Cervicothoracic spine pt. 4: Test 2

Question 1

etiology of age related joint changes

Answer 1

gradual onset due to:
-prior trauma that changes structure/fxn
-sedentary lifestyle with underloading
-genetics
-other diseases (i.e. RA)
-age

Question 2

pathogenesis of ARJC

Answer 2

** Pathogenesis is progressive

frays, blisters, fissuring/tearing of articular cartilage

subchondraln bone penetrated/overloaded

osteophyte or spur formation

Question 3

what are the 2 pathogeneses of articular cartilage

Answer 3

degenerative: more common, typically in older, chondrocytes can’t keep up

acute tears: rare typically in young/active, involves high shear forces

Question 4

structures involved with ARJC

Answer 4

synovial components

-articular cartilage things and joint space narrows

-fibrous capsule slackens and becomes more fibrotic and then stiffens with persistent inflammation

-synovial membrane produces less synovial fluid and nutrients so drying occurs and increases friction

Question 5

structures involved in ARJC that pain is attributed to

Answer 5

subchondral bone and injury to bone marrow

increased interosseous tissue (capsular fibrosis)

synovial membrane inflammation

periarticular tissue inflammation (i.e. ligaments, capsule)

persistent inflammatory response

foraminal narrowing or spinal nerve

Question 6

persistent inflammatory response with age related joint changes can be partly due to what factors

Answer 6

increased local nociceptor sensitivity for greater pain transmission fostering inflammation

local production of nitrous oxide leads to more interstitial inflammation and excess collagen (joint fibrosis)

Question 7

cervical symptoms of age related joint changes

Answer 7

-gradual onset of neck pain

-P! with prolonged positions like FHP or sleeping (due to no refilling of cartilage with synovial fluid)

-moring stiffness after prolonged positions for >30 min

-P!/limit looking in one blind spot and with looking up

-possible paresthesias (compression of spinal N b/c of thin cartilage/narrowing foramen)

-some movement helps but some makes it worse

Question 8

what would limitations be with R sided ARJC

Answer 8

P! with R SB, R RT, and ext

anything that will compress the joint and increase congruency

Question 9

ROM and combined motion scan findings with ARJC

Answer 9

ROM painful and limited; specifically with ext and ipsilateral SB/RT

typically worse on one side, but could be bilateral

capsular pattern of restriction

CM = consistent block often into an ext quadrant OR opposing quadrants consistently blocked

Question 10

Restisted/MMT for ARJC

Answer 10

depends on acuity

Question 11

typical stress test findings for ARJC

Answer 11

likely pain with compression, particularly if added while in ext, SB, and/or RT

PA glides likely painful at involved level

likely + distraction for relief if symptoms are present

Question 12

typical neuro tests results for ARJC

Answer 12

often negative bit could be positive for radiculopathy if spurring creates stenosis on spinal nerve

Question 13

cervical signs in the biomechanical exam for ARJC

Answer 13

accessory motion = hypo mobility

special tests = spurlings may be positive for radiculopathy

Question 14

for early ARJC describe what findings might be present

Answer 14

capsular pattern if there is a past trauma

hyper mobility die to narrowing if no past trauma

Rx = POLICED, JM, CPP, and MET

Question 15

describe the possible findings for intermediate ARJC

Answer 15

capsular pattern with firm end feels

hypo mobility

Rx = JM, MET, and involved AND adj joints for ROM

Question 16

describe the findings for late/advanced ARJC

Answer 16

no capsular pattern; body end feels due to osteophytes

hypo mobility

Rx: JM and MET with greater focus on adj jt motion

Question 17

PT Rx for degeneration

Answer 17

focus on improving integrity of cartilage and mobility

POLICED (pt ed on weight/avoiding provocation and assistive devices to unload involved cartilage)

JM for pain, tissue integrity, and mobility

Question 18

what type of MET would you do for PT Rx for degeneration

Answer 18

ultimate focus on improving motion, cartilage integrity, and neuromuscular benefits

pure strengthening parameters = possible problem

Question 19

efficiency of supplements for articular cartilage issues

Answer 19

glucosamine and chondroitin sulfate have no evidence of minimum clinically important outcomes compared to placebo in knee

Question 20

how might deeper defects in articular cartilage be beneficial

Answer 20

deeper stimulates bleeding by penetrating bone (crossing tide mark) and heal better than superficial lesions (b/c bone is highly vascular)

Question 21

how might deeper defects stimulate a problem with articular cartilage injuries

Answer 21

may fill with a lesser type I collagen instead of original type II

type I collagen resists tension > compression

insufficient patch; lasts about 6 months

limited healing capacity if any with poor conservative outcomes

Question 22

where is RA primarily

Answer 22

primarily in C-spine

possible AA sublux/instability (40-85% prevalence; neuro symptoms may not be present with up to 10 mm sublux)

possible low cervical dislocations

Question 23

prevalence of stenosis

Answer 23

unknown

most common dx for spinal sx in adults > 60

population = typically > 65, younger pts are generally due to instability

30% of asymptomatic individuals had canal narrowing

Question 24

pathogenesis of stenosis ( 2 causes)

Answer 24

narrowing of spinal canal

fibrotic spinal nerve die to persistent inflammation associated with instability

Question 25

explain how narrowing of the spinal canal would be a pathogenesis of stenosis as well as what it could be due to

Answer 25

unilateral > bilateral and/or central

due to:
-IDD
-DJD and/or ARDC (older individuals)
-instability/spondy conditions in the younger population (excessive shear)
-enfolding of ligamentum flavor (loses elasticity=central stenosis)

Question 26

explain how a fibrotic spinal nerve could be a pathogenesis of stenosis as well as the signs/symptoms

Answer 26

persistent inflammation associated with instability

nerve needs larger blood supply with walking and enlarges even further

fibrotic nerve won’t expand so there is compression from the inside out

compromised circulation

same result as narrowing but a different mechanism

Question 27

Other systems involved with stenosis

Answer 27

ischemic compression and venous congestion (spinal nerve or radicular artery supplying spinal nn)

no lymphatic vv in PNS or CNS so there is always a longer inflammatory phase when neural tissue is involved

Question 28

symptoms of lateral stenosis

Answer 28

unilateral UE > spinal P! with segmental paraesthesusas and gripping type pain due to ischemia

decreased pain looking down, standing/walking, or in the morning

increased pain while sitting, looking up, and turning to one side

Question 29

observation/ROM signs for lateral stenosis

Answer 29

increased lordosis

flex/contralateral SB/RT decrease spinal/UE pain

ext/ipsilateral SB and RT increase spinal/UE pain

Question 30

stress test typical findings for lateral stenosis

Answer 30

+ compression especially in extension or ipsilateral RT/SB

distraction relieves pain of UE

positive spurlings

possible + PA pressure at involved level

possible + neuro for radiculopathy

Question 31

BM exam signs for lateral stenosis

Answer 31

AM = hypomobilty

MMT= local muscles inhibited

special tests = spurlings, wainners CPR, and stability test for excess shear

Question 32

central stenosis symptoms

Answer 32

same as lateral + cord S&S

Question 33

central stenosis signs

Answer 33

same as lateral stenosis but no change with SB and RT

cord signs

Question 34

PT Rx for stenosis

Answer 34

directed at foraminal opening

pt edu of foramen and good prognosis

activity modification

manual therapy with MET
-JM to improve thoracic ext
-neural mobilizations

Question 35

MET for lateral stenosis

Answer 35

aerobic- primary improvement may be from increased circulation

local muscle stabilization

Question 36

beliefs on tx for stenosis

Answer 36

no support for static

intermittent = not beneficial in isolation; some support for short/intermediate term neck and neck related arm pain

intermittent more beneficial when following CPRs and added to other interventions like exercise/manual therapy

Question 37

prognosis for radiculopathy associated with stenosis

Answer 37

70% had good or excellent outcomes at 2 years

90% had mild outcomes at ~5 years

CPR indicators for success

Question 38

CPR for radiculopathy associated with stenosis

Answer 38

< 54 years old
non-dominant UE affected
looking down doesn’t worsen symptoms
> 30 degrees flexion

3 or more = +LR 5.2

4 or more = 8.3 for success

Question 39

Rx for radiculopathy associated with stenosis

Answer 39

mechanical traction
no STM
multi modal with manual therapy and local muscle training
thoracic thrust manipulation

Question 40

symptoms that indicate a need for MD Rx for stenosis

Answer 40

indications = presence of constant and/or worsening symptoms

laminectomy without or with fusion

Question 41

significance of radiculopathy surgery for stenosis

Answer 41

surgery with PT resulted in more rapid and greater improvement in P! and subjective reporting during the 1st year that PT alone

difference between the 2 groups was not significant after 2 years

Question 42

characteristics of fusions

Answer 42

can be congenital or autolytic (due to age related joint changes)