Craniomandibular and Cervicothoracic Special Test Flashcards
What is the purpose of the Craniovertebral Forward and Backward Bending PIVM?
This test to evaluate the passive forward and backward bending of the cranium (occiput) in relation to C1 and C2 (Testing for OA); To incriminate a side, use finger to subcranially sidebend
What is the procedure of Craniovertebral Forward and Backward Bending PIVM?
Both hands isolate craniovertebral backward and forward bending while avoiding full cervical spinal movements. Overpressure is applied to assess the EF and the level of reactivity
Normal amount is approximately 10 to 30° of each (forward and backward), Passive movement restrictions are commonly found with patients with CGH, forward head postures and mid-cervical instability
What is the purpose of Flexion-Rotation Test (Craniovertebral Rotation PIVM in Full Cervical Forward Bending)?
The purpose of this test is to evaluate the passive craniovertebral rotation primarily of the C1-C2 segments with the lower cervical spine locked with ligamentous tension. (Testing for AA)
What is the procedure for Flexion-Rotation Test (Craniovertebral Rotation PIVM in Full Cervical Forward Bending)?
Therapist hold Pt. head and puts their neck in full flexed position with the head supported by the head of the therapist’s abdomen. Therapist then gently rotates head to end range in one direction then repeats in the other direction. Left vs. Right is compared.
- Looking for 45° of rotation on each side (nose points to axilla)
- Test is deemed (+) if there a 10° reduction on either side.
What is the purpose of the Craniovertebral Rotation PIVM Test in Full Cervical Lateral Flexion?
This test evaluates the passive craniovertebral rotation primarily of the C1-C2 segments with the lower cervical spine locked with ligamentous and joint capsular tension
What is the procedure for the Craniovertebral Rotation PIVM Test in Full Cervical Lateral Flexion?
The therapist brings the Pts. head and neck into a fully laterally flexed position and then gently rotates the head to the opposite direction of the lateral flexion to the end range in one direction then the other.
- Limitations in movement with this test are believed to be the result of stiffness of the C1-2 spinal segments
What is the purpose of Cervical Downglide (Downslope) PIVM?
To evaluate the passive downglide of cervical segments C2-C3 through C7-T1
What is the procedure for Cervical Downglide (Downslope) PIVM?
The Pts. head rest on the therapist abdomen, the MCP joint of the index finger on both hands is used to contact the articular pillars of C2 the fourth and fifth fingers are supporting the occiput. Pick a side then apply a force that is directed towards their hip area.
- When the C2 articular pillar is contacted, the segment is described as a downglide test of C2-C3 facet joints.
- This starts at C2 and proceeds caudally,
What is the purpose of Cervical Upglide (Upslope) PIVM?
The purpose of this test is to evaluate the passive upglide of cervical segments C2-C3 through T1-T2
What is the procedure of Cervical Upglide (Upslope) PIVM?
The volar pad of the index finger is hooked posteriorly around the articular process and into the laminal, rotation to either side is induced by pulling the articular pillar anteriorly cranially 45° and across
- This starts at C2 and proceeds caudally,
What is the purpose of Central Posteroanterior PAIVM?
To evaluate the passive accessory motion of cervical segments C2-C3 through T1-T2
What is the procedure of Central Posteroanterior PAIVM?
A posterior to anterior force is applied at the targeted vertebrae (Spinous Process) to assess for pain provocation, mobility and EF. The force is slowly increased with each repetition up to four to five repetitions
- The angle of force can be varied to find the plane of motion that has the most resistance to movement or is most painful. The forces can be varied to turn this assessment into a mobilization for treatment affects
What is the purpose of Unilateral Posteroanterior PAIVM?
To evaluate the passive accessory motion of cervical segments C2-C3 through T1-T2
What is the procedure of Unilateral Posteroanterior PAIVM?
A posterior to anterior force is applied at the targeted vertebrae (Transverse Process) to assess for pain provocation, mobility and EF. The force is slowly increased with each repetition up to four to five repetitions
- The angle of force can be varied to find the plane of motion that has the most resistance to movement or is most painful. The forces can be varied to turn this assessment into a mobilization for treatment affects
What is the procedure for TMJ Distraction?
The PTs thumb is placed into the Pts. mouth on the molars. The thumb is used to apply an inferior scooping force against the molars along the ramus of the mandible to distract the joint. The PTs other hand is palpating the TMJ joint (Externally)
What is the procedure for TMJ Lateral Glide?
If the PT is on the patients left side, the PT will place their left thumb into the medial aspect of the patients right molars. The thumb is used to apply a lateral force toward the patients right side and the pad of the third digit is used to palpate the TMJ externally.
What is the procedure for TMJ Medial Glide?
If the PT is standing on the Patients left side, the PT will place their left thumb between the maxillary and mandible incisors, the pads of the 2nd and 3rd digit are in contact with the lateral pole of the Right TMJ. The 3rd digit applies a medial force toward the patient’s left side.
What is the purpose of the Craniocervical Flexion Test (CCFT)?
To assess precision and control to determine if the patient can use the deep neck flexor muscles and hold the contraction
What is the procedure for Craniocervical Flexion Test (CCFT)?
Place airbag/BP cuff behind the suboccipital region of the neck and inflate to 20 mmHG.
- Explain the test and describe to the patient the movement they are doing is “gently nodding you head as though you were saying yes”
- (Stage 1) Ask the patient to slowly nod to 22mmHG and then 24, 26, 28, and 30mmHG.
- (Stage 2) Instruct the patient to slowly nod to 22mmHG and hold the position for 10 second, if successful increase 2 increments up to 30 mmHG. Once max pressure is determined, use this pressure level to measure endurance capacity
(10 reps 10 sec-holds)
What is normal and what are the compensations with Craniocervical Flexion Test (CCFT)?
- Normal performance is the achievement of pressure of at least 26mmHG with the pressure held steady for 10 sec with 10 reps. Ideal performance is 28-30 mmHG.
- Subjects with Neck P! demonstrated reduced activation of deep neck flexor muscles across all stages of the CCFT with increased activation of superficial muscles (Scalenes and SCM)
What is the purpose of the Deep Neck Flexor Endurance Test?
This is to strengthen the deep anterior cervical flexor muscles, also considered a progression from CCFT.
- This is testing the Longus Colli, Longus Capitis and Rectus Capitis Anterior and Lateralis
What is the procedure of the Deep Neck Flexor Endurance Test? What is considered normal?
With patient supine, they will raise their head and hold ~2.5cm off the table and the test stops when the individual can no longer hold head up or maintain craniovertebral flexion.
- Normal performance with individuals without neck pain is being able to complete test for at least 38 seconds, but subjects with neck pain tested at 24 seconds
What is the procedure for Deep Neck Extensor Endurance Test?
Patient is prone with a laser attached at the head and aimed at the floor (table has to be 60cm away from ground). The patient performs a low cervical extension with the craniocervical region maintained in a neural with the face parallel to the floor and is asked to hold the position for 120 seconds
- The test is complete once the laser comes off the center of the target, patients with neck pain will do ~29sec, patients will no pain ~49 sec
What is the procedure of Sharp Purser Test?
One hand with a lumbrical grip is going to stabilize C2, the other arm is going to be in the patients forehead pressing posteriorly.
Perception of excessive posterior glide of the cranium on the stabilized C2 or relief of pain with the manual gliding motion are considered positive finding
What is the procedure for the Alar Ligament Stress Test?
This can be done in supine or sitting
The head and atlas are side bend, Ipsilateral rotation of the axis is prevented by the stabilization of the C2. The EF and the amount of motions are assessed. If the alar ligament is intact, little to no side bend can occur, the EF should be firm capsular. This is then repeated in a craniovertebral forward bent position and backward bent position to test for variation of the Alar Lig.
To be (+), excessive movement in all three motions in all three planes of testing should be evident
What is the procedure for the Anterior Shear Test (Transverse Ligament Stability Test)?
The head of the C1 are then lifted (sheared) anteriorly together while the head is maintained in its neutral position and gravity fixes the rest of the neck. The patient is instructed to report any symptoms other than local pain and soreness.
- Signs of instability from an upper cervical ligament stability test may include increase in motion or empty EF, reproduction of symptoms of instability and production of lateral nystagmus and nausea
What is the procedure for Spurling Test?
The therapist passively side bends the head TOWARD the symptomatic side and applies compressive overpressure to the patient’s head in the direction of the side bending to perform Spurling A test.
- The procedure for Spurling B combines cervical extension and rotation with ipsilateral lateral flexion. Over pressure is then applied
What is the procedure of Neck Distraction Test?
The PT flexes the patient’s neck to a position of comfort by lifting the head off the pillow (20-25°) and gradually applies a distraction force up to 14 kg.
- If this is (+) manual or mechanical cervical traction should be incorporated to POC
- This test is part of the CPR of Cervical Radiculopathy
What is the procedure for ULND 1?
The PT passively depresses the patients scapulae and brings the shoulder to 90-110° of abduction.
1) Extend the wrist/fingers and supinate the forearm
2) ER of the shoulder
3) Extend the elbow
- The results are (+) if the symptoms are reproduced, PT should note the degree of elbow extension where the symptoms occur.
- Both sides should be tested and a difference greater than 10° may be considered a (+) result.
The patient should also do this test with cervical lateral side flexion (Contralateral intensify symptoms and Ipsilateral reduce symptoms)
What is the procedure of ULND Test 2a?
The PT passively depresses the patients scapula with the shoulder in 10° of abduction
1) Supinate the forearm
2) ER the shoulder
3) Extend the wrist/fingers
4) Extend the elbow
- The results are (+) if the symptoms are reproduced, PT should note the degree of elbow extension where the symptoms occur.
- Both sides should be tested and a difference greater than 10° may be considered a (+) result.
The patient should also do this test with cervical lateral side flexion (Contralateral intensify symptoms and Ipsilateral reduce symptoms)
What is the procedure of ULND Test 2b?
The PT passively depresses the patients scapula
1) IR of shoulder
2) Finger and wrist flexion
3) Full elbow extension
- The results are (+) if the symptoms are reproduced, PT should note the degree of elbow extension where the symptoms occur.
- Both sides should be tested and a difference greater than 10° may be considered a (+) result.
The patient should also do this test with cervical lateral side flexion (Contralateral intensify symptoms and Ipsilateral reduce symptoms)
What is the procedure for Rotation-Extension Vertebral Artery Test?
PT instructs patient to look at their forehead throughout the procedure and PT looks at patients eyes throughout the procedure to assess for nystagmus
- The PT will slowly rotate the patients head to the end of the available range, PT hold for 3 to 5 seconds, if its negative PT adds ipsilateral side-flexion and extension and hold for 5-10 seconds and repeat on the other side.
- A delayed response or a report of dizziness, lightheadedness, or nausea is considered positive
- If the test is positive immediately have the patient go to neutral or slightly flexed
What is the procedure for Mandibular Protrusion AROM?
(Horizontal Plane movement)
The patient is instructed to actively protrude the mandible, PT looks for symmetrical protrusion, and note deviations (deviations usually occur to the side to the TMJ mobility deficit). The protrusion is then measured with a millimeter ruler
- The mandible should move past the maxillary incisor by several millimeters
What is the procedure for Mandibular Lateral Excursion?
The patient is instructed to actively move the mandible laterally, a millimeter ruler is used to measure by placing the ruler against the bottom lip with the zero lined up with the space between the 2 central maxillary incisors
- The mandible canine should move past the maxillary canine by several millimeters. Lateral excursion of 10mm is each direction is considered normal ROM, the motion should be equal in each direction
- Lateral excursion will tend to be limited in the direction AWAY from the TMJ with a mobility deficit
What is the procedure for Muscles of Mastication External Palpation?
The PT uses the pads of the second and third digits to palpate the temporalis, the masseter, the suprahyoid and infrahyoid muscles.
-Swelling, tenderness, trigger points, or excessive tension in the muscles is noted
What is the procedure for Muscles of Mastication Intraorbital Palpation?
The PT using gloves will use he tip of their fifth digit to palpate the upper lateral corner of the patients mouth between the teeth and cheek
- Pain provocation, swelling, tenderness, or excessive tension are noted and compared bilaterally
- This is designed to palpate the lateral pterygoid muscle, however the temporalis and masseter are close to this site of palpation
- Can be used to treat by sustaining pressure at the trigger points for up to 90 seconds until tension or tenderness ease with the sustained pressure
What is the procedure for TMJ Lateral Pole Palpation?
The pad of the third digit is used to palpate the lateral pole of the TMJ just anterior to the ear.
- Swelling, tenderness is noted
- Tenderness of the lateral pole is an indication of the TMJ capsule or lateral TMJ ligament which is a sign of TMJ arthralgia
What is the procedure for Posterior Compartment Palpation?
The pad of the third digit palpates the posterior to the condyle of the mandible. The patient is instructed to open their mouth, the PT palpates for tenderness or swelling of the posterior compartment during opening of the mouth. Compare bilaterally, any differences are noted
- Tenderness and swelling of the posterior compartment of the TMJ is an indication of inflammation/irritation of the posterior ligaments and joint capsule of the TMJ which is a sign of TMJ arthralgia
What is the procedure for Forced Retrusion (Compression) TMJ Provocation Test?
The thumb and index finger are used to grasp the patients chin. The opposite hand stabilizes the back of the patients head. With the patient relaxed and the teeth slightly apart, the therapist applies a pressure directed posteriorly and slightly superiorly. Pain provocation is noted.
- Test results are positive if the test increases or reproduces the patients symptoms. This test is not specific to either right or left TMJ, but the force can be directed to one joint at a time to attempt to isolate each joint.
What is the procedure for Forced Biting Provocation Test?
The PT places gauze, a cotton ball, or a tongue depressor between the patients back molars. The patient is instructed to firmly bite down. Pain provocation is noted. The test can be modified to include biting on tongue depressors bilaterally (power stroke test).
- Test results are (+) if the test increases or reproduces the patients symptom
- For the dental stick test, if pain is reproduced in the ipsilateral side it is likely from muscle/tendon irritation (Myalgia) associated with a masticatory muscle disorder; If pain is reproduced on the contralateral TMJ is is likely from TMJ arthralgia
- A confirmatory test can be having the patient bite down with tongue depressors between both sides of molars, pain produced is likely myalgia rather than TMJ arthralgia because both TMJs are unloaded
What is the procedure for Muscle of Mastication Isometric Resistive Provocation Tests (Isometric Test)?
The PT applies a gentle isometric force at the lateral aspect of the chin of the mandible for 10 seconds and ask the patient to hold and meet the resistance. Pain provocation is noted. This is repeated for contralateral lateral excursion, opening (depression), and protrusion
- Tests are considered positive if the test increases or reproduces the patients symptoms.
- In theory, if pain is produces with isometric resisted protrusion, lateral pterygoid myalgia is likely involved
- If there is no pain with isometric resisted lateral excursion or protrusion, the Masseter and/or Temporalis muscles are likely the primarily involved muscles with signs of myalgia
