C-Spine Screen and Differentiation Flashcards
1
Q
What is the goal for screening acuity
A
- Identify the specific tissue that is presumed to be the source or cause of the patient’s pain or dysfunction. The issue is the tissue.
- Confirm the 3-R’s and validate their “pain experience”: reproducible sign, region of origin, & reactivity level
2
Q
What does SPINSS stand for and is used for
A
- Used for acuity
- Severity
- Pain generator
- Irritability
- Nature
- Stage
- Stability
3
Q
What are the key muscles to check for in the neck
A
- Upper traps
- Levator scap
- SCM
- Occipital triangle
4
Q
What are the 3 sections of the cervical spine you should observe during ROM screen
A
- Upper (OA/AA)
- Middle
- CT junction
5
Q
Describe a cervical spine ROM assessment
A
- 1st just watch the movement & observe: ease of motion, areas of restriction or hypermobility (hinge points/skin creases), C1-C2 expect much more rotation
- 2nd record objective number/formal assessment: Gonimeter and/or inclinometer
6
Q
Describe upglides and downslides and facet direction
A
- Upglide: anterior & cranial glide (open)
- Downglide: posterior & caudal glide (closing)
7
Q
What are the cervical spine ROM normal values
A
- Forward flexion: 50º
- Extension: 80º
- Lateral flexion: 40º
- Rotation: 70-90º
8
Q
Describe cervical motion testing/differentiation b/w upper c-spine and lower c-spine
A
- Retraction: upper c-spine flexion (opens OA space) and lower c-spine extension
- Protraction: upper c-spine extension (compresses the OA space) and lower c-spine flexion
- Rotation: OA minimal, AA maximal roughly 50%, and C2-C7 the other 50%
- YES joint = OA
- NO joint = AA
9
Q
Describe the different UE nerve tensioners
A
- Median nerve: waiters carry into extended arm and wrist
- Radial nerve: throwing something behind you with shoulder extension and wrist flexion
- Ulnar nerve: doing a hair flip/putting an OK sign on your eye
10
Q
Myotomes for C1-T1
A
- C1 and C2: neck flexion
- C3: neck sidebending
- C4: shoulder shrug
- C5: shoulder ABD
- C6: wirst extension
- C7: elbow extension
- C8: finger flexion, thumb ABD
- T1: finger ABD
11
Q
On what dermatome is there a three way split between ulnar, median, and radial nerve
A
- C7 dermatome on the back of the middle finger knuckle
12
Q
Describe a peripheral nerve quick screen of the hand
A
- OK sign
- Median (C5-C8): resist pulling apart the OK sign (anterior interosseous)
- Ulnar (C8-T1): resist finger ABD
- Radial (C6-C8): resist wirst extension
13
Q
Reflex screen differences b/w UMN and LMN lesions
A
- UMN: hyperreflexia, reduced MMT, increased tone, normal atrophy until disuse prolonged, semi/entire limb loss of sensory pattern, no fasciculation, up-going/extension Babinski sign
- LMN: hyporeflexia, severely decreased MMT, decreased tone, early atrophy, peripheral nerve or dermatome sensory loss pattern, yes fasciculation, down-going/flexion Babinski sign
14
Q
Purposes of a palpation exam/motion exam of the cervical spine
A
- Confirm the 3-R’s and validate their “pain experience”: reproducible sign, region or origin, and reactivity level
- Introduction of your hands to the patient
- Observe for pain limited motion (started already in the exam flow)
- Movement screen
- Limitations use Goni or inclinometer
15
Q
Describe muscle length testing for upper trap, levitator scapulae, and SCM
A
- Upper Trap: C-Flex+SB C/L + Rot I/L (SP goes C/L VB goes I/L)
- Levator Scapulae: C-Flex+Rot C/L + SB C/L & Depress the shoulder (scapula) All motion away from side of symptoms
- SCM: C-Ext, SB C/L + Rot I/L
16
Q
Describe local mobility
A
- Nerve: Neural Tension
- Joint: PIVMS & PAVMS
- Soft Tissue: Flexibility, Fascia
17
Q
Describe global stability
A
- Activation: isolated muscle contraction/movement pattern
- Acquisition: movement coordination i.e. lumbar & hip
- Assimilation: functional multiplanar movements e.g. lifting/lowering, push/pull, reaching, handling…
18
Q
What are the different ways we can load or put force on a joint
A
- Loading: regional movement differentiation (RMD) testing, single/repeated movements, and/or overpressure/counterpressure
- Force: shear, compression, tension
19
Q
Differential diagnosis of tissue types
A
- Contractile: cramping/dull/ache pain, no paresthesia, intermittent duration, no dermatomal/peripheral nerve distribution, muscle spasm end-feel, ARROM and PROM pain in opposite directions
- Inert: dull/sharp pain, no paresthesia, intermittent duration, no dermatomal/peripheral distribution, boggy/hard capsular end-feel, AROM and PROM pain in same direction
- Neural: burning/lancinating pain, paresthesia, intermittent/constant pain, dermatomal/peripheral distribution, stretch end-feel, AROM and PROM pain varies in direction
20
Q
DDX of tissue type based on MMT
A
- Weak and painless: palsy or a complete rupture of the muscle tendon unit
- Strong and painless: normal
- Weak and painful
- Strong and painful: grade I contractile lesion
- Pain that does not occur during the test but occurs upon the release of the contraction is thought to have an articular source produced by the joint glide that occurs following the release of tension
21
Q
What are the categories for the selective functional movement assessment (SFMA)
A
- FN = functional no pain
- FP = functional painful
- DP = dysfunctional painful
- DN = dysfunctional no pain
22
Q
CPR for C-Myleopathy
A
- Gait deviation
- Hoffmann’s test
- Inverted supinator sign
- Babinski test
- Age >45 years
23
Q
Describe how to perform Hoffmann’s test
A
- Hold patient’s relaxed hand and flick the tip/DIP joint of their middle finger
- Abnormal finding if index and thumb move closer together when tip/DIP joint is flicked
24
Q
Describe how to perform inverted supinator sign (ISS)
A
- DTR for Brachioradialis with abnormal finding = positive ISS test is reflexive finger flexion or elbow extension rather than the normal elbow flexion that occurs with DTR test
25
Describe how to perform Babinski's sign
- Patient supine with bare foot, use the "sharp" end of a reflex hammer and drag it from the lateral aspect of the patient's heel all the way up the lateral side of their foot across the balls of their feet
- Normal findings = toes should flex/curl inward
- Abnormal/positive sign = toes extend and flare/fan out
26
What are the 4 appropriate elements of the physical examination
- Neurological examination (cranial/peripheral)
- Coordination/gait consideration
- Blood pressure
- Auscultation
27
What is the 4 tier remobilization screening process for the cervical spine
- Historical review: PMH, MOI, etc.
- Medical testing & diagnostic imaging
- Clinical screening for segmental stability (upper ligamentous: observation, vitals, A/P ROM, palpation, DTR's): PE testing (A/P ROM screen, muscle screen, MSR's), sharp-purser, transverse lig stress test, & Alar lig stress test
- Clinical screening for VBI (Vertebrobasilar insufficiency): rotation 1st, rotation & extension 2nd (AKA deKleyn's test), & pre-manipulation positional hold
28
Describe difference b/w a sensitive test and a specific test
- Sensitive: SNNOUT -> when negative rules OUT the disease
- Specific: SPIN -> when positive rules IN the disease
29
Describe how to perform the Alar ligament stress test 3 different methods
- Pincer grip to stabilize C2 & rotate head L/R
- Expect 21 degrees or less of rotation
- Positive = more than 21 degrees
OR
- Fix/stabilize C2 spinous process & sidebend or rotate the head
- Normal: C2 spinous process moves immediately opposite direction of SB motion
- If fixed: minimal SB occurs with strong capsular end feel & solid stop
- Positive = C2 does not move or is obviously delayed
OR
- Same test can be performed with patient supine; less preferred method is to palpate with index finger for movement to C/L side of C2 spinous process
- Positive = lack or delayed movement
30
Describe how to perform the Sharp-Purser transverse ligament to Dens test
- Sitting ask patient to flex head... any symptoms?: YES = continue, NO = possibly continue see 1st positive finding
- Localize & grasp C2 spinous process with a key pinch type grip
- Gently apply a translation force through the patent's forehead
- 1st positive finding: any movement felt during a passive translation of the head posteriorly during the blocking of C2
- 2nd positive finding: when symptoms that were felt during forward flexion of the head are relieved during posterior translation of the head
31
Describe how to perform the Transverse ligament stress test
- Patient supine with head and neck in neutral
- With both hands support the occiput with the fingers over the sides
- Apply anterior pressure to C1 without flexion or extension
- Hold for at least 15 sec
- Positives: excessive motion and/or symptoms of DAN's esophageal pressure or lip paresthesia
32
What must be cleared before screening for vascular or other dizziness and its considerations
- Have to clear for ligamentous/osseous SERIOUS pathology then it's OK to test for vascular vs. Cervicogenic vs. vestibular dizziness
- Before progressive loading must clear DAN's & other neuro screen
- Considerations: subjective due to poor indicators b/c all different, no single test is adequate, & objective tests for dizziness still have subjective responses
33
Describe how to perform Hautant's test
- Test for vascular insufficiency or vestibular (differentiate b/w dizziness & vertigo)
- Patient is seated with shoulders flexed to 90º, eyes are then closed, watch for any loss of arm position
- If arms move, cause is nonvascular
- Then ask patient to rotate/extend & rotate the neck and hold position while eyes are closed, watch for any loss of arm position
- If the arms waver, cause is vascular impairment to the brain
- Each position should be held for 10-30 sec
34
Describe how to perform rotation check for body on head (vascular) and head on body (vestibular)
- Hold the patient's head still while standing
- Ask patient to rotate their shoulders and turn their body fully to one side
- Hold for 10 sec
- Repeat to contralateral side
- Alternate position is patient sitting on a rolling stool
35
Describe how to perform pre-screening for VBI/CAD
- Can be done seated or supine
- Rotation first
- Rotation & extension combined
- Test CN's in this position (DAN's) especially hypoglossal nerve (CN XII) and glossopharyngeal (CNIX)
36
Describe the presentation of neck pain with radiating pain
- Narrow band of lacerating pain in the involved extremity
- UE dermatomal paresthesia or numbness & myotomal muscle weakness
- Pain is reproduced or relieved with radiculopathy testing: CPR = ULTTA, Spurling's test, cervical distraction, cervical ROM <60º ipsilateral side
- May have UE sensory, strength, or reflex deficits associated with the involved nerve roots
37
Describe how to perform ULTTA-1 median nerve
- Shoulder girdle stabilization/shoulder depression
- Shoulder ABD
- Wrist/finger extension
- Forearm supination
- Shoulder external rotation
- Elbow extension
- Cervical side bending and release wrist extension
38
Describe neck pain with HA presentation
- Non-continuous unilateral neck pain & associated (referred) HA
- HA is precipitated or aggravated by neck movements or sustained positions/postures
- Positive cervical rotation test
- HA reproduced with provocation of the involved upper cervical segments
- Limited cervical ROM
- Restricted upper cervical segmental mobility
- Strength, endurance, and coordination deficits of the neck muscles
39
Describe how to perform cervical flexion-rotation test
- Flex patients neck and rotate maximally (assess R1-first resistance & R2-end/final resistance)
- Positive if less than 32º (20-28º in pts with CGHA)
- Positive if 10º difference L/R
40
Describe how to perform OA differentiation testing
- Motion testing: chin to shoulder with flexion nodding for contralateral OA
- Ex: to test R OA position in full L rotation then flexion nodding
- Positive = symptom reproduction
- OA testing/treatment: contact lateral mass of C1 AP pressure to ipsilateral eye
41
Describe how to perform AA differentiation testing
- Position head & neck rotated 30º to side to be tested
- Thumb on articular pillar of C2
- Apply PA force to ipsilateral mouth
- Also compare with cervical flexion rotation test
42
Describe how to perform a OA-C1 mobilization or C1-C2
- Therapist's GHJ on patients forehead
- 1 hand stabilize lower level, top hand mobilizes with help of shoulder
