Cervical Certification Exam
1,000 case study: Best responses (good to excellent) were Lumbar sprain/strain at ______ (83.1% and 83.5%), disc herniation at ______ (60.7% and 65.8%), spondy at _____ (58.8%).
L4/L5; L4/L5; L4
1,000 case study: 56% of ____ herniations required more than 20 visits, 55% of ____ spondy patients needed more than 20 visits. Overall, 29% of patients needed more than 20 visits and 17% needed more than 30 vists. All patients are unique, very small percentage may need vastly more than these visits (100). Not every condition will respond in the mean 12 visits in 29 days.
L4; L4
High physical activity in youth prevents future...
LBP
Other 50% of individuals who do not recover pain/disability within 3-6 months of a whiplash injury report continuing symptoms up to ___ years or longer post-injury.
1-2 years
Active lumbar stabilization is divided into 4 stages representing muscle re-education, static stabilization, dynamic stabilization, and functional activities:
1. Abdominal obliques, transversus abdominis, and multifidus are facilitated 2. Lumbar spine is held in mid range while exercising, an alignment termed the "neutral position" 3. Restoration of correct pelvic tilting 4. Proprioceptive training and stabilization activities using a 65-cm gymnastic ball
Treatment parameters for long y-axis distraction
1. Automated distraction is never used to treat acute sciatic radiculopathy caused by IVD herniation. Only manual adjustment under distraction is used for these patients. Automated can be added after patient gets 50% better. Need careful tolerance testing and clinical decision making. 2. Tolerance testing used prior to automated distraction. Any increased extremity pain = don't use automated. Common for patient to feel some discomfort under doctor's contact hand. 3. Tolerance testing is done the same way except that you only hold for the time it takes for axial distraction to occur in the caudal section of the table. Test levels to be adjusted.
Patients who get 50% better but than fail to get further relief in a second month:
1. Continue conservative and rehab care 2. Seek other tx options 3. Being discharged
Benefits of long y-axis distraction
1. Doctor ease 2. Improved patient care 3. Conditions responsible for spinal stenosis like: Disc degeneration, ligament hypertrophy, facet degeneration, degenerative spondylo, degenerative thoracolumbar scoliosis, ligament calcification, and generalized spine pain respond greatly to this
3 beneficial effects of traction:
1. Suction: a subatomic pressure is induced when the bones move apart, with a centripetal effect on the contents 2. Distraction: increase in distance between articular edges may disengage a protrusion that was too large to shift during mere avoidance of compression during recumbency. X-rays have shown an increase in width of the joint of 2.5 mm. 3. Ligamentous tautening: Separation of the vertebrae tautens the PLL, which then exerts centripetal force on a central protrusion
4 capabilities with traction:
1. distraction of the vertebral bodies with enlargment of the intervertebral space producing a suction effect 2. stretching muscles with tautening of the PLL exerting a centripetal force on the adjacent annulus fibrosus 3. Separation of the apophyseal joints 4. Enlargment of the foramina
Proposed clinical objectives of spinal braces:
1. protect injured tissues to improve healing 2. protect spinal cord and nerve roots after unstable fx or dislocation 3. decrease pain 4. provide prophylaxis against reinjury or new injury 5. Correct spinal deformity 6. facilitate early reactivation after back injury
Of the 300,000 new laminectomies performed each year in the U.S., _____% continue to have significant pain.
15%
5-10 lbs of weight for cervical traction is increased to patient tolerance during the next two to three sessions until effective weight of ____ lbs (not to exceed ____ lbs) is reached.
15-20 lbs; not to exceed 35 lbs
Prevalence of chronic pain varies between _____% and ____% in different countries
16% and 71%
Mean IDP decrease as high as ____ KPa. Mean traction forces were as high as ____
168.7 KPa; 119.2 N
Conservative care recommended for at least _____ months before recommending surgical intervention unless severe neurologic deterioration takes place.
2 months
Unattended automated can be applied prior to or following this adjustment. _____ minutes at a distraction rate of _____ inches of decompressive distance. Should the patient feel any discomfort, they can stop it by pressing the stop button.
2.5-12.5 minutes; 0.5 to 2.5 inches
Optimal angle of tractive force in cervical spine is
20-25 degrees of forward neck flexion.
(with Cox decompression) Nerve root compromise improved in ___% to ___% of cases.
21%-80%
6 weeks of extension exercises increased extensor lumbar muscle strength by ____%
22%
GOIC muscles may be considered as _____
3 heads of a single muscle (common insertion)
In cervical spondylotic myelopathy patients undergoing laminoplasty, neck muscle strength recovered to the preoperative value by _____ months and increased to _____% by _____ months in the no pain group, whereas in the pain group, neck muscle strength remained reduced by _____% and did not recover.
3 months; 120% by 12 months; 60%
Mechanical principles of back braces:
3 point fixation with sensory feedback indirect transfer of load direct transfer of load insulation stored energy
(with Cox decompression) Conservatively treated herniations showed ___% of bulges, ___% of focal protrusions, and ___ to ___% of broad-based protrusions, extrusions, and sequestrations improved.
3%; 38%; 75-100%
Most efficacious way of stretching hamstrings =
30 seconds (no more and no less)
subacute (6-12 weeks) - active exercise tx results in ___% fewer work days and cost of care is ____% less at 9-month follow-up compared with conventionally treated patients
30%; 25%
kids who exercised ____ minutes per school day for 2 years showed increased bone mineral content of 3.0 percentage points and in width was 1.3 percentage points greater than the control group
40
After back school, ___% fewer consultations, ___% fewer physical therapy referrals, and __% fewer imaging procedures were ordered.
42%, 59%, 33%
TENS: high-frequency, low-intensity setup. Pulse frequency of 80 (+) and a pulse duration of 30 to 75 microseconds using moderate to strong sensory level intensity (no motor response). Patient should feel tingling/buzzing. ______ minutes with max of _____ per application. Patient should turn off TENS unit for an hour. Should use modification switch M to prevent accommodation to stimulation.
45-60 minutes, max 1 hour
Chronic LBP patients had quads/leg fatigue in ______% of patients, lower level of aerobic fitness than healthy controls
47.5%
3 sets of 20 second distraction sessions. Each 20 second session consists of...
5 four-second decompression distraction motions to the involved spinal level
_____ pounds of weight should be applied initially for cervical traction
5 to 10
_____% improvement will decrease treatment frequency
50%
___% of individuals recover from pain/disability within ___ months of a whiplash injury
50% within 3-6 months
Approx ____% of patients with FBSS report greater than 50% pain relief with SCS
50-60%
The prevalence of neuropathic pain and the degree of deterioration of quality of life (QOL) in 1857 patients with spine related chronic pain of at least 3 months with a VAS of at least 30 showed the overall prevalence of neuropathic pain was _____%.
53.3%
Only _____% of all patients with radiculopathy were diagnosed with neuropathic pain.
56.9%
Pre and post MRI of HNP (with Cox decompression?): ____ of disc herniations decreased in size, ___ unchanged, UUU increased in size
57%, 39%, 2%
Acute/subacute stage of whiplash, conservative treatment for minimally _____ months is recommended, active mobilization is better than passive treatment.
6 months
8 sessions on meditation was good for LBP in people over ...
65 yoa.
Patients with cervical spine myelopathy treated surgically finds up to ___% can expect improvement in their quality of life.
70%
1,000 case study: Overall response to care was ____%
70.7% (good to excellent)
Lumbar disc herniations are seen in ___% of the normal asymptomatic population. In symptomatic patients, ___% showed disc herniations.
76%; 96%
Treatment of subacute/chronic patients with cervical spine disc herniation, ______% were improved at 3 months treated with HVLA.
76.2%
____% of medial, ____% of posterolateral, and ____% of lateral herniated discs retracted under 45 kg of distraction in 28 of 30 patients studied.
78.5%; 66.6%; 57%
1,000 case study: Within 6 weeks, _____% of LBP attacks will resolve. In this... following the algorithms shown earlier in this chapter in making decisions on the management of LBP patients and using Cox protocols accordingly, only _____% of patients progressed to chronic stage of pain. Normally, fewer than _____% of LBP patients progress to the chronic stage.
80-90% 8.7%; 20%
Posterior-to-anterior forces applied during manual traction were as high as ____.
82.6 N
___% of ortho surgeons prescribe spinal orthoses
90%
Worst collar is...
Aspen Vista
Best collar is...
Aspen collar
_____ test for management of chronic LBP rehab is excellent.
Biering-Sorensen
C5-C6 IVD is innervated multisegmentally from neurons of the...
C2-C8 dorsal root ganglion and sympathetic ganglion
In the aged, attention should be given to _____ for stenosis requiring decompression.
C2/C3, C3/C4, and C4/C5
(cervical distraction) Greatest reduction was at ____, then ____, then ______ with a greatly reduced drop at _____.
C4-C5, then C6-C7, then C5-C6 with a greatly reduced drop at C7-C1
When using occipital restraint and applying distraction of C5-C6, all disc pressures from _____ drop.
C4-C7
80% of brachialgia patients show elongated...
C7 transverse processes
DO NOT COMPRESS ____
C7/T1
____ and ____ may cause cervicogenic headaches.
Cervical facet arthropathy and occipital neuralgia
The ______ brace gives above-average correction.
Cheneau light scoliosis
Manual distraction:
Controlled. Can be done manually or with a table. Need a keen sense of tissue-tension
Thoracic spine traction indicated with generalized pain like with _____. With nerve root pain, _____ is treatment of choice.
DDD; Maitland
Can use automated distraction with thoracic adjustment. Can use either occipital or feet restraints, but...
DO NOT USE BOTH RESTRAINTS.
1,000 case study: _____ has the greatest chance of becoming chronic (14%) and _____ is second (10%). Overall, 9% of patients required care for more than 90 days. Critical to prevent condition from becoming chronic.
Disc herniation; facet syndrome
______ techniques are more effective than conventional tx
Dynamic muscular stabilization
Gravity traction:
Either gravity boots, flexion apparatus at the waist, or chest harness application called Gravity Lumbar Reduction. Latter system found to handle 70% of patients with protruding lumbar discs without needing surgical reduction. Also used for lumbosacral strain, mechanical back syndromes, spondylolisthesis, scoliosis, lateral recess stenosis, post-surgical fusion spines, and postsurgical management of patients with residual pain. Approximately, 5% of patients cannot tolerate distractive manipulation.
______ is effective in reducing the intensity and prevalence of LBP in kids.
Exercise
IT IS TRACTION, NOT _____ or _____, THAT DROPS INTRADISCAL PRESSURE
FLEXION OR EXTENSION
______ test is useful to examine children with cervicogenic headaches.
Flexion-rotation
Pfirrmann Grade 1:
Homogenous with a bright, hyperintense white signal intensity and normal disc height
Griffith Grade 2:
Hyperintense (>presacral fat and <CSF) hypointense intranuclear cleft, distinct, normal
Griffith Grade 3:
Hyperintense, although < presacral fat, distinct, normal
Griffith Grade 6:
Hypointense, indistinct, 30% reduction in disc height
Pfirrmann Grade 5:
Inhomogenous with hypointense, black signal intensity. Lost distinction, disc space collapsed. Grading performed on T2-weighted midsagittal fast spin-echo images
Pfirrmann Grade 4:
Inhomogenous with hypointense, dark gray signal intensity. Lost distinction between nucleus/annulus, disc height normal or moderately decreased
Pfirrmann Grade 2:
Inhomogenous, hyperintense white signal. Clear distinction between nucleus/annulus, disc height normal, with/without horizontal gray bands
Pfirrmann Grade 3:
Inhomogenous, intermediate gray signal intensity. Unclear distinction between nucleus/annulus, disc height normal or slightly decreased
Cox:
Manual controlled distraction to IVD space and articular facets with patient positioned on a table designed for its application and described later in the chapter. When under distraction, the facet articulations are manipulated throughout their physiological ranges of motions.
Intermittent traction:
Manual or mechanized. Coplans uses 12 rhythmic distractions per minute. Knees/hips are supported in flexion in order to abolish lordosis and increase the efficiency of traction. A 30 to 40 kg intermittent pull is used for ten minutes.
Griffith Grade 4:
Mildly hyperintense (slightly > outer fibers of annulus), indistinct, normal
______ to address TMD improves manual cervical spine tx for headaches.
Orofacial manual therapy
When to perform protocol 1 vs. 2
Protocol 1 is for radiculopathy Protocol 2 is for no radiculopathy (can have radiating pain, but cannot be dermatomal in nature)
Multifocal lesions of the cervical spine include
RA and endogenous cervical fusions
Chiropractic improves cervical ____ and ____ for whiplash
ROM and pain
Pelvic belt decreased...
SI joint laxity and decreased their mobility.
First thoracic rib ligament creates a narrow interval between the ligament and first rib that the ______ traverses before crossing the first rib superiorly and contributing to the inferior trunk of the brachial plexus.
T1 ventral ramus
For thoracic hernations, contact the posterior arch of the segment below the disc to be distracted (T7-T8 disc, use ___ contact). Use occipital restraint and protocol 1 rules above.
T8 contact
inferior gemellus actions
same as superior gemellus
obturator internus actions
same as superior gemellus
Cervical spine cord compression may lead to ______ due to irritation of the spinothalamic tract.
sciatica
Use positive pole on site of pain because it's _____ and _____ in reaction. Exceptions: inflammation is prolonged to cause distinct organic tissue changes (fibrous adhesions) - use negative pole to _____ and ______.
sedative and acidic; liquefy and vasodilate
79.6% of the nerve fibers innervating the disc were _____ nerves and 20.4% were ______ nerves
sensory; autonomic
It's recommended to check _____ in cases of CSM where standard imaging and clinical manifestations do not fully match.
serum VB12 levels
Both uncoordinated finger motion and trick motion of the wrist were more frequent in myelopathy patients. Uncoordinated finger motion was associated with ______.
severity of myelopathy
Acute phase of low back pain management
short-term rest, ice, meds, gradual muscle stretching/strengthening
Static traction:
shorter periods of traction with higher weights are applied for a few minutes to 30 minutes. Split tables are most effective and reduce friction.
The nerve formed from the vertebral nerve to the disc was termed the...
sinuvertebral nerve.
superior gemellus may be
small, absent, or may be doubled and inserted into the hip joint. May fuse with piriformis or gletus minimus muscle.
Resection of DISH osteophytes shows...
some regrow to cause dysphagia
Failed back surgery syndrome (FBSS) can be helped with ____. BUT!...
spinal cord stimulation (SCS) Success rate has not been more than 41% in the long term. Better to carefully select patients for surgery.
Myelopathy treated surgically responds poorer if caused by _____ than disc herniation.
spondylosis
CSM may be caused by _______, particularly during neck extension.
static and dynamic spinal cord compression
Intermittent traction has the best results when compared to...
static traction, manual traction, and no traction.
Disc herniations in the cervical spine most commonly manifest as....
suboccipital neck pain/headache with/without radiation to the retroauricular or retro-orbital region
Pulsed radiofrequency current for the ______ is safe/effective for patients with shoulder/suprascapular pain and also for headache that is attributed to the lower cervical nerve roots. Should be tried after conservative treatment fails.
suprascapular nerve
The vertebral nerve is the ____ nervous system accompanying the vertebral artery.
sympathetic nervous system
Autonomic roots arise from the ______ which can be traced to the _______ in the mid cervical spine and ______ in the lower cervical spine.
sympathetic plexus; grey rami communicantes; stellate ganglion
Calcification of which ligament is most common in CPPD?
the cruciform ligament (use a CT scan of C1/C2 joint to assess status of this ligament)
Calcium pyrophosphate dihydrate deposition disease is especially acute in...
the elderly
Screws from anterior cervical spine fusion perforate....
the esophagus and pass through the bowel
72-year-old woman with herpes zoster and cervical spinal stenosis at ...
the same spinal level
maximal or submaximal effort can reverse...
the selective atrophy of type 2 fibers in the multifidus muscles in men
a nociceptive pathway that originates in the meninges and carries pain signals through meningeal nociceptors to the spinal trigeminal nucleus and from there to the cortex through relay neurons in the thalamus
the trigeminovascular pathway (involved in migraines)
Neurons in the nucleus of the diagonal band of Broca, the dopaminergic cells group a11/a13, the ventromedial and ventral tuberomamillary nuclei of the hypothalamus contain acetylcholine, dopamin, cholecystokinin, and histamine (respectively).
the trigeminovascular pathway (involved in migraines)?
These forebrain/hypothalamic projections to posterior and lateral posterior may play a role in those migraine attacks triggered by disrupted sleep, skipping meals, and emotional reactions.
the trigeminovascular pathway (involved in migraines)?
(cervical distraction)The hand contact on the arch of the vertebra is made by contacting the spinous process in .... Lift the cervical spine to ....
the web of the first and second digits with the thumb and index fingers gently but firmly securing the arch of the vertebra reduce cervical sagittal lordosis while applying long y-axis distraction.
when the hip is flexed, the superior gemellus aids in...
thigh abduction
Migraines: the headache phase of a migraine attack is mediated by activation of the _______ pathway
trigeminovascular
For upper thoracic spine pain and loss of ROM, do the following
upper 4-6 segments laterally flexed, then flexed and extended
CSF _____ was significantly reduced in cervical spondylotic myelopathy.
velocity
Somatic root stems from the _____ at each segmented level, while the autonomic roots are derived from the _____.
ventral ramus; vertebral nerve
Anterior cervical discectomy and fusion (acdf) has been a _____ procedure in the management of _______.
very successful; cervical radiculopathy and myelopathy
General disc herniation traction treatment should be followed up with a ____
well fitted lumbar support
High power laser therapy is effective in treating....
whiplash
Acute stage of whiplash is associated with
widespread pressure hypersensitivity and reduced cervical mobility
WIth lateral flexion in cervicals, first use...
y-axis decompression
The most effective form of scoliosis care with the least side effects is _____.
yet to be determined
_____ disabled patients more difficult to rehab
young
Workers who perceive a benefit to belt wearing should wear it on a trial basis if:
They are screened for cardiovascular risk by medical personnel Need to be educated on lifting mechanics Full ergonomic assessment has been made of their job Should not be considered for long term use
_______ is the phenomenon of connective tissue becoming more fluid when it is stirred up and more solid when it sits without being disturbed. Poor nutrition and sedentary habits weaken all the connective tissues, stiffen them, and accelerate their biological aging.
Thixotropyis
Contraindications to traction
Tumor Infection Signs of vertebrobasilar or carotid spasm or ischemia Instability (e.g. RA) Pregnancy Acute sprains and strains Claustrophobia with cuffs/harnesses Aortic Aneurysm Vascular insufficiency of the lower extremities TMD (particularly to avoid cervical traction and harnesses that contact the jaw) Advanced cardiovascular disease including uncontrolled hypertension Large disc prolapses causing cauda equina syndrome Lumbago with severe pain on movement Osteoporosis
Griffith Grade 1:
Uniformly hyperintense, equal to CSF, distinct, normal height
_____ patients have less relief
Workers compensation
Spinal Cord Stimulation (SCS) works by...
Works by means of pain gate with greatest concentration of alpha/beta fibers in dorsal columns being stimulated leads to inhibition of C fibers.
Lifetime prevalence of LBP was:
Wrestlers - 54% Tennis players - 32% Football players - 37% Gymnasts - 79% Golfers - 33% Skiers - 65% Rowers - 63%
Protocol I for Cervical Spine
Y-axis distraction with or without flexion. Tolerance test, then apply below patient pain.
General disc herniation traction treatment has an effective treatment time which ranges from ___ to ___
a few days to 2 weeks
Suicide ideation greater if chornic LBP patient is...
a heavy smoker and has issues with alcohol
Patients with chronic neck pain demonstated ____, ____, and ____ during walking with the head movements and at maximum speed compared to the control group.
a narrower step width, a shorter step length, and a slower gait speed
May want to use electric modality before tx if ....
a patient fails tolerance testing.
C3-C8 sinuvertebral nerves arise from...
a somatic and an autonomic root.
The sinuvertebral nerves at C0-C1, C1-C3, and C2-C3 intervertebral levels and their anterior intraspinal distribution arose from two roots...
a somatic root (from the spinal nerve or ventral ramus or both) and a sympathetic root (from the vertebral artery plexus or superior cervical ganglion).
During brace use, patient performs Cox exercises at home, and patient is encouraged to actively participate in rehab both in clinic/at home. Recommend using ...
a wobble board, extension exercises on office machines, and other exercises to gain flexibility and strength as relief allows.
Patient will have better pain relief from TENS unit if they are:
a) well hydrated; b) patient diet is appropriate with enough protein and supplemental amino acids, particularly trytophan and D-phenylalanine; c) electrode pattern and placement sites are correct; d) correct TENS parameters are selected; and e) patient compliance is ensured.
When pain below the knee goes away, increase _____. Add ______ to distraction adjusting. Encourage ____. increase _____
active care intensity; additional ROM; more activity; amount and intensity of rehab
Never use traction when there has been ____ to soft tissue
acute trauma
23.9% of the nerve fibers innervating the disc were ________ nerves, 8.9% were _______ nerves, and 11.5% were ________ nerves. This may explain...
afferent sensory pain-related; efferent sympathetic; efferent parasympathetic This may explain the wide-ranging and chronic discogenic pain that occurs via the somatosensory and autonomic nervous system.
Factors related with VAS scores 6 months after whiplash were ____.
age, dizziness, self-employed workers, and VAS and Northwick Park neck pain questionnaire scores at initial evaluation.
When applied to cadavers at lower cervical regions from C4-C7....
all segments showed a decrease in intradiscal pressure
Following galvanic: 10-15 min of heat followed by 5-10 min of cold. 3-4 heat sessions with 2-3 cold sessions. Begin/end with heat. Then massage with _____
analgesic liniment.
Cervical disc replacement seems about as good as _____, but we don't know its long term safety/efficacy.
anterior cervical discectomy and fusion (ACDF)
Tai-chi is good for patients with...
arthritis
Intradural schwannoma and disc herniation may occur ____
at the same cervical spine level
Back belts do not reduce risk of...
back injury
Leg lifting is not necessarily better than ...
back lifting
Rehab starts at _____, depending on pain and weakness limitations
beginning
Negative recommendations for ___ and ___ with whiplash.
botox and corticosteroid injections
Pain was better for subjects treated with ____ than for those planning ____.
braces; surgery
No difference in scoliosis care outcome is reported for ____ versus ____.
bracing vs. surgery
innervation of the superior gemellus =
branch from nerve to obturator internus from sacral plexus containing fibers from L5-S2 spinal nerves
innervation for inferior gemellus
branch of nerve to quadratus femoris from sacral plexus and lumbosacral trunk containing fibers from L4-S1 spinal nerves
2 bursae in the hip
bursa of obturator inernus (deep to the tendon, winds around lesser sciatic notch). Another sometimes found between common tendon of GOIC and capsule of hip joint. This one usually communicates with bursa of abturator internus. Another one (trochanteric bursa of gluteus maximus) in retrotrachanteric region covers much of the posterior aspect of the greater trochanter and may have multiple compartments
Foramen magnum pump procedure
can use hand or occipital restraints and then contact anywhere along the spine (even sacral base for a full spine decompression).
before/during automated distraction with thoracic adjustments...
careful tolerance testing is performed
Patient needs to feel that the ______ and they are being empowered to master the exercise techniques while being aware of their skills and abilities.
caregiver communicates well
Gluteal muscle nerve entraptment =
cause of proprioception alteration, aterial and/or venous obstruction, sexual dysfunction, perineal and inguinal pain, as well as pelvic and sciatic pain
structure of low back pain class:
causes of LBP Ergonomics Exercise family/friends taught how to apply hot/cold therapy and liniment massage at trigger points return to normal ADLs as pain allows
Tinnitus is analogous to ______.
central neuropathic pain
Increasing _____ with aging is thought to cause cervicogenic headaches to become more frequent.
cervical degenerative joint disease
Brown Sequard Syndrome can be caused by...
cervical disc herniation (also stenosis may contribute to issue)
Vitamin D may be related to .....
cervical disc herniations
For scoliosis with cervical spine
cervical headpiece in rotation to de-rotate convex curve and axial distraction with lateral flexion into the convexity
Sagittal alignment of the cervical spine may play a substantial role in the development of _____, as cervical deformity can lead to ______.
cervical myelopathy; spinal cord compression and cord tension.
Brachioradial pruritus may result from .....
cervical nerve compression, and rarely, it may also stem from degenerative changes
Surgical correction of cervical myelopathy should always take into consideration ________, as decompression alone may not decrease ______.
cervical sagittal alignment; cord tension induced by kyphosis.
Muscle dysfunction is a more crucial factor than disc degeneration as a cause of ________.
cervical spinal instability.
Brown sequard syndrome occurred in a patient with OPLL after .....
cervical spine manipulation and intradural disc herniation
The prevalence of neuropathic pain and the degree of deterioration of quality of life (QOL) in 1857 patients with spine related chronic pain of at least 3 months with a VAS of at least 30 was relatively high in patients with ____ and _____ and relatively low in those with ____ and ____.
cervical spondylotic myelopathy (77.3%) and ligament ossification (75.7%) ; low back pain (29.4%) and spondylosis (40.4%).
Torg-Pavlov ratio was the most important predictive factor of _____ in patients with ____.
cervical spondylotic myelopathy (CSM) in patients with lumbar spinal stenosis (LSS).
Congenital cervical stenosis may be associated with ______.
cervical spondylotic myelopathy.
C1-C2, C2-C3 facet joint injections and C2, C-3 spinal rami blocks were effective and well tolerated for tx of _____
cervicogenic headache.
Predisposition towards respiratory dysfunction in ....
chronic neck pain patients.
Successful treatment of acute whiplash requires....
combination of education, physical treatments such as activation, manual therapy, and gentle exercise
Patient who fails to attain 50% improvement within 1 month of care is evaluated for _____. Give other options. If ______, patient given option of continuing distraction adjustments for another month. If still not 50% better, refer for appropriate consultation, imaging and testing, and (co)management.
compliance; noncompliant
Disc bulges on ____ side and contracts on the _____ side.
concave; convex
With whiplash, the following can amplify or modulate the pain experience and influence recovery
coping skils, self-efficacy, and psychological responses
Prevention of low back pain:
correcting posture, lifting techniques, effective warm-up period, training methods, elimination of negative environmental conditions
Severe sciatica patients are treated _____, less severe nonsciatic pain are treated from ____ to ___, depending on pain and disability.
daily; daily to two to three visits weekly
Most common physical finding in patients with chronic LBP is...
deconditioning
Sagittal alignment of the cervical spine had some impact on the progression of ______ changes of the cervical spine with aging; however, it had no correlation with the occurrence of _____.
degenerative; future clinical symptoms.
Electrical stim used after distraction with hot/cold therapy to involved disc and acupressure points. One positive pad is placed _________ with the negative pad next to it, and the other positive pad can be placed on _______ to sedate the sciatic nerve there, or it can be placed _________ with the negative pad opposite to it. The active pole should be the smaller electrode.
directly over the disc protrusion; the gluteal region or over B54 in the popliteal space
Static lumbar traction opens the ____ and _____, reduces the _____, and opens the anatomic structures of the lumbar spine.
disc and apophyseal joint spaces; herniated nucleus pulposus
Disc herniations may cause erectile dysfunction, but this can be alleviate with...
disc decompression
Muscle degeneration is as common as ___ in lumbar area
disc degeneration
Most common symptoms for VBAI
dizziness, vertigo, light-headedness
inferior gemellus may be
doubled, rarely absent. may fuse with quadratus femoris
DISH leads to
dysphagia
Conservative treatment is ______ in CSM patients. If deterioration occurs, timely ______ is effective.
effective; surgical intervention
Direct current decomposes liquid as it passes through it (_______). The liquid decomposed is the electrolyte and the parts of the separated electrolyte are the ions. Current enters the electrode by the anode (positive pole) and leaves by the cathode (negative pole).
electrophoresis
Pain immediately posterior to greater trochanter may be result of ....
entrapment of nerves to gemelli, obturator internus, and quadratus femoris
Tarlov cysts in the cervical region are treated with .....
epidural steroid injection
Anterior disc nerve innervation is ______. Posterior disc innervated by the _______ and lateral / anterior portions supplied by ________.
equivocal; sinuvertebral nerve; grey rami communicantes from the sympathetic ganglionated chain.
It does not say use y-axis distraction first before what in cervicals
extension
Headache can be caused by neck pain generators in the....
facet joints
Esophageal perforation with anterior cervical disc surgery can be...
fatal or neurologically damaging
Most patients with brachioradial pruritus are ....
female with bilateral presentation
Rotation for cervicals
first y-axis and then rotation
Circumduction for cervicals...
first y-axis decompression, then flexion, followed by lateral flexion. May have cavitations.
Dr. Cox only uses Y-axis decompression until at least 50% relief, then...
flexion and lateral flexion as tolerance testing allows.
No difference between _____ exercises
flexion/extension
Cox doesn't use ____ with long y-axis distraction. Increases _____.
flexion; IDP
obturator internus origin ___ and inserts into ___
from the pelvis surface of the obturator membrane and surrounding bones ; inserts into greater trochanter medial surface in union with gemelli tendons
Protruded L3/L4 disc - L4 nerve root compression - pain in ...
front of the thigh and leg, involves the femoral nerve
Yoga improves...
functional disability, pain intensity, and depression in adults with chronic LBP Also, yoga reduces meds
Elastic lumbar belt wearing in subacute LBP significantly improves...
functional status, pain level, and pharmacologic consumption.
Usually, gluteus maximus has two other bursae associated with it:
gluteofemoral bursa (between tendon of gluteus maximus and vastus lateralis?) and ischiogluteal bursa (between muscle and ischial tuberosity)
anterior aspect of greater are bursae associated with tendons of
gluteus medius and minimus (trochanteric bursa of gluteus medius and trochanteric bursa of gluteus minimus)
Bent knees / straight back not a...
good way to lift
Degenerative disc disease is not ideal for HVLA, but...
great for Cox
Adult scoliotic patients choosing surgical correction show...
greater curve intensity and more frequent leg pain
Cervical cord compression (CCC) was not significantly associated with any myelopathic signs but was significantly associated with _____.
grip and release test, 6-m walking time, step length, and chair-stand time.
______ programs decrease pain and increase bone density and quality of life of both osteoporotic and osteopenic women
group exercise
Too much ___ too early after whiplash is associated with delayed recovery.
health care
Two different mechanisms underlie cervicobrachial pain:
herniated discs and spondylosis.
Chronic phase of low back pain
high intensity exercise to restore lumbar and lower extremity ROM and muscle strength
Cervical spine surgical screw dislodges and ends up in _____
hilum
GOIC function as...
hip stabilizers
Alkaptonuria ochronosis:
homogentisic acid, blue black cartilage, calcified cartilage, black urine.
TMD increases with....
hyperlordosis
Most common signs of myelopathy: _____.
hyperreflexia (94%), Hoffmann reflex (81%), Babinski sign (53%), and ankle clonus (35%).
Griffith Grade 5:
hypointense (=outer fibers of annulus), indistinct, normal
Griffith Grade 7:
hypointense, indistinct, 30-60% reduction in disc height
Griffith Grade 8:
hypointense, indistinct, >60% reduction in disc height
Each sinuvertebral nerve sends a large branch to the disc _______.
immediately below
Spinal cord movements, i.e. cord displacement and velocity in the cranio-caudal axis, were ______ in CSM patients.
increased
Increased levels of spinal cord segments involved = _______.
increased gait deterioration in patients with cervical spine myelopathy
Maternity support belts have insufficient benefit and do cause...
increased pain, fetal heart rate changes, and skin reactions.
Pyramidal signs correlated with _______.
increased severity of myelopathy
Chronic LBP requires ....
interdisciplinary and biopsychosocial tx and exercise therapy
After 6 months of conservative treatment for whiplash, it is recommended to pursue...
interventions
The widened disc space causes ____ to drop and probably creates a negative intradiscal pressure that draws the herniated disc material back into place.
intradiscal pressure
muscle belly of obturator internus is located _____, turns tendinous as it...
intrapelvically; exits through the lesser sciatic foramen
Imaging: DTI for ______. Dynamic MR, but don't use MR for _______ based exclusively on extension MR.
involved tracts; asymptomatic spinal compression
A minor trauma to the neck can lead to ______ spinal cord injury for patients with CSM with cervical instability.
irreversible
Superior gemellus originates at the ______ and inserts onto the ______ in union with the tendon of the obturator internus.
ischial spine; medial aspect of the greater trochanter
Inferior gemellus originates from ____ and also inserts on ____
ischial tuberosity; medial aspect of the greater trochanter in union with tendon of obturator internus
hab starts 0-6 weeks with telling patient...
it's okay to move with acute LBP
for low back pain, Water-based exercises were better than...
land-based exercises
___ herniations regressed greater than ___
larger; smaller ones
Vertebral nerve supplies ___ areas of the cervical discs.
lateral areas
Superior gemellus action =
lateral rotation of the thigh
General disc herniation traction treatment should be less than ___ minutes
less than 10 minutes
Lumbar flexion is good for...
lifting
The interspinous spaces are seen to increase during distraction, with the _____ becoming thinner. It is felt that facet joints separate and the posterior longitudinal ligament stretches.
ligamentum flavum
Static posture ->
local muscular ischemia
With cervical spine cord compression, _______ is rare and is almost always a part of either regional or widespread pain.
localized neck pain
Constant continuous traction:
low weights over long periods of time, up to several hours. Aim = attain a restful and sustained position of the spine.
The anterior and posterior ligaments are stretched under distraction. The posterior longitudinal ligament is stretched, and it may "push back" the herniated disc toward the space. Therefore, the herniated nucleus pulposus is reduced by the combination of ....
lowered intradiscal pressure drawing the nucleus pulposus back into the disc space and retraction of the posterior longitudinal ligament pushing the disc back.
Thoracic spine erector spinae muscles fatigue more than the...
lumbar counterpart in LBP patients
Coexistent cervical spondylotic myelopathy (CSM) and lumbar spinal stenosis (LSS) patients is significantly more common among ____ compared with ____.
males compared with females
Syrinx (syringomyelia, a fluid filled cyst in the spinal cord, usually a chiari malformation sequela)
may resorb following herniated disc surgery
Arm squeeze test positive when VAS of 3 point or higher on squeezing the ______ compared to the AC joint and anterolateralsubacromial area
middle third of the upper arm
Chiro is good. CAM is _____ in the management of chronic headache.
modest
Nerve supply of IVD is....
multisegmental and both sympathetic and parasympathetic.
Sagittal cervical and thoracic curves predict....
neck pain
Associated conditions accompany whiplash like....
neck pain, headache, dizziness, unsteadiness, and restricted function.
innervation of obturator internus
nerve to obturator internus from sacral plexus containing fibers from L5-S2 spinal nerves
Low back belt use can cause a lack of ...
neuromuscular coordination of the abdominal muscles
Surgery and conservative treatment of neck pain with or without radiculopathy or myelopathy show _______.
no difference in clinical outcomes.
Cervical spine stenosis with radiculopathy responds to ______.
non-surgical care.
Athletic activity and sports participation is usually allowed for patients undergoing ____ for scoliosis care. Return to sport after surgical correction is _____, and caution should be taken when decided on participation in collision activities such as football and wrestling.
nonoperative treatment; variable
A new concept in headache etiology is one in which ______ may well be significantly underestimated.
noxious cervical afferent information
____ restraint is primarily used for adjusting the thoracic spine
occipital
Deep tenderness posterior and at the upper one third of the greater torachanter is most likely tenderness of ....
one of the gemelli or obturator internus and quadratus femoris muscles
Single-lesion pathologies of the cervical spine causing sleep apnea include
osteochondromas, osteophytes, etc.
Neural tissue has been found within the _____ of the annulus fibrosus with the posterior disc innervated by the _______ and laterally by the ______.
outer third; sinuvertebral nerve; vertebral nerve (sympathetic chain grey rami).
Maximum gait speed was moderately correlated with _______
pain intensity/disability
Cervical radiculopathy increases postural faults more than...
patients without it
Results indicate that cervical cord compression (ccc) correlates with _____ from an early stage of the disease before ______.
physical performance measures; myelopathic signs appear
Occipital-cervical misalignment pre- and post-cervical fusion surgery may
predispose patients to sleep apnea.
How to treat goic, trochanteric bursitis, etc.
pressure point therapy, positive galvanism and tetanizing current, distraction of gemelli/piriformis/obturator internus tendons, stretch techniques, trigger point injections if all else fails, perhaps acupuncture.
Inflammation of the trochanteric bursa of the gluteus maximus can lead to....
pseudoradiculopathy where sciatica like pain radiates into posterior thigh. Incidence in chronic low back pain patients is 35%.
Pathophys findings on LBP patients:
psoas, erectors, multifidi were smaller. had more fat deposits. had greater disc degeneration. weaker maximal isometric strength of trunk muscles.
Important role of _____ in blood supply of spinal cord has been established. The ______ of these microvessels suggests an important role in intraradicular circulation.
radicular arteries; autonomic nerve innervation
Lumbar braces are recommended for patients with herniated lumbar discs with... When patient gets 50% relief, brace use is reduced to 50% of time, discontinued with another 50%.
radiculopathy, instability (defined in chapter on facet syndrome), degenerative spondys, and severe LBP.
In whiplash, radiofrequency treatment of the ____ of the ramus dorsalis is recommended
ramus medialis (medial branch)
Synovial cysts are....
rare
Crowned dens syndrome is a....
rare CPPD (pseudogout) of the periodontoid tissues
synovial cysts (retro-odontoid cysts) of the atlantoaxial joint are _____
rare with 20 cases reported overall
Foramen magnum pump used as a ...
relaxation type adjustment or preparation prior to other adjustment procedures
Decrease syrinx size by foramen magnum decompression may....
restore cervical lordosis
Effects of back braces on biomechanics:
restrict motion influence posture redistribute load within a segment decrease total spinal load change temp of superficial trunk decrease work of trunk muscles
Axial traction - protruding disc diminishes in volume but rarely _____. Significant intradiscal negative pressures may be produced. Intermittent reduction appears to allow reparative processes to re-establish support.
returns to its normal state
Goals for disc spaces with traction are:
Widening of the IVF Widening of the disc space Traction of the paravertebral muscles and ligaments Correction of vertebral joint deformities Volume increase of disc tissue
Further discussion on the use of traction in flexion/extension/plain distractive modes is decided by:
1. If extension is pain-free and flexion hurts, traction will be comfortable if given in slight extension 2. If both flexion/extension are painful (or neither) distraction of the joints with the articular surfaces parallel may be tried 3. When extension is painful and flexion pain-free, the distraction should fall mainly on the posterior part of the joint. The lumbar spine needs to be in a slight degree of flexion to achieve this.
