Neck and Thoracic Flashcards by L Q

Cervical mobility limitation treatments

Thoracic thrust manip helps all acuity/chronicity levels regardless of CPR for cervical thrust manip
Emphasis of ex and empowering patient
CPR exists for cervical manip

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Cervical manipulation CPR

Symptoms < 38 days
Positive expectation manipulation will help
Cervical rotation ROM asymmetry > 10deg
Pain with PA testing mid-cervical spine

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Neck pain classification

Cervicalgia + mobility deficit
Cervicalgia movement control deficits/WAD
Cervical radiculopathy
Cervicogenic headache

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Cervical radiculopathy
Clinical presentation

Peripheralization/centralization of symptoms
Diminished myotomes, dermatomes, and/or reflexes
Pain with cervical rotation (< 60deg)
Adverse neurodynamics

Most often seen individuals 40s or 50s

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CPR cervical myelopathy

+Hoffman
+Babinski
Inverted supinator sign
Gait deviation
Age > 45 years

Post test probability with 3/5 positive tests 94%, 4/5 is 99%

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Cervical radiculopathy treatment

Upper quarter and nerve mobilization, traction, Thoracic manip or manual therapy

Mechanical traction +ex retained benefits more than ex alone or mechanical traction alone

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Cervicogenic headache presentation

Primarily occipital headache, radiating into head and face. Tends to be unilateral without side shift
Affected by cervical movements or posture

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Trigeminal nucleus

Receives afferents from cn V and spinal nerves 1-3
Nuclei of head, throat, and neck afferents

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Migraine presentation

Multiple triggers, usually not neck movement
Often unilateral with side shift
Located frontal, periorbital, or temporal
Throbbing or pulsating
Can be associated with nausea, vomiting, phonophobia, photophobia

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Tension headache presentation

Location: diffuse, bilateral
Characterization: dull
Triggers: multiple, not typically associated with neck movement
Associated symptoms: decreased appetite, phonophobia, photophobia

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Headache red flags
Possible signs intracranial pathology

Sudden onset severe HA with increasing intensity
Persistently unilateral or focal HA
Headache that wakes patient up
Generalized stiff neck or s/s meningitis
Systemic symptoms
Focal neurologic symptoms

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5 Ds And 3 Ns

Dizziness
Drop attack
Diploplia
Dysarthria
Dysphagia

Ataxia

Nausea
Numbness
Nystagmus

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Cervicogenic headache treatment

Diagnostic block of occipital nerve

Neck coordination, strength, endurance ex, cervical manual therapy, stretching.
Effective for short and long term relief of chronic symptoms. MT+ex > either one alone
Scapular stabilizers should include serratus anterior and lower traps

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Cervicogenic headache special testing

+ cervical flexion-rotation test (< 32 degrees)

Poor deep cervical endurance:
+ cranial cervical flexion test (ccft) (unable to generate 26-30mmHg for 10 seconds)
Neck flexor endurance test < 38 seconds

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Diagnostic cluster cervicogenic headache

Very high specificity and sensitivity
Decreased cervical extension AROM
Limited cervical endurance on CCFT
Palpably tender OA to mid-cervical region

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Primary symptoms of cervical arterial dissection

80% present with head and neck pain, particularly ipsilateral

Vertebral artery:
5Ds And 3Ns
May be affected by cervical rotation

Internal carotid artery:
May be affected by cervical extension
Horner’s syndrome
Miosis+ptosis+anhidrosis

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Emergency procedure if you suspect cervical arterial dissection

Call 911
Rescue and recovery position
Record vitals
Do not give pt anything to eat/drink
Record time

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Cardiovascular disease risk factors
(8 items)

Age (women > 55, men > 45)
Family history (MI and sudden death of direct relative before age 55)
Cigarette smoking
Sedentary lifestyle
Obesity (bmi > 30)
Hypertension
High LDL and low HDL. (High HDL is a negative risk factor)
Diabetic or pre-diabetic

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Unstable angina

Unpredictable chest pain or pressure
Does not alleviate with rest
Does not alleviate with nitroglycerin
S/s consistent with MI
Episodes last > 30min

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Pulmonary embolism
Signs and symptoms

0.97 sensitivity, 0.3 -LR of:
Sudden onset dypsnea
Chest pain

Tachypnea
Wheezing
Hypotension
Pulmonary referral pattern (chest and LUE)

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Wells criteria

> 6 high probability of DVT or PE
4.5 - 6 moderate probability
< 4 low probability

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Revised Geneva score

> = 11 high probability of PE
4-10 moderate
=< 3 low probability

PERC rule

Sensitive test to rule out PE in patients with LOW risk of PE (if all of the below are negative)

Age > 50
Hemoptysis
SpO2 > 94%
HR >= 100bpm
Previous DVT or PE
Recent surgery or trauma in last 4 weeks
Unilateral leg swelling
Estrogen use

Murphy’s sign

Sharp pain with sudden stop of inspiration with palpation to right costal margin with deep inspiration

Suggestive of cholescystitis

Canadian c/s rules High risk factors

Age > 65 Dangerous mechanism (fell > 3 ft or 5 steps, axial load, MVA > 60mph, rollover, ejection, bike collision, , motorized rec vehicle accident) Upper extremity paresthesia Warrants radiograph or CT

Canadian c/s rules Low risk factors allowing ROM assessment

Simple rear-end MVA Able to sit in Emergency Room Ambulatory at any time after injury Delayed onset of neck pain (no immediate pain at time of injury) Absence of midline c/s tenderness upon palpation If no to any of the above, needs radiograph. If yes to all of the above, proceed to checking ROM No --> radiograph Yes --> c/s ROM assessment

Canadian c/s rules

If no high risk factors, or have low risk factors but able to rotate c/s > 45 degrees both ways, pt very unlikely to have fracture Sensitivity 94%

Cervical spine instability special testing

Alar ligament stress test Transverse ligament shear test (anterior shear test) Sharp purser test* *Recommend to test sharp purser first bc it's not provocative

Alar ligament stress test

Positive if no capsular/firm endfeel is noted C2 spinous process moves with head during cervical motion. If head is rotated, c2 will move immediately (in contralateral direction)

Transverse ligament stress test AKA Anterior shear test

Positive test elicits bilateral lower extremity paresthesias

Sharp purser test

Positive test is relief of symptoms, particular lower extremity paresthesias; excessive motion; clunk noted

Olecranon manubrium percussion

Special test for olecranon fracture. Positive if symptomatic side percussion is duller in intensity and pitch Warrants urgent MD referral

Pericarditis clinical signs

Chest pain, pressure, or shortness of breath Exacerbated with lying down, coughing, deep breath Alleviated with bending forward or holding breath

VBAI test

Passively rotate pt for 10 seconds for pre manipulative hold to help rule out VBAI *note 2020 IFOMPT cervical framework no longer recommends premanip holds. Focus on cardiovascular risk factors

Risk factors for chronic neck pain

Weakness in hands

Parsonage-Turner syndrome

Neuritis of brachial plexus. Can present like a c8 radiculopathy

Flexion-rotation test

Strong sensitivity and specificity test for ruling in and ruling out cervicogenic headache Sn=0.86 Sp=1.0

c1-c2 PA assessment

Sn = 0.62 Sp = 0.87 Differentiation to find guilty segment for cervicogenic headache

Cervical rotation lateral flexion

Assesses for elevated first rib contralateral to the side that is rotated, then laterally flexed. Must perform bilaterally to compare

Upper limb tension test (median nerve bias)

Sens=0.97, -LR=0.14 Extremely sensitive test to rule out cervical radiculopathy

Cervical distraction test

Good specificity test to rule in cervical radiculopathy

Spurling's test

High specificity test to rule in cervical radiculopathy Sp=0.92 LR+ = 4.87

Cervical Mechanical traction cpr

Peripheralization with lower c/s mobility testing + shoulder abduction test Age >= 55 + distraction test + ULTT A

Thoracic Vertebral compression fracture clinical cluster to diagnose fracture

Extremely good specificity with 3/4 positives: Female Age > 70 years old Significant trauma Prolonged use of corticosteroids

Thoracic Vertebral compression fracture clinical cluster for r/o fracture

Sn = 0.95, -LR = 0.16 with < 2 positives: Age > 52 No leg pain BMI =< 22 does not exercise regularly female

Adam's flexion test

high sensitivity test for thoracic scoliosis

Neck pain with movement coordination deficits. Treatment strategies

Patient education/ counseling, stretching** coordination, strengthening and endurance exercises for neck

Cervicalgia and mobility deficits Treatment

Cervical and thoracic manual therapy, stretching exercise Neck coordination, strength, endurance exercises

Hangman's fracture

Fracture of posterior elements of C2, resulting in spondylolisthesis of C2 on C3

Jefferson fracture

Fracture of anterior and posterior arches of C1

Clay-shoveler fracture

Fractures of spinous process of lower cervical vertebra

Scheurman's disease Clinical features

Results in significant kyphosis due to anterior wedging of vertebral bodies. Juvenile discogenic disease.

Thoracic disc herniation Clinical features

Most common in patients between 30 to 50 years old