Week 1-2 Unit 1 Flashcards
Describe the Proximal Vertebrobasilar artery
- Originates from aortic arch or common carotid artery: may be compressed by anterior scalene
What are the signs of VBI?
5 D’s
3 N’s
- Dizziness, diplopia, drop attacks, dysphagia, dysarthria,
- nystagmus, nausea, neuro symptoms
Describe Transverse Vertebrobasilar artery
Courses through transverse foramen (C6) to transverse foramen of C2
- Susceptible to osteophytes and subluxations
Describe the Suboccipital part of the Vertebrobasilar Artery
Sigmoid path; runs from exit at C2 to foramen magnum : cranio-cervical motion can affect vascular structure ; broken down into different portions :
- Within transverse foramen of C2
- Between C2 and C1
- Foramen magnum
- between atlas and foramen magnum (upper portion); Superficial, covered by traps, semispinalis capitits, rectus capitis; vulnerable to direct blunt trauma
C-T Junction
C6-T1
- First rib and second rib
- Important because junction points in the spine we are more susceptible to injury
- 1st and 2nd rib attach to T1 and T2
- 1st rib and thoracic outlet has a complex of nerves and vasculature in the region and can become compromised
C1 vertebrae
Atlas
- no vertebral body or spinous process
- widest cervical vertebra
- lateral masses connect to occipital condyles
- posterior arch has groove for vertebral arteries
C2 Vertebrae
Axis
- strongest cervical vertebra
- large superior facets connect to C1
- large bifid spinous processes
- dens : pivot for C1 an head to rotate
Atlanto Occipital
- Atlas + occipital condyles
- capital flexion and extension
- capital side bending
- synovial thin and loose capsule
Atlanto Axial
- 2 lateral facets connect to C1
Median joint: dens connect atlas - pivot joint
- rotation : cranium and C1 rotate on C2 as a unit
Transverse Ligament
- Holds dens against atlas
- prevents dens from pressing posterior against spinal cord
- prevents Atlas from Slipping forward and compressing spinal cord via posterior arch
- If ligament breaks Dens would move backward into spinal cord or atlas would translate forward which would pill posterior arch against spinal cord
Alar Ligament
- Sides of Dens to foramen magnum
- Check ligaments to limit rotation
Anterior Longitudinal Ligament
- Atlantoaxial ligament/ Atlanto-occipital ligament
- Anterior vertebral bodies
- Prevents hyperextension
Posterior Longitudinal Ligament
- posterior vertebral bodies
- resists hyperflexion
- prevents and redirects posterior disc herniation
Sternocleidomastoid OIIA
O= lateral surface of mastoid process of temporal l bon and lateral half of superior nuchal line
I= Sternal Head: anterior surface of manubrium of sternum
Clavicular head: Superior surface of medial third of clavicle
I= Spinal accessory nerve 11 : C3/C4
A=
Unilateral contraction= tilts head same side
Bilateral contraction= extends neck/ flexes head
Rectus capitis Anterior OIIA
O= Base of cranium just anterior to occipital condyle
I= Anterior surface of lateral mass of atlas
I= branches from looop between C1 and C2 spinal nerves
A= flex head
Anterior scalene OIIA
O= Transverse processes of C3-C6
I= first rib
I= cervical spinal nerves C4-C6
A= flexes neck laterally: elevates 1st rib during forced inspiration
Cervical Arthrokinematics : Opening and Closing
Opening:
- Flexion
- Contralateral Flexion ( side bend away)
- Contralateral Rotation (rotate away)
Closing:
- Extension
- Ipsilateral Flexion ( side bend toward)
- Ipsilateral Rotation (Rotate Toward)
Coupled Motions
Neck Pain: Prevalence and Risk Factors
- Recurrence rates and chronicity are high
- Female
- Females in their 50’s
- High job demands
- Smoking history
- Low social/work support
- ## LBP history
Prognostic Indicators of Neck Pain
- high pain
- self reported self-disability
- High Pain Catastrophizing
- High Acute PTS
- Cold Hyperalgesia
- Prior Health: Exercise, neck pain, sick leave
- Age
- Other MSK conditions
Clinical Course of Neck pain
- Most rapid recovery in 6-12 weeks
- Little recovery after 12 months
- Chronic : stable, fluctuating or recurrent
Canadian Cervical Spine Rule (CCR)
Low Risk
Low Risk - Acute imaging not required
1. Able to sit in the ED, or
2. Simple rear-end MVA or
3. Ambulatory at any time or
4. Had delayed onset of neck pain or
5. Do not have midline spine tenderness
6. And are able to rotate head 45 degrees each direction
Canadian Cervical Spine Rule (CCR)
High Risk
- NEED IMAGING
1. >65 years or
2. dangerous MOI or
3. Have parathesis in extremities
Vertebrobasilar Insufficiency VBI
- Damage and occlusion VBA
- MOI: traumatic cervical hyperextension with or without rotation, cervical side flexion
- There may be no complaint of vascular symptoms prior to an infarction except with specific movements
- Potentially life threatening
VBI Causes/ Risk Factors
- Atherosclerotic involvement
- Sickle cell diseases
- RA
- Arterial fibroplasias
- Arteriovenous fistula
- Other congenital syndromes
Proximal Crossed Syndrome
- Elevated, protracted shoulder girdle
- Rotated, abducted, winged scapula
- Forward head
- Decreased GHJ stability
- Increased Levator scap and traps activity
- Shortened pec major, minor and SCM
- weak/lengthened DCFS, rhomboids, serratus anterior, lower traps
Forward Head Posture
- COG, mm LOF
-Myofascial pain - Habitual movement patterns or positions
- Zygapophyseal joints
- Scapulothoracic rhythm
- Postulated changes : open mouth breathing: thoracic hyperflexion
(Zygapophyseal joints, also known as facet joints, are synovial joints in the spine that connect the superior articular process of one vertebra to the inferior articular process of the vertebra above it. )
Cervical Flexion- Rotation Test (CFRT)
- A-A rotation
- Patient in supine
- Fully flex C-spine to lock out lower segments
- Rotate head
- positive test = <32 degrees rotation or 10 degrees visual deficit to either side
- Sn 0.95; Sp 0.97
- LR 0.27 ; +LR 9.4
- MDC 5-7 degrees
- Compare side to side
Cranial Cervical Flexion Test (CCFT)
- testing to see if they can contract and control the muscles
- Positive finding would be if the pt is unable to perform or if they start using superficial cervical muscles like SCM or Scalenes or if they can’t control the force
- Test action of 4 DCFs
- Activation/ endurance
- Pressure biofeedback unit PBU
- Start at 20mmhg
- Increase by 2mmHg hold for 5-10 seconds
- up to 30 mmHg
DCF Endurance
- Perform craniocervical flexion–> mark the crease below pt’s chin
- ask patient to raise head 1 inch off the table
- test stops when the head/neck extends, patient loses the neck crease
- Watch for SCM substitution
- Average time in subjects without neck pain is 39 seconds
What are the tests for neurological symptoms for the neck
- Foraminal compression ( SPURLING’S TEST)
- Distraction test
- Shoulder Abduction Test
- ULTT
Bicep reflex
Brachioradialis reflex
Triceps reflex
Bicep C5
Brachioradialis C6
Triceps C7
UMN reflexs/Signs tests
- Babinski
- Hoffman
- Clonus
- L’hermitte’s
Special Tests (Neurological sysmptoms) ordered from most Sensitive to least Sensitive
- ULTT Median : Sn 0.97, Sp 0.22, +LR 1.3, -LR 0.12
- Spurling’s test: Sn 0.50, Sp 0.86, +LR 3.5, -LR 0.58
- Distraction Test: Sn 0.44, Sp 0.90, +LR 4.4, -LR 0.62
- Shoulder Abduction Test: Sn 0.31- 0.43, Sp 0.8-1.0
What is the test cluster for Radiculopathy
test:
1. restricted cervical rotation
2. (+) ULTT 1 median
3. (+) Spurling’s test
4. (+) cervical distraction
Test Clusters
- 4 (+) tests= Sn 0.24, Sp 0.99, +LR 30.3
- 3 (+) tests= Sn 0.39, Sp 0.94, +LR 6.1
- 2 (+) tests= Sn 0.39, Sp 0.56, +LR 0.88
What are the special tests for Craniocervical Instability
- Modified sharp pursers
- Anterior shear test
- latera/transverse shear
- Alar ligament stress test
- PAIVM’s/ Passive Accessory Motion Testing
Indications for Stability testing of the craniocervical region
- Signs/Symptoms
S & S
- a lump in the throat
- lip paresthesia
- nausea or vomiting
- severe headache and muscle spasm
- Dizziness
- History of neck trauma or any of the causes of instability listed previously
- Patient reports of neck instability usually described as the head feeling heavy
Special Tests for Carniocervical Integrity
- Sharp pursers
- Anterior Shear test
- Alar Ligament stress test
- Lateral Shear test
Localized pain =
Pain in the exact spot
Referred pain=
Exaxmple:
If someone pushes C5/C6 they then feel like their shoulder blade is getting achy: pain that is distant/ far away from the original point
Radicular Pain =
Pain the follows the nerve root pathway
Example:
When you are pushing on C5/C6 and now their thumb is starting to become painful
Cerrvicogenic Headache
Neurodynamic relationship of this may be due o interconnection between trigeminal nerve and first cervical roots
Diagnostic Criteria
- Unilateral pain
- Pain in neck triggered by movement or sustained postures
- Lying down will alleviate symptoms
Reduced ROM
- Possible reduced deep neck cervical flexor strength
- Probably poor posture which increases stress on cervical musculature
Spondylosis
Blanket term: also known aa arthritis, cervical disc disease, DDD, Arthrosis
- Describes degenerative changes in the spine
- As young as 30 years old more than 90% @60y/o
- C5-6 or C6-C7 most common places found at
- + radiographic evidence should not be regarded as symptomatic
Clinical presentation
- Gradual onset of neck or arm symptoms
- increased frequency or severity
- Morning stiffness of neck, improving throughout day
- May present with acute stiff neck, cervical myelopathy and veretbrobasilar insufficiency
Clinical presentation of Spondylosis
- Gradual onset of neck or arm symptoms
- increased frequency or severity
- Morning stiffness of neck, improving throughout day
- May present with acute stiff neck, cervical myelopathy and veretbrobasilar insufficiency
Physical Examination Findings of Spondylosis
- reduced motion in sagittal plane
- decrease in SB
- Capsular pattern
- Possible “giving away” or catch in movement
- Radicular symptoms
Asymptomatic
1. Dysfunctional
2. Unstable
3. Stabilizing
Zygapophyseal Joint Dysfunction; Cervical Facet Syndrome
- Acute cervical joint lock or “wry neck”
- Axial Unilateral pain “Neck locking”
- Can refer NOT RADITATING PAST SHOULDER
- MOI: Sudden closing motion or a sustained position
- Painful, restricted facet closing movement
- (-) neurological signs/symptoms
- Palpation - tender just lateral to midline, regional soft tissue changes
- PA’s- pain at the level of dysfunction
- Radiology: typically unremarkable
- Confirmed by diagnostic intra-articular zygapophyseal injections
Facet Joint Osteoarthritis
( part of spondylosis)
- facet joints will show classic hallmark signs of osteoarthritis
- Degenerative changes are present in asymptomatic patients
Degenerative changes don’t always cause pain
Degenerative Disc Disease (DDD)
- Degenerative process:
1. reduction of muscipolysaccharides in NP
2. Increase of collagen in NP
3. Loss of disc bulk, turgor, and ability to resist compression - less shock absorption, more segmental mobility
Facet compression, subluxation - Uncovertebral compression –> degeneration
- Commonly seen @ C5-C6
Cervical Disc Herniations Etiology
- males in their 30’s
- Most common C5-C6/ C6-C7
- Less common than in lumbar spine
- Posterior and posterior lateral herniations cause most symptoms
- Posterior lateral will cause unilateral radiculopathy
- Central herniations may cause bilateral symptoms (myelopathy)
Cervical Radiculopathy
MOI= Associated usually with degenerative changes, disc herniation
- usually in peoples 40’s-50’s
- Pain radiated from the neck to the extremity/body
- Pain, numbness or weakness, burning due to myotome and muscle involvement–> also especially in the hand a loss of sensation it can affect the persons ability to use their hands because hands rely heavily on their sensibility to perform tasks
Cervical Myelopathy
- Spinal cord compression due to compressive tensile forces (UMN)
- Normally insidious onset, and signs/symptoms are quiet variable
- Most common cause of spinal cord dysfunction in older adults
- referral back to MD is appropriate
- MRI or CT can show spinal stenosis with cord compression-osteophytes, disc herniation, ligamentous hypertrophy
Myelopathy signs
- gait disturbance
- Clumsy hand syndrome–> bilateral hand atrophy
- Lhermitte’s sign
- Spastic paresis (lower>upper)
- Pluri-segmental sensory involvement
- Drop attacks, autonomic disturbances, vertigo
Myelopathy Vs Radiculopathy
Myelopathy =
- bilateral, multilevel weakness in legs or arms
- Usually no sensory component in early stages
- Hyper-reflexia DTR’s
-UMN reflexes
- ( no tests are highly sensitive)
Radiculopathy
- Unilateral weakness ( not multilevel)
- Unilateral sensation disturbances
- + ULTT
- Depressed DTR’s (single level)
Cervical Instability Main Signs
MOI= Trauma, surgery, systemic disease, tumors, degenerative changes
- History of major trauma
- catching/locking/giving way
- Poor muscular control
- Excessively free/loose end feel
- Unpredictability of symptoms
- Spondylolisthesis
Whiplash Associated Disorders (WAD)
- Effects of sudden acceleration-deceleration forces on the neck
Mechanism of Injury
- MVA
- Sporting Injuries involving blow to the head or neck or a heavy landing
- trauma to neck or body
Pulls and thrust on the arm s
- falls, landing on trunk or shoulder
Whiplash Associated Disorders Clinical findings
- Central nervous system signs
- periodic loss of consciousness
- Patient does not move neck even slightly
- Painful weakness or neck muscles
- gentle traction and compression are painful
- Severe muscle spasm
- Complaints of dizziness
WAD Prognostic Factors
- risk factors for persistent problems
- High neck pain intensity
- High self report disability NDI
- High post traumatic stress symptoms
- strong catastrophic beliefs
- Cold hyperalgesia
Dissecting Stroke
Risk factors:
- recent trauma
- Vascular anatomy
Symptoms:
- headache
- neck pain
- visual disturbances
- paresthesia (upper limb. face. lower limb)
- Dizziness
Signs
- unsteadiness
- ptosis
- Weakness
- facial palsy
-Speech difficulties
- Swallowing difficulties
- nausea/vomiting
- Dizziness
- Drowsiness
- Loss of consciousness
- Confusion
Non-dissecting Stroke
Risk factors:
- current or past smoker
- HTN
- High cholesterol
Symptoms:
- Headache
Neck pain
- visual disturbances
- paresthesia
- Dizziness
Signs:
- Unsteadiness
- ptosis
- Weakness
- Speech difficulties
- Nausea/vomiting
- Dizziness
-Drowsiness
- Loss of consciousness
- Confusion
What are the clinical presentations of VBI?
5 D’s
1. dizziness
2. diplopia
3. Drop attacks
4. Dysphagia
5. Dysarthria
3 N’s
1. nausea
2. Numbness
3. Nystagmus
Most common symptoms = vertigo, nausea, headache
CN II, IV, VI Tests
- Purely Motor
- controls pupillary constriction and eye movements
CN XI, XII Tests
- Purely motor
- Innervates traps, SCM, and tongue
Cn V, VII, IX, X
Mixed sensory and motor
Chewing V
Facial Expression VII
Swallowing IX/X
Vocal sounds X
How do you differentiate causes of Dizziness
Vestibular, Vascular, Cervicogenic, Other
- Pt sits or stands, rotates head fully to one side, dizziness reproduced
- Next clinician holds the patients head still while the pt rotates his or her body to achieve end range of cervical rotation to one side
- If dizziness occurs in both steps may be vascular or cervicogenic
- Dizziness only occurs in step 1 but not in step 2 may be vestibular as in step 2 there is no movement of the vestibular apparatus the head is kept still
RA
- Progressive, systemic, inflammatory connective tissue disease affecting primary synovial joints, although non-articular structures as the heart and lungs may be involved
- Woman are 3x more likely than men to have it
- Exacerbation of bilateral symmetrical joint inflammation
- Cartilage/bone destruction
- Swan neck distal IP joints
Boutonniere @PIP - MRI important for early diagnosis
Osteoporosis
- metabolic bone disease characterized by decrease in osteoblastic formation of matrix combined with increased osteoclastic reabsorption of bone which means we have normal bone just not enough of it
- Cortical thinning/loss of trabeculae/ fractures
AP Open mouth shows
Shows articulation of C1 and C2
Assess:
- C1-C2 joint symmetry
- Dens midline between the lateral masses of C1
- C2 spinous process of midline
AP Lower Cervical Spine shows
Demonstrates the lower 5 cervical vertebrae
Cervical Spine Lateral View shows
Shows all 7 cervical vertebra
Cervical Spine: Oblique View
- Can see a lot of the vertebral body
- Can see the intervertebral foramina better
What is the value of CT in the depiction of bone?
Indications for CT for any region of the spine:
1. Acute trauma in adults
2. Degenerative conditions
3. Abnormal conditions at the spinal cord when MRI is contraindicated
When is stenosis diagnosed in the cervical spine?
Stenosis is diagnosed if 10mm or less is present
- Sagittal diameter of spinal canal should equal the diameter of the vertebral body
What is the value of an MRI of the spine?
The value of the MRI is the direct visualization of spinal cord nerve roots and discs
- Images will be displaced in the axial & sagittal slices
- Coronal images are infrequently obtained because any of the soft tissue structures evaluated by MRI are adequately demonstrated in the axial and sagittal plane
Stable VS Unstable Injuries
Stable= Compression fxs, Disc herniations, unilateral facet dislocations
Unstable= refers to the immediate or potential risk to the spinal cord or nerve root
“Significant “ C-Spine injury : Patients should have a radiography if:
- Dangerous MOI
- > 65 y/o
- Paresthesia’s
- Midline tenderness
- Unable to rotate 45 degrees
Lateral View is Diagnostic for radiograph
Abnormal soft tissues
Abnormal vertebral Alignment
Abnormal joint relationships
“cross table lateral”
What does the Swimmers lateral do in a radiograph
Moves the shoulder out of the way in order to see the cervical thoracic junction or C7-T1
Cervical Hyperextension sprain
Injures anterior tissues
Cervical Hyperflexion Sprain
Injures posterior tissues
Sprains =
Severity can range from minimal soft tissue trauma to transient subluxation, to avulsion and compression fractures
Degenerative Changes can Involve the Spine at Multiple Sites
1. DDD
2. Degenerative Joint Disease
3. foraminal Encroachment
- DDD = discs
- Degenerative joint disease = facets
- foraminal encroachment= intervertebral foramina
Foraminal encroachment
- The degenerative changes in all the adjacent structures that can act to diminish the size of the intervertebral foramina
- The degenerative disc, degenerative facet joints and the resultant spondylosis from those processes can all act to narrow the room that the nerve has to exit
- The spinal nerve that’s exiting is then susceptible to mechanical compression and radiating arm pain can result that’s called cervical radiculopathy
What is cervical Myelopathy
- Occurs when the degenerative processes have acted upon the spinal cord and encroached on the spinal cord itself
- The pt can experience clumsiness of the hands, difficulty with fine motor skills, unsteadiness on feet, increased falls, intermittent shooting pain into the arm or legs, hyperreflexia and quadriparesis
- On an MRI you can see the compression on the spinal cord
Neck Pain with Mobility Deficits: examination findings
- motion limitation primary finding
- absence of radiating pain or trauma
- central or unilateral neck pain
(radiating pain to distal UE would exclude someone from this category) - Cervical/thoracic segmental mobility testing + findings
- few positive special tests
- negative neurological screen
Neck Pain with Mobility Deficits: presentation
- Limitations in motion are primarily joint or capsular limitations
- General stiffness and lack of flexibility in cerviothoracic musculature would fit this category best
- May have segmental mobility deficits several levels may or may not be painful
- patients with osteoarthritic findings without radiating pain
Neck Pain with Mobility deficits: Interventions Acute <6 weeks
- thoracic manipulation
- cervical manipulation/mobilization
- cervical ROM exercises
- scapulothoracic and UE stretching and strengthening
Neck Pain with Mobility deficits: Interventions Subacute 6-12 Weeks
- thoracic manipulation and cervical manipulation and or mobilization
- neck and shoulder girdle endurance exercises
Neck Pain with Mobility deficits: Interventions >12 weeks
- thoracic manipulations and cervical manipulation or mobilization
- Mixed exercise for cervical/scapulothoracic regions; Neuromuscular, strengthening, endurance training, aerobic conditioning and cognitive affective elements
- dry needling, laser, or intermittent traction
- education and counseling strategies that promote an active lifestyle and address cognitive and affective factors
What is the corrective exercise for forward head posture?
Capital flexion and lower cervical spine extension or a combined retraction
Accessory Motion Glides Cervical Mobilization : Central PA
(spinous process)
superior anterior glide ( flexion below, extension above
Accessory Motion Glides Cervical Mobilization : Unilateral PA
(articular pillar or transverse process)
Contralateral rotation
Accessory Motion Glides Cervical Mobilization : Transverse glide to spinouse process
Contralateral rotation
Accessory Motion Glides Cervical Mobilization : Side glide (lateral glide)
Lateral gliding /lateral flexion
Accessory Motion Glides Cervical Mobilization : Long axis distraction (traction)
Distraction/decompression
Neck pain with movement Coordination Impairments: patient Presentation
- Neck pain related to trauma or WAD
- A traumatic movement coordination impairments
- reduced muscle recruitment in cervical and shoulder girdle
Neck pain with movement Coordination Impairments: Examination
Impairments in the neck and shoulder girdle strength and endurance tests used:
1. Cranial cervical flexion test CCFT
2. Deep neck flexor endurance test
- Algometric assessment of pressure pain threshold
- trigger points
- Pain at mid and end range cervical motion
- cervical segmental testing involved levels produces neck and referred pain
Algometric = is the measurement of pain sensitivity
Allodynia VS Hyperalgesia
Allodynia= pain to nonpainful stimulus
Hyperalgesia= exaggerated pain perception to painful stimuli
Neck pain with movement Coordination Impairments: Interventions Acuter Phase
Education
- return to normal , nonprovocative pre-accident activities as soon as possible
- minimize use of cervical collar
- Perform postural and mobility exercises to decrease pain and increase ROM
- Use multimodal interventions like:
Strengthening
Endurance
flexibility
Postural
Coordination
Aerobic
Functional exercises
Neck pain with movement Coordination Impairments: Interventions Chronic Phase
- Patient education and advice focusing on reassurance, encouragement, prognosis and pain management
- Mobilization combined with an individualized progressive submaximal exercise program
- Cervicothoracic strengthening, endurance, flexibility and coordination
- Incorporate principles of cognitive behavioral therapy
- TENS to manage pain
Global muscle for cervical stability and muscle control
- SCM
- Scalenes
- Levator scap
- Upper traps
- Erector spinae
- rhomboids
- Mid/lower traps
Deep core muscles of cervical stability and muscle control
Deep neck flexors
- rectus capitis anterior and lateralis
Longus capitis and coli
- Suboccipital muscles (important for proprioception and coordination)
Neck pain with Headache: Presentation
- Non-continuous, unilateral neck pain and associated headache= cervicogenic headache
- headache precipitated or aggravated by neck movements or sustained posture/positions
- Deficits in the upper cervical spine or craniovertebral junction
Neck pain with Headache: Interventions Acute
- provide supervised instruction in active mobility exercise
- Clinicians may utilize C1-C2 self sustained natural apophyseal glide exercise
Neck pain with Headache: Interventions Subacute
- provide cervical manipulation and mobilization
- Clinicians may provide C1-C2 self-SNAG exercise
Neck pain with Headache: Interventions Chronic
- provide cervical or cervicothoracic manipulation or mobilizations combined with shoulder girdle and neck stretching, strengthening, and endurance exercise
Neck Pain with Radiating Pain : Presentation
- pain or numbness/tingling radiating to distal UE or medial scapular border
- UE dermatomal paresthesia/numbness, myotome weakness, and or reflex deficits associated with involved nerve roots
Cluster Findings - Caution using any one test independently
1. Positive ULTT 1 a
2. Spurling’s test
3. Cervical Distraction
4. Cervical ROM
Clinical Predication Rule Cervical Radiculopathy
- Test cluster: spurling test, distraction test, ipsilateral cervical rotation <60 degrees and ULTT
- 99% specificity when all 4 tests positive : LR=30.3
- 94% specificity when 3 tests positive : LR=6.1
Neck Pain with Radiating Pain: Examination
- neurological screen
- Neurodynamic testing ULTT 1a
- Spurlings test
- neck distraction test
- Valsalva test
C1
Head flexion
- SCM
- Deep cervical flexors (longus coli/capitus
C2
Head extension
Dermatomes = mastoid process
- rectus cap Posterior major/minor
C3
Head Lateral Flexion
Scalenes
Dermatomes = supraclavicular fossa
C4
Shoulder Elevation
Upper traps
Dermatomes = upper traps
C5
Shoulder Abduction
Dermatomes = lateral deltoid/anterolateral arm
- supraspinatus, infraspinatus, rhomboids, deltoids, biceps
C6
elbow flexion
Dermatomes= thumb
- biceps, brachioradialis, brachialis, supinator, extensor carpi radialis
C7
elbow Extension
Dermatomes = 3rd digit/forearm/posterior arm
- Triceps, flexor carpi ulnaris and radialis, extensor digitorum
C8
Thumb extension
Dermatomes = 5th digit/ ulnar border of hand
- Extensor pollicis longus and brevis, flexor digitorum superficialis and profundus, flexor carpi ulnaris, extensor carpi ulnaris
T1
Finger abduction
Dermatomes= medial arm towards elbow
- Dorsal/palmar interossei, abductor digiti minimi
Interventions for Acute Radiculopathy
- Mobilizing and stabilizing exercises
- Low level laser
- Possible short term use for cervical collar
- Monitor symptom irritably and adjust accordingly
Interventions for Chronic Radiculopathy
- Intermittent Cervical Traction
- Combined exercise and manual therapy
- stretching and strengthening exercises
- cervical and thoracic mobilization/manipulation
- provide education and counseling to encourage participation in occupational and exercise activities
- Consider use of upper quarter nerve mobilizations (slides, glides, flossing)
what is the Clinical Prediction Rule for Cervical Traction Responders?
- Peripheralization of symptoms with lower cervical mobility testing
- Positive shoulder abduction sign
- positive cervical distraction test
- Positive ULTT
- Age 55 or older
- 3/5= highly likely benefit from cervical traction
