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PHTY3260 > L5: Physical examination of the cervical and thoracic spines and upper quadrant > Flashcards

L5: Physical examination of the cervical and thoracic spines and upper quadrant Flashcards

1
Q

What are 7 aims of the physical examination?

A
  1. To confirm/reformulate diagnostic hypothesis(es)
  2. To confirm MSproblem
  3. To understand the mechanisms of pain and physical impairments linked to pain syndrome

Make the pattern fit between symptoms and physical signs

  1. To detect the physical impairments related to provocative functional activities, work practices
  2. To gain precise information to inform the treatment program
  3. To document outcome measures
  4. To establish the overall goals of treatment

Key aspect of patient centred care= shared decision making

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2
Q

What are 6 features of the physical examination?

A
  1. Postural assessment(static and dynamic)+ provocative postures
  2. Articular System
    • Active movements –including patient specific provocative movements
    • Manual examination (PAIVM’s; PPIVM’s)
    • Tests of adjacent joints/regions
  3. Neural System
    • Neurological examination
    • Tests of neural tissue dynamics / mechanosensitivity/ CI for CCFT
  4. Tests of muscle function
    • Tests of cervical and axio-scapular motor/muscle control
    • Tests of muscle length
    • Tests of muscle strength and endurance
  5. Somatosensory function
    • Tests of kinaesthesia, balance, eye movementcontrol
    • Proprioception
  6. Function/work specific tasks aggravating the pain disorder
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3
Q

What are 3 features of the articular system in the physical examination?

A
  1. Active movements –including patient specific provocative movements
  2. Manual examination (PAIVM’s; PPIVM’s)
  3. Tests of adjacent joints/regions
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4
Q

What are 2 features of the neural system in the physical examination?

A
  1. Neurological examination
  2. Tests of neural tissue dynamics / mechanosensitivity/ CI for CCFT
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5
Q

What are 3 features of the test of muscle function in the physical examination?

A
  1. Tests of cervical and axio-scapular motor/muscle control
  2. Tests of muscle length
  3. Tests of muscle strength and endurance
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6
Q

What is a feature of the function/work specific tasks aggravating the pain disorder in the physical examination?

A

Function/work specific tasks aggravating the pain disorder

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7
Q

What are 4 considerations in physical examination?

A
  1. The inter-related function of the articular, muscle and neural systems and the CNS control
  2. The effect of painon performance
  3. The relationship between pain, functional limitations and posture, movement and muscle function
  4. The motivation and reactions of the patient
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8
Q

What are 3 considerations to plan the order of the tests in the physical examination?

A
  1. Consideration of patient comfort (st-sitting-lying)
  2. Allows the assessment of the interaction between systems (articular, muscle, neural)
  3. Promotes an analysis of the functional limitations expressed by the patient
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9
Q

What is the proposed order of testing in the physical examination?

A
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10
Q

What are the 3 systems is the dominant driver in the patient?

A
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11
Q

Demonstrate a postural analysis of a 45 year legal secretary who complains of pain after working at the computer for 4 hours.

  • What components would you include?
    • How would you interpret your findings?
A

Postural analysis

  • TDT (mimic posture and the effect of correction)
  • If she gets better = (gives direction of treatment), muscles system is the problem
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12
Q

What are the 2 principles of postural analysis?

A
  1. Interpretany deviations on a multifactorialbasis
  2. Observe and classify natural spinal sitting posture
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13
Q

What are 4 features of interpret any deviations on a multifactorial basis as principles of postural analysis?

A
  1. Make a global postural classification
  2. Perform an analysis of muscle form
  3. Observe for any evidence of protection of neural structures
  4. Analyse any patient specific provocative postures
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14
Q

What are 3 features of “observe and classify natural spinal sitting posture” as principles of postural analysis?

A
  1. Analysisof postural correction to upright neutral posture
  2. Analysis of scapular position and scapular muscle control
  3. Effect of postural correction on neck pain and movement
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15
Q

What are 4 body areas for the examination of active movements?

A
  1. Cervical and Thoracic spines
  2. Cervical spine
  3. Thoracic spine
  4. Ribs
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16
Q

What are 2 features of cervical and thoracic spines in the examination of active movements?

A
  1. Primary planes: F, E, Rot, LF
  2. Patient specific provocative movements or combinations
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17
Q

What is a feature of cervical spine in the examination of active movements?

A

Upper C: F-E (nod), Head Rot in F (C1-2 rotation)

18
Q

What are 2 features of the thoracic spine in the examination of active movements?

A
  1. Upper (C/Th) -with cervical rotation -unilateral arm elevation (Ext, ipsilatRot,LF)
  2. Middle thoracic –bilateral arm elevation (ext)
19
Q

What are 2 features of the ribs in the examination of active movements?

A
  1. full inspiration/expiration
  2. spinal movements
20
Q

What are 4 observations in the physical examination?

A
  1. Rhythm and control of movement
  2. Acute compensations (eg. opening mouth)
  3. Movement at an intervertebral level (and ribs for thoracic area)
  4. Patterns of movement restrictions (patho-anatomical indications?)
21
Q

What are 4 things we are looking for in the physical examination?

A
  1. Disc
  2. Muscle
  3. Neural
  4. Where is the movement happening?
  5. Where is not moving?
  6. How well controlled is the movement?
  7. Does this relate to what ptreports in the history?
22
Q

What are the 4 typical features of nociceptive sources of pain?

23
Q

What are 5 progressions of tests when appropropiate in the physical examination?

A

With care as they are potentially provocative

  1. Overpressure to primary plane movements
  2. Repeated movements
  3. Combined movements (based on related movements (egExt and LF)
  4. Sustained movements
    • compromise the IV foramina if suspect subtle nerveroot signs egRot, ExT), OR
    • test vertebral artery
  5. Tests of axial compression (Spurling’stest) or distraction

Spurling’stest= Ext+LF+Rotwith added compression to compromise the size of the IV foramina -arm pain reproduction

24
Q

What is the Spurling’s Test in the physical examination?

A

Ext+LF+Rotwith added compression to compromise the size of the IV foramina -arm pain reproduction

25
What are 4 ***manual examinations*** in the **physical examination**?
1. Palpate spinal alignment 2. Palpate soft tissues long and segmental muscles for spasm, inhibition 3. Examine regional segmental motion (PPIVM’s) * Eg. ranges, restrictions, compare sides 4. Manual provocative tests (PAIVMs) for pain and muscle reaction provocation in accessory movement directions
26
What are 3 ***signs of symptomatic joint dysfunction*** in the **physical examination**?
1. Altered quality of resistance to induced motion andaltered “end feel” (muscle spasm, fibrous restriction) 2. Abnormal displacement (hypo/ hypermobility) 3. Pain provocation: local or referred Compare sides
27
What are 2 characteristics for ***cervical disorders*** for the **neurological examination?**
1. all patients with pain referred into the arm (below tip of shoulder) 2. with sensory disturbances
28
What are 2 characteristics for ***thoracic disorders*** for the **neurological examination**?
1. Sensation only is tested 2. But consider examining gait, lower limb neuro, babinski/clonus
29
What are 3 ***clinical tests of condution of the spinal nerve*** for the **neurological examination**?
1. testing of muscle innervated by that nerve 2. reflexes 3. sensation
30
What are the cervical dermatomes?
31
What are the 3 characteristics of ***neurodynamic tests*** **(**Neural System Movementand Sensitivity to Movement) in the **neurological examination?**
1. Lack of free movement of neural tissues or inflammatory irritation of neural structures cancontribute to the pain state 2. The nerve may become allodynicand can be sensitive to movement 3. May not have positive neurological ie.conductiontests NB: Muscles protect nerves, so any restriction to test movements will be caused by pain and muscle spasm Not used routinely (as it is very provocative) unlike SLR (lumbar spine)
32
What are the 3 ***upper limb neurdynamic tests (ULNT)*** in the **neurological examination?**
Test of brachial plexus 1. median nerve bias 2. ulnar nerve bias 3. radial nerve bias
33
What are the 2 ***upper cervical region tests*** in the **neurological examination**?
1. Cranio-cervical flexion 2. Sensitisedby SLR and ULNT Nb: Neural tissue attachments C2 and occiput; dural connections to rectus capitisposterior minor and LigFlavum-assess prior to CCFT
34
What are the 3 ***thoracic region tests*** in the **neurological examination**?
1. SLR 2. PNF 3. Slump (Very provocative)
35
What are 5 characteristics to ***"make the pattern fit for neural tissue mechanosensitivity"*** in the **neurological exam?**
1. Protective posture (egsubtly raised shoulder- Antalgic posture) 2. Reduction in movement that may stress the nerve 1. ↓contralateral cervical LF range 2. ROM Shoulder abduction varies with neck position 3. Tenderness to palpation of nerve trunks 4. Positive provocation test (egULNT) 5. Relevant joint/muscle dysfunction (egC5-6 joint pain and movement dysfunction)
36
What are 3 tests of the ***muscle system*** in the **physical examination?**
1. **Tests of motor control** * muscle activation and holding capacity of the deep and postural stability musclesof the cervical and axio-scapular regions (initial assessment) 2. **Tests of muscle length** (as appropriate) 3. **Tests of muscle strength and endurance** (progressive assessment)
37
What are 3 tests of the ***cervical somatosensory function*** in the **physical examination**?
1. Tests of kinaesthetic sense * Relocation to natural head posture (joint position error: JPE) * Movement sense 2. Tests of balance 3. Tests of eye movement control
38
What are 4 assessments of functional and workplace practices?
1. Understand patients work, sport or recreation practices (initial assessment) 2. Analyse the presence of any adverse work, sport practices (initial assessment) 3. Workplace visit, sports analysis (progressive assessment) 4. Functional capacity assessment (progressive assessment)
39
What is the musuloskeletal neck pain flow chart?
40
What are 5 main key points of the patient interview and the physical examination?
1. Provisional pathoanatomicaldiagnosis 2. Main drivers of symptoms 3. A definitive physical diagnosis 1. Basis forselection of initial treatment techniques 4. Assessment is a progressive process 1. Re-evaluatefor effect, progress treatment 5. Established clear and quantitative outcomes 1. measures of pain (VAS/NRS) 2. measures of functional ability\* 3. physical impairment and physical performance \* Shared decision making (patient and physiotherapist) to determine short and long term goals of treatment
41
What are 6 recording ***impairments*** in the **physical examination**?
1. Postural assessment 1. slump sit, downward rotation (R) scapula 2. correction of posture increases (R) rotation 3. \*correction of scapular posture increases (R) rot and decreases pain 2. Articular System 1. Active movements 1. Ext 20⁰ pA; LF (R) 10⁰ pA; Rot (R) 60⁰pA ; combined (worst LF+Ext) pA+B 2. Manual examination 1. PPIVM: C2-3 LF(R) mod hypomobilityslpA 2. PAIVM: C2-3 mod hypomobilitypA 3. Tests of adjacent joints/regions √√ (full range, n pain OP) 3. Tests of muscle function 1. CCFT:–poor retraction pattern 2. Scapular holding: –fatigue with 2 reps (PAIVMs ↓ pain, slhypomoblity) 3. Extensors:–fatigues with 5 reps 4. Neural System –N/A 5. Somatosensory function-N/A 6. Function/work specific tasks 1. poor posture at work –screen too high; slump sits, few breaks

PHTY3260 (27 decks)

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