Introduction and Examination Spine Flashcards
ICF Patient Management
Treat the patient for who they are, not the health condition. Contextual factors play a very large role.
Why can it be bad if someone gets an mri first?
MRIs are advanced imaging and so they will likely find something. This does not mean that that something is clinically relevant but they will tell the patient all of these things and can create fear avoidance or other false beliefs.
What are the 4 primary clinical patterns of neck pain?
- Joint/Soft Tissue Mobiltiy Deficits
– Upper thoracic
– Mid cervical
– Upper cervical - Neurodynamic mobility deficits (Neurogenic pain)
- Motor Deficits: Control and Coordination/Endurance
- Altered Cognition/Beliefs
Each clinical pattern has both ____ and ____ findings which are unique (pattern recogntion)
However there tends to be a lot of ____ with each patten as well.
objective and subjective
overlap
Those that received the matched intervention for neck pain displayed…
- Greater chandge in NDI (Neck Disability Index)
- Greater chang in the pain rating scale (decreased)
- Greater % who acheived minimal detectable change in the NDI
- Less OVERALL health care costs
Components to the Examination/Evaluation
Component 1: Medical Screening
Component 2: Differentiation of impairments, activity and participation restricitons associated with health condition
* Identify source of pain
* Identify patterns of symptoms
Component 3: Diagnosis of SINSS
Component 4: Match the intervention based on findings
Component 1: Medical Screening
What fundamental question must we awnser?
Is PT appropriate for this patient?
If YES - 2 options
* Tx appropriately
* Tx and refer (non-urgent)
If NO - 2 options
* REFER back to MD (urgent or non urgent)
* No Tx (inappropriate to treat)
What are 4 helpful screening tools?
- Past Medical Hx/Medical Screening Questionnaire
- Ransford Pain Diagram/Visual Analog Pain Scale
- Functional Outcome Measures (NDI)
- Psychological Risk Factors (Fear Avoidance Beliefs/Physical activity questionnaire or tampa scale of kinesiophobia)
Ransford Pain Diagrapm and VAS
What does Central Sensitization look like?
- Used to ID pain patterns and types of pain
Associated with Central Sensitization
- Total arm Sx
- B UE Sx
- Drawings showing expansion and magnification (Circles of pain, use of arrows, draw outside the lines)
Draw the Cervical Referral Patterns
Neck Disability Index
- Disease Specific Health Related Quality of Life Questionnaire
- Test re-test reliability: .89
- 50 points or double for % disability rating
- Minimally Clinical Important Difference: 5-7 points
Cogntion/Beliefs Screening
- Assist in determining the prognosis of care
- Fear avoidance beliefs are the greatest negative factor on prognosis
- Have to focus on pain education snd self management strategies
Red Flag Definition
Signs or Sx associated with serious medical condition that requires immediate medical attention or referral within 24-48 hours.
Yellow Flags Definition
Signs and Sx associated with continuing with exam but with caution
Medical Screening for Serious Conditions in the Cervical Region
- Post Trauma - Need for radiographs
– Canadien C Spine Rules - Upper Cervical Laxity/Instability
– Beware of risk factors and warning signs Ligamentous testing - Cervical Myelopathy and general neuro screen
– Beware of risk factors and warning signs
– UMN testing
– LMN tetsing - Cervical Artery Insufficency
– Beware of risk factors and warning signs
– Cervical ROM with gradual progression of forces
– CN assessment
When is a radiologic testing needed following trauma?
Canadien C-Spine Rule
High Risk if:
* Equal or greater to 65 years old
OR
* Dangerous mechanism
OR
* Parethesia (numbness/tingling) in extremities
REFER HIGH RISK
Low Risk if:
* Simple rear end motor vehicle collision OR
* Sitting position in the emergency department OR
* Ambulatory at any time OR
* Delayed onset of neck pain OR
* Absence of midline cervical-spine tenderness
Are they able to rotate neck actively? Greater than 45 degrees left and right?
– If yes, NO RADIOGRAPHY
– If no, YES Radiography
Negative Prediction Value: 100%; Used to rule OUT
If you suspect someone needs cervical imaging, what do you ask for?
- Normal series:
– Open mouth view
– Lateral view
– AP view - Flexion/Extension stress view (to the right)
- Possible CT Scan
What happened?
- Transverse Ligament Tear
- Dens is no longer held to arch of C1 by the ligament creating a massive distance between. PT is likely experiencing numbness and tingling and possible UMN presentation.
Upper Cervical Instability - Risk Factors
- Hx of trauma
- Ra (Connective Tissue Disorder)
- Congenital dysplasias (Ex: MArfan’s Syndrome, Down’s Syndrome)
- Pregnancy (laxity due to hormonal changes)
Upper Cervical Instability - Subjective Complaints (Warning Signs)
- Neck pain, suboccipital pain and/or headaches
- Self Limited ROM and feeling of instability
- Nausea and/or dizziness
- Cervical myelopathy symptoms
What are the 3 tests for ligamentous stability of upper cervical?
- Sharp Purser Test
- Alar Ligament Test (aka: lateral sheer test)
- Abberrant motions of neck
Cervical Myelopathy - Risk Factors
- Cervical Instability (traumatic vs systemic)
- Central canal stenosis (Space occupying lesion of central canal; ex: tumor or large bony mass OR severe degenerative changes)
Cervical Myelopathy - Signs and Sx (Warning Signs)
- Bilateral Sx
- Sensory disturbances in hands (non-dermatomal)
- Non myotomal weakness
- Loss of dexterity in hands
- Unsteady/clumsy gait
- UMN findings
Cervical Myelopathy Testing
- UMN Testing
– Babinski
– Ankle Clonus
– Hoffman’s Sign
– Reflex Testing - hyperreflexia
– Gait or balance (Rhomberg Testing) - Positive Lhermitte’s Sign (Electric shock sensation down spine during neck flexion
- Atrophy of hand intrinsics
Cervical Artery Disease - Referral Pain Pattern
Vertebral and facets present the same (1)
Internal Carotid and Upper cervical present the same (2)
Cervical Artery Disease (CAD) - Risk Factors
- Cardiac Disease
- Artherosclerosis
- Previous stroke
- Smoking
- Diabetes Mellitus
- Hx of Whiplash
Low Risk: No more than 1 RF or Sx
Moderate Risk: 2 or more RF
High Risk: Known cardiovascular or pulmonary disease
Cervical Artery Disease - Subjective Complaints (Warning Signs)
- Pain Referral Patterns corresponding with Arteries
- 5 D’s And 3 N’s
Drop Attacks (sudden fainting)
Dizziness (related to neck movements)
Dysphagia (difficulty swallowing)
Dysarthria (poor articulation)
Diplopia (double vision)
Ataxia
Nystagmus
Nausea
Numbess
Clinical Recommendations for Screening for CAD
- Identify risk factors and warning signs
- Assess dizziness during sustained rotation of cervical spine
- Assess dizziness during sustained extension of cervical spine
- Cranial nerve assessment
- Cardiac assessment (elevated HR and BP)
If concerns, refer to appropriate medical provider for Doppler U
Component 2: Differentiation of MS impairments associated with clinical patterns
- Neck Pain with Altered Cognition and Beliefs
- Neck pain with Joint and Soft Tissue Mobility Deficits
- Neck pain with Neurodynamic Mobility Deficits
- (Radiating Pain)
- Neck Pain with Motor Coordination Deficits
- Neck pain with Headaches (unique subset)
Sources of Pain
Nociceptive Pain
* Pain is proportionate to the mechanism and nature of the injury
* Aggravating and alleviating factors
* Intermittent sharp or dull ache
* No dysesthesia, burning or shooting
Peripheral Neurogenic
* Lesion or dysfunction in the peripheral N, dorsal root ganglia or dorsal root from trauma, compression, inflammation or ischemia.
* Pain in dermatomal or cutaneous distribution
* ULTT and sensitivity to nerve palpation
Central Sensitization
* Amplification of neural signaling within the central or peripheral nervous system that elicits pain hypersensitivity
* Pain is disproportionate to the mechanism or nature of the injury
* Difficulty describing aggravating and alleviating factors
* DIFFUSE tenderness
* Psychosocial issues – Affected by emotions, beliefs, etc.
Cervical and Thoracic Examination:
Standard and Differentiating Elements
Standard Elements
* Subjective interview
* Postural Assessment
* Gross Cervical, Thoracic & Upper Quarter ROM assessment
– AROM, PROM and overpressure (if indicated)
Differentiating Elements
* Joint Mobility Assessment: Upper & mid cervical, upper thoracic
* Soft Tissue Assessment: Palpation and Flexibility
* Neurological screen and Neurodynamic mobility
* Motor Coordination Assessment
Assessment of Condition Severity and Irritability is based on what 3 components?
- Amount needed to cause/provoke the sx
- Severity of sx provoked
- Activity and time to ease sx
Match intervention through…
Impairement-Based Intervention Approach
Impairment distribution will…
Include multiple areas of impairments. Therefore, Tx time should reflect this distribution.
What is an asterik sign? What is it used for?
- Compareable sign to determine if Tx is working and refines your clinical reasoning.
- Used within or between sessions
Summary of Cervical Examination
- Plan your examination
- Rule in or our different Dx
- Remember that there is overlap with clinical diagnosing patterns so must differentiate
- Gain a movement pattern baseline
- Reassess patient’s progress toward the patient’s goals
