Cervical Spine

Question 1

Neck pain risk factors

Answer 1

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.

Question 2

Clinical course of neck pain

Answer 2

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.

Question 3

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

Answer 3

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

Question 4

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

Answer 4

1. Prior history of other MSK disorders

2. Older age

Question 5

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

Answer 5

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

Question 6

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

Answer 6

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

Question 7

What constitutes a positive cervical flexion-rotation test?

Answer 7

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

Question 8

Findings in patients with neck pain with mobility deficits

Answer 8

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

Question 9

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

Answer 9

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

Question 10

Findings in patients with neck pain with headache

Answer 10

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.

Question 11

Findings in patients with neck pain with radiating pain

Answer 11

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

Question 12

Neck pain prevalence, demographics, etc.

Answer 12

• 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.

Question 13

Upper cervical ligaments

Answer 13

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.

Question 14

Function of ligamentum nuchae

Answer 14

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

Question 15

Scalene attachments/role in relation to ribs

Answer 15

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

Elevates ribs when neck is fixed.

Question 16

What muscles does C2 nerve run through?

Answer 16

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

Question 17

Arthrokinematics of c-spine

Answer 17

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

Question 18

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

Answer 18

Refer pt for immediate medical management.

Question 19

Candian C-spine rules

Answer 19

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

Question 20

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

Answer 20

Sepsis, septic arthritis

Question 21

MCID for numeric pain rating scale

Answer 21

1.3

MDC = 2.1

Question 22

NDI MCD

Answer 22

10 points (out of 50)

Question 23

Patient-specific functional scale vs. NDI

Answer 23

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

Question 24

FABQ

Answer 24

Work subscale has the best corelation with NDI.

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

Question 25

Upper cervical instability tests

Answer 25

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.

Question 26

Evidence for VBI testing/ correlation with HVLA

Answer 26

- 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.

Question 27

Sxs that should > suspicion of VBI

Answer 27

``` 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.

Question 28

Most common cause of suddent onset VBI

Answer 28

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

Question 29

When not to stretch upper trap

Answer 29

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

Question 30

Typical starting point for most patients with mobility deficit

Answer 30

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

Question 31

Mechanism of pain relief with manual therapy

Answer 31

Stimulating descending inhibitory pain mechanisms - particularly PAG area.

Question 32

Thrust vs. nonthrust manual therapy

Answer 32

Thrust patients almost always do better.

Question 33

Predictors of positive response to cervical spine manipulation

Answer 33

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 2. + Expectation of manipulation efficacy 3. >10 degree difference side to side rotation ROM 4. Pain with PA spring testing of middle c-spine

Question 34

CPG for positive response to thoracic manipulation

Answer 34

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.

Question 35

Normal upper cervical rotation AROM

Answer 35

39-45 degrees

Question 36

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

Answer 36

4-8 degrees

Question 37

Objective findings to differentiate patients with migraines vs. cervicogenic HA

Answer 37

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

Question 38

Normal/ Abnormal performance on cranial cervical flexion test

Answer 38

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.

Question 39

Neck flexor muscle endurance test

Answer 39

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)

Question 40

Assessment of muscle length in patients with sprain/strain

Answer 40

Typically not indicated.

Question 41

Single best neurological screen for cervical radiculopathy

Answer 41

Biceps DTR

Question 42

Best screen for cervical radiculopathy

Answer 42

ULTTA

Question 43

Predictors of patients most likely to achieve success with PT

Answer 43

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.

Question 44

Predictors of patients likely to respond well to intermittent cervical traction

Answer 44

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.

Question 45

Interventions for neck pain with mobility deficit - ACUTE

Answer 45

B: Should do thoracic manipulation, program of neck ROM exercises, and scapulothoracic and upper extremity stretching and strengthening C: May do cervical manipulation/moblization

Question 46

Interventions for neck pain with mobility deficit - SUBACUTE

Answer 46

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

Question 47

Interventions for neck pain with mobility deficit- CHRONIC

Answer 47

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.

Question 48

Interventions for neck pain with MCD/WAD- ACUTE

Answer 48

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

Question 49

Best self report questionnaire to predict future disability

Answer 49

FABQ

Question 50

Craniocervical flexion training va. Cervical endurance training

Answer 50

Craniocervical flexion resulted in better improvements in pain/ function

Question 51

Interventions for neck pain with MCD/WAD - CHRONIC

Answer 51

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

Question 52

Interventions for neck pain with HA - ACUTE

Answer 52

B: AROM C: C1-2 self-SNAGs

Question 53

Interventions for neck pain with HA - SUBACUTE

Answer 53

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

Question 54

Interventions for neck pain with HA - CHRONIC

Answer 54

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

Question 55

Interventions for neck pain with radiating pain - ACUTE

Answer 55

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

Question 56

Interventions for neck pain with radiating pain - CHRONIC

Answer 56

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

Question 57

% of patients expected to follow each trajectory for WAD

Answer 57

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

Question 58

Orientation of facet joints in each part of the spine

Answer 58

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

Question 59

Cervical myelopathy CPR

Answer 59

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

Question 60

Well's Criteria scores

Answer 60

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