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Musculoskeletal Lecture > Cervical Spine Examination and Intervention > Flashcards

Cervical Spine Examination and Intervention Flashcards

1
Q

Subjective information

A
  • area of symptoms

- behavior of symptoms

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2
Q

behavior of symptoms: chemical

A

acute, inflammatory

  • constant pain
  • high levels of pain
  • often diffuse (broad area)
  • recent onset
  • easy aggravation of pain by all movements
  • takes time to calm down
  • responds favorably to NSAIDS
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3
Q

behavior of symptoms: mechanical

A
  • intermittent pain
  • variable levels of pain
  • usually local
  • fairly recent to chronic
  • changes in position or movements in a particular direction ease pain
  • symptoms short lived
  • variable response to NSAIDS
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4
Q

special questions

A
  • are you experiencing any dizziness, light headedness?-vestibular/vascular
  • are you experiencing any trouble talking or swallowing?
  • are you experiencing any change in your vision
  • any difficulty walking or change in your ability to walk? any drop attacks? (compression of spinal cord)
  • are you having any difficulty holding on to small objects or writing? (fine motor movements, usually bilaterally)
  • do you have any numbness or tingling in BOTH hands and/or feet? (bad)
  • are you having any difficulty concentrating or remembering things?
  • addition of red flag questions
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5
Q

NDI

A
  • neck disability index
  • 10 item condition-specific self-report questionnaire
  • 7 items measure funcitonal status
  • 3 remaining:
  • -pain intensity
  • -concentration
  • -headache
  • 0-50, lower is better
  • drop in 5 points to indicate a change in position
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6
Q

pt specific funcitonal scale

A
  • generic scale where the PT asks the pt to identify 3 items that they find difficult to complete secondary to their symptom, injury or disorder
  • pt rates each item on scale 0-10
  • 0=unable to perform activity
  • 10=able to perform as well as they could prior to onset of symtpom/disorder
  • final score=average of the 3 scores
  • ADL, not activities performed in the clinic
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7
Q

OBJECTIVE EXAMINATION

A

s

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8
Q

Common medical diagnosis for pt presenting with neck pain

A
  • herniated disk
  • cervical radiculopathy
  • stenosis
  • spondylosis
  • spondylolysis
  • spondylolesthesis
  • wiplash
  • cervicogenic headaches
  • post-surgical
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9
Q

purpose of physical examination

A
  • confirm initial hypothesis from subjective exam
  • clarify options for treatment
  • determine if the pt is appropriate for physical therapy intervention, is a referral appropriate?
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10
Q

physical examination: review of systems

A

Upper quarter screen

  • cardiovascular
  • integumentary
  • neuromuscular
  • communication, ability, affect, cognition, language and learning
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11
Q

physical examination: cervical spine exam

A
  • observations: posture, structural alignment
  • active ROM
  • repeated movements
  • passive ROM
  • passive accessory motion testing
  • muscle performance testing: strength, endurance, and flexibility
  • special tests (only if needed)
  • palpation
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12
Q

observations

A
  • performed in sitting or standing: patient comfort, note position
  • visual inspection of head and neck: poking chin, visual evidence of wry neck
  • observe shoulder girdle: one shoulder elevated in comparison to the other, rounded shoulders
  • symptoms tend to coincide with postural deformity
  • -the length of time decides treatment (long term, might not bother)
  • -poking chin/kyphotic deformity and wry neck try to correct with posture change
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13
Q

observations: function

A
  • ability to transfer (sit to stand, sit to supine, etc)
  • gait analysis: frequent loss of balance/unsteady gait
  • willingness to move (especially after trauma)
  • -guarding
  • -instability-loss of integrity of ligaments
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14
Q

AROM

A
  • looking at available range of motion: normal vs abnormal (pure planar movement)
  • describe quality of movement and report any deviations
  • keep track of location of symptoms and how they change with each movement
  • not just “is it painful, but where is it painful”
  • proliferation vs centralization
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15
Q

active movements of the cervical spine

A
  • flexion: 45
  • extension: 45
  • side bending: 45
  • rotation: 60
  • retraction: upper cervical flexion and lower cervical extension
  • protraction: upper cervical extension/lower cervical flexion
  • combined mvmts (Ext/SB/ROT)-quick screen to assess pain provocation: way to shorten by looking at 2 mvmts at once
  • overpressure: applied at end of AROM to clear motion/direction as potential source of pain/limitation (ROM cleared by overpressure)
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16
Q

repeated movement testing

A
  • movements used for the purpose of assessment and management of pain
  • clasification of sub-groups
  • derrangment
  • dysfunction
  • postural
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17
Q

repeated movement testing

A
  • looking for centralization=good prognosis
  • examination is conducted in a sitting position with good posture feet on floor
  • movements include: (not necessarily in order, sagittal plane)
  • -retraction
  • -retraction with extension
  • -protraction
  • -rotation or side-bending (in the presence of a structural deformity or if sagittal plane movements expose a lateral component)
  • skip sagittal if: poking chin/torticollis. begin with patient generated rotation while laying down, passively if needed
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18
Q

repeated movement testing: assessment of repeated movements

A
  • sudden vs chronic
  • pain during movement vs pain at end of range
  • varied response to RMT vs consistent response
  • -peripheralization/centralization
  • -pain in one or more direction
  • -ROM
  • postural: repeated movements have no effect
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19
Q

PROM

A
  • usually performed in the supine position for maximum patient relaxation
  • examiner uses cradle hold or chin cradle hold to move patients head into desired ROM
  • examiner is looking to assess
  • -movement between segments
  • -end-feel
  • -patients response to movement
  • check least painful to most painful movements
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20
Q

passive accessory motion testing

A
  • performed in prone or supine
  • examiner is looking to assess
  • -movement
  • -endfeel
  • -patients response to the movement (concordant sign)
  • graded hypomobile, hypermobile, normal end feel
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21
Q

PAMT: general

A
  • slide gliding (lateral glide)
  • anterior gliding
  • posterior gliding
  • distraction/traction
  • lateral glide test: valid test that is able to identify hypomobile segment and side in cervical spine
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22
Q

PAMT:specific

A
  • posterior to anterior CVP
  • posterior to anterior UVP
  • transverse VP
  • anterior to posterior UVP
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23
Q

Muscle performance testing

A
  • resisted isometric testing: provides the clinician with information regarding tissue reactivity
  • MMT:provides the clinician with information regarding strength
  • deep neck flexor testing with or without cuff (endurance)
  • -craniocervical flexion test: pt with cervicogenic headaches may have reduced deep neck flexor control
  • -neck flexor endurance test
  • -pt with neck pain demonstrated impaired neck flexor endurance compared to controls without neck pain
24
Q

special tests

A
  • variety of special tests
  • some tests should always be performed, especially if manipulation of the cervical spine is going to be considered in the treatment plan
  • provocative vs pain reducing?
25
Q

tests for neurological symptoms

A
  • cranial nerve testing
  • DTR/MSR: biceps, brachioradialis, triceps
  • myotomes (C2-T1)
  • sensation: dermatomal pattern
  • spurlings test: sensitivity 11-100%, specificity 74-100%
  • distraction test: sensitivity: 40-44%, specificity 90-100%
  • upper limb nerve tension test (ULNTT)
  • special tests for UMN lesion
26
Q

ULNTT

A
  • looking at the mechanical and physiologic abilit yof the nervous system
  • -peripheral nerves: median, radial, ulnar
  • positive findings include (one or more of the following
  • -reproduces pt pain
  • sensitizing movement alters pain
  • difference from side to side (ie ROM)
27
Q

tests used to identify UMN lesions

A
  • babinskis reflex
  • hoffmanns sign
  • rhomberg test
  • lhermittes sign
28
Q

tests for vascular signs

A

vertebral artery tests

  • rotation in sitting
  • other variations reported in Magee
  • -extension, lateral flexion
  • -extension, rotation
  • -extension, rotation, lateral flexion
29
Q

tests for cervical spine instability

A
  • alar ligament test
  • transverse ligament test
  • modified shar-pursers test
  • aspinall’s test: opposite sharp pursers-when trauma or damage to cervical spine. patient put completely protracted to cut off spinal cord-hopefully reproduce symptoms
  • tectorial membrane test
  • -deep structures in neck
  • -supine, passively bringing into flexion
  • -too much mvmt=bad
30
Q

palpation

A
  • performed in supine or sitting
  • palpate structures on the anterior, lateral, and posterior aspect of cervical spine
  • note the following:
  • -soft or bony
  • -tenderness or pain
  • -muscle tone
  • -skin texture and temp
  • -skin mobility
31
Q

assessment of findings

A

what does it all mean?

32
Q

assessment of the physical examination findings

A
  • medical diagnosis? (cluster of signs and symptoms, PT diagnosis differs from physician
  • musculoskeletal practice pattern? (guide to PT)
  • does this pt fit in to a classification?
  • -derangement (direction of preference, constant pain), dysfunction, postural
  • -treatment based classification (those that respond to manip, etc)
  • pain vs stiffness?
  • -influence prognosis/intervention
33
Q

differential diagnosis

A
  • trauma
  • upper cervical vs lower cervical
  • cervicogenic headaches vs ICAD
  • cervical radiculopathy vs TOS: wainner’s CPR for cervical radiculopathy
  • neck vs shoulder pain
34
Q

trauma (indicates need for imaging)

A
  • following a MVA or fall from height (5ft) or down 5 stairs, the clinician should be suspicious of serious injury in the presence of vague clinical signs
  • -injury to C1-C2 (odontoid fx, hangmans fx, burst fx of C1)
  • canadian C spine rules
35
Q

canadian c spine rules (Trauma)

A
    • test indicates a referral
  • cognitively impaired, displays neurologic symptoms in extremities
  • age of >65
  • fearful of moving head upon command
  • involved in a distraciton based injury (MVA)
  • demonstrates midline pain
36
Q

cervicogenic HA vs ICAD: Cervicogenic headache

A
  • originate from the upper cervical spine (OA, AA, and C2-3)
  • symptoms typically noed in the sub-occipital region temporal bone, frontal bone, and orbital region
  • symptoms change with movement testing
37
Q

ICAD

A
  • internal carotid arterial dissection
  • intense lateral neck pain
  • sudden intense headaches noted in the temporal region (unilateral)
  • neck pain on the same side of HA
  • “worst headache of my life”
  • may present with upper motor neuron signs
  • -check CNs
  • MEDICAL EMERGENCY
38
Q

cervical radiculopathy vs TOS: cervical radiculopathy

A
  • pt will most likely report neck and arm symptoms
  • pain likely referred pain (scapula and UE)
  • parasthesias follow a dermatomal pattern
  • neuroscreen will reveal weakness in a particular myotome and abnormal MSR/DTR
  • only presents on side, ideally it reduces through compression
39
Q

TOS

A

thoracic outlet syndrome

  • patient will present with a variety of symptoms including neck pain and shoulder pain
  • “arm feels heavy or weak”
  • “hand feels cold”
  • reports difficulty with repetitive arm movements at or above shoulder level
  • MSR/DTRs, sensation testing and myotome testing mixed results
  • collection of symtpmts
  • no particular pattern like a radiculopathy, 1 dermatome, unaffected strength
  • activities at shoulder/shoulder level
  • present symptoms
  • stiffness in neck
40
Q

cervical radiculopathy vs tos

A
  • non-specific/no trauma

- repetitive overuse/postures

41
Q

wainner’s CPR for cervical radiculopathy

A

combination of 4 criteria:

  1. cervical spine rotation of less than 60 deg
  2. (+) spurlings test
  3. (+) distraction test
  4. (+) upper limb nerve tension test
    - 2 out of 4 criteria+LR=.88
    - 3 out of 4 criteria+LR=6.1 (strong suspicion that its a radiculopathy)
    - 4 out of 4 criteria+LR=30.3 (guarrentees thats what youre dealing with)

-UQS may not reveal much, so use this is radiculopathy suspected

42
Q

neck vs shoulder

A
  • the neck and the shoulder can present with similar pain presentations,
  • things the clinician needs to consider:
    1. onset of symptoms: insidious onset should raise suspicion
    2. location of symptoms: symptoms below the elbow are consistent with mechanical neck pain (pain, parasthesias)
    3. examination of the neck changes shoulder pain/function
  • symptoms in shoulder area and travel below elbow=cervical spine
  • SHOULDERS DO NOT REFER PAST ELBOW
  • shoulder= generally local, deep to shoulder, deep scapula could be C7 referal
43
Q

PT intervention

A

s

44
Q

basic managing principles

A
  • stages of recovery (acute, subacute, chronic-subjective history)
  • exam findings (targeting interventions to address impairments)
  • Pts belief goals (what works for them, might be able to use. need to get pt to buy into what youre doing, so if that makes them comfortable do it)
  • evidence to support what youre doing: some. weak in areas. do what works for pt. nothing works 100% every time for every pt
  • test-tx-retest-tx
45
Q

basic managing principles 2

A
  • should follow a progression
  • ex: pt who presents with hypomobility should start with treatments addressing the limitations in mobility
  • eventually, this pt will progress to activities to improve strength or posture depending on underlying factors and how the pt is progressing
46
Q

clinical practice guidelines: neck pain

A
  • see blckboard note
  • guidelines developed to help clinicians with delivery of PT
  • recommendartions for examination and intervention
47
Q

interventions

A 
mobility deficits: (loss ROM)
-directional preference
-hypermobility vs hypomobility
classifications:
-pain control
-neuromobilization(radiculopathy, may have DoP)
-traction (radiculopathy, stenosis)
48
Q

directional preference

A
  • responded favorably to repeated movement testing
  • move in the direction that reduces symptoms or centralizes peripheral symptoms-tends to be in painful direction
  • consider pt generated forces before clinical generated forces
  • exhaust the sagittal plane before moving into coronal plane movements
  • GO TOWARDS PAIN
  • -derangements and dysfunction
  • -deep structures
  • muscles are superficial (treat in direction away from pain)
49
Q

directional preference: force progression

A
  • ideally treatment could be completed in sitting
  • pt generated forces before clinician generated forces
  • alternate positions include (if sitting is not tolerated) prone/supine
  • clinician overpressures and non-thrust/thrust manip useful to assist pt with process
  • repetitions vary based on response to movements (typically perform 30 reps before see a change)
  • RM performed every couple hours
50
Q

interventions addressing hypomobility

A
  • pt education
  • thrust and non-thrust manip to cervical spine
  • soft tissue mobilization and stretching of restricted connective tissue (PNF techniques/MET)
  • AROM/PROM in to restricted movements
  • postural education
  • muscle performance training
51
Q

development of a CPR to identify pt with neck pain likely to benefit from TJM (manipulation)

A

4 criteria
1. symptoms duration less than 38 days
2. positive expectation that manip will help
3. 10 deg or greater difference in rotation
4. pain with PA spring testing of middle cervical spine
when 3 out of 4 criteria present probability of successful outcome improved from 39 to 90%

52
Q

thoracic spine TJM vs cervical spine TJM for neck pain

A
  • study: CPR identified subgroup of pt with neck pain who benefit from a TJM to the upper thoracic spine
  • study: unable to validate CPR, but pt who received TJM to thoracic spine presented with improved measure
  • study: pt responded better to cervical spine manip compared to thoracic manip for mechanical neck pain
53
Q

interventinos addressing hypermobility

A
  • pt education
  • local modalities in acute/irritable conditions
  • stabilization activities
  • -local muscle endurance
  • -motor control/learning
  • address postural muscle strength/endurance
54
Q

pain/inflammation control

A
  • based on the findings at the initial assessment
  • local modalities
  • pt education
  • -activity awareness/modification/avoidance
  • -relaxation/breathing techniques
  • manual therapy
  • -intermittent cervical traction
  • -grade 1 and 2 non-thrust manips
  • AROM/PROM in pain free range
  • progress towards a mobility classification when symptoms are improved
55
Q

5 Ds

A 
diplopia-double vision
dysphagia-trouble swallowing
dysarthia-trouble talking
dizziness
drop attacks

Musculoskeletal Lecture (4 decks)

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