PTA 2.4 Flashcards
1
Q
What are the types of primary head ache?
A
Tension Type Headache
Migraine
Cluster Headache
2
Q
What are the types of secondary headache?
A
Cervicogenic headache
Medication overuse headache
3
Q
Which headache has the highest prevalence?
A
Tension Type Headache TTH (69%)
4
Q
Which headache has the lowest prevalence?
A
Head ache due to brain tumor (0.1%)
5
Q
What is the peak age of having headaches?
A
40 years
6
Q
How many sick days per 1000 employees are there for migraine?
A
270 days
7
Q
How many sick days per 1000 employees are there for TTH?
A
820 days!!!
8
Q
When and in wich gender is cervicogenic headache more prominent?
A
Females
43 years
9
Q
When and in which gender is TTH more prominent?
A
Females
20-45 years
10
Q
When and in which gender is migraine more prominent?
A
Females
35-45 years
11
Q
When and in which gender is cluster head ache more prominent?
A
Males
20-40 years
12
Q
Where is pain located, where does it start and what type of pain is associated with cervicogenic headache?
A
Starts in the neck
Unilateral without sideshift
Dull not throbbing pain
13
Q
Where is pain located, where does it start and what type of pain is associated with TTH?
A
Pain starts in occipital edge
Bilateral (like a band)
Oppressive pain
14
Q
Where is pain located, where does it start and what type of pain is associated with migraine?
A
Starts in frontotemporal region
Unilateral with sideshift
Throbbing pain
15
Q
Where is cluster headache located?
A
Unilateral
16
Q
How intense is cervicogenic headache?
A
Medium to severe intensity
17
Q
How intense is TTH?
A
Moderate to medium intensity
18
Q
How intense is migraine pain?
A
Medium to severe
19
Q
How intense is cluster headache
A
Very high intensity - suicidal headache
20
Q
What are the episode characteristics of cervicogenic headache?
A
Varying duration
21
Q
What are the episode characteristics of TTH?
A
30 minutes to 7 days
22
Q
What are the episode characteristics of migraine?
A
4 to 72 hours
23
Q
What are the episode characteristics of cluster headache?
A
7 days to 1 year with pain free periods of above 1 month
Chronic = over 1 year without pain-free periods
24
Q
Is cervicogenic headache triggerable?
A
Yes
25
Is TTH triggerable?
No
26
Is Migraine triggerable?
(No)
27
Which areas can also be affected in cervicogenic headache?
Ipsilateral arm or shoulder pain (not radicular)
28
Which types of headaches usually don’t cause other pain areas like arm or shoulders?
Migraine and TTH
29
Which type of headache is often associated with ROM limitation of the cervical spine?
Cervicogenic headache
30
Which type of headache can possibly show ROM limitation?
TTH
31
Which type of headache usually doens‘t show ROM limitations?
Migraine
32
Does not get worse during exertion
Possible photo-phonobia
Possible nausea
Which type of head ache is this?
Cervicogenic headache
33
Does not get worse during exertion
Possible photo-phonobia
No nausea
Which type of headache is this?
TTH
34
Photo-phonobia present
Nausea present
Auras possible
Which type of headache is this?
Migraine
35
Red eyes
Tears
Swollen drooping eyelid
Sweating face
Constricted pupil
Stuffy/runny nose
Restlessness
Which type of headache is this?
Cluster headache
36
Indomethacin, sumatriptan, ergotamine show no effect in which type of headache?
Cervicogenic headache
37
Amitriptylin, short-term paracetamol and NSAIDs are common medication for which type of headache?
TTH
38
Porfylacticum and Triptanen are common medications for which type of headache?
Migraine
39
Profylacticum, oxygen inhalation, sumatriptan, nose spray are common medications for which type of headache?
Cluster headache
40
What are the criteria to diagnose TTH?
Minimum 2 out of 4:
- Bilateral pain
- Pressing pain
- Moderate intensity
- Not influenced by daily activities
Additionally 1 of the following:
- No nausea and/or vomiting
- Photophobia and/or Phonophobia
41
Which type of migraine has disturbed vision on both sides?
Eye migraine/ophthalmic migraine
42
Which type of migraine has disturbed vision on one side?
Retinal migraine
43
With which findings can you diagnose migraine?
Minimum 2 of the following:
- Unilateral
- Pulsating
- Moderate to intense pain
- Exacerbated by daily exertion or avoidance of these activities
Minimum 1 of the following:
- Nausea and/or vomiting
- Photophobia and/or Phonophobia
44
Which form of neuralgia in headaches is most common?
Trigeminal neuralgia (cranial nerve 5)
45
What are pain characteristics of cranial neuralgia?
Pain has at least 1 of the following characteristics
- Intense
- Sharp
- Superficial
- Stabbing
- Trigger area or trigger factors
46
How often is trauma the cause of cervicogenic headache?
In 57% of cases
47
Which segment is most often symptomatic in cervicogenic headache?
C1/C2 (upper cervical spine)
48
How many patients with cervicogenic headache also experience other types of headache?
17.5%
49
Which characteristics should be given to diagnose cervicogenic headache?
1. a1) Provocation by neck movements or separate main positions like (e.g. talking to neighbour while eating, painting the ceiling)
a2) Painful pressure points on affected side in occipital region
b) Decreased ROM
c) Unilateral neck, shoulder or arm pain → vague, generally not radicular, sometimes though radicular pain
**→ Combination of b) and c) is satisfactory but for scientific work only with a1)**
2. Sometimes anaesthetic blocks needed to confirm CGH (mandatory for scientific work)
3. Usually unilateral without side change (for scientific work)
50
Excessive use of medication
Use of medication > 3 months
Paracetamol or NSAIDs for ≥ 15 days per month
Triptans ≥ 10 days per month
These factors indicate which type of headache?
Medication overuse headache
51
Which specific red flags require immediate action by the GP?
1. Acute severe headache possibly combined with neck pain?
-> meningitis, CVA, subarachnoid bleeding
2. Neck stiffness/neurological symptoms?
-> Meningitis, brain tumor
3. Headache with fever and reduced consciousness?
-> Meningitis
4. Headache with focal neurological symptoms?
-> Brain tumor
5. Increase of headache less than 6 weeks after cranial trauma?
-> sub/epidural hematoma
6. Headache with atypical aura (> 1 hour), weakness?
-> CVA
7. Headache with aura after starting anti baby pill?
-> CVA
8. Headache during pregnancy (third trimester)?
-> (pre-)eclampsia
9. Headache, dizziness, nausea, lethargy
-> CO-intoxication
52
Which region specific red flags for headache require immediate referral to another specialist?
1. Headache < 6 years?
-> Brain tumor, hydrocephalus
2. New episode of headache age ≥ 50?
-> Brain tumor, arteritis temporalis, malignant hypertension
3. Headache with visual problems; acute loss of vision, diplopia?
-> Arteritis temporalis, acute glaucoma
4. New headache in patients with cancer, HIV, immunodeficiency?
-> Brain tumor, brain abscess, meningitis
5. Progressive increase of headache within weeks or longer?
-> Brain tumor
6. Headache with signs of increased pressure?
-> Brain tumor
7. Headache with morning vomiting, vomiting not related to headache?
-> Brain tumor, cerebral sinus thrombosis
8. Headache with personality change or deterioration of school performance?
-> Brain tumor
53
How many patients with migraine also have TTH?
83%
54
How many patients with TTH also have migraine?
23%
55
What is the clinimetric tool called HIT-6?
Headache Impact Test 6
- Measures impact of headache on daily life, at home, job, school, hobbies, social life
- Score above 50? → High impact on life and doctor should be seen
56
What is the clinimetric tool called HDI?
Headache Disability Index
- Measures frequency, intensity and impact on quality of life
- The higher the percentage the bigger the impact and disability
57
Which common trigger points are present in TTH?
M. Masseter
M. Sternoclaidomastoid
M. Splenius
M. Trapezius
Suboccipital region
58
What are the clinically most useful tests in the assessment of cervical spine and head ache?
- Manual joint palpation
- CCFT
- FRT
- Active ROM
- Head forward position
- Trigger point palpation
- Muscle tests of shoulder girdle
- Passive physiological intervertebral movements
- Reproduction and resolution of headache symptoms
- Screening of thoracic spine
- Combined movement tests
59
Spinal manipulation may be effective for which type of headache?
Migraine and TTH
60
Spinal manipulation + exercise program might be effective for which type of headache according to article by Bronfort et al?
Cervicogenic headache?
61
Which structure should be part of mobilising in head ache?
- Cervical spine
- Upper cervical spine (C0, C1, C2)
- Cervico-thoracic junction
- Thoracic spine
- Stretching muscles
**→ FROM UNSPECIFIC TO SPECIFIC**
62
What is the composition of stability training of the cervical spine in headache patients?
- Activating deep neck flexors
- Strength endurance training for local and global neck muscles
- General strength training of the neck muscles
- Build-up from isolated to functional training
→ Improve proprioception, strength and posture (the quicker the deep neck flexors are activated the better)
→ Low-load deep neck flexor training provides pain relief
→ High-load training for strength and endurance
63
What does low-load deep neck flexor training provide?
Pain relief
64
What are the training parameters for stability training in headache patients?
6 weeks
2x per day
5min per session
65
What are the components of functional training is headache patients?
Multimodal intervention that includes postural, manual, visual, relaxation and psychological training
→ way more effective than traditional ultrasound or electro stimulation treatment
Cervico-thoracic stabilisation
Ergonomics
Postural training
Overall strength and fitness
66
What are good exercises for cervico-thoracic stabilisation during functional training in headache patients?
→ Regain dynamic control of cervico-thoracic region
→ Shoulder shrugs with resistance
→ Scapular retractions
→ Serratus punch
→ Tree hugs
→ Upright rows
→ Lateral arm raise
→ Cervical retraction against gravity
67
What are the treatment specifics for tension type headache?
- Lifestyle advice
- Avoid provocation
- Avoid drug overuse
- NSAIDs and paracetamol for attacks
- Amitriptyline for serious long-lasting pain
- Relaxation training
- Cognitive behavioural therapy
→ Passive mobilisation of cervical and thoracic spine according to McKenzie
→ Training of the deep neck flexors
→ Postural training
68
What are the parameters of treatment for tension type headache?
8 weeks of therapy
1x per week
30 minutes
+ homework exercises
69
What is the goal of tension type headache treatment?
- **Improve ROM**
- **Improve cranio-cervical muscle endurance and strength**
- **Improve posture**
70
What are the treatment specifics for migraine?
- Explain factors that provoke migraine (triggers)
- Medication based stepped care programme
- Combination of:
- Amitriptyline
- Aerobic training
- Relaxation therapy
→ Fewer days of migraine and reduction of pain during attacks
71
What are the training parameters for migraine therapy?
Walking, cycling or cross trainer
3x per week
45 minutes
→ still not statistically relevant
72
What are the treatment specifics for cluster headache?
- Oxygen inhalation
- Sumatriptan injection or nose spray
- Relaxation techniques
73
What are the treatment specifics for cervicogenic headache?
- Manual therapy + exercise therapy
- Effects of manual therapy:
- Stimulates neuro-inhibitory system
- Activates lateral inhibitory paths of grey matter of midbrain
- Deep neck flexor training
- Strength training of the neck
- Proprioception training
- Muscle energy techniques → Stretches
74
What does CANS stand for?
Complaints of the arms, neck and shoulders
75
What is photophobia?
Abnormal sensitivity to light
76
What is phonophobia?
Abnormal sensitivity / (fear) of sound
77
What is typical for CANS?
- Pain and/or other symptoms in the arms, neck and/or shoulders
- Affected by physical activity
- Within the context of work, household activities, hobbies, sports or study
- **Repeated movements for long period of time**
- **Prolonged static posture in which arm, neck and/or shoulder are involved**
- **Imbalance between load and carry-ability**
78
What are risk factors for peripheral nerve injury in the upper extremity?
- Superficial position of nerves
- Long course through an area at high risk of trauma
- Narrow path through bony canal
79
Which type of peripheral nerve injury or entrapment in the upper extremity is most common?
Carpal tunnel syndrome
80
What are the nerves of the brachial plexus?
Musculocutaneous nerve
Axillary nerve
Median nerve
Radial nerve
Ulnar nerve
81
Where does the musculocutaneous nerve originate and what does it innervate?
- Carries fibres from C5, C6, C7
- Innervates flexor compartment of the arm
82
Where does the median nerve originate and what does it innervate?
- Carries fibres from C6, C7, C8, T1
- Innervates flexors of forearm and parts of the hand
83
Where does the ulnar nerve originate and what does it innervate?
- Carries fibres from C7, C8, T1
- Innervates intrinsic muscles of the hand
84
Where does the radial originate and what does it innervate?
- Extension of the posterior cord
- Carries fibres from C5, C6, C7, C8, T1 (contains all spinal levels)
- Innervates all extensors of the upper limb
85
Where does the axillary nerve originate and what does it innervate?
- Carries fibres of C5, C6
- Innervates muscles around the shoulder
86
What is neuropraxia?
- Compression of nerve tissue
- Reversible conduction block
- Common forms:
- Radicular syndrome
- Pseudoradicular syndrome
- Peripheral nerve entrapment
87
What is axonotmesis?
- Demyalination + axon loss
- Endoneurium is intact
- Neuron can grow back
88
What is neurotmesis?
- Demyalination
- Tear of neuron and endoneurium
- Impaired healing
89
What are examples of Pseudoradicular Syndrome OR Peripheral Nerve Entrapment?
- Saturday Night Palsy
- Radial Tunnel Syndrome
- Cubital Tunnel Syndrome
- Guyon’s Canal Syndrome
- Pronator Teres Syndrome
- Carpal Tunnel Syndrome
90
What type of brachial plexus injury is Erb‘s palsy?
Axonotmesis/Neurotmesis
91
What type of brachial plexus injury is Klumpke‘s Paralysis?
Axonotmesis/Neurotmesis
92
What type of brachial plexus injury is Paralysie des amoureux?
Neuropraxia
93
What type of brachial plexus injury is thoracic outlet syndrome (TOS)?
Neuropraxia
94
How many cases of CRS are due to spinal stenosis?
70-75% of cases
95
How many cases of CRS are due to disc herniation?
20-25%
96
What are other causes of CRS despite spinal stenosis and herniation?
Tumors or osteophytes
97
What should be given in a patient to diagnose CRS according to several authors?
- Upper extremity shows objective neurological signs
-> reduced tendon reflexes, muscle weakness, sensory disorders
- Patient should score positive on provocation and reduction tests
98
What are the different types of TOS?
Vascular TOS
-> Arterial or venous
Neurological TOS
True TOS
Symptomatic TOS
99
What are causes of true TOS?
Due to congenital abnormalities
- Enlarged transverse process of C7
- Cervical ribs
- Enlarged scalene muscles
100
What are causes of symptomatic TOS?
- Usually intermittent
- Arises from bad posture
- Lower anterior chest wall
- Drooping shoulders
- Forward flexed neck
101
How many TOS cases are of vascular origin?
2%
102
How many cases of TOS are of neurological origin?
98%
103
What are typical compression points in TOS?
Posterior scalene port
Costoclavicular space
Subcoracoid tunnel
104
What three properties does a nerve need to function properly?
Ability to stretch, slide and be compressed
105
What are the 3 components of neurodynamics?
Neural structures
Mechanical interface
Innervated structures
106
What’s the mechanical interface in neurodynamics?
- Musculoskeletal system
- Like a flexible telescope that follows the movements of the nervous system
- Tendons, muscles, bones, intervertebral discs, ligaments, fascia and blood vessels
107
What are the innervated structures in neurodynamics?
- Excessive stretching of innervated tissue can cause excessive strain on peripheral nerve tissue
- E.g. muscle stretch of the quadriceps muscle can increase the tension on the femoralis nerve
108
What are the 2 categories of malfunction of the neurodynamic system?
Specific non-serious complaints:
- CRS and LRS
- ULTT 1 increases tension on median nerve → high sensitivity to rule out CRS
- SLR is a high- sensitivity test (useful for ruling out) LRS
- Crossed SLR is highly specific (useful for determining the presence) LRS
Non-specific non-serious complaints:
- Neuromechanosensitivity (hypersensitivity of nerve/aspecific disorder) → neurodynamic mobilisation effective
109
What should be the initial hypothesis in a patient with unilateral radiation?
Radiation due to neuromechanosensitivity
110
What are the characteristics of patient profile 1 of CANS?
- Impairment of function and/or anatomical features
- No limitations in activities and participation
111
What are the characteristics of patient profile 2 of CANS?
- Impairment of functions and/or anatomical features
- Limitations in activities
- Participation problems
- Correlation between disorder, activities and participation
-> understandable and recognizable by both physio and patient
112
What are characteristics of patient profile 3 of CANS?
- Disorders in functions and/or anatomical features
- limitations in activities
- Problems in participation
- According to physio there is discrepancy between present disorder and limitations in activities and participation
- Inadequate behaviour in dealing with issue by patient may be present
113
What are the main differences between profile 2 and 3 in CANS?
Profile 2: Patient has complaints and limitations but tries to maintain level of functioning, activities and participation
Profile 3: Patient has similar complaints but is catastrophising and therefor limits himself/herself in functioning etc.
114
What are prognostic factors in CANS patients?
- Longterm stress
- Depressive mood
- Unrealistic beliefs (pain-related fears)
- Catastrophising
- Low satisfaction with work situation
- Decreasing work load on one hand, increasing activity and participation restriction on other hand
115
How is the Adson Test for vascular TOS executed and when is it positive?
- **Sensitivity 79% / Specificity 76%**
- Patient sits
- Rotation and lateral flexion of head to test side
- Deep inhalation, hold for up to 30 seconds
- Palpate radial pulse on test side and look for change (modified in 15° shoulder abduction)
- Positive if pulse declines/disappears OR if patient’s symptoms are provoked
116
How is the Wright Test for vascular TOS executed and when is it positive?
- **No knowledge of accuracy**
- Patient sits
- Passively bring tested arm into 90° of abduction, 90° external rotation
- Elbow is flexed to max 45°
- Hold arm in this position and palpate radial pulse for 1 minute
- Move arm in to hyper adduction and repeat for 1 minute
- Positive if pulse declines/disappears OR if patient’s symptoms are provoked
117
How is the Roos Test for vascular TOS executed and when is it positive?
- Arms abducted to 90°
- Elbows flexed to 90°
- Squeeze hands for 3 minutes
- Positive if patient experiences heaviness, ischemic pain, weakness or numbness and tingling of the hands
118
How is the Eden Test for vascular TOS executed and when is it positive?
- **No knowledge of accuracy**
- Can be used if other tests can’t be conducted due to limited ROM in shoulders or arms
- Patient sits straight in “military” position, chest out and shoulders back
- Patient can also inhale and hold to improve effect
- Physio extends shoulders
- Palpate radial pulse for up to 1 minute on both sides
- Positive if pulse declines/disappears OR if patient’s symptoms are provoked
119
How is the Phalen Test for carpal tunnel syndrome executed and when is it positive?
- Sensitivity of 85% / Specificity 89%
- Compression of median nerve is tested
- Flex wrists maximally and hold dorsal sides together
- Hold for 1 minute
- Positive if tingling in thumb, index finger, middle finger and lateral half of ring finger → Carpal Tunnel Syndrome
120
How is the Median nerve compression test executed and when is it positive?
- Patient sits with resting arm
- Palpate carpal region and compress
- Positive if carpal tunnel symptoms are provoked
121
What are the therapy variables for neurodynamic treatment?
- Intensity
- Duration
- Gradation
- Slider vs tensioners
→ Sliders hardly lead to an increased tension in the nerve, but do lead to displacement with regard to the mechanical interface
- Openers vs closers
→ Opening and closing techniques consist of movements of the joint, muscle and fascia
→ Aim is to exert a mechanical influence on the nerve structure
→ Opener will (temporarily) reduce the compression on the nerve
→ Closer will (temporarily) increase the compression on the nerve
122
What are the most appropriate neurodynamic techniques to reduce pain and calm the nerve irritation?
Openers and sliders (and the combination of the two)
123
Why first flossing then stretching in neurodynamic treatment?
to make sure there is no obstruction present!!
124
What are the main recommendations for neurodynamic treatment?
- Be gentle and get patient moving
- Treat primary problem that is affecting the nerve (e.g. disc etc.)
- If nerve is primary problem -> treat nerve!
- If irritable consider sliding! Work away from painful segment!
- If less irritable consider tensioning! Work towards painful segment!
- Reps, sets, durations based on treatment goals and patient
- External soft tissue Mobilisation as adjunct
125
What should you ask the patient during neurodynamic assessment or treatment?
How does it feel?
- Position?
- Type of stretch?
- Blockage or obstruction?
126
How fast should neurodynamics be executed?
- Make sure patient is able to control movement
- Patient feels what’s going on
- 1-2 sec per direction maybe?
- CONTROLLED
127
What is the triage of diagnostics in low back pain?
- Non-specific low back pain (**95% of cases**)
- Specific non-serious low back pain (**approx. 5% of cases**) → like nerve root irritation/sciatica
- Specific serious low back pain (**approx. 1% of cases**) → like spinal cord injury, tumour, fracture
128
What is the incidence and prevalence of LSR?
Incidence 12/1000 patients
Prevalence 36/1000 patients
129
What are risk factors for LSR?
- Tall statue
- Heavy physical work
- Mental stress
- Prolonged smoking
- Frequent and prolonged driving
- Genetics
130
What are common characteristics of radicular leg pain?
- Radiating pain into one leg
- Dermatomal pattern
- Sharp pain
- Clear localization
- Postural influence
- Increase with coughing and sneezing
- Leg pain > back pain
- Muscle weakness, sensory loss and parasthesis
131
What are common characteristics of a herniated nucleus purposes?
- Subacute onset
- Recovery usually < 12 weeks
- Pain:
→ Sharp
→ Burning
- Physical examination:
→ Diminished strength and sensation
→ Positive radicular provocation tests
132
What is the typical age range for a bulging disc?
20-50 years
133
What is the pathology in a bulging disc?
Damage to NP causes distortion of AF
- causes pressure on surrounding structures
- AF stays intact
134
What are typical signs and symptoms of a bulging disc?
Weakness
Pain
Tingling
Numbness
135
How are symptoms with a bulging disc provoked?
When sitting or bending
136
What is the typical age group for a protrusion?
35-50 years
137
What is the pathology in a protrusion?
Fissures in surrounding AF due to degeneration or trauma
NP pushes from the insight -> causes pressure on surrounding structures
138
What are typical signs and symptoms of a protrusion?
Local pain lumbar spine
More pain in the morning
Provocation with sitting and bending
No or minimal leg pain
139
What are risk factors for a protrusion?
Smoking
High BMI
Age
Gender
Occupation
History of trauma
Genetics
140
What is the main age group for a Prolaps?
30-50 years
141
What is the injury mechanism in a Prolaps?
AF is ruptured and NP squeezes out and puts pressure on structures
142
What are typical signs and symptoms of a prolaps?
Severe low back pain
Pain in the leg
Gradual increase of symptoms over weeks
Key muscle weakness
143
What are some risk factors for a Prolaps?
Male
Obesity
Smoking
144
What is the typical age range for lumbar spinal stenosis?
60 years or older
145
What type of pain is typical in lumbar stenosis?
Burning
Dull
With heavy and tired feeling
146
What provokes or reduces symptoms in lumbar spinal stenosis?
- Provocation: Lumbar extension (Standing/Walking)
- Reduction: Sitting and forward bending → opening/widening the spinal canal
147
What are typical signs and symptoms in lumbar stenosis?
Radicular pain in both legs
Tingling
Numbness
Weakness of legs
Problems with bowel or bladder?
Intermittent claudication in the calves
148
What is the typical age for piriformis syndrome? And which gender is more affected?
30-40 years
Female
149
What is the cause of piriformis syndrome
Tightening or swelling of piriformis due to injury, spasm or muscle imbalance (e.g. weak glutes)
Weak piriformis which is overused
Tightness due to inactivity and sedentary lifestyle
Sacroiliac and/or hip joint may be irritated
150
What are typical signs and symptoms of piriformis syndrome?
Pain in the buttock
Pain when walking uphill
Tingling
Numbness
Shooting pain
151
What is a common cause for cauda equina syndrome?
Massive herniation in lumbar spine
152
What are typical symptoms of cauda equina syndrome?
Saddle anaesthesia
Uni or bilateral motor deficits
Severe pain
Sexual dysfunction
Bowel or bladder dysfunction
153
What is saddle anaesthesia?
Sensory disturbance or loss of anal, genital and buttocks region
154
How is the Slump Test executed, what does it test for and when is it positive?
- Maximally stretching neural structures of vertebral canal and foramen
- Provoke shooting, burning pain and neurological symptoms in the lower limbs
- Positive test can indicate herniation or nerve root entrapment
- Patient sitting at end of table
- Patient puts hands behind back and flexes lumbar and thoracic spine (slump)
- Head is kept in neutral position
- Push on patients shoulder girdle with one arm, ask patient to flex head look for provocation
- Apply pressure on neck and head and ask patient to extend knee on affected side
- Passively dorsiflex foot with other arm
**→ Stretching sensations are NOT indicators for a positive test**
155
How is the Prone Knee Bend Test executed, what does it test for and when is it positive?
- Also called Reverse Lasegue Sign
- Patient lies prone
- Maximally flex knee passively
- Hold position for 45-60sec and look for reproduction of complaints
- If unable to flex knee past 90°, flex knee maximally and add passive hip extension
- **Positive if unilateral neurological pain in lumbar area, buttock or posterior thigh → possible L2 - L4 nerve root lesion**
- Watch for pelvic tilt → could cause back pain → false positive
156
How is the SLR Test executed, what does it test for and when is it positive?
- **Sensitivity 91%; Specificity 26%**
- Assess unaffected leg first
- Passively flex hip while keeping knee fully extended
- **35°-70° → Tension in sciatic nerve roots over intervertebral discs**
- **Above 70° → Mostly joint pain**
- IF pain in neurological pain zone:
- Move out of pain zone
- Then dorsiflex ankle passively → Bragard’s Sign
- Or ask patient to maximally flex head → Neri’s Sign
- Pain still there → damage to dura mater or spinal cord pathology (e.g. herniation
157
How is the Crossed SLR Test executed, what does it test for and when is it positive?
- **Sensitivity 28%; Specificity 90%**
- To confirm LRS (especially large axillary protrusions)
- Patient in supine lying position
- Passively flex patients uninvolved leg at the hip to about 60-70° with knee extended
- **Positive if shooting pain in affected leg**
158
How is the cluster of cook to include/exclude lumbar spinal stenosis executed?
- Bilateral symptoms?
- Leg pain more than back pain?
- Pain during walking/standing?
- Pain relief upon sitting?
- Age > 48 years?
- **0/5 positive? → 96% sensitivity (that condition isn’t present)**
- **4/5 positive? → probability is 76% and imaging should be initiated**
159
Which spinal levels are most commonly effected in bulging or herniation?
L4/L5
L5/S1
160
Reflex testing is highly sensitive or highly specific?
Highly specific?
161
What is the 5 grade scale for reflex testing?
0 → no response → always abnormal
1+ → slight but definitely present response (may or may not be normal)
2+ → brisk response (usually normal)
3+ → very brisk response (may or may not be normal)
4+ → clonus → always abnormal
162
What can be tested in the assessment for piriformis syndrome?
- Strength tests hip extensors
- Strength tests hip abductors
- Strength tests hip external rotators
- Functional Testing of pelvis and hip control
- Muscle length test piriformis
- Strength test piriformis
163
How is the cluster of wainner conducted, what does it test for and how is sensitivity and specificity distributed?
1. Test -> ULTT1 (good to rule out cervical radiculopathy due to high sensitivity)
Sensitivity 97%, specificity 22%
2. Test -> Cervical rotation
Sensitivity 89%, specificity 49%
3. Test -> Traction Distraction Test
Sensitivity 44%, Specificity 90%
4. Test -> Spurlings Test A
Sensitivity 50%, Specificity 86%
3/4 positive -> likelihood ratio of 6.1%
4/4 positive -> likelihood ratio of 30.3%
164
Which structures does the Adson Test for TOS assess?
Tests for compression of subclavian artery by cervical rib or tight anterior and middle scalene muscles
165
Which structures does the Wright Test for TOS assess?
Compression of axillary interval (space behind pecs minor) due to tightness
166
Which structures does the Roos Test affect in testing for TOS?
Compresses all three compartments of TOS
→ Scalene triangle
→ Costoclavicular space
→ Retropectoralis minor space
167
Which structures does the Eden Test for TOS compress?
Compresses the costoclavicular segment
168
What postural advice could you give for proper spinal alignment?
- Neutral pelvic position
- Have patient feel their pelvic bones as they move into forwards or backward tilt
- Show symphysis and sternum position for reference
169
What are the main characteristics for treatment of lumbosacral radicular syndrome?
- Simple to treat
- Patient can fully recover from this
Active coping style is very important
→ Let client move
→ As much axial compression as possible
Exercising
→ Walking exercises
→ Coordination exercises
→ Dual tasking
Daily (homework) exerises
Adress coping style!! Make moving interesting and challenging for patient!!
170
What is phase 1 of treatment in lumbosacral radicular syndrome?
- SI joint mobilisation
- Stretching dorsal side of pelvis → glute max and hamstrings
- Treat it locally
- Education on pain
171
What is phase 2 of treatment in lumbosacral radicular syndrome?
- Strengthen local stabilizers
- Adress weight loss strategies
172
What is phase 3 of treatment in lumbosacral radicular syndrome?
- Weight loss strategies
- Maintenance of exercises
- Surgery?
173
What are things to focus on in treatment of lumbar herniation?
- Make sure there is no motor failure in lower limb
- If there is motor failure → Patient has to GP and neurologist!!
- If no motor failure → Treatable
- Increasing load capacity of global and local stabilizers of low back
- Walking is very important (aerobic conditioning)
- Gradual build-up
- Discuss psychosocial factors (relax, anxiety etc…)
- Passive lifestyle is often the cause therefor inform and guide
174
When should you use McKenzie mobilizations?
Lumbar herniation treatment
175
What advice should you give a patient with lumbar herniation?
- Return to normal daily life is possible
- Compliance and daily activity is key
- At least 2l of water per day to get disc volume back to normal
176
What are key aspects in the treatment of a prolapse?
- Centralize the pain as starting point of treatment
- Neurodynamics
- McKenzie mobilisations
- Stretching and strengthening
- Active coping style
177
What are characteristics of the treatment of lumbar stenosis?
- Goal is not full recovery → not possible
- Goal is to gain more mobility in hip, thoracic spine, lumbothoracic area
→ Compensation for stiffness in lumbar spine (flexion and extension limitation)
- Stretches and mobilizations of these areas
→ e.g. iliopsoas stretch
Article:
- No clinical significance in surgical or non-surgical approach
- Level of functioning and decompression was either similarly successful or unsuccessful in both groups
178
What is done during phase 1 of lumbar stenosis treatment?
Phase 1 (6 weeks):
- Bedrest (if necessary)
- Education
- Corset
- Flexion based exercises
- Walking, jogging
- Hydrotherapy
- Stretching of lumbar spine
179
What is done for treatment during phase 2 of lumbar stenosis therapy?
**Phase 2** (6 weeks):
- Aerobic exercises
- Hydrotherapy
- Core stability exercises
- Manual therapy
180
What is done in phase 3 of lumbar stenosis therapy?
**Phase 3** (6 weeks):
- Specific strength training
- Increase aerobic capacity
- Increase flexibility
181
What are characteristics of peripheral nerve entrapment therapy like piriformis syndrome?
- Local treatment
- Stretching of dorsal side of hip
→ Glute max
→ Piriformis
→ Hamstrings
- Mobilisation of SI joint
- Life style advice:
→ Active lifestyle and movement is key
182
What does phase 1 of piriformis syndrome treatment look like?
**1st phase** (0-4 weeks):
- Non-weight bearing exercises
- 3x 15 reps
- Isolated muscle recruitment
- Bilateral bridging
- Side-lying clams to target hip abductors
183
What does phase 2 of piriformis syndrome treatment look like?
**2nd phase** (4-9 weeks):
- Weight bearing strengthening
- 3x15 reps
- Double-leg movement to single-leg movements
- Side steps
- Squats
- Single leg sit to stand/ stand to sit
- Step up/ step down
184
What does phase 3 of piriformis syndrome treatment look like?
**3rd phase** (9-14 weeks):
- Functional training
- 3x 15 reps
- Lunges
- Double-leg vertical jumps
- Double leg jump / single-leg landing
- Lateral jumps
185
Which spinal segments are mainly effected in cervical radiculopathy?
C5-C6
C6-C7
186
What is the key muscle for spinal level S2?
Glute max
187
What are the key muscles for spinal level S1?
Triceps surae
Peroneal muscles
188
What are key muscles for spinal level L5?
Glute medius
Extensor hallucis longus
Extensor digitorum brevis
189
What are key muscles for spinal level L4?
Tibialis anterior
190
What are key muscles for spinal level L3?
Quads
191
What are key muscles for spinal level L2?
Iliopsoas
Adductors
Rec fem
Vastus medialis
192
What are key muscles for spinal level Th2-Th12?
Internal and external intercostal muscles
193
What are key muscles for spinal level C8?
Adductor pollicis
Abductor digiti minimi
Extensor pollicis
Flexor and extensor carpi ulnaris
194
What are key muscles for spinal level C7?
Long head of triceps
Flexor carpi radialis
Opponens pollicis
195
What are key muscles for spinal level C6?
Biceps
Extensor carpi radialis
196
What are key muscles for spinal level C5?
Delts
Supraspinatus
197
What are key muscles for spinal level C4?
Diaphragm
Traps
Rhomboids
198
What are key muscles for spinal level C3?
Traps descendens
Levator scapulae
199
What are key muscles for spinal level C2?
Obliques capitis superior
Rectus capitis posterior minor and major
Sternocleidomastoid
200
What are key muscles for spinal level C1?
Rectus capitis anterior and lateralis
201
Which spinal level is tested with the biceps tendon reflex and what is the mnemonic?
C5 - C6
Pick up sticks!
202
Which spinal level is tested with the brachioradialis reflex?
C5 - C6
203
Which spinal level is tested with the triceps tendon reflex and what is the mnemonic?
C7 - C8
Lay them straight!
204
Which spinal level is tested with the patella tendon reflex and what is the mnemonic?
L3 - L4
Kick the floor!
205
Which spinal level is tested with the hamstrings reflex?
L5, S1-S2
206
Which spinal level is tested with the Achilles tendon reflex?
S1 - S2
Buckle my shoe!
207
What are typical symptoms of radial tunnel syndrome?
- Nagging pain that can cause fatigue
- Pain and tenderness outside of elbow stretching down to forearm
- Usually 4cm distal to lateral epicondyle
- Muscle weakness in wrist can be present
- Often provocation by elbow extension, lifting things, forearm rotation, wrist flexion
- All symptoms very similar to lateral epicondylalgia
208
What are common symptoms of cubital tunnel syndrome?
- Numbness and tingling in the hand or ring and little finger, especially when the elbow is bent
- Numbness and tingling at night
- Hand pain
- Weak grip and clumsiness due to muscle weakness in the affected arm and hand
- Aching pain on the inside of the elbow
-> Symptoms very similar to golfer‘s elbow
209
What are common symptoms of carpal tunnel syndrome?
- Numbness, tingling, burning, and pain — primarily in the thumb and index, middle, and ring fingers
- Pain may wake up people at night
- Occasional shock-like sensations that radiate to the thumb and index, middle, and ring fingers
- Pain or tingling that may travel up the forearm toward the shoulder
- Weakness and clumsiness in the hand — this may make it difficult to perform fine movements such as buttoning your clothes
- Dropping things — due to weakness, numbness, or a loss of proprioception (awareness of where your hand is in space)
210
What are the Canadian C Spine Rules?
Screening tool for the cervical spine to check if imaging is necessary
1. Any high risk factor which mandates radiography?
- Age ≥ 65?
- Dangerous mechanism?
- Paresthesias of extremities?
-> 1 of them yes -> imaging!
-> all negative -> continue to 2.
2. Any low risk factor which allows safe assessment of ROM?
- Simple rear end motor vehicle collision?
- Sitting position in ER?
- Ambulatory at all times?
- Delayed onset of neck pain?
- Absence of midline c-spine tenderness?
-> 1 of them no -> imaging!
-> all positive -> continue to 3.
3. Able to actively rotate head side to side (45°)?
-> If unable -> imaging!
-> If able -> continue assessment
211
What are dangerous mechanisms according to the Canadian c-spine rule?
- Fall from elevation ≥ 3 feet or 5 stairs
- Axial load to head (e.g. diving)
- High speed collision ≥ 100km/h, roll-over, ejection
- Motorized recreational vehicles
- Bicycle struck or collision
212
What is NOT a simple rear end collision according to the Canadian c-spine rules?
- Pushed into oncoming traffic
- Hit by bus or large truck
- Roll over
- Hit by high speed vehicle
213
What is meant by delayed onset of neck pain according to the Canadian c-spine rules?
Not immediate onset of neck pain
