More stuff to remember

Question 1

Why is the location of the vertebral artery in the neck particularly important for protecting it?

Answer 1

• It runs at the axis of flexion/extension (mediolateral axis), which helps protect it from excessive stretching or pinching during flexion/extension (other movements can disrupt it more)

Question 2

What is the overall incidence (words, not numbers) of cancer, infection, and fracture in the C-spine?

Answer 2

• Cancer: relatively uncommon (more often than rare)
• Fracture: rare
• Infection: rare

Question 3

Who is the Canadian C-Spine Rule for?

Answer 3

• For alert and stable trauma pts where c-spine injury is a concern

Question 4

Canadian C-Spine Rule: What is the first question, and what are the three things that need yes/no answers?

What do you do next?

Answer 4

• Any High-Risk Factor Which Mandates Radiography?
  
  • Age equal or greater to 65, or
  • Dangerous mechanism, or
  • Paresthesias in extremities

If yes, send to radiograph

If no to all, ask second question?

Question 5

Canadian C-Spine Rule: What is considered a dangerous mechanism? (5)

Answer 5

1. Fall from elevation equal or greater to 3 feet/5 stairs
2. Axial load to head, e.g. diving
3. MVC high speed (> 100km/hr), rollover, ejection
4. Motorized recreational vehicles
5. Bicycle collision

*MVC = Motor Vehicle Collision/Accident

** 100km/hr = 62 mph

Question 6

Canadian C-Spine Rule: What is the second question, and what are the five things that need yes/no answers?

What do you do next?

Answer 6

Any Low-Risk Factor Which Allows Safe Assessment of Range of Motion?

1. Simple rearend MVC*
2. Sitting position in ED
3. Ambulatory at time
4. Delayed** onset of neck pain
5. Absence of midline c-spine tenderness

If yes to any, ask question 3

If no to all, send for radiograph

*MVC = Motor Vehicle Collision/Accident

**Delayed: i.e. not immediate onset of neck pain

Question 7

Canadian C-Spine Rule: What is the third question, and what is the one thing that needs a yes/no answer?

What do you do next?

Answer 7

Able to Actively Rotate Neck?

• 45* left and right

Able, no radiograph

Unable, send for radiograph

Question 8

Canadian C-Spine Rule: What are four exceptions to the definition of Simple Rearend MVC?

Answer 8

Simple Rearend MVC Excludes:

1. Pushed into oncoming traffic
2. Hit by bus/large truck
3. Rollover
4. Hit by high speed vehicle

*MVC = Motor Vehicle Collision/Accident

Question 9

How does cervical rotation and extension affect the vertebral artery?

Answer 9

• It can cause Internal Carotid Artery Dissection.These movements compress the artery against the transverse process of the upper cervical vertebra
• Vertebral Artery Dissection is associated with contralateral cervical rotation that stretches or compresses the artery between the 1^st two cervical vertebra

(I thought extension was one of the movements that the v-artery was mostly protected from)

Question 10

Should you do end range CAD provocative test if pt’s index of suspicion for CAD is low?

Answer 10

No, there is no need.

Question 11

What is cervicogenic dizziness (CD)?

Answer 11

A specific sensation of altered orientation in space and disequilibrium originating from abnormal afferent activities from the neck.

Dr. Mincer thought it best matched the disequilibrium type of dizziness, but later I think she said it could have a vascular cause too (but I don’t think she went as far as to say presyncope was cervicogenic dizziness). Maybe she meant just cervicaogenic dizziness that is appropriate to treat with PT (since we would not treat the vascular issues).

Question 12

What are 6 CAUSES of dizziness?

Answer 12

1. Cardiovascular
2. Neurological
3. Metabolic
4. Psychiatric
5. Vestibular
6. Cervicogenic (cervical MSK origin)

Question 13

WHat does CSI stand for?

Answer 13

Cervical Spine ligamentous instability

Question 14

Why is rheumatic disease important to identify? (3 points)

Answer 14

• RA is the most common inflammatory disease that affects the C-spine
• The diarthroidal joints (dens joints) are primarily affected, but extra-articular features manifest in the skin, eyes, lungs, and nervous system.
• These effects occur early in the disease process

Question 15

What can lead to ACS?

Answer 15

Increased myocardial oxygen and nutrition requirements relating to exertion, emotional stress or physiological stress, such as dehydration, blood loss, and infection or surgery, can lead to ACS.

Question 16

What is Angina? How is it described? (include percentages)

Answer 16

Angina is a typical symptom of myocardial ischemia often describe as a sensation of substernal or retrosternal chest pressure, squeezing, or heaviness during exertion of 70% to 90% incidence, but only 33% or less complain of chest pain.

Question 17

What is a key sign of ACS in women?

Answer 17

A key sign of ACS in women is unexplained severe, episodic fatigue that interferes with performing daily activities. (emphasized in class)

Question 18

What can occur up to a month prior to an acute MI?

Answer 18

Weakness, fatigue, trouble sleeping, and nausea may occur up to a month prior to an acute MI.

Question 19

What are some less common warning signs of heart attack, especially in women? women? (9 points)

Answer 19

1. Unusual chest pain quality and location (ie. burning, heaviness; left chest), and stomach or abdominal pain
2. Continuous midthoracic or interscapular pain
3. Continuous neck or shoulder pain
4. Isolated right biceps pain
5. Pain relieved by antacids
6. Pain unrelieved by rest or nitroglycerin
7. Nausea and vomiting
8. Flu-like manifestations without chest pain/discomfort
9. Unexplained intense anxiety, weakness or fatigue, breathlessness, and dizziness.

Question 20

How can the cluster of 5 tests be used to rule cervical myelopathy in/out?

Answer 20

1. Age > 45 years (THIS CONFLICTS WITH 55 AND 70 ABOVE)^^^
2. Positive Babinski sign
3. Positive inverted supinator sign
4. Positive Hoffman
5. Gait dysfunction described as (SAW) Spastic, Ataxic or Wide-based gait

Absence of a + finding, or presence of 1 of 5 tests, provides a moderate level of confidence that the patient does not have CM, whereas 3 of 5 positive test findings assists with ruling in CM if CM is suspected. based on clinical examination, a referral for additional testing is warranted.

Hoffman, Babinski’s, Clonus, and Deep tendon reflexes associated with hyperreflexia are more specific than sensitive, and therefore considered better tests for ruling in CM. The inverted supinator sign (i.e. finger flexion or elbow extension during the brachioradialis reflex test) may be the most sensitive test for ruling out CM.

Question 21

What are the two most common causes of cervical radiculopathy?

Answer 21

• Most common is degeneration of the c-spine (which includes loss of disc height, degeneration of disc, osteophytes) – 68%,
• second most common is due to disc herniation. – 22%

Question 22

What is the relative frequency of cervical radiculopathy by level?

Answer 22

• 7^th spinal nerve most commonly affected (70%)
• 6^th spinal nerve root next most common affect
• 8^th spinal nerve root is the next most commonly affected

Question 23

What are the typical symptoms of cervical radiculopathy? (General)

Answer 23

• Symptoms with this classification include
  
  • Neck pain with an associated radiating or narrow band of lancinating pain in the involved upper extremity, upper extremity paresthesia, and related numbness and weakness

Question 24

• What 7 clinical findings that assist with diagnostic classification of cervical radiculopathy?

Answer 24

• Clinical findings that assist with diagnostic classification are
  
  1. Upper extremity symptoms
  2. Radicular or referred pain produced or aggravated with Spurling’s test
  3. ULNDTs
  4. Decreased with neck distraction
  5. Decreased cervical rotation of less than 60 degrees to the involved side
  6. Signs of nerve root compression (hard neural signs)
  7. Success in reducing UE symptoms using initial examination and intervention procedures, such as distraction.

Question 25

Explain the 4 cluster test CPR for cervical radiculopathy

Answer 25

• 4 cluster test CPR-** **RUDS
  
  • ULTT A (most useful test when used alone for ruling out CR)
  • Cervical Rotation less than 60 degrees to the involved side
  • Distraction test
  • Spurling test A
• If 3 items are positive, the probability of CR increases 65%
• If all 4 items are present, the probability of CR increases to 90%.
• The test item cluster produces larger posttest probability changes for diagnosis of CR than any single test item.

Question 26

What is the NDI? (name, number of items, highest score, etc)

Answer 26

• Neck Disability Index
• Used Oswestry Low Back Pain Index as a template
• Consists of 10 items (4 pain intensity, headache, concentration and sleep; 4 inquire about lifting, work, driving, and recreation; 2 about personal care and reading activities).
• Each item is scored 0-5
• Scored as a percentage out of 50 (total score/50 x 100)
• If one item is left blank score is out of 50
• Higher scores represent higher perceived disability
• Scores of 40-50 and 0-10 approach a ceiling and floor effect, respectively in which case use of the PSFS should be considered.

Question 27

NDI: What is the non-validated interpretation of scores (5 levels)

Answer 27

• Non-validated interpretation of scores
  
  • 0-4 no disability
  • 5-14 mild disability
  • 15-25 moderate disability
  • 25-34 severe disability
  • > 35 complete disability

Question 28

What is the general somatic referral pattern of the zygapophyseal joints in C2-C7? General referral pattern of the AO and AA joints?

Answer 28

Zygapophyseal joint referral (general)

• C2 - C3 refers superiorly to the head
• C3 - C4, C4 - C5 referral is primarily over the posterior neck
• C5 - C6 spreads across the supraspinous fossa of the scapula
• C6 - C7 spreads more inferiorly over the scapula

AO and AA joints can produce neck pain in the suboccipital region and headache.

Question 29

What are the borders of neck pain (by definition)?

Answer 29

Neck pain, by definition, is located in an area bound by the T1 spinous process, the superior nuchal line, and laterally by the lateral margins of the neck. However, persons with neck pain report symptoms from the inferior border of the scapula to the head and face, with or without referral to the UE and trunk.

Question 30

How do pts describe somatic referred pain?

Answer 30

Pts describe somatic referred pain as deep, dull aching and expanding into wide areas that are difficult to localize

Question 31

Are neurologic signs absent in somatic referred pain?

Answer 31

Somatic referred pain does not involve spinal nerve or nerve roots, so neurological signs are absent.

Question 32

How does 24 hour behavior: When is pain at night mechanical; when is it concerning?

Answer 32

• Pain at night is mechanical in origin when:
  
  • Pt reports inability to lie on the involved side
  • Symptoms relieved by change in position
• If the pain is most intense at night and the patient is unsure of what wakes her, reports she must get up and walk around, and has difficulty returning to sleep consider:
  
  • Active inflammatory component
  • Neoplasm

Question 33

Most musculoskeletal conditions are (better/worse/the same) in the morning?

Answer 33

Most musculoskeletal conditions are better in the morning

Question 34

What should we determine if a pt reports night pain? (3)

Answer 34

Need to determine: frequency, provocative position and symptoms produced

Question 35

What do the following suggest about morning pain?

• Worse in morning
• Unchanged in morning
• improved in morning and remain better with movement
• improved in morning but worsen with activities of the day

Answer 35

• Worse in morning - may be due to poor sleeping posture
• Unchanged in morning - nonmechanical or minor mechanical
• improved in morning and remain better with movement - mechanical with good prognosis
• improved in morning but worsen with activities of the day - mechanical with limited prognosis

Question 36

What is a role of the coordination deficits classification in relationship to other classifications?

Answer 36

• Most patients with neck pain, regardless of the initial classification, require assessment and intervention or muscle performance deficits for optimal recovery

Question 37

FABQ: What are the cut-off scores for neck? What were lumbar cut-off scores? (for comparison)

Answer 37

• Cut-off scores for neck
  
  • FABQ-Total = 48
  • FABQ-Work = 18
  • FABQ-PA = 15
• Cut-off scores for lumbar (for comparison/review)
  
  • FABQPA = >14 (score range 0-24)
  • FABQW => 29? or >20 (score range 0-42)

Question 38

How was FABQ adapted for the neck?

Answer 38

The word “neck” is substituted for the word “back” when used in patients with neck pain