What are the attachments of the rectus capitus anterior and lateralis? What do they do?
A
- anterior: lateral mass of C1/root of transverse px of C1 and base of occipital bone. Flexes.
- lateralis: transverse px of C1 to the occipital bone. Rotates ipsilaterally.
23
Q
What are the varied actions of the SCM?
A
- unilaterally: rotation contralaterally and side bend ipsilaterally
- bilaterally: extension
- can assist respiration when the head is fixed
24
Q
What are the attachments and actions of the longus capitis?
A
- anterior tubercles of transverse px of C3-6, and inferior surface of basilar part of occipital bone. Flexes, with slight assist for rotation ipsilaterally
25
What are the attachments and actions of the longus colli?
- multiple attachments to bodies and transverse pxs of C3-T3. Flexes and rotates.
26
What are the attachments and actions of the anterior scalene?
- anterior tubercles of transverse px of C3-6 and scalene tubercle/ridge on upper surface of 1st rib
- if neck is fixed, elevates the 1st rib. If rib is fixed, laterally flexes ipsilaterally and rotates contralaterally
27
What are the attachments and actions of the middle scalene?
- posterior tubercles of transverse pxs of C2-7 and upper surface of 1st rib behind subclavian groove.
- if neck is fixed, elevates the 1st rib. If rib is fixed, laterally flexes ipsilaterally and rotates contralaterally (same as anterior scalene)
28
What are the attachments and actions of the posterior scalene?
- posterior tubercles of the transverse pxs of C4-6 and outer surface of the 2nd rib behind the serratus anterior
- if neck is fixed, elevates the 2nd rib. If rib is fixed, laterally flexes ipsilaterally
29
What are the muscles of the anterior lower c-spine? (8)
- SCM, A/M/P scalenes, longus colli, longus capitis, splenius capitis, splenius cervicus
(a couple of these are actually kind of posterior)
30
What are the attachments and actions of the splenius capitis?
- ligamentum nuchae lower half/spinous pxs of C7-T3 to lateral nuchal line and mastoid px
- Bilaterally: extends
- unilaterally: laterally flex and rotate ipsilaterally
31
What are the attachments and actions of the splenius cervicus?
- spinous pxs of T3-6 to the posterior tubercles of C1-3 immediately anterior to the levator scapulae attachment
- Bilaterally: extends
- unilaterally laterally flexes and rotates ipsilaterally
32
Greater occipital neuralgia is associated with nerve compression where?
- the greater occipital nerve (C2) pierces the semispinalis cervicus. If entrapped, it can lead to greater occipital neuralgia.
33
What other muscles have attachments to the C-spine that can alter mechanics? What are their general attachments?
- Upper traps: nuchal line, external occipital protuberance, ligamentum nuchae, spinous px of C7
- levator scap: transverse px of C1-4
- rhomboids minor: ligamentum nuchae and spinous pxs of C7-T1
34
T or F;
There is not consensus about what happens arthrokinematically in the C-spine.
- T
| - weird
35
What are the two models for arthrokinematics of the C-spine?
- When in a neutral position, the upper C-spine will sidebend/rotate in opposite directions. When either flexed or extended, then sidebend and rotation will occur ipsilaterally. Lower C-spine always sidbends/rotates ipsilaterally.
- Other model: lower c-spine sidebend/rotation is ipsilaterally when flexed, opposite when extended.
...I feel like we should know this
36
What are 3 appropriate intake outcome measure forms per this author?
- NDI
- patient-specific functional scale (PSFS)
- Fear-avoidance beliefs questionnaire (FABQ)
37
What questionnaire can be helpful to help screen for medical conditions? What conditions is it designed to help the clinician be aware of the potential for?
What should the clinician do if the pt answers positively to some of the questions?
- Head and Neck Medical Screening Questionnaire
- subarachnoid hemorrhage/stroke
- vertebrobasilar insufficiency
- meningitis
- primary brain tumor
- mild TBI/postconcussion syndrome/subdural hematoma
It's meant as a screen. If they answer yes to some of them, and it can't be ruled out in the clinic, they should get a consult or immediate workup depending on which diagnosis is of concern
38
What is the Neck and Shoulder Screening Questionnaire designed to help with? Which diagnoses are associated?
- screening for:
- cervical fx or ligamentous lesions
- cervical cord lesion
- Pancoast tumor
- septic arthritis (SC joint)
39
T or F;
Zygapophyseal irritation/sources of C-spine pain create pain in predictable patterns.
- T
- One study found a fairly consistent pattern of pain. Use of segmental pain charts to help localize the source of pain was found reliable on another study.
- It's probably worth it to note more precisely where pain is, per pt report.
(This is in the section on NPRS and diagram for intake)
40
T or F;
Diagnosis by a trained manual manipulative therapist can be as accurate as radiologically controlled diagnostic blocks.
- T
| - too early to make assumptions about inter-rater reliability though; this was off of one study, with one therapist.
41
What is the MDC and MCID for the NPRS?
- MDC: 2.1 (minimum amount of change that exceeds measurement error)
- MCID: 1.3 (minimum amount of change that the pts perceive as beneficial)
42
If a pt demonstrates desynchronized pain relationships (e.g., stating 9/10 pain, but not demonstrating being very uncomfortable) what may be the driver?
- should be questioning fear avoidance beliefs/behaviors
43
What is the MDC and MCID for the NDI?
- MDC: 5.0-9.5 points depending on the study. 5 is likely to be standard though; the 9.5 is newer from a larger study
- MCID: 5-10 points. Standard is 10 (20 percentage points).
44
What is the most commonly used self-report measure for cervical pain?
- the NDI
| - has been studied a lot with good reliability
45
What is an advantage of using the PSFS over the NDI?
- the PSFS may be more responsive, as it uses more specific/relevant tasks/actions than the NDI
- There is some research supporting this, with the PSFS likely being a much stronger measure of pt improvement, while the NDI was only a little better than chance
- PSFS also correlates closely with Global Rating of Change Scale and NPRS scores, while the NDI does not.
46
What is the MDC and MCID for the PSFS?
- MDC: 2.1
| - MCID: 2.0
47
T or F;
The FABQ-W (work) and -PA (physical activity) subscales are completely separate. They are treated as essentially separate measures.
- T
48
T or F;
The FABQ-W subscale prognosis is sensitive in identifying pts that may develop prolonged work incapacity.
- T
49
What is the implication of much of the FABQ research for neck pain in general?
- presence of prolonged disability in pts with neck pain is at least partially influenced by fear-avoidance beliefs and nonorganic behavior; higher the fear-avoidance beliefs, the higher the risk of prolonged disability
50
What are the subcategories of neck pain via the ICF model?
- neck pain with mobility deficits
- neck pain with headaches
- neck pain with movement coordination impairments
- neck pain with radiating pain
51
What are the clinical hallmarks of neck pain with mobility deficits?
- age > 50
- acute symptoms (< 12 weeks)
- symptoms isolated to the neck
- restricted cervical ROM
52
What hallmark symptom presentation is associated with the neck pain with mobility deficits category?
- unilateral neck pain
- neck motion limitations
- often linked to a recent unguarded/awkward position or movement
- can have referred UE symptoms
53
What are the body function impairments assocaited with the neck pain with mobility deficits category?
- limited cervical ROM
- neck pain reproduced at end ranges of active AND passive ROM
- restricted cervical and thoracic segmental mobility
- neck and neck-related UE pain reproduced with provocation of the involved cervical or thoracic segments
54
What is a primary concern to rule out prior to treatment for neck pain with mobility deficits?
- since the assumption is that hypomobile segments are causing the symptoms, must ensure that there are no unstable/hypermobile segments that would contraindicate the techniques that one would use to treat the hypomobility
55
A pt comes in with acute unilateral neck pain following a fall, with restricted ROM, otherwise fitting into the category for neck pain with mobility deficits. They also have a hx for a chronic pulmonary condition. What are some further concerns/screening questions that should be taken into account?
- while an awkward position/motion is associated with mobility deficits, the fall increases the potential for fx.
- depending on management for their pulmonary condition, they may be taking corticosteroids chronically, which may increase the risk for fx or ligamentous instability.
- these things need to be cleared out prior to mobs
56
What are 3 diagnoses that may be associated with long term corticosteroid use?
- RA
- systemic lupus erythematosus
- pulmonary conditions
57
What 3 special tests can be used to screen for ligamentous insufficiency?
- Sharp-Purser test
- Alar ligament test
- central AP pressures assessing for midline tenderness and segmental mobility
58
What do the Sharp-Purser and alar ligament tests assess for?
- SP: integrity of the transverse/cruciform ligament at C1-2
- alar: tests the alar ligaments. Stability of the atlanto-occipital junction
59
Describe execution of the Sharp-Purser test.
- pt is seated. Therapist stabilizes the spinous px of the axis (C2), brings the head into 20-30* flexion, and then delivers a translatory force posteriorly at the forehead.
- Positive test is cranial movement without the axis moving. Other positive signs are (1) reproduction of myelopathic symptoms upon the initial flexion, or (2) decrease in symptoms with the posterior force
- Indicative of the atlas subluxing anteriorly. The posterior force reduces the subluxation. Thus, probalby not much force needed
- Negative test is immediate posterior axis movement with posterior force
60
Describe execution of the alar ligament test.
- Pt in supine. Therapist stabilizes C2 spinous px with thumb and index finger, then side bends head to side opposite the stabilizing thumb. Should feel the spinous px immediately move into the thumb (negative test)
- A delay of the spinous px movement is a positive test
- can test the other side without moving hands; essentially the spinous px should immediately move contralateral to the side bend
61
Is the Sharp-Purser test more sensitive or more specific?
- more specific (0.96) than sensitive (0.69)
| - reliability has not been examined
62
What 5 criteria have been found to be associated with a low probability of injury and unlikely to need imaging?
- no midline cervical tenderness
- no focal neurological deficit
- normal alertness
- no intoxication
- no painful or distracting injury
63
In addition to screening for instability, what else should be screened for prior to initiating manual techniques or exercises designed to restore mobility in a pt w/ mobility deficits?
- vertebrobasilar insufficiency
64
T or F;
Current evidence has established a link between risk of vertebrobasilar artery stroke and high-velocity, low amplitude thrust manipulation, compared to primary medical physician care.
- F; it is not linked based on current research
- also, no strong evidence of increased risk of serious adverse events with use of cervical manipulation or mobilization with pts with neck pain
65
T or F;
Current research is unable to support premanipulative cervical artery screening tests ability to accurately identify those at risk.
- T
- Symptoms detected may not be related to blood flow as well
- There are instances where VBI testing has identified pts with abnormal vascular conditions, however there is other evidence that shows that VBI testing is unable to ID at risk pts.
66
What are general signs of VBI? (5)
- tinnitus
- vertigo
- dizziness
- visual-perceptual disturbances
- fainting
67
What % of pts with vertebral artery dissection have c/o head and/or neck pain?
- 90%. Often unilateral and suboccipital.
68
A pt comes in with acute L-sided neck pain, which they haven't ever felt before. They can't think of any thing specific that set it off, but they were painting the ceiling around the time they started to notice it.
Is this concerning for vertebral artery dissection?
- unilateral acute neck pain that is unfamiliar is fairly common with a vert. a. dissection
- often can be associated with trauma or spontaneous; or mild trauma such as painting a ceiling
- however this isn't enough to be really worried; but certainly keeps it in the differential
69
A pt with acute L-sided neck pain describes the pain as fairly dull and generally mild. Additionally, they have a fair amount of restriction with L rotation. Also of note, they have some new tinnitus.
Is this concerning for vert a. dissection?
- the presentation of pain is less consistent. VA dissection is more likely to have severe, sharp pain
- the pain with a clear ROM limitation is also less consistent; would be more concerning of they have normal ROM (or they may be more an instability pt)
- The tinnitus is more concerning. Brainstem ischemia symptoms can occur within hours to 14 days of initial injury.
70
What are the major signs of brainstem ischemia from vertebral basilar insufficiency? (5)
- N/V
- dizziness/giddiness/vertigo/light headedness
- numbness (most often unilateral facial; sometimes UE/trunk)
- Ataxia/unsteadiness of gait (most common)
- Diploplia
71
What is a concern of conducting physical VBI tests?
- the tests themselves may place more strain on the vertebral artery structures than the interventions
- tests in supine to end range rotation and extension are more likely to compromise the VB system than those done in mid-range/neutral positions.
72
What is the most common cause of sudden-onset VBI?
- trauma, specifically:
- high-velocity, flexion-distraction and rotational forces
- may occur during whiplash
73
What tool is recommended for use when assessing thoracic/cervical ROM?
- fluid inclinometer
74
T or F;
Even in instances with severe degenerative changes, pts should still be able to bring their chin to their chest when measuring flexion AROM.
- T
75
When assessing cervical ROM, what else should be done to help inform the exam?
- looking to see what provokes symptoms. If symptoms are not provoked during ROM assessment, then add overpressure for provocation
76
What pt positions are appropriate for segmental mobility assessment?
- prone or supine
77
If only doing one assessment of segmental mobility, what direction should be used? What is being assessed?
- PA glides
| - looking for joint mobility assessment and provocation of symptoms
78
What is the technique and indications from a supine segmental mobility assessment?
- grasp articular pillars and passively extend the segment. Then assess mobility to the L and to the R. If limited going to the L, then considered a "closing" problem on the R, and will expect limitations in extension, R SB, and R rotation.
- Next, passively flex at the segment. Then repeat L and R mobility assessment. If limited to the L, then considered an "opening" problem on the L, and will expect limitations in flexion, R SB, and R rotation
79
With a "closing" problem on the L, what movements would be expected to be restricted?
- extension, L SB, L rotation
80
With an "opening" problem on the L, wha tmovements would be expected to be restricted?
- flexion, R SB, R rotation
81
What muscles are commonly associated with neck mobility deficits due to decreased muscle length? (5)
- pec minor
- pec major
- anterior/middle scalenes
- levator scap/posterior scalene
- upper trap
82
How would one determine if there is pec minor tightness/muscle length issues? What might it be confounded by?
- pt lies in supine. Look at transverse plane. If one shoulder lies more anteriorly, it's indicative of decreased pec minor muscle length.
- May also have pec major tightness, or GH restrictions
83
When assessing for UT muscle length involvement in neck pain, what may create a false positive?
- If the scapula is already in a depressed/downward oriented position, then symptom reproduction may be the result of stretching an already elongated muscle...which probably shouldn't be stretched.
84
What is the general continuum for intervention for neck pain with mobility deficits?
- mobilization/stretching on one end
| - strength, coordination, endurance on the other
85
T or F;
Unilateral PA mobilizations are not appropriate for C-spine intervention. Only central PAs are supported to be effective.
- F; you can/should do both as appropriate
| - However, there's not a lot of peer reviewed literature to support specific unilateral techniques
86
T or F;
Non thrust mobilization is less effective for AROM and pain than a single thrust manipulation.
- T; according to one study.
- However, when comparing nonthrust manipulation to thrust manipulation, there doesn't seem to be a difference. Unsure what they mean by nonthrust manipulation...
87
A pt has heard that thrust manipulation is more effective than mobilizations to treat neck pain, but they can't relax with passive assessment. What can you tell them to give them a rationale that it's ok if they don't get a manip?
- Other evidence shows no difference in speed of recovery for those with acute neck pain
- Also, research hasn't shown a difference in those with subacute or chronic neck pain for pain, disability, or pt satisfaction at short term follow-up
88
T or F;
Thoracic manips are just as effective for treating acute neck pain as cervical manips.
- F; cervical manips are found to have greater improvements in pain and disability
89
What are the benefits of HVLA manips over nonthrust mobilizations for neck pain?
- when both cervical and thoracic manips are conducted, there are better outcomes for:
- pain/disability
- PROM rotation for C1-2
- improved motor performance of deep neck musculature
- This is at 48 hr follow-up, so the benefits are in the short term.
90
What is the current most accepted theory for why there are effects from spinal thrust manipulation?
- acts by stimulating central inhibitory mechanisms from the periaqueductal gray matter
- e.g., neurophysiological changes, not necessarily mechanical changes
91
If C-spine manips are better than T-spine manips, is it still advised to do T-spine manips for neck pain?
- Yes
- C and T-spine manips, with exercise were found to create greater improvements in pain/disability than just the C-spine manips and exercise
92
Is kinesiotape appropriate for neck pain treatment?
- yes; was found to be as effective as cervical manips for pain and disability, although not as much of an effect on ROM
93
Is a treatment plan that just does manips/mobs and doesn't incorporate exercise appropriate for neck pain with mobility deficits?
- not really. Cochrane review in 2004 found that exercise with manual treatment is more effective.
94
What is the CPR that predicts who is likely to derive short-term improvements from cervical manips that has 6 criteria?
How many factors are needed?
- initial scores on NDI of < 11.5
- having B involvement pattern
- not performing sedentary work for > 5 hrs per day
- feeling better when moving the neck
- symptoms not aggravated with extension
- dx of spondylosis without radiculopathy
- 4 of 6 increases likelihood of success from 60% to 89%
95
What is the CPR that predicts who is likely to derive short-term improvements form cervical manips that has 4 criteria?
How many should be present?
- symptom duration < 38 days
- positive expectation that cervical manips will help
- side-to-side difference in rotation ROM >/= 10*
- pain with posteroanterior spring testing of the middle cervical spine
- 3-4 is probably the best predictor (95% or >). With 2, the % for success was 68%
96
A pt asks why he should come to PT as opposed to just getting care from his PCP. What support is there?
- manual therapy has been shown to be more effective in the short term (7 weeks) than PCP care, and to a lesser extent, than exercise from PT.
- in the long-term (13 weeks and >) it doesn't seem to matter.
- Bottom line is that pts are likely to see increased rates of progress with PT
97
T or F;
Cervical manips have been found to be effective at treating lateral epicondylitis.
- T. Weird.
- Effects are likely due to the changes in central inhibition of pain
- essentially shorted the number of visits required
98
T or F;
High force (90N) mobilization is more effective for spinal stiffness and pain than low force (30N) mobilization.
- T
| - at short term follow-up.
99
What is the 6 criteria CPR for those with mechanical neck pain that may benefit from thoracic spine manips?
How many should be present?
- symptom duration < 30 days
- no symptoms distal to the shoulder
- symptoms not aggravated by looking up per report
- FABQ-PA score < 12
- diminished upper thoracic kyphosis (T3-4)
- cervical extension < 30*
- with 3 present, probability for improvement increases from 54% to 86%
** of note, a repeat study did not support the validity of the CPR
100
How do thoracic manips compare with:
- placebo
- C-spine manips
- T-spine mobilizations
- better than placebo
- not better than C-spine manips
- better than T-spine mobs
101
How quickly and how long can one expect to see positive impacts from thoracic manips for acute or subacute mechanical neck pain?
- should occur immediately following the intervention
| - effects can last 6 months after 3 weeks of T-spine manips
102
T or F;
T-spine manips only impact pain; won't affect ROM.
- F; also have effects on cervical ROM
103
Describe the presentation for an "opening" problem on the R, and the C-spine manip technique to improve the ROM.
- pain on the R side with flexion, and/or L sidebending, and/or L rotation
- pt in supine, place MCP of R index finger on R facet joint. Place MCP of L index finger on L articular pillar of targeted segment (upper vertebra; e.g. C5 if treating C5-6). Bring pt into upper cervical flx (chin tuck), then flex c-spine until motion is felt at involved segment. Then take up slack into L rotation/SB, establishing fulcrum. Then apply HVLA force into L rotation w/ R hand.
- Variation would be to create R translation force in flexion. Wouldn't need to SB/rotated to the L.
104
If you're doing a non-thrust mobilization for an opening problem on the R, would it be an upglide or downglide?
- upglide. Pressure at the articular pillar.
105
Describe the presentation for a "closing" problem on the R, and the C-spine manip technique to improve ROM.
- R-sided pain with extension, R SB, and/or R rotation.
- pt in supine. Palpate articular pillars of involved segment. Extend neck with segment at apex. Create L directed translatory force. Apply HVLA force into L translation and inferiorly. Essentially a downglide.
106
Describe the execution of a generalized thoracic distraction. When would it be used?
- for pts with general T-spine pain
- pt clasps hands behind neck, then flexes forward so elbows are pointing downward. Therapist is behind pt, and pulls pt's elbows towards pt's lower ribs. Pt's T-spine is braced on therapist chest. HVLA thrust is performed in an upward direction.
107
Are cervical self-mobs appropriate for pts w/ neck mobility limitations?
- Yes
108
Describe a self-mobilization technique to improve flexion, R rotation, and/or R SB.
- Pt places R fingers on L articular pillar of target segment. Then gently flexes neck and rotates to the R ("look down and to the R"). R hand gently assists motion at that segment.
109
Describe a self-mobilization technique to improve extension, R rotation, and/or R SB.
- Pt takes towel and wraps around R side of neck. Gently pull downward and to the L while extending and looking to the R.
- basically doing a downglide.
