Midterm Cards Flashcards
Can a t-spine manip help cervical pain in a patient w symptoms distal to the shoulder?
No
Can a T spine manip help a patient with C spine dysfunction who has pain with looking up
No
Can a T spine manip help a patient with C spine dysfunction who has over 30 degrees of cervical extension
No
It can help C-spine extension UNDER 30
What are the 3 signs of a positive neuroprovocation test
Reproduces pt symptoms
test response altered by distant component
test different from R and L
What tissues take the longest to heal?
Insertional tendon tear (up to 2 years)
Articular cartilage repair (up to 2 years)
Ligament graft (up to 2 years)
What is the lhermitte sign
a pathological UMN reflex,
have pt flex neck down, and they will feel a shock sensation down their spine
where are the 3 sites the dura is tethered to the spinal canal?
C6 T6 L4
If all ULTT are negative, what condition can you rule out?
Cervical radiculopathy
3 or more positive ULTT has strong predictive value for cervical radiculopathy
The alar ligament is at what joint
the transverse ligament is at what joint
C0 C1
C1 C2
Cervical discs are named after the vertebrae ________
above the disc
NP of the disc rapidly fibroses by _______ of life
3rd decade
most 40+ people have evidence of cervical disc degeneration
C1 to C3 refer pain where?
C4 to C8 refer pain where?
Up to head and neck
Down to shoulder/chest/UE/back
The vertebral artery is most vunerable to compression at what joint
C1/C2
What are the high risk factors of the canadian c spine rules?
Age 65+
Dangerous mechanism
Paresthesias in extremities
When using canadian c-spine rules, if a pt has a low risk factor mechanism, what must they be able to do in order to not qualify for radiography
actively turn head 45 degrees
IN what demographics are the canadian c spine rules not applicable
Glassgow coma scale under 15
Age under 16
pregnant
non-trauma
vertebral disease
paralysis
previous c-spine surgery
unstable vitals
Forward head posture is associated with:
OA flexion _______mobile
AA rotation _________mobile
OA extension _______mobile
hypo
hypo
hyper
What nerve compression sends symptoms to the posterior neck/medial scapular border
C4
What nerve compression sends symptoms to superior aspect of shoulders
C5
What nerve compression sends pain to the posterior neck, scapula, posterior upper arm, forearm, and hand
C7 (most common)
What is the CPR for whether T-Spine manip can help C-spine facet joint dysfunction
Symptoms less than 30 days
no symptoms distal to shoulder
looking up does not aggravate symptoms
FABQ under 12
Diminished upper t spine kyphosis
Cervical ext ROM is less than 30
3 or more has a 86% chance
Cervical spine instability is associated with:
__________ of symptoms
Head feels heavy
Reports of HA
Altered ROM
Hx of trauma
unpredictability
What are the 3 mandatory questions for Pts with neck pain
Any dizziness/blackouts/drop attacks?
Any history of RA, inflammatory arthritis, or treatment w/ systemic steroids
any neurological symptoms in legs?
How do you clear the transverse ligament?
Modified Sharp Purser
or
Supine liftoff test
What is considered a positive modified sharp purser?
reduction of symptoms when you apply force to pt forehead while stabilizing the C2 SP
Are positive C-spine tests urgent or emergent?
What other parts of your exam should you preform if you find a positive
Urgent, they can drive themselves to the emergency room, no need to call ambulance
do not continue with exam, BESIDES clearing the rest of the ligaments so that way you can call the doctor and let them know what the extent of injury is
The alar ligament test is for what joint?
C0 C1
What is considered a positive Alar ligament test
not feeling movement of C2 SP when rotating or sidebending pt head passively
How should resisted isometric testing be preformed in the cervical spine
neutral position
How do you test the UT muscle length?
How do you test levator scapulae length?
Max flexion + contra sidebend and ipsilateral rotation, depress shoulder (Different than therex)
max flexion + contra rotation and contra side bend, depress shoulder
How to assess SCM length?
Contralateral sidebend w/ neck in extension + ipsilateral rotation
How to assess scalene length?
Extend and contralaterally sidebend neck ( same as SCM but without rotation)
What is considered a positive spurling test?
What is this test good for?
Reproduction of symptoms into ipsilateral extremity
Good for ruling in cervical radiculopathy, however bad for ruling out
How do you preform the spurling test?
Sidebend head and apply direct inferior force to head for 5-8 seconds
What is the CPR for cervical radiculopathy
C-Spine rotation to painful side is less than 60
positive spurling
positive MEDIAN nerve ULTT
Distraction test relieves symptoms
What ULTT is in the cervical radiculopathy CPR?
ULTT 1, median N
Which is included in the Cervical Radiculopathy CPR:
Compression or distraction test:
distraction test (expected to relieve symptoms)
The cranio-cervical flexion test tests for what?
Assesses endurance of deep neck flexors
useful for pt’s with headache and movement coordination impairment
What is the norm in the neckflexor endurance test for men?
Women?
Men 38.9 seconds or more
women 29.4 seconds or more
What is considered a positive cervical flexion rotation test
what group of patients is this test useful for
ROM loss to one side is more than 10 compared to other side
or reproduction of symptoms
Neckpain with headaches
What is considered a positive shoulder abduction test?
If pt symptoms are reduced or relieved when they put their hand on their head
assesses for presence of radicular symptoms
What do studies show about cervical collars?
They delay recovery, however they can be used if patient has severe capsular restriction
What does the subacute phase for c-spine treatment consist of
Postural stability training of entire spine
full integration of upper and lower kinetic chains
ergonomic changes to workspace
overall strength and cardiovascular fitness
what phase is the most important to prevent chronic injury?
subacute
T or F: Patients can change treatment buckets in the c-spine
T
Pt w/ limitations in neck pain that consistently reproduces symptoms
neck pain w/ mobility deficits
What test is really good for Neck pain patients with movement coordination impairments
craniocervical flexion test (with the BP cuff)
note: also good for headache pts
Pts who have an MOI of trauma, whiplash, or hypermobility with no clear onset
Movement coordination impairments (cervical)
What is the most important component of treating Neck pain w/ WAD
pt education: must stay active, recovery expected in 1st 2-3 months!
What test will come back positive for patient’s with neck pain w/ headaches
Cervical flexion rotation test
How do the headaches for patients with neckpain w/ headaches present?
unilateral neck pain with referred headache that goes away
(not continuous headache)
Pt’s with cervicogenic headache often have mobility deficits where?
OA, AA, C2-C3
What are the 2 headache types that PTs treat?
Tension and Cervicogenic
Refer for cluster or migraine
Before you treat the C-spine, you must __________
in what order do you treat the C-Spine?
rule out T-spine hypomobility
then start with mobility deficits at CTJ and move up
T or F: Specific kind of exercises are best for treating patient’s with chronic neck pain
F, all exercise proven effective, and exercise proven better than placebo
Should you do PT to restore full mobility after a cervical fusion?
F, they will not get all of the motion back
Pt comes into your clinic post-op after a neck surgery, what’s the first thing you do
get the operative report!
Where does the majority of rotation in the T-Spine come from?
CTJ and TLJ
What ribs are considered atypical
T1 T10, T11, T12
the ribs articulate with respective vertebrae instead of costal facets
T - spine rule of 3s
T1-3 SP same level
T4-6 SP 1/2 level down
T7-T9 SP 1 level down
T10 SP 1 level down
T 11 1/2 level down
T12 same level
Where is the spinal canal at it’s narrowest???
T4-T9
When the diaphragm contracts it __________
descends
In the T-Spine region, a trauma event more commonly affects ______, insidious onset is more common in ___________
Ribs
T- Spine
Pt with chest pain, pallor, sweating, dyspnea, over 30 mins
Myocardial infarction call EMS
Pt with compression symptoms in C8-T1
possible pancoast tumor
Pt with significant difficulty breathing, chest, shoulder, upper abdominal pain
Pulmonary embolism, call 911
Pt with decreased breath sounds
Pneumothorax, call 911
Pt w/ C4 dermatome problems
potentially d/t cholecystitis due to irritation of diaphragm
Pt w/ thoracic pain that is difficult to reproduce during exam
no neuro symptoms
Postural dysfunction
Thoracic disc pathology is more common where?
Lower T Spine
Pt with thoracic pain:
Pain w/ active and passive motion in 1 direction or more
dural signs w/ or w/o radiculopathy
pain with coughing
thoracic disc pathology
Pt w/ pain with deep breathing, trunk rotation and sneezing
Potential rib dysfunction
you can expect to find localized pain 3-4cm from midline
Pt with trunk pain that increases with isometric contraction and or passive stretching
worse with deep inspiration or cough
abdominal muscle strain/contusion
Thoracic:
Pt w/ pain w/ movement in all directions
pain is out of proportion to injury
positive compression test
Hyperflexion injury
Potential thoracic vertebral fracture
Pt with thoracic pain, articular signs with movement in all directions
Fall, MVA, or other high energy blow to chest cavity
paradoxical movement of chest wall
Flail segment! AMBULANCE NOW!
precautions for scapular fx:
NWB on affected arm
What do we need to be careful of with SC joint dislocations
posterior dislocation can be life threatening
What is scheuermann disease
Juvenile kyphosis found in 10% of population
equally as common in men and women
increased pain with thoracic extension and rotation
end plate may crack causing disc hernation
Where can T4 syndrome occur
Can occur from levels T2-T7 but always includes T4
Pt with history of headaches, UE pain (Can be bilateral and non-segmental)
night pain in sidelying or supine
positive slump test and positive ULTT
One thoracic segment more prominent than the rest and hypomobile
T4 syndrome
Note: can occur from T2-T7 but always includes T4
Pt with paresthesia in UE that is non-dermatomal
has increased scalene tone
1st rib dysfunction
Pt w/ shoulder pain
negative contractile testing
not painful to palpation of shoulder
loss of full shoulder girdle elevation
pt hx not consistent with typical shoulder patient
2nd rib dysfunction
T or F: you can isolate individual thoracic segments for mob/manips
F, it’s extremely difficult to isolate one segment of the thoracic
What should we do first, stretch the tight muscles OR work on strength
AKA: Stretch anterior chest vs scap squeezes
stretch first so you can work through increased ROM
T or F: Thoracic manip can help with LBP
F
which procedure are you more likely to see in the thoracic spine:
Laminectomy or laminoplasty
laminectomy
laminoplasty used only in cervical usually
After ______ months of conservative treatment for TOS, a patient should consider 1st rib decompression if their symptoms have not resolved
4-6 months
Pt with thoracic pain is experiencing incontinence, what are we suspecting?
UMN signs d/t spinal cord susceptibility in narrow canal at T4-T9
Dowager’s hump vs Humpback posture
Dowager’s hump= many anteriorly wedged vertebrae
Humpback = 1-2 anteriorly wedged vertebrae
When assessing rib motion, what is the cue that we give the patient
What does a rib dysfunction feel like?
Take a deep breath, hold, breathe in more -> breathe out, hold, breathe out more
feels like 1 rib is not rising/depressing with the others
When doing resisted testing for Thoracic spine, what position do we test in?
Test in lengthened positions following AROM unless there is pain
if pain, then assess in neutral
What muscle being tight may pitch the scapula forward into anterior tilt?
pec minor
What is the location for prone CPA’s in the thoracic?
Prone UPAs?
PA rib springing?
CPA- fingers on or around SP
UPA- 2 finger widths over on lamina
PA rib springing- 3 finger widths over
When would you do anterior rib springing?
In what kind of patient would this be done?
How many ribs in front can you do this on?
Anterior chest pain ONLY
example: Rower
T1-T7
What is the CPR for rib dysfunction
Positive spring test
Positive ipsilateral scalene tone
Positive cervical rotation lateral flexion test
Height of rib is in 1/2 inch elevation
The CPR for rib dysfunction includes what 2 special tests
Spring test
Cervical rotation lateral flexion test
CPR for rib dysfunction:
Increased _________ tone
Height : ____________
Positive spring test
Positive CRLF test
scalene tone
1/2 inch superior elevation
When preforming the 1st rib springing test, you sidebend the patient’s head _________
In what direction is the force applied
Toward side being tested
Anterior, medial, and inferior
How do you preform the cervical rotation lateral flexion test?
Head rotated away from side being tested
ipsilateral side flexion (ear toward chest)
Where is the gall bladder located?
RUQ
Where is the duodenum located
RUQ
Where is the liver located
RUQ
Where is the stomach located
LUQ
Where is the sigmoid colon located
LLQ
Where is the appendix located
RLQ
Where is the Spleen located
LUQ
What is considered a wide aortic pulse?
If pain is provoked what should we do?
3cm or more
call doctor!
pt’s with concussion have higher __________ levels
glucose
How much force causes a concussion?
More likely to be caused by what kind of force?
70-120g or 5582 Rad/s rotational force
rotational forces
What is the criteria for concussion
MOI
one symptom
What is the most common symptom of a concussion
Somatic: headache
cognitive: feeling slowed down
T or F: Children have a longer symptom duration after a concussion and heal slower
T
What are the components of a sideline assessment post-concussion
SCAT 6
Cervical spine clearing
CN test
What are the concussion red flags
neck pain/tenderness
double vision
LOC
Weakness/tingling burning in more than 1 extremity
vomiting
severe or increasing headache
Glassgow coma score under 15
increasingly restless agitated or combative
(and other obvious ones)
What is the criteria for post-concussion syndrome?
more than 3 persistent symptoms at rest
30 days or more following concussion
What are the 3 causes of Post concussion syndrome
autonomic dysregulation
inflammation of gut-brain axis
Visual/vestibular/cervical systems
T or F: Pt’s with early physical activity have higher risk of post concussion syndrome
F
Second Impact syndrome is most common in what population
What are the major symptoms
Athletes under 21
Loss of eye movement, dilated pupils
What food to avoid w/ concussion
caffeine and alcohol
processed foods/sugars
artificial sweetener
fad diets
when preforming the BCTT, what level of symptoms should the test be canceled
7/10 or more
6/10 or less is okay
What counts as a fail on the BCTT
Worsening of wellbeing score by 3 or more points
Post-Concussion exercise recommendations
at least 5 times a week for 20-30 mins at a rate of 80-90% of their symptom threshold
from lab: goal can be 30-45 mins, do not work out longer than 45 mins!
When preforming the convergence test we measure the distance at which they start to have _________-
double vision!
not blurriness
T or F: HIIT training is indicated early in concussion managment
F
What is the sequence of the TMJ mandibular neurodynamic test?
why would you perform it?
Capital flexion (if asymptomatic, then full cervical flexion)
contra side bending
open mouth slightly
contra lateral deviation
do if you suspect neural cause of symptoms (e.g. N/T, tinnitus, drooping of face, slurred speech, etc.)
What % of neck pain patients have TMD?
33%
What population is TMD more common in
x3-x5 more common in women of reproductive age
how much freeway space is normal between teeth?
2-4mm
the superior part of the TMJ disc does ________
the inferior part does _________
translation
rotation
which muscle connects directly to the TMJ disc and guide the disc?
lateral pterygoid
what are the 4 muscles that elevate the mandible?
Masseter
Temporaiis
Lateral pterygoid
medial pterygoid
when the TMJ opens, what occurs first?
Rotation for the first 20-25mm of motion
followed by translation
When the TMJ laterally deviates, what happens ipsilaterally and contralaterally?
Ipsilateral rotation
contralateral translation
what is considered normal TMJ opening
what is functional opening?
40-60
35
How much lateral deviation is normal at the TMJ
How much protrusion is normal?
10mm
5-10mm
excessive contraction of the lateral pterygoid causes what?
a second closing click
what are the 2 associated conditions with TMD
Headache
neck pain
a C- shaped opening (capsular pattern) deviates toward which side _________
A deflection due to anterior disc displacement is typically ________
the side of the restriction
toward side of displaced disc
an MET to resist closing of the TMJ does what?
increases opening
painful arc is a sign of ___________
RC pathologies
What does SICK scapula stand for
malposition of scapula
inferior medial border
pain at coracoid
DysKinesia
Neers test can indicate an _________
overuse injury to supraspinatus or bicep tendon
hawkins kennedy test indicates ________
supraspinatus tendinopathy
What does a positive cross body abduction test show
Subacrominal impingement or AC jt pathology depending on location of pain
A positive speeds test indicates
long head of biceps tendinopathy
The full and empty can tests are for what muscle?
which do you do first?
which gives a better indication of supraspinatus strength
supraspinatus
full can
full can
the infraspinatus test takes place with the arm in what position
45 degrees out in scapular plain with 90 degrees flexion, maintain ER against resistance
the ER lag sign indicates what
Infraspinatus tear
the bellypress test and liftoff test is for what muscle?
subscapularis
the IR lag sign indicates what
subscapularis tear
a positive drop arm test indicates what
large to massive RC tear
the apprehension test indicates what
what is considered a positive test
anterior shoulder instability
apprehension, not pain
When would you preform a Jobe Relocation test?
what kind of pressure do you apply to shoulder?
What is considered a positive test
If there is a positive apprehension test
posterior pressure towards ground
if symptoms resolve w/ pressure and ER increases -> anterior shoulder instability
A positive sulcus sign indicates what
inferior or multidirectional instability
what tests indicate a slap lesion
obriens test and biceps load test
what is the open packed position of the shldr
55 abd + 30 degree horizontal add
what ligament is the main static stabilizer of the abducted shoulder
inferior GH ligament
what is the thinnest part of the GH joint capsule
Posterior
what tendon is most involved in overuse syndromes
supraspinatus
what is the only joint that connects the axial skeleton to the shoulder girdle
sternoclavicular
______% of shoulder pain patients are in PT for RTC dysfunction
50-70%
the mechanism of multidirection shoulder instability is typically ________–
insidious
Out of the 4 types of AC joint sprains, which types can be treated conservatively?
1 and 2
3 and 4 need surgery
What kind of exercise levers do we want to start with when rehabing the shoulder
short levers (flex the elbow)
What are the 4 goals necessary to progress to the subacute phase for the shoulder
All uninvolved muscles 4+/5
Pain free elevation to 120
Scapular control present
Evidence of tissue healing
What kind of shoulder mob is specifically for frozen shoulder
long axis distraction w/ ER windup
How many structures attach to the 1st rib
32
What is critical for throwing athletes?
endurance of RTC
the shoulder is typically injured during what phase during throwing
deceleration phase, these pts need to train eccentrics
For a full thickness RTC repair, how long do we wait before doing AAROM
6 weeks
for a partial RTC tear, how long until we do AAROM
immediately, wait 6-8 weeks to progress to strengthening
How long must we wait before we can strengthen after a full RTC repair
12 weeks (0-6 of passive, 6-12 of AAROM)
what are the initial precautions of a RTC repair
no active ER, no passive IR beyond neutral
What does research say about the outcomes of RTC repair with and without early PROM
same either way, early PROM not necessary
same amount of cuff detachments, same outcomes at 12 weeks
For anterior instability we want to avoid endranges of ________ initially
for posterior instability we want to avoid end ranges of _______ initially
abd/er
add/ir
bankart repair timeframe
Sling:
P/AAROM:
Strengthening:
Return to sport:
4 weeks sling
4 weeks P/AAROM
4 weeks strengthening
6 months return to sport
patient’s with type _____ SLAP lesions require surgery
2-4
For SLAP repair, no active bicep contraction until _______
12 weeks
when would we want to use progressive anterior mobilization for the GH
only if significant reduction in capsular volume/frozen shoulder
Pt has come to your clinic w/ midline tenderness after a low speed MVC
straight to get imaging!
Pt has come to your clinic w/ paresthesia down their arm after a low speed MVC
straight to get imaging!
Cervical myelopathy most often occurs at what level?
C5-C6
What level disc herniation will refer to the posterior neck and medial scap
C4
What level disc herniation will refer to the superior shoulder
C5
What level disc herniation will refer to refer to the lateral arm
C6
What level disc herniation will refer to the posterior arm
C7
What level disc herniation will refer to the medial arm
C8
pt has neck pain in mid range that worsens at end range
pt likely has neck pain w/ movement coordination impairments
When is recovery expected for movement coordination impairments of the c-spne
2-3 months
Cervicogenic headaches present in what pattern?
rams horn
A laminectomy is indicated for what 2 pathology?
A laminoplasty is indicated for what pathology?
Laminectomy- DDD, stenosis
Laminoplasty- multi level spondylitic myelopathy
What are the steps to adson’s test
15 degrees shldr abduction
pt holds breath, tilt head back and rotate head towards side tested
PT palpates radial pulse
What are the steps to the costo-clavicular test
pt in exxagerated military posture, protrudes chest while depressing and retracting scap for 60 seconds
PT palpates radial pulse
In the addison’s TOS test, the pt looks _________
in the hyperabduction test, the pt looks ____________
towards side being tested
away from side being tested
what is the pt position for an upper t-spine manip?
what is the pt position for a lower t-spine manip?
how does the pt rotate and sidebend
fingers laced around head
arms crossed across chest
sidebend away, rotate toward
review the steps
What’s the first step of the sharp purser test?
Pt is asked to preform ACTIVE CV neck flexion and note symptoms
Where do you place your hands for the supine liftoff test?
PT places both index fingers horizontally along C1 lamina while supporting base of pt’s skull w/ remaining fingers
providing shearing force at C1 to see if C1/C2 moves excessively
During the Alar ligament test, movement of _________ should immediately be felt with CV sidebending or rotation
C2 SP
Thoracic resisted testing is done at _______
Cervical resisted testing is done at ________
Shoulder resisted testing is done at __________
end range
neutral
mid range
Hawkins kennedy is a passive or active test?
Passive
during the sulcus sign test you bring the arm to _________
apply inferior distraction
a positive test is______
20-50 abd
depression greater than 1 finger
