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Clin Phase II Lecture > Week 2 Reading > Flashcards

Week 2 Reading Flashcards

1
Q

What is the evaluation strategy laid out in the CSPE for neck pain and arm symptoms?

A

1 - Rule out fractures and nonmechincal causes (disease)
2 - check neuro involvement
3 - Identify pain generator or cause of neuro damage
4 - Pain generating biomechanical/functional lesions
5 - Identify any pain relieving postures
6 - phase of injury
7 - check severity of the condition
8 - determine need for imaging or other neurophysiological lesions
9 - identify local complicating factors
10 - identify psychosocial issues or other chronicity
11 - Identify contributing or sustaining factors
12 - Set outcome measures
13 - establish a prognosis

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2
Q

Evaluation strategy acronym

A

Fat Nerds Generate Big Red Panda Services, Imagining Computer Social Cats Out Partying

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3
Q

Red flags for suspected fractures

Radiographs indicated

A

High impact injury
Head/neck trauma due to fall
Older than 50 with moderate or low impact injury
Cervical trauma in patients with impaired mentation
Patients with special risks (another card)
Headache or trauma with focal neurological deficits
Significant spasm or tenderness after trauma

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4
Q

What are some things that patients with special risk of fracture may have?

A 
Fused spinal segments
Down's syndrome
Marfan's syndrome
Os odontoideum
Klippel-Feil syndromes
Underlying inflammatory diseases such as RA
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5
Q

Indicators for fracture (not red flags)

A

Sharp, severe, intolerable pain
Rust’s sign - fracture instability, severe sprain
Significant neck flexor weakness, post traumatic - fracture or structural instability

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6
Q

Red flags for disease from history

A 
Prior history of cancer
Unexplained weight loss
Unvarying symptoms
Diffuse cape-like distribution of pain/temperature loss
Horner's syndrome
Fever/chills
Recent bacterial infection
Palpable mass
Pain unimproved with a month of treatment
Neck pain with urinary retention/incontinence
Multiple joint involvement 
Currently taking anti-coagulants
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7
Q

Peak incidence of radicular syndromes is what age?

A

50-54 yo

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8
Q

What three clues provide strong suspicion of radicular syndrome

A

Pain radiating into the forearm or hand
Paresthesia to the fingers
Neurological symptoms

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9
Q

What five clues provide a weaker suspicion of radicular suspicion

A

Pain radiating past the GH joint but not past the elbow
Moderate to severe trauma to the neck
Neck and leg symptoms
Suspected diagnosis which has the potential to affect nerve roots

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10
Q

The two leading causes of cervical radicular syndromes

A

Herniated discs

Osteophytic spurs

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11
Q

Onset of neck pain and additional symptoms in cervical radiculopathy

A

Other symptoms appear after an average of 18 days

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12
Q

Classic characteristics of arm pain in nerve root pain

A

Lancinating or shooting quality
Radiating into the extremity in a narrow band less than two inches wide
Often exceeds the intensity of the neck pain
Dermatomal
Aggravated by minor movements, coughing or sneezing

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13
Q

Symptom behavior of nerve root symptoms (history)

A

Sx may be unrelenting for 24 hours

Pain can seem to be worse at night

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14
Q

Patient’s symptoms that change with PE

A

responsive to treatment or activities that open or close the IVF
Or increase or decrease the tension on NR
Both or one
No apparent pattern

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15
Q

Red flags from Ancillary Studies

A

Elevated ESR or CRP

Anemia

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16
Q

Strong suspicion of radicular syndrome

A

Pain radiating into the forearm or hand
Paresthesia to the fingers
Neurological symptoms

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17
Q

Weaker suspicion of radicular syndrome

A

Interscapular pain
Pain radiating past the GH joint but not past the elbow
Neck and leg symptoms
Suspected diagnosis which has the potential to affect nerve roots

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18
Q

Two leading causes of cervical radicular syndromes

A

Herniated discs and osteophytic spurs

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19
Q

Typical symptoms of cervical radiculopathy

A

Unilateral neck pain (MC)
Radiating arm pain (MC)
Finger paresthesia
occasional neurological complaints

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20
Q

Time interval between the onset of neck pain and the other symptoms

A

averaged 18 days in one study

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21
Q

Classic characteristics of arm pain in radiculopathy

A

Lancinating or shooting quality
Radiating into the extremity in a narrow band less than two inches wide
Often exceeds the intensity of neck pain
Dermatomal and easily aggravated by minor movements, coughing, sneezing

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22
Q

Three qualities of paresthesia in radiculopathy

A

Radicular symptoms are characterized by proximal pain and distal paresthesia in the distribution of the affected nerve root
Paresthesia may fit more commonly into known dermatomal patterns
Numbness in the extremities may develop with minimal or no pain

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23
Q

Acute nerve root symptoms may be __ ___ _ ___ and pain can seem ___ __ ___

A

24 hours a day; worse at night

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24
Q

Radicular syndrome symptoms respond to what three things

A

May be responsive to procedures or activities that open and/or close the IVF
May respond to increased or decreased tension on the nerve root
May demonstrate no apparent pattern at all

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25
Q

3 key physical presentation of radicular syndrome

A

Observation of painful postures and ROM
Orthopedic tests that aggravate or alleviate the extremity symptoms
ID any neurological deficits

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26
Q

Diagnostic cluster for radicular syndrome

A

Symptoms reproduced with one version of spurling’s test
Symptom reduction with cervical distraction
Symptom reproduction with an upper limb tension test
Cervical rotation reduced to less than 60 degrees toward the side of pain

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27
Q

Preliminary Obcervation and Range of Motion

A

Rust’s sign
Bakody’s sign - cervical disc herniation
Pain relief by putting palm to chest
Reduced rotation

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28
Q

Reproduction of symptoms with cervical compression and lateral flexion means ___ _ ___ NR is irritated and pathologically compressed

A

C6-C8

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29
Q

reduction of pain with shoulder abduction was ___ ___ ___ ___ and a negative test was ___ ___

A

Useful to rule in; not useful

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30
Q

Three positive results for ULTT

A

Symptom reproduction
>10% reduction of elbow extension compared to normal side
Symptoms aggravated by contralateral flexion and relieved by ipsilateral flexion

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31
Q

Likelihoods of DTR

A

Abnormal DTR in UE increases LR by 2.5

Abnormal biceps reflex is 10 times more likely to have root involvement

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32
Q

Which are more predictive deficits or pain distribution?

A

Deficits

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33
Q

Which cervical nerve roots are most affected?

A

C6 or C7

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34
Q

Clues for C5 radiculopathy

A

Pain in suprascapular region

Deltoid is weaker than biceps

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35
Q

Clues for C6 radiculopathy

A

Anterior or posterior deltoid, posterolateral arm or dorsal radial forearm
Pain in suprascapular region with lateral aspect of arm and forearm
Sx in multiple fingers

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36
Q

Clues for C7 radiculopathy

A

Pain in the scapular or interscapular region suggests a C7 or C8 root lesion
Pain in posterior deltoid, posterolateral arm or dorsal radial hand
Depressed triceps reflex (strongest clue)

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37
Q

Three symptoms of spondylolotic radiculopathy

A

Root pain is proximal, rarely extending below the elbow
Sensory symptoms are more common than motor
Paresthesia are often in the distal territories of the affected roots

38
Q

Three signs of spondylolotic radiculopathy

A

Hyporeflexia
Atrophy
Progressive weakness including loss of grip strength

39
Q

Joints to be evaluated for lesions along the kinetic chain

A 
First and second rib
AC and SC joint
GH joint
Elbow joint
Carpal bones, distal radial
40
Q

Differential diagnoses for a radicular syndrome

A 
Disc herniation
Spondylotic compression
Stenosis
Traction injuries
Root adhesions/fibrosis
Tumors
Fracture
Instability
Infection 
Chemical irritation or NR
41
Q

Six clinical suspicions for Cx disc herniation

A 
Neck pain and decreased Cx AROM
Arm pain centralizes
Bakody's sign or positive shoulder abduction test
Positive valsalva maneuver
Positive compression/distaction
Decreased biceps reflex
(No evidence of osteophytes or spurs)
42
Q

Clinical tip for osteophytes

A

Older patients with absence of other diagnosis

43
Q

Findings that lessen likelihood of osteophytes

A

Little evidence of degenrative changes on radiograph
Arm pain centralizes with repetitive or sustained neck position
Bakody’s sign
Positive valsalva

44
Q

___ __ ___ nerve roots are the most commonly affected NR

A

C6 or C7

45
Q

C2 Nerve Root radiation

A

Pain at craniocervical junction with radiation to the posterior aspect of the head may suggest C2 radiculopathy

46
Q

C3-4 NR radiation

A

Discomfort about the posterior neck, occiput, and over the trapezius muscle to the shoulder

47
Q

C5 NR radiation and affected muscles

A

Pain in suprascapular region
Paresthesia to the fingers
Weak biceps/biceps reflex

48
Q

C7 NR Most common findings

A

Decreased triceps reflex
Weak elbow extension
Sensory loss over middle finger

Posterior deltoid, posteriolateral arm, dorsal radial hand

49
Q

C8 NR Most common findings

A

Sensory loss over little finger
Decreased triceps reflex
Weak finger flexors

scapular/interscapular/medial arm

50
Q

C6 NR most common findings

A

Decreased biceps or brachioradialis reflex
Sensory loss over the thumb
Weak wrist extension

anterior/posterior deltoid, posterolateral arm, dorsal radial arm, suprascapular region

51
Q

Symptoms of spondylolotic radiculopathy

A

Proximal root pain, rarely below the elbow

Distal paresthesia

52
Q

Signs of spondylolotic radiculopathy

A

Hyporeflexia
Atrophy
Progressive muscle weakness and loss of grip strength

53
Q

Theories for causes of Complex Regional Pain Syndrome

A

Hypersensitized central nervous system, sensitized peripheral receptors, a modified role for sympathetics

54
Q

The five main types of symptoms associated with Complex Regional Pain Syndrome

A

Pain, autonomic dysfunction, edema, movement disorder and dystrophy

55
Q

Features of pain in CRPS

A

severe, burning pain becoming regional with palmar and plantar dominance

56
Q

Are spasms, increased reflexes and muscle weakness common in CRPS

A

Yes

57
Q

4 common causes of somatic referred pain

A

Facet syndrome
Internal disc derangement
Subluxation syndrome
Myofascial pain syndromes

58
Q

What is a common DDX from the spine that can closely mimic cervical radiculopathy?

A

Facet syndrome

59
Q

In chronic pain from whiplash 40-68% of patients pain was from what?

A

Facet pain

MC C5-6;2-3

60
Q

Palpatory findings for cervical facet syndromes (best evidence)

A

Tenderness over facets
Tissue changes over the facet
Joint restriction

61
Q

Joint loading findings for cervical facet syndrome

A

Local pain with active or passive extension
Local pain with cervical compression
Local pain in the quadrant position or cervical kemps

62
Q

Sources of pain in internal disc derangement

A

Pressure of discal material against the Posterior Longitudinal Ligament
Tears in the thicker anterior annulus

63
Q

Clinical presentation of Internal Derangement

A

Neck pain with or without referred pain
Self-limited episodes in younger people with acute torticollis
Intermittent scapular pain
May be aggravated by cervical compression
Less likely to have localized tenderness over the facet

64
Q

Somatic referred pain from internal derangement may be improved by what motions?

A

Chin retraction, neck extension, or another direction

65
Q

Elderly patient with scleratogenous diffuse bilateral neck pain

A

Central disc bulge or herniation without myelopathy or radiculopathy
Irritated PLL or dura mater
Not very common

66
Q

Key physical exam findings for subluxation syndromes/joint dysfunction

A

Reproduction of dorsal pain with head rotated to the symptomatic side
Sometimes a positive doorbell sign
Palpable joint dysfunction in the lower cervicals
Symptom relief with cervical manipulation

67
Q

2 or more of the following criteria are required for joint dysfunction/subluxation syndromes

A

Altered motion by palpation (all-encompassing use)
Tenderness or dysesthesia elicited by static or motion palpation
Palpable spasm or change in tissue texture near joints
Reduction of tenderness with joint challenge
Palpable malposition

68
Q

Under what circumstance may subluxation cause radicular pain

A

when present with anatomical changes such as stenosis or other degenerative changes causes ischemia to the NR

69
Q

Arm symptoms associated with neck subluxations are likely associated with what?

A

Somatic referred phenomenon

70
Q

How can myofascial pain syndromes can mimic a radicular syndrome?

A

Referred pain, numbness, or paresthesia

71
Q

T/F a sensitive spot in a muscle identifies an MFTP

A

False

Taut band, palpable mass, recreation of familiar pain, Muscle has painful limitation to stretch

72
Q

Essential criteria for MFTPs

A

Exquisite spot tenderness of a taut band or a nodule in a taut band
Pressure on the TP reproduces the patient’s pain AND patient recognizes the same pain that they complain of
Painful limitation to full stretch of the muscle

73
Q

Confirmatory observations for MFTPs

A

Local twitch sign (low sensitivity and high specificity)
Referred pain or altered sensation in an area that the patient can identify as their Sx
Electromyelographic evidence of spontaneous activity in the area of MFTP

Pain/paresthesia in expected referral pattern but not familiar is a latent MFTP

74
Q

Three evaluation steps for an identified myofascial pain syndrome

A

Assess other muscles in the same functional unit for dysfunction
Identify activities that may have to the development of the syndrome
identify any other structural or functional causes that result in the persistence of the TP (chest breathing, LLI, pelvic distortions, etc.)

75
Q

Joints that should be evaluated in the case of multiple joint lesions along the kinetic chain

A 
First and second rib
Acrioclavicular joint and sternoclavicular joint
Glenohumeral joint
Elbow joint
Carpal bones, distal radial-ulnar joint
76
Q

T/F reproduction of the pain that the patient complains of when palpating a tender territory is indicative of multiple lesions in the kinetic chain

A

F
It is possible that this is hyperalgesia from NR irritation or central sensitization at the cord level

So possible but not a definitive clue. Direct therapy at the region in question to see if it alleviates symptoms

77
Q

DDX list for radicular syndrome

A 
Disc herniation
Spondylotic compression
Stenosis
Traction injuries
Root adhesions/fibrosis
Tumors 
Fracture
Instability
Infection
chemical irritation
78
Q

The two most common causes of radicular pain syndrome are

A

Disc herniations

Spondylotic spurs and osteophytes

79
Q

Clues that strengthen the suspicion of cervical disc herniation

A

Neck pain and decreased active cervical ROM
Arm pain centralizes with repetitive or sustained neck positions
Bakody’s sign or positive shoulder abduction test
Positive Valsalva maneuver
Positive cervical compression/distraction tests
Decreased biceps reflex
No evidence of osteophytes or significant spurring on radiograph

80
Q

The first differentiation in older patients with radiculopathy

A

Spondylotic compression

81
Q

Findings that cast doubt on spondylotic compression as a diagnosis

A

Little evidence of dengerative changes on the radiograph
Arm pain that centralizes with repetitive or sustained neck positioning - herniation
Bakody’s sign or positive shoulder abduction test - herniation
Positive Valsalva maneuver - herniation or tumor

82
Q

What can cause direct trauma/traction to the NR

A

Whiplash injuries
Compressive force to the top of the head (esp. in ext.)
Traumatic shoulder depression with cervical side in c/l LF

83
Q

Findings that suggest NR adhesion

A

Intermittent arm pain (if constant mb significant acute inflammation or other Dx)
Increased arm pain with cervical flexion that is brief and resolves rapidly when tension is released
Sx produced at end range of NR stretch
Patient present with deviation of the neck towards the affected side with flexion/extension
No significant improvement in ROM with repetition

84
Q

significant instability is defined as

A

> 3-4 mm of movement on flexion-extension radiographs

85
Q

Infections of the spine are associated with what ancillary finding

A

ESR over 50 mm/hr

86
Q

Differential diagnosis for a myelopathic syndrome

A 
Disc herniation
Spinal stenosis
Tumors
(Structural) instability
Neurapraxis injury
Fracture
Cord/meningeal adhesions/fibrosis
Infection
87
Q

The two most common causes of cervical cord compression

A

Cervical disc herniation and spinal canal stenosis

88
Q

Significant cord compression is considered a contraindication to what?

A

Manipulative therapy

89
Q

Diagnosis of disc herniation requires what ancillary test?

A

MRI, advanced imaging

90
Q

Summary of effects of spinal stenosis

A

Motor deficits are more likely
Myelopathy is more likely
Post-traumatic symptoms are more likely

Clin Phase II Lecture (6 decks)

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