MSK II Exam 1

What were the diagnostic criteria for fibromyalgia as set by the American College of Rheumatology in 2001? (old criteria)

1. Widespread musculoskeletal pain for more than 3 months 2. Pain induced by palpation of tender points --> Painful sensitivity to 4 kg of pressure at 11 or more of the 18 defined tender points

What are some interventions for CHRONIC "neck pain with mobility deficits" according to the practice guidelines?

Broader approach than other stages of pain (not just ROM!) Thoracic manipulation Cervical mobilization Combined cervicoscapulothoracic exercise plus mobilization or manipulation Mixed exercise for cervicoscapulothoracic region (coordination, proprioception, postural training) Supervised individualized exercise "Stay active" lifestyle encouraged Modalities = dry needling, low level laser, pulse or high-powered ultrasound, intermittent mechanical traction, repetitive brain stimulation, TENS, electrical muscle stimulation

Describes the motions for PPIVMS of the upper cervical spine for -CO-C1 -C1-C2 -C2-C3

CO-C1 --> Mainly flexion/extension --> Minimal sidebending --> Can feel occipital condyles rolling as you flex/extend C1-C2 --> Mainly rotation and sidebend C2-C3 --> Flexion, extension, rotation, sidebend (like the rest of the lower cervical spine)

What should you do if the positional test for VBI screen is positive?

Cease testing Avoid cervical joint manipulation/mobilization, end range rotation, exacerbating positions Avoid end-range positions during treatment If severe symptoms (I.e. drop attack, nystagmus), refer out for further investigation

What are some common symptoms of neck pain with mobility deficits?

Central and/or unilateral neck pain without radiculopathy Limitation in neck motion that consistently reproduces symptoms Associated (referred) shoulder girdle or UE pain may be present People with cervical spondylosis WITHOUT any myelopathy or radiculopathy, they will fit into neck pain with mobility

What is the focus of rehab Week 2-4 after an ACDF?

Cervical AROM with 2 finger resistance Aerobic exercise Isometrics to strengthen deep neck flexors (isometrics) Progress to lifting up to 30 lbs

What are common causes of compressive cervical myelopathy?

Cervical disc herniation Narrowing of spinal canal due to degenerative changes

What is the resting position of the cervical spine?

Cervical lordosis with midpoint in C4-5 interspace

chronic cervicogenic HA interventions (>12 weeks)

Cervical manipulation (mostly short term relief) Cervical and thoracic manipulation (mostly short term relief) Exercise for cervical and scapulothoracic region: strengthening and endurance exercise with neuromuscular training, including motor control and biofeedback elements Combined manual therapy (mobilization or manipulation) plus exercise (stretching, strengthening, and endurance training elements)

subacute cervicogenic HA interventions (2-12 weeks)

Cervical manipulation and mobilization: OA, C1, C2 mobs and suboccipital stretch/STM Exercise C1-C2 self-SNAG Ergonomic intervention DNF/DNE training

What are some interventions for SUBACUTE "neck pain with mobility deficits" according to the practice guidelines?

Cervical mobilization or manipulation Thoracic manipulation Cervicoscapulothoracic endurance exercise

What are the muscle imaging findings for WAD?

Changes in muscle disposition for people with whiplash, WITH changes in flexors and extensors People with degenerative pathologies at baseline have greater risk of chronic pain from whiplash There are other stresses that may contribute to the chronic sx Those with severe whiplash have white fatty infiltrate in the muscles

What is congenital muscular torticollis?

Characterized by a head tilt to one side or lateral neck flexion with the neck rotated to opposite side due to unilateral shortening or fibrosis of SCM --> Postural deformity of the neck evident at birth or shortly after --> EX: Sidebent to right and rotated to left due to issues with right sternocleidomastoid

What are some behaviors that can be identified as yellow flags?

Extended rest Reduced activity level High pain Excessive reliance on braces, walker, crutches, etc. Poor sleep quality Smoking/drinking to cope

sudden onset/acute torticollis: description and tx

Facet or disc dysfunction (woke up in a crazy position and now stuck OR due to a quick motion) --> Usually self-resolves in 1-2 weeks but PT can help speed it up tx: if you suspect disc pathology at C2-3, no manipulation and use soft cervical collar; if stuck in rotation at C1-2, no manipulation

What has shown to be beneficial for axial or discogenic pain, spinal stenosis, or post surgery syndrome?

Fair evidence for local anesthetics with or without steroids

What is Wry Neck Deformity?

GENERAL TERM. Can also be known as torticollis or acute facet joint lock --> Stuck in one position and can't get out of it --> Can be congenital (baby) or acquired (slept in funny position and stuck in there)

What will you see during a joint play assessment of a person with DJD/cervical spondylosis/osteoarthritis?

Generalized hypomobility of the spine

What will some things that you will see when you are examining a person with DJD/cervical spondylosis/osteoarthritis?

Generalized neck pain Morning stiffness Poor posture Decreased ROM (especially extension, SB, rotation)

What type of injection has shown to have positive results for a cervical disc herniation?

Good evidence for cervical epidural injection, local anesthetics, and steroids Fair evidence for only local anesthetics

What are the outcomes after an ACDF?

Good short term reduction in pain and symptoms No difference in long term outcomes from non-surgical treatment Spinal fusion is associated with adjacent segment disease (transitional syndrome)

What are the grades of cervical myelopathy?

Grade 1 (Mild) -UMN signs with normal gait -Can be treated conservatively Grades 2-5 (Moderate to Severe) -UMN signs and worsening gait disturbances -Poor prognosis -Treated surgically (surgical decompression)

What is the function of the uncovertebral joint?

Guides flexion and extension while limiting side bending Reinforces the intervertebral disc (IVD)

What other sx are seen in a Concussion/Mild TBI?

HA, dizzy (vertigo or imbalance), nausea, foggy, fatigued, mood change, light/noise sensitivity, sleep disturbance, irritable, numbness/tingling, difficulty concentrating, extraocular ms weakness (blurred/double vision, saccade/smooth pursuit), nystagmus, ringing in ears (less common)

buffalo concussion treadmill test

HR, RPE, NPRS, sx measured at rest treadmill speed 3.2 mph for pts up to 5'10" (3.6 mph for taller) record all measures every 1 min increase incline by 1 grade every 1 min stop criteria: pt request, sx increase >2 pts, rapid progression of complaints, 90% MHR with low RPE -helpful to understand the limit of safe exercise for prescription

What happens to the nucleus pulposes as you age?

Less fluid and less shock absorption --> 60s and beyond, the disc lose their height and there's less space for the IV nerves

How can we adjust someone's ergonomics to help protect the upper cervical spine?

Limit function (use soft cervical collar for limited periods of time) Avoid aggravating movement patterns Address poor postures in all parts of life activities

What are some exam findings that you would expect to see if a person has "neck pain with mobility deficits"?

Limited cervical ROM Neck pain reproduced at end ranges of active and passive motions Restricted cervical and thoracic segmental mobility Intersegmental mobility testing reveals restriction Neck and referred pain reproduced with provocation of involved cervical and upper thoracic segments or cervical musculature Deficits in cervicoscapulothoracic strength and motor control may be present in individuals with subacute or chronic neck pain

What is the Quadrant/Spurling's Test?

Load a specific part of spine and look for symptoms Patient in sitting and asked to extend, rotate, and PT applies compressive force through top of head (narrows intervertebral foramen) positive: reproduction of sx

What is the technique for strain-counterstrain (positional release)?

Locate and palpate tender point while the involved muscle is passively shortened Once the position of maximum relaxation is found, hold 90-120 seconds Slowly return to resting position

What are the deep neck flexors?

Longus colli Longus capitis Rectus capitis anterior Rectus capitis lateralis

What needs to be included in the observation portion of an upper cervical spine evaluation?

Look at the position of the head on the neck --> Look straight at the person and look to see if their eyes are level --> Look from the side for forward head posture --> Look at rotation and quality of movement

What is the flexion rotation test? What is a positive test?

Looks for C1-C2 restriction (could indicate cervicogenic headache) --> PT puts patient in passive full cervical flexion, then passively rotates patient's head --> Normal = 44 degrees of rotation --> Positive test = ROM is decreased by 10 degrees or more compared to contralateral side

What is considered a "chronic" condition, by the clinical practice guidelines for neck pain?

Low irritability --> Pain that worsens with sustained end-range spinal movements/positions --> Pain with overpressure into tissue resistance

What are some exercises to use when managing a patient with whiplash in acute phase (0 to 12 weeks)?

Low load isometric AROM exercises Gentle segmental stabilization exercises for deep flexor/extensor muscles Stabilization exercises as tolerated Scapular stabilization exercises Cervical kinesthetic retraining (including balance; head relocation; & eye mvmt control) Aerobic conditioning Dynamic muscular control in neutral spine Strenghten shoulder girdle retractors/depressors

What muscles should be tested for motor control during an upper cervical spine evaluation?

Lower traps Serratus anterior Deep neck flexors Neck extensors

What are some Mulligan techniques that you can use with patients who have neck pain?

Mobilization with movement (MWM) Natural Apophyseal Glides (NAGs) Sustained Natural Apophyseal Glides (SNAGS) Spinal mobilization with limb movement (SMWLMs)

What is considered a "subacute" condition, by the clinical practice guidelines for neck pain?

Moderate irritability --> Pain at midrange motions that worsen with end-range spinal movements --> Pain with tissue resistance

What is disc degradation?

More aggressive and accelerated process than disc degeneration --> May be caused by unequal load distribution in intervertebral disc, leading to tears in annulus fibrosis and disc herniation

What age-related changes happen to the intervertebral discs in your 60s and beyond?

More degenerative changes -May see osteophytes form to create stability

What are some common causes of cervical radiculopathy?

Most often caused by compressive or inflammatory pathology -Disc herniation posterolaterally -Chemical inflammation from disc herniation -Cervical osteophyte -Stenosis of intervertebral foramen -Tumor -Fracture

What are the arthrokinematics of rotation in the facet joints of the lower cervical spine?

Motion around a vertical axis (coupled with ipsilateral sidebending)

What is Fryette's Laws? Which one do we use frequently?

Movement patterns for the spine (most have been disproven EXCEPT) --> If movement in one plane is introduced to the spine, any motion occurring in another direction is restricted --> EX: if cervical spine is fully flexed, cannot do any rotation or side-bending

What are the red flags for Concussion?

Ms weakness, hemiparesis Visual field deficit Pupillary abnormality Horner syndrome Vomit 2+ times Persistent neurological changes or deterioration Fx, skull depression, SCI Unconscious >1 min Seizure Severe worsening HA Incontinence

What are some interventions for treating a person with fibromyalgia?

Multidisciplinary, holistic approach is needed Need a good balance between an overly vigorous approach that will exacerbate symptoms and under-activity that will lead to disuse atrophy and increased symptoms Aerobic conditioning Strengthening Pharmaceutical interventions Exercise dosage: 30-60 min, 2-3x/week; initial load of 40% 1RM

What are the components of a full neurological exam?

Myotomes Sensory testing (sharp/dull, hot/cold, light touch) DTR Tests for cervical radiculopathy Tests for pathological UMN reflex or spinal cord compression

Describe the components of a concussion/Mild TBI examination?

NECK PAIN --> Examine/evaluate for cervical MsK impairments --> Special tests, muscle, joint, neuro exam SX: HA OR DIZZY --> Vestibulo-oculomotor --> Orthostatic hypotension --> Autonomic impairments that may contribute to dizziness and/or headache --> Motor function impairments per patient tolerance MAY NEED TO --> Provide basic interventions as indicated for sx relief to support additional testing --> Delay tests until future session as needed according to patient tolerance TAKE NOTE OF SEVERITY AND IRRITABILITY --> Frequency of symptom provocation and victor of movement required to reproduce symptoms (s) --> How quickly and easily symptoms are provoked

What are NAGs?

Natural Apophyseal Glides -Used for cervical and upper thoracic spine -Oscillatory mobilization instead of sustained glides -Applied to facet joints C2 to T3 -Midrange to endrange facet joint mobilizations applied anterosuperiorly along treatment planes of joints selected

What functional outcome measures can be used for cervical pain?

Neck Disability Index (NDI) Patient Specific Functional Scale (PSFS) Global Rating of Change (GROC)

What are some common symptoms of "neck pain with radiating pain"?

Neck pain with radiating (narrow band of lacinating) pain in involved extremity Upper extremity dermatomal paresthesia or numbness and myotomal muscle weakness

What is a typical patient presentation of Wry Neck Deformity?

Neck stiffness and pain Loss of ROM Spasm of surrounding neck muscles (upper traps or SCM)

What are some interventions for postural dysfunction syndrome?

Need to correct cause of pain Posture correction (reposition head to neutral pose) Self treatment (stretching pecs, strengthening scapular muscles and deep neck flexors) Aerobic conditioning; good for the spine Monitor backpack use (should be at or below 20% of body weight up to 25 lbs) Important for people to not stay in static position for prolonged periods of time; standing desks are very helpful; pt education is important so inform pts to get moving!

What are some red flags for the cervical spine (6)?

Neoplastic conditions (cancer) Cervical fracture Upper cervical ligamentous injury/instability Cervical Arterial Dysfunction (VBI) Systemic of inflammatory disease Cardiac problems

Does upper cervical spine (above C2) sidebending and rotation take place on opposite sides or the same sides?

Occur on opposite sides, regardless of whether these vertebra are in flexion or extension

What view is needed to get the best view of the atlanto-axial joint on x-ray?

Odontoid view taken with an open mouth -Normal = C1 lateral masses should be parallel to and aligned with upper facets of C2

What screening tool can be used for red flags?

Optimal Screening for Prediction of Referral and Outcome - Review of Systems (OSPRO-ROS) --> Used to identify red flag responders with high accuracy --> 23 item version identifies 100% of red flags --> 10 item version identifies 94.7% of red flags

What screening tool can be used to identify yellow flags?

Optimal Screening for Prediction of Referral and Outcome - Yellow Flag (OSPRO-YF) Fear Avoidance Behavior Questionnaire Pain Catastrohpizing Scale

What PAIVMS are used in the cervical spine?

PA glide (posterior-anterior glide) -Pushing vertebrae anteriorly -Central = push on spinous process -Unilateral = push on articular pillar assess at grade III

What muscle length tests are important to do for the cervical spine?

PEC MAJOR (STERNOCOSTAL HEAD) --> Normal length: arms rest on table, full shoulder flexion PEC MINOR --> Compare scapular for anterior tipping --> Distance from the surface of the table to the posterior surface of the scapula superiorly

What are the symptoms of cervical radiculopathy?

Pain in neck going down to arms Distal paresthesia Hypoesthesia or anesthesia with increased pressure Motor weakness Decreased or absent reflexes

What are some signs of CARDIAC problems that you should be concerned about when doing a cervical evaluation?

Pain with exertion Headache Pallor Sweating Dyspnea Nausea Presence of risk factors (history of CAD, history of HTN, smoking history, elevated cholesterol) Men >40 and women >50

What are yellow flags?

Pain-associated psychological distress that adversely influence outcomes for musculoskeletal pain

What are some important tests and measures for facet dysfunction?

Palpation to feel for localized changes (thickening or swelling) ROM (restricted combined movements) Neuro exam (usually normal) Joint play assessment (PPIVMS, PAIVMS)

What is disc degeneration?

Part of normal aging process --> Includes splits in annulus fibrosis, changes in intervertebral discs --> Intermediate instability followed by fibrosis of posterior joints and capsule and osteophyte formation

What are some interventions for treating a patient with congenital muscular torticollis?

Passive stretching Positioning for active movement away from tightness and use of prone positioning Neck/Trunk AROM Parent education for home programs Prone positioning while awake for greater than 1 cumulative hour per day to strengthen neck extensors Asymmetrical handling to activate weak neck musculature Development of symmetrical movement Active ROM towards limited side Feeding from alternate sides Environmental adaptations; parent/caregiver education

What is the Patient Specific Functional Scale (PSFS)?

Patient chooses 3-5 activities that they are unable to do or have difficulty doing --> Rate on 11 point scale from 0 to 10 --> 0 = unable to perform activity --> 10 = able to perform activity at pre-injury level

What are some things to use when managing a patient with chronic whiplash (more than 12 weeks after injury)?

Patient education/reassurance Active exercise Multidisciplinary approach (psychological, medications) Biopsychosocial, such as pain and sleep

How can you do a first rib assessment in SITTING?

Patient in sitting with head rotated away from side being tested Radial side of PT's mobilizing index finger on dorsal aspect of first rib Mobilize first rib in ventral/slightly caudal direction Assess: quality of movement, end feel, symptoms (compare both sides)

How do you test for clonus?

Patient in sitting with knee flexed 45-60 degrees PT rapidly dorsiflexes foot and maintains pressure into dorsiflexion OR with wrist extension positive: 3+ beats

How can you do a first rib assessment in SUPINE?

Patient in supine with head sidebent towards test side and rotated away from test side Mobilize rib towards contralateral ASIS Assess: quality of movement, end feel, symptoms (compare both sides)

What is the Global Rating of Change (GROC)?

Patient rates degree of improvement or worsening form "a very great deal worse" to a "a very great deal better" --> Compare pain now to pain at initial visit

What are some things to use when managing a patient with whiplash in the acute phase (0 to 12 weeks)?

Patient reassurance/education (return to usual activity/exercise, disuse of collar) Postural re-education Body mechanics for ADLs, rest, work activities Breathing pattern exercises (avoid high costal breathing) TMJ and shoulder relaxation Electrical stimulation Exercise

What are the TDR Outcomes compared to ACDF?

Patient selection and surgeon skill critical Better clinical outcomes Greater segmental motion Lower rates of subsequent surgical procedures Adjacent segment secondary surgery rates lower in the TDR patients Longer term follow-up needed

What is mobilization with movement (MWM)?

Concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to end range applied by the patient --> Passive end-range overpressure (or stretching) is then delivered without pain as a barrier Parameters -P = pain-free -I = instant result -LL = long lasting

Where is the transverse ligament and what does it do?

Connects medial aspects of lateral masses of atlas (C1) to prevent anterior translation of C1 on C2

What is the function of the ligamentum flavum?

Connects the lamina of adjacent vertebrae Continuous with joint capsule (reinforcement)

What does the alar ligament do?

Connects the odontoid process to occipital condyles to prevent excessive rotation and side-bending EX: side-bending to the left = C2 will rotate to left + C2 spinous process goes to right + right alar ligament tightens

What is the significance of patients with neck pain and superficial neck extensors?

Patients with neck pain often display increased activation of the superficial neck extensors and delayed activity in semispinalis cervicis and multifidus Patients with mechanical neck pain have deficiencies in maximal strength, endurance, precision during dynamic movement, and sustained isometric contraction, efficiency of contraction, and repositioning acuity

What are some other diagnoses that look like cervical radiculopathy (differential diagnosis)?

Peripheral nerve disorders TOS Brachial plexus syndrome Systemic disease Cancer (Pancoast)

What are some characteristics of patients who respond well to cervical traction?

Peripheralization with lower cervical spine mobility C4 through C7 Positive shoulder abduction test >55 years old Positive upper limb tension test A Positive neck distraction test If 3 of 5 are present, 79.2% likely that traction will help If 4 of 5 are present, 94.8% likely that traction will help

What should you do if there is a positive result from the Modified Sharp Purser test?

Physical therapy is not indicated Need cervical collar Immediate referral to MD is needed

What is a PEEK cage?

Plastic or titanium cage where the bone goes in --> Used to maintain "disc" height while bone is healing to protect it

What are some things that you will find during the examination of a patient with clinical instability of the cervical spine?

Poor neuromuscular coordination/control (cranial cervical neck flexion test) Abnormal joint play (usually fairly lax, need to assess translatoric motion Will see motion that is not smooth throughout ROM (segmental hinging, pivoting, fulcruming)

What is postural dysfunction syndrome?

Poor posture at sustained end-range positions and postures cause pain: end range stress or static loading on normal tissues sx: gradual onset (no trauma), dull aching pain, sustained postures, pain is better with exercise/movement

What should be palpated in an upper cervical spine evaluation?

Position patient in neutral spine alignment (educate them on correct posture) Feel for tension/reactivity in superficial muscles Assess first rib elevation (tightness in scalenes) Palpate for alignment of anterior surface of transverse processes of vertebrae

What is a test cluster that points towards cervical radiculopathy?

Positive Spurling's Test Upper limb tension test 1 is positive Cervical distraction test is positive Less that 60 degrees cervical rotation towards the symptomatic side positive tests for all 4 = 0.99 specificity

What are the neurological structures of the cervical spine?

Spinal cord Cranial nerves Dura mater Cervical spinal nerves

What are Spinal mobilization with limb movement (SMWLM)?

Spinal mobilization with limb movement -Transverse pressure is applied to the side of the relevant spinous process while patient concurrently moves limb through previously restricted ROM

What are indications for a discectomy?

Strong indications: acute myelopathy or myeloradiculopathy, progressive neurological deficit other indications: failure of conservative treatment, significant motor deficit, severe incapacitating pain with no response to other treatments

What are the contraindications for traction?

Structural disease - tumor or infectious (fracture, severe osteoporosis, TB of the bone, bone tumors) Vascular compromise Any time movement is contraindicated (fracture, recent fusion, ligamentous rupture, evidence of instability) Impaired cognitive function Claustrophobia

TMJ arthrokinematics: depression

early phase: posterior rotation; 0-26 mm late phase: rotation, anterior and inferior translation of condyle and disc together; 26-50 mm close packed position: maximal opening

TMJ ROM norms

opening: 40-45 (males), 45-50 (females); 38 = WFL lateral deviation: 1/4 depression; 8-10 mm protrusion: 6-9 mm retrusion: 3-4 mm assess 3x: w/o pain, w/ pain to end range, then with posture correction (increases ROM)

TMJ s curve (deviation)

pain-free: muscle imbalance or incoordination painful: disc displacement with reduction (joint sound)

balance error scoring system (BESS) test

part of ellis PCD assessment

vestibular/ocular-motor screening (VOMS) for concussion

part of ellis PCD assessment

Anterior disc displacement without reduction (ADDWOR)

permanently anteriorly dislocated disc causes: maximally stretched/ruptured ligaments and/or decreased elasticity of retrodiscal fibers progression of ADDWR but no longer reduces TMJ/ear pain limited opening: <20-30 mm, ipsilateral C curve no anterior translation (limits contalateral lat deviation and ipsilateral protrusion) tx: joint mobs, STM, proprioception to reduce more joint compression

concussion pathophysiology

phase 1: axonal stretching phase 2 -release of excitatory AAs and efflux of K+ = hyperglycolysis -persistent Ca2+ influx causes vasoconstriction -Na/K pump works to restore membrane potential = increases demand for ATP = increase in glucose metabolism = disparity b/t supply and demand

cervicogenic HA: expected exam findings

positive CFRT HA reproduced with provocation of involved upper C spine segments reproduction of sx with assessment of PPIVMs and PAIVMs limited cervical ROM restricted upper C spine segmental mobility DNF/DNE deficits weakness of postural muscles shortened UT, levator scap, scalenes

TMJ c curve (deviation)

unilateral hypo- or hypermobility decreased ipsilateral or increased contralateral hypo: capsular, muscle spasm, OA, disc displacement w/o reduction hyper: EDS, dislocation, etc.

myofascial pain syndrome (TMD)

very common form of TMD, may not involve TMJ tho pain originates from myofascial structures: often chronic with presence of trigger points sx: facial/ear/jaw/tooth pain, HAs, dizziness, limited opening, swallowing difficulties tx: STM, muscle relaxation, motor control exercises, posture Temporalis: maxillary teeth, TMJ, retro-orbital area/temple, or around eyebrow Masseter: maxillary and mandibular teeth, ear (may cause tinnitus), or sinuses Lateral pterygoid: sinuses/cheek bone Medial pterygoid: ear or lateral TMJ

vestibulo ocular PCD tx

vestibular rehab based program -gaze stabilization VOR eyes/head separate movement -visual motion sensitivity training -educate on provocative sx, habituate to environments accommodations if necessary vision rehab program -visual tracking -pencil push ups -brock string -minimize screen time -refer to optometry for advanced cases balance training: EO, EC, BOS, surface convergence and gaze stability

What are the arthrokinematics of extension at the occipito-atlantal joint?

vex on cave Occiput slides anteriorly and rolls posteriorly

What are the arthrokinematics of flexion at the occipito-atlantal joint?

vex on cave Occiput slides posteriorly and rolls anteriorly

What can you see in the lateral x-ray view of the cervical spine?

- Intervertebral disc height -Spacing of intervertebral discs -Lordosis of the spine -Presence of osteophytes -Shape of vertebrae -anterior and posterior vertebral lines -ADI?

What are some things you will find when examining a person with fibromyalgia?

1) Tender points 2) Allodynia (pain in response to a non-nociceptive stimulus; assessed cutaneously by brushing the skin and asking about pain, which will be painful) --> May have trigger points but not necessary for diagnosis 3) Decreased ROM, strength, and endurance

What are some other signs/symptoms of VBI?

-Ataxia of gait -Mid-upper cervical pain -Occipital pain/headache -Acute onset of pain "unlike any other" -Vomiting -Hoarse voice -Short term memory -Hypotonia/limb weakness -Anhidrosis (lack of facial sweating) -Hearing disturbances -Malaise -Perioral dysthaesia -Photophobia -Pupillary changes -Clumsiness and agitation -Tinnitus -Cranial nerve dysfunction or positive cranial nerve signs -Unconsciousness -Metallic taste

What special tests should be used when examining a person with DJD/cervical spondylosis/osteoarthritis?

-Cervical compression test -Cervical distraction test -Spurling's test

What are some interventions for cervical disc herniation?

-Cervical traction if cervical distraction test is positive -Posture correction -Centralization exercises (lower cervical extension + upper cervical flexion) -C spine and scapular strengthening program once symptoms have died down

What are some other causes for atlantoaxial instability?

-Congenital origin (ex. DS) -Arthritis -Acquired injury

How do you assess the integrity of spinal nerves?

-Deep tendon reflexes -Myotomes -Dermatomes -Sclerotomes: area of bone or fascia supplied by a single nerve root

What are the safety tests for the cervical spine?

-Dizziness Test -Alar ligament test -Modified Sharp Purser Test

What are the motions at the facet joints of the lower cervical spine?

-Flexion -Extension -Sidebending -Rotation

What tests are used to test for pathological UMN reflexes or spinal cord compression?

-Hoffman's reflex -Lhermitte's reflex -Babinski sign -Inverted supinator sign -Clonus

What is the patient presentation of abnormal ADI?

-Holds head in extension with posterior muscles in spasm -Pain with flexion -Doesn't want to flex neck

Subjective questions during PT exam for CMT?

-Medical history of child -Birth history of child/pregnancy -Torticollis/plagiocephaly history

What are the muscles of the suboccipital triangle?

-Oblique capitis inferior -Oblique capitis superior -Rectus capitis major -Rectus capitis minor

What are some things that you will find when you are examining a patient with cervical disc herniation?

-Pain that worsens with coughing/sneezing/Valsalva maneuver (may refer to scapular region) -Posture (holds head in sidebent position away from affected side) -Limited/painful ROM in all directions -Repeated motions that cause centralization or peripheralization -abnormal neuro exam -Special tests (cervical compression, cervical distraction, Spurling's) -Palpation (acute = muscle guarding, chronic = tight/tender muscles)

What are the risk factors for a disc herniation?

-Smoking -Sedentary lifestyle -Poor posture -Excessive lifting

What are some additional support structures that might be used in an anterior cervical plate fixation (ACDF)?

-Synthetic alternatives -PEEK cage

What are some other diagnoses that look like a disc herniation?

-Thoracic outlet syndrome -Brachial plexus injury

What are the suggested cut-offs for the NDI?

0 to 8% = no pain and disability 10 to 28% = mild pain and disability 30 to 48% = moderate pain and disability 50 to 68% = severe pain and disability >70% = complete disability

What is the incidence of congenital muscular torticollis?

0.3 to 2% of newborns

What is the Clinical Classification of WAD? (expansion of Quebec Task Force classification)

0: No neck complaint, no physical signs 1: Neck complaint of pain, stiffness or tenderness; no physical signs 2A: neck pain plus motor impairment, decreased ROM, altered muscle recruitment patterns, sensory impairment, local cervical mechanical hyperalgesia 2B: 2A plus psychological impairment, elevated psychological distress according to GHQ 28 or TAMPA 2C: 2B plus increased joint position error, generalized sensory hypersensitivity (mechanical, thermal, upper limb tension test), sympathetic nervous system disturbance, elevated levels of acute posttraumatic stress (IES)* 3: 2C plus neurological signs of conduction loss including decreased or absent deep tendon reflexes, muscle weakness, sensory deficits 4: Neck complaint and fracture or dislocation

What is the Quebec Task Force Classification of WAD?

0: no neck complaint, no physical signs I: neck complaint of pain/stiffness/tenderness, no physical signs II: neck complaint and MSK signs (ROM, pt tenderness) III: neck complaint and neuro signs (DTRs, weakness, etc.) IV: neck complaint and fx or dislocation

What is the general outline when doing cervical examination

1) Systems review 2) Nerve palsy: Spinal accessory, long thoracic, axillary nerves 3) Clinical Examination (Tests and Measures): o Observation/Postural Assessment/Functional Testing o Shoulder screening o Cervical AROM/PROM/Combined Motions o Special Tests o Neurological Testing o Neurodynamic Testing o Biomechanical Examination o Cervical/Thoracic PPIVMs and PAIVM's o Thoracic and First Rib Screening o Muscle length assessment o Muscle Performance

What are the LINES of the Lateral View for the cervical spine x-ray?

1) Anterior vertebral line: if spine is in alignment, we should see a lordosis and a smooth, unbroken line along the anterior vertebral bodies 2) Posterior vertebral line: line along posterior aspect of the vertebral bodies, it also looks like a smooth and unbroken line 3) Spinolaminar line: nice, smooth, and unbroken --> In between the posterior vertebral line and spinal laminar line is the spinal canal; this gives us the width of the spinal canal along the cervical spine 4) Posterior spinous line: alignment of the spinous processes; spinous process of C2 is very prominent and there's really no spinous process on C1

What motions cause vertebrobasilar insufficiency?

1) End range rotation 2) Rotation + extension + traction

What interventions should be used for facet dysfunction?

1) Joint mobilization on locked side --> Central PA glide: glides both facets; used if it's too painful to push directly on the locked/affected side --> Unilateral PA glide: directly mobilize locked facet 2. Combined movements 3. Mobilization with movement 4. Muscle energy techniques: restore motion in the spine by using muscles to mobilize the joints; hold-relax techniques and auto/reciprocal inhibition 5. ROM exercises (key after joint mobilization to maintain new ROM)

What are some scales that you can use after a whiplash injury?

1) Neck Disability Index 2) Impact of Events Scale (IES) --> Self-report measure that assesses subjective distress caused by traumatic events (can be used to screen 3-6 wks post injury) 3) TAMPA Scale for Kinesiophobia (TSK) --> Measures fear of reinjury due to movement

What are some red flags when doing a headache evaluation?

1) Persistent, unrelenting headache (doesn't go away, gets worse) 2) Associated with trauma (intracranial bleed) 3) Supine significantly increases pain/headache (ICP) 4) Visual changes, nystagmus, pupil dilation, diplopia (brainstem issue) 5) CNS signs or symptoms (test cranial nerves) 6) Fever, weight loss/gain (cancer, infection) 7) Headache onset with sneeze, cough, exertion (ICP issue) 8) Severe unrelenting temporal pain (temporal arteritis associated with polymyalgia rheumatica)

What are two components of quantitative sensory testing?

1) Quantitative sensory testing (QST) is a feasible clinical method to measure responses to sensory stimuli and may be used as an indicator of neural function or altered pain sensitivity 2) Thermal pain thresholds are measured using a computer-controlled device, which generates and very accurately records the response to a warm, cool, hot or cold sensation

What are the three components of VBI Screening?

1) Subjective screening (medical history) 2) AROM of neck (ask about symptoms during it) 3) Positional test *Won't identify all patients at risk of suffering adverse reaction --> If subjective screening and AROM are negative, do positional test

What do you look at for medical screening of neck pain?

1. Appropriate for PT (green flags) 2. Appropriate for PT with consultation (yellow flags) -Iatrogenic factors -Beliefs -Coping strategies -Distress -Illness behavior -Willingness to change -Family reinforcement 3. Not appropriate for PT (red flags) -Organic pathology -Concurrent medical problems 4. Occupational blue flags -Work status 5. Socio-occupational black flags -Health benefits and insurance -Litigation -Work satisfaction -Work conditions -Work characteristics -Social policy

What are the goals of managment when treating whiplash in the acute phase (0 to 12 weeks)?

1. Decrease pain 2. Minimize muscle spasm 3. Promote optimal healing

What are the goals for the interventions to treat clinical instability of the cervical spine?

1. Enhance the function of the spinal stabilizing subsystems (deep neck flexion, scapular stabilizers) 2. Decrease stress on involved spinal segments

What are the four components of the clinical practice guidelines for neck pain?

1. Medical Screening 2. Classify Condition 3. Determine Condition Stage 4. Intervention Strategies

What are the important components of an upper cervical spine evaluation?

1. Observation 2. Medical Screening 3. ROM of neck 4. Palpation 5. Manual Exam 6. Muscle Length Assessment 7. Muscle Control Assessment 8. Cervical Kineasthetic Evaluation

What are the four parts of the vertebral artery?

1. PROXIMAL Branches from subclavian artery to transverse foramen of C6 2. TRANSVERSE From transverse foramen of C6 to transverse foramen of C2 3. SUBOCCIPITAL From transverse foramen of C2 to point of entry into spinal canal Can be compromised by tight muscles, extreme extension, extreme rotation 4. INTRACRARNIAL Penetrates dura mater, travels into subarachnoid space at level of foramen magnum (forms basilar artery when both come together)

What are the stages of a disc herniation?

1. Protrusion 2. Prolapse 3. Extrusion 4. Sequestration

What is the Modified Sharp Purser Test?

1. Slowly flex head/neck and ask about symptoms 2. If no serious symptoms provoked, stabilize C2 with one hand and apply posterior force to forehead positive: sx provoked by flexion or clunk with posterior force to head

What is the positional test of the VBI screen?

1. Sustained rotation to one side for 10 seconds (ask about symptoms, look for nystagmus) 2. Rest in neutral position for 10 seconds 3. Sustained rotation to other side for 10 seconds (ask about symptoms, look for nystagmus)

What is the Neck Disability Index (NDI)?

10 items, each scored from 0-5 Max score of 50 points Scores doubled and interpreted as a percentage

What is the MCID of the NPRS?

2 points (best/worst/current in last 24 hours)

What is the MCID of the PSFS?

2 points for patients with cervical radiculopathy

What percentage of your neck height is made up of intervertebral discs?

25% -Creates lordosis of the cervical spine

When should infants with CMT be reassessed?

3 to 12 months following d/c from direct physical therapy intervention or when child initiates walking

TMJ epidemiology

35% of population women > men 21-50 yo have highest prevalence 5-10% seek tx, 15% of those have chronic TMD 30-40% with sounds are pain-free ear pain is most common sx (>80%) HA in 40% >38% have parafunctional habits

What are the 3 common trajectories for recovery from whiplash?

45%: complete recovery 39%: mild symptoms 16%: chronic pain and disability

What are the 5 Ds and 3 Ns of VBI?

5 Ds -Dizziness -Diplopia -Dysarthria -Dysphagia -Drop attacks 3 Ns -Nausea -Nystagmus -Facial numbness + ataxic gait

What is the MCID of the Neck Disability Index?

5 to 9.5 points or 10-18% for neck pain 7-8.5 points or 14-17% for cervical radiculopathy

What are two common presentations of cervical myelopathy?

50% = pure myelopathy (UMN signs below level of lesion) 49% = myelopathy and radiculopathy (LMN or UMN-LMN signs below level of lesion)

What percentage of people who got an epidural injection had relief from neck pain symptoms?

60%

What are three possible causes for cervical myelopathy?

ACQUIRED: due to cervical stenosis (often degenerative disease superimposed on congenitally narrow spinal canal) TRAUMATIC: spinal shock, hematomyelia, spinal epidural hematoma, barotrauma, electrical injuries, compression by bone fracture --> May follow minor trauma in setting of spinal stenosis SPINAL CORD TUMOR --> 15% of primary CNS tumors are intraspinal --> 55% are extradural --> 40% intradural extramedullary (primarily meningiomas, neurofibromas) --> 5% intramedullary spinal cord tumors

How many spinal nerves are there in the cervical region? What are their locations?

8 spinal nerves C1 nerve = between occiput and C1 C2 nerve = between C1 and C2 Cervical spinal nerve roots exit above the vertebra of the same number (C5 disc herniation will affect C6 nerve); switches at T spine

functional opening ranges of TMJ

>38 mm: can eat normally, utensils 30-38 mm: can use fork 20-30 mm: can eat food using fingers 10-20 mm: push food in mouth <10 mm: drinking only

What are some signs of neoplastic conditions in the cervical spine?

>50 yo Unexplained weight loss of 10 pounds in 6 mo. No relief with treatment over the past month Prior hx of cancer (higher risk of metastasis if history of breast, lung, prostate cancer) Constant pain with no relief with bed rest Night pain

Define: Post-Concussion Syndrome

A complication of concussion signs and symptoms lasting longer than the regular recovery period or more than 3 months assessed at >3 weeks post-concussion

What is a tender point?

A point that is tender to palpation

What tests and measures should be done when examining a person with cervical pain?

A. Observation of Posture/Posture Analysis B. Shoulder Screen C. Cervical AROM/PROM/Combined motions D. VBI screening E. Clinical tests for upper cervical instability F. Neurological Exam G. Joint Play Assessment H. Thoracic and First Rib Assessment I. Muscle Length Tests J. Muscle Performance

What is Upper Limb Tension Test 1?

AKA Median Nerve Tension Test -Shoulder depression -Shoulder abduction (110 degrees) -Shoulder ER (80 degrees) -Forearm supination -Wrist/finger extension -Elbow extension Sensitizing movement -Sidebend towards test arm = decrease symptoms -Sidebend away from test arm = increase symptoms

What is Upper Limb Tension Test 2?

AKA Radial Nerve Tension Test -Shoulder depression -Shoulder abduction (much less than in picture!) -Shoulder IR -Forearm pronation -Wrist flexion/ulnar deviation -Finger/thumb flexion Sensitizing Movement -Sidebend towards test arm = decrease symptoms -Sidebend away from test arm = increase symptoms

What is Upper Limb Tension Test 3?

AKA Ulnar Nerve Tension Test -Shoulder depression -Shoulder abduction -Elbow flexion -Forearm pronation -Wrist extension/radial deviation Sensitizing Movement -Sidebend towards test arm = decrease symptoms -Sidebend away from test arm = increase symptoms

What is a functional unit?

AKA mobile unit or motion segment Includes: -2 adjacent vertebrae -Intervertebral disc between adjacent vertebrae -Facet joints (one on left, one on right) -All associated ligamentous structures In movement, the superior vertebra is the reference vertebra --> ex: C5 motion = C5 moving on C6

What are some advantages of manual cervical traction?

Able to be more specific as to which segments are being mobilized Easier to adjust force minutely Good for acute, position-specific patients Good if not using traction for a long period of time during treatment session

What is a diagnostic test cluster for cervical myelopathy?

Age over 45 years old Positive Hoffman's, Inverted Supinator, and Babinski sign Gait abnormality

What is clinical instability of the cervical spine?

Active and neural subsystem failures in the cervical spine causes minor cervical instability --> Active subsystem = muscles --> Passive subsystem = ligaments, joint capsule, joint/bony stability --> Neural subsystem: neural structures/control --> Neutral zone: area where motion occurs against minimal passive resistance (passive structures are slack so rely on active and neutral subsystems) --> Neutral zone increases relative to total ROM and active/neural subsystems can't/don't compensate for this increase

acute cervicogenic HA interventions (0-2 weeks)

Active mobility exercise Exercise C1-C2 self-SNAG: push through a little bit of discomfort Ergonomic intervention DNF/DNE training (to prevent future neck pain and instability)

What are the elements of a shoulder screen as part of the cervical clinical exam?

Active shoulder elevation Active abduction Active abduction/ER Active adduction/IR Scapular motion with each of the above movements PROM with endfeel / overpressure Resisted movements

What is a basic classification system for WAD?

Acute = up to 12 weeks after injury Chronic = more than 12 weeks after injury

What are some interventions to use if someone has acute "neck pain with movement coordination deficits" according to the clinical guidelines?

Acute if prognosis is for a quick/early recovery -Education to remain active, act as usual -HEP (pain free cervical ROM, postural training) -Monitor for acceptable progress -Minimize collar use

What will you see when you palpate a person with DJD/cervical spondylosis/ostearthritis?

Adaptively shortened tissues that are tender and dense Decreased mobility

What are some important guidance progressions to remember when prescribing exercise for patients with neck pain?

Always maintain neutral position of lumbar and cervical spine Phase I: Localized contractions of deep neck muscles with chin tuck, progress to slight lift. Phase II: Multi-limb, dynamic; examples are, alternate arms/legs on knees, prone T's and Y's with head support in neutral Phase III: Multi-plane, dynamic, functional; examples and diagonal TB patterns, and prone activities with unsupported head. --> Promote general aerobic activity and strengthening

What tools can be used to determine if a patient needs a cervical x-ray? (3)

American College of Radiology Appropriateness Criteria Canadian C-Spine Clinical Prediction Rule NEXUS (National Emergency X-Radiology Study)

What are factors that have NO effect on outcome of WAD?

Angular deformity of the neck Impact direction Seating position Awareness of collision Vehicle speed

What are the characteristics of lower cervical spine and C2-T3 Region?

Bifed spinous process Foramen transversarium (canal for vertebral artery) Articular pillar (all facet joints stacked on top of each other) Spinal cord passes through vertebral arch

What does the vertebral artery supply?

Blood flow to hindbrain (brainstem, medulla, pons, cerebellum, vestibular apparatus)

What are two ANTERIOR approach surgeries that can be used to help with neck pain?

Anterior cervical discectomy with/without fusion (ACDF) Artificial disc replacement (ACD or TDR)

What are the ligaments of the lower cervical spine?

Anterior longitudinal ligament (ALL) Posterior longitudinal ligament (PLL) Supraspinous ligament Interspinous ligament Ligamentum flavum

What 4 views are required for adequate cervical spine radiographs?

Anteroposterior view (AP view) True lateral view (includes ADI; all 7 cervical vertebrae and C7-T1 junction) Open mouth odontoid view (C1-C2) Oblique View R/L

What is myelopathy?

Any pathological condition of the spinal cord (i.e. compressive cervical myelopathy)

What are Passive Physiological Intervertebral Motions (PPIVMS)?

Assess physiological motion at every segment -Look at: end feel, quantity, symptom provocation -Completed for flexion, extension, side bending, rotation for a cervical spine exam -Should have more motion in mid-cervical spine than at either end

What is translatoric (shear) joint play (C2 to T1)?

Assesses A/P motion of each mobile unit -Patient in sidelying with head craddled in PT's right hand/forearm -PT's left hand palpates between 2 spinous processes -PT's right hand moves to palpate vertebra being tested -PT moves head/neck in AP direction parallel to intervertebral disc

What is spinal segmental ROM?

Assessing the ROM of each mobile unit -People can develop issues at anatomic transition points (C2 and C3, lumbosacral area, cervicothoracic area, thoracolumbar area)

How do you test the motor control of the neck extensors (suboccipital muscles)?

Assure proper scapulothoracic position during these exercises Localize the movement to isolate craniocervical movement (focus on deep neck flexion or deep neck extension) When doing extension or rotation, be sure to do chin tuck first Document any aberrant, jerky movements or movements that are not isolated to the upper cervical spine

How long is a patient usually on precautions after an ACDF?

At least 12 weeks (no traction, cervical mobs) to allow the bones to heal --> could take 1 year to fully heal

What are the treatment recommendations for VBI?

Avoid manual techniques that place neck in end-range positions Use thoracic techniques instead of cervical techniques Use minimal force with manual techniques

What are the discharge criteria for a person with neck pain?

Based on patient function Functional stability/endurance Pain 2/10 80% ROM Strength 4/5 Premorbid activity level Independent HEP Balanced posture

Where is the first intervertebral disc located?

Between C2 and C3

What is the facet (zygapophyseal) joint?

Between inferior facets of upper vertebra and superior facets of lower vertebra Joints are at a 45 degree angle from transverse plane Each joint has its own capsule around it Very close to spinal nerves so if osteophytes or blockages occur, impingements can occur and cause symptoms

What is the uncovertebral (von Luschka) joint?

Between uncinate process of lower vertebra and uncus of upper vertebra

What is a Jefferson fracture?

C1 ring fracture that looks like it exploded -Seen on x-ray by a lateral displacement of one or both lateral masses in an odontoid view x-ray

Where does the cervical spine refer pain?

C2-C3: back of the head and behind the ear C3-C4: neck C4-C5: level of ear to top of scap C5-C6: bottom of neck to top third of scap C6-C7: middle to inferior of scap

What areas will you most commonly see a disc herniation?

C5-6 or C6-7

Why is the dura mater important to consider with the cervical spine?

Can cause pain but not in a dermatomal pattern -If dural sleeve of nerve root is pinched, it will cause pain in dermatomal pattern

What are some characteristics of C1?

Can palpate transverse processes next to mandible No vertebral body or spinous process Two lateral masses

How do you quantify cervical AROM/PROM/coupled motions?

Can visually estimate cervical ROM if not in a legal case or worker's compensation case (then must document exactly with inclinometer or goniometer) Flexion = 45 degrees Extension = 45 degrees Side bending = 45 to 60 degrees Rotation = 75 degrees

What is a Pancoast tumor?

Carcinoma of apex of the lung -Can erode ribs and involve lower brachial plexus -Can cause C7-T1/C8-T1/ulnar nerve palsy -Can cause weakness/atrophy of intrinsic hand muscles -Can interrupt sympathetic ganglia and cause Horner's syndrome ipsilaterally (constriction of pupils miosis, drooping eyelid ptosis) -Can cause shoulder (primary sx in 90%) and arm pain -Progresses from nagging to burning -Seen most commonly in men over 50 with history of smoking

What attitudes and beliefs can be identified as yellow flags?

Catastrophizing (thinking the worst) Finding painful experiences unbearable (reporting extreme pain disproportionate to condition) Fear of movement Believe pain is harmful or disarming Believe that all pain must be gone in order to return to activity/work Expects that pain will increase with work/activity Believe that pain is uncontrollable Passive attitude to rehabilitation

Describe the peripheralization of sx with chin tucks

Chin tucks: upper cervical flexion and lower cervical extension; then have them protract or flex to see if their sx peripheralize with these movements --> If we can get the patient, by using the repeated movements, to centralize their pain, then this is a good exercise to do to keep doing at home! --> Premise of Mckenzie approach: loading/unloading via repeated movements in one direction tests tissue response

What is the the cranial cervical neck flexion test (CCFT)?

Clinical test of action of deep cervical flexors (longus capitis and longus colli): Test of neuromuscular control to initiate/maintain isolated cranial and cervical flexion 1) Put pressure biofeedback unit under patient's neck and inflate to 20 mmHg 2) Have patient do deep neck flexion to various pressures (22, 24, 26, 28, 30 mmHg) and sustain it for 10 seconds

What are the characteristics of the AA jt?

Close to the transverse plane Axis of rotation is the dens

What is indicative of central sensitization?

Cold hyperalgesia and reduced pressure pain threshold

What are some interventions to use with someone who has CHRONIC "neck pain with radiating pain" according to clinical practice guidelines?

Combined exercise (stretching and strengthening elements plus manual therapy for cervical and thoracic region) Education to participate in occupational and exercise activity -Intermittent cervical traction

What are the predictors of chronicity of non-specific neck pain?

Comorbidity of back pain Older age Patient expectation of treatment Previous neck pain Psychological risk factors Baseline neck pain/disability levels

What are the arthrokinematics of sidebending in the facet joints of the lower cervical spine?

Contralateral upglide and ipsilateral downglide ex. SB to left = downglide on left, upglide on right ex. SB to right = downglide on right, upglide on left

Is most spinal motion coupled or uncoupled?

Coupled -Results in greatest ROM and softest end feel Uncoupled = more restricted ROM and harder end feel

If an infant has congenital muscular torticollis, what other things might they present with?

Cranial deformation Hip dysplasia Brachial plexus injury Distal extremity injury

What tests can you use to look at the motor control of the deep neck flexors?

Craniocervical neck flexion test (CCFT) Neck flexor endurance test

What can you see on the odontoid view/open mouth (Dens view) of the cervical spine?

Occiput/occipital condyles Alignment of C1 lateral masses with C2 dens C2 vertebral body Spinous processes of C2 and C3

What is the Dizziness test?

Differentiate VBI from BPPV (Benign Paroxysmal Positional Vertigo) with trunk rotation vs head rotation 1. Patient seated: rotate head to right and left 2. Head facing straight ahead, rotate shoulders right and left Dizziness in both cases: VBI Dizziness only with 1 = semicircular canals of ear

Anterior disc displacement with reduction (ADDWR)

Disc anterior to condylar head at rest causes: macrotrauma to retrodiscal ligaments (progression of hypermobility), microtrauma to disc (thinning) can cause secondary retrodiscal issue, joint/muscle pain with opening: reduction of disc (click), ipsilateral S curve, anterior translation with condyle reciprocal click (on and off): evidence says not great for dx tx: joint mobs, proprioception, STM

What commonly causes "neck pain with radiating pain"?

Disc herniation with radiculopathy DJD of neck with radiculopathy

What are some common conditions that would be classified as "neck pain with mobility deficits"?

Disc herniation without radiculopathy or myelopathy Hypomobile facet joints OA/DJD of neck without radiculopathy or myelopathy

What is the atlas dens interval (ADI)?

Distance between dens and anterior arch of atlas Adults: <3 mm Children: <4.5 mm

What are the mechanical effects of traction?

Distraction/separation of vertebral bodies Distraction of facet joints Increased ligamentous tension Stretches joint capsules, tendons, and spinal muscles Widening of intervertebral foramen Straightening of spinal curves

How do you bias C2 on C3 during PAIVMS?

Do a central or unilateral glide at 45 degrees towards feet on C2

How do you bias C2 on C1 during PAIVMS?

Do a straight PA central or unilateral glide on C2

How do you administer the neck flexor endurance test?

Do chin tuck then lift head off table 2.5 cm from supine position for as long as possible Median holding time = 36-38 seconds

TMJ subjective exam

ENT, dental hx, PSH, trauma/falls, cervical injury, psych/stress social hx, date of onset, imaging, parafunctional habits pain: location, description, severity, provocation/alleviation, sounds/locking/catching other sx: HA, tinnitus, stuffiness, dizziness, facial fatigue changes in pain, chronic pain

Return to Activity after a Concussion/mild TBI: PT Implication and Rehabilitation Stage

Each stage requires 24-48 hrs of symptoms free before progressing Stage 1: Rest Stage 2: Light aerobic exercise Stage 3: Sport-specific exercise Stage 4: Non-contact training drills Stage 5: Full contact practice Stage 6: Return to Play

What is key for treating congenital muscular torticollis?

Early intervention --> Infants identified early with postural CMT have shorter treatment episodes --> If identified later (after 3-6 months old, have SCM mass CMT), typically have longest episodes of conservative treatment and may ultimately undergo more invasive procedures

What are some interventions to use if someone has chronic "neck pain with movement coordination deficits" according to the clinical guidelines?

Education (prognosis, encouragement, reassurance, pain management) Cervical mobilization Individualized progressive exercise (low-load, endurance, flexibility, functional training, cervicoscapulothoracic strenghtening, vestibular rehab, eye-head-neck coordination, neuromuscular coordination elements) TENS ** Using a cognitive behavioral approach: stress management! Multimodal approach

What is the focus of rehab while a patient is still in the hospital after an ACDF?

Education on log rolling technique and cervical collar Walking progression Temporary hoarseness because surgery is done near recurrent laryngeal nerve Difficulty swallowing due to swelling Dizziness because surgery is near the sympathetic chain *The last three focuses should go away quickly; if you see these in outpt 3-4 weeks after surgery, refer back to MD to ensure that everything is stable

How can you test the motor control of the lower traps?

Engage lower traps in sitting and hold it while raising UE to 90 degrees of flexion --> Look for muscle compensations, quality of movement

What are some research-informed interventions for the upper cervical spine?

Ergonomics/protect the joint Change ROM restrictions Address motor control deficit Work on sensory motor function (cervical kinesthetic tx) Education: pain processing, fear avoidance, desensitize to movement Aerobic exercise

What is atlantoaxial instability?

Excess anterior motion of C1 on C2 -Can cause impingement on spinal cord because spinal canal narrows -Need flexion x-rays to see this

What are some interventions to use with someone who has ACUTE "neck pain with radiating pain" according to clinical practice guidelines?

Exercise: mobilizing and stabilizing elements Low-level laser Possible short-term collar use Would expect to see cervical traction and centralization exercises but had mixed evidence so not included

What should you ask about when examining a person with whiplash?

FORCE OF IMPACT Speed of travel Type of vehicle Seatbelt Headrest Airbag DIRECTION Where the car was hit Symmetry of impact Position of victim in car/position of head

What structures can be injured in Whiplash Associated Disorders (WAD)?

Facet joints (injury to joint capsule, cervical spine meniscoids) Intervertebral discs (tears to ALL, rim lesions of anterior annulus fibrosis) Muscles (fatty infiltrates in neck muscles develop between 4 weeks and 3 months post-injury if have severe pain/disability) Ligaments Neurological structures (potential damage to nerve roots and dorsal root ganglion; mild traumatic brain injury/concussion) TMJ Other

True/False: if pt is ABLE to actively rotate their neck 45 deg L/R, radiography is appropriate based on the Canadian C-Spine Rule

False

True/False: pts with coordination impairments tend to have good quality of motion, not quantity

False: typically pts with coordination impairments have good ROM and tend to be flexible, but the quality of their movement may come from mid cervical or you MAY see some fulcruming, where they SB and they're fulcruming in one of the areas; the rest (above and below) may also be hypomobile!

Does fibromyalgia primarily affect males or females?

Females --> Twice as common as RA in general population

What is SCM mass congenital muscular torticollis?

Fibrotic thickening of SCM, passive ROM limitations (most severe presentation)

What do you need to ask about pain when you are examining a patient?

Fill out pain diagram (fill in area of pain) Rate pain on scale from 0 to 10 now, at best, and at worst Ask about: site, onset, nature/description, mechanism of injury, functional status, pillows used, mattress life, ability to sustain positions and tolerance to them

What is a positive inverted supinator sign?

Finger flexion and slight elbow extension

When does most of the recovery from WAD occur?

First 2-3 months after injury 50% reported neck sx 12 months after injury

What are some interventions for a person with DJD/cervical spondylosis/osteoarthritis?

Focus on joint mobilization of cervical and thoracic spine ROM exercises Soft tissue mob: paraspinals, UT Posture correction Strengthening/endurance training to maintain new ROM Central and lateral PAs (sometimes in supine position bc they tolerate it better)

When can an infant be discharged from PT for congenital muscular torticollis?

Full passive ROM within 5 degrees of non-affected side Symmetrical active movement patterns throughout the passive range Age-appropriate motor development No visible head tilt Parents/caregivers understand what to monitor as the child grows

cervicogenic HA tx for all stages

Functional training: sleeping position, computer set up, phone usage DNF/DNE Postural training with laser Scapular stabilizers Aerobic exercises: brisk bike or walk 45 mins 3x/week Relaxation exercise program 1-2x/day

Describe the characteristics of a Concussion (Mild TBI)?

Functional, not structural damage Imaging studies negative

What should you do if there is a positive result from the alar ligament test?

Further diagnostic testing may be indicated Upper cervical joint mobilization or ROM exercises contraindicated Notify patient's physician

What is Transitional Syndrome/ Adjacent Segment Disease?

Fuse one area of the spine = areas above/below compensate and become hypermobile --> Later on (years), may have disc herniation above/below fusion and require additional surgeries --> Re-op rate 10 years after cervical fusion is 22%

What are the indications for traction? What is the goal?

Herniated nucleus pulposus (HNP) DJD of the cervical spine Joint/facet hypomobility Muscle guarding Goal: Maximize symptom reduction and centralization of sx

What are some predictors of poor outcomes following whiplash?

High baseline pain (more than 5.5/10) Report of headache at time of injury Less than post-secondary education No seatbelt use during accident Report of low back pain at time of injury High NDI score (greater than 14.5/50) Preinjury neck pain Report of neck pain at time of injury (regardless of intensity) High catastrophizing Female WAD grade 2 or 3 WAD grade 3 alone Presence of psychological distress/post-traumatic stress Cold sensitivity

What is considered an "acute" condition, by the clinical practice guidelines for neck pain?

Highly irritable --> Pain at rest or with initial to midrange spinal movements (before tissue resistance) --> Usually but not always a recent injury (could be an acute exacerbation of a chronic issue)

How are intervertebral discs innervated?

Sensory nerve fibers found throughout the annulus fibrosis (specifically from sinuvertebral nerve)

What causes an injury to the cervical spine in a rear-end collision MVC?

Hyperextension followed by hyperflexion

What causes an injury to the cervical spine in a head-on collision MVA?

Hyperflexion followed by hyperextension

What is a trigger point?

Hyperirritable spot within a taut band of skeletal muscle --> Painful on compression or muscle contraction --> May respond with a referred pain pattern distant from trigger point --> Nodules are palpable within the muscle --> can be treated!

What are the four classifications of neck pain based on the clinical practice guidelines?

I. Neck pain with mobility deficits II. Neck pain with Headaches III. Neck pain with Movement Coordination impairments IV. Neck pain with radiating pain

Describe the angle of force for someone with spondylosis or DJD vs. someone with herniated nucleus pulposus

If someone has spondylosis or DJD, we treat them with a bit of flexion because we're trying to open up the spaces If someone has a herniated nucleus pulposes, we need to keep them in neutral, because if we have them in a flexed position, we may influence the pulposes with posterior migration of the disc herniation

What is the prognosis if the sx are centralizing with the repeated movements as an intervention?

If the sx is centralizing, it means that pt has good prognosis

Differential diagnosis when considering facet joint dysfunction

If you suspect a facet dysfunction and their Neuro exam is NOT normal, start thinking about disc herniation or something ELSE that's going on

Define: Cervical Arterial Dissection

Immediate referral to ER - Tear in the artery wall - More commonly affecting vertebral artery - Acute onset of headache or neck pain described as "unlike any other" - May be recent trauma - Neurological symptoms

How do you test the endurance of the neck extensors (suboccipital muscles)?

In a position against gravity BUT watch chin position (need to ensure craniocervical flexion is maintained) Document how long they are able to maintain correct position Are they able to maintain their neck without dropping down; stopping the test if they can't hold

What is the diagnostic criteria to diagnose fibromyalgia set by the American College of Rheumatology in 2010? (current criteria)

Includes pain and other symptoms using Widespread Pain Index (WPI) and Symptom Severity Score (SS score) WPI Scale score 7 or higher AND SS score 5 or higher OR WPI score 3-6 AND SS score 9 or higher Symptoms at similar level for at 3 months Does not have disorder that would otherwise explain the pain

What age-related changes happen to the intervertebral discs in your 30s and 40s?

Increased incidence of disc herniation and radiculopathy caused by disc herniation

What are the physiological effects of traction?

Increases circulation Mechanoreceptor input Decreases pain

What is strain-counterstrain (positional release)?

Indirect technique for the treatment of somatic dysfunction, using passive positioning of the body into a position of ease rather than into motion restriction to evoke a therapeutic effect --> For muscle tightness, shorten the muscle rather than lengthen it

When is Cervical Disc Arthroplasty NOT indicated?

Infection in the spine or surrounding areas Osteoporosis or osteopenia Severe degenerative changes/facet disease Cervical instability Allergy to the metals and other materials in the artificial disc Hybrid procedure for multi-level: ACDF and TDA

What are the arthrokinematics of extension in the facet joints of the lower cervical spine?

Inferoposterior glide of both facets (aka downglide or closing)

What is upper crossed syndrome?

Inhibited neck flexors and rhomboids/serratus anterior AND tight upper traps/levator scap and pectorals

What is an interlaminar injection?

Injection between lamina of two adjacent vertebra --> Guided by ultrasound (fluoroscopy) --> Medication is close to the assumed site of pathology (not as specific)

What is a transforaminal injection?

Injection into intervertebral foramen --> Guided by ultrasound (fluoroscopy) or CT scan --> More target specific (to the nerve) but can have more potential complications --> Considered for pts with cervical radiculopathy from degenerative disorders

What is central sensitization?

Injured and uninjured parts of body exhibit lower pain thresholds due to an alteration in central pain processing --> Pain is no longer coupled with noxious stimuli --> Essentially, things that should not be painful are painful; high levels of pain, but is not associated with any tissue damage

What are the two major arteries of the cervical spine region?

Internal carotid Vertebral artery

What happens at the intervertebral disc during flexion?

Intervertebral disc is compressed anteriorly Posterior structures are stretched Nucleus pulposus goes posteriorly

What age-related changes happen to the intervertebral discs in your 50s?

Intervertebral discs start to dry out and lose height, start to see degenerative changes

What are the joints of the lower cervical spine?

Intervertebral joints Facet (zygapophyseal) joints Uncovertebral joints

What are the symptoms of clinical instability of the cervical spine?

Intolerance to prolonged static postures Fatigue with inability to hold head up Symptoms decrease/feel better with external support (i.e. cervical collar, holding neck with hands) Frequent need for self-manipulation (cracking neck) Feeling of instability Lack of control with movement (deviates L/R during flexion/extension) Frequent episodes of acute attacks (can't always tell you what made it worse) Sharp pain, possibly with sudden movements Unpredictable symptoms

TMD

Intra-articular Internal disc displacements -Anterior: with/out reduction; most common -Posterior (rare) Joint arthralgias -Hypermobility -Hypomobility -Arthritis -Capsulitis/synovitis and capsular fibrosis Extra-articular: muscle disorders Muscle spasm Tendinopathy Myofascial pain syndrome

What are some interventions to use for the cervical spine?

Joint mobilization Repeated movements to centralize pain Cervical traction Neck stabilization exercises Education Mulligan Technique Muscle energy Strain-counterstrain (positional release) Soft tissue mobilization (STM) Instrument assisted STM Dry Needling Taping Modalities

Describe the Cervical Kinesthetic Assessment

Joint position sense (laser) Balance assessment Oculomotor assessment

What are three POSTERIOR approaches that can be used surgically for cervical spine decompression?

Laminectomy: removal of vertebral lamina to decompress spinal cord (with/out fusion) Laminoplasty: lamina is moved posteriorly to expand space for spinal cord Foraminotomy: intervertebral foramen/canal is enlarged to decompress nerve root; only portions that are pressing on nerve are removed

What are some key tests and measures when assessing someone with postural dysfunction syndrome?

MMT Muscle length assessment (especially pec major and pec minor) Ergonomic assessment of workspace

What do you do to manage cervical radiculopathy?

MULTIMODAL APPROACH Cervical traction (manual or mechanical) to centralize symptoms Centralization exercises Patient education Manual therapy (cervical and thoracic joints) Strengthening exercises for deep neck flexors, scapulothoracic muscles

What diagnostic studies are used before a person has surgery on their neck?

Magnetic Resonance Imaging (MRI): most sensitive for detecting soft tissue abnormalities Electromyography (EMG) Nerve conduction study (NCS)

What are two risky situations where a cervical fracture could be possible?

Major trauma without proper imaging clearance Minor trauma in patients with severe osteoporosis without proper imaging clearance

What does the internal carotid artery supply?

Majority of blood flow to the brain (80%)

What should you consider for alternative, complementary, and adjunct therapies of pts?

Make sure that it's not conflicing with the therapy they're having and that they're going to reputable practictioners

Explain clinical instability of cervical spine in relation to neutral zone and motor control

Midrange of motion is where all passive structures are in a fairly lax position; so movement in this zone is controlled by our musculature and requires good motor control Pts who have altered movement control/movemenmt coordination impairments have inc. neutral zone with lax joints and poor motor control It is a non-radiographic instability; this is NOT a grossly unstable jt and it is NOT visible on imaging Pt has laxity in the joint and POOR CONTROL IN THEIR MID RANGE

What are 4 things that physical therapists can use to manage (mild) cervical myelopathy?

Manual therapy (thoracic mobilization/manipulation and cervical traction) Exercise (cervical stabilization) Balance training Core stability

What can occur if congenital muscular torticollis goes untreated?

May lead to positional plagiocephaly (cranial asymmetry with flattening of one side of the head) and require cranial orthosis

Why do we need to be cautious about using MRI when a person has neck pain?

May see an abnormality but it may be asymptomatic --> Need to check to make sure there is clinical correlation

How can you test mechanical pressure pain thresholds?

Measured with pressure algometer over neck, nerves and remote sites (like the leg) Patient asked to push switch when pressure becomes painful Threshold is recorded and compared to age-matched norms

What are some common symptoms of "neck pain with movement coordination impairments" according to the practice guidelines?

Mechanism of onset linked to trauma or whiplash Associated (referred) shoulder girdle or UE pain Associated varied non-specific concussive signs and symptoms Dizziness/nausea Headache, concentration or memory difficulties Confusion Hypersensitivity to mechanical, thermal, acoustic, odor or light stimuli Heightened affective distress

What are the questions to consider for the hx of their cervical pain episode?

Mechanism of this Injury - traumatic vs non Onset - how did this start? Symptom duration? Treatment (what treatments if any; effect of treatment) Any prior similar episode Previous tests and treatments

What muscles stabilize the scapula and are important to assess when doing a cervical spine exam?

Mid-trapezius Lower trapezius Rhomboids Serratus anterior

Can you fully diagnose a disc herniation without imaging?

No

What is spasmodic torticollis?

No continuous muscle length issue (it comes and goes), no joint signs, no MOI --> Could be neurological condition with or without a tick --> Could be transient --> May treat for a few sessions and if there is no change, refer back

What are the indications for surgical interventions for the cervical spine?

No improvement after 6-12 weeks of non-surgical treatment Neurologic compression (progressive motor deficit with radiographic clinical correlation) Instability Deformity

Can you do a central PA on C1?

No, because there is no spinous process Can only do unilateral

What are the 7 indications for referring infants to physician when screening for CMT?

Nonmuscular causes of asymmetry (eg, poor visual tracking, abnormal muscle tone, extra-muscular masses) Associated conditions (ex. CD: cranial deformation) Asymmetries inconsistent with CMT If the infant is older than 12 months and either facial asymmetry and/or 10 to 15 deg of difference exists in passive or active cervical rotation or lateral flexion The infant is 7 months or older with an SCM mass If the side of torticollis changes The size or location of an SCM mass increases

Is diagnostic imaging beneficial after a whiplash injury?

Not always helpful for prognosis (good for ruling out fracture or ligamentous injury)

What happens at the intervertebral disc during sidebending?

Nucleus pulposus moves to contralateral side Intervertebral disc compressed ipsilaterally Contralateral structures are stretched

What are the three components of an intervertebral disc?

Nucleus pulposus: jello middle Annulus fibrosis: lacking posteriorly in cervical spine Vertebral endplate: hyaline/fibrocartilage, nutrients diffuse

hypomobility TMD: arthritis

OA: limited opening AROM, pain with closing and palpation of TMJ, crepitus throughout ROM, radiographic evidence RA: ask in PMH tx: joint mobs, postural strengthening, joint protection strategies

describe the multimodal/interdisciplinary approach to concussion tx

OT: cognitive retraining, memory AT: functional training, exertional tolerance, return to sport, sideline and equipment physician: medical management, mental health PT: C spine, vestibular, balance, gait, autonomic dysfunction, exertional tolerance, aerobic exercise

Discuss what to do in the Observation of Posture/Posture Analysis during a cervical clinical exam?

Observation begins as soon as the patient walks in the door Try to quantify in some way (min, mod, severe) Should be done in sitting, standing, and with dynamic movements

What are the two joints of the upper cervical spine?

Occipito-atlantal joint (OA joint) Atlanto-axial joint (AA joint)

What will you see on exam if a person as "neck pain with movement coordination impairments" according to the clinical guidelines?

Positive cranial cervical flexion test Positive neck flexor muscle endurance test Strength/endurance deficits of neck muscles Neck pain with midrange motion that worsens with end-range motions Positive pressure algometer Point tenderness (may include myofascial trigger points) Sensorimotor impairment (may include altered muscle activation patterns, proprioceptive deficit, postural balance/control) Neck and referred pain reproduced by provocation of involved cervical segments

Describe the POSITIVE FINDINGS for Scapular Dyskinesis: Open Chained

Positive findings include: winging, loss/lack of control when lifting, loss/lack of control when lowering, and scapular asymmetry

Will the neuro exam be normal for someone with DJD/cervical spondylosis/osteoarthritis?

Potentially -May not be if they also have myelopathy or radiculopathy

How do you assess the lower cervical spine for ROM?

Preposition the upper cervical spine (C1-2) into flexion (via chin tuck) before assessing

What is postural congenital muscular torticollis?

Presents as infant's postural preference but without muscle or passive ROM restrictions (mildest presentation)

What are the PRIMARY motions of the occipito-atlantal joint? How much do they move?

Primary: Flexion and extension (25 to 30 degrees) Other: Side bending 10 deg

What is the focus of rehab Week 1-2 after an ACDF?

Progress walking and endurance Gentle, pain-free AROM No lifting more than 10 lbs (jug of milk)

What is the treatment approach for concussion?

Provide individualized targeted interventions for identified impairment areas Match interventions and dosing to level of irritability in those areas Monitor symptoms and identified impairments at every session Periodically assess/reassess all impairment domains and selected outcome measures and adjust/progress plan of care as indicated Monitor mental health, patient's recovery mindset, and patient/family barriers, preferences, and priorities and adjust plan of care to accommodate as indicated Incorporate injury prevention and brain health promotion strategies

How do you assess joint position error?

Pt has head laser on and stands 90cm (approx 3 feet) away from target Instructed to close eyes, rotate head, return to center, open eyes Distance from center is measured 3 trials recorded >4.5 degree error: associated with dizziness and cervical joint position error For tx: can stand farther from target to make it harder

What are Passive Accessory Intervertebral Motions (PAIVMS)?

Pushing on bones to assess motion --> Look at motion, end feel, symptoms

What is os odontoideum?

Separation of dens from axis

What should you OBSERVE when doing cervical AROM/PROM/combined motions?

Quality and quantity Apply overpressure when appropriate (if patient is not in pain) Try to differentiate if ROM restrictions are caused by soft tissue restrictions -shrug shoulders to see if sidebend ROM will increase -open mouth to see if extension ROM will increase

What is the focus of rehab Week 4-6 after an ACDF?

RETURN TO PLOF Progress lifting <10-30 lbs. Progress deep Neck muscle strengthening to multi-limb, dynamic; ex. alternate arms/legs on knees, prone T's and Y's with head support in neutral UE resisted exercises

Describe the Research-informed Interventions for UCS

ROM DISTURBANCES Joint mobilization Traction MS length A / AA/ P ROM Gravity eliminated to against gravity Functional progressions EDUCATION --> Change pain processing and psychosocial distress: address fear avoidance and desensitize to movement --> Sensory motor processing (explain pain, acute vs chronic importance or normal motion vs guarded motion, change pain behaviors) --> Multimodal approach - medical team --> Importance of aerobic exercise CHANGE MOTOR CONTROL PATTERNS/PROGRESSIONS --> Feedforward mechanism (anticipatory/automatic) --> Patterning in isolation then co-contraction --> Endurance strength/function --> Retrain normal movement patterns (ROM)

Radiculopathy vs. Spondylopathy

Radiculopathy: 40-50s Spondylopathy: older population (60+)

What are some diagnostic imaging sources/tests that are used to diagnose cervical radiculopathy?

Radiographs MRI EMG Nerve conduction tests

What are the Deep Neck Extensor (suboccipital) muscles to consider for Motor Control Assessment?

Rectus capitus posterior major: head extension and ipsilateral rotation Rectus capitus posterior minor: head extension and ipsilateral rotation Obliquus capitus superior: head extension and side bending Obliquus capitus inferior: ipsilateral head on-neck rotation

What is an anterior cervical discectomy and fusion with anterior cervical plate fixation (ACDF)?

Remove the offending disc and any osteophytes Autograft (from patient's illium) or allograft of bone placed where intervertebral disc used to be Most often done with small anterior plate and screws for protection and stabilization as the bone graft incorporates

A patient who has limited motion and localized right-sided pain with extension, right side-bending and right rotation most likely has restricted facet motion in what direction on what side?

Restricted downglide on right and/or restricted upglide on left Documented as -Motion restriction = right facet cannot downglide -Positional fault = right facet is flexed, rotated left, sidebent left (stuck in upglide position)

What movements (AROM) should you look at/use for repeated movements to centralize pain?

Retraction = upper cervical flexion + lower cervical extension Retraction with extension = upper and lower cervical extension Protraction = upper cervical extension + lower cervical flexion Flexion Baseline = repeat movement 10-15 items, then reassess symptom response

What are some arthritic causes that could cause atlantoaxial instability?

Rheumatoid arthritis Psoriatic arthritis Reiter syndrome (reactive arthritis) Ankylosing spondylitis Systemic lupus erythematosus (SLE)

What is the primary motion at the atlanto-axial joint? How much?

Rotation (45-50 degrees)

Is Rotation test appropriate for VBI Physical exam?

Rotation test is no longer recommended in the 2020 framework Having rotation may provoke symptoms, so be mindful!

What is the function of the anterior longitudinal ligament?

Runs along anterior surface of vertebral bodies Taut in extension

What is the function of the posterior longitudinal ligament?

Runs along posterior surface of vertebral bodies Prevents posterior bulging of intervertebral discs Taut in flexion

What is the function of the interspinous ligament?

Runs between spinous processes Taut in flexion

What is the function of the supraspinous ligament?

Runs between tips of spinous processes Taut in flexion

What screening tools should you consider when doing a PT Eval/Treatment after a Concussion (mild TBI)?

SCAT 5: -Glasgow scale -Standardized assessment concussion (SAC) -Balance and coordination Immediate post-concussion assessment & cognitive testing (ImPACT): can be used for baseline Concussion recognition tool 5 (CRT5): designed to identify mTBI to remove from play

What is muscular congenital muscular torticollis?

SCM tightness and passive ROM limitations

What are the two modes of cervical traction?

STATIC: used if very irritable, severe arm pain INTERMITTENT: increases circulation and helps with mechanoreceptor input for the joints --> Used as a joint mobilization technique --> Duty cycle of 1:1 or 1:3

Does lower cervical spine (C2-T3) sidebending and rotation take place to opposite side or the same side?

Same side

What muscles should be tested for length when doing an upper cervical spine evaluation?

Scalenes Upper trapezius Levator scapulae SCM suboccipitals

When doing an ergonomic assessment of a desk, what are some important parameters?

Screen should be 18-28 inches from person's face Top of screen should be just below eye level Shoulders relaxed and forearms parallel with ground or tilted slightly up Lower back support and thighs should be horizontal/parallel to ground Feet flat on floor and forearms and hands should be in a straight line

What is the focus of rehab 3-6 months after an ACDF?

Self-progress to higher level activities BUT no overhead lifting Exercises that include multi-limb dynamic movements; ex. alternate arms/legs in quadruped, prone Ts and Ys with neck in neutral Multi-plane, dynamic functional exercises ex. diagonal theraband patterns, prone exercises with unsupported head

How do you test the motor control of the serratus anterior?

Serratus punches

What is the patient presentation of someone with a cervical fracture?

Severe limitation during neck AROM in all directions

What is the patient presentation of a person with an upper cervical ligamentous injury/instability?

Severe limitation during neck AROM in all directions Signs of cervical myelopathy Occipital headache and numbness

What is the alar ligament test?

Sidebend occiput and palpate for immediate movement of C2 spinous process in opposite direction positive: C2 SP does not start to move with SB

What is the rehabilitation for Post-Op Disc Arthroplasty?

Similar to ACDF but no concerns about healing fusion Generally will progress faster than ACDR Surgeon dependent (May have some restrictions for first 1-3 weeks) --> Phase 1 Protection phase --> Phase 2 Intermediate --> Phase 3 Advanced strengthening --> Phase 4 Return to activity

What are the indications for an artificial disc replacement?

Skeletally mature Clinically symptomatic cervical radiculopathy and/or myelopathy due to neural compression between C3 and C7 (1 level or 2 contiguous levels) Failed non-surgical treatment after 6 weeks Showed signs of progressive clinical deterioration with non-surgical treatment Intractable radiculopathy (arm pain and/or a neurological deficit) with or without associated arm pain Myelopathy (due to abnormality localized to level of the disc space)

traumatic torticollis: description and tx

Something got jammed when moving too much --> Seen commonly in young hypermobile females --> Usually has happened before and quickly resolved --> Usually associated with a motor control deficit tx: joint mobs followed by stabilizing exercises, restore ROM, address motor control

acquired muscular torticollis: description and tx

Spasm in SCM causes ipsilateral lateral flexion and contralateral rotation --> No joint restrictions or abnormalities tx: soft tissue mobilization and stretching, functional adaptation, ROM

With what types of torticollis should a PT refer out if there is no muscular involvement or concern (for CNS/PNS signs)?

Spasmodic Drug-induced (antipsychotics) Hysterical (psychological, no objective signs)

What can you see in the AP view of the cervical spine?

Spinous processes Transverse processes Alignment of vertebral bodies

post-viral torticollis: description and tx

Spontaneous onset in child or adolescent after an upper respiratory infection --> Causes temporary insufficiency of upper cervical spine --> Manual therapy including traction is contraindicated

Return to Activity after a Concussion/mild TBI: Exercises Allowed for each stage

Stage 1: Complete physical/cognitive rest without symptoms Stage 2: Walking, swimming, or stationary cycling keeping intensity <70% max predicted HR. No resistance training Stage 3: Running drills - no head impact activities Stage 4: Progression to more complex training drills Stage 5: Normal training activities Stage 6: Player rehabilitated

What interventions can be used to treat clinical instability of the cervical spine?

Strengthening exercises (deep neck flexion, scapular stability exercises) Posture education Motor control/proprioception exercises to stabilize Mobilize segments that are hypomobile and proximal/distal to problem area --> ex: you have pt with increased segmental mobility in their mid-cervical spine, but have HYPOmobility in their upper cervical spine and thoracic spines; thus we need to MOBILIZE their thoracic spine and cervical spine and focus on mid-cervical spine to achieve these goals

What are some interventions to use if someone has sub-acute "neck pain with movement coordination deficits" according to the clinical guidelines?

Sub-acute if prognosis is for prolonged recovery trajectory -Education (activation, counseling) -Combined exercise (active cervical ROM, isometric low-load strengthening, manual therapy) -Physical agents (ice, heat, TENS) -Supervised exercise (active cervical ROM or stretching, strengthening, endurance, neuromuscular exercise)

What are three examples of mechanical cervical traction?

Suboccipital grip (Saunders) Head halter (over the door) Pronex Pneumatic Traction Unit

What is the clinical course of cervical radiculopathy?

Substantial improvements tend to occur within the first 4-6 months post-onset Time to complete recovery from 24-36 months in 83% of patients

Why do we need to test the motor control of the deep neck flexors?

Superficial muscles (i.e. scalenes, SCM) are moving muscles, not meant to stabilize or hold positions Deep muscles (i.e. longus colli, longus capitis) are stabilizing muscles that must activate before the superficial muscles can move the head/neck A person needs to be able to control both separately in order to function properly

What are the arthrokinematics of flexion in the facet joints of the lower cervical spine?

Superoanterior glide of both superior facets (aka upglide or opening)

What are some surgical interventions for congenital muscular torticollis?

Surgical lengthening or release of SCM Injections of Botox

What are SNAGs?

Sustained Natural Apophyseal Glides -Therapist applies sustained apophyseal glide while patient performs symptomatic movement -Must result in full range pain free motion -Can be applied to all spinal joints, rib cage, SI joint

What is a positive test for an upper limb tension test?

Symptom reproduction More than 10 degree difference in elbow extension side to side

How many epidural injections to the neck can a patient get per year?

Symptoms may decrease after 1, 2, or 3 injections but should not have >3 per year

What is centralization of symptoms?

Symptoms that go from distal to proximal (usually caused by repeated extension)

What is peripheralization of symptoms?

Symptoms that go from proximal to distal (usually caused by repeated flexion)

Objective measures during PT exam for CMT?

Systems review (visual function, hip screen, neurological screen, pain assessment, skin screen) Physical assessment (clinical observations, anthropometrics, ROM, muscular palpation)

What are the treatment parameters for traction? Time Force Angle of Pull

TIME -->Acute condition/herniated nucleus pulposus = 5-10 minutes --> Other conditions = 15-30 minutes FORCE --> 8 to 10 lbs or 7 to 10% of patient's body weight to start ANGLE OF PULL --> C1 to C5 = 0 to 5 degrees flexion --> C5 to C7 = 25 to 30 degrees flexion --> 25 to 35 degrees flexion = good for facet joint separation (like DJD) --> 0 degrees flexion = good for herniated nucleus pulposus

What are some signs of systemic or inflammatory disease?

Temperature >98.6 BP over 160/95 Resting HR >100 Resting respiratory rate >25 Excessive fatigue

What should you test after a whiplash injury?

Test transverse and alar ligaments Neuro exam (including cranial nerve testing) Scapular muscle MMT Neck ROM (including segmental mobility of cervical and thoracic spine) Palpation Quantitative Sensory Testing Cervical kinesthetic assessment

What is the neck flexor muscle endurance test?

Tests ability to lift head and neck against gravity and sustain it --> Normal = mean of 39 seconds --> Neck pain mean = 24 seconds

When performing the cervical radiculopathy examination, what are other considerations when assessing the cervical spine?

The cervical spine can also refer pain to the medial scap border or supra scapula area so pts with disc herniations may complain of pain in these areas Treat secondary impairments if present, but treat the primary cause, which is the cervical spine and the IV disc

What is the difference between Neck Disability Index (NDI) and PSFS?

The patient is selecting the activity themselves with PSFS, so it is more sensitive/responsive to smaller changes compared to NDI where the questions are already pre-determined

How can you test thermal sensitivity?

Thermal pain thresholds measured using a computer-controlled device that generates and accurately records response to warm, hot, cool, cold sensations --> Patient asked to push switch when sensation becomes painful --> Sensory threshold recorded and compared to age-matched norms OR Bag of ice held against skin for 10 seconds -Sensation rated over 5/10 strongly suggests presence of cold hyperalgesia -Sensation rated less than 1/10 strongly suggests absence of cold hyperalgesia

What are some interventions for ACUTE "neck pain with mobility deficits" according to the practice guidelines?

Thoracic manipulation Cervical mobilization or manipulation Cervical ROM, stretching, isometric strengthening exercise Education to stay active including home cervical ROM and isometric exercises Supervised exercise including cervicoscapulothoracic and UE stretching, strengthening, and endurance training General fitness training (stay active)

What is a positive Hoffman's reflex?

Thumb flexion and index finger flexion

What factors influence outcomes in neck pain?

Timing of PT (early PT = lower healthcare utilization like imaging or opioids, lower costs) Symptoms duration (less than 1 month) Inclusion of manual therapy <65 years old

What is DJD/Cervical Spondylosis/Osteoarthritis?

Tissue changes/degeneration that progress over time Typically start at the IV disc: nucleus pulposes, then overtime the outside part of the annulus and then get some osteophyte formation; tend to get narrowing of the disc Usually seen in older patients and have degenerative changes in other joints too Clinical signs don't always correlate with imaging Can present with a wide range of sx and can have radiculopathy and myelopathy in severe cases

What type of injection has shown to have positive results for cervical radiculopathy due to degenerative disease?

Transforaminal epidural steroid injections guided by fluoroscopy/CT

What are the three types of injections that can be used for neck pain?

Transforaminal injection Interlaminar injection Epidural injection

What is vertebrobasilar insufficiency?

Transient or permanent reduction or cessation of blood supply to hindbrain through right and left vertebral arteries and the basilar arteries Rare (1 in 400K)

What are the superficial muscles of the cervical spine?

Trapezius (upper, middle, lower) Sternocleidomastoid Levator scapulae Scalenes (anterior, middle, posterior)

What are the indications for stability testing of the upper cervical spine?

Trauma or other causes of instability Report of instability (head feels heavy) Lip or tongue paresthesia Nausea or vomiting Severe headache or muscle spasm Dizziness Lump in throat Signs of cord compression (i.e. bilateral or quadrilateral paresthesia)

What are some ways that a person can acquire atlantoaxial instability?

Trauma/fracture Grisel syndrome caused by retropharyngeal abscess (spontaneous AA subluxation) Recurrent upper respiratory tract infections

What are some types of acquired torticollis?

Traumatic (micro induced) Sudden onset/acute Muscular Post-viral Spasmodic Drug-induced Hysterical

Define: Transverse Ligament injury Classification

Type I: Disruption of the ligament without an osseous component Type II: Fracture or avulsion involving the tubercle for insertion of the C1 lateral mass, without disruption of the substance of the ligament

What do you need to document when doing joint mobilizations of the cervical spine?

Type of technique (central vs. unilateral) Grade Level treated Duration AROM exercises completed after it ex: Central PA, grade II to C6, 3x10 for 5 mins

When does a patient s/p ACDF start outpatient PT?

Typically 3-6 weeks after surgery

What are the symptoms of compressive cervical myelopathy?

UMN signs/symptoms - Multisegmental weakness and/or sensory changes -Sensory disturbance of hands - Muscle wasting of intrinsic hand muscles - Spasticity - Hyperreflexia - Clonus - Balance and gait disturbances - Presence of pathological reflexes (Babinski, Hoffman, etc.) - Sudden change in bowel and bladder function

What is the mechanism of injury for facet dysfunction?

Unilateral neck pain or locking (synovial folds of facet joints get caught in joint) Can be atraumatic (sleeping in funny position) or traumatic

What are the two major regions of the cervical spine?

Upper cervical spine (occiput, atlas C1, axis C2) Lower cervical spine (C2 to T3)

What are the special tests for cervical radiculopathy?

Upper limb tension tests Cervical distraction test Cervical compression test Quadrant/Spurling's test

What is the Canadian C-Spine Clinical Prediction Rule?

Used to determine need for x-ray after neck trauma -Better diagnostic accuracy than NEXUS

What is the cervical distraction test?

Used to identify cervical radiculopathy Distract occiput from cervical spine and ask about symptoms Distraction force of up to ~14 kg is applied positive: sx decrease

What is the cervical compression test?

Used to identify cervical radiculopathy Downward force applied through patient's head positive: sx are reproduced

What are muscle energy techniques?

Uses voluntary muscle contractions exerted against a precise counterforce to increase joint ROM --> Similar to PNF: autogenic and reciprocal inhibition -Engage restrictive barrier in all planes -Provide gentle isometric resistance -Hold for 5-10 seconds -Wait for complete relaxation of muscles -Reposition to engage new barriers -Repeat sequence 7-10x

What is the typical mechanism of injury for Whiplash Associated Disorders (WAD)?

Usually due to motor vehicle collision (MVC), sporting injury, or a fall

What are some risk factors for vertebrobasilar insufficiency (VBI)?

Vertebral artery asymmetry (abnormal anatomy) Anomolous course of vertebral artery (abnormal anatomy) Atherosclerosis HTN OA Ligament laxity DM Hyperlipidemia Smoking History of TIA or CVA Genetic clotting disorders

What should be included in the medical screening portion of an upper cervical spine evaluation?

Vertebral artery screening (history, ROM, positional test) Ligament instability (alar, transverse) Cranial nerve assessment

What are some characteristics of C2?

Very prominent bifed spinous process Usually the first spinous process that you feel Odontoid process (dens)

How is cervical myelopathy diagnosed?

Via neuro exam and confirmed through MRI

What is the focus of rehab after an ACDF (post-op) ?

Walking program Deep neck strengthening Stabilization exercises Ice 10 min up to 3x/day Lifting and activity restricted for first 6 weeks No traction or manipulation for 3 months, no joint mob near the replaced segments

Why do we need to look at muscle length when doing an upper cervical spine evaluation?

We are looking for contributing factors that could be causing the pain --> If someone is in pain, they won't want to move --> If they don't move, there will be adaptive shortening of the muscles that could cause more pain

When should you refer for consultation with congenital muscular torticollis?

When outcomes aren't fully achieved: -Asymmetries of head, neck, trunk are not resolving after 4-6 months of initial intense treatment -6 months of treatment with only moderate resolution -Infant is older than 12 months on initial exam and either facial asymmetry and/or 10 to 15 degrees of difference between right and left sides for any motion -Infant older than 7 months on initial exam and a tight band or SCM mass is present -Side of torticollis changes

What are some conditions that are classified as "neck pain with movement coordination impairments"?

Whiplash Clinical instability of the spine

What are some signs and symptoms of cervical myelopathy?

Wide base of support or unsteady gait Hyper-reflexia (87%), clonus Presence of pathological reflexes (Babinski, Hoffman's) Sensory disturbance in hands beginning in fingertips and progressing proximally Intrinsic muscle wasting of hands Loss of dexterity of the hands; difficulty with buttoning/unbuttoning shirt; opening cans Nonspecific weakness of extremities Sphincter disturbance Spasticity May be accompanied by neck pain, headaches, dizziness, radicular arm pain Symptoms are often unilateral or absent in upper extremities and bilateral in lower extremities Progressive hx with stable neurological function btw exacerbations

What are some characteristics of fibromyalgia syndrome?

Widespread pain Morning stiffness Fatigue Sleep disturbances Tenderness to palpation at multiple points Depression/anxiety Short term memory loss/lack of concentration Comorbidities (IBS, TMJ pain)

Describe: Balance and Gaze Assessment

You start off in supine, then go all the way to tandem Sx: dizziness, nausea, headaches, ringing in the ears, and feelings of imbalance Eye control: nystagmus, smooth pursuit, assess for visual changes DOCUMENTATION: How long it takes sx to come on, what they were, and how long it took for sx to resolve

concussion recovery risk factors

age: younger pts take longer to recover with peak at 13-17 (<13 heals faster); older adults prolong impairment sex: F have worse outcomes psych hx: depression, anxiety, other PMH/family hx of migraine

allodynia vs hyperalgesia

allodynia: association of pain with non-noxious stimulus hyperalgesia: heightened response to pain

TMJ physical exam

anatomy: teeth, cranial nerves (CN V), AO, subocc, SCM, scapular mm, cervical facet jts cervical/thoracic posture: pulls mandible into retrusion and depression (evidence insufficient) resting head on hand, facial asymmetries with speaking, smiling, blinking parafunctional habits opening/closing: C or S curve; pain? ROM: opening, lateral deviation, protrusion/retrusion palpation: extra- and intra-oral joint mobility resisted testing special tests

TMJ disc articulations

anterior: temporal bone (articular eminence), mandibular condyle, superior head of lateral pterygoid posterior: retrodiscal lamina/ligament medial and lateral ligaments

trigeminal autonomic cephalalgias

attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combo of those duration: 15-180 mins freq: every 2 days-8x/day pain: associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead/face sweating, miosis, ptosis/eyelid edema, restlessness or agitation

TMD muscle disorders

can be direct or indirect injury no joint sounds palpation of muscles reproduces and refers pain ipsilateral pain with activation, end range (decr ROM), inconsistent mandibular control masseter/temporalis: pain with palpation, possible trigger points, pain with end range/stretching, pain with activation (clenching), opening may be limited <40 mm lateral pterygoid: lateral facial pain (periauricular), pain with protrusion, opening, and contralateral lateral deviation tx: STM, posture, motor control, muscle relaxation, pt education about parafunctional habits, isometrics (to relax)

vestibulo-ocular PCD

can be r/i with sx at rest and no sx exacerbation by graded treadmill test sx: dizziness, vertigo, nausea, lightheadedness, gait/postural instability (possibly at rest), blurred/double vision, difficulty tracking objects, motion sensitivity, photophobia, eye strain/brow ache, HA worsens with vestibulo-ocular activities (ex. reading), balance impairments, impaired VOR, fixation, convergence, horizontal/vertical saccades

Differential diagnosis for cervical radiculopathy

carpal tunnel syndrome

hypomobility TMD: capsulitis and synovitis

causes: macro/microtrauma, tears or lengthening -> altered disc movement capsular pattern: limited opening <25 mm, ipsilateral C curve, limited contralateral lateral excursion ROM limited ipsilateral protrusion (lack of anterior translation) pain: biting, at rest, end-range accessory motion testing, ROM testing, palpation of lateral capsule/TMJ (esp posterior) tx: start with grade II jt mobs, proprioception, postural exercises

TMJ differential dx

cervical dysfunction peripheral and cranial neuralgias (especially trigeminal)

TMJ arthrokinematics: elevation

condylar head and disc translate posteriorly and superiorly (initiated by tension in retrodiscal ligament), then condylar head rotates anteriorly ("power stroke" eccentric contraction of superior head of lateral pterygoid)

posterior disc displacement (TMD)

disc is posterior to condyle causes: excessive opening beyond normal physiological ROM opened lock: unable to close mouth very painful, usually an ED situation to be relocated tx: motor control, proprioception to avoid end range, altered eating, manual therapy, postural exercises

explain how treat central sensitization (pt education and exercise)

education central sensitization = hyper responsive nervous system to protect tissues; pain is feedback tissue tolerance is lower so protect by pain line is lower have to get past that line to begin graded exposure and teach nervous system not to react exercise graded exposure: building intensity, duration, resistance over time stay below flare up line global vs. local exercise: walking, biking vs. DNF/DNE, UE

post concussion assessment classifications

ellis: 3 weeks post-concussion -PCD is split into 3 categories on results of clinical testing and pt sx -buffalo concussion treadmill test (physiologic) -BESS (balance) -VOMS (vestibulo-ocular) -cervical JPE (cervicogenic) collins: 1 week post-concussion -6 unique categories, not mutually exclusive: cognitive, cervical, vestibular, migraine, ocular, mood -based on pt sx and clinical testing -ensures multidisciplinary interaction as pt may need outside referrals (psych, neuro, etc.)

hypermobility TMD

excessive AROM opening >40-50 mm subluxation or dislocation TMJ/capsule TTP but no crepitus painful muscle guarding/tension may be asymptomatic joint sounds at end range of opening deflection to contralateral side may lead to disc displacement d/t altered joint mechanics tx: muscle activation, proprioception, avoid end range, manual therapy

TMJ disc characteristics

high water content: mobile when loaded; if you load part of the disc, the water is shifted to another part of the disc thin intermediate region: avascular/aneural, location of force during every bite thicker anteriorly and posteriorly: maximizes congruency to reduce pressure elasticity: superior > inferior

Describe the accuracy of the Upper Limb Tension Test (ULTT)

if someone has a positive upper limb tension test, it does not tell us WHERE the issue is (they may have issue of their nerves from their spinal nerve root, dura, brachial plexus, all the way down to the peripheral nerves)

physiologic PCD tx

includes cognitive, migraine, mood physical and cognitive rest: encourage normal daily routines and sleep schedule (no naps) accommodations if necessary sub sx-ic threshold moderate aerobic exercise program (based on treadmill test) require pts to actively participate in goal setting relaxation techniques avoid passive tx and modalities referral for mood and migraine

TMJ special test: separation clench

indication: distinguish b/t joint arthralgias and muscle disorders bite on tongue depressors placed between back molars bilateral depressors: pain indicates muscle or tendon pain unilateral depressors -ipsilateral pain: muscle or tendon -contralateral pain: jt arthralgia, capsulitis, synovitis, disc, etc.

What can you see in the oblique view of the cervical spine?

intervertebral foramen

TMJ arthrokinematics: lateral excursion

ipsilateral condyle: rotation/spin contralateral condyle: translation

TMJ muscles: lateral excursion

ipsilateral temporalis and masseter (unilateral contractions) contralateral medial and lateral pterygoids (unilateral contractions)

TMJ muscles: depression

lateral pterygoid (inferior fibers), suprahyoids, infrahyoids

what is second impact syndrome?

occurs when someone suffers a second concussion before recovering from a first brain loses ability to regulate ICP and CPP very rare! only 17 cases outcomes: permanent neurological impairment, death must consider this when pts return to sport

TMJ osseous structures

mandibular condyle -> mandibular neck -> ramus -> angle mandibular fossa of temporal bone -> articular eminence coronoid process synovial joint fibrocartilage

cervicogenic PCD tx

manual therapy: upper/lower C spine, upper T spine, stretching DNF/DNE JPE training: always progress; position, distance, UE movement, function, etc. periscapular motor control/strength

TMJ muscles: retrusion/retraction

masseter (deep fibers), temporalis, suprahyoids (digastric)

TMJ muscles: protrusion

masseter (superficial fibers), medial and lateral pterygoids

TMJ muscles: elevation

masseter, temporalis, medial pterygoid, lateral pterygoid (superior fibers)

TMJ joint mobility

medial/lateral glides -extraoral (did med in lab) -intraoral (did lat in lab) caudal glide/distraction: intraoral anterior glide: intraoral; opened 20-26 mm and pull on back mandibular molar basically anterocaudal translation: intraoral (did in lab); hooking motion using fingers under chin

primary headaches

migraine with/out aura tension HA trigeminal autonomic cephalalgias others: cough, exercise, sex, cold

cervicogenic HA differential dx

migraines: pulsating, unilateral, nausea, disabling, 4-72 hours in duration tension HAs: bilateral, episodic, tight band around head; difficult to distinguish from CGHA TMD vascular insults often a dx of exclusion after other HAs have been r/o

cervical collar use (evidence)

minimize usage may be used for quick relief when really irritable (5-10 mins max) do not let it become a crutch! give them other strategies such as leaning against the wall to rest neck wean pt off if they come in with it

TMJ intervention summary

must treat both sides pt education: sleep, ergonomics, relaxation, posture, pain science, stress manual therapy: STM, manual releases, IASTM, joint mobs (even if capsular issue), PROM, stretching therex: TMJ isometrics, posture, cervical mobility/strength, chin tucks, sidelying spinal rotation neuromuscular re-ed: relaxation (contract-relax), muscle coordination (touch and bite finger on same spot every time), joint proprioception (resting position vs. controlled mvts w/ mirror; and maintain during other exercises) Rocobado 6x6 = 6 reps 6x/day modalities: ice/heat are good, dry needling good; cold/LLLT and TENS maybe, US no

What nerve roots are most commonly affected by cervical radiculopathy? Which spinal segments are involved?

nerves: C6 and C7 because they're lower down the spine and have longer lever arm segments: C5 and C6 (nerves exit above)

What are the common sx of cervicogenic HA?

non continuous, unilateral neck pain and associated (referred) HA HA is precipitated or aggravated by neck movements or sustained postures dull ache that begins in neck or occipital region ram's horn pattern

TMJ arthrokinematics: protrusion/retrusion

protrusion: anterior translation; component of maximal opening retrusion: component of closing from maximal opening

physiologic PCD

r/i by symptomatic graded treadmill test (regardless of sx at rest) sx: HA exacerbated by physical/cognitive activity, nausea, intermittent vomiting, photophobia, dizziness, fatigue, difficulty concentrating, slowed speech

Clustered Findings for Cervicogenic Headache

restricted ROM palpable upper c joint dysfunction impairment in CCFT 100% sn, 94% sp CGHA

jaw functional limitation scale

score each item 0-10 0 = no limitation 10 = severe limitation so higher scores = worse function

What are the risk factors for cervical disc pathology?

smoking sedentary lfestyle poor posture excessive lifting

What are the cervical erector spinae muscles?

splenius capitis and splenius cervicis

80% of HA diagnosis is from the ________ part of your examination

subjective

non-cervicogenic HA

sx often severe and drastically limit daily activities can be pre/post menstrual cycle respond to vasoconstrictors like caffeine can be a result of diet: chocolate, wine, aged cheese sx: nausea, vomiting, light/sound sensitivity can be associated with concussion or whiplash, but not usually cervicogenic

TMJ red flags

tooth-related pain primary headaches secondary headaches: systemic, related to c spine, teeth, sinus/ear infection recent fevers/infections (ear/sinus) pain w/ eye movement and changes in vision (optic neuritis) hx of cancer psych disorders recent trauma (broken jaw) immediate referral needed: CNS signs: gait, balance, severe HA, weakness, slurred speech, hx of CVA, altered mental status sx and hx of cardiac pathology: can refer to orofacial area, can be angina; HTN can cause severe, systemic HAs