Cervical Exam Flashcards
When does age becomes a risk factor for poor outcomes in cervical pathology?
> 40
What activity is related to a poor outcome of cervical treatment?
- Bicycling
What co-existing problem is related to poor outcomes of cervical treatment?
Low back pain
What 3 psychosocial factors are related to poor outcomes in cervical treatment?
- “worrisome” attitude
- Poor QoL
- “Less vitality”
What cervical PMH is related to poor outcomes of cervical treatment?
- Long history of neck pain
Does a “wait and see” approach work with mechanical neck pain?
No. The earlier a patient sees a PT. the better the outcome
What is the 1st question of the canadian cervical spine rules?
- Older than 65?
Dangerous mechanism of injury?:
- Fall from >1m or 5 stairs
- Axial load to head
- High speed MVA (100km/h)
- Motorized recreational vehicle
- Bicycle collision
- Parathesias in extremities?
If a patient answers yes to any of the first c-spine rules, what is the course of action? What if the patient answers no?
Yes: Get x-rays
No: Move on to #2…
What is the 2nd cervical spine rule question?
Are there low-risk factors that allow safe assessment of ROM?
- Simple rear-end motor vehicle accident?
- Normal sitting posture in exam?
- Ambulatory at any time since injury?
- Delayed onset neck pain and absence of midline tenderness?
If a patient answers yes to all of the #2 questions, what is the course of action? What if a patient answers no to any of the questions?
Yes to all: Ask #3
No to any: Get an x-ray
What is the 3rd cervical spine rule?
- Can the patient rotate the neck 45 degrees each direction?
If the patient answers no to the 3rd question, what is the course of action? If the patient answers yes, what is the course of action?
Yes: Proceed with exam
No: X-rays
What is VAS?
Visual analogue scale (pain)
What is NPRS?
Numerical pain rating scale
What is the MCID of VAS and NPRS?
2 points
What is the MCID for the Neck Disability Index?
5 points
What is GROC?
Global Rating of Change
15 statements from - 7 to + 7 (getting worse to getting better)
How is posture assessed during the examination?
- Note deviations, correct, note change in symptoms
What should be assessed in a postural exam of the cervical spine in the frontal plane?
- Lateral flexion
- Scapular position (elevated/ rotated/ winging
What should be assessed in a postural exam of the cervical spine on the transverse plane?
- Rotation
What should be assessed in a postural exam of the cervical spine in the sagittal plane?
- Eyes and mandibles horizontal
- Forward head posture
- Protracted and retracted shoulder
Which type of postural deviation is very common in the c-spine?
- Forward head posture
What muscles should be assessed for symmetry in an exam of the c-spine?
- Traps
- Deltoids (all 3)
- Pec major
- SCM
- Infraspinatus
- Latissimus dorsi
- Erector spinae
What term refers to the willingness to move?
Kinesiophobia
What 7 things should be assessed during palpation of the c-spine?
- Temperature
- Skin mobility
- Fascial tightness
- Muscle spasm
- TrP
- Tender Points
- Bony prominences
What 4 bony prominences should be palpated?
- Mastoid
- Nuchal line
- Spinous processes
- Articular pillar/ facets
How is cervical axial rotation measured in supine?
- Head is lifted off the surface so that it does not translate during rotation
** Review Cervical ROM **
** Review Cervical ROM **
What is the quadrant position of the cervical spine?
Combined movements of:
- Extension
- Rotation towards the tested side
- Side bending towards the tested side
What type of pain will be felt in the quadrant position is there is mechanical or joint related neck pain?
- Localized pain
What type of pain will be felt if a nerve root is impinged in the quadrant position?
- Radicular pain
- Change in sensation
How can the upper or lower C-spine be targeted in measurement of flexion?
- Retraction stresses the lower C-spine
- Protraction stresses the upper C-spine
What is a good test item cluster for the radiculopathy?
- Distaction
- Compression
- Spurlings
List the least to most aggressive tests for radiculopathy for the following:
- Spurlings
- Quadrant
- Compression
- Compression
- Spurlings
- Quadrant
Describe the cervical distraction test.
- Pt supine
- Top hand on forehead to prevent flexion
- Bottom hand cups occiput
- Lift head
- Distact
- Hold for about 10 seconds
- Assess for reduction in symptoms
Describe the cervical compression test.
- Pt sitting
- Standing behind Pt
- Place elbows anterior to shoulder and correct posture
- Lock hands over head
- Compress downwards
- Hold for 10 seconds (30 seconds?)
- Assess for reproduction of symptoms
Describe Spurling’s cervical test.
- Pt sitting
- Standing behind Pt
- Hold contralateral shoulder
- Laterally flex to the same side
- Provide axial load through C-spine
What is the O/C1 specific segmental motion test?
- Pt supine
- Full rotation to non- symptomatic side
- Passively nod head in both directions using the mastoid processes for the axis of motion
What is the sidebend challenge?
- Pt supine
- Protract the patients head
- Move the head side to side, and stress at the end of motion
- Retract
- Move head side to side, and stress at the end of motion
What is the flexion extension challenge?
- Pt supine
- Rotate the patient’s head 45 degrees to one side
- Protract or retract the head (Retract tests posterior, protract tests anterior)
- Stress in a diagonal plane to assess the passive and active stabilitations of the O/C1 joint
How is segmental motion of the AA joint assessed?
- Pt supine
- Neck placed into end-range flexion
- Rotate neck axially, and compare sides
Describe a lateral glide of C2 - C7.
- Pt supine
- Lift head off pillow
- Palpate articular pillar
- Laterally glide vertebra combined with lateral translation of head
What facets are opened, and which are closed in a lateral glide of C2 - C7?
Upper C-spine: - Side towards motion opens - Side away from motion closes Lower C-spine - Side towards motion closes - Side away from motion opens
Describe an upslope of C2 - C7.
- Pt supine
- Palpate articular pillar
- Lift head and pull across the neck at a 45 degree angle (fingers aligned in this position)
- Rotate the head away from the palpated side during the motion (combine some sidebend as well)
Describe a downslope of C2 - C7.
- Pt supine
- Palpate articular pillar, place MCP on anterolateral aspect
- Provide an axial load through the c-spine
- Push pillar posteriorly and inferiorly combined with a side bend motion of the neck
Describe a CPA of the C-spine.
- Pt prone
- Locate the targeted spinous process and place the tips of the thumbs on it
- Keep thumbs straight, wrist and elbows locked, and shoulders over arms
- Gather the lateral neck tissue
- Mobilize in anterior direction
What facets open and close in a CPA of the c-spine?
- The joints above the CPA close
- The joints below the CPA open
Describe a UPA of the C-spine.
- Pt prone
- Palpate spinous process of targeted vertebra
- Slip laterally off to the articular pillar
- Mobilize anteriorly keeping proper form
What facets open and close during a UPA of the C-spine?
- Ipsilateral joints close above the targeted vertebra, and close below
- Contralateral joints open above the targeted vertebra, and close below
If a patient is hypomobile in one direction, but a mobilization cannot be performed because pain onsets before the movement barrier, what can be done?
Mobilize in the opposite direction until symptoms subside, and then reattempt the mobilization
Describe the flexibility test of the levator scapula, splenius cervicus, and posterior scalene.
- Pt side lying with head laterally flexed towards table, and neck flexed forward slightly
- Head stabilized
- ## Press shoulder into retraction, depression, and upward rotation
Describe the flexibility test of the upper trapezius and SCM.
- Pt supine with head at the edge of the table
- Depress shoulder
- Laterally bend away and rotate towards the targeted side
Describe the flexibility test of the middle and anterior scalene.
- Pt supine with head over the edge of the table
- Retract the head
- Depress shoulder
- Rotate towards the targeted side
- Side bend away from the targeted side
How is strength grossly tested in the c-spine?
- Isometric break tests of FLX/EXT, lateral FLX/EXT, and rotation
How is deep neck flexor endurance tested?
- Pt supine
- Chin tucked
- Head is lifted slightly off the table
- Place hand under head
- Hold for about 30 seconds
- If patient makes contact with hand for more than 1 second, it is a positive test
How long are non-symptomatic patients able to hold their head with their DNF as compared to symptomatic patients?
Non-symptomatic: 38.95
Symptomatic: 24.1
What spinal segments are being tested by DTRs of the biceps, brachioradialis, and triceps?
C6: Biceps/ brachioradialis
C7: Triceps
What are 5 positive tests of upper neuron dysfunction?
- Hyperreflexive DTRs
- (+) Hoffmann’s
- (+) Babinski
- (+) Clonus
- Glove like paresthesias
What is indicative of myelopathy?
Bilateral paresthesias
Describe Hoffmann’s reflex.
- Flicking of DIP of middle finger leads to twitch of other digits
Describe the Babinski reflex.
- Light touch along the plantar surface of the foot leads to dorsiflexion of the big toe, and flaring of the other toes
Describe Clonus of the wrist and hand.
- Assure relaxation of the tested tissues
- Apply quick motion into wrist extension or ankle dorsiflexion
- Assess rhythmic beating
How is Clonus graded?
Number of beats (1,2… continuous)
** Study peripheral nerve distribution **
** Study peripheral nerve distribution **
Describe Dermatome screening locations for C5 - T1.
C5: Deltoid insertion C6: Webspace of thumb C7: Dorsal surface of 3rd digit C8: Hypothenar eminence T1: Long flexor muscle belly
What is indicated by glove like paresthesias?
- Peripheral artery disease
- Upper nervous system lesion
Describe the myotome tests for C1 - T1.
C1-2 = Cervical Flexion C3 = Cervical Lateral Flexion C4 = Shoulder Shrug C5 = Shoulder Abduction C6 = Elbow Flexion (wrist extension) C7 = Elbow Extension (wrist flexion) C8 = Thumb Extension (ulnar deviation) T1 = Finger Abduction/Adduction
What is the valsalva maneuver useful in assessing?
- Disk pain
How can the valsalva maneuver be assessed clinically?
During history: - Does it hurt when you cough or sneeze? During exam: - Perform "bathroom procedure" while holding breath - Cough - Sneeze
What is the brachial plexus compression test?
- Pt sitting
- Apply pressure above clavicle on symptomatic side targeting lateral scalenes
- Assess radicular symptoms
What is the cervical hyperflexion test?
- Pt sitting
- Flex head to pain or end-range
- Assess for reproduction of symptoms
- Can be referred to same level on T-spine
What is the shoulder abduction test?
- Pt sitting
- Assess resting symptoms
- Place hand on head
- Assess symptoms
- if pain reduced, it is a positive test
What is the cranial cervical flexion test?
- Pt hooklying
- Head and neck positioned and propped into midrange neutral
- Place blood pressure cuff into cervical lordosis/ hollow at 20 mmHg
- Patient flattens C-spine in 2 mmHg intervals, holding for 10 seconds each time
- Check with the head in different positions/ with a chin tuck
The test is positive if: - Patient can’t increase pressure at least 6 mmHg
- Can’t hold for 10 seconds
- Uses SCM to produce the motion
- Cervical extension or chin movement occurs
If a patient has a positive cranial cervical flexion test, what are the implications?
- DNFs deconditioned
- Patient categorized into neck pain with movement coordination impairment
What are 3 pathological responses to Upper Limb Tension Tests?
- Reproduction of symptoms
- Sensitizing test alters the symptoms
- Side to side asymmetry of symptoms
What are 6 normal responses to upper limb tension tests?
- Deep ache in cubital fossa
- Deep ache/ stretch in radial forearm/ hand
- Tingling in fingers supplied by appropriate nerve
- Stretch in anterior shoulder
- Increase in symptoms with contralateral c-spine lateral flexion
- Decrease in symptoms with ipsilateral c-spine lateral flexion
How is the median nerve ULTT performed?
- Shoulder depressed
- Shoulder abducted 110 degrees with slight extension
- Forearm supinated
- Wrist and fingers extended
- Ulnar deviation
- Elbow moved from flexion to extension
- Lateral flexion may be performed to sensitize the procedure
- May stop the test at any point if symptoms are reproduced
How is the radial nerve ULTT performed?
- Shoulder depressed with hip
- Start in 10 degrees shoulder abduction
- Internally rotate shoulder
- Extend the elbow
- Pronate the forearm
- Flex and ulnar deviate the wrist
- Tuck thumb into fist (?)
- Move into abduction
- Sensitive into or out of lateral flexion
How the ulnar nerve ULTT performed?
- Shoulder depressed with hip
- Shoulder abducted into 90 degrees
- Elbow flexed
- Forearm pronated
- Wrist extended and radial deviated
- Fingers extended
- ER shoulder
- Move shoulder into abduction
- Sensitive with lateral flexion
What are the special tests for upper C-spine instability in order?
- Sharp-purser test
- Alar ligament stability
- Upper cervical flexion test
- VBI test
Stop at any point if the test is positive; this is a red flag
What is the modified Sharp-Purser test?
- Pt sitting
- Tuck chin/head to turn on symptoms
- Stabilizes C2 on spinous process
- Use forearm to stabilize C-spine
- Drive C1 and head back onto C2 to turn off symptoms
Describe the Alar Ligament Stability Test/
- Pt sitting
- Head slightly flexed
- Palpate SP of C2
- Passively side flex or rotate while assessing movement of SP of C2
- C2 should rotate to the opposite side
Describe the upper cervical flexion test.
- Pt supine with no pillow
- Hold head with fingers on C1 and thumbs cupping head
- Hold C1 on posterior arch (directly beneath occiput through muscle)
- Lift the head using fingers (lumbricales)
- Assess excessive movement or reproduction of symptoms
What are the 4 diagnostic categories of patients with neck pain?
- Neck Pain with Mobility Impairments
- Neck Pain with Headache
- Neck Pain with Movement Coordination Impairments
- Neck Pain with Radiating Pain
To which category are patients with sprains and strains of the C Spine and whiplash assigned?
- Neck Pain with Movement Coordination Impairments
To which category are patients with headache associated with neck movement and position, or cervicocranial syndrome assigned?
- Neck Pain with Headache
To which category are patients with: spondylosis with radiculopathy, cervical DDD with radiculopathy, or cervical myelopathy assigned?
- Neck pain with Radiating Pain
To which category are patients with: cervicalgia, or pain in thoracic spine assigned?
- Neck pain with mobility impairments
What 2 main factors affect the assignment of a patient into a diagnostic category?
- Patient’s main complaints
- Relevant impairments
What treatments should be used at a minimum? How can they change?
- Treat at least according to Clinical Practice Guidelines
- May modify or add treatments
What treatment category can be referred to as Mechanical Neck Pain?
- Neck Pain with Mobility Deficit
Is mechanical neck pain typically unilateral or bilateral?
Unilateral.
Is mechanical neck pain typically general or localized?
Localized
To where can mechanical neck pain be referred?
- T-spine
- Scapula
- Upper brachium
Past what landmark does referred mechanical neck pain typically not travel past?
The elbow
How can the local and referred pain of Neck Pain with Mobility Deficit typically be reproduced?
- On specific motions
What clues should be assessed in Neck Pain with Mobility Deficits?
- Irritability
How is motion altered in patients categorized to the Neck Pain with Mobility Deficit category?
- Restriction in AROM, PROM with an altered endfeel
- Joint play, and accessory motions
- Flexbility
Why may flexibility be difficult to assess in patients with Mechanical neck pain?
- Lack of vertebral motion at vertebral segment
What are the 5 relevant special tests for patients categorized into the Mechanical Neck Pain category?
- Distraction
- Compression
- Spurlings
- Quadrant
- Cranial Cervical Flexion
Which muscle group tends to be weak in patients with mechanical neck pain?
- Deep Neck Flexors
What are the 6 indicators for cervical manipulation interventions for patients with Neck Pain with Mobility Deficit?
- NDI < 11.5 (Pain not too severe)
- Bilateral pattern of involvement
- Do not perform sedentary work (No desk job)
- Cervical extension does not aggravate symptoms
- Spondylosis without radiculopathy
- Neck movement relieves symptoms
What is the suggested dosage for cervical manipulation of a patient with Neck Pain with Mobility Deficit?
- Up-slope glide once per hypomobile segment
What are 6 indications for manipulation of the T-spine in patients with Neck Pain with Mobility Deficit?
- Symptoms < 30 days
- No symptoms distal to the shoulder
- Looking up doesn’t aggravate symptoms
- FABQPA score of < 12 (Fear avoidance belief questionnaire
- Decreased upper T-spine kyphosis
- C-spine extension < 30 degrees
What percentage of patients with mechanical neck pain benefit from t-spine manips?
- 54 %
What percentage of patients with mechanical neck pain benefit from t-spine manips when following CPR rules?
- 86 %
What are the 4 t-spine manips indicated by the CPR rules?
- Seated distraction manipulation twice
- Supine upper thoracic manipulation (trigger) twice
- Supine middle thoracic manipulation (trigger) twice
- Upright AROM rotation in cervical flexion
What type of headaches respond well to physical therapy?
- Tension
- Cervicogenic
What types of headaches do not respond especially well to physical therapy?
- Migraine
- Sinus
- Cluster
Is tension headache unilateral or bilateral?
Bilateral
How often do tension headaches occur?
- 15 days/ month for the last 3 months
What type of pain is felt in a tension headache?
- Pressing or tightening headache
Does pain increase or decrease with activity in a tension headache?
Neither. It is unaffected
What types of sensory input are patients with tension headaches sensitive to?
- None
How often to patients with tension headaches experience vomiting or nausea?
Never
What must not be involved for a headache to be termed a tension headache? (5 bullets)
- Secondary headache
- Whiplash
- Surgery
- CNS involvement
- Red flags
What are 4 indications for TrP therapy in tension headaches?
- Headache duration 8.5 hours per day
- Headache frequency < 5.5 days per week
- SF-36 Body pain < 47
- SF-36 Vitality < 47.5
What muscles are typically treated for trigger points when indicated in tension headaches?
- Temporalis
- Suboccipital
- Upper trapezius
- Sternocleidomastoid
- Splenius cervicus
- Semispinalis capitis
What are the 3 interventions indicated by tension headaches?
- Pressure release
- Muscle Energy Techniques
- Soft Tissue work
Is neck pain associated with cervicogenic headaches?
May or may not be present
What type of pain is felt in a cervicogenic headache?
- Persistent. sharp to dull pain
How can the dizziness from cervicogenic headaches be differentiated from that of the vestibular system?
- Move the head on the body
- Move the body on the head (will provoke dizziness in patients with cervicogenic dizziness, but not vestibular)
What are 5 prescriptions for cervicogenic headaches?
- Cervical mobilizations/ manipulations
- Stretching
- Coordination
- Strengthening
- Endurance training
What is the typical mechanism of injury for Neck Pain with Coordination Impairments?
- Traumatic injury to neck (hyperextension/ hyperflexion)
- Commonly motor vehicle accidents
What is the major symptom of Neck Pain with Coordination Impairments?
- Mid-range neck pain, with an increase at end-range
What type of injury is commonly categorized as Neck Pain with Movement Coordination Impairments?
Whiplash
What type of pain is associated with Neck Pain with Movement Coordination Impairments?
- Referral into shoulder girdle and/or upper arm
What muscles are typically affected in patients with Neck Pain with Movement Coordination Impairments?
- Deep neck flexors
What is extremely important in the treatment of acute Whiplash injuries?
- Prevent progression to the chronic stage
How can the psychosocial aspects of a patient with whiplash injury be managed by the PT?
- Be gentle with their interventions
- Pay attention to the patient’s psyche
- Encourage, and ensure that they will get better
- Pay attention to the language used to describe their condition and future function
What muscles groups are strengthened in patients with Neck Pain with Movement Coordination Impairments?
- DNF
- Posterior neck muscles
Besides strengthening, coordination, and endurance, what other therex is appropriate to patient’s with whiplash?
- Stretching (after the symptoms are less acute)
What are 4 indications that a patient with whiplash is at high risk for persistent disability?
- Collision occurring at a location other than a city intersection
- Upper back pain since the collision
- Neck pain persists for 2 weeks post accident
- Shoulder pain persists for 2 weeks post accident
How many of the 4 indications need to be answered affirmatively to place the patient into the high risk for persistent disability category?
Either both: city inter section + upper back pain
OR
Yes to:
Neck pain 2 weeks after accident
OR
Shoulder pain with either city intersection or upper back
What are the 4 indications for placement of the patient into the category of cervical radiculopathy?
- Cervical rotation toward involved side < 60 degrees
- (+) ULTT for the Median Nerve
- (+) Cervical distraction test
- (+) Spurling’s A test
What is the MCID of the NDI scale?
7 points
What is MCID of the PSFS scale?
2 points
What is the MCID of the NPRS?
2 points
What is the MCID of the GROC?
5 points
What are the CPR for the use of traction with patients categorized into Cervical Radiculopathy?
- Age > 54
- Shoulder Abduction Test
- ULLT Median Nerve
- Symptoms peripheralize with CPA at C4 - C7
- Distraction test
What are the parameters for distraction when the patient meets the CPR for traction for Cervical Radiculopathy? (Duration? Position? Time on: Time off? Load?)
- 15 minutes
- Supine with 24 degrees of cervical flexion
- 60 seconds on: 20 seconds off (50 % of load in off time)
- Begin at 10 - 12 lbs, then increase if neccessary
What 2 exercises were combined with traction in treatment of Cervical Radiculopathy?
- Scap retraction to correct Forward Head Posture
- DNF Training
Describe side bend assessment.
- Lateral bend to same side with a localized medial pressure on the lateral articular pillars
What are 3 interventions for Neck Pain with Radiating Pain from the Clinical Practice Guidelines?
- Upper quarter and nerve mobilization procedures
- Traction
- Thoracic mobilization/ manipulation
Describe the upper quarter nerve mobilization procedure (not sure on this one).
- Cervical lateral glide in a neuromobilization position (ULTT)
