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PHTY301 > Week 9 Upper cervical spine issues > Flashcards

Week 9 Upper cervical spine issues Flashcards

1
Q

Things from Hx that indicate upper cervical ligamentous instability

A

Trauma. Wad, diving accident, falling on head
Chronic arthritic conditions - RA (24-70%)
Long term cortico-steroid use
Congenital disorders - Down’s syndrome

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2
Q

Signs and symptoms upper cervical ligamentous instability

A 
Severe muscle spasm
'Head feels as if it will fall off"
Lump in throat
Lip parasthesia
Severe headace, nausea, vomiting
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3
Q

P/E upper cervical ligamentous instability

A

Sharp purser test
Lateral flexion alar ligament stress test
Rotation stress test (>30 degree positive)
Soft end feel
Nystagmus/pupil cha nges

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4
Q

Positional dizziness VBI

A

extension and rotation

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5
Q

Intrinsic and extrinsic VBI

A

I: artheroclerosis, thrombus

e - compression, dissection

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6
Q

What physio techniques cause VBI

A

quick high velocity manip, tears lining of artery > stops blood flow > clot

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7
Q

Location VBI

A

Serious verterbro-basilar complications occur between transverse foramina axis and atlas during contra-lateral rotation

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8
Q

Ischaemic signs and symptoms (5 Ds , 3Ns etc)

A 
5 Ds 
Dizziness 
Diploplia
Dysarthria
Dysphagia
Drop attacks

3 Ns
Nausea/vomiting
Numbness
Nystagmus

PLUS
ataxia

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9
Q

5 Ds

A 
5 Ds 
Dizziness 
Diploplia
Dysarthria
Dysphagia
Drop attacks
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10
Q

3 Ns

A

3 Ns
Nausea/vomiting
Numbness
Nystagmus

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11
Q

Type of dizziness VBI

A
  • Light headedness, unsteadiness or giddiness

* Generally not vertigo (spinning)

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12
Q

How long does VBI last

A

Transient: seconds to hours

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13
Q

Triggers VBI

A

Triggers: neck rotation and extension

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14
Q

VBI screening and effectiveness

A
  • Four stages
  • History (Subjective examination)
  • Physical examination
  • During treatment of the cervical spine
  • Following treatment

(• Screening tests of poor diagnostic value)

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15
Q

Differential VBI dizziness

A

Benign Positional Paroxysmal Vertigo

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16
Q

APA Pre manipulative Testing Guidelines

A
  • De Kleyn’s test – EOR extension and rotation
  • supine and sitting
  • Hold 10 seconds
  • Monitor for signs and symptoms
  • Observe for signs of nystagmus
  • Simulated manipulation pos’n
  • EOR ext and rotation
  • Positive if dizziness provoked
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17
Q

Signs and Symptoms verterbral artery dissection

A 
• Moderate to severe posterior neck pain
and/or occipital headache +/- dizziness
• Acute onset
• Reports neck stiffness; no decreased ROM
• Minor mechanical trauma
• Ischemic symptoms (5Ds, 3Ns + ataxia):
delayed presentation (hours to days)
Possible visual disturbances
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18
Q

What to do if strongly suspect VBI or VA dissection

A

If reported symptoms are clearly indicative of VBI or
VA dissection then provocative testing is not
performed and medical opinion should be sought
prior to undertaking PE or Rx.

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19
Q

Cervicogenic dizziness

A 
Dizziness
described as
imbalance or
disequilibrium
Associated with
neck pain or
stiffness
Provoked by
head
movements or positions
20
Q

Diagnosing cervicogenic dizziness

A

1) Type of dizziness: unsteadiness not vertigo
2) Eliminate other causes for dizziness or
unsteadinesss such stroke, spinal cord
pathology, cerebellar ataxia, Parkinson’s disease
3) Neck pain and/or stiffness
4) Dizziness brought on with neck movements
5) Physical tests: ROM, cervical signs on palp

21
Q

What is vertigo and what causes it

A

• A sensation of movement, usually rotary,
whirling or spinning
• Accompanied by nausea and vomiting
• Lesions of CNS OR peripheral vestibular
disorders eg BPPV

22
Q

What is BPPV

A 
Benign paroxysmal positional vertigo
(BPPV)
• Brief, intense, severe
rotational vertigo
• Debris from utricle
• Usually posterior
semicircular canal
• The most common causes
of vertigo (20-30%)
• Precipitated by changes in
head position
23
Q

How to differentiate vertigo

A 
Differentiate by:
Standing – hold patient’s head and ask them to
rotate trunk on head keeping feet still
Quality of dizziness
• Hallpike Dix manoeuvre
• Nystagmus habituates
24
Q

What is the Dix-Hallpike test

A 
Dix-Hallpike test
• Manoeuvre for right-sided
BPPV
• Head turned 45 degrees
to the right
• Patient taken quickly
into supine head-hanging
(Bronstein 2003)
• Positive if nystagmus
25
Q

Underlying pathology Cervical headaches

A

 Convergence C1,C2, C3 and trigeminal nerve
 Convergence within the Trigeminocervical Nucleus
 Neurones receive both cervical and trigeminal input
(extensive receptive fields)
 Unable to correctly interpret the source of the information
 Pain is perceived in the head, as well as in the neck

26
Q

Cervicogenic headache. S&Ss of neck involvement

A 
Neck pain related to the
headache
• Head pain reproduced by neck
movement /postures
• Head pain produced by PAIVMs
• Findings on PPIVMs
• Restricted ROM neck (espec
upper C/S)
• Ipsilateral neck, shoulder, arm
pain
• Confirmatory pain blocks
• Unilaterality
27
Q

Characteristics of cervicogenic headache

A 
• Mod-severe non-lancinating, nonshooting
pain starting in neck
• Fluctuating continuous pain
• Varying duration episodes
• 5 D’s
• Female
• Only marginal response to
indomethacin
• May be Hx neck or head trauma >
medium severity
28
Q

Headache red flags

A

 Severe headache of sudden onset ( +/- neck stiffness , nausea
& vomiting)
 Subacute headache progressively worsening
 Severe headache with nausea and vomiting
 Headache with associated neurological signs or change in
Csness
 Temporal headache onset > 50 years
 Headache with no associated aetiology

29
Q

What type of headache can physio help

A

cervicogenic

components of a headache consistent with a neck component

30
Q

Treatment for acute episodic headache

A 
Focus on treating
movement impairment &
clinical signs: Manual
therapy such as PJMs and
SNAGs
• Identification of
precipitating factors
• More rapid response to
treatment
31
Q

Treatment for chronic continuous headaches

A 
• Focus on aetiological &
perpetuating factors
• Greater emphasis on selfmanagement
& exercise
(motor re-training)
• Concurrent pharmacological
treatment
• Slow response to treatment
32
Q

Specifc physical treatment for headaches

A

Articular system dysfunction- treat joint/signs limited
motion segments : joint mobilisations, SNAGs
• Muscle – treat length, strength and endurance deficits
• Treat altered neuromuscular motor control muscle
(deep neck flexors, extensors)
• Postural – forward head posture
• Neural – neural tissue mechanosensitivity
• Identification of precipitating factors eg work station
• Self-management & exercise (motor re-training)

33
Q

What are indications of poor predictive response to treatment of headaches

A

– Long standing, continuous headaches
– Irregular, low grade headaches
– Global cervical tenderness
• Particularly when irritable
– Headaches associated with upper cervical instability
– Post trauma cervicogenic headaches eg MVA
– Questionable headache diagnosis or overlap

34
Q

Biopsychosocial approach to headache treatment

A

Pain processing can be influenced by past experiences,
culture, attitudes, and beliefs about pain
Despite the Headache type the CT nucleus can be influenced by
allergies, dietary intolerances, sleep disturbances, stress, anxiety and
hormonals changes
Also visual, somato-sensory and olfactory changes can influence
response

35
Q

Headache treatment modalities

A 
PAIVMS
Heat/cold
Sensorimotor training
Analgesics
PPIVMS
Traction
Therapeutic exercise
Trigger points
36
Q

Headache outcome measures

A

Activity restrictions due to headaches

Quality of life outcome measures

37
Q

What happens to the local muscle system of the neck in response to neck pain

A

Switches off in response to neck pain (as in lumbar spine)

does not automatically switch back on with resolution of symptoms

38
Q

What happens after the local muscle system switches off due to pain

A

•The global muscle system dominates the movement pattern and take
over to provide postural stability with consequent aberrant
movement patterns

39
Q

What are the muscles of the anterior local system

A

Longus capitis
Longus colli
Rectus capitus anterior
Rectus capitus lateralis

40
Q

What is the global muscles of cervical spine?

A

SCM
scalenes
trapexius
levator scapula

41
Q

What do the deep neck flexors do

A

Deep Neck Flexor Muscle Function
• To stabilize the cervical joints
• (Type 1 fibres – slow twitch)

42
Q

Muscle function in patients with neck pain

A

Abundant evidence that there are changes in cervical muscle
function in patients with neck pain disorders (Falla , Jull, Hodges
2004)
• Muscle responses do not automatically reverse in response to pain
alleviation in cervical region
• There is a relationship between the magnitude of change in pain
and improvement in DCF activation after training (Falla, O’Leary, Jull
2010)
• Therefore all patients with cervical pain episode should have
retraining of these muscles to help prevent recurrence of episodes
of pain

43
Q

Deep neck flexor training

A 
Ask patient to gently nod the head forward
• Look for:
– overactivity of superficial muscles
– activity too fast/ too strong
– should NOT provoke neck pain
– precision is emphasized
If the patient can do this start

Can be trained with PBU

NB It is not a retraction movement

44
Q

Progression deep neck flexors

A

Progressively increasePBU t0 30 mm

Inc. time held
Inc. repetitions

  1. Add load – ask patient to hold position in supine and just lift
    the weight of head off the bed
  2. Gently apply pressure to forehead
  3. Add rotation to right and left maintaining head position
    • Other strategies:
    • Perform in sitting – good to do at home, in car, at work ( ask
    patient to feel the superficial muscles to ensure they are
    relaxed )
    • Add in to functional tasks
45
Q

What are the local deep neck extewnsors

A 
Local Deep Neck Extensors
• Rectus capitus posterior minor and major
• Semispinalis capitus and cervicus
• Splenius capitus and cervicus
• Obliquus capitus superior and inferior
46
Q

Things to watch for during movement control assessment

A

Chin lead

Head drop

PHTY301 (9 decks)

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