Exam 2 Prep: SIJ, Cervical Spine, Thoracic Spine Flashcards
1
Q
What is the function of the Uncinate processes/Joints of Luschka? Where are they located?
A
-C3-C7
-Prevents a vertebra from sliding backwards off the vertebra below and limits lateral flexion
-Increase the joint surface of the above segment with the lower segment
-Develop in second decade of life
-Contribute significantly to control sagittal and coronal ROM
2
Q
What occurs because of uncinate process degeneration?
A
It is one of the chief reasons behind cervical spondylogenic changes and cervical radiculopathy
3
Q
Why is coupled motion in the C/S ipsilateral?
A
Because of uncovertebral joints
4
Q
What are unique characteristics of the discs in the C/S?
A
-Annulus fibrosis does not encompass the entire perimeter of the disc… no posterior annular fibers
-Fibers are arranged vertically in the cervical spine and there are no oblique fibers
5
Q
What is the facet orientation in the C/S?
A
About 45 degrees of angulation in the frontal plane
6
Q
How are the nerve roots identified in the cervical spine?
A
Identified by the caudal segment of the intervertebral foramen i.e. a C4-5 disc bulge would effect the C5 nerve root
7
Q
How much of the foraminal space in the cervical spine does the nerve root occupy?
A
25-33%
8
Q
Where is the vertebral artery most vulnerable to compression and stretching?
A
C1-C2 because of rotation
9
Q
What degrees of extension and cervical rotation can reduce the lumen of the vertebral artery?
A
About 20 degrees of extension and 20 degrees of rotation can reduce the lumen of the vertebral artery to the point where blood flow is compromised or non-existent
10
Q
What are signs and symptoms of cervical myelopathy?
A
-Sensory disturbances of the hands
-Muscle wasting of hand intrinsic muscles
-Hoffman’s reflex
-Hyperreflexia
-Bowel and bladder problems
-Multisegmental weakness and/or sensory changes
11
Q
What are red flags for vertebral artery insufficiency or other arteries about the neck?
A
-Drop attacks
-Dizziness related to movement
-Dysphagia
-Dysarthria
-Diplopia
-Positive cranial nerve signs
12
Q
What are the biomechanics of the cervical spine when flexing?
A
Superior and anterior glide of the superior articulating surface on the inferior articulating surface bilaterally
13
Q
What are the biomechanics of the cervical spine when extending?
A
Inferior and posterior glide bilaterally
14
Q
What are the biomechanics of the cervical spine when rotating?
A
-Superior and anterior glide of the superior facet on one side and inferior and posterior glide on the opposite side
-Ex: left rotation=superior and anterior glide of the R facet and inferior and posterior glide of the L facet
15
Q
How much motion does the upper cervical spine contribute?
A
-60% of rotation
-40% of flexion/extension
-45% of overall neck motion
16
Q
What is the function of the alar ligament?
A
-Protects normal craniovertebral motion
-When rotating, the contralateral alar ligament is taut
-Limits flexion, contralateral rotation and side bending
-Connects the superior part of the dens to the fossa on the medial side of the occipital condyles
17
Q
What is the main function of the OA joint?
A
-Occipital-atlanto joint
-Occipital condyles and superior articulating facets of the atlas slope downward and medially to promote upper cervical extension
18
Q
What is coupled motion in the upper cervical spine?
A
Side bending and rotation are always opposite
19
Q
Which scaleni muscles attach to the 1st rib?
A
Anterior and middle
20
Q
Which scaleni muscles attach to the 2nd rib?
A
Posterior scalene
21
Q
What are the arthrokinematics at the OA joint?
A
-Flexion: posterior glide of occipital condyles
-Extension: anterior glide of occipital condyles
22
Q
What is an important restraint of craniovertebral flexion? What is it?
A
-Tectorial membrane
-Broad band that covers the odontoid process
23
Q
What happens to the disc between C1 and C2? What happens if the natural process for this disc does not occur?
A
-There is no disc as it gets absorbed into the body of C2
-If this does not occur, it is called os odontoideum
24
Q
What are the joint surfaces of the AA joint like?
A
2 slightly convex surfaces
25
What is the function of the transverse ligament?
-Stretches between tubercles on the lateral masses of the atlas and connects the atlas with the dens of the axis
-Counteracts anterior translation of the atlas relative to the axis, thus maintaining the correct position of the dens on the anterior arch of the axis
26
What muscles in the upper cervical spine play a big role in proprioception? Why?
-Suboccipital muscles
-They have increased amounts of muscle spindles
27
What is the rule of thirds for the AA joint?
-1/3 of the anterior to posterior inside diameter of the atlas is occupied by the spinal cord
-1/3 is occupied by the dens
-The remaining 1/3 is potential space
28
What are the short deep neck flexors?
-Rectus capitis anterior
-Rectus capitis lateralis
29
What are the arthrokinematics of the AA joint?
-Since both the superior and inferior facets of the AA are convex, the amount of flexion and extension at this joint are very limited
-Axial rotation occurs through downward and forward glide of one lateral mass and a downward and backward glide of the other
30
What patients should be screened for vasculogenic issues and upper cervical spine screen?
Patients with trauma or concerns of instability or vasculogenic diseases
31
What are the Canadian C-Spine rules for getting radiographs?
-Age ≥ 65 years OR dangerous mechanism OR paresthesias in extremities: if YES, get radiograph
-Any low-risk factor which allows safe ROM assessment such as simple rearend MVC, sitting position, ambulatory at any time, delayed onset of neck pain, or absence of midline C-spine tenderness: if NO, get radiographs
-If unable to rotate neck 45 degrees left and right get radiograph
32
What are special considerations for subjective history for C-spine?
if they complain of...
-Dizziness
-Visual disturbances
-Paresthesias or numbness
-Ataxia
-Drop attacks
-Problems walking
-Clumsiness
-Tendency to stumble or fall
-Amnesia
-Fainting
-Trouble concentrating or staying alert
-Deafness
-Speech deficits
-Tiinitus
33
What are signs and symptoms of neoplastic conditions in the C-spine?
-Previous history of cancer
-Unexplained weight loss
-Constant pain with no relief with bed rest
-Night pain
-Over age 50
34
What are signs and symptoms of upper cervical ligamentous instability?
-Occipital headache and numbness
-Severe limitation during neck AROM in all directions
-Signs of cervical myelopathy
35
What are Cloward's areas?
-Possible areas of symptoms for disc pathologies
-C3-4: C7-T2 interscapular area
-C4-5: T3-T4 interscapular area
-C5-6: T5-T6 interscapular area
-C6-7: T7 interscapular area
36
What is the purpose of the upper cervical spine screen aka "hands off" exam?
-Screen for serious signs of pathology
-Assess a patient's neurologic status
-Assess a patient's risk for vasculogenic events
-Develop a working hypothesis and figure out which areas need further biomechanical assessment
37
When is an upper cervical spine screen performed?
-Acute neck pain
-Within 6 weeks of trauma
-Hands off initially
-Includes fracture tests
-Includes vasculogenic event risk assessment
-Includes cranial nerve assessment
38
What is included in the upper cervical sprine screen?
-Active rotation (ipsilateral before contralateral)
-Active SB
-Active flexion
-Sharp purser and compression in neutral
-Neurologic screen: UE and cranial nerve
-Vasculogenic screen
-Craniovertebral stress tests
-Monitor for red flag symptoms throughout
39
What should be included in the observation portion of a C-spine exam?
-Posture in sitting, standing, etc.
-Muscle atrophy
-Lordosis
-Scoliosis
-Assess bilateral hands for signs of radiculopathy
40
What is included in the objective portion of a C-spine exam?
-Observation
-AROM
-Overpressure if pain free (except in extension)
-Resistance
-Quadrant testing (extension, ipsi SB and rotation)
-Neuro exam
-PROM all cardinal planes with eyes open
-Deep neck flexor assessment
-Palpation
-Special tests as indicated
41
What is normal flexion ROM of the C-spine?
80-90 degrees
42
What is normal extension ROM of the C-spine?
70 degrees
43
What is normal SB ROM of the C-spine?
20-45 degrees
44
What is normal rotation ROM of the C-spine?
80 degrees
45
What is the clinical prediction rule for cervical radiculopathy?
1. Positive ULTT (test A)
2. Involved cervical rotation ROM less than 60
3. Positive distraction test
4. Positive Spurling's test A
-2 or more positive, but all 4 is very likely
46
How were patients with cervical radiculopathy treated in accordance with the CPR's?
-Postural education
-Thoracic thrust
-Exercise
-Cervical traction
47
What are common cervical spine pathologies?
-Acute cervical facet dysfunction
-Forward head posture associated myofascial pain syndrome
-Cervical muscular headache
-HNP w/o nerve root involvement
-HNP w/ nerve root involvement
-Whiplash
-RA
-Cervical spondylosis
-Cervical stenosis
48
What is the subjective history for acute cervical facet dysfunction?
-Unilateral neck pain or "locking"
-Acute onset, slept wrong
-Symptoms radiate past the GHJ and into the upper back
-Typically resolves in 1-2 weeks, but reoccurrence are common
49
What is the mechanism of injury for acute cervical facet dysfunction?
-Sudden backward, SB, or rotation
-Sustained position
50
What are risk factors for acute cervical facet dysfunction?
-Degeneration of the spine/spondylosis
-Secondary trauma from sports or following MVA
51
What are the objective findings of acute cervical facet dysfunction?
-Motion restriction associated with closing or down gliding of the mid cervical facets
-Cannot rotate or SB
-Painful AROM in 3/6 motions
-+ unilateral PA on involved segment
-Local muscle guarding and spasm
52
What is the prognosis and treatment for acute cervical facet dysfunction?
-Prognosis is excellent
Treatment is as follows
-Control pain and acute symptoms
-Joint mob involving combos of flexion or extension and rotation with traction superimposed, initially applied in pain free direction
-After full AROM restored, strengthening is progressed
53
What is forward head posture?
-Can often result in myofascial pain syndrome
-Often co-exists with upper crossed syndrome
-Insidious onset of persistent neck and shoulder girdle aching and muscular tension
-Aggravating factors are repeated inefficient muscle use
-Symptom reproduction with trigger points
54
What is the management of forward head posture associated with myofascial pain syndrome?
-Interventions to diminish muscular tension
-Ergonomic cueing
-Treat trigger points
-Treat muscular imbalances
-Postural education
55
What is cervical muscular headache?
-Progression of myofascial pain syndrome from forward head posture
-Progressed to headaches
-Headache onset with postural static loading of neck or forward head posture
56
What are the objective findings with cervical muscular headaches?
-Neuro screen negative
-Suboccipital muscular tension, tenderness, and tightness as well as symptom provocation
-Unilateral or bilateral OA flexion limitations
57
What is the treatment for cervical muscular headache?
-Soft tissue mobilization
-Joint mobs to craniovertebral region
-Postural and ergonomic education and retraining
58
What are the findings with HNP protrusion w/ out spinal nerve root involvement in the C/S?
-Clinical picture not as well defined as with lumbar
-Increased pain with sitting and with neck flexion
-Often lacks extension, and extension may cause increased centralization of pain
-Forward head posture
59
What is the treatment for HNP w/o nerve root involvement in the C/S?
-Maintaining correct posture to allow disc to heal
-Neck flexibility and strengthening
60
Where are disc herniations most common in the C/S? What are they most often caused by?
-Most common at C5-6 segment, affecting C6 nerve root
-Most often caused by DDD
-Needs MRI/CT scan to determine diagnosis
61
What are the findings for HNP w/ spinal nerve root involvement?
-Gradual worsening with symptoms starting centrally at the base of the neck, then spreading to the shoulder and the arm as the condition worsens
-Pain referred to upper thoracic area
-Interscapular pain (Cloward's areas)
-Attempts to correct forward head posture increase peripheral symptoms as the protrusion is too large to be reduced
62
What is the treatment for HNP w/ nerve root involvement in the C/S?
-Reduce protrusion and restore normal posture
-Manual traction combined with passive axial extension and/or passive backward bending exercises
63
What injuries can result from whiplash?
-Anatomic injury to longus coli and SCM
-Anterior column ligamentous tears
-Annular tears of anterior discs
-Sympathetic nervous system plexus damage
-Nerve root trauma
-Esophageal damage
-Closed head injury
64
What is a whiplash injury?
-Acute soft tissue trauma following hyperextension of the neck
-Worsening of symptoms 12-24 hours later
-Imaging negative
-Hard neuro signs absent
-With or without loss of consciousness
65
What is the mechanics of whiplash injury?
Hyperextension and hyperflexion
66
What are the Whiplash Associated Disorders (WAD) classifications?
-WAD 0: no complaints or physical signs
-WAD 1: neck complaints only, but no physical signs
-WAD 2: neck complaints and musculoskeletal signs
-WAD 3: neck complaints and neurological signs
-WAD 4: neck complaints and fracture/dislocation
67
What are symptoms associated with whiplash?
-Localized and referred pain
-Paresthesias
-Diffuse muscular tension, tenderness, and weakness
-Movement restrictions in the upper quarter
-Headache
-Blurred vision
-Dizziness
-Dysphagia
68
What is the prognosis for whiplash?
-40% will continue to have symptoms at 6 months
-10-25% will continue to have symptoms at 2 years
69
What are treatment options for whiplash injuries?
-Reduce muscle spasm
-Passive modalities early
-Soft collar: need to start weaning immediately
-Progress to active therapies
-Counseling/CBT as needed
70
What patients are at poor risk of recovery after whiplash injuries?
-Neck disability index (NDI) scores greater than 15/50
-Visual analog scale (VAS) greater than 5/10
-Poor expectation of recovery
71
What are subjective findings of RA in the cervical spine?
-Neck pain
-Cervicogenic headaches
-1/4 experience neck pain at the time of diagnosis
-Worse in the morning and with inactivity
72
What are precautions with RA of the C/S?
High cervical instability so keep hands off the neck!!!
73
What are treatments for RA of the C/S?
-Hands off the neck!
-Modalities, STM to proximal shoulder regions
-Gentle mid range postural awareness
-Isometric strengthening
-Positional support with ADL's
74
What is cervical spondylosis?
-Chronic degenerative condition that affects contents of spinal canal and nerve roots, cervical vertebral bodies, and IV discs
-Changes in the osseous and fibroelastic boundaries of the spinal canal
75
What is the main risk factor for cervical spondylosis?
Advancing age
76
What is the clinical presentation of cervical spondylosis?
-Initial clinical presentation is hypermobility of segment but progresses to chronic hypomobility
77
What structural changes occur in cervical spondylosis?
-Disc bulges outward
-Angle of tension on ligaments changes
-Weight bearing develops on uncinate processes anterior and laterally
78
What are signs and symptoms of cervical spondylosis?
-Slow onset
-Can be asymptomatic for a long time
-Exacerbated by minor trauma
-Pain and muscle guarding
-Radiculopathy
-Long term hypomobility and progressive stiffness
79
What are treatment options for cervical spondylosis?
-Treatment will depend on the stage
-Address limiting impairments
-Mechanical traction
-Electrotherapeutic modalities to control pain and increase extensibility of connective tissues
-Molded cervical pillows
-Limited immobilization of C/S with collar if nerve root irritation is significant
-Manual techniques: stretch, ROM exercises, isometrics
80
What is cervical stenosis?
-Narrowing of the spinal canal
-Can be central or lateral
-Associated with spondylosis
-Usually in patients over 50
-Chronic and slowly progressive
81
What structural changes lead to cervical stenosis?
-Disc space narrowing leads to loss of cervical lordosis
-Loss of disc height also leads to buckling of the ligamentum flavum posteriorly
-Osteophytes form at the facets, uncovertebral joints, and posterior vertebral margins
82
What are the signs and symptoms of cervical stenosis?
-Symptoms aggravated by neck extension
-Neck pain
-Pain, weakness, or numbness in the shoulders, arms, and legs
-Hand clumsiness
-Burning sensations, tingling, and pins and needles in the involved extremity
83
What are signs and symptoms of cervical myelopathy?
-Neck pain, headaches, dizziness
-Radicular arm pain
-May have only bilateral LE symptoms
-Bowel and bladder disturbances
-Hyperreflexia
-Multisegmental weakness
-Intrinsic wasting and sensory disturbances of the hands
-Hoffman and Babinski signs
-Loss of dexterity
-Wide based unsteady gait
84
What is cervical myelopathy?
A disorder of the cervical region of the spinal cord that disrupts or interrupts the normal transmission of the neural signals
85
What are the major mechanisms that cause cervical myelopathy?
-Direct compression of the spinal cord by bony or fibrocalcific tissues
-Ischemia caused by compromise of the vascular supply to the cord
-Repeated trauma secondary to normal flexion and extension of the neck
86
What are the risk factors and prognosis for cervical myelopathy?
-Present in 90% of individuals by age 70
-Most common spinal cord dysfunction in people over 55
-Males > females
-Asian descent
-Prognosis worse the more severe the stage
87
What are the stages of cervical myelopathy?
-Mild: involves hand and arm symptoms, but does not prevent performance of normal ADL's
-Moderate: considerable difficulty using their arms and legs, which affects performance of ADL's
-Severe: requires ambulatory aides, and often confined to bed, chair, or home
88
What is the test cluster for cervical myelopathy?
-Gait deviation
-Hoffman's reflex
-Inverted supinator sign (C6 DTR with finger flexion)
-Babinski reflex
-Age > 45
89
What is a Jefferson fracture?
-Burst fracture of C1 vertebra
-C1 is subject to fracture under load
-Difficult to diagnose as there are no neuro deficits
-Requires open mouth CT scan
-Associated with vertebral artery injury and AA or OA instability
90
What is the mechanism of injury of a Jefferson fracture?
Compression with flexion or compression with extension
91
What is a Hangman's fracture?
-Bilateral fracture of parts interarticularis at C2
-Requires X-Ray or CT scan
92
What is the mechanism of injury of a Hangman's fracture?
-Distraction with hyperextension or forceful hyperextension centered on chin
-Can also occur with hyperflexion of C/S
93
What is a type I dens fracture?
-Avulsion fracture
-Stable
94
What is a type II dens fracture?
-Fracture through the base of the dens
-Unstable
-Most typically occurs with excessive extension of C/S
-Can also occur with hyperflexion
95
What is a type III dens fracture?
-Fracture through the body of C2 and may involve a variable portion of the C1 and C2 facets
-Unstable
96
What can make a dens fracture more stable?
If facets are intact, the fracture is more stable
97
What imaging is required for dens fractures?
CT scan
98
What is a halo device?
-Most common device for treatment of unstable cervical and upper thoracic fractures and dislocations as low as T3
-Provides greater motion than other cervical orthoses
-Made of graphite metal, with pin fixation on the frontal and parietal-occipital areas of the skull
-The halo ring attaches to the vest anteriorly and posteriorly via 4 posters
-Underarm straps for tightening
-Extends down to umbilicus
99
What happens if there is improper fit of a halo device?
-Can allow 31% of normal spine motion
-Compressive and distractive force can occur with variable fit of the vest
100
What is the best use of halo devices for upper cervical spine injuries?
A full length halo vest that extends to the iliac crest
101
What are indications for a halo device?
-Dens type I, II, or III fractures
-C1 fractures with rupture of the transverse ligament
-AA instability with RA and ligamentous disruptuon
-C2 neural arch fractures and disc disruptions
-Bony, single column cervical fractures
-Cervical arthrodesis
-Cervical tumor resection in an unstable spine
-Debridement and drainage of infection in unstable spine
-Spinal cord injury
102
What are the motion restrictions of halo devices?
-Flexion and extension limited by 90-96%
-Lateral bending is limited by 92-96%
-Rotation is limited by 98-99%
103
What are complications of halo devices?
-Neck pain or stiffness
-Pin loosening
-Pin site infection
-Scarring
-Pain at pin sites
-Pressure sores
-Redislocation
-Restricted ventilation
-Dysphagia
-Nerve injury
-Dural puncture
-Neurological deterioration
104
What are some considerations for halo devices?
-Used for 3 months to allow for adequate bone healing
-Use of an HCO after removal of the halo
-40-45% of patients with facet dislocation achieve stability with the halo vest
-70% without facet dislocation achieve stability
-Patients with facet dislocation have higher likelihood of SCI
-Thorough neuro exam before and after the reduction of facet dislocation is important
105
What is a head cervical orthosis (HCO)?
-Include the occiput and chin in order to decrease ROM
-Supported chin area
-Generally used in stable spine conditions
-Long term use of HCO's has been associated with decreased muscle function
106
What are the primary HCO's?
-Philadelphia collar (most common)
-Miami J collar
-Malibu collar
107
What is a Philadelphia collar?
-Semi-rigid HCO with a 2-piece system of Plastizote foam
-Plastic struts on the anterior and posterior sides are used for support
-Upper portion of the orthosis supports the lower jaw and occiput, while the lower portion covers the upper thoracic area
-Comes in various sizes and is comfortable
-Velcro straps are used for easy donning and doffing
-Difficult to clean
-Thoracic extension can be added to increase motion restriction
108
What are indications for a Philadelphia collar?
-Anterior cervical fusion
-Halo removal
-Dens type I fracture
-Anterior discectomy
-Suspected cervical trauma in unconscious patient
-Teardrop fracture of the vertebral body
-Cervical strain
109
What are the motion restrictions of a Philadelphia collar?
-Flexion and extension are limited by 65-70%
-Rotation is limited by 60-65%
-Lateral bending is limited by 30-35%
110
What are cervicothoracic orthoses (CTO)?
-Provide greater motion restriction in the middle to lower cervical spine from the added pressure on the body
-The upper cervical spine has less motion restriction
-Used in minimally unstable fractures
111
What motion does cervical orthoses control the best?
Flexion
112
What is the most effective non-surgical way to stabilize the cervical spine?
Halo device
113
What are the drawbacks to cervical collars?
-The soft tissue structures around the neck limit the application of aggressive external force
-The high level of mobility at all segments of the cervical spine makes it difficult to restrict motion
-Cervical collars offer no control for the head or thorax, therefore, motion restriction is minimal
114
What is a soft collar?
-Common, light weight orthotic device made of polyurethane foam rubber with a stockinette cover
-Velcro closure straps are used for easy donning and doffing
-Patients find the collar comfortable to wear, but is easily soiled with long term use
115
What are indications for a soft collar?
-Warmth
-Psychological comfort
-Head support when acute neck pain occurs
-Relief from minor muscle spasm associated with spondylolysis
-Relief from cervical strain
116
What are the motion limitations with soft collars?
-Flexion and extension limited by 5-15%
-SB is limited by 5-10%
-Rotation is limited by 10-17%
117
What is a hard cervical collar?
-Similar in shape to soft collars but are made of Plastizote, a rigid polyethylene material
-Ring shaped with padding
-Adjustable height
-Velcro straps for easy donning and doffing
-More durable than soft collars
118
What are indications for hard collars?
-Head support with acute neck pain
-Relief of minor muscle spasm associated with spondylosis
-Psychological comfort
-Interim stability and protection during halo application
119
What are the motion restrictions with hard collars?
-Flexion and extension are limited 20-25%
-Less effective at limiting SB and rotation
-Better than a soft collar in motion restriction
120
What are the different surgical procedures for the cervical spine?
-Total disc replacement (TDR)
-Anterior cervical discectomy and fusion (ACDF)
-Cervical disc arthroplasty
-Posterior cervical laminoforaminotomy
-Posterior cervical fusion (PCF)
121
What are the indications for anterior cervical discectomy and fusion (ACDF) surgery?
Cervical disc herniation causing radiculopathy or myelopathy
122
What are the indications for cervical disc arthroplasty (CDA)?
-Degenerative disc disease with symptomatic radiculopathy or myelopathy in a single level of the C/S
-Preserves physiologic motion
123
What are the indications for posterior cervical laminoforaminotomy?
Foraminal stenosis or radiculopathy with nerve root compression
124
What are the indications for posterior cervical fusion (PCF)?
Degenerative cervical spine with instability or deformity such as spoynlolisthesis or scoliosis
125
What are considerations for cervical total disc replacement?
-Typical C/S levels are C4-5, C5-6, or C6-7
-The rate of adjacent segment disease is about a quarter to a third of what it is with fusions
-1-2 days @ hospital
-May or may not have soft collar depending on the surgeon
-Usually can drive after 1 week
-Most patients are back to work in 2-6 weeks (not manual laborers)
-Once endplates secure to the bone, the patient needs to restrict hyperextension
126
What are contraindications to cervical traction?
-Vertebral fracture
-Vertebral dislocation
-Hypermobility
-Disease/infection
-Vertebral artery dysfunction
127
What are the potential benefits of manual cervical traction?
-Stretches muscles and joint structures
-Enlarges intervertebral spaces and foramen
-Creates centripetally directed forces on disc and surrounding soft tissue
-Mobilizes vertebral joints
-Increases joint proprioception
-Relieves compressive effects of normal posture
-Improves arterial, venous, and lymphatic flow
128
What amount of force should be used for cervical traction?
Start with 20 lbs of force
129
What are the treatment parameters for mechanical cervical traction?
-Supine
-Neck flexed 20-30 degrees
-45 degrees to target lower C/S
-Traction harness pulls on occiput
-Intermittent pull: minimum of 7 seconds
-20-25 minutes treatment time
130
What is the cervical traction prediction rule?
-Peripheralization with mobility testing
-+ shoulder abduction test
-Age greater than or equal to 55
-+ ULTT
-+ cervical distraction test
-79.2% success with 3 factors
-94.8% success with 4 factors
131
What are the different types of headaches?
-Sinus
-Cluster
-Tension type
-Migraine
-Cervicogenic
132
What are primary headaches?
-Migraine
-Tension type
-Cluster
133
What are secondary headaches?
-Any headache that is a symptom of an underlying problem
-Medication overuse headache
-Cervicogenic headahe
134
What are risk factors for migraine headaches?
-Begins at puberty
-Most affects those aged 35-45
-Women 2x as likely
-Hormone changes
-Family history
-Childhood history of cyclic vomiting and motion sickness
135
What are migraines caused by?
-Pain producing inflammatory substances around the nerves and blood vessels of the head
-Trigeminocervical nucleus dysregulation
-Vasculogenic
-Immunologic
-Neurogenic
136
What are signs and symptoms of a migraine headache?
-Recurrent
-Moderate to severe intensity
-1 sided
-Pulsating
-Aggravated by physical activity
-Nausea
-Photophobia, phonophobia
-Duration of hours to 2-3 days
-Frequency: varies from 1x/year to 1x/week
-In children attacks tend to be shorter and associated with abdominal symptoms
137
What are common triggers of migraines?
-Stress
-Certain foods (chocolate and cheese)
-Wine and coffee
-Missing a meal
-Menstruation
138
What is migraine with aura?
-1/3 of all pts with migraine have aura
-Visual aura most common: zigzags, stars, flashes, scotoma, hemianopsia
-Less than 30 minutes of aura symptoms
139
What is tension type headache?
-Most common primary headache
-Muscle tension in neck, scalp, or face due to stress, poor posture, or overuse
-Begins in teenage years
-Women 3x more affected
-Episodic (< 15 days/month) or chronic (> 15 days/month)
140
What are risk factors for tension type headaches?
-Poor posture
-Women
-Irregular sleep patterns
-Eye strain
141
What are the symptoms of tension type headaches?
-"Pressure" or "tightness"
-Recurring bandlike pressing headache with few migranous features
-Bilateral, dull, non-throbbing mild pain
-Symptoms generally last less than 24 hours
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What is the diagnostic criteria for episodic tension type headaches?
A. At leat 10 previous HA episodes fulfilling criteria B through D; less than 180 days per year
B. HA lasting 30 minutes up to 7 days
C. At least 2 of the following
-Pressing or tightening quality
-Mild to moderate intensity
-Bilateral location
-No aggravation by walking stairs or similar routine
D. both of the following
-No nausea or vomiting
-Photophobia and phonophobia are absent, or one but NOT the other present
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What is a cluster headache?
-Severe unilateral pain due to activation of trigeminal autonomic reflex
-Uncommon
-Men 6x as likely
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What are risk factors for cluster headaches?
-Males > females
-Smoking
-Alcohol use
-High altitude exposure
-Average onset 30
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What are the symptoms of cluster headaches?
-Severe, brief symptoms with frequent recurrent (up to several times a day)
-Bruning, piercing, or neuralgic pain
-Unilateral
-Less than 3 hours
-Clustering over time
-Predominantly periorbital
-Other locations include frontal and temporal areas
-Ipsilateral lacrimation
-Miosos or ptosis of pupils
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What are the common triggers for cluster headache?
Alcohol and stress
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What is medication overuse headache?
-Caused by chronic and excessive use of medication to treat HA
-Most common secondary headache
-Affects up to 5% of some populations
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What are some treatments for headaches?
-Cost effective medications
-Simple lifestyle modifications
-Patient education
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What are some conditions to rule out when evaluating someone with headaches?
-Fractures, dislocations, and instability with traumatic conditions
-Tumors
-Inflammatory disorders
-Infection
-Visceral referral
-VBI/CAI especially dissection in progress
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What should be included in the subjective for headaches?
-Determine any red flags
-Determine any obvious trigger or causes from the environment, dietary, or medication sources
-Attempt to discern among different types of common HA presentations, especially those that benefit from or require meds
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What are headache presentations that warrant concern and the need for medical attention?
-Sudden onset of new severe HA
-Progressively worsening HA
-Onset after physical exertion, straining, or coughing
-Associated with drowsiness, confusion, memory loss, focal neuro signs, or fever
-Onset after 50 years of age
-Symptoms of neuro/CNS dysfunction
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What is a cervicogenic headache?
-Unilateral pain that starts in the neck
-Usually accompanies decreased neck ROM
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What is the diagnostic criteria for cervicogenic headaches?
-Source of pain must be in the neck and perceived in the head or face
-Evidence that the pain can be attributed to the neck
-Pain resolves within 3 months after successful treatment of causative disorder or lesion
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What population is cervicogenic headaches most common in?
-30-44 years old
-Men and women affected equally
-Pericranial muscle tenderness of involved side
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What structures are the source of pain in cervicogenic headaches?
-Structures innervated by the C1-C3 spinal nerves
-Upper cervical synovial joints and ligaments
-Muscles of the subcranial spine
-Discogenic (C2-3)
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What is the pathophysiology of cervicogenic headaches?
-C1-C3 nerves relay pain signals to the nociceptive nucleus of the head and neck (trigeminocervical nucleus)
-Thought to be the cause of referred pain to the occiput and eyes
-Aseptic inflammation & neurotransmission within C-fibers caused by cergical disc pathology is thought to worsen cervicogenic headaches
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What are risk factors for cervicogenic headaches?
-Neck trauma
-Strain
-Chronic spasm of scalp, neck, shoulder
-Lower threshold for pain
-DDD
-DJD
-Poor posture
-Muscular imbalances
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What is the most important clue when diagnosing cervicogenic headaches?
That the headache was precipitated from neck movement
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How are forward head posture and cervicogenic headaches related?
-Occiput and C1/2 are hyperextended with a flattened lordosis
-Facet joint dysfunction leads to abnormal afferent information affecting the tonic neck reflex and encourages gradual adaptation of forward head posture
-Upper cervical extension leads to compression of craniocervical structures including greater and lesser occipital nerves
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What are the treatment options for cervicogenic headaches?
-PT considered first line of treatment
-Manipulation maneuvers are thought to stimulate neural inhibitory systems
-Manual therapy
-Deep neck flexor strengthening
-Postural education
-NAGS or SNAGS (C1 on C2 rotation mobilizations)
