Module 6 part 1 (through special tests) Flashcards
What is one reason the discs in the c-spine allow more motion than discs in the lumbar spine?
The discs in the c-spine are closer in height to the vertebral bodies in the c-spine, which allows more motion.
Which tests are best for screening for a cervical spine source of pain?
- Upper Limb Neurodynamic Tests (ULNDT; Median nerve biased)
- Posterior to anterior (PA) Passive accessory test (PAVIM)
- Spurling’s test
**Palpation side glide was listed too, but it turns out this is not helpful for levels C5-C6 and is a diagnostic test for some unknown problem at C2-3, so Dr. Mincer said to exclude it from our screening tests.
These are for screening pts with shoulder pain for neck pain and involvement (sort of like using the quadrant test to screen L-spine to clear or implicate the L-spine when looking at PGP or hip pain).
What are you screening for with the c-spine screening tests?
(Medial Nerve ULNDT, PAIVMs, Spurling’s Test)
These are for screening pts with shoulder pain for neck pain and involvement (sort of like using the quadrant test to screen L-spine to clear or implicate the L-spine when looking at PGP or hip pain)
What is the presumed relationship between forward head posture and neck pain?
FHP may be due to anterior translation of the head, lower cervical spine, or both, and may result in upper cervical extension. The cause of neck pain related to FHP may be due to an increase in compressive force on the cervical zygapophyseal joints and altered muscle activation b/c of lengthening of anterior neck muscles and shortening of posterior neck muscles.
Results DO NOT reveal a strong association between FHP and neck pain or neck pain and headache
**this answer is basically word for word what is in the book. However, we also learned that the muscles posterior to the axis of the upper c-spine and anterior to the axis of the lower c-spine shorten.
How does one assess whether abnormal posture is contributing to a patent’s pain?
Observed postural deformities should be corrected passively by the clinician or actively by the patient to note any change in the patients symptoms and assist in establishing a provocative or easing link between the posture and the patients problem. Provocative postures require further assessment of mobility, muscle activation patterns, and dynamic motor control.
**The pt must have sufficient ROM to correct deviations from normal. Posture should be comfortable and maintained with minimal activity of the superficial trunk muscles. The pt should be able to easily move in and out of functional postures as required by ADLs, work, or recreation.
What should be included in shoulder girdle screening?
A standard examination for the shoulder girdle does not exist (uh oh davies!), but the exam should adequately determine whether a primary shoulder problem exists or reveal any secondary sources of symptoms. Shoulder girdle, UE and TMJ may be assessed in sitting.
T/F: Individuals with neck pain tend to have reduced balance (sort of like individuals with LBP)
True
Compared to controls, pts with idiopathic and whiplash-induced neck pain have deficits in standing balance, with both groups significantly less likely to complete the eyes closed tandem test for 30 seconds.
What three additional areas is it important to consider and screen/examine in pts with neck pain?
- Shoulder girdle
- TMJ
- Thoracic Spine
Describe normal position of the scapula during resting?
The optimal position at rest is not agreed upon since variabliity between asymptomatic individuals is common. However here are some general guidelines
Pt should be in lumbopelvic upright posture. A kyphosis is present in the t-spine with a neutral head on neck and neck on trunk posture.
The scapulae should be flat against the thoracic wall.
- Superior angle at ~T2-T3 spinous processes
- Spine of the scapula at ~T3-T4 spinous processes
- Inferior angle at ~T7-T9 spinous processes
The medial borders are parallel to the spine or in 2-3* of upward rotation.
Scapula lies in 30 degrees of internal rotation (scapular plane) with respect to the frontal plane and 8 degrees of anterior tilt.
Describe normal movement of the scapula?
What is the typical pattern of abnormal movement, and what is this pattern called?
During elevation (I think they mean scaption) in the plane of the scapula, the scapula upwardly rotates, posteriorly tilts, and externally rotates. These motions occur with scapular retraction and elevation, and clavicular elevation, retraction, and posterior rotation.
Scapular dyskinesis is classified by altered scapular motion - visualized by decreased upward rotation, decreased external rotation, and/or decreased posterior tilt.
How do you determine the relevance of an altered scapular position during movement?
To determine the relevance of an altered scapular position during movement, the clinician manually corrects, or the pt actively corrects, the scapular position. The pt then repeats the movement and compares the symptoms with and without scapular correction. An immediate decrease in neck or shoulder symptoms or change in available motion suggests that poor scapular stabilization is relevant to the pt’s problems and serves to educate the pt and direct further exam and intervention.
Why is important to consider the TMJ in pts with neck pain?
In some pts with neck pain, symptoms are reported in the TMD region necessitating some level of TMD examination based on working hypothesis. A close biomechanical relationship exists between the C spine and TMD. Mandibular opening and closing are linked to craniocervical extension and flexion, respectively; alterations in movement and motor control in either region may affect coordination and create disorders of one or both areas.
What is the best screening test for TMJ in pts with neck pain?
Mouth opening is recommended as a screening procedure to implicate the TMJ and assist in discriminating between patients with and without a TMJ disorder.
Neck Torsion Nystagmus Test
- Purpose
- How to Perform
- Interpretation
Purpose:
- The neck torsion nystagmust test is considered by some to assist with detecting cervicogenic dizziness. However, diagnostic utility of this test is unknown.
Perform:
- The head is held stationary while the neck and trunk are rotated. (part 1)
- To further implicate the vestibular system using rotation as the provocative movement, the vestibular system is biased by moving the head and truck en bloc (all together). (part 2 sometimes performed)
Interpretation
- if symptoms are provoked during part 1, cervicogenic dizziness is considered because keeping the head still minimizes the vestibular system while stimulating the neck structures (somatic & vascular)
- If dizziness and/or nystagmus are not produced with the neck torsion test (part 1), the vestibular system or vascular system is implicated.
- To further implicate the vestibular system using rotation as the provocative movement, the vestibular system is biased by moving the head and truck en bloc (all together). (part 2)
- Rotation of the head occurs, but the c-spine does not, stimulating only the vestibular system.
- Provocation of symptoms suggests a vestibular component since the c-spine is maintained in neutral (ie, rotation is not allowed).
Differentiating between which two conditions can be a challenge in pts with with dizziness or positional vertigo and neck pain?
What are some ways to differentiate them?
In patients with dizziness or positional vertigo and neck pain, differentiationg between a vestibular disorder such as BPPV and VBI can be a challenge.
- BPPV is relatively common compared to VBI.
- It is unlikely that VBI would present with an isolated symptom of dizziness or the nystagmus associated with BPPV.
You can use the VBI provocation tests and Dix Hallpike manuver to help differentiate between the two. Both position the pt similarly, but there are slightly different s/s for each to be positive and the positions actually are different.
VBI Tests
- Purpose
- How to Perform
- Interpretation
Purpose
- Test for VBI and/or distiguish between VBI and BPPV in pts with dizziness or positional vertigo and neck pain.
How to Perform (there are several versions of how to perform, but below is generally what we learnred this semester)
- Passive Test
- Pt is in supine with therapist supporting head off table (make sure pt’s head is off table far enough that they could get arms off table if they tried)
- PT fully extends c-spine and holds for 10 seconds, continually assessing for s/s and keeping the pt talking with eyes open.
- If no s/s, PT moves pt’s head into end-range rotation while still in end range extension, and assesses for 10 more seconds.
- Repeat rotation on other side
Interpretation
- Reproduction of the 5D’s (dysarthria, dplopia, dysphagia, dizziness, drop attacks)
- Other neurolotical s/s (tons of them are possible, do not limit yourself too much) Examples:
- Ataxia
- Nausea
- Numbness of unilateral face
- nystagmus
**would probably only perform this test on someone who had a moderate risk ratio for VBI. The test is unneccessary in someone with low risk ratio, and the person should be referred (basically assumed positive) if they have a high risk ratio (and the risks of the test outweigh the benefits).
AROM c-spine: what are 3 important general things you should be assessing?
- Quality
- Quantity
- Symptom response
AROM in c-spine: what are 7 descriptions of symptom response?
Symptom response:
- produced,
- abolished,
- no effect,
- increased,
- decreased,
- peripheralized, or
- centralized.
AROM in c-spine: what are some specific areas (3) that should be observed and what are you looking for (3) and assessing for (3)?
Obervations cover:
- Upper c-spine,
- lower c-spine
- upper T-spine
Look for
- ease of movement
- quality of the curve
- recovery from motion
Assess for
- behavior of symptoms during movement or at end range
- any change in intensity or location from rest position
- where in the range the symptoms change
**observation of the quality of motion allows for assessment of intersegmental motion and muscle function
How can we determine relevance of movement deviations during ROM in c-spine?
Correct the deviation and see if the symptoms change. If correction alters pt’s symptom, relevance is established.
C-spine AROM: flexion
How does the pt perform, and what are some special things to look for/problems you may notice?
Pt is asked to look down and bring chin to their chest.
- During flexion and extension, observe for initiation of motion from the lower c-spine.
- Hypertonicity of cervical extensor muscles may be a protective response to limit flexion or loss of deep cervical extensor control.
- On return to neutral from flexion, excessive craniocervical extension suggests dominant superficial extensors and loss of deep craniocervical flexor control
C-spine AROM: extension
How does the pt perform?
What problems may you see during extension?
During return from extension?
Pt is asked to look up to the ceiling and look back along the ceiling with her eyes
- Moving into extension: these things suggest poor eccentric control of extension
- Unwillingness to allow the head to move posteriorly behind the frontal plane of the shoulders with a dominant upper cervical extension pattern
- Head drops or translates back ard and may be painflul or described as feeling a loss of control.
- Return from Extension
- On return from extension, a poor control strategy is initiated by the SCM and anterior scalene muscles, resulting in lower cervical flexion, but not upper cervical flexion.
- Recovery from exetension is poor when upper cervical flexion is absent or delayed
C-spine AROM: lateral flexion
How does the pt perform?
What might cause restriction of lateral flexion (2ish)?
Pt is asked to bring ipsilateral ear toward ipsilateral shoulder.
- Restriction of lateral flexion may be due to segmental dysfunction or muscular restriction of several segments often associated with short scalenes or neural tissue sensitivity.
In pts with chronic neck disorders, how do restrictions in rotation, extension, and lateral flexion compare to each other?
In pts with chronic neck disorders, extension and rotation deficits are greater than lateral flexion deficits.
C-spine AROM: Rotation
How does the pt perform?
What are three regions of restriction and what would you see that suggests restriction in each region?
Pt is asked to look and turn her head to the left or right.
Mobility deficits in rotation may occur in the upper cervical, lower cervical or upper thoracic regions.
- Observations of the quality of motion assists in locating the region.
- Upper thoracic restrictions my prsent as a loss of end-range motion.
- Lower cervical motion loss may be noted when the head turns easily on the neck, but motion remains limited
- Upper cervical motion loss is suspected when rotation occurs mainly through the lower region with little head on neck rotation observed
C-spine AROM: How can you assess just Upper Cervical Rotation?
To actively test rotation occurring primarily at the AA joint, the pt flexes the head and neck, bringing the chin to the chest. While maintaining flexion, the pt rotates her head to each side. Quality, quantity, and symptom response are recorded
C-spine AROM: How can you assess just Upper Cervical flex/ext?
The pt is asked to perform head nodding or “yes” motions for flexion and extension with the lower c-spine in neutral
Repeated motions: what is retraction in the c-spine analogous to in L-spine?
extension
Repeated Motions: When should pt OP and PT OP be added?
Repeated movements occur actively by the pt with added pt overpressure as needed. Clinician forces are added only to gain further understanding or to alter the loading strategy of the response to the repeated movements.
C-Spine: Upper Limb Neurodynamic Test (median nerve bias)
- Purpose
- Procedure
- Interpretation
Purpose
- a test to challenge movement of the median nerve relative to its surroundings through the neck and UE
Procedure
- Pt is supine with the examiner on the side to be tested. Baseline symptoms are assessed and reassessed after each step in the test procedure.
- Depresses the shoulder girdle (other part of book said to just stablize it)
- Abducts the shoulder to 110* (other part of book said 90-110*) with slight extension keeping the elbow in 90* flexion
- Forearm is then maximally supinated
- Wrist and finger extension
- Elbow extension is added while maintaining all all of the previous movmentes.
- Testing is stopped at onset of symptom reproduction and a sensitizing manuver is added slowly to determine the effect on the symptoms.
- Sensitizing manuver is lateral flexion of the neck to the contralateral side (should increase symptoms)
Interpretation
- A positive test is
- reproduction pt’s symptoms, an
- increase in symptoms with the sentsitizing manuver, and an
- asymmetrical response such as limited elbow extension compared to the univolved side.
**Also known as upper limb neural tension tests (ULTT)
Here were the instructions from the Book Website:
WEB: Face the patient’s head with the near hand pressing into the table stabilizing not depressing the superior aspect of the patient’s shoulder & the other hand holds the patient’s hand in neutral with the elbow flexed to 90° & supported on the examiner’s thigh. Add the following sequentially & assess response to each component: glenohumeral abduction up to 90°- 110°, if available wrist/finger extension & forearm supination glenohumeral external rotation elbow extension. With the onset of patient’s symptoms or new symptoms, structural differentiation is necessary.
How do you assess flexibility of the upper trap and SCM?
Pt supine
Passivly flex, contralateral lateral flexion, ipsilateral rotation
Depress shoulder with other hand
How do you assess flexibility of the suboccipital muscles?
Pt supine
support occiput with one hand and provide upper cervical flexion through the forehead with the other hand.
Can also use a towel or strap
CCFT: What are 3 things that suggest poor endurance of the deep neck flexors?
- Inability to hold the pressure steady
- a decrease in pressure
- recruitment of the superficial flexors
