Cervicothoracic spine 2 Flashcards
what is the etiology of TOS
forward head posture creates upper thoracic joint hypomobility into extension
scalenes compress
trauma (WAD)
differential diagnosis
how does FHP influence TOS
increased tension of subclavian fascia on axillary artery which doesn’t allow clavicle to roll anteriorly
issues specifically with overhead activities bc of the need for the clavicle to roll
how does chest breathing influence TOS
excessive use of accessory respiratory muscle
scalenes guard and press downward on inferior structures
what are spinal nerve symptoms
segmental, related to the segment that the nerve exits
slower onset of numbness
what are peripheral nerve symptoms
nonsegmental, several segments contribute
quicker onset of numbness
what are thoracic outlet syndrome symptoms
UE glove/sleeve-like paresthesia’s
coldness and swelling with vascular compromise
what activities increase TOS symptoms
raising arms for prolonged perior
sleeping
poor sitting posture
what would you expect to observe during the scan for TOS
FHP
possible UW discoloration d/t degree of artery involvement
what muscle groups are expected to be weak with TOS
posterior shoulder nad posterior throacic
what is expected during the scan for TOS
ROM: indications of upper thoracic restriction
RST: decreased strength/endurance in post. shoulder/scap
Neuro: non-segmental hypoactivity, ULTT +
what is the cause of dural tension restriction
decreased elasticity or inflammation
what is the PT rx with acute dural tension restriction
paresthesia’s at rest
POLICED - NO C
motion w/o resistance/symptoms
STM over segmental level
what is the PT rx with persistent dural tension restriction
paresthesia’s at resistance
motion with resistance
neural mobilization with resistance at end range once acuity settle
what are the S&S of dural tension restriction
paresthesia’s increased from both ends
what are the S&S of dural gliding restriction
paresthesia’s increased from one end but relieved from the other
what is the cause of dural gliding restriction
adhesion
what is the PT rx for acute dural gliding restriction
POLICED - no C
motion w/o resistance/symptoms
STM over segmental level
what is the PT rx for persistent dural gliding restriction
motion with resistance
neural mobilizations at mid range
what factors about the pt determine if the neural mobilizations will be successful
absence of neuropathy
older age
small ROM deficits with median nerve
what is expected in accessory motion tests with TOS
more often a unilateral upper thoracic hypomobility
less often limited 1st rib inferior glide
what is included with PT rx of TOS
postural/ergonomic changes
diaphragmatic breathing
MT/MET in cervicothoracic region to improve mobility
MET to increase strength/endurance in post shld/scp muscles
what is dowager’s hump
why does it develop
fat pad over upper C/t junction that develops with atrophy and shearing
wedging of vertebra d/t osteoporosis with persistent FHP
what are common thoracic restrictions
bilateral loss of thoracic extension that causes lower cervical instability
unilateral loss of upper thoracic extension contributes to unilateral TOS
what is the general rx for sitting FHP
MT/MET with local muscle focus to improve posture
posture education
ergonomic improvements
breathing training
what is the cause of an acute internal disc derangement
trauma
what is the most prevalent IDD
chronic or persistent
what sections of the annulus are hyper-/hyponeural
what type of cartilage is each section made of
hyperneural: outer portions, type 1 collagen
hyponeural: inner portion, type 2 collagen
t/f
the inner annulus is vascular
false
Th outer portion of the annulus is vascular
what is the function of the nucleus
resists compression
dense connective tissue
avascular
t/f
the annulus and nucleus move independently of each other
false
the annulus and nucleus move as a unit
deformation but not migration of the nucleus with motion
describe the vertebral end plate
highly innervated and vascularized
assists with nutrient diffusion for disc
covers nucleus and most of annulus with connective tissue
weak link of intervertebral joint
may calcify which limits diffusion
where is IDD rare in the spine
throacic - narrowest canal
C2-6 - additional stability from UV joints
what area of the disc is IDD most prevalent
posterolateral portion of disc
(transition of annulus in to endplate is weak spot)
what structures are involved with acute IDD
most common - annular tear and end plate avulsion
least common - NP herniation
what happens once disc structures are damaged
large autoimmune inflammatory response
-increase in water to the area = increases osmotic pressure
-spinal nerve sensitized = paresthesias
extended inflammatory phase
what are typical postlateral IDD symptoms
dull/achey spinal pain
radiculopathy
referred pain to respective areas
decreased pain when unloaded
increased neck pain and paresthesia’s looking down
increased pain in morning
what radiculopathy symptoms are common with postlateral IDD
possible segmental paresthesia
what ROM is expected with IDD postlateral IDD
all motions can increase pain
FLX and possible contralateral SB and RT from injured area
EXT and possibly SB and RT toward pain less limited
why is FLX and contralateral SB/RT away from injured area in IDD less painful
pressure from pushing swelling toward spinal nerve
tension on annulus and endplate tear dura
what is centralization of symptoms
abolition of distal/spinal pain in distal to proximal direction in response to repetitive motions or sustained positions
what are typical postlateral IDD signs
MMT and RST: vairable
ST: possible + with compression/distraction/PA pressures
Neuro: +
what is the PT rx for acute IDD
aggressive nonsurgical treatment is successful
POLICED
intermittnet traction
neural mobilizations
MET
what is the focus of MET with acute IDD
tissue proliferation and stabilization of local muscles
what section of the spine most commonly has persistent IDD
lumbar
what part of the cervical spine is most involved with persistent IDD
C5,6
C6 spinal nerve
what is the etiology fo persistent IDD
acute IDD
sedentary lifestyle
genetics
what is the pathogenesis of persistent IDD
in-growth of nocicpetive fibers from acute IDD healing can lead to persistent inflammation and nociplastic pain
persistent inflammation brings excessive and destructive proteins and low grade inflammation enters disc
what is the process of gradual onset of persistent IDD
less GAGs - more fibrotic an dehydrated nucleus
more acidic disc which limited proliferation
annular disorganization
thinning/loss of cartilage at end plates
increased inflammation of fatty deposits in vertebra
what are the categories of herniation per Miller
protrusion: nucleus migrates but remains contained in annulus
extrusion: nucleus migrates thru outer annulus
free sequestration: nucleus breaks away from annulus
what are changes that are likely to happen with disc, facets, and/or foramen with persistent IDD
disc: instability can develop
facets: increased load bearing
foramen: stenosis can develop
all narrow, cards in deck with rubberband example
is it common for pt to not have symptoms with persistent IDD
if not, why
no since the tissues have time to adapt/compensate for the structure changes
what is the PT rx for persistent IDD
possibly like acute IDD
consider primary driver of symptoms
what is the negative outcome predictor for persistent IDD
peripheralization
what is the MD rx for acute and persistent IDD
antibiotic treatment
laminectomy
partial discectomy
cervical fusion
total disc replacement
what is functional instability
instability that can be stabilized with muscle activity or positioning
what is mechanical instability
instability that cannot be completely stabilized with muscle activity or positioning
what portion of the cervical spine has the highest prevalence of functional/mechanical instability
C5-C7
what is the etiology of functional/mechanical instability
traumatic or recurrent sprains
age related disc changes
repetitive extension activities
creep d/t poor posture
adjacent joint hypomobility
connective tissue disorder
what structures are involved with mechanical/functional instability
passive restraints
active stabilizers or local muscles inhibited
neurological function
what are the symptoms of functional instability
predictable pain
recurrent spine and referred pain
decreased pain with position changes
increased pain with prolonged positions, looking up, sudden, and strenuous ADLs
catching
easy self manipulation
what ROM is expective with functional instability
acute - aberrant motion
limited and painful with ext
better flexion
what scan findings are expected with scan for functional instability (CM, RST, neuro)
CM: inconsistent block
RST: painful if acute
neuro: _-
what is expected with accessory motion with functional instability
hypermobile accessory motion with possible adjacent ypomobility
what muscles are inhibited with functional instability
local muscles
what are the symptoms of mechanical instability
same as functional instability but worse with:
-unpredictable pattern
-worsening symptoms with more frequent episodes
- increased pain with trivial and lesser ADLs
what is the PT rx with functional/mechanical instability
like ligamentous sprain
POLICED
postural education of sitting tall
bracing/taping PRN
what is the focus of MET for functional/mechanical instability
stabilization of local muscles
hyperextension of contraindicated
what cartilage is commonly affected with age related joint conditions
articular cartilage
what are the most common sections affected by age related joint changes
C5-7
L4-S1
what joints are most commonly affected by age related joint conditions
hip and knee
what is the general funciton of type 2 collagen
resists compression
what is the etiology of age related joint changes
prior trauma
sedentary lifestyle with underloading
genetics
other disease
what happens with age related joint changes
articular cartilage thins and joint space narrows
fibrous capsule slackens and becomes more fibrotic and with persistent inflammation and then stiffens
synovial membrane produces less synovial fluid = increase friction
what is pain attributed with age related joint changes
subchondral bone and injury to marrow
increased interosseous tissue
synovial membrane inflammation
periarticular tissue inflammation
persistent inflammatory response
foraminal narrowing on the spinal nerve
what are the cervical symptoms with age related joint conditions
gradual onset of neck pain
pain with prolonged position (<30 mins)
morning stiffness
pain and limitation when looking in blind spot
possible paresthesia’s
some movements help and others increase pain
what are the cervical scan components of age related joint conditions
ROM: P!/limitation with ext, ipsilateral SB/RT
CM: consistent bock in ext quadrant or opposing quadrant
RST: depends on acuity
ST: P! compression, PA (+)
Neuro: (-), could be (+) with radiculopathy
what special test can be used for age related joint conditions in cervical region
spurlings to test for radiculopathy
what is the PT for articular cartilage degeneration
improve integrity of cartilage and mobility
POLICED
JM for pain, tissue integrity, mobility
what is the focus of MET for articular cartilage degeneration
improve motion
cartilage integrity
neuromusclular benefits
where is RA most likely in the spine
c-spine
what is the pathogensis of stenosis
narrowing of spinal canal d/t IDD, DJD or age related disc changes
fibrotic spinal nerve d/t persistent inflammation
narrowing form the outside in
what population is most affected by stenosis
> 65 years
does the CNS and PNS have lymphatic vv?
What is the significance?
no, longer inflammatory phase when nerve tissue is involved
slows healing process
what are lateral stenosis symptoms
unilateral UE
spinal pain with segmental paresthesia’s
decreased pain when looking down, standing/walking
increased pain when sitting, looking up, turning to 1 side
what would you expect to find in the scan for lateral stenosis
increased lordosis
ROM: flx/contralaterl SB/RT lower spinal UE pain
ext/ipsialteral SB/RT increase spinal/UE pain
ST: + compression, spurlings, PA level
neuro: possibly +
what special tests are used to confirm lateral stenosis
spurlings
wainner’s CPR
stability test - excessive shearing
what is the PT rx for stenosis
pt education
activity modification
MT - improve thoracic ext and neural mobilizations, mechanical traction
what is the MET for stenosis
aerobic - improves circulation
local muscle stabilization
