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OCS > Cervical Spine > Flashcards

Cervical Spine Flashcards

1
Q

Neck pain risk factors

A

Female, >40 yo, coexisting LBP, long/prior history of neck pain, cycling as regular activity, loss of strength in the hands, worrisome attitude, poor QOL, less vitality, smoking history.

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2
Q

Clinical course of neck pain

A

Variable
High rate of recurrence/chronicity (50% fully recover within 1 year). Episodic coures is most common.
~6 mo average for clinically meaningful decrease in pain intensity
Recovery appears to happen most rapidly in first 6-12 weeks, with rate of recovery slowing considerably after this window.

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3
Q

Risk factors for persistent problems when captured in acute or subacute WAD (<6 weeks from injury)

A
  1. High pain intensity
  2. High self-reported disability scores
  3. High post-traumatic stress symptoms
  4. Strong catastrophic beliefs
  5. Cold hyperalgesia
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4
Q

Risk factors for persistent problems in work-related or nonspecific neck pain

A
  1. Prior history of other MSK disorders

2. Older age

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5
Q

When imaging is indicated according to neck pain classification (in the absence of red flags):

A
  1. With mobility deficits - not indicated
  2. With radiating pain - MRI if non-resolving. CT to ID bony injury or ligamentous disruption.
  3. With movement coordination impairment - Should not use MRI to examine alar or transverse ligaments as routine work up.
  4. Painful and traumatic myelopathy - MRI
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6
Q

When imaging is indicated according to neck pain classification (in the absence of red flags):

A
  1. With mobility deficits - not indicated
  2. With radiating pain - MRI if non-resolving. CT to ID bony injury or ligamentous disruption.
  3. With movement coordination impairment - Should not use MRI to examine alar or transverse ligaments as routine work up.
  4. Painful and traumatic myelopathy - MRI
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7
Q

What constitutes a positive cervical flexion-rotation test?

A

rotation <32 degrees, or 10 degrees reduction of either side.

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8
Q

Findings in patients with neck pain with mobility deficits

A
  1. Central and/or unilateral neck pain
  2. Limitation in neck motion that consistently reproduces symptoms. Pain reproduced at END RANGE of A/PROM.
    (Associated shoulder girdle or UE pain may be present)
  3. Restriction and reproduction of pain with segmental mobility testing. Pain may also be reproduced with provocation of cervical musculature. Primarily concerned with lower c-spine (C3-7)
  4. Deficits in cervicoscapulothoracic strength and motor control may be present in individuals with subacute or chronic neck pain.

Acute pts often have onset linked to recent unguarded/awkward movement or position

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9
Q

Findings in patients with neck pain with movement coordination impairment (WAD)

A
  1. Mechanism of onset linked with trauma/whiplash
  2. Associated shoulder girdle or UE pain
  3. Associated varied nonspecific concussive signs/symptoms, dizziness, nausea, headache
  4. Positive cranial cervical flexion test
  5. Positive neck flexor muscle endurance test
  6. Positive pressure algometry
  7. Neck pain with MIDRANGE motion that worsens with END RANGE
  8. Point tenderness, trigger points
  9. Sensorimotor/ proprioception impairment
  10. Pain reproduced by provocation of involved cervical segments.

Often more chronic in nature in clinic

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10
Q

Findings in patients with neck pain with headache

A
  1. Noncontinuous, unilateral neck pain and associated headache
  2. Headache precipitated by neck movements or sustained positions/postures.
  3. Positive cervical flexion-rotation test
  4. HA reproduced with provocation of upper cervical segments
  5. Limited cervical ROM, especially upper cervical
  6. Limited strength/endurance/coordination of neck muscles.
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11
Q

Findings in patients with neck pain with radiating pain

A
  1. Neck pain with radiating (narrow, lancinating pain) into UE.
  2. UE dermatomal paresthesias or numbness, myotomal weakness
    • radiculopathy testing (ULTT, Spurlings, distraction, rotation ROM - 3+ positive)
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12
Q

Neck pain prevalence, demographics, etc.

A
  • 25% of patients seen in PT
  • Most common in females, 5th decade
  • 25% experience recurrence within one year. 30% develop chronic sxs
  • Cost associated is second only to lumbar pain in annual worker’s comp costs in US.
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13
Q

Upper cervical ligaments

A

Alar ligaments: From dens to occiputal condyles (one on each side)
Cruciform ligaments: Includes transverse ligament.
Transverse ligament: Attaches on either side of C1, wraps around dens.

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14
Q

Function of ligamentum nuchae

A

Increases depth of cervical spinous processes for muscular attachment.
Limits flexion ROM

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15
Q

Scalene attachments/role in relation to ribs

A

Anterior and middle scalenes: Attach to first rib.
Posterior scalenes: Attach to second rib.

Elevates ribs when neck is fixed.

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16
Q

What muscles does C2 nerve run through?

A

Semispinalis cervicus. Entrapment of the nerve can lead to greater occipital neuralgia.

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17
Q

Arthrokinematics of c-spine

A

Not well understood. No consensus as to what actually occurs.

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18
Q

What to do if you have a patient with suspected bactrial meningitis

A

Refer pt for immediate medical management.

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19
Q

Candian C-spine rules

A
  1. X-Rays required if patient has 2+ high risk factors (65+, paresthesias in extremities, dangerous mechanism of injury)
  2. If <2 high risk factors, check if they are appropriate for ROM assessment. (Can assume seated position, can walk, delayed onset of pain, no midline tenderness, low impact MVA).
    - If they aren’t appropriate for ROM assessment > Xray
  3. Assess ROM. If <45 deg in one direction > Xray
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20
Q

What does use of intravenous drugs put patient at increased risk for?

A

Sepsis, septic arthritis

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21
Q

MCID for numeric pain rating scale

A

1.3

MDC = 2.1

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22
Q

NDI MCD

A

10 points (out of 50)

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23
Q

Patient-specific functional scale vs. NDI

A

PSFS is more responsive. May be more meaningful for patients.

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24
Q

FABQ

A

Work subscale has the best corelation with NDI.

Higher score = higher FAB = higher risk for prolonged disability.

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25
Q

Upper cervical instability tests

A

Sharp purser = Transverse ligament (cruciform)

  • Positive: head moves posteriorly without axis moving; reproduction of sxs during flexion; decrease in sxs with posterior force.
  • 69% Sn, 96% Sp

Alar ligament test
- Positive: Delay in movement of spinous process of C2

*Pts with instability can initially present like patients with mobility deficit. Make sure to screen for instability.

26
Q

Evidence for VBI testing/ correlation with HVLA

A
  • No evidence of excess risk for stroke with cervical HVLA, no link with occurrence of serious adverse events.
  • Negative VBI testing may neither predict the absence of arterial pathology NOR the propensity of artery to be injury during HVLA. (Neither Sn or Sp)
  • If there is high suspicion of VBI based on patient’s history, passive end range provocative testing should be avoided, pt referred.
27
Q

Sxs that should > suspicion of VBI

A 
Vertigo
Tinnitus
Dizziness
Visual-perceptual disturbances
Fainting

Most common sx of vertebral artery dissection = pain in head and neck, usually unilateral and suboccipital. 25% have sudden onset of pain.

28
Q

Most common cause of suddent onset VBI

A

High velocity, flexion-distraction and rotational trauma. Proceed with heightened suspicion of VBI in any patient with hx of this type of trauma.

29
Q

When not to stretch upper trap

A

Patient presents with depressed/ downwardly rotated scapula. Trap is already lengthened.

30
Q

Typical starting point for most patients with mobility deficit

A

Mobility interventions. Progress to stability exs to maintain mobility gains as needed.

31
Q

Mechanism of pain relief with manual therapy

A

Stimulating descending inhibitory pain mechanisms - particularly PAG area.

32
Q

Thrust vs. nonthrust manual therapy

A

Thrust patients almost always do better.

33
Q

Predictors of positive response to cervical spine manipulation

A

Tseng study (4+ positive):

  1. Initial NDI <11.5
  2. Bilateral pain
  3. Do not perform sedentary work >5 hours per day
  4. Feel better when moving the neck
  5. Extension does not increase pain
  6. Have dx of spondylosis without radiculopathy

Puentedura study (3+ positive):

  1. Sxs <38 days
    • Expectation of manipulation efficacy
  3. > 10 degree difference side to side rotation ROM
  4. Pain with PA spring testing of middle c-spine
34
Q

CPG for positive response to thoracic manipulation

A

3+ present

  1. Sxs <30 days
  2. No sxs distal to shoulder
  3. Extension does no increase pain
  4. <12 FABQ
  5. Diminished upper thoracic kyphosis
  6. Cervical extension AROM <30 deg.
35
Q

Normal upper cervical rotation AROM

A

39-45 degrees

36
Q

Normal cervical rotation that occurs at each level below C1-2

A

4-8 degrees

37
Q

Objective findings to differentiate patients with migraines vs. cervicogenic HA

A

Pts with cervicogenic HA have less ROM into flexion and extension and upper cervical hypomobility (joint and muscle)

38
Q

Normal/ Abnormal performance on cranial cervical flexion test

A

Normal: Increase in pressure 16-30 mmHg, maintained for 10 seconds.
Abnormal:
- Unable to generate an increase in pressure at least 6 mmHg
- Unable to hold generated pressure for 10 seconds
- Uses superficial neck muscles
- Sudden movement of chin or extending neck forcefully against the pressure device.

39
Q

Neck flexor muscle endurance test

A

Stopped when pt loses skin fold or touches therapist’s hand for >1 second.

Mean time for patients without pain: 39 seconds.
Mean time for patients with pain: 24 seconds.
Mean time for men: 39 seconds.
Mean time for women: 29 seconds.

(Study also found sedentary patients had better score than active patients, but smaller sample size)

40
Q

Assessment of muscle length in patients with sprain/strain

A

Typically not indicated.

41
Q

Single best neurological screen for cervical radiculopathy

A

Biceps DTR

42
Q

Best screen for cervical radiculopathy

43
Q

Predictors of patients most likely to achieve success with PT

A
  1. Age <54 years
  2. Dominant arm not affected
  3. Sxs do not worsen with looking down
  4. Tx including manual therapy, cervical traction, and DNF strengthening for at least 50% of visits.
44
Q

Predictors of patients likely to respond well to intermittent cervical traction

A
  1. Peripheralization with lower cervical spine mobility testing
  2. Positive shoulder abduction sign
  3. Age > 55 years
  4. Positive ULTTA
  5. Relief of sxs with manual distraction test.
45
Q

Interventions for neck pain with mobility deficit - ACUTE

A

B: Should do thoracic manipulation, program of neck ROM exercises, and scapulothoracic and upper extremity stretching and strengthening

C: May do cervical manipulation/moblization

46
Q

Interventions for neck pain with mobility deficit - SUBACUTE

A

B: Should provide neck and shoulder girdle endurance exercises
C: May provide thoracic/cervical manual

47
Q

Interventions for neck pain with mobility deficit- CHRONIC

A

B: should include multimodal approach of:

  • Thoracic and cervical manual
  • Cervical/scapulothoracic NMR, stretching, strengthening, endurance training, aerobic conditioning,
  • Dry needling, laster, intermittent traction

C: May counsel patient on active lifestyle, cognitive/affective factors.

48
Q

Interventions for neck pain with MCD/WAD- ACUTE

A

B: Education to return to normal activity, postural and mobility exercises (for pain and mobility), education that recovery is expected within 2-3 mo
B: Multimodal approach of manual, exercise for patients expected to have slow recovery
C: For patients at low risk for chronicity, may provide single session of early advice/ exercise instruction, TENS
F: Monitor status to ID delayed recovery

49
Q

Best self report questionnaire to predict future disability

50
Q

Craniocervical flexion training va. Cervical endurance training

A

Craniocervical flexion resulted in better improvements in pain/ function

51
Q

Interventions for neck pain with MCD/WAD - CHRONIC

A

C: Patient education/encouragement
C: Mobilization + submaximal exercise program
C: TENS

52
Q

Interventions for neck pain with HA - ACUTE

A

B: AROM
C: C1-2 self-SNAGs

53
Q

Interventions for neck pain with HA - SUBACUTE

A

B: Cervical manual
C: C1-2 self-SNAGs

54
Q

Interventions for neck pain with HA - CHRONIC

A

B: Manual (cervical or CT) + Shoulder girdle and neck stretching/strengthening/ endurance.

55
Q

Interventions for neck pain with radiating pain - ACUTE

A

C: Mobility and stability exercises, laser, short term us of collar

56
Q

Interventions for neck pain with radiating pain - CHRONIC

A

B: Mechanical intermittent traction in combo with exercises and manual
B: Education/counseling for active/normal lifestyle

57
Q

% of patients expected to follow each trajectory for WAD

A

40-45% mild disability
40-45% moderate improving to mild
16% chronic

58
Q

Orientation of facet joints in each part of the spine

A

Cervical spine: 45 degrees to the transverse plane, more parallel to frontal plane than other regions. Allows for more rotation and side bending.

Thoracic Spine: Increasingly more sagittal down the spine

Lumbar: Most sagittal orientation

59
Q

Cervical myelopathy CPR

A
  1. Gait deviation
  2. Positive Hoffmann’s test
  3. Positive inverted supinator sign
  4. Positive Babinski test
  5. Age > 45 years
60
Q

Well’s Criteria scores

A

> 3: High Probability
1-2: Moderate Probability
0: Low Probability

OCS (8 decks)

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