cervical spine Flashcards
1
Q
Whiplash associated disorders
A
- 80% of patients with WAD will reports symptoms up to 12 months
- 20-25% report severe disability
- little to no consistent evidence of boney or soft tissue injury
2
Q
Signs and symptoms of WAD
A
- pain
- stiffness
- HA
- sleep disturbance
- cognitive interference
- sensory hypersensitivity
- heightened distress and anxiety
3
Q
NEXUS criteria for imaging
A
- no posterior midline tenderness
- no evidence of intoxication
- a normal level of alertness
- no focal neurological deficit
- no evidence of a painful distracting injury (an injury thought to be painful enough to distract from a secondary neck injury)
4
Q
Canadian C-spine rules
A
- high risk factors
- -age >65 y/o
- dangerous MOI
- parasthesia in extremities
- low risk factors
- -simple rear-ended MVA
- -sitting position in ER
- -delayed onset of neck pain
- -absence of midline C-Spine tenderness
- -able to actively rotate >45 degrees
5
Q
Signs of neuropathy
A
- SLANSS score >12
- cold hypersensitivity
- allodynia or hyperalgesia
- non-mechanical patterns or symptoms
6
Q
Hypotropia
A
one eye deviated down
7
Q
Hypertropia
A
one eye deviated up
8
Q
Exotropia
A
one eye deviated out
9
Q
Esotropia
A
one eye deviated in
10
Q
Low risk WAD patients
A
- 25-30%
- educate, reassure, and follow from arms length
11
Q
Moderate risk WAD patients
A
- 50-65%
- advice, education and reassurance, watchful waiting with in person follow up.
12
Q
High risk WAD patients
A
- 10-20%
- identify primary risk profile and consider initiating early targeted intervention
13
Q
High confidence of risk factors for chronicity
A
- high pain >6/10
- high neck related disability
- post traumatic stress symptoms
- catastrophizing
- cold hypersensitivity
- mechanical hypersensitivity
14
Q
High confidence of no effect on outcome
A
- angular deformity of the neck
- impact direction
- seating position
- awareness of collision
- head rest in place
- older age
- vertical speed
15
Q
Predisposing factors for the development of chronic neck pain
A
- > 40 y/o
- co-existing LBP
- loss of strength in hands
- worrisome attitude
- poor quality of life
- long hx of neck pain
- cycling as a regular activity
- less vitality
16
Q
Risk factors for new onset neck pain
A
- female sex
- older age
- high job demands
- being an ex smoker
- low social or work support
- previous hx of neck or low back disorders
17
Q
Recovery from WAD timeline
A
- most of the recovery occurs within the first 6-12 weeks post injury with rate of recovery slowing afterwards.
18
Q
Individuals can follow 1 of 3 trajectories with recovery from WAD
A
- mild problems with rapid recovery 45%
- moderate problems with some but incomplete recovery 40%
- severe problems with no recovery 15%
19
Q
Risk factors for persistent problems when captured in acute or subacute WAD <6 weeks
A
- high pain intensity
- high self reported disability score
- high post traumatic stress symptoms
- strong catastrophic beliefs
- cold hyperalgesia
20
Q
Symptoms of cervical radiculopathy
A
- pain radiating into arm coupled with motor, reflex, and/or sensory changes in the upper limb
- parasthesia or numbness
- median nerve test may be useful
21
Q
Patients considered high risk for cervical fracture if…
A
- age >65 y/o
- dangerous MOI
- parasthesias in extremities
22
Q
Risk factors indicating safe cervical ROM assessment
A
- patient able to sit in emergency room department
- was in a simple rear-end MVC
- patient is ambulatory at any time
- delayed onset of neck pain
- no midline cervical spine tenderness
- patient able to actively rotate the head 45 degrees in any direction.
23
Q
Symptoms of cervical radiculopathy
A
- positive spurling
- positive traction/distraction test
- valsalva test
- negative neurodynamic test may rule it out
24
Q
Cervical flexion rotation test
A
- maximally flex cervical spine then rotate R and L
- (+) if restriction of ROM, ROM <32 degrees
- mean for healthy individuals = 39-45
- patients with cervicogenic HA = 20-28 degrees
25
4 categories to classify neck pain
1. neck pain with mobility deficits
2. neck pain with movement coordination impairments (including WAD)
3. neck pain with HA
4. neck pain with radiating pain
26
Neck pain with mobility deficits symptoms
- central and/or unilateral neck pain
- limitation in neck motion that consistently reproduces symptoms
- associated shoulder girdle or UE pain may be present
27
Neck pain with mobility deficits symptoms expected exam findings
- limited cervical ROM
- neck pain reproduced at end range active and passive motions
- restricted cervical and thoracic segmental mobility
- intersegmental mobility testing reveals characteristic restriction
- neck and referred pain reproduced with provocation of the involved cervical and upper thoracic segments or cervical musculature
- deficits in cervicoscapulothoracic strength and motor control may be present in individuals with subacute or chronic pain.
28
Neck pain with movement coordination impairments (WAD) common symptoms
- mechanism of onset linked to trauma or whiplash
- associated (referred) shoulder girdle or UE pain
- associated varied non specific concussive signs/symptoms
- dizziness/nausea
- HA, concentration, or memory difficulties, confusion, hypersensitivity to mechanical, thermal, acoustic, odor, or light stimuli, heightened affective distress
29
Neck pain with movement coordination impairments expected exam findings
- (+) cranial cervical flexion test
- (+) neck flexor endurance test
- (+) pressure algometry
- strength and endurance deficits of neck muscles
- neck pain with mid-range motion that worsens with end-range positions
- point tenderness may include myofascial trigger points
- sensorimotor impairment may include altered muscle activation patterns, proprioceptive deficits, postural balance or control
- neck and referred pain reproduced by provocation of involved segments
30
Neck pain with headaches common symptoms
- non continuous unilateral neck pain and associated HA
| - HA is precipitated or aggravated by neck movements or sustained positions/postures
31
Neck pain with headaches common exam findings
- (+) cervical flexion rotation test
- HA reproduced with provocation of the involved upper cervical segments
- limited cervical ROM
- restricted upper cervical segmental mobility
- strength, endurance, and coordination deficits of the neck muscles.
32
Neck pain with radiating pain common symptoms
- neck pain with radiating pain into involved UE
| - UE dermatomal paresthesia or numbness, and myotomal muscle weakness
33
Neck pain with radiating pain expected findings
- neck and neck related radiating pain reproduced or relieved with radiculopathy testing
- - (+) test cluster: upper limb mobility, spurling's test, cervical distraction, cervical ROM
- may have UE sensory, strength, or reflex deficits associated with the involved nerve roots
34
Treatment for acute neck pain with mobility deficits
- thoracic manipulation
- neck ROM exercises
- scapulothoracic and UE stretching and strengthening
- cervical manipulation/mobilization (C level)
35
Treatment for subacute neck pain with mobility deficits
- provide neck and shoulder girdle endurance exercises
| - may provide thoracic manipulation and cervical manipulation/mobilization
36
Treatment for chronic neck pain with mobility deficits
- thoracic manipulation and cervical manipulation/mobilization
- mixed exercise for cervical/scapulothoracic regions: neuromuscular exercise, stretching, strengthening, endurance training, aerobic conditioning, and cognitive affective elements
- dry needling, laser, or intermittent traction
- may provide trunk, shoulder girdle, and neck endurance exercises, patient education and counseling strategies.
37
Treatment for neck pain with movement coordination impairments
- education of the patient to: return to normal, nonprovocative preaccident activities ASAP, minimize use of collar, perform postural and mobility exercises to decrease pain and increase ROM
- reassurance to the patient that recovery is expected to occur within the first 2-3 months
- manual therapy
38
Chronic neck pain with movement coordination impairments
- patient education
- mobilization combined with an individualized, progressive submaximal exercise program with cervicothoracic strengthening, endurance, flexibility, and coordination
39
Treatment of neck pain with headache
- coordination
- strengthening
- endurance exercises
40
Treatment of acute neck pain with headache
- supervised instruction in active mobility exercises
| - may utilize C1-2 self SNAG exercise
41
Treatment of subacute neck pain with headache
- cervical manipulation and mobilization
| - C1-2 self SNAG exercises
42
Chronic neck pain with headache
- cervical or cervicothoracic manipulationor mobilizationcombined with shoulder girdle and neck stretching, strengthening, and endurance exercises
43
Treatment for neck pain with radiating pain
- use upper quarter and nerve mobilizations
- specific repeated movements to promote centralization
- mechanical intermittent cervical traction combined with manual therapy, strengthening exercises
44
Treatment of acute neck pain with radiating pain
- mobilizing and stabilizing exercises, laser, short term use of a cervical collar
45
Treatment of chronic neck pain with radiating pain
- mechanical intermittent cervical traction, combined with stretching and strengthening exercise, cervical and thoracic mobilization/manipulation
- education and counseling
46
Low or very low effect with the following for WAD
- TENS
- ER education
- ROM exercises
- thoracic manipulation
- massage
- NSAIDs and acetaminophen
- active interventions improve recovery but parameters unclear.
47
Some evidence supports the use of the following for WAD
- ROM
- low load isometrics
- postural endurance and strengthening exercises
- may use neuro re-ed as well
48
3 trajectories of acute WAD
- rapid complete recovery 20-30%
- slow-recovery 55-60%
- non-recovery, chronic disability 10-15%
49
Chronic WAD
- 50% with WAD report symptoms 12 months later, 20% will report severe disability or interference
50
Chronic WAD symptoms may be due to...
- maladaptive beliefs and cognitions
- stress system dysregulation
- genetic vulnerability
- injury to CNS
51
Low to moderate confidence for treatment of WAD
- exercise
- combined strength/ROM/flexibility programs
- yoga
- cervical manipulation, similar outcomes to K-tape
- acupuncture or dry needling
- intermittent traction (short term benefits)
- scapulothoracic endurance training
52
Muscle function and coordination are disturbed in chronic and acute WAD
- increased fatty infiltrate
- not seen in non-traumatic
- some evidence shows targeted exercise can address the muscle structures
53
Indications for cervical flexor training
- functional issues
- -> poor active control of cervical extension in upright posture
- -> forward head postures
- -> difficulties lifting head off bed
- patient responds well to cervical flexion exercises
54
Indications for extensor training
- functional issues
- -> poor active control of upright cervical flexion
- -> forward head posture
- -> prominent reports of sensorimotor disturbances and positive sensorimotor tests
- patient responds positively following extension exercises.
55
Fatty infiltration
- higher in cervical extensors and appears greatest in the non-recovered WAD group
- clinical observation of altered kinematics may be explained by increased fatty infiltration
56
Facet involvement in WAD
- about 60% of patients with WAD may have pain from the facet joints
- most common facets injured are C2/3 and C5/6
57
C2/3 facet referral pattern
-occipital region
58
C2/3, C3/4 facet referral pattern
- sub occipital region
59
C3/4, C4/5 facet referral pattern
- lower cervical region
60
C4/5, C5/6, C4, C5 facet referral pattern
- cervicothoracic region
61
C4/5, C5/6, C4 facet referral pattern
- upper trap/cervicothoracic region
62
C6/7, C6, C7 facet referral pattern
- rhomboids/upper trapezius
63
C7/T1, C7 facet referral pattern
- rhomboids/lower trapezius
64
Cervical ligaments
- alar ligament connect the sides of the dens to tubercles on the medial side of the occipital condyle. Check side to side movement when the head is turned
- transverse ligament prevents anterior displacement of C1 and C2
65
Anterior neck muscles
- sternocleidomastoid
- scalenes
- platysma
- hyoids
- deep neck flexors
66
Posterior neck muscles
- upper trapezius
- levator scapula
- paravertebrals
- suboccipitals
67
Kinematics of atlanto-occipital joint
- allows for flexion and extension
68
Kinematics of atlanto-axial joing
- provides rotation, about 50% of all rotation comes from this joint
69
Cervical side bending kinematics
- atlas may slide a little in the direction of the weight of the head
- no true side bending at AA joint
- occurs with facet gliding during SB C2-C7
- -> SB R, ipsilateral side moves inferiorly, contralateral side moves superiorly
70
Cervical ROM
- flexion: 80-90 degrees
- extension: 70 degrees
- side bend: 20-45 degrees
- rotation: 70-90 degrees
71
-5 D's AND, 2 N's
```
5 D's
- dizziness
- diplopia
- drop attacks
- dysarthria
- dysphagia
AND
- ataxia
- anxiety
2 N's (provoked with cervical movements)
- nausea
- numbness
- nystagmus
```
72
Red flags of headache
- sudden onset of severe HA (not likely referred to PT for this)
- worsening or changing symptoms without known cause (neurological signs, dizziness)
- headache triggered by cough, valsalva, exertion (subarachnoid hemorrhage, mass lesion)
- headache triggered during pregnancy, delivery, post-partum (carotid A dissection, pituitary apoplexy, corticol vein/cranial sinus thrombosis
- onset of HA >50 y/o
73
Yellow flags with HA
- FABQ
| - behaviors (extended rest, withdrawal from ADLs, high reported pain score, excessive use of aides, self medication)
74
Differential diagnosis of HA
- cervical arterial dysfunction
- upper cervical instability
- pancoast tumor
- cervical myelopathy
- neck pain with radiating pain
- neck pain with movement coordination impairments
- neck pain with mobility deficits
75
Vertebral artery
- 11% of cerebral blood flow
- supplies posterior cranial circulation
- greatest stress with upper cervical rotation
76
Carotid artery
- 89% of cerebral blood flow
- supplies anterior cranial circulation
- greatest stress with mid cervical extension
77
Risk factors for arterial dysfunction
- female ages 30-39
- hx of migraines
- oral contraceptive use
- diabetes
- hypertension
- hx of smoking
78
Clinical features of vertebral A dissection
- non-ischemic (local) signs and symptoms
- -> ipsilateral posterior neck pain and occipital HA
- -> C2-C6 cervical nerve root impairment (rare)
79
Hind brain TIA
- 5 D's, nausea, nystagmus, facial numbness, ataxia, vomiting, hoarseness, short-term memory loss
- limb weakness, anhidrosis, hearing disturbances, malaise, perioral dysthesia, photophobia, papillary changes, clumsiness, and agitation
80
Hind brain stroke
wallenberg's syndrome
- hoarseness
- dizziness, nausea, and vomiting
- rapid involuntary eye movements
- difficulty with balance and gait coordination
- problems with body temperature sensation
- lack of pain and temperature sensation on one side of the face, or different symptoms on each side of the body
- uncontrollable hiccups
- loss of taste on one side of the tongue
- decreased sweating
- changes in HR and BP
81
Non-ischemic (local) signs and symptoms of internal carotid dissection
- horner's syndrome, ptosis (falling of upper eyelid), anhydrosis, miosis (constricted pupil), facial flushing, enopthalmas (retracted eyeball)
- pulsatile tinnitus
- cranial nerve palsies (usually 9-12)
82
Ischemic (cervical or retinal signs and symptoms) of internal carotid dissection
- TIA
- ischemic stroke
- retinol infarction
- greatest stress with mid cervical extension
83
Clinical presentation of cervical instability
- spinal cord signs
- C1-2 instability influences spinal cord stability and cuase signs of cervical myelopathy
- occipital HA and numbness
- movement limitations (often severe) d/t protective muscle spasms
- locking of neck with certain movements
- crepitations
- insufficient muscle control
- often feel better in AM than PM
84
Symptoms of cervical myelopathy
- instability walking/balance problems/stumbling
- ataxia
- sensory loss/motor loss in patchy distribution
- loss of bowel/bladder control
- hyperreflexia
- pathological reflexes (babinski, clonus, hoffman's)
85
Klippel Fiel Syndrome
- congenital fusion of any two of seven vertebrae. Can be single or multiple levels
86
Ehlers Danlos syndrome
- connective tissue disorder leads to decreased stability
87
Arnold chiari malformation
- downward displacement of cerebellar tonsils through foramen magnum
- spinal cord compression symptoms
- decompression surgery
- often leads to chronic HA
- most often congenital but may be due to ehlers danlos syndrome or marfans
88
Neurological exam
- cranial nerves
- myotomes
- dermatomes
- upper motor neuron testing (babinski, hoffman's, clonus, rhomberg)
- cervical AROM and PROM
- special tests (sharp purser, transverse ligament test, alar ligament test)
89
Positive sharp's purser test
- dorsal movement of occiput and C1
- possibly a click or clunk
- reduction in symptoms
- a stable segment should not allow any movement with a hard elastic end feel
90
Cervical radiculopathy
- disease of cervical spine root, most often caused by cervical disc herniation or other space occupying lesion resulting in nerve root impingement, inflammatory or both.
- strength loss in myotomal distribution, sensory loss in dermatomal distribution. Diminished or absent reflexes.
91
Pancoast tumor
- tumor of apical lung
- can involve caudad cervical nerve roots
- can initially mimic cervical radiculopathy
- typically smokers
- horner's syndrome (develps due to secondary sympathetic nervous system damage)
92
Cervical myelopathy
- can occur d/t cervical spondylosis
- long tract signs (weakness, spasticity, hyper reflexia)
- lhermitte's sign: cervical flexion produces electrical sensation from spine into extremities.
93
Cervical myotomes
- C4: shoulder shrugging
- C5: shoulder ABD
- C6: biceps and wrist extension
- C7: triceps
- C8: finger flexion
- T1: finger inter ossei
94
Individuals with cervical radiculopathy likely to respond to PT
- age <54 y/o
- dominant arm not affected
- looking down doesn't aggravate symptoms
- multimodal prescription for 50% of visits (OMPT, traction, DNF strengthening)
- -> 3 variables present: +LR=5.2
- -> 4 variables present: +LR=8.3
95
Those likely to respond to cervical traction
- age >55 y/o
- shoulder ABD test
- ULTT A
- symptom peripheralization with lower cervical C4-C7 P-A motion testing
- neck distraction test (>4 variables present: +LR=11.7)
96
Traction parameters
- 15-24 degrees of flexion
- 60 seconds on, 20 seconds off (50% pull during off time)
- 10-12 lbs of pull initially
- -> adjusted to optimally decrease symptoms
- -> moderate to strong to strong without aggravation
- -> max pull of 40 lbs
- -> any pull 23 lbs
- 15 minutes duration
- f/u with exercise
- 6 sessions over 3 weeks
97
Cervical headache
- a HA arising from dysfunction or inflammation of the musculoskeletal structures of the upper cervical spine. Most common symptom following head or cervical trauma
98
Cervicogenic HA symptoms
- unilateral HA with neck/suboccipital symptoms aggravated by movement
- HA produced/aggravated with provocation of ipsilateral posterior cervical myofascia and joints
- restricted cervical ROM
- restricted segmental mobility
- abnormal/substandard performance on cranial cervical flexion test
99
Migraines
- prevalence 10%
- occurs upon waking or later in the day
- lasts 4-24 hours
- increased sensitivity to light, noise, and tension
- nausea, vomiting
- may be triggered by vomiting
100
Classic or neurologic migraine
- aura, vision loss, weakness, vertigo
101
Cluster HA's
- unilateral
- usually male
- nocturnal
102
Tension HA's
- bilateral symptoms
- moderate intensity
- pressure without throbbing
- tightness or aching
- lasts 30 min-7 days
- provoked by fatigue, nervous strain, depression, anxiety
103
Meningeal criterion
- meningitis/subarachnoid bleed
- steady, deep pain, generalized, bioccipital, frontal
- single episode, rapid evolution, hours to minutes
- neck stiffness bending forward
- (+) kernig sign (unable to perform SLR d/t neck pain)
- (+) brudzinski sign (supine head flexion leads to flexion of LE)
- (+) Llhermitte's sign (cervical flexion in sitting leading to electric shock to LE)
