Head and neck Flashcards
What are red flags for head, face and neck pain?
Age 50 (malignancy) or >70 (fracture)
Previous history of cancer
Constitutional symptoms
Failure to improve with conservative care (4-6 weeks duration)
Recent urinary tract infection or urinary problems Drug use
Immuno-compromised
Pain not relieved by rest or laying down
Severe, constant night pain
Progressive neuro problems
Back pain accompanied with abdo, pelvic or hip pain History of trauma
Significant morning stiffness in all movements
Skin rash
Differ between systemic vs mechanical Pain
Systemic: Awakens at night Deep aching, throbbing Reduced by pressure Constant or waves/spasm Cyclical, progressive symptoms
Mechanical: Sharp dec. with rest dec. by change in position dec. whenstressfulaction is stopped dec. of A/PROM dec. accessory motions
Concussion:
Differ between Acute and Late (delayed)
Acute: Light-headedness Vertigo/dizziness Delayed motor or verbal responses Memory or cognitive dysfunction Headache Balance/coordination problems Concentration difficulties LOC Blurred vision Photophobia Tinnitus Nausea/vomiting Slurred or incoherent speech
Late (delayed):
Persistent low grade headache Easyfatigable
Sleepirregularities
InabilitytoperformADLs
Depression/anxiety
Lethargy
Memory dysfunction
Light-headedness
Personalitychanges
Low frustration tolerance / irritability
Intolerance to bright lights and/or loud sounds
Facial Pain:
What are probable Dx for FP
What are the more serious disorders which we must rule out?
What are the things we must consider if patient isnt responding and serious conditions are already ruled out?
Probable:
- dental pain
- maxillary sinusitis
- trigger point
Serious disorders- rule these out
- cardiovascular referral
- carcinoma
- metastases
- sever infection
Pitfalls:
- TMJ dysfunction
- migraine
- eye disorders
- chronic dental problems
- parotid gland
- acute glaucoma
- cranial nerve neuralgias
Presentation:
Pain usually aggravated by thermal changes
Pain will not cross the midline Usually specific to tooth
What is it?
Managemnt?
Dental Caries
management: refer to dentist
Presentation: acute stages Facial pain and tenderness over sinuses Toothache Headache Nasal discharge Postnasal drip Rhinorrhea Cough worse at night – why? Prolonged fever
Presentation: Chronic Vaguefacialpain Nasalobstruction Toothache Malaise Halitosis
What is it? management?
Sinusitis
Management:
- sinus drainage techniques
- FESS (functional endoscopic sinus surgery) for chronic sinusitis
- over the counter medication
- referral to GP
Presentation:
Middle aged or older patient
Complains of sharp electric excruciating pain over the mandibular and maxillary divisions of trigeminal nerve
Pain is recurrent but can be in remission for months to years
Spontaneous onset
Patient possibly considering suicide
What is it?
Examination? Managment?
Trigeminal Neuralgia
Examination
Neurological examination should be negative
If positives are found, especially in younger individuals, suspect multiple sclerosis.
Management
Referral to GP for management
Current medical management includes carbamazepine Disorder may remit within 6-12 months.
Presentation:
Complains of deep electric or stabbing pain in the mouth
May wake them at night
What is it? What examinations would you do? Managment?
Glossopharyngeal Neuralgia
Examination
Neurological examination should be negative
Management
Referral to GP for management
Current medical management includes carbamazepine Disorder may remit within 6-12 months.
TMJ Pain
- often overlooked
- if a chronic cervical problem particularly around C3 then look at TMJ
- rule out any dental problems, fractures and dislocations.
s
Presentation:
-pain or tenderness especially with protrusion or lateral movement, chewing on opposite side or opening the mouth widely.
Ddx
Cause, examinations you would conduct? management?
Capsulitis:
Cause:
-over stretching of the capsule (wide yawning, dental procedures, microtrauma from poor chewing habits)
examination:
- movement that stretches the joint capsule
- movement that aggravate as mentioned above
- condylar stretch-pushing mandible forward with mouth open.
Managemnet:
- avoid aggravating factors
- ice and rest in early stages
- ensure propper dentition
- re-educate on jaw opening and chewing
Presentation:
Pain that is worse with full closure on the ipsilateral side
What would be the cause, examination and management you would conduct?
Synovitis
Cause?
- Acute direct trauma
Anterior disc displacement
Hypertonic temporalis mucsle
Examination
Condylar compression
Lateral deviation in opening/closing
Management
Avoid aggravating factors
Ice, rest and muscle relaxation in early stages Adjusting in no inflammatory stages
17
Presntation:
? Popping or clicking when opening and closing the mouth
what could it be?
Cause?
exam?
managament?
Disc derrangement with reduction
Cause
? Opening click – condylar head rests posterior to disc, the condyle is translating to central portion of disc on opening
? Closing click – weakness of posterior ligament, the disc is not pulled backwards and the condyle slips to be posterior to the disc
Examination
? Palpation for click
Management
? Adjustments and or mobilisations
18 Presentation:
? Patient complains of not being able to open the mouth fully ? Pain without popping although previous popping may occur ? Possible tinnitus, suboccipital pain or dysphagia
What is it?
Cause?
exam?
managament?
Closed lock
Cause
? Anteriorly displaced disc
Examination
? Patient unable to place 3 fingers between teeth
Management
? Adjustments and or mobilisations
19 Presentation:
? Acute locking of jaw when fully opened
? Apprehension with opening of mouth
? Possible hx of trauma or prolonged opening of mouth
What?
Cause?
Examination?
Management?
Acute open lock
Cause
? Trauma or hypermobility allows condyle to be dislocated anteriorly to the articular
eminence
Examination
? Obvious
? Rule out fracture if direct trauma
Management
? Bilateral adjustment with downward traction to relocate
Whats probable Dx for neck pain?
20
What are serious disorders to rule out with neck pain?
Pitfalls- things to consider if pt not responding and serious cd already ruled out?
Probable Dx
? Vertebral dysfunction
? Traumatic strain/sprain or whiplash
? Cervical spondylosis
Serious disorders – rule these out! ? Cardiovascular referral
? Angina, subarachnoid haemorrhage
? Neoplasia
? Severe infections ? meningitis
? Vertebral fractures or dislocations - refer to table 2.2 in Souza
Pitfalls – things to consider if patient not responding and serious already ruled out ? Disc prolapse ? Myelopathy ? Cervical lymphadenitis ? Fibromyalgia ? TOS ? Polymyalgia rheumatica ? AS ? RA ? Oesophageal foreign bodies and tumours ? Paget’s disease ? Trigger points!!
Presntation
- local pain
- reffering into neck and arm not following any particular dermatomes
- Pain with movment
- often history of mild-moderate trauma but common to be insideous
What u thinkin?
Exam findings you would expect?
Management?
Vertebral dysfunction (facet or reffered pain
24
Examination
? No hard neurologic findings (DTR, strength, sensation normal) ? Restricted motion at problem facet
? Positive cervical compression in multiple directions
? Trigger points and associated muscle spasms
Management
? Manipulation/Mobilisations have been shown to reduce symptoms in patients with mechanical neck pain ? Soft tissue techniques
? PT modalities
? Postural correction + strengthening of DNF
Presentation
- moderate to sever pain
- cadult: head held to one side in rotation and sometimes flexion
What?
exam findings?
Managment?
Torticollis
Examination
? Restricted motion in all directions, though will be held to one side ? Painful spasm of the SCM unilaterally
Management ? Little research has been done on manual or physical therapy in adult torticollis ? An impairment based approach (pain control, ROM, postural cueing) ? Manipulation/Mobilisations ? Soft tissue techniques ? PT modalities
Presentation:
- neck and arm pain
- worse in morning
- hx of trauma
- usually unilateral
- aggravated by flexion and extension
- restricted movement
- pain relieved when placing hand on head
What?
Exam findings?
management
26
Disc herniation with radiculopathy
Examination
? 90% probability of CR if 4/4 tests are positive (65% if 3⁄4)- (Wainner, Spine 2003) ?
Look at slide 28 with cervical spine refferal pattens on it
do it
Presentation:
- pain and stiffness of neck
- hx of trauma
- pain usually felt in neck and upper shoulder
- headache common
- delayed symptoms common usually 24 hrs but can be longer
What u think it is?
How would you manage it?
31
Acceleration hyperextension injury (Whiplash)
Management:
? Depends on grading
? Active exercise – ROM, mobilising, muscle re-education (Grade A evidence) ? Patient education – reassurance, ‘act as usual’. (Grade B)
? Passive joint mobilisation/manipulation (Grade C) - WAD3 is contraindicated ? Soft tissue techniques
? Rest
? Ice
? NSAIDS
? Soft Collar ! No immobilisation
? X-ray
? Recovery can take a long time!
Different grades:
? Grade 1 – neck pain, stiffness or tenderness
? Grade 2 – neck symptoms and musculoskeletal signs ? Grade 3 – neck symptoms and neurological signs
? Grade 4 – neck symptoms and fracture or dislocation
Presentation: ? Swelling or puffiness in the arm/hand ? Feeling of heaviness in arm/hand ? Deep, boring toothache like pain in the neck and shoulder region ? of symptoms at night ? Hands and arms easily fatigues ? Parathesias in medial forearm and palm ? Difficulty gripping ? Cramps of muscles of medial forearm ? Arm and hand pain
What u think it is?
Causes?
Exami findings?
Management plan
31
Thoracic Outlet Syndrome:
Causes: ? Brachial plexus, subclavian or axillary artery compression ? Cervical rib ? Scalene muscles ? Costoclavicular area ? Subcorocoid area ? Pec minor and subclavius muscle
Exam findings: \+ roos test \+ Wright test \+ Adson's Halstead's \+Note- these tests must reproduce the symptoms and dimish teh pulse (if its easy to distinguish initially)
Causes: ? Brachial plexus, subclavian or axillary artery compression ? Cervical rib ? Scalene muscles ? Costoclavicular area ? Subcorocoid area ? Pec minor and subclavius muscle
Management plan:
? Generally conservative
? First rib manipulation/mobilisation ? Exercises/Stretches
? Lengthen shortened tissues
? Strengthen weak muscles
? Restore correct biomechanics (taping or bracing)
? Modalities (learn this in CHI423) ? NSAIDs
Presentation:
? Widespread pain, stiffness and tenderness of muscles, tendons and joints without signs of inflammation
? Fatigue
? Sleep and mental/emotional
disorders are common
? Diagnosed by 11 out of 18 tender points, but clinical picture is most important
What is it?
Management plan?
Fibromyaglia:
Management:
? NSAIDs to reduce inflammation ? Manipulations as indicated ? Exercises/Stretches ? Lengthen shortened tissues ? Strengthen weak muscles ? Restore correct biomechanics ? Most effective treatment combines patient education, stress reduction, regular exercises and medications.
Presentation: Morning stiffness ? Often takes > 1 hour to be able to move joints comfortably ? Generalised pain throughout multiple joints ? Symmetric distribution ? Possible tenderness and swelling of affected joints ? Females > Males ? Age typically 20-40 years
RA
Managment plan:
? NSAIDs to reduce inflammation
? Manipulations are contraindicated in the inflamed stage
? The inflammation stage is often unpredictable so manual therapies should be administered with caution
Presentation: ? Neck pain and/or shoulder pain, stiffness ? Wide-based clumsy, incoordinated gait ? Loss of hand dexterity ? Parathesias in one or both arms, hands ? Visible change in handwriting ? Difficulty manipulating buttons or handling coins ? Low back pain
Whnat is it?
Examination findings?
Management?
Cervical myelopathy:
? Hyper-reflexia
? Positive Babinksi test (plantar response) – thought to be the most reliable sign
? Positive Hoffman sign
? Lhermitte’s sign
? Urinary retention followed by overflow incontinence (severe myelopathy)
Management:
- imaging
- refer
Presentation: ? Severe muscle spasm ? Reluctance to move the head particularly into flexion ? Patient feels like there is a lump in throat ? Lip or facial paralysis ? Severe headache ? Dizziness ? Nausea ? Vomiting ? Soft end feel ? Nystagmus ? Pupil changes
What is it?
Exam findings?
Management plan?
Cervical Instability:
Exam:
there are some tests but debatable as to whether or not they should be carried out.
Managment plan:
-obtain images
AP, lateral, flexion/ extension studies
Look at slides 36-39
a
