Exam 2 Flashcards
What key findings are red flags for a cervical myelopathy?
sensory disturbance of the hands
muscle wasting of intrinsic hand muscles
unsteady gait
hoffmans reflex
hyperreflexia
bowel and bladder disturbance
multisegmented weakness
What key findings are red flags for a neoplastic condition?
> 50 years old
previous history of cancer
unexplained weight loss
night pain
no relief with rest
what key findings are red flags for an upper cervical ligamentous instability?
occipital headache and numbness
Severlly limited neck AROM
cervical myelopathy red flags
what key findings are red flags for a vertebral artery insufficiency?
drop attacks
dizziness
dysphasia
dysarthria
diplopia
Positive cranial nerve signs
What key findings are red flags for an inflammatory/systemic disease?
Temp >100*F
BP> 160/95
Pulse>100
RR> 25
Fatigue
What key findings are red flags for a fracture?
Age> 65
Trauma
prolonged use of corticosteroids
Severly limited neck ROM
Positive neurologic signs
Case study: Patient presents with worsening neck pain, patchy neurologic findings, signs of infection (fever), and bladder symptoms issues breathing. Potential diagnosis?
Cervical abscess at or around C3-C5 causing compression of spinal cord.
Note: breathing issues (phrenic nerve compression). Infection/ fever (potential abscess)
What are the 5 classifications described in the childs paper?
Mobility, centralization, Condition, pain control, headache reduction
What are the potential examination findings common in mobility group?
recent onset of symptoms
No radicular symptoms
restricted rotation ROM
discrepancy in side bending ROM
You are doing evaluating a patient and they do not show positive signs for the compression or distraction tests. what classification group do they fit in?
Mobility
What are the potential examination findings common in the centralization group?
radicular symptoms
signs of nerve root compression
Diagnosis of “cervical radiculopathy”
Within the evaluation you ask the patient to perform repeated movements for 3 sets of 10. At the end of the 3 sets the patient’s radicular symptoms localize to the neck region. What classification group do they most likely fit in?
Centralization group
What are the potential examination findings common in the conditioning and exercise tolerance group?
Lower pain and disability scores
long duration of symptoms
no signs of nerve root compression
no peripheralization of symptoms
What are the potential examination findings common in the pain control group?
High pain and disability scores
Recent onset of symptoms
Traumatic onset
referred symptoms
poor overall tolerance to examination
What are the potential examination findings common in the reduce headache group?
Unilateral headache and neck pain
headache made worse by head movement
Headache made worse with pressure to posterior neck
Your patient presents with a recent onset of symptoms, restricted range of motion, but no signs of radicular symptoms. What are some potential intervention types?
Cervical and thoracic spinal mobilization/manipulation
Active ROM exercises
(Mobility group)
Your patient presents with a positive compression and distraction test. What are some potential intervention strategies?
Mechanical/manual traction
repeated movements
Your patient presents with hypermobility, low pain scores, and no signs of peripheralization/centralization during ROM. what are some potential intervention strategies?
Strength and endurance exercise for the neck and upper quarter
Aerobic conditioning
(conditioning and exercise group)
Your patient presents with bilateral headache, limited ROM, and multisegmented weakness. What are some potential intervention strategies?
trick question baby. These are signs of upper ligamentous instability. refer back to physician
Your patient presents with unilateral headache, and headache triggered by neck movement/pressure. What are some potential intervention strategies?
Cervical spine manipulation
Strengthening of neck and upper quarter muscles
Posture education
(Reduce headache)
Your patient presents with referred symptoms, poor tolerance to examination, and high pain scores. What are some potential intervention strategies?
Gentle AROM, Physical modalities, activity modification
What are some things you may ask your patient during the subjective exam, in regard to patient profile?
Occupation (what they do, how many hours do they work, what is work environment like)
Length of employment (any recent work changes?)
Physical restrictions or limitations currently?
Hobbies (goals?)
What are some potential concerns you may hear during the patient profile subjective exam?
They have stressful/harmful work environment
Extreme physical activity
sedentary lifestyle
Fear avoidance beliefs
What kind of questions can help you determine the area of symptoms?
Can you show me where your pain is?
Can you describe how your pain feels?
Do you have pain all the time?
Are you in pain right now?
Does the intensity of pain change throughout the day?
What is the single most important aspect of the patient interview?
area of symptoms, it helps us determine the initial hypothesis
True/false?
Your patient has a recent onset of constant pain at high levels that is made worse with all movement. This a behavior of mechanical pain.
False. this is the behavior of chemical pain.
Patient will also respond favorably to NSAIDS, and it will take time for pain to calm down
Your patient c/o long term intermittent pain that varies. They describe their pain as short lived and changing depending on position. What behavior classification does this patient fit in?
mechanical pain behavior
What questions can you ask to determine the behavior of your patients symptoms?
Are there any positions that make your symptoms worse?
Does your pain get better or worse throughout the day?
True/false?
It is not concerning if your patient can’t describe any agitating factors/they feel worse in unloaded positions
False.
If symptoms are not influenced by activity it may not be a mechanical issue. Should consider reffering back to physician
What is the general prognosis for a back pain patient with the inability to sleep?
poor prognosis
What type of questions should you ask in the history portion of the evaluation?
When did this problem begin?
Any recent changes in your lifestyle/job?
Have you had any treatment for this before?
What types of things would be red flags in the history portion of the evaluation?
Rapid progression
no relief of symptoms
insidious onset
The neck disability index is a questionare with a score 0-50. What is the cutoff for prognosis?
a score >30% is correlated to a poorer prognosis
What is the numeric pain rating scale?
questionare about pain on a scale 1-10. currently, best, worst, and over the past 24 hours
What is the patient specific functional scale?
Patient identifies three items they find difficult to complete, and rates the difficulty from a scale 0-10 (0- unable to complete, 10 unable to complete as well as they could prior to disorder)
what is the global rating of change scale?
patient rates how much they feel they have improved since beginning treatment. -7 (great deal worse) 0 (the same) +7 (very great deal better)
A patient puts they are unsure/agree that movement may make their pain worse. Is this a cause for concern?
Yes, should be a concern for fear avoidance behavior. further assessment is needed
What is the purpose of the physical examination during initial evaluation?
Helps to support/refute initial hypothesis made during subjective
Clarifies treatment options
What are some things you want to look for while observing the patient?
ability to sit-stand, sit-supine, gait analysis, willingness to move
What are some things you want to look for while evaluation ROM?
Normal v.s abnormal range, quality of movement, symptoms changes while moving
What is the normal ROM for flexion?
45*
Normal ROM for extension?
45*
Normal ROM for side-bending?
45*
Normal ROM for rotation?
60*
Retraction consists of what two movements?
upper cervical flexion and lower cervical extension
Protraction consists of what two movements?
Upper cervical extension and lower cervical flexion
What is the benefit of using a combined movement during a screen?
Quick screen to assess pain provocation (can rule out multiple things as once)
What is the benefit of overpressure?
Clears a motion as potential source of pain/limitation
What is the optimal position for performing repeated movement testing?
Good posture sitting, with feet on the floor.
What are assessing when you do passive range of motion?
movement between segments
end feel
patient response to movement
What is PAIVM?
Passive accessory intervertebral motion testing
Examining movement, end-feel, response to pain
What are the grades of PAIVM?
Hypomobile, hypermobile, normal end-feel
What are the two main types of PAIVM testing?
general: distraction/traction
Specific: CVP/UVP
what information does resisted isometric break testing provide?
information regarding tissue reactivity
what information does MMT provide?
evaluates strength
What information does deep neck flexor testing provide?
endurance of the neck muscles
What are the two main types of deep neck flexor tests?
Craniocervical flexion test
Neck flexor endurance
What tests can you use for neurological symptoms?
Cranial nerve testing
Deep tendon reflexes
myotome testing
sensation testing
ULNTT
Special tests (babinski, hoffmans)
Are the babinski reflex and hoffmans sign tests more specific or more sensitive?
specific (Rule- IN)
Is elvys test sensitive or specific?
Sensitive (Rule-Out)
what are some things you look for during palpation?
soft/bony
Tender/painful
muscle tone
skin texture
temperature
Skin, muscle, nerve mobility
what are some potential diagnoses for a patient with neck pain?
Herniated disc
Cervical radiculopathy
Stenosis
Spondylosis
whiplash
cervicogenic headaches
Post-surgical
What are the three MDT classifications?
derangement, dysfunction, postural
What are some potential intervention techniques for treating cervical spine?
directional preference
education
hypo/hypermoility
pain control
conditioning
reduce headache
neuromobilization
what should you include in your patient education?
Prognosis and plan
stages of healing
management of healing
posture awareness
prevention
Home exercise program
Describe derangement syndrome.
presence of directional preference with rapid change in symptoms. associated with obstruction of a particular joint
Describe dysfunction syndrome.
symptoms stem from typical mechanical deformation of structurally impaired tissue
Describe postural syndrome?
symptoms associated with no pathophysiological abnormalities but abnormal stress to tissue
what does directional preference mean?
patient responds favorably to repeated movement testing.
Centralization of symptoms
How do you progress directional preference?
completed in sitting
Patient generated force–> clinician generated force
3 sets of 10
What visceral organs/ organ systems can potentially cause referred pain?
- Cardiopulmonary system
- GI system
- Urinary system
what are the intervention strategies for addressing hypomobility?
patient education
thrust-non-thrust manipulation
Soft tissue mobilization
PROM/AROM
Postural education
Muscle performance training
What are some neck strengthening exercises?
Deep neck flexor strengthening
Lower and middle trap strengthening
Serratus anterior strengthening
what are the intervention strategies for addressing hypermobility?
Patient education
Modalities
stabilization (muscle endurance, motor control)
postural strengthing
what are the intervention strategies for addressing pain control?
modalities
patient education (modifcations/ breathing techniques)
Manual therapy (grade I, II non-thrust)
AROM/PROM in pain free range
Reclassify when pain subsides
Cause of thoracic pain with these symptoms:
- Older than 50yo
- Weight change
- Failure to improve conservative care
- Night pain, constant pain, no relief with bed rest
Cancer
Cause of thoracic pain with these symptoms:
- Over 65 yo
- h/o corticosteroid use
- trauma (may be minimal in the elderly)
Fractures
What are the intervention strategies for a cervicogenic HA?
Cervical spine manipulation/mobilization
strengthening
Postural education
Where do cervicogenic HA stem from?
upper cervical spine (OA, AA, C2-C3)
What is the relevant anatomy that could be the source of thoracic pain?
- disk
- ligaments
- costosternal joint
- costotransverse joint
- costovertebral joint
- Intervertebral joint
- dura
- visceral organs
Special questions relative to T-spine subjective exam?
- Does the pain change with inspiration/ expiration or both?
- Is the pain affected by coughing, sneezing, or straining?
- Are there any changes in sensation, feelings of numbness, or tingling?
- Any difficulty with maintaining your balance while walking?
- Any changes in bowel and bladder function?
what indicates a positive finding for the ULNT testing?
Reproduces patients pain
sensitizing movement alters pain
difference in side to side
when would you use neuromobilization?
Presence of radicular symptoms or peripheral neurologic symptoms
which way is the head side bending to when doing a slider?
toward the outstretched arm
What are some outcome measures used to determine pain/function of a pt that can be used for the thoracic spine?
- Neck Disability Index (upper)
- Oswestry Disability Index (lower)
- NPRS
which way is the head side bending to when doing a tensioner?
away from the outstretched arm
What anatomy group can cause thoracic pain, but cannot be treated by PTs?
Visceral Organs
what are the 4 variables included in the manipulation clinical prediction rule?
Recent onset (>38 days)
Expectation for success with manipulation
10 degree difference in cervical AROM rotation
Pain with PA CVP
What are constitutional symptoms?
Symptoms that cause fatigue
The higher a patient scores on an Oswestry Disability Index, the BLANK their pain is
Higher (Increase in score = Increase in
List the sequence of events in order of a thoracic spine exam
- Observations
- Cervical spine screen (especially if sx are proximal to the inferior angle of the scapula)
- AROM/ AROM w/overpressure
- Repeated movements
- PROM
- Passive Accessory Motion Testing
- Muscle performance testing
- Special tests
- Palpation
Which way does the ribcage lean towards with structural scoliosis
Opposite
When do you examine the C-spine during a T-spine eval?
BEFORE examining the T-spine
What are 4 things you would examine during a cervical spine examination?
- AROM
- Repeated movements
- PROM
- Joint play
List the 3 movements performed with repeated movements of the T-spine
- Flexion
- Extension
- Rotation
In what position does the patient perform Passive Intervertebral Movement Testing (PIVM)?
Patient is seated
Where on the T-spine are PIVMs being performed?
At each segment
Components of passive accessory motion testing (PAMT)?
- CVP
- UVP
- TVP
- PA over angle of rib
Where on the spine can you use PAMT?
All segments from T2-down
What 4 muscle groups are involved in MMT of abdominal musculature?
- rectus abdominus
- obliques
- erector spinae
- quadratus lumborum
What are the 3 areas for the thoracic outlet?
- through scalenes
- through pec minor
- through ribcage and clavicle
What is percussion?
The tapping on an area of the body, used to identify kidney pain/ complication
What are the areas in the body where auscultation is used?
Stomach, heart, lungs
What is the nerve test of the thoracic spine?
Slump Test
What are the 3 components of special testing for the T-spine?
- Thoracic outlet syndrome
- Neurologic involvement
- General medical screening
What do the slump test, DTRs/ MSRs, and dermatomes test for?
Neurological symptoms
What are the criteria that indicate a patient will neck pain will benefit from TJM?
Symptom duration <38 days
Positive expectation that manipulation will help
10* or gretter difference in rotation
Pain with PA spring testing @ middle cervical spine
What are the 4 criteria for wainners rule for cervical radiculopathy?
Cervical spine rotation <60 degrees
Positive spurlings test
Positive distraction test
Positive ULNTT (elvy’s test)
What muscles are you targeting with cervical neck strengthening and endurance exercises?
deep neck flexors
True or false? simple advice is not as effective as a more intense and comprehensive exercise program
Treatment for Headache with neck pain in acute stage?
cervical mobilization
active mobility
Treatment for headache with neck pain in sub-acute stage?
Cervical manipulation/mobilization
Exercise
Treatment for headache with neck pain in chronic stage?
Cervical manipulation/mobilization
Neck stretching
shoulder girdle strengthening
Endurance exercise
what is apical breathing?
breathing with neck and shoulder accessory muscles
Far less efficient than diaphragmatic breathing
Related to TMJ what would a c-curve opening look like?
mouth deviates to the side then back to the midline
Disc w/reduction
If a patient has a C-curve opening of the mouth what side is likely affected?
ipsilateral to the side the mouth deviates to
Related to TMJ what would a S-curve opening look like?
deviation one way and then overshoot then back to midline
What does a S-curve opening indicate?
neuromuscular/motor control dysfunction
Often seen in hypermobile patients
Related to TMJ what does a deflection pattern of opening look like?
deviation one way then further deviation in that movement
toward affected side
What does a TMJ deflection pattern indicate?
a block
typically anterior disc w/out reduction
What muscles should you palpate when evaluating TMJ?
masseter, temporalis, suboccipitals, upper trap, SCM, scalened, medial pterygoid
What are you looking for when you palpate the TMJ?
Tonicity of the muscles, pain provocation
What is the normal AROM for depression (opening) of the TMJ?
Males and females?
Males: 40-45
Femaled: 45-50
What is the normal AROM for lateral deviation of the TMJ?
10-12 mm
what is the normal AROM for protrusion of the TMJ?
6-9mm
What is the normal AROM for retrusion of the TMJ/
3 mm
What are the grades for MMT of the TMJ?
Functional: w/ or w/out pain
Weak functional: w/ or w/out pain
Non-functional: w/ or w/out pain
Absent: no movement
What is the purpose of joint play assessment of the TMJ?
assess amount of motion and pain response to movement
What types of movement do you assess during joint play of TMJ?
Distraction
Anterior glide
posterior glide
medial glide
lateral glide
*****Must compare bilaterally
What does cranial nerve 5 control/innervate?
sensation to face
muscles of mastication
What does cranial nerve 7 control/innervate?
raising of the eyebrows
frown/smile
closing eyes tightly
puffing out the cheeks
exposing upper and lower teeth
what cranial nerve does the Jaw jerk reflex test? when would you use it
Tests cranial nerve 5
Use when patient has substantial face pain
Patient is doing the cotton ball test. They have the cotton ball on the right side of their mouth and are experiencing pain on the ipsilateral side. What is the potential cause of this pain?
myofascial pain
Patient is doing the cotton ball test. They have the cotton ball on the right side of their mouth and are experiencing pain on the contralateral side. What is the potential cause of this pain?
joint pain
which pathology is more chronic anterior disc with reduction or anterior disc without reduction?
anterior disc without reduction
What are some common findings in a patient with anterior disc with reduction?
clicking, catching, locking
limited opening AROM
ipsilateral soreness
What are some common findings in a patient with anterior disc WITHOUT reduction?
No clicking
History of pain
Difficulty opening mouth wide
You are evaluating a patient who has c/o clicking when they open their mouth. When asked to open their mouth the patient presents with C-shaped deviation to the right side. what is the most likely diagnosis?
Right sided Anterior disc with reduction
You are evaluating a patient who c/o pain in jaw. During your evaluation you find they have limited ROM with protrusion and opening. They also show signs of defection to their left side. What is the most likely diagnosis?
Left sided anterior disc without reduction
Both anterior disc with and without reduction will present with decreased____ during joint play?
anterior glide
The method used to examine tissue temperature and texture
Palpation
What are some common TMJ hypomobile subjective statements?
jaw pain
difficulty opening
macro-trauma
history of bruxism (microtrauma)
What are some common objective findings in an individual with hypomobile TMJ?
decreased ROM (opening, lateral deviation, protrusion)
C-shaped opening
hypomobile during joint play
Affected side is tender to palpation
What are some common subjective findings in an individual with hypermobile TMJ?
Jaw pain with movement
Double jointed/ overall very flexible
Insidious onset of pain
What are some common objective findings in an individual with hypermobile TMJ?
S-shaped opening
Excessive ROM
decreased coordination
Affected side is painful
Hypermobile during joint play
Where is the location of pain if its origin is cardiac?
Mid-thoracic spine to thoracolumbar spine
Where is the location of pain if its origin is pulmonary?
Scapula
What are some common subjective findings in an individual with myofacial TMJ pain?
Pain
muscles feel tired after chewing
trigger points
cervicogenic headaches/ tight neck muscles
Think they are hypersensitive
Where is the location of pain if its origin is urinary/ renal?
Posterior costovertebral angle
Where is the location of pain if its origin is gastrointestinal?
Lumbar spine
What are some common objective findings in an individual with myofascial TMJ pain?
Limited ROM due to muscle spasms
Muscles are tender to palpation
MMT: strong but painful
Joint play: Within NORMAL limits
What are some common objective findings in an individual with cervical referred TMJ pain?
Symptoms change with repeated cervical motions
Forward head posture
TMJ motion, strength, joint play within NORMAL limits
A biton index
A Biton index score greater than 5 reflects what about an individual’s mobility?
Hypomobility
What is diaphragmatic breathing used to help with?
Pain control and anxiety
Patients presenting with what symptoms can benefit from neuro mobilization
Mechanical and neurological symptoms
What are some common subjective findings in an individual with cervical referred TMJ pain?
jaw pain altered by neck movement
soreness in neck
cervicogenic headache
soreness by the end of the day
What grade of manual therapy should you do for patient who is the pain category with TMD?
Grade I and II
What grade of manual therapy should you do for a patient who is in the hypomobile category with TMD?
Grade III and IV
True/false. Manual therapy is more effective than home exercise in treating patients with TMD?
False
Most effective treatment is to combine manual therapy with home exercise
What are some general examples of Manual therapy for TMD?
Soft tissue mobilization
joint mobilization
mobilization with movement
cervical/thoracic spine mobilization
cervical traction
What are some examples of general exercises that can be used for TMD treatment?
Rocabado exercises
posture related exercise (scap retraction, push up +, A, Y, T)
Repeated movements
jaw strengthening/ control
Why does bad posture contribute to TMD?
A forward head posture increases the affect of gravity.
Requires more upper cervical muscle requirement
Increases upper cervical compression
Increases stress of SCM
Specific treatment types for TMJ disc pathology?
Normalize muscle tone of pterygoid
normalize movement (joint glides)
Rocabados exercise
improve posture
Specific treatment types for TMJ hypomobility?
Mobilizations: distraction, anterior glide
Stim PRN for muscle restriction
Specific treatment types for TMJ hypermobility?
Rocabados
Posture
Stim PRN
Specific treatment types for TMJ myofascial pain?
soft tissue mobilization
posture
trigger point
muscular endurance training
breathing
specific treatment types for cervical referred TMJ pain?
Cervical spine Intervention techniques!
