Exam 1: Examination, Radiography, C-Spine, & TMJ Flashcards
Examination includes gathering data about:
health condition (ICD-9/10); bodily structure & function; activity capacity (functional limitation); participation restriction (disability)
Six main steps of an examination
examination, evaluation, diagnosis, prognosis, intervention, & outcomes
An examination consists of:
history; systems review; scan exam; observation; joint play, ROM, MMT; palpation; special tests; neurologic testing; functional tests
A systems review consists of:
cardiovascular, neuromuscular, cardiopulmonary, cognition, & integumentary
According to Dr. English, the physical examination can be broken down into what three steps?
- systems review
- scanning exam
- focused exam
What are some important considerations when choosing tests & measures?
reliability, validity, who it was originally developed for, sensitivity to change, & efficiency
Short term vs. long term goals
short term goals are goals that you anticipate the pt. achieving before the end of treatment, while long term goals are the expected outcome of the treatment
Examples of therapeutic interventions include:
therapeutic exercise, neuromuscular reeducation, manual therapy, therapeutic activities, gait training, modalities, soft tissue/joint mobilizations
Pain assessment
site (origin); onset; characteristics; radiate; associations; time; exacerbating/relieving factors; severity
Words used to describe the quality of pain
- cramping, dull, aching: muscle
- dull aching: ligament, joint capsule
- sharp, shooting: nerve root
- sharp, bright, lightning-like: nerve
- deep, nagging, boring: bone
- sharp, severe, intolerable: fracture
- throbbing, diffuse: vascular
Red flags (general)
sudden onset with no precipitating event; a traumatic precipitating event; intensity that is not reduced with changes in position or medication; age; pain that interferes with sleep; bilateral, multiple locations
Red flags (cancer)
persistent night pain, constant pain, unexplained weight loss, loss of appetite, unusual lumps or growths, unwarranted fatigue
Red flags (cardiovascular)
shortness of breath; dizziness; chest pain or heaviness; pulsating pain in the face, neck, arm, or stomach; constant and severe pain in calf or arm; discolored or painful feet; swelling with no history to explain
Red flags (gastrointestinal)
frequent or severe abdominal pain, frequent heart burn or indigestion, frequent nausea or vomiting, change or problems with bowel & bladder, unusual menstrual irregularities
Red flags (neurologic)
changes in hearing or vision; frequent or severe headaches with no history of injury; problems with speech or swallowing; sudden weakness; problems with balance, coordination, or falling; drop attacks
The five steps of a physical exam are:
1) inspection
2) mobility
3) neuromuscular
4) palpation
5) special tests
Assessment of mobility includes:
AROM, PROM, resisted motion, passive accessory motion, functional movement
Inert tissue involvement will exhibit:
pain in the same direction
Contractile tissue involvement will exhibit:
pain in opposite directions
Options for assessing passive and active ROM and their indications
1) Pain and decreased ROM in all directions: entire joint involvement
2) Pain and decreased ROM in 1-2 directions: acute pathology
3) No pain, decreased range: progressed pathology
4) No pain, full range: no lesion of inert tissue
Options for assessing passive accessory motion and their indications
1) normal range and painless: no lesion
2) normal range and painful: mild sprain
3) decreased range and painless: contracture/adhesion
4) increased range and painful: moderate or severe sprain
5) increased range and painless: complete rupture
Options for assessing resisted ROM and their indications
1) strong and pain-free: no lesion
2) strong and painful: mild or moderate strain
3) weak and pain-free: interruption of nerve supply or complete muscle/tendon rupture
4) weak and painful: moderate to severe strain; or painful inhibition d/t acutely inflamed adjacent structure
PNS lesions
peripheral nerve, nerve roots, trunks/plexus, axon, cell bodies, neuromuscular junctions
Neurologic testing of C5
dermatome: lateral aspect of the shoulder to the elbow; myotome: deltoid or biceps; DTR: biceps
Neurologic testing of C6
dermatome: aspect of elbow to thumb and index finger; myotome: biceps or wrist extension; DTR: brachioradialis
Neurologic testing of C7
dermatome: middle finger; myotome: triceps or wrist flexion; DTR: triceps
C8 dermatome
ring and little finger
T1 dermatome
medial aspect of arm
CNS lesions
spinal cord & brain, muscle tone (spasticity), DTRs (hyperreflexia), balance (decreased)
Signs of upper motor lesions
ataxia (present), clonus (more than 2 beats), Babinski’s (positive: upgoing), Hoffmann’s (positive: flexion of thumb)
Grading of DTRs
0: absent
1: diminished (hyporeflexia)
2: normal
3: exaggerated (hyperreflexia)
4: clonus
Radiating vs. referred pain
radiating (radicular) pain is pain felt due to direct irritation of a nerve root and usually follows a dermatomal distribution; referred pain is pain felt in a part of the body which is a distance from the tissues that caused the pain and is usually referred distally
Grading of palpation
0: pt. does not report pain
1: pt. c/o some pain
2: pt. c/o pain and winces
3: pt. winces and withdraws part
4: pt. will not allow palpation
Reliability coefficients
> .90: excellent reliability
.75-.90: good reliability
.50-.75: moderate reliability
Sensitivity
proportion of pt’s with the target disorder who have a positive test result (i.e. true positive rate)
Specificity
proportion of pt’s without the target disorder who have a negative test result (i.e. true negative rate)
Why do PTs need to know imaging?
medical screening aspects, understanding of pathology/pathomechanics, implications of results on decision-making, understanding diagnostic algorithms, interpreting for pts.
How do air, fat, water, and bone appear on a radiograph?
- air: black - radiolucent
- fat: dark gray - semilucent
- water: light gray - semi-opaque
- bone and metal: white - radiopaque
Radiography demonstrates:
fractures, bony lesions (osteoblastic vs. osteolytic), dislocations/subluxations, edema
Radiography views
- A-P or P-A
- lateral
- oblique
- special
*minimum of two views 90 degrees of one another
Fat Pad sign
effusion of elbow joint displaces fat pads; occult radial head fx. or other intra-articular injury
Computed Tomography (CT)
x-ray beam and detector move about subject in arcuate path; acquires 32/64 images per revolution; computer stores and reconstructs images in slices in multiple planes/angles
Pros & cons of computed tomography
Pros: more sensitive than standard radiographs in detecting fractures and readily demonstrates bony changes
Cons: not as sensitive as MRI in discriminating soft tissue differences
Pros & cons of radiography
Pros: convenient and inexpensive
Cons: less sensitive than other modalities with some features
Magnetic Resonance Imaging (MRI)
Tissues exposed to radiofrequency waves in strong magnetic field in which nuclei of atoms align to magnetic field. At cessation of waves nuclei relax back to normal and tissues produce varying frequencies of resonance as a result of absorbed radiofrequencies. A computer then constructs images from various emitted frequencies.
Pros & cons of MRI
Pro: very sensitive to many conditions, particularly those of soft tissue origin
Con: expensive
Magnetic Resonance Arthrography (MRA)
contrast injected directly into joint, distends joint capsule; potential fill and demonstrates anatomical discontinuities
Bone Scintigraphy
radiopharmaceuticals injected IV and concentrates in area of hyperfunction, indicates increased bone activity; poor specificity
Dual Energy X-Ray Absorptiometry (DEXA)
measure of bone density; calculation based on amount of radiation absorbed
T score of less than -2.5
osteoporosis
T score of -1.0 to -2.5
osteopenia or low bone mass
One-third of cervical fractures occur at __, while one-half occur at __ or __.
C2; C6 or C7
What are the grades of muscle strain and what is the relationship between ROM?
Grade 1: mild; pt. demonstrates >60% AROM
Grade 2: moderate; pt. demonstrates 30-60% AROM
Grade 3: severe; pt. demonstrates
Sinuvertebral n. (recurrent meningeal n.)
nerve that branches off the dorsal root to provide sensory innervation to the structures in the spinal canal (i.e. dura mater and some of the disc)
Possible contributors to neural irritation/impingement
- disc hyperflexion injury
- disc degeneration
- facet joint inflammation, arthritis
- osteophytes
- disc dehydration and dessication
- increased compressive forces on vertebral endplates, facet surfaces
- cartilage deterioration, bony growth, (spurs, calcium deposits)
Possible contributors to neural irritation/impingement
- disc hyperflexion injury
- disc degeneration
- facet joint inflammation, arthritis
- osteophytes
- disc dehydration and dessication
- increased compressive forces on vertebral endplates, facet surfaces
- cartilage deterioration, bony growth, (spurs, calcium deposits)
Spurlings test
ipsilateral lateral flexion and axial compression; positive test results in reproduction of pt’s symptoms; Sn = .86; Sp = .50
Quadrant test
ipsilateral rotation, extension, and lateral flexion; positive test results in reproduction of pt’s symptoms
Upper Limb Tension Test (ULTT)
Sn = .97; Sp = .22
Supine Distraction
Sn = .32; Sp = 1
Neck Pain with Radiculopathy: Clinical Prediction Rule
- Spurlings: positive
- Distraction: positive
- ULTT (median): positive
- Less than 60 degrees of rotation to involved side
- if 3/4 are positive: LR = 6:1; if 4/4 are positive: LR = 30
T-Spine Manipulation in People with Neck Pain: Clinical Prediction Rule
- sx.
The pain neuromatrix is composed of:
sensory discriminative, emotional/affective, & cognitive evaluation
Primary headaches
migraine, trigeminal autonomic cephalagia, & tension-type headache
Diagnostic criteria for migraines
lasts 4-72 hours with 2 of these 4: unilateral, moderate to severe intensity, increased with physical activity, and pulsating quality; at least 1 of: N/V, photophobia or phonohobia; may be associated with an aura
Diagnostic criteria for tension-type headache
lasts from 30 mins. to 7 days with at least 2 of the following: bilateral location, bilateral pressing (not pulsating), mild or moderate intensity, and not increased with physical activity; no N/V and either photophobia or phonophobia or neither
The two primary symptoms of TMD are:
pain & dysfunction
“Clicking” test
used to discern anterior disc displacement; Sn = .82-.86; Sp = .19-.24
Quebec Task Force Whiplash Association Disorder grading criteria
Grade 0: no complaint
Grade 1: pain/stiffness/tenderness only
Grade 2: pain/stiffness/tenderness and musculoskeletal signs
Grade 3: pain/stiffness/tenderness, musculoskeletal signs, and neurological signs
Grade 4: fracture/dislocation
Vertebral aa.
branch off subclavian aa. and travel superiorly through C1-C6 transverse foramen before passing through the foramen magnum and joining together to form the basilar aa.; stressed by rotation, extension, and traction
Mechanisms of injury to the vertebral aa.
manipulations, whiplash, atherosclerosis, and cervical spinal stenosis
Neural signs for CNS pathology
bilateral or widespread sensory loss; bilateral or widespread loss of strength; altered muscle tone: spasticity, ataxia; hyperreflexia; positive Babinski’s, positive clonus (more than 2 beats)
Neural signs for PNS pathology
dermatomal or peripheral n. or sensory loss; myotomal or peripheral n. loss of strength; hyporeflexia
Red flags for upper ligamentous instability of the cervical spine
occipital numbness, CNS signs, severe restrictions in all directions
Interventions for acute cervical pain
limited hands on intervention, AROM in pain-free range, ice, TNS, dry needling, early activation of DCF if tolerated, and education (i.e. reassurance, breathing, relaxation, ergonomics)
Preauricular palpation
used to discern joint arthralgia and inflammation; Sn = .92; Sp = .21
Routinely encountered pulse sequences with MRI
- T1 and T2 weighted
- proton density weighted
- short tau inversion recovery (STIR)
T1 weighted pulse sequences show:
Fat, bone marrow, intervertebral disk, white matter
T2 weighted pulse sequences display:
CSF, water, intervertebral disk, gray matter
Short Tau Inversion Recovery (STIR) best displays:
tissue response or effusion/edema; “fluid signal”
PICO
Problem, Intervention, Comparison, Outcome
Trigeminal autonomic cephalagia (TAC)
severe unilateral orbital pain occuring in cyclical patterns that last 15 mins to 2 hrs.; affects men > women; sudden onset, tearing, rhinorrhea, “alarm clock” HA
