CERVICAL SPINE Flashcards
1
Q
In the cervical spine if you do Right side flexion you will get _____ rotation
A
Right
2
Q
Where do cervical disc issues refer to
A
medial border of scapula
3
Q
What is the purpose of a cervical scan
A
- Out rule serious pathology e.g. Tumour, #, vertebral artery compromise
- Determine suitability for physiotherapy treatment
- Zero in on the appropriate area
- Formulate a treatment plan that may include co-treatment with physician
4
Q
When should a cervical scan be performed
A
for every patient with neck pain or upper extremity pain (apart from those with obvious local injury)
5
Q
Components of a subjective cervical scan
A
- Name
- Age
- Occupational demands
- Activity levels
- Insideous or traumatic? Forces + movement involved?
- Aggravating + easing
- Onset of pain
- Pain location + behaviour
- Diurnal variation
- Visual analog scale
- Effect on ADL, work, leisure
- Sleep, sleep setup
- PMhx
- Previous treatment and response
- Fhx
- Meds
- General health
- Investigations AND results
- Mandtory questions
- Bilateral or quadrilateral paraesthesis or anaesthesia
- Bowel and bladder symptoms
- Neuro symptoms
- 5Ds + 2Ns
- Headaches or upper respiratory tract infections
6
Q
What would indicate a cervicogenic headache
A
- One sided
- Restricted ROM one way
- Point tenderness on cervicogenic PIVMs
7
Q
Why do you ask about recent upper respiratory tract infections?
A
Ligament laxity
8
Q
What is included in a cervical scan objective
A
- Active ROM tests (upper and mid cervical)
- Clear UE with scratch test
- Special active tests
- Passive tests
- Cervical muscle tests
- Neurological tests
- Arterial patency tests
- Traction + compression
- Craniovertebral stability tests
- Palpation
- PA Pressures
9
Q
What do you note when doing active ROM tests
A
- Willingness to move
- Axis of movement
- ROM
- Pain
10
Q
What is the special active test you include in a cervical scan
A
Foraminal compression test or Spurlings
11
Q
What is the active motion in a Spurlings test
A
Extension, ipsilateral SF and Rotation
12
Q
A spurlings test will be symptomatic in which patient group
A
Compromised foramen or irritable nerve root
13
Q
When would you consider doing a passive overpressure in a cervical scan
A
If there is pain free active ROM and the subjective history is not indicative of an irritable condition or neurologic, ligamentous, or vascular damage
14
Q
When should you do cervical muscle tests
A
Following assessment of stability and ability to contract deep neck flexors
15
Q
when conducting cervical muscle tests, what could the finding of painful weakness of the short neck flexors indicate?
A
Serious pathology in that region such as isntability or fracture
16
Q
What is a contraindication to testing cervical muscles
A
Presence of 5Ds
17
Q
What is included in the neurological tests of a cervical scan
A
- Dural mobility (slump, SLR, UL tension tests)
- Cord tests (plantar response + clonus)
- Conduction tests = motor, sensory, reflexes
18
Q
What is weakness of the hand intrinsics not typically associated with? What may be a serious cause?
A
Not associated with disc pathology in cervical spine
Serious cause: tumour at apex of lung
19
Q
What are the arterial patency tests included in the cervical spine scan
A
- Upper limb pulses
- Vertebral artery tests
20
Q
What are the 3 craniovertebral stability tests included in the cervical scan
A
Anterior
Vertical
Rotation
21
Q
- Neck disability index ? Scoring? clinically important change? What does it not take into account?
A
- Outcome measure
- 50 points = 100% patient rated max disability
- CIC : 5 points
- Does not take into account emotional or psychological factors
22
Q
What is the best way to correct posture
A
Cueing sternum up
23
Q
What region of the cervical spine does rotation occur in
A
Craniovertebral
24
Q
What region of the cervical spine does side flexion occur in
A
mid cervical
25
how do you cue for craniovertebral extension
Jut chin out and look up at a 45 degree angle
26
How do you cue for craniovertebral flexion
chin to adams apple
27
how do you cue for craniovertebral side flexion
ear to neck
28
How do you cue for craniovertebral rotation
Hard to isolate
29
Is a difference side to side of the scratch test normal?
yes
30
What is a sign to stop spurlings
arm pain at any point in the test
31
What is the expected response in alar ligament testing
for the SP of C2 to move the opposite direction
32
What is a positive on a craniovertebral stability test
- Spinal cord symptoms
- Vertebral artery symptoms
- Pain
- Laxity
- Empty end feel
33
What is needed to rule in a radiculopathy (nerve compression)?
- Positive spurlings
- Relief with traction
- Loss of ipsilateral rotation
34
What can rule of a nerve compression?
- negative ULTT
35
What are the Canadian Cspine Xray rules?
- Age >65
- Dangerous mechanism
- Unable to achieve 45 degrees of rotation left and right, paraesthesia in extremities
36
What is a positive neurodynamic test
- Reproduction of the patients symptoms and/or
| - Restriction of mobility when compared with the opposite side
37
What should you do following a positive neurodynamic test
- Educate patient to stay out of positions of neural tension
- Mobilise the nervous system grade 1-3
- Continually monitor symptoms
- Treat based on irritability of the condition
- Remember the latent effect of neural mobilisations
- Always treat interface
38
What are contraindications to neurodynamic testing
- Neurological signs
- Condition worsening
- Undiagnosed condition
- Spinal cord or cauda equina compromise
39
What is the normal response of a median nerve bias neurodynamic test
- Stretch sensation in the antecubital fossa
| - Tingling in thumb and first 3 fingers
40
What is the normal response of a radial nerve bias neurodynamic test
- Stretch sensation in lateral forearm
| - Stretch or pain in the lateral upper arm
41
What is the normal response of an ulnar nerve bias neurodynamic test
- Stretch pain hypothenar eminence and med 2 fingers
| - Pins and needles same distribution
42
Do you depress the scapula in median nerve bias 1
No just prevent it from elevating
43
What are the known positions of vertebral artery compromise
Extension
Rotation
Traction
44
When do you complete craniovertebral stability tests
- As part of cervical scan
| - Always prior to manual therapy techniques of the craniovertebral region
45
What is a positive finding on a craniovertebral stability test
- Soft end-feel with pain and/or spasm
- Lump in the throat/shortness of breath
- Spinal cord signs
- Vertebral artery signs
46
What may be another cause for the sensation of a lump in the throat/shortness of breath
swelling post MV
| Retropharyngeal haematoma
47
What is the process of events if a positive is found on a craniovertebral stability test
- Pt put in hard collar
| - Referred back to doctor for possible MRI, open mouth X-ray, orthopaedic consult and stabilisation
48
In the anterior (sharp purser/supine anterior shear) tests what structures are being tested
Transverse ligament
| Dens
49
In the Vertical stability test what structures are being tested
- Tectorial membrane
- AO
- AA anter and post membranes
- All vertically orientated ligaments
50
In the rotational kinetic stability test what structures are being tested
alar ligament
| joint capsule
51
What are the two anterior stability tests
Sharp purser test
| Supine anterior shear tests
52
Do not do the anterior shear test if what other test is position
Sharp purser
53
On the sharp purser, if positive when the patient actively flexes the neck what occurs at the bones
produces an anterior subluxation of C1 on C2
54
In the anterior shear test what do you move anteriorly
Occiput and C1
55
In the vertical stability test for the CV complex - what is being stabilized
C2
56
What ligament is the kinetic test testing
alar ligament
57
On the kinetic test what would indicate a torn alar ligament
Lack of or delayed movement
58
What is the therapist role in the alar ligament stability test
Fix the lamina of C2 preventing SF or Rotation
| Other hand passively SF head about a saggital axis
59
What are the mid cervical stability tests
Vertical (compression + traction - fix caudal vertebra)
| A/P
60
What would lead you to be cautious when doing mid cervical stability tests
- Creased in midcervical spine
- Pt complains of clicking
- Xray shows DDD or osteophytes or anterolisthesis
61
Structures being tested in mid cervical traction
Disc
| Longitudinal ligaments
62
Structures being tested in mid cervical compression
disc
vertebral body
Facet joint
63
Structures being tested in mid cervical anterior shear
- All ligs
| - capsule
64
Structures being tested in mid cervical posterior shear
all ligs
| capsule
65
If you find stiffness of a segment on a PIVM, how do you confirm this finding?
PAVM
66
If you find excessive mobility on a PIVM, how do you confirm this finding
stability testing
67
What is the mechanism for reduction of pain via PIVM
Mechanoreceptor effect
| Vascular pumping
68
In PIVM you sideflex ____ and rotate ____ (Direction
Away
| Towards
69
What are you comparing side flexion and rotation PIVMS to
the other side and other levels
70
What angle do you mobilize a cervical vertebra at?
45 deg (think about facet joint)
71
Contraindication to PA pressure at cervical spine
- Local inflammation
- Local fracture
- Active Neoplasm or Infection
- Local instability
- Acute trauma
- Vascular pathology in vertebral or carotid arteries
72
What are precautions to PA pressure in the cervical spine
- Osteoporosis
| - Anti-coagulant med
73
On a facilitated segment you may notice a ____ on testing PAs
reactive spasm
74
Postural neck pain History and signs
History:
- Gradual onset central/bilateral symptoms local or referred.
- Agg: Prolonged postures, sitting lying
- Ease: altered position or motion
Signs:
- FHP + associated poor thoracic spie posture
- May have decreased CV flexion
- Painful extension
- Weak C-V flexion
- P/A may be tender +/- spasm
75
Postural back pain - Treatment
- Exercise
- Postural/ergonomic advice
- Soft tissue Rx
76
Spondylosis/DJD/DDD - history + signs
History:
- Longer history of problems
- Older age group
- Possibly post traumatic events
- C/O stiff/worse withs tatic postures, better with some motion
Signs:
- Xray = OA and osteophytes
- Capsular pattern of restriction = bilateral loss of SF, rotation, painful extension, full flexion
- +/- postural component
- P/As +ve stiff, +/- pain
- End feels - hard capsular/bony (osteophytic)
77
Spondylosis/DJD/DDD treatment?
- PAs
- Exercise
- Postural/ergonomic advice
- Soft tissue Rx
78
Cervical disc lesion history
- Acute onset
- Often intrascapular pain +/- radicular pain
- may be related to trauma or poor positioning
- Worse with specific movements (usually flexion)
- Cough/sneeze aggravate
- Better lying down
Signs:
- Deformity
- neck held in flexion or side flexed
- Reduced motion (particularly flexion and rotation/sideflexion to side of pain)
- Compression increases/traction decreases
- +/- nerve root signs
- +/- dural signs
79
Cervical disc lesion treatment
- Traction
- Soft tissue Rx
- Exercise and postural/ergonomic advice
80
Cervical radiculopathy History and signs
```
History:
- Onset often acute but may be slower or progressive
Sings:
- Decreased motion: ext/SF/rotation to same side due to pain
- +ve spurlings
- Opposite movement may be tight (flex/contralateral SF + rotation)
Relief with traction
- Neuro signs
- +/- nerve root signs
- +/- dural signs
- P/A stiff/painful
- Unilateral PA stiff/painful
```
81
Cervical radiculopathy treatment
- Traction
- PA
- Soft tissue Rx
- Exercise and postural/ergonomic advice
82
Cervical radiculopathy causes
- Disc
- Z-joint swelling/thickening
- Degenerative changes - osteophytes, UV joint degenerative changes
83
Isolated Z-joint dysfunction - History and Signs
History:
- Onset: acute (wry neck) or may be gradual
- Pain unilateral local +/- referred to arm, scapula, head
- Agg: motion
- Ease: rest
SIgns:
- Restricted motion - stretch pattern - F/SF/ rot away
- Compression: E/SF/rotate towards
- Segmental muscle guarding
- P/As decrease unilat over joint +/- pain
84
Isolated Z joint dysfunction treatment
- Unilateral PAs,
- soft tissue Rx,
- Exercise
- postural/ergonomic advice
85
Cervical instability History + Signs
History:
- Trauma/repeat episodes/consistently inconsistent/posture
- Local +/- referred pain
- Agg: static posture/sleep positions
Signs:
- Poor posture, often head forward, may have flattened C curve due to spasm/guarding decreased active ROM
- Segmental multifidus spasm
- Weak deep cervical flexors
- P/As = reactive spasm +/- pain or increased translation
- May note other segments with hypomobility
- Stability tests positive for pain and/or soft end-feel
86
Cervical instability treatment:
Stabilisation program
Strengthening
Soft tissue Rx
Exercise and postural/ergonomic advice
87
Generalized mechanical dysfunction Signs
+/- Postural imbalance
+/- Muscle imbalance
+/- Segmental dysfunction - restriction or hypermobility
88
Generalized mechanical dysfunction treatment
Per findings
89
Acceleration/deceleration injury synonyms
Whiplash
Whiplash associated disorders
Cervical sprain/strain,
Cervical soft tissue injury
90
Quebec task force classification Grades
Grade 1: Neck complaint or pain, stiffness, or tenderness only, no physical signs
Grade 2: Neck complaint & MSK signs (Decreased ROM, point tenderness)
Grade 3: Neck complain & neurological signs (weakness, sensory deficit, decreased reflexes)
Grade 4: Neck complaint + fracture or subluxation
91
What are the key management principles for Acceleration/deceleration injury
- Early motion and return to activity are important for healing and return to function
- Patient participation and self-management are integral to recovery
- Evidence in the literature suggests early intervention by PT is effective in decreasing pain and improving mobility
92
How Acceleration/deceleration injury Goals of Treatment decided
- Formulated for each individual following a detailed assessment
- based on: assessment findings, stage of tissue repair, requirements of that individual
93
Components of treatment for Acceleration/deceleration injury
1. Application of controlled forces (not too much or too little)
2. Optimizing physical performance - restoring joint function, strength, flexibility, etc.
3. Pain management techniques
4. Client education
5. Ongoing evaluation
94
Muscles of cervical region which tend to tighten
- Pec major and minor
- Upper trapezius
- Lev scap
- SCM
- Rectus Capitis Major and minor
- Superior and inferior occipital
95
Muscles of cervical region which tend to weaken
- Serratus anterior
- Rhomboids
- Mid and lower trapezius
- Deep neck flexors
- longus Colli
96
Should you restore articular mobility or soft tissue length first
articular mobility
97
How do deep neck flexors alter the movement patterns with the superficial muscles
They react to pain and injury with inhibition or altered movement patterns
98
What is the relationship between deep neck flexors and cervicogenic headaches
Reduced endurance of DNF can cause cervicogenic headaches. DNF change from fibre type 1 (tonic) to fibre type 2 (phasic)
99
What other (not DNF) muscles group have been found to be linked to neck pain
Suboccipital extensors
| Scapular stabilizers
100
How do you progress stabilisation in the cervical spine via DNF
- Determine starting position, hold time
- Ensure action is coming from DNF and not superficial
- Increase speed of contraction
- Add load
- Add functional tasks
101
When using a biofeedback unit to assess and train DNF at what increment should you increase
2mmHg
102
How do you set someone up to test DNF
Tip of tongue on roof of mouth, lips together, teeth apart.
| Do tiny nod/slide back of head up pillow
