C-spine exam Flashcards
incidence of neck pain
22-70% of the population will have neck pain at some point in their life
10-20% of population of report neck pain at any one point in time
54% have experienced neck pain within the last 6 months
severity of neck pain incidence
up to 44% will become chronic (> 6 mo)
5% will become disabled
second only to LBP in workers comp
typically 25% of patients receiving OP PT
common medical diagnoses
arthritis disc pathology trauma (fractures, dislocations, etc) tumors infection torticollis myofascial pain syndrome whiplash
for most coming to PT:
- clear diagnostic criteria is not established
- pathoanatomical cause is not identifiable
risk factors for poor outcome
- age >40
- co-existing LBP
- long hx of neck pain
- bicycling as regular activity
- loss of strength in hands
- “worrisome” attitude
- poor quality of life
- “less vitality”
tincture of time
does the “wait and see,” “time heals all wounds” work with mechanical neck pain??
“the changes in pain scores over the varying trial periods in these untreated subjects with chronic mechanical neck pain were consistently small and not significant”
patient management
follows same sequence as learned for the extremities:
- exam
- eval
- diagnosis
- prognosis
- intervention
- re-eval/outcomes
exam
follows same process as for extremities:
HISTORY PHYSICAL EVAL: -observation- posture, symmetry, edema, color -palpation-mobility, tenderness, TrP -clear above and below -ROM/flexibility
History
PMH- (intake form)
HPI- (intake form)
Systems Screen-
Subjective-
- listen for red/yellow flags
- VAS or NPRS
VAS
visual analog scale
NPRS
national pain rating scale
MCID
minimal clinical ? difference
=2 point difference in VAS or NPRS to say there is a significant difference
observation
POSTURE
MUSCLE SYMMETRY
KINESIOPHOBIA
posture
note deviations, correct and note change in symptoms
Frontal Plane:
- lat flexion
- rotation
- scapular position (elevated/rotated/winging)
Sagittal Plane:
- eyes & mandible normally horizontal
- forward head posture- common!
- protracted/retracted shoulder
muscle symmetry
hypertrophy, atrophy, spasm
- upper//mid/lower trap
- deltoid x3
- pec major
- SCM
- infraspinatus
- lat dorsi
- erector spinae
kinesiophobia
how comfortable/willing are they to move?
palpation
temperature skin mobility fascial tightness muscle spasm (localized vs. general) Trigger points tender points bony prominences -mastoid -nuchal line -spinal processes -articular pillar -facets
motion testing
AROM –> PROM (overpressure)
- 2 methods flexion
- 2 methods extension
- protraction/retraction
- lateral flexion
- rotation
- distraction
- compression
- spurling’s
- scapular mobility
- segmental motion
- local sign
- referred sign
- quadrant
local sign
maximally close down 1 side- facet
*if there is degeneration you can expect local sharp pain
referred sign
when facet closes, intervertebral foramen closes (stenosis and hypertrophy, disc protrusion)
will pinch the nerve root coming through there
to maximally stress the upper c-spine
retract for flexion
protract for extension
to maximally stress the lower c-spine
protract for flexion
retract for extension
quadrant
(pg 120)
PASSIVE MOTION
extend–> ipsilateral lat flexion –> ipsil. rotation
palpate thumb lateral to spinous process
motion testing amount of stress
compression –> spurlings –> quadrant
segmental motion testing
- OA specific
- sidebend challenge
- F/E challenge
- AA specific
- lateral glide
- rotation upslope/downslope
- PA in prone (CPA, UPA)
*Fryette’s law: by max rotating we can be confident that they aren’t contributing to flex/ext
in pre position R rotation
protraction= R extension, L flexion retraction= L extension, R flexion
if trying to stretch the L posterior OA
side bend L and retract
OA (O/C1) primary motion
=flexion extension
max rotation –> F/E testing
AA (C1/C2) primary motion
=rotation (45 deg)
max flexion –>rotation
flexibility tests
Levator, splenius cerv., post. scalene
upper trap & SCM
middle & anterior scalene
suboccipitals
strength testing
ISOMETRIC
DEEP NECK FLEXOR ENDURANCE
CRANIAL CERVICAL FLEXION TEST
isometric strength testing
provide counter-force stabilization
EASY increase/decrease of force
- flex/ext
- lat flexion
- rotation
deep neck flexor endurance
pt. supine; actively chin tucks and holds up off hand/table.
+ test= loss of chin tuck or patient’s head touches clinician hand for >1 sec
- patients with neck pain: mean=24.1 secs
- patients w/out neck pain: mean= 38.95secs
neurological testing
(upper motor neuron lesion VS. cervical radiculopathy VS. peripheral nerve lesion??)
MSR (musculoskeletal reflexes)
- biceps- C6
- brachioradialis- C6
- triceps- C7
Hoffmann’s reflex
Babinski
Clonus
Sensation testing
- circumferential
- monofilament
upper motor neuron lesions
=spinal cord and above
- Hoffman
- Babinski
- Clonus
- myotomes
-DTR (exaggerated reflex)
lower motor neuron lesions
=nerve
- ULTT
- compression/distraction
- Spurling
- Quadrant
- dermatomes
- sensation (glovelike, peripheral, derm)
-DTRs (diminished reflex)
peripheral nerve distribution
slide 21
dermatomes
slide 22
Hoffman’s reflex
tests for upper motor neuron lesion
flick 3rd DIP
+ test= other fingers contract/twitch
Babinski
tests for upper motor neuron lesion
stroke on sole of foot from heel to toes
+ test= toes flare/extension
**normal in babies
Clonus
ankle- DF
wrist- extension
relax first and then quick stretch and hold
-similar to DTR– causes excitation of muscle
-can grade by number of contractions
=sustained clonus if there are numerous contractions
tests for cervical radiculopathy
compression test spurlings test distraction test quadrant test brachial plexus compression test cervical hyperflexion/extension tests valsalva maneuver ULTT shoulder abduction test
C1-2 myotome
cervical flexion
C3 myotome
cervical lateral flexion
C4 myotome
shoulder elevation
C5 myotome
shoulder abduction
C6 myotome
elbow flexion
wrist extension
C7 myotome
elbow extension
wrist flexion
C8 myotome
thumb extension
ulnar deviation
T1 myotome
finger abduction/adduction
ULTT
upper limb tension test
median
ulnar
radial
pathological responses to ULTT
- reproduction of symptoms
- a sensitizing test alters the symptoms
- side to side asymmetry of symptoms
normal responses to ULTT
- deep ache in cubital fossa
- deep ache/stretch in radial forearm/hand
- tingling to fingers supplied by appropriate nerve
- stretch in anterior shoulder
- above responses ^ with contralateral c-spine lateral flexion
- above responses decrease with ipsilateral c-spine lateral flexion
upper c-spine instability tests
sharp purser
alar ligament stability
upper cervical flexion test
diagnosis
neck pain w/ mobility impairments
- cervicalgia
- pain in the thoracic spine
neck pain with headache
- headache w/ neck movement/position
- cervicocranial syndrome
neck pain with movement coordination impairments
- sprain & strain of c-spine
- whiplash
neck pain w/ radiating pain
- spondylosis w/ radiculopathy
- cervical disc disorder w/ radiculopathy
- cervical myelopathy
clinical reasoning
- identify main patient complaints
- identify important (relevant) impairments
- classify patient according to best evidence (CPG)
- consider at a minimum, treatments according to CPG (is there a need to modify? is there a need to add treatments?)
S/S neck pain w/ mobility deficit “mechanical neck pain”
PAIN DESCRIPTION:
- unilateral localizable neck pain (rarely bilateral)
- referral into T-spine
- referral into scapular, upper brachial (rarely below elbow)
- local and/or referred pain reproduced on specific motions
MOTION:
- restriction in AROM, PROM (abnormal end feel)
- assess upper vs. lower c spine
- joint play (PIVM)
- strength/endurance (esp. DNF)
- flexibility may be difficult to assess bc of lack of vertebral motion
RELEVANT SPECIAL TESTS:
- distraction/compression/spurling’s/quadrant
- cranial cervical flexion test
**LISTEN/ASK FOR CLUES OF IRRITABILITY
neck pain w/ mobility deficit CPR intervention
cervical manipulation for neck pain
thoracic manipulation for neck pain
6 variables for cervical manipulation for neck pain w/ mobility deficit
NDI <11.6
bilateral pattern of involvement
not performing sedentary work
neck movement relieves
cervical extension does not aggravate
dx of spondylosis w/out radiculopathy
(+LR of 5.3 if 4 or more of 6 is present)
interventions: cervical manipulation for neck pain w/ mobility deficit
up-slope glide once per hypomobile segment
not validated yet
6 variables for thoracic manipulation for neck pain w/ mobility deficit
symptoms <30
+LR of 5.5 if 3 of 6 present
(chance of successful outcome 54-86%)
interventions: thoracic manipulation for neck pain w/ mobility deficit
- seated distraction manipulation twice
- supine upper thoracic manip (trigger) twice
- supine middle thoracic manipulation (trigger) twice)
- upright AROM rotation in cervical flexion
(not validated yet)
types of headache
migraine: 1 sided, 4-72 hours, “throbbing”
sinus: widespread, until treated, “dull”
cluster: 1 sided, 15 min-3 hours, “sharp”
tension: widespread, hours, “dull”
cervicogenic
neck pain w/ tension headache –S/S
- bilateral
- 15 days/month for last 3 months
- pressing or tightening pain (NPRS <6/10)
- no increase in pain w/ physical activity
- no photophobia, phonophobia, vomiting, nausea
- no evidence of secondary headache
- no whiplash, surgery, CNS involvement, or red flags
CPR for TrP in tension headaches
predictor variables: (>=2 is +LR 5.9)
- headache duration 8.5 hours/day
- headache frequency <47.5
Intervention:
- pressure release, MET, soft tissue
- temporalis, suboccipital, upper trap, SCM, splenius and semispinalis capitis
S/S– neck pain w/ cervicogenic headache
- may or may not have associated neck pain
- persistent, sharp to dull pain
- symptoms change w/ change in neck position (head on body, body on head)
- dizziness may be present– differentiate from vestibular or orthostatic hypotension
*w/out vestibular system- hold head still and pt move body bak and forth (if still dizzy= cervicogenic and not vestib.)
Rx– neck pain w/ cervicogenic headache
- cervical mob/manip
- stretching
- coordination, strengthening, endurance
S/S– neck pain w/ movement coordination impairments “whiplash”
-often traumatic (MVA)
-neck pain, headaches, referral into shoulder girdle and/or upper arm
-mid range neck pain increase at end range
DNF loss of strength, endurance, control
***PAIN IN MIDRANGE
Rx– neck pain w/ movement coordination impairments “whiplash”
prevent progression to chronic
- be gentle
- watch psychological effects
- pay attention to PT-pt interaction
coordination, strengthening, endurance
-DNF and posterior neck muscles
stretching
cervical whiplash prognosis–4 variables (questions) to not having a persistent disability
1: did collision occur at location other than city intersection?
2: upper back pain since collision?
3: still have neck pain at 2 wks post accident?
4: still experience shoulder pain 2 wks post accident?
HIGH RISK=
- yes to 1 and 2
- no to 1 and 2; yet to 3, 4
LOW RISK=
-No to 3 and 4
cervical radiculopathy S/S
test item cluster (TIC)
-cervical rotation toward involved side s A test
cervical radiculopathy prognosis
short term outcomes
4 variables:
-age 50% visits (manual therapy, traction, DNF training)
interventions for neck pain w/ radiating pain
from CPG
- upper quarter and nerve mobilization procedures
- traction
- thoracic mob/manip
