2. C/S Examination Flashcards
1
Q
Neck pain may be assoc’d w/….
A
HAs
LBP
Hx of MVA
*2nd most common reason for referral to PT, w/ neck pain making up 25% of pts seen for tx
2
Q
Symptoms of CS Dysfunction
A
- Neck pain
- HAs (cervicogenic)
- Upper thoracic/scap pain
- TMJ/craniofacial pain
- UE pain (separate card)
- radicular vs referred
- UE neurologic sx’s
- parasthesias, numbness, reflex changes, weakness
- Balance, auditory, visual disturbs
- Cervical myelopathy
- Vert aa occlusion
- Vestib dysf
3
Q
Sx’ of CS Dysf
UE Pain
Elaborate…
A
- Radicular→ along dermatome; due to compression/irritation of nerve root
-
Referred→ somatic referral into UE from various cervical tissues
- joints, ligs, mm’s
4
Q
Interventions for CS
A
- Evidence lacking
- High degree of variation of tx strategies= high degree uncertainty about optimal tx
- Pts w/ neck pain lag behind LBP and knee pain in response to PT
- Pathoanatomic source of neck pain cannot be ID’d in the majority of pts
5
Q
Basic Exam for Pts w/ Neck Pain
Always what?
A
ALWAYS take thorough hx
ALWAYS have pt compete SRO tool
6
Q
Basic Exam for Pts w/ Neck Pain
Do more, less, enough of what?
A
- LESS→ in pts w/ high irritability/acute inj
- avoid irritating pt or worsening patho or injury
- MORE→ in pts w/ low irritability/subacute/chronic
- ENOUGH→ to make a sound tx decision and classify into subgroup
7
Q
More on Exam for pts w/ Neck Pain
A
- Do high lvl functional testing as pts are improving any and may be ready for return to sport or work
- sport specific, work-related functional tasks
- GOAL: By end of exam, be able to classify into subgroup!!
8
Q
Suggested Order of Examination for Neck Pain
A
see pics
9
Q
Exam: Hx
Start by asking Gen questions about injury/problem, then proceed down list
A
see pics
10
Q
More questions to ask!!
A
see pics
11
Q
Self Reported Outcome tools for CS region
Global Rating of Change Scale
*can be used for any region of body
A
see pics
12
Q
More SROs for Neck Pain
A
PSFS
NDI (see pics)
- NDI
- We want LOW, LOW=LESS disability
- MDC= 5/50 for uncomplicated neck pain; 10/50 for radiculopathy
- NOTE: double value if using % score
- MDC= 5/50 for uncomplicated neck pain; 10/50 for radiculopathy
- We want LOW, LOW=LESS disability
13
Q
MacDermid et al 2009
NDI
Takeaways
A
- NDI is reliable, valid and responsive
- Scored out of 50
- 40-50, or 0-10= approaching ceiling/floor effect
- Score outside 10-to-40 range→ supplement w/ PSFS
- 0-4=no disability
- 5-14=mild
- 15-24=moderate
- 25-34=severe
- >35=complete disability
14
Q
Ex. NDI
Upon initial exam, Sachiko’s NDI score was 20/50 and weeks later is 16/50. Can you confidently say based on this info her disability has lessened?
A
NO!!!
does NOT meet MDC
15
Q
UQ Neuro Screen
Myotomes
A
- C1-2→ cervical flexion
- C3→ cervical LF
- C2-C3-C4→ shoulder elevation
- C5→ shoulder ABD
- C6→ forearm PRO
- C5-C6→ elbow flex
- C6→ wrist ext
- C7→ elbow ext/wrist flex
- C8→ thumb extension (thumb for thumb)
- C8→ gen. grip (mult mm’s/lvls but mostly C8)
- T1→ hand intrinsics→ Abd Digiti Minimi
16
Q
UQ Neuro Screen
Dermatomes
*pts eyes closed, light brushing over dermatomes B/L
A
- C2,3→ post neck
- C4→ AC jt
- C5→ lat aspect of upper arm
- C6→ lat aspect forearm, hand; thumb, index finger (D1/D2)
- C7→ middle finger (D3)
- C8→ ring/little finger (D4/D5); medial aspect of hand/wrist
- T1→ medial forearm
- T2→ medial arm, axilla forearm
*NOTE: in general, derms in UE overlap. This is why radiculopathies typ may cause PARTIAL NUMBNESS or PARASTHESIAS, but are unlikely to result in complete anasthesia
17
Q
UQ Neuro Screen
DTRs
A
- C5, 6→ Biceps
- C6→ Brachioradialis
- C7→ Triceps
See pics for scoring
18
Q
Patho Reflexes for Upper Motor Neuron Lesions/Myelopathy
Hoffman’s Sign
A
see pics
19
Q
Pathological Reflexes for UMN Lesions/Myelopathy
Babinksi’s
A
see pics
20
Q
Peripheral Joint Screening:
Look for symptom repro/aggravation and/or limtd or abnormal motion
A
- Cursory assess of UE function→ forms, remove shirt/coat, reaching OH
- Cursory observation and inspection of UE jts
- Shoulder/Elbow→ Apley Scratch Tests; reach overhead
- Wrist/Hand→ Grip test; wrist/finger AROM
21
Q
Observation/Inspection
Posture
A
- FHP? If yes, can they reverse it?
- Torticollis? Acute wry neck (adult version of torticollis)
- Scapular pos (protracted? elevated?)
- Cervicothoracic junction (C7-T1)→ Dowager’s Hump?
- T-spine
- Kyphosis normal, flattened, excessive?
- scoliosis? rib hump?
22
Q
Mvmt Patterns & ROM Testing
A
- Includes:
- Cervical AROM testing
- *Keep order consistent bc any 1 mvmt can influence ROM of mvmt that follows!
see pics for instructions
23
Q
Mvmt Patterns & ROM Testing
Recommended Order of Testing:
A
- L. rotation
- R. rotation
- EXT
- FLEX
- L L/F
- R L/F
24
Q
Passive ROM: 2 options
A
- Apply manual overpressure to single AROM mvmts
- Perform w/ pt in Supine to eliminate mm tension and assess mobility of spine
25
Differentiation of “Intrinsic” vs. “Extrinsic” Cervical ROM restrictions
## Footnote
**Cross-arm Cervical ROM test**
\*If no longer restricted w/ arms up= mm tension
\*If still restricted w/ arms up= CS issue
26
**Cervical Passive Interverterbral Mvmts (PIVM)**
* Record as normal, hypOmobile, hypERmobile
* Record as painful or not
* Perform in following order:
1. **O-A jt→ lateral glide**
2. **Mid and Lower cervical segment lateral glides**
* **NOTE the diff in _mobility and pain response bw sides_**
27
Mid and Lower Cervical Segment Lateral Glides
* PT uses abdomen to exert constant gentle stabilizing pressure against apex of pts head; force applied w/ therapists 2nd MC head to “push” pts articular pillar @ the desired lvl (or you can reach underneath and pull)
* PT glides ea segment starting @ C2 and ending @ C6 L then R
* **Diff in mobility and pain response bw sides noted @ ea segment**
28
**P-A glide (Spring Tests) on Cervical Spine**
* Pressure applied B/L (P-A) glide
* Pressure applied U/L (just off side to SP) to assess **segmental rotation**
* Push down on **Rt Side of SP== L rotation**
* Push down on **L Side of SP== R rotation**
* uncomfortable
* **More comfortable if P-A force directed slighly SUP towards pts eyeballs (along plane of facets jts)**
* **CS spring tests (P-A) not as commonly used today as in past**
29
These tend to **shut down w/ chronic neck pain or inflammatory CS neck pain**
DCFM's!!!!
30
Testing of the DCFM's:
## Footnote
**Craniocervical Flexion Test**
**CCFT**
* Tests **neuromsk control and endurance** of the **Longus capitis and Longus colli**
* **Primary functional action** is to sustain low int contraction to support Cervical jts during functional acts
* **Primary anatomical action** is to flex the head on a stable C/S
31
Craniocervical Flexion Test
* Test Motion: Pt asked to gently and slowly perform head nodding motion as if saying “yes”. If pt able to demonstrate this w/out compensatory mvmts: **proceed to steps below**
* air filled cuff placed bw occiput and C7 w/ pt in hooklying
* Pts face must be horiz.
## Footnote
**Stage 1 vs Stage 2 see pics**
32
Assess of **Atlanto-Axial Jt Rotation**
w/ pts neck in **full passive flexion→** PT rotates pts head **L THEN R**
## Footnote
**\*diff in mobility and pain response bw sides noted**
33
**Special Tests**
**Atlanto-Occipital Joint**
**Alar Lig Stress Test**
see pics for description
* **Normal Findings→** Normally, there should be **minimal mvmt of the head and C1 into LF**
* **When head LF to Right→** C2 rotates to the Right.
* PT will feel SP of C2 move toward Left (**R rotation of C2 causes its SP to move to L)**
* **When head LF to Left→** C2 rotates to the Left
* PT will feel SP of C2 move to R (**L rotation of C2 causes its SP to move to R)**
* **If you DO NOT feel mvmt of C2 SP→** this suggests instability of the **alar lig**, very serious (Red Flag) problem
* \*\* You are feeling for **ipsilateral rotation of C2--- that is what you are palpating w/ this test!!!**
34
**Transverse Lig Tests OR Anterior Sheer Test**
\* RED FLAG if POSITIVE!!!
* INCd parasthesias of B/L upper or lower extrems==\> **cervical myelopathy and instability of Transverse Lig**
35
Sharp-Purser Test
The “clunk” one
* **NOTE:** if this test is **Positive→** pt likely had an upper CS subluxation of C1 (Atlas) on C2 (Axis) @ rest, i.e. before doing test. Test maneuver actually reduces the subluxation, and thus a “clunk” and/or reduction in sxs is noted. **If this test is (+), there is clearly instability/hypERmobility at C1/C2. Referral to spine surgeon or neurosurgeon is indicated, _as this is a very serious problem_!!!**
36
Vertebral Artery Test → purported to test for **vertebrobasilar artery insufficiency (VBI)**
## Footnote
**\*ALWAYS DO THIS TEST JUST TO BE SAFE!!!**
**Supine or Seated**
* **VBI:** occlusion of blood flow during cervical rotation or extension in **the area of junction for vertebral and basilar arteries**
* controversy as to if this test is effective in determining VBI
* **Although true cases of VBI are rare, ignoring suspicion that a pt has VBI risks causing a catastrophic injury\*\*\*\***
37
Best special tests to detect **Cervical Radiculopathy**
## Footnote
**ALL of them:**
1. Shoulder ABD test
2. Spurling's Test
3. Traction/neck distraction
4. ULTT
38
Best Special Tests to detect **Cervical Radiculopathy**
## Footnote
**HIGH SPECIFICITY/Low to Mod sensitivity: 3**
**\*good for Ruling IN**
1. Shoulder ABD test
2. Spurling's Test
3. Traction/Neck distraction
39
Best special tests to detect **cervical radiculopathy**
## Footnote
**MOD-HIGH Sensitivity**
**\*good for Ruling OUT**
Upper limb tension test (ULTT)
40
When pts hx and other phys findings indicate possible cervical radiculopathy
## Footnote
**These tests Rule IN cervical radiculopathy**
**\*think SpPIN**
POSITIVE:
Spurlings
Neck distraction
Shoulder ABD test
41
When pts hx and other phys findings indicate possible **cervical radiculopathy:**
## Footnote
**This test Rules OUT cervical radiculopathy: 1**
**\*think SnNOUT**
NEGATIVE
ULTT
42
Shoulder ABD test
\*cervical radiculopathy test
NOTE: **If this test INCs sx's→ could be _brachial plexopathy_**
* We are looking for **RELIEF OF SX'S W/ THIS TEST!!! → puts nerves slack**
43
Spurling's Test
\*cervical radiculopathy
Provocation test \*\*\*
can add EXT and Rot **towards symptomatic side\*\*\***
44
Neck Distraction Test
\*cervical radiculopathy
NOTE: if this test INCs sx's→ could be brachial plexopathy
\***We are looking for RELIEF OF Sx's w/ this test**
45
Upper Limb Neural Tension Test
ULTT
\*cervical radiculopathy
Rules OUT (SnNOUT)
Provocation test
We are looking for repro or inc in neck/arm sx's for this test\*\*\*
46
Valsalva's Maneuver
**pt instructed to take a deep breath and hold it while attempting to exhale for 2-3s**
\*Reproduction or an INC in sx's==\> **POSITIVE TEST**
47
Palpation
\***soft tissues are palpated for _tenderness, repro of sx's, and/or fibrosis or tightness_**
* SCM (avoid direct downward pressure)
* Scalenes
* Semispinalis cervicis/capitis
* Splenius capitis (splays)
* Upper traps
* Mid traps
* Lower traps
* Lev scap
* Suboccipitals w/ **pt in supine**
