Lecture 6 - The Neck and Upper Back Flashcards
What is the theory behind neural tissue provocation tests?
Protective muscle tissue response occurs when muscles supplied by nerves contract to protect the nearby neural tissue from movement
In what progressive order should you provoke the neural tissue and when should you stop?
Shoulder, forearm, wrist, fingers, elbow, contralateral cervical side flexion
You should stop as soon as there is onset muscle resistance. You should not be getting to the stage of pins and needles or pain as this will be overly provoking the neural tissue
When is contralateral side flexion to add another level of sensitisation usually indicated in NTPTs
Chronic, non-irritable or non-sensitised conditions
What can NTPT be used for besides assessment?
Treatment to mobilise affected neural tissue
Very gentle so as not to further irritate or damage the neural tissue
What are three indications that neural tissue predominates?
Contralateral side flexion can cause provocation of symptoms earlier in range of symptom provoking movements
Sensitivity in neural tissue provocation tests
If side glides with a light depression of the shoulder at relevant cervical level alleviates/helps with symptoms
How should you treat neural tissue issues with NTPT?
With an active and ongoing inflammatory condition, gentle oscillations of surrounding anatomical structures and tissues
With a chronic condition, stronger grade oscillation of surrounding anatomical structures and tissues
What are the indications and contra-indications for using NTPT as treatment
Indications - neural tissue dysfunction indicated
Contra-indications -
Progressive neurological pathology
Neurological deficit
Canal stenosis
When treatment exacerbates the symptoms/causes distal symptoms
When other treatment is indicated
What is ULTT1 and what nerve does it test for?
Median nerve
Shoulder girdle depression, shoulder abduction and external rotation, supination, wrist extension, finger extension, elbow extension, cervical side flexion
What is ULTT2a and what nerve does it test for?
Median nerve
Shoulder girdle depression, elbow extension, lateral rotation of whole arm, wrist, finger and thumb extension
What is ULTT2b and what nerve does it test?
Radial nerve
Shoulder girdle depression, elbow extension, medial rotation of whole arm, wrist, thumb and finger flexion
What is ULTT3 and what nerve does it test for?
Ulna nerve
Shoulder depression, abduction and external rotation, pronation, wrist extension, finger extension, elbow flexion
How do you locate C2?
First prominent vertebrae after the occiput
How do you identify C6
Disappears on neck flexion
How do you identify C7?
Prominent round vertebrae at base of neck, doesn’t disappear on neck flexion but the one above it should
What adaptations do the cervical vertebrae have to allow for the nuchal ligament
Bifid spinous processes
What adaptation do the thoracic spinous processes have for the ribs
Costal demi facets so the ribs can articulate
What are C1 and C2 called and what is their articulation called
C1 = Atlas
C2 = Axis
Atlo-axial joint
How do you test the myotomes at each nerve root
C1 and C2 - Resisted neck flexion
C2 - Resisted neck extension
C3 - Resisted neck side flexion
C4 - Resisted Shoulder elevation
C5 - Resisted shoulder abduction (deltoid)
C6 - Resisted elbow flexion (biceps)
C7 - Resisted elbow extension (triceps) and resisted wrist extension
C8 - Resisted finger flexion and thumb extension (extensor pollucis longus and flexor digitorum profundus)
C8 and T1 - Resisted finger abduction and adduction
How do you test reflexes in the upper limb?
Biceps reflex - Tap on biceps tendon
Triceps reflex - Tap on triceps tendon (inserts into olecranon process)
Deltoid reflex - Tap on tendon which attaches into deltoid tuberosity on the middle portion of anterolateral surface of humerus
Upper Trapezius reflex - Tap thoracic spine
Pronator reflex - Tap on tendon which attaches into middle one third of anterolateral aspect of radius
Brachioradialis - Tap on tendon which attaches into lateral aspect of distal radius just below wrist joint line in line with thumb
What are the 5Ds and 3Ns and what are their purpose?
To screen for serious cervical and upper back pathologies, particularly Vertebrobasilar insufficiency (lack of blood flow to posterior areas of brain)
5Ds:
Dizziness
Dysarthria - speech difficulties/differences
Dysplopia - Double vision
Dysphagia - Swallowing difficulties
Drop attacks - Sudden loss of consciousness
3Ns:
Nausea
Nystagmus - uncontrolled eye movements
Numbness/paraesthesia
What upper motor neuron tests should you perform in a neurological screening with upper back and neck issues
Hoffman’s - flick on the middle fingernail, if thumb and index finger come together, positive
Babinski - run object down lateral side of foot
Clonus - rapidly put foot into dorsiflexion, more than 3 beats = positive sign
What is the OIA of Levator scapulae
- Origin - C1-C4 transverse processes
- Insertion - medial border of scapula
- Action - shoulder elevation (pulling the scapula superomedially), neck extension, ipsilateral side flexion
What is the OIA of Upper trapezius
- Origin - external occipital protuberance and nuchal ligament
- Insertion - into posterior border of clavicle
- Action - rotates and elevates the scapula and extends the neck
What is the OIA of rhomboid major
- Origin - T2-T5 Thoracic vertebrae and the supraspinous ligament
- Insertion - Medial border of scapula
- Action - Retracts and rotates scapula
What is the OIA of rhomboid minor?
- Origin - C7 and T1
- Insertion - Medial border of scapula (upper 1/3 near root of spine of scapula)
- Action - Retracts and rotates scapula and presses scapula into thoracic wall
What is the OIA of sternocleidomastoid
- Origin - Two heads, sternal head originates from anterior surface of the manubrium of the sternum and the clavicular head originates from medial one third clavicle
- Insertion - Mastoid process (located behind ear lobe) on the temporal bone
- Action - Flexion, ipsilateral side flexion and contralateral rotation (also elevate the clavicles and sternum to help with breathing)
What is the OIA of latissimus dorsi
- Origin - Spinous processes of T7-L5, iliac crest, inferior 4 fibs and inferior angle of scapula
- Insertion - Intertubercular sulcus of humerus
- Action - Shoulder extension, adduction and internal rotation
What is the OIA of erector spinae
- Origin & insertions = complex for these, in general they originate from the lumbar and lower thoracic regions and insert into upper thoracic and cervical regions (also have attachments on iliac crest, mastoid process and ribs)
- Action - Neck extension, back extension, lateral flexion and rotation of the back, stabilising the pelvis if balancing on one leg
Why is the neck vulnerable to extension loading?
There are less anterior neck muscles
What can tight upper traps and levator scapulae cause?
Compressive loading of the cervical spine as they pull the vertebrae they attach to together
What active movements should you do for upper neck and back?
Left/right head rotation (repeat with arms supported to take tension out of neck and shoulder muscles)
Lateral side flexion of neck
Flexion and extension of neck
Left/right thoracic rotation (fix body lower down and have patient cross hands over chest)
Lateral side flexion of trunk
Flexion and extension of trunk
What is cervical spondyloarthritis
Degenerative changes to the vertebral column, most common cause is spinal osteoarthritis
What is myelopathy and when should you refer on
Neurological deficit relating to spinal cord, if degenerative myelopathy is suspected refer on as this is a neurological issue and could require surgery
What is whiplash
Whiplash is a self limiting condition with treatment that involves reassurance and education on normal movements
What should be escalated and to whom regarding whiplash
Someone with suspected serious injuries or at high risk for serious injury should be sent to A&E and referred for radiography
High VAS or NDI (neck disability index) scores could consider referring to whiplash associated disorders specialist
If negative psychology could be appropriate for a CBT programme or similar
If symptoms not improving despite interventions consider escalation of management
What is acute torticollis and how would you treat it?
Sudden neck pain and muscle spasms due to neck sprains, irritations of muscles etc
Usually will relieve by itself but gentle exercises, soft tissue work, painkillers and heat/ice to relieve pain
What is polymyalgia rheumatica and what should you do if noticing this?
Very stiff muscles upon waking up that follow an inflammatory pattern
Refer to rheumatology
What is a cervicogenic headache
Referred pain from neck into the head can be due to a variety of causes of pain in the neck from less serious to much more serious such as a fracture
How do you perform a PPIVM at C1/2
Have the patient in sitting
Fix C2 with your thumb which will isolate movement of C1 on C2
Passively perform side rotation, when you feel pressure against your thumb, that’s the limit of C1 on 2’s movement
How do you perform cervical spine rotation PPIVMs?
Have the patient in supine with one hand supporting under their occiput
Put fingers in joint spaces and rotate the head
How do you perform cervical side flexion PPIVMs
Have the patient in supine with one hand supporting under the occiput
Put fingers in joint spaces and perform side flexion
How do you perform a rib PA PAIVM
Have patient in prone, fix the spinous process above the rib, and do a PA glide on rib using lateral border of hand (can also be done in sitting and side lying)
How do you perform a PA Thoracic vertebra PAIVM and why
Have patient in prone, use pisiform or lateral border of hand to push from posterior to anterior on the spinous processes of the upper thoracic and cervical vertebrae
PA movement of vertebrae is needed to perform flexion so this is particularly indicated if flexion is limited
How do you perform a PA unilateral cervical vertebrae PAIVM and why?
Have patient in prone, use thumb in a PA direction (gliding towards the eye) on the superior articular processes on the necessary side
PA movement of the superior articular processes which are the concave surface in the facet joints assists with flexion
How do you perform a transverse glide of the upper thoracic vertebrae and why
Have patient in prone
Use thumbs to glide spinous processes in a transverse direction
This assists with side rotation if this is limited
How would you perform a transverse glide of cervical vertebrae and why?
Have patient in supine, support occiput with one hand, use thumb to gently glide the spinous processes of cervical vertebrae transversely
Transverse accessory movement is needed for side rotation
What is a NAG/SNAG
(Sustained) natural apophyseal glides
PAIVMs accompanied by active movement from the patient to see if symptoms and range improve
This should be instant, if not, a SNAG/NAG is not indicated
How do you perform a rotation NAG for right side neck rotation and why
Transverse glide C1 on left side and then patient turns head to the right
This is indicated if blocking C2 and performing this movement shows early movement of C2 hence indicating stiffness in C1/C2
How do you perform a unilateral flexion SNAG and why?
Wrap your hands around the patient’s head and have their forehead rest on your abdomen, have your pinky finger resting on the lamina of the appropriate vertebra, glide upward toward the eye as this is the direction of the joint
If flexion is limited
