Neck and Thoracic Flashcards
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
Cervical manipulation CPR
Symptoms < 38 days
Positive expectation manipulation will help
Cervical rotation ROM asymmetry > 10deg
Pain with PA testing mid-cervical spine
Neck pain classification
Cervicalgia + mobility deficit
Cervicalgia movement control deficits/WAD
Cervical radiculopathy
Cervicogenic headache
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
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%
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
Cervicogenic headache presentation
Primarily occipital headache, radiating into head and face. Tends to be unilateral without side shift
Affected by cervical movements or posture
Trigeminal nucleus
Receives afferents from cn V and spinal nerves 1-3
Nuclei of head, throat, and neck afferents
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
Tension headache presentation
Location: diffuse, bilateral
Characterization: dull
Triggers: multiple, not typically associated with neck movement
Associated symptoms: decreased appetite, phonophobia, photophobia
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
5 Ds And 3 Ns
Dizziness
Drop attack
Diploplia
Dysarthria
Dysphagia
Ataxia
Nausea
Numbness
Nystagmus
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
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
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
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
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
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
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
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)
Wells criteria
> 6 high probability of DVT or PE
4.5 - 6 moderate probability
< 4 low probability
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
