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Ortho - Cervical/ SIJ > Cervical > Flashcards

Cervical Flashcards

1
Q

Indications for repeating neurological examination.

A
  1. Neurological Impairments (abnormal findings only) should be re-examined at each follow-up to monitor pt’s condition whether indicative of improvement or deterioration
  2. Marked change in severity or area of symptoms
  3. Peripheralization of symptoms
  4. New reports of weakness, anasthesia, parasthesia
  5. Development of symptoms suggestive of UMN or cranial nerve involvement
  6. ** REPEAT full neuro exam if pt has COMPLETE and DRAMATIC relief of pain - as this is indicative of COMPLETE conduction loss
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2
Q

What are standard segmental neurological examination procedures of UE

A
  1. Sensory examination (Dermatomes)
  2. Myotomes (Isometric Testing)
  3. Deep Tendon Reflex Testing (DTRs)
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3
Q

Screening for UMN involvement in upper quarter disorder include…

A
  1. DTRs for hyper-reflexia (UE and LE)
  2. Babinski sign
  3. Hoffman’s sign (UE analog to Babinski sign)
  4. Inverted Supinator sign
  5. Clonus
  6. Muscle tone of UE and LE for velocity dependent hypertonia (spasticity)
  7. Sensory examination for non-dermatormal distribution of impairment in UE and LE.
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4
Q

Nerve Root Involvement include any combination of the following….

A
  1. PAINLESS, WEAKNESS of isometric strength (myotomes)
  2. PAINLESS, WEAKNESS of DTRs
  3. Altered sensation in dermatomes
  4. Positive neurodynamic tests
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5
Q

Peripheral Nerve Involvement will exhibit some combination of the following….

A
  1. PAINLESS, WEAKNESS of isometric strength in muscles innervated by the peripheral nerve DISTAL to site of lesion
  2. Altered sensation in peripheral nerve distribution
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6
Q

What is an important element of the neurological examination in order for it to be CONCLUSIVE and WHY?

A

In order for the neurological exam to be conclusive, it is important that the exam does not provoke symptoms BECAUSE provocation of symptoms inhibits maximal effort during isometric testing and prevents full relaxation for DTRs.

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7
Q

What is the preferred pt positioning for isometric testing examination? Explain your answer.

A

Supine is usually the preferred pt positioning during testing because it enhances stabilization and prevention of unwanted movements.
Also, supine is often the position of most comfort and maximizes the possibility of relaxation during reflex testing.

**Make sure that regardless of pt position chosen, all re-examination needs to be performed in the same position

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8
Q

What could painful weakness with isometric testing conclude?

A
  1. Impairment of local myotendinous unit
  2. Potential neurological impairment
  3. Pain related to isometric contraction of neck/trunk muscles around painful spinal structures as pt stabilizes themselves during exam
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9
Q

What are you as the PT looking for during isometric testing to make the strongest case for neurological involvement?

A

PAINLESS WEAKNESS!

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10
Q

Provocation of pain/symptoms with decreased DTR response can be indicative of…

A

Neurological weakness or pain inhibition

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11
Q

Painless decrease in DTR response would suggest…

A

Impairment in impulse conduction associated with reflex arc

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12
Q

What are common tools for standardized assessment of disability associated with neck pain can be used?

A
  1. Neck Disability Index (NDI)

2. Patient-Specific Functional Scale (PSFS)

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13
Q

Briefly describe the NDI.

A

It involves 10 items for self-report of functional status.

  • 7 items assess functional activities: personal care, lifting, reading, work, driving, sleeping, and recreation
  • 3 items address concentration, headache, and pain intensity

It measures both physical and mental health-related factors.

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14
Q

Briefly describe the PSFS.

A
  • Pts are asked to identify 3 activities they find difficult to perform because of their neck pain and rate the difficulty of performing each on a scale from 0-10
  • At reassessment, pts are asked to rate these 3 activities again and a detectable change is 2 or more OR 1 point change when using the average of the 3 nominated activities.
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15
Q

What is an important criteria to distinguish in order to note symptom response?

A

The PT must establish a baseline of symptoms before each movement

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16
Q

What motions might you see with a pt who has deficits in upper cervical mobility?

A

Head may often deviate into lateral flexion toward the same side of rotation (eg, head will laterally flex to the right when actively rotation to the right).

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17
Q

How do you test the lower cervical quadrant?

A

Extension, Lateral Flexion (translation), and Ipsilateral Rotation

**Note - PT must reach end-range of each component before proceeding to the next component.

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18
Q

When is it appropriate to administer the Spurling’s test and lower cervical quadrant?

A

Only use this test when ALL active movements and overpressures are unremarkable

**Do Lower cervical quadrant test first before Spurling’s test.

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19
Q

What is the key difference between using the Slump Test for UE compared to LE?

A

Typically with UE, examine slump test with BILATERAL ankle DF + knee extension

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20
Q

What is the rationale for bilateral ankle and knee movement with Slump Test for UE?

A

The rationale is to create greater mechanical loading of neuromeningeal tissues with the spinal canal

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21
Q

When is passive C1-2 rotation (flexion-rotation test) indicated?

A

In patient with upper cervical (+) or (-) headache symptoms

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22
Q

In what position must the head be placed in order to clinically examine muscle strength and endurance of deep cervical flexors? And why this position?

A

The preferred position to assess deep neck flexors is in the position of upper cervical flexion (chin tuck + head lift).

This is to decrease the dominance of the SCM.

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23
Q

Why must upper thoracic segments (T1-3) be included in cervical palpation exam?

A

Because the upper thoracic spine contributes to movement of the cervical spine into end-range positions

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24
Q

How can central P-As with an assymmetrical distribution of symptoms be more comparable during your examination?

A

Central P-As inclined from the side of symptoms may often be more comparable than straight central P-As

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25
Q

What is the most efficient and sensitive procedure to ‘clear’ or ‘scan’ the cervical spine?

A

P-A pressures

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26
Q

Cervical radiculopathy is most common with what population.

A

Patients between 30-55 years of age, but it’s unclear whether a gender preference exists

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27
Q

Cluster headaches is most common with what population

A

Males between 20-50 years of age

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28
Q

What are the risk factors for neck pain?

A
  1. Older age (45-55 yrs of age)
  2. Female
  3. High job demands
  4. low social/work support
  5. ex-smoker
  6. History of LBP
  7. History of neck pain
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29
Q

Musculoskeletal symptoms located in the upper cervical, head, and facial regions are usually due to…

A

Segmental levels of Occiput - C3

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30
Q

Why do somatic referral to the head occurs?

A

Because spinal nerves from C1-C3 innervate somatic structures in this region

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31
Q

Why does somatic referral to the face and temporomandibular region occurs?

A

Because of convergence between afferent fibers from spinal nerves C1-C3 and afferent fibers from the trigeminal nerves

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32
Q

Musculoskeletal symptoms located in the neck, scapula, shoulder, and upper extremity dysfunctions are most commonly related to what levels?

A

C3 - C7

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33
Q

Somatic referral from low cervical intervertebral discs (Cloward’s areas) can refer where?

A

Along the medial border of the scapula or along the midline of the upper and middle thoracic spine

34
Q

C6/C7 discs can refer symptoms where?

A

The anterior chest region

35
Q

What are the general guidelines for using the distribution of symptoms to assist in hypothesizing the type of referred pain responsible for upper quarter symptoms?

A
  1. Pain over the shoulder girdle and upper arm may be somatic referred pain OR radicular referred pain
  2. Pain in the forearm and hand is NOT LIKELY to be somatic referred pain, INSTEAD it is more likley to be radicular referred pain
36
Q

Patients with neck pain commonly report symptoms where?

A

Upper limb, head, and upper back

37
Q

What is Bakody’s sign and what is this indicative of?

A

Bakody’s sign is the resting of the hand or arm on the top of the head to relieve cervicobrachial symptoms.

Bakody’s sign is indicative of C4 or C5 nerve root involvement, as this position reduces loading of the neural tissues, particularly the C5 nerve root.

38
Q

If pt’s most intense symptoms during the waking hours, what can be suggestive of?

A

Individuals suffering from ‘mechanical’ spinal pain

39
Q

When pt’s indicate that their pain is worse in the a.m., if worse before getting out of bed or trouble sleeping… what could this be suggestive of?

A

May be a problem with sleeping posture and may need to investigate size/number/content of pillows.

40
Q

If morning stiffness lasting >1 hour be suggestive of?

A

Suggestive of a significant inflammatory component in the disorder and may need to screen as appropriate for any potential inflammatory spondyloarthropathy. (eg Rheumatoid arthritis, axial spondyloarthritis, Reiter’s syndrome)

41
Q

If pain is worse EOD could be suggestive of?

A

May be reflective of a postural component or strictly mechanical problem that is irritated by repetition of aggravating activities during waking hours.

42
Q

When should your suspicion of systemic pathology with your pt increase?

A

When night pain is more intense than pain during waking hours, and the patient is not able to return to sleep or relieve it with change in position or recumbency

43
Q

What questions would you ask to screen for symptoms of vertebrobasilar insufficiency/ cervical arterial dysfunction?

A
  1. Dizziness
  2. Drop attacks
  3. Diplopia
  4. Dysphasia
  5. Dysarthria
  6. Nystagmus
  7. Nausea
  8. Unilateral Numbness of ipsilateral face or contralateral body
  9. Ataxia
44
Q

Who are pts that are candidates for upper cervical stability testing?

A

Those that report headache, occipital numbness, dizziness, nausea, and tinnitus.

Significant limitations in ROM and difficulty with holding head up/ desire for external support may increase your suspicion

45
Q

What are cardinal symptoms for caution with upper cervical stability examination?

A
  1. Facial and perioral paresthesia/anasthesia
  2. Drop attacks (however, very very rare)
  3. Bilateral, quadrilateral, or hemilateral paresthesia/ anasthesia
  4. Nystagmus produced by active or passive movements of head/neck that is not BPPV
46
Q

Instability of the upper cervical segments is more often due to disease processes than trauma. Medical screening for what type of diseases should be on your radar?

A
  1. Rheumatoid Arthritis
  2. Klippel-Feil syndrome, where mid/lower cervical segments don’t separate during development
  3. Axial Spondyloarthritis as upper segments attempt to compensate for motion lost at mid/lower segments
  4. Down syndrome and atlantoaxial instability
  5. Disorders such as Ehlers-Danlos syndrome or Marfan’s syndrome where connective tissue integrity is compromised
47
Q

Whenever features of the patient interview indicate that upper cervical stability testing is a high priority, when should it be completed in regards to the application of any passive overpressures to physiological movements?

A

Stability testing should be completed BEFORE application of any passive overpressures

48
Q

Describe the gradual increasing force of a pt initial evaluation testing.

A
  1. Pt interview
  2. Active movements (No overpressure) + Neuro exam PRN
  3. Upper cervical stability tests
  4. Active movements (Overpressure) + upper cervical combined movements PRN
  5. PA exam
49
Q

What is the clinician primarily assessing for when examining upper cervical stability?

A
  1. Laxity via amount of movement and end-feel
  2. Reproduction of symptoms other than pain (eg dizziness, nausea, feeling of instability), WITH particular attention to vascular and/or neurological symptoms (nystagmus, dysarthria, etc).
50
Q

What could you use to stress the transverse ligament of the cervical spine?

A
  1. The Sharp-Purser test (however there is debate about the usage of this test for upper cervical stability)
  2. Anterior shear test
51
Q

When should the anterior shear test not be performed?

A

If craniovertebral flexion during upper cervical movement examination provokes neurological or vascular symptoms. It should be assumed that transverse ligaments laxity is present until proven otherwise by more definitive diagnostic imaging/examination

52
Q

How would you test the integrity of the alar ligaments?

A

You can assess this integrity by the alar ligament test via craniovertebral lateral flexion

53
Q

What constitutes a positive finding with the alar ligament test?

A

A positive test would REQUIRE laxity present in ALL 3 positions

54
Q

Why would neurological impairment of the upper cervical most likely not be due to neurological compression?

A

Neurological impairment of the upper cervical most commonly due to vascular impairment of the verterbrobasilar/ internal carotid system and less likely neurological compression because of the relatively large spinal canal in this portion of the cervical spine

55
Q

What defines as neurological symptoms?

A
  1. Dizziness/Imbalance
  2. Nausea/vomiting
  3. Blurred or Impaired vision
  4. Tinnitus
  5. Arm or leg weakness
  6. Confusion or disorientation
  7. Depression or anxiety
56
Q

Who are candidates for cervical artery examination?

A

Pts who report dizziness, vertigo, nausea, tinnitus, neck pain, and headaches; because insufficiency in the cervical arterial circulation may be related to these symptoms

57
Q

When should concern for potential cervical arterial dissection should increase?

A

It should increase in pts who report the following:

  1. Recent onset neck pain/ headache that is ‘unusual’ in quality, is moderate/ severe in intensity, and is associated with recent minor mechanical trauma/ strain to the neck or recent infection.
  2. Specifically question for associated transient ‘ischemic’ features in preceding month including:
  • visual disturbances
  • balance or gait disturbances
  • speech difficulties
  • limb weakness or paresthesia
58
Q

What is the intention of sustained movements?

A

The intention is to stress each vertebral artery. It is thought that rotation stresses the contralateral vertebral artery

59
Q

What time frame, in regards to neck pain, is associated with increased odds of achieving clinically important reductions in pain and self-reported disability?

A

Within 4 weeks of the onset of symptoms.

60
Q

Pt’s experiencing spinal pain have the following expectations…

A
  1. Undergo a well-executed physical examination so they can receive an accurate diagnosis (they want to validate their pain)
  2. Receive intervention/ management that leads to pain relief
  3. Receive instructions/ advice on how to manage their spinal pain
  4. Establish an interpersonal relationship with their health care provider (patient centered communication)
61
Q

What are the contraindications to the use of passive movement for examination?

A
  1. Malignancy of targeted body region
  2. Cauda equina problems
  3. Medical ‘red flags’ suggesting neoplasm, recent fracture, other non-musculoskeletal pathology
  4. UMN findings (undiagnosed)
  5. Rheumatoid collagen necrosis (especially upper cervical spine)
  6. Unstable upper cervical spine
  7. Cervical arterial dysfunction
  8. Pyschogenic disorders
  9. Lack of patient consent
62
Q

What are the precaution to use of passive movement for examination?

A
  1. Active, acute inflammatory conditions
  2. Systemic diseases
  3. Osteopenia/ Osteoporosis
  4. Long-term use of therapeutic steroids
  5. Immediately post-partum
  6. Blood-clotting disorder
  7. Spondylolisthesis/ structural instability/hypermobility
  8. Irritable disorder (especially nerve root problem)
63
Q

What grade is best used for addressing ‘end-range’ stiffness?

A

Grade IV - small amplitude oscillations

64
Q

What grade is best used for addressing ‘through range’ stiffness?

A

Grade III - large amplitude oscillation

65
Q

How can the vigor of spinal mobilizations be progressed for those with stiffness > pain?

A
  1. By applying central or unilateral P-A pressures in an inclined direction that addresses the most comparable directions of stiffness
  2. By placing the cervical spine nearer to the end-range of the most restricted physiological movement
66
Q

What should the clinician complete prior to applying central or unilateral P-A pressures with the cervical spine out of the neutral position?

A

The clinician should complete upper cervical stability testing and vertebral artery/cervical artery testing. AND this must be done with care and only with non-irritable disorders

67
Q

When is it acceptable to provoke some level of symptoms during passive mobilization techniques?

A

When stiffness is the primary impairment, even though the patient still reports symptoms of pain, when the disorder is NON-irritable. (stiffness > pain)

68
Q

What is an option for reducing the vigor of grade III or IV mobilizatoins?

A

It is to place the cervical spine in more of a mid-range position (eg performing P-As with head segment of the table positioned so that the low cervical spine can be in more relative flexion)

69
Q

What other options is available if manual therapy applied directly to the cervical region to change patients’ levels of neck pain is not tolerated?

A

Manual therapy techniques applied to hypomobile segments in the upper/middle THORACIC spine may be another option.

70
Q

When performing cervical rotation mobilization, in what direction should you be rotating your pt’s neck?

A

Rotate AWAY from the painful side of symptoms

71
Q

Describe the sliding technique.

A

A movement that lengthens the nerve bed is counterbalanced by a simultaneous movement that shortens the nerve bed.
It creates significant longitudinal movement of the nerve relative to the surrounding tissues without significant increases in nerve strain

72
Q

Describe tensioning technique

A

It ONLY involves movements that lengthen the nerve bed.
This produces significant longitudinal movement of the nerve relative to the surrounding tissues along with significant increases in nerve strain

73
Q

What is essential of nerve gliding techniques?

A

It is ESSENTIAL that it does not place a sustained tensile load on the neural tissues.
It should ONLY create a STRETCH sensation in rhythm .

74
Q

What is a contralateral cervical lateral glide able to create?

A

IT is able to create longitudinal movement of the MEDIAN nerve in the forearm when the limb is prepositioned in 30 degrees of abduction with the elbow extended.

75
Q

What is usually the BEST indication of value of the previous ‘in-clinic’ session?

A

Pt response over the first 24 hours after intervention

76
Q

What are the parts of the pt interview?

A
  1. Patient profile
  2. Establishing the ‘kind of disorder’
  3. Location and description of symptoms (body chart)
  4. Behavior of symptoms
  5. History of current condition
  6. Past history related to current condition
  7. Special/ precautionary questions (includes medical screening)
77
Q

Cluster headaches most commonly affect what population?

A

Males between 20-50 y/o

78
Q

Musculoskeletal symptoms located in the upper cervical, head, and facial regions are usually due to what?

A

Dysfunction in segmental levels occiput - C3

79
Q

Musculoskeletal symptoms located in the neck, scapula, shoulder, and upper extremity are most commonly related to what?

A

Dysfunction in segmental levels C3 - C7

80
Q

Why would questions regarding vision/ eyewear be relevant to know?

A

Because vision issues may significantly affect cervical posture (eg, upper cervical extension to use bifocals or to get closer to the computer screen)

Ortho - Cervical/ SIJ (2 decks)

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