TRUNK

Question 1

Components of bio-psycho-social model

Question 2

Causes of trunk condition & role of PT

Answer 2

Causes multifactorial in nature: bio-psycho-social approach

Role of Physiotherapist & priorities:
• Differential Diagnosis & Screening for Referral
• Multidimensional Evaluation
• Educate & Reassure
• Avoid passive strategies dependency, promote active strategies • Empowerment of Patient: should participate in own management

Question 3

PAIN MECH: 3 ≠ parts + def

Answer 3

NOCICEPTIVE: pain arising from actual or threatened damage to non- neural tissue & due to activation of nociceptors = pain associated with acute actual tissue damage & inflammatory conditions

NEUROPATHIC: pain caused by lesion or disease of somatosensory nervous system

NOCIPLASTIC = CENTRAL SENSITIZATION: pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage causing activation of peripheral nociceptors or evidence for disease or lesion of somatosensory system causing pain

Question 4

BIOMEDICAL MODEL

Answer 4

• Diagnosable specific disease / Impairment [TAG]
• Specific Pathological cause / Pain Generator
• Paternalistic approach
• Findings oriented treatment
• Evidence based

Question 5

≠ types of MSK conditions

Answer 5

• Serious Diseases [<1% cases in primary care]
• Specific pathologies [5-10% cases in primary care]
• Non specific spinal MSK condition [90-95% cases in primary care]
  Non specific MSK condition = MSK condition not attributable to recognizable, known specific pathology

Question 6

Terminology ICF: impairment, activity, participation, environmental factors, personal factors, stage & outcome

Answer 6

IMPAIRMENT
Problems in body function & structure such as significant deviation or loss
- Physical&raquo_space; anatomical, structural, imaging
- Functional / Physiological&raquo_space; Pain, R.O.M.
- Psychological&raquo_space; Yellow Flags: anxiety, catastrophizing, fear avoidance belies
- Kinesiophobia, passive coping

ACTIVITY: Activity limitations | restriction (Disability)

PARTICIPATION: Social activities

ENVIRONMENTAL / EXTERNAL FACTORS: Family, work, social…

PERSONAL / INTERNAL FACTORS: Gender, age, comorbities, literacy, education, coping…

STAGE
- Recent < 3 months
- Persistent > 3 months

OUTCOME
- Immediate : closest to immediately following intervention - Short term : 1 month – 3 month
- Intermediate term : closest to 6 months
- Long term : closest to 12 months

Question 7

GENERAL CONSIDERATION OF NECK PAIN: def, epidemiology, risk factors, imaging, prognosis, OM, grades, impairment classification, special test

Answer 7

D = Symptoms located as outlined with or without radiation to head, trunk & upper limbs

E: Prevalence : between 22 to 70% lifetime prevalence - 10 to 20% at any given time
- 54% in last 6 month
Clinical course :
- Idiopathic nonspecific : Improvement within first 6.5 weeks
- Chronic/recurrent : 47% of “general improvement” within 6 month - Radiculopathy : 43% no symptoms after 6 months

RF: - Female
- Prior history of neck pain
- Older age
- High job demand
- Smoking
- Low social/work support
- Prior history of MSK condition (spine)

I: Pathoanatomical features:
- Specific features or pain generator rarely identifiable
- Exclude red flags (potential serious condition, as cervical arterial pathology, fracture…) - Recognize Specific Conditions (Myelopathy)
Imaging:
- Canadian C-Rule (see fracture)
- Recent neck pain : not change prognosis, except if serious condition suspected - Radiating pain with severe neurological signs : MRI

P: Prognosis factors:
- High pain intensity (NPRS > 6)
- High self-reported disability (Neck Disability Index > 30%)
- High pain catastrophizing (Pain Catastrophizing Scale >= 20)
- High acute post traumatic stress symptoms (Impact of Events Scale-Revised >33) - Cold hyperalgesia
Prognosis variable:
- Lower social support
- Preference for passive coping strategies
Recurrence for non-traumatic : 50 to 85% (same/new problem) within 1 to 5 years
In addition to medical conditions, clinicians should be aware of psychosocial factors contributing to patient’s persistent pain & disability, or contributing to transition of acute condition to chronic, disabling condition
Researchers shown that psychosocial factors = important prognostic indicator of prolonged disability & delayed recovery

OM: - Neck disability index
- Patient Specific Functional Scale (PSFS)
Physical Impairment Measure:
- Active R.O.M (goniometer)
- Passive R.O.M (PPIVM and PAIVM)
- Cervical flexion-rotation test (CFRT)
- Spurling
- Neck distraction test
- Neurodynamic
- Cranial cervical flexion & neck flexors endurance test - Pressure Pain Threshold

GRADES:
- Grade I : No signs of major structural pathology & no/minor interference with daily living - Grade II: No signs of major structural pathology, but major interference with activities of daily living
- Grade III: No signs of major structural pathology, but presence of neurologic signs
- Grade IV: Sings of major structural pathology

IC: Neck pain, without symptoms or signs of serious medical or psychological conditions, classified into following ICF impairment-based category, with following impairments of body function:
- NP with mobility deficit
- NP with headache
- NP with movement coordination impairments (Whiplash) - NP with radiating pain (Radiculopathy)

ST: Special tests used during physical examination by clinicians in physical therapy & orthopedics. Tests used to rule in or out whether patient has certain musculoskeletal problem. Helpful in diagnosing orthopedic conditions & injuries
✔ Physical examination measures useful in classifying patient in ICF impairment based category

Question 8

Cx SERIOUS PATHO: ≠ types

Answer 8

Cervical arterial patho
Spinal fracture
Cervical spine anatomical instability
Cervical fracture

Question 9

CERVICAL ARTERIAL PATHO: risk factors, preischemic symptoms, ischemic symptoms

Answer 9

RF: - Rare
- Recent trauma
- Vascular anomaly
- Current or past smoker - Migraine
- High cholesterol
- Recent infection
- Hypertension
- Oral contraception
- Family history of stroke

Preischemic symptoms:
- Ipsilateral posterior neck pain - Occipital headache

Ischemic symptoms:
- Imbalance
- Weakness in UL & LL
- Dysphagia, dysarthria & aphasia - Facial palsy
- Ptosis
- Nausea
- Vomiting
- Dysphagia
- Drowsiness
- Confusion
- Loss of consciousness

Question 10

SPINAL FRACTURE: causes & risk factors

Answer 10

C: Usually, trauma or injury

Risk factors:
- Age
- Prolonged use of corticosteroids
- Trauma
* Compressive or axial force
* Fall > 3m
* Motor Vehicle Collision (MVC) > 100km/h
- Osteoporosis

Question 11

CERVICAL FRACTURE: Canadian cervical spine rules

Answer 11

Image

Question 12

CERVICAL SPINE ANATOMICAL INATABILITY: risk factors, clinical test: lack of validity, self reported symptoms

Answer 12

Risk Factors:
Traumatic event - Fall
- Trauma
- MVA
Non-traumatic event
- Rheumatoid arthritis
- Down syndrome
- Ankylosing spondylitis
- Prolonged oral contraceptive - Prolonged corticosteroid use

Clinical test: lack of validity
Provocating ligamentous structure for symptoms reproduction
- Tectorial membrane
- Transverse ligament
- Alar ligament

Self-reported symptoms
- Recent onset of headache described as “never complained” or ”unusual”
- Impaired ROM, with sharp pain at permitted end range or sudden mvt
- Transient Neurological Symptoms
• Upper Motor Neuron Signs
• Cranial Nerve Palsy
• Partial Horner’s Syndrome

Question 13

Cx SPECIFIC DISORDERS: ≠ types

Answer 13

Myelopathy
Cervical radiculopathy

Question 14

MYELOPATHY: description, subjective examination & special tests

Answer 14

D: Space-occupying lesion within cervical spine with potential to compress spinal cord (Central Nervous System involved)

SE: Symptoms may appear in LL first with gait related changes:
- Upper motor neuron changes
- Dysfunctional corticospinal & spinocerebellar tract
Later on, lower motor neuron findings in UL
- Loss of strength
- Atrophy
- Fine finger movement difficulties

ST: 1. Peripheral neurological examination (Dermatomes, Myotomes, Deep Tendon Reflexes)
2. Upper Motor Neurons – Myelopathy - Lhermitte sign
- Hoffmann ś test
- Babinski ś sign
- Clonus
- Romberg

Question 15

CERVICAL RADICULOPATHY: description, subjective examination & special test

Answer 15

D: Neck pain with radiating pain

SE: - Signs of nerve root involvement present
- Neck pain with radiating pain in involved extremity (lancinating, burning, electric pain, OR paraesthesia)

ST: 1. Wainner’s Cluster [3/4]
- ULNT 1
- Painful ipsilateral cervical rotation < 60°
- Distraction test
- Spurling test
2. Peripheral neurological examination
- Dermatomes
- Myotomes
- Deep Tendon Reflexes

Question 16

Tableau myelopathy radiculopathy….

Answer 16

Tableau

Question 17

NECK PAIN WI5G MOBILITY DEFICITS: ICF categories (subjective exam + special test) & treatments (recent, subacute & persistent)

Answer 17

ICF: Segmental / somatic dysfunction
SUBJECTIVE EXAMINATION:
- Central and/or unilateral neck pain
- Limitation in ROM (reproduction of symptoms at end of range of passive & active motions)
- Associated/referred shoulder girdle pain
SPECIAL TESTs:
1. Limited & painful end range active / passive ROM
2. Spring test
3. Trigger points

Recent
- Education (reassurance & advice to stay active) + home exercise - Manual therapy (cervical and thoracic)
- Stretching
- ROM
- General fitness training

Subacute
- Manual therapy
- Cervicoscapulothoracic endurance exercise

Persistent
- Education
- Manual therapy
- Cervicoscapulothoracic neuromuscular exercises - Dry needling, tens…

Question 18

NEKC PAIN WITH MVT COORDINATION IMPAIRMENT: description, prevalence, recovery, subjective examination, special test, prognosis & treatments

Answer 18

D: Bony or soft tissue injury resulting from rear-end or side impact, predominantly in motor vehicle accidents & from other mishaps as result of acceleration-deceleration mechanism of energy transfer to neck

P: ∼75% of MVC
- Mild disability: 45%
- Moderate : 39% - Severe: 16%

R: First 2-3 months
- Up to 50% report ongoing pain & disability after 12 months

SE: - NP associated with referred pain to UL
- Mechanism of onset linked to trauma or whiplash
- Associated nonspecific signs & symptoms (Dizziness/nausea, Headache, Hypersensitivity to thermal)
- CENTRAL SENSITIZATION

ST: 1. Craniocervical flexion test
2. Neck flexor muscle endurance test (Harris test)
3. Neck extensor muscle endurance test
4. Sensorimotor impairment (Altered muscle activation patterns, Proprioceptive deficit, Postural balance)

P: tableau

T: Recent
- Education: advice to remain active & act usual
- Pain-free cervical gradual ROM exercises

Subacute
- Education: pain science, activation & counseling
- Active cervical ROM
- Exercise
* Isometric strengthening exercises
* Stretching
* Neuromuscular exercises: posture, coordination, stabilization - Manual Therapy
- EPA (tens)

Persistent
- Education: pain science, reassurance
- Manual therapy
- Progressive exercises
* Eye-head-neck coordination EPA (tens)
- COLLAR NOT RECOMMENDED

Question 19

CERVICOGENIX HEADACHE: types, red flags, subjective examination, special test & treatment

Answer 19

T: 3 main types of headaches
- Primary : idiopathic (migraine, tension type headache…)
- Secondary : underlying condition (TMJ, cervicogenic headache, trauma…) - Cranial neuralgia
Cervicogenic headache = secondary type headache - Mild to intense pain
- Non-pulsatile pain
- Usually starts at neck level then headache
- Same side
- Cervical range of motion reduced
- Symptoms made significantly worse by provocative maneuvers
- Present other symptoms (Nausea, photo/phonophobia, blurred vision)

RF: TRIAGE FOR SERIOUS CONDITIONS:
- Cervical Artery Dissection
- Upper Cervical anatomical instability

SE: - Noncontinuous & Non-pulsatile mild to intense pain
- Usually starts at neck level then headache
- Same side
- Cervical range of motion is reduced
- Symptoms made significantly worse by provocative maneuvers, neck movements, or sustained positions/postures
- Present other symptoms (Nausea, photo/phonophobia, Blurred vision)

ST: 1. Limited ROM [especially rotation]
2. Cervical flexion-rotation test
3. Upper Cx spring test!!

T: Acute = Self-SNAG : C1-C2
Subacute = Self-SNAG: C1-C2 & Manual therapy
Chronic =
- Manual therapy (cervical and thoracic)
- Exercise (cervicoscapulothoracic)
* Strengthening and endurance
* Neuromuscular
* Motor control (biofeedback)

Question 20

REGIONAL INTERDEPENDENCE

Answer 20

Serves as base for Cx
- Cervicothoracic junction
- Findings of C-T stiffness & mvt impairment in neck pain, headaches, upper extremity
- Posture

Pain referral patterns
- Cx & UL : no direct innervation from Tx (except first thoracic nerve root)
- Uncommon to cause referred pain to Cx or UL

Question 21

SCREENING FOR REFERRAL: cardiac & visceral disorder

Answer 21

In case of anterior chest wall pain
- Differential diagnosis: Triage for cardiac & visceral disorder
- Tx spine can refer / mimic pseudoanginal or pseudovisceral pain

Abnormal vital signs
- High BP & HR
- Shortness of breath - General fatigue
- Asymmetric pulses

Question 22

THORACIC CAGE: mechanical

Answer 22

Consider Thoracic spine as flexible
- Contribute to other joint movement
- Cervicothoracic junction
- Thoracolumbar junction

Thoracic spine cage
- Ribs
- Costovertebral joint
- Facets joint

Question 23

RIB (types, subjective & objective examination)
VERTEBRAL BODY (types)
DISC (types)

Answer 23

RIB:
T: Trauma
- Fracture!! - Sprain
Non trauma
- Stress fracture (coughing)
- Metastasis
- Arthrosis

SE: Localized pain: Breathing & Coughing

OE: Palpation & Mobilization of rib away from site of pain

VERTEBRAL BODY:
T: - Fracture
- Scheuermann’s disease

DISC:
T: - Herniated disc: very rare
- Discarthrosis

Question 24

LOW BACK PAIN: GENERAL CONSIDERATION: description, epidemiology, clinical course, risk factors, imaging, OM, prognosis, prognosis factors, impairment classification & special test

Answer 24

D = Defined by location of pain, typically between lower rib margins & buttock creases. Commonly accompanied by pain in one or both legs

E = Low back pain
- 1-2%: serious or systemic red flag
- 5-10%: specific pathology
- 85-90%: non-specific pathology
Prevalence
- Lifetime prevalence – 84%
- By 20 y –70 to 80%
- Common health condition
• Epidemic
• First cause of work absence • Economic burden

CC: - Recurrent condition
- Time of improvement not accurate
- At 1 year follow-up (onset < 6 month)
• 21% pain-free
• 55% low disability – low pain
• 10% low disability – high pain
• 14% high disability - variable amount of pain
- At 1 year follow-up (onset > 6 month) • 12% pain-free
• 52% low disability – low pain
• 16% low disability – high pain
• 20% high disability - variable amount of pain

RF: Individual
- Genetics
- Degenerative changes & muscle strength not strongly related - Psychosocial factors
• Physical distress
• Kinesiophobia / Fear Avoidance Beliefs
• Depression
Work related
- Operating heavy equipment
- Smoking
- Prior history of MSK condition
- Job satisfaction

I: tableau

OM: Assessment of psychometric factors
- StarT Back Tool
- FABq
Assessment of Function
- Patient Specific Functional Scale
- Modified Oswestry disability index - Roland-Morris disability index

P: In addition to medical conditions, clinicians should be aware of psychosocial factors contributing to patient’s persistent pain & disability, or contributing to transition of acute condition to chronic, disabling condition.
Researchers shown that psychosocial factors important prognostic indicator of prolonged disability & delayed recovery

PF: Recurrent pain
- History of previous episodes
- Excessive spine mobility
- Excessive mobility in other joints
Persistent pain
- Presence of symptoms below the knee - Psychological distress or depression
- Fear of pain
- Kinesiophobia
- Low expectation
- High pain intensity
- Passive Coping

IC: Low back pain, without symptoms or signs of serious medical or psychological conditions, classified into following ICF impairment-based category, with following impairments of body function:
- LBP with mobility deficit
- LBP with movement coordination impairments - LBP with chronic generalized pain
- LBP with radiating pain (radiculopathy)

ST: Special tests used during physical examination by clinicians in physical therapy & orthopedics. Tests used to rule in or out whether patient has certain musculoskeletal problem. Helpful in diagnosing orthopedic conditions & injuries Physical examination measures useful in classifying patient in ICF impairment- based category

Question 25

LOW BACK PAIN: GENERAL CONSIDERATION: triage

Answer 25

Tableau

Question 26

LOW BACK PAIN: SERIOUS PATHO: alerting fractures, diagnostic & referral of each

Answer 26

VERTEBRAL FRACTURE
AF: - Older age
- Prolonged corticosteroid use
- Severe trauma
- Presence of contusion or abrasion
D: - Imaging immediate
- Laboratory test: ESR
R: Spine surgeon

MALIGNANCY
AF: - History of malignancy
- Strong clinical suspicion
- Unexplained weight loss
D: - Imaging immediate
- Laboratory test: ESR
R: Oncologist

SPINAL INFECTION
AF: - Fever or chills
- Immune compromised patient
- Pain at rest or at night
- IV drug user
- Recent injury, dental or spine procedure
D: - Imaging immediate
- Laboratory test: ESR, CBC & CRP
R: Infectious disease specialist

AXIAL SPONDYLOARTHRITIS
AF: - Chronic back pain
- Inflammatory back pain
- Peripheral manifestations
- Extra articular manifestations
- Positive family history of spondyloarthritis
- Good response to non-steroidal anti-inflammatory drugs
D: Refer to rheumatologist if strong suspicion of axial spondyloarthritis
R: Rheumatologist

CAUDA EQUINA SYNDROME
AF: - New bowel or bladder dysfunction
- Perineal numbness or saddle anaesthesia
- Persistent or progressive lower motor neuron changes
D: Imaging MRI
R: Spine surgeon

Question 27

SPECIFIC DISORDERS OF BACK: ≠ types

Answer 27

Stenosis
LBP with radiating pain (sciatica & lumbar radiculopathy)
LBP with mobility deficit (segmental & somatic dysfunction)
LBP with coordination impairments (instability)
Chronic generalized pain (persistent somatoform pain disorder)
Sacro-iliac joint pain

Question 28

STENOSIS: description, subjective exam & special test

Answer 28

D: - Caused by narrowing of spinal canal or foramina due to combination of degenerative changes such as facet osteoarthritis, ligamentum flavum hypertrophy & bulging discs
- Expert consensus: diagnosis of clinical syndrome of lumbar spinal stenosis requires both presence of characteristic symptoms & signs as well as imaging confirmation of narrowing of lumbar spinal canal or foramina
- Symptoms of lumbar spinal stenosis thought to result from venous congestion or ischaemia of nerve roots in cauda equina due to compression

SE: - Neurogenic claudication limiting walking tolerance
- Older patient, bilateral leg pain or cramping with or without LBP
- Bilateral leg pain exacerbated by extended posture (standing)
- Relieved by flexion (sitting, bending forward & recumbent posture)

ST: 1. Normal neurological assessment during rest (sometimes mild Motor weakness or sensory changes on lower limbs)
2. Antalgic postures (stooped standing & walking)
3. Straightened posture amplify leg pain or numbness
4. Wide based gait

Question 29

LBP WITH RADIATING PAIN: description, subjective exam & special test

Answer 29

D: Lumbar radiculopathy
causing pain radiating down
lower extremity = sciatica

SE: - Signs of nerve root involvement (loos of function) present
- LBP with radiating pain in involved extremity (lancinating, burning, electric pain, OR paraesthesia)

ST: 1. Kemp’s test
2. Neurodynamic [SLR, SLUMP, PKB, SLUMP knee bend]
3. Peripheral neurological examination
- Dermatomes
- Myotomes
- Deep Tendon Reflexes
4. Mechanical Diagnosis (symptoms changes in response to repeated direction-specific mvts)

Question 30

LBP WITH MOBILITY DFICIT: subjective examination & special test

Answer 30

SE: - Acute low back / buttock pain
- Onset of symptoms often linked to recent unguarded / awkward movement or position
- Lumbar ROM limitation
- Restricted thoracic / lumbar segmental mobility

ST: 1. Limited and painful end range active / passive ROM
2. Fingertip to floor / Schober test
3. Spring test
4. Mechanical Diagnosis (symptoms changes in response to repeated direction-specific movements)

Question 31

LBP WITH COORDINATION IMPAIRMENTS: subjective examination & special tests

Answer 31

SE: Chronic, recurring low back pain & associated (referred) lower extremity pain
- Pain at rest or reproduced with initial to mid-range movements
- Pain worsens with sustained end-range movements or position

ST: 1. Prone Instability Test
2. Aberrant movements
- Painful arc with flexion or return from flexion
- Instability catch sign (active flexion test)
- Gower’s sign
- Inverted lumbopelvic rhythm
3. Endurance testing [supine & prone bridge]

Question 32

CHRONIC GENERALIZED PAIN: subjective examination & objective examination

Answer 32

SE: - Low back and/or low back–related lower extremity pain with symptom duration of more than 3 months
- Generalized pain not consistent with other impairment-based classification criteria
- Influence of behavioral, cognitive & affective factors such as depression, fear-avoidance beliefs & pain catastrophizing

OE: 1. Catastrophizing Scale 2. Fear-Avoidance Beliefs Questionnaire

Question 33

SACRO ILIAC JOINT PAIN: subjective examination, special test

Answer 33

SE: - Pain localized at Fortin Area
- No responders to Mechanical Diagnosis (symptoms changes in response to repeated direction-specific movements)

ST: Laslett’s Cluster [positive when 3/6] - Distraction
- Compression
- Thigh Thrust
- Sacral Thrust
- Gaenslen’s ipsilateral & controlateral
Amount of motion in SIJ pathology is extremely small: < 2 mm & < 2 deg
- Symmetry & motion tests => poor inter- tester reliability, low sensitivity & low specificity
- Static palpation tests => “poor” inter- examiner reliability

Question 34

SPECIFIC DISORDERS OF BACK: central sensitization & low back pain management

Answer 34

CS: Altered mechanism of pain processing within central nervous system (enhanced synaptic excitability, lower threshold of activation & expansion of receptive fields of nociceptive input)
- Pain distribution widespread & does not follow anatomical pattern. Pain easily be provoked with low-intensity stimuli that would not normally generate pain (light touch)
- Key feature of pain = disproportionate mechanical provocation patterns in response to clinical examination
- Central sensitization has strong association with psychological factors such as negative beliefs, pathological anxiety or depression & poor coping strategies
- Patients require multidisciplinary approach to pain management, including pharmacological intervention, psychotherapy & specialized rehabilitation

LBP management: pictures

Question 35

RADICULOPATHY: physiopathology, causes, symptoms, exam

Answer 35

P: Nerve root distortion
- Intraneural oedema
- Localized inflammatory response (chemical pain mediator within disc) - Focal nerve ischemia (impaired circulation)

C: - Herniated disc
- Degenerative spine component
* Degenerative change in disc
* Hypertrophy of ligamentum flavum * Osteophyte formation

S: Neuropathic Pain
- Sharp, electric shock, burining
- Generally well localized (radicular distribution)
- Radiation below elbow/knee
Neurological Deficits
- Motor weakness (myotome)
- Sensory deficits (dermatome)
- Diminished deep tendon reflexes

E: Subjective
- Quality of pain
Objective
- Neurological Examination
- Provocative manoeuvres
* Spurling test (Cx) / Kemp test (Lx) * Distraction
* Neural tension test/Neurodynamics

Question 36

MYOTOMES

Answer 36

Motor weakness
- C1/C2 : Cervical flexion
- C3 : Cervical lateral flexion
- C4 : Scapula elevation
- C5 : shoulder Abduction
- C6 : Elbow flexion
- C7 : Elbow extension
- C8 : Thumb extension
- T1 : Finger Abduction
- L1/L2 : Hip flexion
- L3 : Knee extension
- L4 : Ankle dorsiflexion
- L5 : Big toe extension
- S1 : Ankle plantar flexion
- S2 : knee flexion

Question 37

DERMATOMES + grading

Answer 37

Deep Tendon reflexes
- C5/C6 : Biceps
- C6 : Brachioradialis
- C7 : Triceps
- L4 : Patellar
- L5/S1 : Achilles

Grading:
0 = no response; always abnormal
1+ = slight but definitely present response; normal or not
2+ = brisk response; normal
3+ = very brisk response; normal or not
4+ = tap elicits repeating reflex (clonus); always abnormal
5+ = sustained clonus; always abnormal