Lecture 1 Flashcards
(92 cards)
1
Q
Is Cervical Myelopathy Easily diagnosed?
A
No
2
Q
What age group typically gets cervical myelopathy?
A
Older (50+)
3
Q
What does myel mean?
A
Spinal cord
4
Q
What is Cervical Myelopathy?
A
Compression of the spinal cord
5
Q
What causes Myelopathy? (GDP)
A
Anything that compresses the spinal cord
Stenosis of the spinal canal / herniated disc / Bone spurs /hypertrophy of ligaments
6
Q
Is cervical myelopathy common?
A
No
7
Q
How do we treat mild myelopathy?
A
Surgery or supervised trial of structured rehab
- If rehab and either failure to improve or worsening, then surgery is indicated
8
Q
How do we treat moderate to severe cervical myelopathy?
A
Surgery recommended
9
Q
How many Signs/Symptoms do we need ro rule in cervical myelopathy?
A
3+
10
Q
What are the 5 cervical myelopathy signs and symptoms to rule it in?
A
1) Age > 45
2) Unstready gait
3) Positive Hoffman reflex
4) Inverted supinator sign
5) Positive Bbinski sign
Need at least 3 to rule in
11
Q
What are some common diseases that go along with upper cervical instability (make it more likely)
A
Ehlers-Danlos syndrome
Down syndrome
Marfan syndrome
Trauma
RA
When you start seeing these diseases your first thought should be upper cervical instability - I need ot rule this out
12
Q
What is the highest risk factor for cancer?
A
Previous history of cancer
12
Q
Aside from a previous history of cancer, what is another very strong indicator of cancer?
Define how much it is
A
Unexplained weight loss
(loss of 5-10% of body weight over 3-6 months)
13
Q
Why might no relief when lying flat indicate cancer?
A
Joints / muscles typically calm down when lying flat - however, if theres cancer that pressure will remain
13
Q
What are the two high level of evidence to indicate cancer?
A
1) Previous history of cancer
2) Unexplained weight loss
13
Q
Do you have a higher risk of cervical arterial disection with exercise or cervical manipulation?
A
Exercise (cervical manipulation is sage)
14
Q
What is a large indicators for systemic (whole body) or inflammatory disease?
These symptoms plus what would start to clue us in to this?
There are 5
A
Elevated or decreased BP not consistent w/ the activity being done
Increased resting pulse (or higher than normal) > 90bpm
Increased respiration> 20 bpm
Fatigue or malaise (generally unwell)
Temperature
These symptoms plus a recent surgery would start to clue us in. - even going in to do a spinal tap could cause this.
14
Q
What are the 5D’s and 3N’s related too?
A
Cervical Artery Dysfunction (vertebral artery)
15
Q
What are the 5 D’s?
What are they related too?
A
1) Diplopia
2) Dizziness
3) Dysphasia (hard time swollowing)
4) Dysarthria (hard time speaking due to weak muscles)
5) Drop attacks
Cervical artery dysfunction
16
Q
What are the 3N’s?
What are they related too?
A
1) Nausea
2) Numbness
3) Nystagmus (shaking of eyes)
Cervical Artery Dysfunction
17
Q
How do we assess Cervical Artery Dysfunction?
A
Patient seated w/ feet on growned - lean forward w/ elbows on thighs head turned to side. Have them talk to you
18
Q
What are the 3 most common symptoms of vertebral artery dissection (cervical artery dysfunction)
A
Dizziness/vertigo
Headache
Neck pain
19
Q
What is the difference between a disecting stroke and non disecting stroke?
A
Disecting = some type of trauma has ruptured the artery
Non = some type of claduication or impeding of blood flow is present
20
Q
60% of patient with vertebral artery dysfunction present with what kind of pain where?
Do they get this before or after 5 D’s and 3 N’s?
A
Dull Pain / posterior ipsilateral neck pain (note it presents as musckuloskeletal because it comes w/ turning neck)
Get this before 5 D’s and 3 N’s
21
Whats more important to cervical artery disease - patient demographics or our tests
Patient demographics
22
What 3 symptoms come with horners syndrome
Ptosis - eyelid drooping
Miosis - pupillary constriction
Anhydrosis - Lack of facial sweating
23
Internal Carotid Artery dysfunction / dissection causes what 8 signs and symptoms
1) Ipsilateral head or neck pain
2) Horners syndrome (ptosis)
3) Pulsatile tinnitus (coming and going)
4) Five D's Three N's
5) Cranial nerve palsies (nerve loss of function) (blood flow)
6) Transient ischemic attack sx's (temporary loos of blood flow to the brain)
7) Ischemic stroke sx's (insufficent blood flow to the brain)
8) Visula changes (not enough BF to eyes)
NOTE: Horners syndrome is caused when there is a disturbance to the sympathetic nerves (that cause it). basically w/ internal carotid dysfunction blood flow is kept from these nerves presenting w/ horners syndrome
Tinnitus because of the reduced bloood flow to the ear and the nerves dying
24
Ischemic defintion
No enough blood flow to a particular organ
25
Two charts that i need to learn that i skipped
26
What causes migrains?
Vascular changes
27
What are the 9 risk factors for dissecting vascular events?
1) recent trauma
2) Known vascular anomaly
3) Current or past smoker
4) History of migraine-type headache (vascular issue)
5) Hypercholesterolemia
6) Recent infection
7) Hypertension
8) Oral contraception
9) Family history of stroke
NOTE: Absence of risk factors does not rule out neuro-vascular event
28
What are the 9 risk factors for non-dissecting vascular events
1) Current or past smoker
2) Hypertension
3) Hypercholestermia
4) History of migraine type headache
5) Known vascular anaomly
6) Family history of stroke
7) Oral contraception
8) Recent infection
9) Recent trauma
29
KNOW: Subjective is king for vascular events in the cervical spine (dissecting / non)
30
Is vertebral artery testing a good test?
Not that great (get patient to do it their self)
31
When screening for cervical arterial dysfunction what should we do? (4)
Blood pressure examination (vitals)
Cranial nerve examination (part of neuro screen)
Pulse palpation / ausculation of carotid arteries (put finger on carotid)
Proprioceptive tests (romberg; tandem gait)
32
Learn referral pattern chart
33
Who gets OA?
| 2 things
Older patients or repetitive trauma
34
**When should we do a neuro screen?**
When symptoms present above our external occipital protuberance, past our acromium or past our gluteal fold
Think numbness / tingling / this is more talking about vauge pain with potentially numbness / tingling
35
36
KNOW: C-Spine neuro testing
* Sensation testing of upper quater
* Strength testing of Upper quarter
* Deep tendon reflexes
* Cranial Nerve screen
* Upper motor neuron signs
* - Hoffman
* - Babinski
* - Inverted Supinator sign
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37
What does the Sharp-Purser Test examine?
Transverse ligament
38
What does the Alar Ligament Stress Test examine?
Alar ligament
39
What does the Anterior Shear Test examine?
Transverse ligament
40
How do you test modified sharp-purser?
Patient is seated, therpist standing to side
Webspace of inferior hand across spinous process of C2
Superior arm placed across patients forehead; hand cupping occiput
Superior arm pushed the hea posterior and superior direction; inferior hand blocks motion at C2
Test for transverse ligament
41
What is a positive sharp-purser test?
| What does it feel like (2 things)
Perception of excessive posterior glide of the cranium on C2 (lax ligament make it go back easily)
Relief of pain with manual gliding
(remember - this ligament runs behind the dens so pushing posteriorly will cause it to become more lax [moving closer to its insertions])
| Tests the transverse ligament
42
How do you position a patient for the Alar ligament Stress test? / where is the therpaist
What are the 3 positions we test it in
What is the expected negative response?
What does a positive test indicate?
Patient is supine with head on pillow - top of head even with table edge
Therapist is standing at the patient's head
- Hand under head - pinch grip on spinous process/laminae / articular pillars of C2
- Hand on top of head used to **side bend atlantoaxial joint** (bending neck sideways)
Tested in craniovertebral neurtal / flexion / extension (note we are side bending in these positions)
Expected negative response: Ipsilatearl rotation of C2 with minimal side bend movement (SP moves contralaterally)
Positive test = excessive movement without or before C2 SP movement
43
Where does the alar ligamnet originate and insert
Origin: inside the skull (just lateral to brainstem)
Insertion: Ontop of the dens
44
What position is the patient / therapist in for the anterior shear test?
How does the therapist move the head
What is a positive anterior shear test?
* What is the potential posititve
How long should therapist hold this position?
Does this test give us good information on Sp/Sn?
Patient = supine with head and c-spine supported by therapist
Therapist: standing at patients head
- Support occiput
- Index fingers under C1 transverse process
Therapist moves the head anteriorly (which essentially stretches the transverse ligament because it goes over the dens [and starts behind the dens) this movement moves the dens forward (further away of the transvese ligament origin) stretching it out
Positive test = increase in motion / empty end feel or reproduction of symptoms of ligamentous instability OR production of lateral nystagmus or nausea
Potential positive = feeling lump in throat
Hold for up to 10 seconds
No good infor
45
Does palpation typically have a greater inter rater relability or intra?
Intra
46
If a patient has neck pain where should you typically check?
The shoulder
47
**How many degrees of cervical extension do we need to look at the ceiling?**
40-50 degrees
48
**How many degrees of cervical rotation do we need to look over the shoulder when driving?**
60-70 degrees
49
Define PPIVMs
Passive Physiological Intervertebral Motion
50
Define PAIVMs
Passive Accessory Intervertebral Motion
51
Is flexing C1 on C2 PPIVM or PAIVM
PPIVM
Its doing the actual physiological motion of the bone instead of some accessory (or arthrokinematic) motion that the bone does
52
Is an upglide an example of a PPIVM or PAIVM?
PAIVM because its specifically doing the accessory motion (arthrokinematic motion) of the joint instead of the physiological function
53
PPIVMs / PAIVMs are reserved for what structure?
The spine (has vertebral in the name [V])
54
What are PPIVMs / PAIVMs used for?
Do they have a high intra or inter rater relability
I think its litteraly just to assess the motion at the joints (accessory [arthrokinematic] & physiological movement)
Intra
55
PPIVMs / PAIVMs are not to be used in ______
Isolation
Me doing it over and over again makes me pretty good at it (high intra rater relability).
So we should use it multiple times on the patient to see how they're progressing
56
Forward bending / Backward bending / Side bending / Rotation are all examples of _______ motion
Cervical PPIVMs
57
KNOW: "How would you desribe your pain? Is that the pain that brough you in today."
58
Upglide, lateral glide, Downglide (supine)
Centeral Posterior to Anterior (PA) glides, Unilateral PA glides (prone)
All of the glides listed above are PPIVMs or PAIVMs?
PAIVMs
Note: any glide is a joint assessment or accessory movement which is and A in PAIVMs
59
What is the purpose of the craniovertebral rotation (cervical flexion-rotation) test?
Useful for classifying for mobility deficits and headaches
60
How many different ranks are there on a passive intervertebral motion grading system (PAIVM + PPIVM)
0 is what? How do we treat it (starts at 0 goes through 6)
What are the others and their treatments
7 (0-6)
0 = ankylosing or non dedtectable movement. No treatment (can't move a bamboo spine)
1 = considerable limitation in movement. Treatment = mobilization/manipulation
2 = slight limitation in movement. Treatment = mobilization / manipulation
3 = normal. No treatment
4 = Slight increase in motion. No treatment or stabilization exercises
5 = considerable increase in motion. Stabilization exercises and treatment of neighboring hypomobility
6 = Stabilization exercises and treatment of neighboring hypomobility; external support OR fusion
61
Where are **Central** Posterior to Anterior (CPA) glides directed at?
What motion does this push you into
Is it a PPIVM or PAIVM?
The spinous process
Note: The patient is in prone and you're pushing down on the SP creating a shearing for anterior which gives you some extension
Its a glide so its a PAIVM
62
Uni**lateral** Posterior to Anterior glide is performed where?
Transverse process (or facet joint)
NOTE: The motion it creates is debated
63
What is the stuck drawer mechanism?
When it hurts a little bit you just continue pushing and jamming on it still it gets unstuck
64
Does a CPA open or close down on facet joints?
Closes down on facet joints (cerivical spine)
You're essentially pushing the the spinous process jamming them together pushing you into extension)
65
**How do we open facet joints up (arthrokinmatic explanation then things we would do to achieve this)**
We open up facet joints by closing down facet joints on the contralateral side
We can do an upglide or downglide on the ipsilateral side OR do a Unilateral posterior glide (this is pressing down on the contralateral transverse process to open the ipsilateral transverse process)
66
Most headaches originate from where?
| What anatomical location
Upper cervical spine
67
A special test for mobility deficits w/ neck pain is the shoulder girdle passive test. What is it
If they have decreased pain / increased ROM once they elevate their shoulder its proably leading us to believe its some kind of soft tissue issue
68
Neck Pain w/ mobility deficits has a clinical prediction rule called the cervical spine thurst manipulation clinical preidction rule. This in dicates that they need _/4 of these to have a good chance of therapy working on them
What are the 4 and how many do they need
1) Symptom duration < 38 days
2) Positive expectation of therapy
3) Side to side difference in ROTATION of > 10 degrees
4) Pain with PA testing of the middle cervical spine (basically pain when performing UPA's and CPA's)
They need 3/4 of these for the clinical prediction rule to be good. (good chance manipulation is going to help)
Its called cervical spine THRUST manipulation clinical prediction rules because its speaking to the liklihood of manipulation benefiting these patients (need 3/4)
69
A patient presents with neck pain and mentions mobility dysfunction. They state an onset of their symptoms 18 days ago and are excited and ready to start therapy. You measure their cervical rotation and find that they get 35 degrees of rotation on the right and 55 on the left. You then decide to the do a CPA test on the patient and they wince in pain. What is the most appropriate manual therapy intervention?
Cervical spine manipulation (4/4)
NOTE: if they fit this and don't have any of those red flags that were talked about with VBI this would be the best thing to do.
70
What are the 5 special tests we do for neck pain w/ radiating pain?
Valsalva Test
Shoulder Abduction Test
Spurling Test
Distraction Test
Neurodynamic Test
71
How is the valsalva Test performed?
What is a positive valsava test?
Examiner asks patient to take deep breath and hold it while bearing down, as if moving the bowels
Positive = Increased pain in neck
* The point in this test is to close down the spine and see if it reproduces any of their symptoms
| NOTE: this test is a special test for radiating neck pain
72
When we say someone is having disc issues what kind of pain is produced (better said, where does that pain go [the path])
Follows a radicular path, or follows that nerve root
Specific dermatome and paired myotome
73
How is a shoulder abduction test performed?
| This is one of the special tests for neck radiating pain
Hand of symptomatic side placed on head while patient is sitting
Positive = symptoms reduced or alieveated
* this puts the nerve on slack, and takes pressure of muscles that could be pulling.
74
KNOW: If putting hand on head alievates symptoms its a really good chance that a nerve is involved in their pain
75
Cervical / Lumbar stenosis are worse with flexion or extension?
Worse with extension
* Pinching down
76
How is Spurling's Test A done?
What is a positive test?
| This is a neck radiating pain special test
Patients head put in side bending and provide compressive force - I am not further side pressing it but pressing down through the axis
Radicular symptoms reproduced (symptoms come back)
| NOTE: A better than B
77
How is the distraction test for neck pain w/ radiating pain performed?
What is a positive test?
Patient in supine. Place patients neck into slight flexion and apply distraction force
Positive = symptoms alleviated (NOT JUST THE **NECK PAIN FEELING BETTER --> IT MUST ALLIEVAITE DISTAL SYMPTOMS)**
78
How many neurodynamic tests are there? Name them in order.
What is a positive
| NOTE: This is part of the special tests for neck pain w/ radiating pain
3
Upper Limb Tension Test 1 = Median nerve (most important) - for this test item cluster were really just looking at median
Upper Limb Tension Test 2 = Radial nerve
Upper Limb Tension Test 3 = Ulnar nerve
(alphabetical order)
Positive = Radiular symptoms reproduced or > 10 deg difference contraltarelly
| Picture specifically for radial nerve (which is what we care about)
79
**There are three parts that mark up neurodynamic testing or adverse neural dynamics (AND). what are they** (ON TEST)
- On practicals / Tests
| one of the special tests for neck pain w/ radiating pain
1) Reproduces patients compreable pain (what they came in with) - not just that its really tight but that it reproduces that neural numbness / pain
2) Needs to be a side to side difference greater than or = to 10 degrees. Normally measured at elbow flexion extension (could be at wrist but normally stuck at elbow)
**3) You're able to change their symptoms based on proximal or distal segment changes. Meaning I can tension the nerve and bring on their wrist pain by moving their head or relaxing their shoulder. I can bring on or take away symptoms by changing something else along the change**
NOTE: If we bring on some pain but its not the same pain thats still a negative they need to have all 3 for it to be considered neuraldynamic positive
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NOTE: While there are 5 tests when testing for neck pain with radiating pain (cervical radiculopathy) when they do not have positive neurodynamic testing (one of the 5 special tests) than that should greatly shift me away from thinking it is this
81
We talked about special tests before for neck pain w/ radiating pain. However, which specific special tests make up the robert W test item cluster?
Which one is the strongest preductor?
How many do you need present to rule this in?
| NOTE: This is the test item cluster cervical radulopathy
1) Cervical rotation less than or = to 60 degree toward symptomatic side
2) Positive Upper Limb Tension Test 1 - neurodynamic testing of the median nerve
3) Positive Spurling A Test
4) Positive Distraction Test
#2 is the strongest predictor
You need at least 3 present
NOTE: This tells us that it sounds nervy. Doesnt tell us the level --> something is pissing off the nerve. We calm it down by taking slack off the nerve
82
A negative Positive Upper Limb Tension Test indicates what?
Negative essentially rules out cervical radiculopathy (neck pain w/ radiating)
83
Neck Pain w/ Movement Coordination Impairments patients are
Whiplash patients
84
What are the two tests for Neck pain w/ Movement coordination impairments
how are they performed
| whiplash
Cranial Cervical Flexion Test:
Patient presses into BP cuff to get to a certain mmHG then hold for 10 seconds - and then do they have the control to get to a harder goal. Do cranial cervical flexion + endurance
* Normal perforamnce at least 26 mmHG for 10 seconds
* Ideally want them to get 30 mmHg
Deep Neck Flexor Endurance Test
Doing a chin tuck and lifting head (make a double chin)
* We really want at least 2 CM
* We want to really try to not turn on SCM
* Chin to throat not chin to chest (give yourself a double chin --> do this then lift head up)
* Average without neck pain is 24 seconds
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