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medbridge course Flashcards

1
Q

what percentage of whiplash patients report continued symptoms at 1 year

A

80% with 25% of those reporting severe symptoms

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2
Q

Describe relative motion of the head neck during a rear end whip lashe

A

the total motion of the head and neck are typically within normal physiologic ranges, but the combined motion of upper cervical flexion with lower cervical extension creates the nonphysiologic loading

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3
Q

what is the nexus criteria for x-ray with neck pain

A

no x-ray needed if all are negative

  • no posterior midline tenderness
  • no evidence of intoxication
  • a normal level of alertness
  • no focal neurological deficits
  • no evidence of a painful distracting injury - hurts enough that the don’t notice the femur fracture
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4
Q

what is the Canadian c-spine rule

A

3 levels to assess alert, stable individuals with cervical trauma older than 16
x-ray if
1. High risk variable are present - 65 or older, dangerous mechanism, UE parasthesia
2. Safe for ROM assessment? Absence of low risk variables for safe ROM assessment are present - simple rear end MVA, sitting in ER, ambulatory at any time, delayed onset neck pain, absence of midline cervical tenderness
3. Can not rotate Greater than 45 degrees

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5
Q

Describe quality of motion assessment with isometric holds in the cervical spine for both flexion and extension

A

Manually move them to a position of NWB and good cerivcal posture, slowly release the hold and observe for motion

  1. they should be able to hold the neutral position
  2. upper cervcial extension in prone and supine could signal weak longus coli (prone no flexor balance, supine SCM dominate anterior musculature)
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6
Q

what is the SLANSS test

A

Yes/no Patient Questionnaire used to identify neurogenic classification of pain (score greater than 12)

  1. pins and needles
  2. affected area changes color
  3. affected area abnormally sensitive to touch
  4. sudden unpredictable burst of pain
  5. burning pain
  6. rubbing area more pain compared to other side
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7
Q

what are tropia and phoria

A

tropia - vertical displacement of the eye with ocular alignment testing (hyper [up] and hypo [down])
phoria - lateral displacement of the eye with ocular alignment testing (exo- [away from midline], eso- [towards midline])

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8
Q

what proportion of WAD injuries will fall into the 3 risk categories for chronicity

A
  1. low risk 25-30%
  2. moderate risk 50-65%
  3. high risk 10-20%
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9
Q

what are the key variable to assessing risk for development of chronic neck pain with WAD

A
  1. high pain intensity (greater than 6/10)
  2. High NDI score
  3. High post trauma stress
  4. pain catostrophzing
  5. cold hypersensitivity
  6. Mechanical hyper sensitivity
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10
Q

what variable appear unrelated to pain chronicity following WAD

A
  1. angular neck deformity
  2. impact direction
  3. seating position
  4. awareness of collision
  5. head rest in place
  6. older age
  7. vertical speed
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11
Q

Describes Sterlings CPR for identifying individuals at high risk of developing chronic neck pain after an MVA

A

2013 Sterling - Starts with NDI

  • Greatest risk - NDI greater than 40, over 35, high post accident stress - needs medical management
  • least risk - NDI less than 32, age less than 35 - full recovery - provide with education encouraging them to stay active and 2-3 months it should resolve
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12
Q

What potential sources of pain have been identified in neck pain following WAD

A
  • intra-articular hemorrhage
  • capsule tear
  • meniscoid contusion
  • articular, subchondral fracture
  • articular pilar fracture
  • annular tear
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13
Q

How does chronic neck pain with coordination impairment impact the muscles of the neck

A

infiltration of fat into all the muscle of the neck

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14
Q

what does “current” evidence indicate about brain stem and spinal cord lesion with WAD

A

potential injury to these areas, but the evidence and ability to study is lacking

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15
Q

Describe the anatomical parts of the alar ligament

A
  1. Occipital - dens to occipital condyles
    2 atlantal - Dens to lateral mass of CI
    Angle of orientation is 150 to 180 degrees
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16
Q

What upper cervical ligament is most important for controlling anterior displacement of C1 on C2

A

transverse ligament

- 7-8mm wide

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17
Q

What region of spine facets has the greatest sagittal plane orientation

A

NOT the cervical, these are oriented to allow for the greatest degrees of rotation and side bending relative to the other regions

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18
Q

What is the standardized procedure for identifying cold sensitivity

A

Neurosensory analyzer gold standard

- ice cube for 5 seconds on the affected area rating pain greater than 13 (0-20 scale) is considered hyperalgesia

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19
Q

what role does MRI play identification of pain source in whiplash related disorders

A

does no do well with identifying source of pain

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20
Q

What does 5D’s and 2N’s stand for

A

Helps clear cervical spine for serious pathology associated with VA and VBA

  • 5D’s - dizziness, drop attacks, diplopia, dysarthria
  • And - ataxia, anxiety
  • 2N’s - nausea, numbness, nystagmus
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21
Q

what could draw your attention to possibility of cancer

A
  • past personal history or one-off family history
  • age over 50 or under 20
  • no relief with complete bed rest
  • recent, unexplained weight loss (10% in less than one month)
  • severe night pain unaffected by posture or position
  • night pain disturbing sleep
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22
Q

what are some headache red flags

A
  1. sudden onset of severe headaches
  2. worsening or changing of symptoms
  3. headaches triggered by cough, valsava, exertion
  4. headache triggered during pregnancy, delivery or post partum
  5. onset of heated over 50 (temporal artris)
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23
Q

Describe relative blood flow to the brain from the vertebral artery and carotid artery

A

VA - 11% - posterior region

CA - 89% - anterior region

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24
Q

who has the greatest risk for cervical arterial dysfunction

A
  1. females 30-39
  2. history of Migrane
  3. oral contraceptive use
  4. DM
  5. HTN
  6. Smoking
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25
Q

what motions place the greatest stress on the blood flow to the brain

A
  1. upper cervical rotation impacts vertebral artery

2. mid cervical extension impacts the carotid artery

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26
Q

where does pain associated with he vertebral artery refer

A
  • upper trap region

- side of the scalp region

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27
Q

How will hind brain impairment present and what cervical pathology would it draw your attention to

A

Vertebral artery dissection

  • 5Ds And 2Ns
  • limb weakness, anhidrosis, hearing disturbances, malaise, perioral dysphasia, photophobia, papillary changes, clumsiness and agitation
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28
Q

what are some signs and symptoms of carotid artery dissection

A

non-ischemic signs and symptoms

  • Horner’s syndrome, mitosis (constricted pupil), drooping eye lid (ptosis), absence of face sweating (anhidrosis), enopthalmos (retracted eyeball)
  • pulsatile tinnitus
  • cranial nerve palsies (9-12 typically)
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29
Q

where does pain associated with he vertebral artery refer

A
  • upper trap region

- side of the scalp region

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30
Q

How will hind brain impairment present and what cervical pathology would it draw your attention to

A

Vertebral artery dissection

  • 5Ds And 2Ns
  • limb weakness, anhidrosis, hearing disturbances, malaise, perioral dysphasia, photophobia, papillary changes, clumsiness and agitation
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31
Q

what are some signs and symptoms of carotid artery dissection

A

non-ischemic signs and symptoms

  • hornet’s syndrome, mitosis (constricted pupil), facial flushing, enopthalmos (retracted eyeball)
  • pulsatile tinnitus
  • cranial nerve palsies (9-12 typically)
32
Q

what is a jefferson’s fracture

A

comminuted fracture of ring of C1

33
Q

Subjectively what might someone with upper cervical instability report

A
  • occipital headaches and numbness
  • guarded movement
  • locking of the neck
  • crepitation
  • head feels heavy or tired
  • feels better in the morning
34
Q

What cervical pathologies requiring additional medical assessment might report symptom production with valsalva type loading

A
  • arterial dissection

- type I arnold-chiari malformation

35
Q

What pathologies are associated with upper cericval instability

A
  • Klippel Fiel - congenital fusion of cervical segments
  • ehlers-Danlos
  • Arnold-chiari
  • down’s syndrome
36
Q

What to upper cervical instability tests should you perform together

A
  1. supine transverse ligament or anterior shear test- slide C1 forward, if symptoms are produced immediately do sharp-purser
  2. sharp-purser - seated, stabilize C2, nod and mobilize head back by pushing at the forehead
37
Q

what is the diagnosis cluster for cervical radiculopathy

A
  1. ULTT-a or 1
  2. postive spurlings
  3. positive distraction test
  4. cervcial rotation less than 60 to ipsalateral side
38
Q

what clinical signs could help you differentiate a pancoast tumor from cervcial radiculopathy

A
  • hornet’s syndrome do to sympathetic involvement
  • symptoms include same side miosis (a constricted pupil), partial ptosis (a weak, droopy eyelid), apparent anhydrosis (decreased sweating), with apparent enophthalmos (inset eyeball
39
Q

Myotome assessment of cervical spine

A 
c01 - passive flexion extension
c12 - passive rotation with neck flexed less than 40 degrees
C3 - c1-c3 neck flexion and side bending
c4 - shrug
c5 - abductin
c6 - bicep or wrist ext
c7 - tricep
c8 - finger flexion
t1 - first interossei
40
Q

what is the difference between a cervical radiculopathy and myelopathology

A

myelopathy - compression of the spinal cord presenting with arm and leg impairments
radiculopathy - irritation to the nerve roots

41
Q

what cluster of test would suggest someone is likely to benefit from cervical traction for symptom control

A
  1. age over 65
  2. shoulder abduction test
  3. ULTT-A
  4. symptom peripheralization with lower cervical PA testing
  5. Neck distraction test
42
Q

describe the treatment parameters of the traction treatment cluster study

A
  1. traction at 15-14 degrees flexion with “moderate to strong pull” average 23# up to 40#, intermittent for 15 minutes
  2. Exercises for posture and DNF
  3. 6 weeks
43
Q

what is the DNF prayer

A

position thumb up hand against chest with the thumb at about midcerivcal spine
- nod and try and touch the thumb with the chin

44
Q

how do you perform a self SNAG to the upper cervical spine

A

position mobilization strap at the upper cervical spine

- rotate your head and assist the rotation with the mobilization strap

45
Q

When treating patients in the neck pain with mobility impairments classification at what point should you address thoracic impairments

A
  • you want to begin day one to address the thoracic impairments with manual therapy along with thoracic and cervical exercise
46
Q

how do the APTA clinical guidelines define cervicogenic headaches

A
  1. unilateral headache with heck/suboccipital symptoms aggravated by moment
  2. headache produced with provocation of ipsilateral posterior cervical myofascia and joints
  3. restricted cervical ROM
  4. restricted segmental mobility
  5. abnormal/substandard performance on cranial cervical flexion test
47
Q

How would the symptoms of cervical headache differ from migraine

A
  • CH onset 33 versus MI 18
  • CH posterior, MI anterior
  • CH unilateral, MI can be both sides
  • MI frequent nausea
  • MI frequently throbbing type pain
  • CH position specific provocation
48
Q

why does upper cervical impairment refer up instead of down like everything else

A

Convergence of the trigeminal afferents and C1-C3 occurs in the trigeminocervical nucleus

49
Q

What does the evidence indicates about the role of fatigue, depression, worry and anxiety in cervicogenic headaches

A

It does not effect them because these variables would fall in the tension headache category

50
Q

what is the pathoanatomic theory behind aura or headache premonition with migraines

A

vasospasm within the cerebral cortex

51
Q

what are the differentials for meningeal irritation

A
  1. steady, deep pain bioccipital and/or frontal
  2. singel episode progressing rapidly over several hours or minutes
  3. neck stiffness bending forward
  4. Postive kernig sign - inability to perform SLR
  5. positive brudzinski sign - flexion of head patient will flex legs
  6. positive Lhermitte sign - flexion of head produces shocking in the legs
52
Q

what is brudzinski sign, lhermitte sign and kernig sign

A

B- flexion of the head produces flexion of the legs
I- flexion of head produces shocking in legs
K- unable to perform SLR due to neck and head pain

53
Q

differentials for temporal arteritis

A
  • unilateral or bilateral temporal pain
  • older than 50
  • temporal arteries thick, TTP, throbbing, burning
  • intermittent initially then becomes constant
  • loss of vision, fever, weight loss
    EMERGENT REFERRAL
54
Q

What type of subjective reports would you expect with cerivcogenic headaches

A
  • symptoms shoulder follow a cerivcal distribution (suboccipital, occipital, occipitofrontal, orbital areas)
  • unilateral and typically start in the neck
  • should be associated with neck postures or moments
  • should not have diffuse, deep, throbbing, isolated to eyes or associated with any neurologic or cognitive symptoms
55
Q

what is hoffman’s sign for cervical myleopathy

A

flick middle finger down

- produces index finger flexion

56
Q

what type of manual therapy has demonstrated the greatest benefit for cerivcogeneic headaches

A

cervical joint work WITH exercise

- upper cervical SNAG as well as cervical mobilization and manipulation

57
Q

What does the evidence indicate about treatment of acute WAD in physical therapy

A

low data to support any particular treatment modality

  • Active intervention is the most supported at a “B” level of support
  • identifying specific needs of each patient is important
58
Q

what are some suggested mechanisms for transitioning into chronic WAD

A
  1. maladaptive beliefs and cognition
  2. stress system dysregulation
  3. genetic vulnerability
  4. injury to the central nervous system
59
Q

How is the evidence for treatment of chronic WAD different than acute WAD

A

the evidence for treatment modalities with chronic WAD is stronger than treatment of acute WAD

60
Q

What does the evidence indicates regarding exercise with chronic WAD

A

low to moderate evidence

  • exercise helps, but exact dosing of exercise is undetermined
  • supervised or structured exercise is best
  • Qi Gong
61
Q

what does the data indicate regarding dry needling with chronic WAD

A

OPTIMA review no benefit versus placebo, ICON review moderate benefit versus placebo

62
Q

What does the evidence suggest about mind body based interventions

A
  • low to moderate evidence for relief of pain
63
Q

Can scapular exercise improve symptoms related to chronic wad

A

yes, 10 weeks of 2 minutes per day of scapulothoracic training have show low to moderate evidence for improve symptoms related to chronic WAD

64
Q

Describe the model of pathology for weak neck flexors and forward head posture

A

By keeping the head in front on the COG you can create an extension biased positioned and avoid use of flexors

65
Q

what are some functional observations you may make with someone with weak neck flexors

A
  1. forward head posture
  2. pokey chin extension - upper cervical compensation with avoidance of bringing the head into a flexion biased relationship to COG
  3. lifting head from the table when getting up
66
Q

what type of functional observations would you make with weak cervical extensors

A
  1. poor active control of cervical flexion
  2. flexion biased forward head position
  3. prominent reports of sensory motor disturbances such as headaches or laser impairment
67
Q

How does muscle morphology change in chronic WAD

A

fatty infiltrate that is greatest in the extensor group of muscles

68
Q

what did O’leary et al 2015 find regarding cervical exercise

A

WAD based group demonstrated increase muscle volume with 10 week exercise program

69
Q

What is a brock string

A

tool for training convergence impairments where a string has 3 different beed or focal points. The string is head at the nose and the person shifts their focus to each point

70
Q

what facet joint are most commonly involved in WAD and where do they typically refer

A

C2/3 - occipital and suboccipital region

C5 - CT junction and upper trap region

71
Q

what cervical segment refers along the shoulder blade

A

C7/t1

72
Q

Describe the outcomes for medial branch blocks

A

50% of recipients had complete symptom resolution at 400 days, but only 45% of chronic WAD met the IC

73
Q

Post traumatic stress disorders occur in what percentage of people with WAD

A

15-20%

74
Q

What type of behavioral therapy has shown good promise with chronic WAD pain management

A

trauma- focused cognitive behavioral therapy

75
Q

how will internal carotid artery impairment present

A

frontal headaches

horner’s syndrome

cervical (6 decks)

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