Week 2 Reading

Question 1

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

Answer 1

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

Question 2

Evaluation strategy acronym

Answer 2

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

Question 3

Red flags for suspected fractures

Radiographs indicated

Answer 3

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

Question 4

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

Answer 4

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

Question 5

Indicators for fracture (not red flags)

Answer 5

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

Question 6

Red flags for disease from history

Answer 6

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

Question 7

Peak incidence of radicular syndromes is what age?

Answer 7

50-54 yo

Question 8

What three clues provide strong suspicion of radicular syndrome

Answer 8

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

Question 9

What five clues provide a weaker suspicion of radicular suspicion

Answer 9

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

Question 10

The two leading causes of cervical radicular syndromes

Answer 10

Herniated discs

Osteophytic spurs

Question 11

Onset of neck pain and additional symptoms in cervical radiculopathy

Answer 11

Other symptoms appear after an average of 18 days

Question 12

Classic characteristics of arm pain in nerve root pain

Answer 12

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

Question 13

Symptom behavior of nerve root symptoms (history)

Answer 13

Sx may be unrelenting for 24 hours

Pain can seem to be worse at night

Question 14

Patient’s symptoms that change with PE

Answer 14

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

Question 15

Red flags from Ancillary Studies

Answer 15

Elevated ESR or CRP

Anemia

Question 16

Strong suspicion of radicular syndrome

Answer 16

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

Question 17

Weaker suspicion of radicular syndrome

Answer 17

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

Question 18

Two leading causes of cervical radicular syndromes

Answer 18

Herniated discs and osteophytic spurs

Question 19

Typical symptoms of cervical radiculopathy

Answer 19

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

Question 20

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

Answer 20

averaged 18 days in one study

Question 21

Classic characteristics of arm pain in radiculopathy

Answer 21

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

Question 22

Three qualities of paresthesia in radiculopathy

Answer 22

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

Question 23

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

Answer 23

24 hours a day; worse at night

Question 24

Radicular syndrome symptoms respond to what three things

Answer 24

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

Question 25

3 key physical presentation of radicular syndrome

Answer 25

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

Question 26

Diagnostic cluster for radicular syndrome

Answer 26

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

Question 27

Preliminary Obcervation and Range of Motion

Answer 27

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

Question 28

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

Answer 28

C6-C8

Question 29

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

Answer 29

Useful to rule in; not useful

Question 30

Three positive results for ULTT

Answer 30

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

Question 31

Likelihoods of DTR

Answer 31

Abnormal DTR in UE increases LR by 2.5 | Abnormal biceps reflex is 10 times more likely to have root involvement

Question 32

Which are more predictive deficits or pain distribution?

Answer 32

Deficits

Question 33

Which cervical nerve roots are most affected?

Answer 33

C6 or C7

Question 34

Clues for C5 radiculopathy

Answer 34

Pain in suprascapular region | Deltoid is weaker than biceps

Question 35

Clues for C6 radiculopathy

Answer 35

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

Question 36

Clues for C7 radiculopathy

Answer 36

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)

Question 37

Three symptoms of spondylolotic radiculopathy

Answer 37

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

Question 38

Three signs of spondylolotic radiculopathy

Answer 38

Hyporeflexia Atrophy Progressive weakness including loss of grip strength

Question 39

Joints to be evaluated for lesions along the kinetic chain

Answer 39

``` First and second rib AC and SC joint GH joint Elbow joint Carpal bones, distal radial ```

Question 40

Differential diagnoses for a radicular syndrome

Answer 40

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

Question 41

Six clinical suspicions for Cx disc herniation

Answer 41

``` 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) ```

Question 42

Clinical tip for osteophytes

Answer 42

Older patients with absence of other diagnosis

Question 43

Findings that lessen likelihood of osteophytes

Answer 43

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

Question 44

___ __ ___ nerve roots are the most commonly affected NR

Answer 44

C6 or C7

Question 45

C2 Nerve Root radiation

Answer 45

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

Question 46

C3-4 NR radiation

Answer 46

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

Question 47

C5 NR radiation and affected muscles

Answer 47

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

Question 48

C7 NR Most common findings

Answer 48

Decreased triceps reflex Weak elbow extension Sensory loss over middle finger Posterior deltoid, posteriolateral arm, dorsal radial hand

Question 49

C8 NR Most common findings

Answer 49

Sensory loss over little finger Decreased triceps reflex Weak finger flexors scapular/interscapular/medial arm

Question 50

C6 NR most common findings

Answer 50

Decreased biceps or brachioradialis reflex Sensory loss over the thumb Weak wrist extension anterior/posterior deltoid, posterolateral arm, dorsal radial arm, suprascapular region

Question 51

Symptoms of spondylolotic radiculopathy

Answer 51

Proximal root pain, rarely below the elbow | Distal paresthesia

Question 52

Signs of spondylolotic radiculopathy

Answer 52

Hyporeflexia Atrophy Progressive muscle weakness and loss of grip strength

Question 53

Theories for causes of Complex Regional Pain Syndrome

Answer 53

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

Question 54

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

Answer 54

Pain, autonomic dysfunction, edema, movement disorder and dystrophy

Question 55

Features of pain in CRPS

Answer 55

severe, burning pain becoming regional with palmar and plantar dominance

Question 56

Are spasms, increased reflexes and muscle weakness common in CRPS

Answer 56

Yes

Question 57

4 common causes of somatic referred pain

Answer 57

Facet syndrome Internal disc derangement Subluxation syndrome Myofascial pain syndromes

Question 58

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

Answer 58

Facet syndrome

Question 59

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

Answer 59

Facet pain | MC C5-6;2-3

Question 60

Palpatory findings for cervical facet syndromes (best evidence)

Answer 60

Tenderness over facets Tissue changes over the facet Joint restriction

Question 61

Joint loading findings for cervical facet syndrome

Answer 61

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

Question 62

Sources of pain in internal disc derangement

Answer 62

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

Question 63

Clinical presentation of Internal Derangement

Answer 63

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

Question 64

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

Answer 64

Chin retraction, neck extension, or another direction

Question 65

Elderly patient with scleratogenous diffuse bilateral neck pain

Answer 65

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

Question 66

Key physical exam findings for subluxation syndromes/joint dysfunction

Answer 66

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

Question 67

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

Answer 67

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

Question 68

Under what circumstance may subluxation cause radicular pain

Answer 68

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

Question 69

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

Answer 69

Somatic referred phenomenon

Question 70

How can myofascial pain syndromes can mimic a radicular syndrome?

Answer 70

Referred pain, numbness, or paresthesia

Question 71

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

Answer 71

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

Question 72

Essential criteria for MFTPs

Answer 72

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

Question 73

Confirmatory observations for MFTPs

Answer 73

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

Question 74

Three evaluation steps for an identified myofascial pain syndrome

Answer 74

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.)

Question 75

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

Answer 75

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

Question 76

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

Answer 76

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

Question 77

DDX list for radicular syndrome

Answer 77

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

Question 78

The two most common causes of radicular pain syndrome are

Answer 78

Disc herniations | Spondylotic spurs and osteophytes

Question 79

Clues that strengthen the suspicion of cervical disc herniation

Answer 79

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

Question 80

The first differentiation in older patients with radiculopathy

Answer 80

Spondylotic compression

Question 81

Findings that cast doubt on spondylotic compression as a diagnosis

Answer 81

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

Question 82

What can cause direct trauma/traction to the NR

Answer 82

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

Question 83

Findings that suggest NR adhesion

Answer 83

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

Question 84

significant instability is defined as

Answer 84

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

Question 85

Infections of the spine are associated with what ancillary finding

Answer 85

ESR over 50 mm/hr

Question 86

Differential diagnosis for a myelopathic syndrome

Answer 86

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

Question 87

The two most common causes of cervical cord compression

Answer 87

Cervical disc herniation and spinal canal stenosis

Question 88

Significant cord compression is considered a contraindication to what?

Answer 88

Manipulative therapy

Question 89

Diagnosis of disc herniation requires what ancillary test?

Answer 89

MRI, advanced imaging

Question 90

Summary of effects of spinal stenosis

Answer 90

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