OCS - Cervical Spine and Cranial Nerves

A 68 year old male presents to PT with forward head posture and hx of decompression and laminectomy at C3-C4 two years ago. Your examination reveals that he only has pain at end range with cervical retraction. According to the McKenzie method, which group should you classify this pt?

Dysfunction -- typically pt's are classified into the dysfunction category when they experience pain at end range

Treatment Based Classification - CPG Recommendations Recent onset of sx No radicular sx

Mobility Manual therapy and exercise Cervical mobilization (thrust and non-thrust) Thoracic mobilization (thrust) ROM and flexibility exercise

You are considering performing a cervical manipulation on a patient. You review the medical history. Which pathology is not predisposed to cervical instability or ligamentous laxity? a. RA b. Cervical spondylolisthesis c. Morquio syndrome d. Marfan syndrome

b. Cervical spondylolisthesis -- though a common cause of cervical radiculopathy and probably not the best treatment of choice, it has not been shown to be associated with cervical instability

Which of the following is not a sign of cervical myelopathy? a. gait disturbance b. Grade 1+ biceps tendon reflex c. positive Babinski's test d. positive inverted supinator sign

b. Grade 1+ biceps tendon reflex

The best neurologic screening test to rule in the diagnosis of cervical radiculopathy is: a. weak abductor pollicis brevis demonstrated on MMT b. decreased light touch sensation in a dermatomal pattern c. reduced or absent Biceps Brachii DTR d. Positive Hoffman's reflex

c. reduced or absent Biceps Brachii DTR -- corresponds to the C5 nerve root, a relatively common level to be affected by a radiculopathy

Bassett's Lesion

entrapment of the lateral antebrachial cutaneous nerve; it only affects sensation to the skin of the lateral forearm, is most common in overhead athletes and is reproduced with extension and pronation of the elbow.

Oculomotor-3

eye movement (up, down and medial) lid elevation pupil constriction

Trochlear-4

eye movement downward and medial, motor controls the superior oblique muscle of the eye

Abducens-6

eye movement, motor lateral rectus muscle, responsible for outward gaze

Facial-7

facial expressions, motor facial symmetry open eyes wide, close them tight smile, puff cheeks taste (anterior 2/3 tongue) secretion of tears and saliva

Trigeminal-5

facial sensation, chewing, BOTH stimulates movement in the jaw muscles test masseter with clenching

Charcot-Marie-Tooth disease

hereditary condition characterized by progressive degeneration of the muscles of the lower leg -disorder affects the tibialis anterior (weak) and peroneus brevis (and sometimes longus)(strong), intrinsic muscles of the hands and feet => cavovarus and hammer toes, also associated with scoliosis and hip displasia as well

TLA Test

https://www.youtube.com/watch?v=xYAUxdXfDyU

Headache red flags

-Sudden onset -Worsening or changing of sx - neuro signs, dizziness -Headache triggered by cough, valsava, exertion (subarachnoid hemorrhage) -Headache triggered by pregnancy, delivery -age >50

What pathology is involved with degenerative spinal stenosis?

-The intervertebral disc undergoes significant degenerative changes -subsequently this leads to collapse of the disc and facet arthritis which tends to narrow the neural foramina -narrowing of the spinal canal may result anteriorly from disc protrusion or posteriorly from ligamentum flavum and facet hypertrophy -on a mechanical basis, the neural foramina are then more narrowed with lumbar extension than with lumbar flexion

High Confidence of No Effect on Outcome with WAD

-angular deformity of neck -impact direction -seating position -awareness of collision -head rest in place -older age -vertical speed

Klippel Fiel Syndrome

-congenital fusion of any two of the seven cervical vertebrae, can be single or multiple levels

High Confidence Risk Factors for Chronicity with WAD

-high pain intensity ( > 6/10) -high neck-related disability -PTSD sx -Catastrophizing -Cold hypersensitivity -Mechanical hypersensitivity

Candidate Lesions following WAD

-intra-articular hemorrhage -capsule tear -meniscoid contusion -articular, subchondial fx -articular pillar, fx -annulus tear

Treatment based classification for Neck Pain (4) per CPG

-neck pain with mobility deficits -neck pain with movement coordination impairments (WAD) -neck pain with headaches (cervicogenic) -neck pain with radiating pain (radicular)

Clinical presentation of cervical instability

-occipital headaches and numbness -movement limitation (often severe) due to protective muscle spasm -locking of neck with certain movements -crepitation -insufficient muscle control: "my head feels heavy / tired" -often feel better in the morning than evening

Indications for Cervical Flexor Training

-poor active control of cervical extension in upright postures -forward head posture (craniocervical extension) -difficulties lifting head off bed

Indications for Cervical Extensor Training

-poor active control of upright cervical flexion -forward head posture (lower cervical flexion) -reports of sensorimotor disturbances and positive sensorimotor tests

Screening questions for increased risk of Cancer

-prior hx of cancer >50yo OR <20yo -no relief with complete bed rest -severe pain unaffected by posture or position -night pain disturbing sleep

Challenges with managing WAD

-recovery rates range from 20-80% after 12 months, leaving a significant number with persistent problems -little to no consistent evidence of "bony or soft-tissue injuries" -a number of psycho-social factors (coping, expectations, anxiety and depression) have been identified as prognostic of WAD recovery -little to no consistent evidence to support early active intervention over single sessions of advice and education

Clinical Presentation of Cervical Instability

-spinal cord signs -C1-2 instability influences spinal cord integrity and cause signs of cervical myelopathy -instability with walking / balance problems / stumbling -ataxia -sensory loss/motor loss in patch distribution -hyperreflexia -pathological reflexes: Babinski, Clonus, Hoffman's reflex

Neck pain with head aches

-spinal manipulation therapy (SMT) without rotation or extension -cervical and upper thoracic SMT showed significant reduction of headache intensity C1-C2, self SNAG low load endurance cervico-scapular muscle exercise 2x per day

Cervical flexion and rotation test

-supine full flexion then full rotation -norm = 40-45 degrees -subjects with significantly less rotation have C1-C2 dysfunction Sn 91, Sp 90

CPG Cervicogenic head ache findings

-unilateral HA with neck/SO area sx aggravated by movement -HA produced / aggravated with provocation of ipsilateral posterior cervical myofascia and joints -restricted cervical ROM -restricted segmental mobility -abnormal/substandard performance on cranial cervical flexion test

Temporal arteritis

-unilateral or bilateral - usually temporal -age >50 -temporal arteries thickened (throbbing, aching, burning) -intermittent, then after a while become continuous -loss of vision, fever, weight loss EMERGENT REFERRAL

Brain Tumor Risk Factors

-variable intensity, may wake pt -nausea and vomiting -papilledema (condition in which increased pressure in or around the brain causes the part of the optic nerve inside the eye to swell. Symptoms may be fleeting disturbances in vision, headache, vomiting, or a combination) -impaired mentation -seizures

Cervical side bending

0-45 degrees occurs with facet gliding C2-C7 As SB: see facet on one side move/glide up and the other side moves/glides down

Vertebral artery

11% of cerebral blood flow posterior circulation greatest stress with upper cervical rotation

vertebral artery

11% of cerebral blood flow supplies posteriorly greatest stress with upper cervical rotation

Traction Parameters

15-24 degrees based on ROM 60s on, 20s off (50% pull during off time) 10-12 pounds of pull initially moderate to strong without aggravation max pull 40 pounds average pull: 23 pounds +/- 5.6 pounds 15 minutes duration follow up with exercise (chin tuck, posture) 6 session over 3 weeks

Shoulder Abduction Test

indicates compression of neural structures within intervertebral foramen When a patient rests their affected arm on their head and symptoms are relieved, this is considered a positive shoulder abduction test

Paget-Schroetter syndrome

is a form of upper extremity deep vein thrombosis (DVT), a medical condition in which blood clots form in the deep veins of the arms. These DVTs typically occur in the axillary or subclavian veins Commonly occurs in young active males involved in sports that require UE movement overhead Pain, redness and swelling in the arm

What is the most common pain pattern of herniated cervical disc?

neck pain with radiation into the scapular area and down the lateral aspect of the arm into the forearm and hand

What abnormal findings are expected with a C8-T1 disc herniation? (C8 affected)

numbness in the ulnar nerve distribution of the little finger and ring finger, a claw hand deformity, weakness of the triceps muscle, and absence of the triceps reflex. Weak thumb extension and wrist ulnar deviation

Phalen-Dickson sign

physical finding when the pt stands or walks with hip and knee flexion, thought to be due to nerve irritation from spine instability and micromotion -- becomes more pronounced as a spondylolisthesis progresses

Glossopharengeal-9

swallowing, mouth, throat sensation, BOTH Gag reflex and swallow

What part of the spine are the joints of Luschka located?

the cervical spine only b/t the 3rd and 7th cervical vertebrae -- these structures are commonly associated with degenerative spine conditions and cervical radiculopathy

spondylolisthesis

the forward slipping movement of the body of one of the lower lumbar vertebrae on the vertebra or sacrum below it usually occurs at L5-S1 often times pt may have hamstring contracture

Hypoglossal-12

tongue movement, motor extend the tongue and inspecting it for atrophy, fasciculations, and weakness (deviation is toward the side of a lesion). -- should stay in midline

Stability between the Atlas and the Axis depends on what ligaments?

transverse ligaments alar ligaments apical ligament of the dens (odontoid process)

Tension Headache -- PT can treat

Age of onset: 10-50 Location: both sides of head or the entire head Duration: 30 minutes to > 7 days Frequency / Timing: varies Severity: dull to moderate ache, may vary Quality: tight pressure around the head Associated Features: tight or sore shoulder muscles

Cluster Headaches

Age of onset: 15-40 Location: one sided around or behind the eye Duration: 30 minutes - 2 hours Frequency / Timing: 1-8 times/day, usually at night Severity: very, very severe Quality: boring, stabbing, piercing Associated Features: facial sweating, one side tearing, nasal congestion Men > women

Migraine

Age of onset: 5-40 Location: One sided, around the temple Duration: Several hours to 3 days Frequency / Timing: Varies Severity: Moderate to very severe Quality: Throbbing, pulsing, strong Associated Features: Light/sound sensitivity, nausea, vomiting, visual disturbances

Cervicogenic Headache - PT can treat

Age of onset: Varies Location: Base of the neck, side of the head or behind the eye Duration: 1-6 hours Frequency / Timing: daily Severity: moderate to severe Quality: dull ache to severe Associated Features: neck pain, occasional nausea

Neck Pain With Movement Coordination Impairments (WAD)

"head feels heavy" Common symptoms Mechanism of onset linked to trauma or whiplash Associated (referred) shoulder girdle or upper extremity pain Associated varied nonspecific concussive signs and symptoms: Dizziness/nausea Headache, concentration, or memory difficulties; confusion; hypersensitivity to mechanical, thermal, acoustic, odor, or light stimuli; heightened affective distress Expected exam findings Positive cranial cervical flexion test Positive neck flexor muscle endurance test (39 seconds male, 29 seconds female) Global neck weakness Positive pressure algometry Strength and endurance deficits of the neck muscles Neck pain with mid-range motion that worsens with end-range positions Point tenderness may include myofascial trigger points Sensorimotor impairment may include altered muscle activation patterns, proprioceptive deficit, postural balance or control Neck and referred pain reproduced by provocation of the involved cervical segments

Meyerding Classification System of Spondylolisthesis

% of displacement of 1 vertebra over the other Grade 0 = no displacement Grade 1= 1-25% Grade 2 = 26-50% Grade 3 = 51-75% Grade 4 = 76 - 100%

Upper Motor Neuron Testing

-Clonus -Hoffman's reflex -Rhomberg's -Babinski

Arnold-Chiari malformation

-Downward displacement of the cerebellar tonsils through foramen magnum -spinal cord compression sx -decompression surgery -often leads to chronic head aches -most often congenital but can be acquired

vertebral artery pain distribution

-Ipsilateral posterior neck pain/occipital head ache

McKenzie: Dysfunction Syndrome

-Pain appears immediately when shortened tissues are stretched -the pain eases and then stops upon removal of end range stress -Mechanism of pain: due to absence of adequate movement while tightness of soft tissues is occurring

meningeal irritation signs

-Positive Kernig sign: SLR -Positive Brudzinski's sign: supine head flexion -Positive Llhermitte's sign: cervical flexion in sitting -steady, deep pain, generalized bi-occipital frontal

Vertebral Artery Test

-Pt supine with head over the edge of table -Examiner supports the head, rotates it sub-maximally to one side and brings it into extension and holds 30 seconds (while patient asked to count, or PT talking with pt) -Pt's head is brought back to neutral and is closely watched for sx for another 30 seconds (+) TEST: dizziness, visual disturbances, disorientation, blurred speech, nausea/vomiting Weak clinical value

Diagnostic cluster for cervicogenic head aches

1. Decreased AROM cervical extension is a part of the cluster, not AROM cervical flexion •Although it has been seen that those with cervicogenic headaches have deficits in deep neck flexor strength, the cluster includes the assessment through the 2. craniocervical flexion (BP cuff) test, not the deep neck flexor endurance test 3. Painful palpation of the upper cervical spine, including C1-C2, was one of the characteristics included in the cluster by Jull et al. Sn 100% and a Sp of 94% in identifying CGH sufferers

5D's

1. Dizziness 2. Drop Attacks 3. Diplopia 4. Dysarthria - unclear articulation of speech 5. Dysphagia - difficulty swallowing

CPG discusses 5 constructs for assisting in the development of determining neck pain clinical course and prognosis:

1. High pain intensity: NPRS > 6/10 2. High self reported disability: NDI > 30% 3. High pain catastrophizing: > 20 4. High post traumatic stress sx: Impact of Events Scale-Revised score > 33 5. Cold hyperalgesia

CPR for cervical radiculopathy

1. Positive Upper Limb Tension Test A 2. Involved cervical rotation < 60 degrees 3. Positive Distraction Test 4. Positive Spurling's A

Brighton criteria 9 point scale

1. metacarpal-phalangeal joint of the fifth finger can be hyperextended more than 90° 2. thumb can be passively moved to touch the ipsilateral forearm 3. if the elbow extends more than 10° 4. if the knee extends more than 10° 5. With knees locked straight and feet together, if the patient can bend forward to place the total palm of both hands flat on the floor just in front of the feet, it is considered positive scoring = 1 point.

Test Cluster for Cervical Radiculopathy

1. positive upper limb tension test A (ULTT-A) 2. positive Spurling's test 3. positive Distraction test 4. Cervical rotation < 60 degrees to the ipsilateral side 3+ = +LR 6.1 4+ = +LR 30.3

McKenzie: Derangement Syndrome

20-55 years -- lumbar region 12-55 years -- cervical region There is usually a sudden onset of pain disabling type (within a few hours)

Risk Factors for Neck Pain

Age >40 Co-existing LBP Long hx of neck pain Cycling as a regular activity Loss of strength in the hands Worrisome attitude Poor quality of life Less vitality

When screening Vertebral Artery or Vertebral Basilar Artery: Check for the following

5D's 2A's 3N's

Carotid artery

89% cerebral blood flow supplies anterior cranial circulation greater stress with mid-cervical extension

carotid artery

89% of cerebral blood flow supplies anterior cranial circulation greater stress with mid-cervical extension

Cervical Flexion Rotation Test

<32 degrees of rotation ROM or 10 degree difference side to side (norm = 44 degrees) Sn 70 Sp 70 +LR 2.33

Risk factors of cervical spondylosis?

> 60 male prior neck trauma and / or surgery herniated disc severe arthritis repetitive lifting or twisting overweight smoking

Upper Limb Tension Test

A patient does not necessarily need to exhibit a reproduction of symptoms. Instead, tension that creates a side to side difference of greater than 10 degrees of elbow extension or wrist extension is also considered a positive finding

Neck Pain With Headache (Cervicogenic)* Treatment

Acute B Evidence Clinicians should provide supervised instruction in active mobility exercise. C Evidence Clinicians may provide C1-2 self-sustained natural apophyseal glide (self-SNAG) exercise. Sub-acute B Evidence Clinicians should provide cervical manipulation and mobilization. C Evidence Clinicians may provide C1-2 self-SNAG exercise Chronic B Evidence Clinicians should provide cervical or cervico-thoracic manipulation or mobilizations combined with shoulder girdle and neck stretching, strengthening, and endurance exercise.

Neck Pain With Movement Coordination Impairments (WAD) Treatment

Acute B Evidence: Education of the patient to return to normal, non-provocative pre-accident activities as soon as possible Minimize use of a cervical collar Perform postural and mobility exercises to decrease pain and increase ROM Reassurance to the patient that recovery is expected to occur within the first 2 to 3 months. Clinicians should provide a multimodal intervention approach including manual mobilization techniques plus exercise (eg, strengthening, endurance, flexibility, postural, coordination, aerobic, and functional exercises) for those patients expected to experience a moderate to slow recovery with persistent impairments. C-Evidence Clinicians may provide the following for patients whose condition is perceived to be at low risk of progressing toward chronicity: A single session consisting of early advice, exercise instruction, and education A comprehensive exercise program (including strength and/or endurance with/without coordination exercises) Transcutaneous electrical nerve stimulation (TENS) F Evidence Clinicians should monitor recovery status in an attempt to identify those patients experiencing delayed recovery who may need more intensive rehabilitation and an early pain education program. Chronic Level C Evidence • Patient education and advice focusing on assurance, encouragement, prognosis, and pain management

Neck Pain With Mobility Deficits Treatment

Acute B evidence: Clinicians should provide thoracic manipulation, a program of neck ROM exercises, and scapulo-thoracic and upper extremity strengthening to enhance program adherence. Cervical mobilization or manipulation -- C evidence Subacute B evidence Clinicians should provide neck and shoulder girdle endurance exercises. Clinicians may provide thoracic manipulation and cervical manipulation and/or mobilization -- C evidence Chronic B Evidence - Clinicians should provide a multimodal approach of the following: • Thoracic manipulation and cervical manipulation or mobilization • Mixed exercise for cervical/scapulothoracic regions: neuromuscular exercise (eg, coordination, proprioception, and postural training), stretching, strengthening, endurance training, aerobic conditioning, and cognitive affective elements • Dry needling, laser, or intermittent mechanical/manual traction C Evidence - Clinicians may provide neck, shoulder girdle, and trunk en- durance exercise approaches and patient education and counseling strategies that promote an active lifestyle and address cognitive and affective factors.

Neck Pain With Radiating Pain (Radicular) Treatment

Acute C Evidence Clinicians may provide mobilizing and stabilizing exercises, laser, and short-term use of a cervical collar. Chronic B Evidence mechanical intermittent traction, combined with other interventions such as stretching and strengthening exercise plus cervical and thoracic mobilization/ manipulation. B evidence Clinicians should provide education and counseling to encourage participation in occupational and exercise activities.

Individuals with cervical radiculopathy likely to respond to PT interventions

Age < 54 Dominant arm not affected Looking down doesn't aggravate sx Mutli-modal prescription for over 50% of visits (traction, deep neck flexors strengthening) 3 variables present +LR 5.2 4 variables present +LR 8.3

CPR: Patient's likely to respond to traction

Age > 55 + shoulder abduction test + ULTT A Sx peripheralization with lower cervical (C4-C7) PA motion testing + neck distraction

Sprengel's Deformity

An undescended scapula brought about by attachment to cervical vertebrae by either bone, cartilage, or fibrous attachment. The condition is fairly rare. May also be seen with Klippel-Feil Syndrome

internal carotid artery dissection

Artery that supplies blood to the brain, eyes, eyelids, forehead, nose, and internal ear. Headache. Scalp pain. Eye pain. Neck pain. One eye with a droopy lid and small pupil (partial Horner syndrome) Weakness or numbness on one side of your body. Having trouble understanding speech or speaking. Pulsing sound in an ear.

2A's

Ataxia Anxiety

Which cervical level provides the most rotation?

Atlantoaxial joint -- C1-C2

What are the top 2 vertebrae called (C1, C2) ?

Atlas Axis

Clay Shoveler's Fracture

Avulsion fracture of the spinous process in the lower cervical and upper thoracic region Stable fx. MOI: Flexion Radiographic findings: Avulsion of posterior aspect of spinous process; frequently an incidental finding

During passive cervical rotation to the right, where may the vertebral artery get compressed?

Between the 1st and 2nd cervical vertebrae on the left; rotating right will stress the vertebrobasilar artery on the left

Spurling's Test

Bring pt's head into extension and lateral SB and assess if sx occur distal to the elbow If pt does not reports any sx, you can make the test more provocative by adding axial compression Sn 92 Sp 95 +LR 18.4

Quadrilateral space syndrome characteristics

Fatty infiltration of the teres minor and compression often axillary nerve. This can mimic cervical radiculopathy and cause pain in the quadrilateral space on the posterior shoulder.

Most common facets joints to be injured with WAD:

C2/3, C5/6 -the prevalence of cervical -zygapophysial joint pain is 60% with WAD -facets joints are pain generators

What are the most common levels of cervical spondylosis?

C5-C6, C6-C7

What are the most commonly affected levels with cervical radiculpathy?

C7 (C6-C7 disc herniation), followed by C6 (C5-C6 disc herniation)

According to the American College of Radiology, which imaging modality is recommended for sudden, severe headache?

CT of the head without contrast

Causalgic Pain

Causalgic pain is described as a constant usually burning pain that results from injury to a peripheral nerve and is often considered a type of complex regional pain syndrome.

Treatment Based Classification - CPG Recommendations Radicular sx Sx distal to the elbow

Centralization Activities to promote centralization Individuals likely to respond to traction: CPR 1. Age >55 2. + shoulder abduction test 3. ULTT-A 4. Sx peripheralization with lower cervical (C4-C7) P-A motion testing 5. Neck distraction test > 4 variables present: =LR = 11.7

What is the primary movement of Atlanto-Occipital Joint?

Cervical flexion and extension

Strong Evidence Interventions of Neck pain

Cervical mobilization / manipulation Strength and coordination exercise Patient education

What is cervical spondylosis?

Combination of DDD and osteophyte formation

Neck Pain With Mobility Deficits

Common symptoms Central and/or unilateral neck pain Limitation in neck motion that consistently reproduces symptoms Associated (referred) shoulder girdle or upper extremity pain may be present Expected exam findings Limited cervical ROM Neck pain reproduced at end ranges of active and passive motions Restricted cervical and thoracic segmental mobility Intersegmental mobility testing reveals characteristic restriction Neck and referred pain reproduced with provocation of the involved cervical or upper thoracic segments or cervical musculature Deficits in cervico-scapulo-thoracic strength and motor control may be present in individuals with subacute or chronic neck pain "Every-time I move this way I feel it here"

Neck Pain With Radiating Pain (Radicular)

Common symptoms Neck pain with radiating (narrow band of lancinating - piercing or stabbing sensations) pain in the involved extremity Upper extremity dermatomal paresthesia or numbness, and myotomal muscle weakness Expected exam findings Neck and neck-related radiating pain reproduced or relieved with radiculopathy testing: positive test cluster includes: ULTT-A Spurling's test + cervical distraction cervical ROM loss (involved side cervical rotation <60 degrees) May have upper extremity sensory, strength, or reflex deficits associated with the involved nerve roots

Neck Pain With Headache (Cervicogenic)*

Common symptoms* Noncontinuous, unilateral neck pain and associated (referred) headache Headache is precipitated or aggravated by neck movements or sustained positions/postures Expected exam findings Positive cervical flexion- rotation test Headache reproduced with provocation of the involved upper cervical segments Limited cervical ROM Restricted upper cervical segmental mobility Strength, endurance, and coordination deficits of the neck muscles "When you have a head ache does your neck feel worse?"

Risk Factors Cervical Artery Dysfunction

Female 30-39 Migraine Oral contraceptive use DM HTN Smoking

According to the McKenzie method, if a patient's unilateral radicular sx centralize from their hand to their elbow with repeated cervical retraction, the patient should be classified into which group?

Derangement -- if a pt's sx centralize or peripheralize further up or down the arm, they would be classified into the derangement group

Treatment Based Classification - CPG Recommendations No radicular signs / sx Chronic Sx

Exercise and conditioning Conditioning and strengthening exercise

Horner's syndrome

Eye disorder cause by damage to cervical sympathetic nerve The sympathetic nervous system regulates heart rate, pupil size, perspiration, blood pressure and other functions that enable you to respond quickly to changes in your environment. -ptosis -swelling of lower lid absence of sweating on affected side of face

Disability Measures for Neck

FOTO -- Focus on Therapeutic Outcomes NDI PSFS - Patient Specific Functional Scale GROC - Global Rating of Change

Facet Gliding

Facets are oriented 45 degrees to transverse plane And they are // to frontal plane => allows for movement in all directions Cervical extension: facets glide inferiorly and posteriorly = closed pack position

When ruing out a sinister pathology, a PT should use highly sensitive tests to decease the likelihood of _____?

False negative

True of False: The vertebral artery basilar insufficiency test is valid and reliable

False: The test has not been validated and a negative vertebral basilar insufficiency test dow not rule out a dissection in progress

True or False: There is increased risk of vertebral artery insufficiency for chiropractic care vs care by a PCP

False: There is no increased risk of vertebral artery insufficiency for chiropractic care vs care by a PCP -- no increased risk of stroke with chiro vs PCP

referring to patient in 27: What would be the most likely diagnosis if no nerve entrapment or neuropathy is present?

Flexor pollicis longus rupture

Disability measures for cervical spine

Focus on Therapeutic Outcomes (FOTO) NDI Patient Specific Functional Scale (PSFS) Global Rating of Change (GROC)

Jefferson fracture

Fracture of C1 (atlas) caused by a compressive downward force from the occipital condyles

Tension head aches

Generalized bilateral sx moderate intensity pressure without throbbing tightness or aching lasts 30 minutes intermittently for up to 7 days provoked by fatigue or nervous strain associated with depression, worry, anxiety

MAA: NSW (motor accident authority) Guidelines 2015 with WAD

Level B evidence: -practitioners should advise patients that exercise is effective for the management of acute WAD -practitioners should provide neck specific exercises such as ROM, low load isometrics, postural endurance, and strengthening exercises

HINTS exam - peripheral vs. central findings

Head-Impulse: + equals peripheral Nystagmus: -peripheral: at rest, horizontal, unidirectional -central: gaze evoked, direction changing Test-of-Skew: alternate cover test Abnormal: small vertical corrective movement that occurs once the cover is removed

Vagus-10

Heart rate, breathing, gastrointestinal function and sensation, BOTH functions, such as digestion, heart rate, and respiratory rate, as well as vasomotor activity, and certain reflex actions, such as coughing, sneezing, swallowing, and vomiting say "ah" - uvula should stay straight blood pressure and HR digestive organs

Canadian Cervical Spine Rules

High Risk Factors: -65yo -have had a dangerous mechanism of injury -have paresthesias in the extremities Dangerous MOI: -fall from greater or equal to 3 feet or 5 stairs -axial load -MVC of 65 mph or greater, roll over or ejection -Bike collision -ATV accident Low Risk Factors - indicate a safe cervical ROM assessment can be done if: · able to sit in the ED · has had a simple rear-end MVC · is ambulatory at any time · has had a delayed onset of neck pain · does not have midline cervical spine tenderness If the low risk factors are cleared, then ok to assess ROM If able to actively rotate the head 45 degrees in each direction, imaging in the acute stage is not required for those who are classified as low risk - if unable to rotate the head 45 degrees and have any of the low risk factors, they need imaging

What syndrome is common after internal carotid artery dissection and results in ptosis, miosis (contriction of pupil), anhidrosis and enopthalmosis (posterior displacement of the eyeball within the orbit)?

Horner's Syndrome

Risk Factors for Upper Cervical Instability

Hx of trauma Throat infection Congenital collagenous compromise (Down's Ehler's-Danlos) Inflammatory arthritides (RA, ankylosing spondy) Recent head, neck, dental surgery

What is the most commonly affected cranial nerve if a patient has a internal carotid artery dissection?

Hypoglossal -- CN XII Followed by: glossopharyngeal CN IX vagus CN X Spinal Accessory CN XI

Cranial Cervical Flexion Test

Inflate biofeedback unit to 20 mmHg Have pt perform a head nod as if the back of their head is sliding up the bench. The pt tries to achieve a pressure increase of 2mmHg from 20-22 mmHg and hold 2-3 seconds The process is repeated for each 2 mmHg increment for a total of 5 stages until 30 mmHg is reached The stage / pressure increase that the pt is able to achieve and hold for 2-3 seconds with correct cranio-cervical flexion is the baseline measure

Same patient as in 22: If the patient tested positive for cervical radiculopathy, what is the best intervention for this patient?

Intermittent mechanical traction

Morquio Syndrome

Is a rare metabolic disorder in which the body cannot process certain types of sugar molecules called glycosaminoglycans Signs and Sx: Short stature, with a very short torso Abnormal bone and spine development, including severe scoliosis Bell-shaped chest with ribs flared out at the bottom Hypermobile joints Knock-knees Large head Widely-spaced teeth Possible heart and vision problems

Klippel-Feil Syndrome

Klippel Feil syndrome (KFS) is a congenital , musculoskeletal condition characterized by the fusion of at least two vertebrae of the neck. Common symptoms include a short neck, low hairline at the back of the head, and restricted mobility of the upper spine. A significant scoliosis is present in up to 60% of these patients (congenital or compensatory) Up to 30% of patients also experience deafness

Prognosis Based Assessment with WAD and recommended tx

Low Risk: (25-30%) Educate, reassure and follow from arm's length -Avoid over treatment -- if recovery is expected, let it happen; follow up in 1 month to ensure recovery as expected Moderate Risk: (50-65%) Advice, education and reassurance, watchful waiting with in-person follow-up, identify trends and intervene if trajectory appears to be not improving -probably suitable for PT management but should monitor closely to ensure recovery is occurring High Risk: (10-20%): identify primary risk profile and consider initiating early targeted intervention -tx may include addressing fear of movement as much as tissue damage, pharmaceutical or other sx management, psych

Treatment Based Classification - CPG Recommendations Primary c/o headaches Cervicogenic Headaches

Manual therapy Neck flexor / scapular strengthening -SMT without rotation or extension -Cervical and upper thoracic SMT showed significant reduction in head ache intensity -C1-C2 self SNAG -low load endurance cervico-scapular muscle exercise twice per day -combined SMT and cervico-scapular muscle exercise showed statistically significant reductions in all outcomes

A patient reports a pulsating / pounding head ache, unilateral in nature, duration lasting 4-72 hours, and nausea. What would be the most likely diagnosis?

Migraine

Migraine VS Cervicogenic Headache

Migraine / CGH Age: 18yo 33yo Headache onset anterior post h&n pain area 50% Uni mostly uni nausea Very freq infrequent photo/phono freq infrequent throbbing very freq infrequent pain inc. with bending usually helps increases position provoked no yes

Myelopathy vs. Radiculopathy

Myelopathy vs. Radiculopathy Bilateral Unilateral Spine involved Hyporeflexive Clonus No UMN signs Babinski Ataxia Inverted Supinator

3N's

Nausea Numbness Nystagmus

Cervical Myelopathy—from cervical cord compression

Neck pain with bilateral weakness and paresthesias in both upper and lower extremities, often with urinary frequency. Hand clumsiness, palmar paresthesias, and gait changes may be subtle. Neck flexion often exacerbates symptoms. Weakness, spasticity, hyperreflexia Lhermitte's sign

Os odontoideum (OO)

Normally developed cephalic part of the dens is not fused with the C2 body smooth wide lucent defect between the body of C2 and dens Congenital anomaly; the dens is either completely absent or incompletely fused; most commonly pt is asymptomatic and it is discovered incidentally If there is marked instability, however, patient may undergo C1-C2 fusion

What abnormal findings are expected with a C6-C7 disc herniation? (C7 affected)

Numbness in the long finger and potentially in the index finger, weakness of the triceps, and absence of the triceps reflex

Treatment Based Classification - CPG Recommendations Acute onset of sx Traumatic mechanism

Pain control Gentle ROM and activity WAD group Manual therapy, exercise Instruction to "act as usual" Education

Same patient as in 22: What kind of malignancy will cause radiculopathy in a C8-T1 nerve root distribution?

Pancoast tumor

Klumpke's palsy

Paralysis of lower plexus including 7th and 8th cervical and 1st thoracic nerves - Paralysis of wrist/hand (limp hand, fingers don't move) -Often with ipsilateral Horner's syndrome (miosis, ptosis, and facial anhidrosis

Lhermitte's sign

Patient is long sitting on table. Passively flex patient's head and one hip while keeping knee in extension. Repeat this step with other hip (+) TEST: pain down the spine and into the UE or LE => Dural or Meningeal irritation

ULTT-A

Patient supine: Scapular depression GH abduction to 90 Forearm supination Wrist and finger extension ER shoulder Elbow extension SB neck away

What part of the cervical disc is weakest?

Posterior -- the annulus fibrosis is thick anteriorly but thin and weak posteriorly

Migraine

Prevalence 10% Occurs upon waking or later in the day Lasts 4-24 hours Increased sensitivity to light, noise, and tension Nausea and vomiting Sometimes triggered by alcohol, certain foods, sleep deprivation

exophthalmos

Protrusion of an eye out of its socket -- seen in Grave's disease

Traction / Distraction Test for cervical radiculopathy

Pt lies supine Examiner hooks their index fingers under the pt's occiput and applies longitudinal distraction Sn 44 Sp 90-97 Moderate clinical value

Bakody's sign

Pt presents with arm raised above head bc it alleviates/reduces their sx

What is neck-tongue syndrome? -- which can be suggestive of alar ligament instability?

Rare clinical entity characterized by sudden episodes of intense pain in upper cervical or occipital area associated with ipsilateral hemi-tongue presenting as numbness, abnormal writhing movement, dysarthria, and lingual paralysis aggravated with neck movement

Other objective measures advised to perform with WAD

Recommended to perform oculomotor tests and concussive tests -Vergence, smooth pursuit, saccades, cover uncover, joint position error -SCAT3, observed difficulty with word finding, concentration

During cervical artery dissection, which arteries would you suspect to be involved?

Vertebrobasilar (which is the posterior arterial system perfusing the hindbrain) and the internal carotid artery (which is the anterior arterial system, perfusing the cerebral hemispheres and eyes)

Posterior triangle of the neck

SCM, trapezius, clavicle Nerves: Spinal accessory, dorsal scapular and upper and middle trunks of the brachial plexus

Posterior Neck MM

SO Levator Scapulae Paravertebrals Trapezius

Anterior cervical MM

Scalenes Platysma Longus captis/colli SCM Hyoids

Sterling CPR (2013)

See Image *PDS -- Post-traumatic Diagnostic Scale

Sterling CPR for NDI

See Image *PDS -- Post-traumatic Diagnostic Scale

From anterior to posterior: Anterior longitudinal ligament, intervertebral disc, posterior longitudinal ligament, spinal cord, ligamentum flavum

See Image -- know the anatomy

SINSS

Severity (intensity) Irritability (amount of activity required to worsen symptoms) Nature (structure involved, pathology responsible for producing the signs or symptoms) Stage (Acute--> less than 3 weeks, Sub-acute--> greater than 3 weeks but less than 6 weeks, Chronic--> greater than 6 weeks) Stability (change since onset)

Somatic Pain

Somatic pain is described as dull or achy, and is often seen in those who have common musculoskeletal pathologies.

Klumpke's palsy

Symptoms include paralysis of intrinsic hand muscles, flexors of the wrist and fingers, flexor carpi ulnaris and ulnar half of the flexor digitorum profundus and C8/T1 dermatome distribution numbness •Pt presents with a claw hand

Anterior shear test

Tests integrity of transverse ligament -support occiput while the index fingers are placed in the space b/t the occiput and C2 spinous process -the head and C1 are moved anteriorly as one unit on the cervical spine -the patient reports any sx other than local soreness

Most common level for cervical radiculopathy

The C7 level is the most common level of radiculopathy. The C7-T1 region is a transitional area, meaning lots of motion occurs here and hence pathology is commonly seen in this region. It is commonly agreed upon in the literature that the C6-C7 nerve roots are most commonly at risk for the development of cervical radiculopathy

McKenzie: Postural Syndrome

Usually < 30yo Sedentary occupation / under-exercised Onset: insidious and gradually worsening Pain free when active or moving Always intermittent

What is the function of the alar ligaments?

The function of the alar ligaments is to limit the amount of rotation of the head, and by their action on the dens of the axis, they attach the skull to the axis, the second cervical vertebra

Characteristics of WAD: S-Shape Features

This abnormal movement, referred to as the "S-shape" phase of neck motion. Flexion at the upper spinal levels and extension at the lower levels that can can exceed physiologic limits potentially inducing sub-failure injuries to a number of vulnerable tissues e.g. facet capsules, disc tissue, tears/ruptures to ligaments, and even fractures.

What artery has an intimate relationship with the cervical spine and serves as the major source of blood to the cervical cord and cervical spine?

Vertebral artery (which originates from the subclavian artery)

Parsonage-Turner syndrome

Trademark sign is severe pain at onset which resolves but muscle weakness progresses Neurogenic muscle edema corresponding to a particular nerve: Suprascapular nerve: Supraspinatus, Infraspinatus Axillary nerve: Teres minor, Deltoid. Acute pain followed by weakness. Associations: Vaccinations, Viral illness, General anesthesia Generally occurs in 5th decade of life AKA brachial neuritis

Which ligament prevents the dens of the axis from pressing on the spinal cord during active cervical flexion and is commonly compromised during trauma?

Transverse ligament

Tear drop fracture

Triangular fracture fragment of anterioinferior aspect of affected vertebra; C5 most common; often from hitting head on bottom of pool when diving

True of false: Upper cervical instability testing is not valid or reliable

True

True or False: Sharp Purser test is only truly diagnostic for subjects with RA or Down's Syndrome.

True: The sharp purser tests for transverse ligament compromise, however, it was only validated in subjects with RA and down's syndrome, which limits the applicability of the test to other patient population Also -- it may be dangerous to perform the test after a traumatic MOI

Pancoast tumor

Tumor of the apical lung Can involve lower cervical nerve roots Can initially mimic cervical radiculopathy Horner's Syndrome

Hangman's fracture

Unstable, serious fracture of posterior elements of C2 usually with C2 anterolisthesis on C3. Caused by hyperextension and distraction (head against dashboard).

Hangman's fracture

Unstable, serious fracture of posterior elements of C2 usually with C2 anterolisthesis on C3. Caused by hyperextension and distraction (head against windshield).

Wallenberg syndrome

Wallenberg syndrome is a rare condition in which an infarction, or stroke, occurs in the lateral medulla. The lateral medulla is a part of the brain stem. Oxygenated blood doesn't get to this part of the brain when the arteries that lead to it are blocked. A stroke can occur due to this blockage Unilateral vocal fold paralysis, dysphagia, facial paralysis, contralateral sensory arm abnormalities. Only disorder in CNS that produces a full unilateral vocal fold paralysis. aspiration during and after swallow

Facet Gliding superior and anterior

With flexion, facets glide superiorly and anteriorly

Kernig's sign

a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down

Erb's Palsy

a paralysis of the arm that most often occurs as an infant's head and neck are pulled toward the side at the same time as the shoulders pass through the birth canal

Visceral Pain

a poorly localized, dull, or diffuse pain that arises from the abdominal organs, or viscera

Enophthalmos

a posterior displacement of the eye within the socket - can occur with Horner's syndrome but not always; Miosis, ptosis and anhidrosis are all more characteristic of Horner's syndrome

When considering electrodiagnostic testing, which of the following is most consistent with the physiologic demonstration of a muscle spindle stretch reflex? a. H-reflex b. F-reflex c. G-reflex d. Spontaneous potentials

a. H-reflex -- Reason: This is a common somatosensory evoked potential that represents latency of a muscle stretch reflex. --F and G reflexes are not real reflexes --Spontaenous recordings can be seen for several reasons, even upon inserting a needle, but are not associated with muscle spindle reflexes.

A 21-year-old male self referred to physical therapy for neck pain and stiffness. The symptoms started about two days ago, and the patient attributed it to a tough rugby game. He did not have any trauma during the rugby game. However, he has noticed that he has gotten intermittent headaches a few times each day since the onset of symptoms, and this morning he was running a fever and vomited. Now he just feels nauseous. During examination, the physical therapist flexes the patient's neck while in a supine position, and the patient's hip and knees spontaneously flexed at the same time. Which of the following diagnoses is this patient experiencing? a. Meningitis b. Migraine headaches c. Neurodynamic/dural tension d. Vertebral artery dissection

a. Meningitis -- Reason: This patient exhibits a positive Brudzinskis sign when the physical therapist passively flexes the neck. The presence of neck pain and stiffness combined with the constitutional symptoms of fever, vomiting and nausea, should point the physical therapist to a non-musculoskeletal condition. This patient likely has viral or bacterial meningitis. (Thomas 2002) --The patient does have neck pain, headaches, and some of the classic symptoms associated with migraines, such as nausea and vomiting. However, this patient also has a curious response to passive neck flexion, which would lead one away from thinking this patient has migraine headaches. --The response by the patient when the physical therapist passively flexed the neck is positive for an increase in dural tension. However, the patient has other symptoms, such as neck stiffness, vomiting, nausea and headaches, that point away from a condition that can be managed with physical therapy intervention. --Although this patient does have headaches, nausea and has vomited and these are all signs associated with a vertebral artery dissection, the spontaneous hip and knee flexion during passive neck flexion directs one away from a vertebral artery dissection.

What artery passes thru the quadrilateral space in the shoulder? a. Posterior circumflex artery b. anterior circumflex artery c. axillary artery d. brachial artery

a. Posterior circumflex artery (and the axillary nerve) pass thru the quadrilateral space and encircles the humeral head

A 55 yo female is referred to PT for lumbar radiculopathy. She describes her sx as bilateral pins and needles going from the lower buttock to her knees. The pins and needles sensation started over 1 year ago. More recently, she reports bilateral anterior thigh numbness. Sx are only noticeable while sitting for prolonged periods of time. What body region needs to be screened prior to initiating tx? a. cervical spine b. thoracic spine c. lumbar spine d. visceral organs

a. cervical spine -- although the patient's sx are suggestive of lumbar radiculopathy, bilateral sx should make the PT suspicious of cervical myelopathy. Thereby, the cervical spine should be screened (note - with lumbar stenosis, sx would improve with sitting)

A pt was involved in a MV collision, where their car was rear-ended at a stop light by a Mack truck. Although the pt initially reported no pain, they experienced a gradual onset of pain over the next 24 hours, escalating to 9/10. The pt is presenting to a PT employed in an ED setting 48 hours after the accident. The pt reports it is difficult to turn the head to the right or left and it is difficult to look up. Th pt also reports being very angry at the truck driver , who was on their cell phone prior to the collision and references that they have already sought the advice of an attorney. Upon a screening exam, the PT noted cervical rotation is limited to 10 degrees in each direction and no cervical extension is possible prior to increase in pain to 10/10 on a NPRS. The PT is concerned about barriers to recovery. In this case the PT is concerned about _____. a. pt's legal consultation b. limited ROM c. traumatic MOI d. high level of pain

a. pt's legal consultation -- financial compensation has been correlated with increased levels of disability with whiplash associated disorders

A 61 yo woman is referred to PT for neck and shoulder pain. She c/o pain radiating into her 4th and 5th digits of her left hand that started 4 weeks ago. She reports having pain at night, but is able to sleep thru it. When she first noticed the pain she rated it as 8/10 and went to urgent care. Since then it has decreased in intensity. She reports the pain comes and goes. Weight training, lifting her arms, opening a jar all reproduce her pain. She denies hx of cancer. She has been diagnosed with osteopenia of the spine and has arthritis in hands and lower spine. She currently is taking gabapentin. Her cervical ROM is restricted and he has reproducible radiculopathy with left cervical rotation. What is the most likely dx? a. spondylosis b. C7-T1 disc herniation c. radial neuropathy d. C5-C6 herniation

a. spondylosis -- bc of her age, otherwise, b would be a good answer Spondylosis refers to degenerative changes in the spine such as bone spurs and degenerating intervertebral discs between the vertebrae. Spondylosis changes in the spine are frequently referred to as osteoarthritis

Atlanto-axial joint (AA joint)

articulation between the atlas and axis, C1-2 Rotation (50% of c-spine rotation) designed for maximal rotation, no true sidebending Also provides 25 degrees flexion and extension

atlanto-occipital joint

articulation between the atlas and the cranium, C0-1 Flexion and Extension

A 55-year-old female comes into your clinic with complaints of neck pain. She works in an office spending many hours at a computer. She states her pain is worse at the end of the day but her primary complaint is neck pain disturbing her ability to sleep. She feels she cannot find a relieving position at night time. Her past medical history includes HTN, DM, and is currently in remission for breast cancer (2 answers) a. Night pain not relieved with position change b. Age 55 c. Female gender d. Previous history of cancer

b. Age 55 d. Previous history of cancer

A patient is referred to PT by a PCP for mechanical neck pain. Your evaluation revealed a positive flexion rotation test for C1-C2 PROM. Which intervention below will result in the most immediate relief? a. deep neck flexor strengthening b. C1-C2 manipulation and upper thoracic manipulation c. C1-C2 mobilization and upper thoracic mobilization 4. Atlanto - occipital manipulation

b. C1-C2 manipulation and upper thoracic manipulation

Which nerve root would cause sx to the dorsal and lateral neck down to the anterior portion of the clavicle, the trapezius and the ACJ? a. C2-C3 b. C3-C4 c. C4-C5 d. C6-C7

b. C3-C4 -- C4 nerve root is between C3 and C4 and this fits the pattern of the C4 dermatome

A 34 yo patient is referred to you for cervicogenic headaches. She reports an increase in headache and neck pain by the end of her workday as a secretary. Which of the following is the best treatment option? a. cervical manipulation b. Grade III, IV mobilizations and deep neck flexor strengthening c. Cervical mobilization grades I-IV d. thoracic manipulation

b. Grade III, IV mobilizations and deep neck flexor strengthening -- evidence supports the combination of cervical mobilizations and deep neck flexor strengthening in the treatment of cervicogenic headaches. No single treatment appears to be superior to the other

A 52 yo female patient presents to PT for a preoperative consultation. She has failed conservative tx for cervical radiculopathy, with no changes in paresthesias and muscle weakness down her left arm. If surgery is indicated, what is the most likely surgery to be performed? a. Posterior microendoscopic disc fusion b. anterior cervical discectomy and fusion c. artificial disc replacement d. laminectomy

b. anterior cervical discectomy and fusion -- can remove the retracted lesion without having to retract the spinal cord

Your patient no longer has neck pain or hand numbness. She now c/o inability to move her thumb. Sensation is normal. No swelling or atrophy is present. CTS test is negative. She is unable to oppose the tip of her thumb to the tip of her index finger. What nerve has been affected based on these sx? a. ulnar b. anterior interosseous c. posterior interosseous d. median

b. anterior interosseous

Q73 continued: Which is NOT an appropriate intervention for the PT to prescribe for this pt? a. bed rest b. anti-inflammatory medication c. ice, electric stimulation d. cervical collar

b. anti-inflammatory medication -- while anti-inflammatory meds are indicated for this pt, PT Rx of pharmaceutical medication is beyond the Description of Advanced Specialty Practice, though some PTs in federal govt. settings do have this privelege

Q73 continued: What is the most likely MOI for this pt? a. rapid sigmoid cervical extension b. combined cervical extension and rotation c. forceful collision of the occiput with the head-rest d. protective muscle spasm

b. combined cervical extension and rotation -- most injuries occur with head in a rotated position out of anatomic alignment. IN fact, head position is the only accident factor correlated with sx duration

Which of the following has the lowest risk of causing post-treatment adverse reactions? a. NSAIDs for OA b. mid to lower cervical manipulation in mid range c. amitriptyline d. C1-C2 manipulation at end range or motion

b. mid to lower cervical manipulation in mid range

Which muscle is not innervated by the anterior interosseous nerve branch? a. radial half of flexor digitorum profundus b. pronator teres c. flexor pollicis longus d. pronator quadratus

b. pronator teres -- innervated by the median nerve

A 34 yo is referred to your clinic for a new onset of dizziness. You are concerned she may have vertebrobasilar insufficiency. You passively rotate the cervical spine to end range, which reproduces the patient's dizziness. As you hold the position, the intensity of the dizziness deceases. What do your exam findings suggest? a. confirm suspicion of vertebrobasilar insufficiency b. suggest a dx of BPPV c. confirm a diagnosis of migraine without aura d. identify cervical facet dysfunction

b. suggest a dx of BPPV -- if a patient has vertebrobasilar insufficiency, you would expect the dizziness to continue to intensify as you hold the patient's head in end range cervical rotation. With BPPV, the dizziness should decrease as you hold this position.

What is true concerning a cervical rib? a. the dx is usually made after acute onset of local sx b. the cervical rib may be asymptomatic in many instances c. a cervical rib is a common occurrence d. the cervical rib always occurs bilaterally

b. the cervical rib bay be asymptomatic in many instances -- the presence of a cervical rib does not correlate to any sx in most individuals

Jefferson fracture

burst fracture of C1

Ehlers-Danlos syndrome

defects in collagen synthesis and structure; hyper-elasticity, instability

A 37 yo male presents to PT with flu like sx, malaise, decreased active lumbar SB and limited chest expansion. What is the most likely dx? a. Klippel-Feil syndrome b. Sheurmann's disease c. Ankylosing spondylitis d. RA

c. Ankylosing spondylitis

Which of the following levels of the cervical spine is most at risk for radiculopathy? a. C4-C5 b. C5-C6 c. C6-C7 d. C7-T1

c. C6-C7 -- Reason: It is commonly agreed upon in the literature that the C6-C7 nerve roots are most commonly at risk for the development of cervical radiculopathy (Wainner and Gill 2000).

According to the McKenzie method, a patient with neck pain can be classified into 1 of 3 syndromes. Which of the following is not one of the define McKenzie syndromes? a. Derangement b. Dysfunction c. Disorder d. Postural

c. Disorder

Psychosocial factors that have been identified to impact prognosis of WAD include all of the below except: a. Anxiety b. Expectation c. Fear d. Depression

c. Fear -- Reason: Coping, Expectations, Anxiety, and Depression have been identified by Walton et al. prognostic of WAD recovery.

If a physical therapist chose to utilize one of the following interventions, which would be least likely to impact a patient with cervical radiculopathy's symptoms? a. Cervicothoracic junction joint manipulation b. Lateral glides with second person performing upper limb tension test c. Lower thoracic joint manipulation d. Mid thoracic joint manipulation

c. Lower thoracic joint manipulation -- Reason: There have been several studies showing the positive outcomes, at least in the short term, through the use of thoracic manipulation in those individuals with neck pain. However, none of these studies utilize lower thoracic joint manipulation. Instead, they target the CT junction, upper and mid thoracic regions.(Cleland 2010)

A 32yo male presents with paresthesia in the medial border of both the palmar and dorsal aspect of the right hand following a racquetball match. The pt reports no hx of any trauma of the hand. The PT is most likely to provoke a pain response with the following test: a. posterior-anterior glide at C5 b. ULTT-A c. Posterior-anterior glide at C7 d. Findelstein's Test

c. Posterior-anterior glide at C7 -- the sx are consistent with an Ulnar nerve distribution. The Ulnar nerve has contribution form the C7 level, and this level may be symptomatic at the cervical spine

Non-acute medical causes of thoracic pain include: a. pulmonary embolis b. aortic dissection c. peptic ulcer disease d. pleurisy

c. peptic ulcer disease

Which of the following would indicate the pt is not a good candidate for cervical manipulation? a. mechanical neck pain that started 30 days ago b. severe spondylosis without radiculopathy c. radicular sx to mid forearm d. score of 10 on NDI

c. radicular sx to mid forearm -- this is usually an indication that centralization procedures rather than manipulation should be implemented; in general, patients with lower pain and low irritability levels, recent onset of neck pain, asymmetrical AROM deficits and concordant sx reproduced with PA mobilizations will benefit from a cervical manipulation

Which of the following are true re: the risk factors and benefits of cervical manipulation/mobilization? a. screening tests can accurately predict patients likely to experience an adverse event from mob/man b. translational manipulation is the most frequently reported manipulation technique associated with adverse events c. there is little evidence to support the notion that mobilization is safer than manipulation in the cervical spine d. the risk of injury from cervical manipulation is likely over-reported

c. there is little evidence to support the notion that mobilization is safer than manipulation in the cervical spine -- there is truly very little evidence to support mobilization or manipulation in the cervical spine from a positive or negative perspective

A physical therapist is examining a patient who presents with complaints of dizziness, and a history of a recent diagnosis of multiple sclerosis. The physical therapist performs a vertebral artery test and a Dix-Hallpike maneuver. Both of these tests were negative. Which of the following statements are true? a. The negative vertebral artery test definitively rules out vertebral artery insufficiency. b. The negative vertebral artery tests rules in vestibulogenic dizziness c.Vertigo is seen in patients with multiple sclerosis, but is not a common first symptom d. Vertigo, dysequilibrium, and presyncope all refer to the same thing and are indicators of a positive vertebral artery test

c.Vertigo is seen in patients with multiple sclerosis, but is not a common first symptom -- Reason: Although early symptoms of multiple sclerosis are varied dependent on the individual, vertigo is not a common first symptom. Optic neuritis is a most common symptom, and the first episode will often occur several years prior to the diagnosis of multiple sclerosis. (Poser and Brinar 2001) --Based on the poor sensitivity of the vertebral artery test, vertebral artery insufficiency cannot be ruled out with the use of the vertebral artery test alone. --The negative findings from the vertebral artery test have no impact on determining the potential for vestibulogenic dizziness. --Vertigo, disequilibrium and presyncope are common symptoms seen in those with a peripheral or central vestibular disorder, and do not point to a vertebral basilar insufficiency issue.

Cervical rotation lateral flexion test

cervical rotation lateral flexion test (CRLF test), used to examine patients with thoracic outlet syndrome (TOS) symptoms to detect possible restriction of the movement of the first rib. Rotate head away from affected side Lateral flexion is added in the opposite direction (+) if no movement of lateral flexion or if bony restriction blocks the movement

"cock robin" position

congenital muscular torticollis

NEXUS criteria

criteria used to clinically rule out a c-spine fracture (PE Neck) -no posterior mid-line tenderness -no evidence of intoxication -normal level of alertness -no focal neurological deficit -no evidence of painful distracting injury

A physical therapist decides to use the Patient-Specific Functional Scale (PSFS) with a patient. Which of the following is correct regarding the PSFS? a. A patient provides two activities that are difficult to perform and rates their activities on a 0-10 scale. b. When rating activities on a 0-10 scale, 0 means the patient can currently perform the activity as well as they could prior to the onset of their symptoms. c. Each individual score from each activity is used, and no average of the activities is used to determine a final score. d. A patient provides three activities that are difficult to perform and rates their performance on a 0-10

d. A patient provides three activities that are difficult to perform and rates their performance on a 0-10 -- Reason: The rating on a 0-10 scale is done for three activities, with 0 being the inability to perform the activity and 10 showing the ability to perform the activity as well as was done prior to the onset of symptoms. (Westaway 1998 and Childs 2008)

Conditions that may warrant immediate cervical surgery to limit catastrophic loss from severe neurological compression include: a. spinal tumor or infection b. acute injury causing hemorrhage or instability c. RA d. All of the above

d. All of the above

If your patient with neck pain starts to develop sx related to hindbrain ischemia, all of the following cranial nerves would likely be involved except: a. CN V and VI b. CN III and IV c. CN XI and XII d. CN I and II

d. CN I and II -- sx related to the hindbrain commonly affect the CN that originate in the vertebrobasilar area. However, vertebrobasilar insufficiency is unlikely to cause dysfunction of CN I and II given their position

Per patient in 34: According to the McKenzie method, which would be the best treatment? a. C3 posterior anterior grade II mobs b. manual txn c. passive upper cervical flexion stretch d. cervical retraction

d. Cervical retraction -- if a patient fits the McKenzie dysfunction syndrome, they should perform exercises into the direction that causes their pain

Q73 continued: The PT provides the pt with info about the condition. Which of the following is true? a. complete resolution of sx is common at 8 weeks b. most patients with this condition will have chronic sx c. If neck pain persists > 3 weeks, flexion/extension radiographs are indicated d. Cold-hypersensitivity can be a sign of a more serious injury

d. Cold-hypersensitivity can be a sign of a more serious injury -- according to Sterling et al., cold hypersensitivity is correlated with worse outcomes and may be indicative of a more serious injury

The Cervical Flexion Rotation Test is used to assess upper cervical spine rotation ROM. This test is considered to have: a. High specificity, low sensitivity b. Low specificity, high sensitivity c. Low specificity, low sensitivity d. High specificity, high sensitivity

d. High specificity, high sensitivity - Reason: This test has been shown to be 90% specific and 91% sensitive.

A patient presents to the ED with cervical spine pain after a fall from a ladder. The physician orders imaging, including AP, lateral, and open mouth views. What might the physician be looking for with the open mouth view? a. Flexion Teardrop Fracture b. Hangman's Fracture c. Occiput Fracture d. Jefferson Fracture

d. Jefferson Fracture -- Reason: A Jefferson fracture refers to a burst fracture of C1. This unstable fracture to the upper cervical spine is best seen in an open mouth view. --A flexion teardrop occurs with severe flexion and compression forces, most commonly occurring C4-C6 levels. This is best identified with a lateral view. --Hangman's fracture refers to par interarticularis fractures of C2, these are best identified with lateral views in an x-ray. --Although open mouth view may be taken with concern for occiput fractures, AP and lateral views should also demonstrate fracture as well.

A 12-year-old female was pushed forward while carrying a heavy school backpack. Within a few hours, the girl presents with neck pain. There was no impact to the neck or fall during the push. She presents to your clinic with neck pain and cock-robin posture and is unable to rotate her neck to neutral. Your neuro test is normal. What might you be concerned about? a. Neck pain with radiating pain b. Cervical myelopathy c. Hypertonic sternocleidomastoid d. Upper cervical instability

d. Upper cervical instability -- Reason: With this presentation and the inability to return to her neck to a neutral position, there is concern for atlanto-axial rotary instability or subluxation. --Although the patient may present with cock-robin posture due to hypertonic SCM, they would usually be able to return to neutral if prompted with a typical torticollis presentation.

Same patient as in 22: What is not part of the cluster of test used to rule in cervical radiculopathy? a. spurling's b. distraction c. ULTT-A d. active cervical rotation < 45 degrees

d. active cervical rotation < 45 degrees (The 4th part of the cluster is active cervical rotation <60 degrees)

You're treating a pt with thoracic spine pain. She has a long-term hx of corticosteroid use. What would increase your suspicion of a compression fracture? a. prior hx of back pain b. insidious onset c. male gender d. age > 50

d. age > 50 the combination of long term corticosteroid use and age > 50 should significantly increase your suspicion of a compression fracture

Which of the following fractures have a high incidence of nonunion bc of a threatened or tenuous blood supply? a. talus fx b. scaphoid fx c. odontoid fx d. all of the above

d. all of the above

A pt that presents with diffuse cervical pain and numbness and tingling in both extremities is likely to have a dx of: a. cervical radiculopathy b. mechanical neck pain c. upper cervical crossed syndrome d. cervical myelopathy

d. cervical myelopathy -- diffuse cervical pain, and bilateral sx suggest a dx of cervical myelopathy, or entrapment of the cervical spinal cord. This pt may also present with a +Hoffman reflex and/or Babinski Sign. Other signs of cervical myelopathy include ataxic gait

A skilled orthopedic manual PT performs a C1-C2 rotary high velocity low amplitude manipulation to the left. Where should the clinician expect the cavitation to occur? a. single audible pop of left unilateral C1-C2 b. single audible pop of right unilateral C1-C2 c. multiple audible pops of unilateral C1-C2 d. multiple audible pops of bilateral C1-C2

d. multiple audible pops of bilateral C1-C2

A PT is examining a 25yo pt after a fall from a horse. The pt reports not losing consciousness and negative radiographs in the ER. Since the injury on week ago, the pt has experienced severe spasms of the upper cervical spine and pain that increases with cervical flexion. The PT should: a. perform a Spurling's test b. perform a vertebral artery test c. perform cervical ROM with overpressure d. perform a Sharp-Purser test

d. perform a Sharp-Purser test -- severe spasms after a high-risk trauma can be a sign of upper cervical instability, which is not always noted with acute radiographs. The PT should screen this pt for ligamentous instability

Which of the following are not ABSOLUTE contraindications for manual therapy? a. osteomyelitis b. nerve root compression with increasing neurological deficits c. influenza with fever d. pregnancy

d. pregnancy -- pregnancy is a relative contraindication to manual therapy

What is true of Froment's sign? a. reduction of patient's sx with shoulder abduction b. weakness of the adductor pollicis and flexor pollicis brevis muscles c. inability to adduct the 5th finger d. weakness of the adductor pollicis, flexor pollicis brevis and first dorsal interosseous muscles

d. weakness of the adductor pollicis, flexor pollicis brevis and first dorsal interosseous muscles -- b, c, and d all suggest ulnar nerve entrapment, however, only answer choice d accurately describes Froment's sign

What abnormal findings are expected with a C5-C6 disc herniation? (C6 affected)

decreased sensation in the thumb and index finger, with weakness of the biceps, triceps, and/or wrist extensors, and absence of the brachioradialis reflex

spodylolysis

defect of the pars interarticularis; when occur bilaterally it allows a spondylolisthesis to occur usually occurs on L5 vertebra

Scheurmann's Kyphosis

found in younger patients • Scheuermann kyphosis is defined as anterior wedging of ≥5º in at least three adjacent vertebral bodies • The estimated prevalence of Scheuermann kyphosis ranges from 4 to 8 percent. • Scheuermann kyphosis is more common among boys than girls. • Tall boys are at increased risk for severe disease This condition (also called Scheuermann's disease) occurs when the front of the upper spine does not grow as fast as the back of the spine, so that the vertebrae become wedge-shaped, with the narrow part of the wedge in front. The wedge-shape of the vertebra creates an increase in the amount of normal kyphosis (front angulation of the thoracic spine)

A patient is referred to you for right lateral cervical foramen narrowing at C5 and C6 resulting in radiculopathy. Upon observing their posture at initial examination, what is the most likely position of the patent's head to avoid reproduction of their radiculopathy?

head rotated and SB to the left and slightly flexed

Vestibulochoclear (Auditory)-8

hearing balance

Same patient as in 22: What visceral structure can cause radiculopathy in a C8-T1 nerve root distribution?

heart

Types of head aches

see image

Spinal Accessory-11

shoulder shrug, motor swallowing

olfactory-1

smell, sensory Ask patient to identify scent / odor

Cluster head aches

unilateral; retro orbital area 90% males usually nocturnal occurs 1-2 hours after falling asleep

Optic-2

vision, sensory Snellen chart visual acuity test for accommodation - as target gets closer, look for pupil constriction

WAD

whiplash associated disorder

Craniocervical Flexion Test

• Patient is supine with biofeedback unit underneath head inflated to 20 mmHg • With head stationary, patient performs craniocervical flexion in 5 (2mmHG) increments and tries to hold each position for 10 seconds • Normal response: can increase pressure between 26-30 mmHg and maintain for 10 seconds without substitution • Abnormal response: cannot generate increase in pressure of at least 6 mmHg, cannot hold generated pressure for 10 seconds, uses superficial neck muscles to perform motion

Nexus vs Canadian C-spine rules

•Canadian c-spine rules take into consideration mid-line tenderness and Upper Extremity Paresthesia and NEXUS considers neurological deficit and mid-line tenderness •Age is not a factor in the NEXUS and intoxication is not featured in the Canadian rule •Distracting injury not considered in Canadian rule •65 years old or greater rule is unique to the Canadian rule

Risk Factors Cervical Arterial Dysfunction

•Female 30-39 •Migraine •Oral contraceptive use •Diabetes •HTN •Smoking

WAD Outcome Measures (3)

•NDI •Whiplash disability questionnaire •Northwick park neck disability questionnaire

Other considerations about cervical instability

•Patients with Down's syndrome have congenital compromise of their collagen, which can lead to ligamentous instability throughout their entire body, including the upper cervical spine • Individuals with psoriatic arthritis could be at risk for upper cervical ligamentous instability due to the inflammatory effects of this arthritis, but it is not the most at risk population •Although individuals with systemic lupus erythmatosus exhibit inflammatory effects, this population has been seen to have far fewer cases of upper cervical ligamentous instability than those with Down's syndrome •Osteogenesis imperfecta is characterized by breaking of bones with no apparent cause, and although there is involvement of collagen mutations in this disease, this population is not at the highest risk for upper cervical ligamentous instability

Other considerations about cervical instability

•Reduced intervertebral disc height is a cause of vertebrobasilar insufficiency due to the potential for reducing the overall height of the cervical spine •If an individual's posture changes and consequently changes the lordosis of the cervical spine, there may be diminished vascularization of the arterial supply, which may lead to vertebrobasilar insufficiency •Ligamentous thickening could lead to compression of the arterial supply.

Detailed Neural Assessment - for signs of neuropathy

•SNANSS score > 12 - indicated neuropatholocial origin •Cold hypersensitive •Allodynia (brushing of the skin causes pain) or hyperalgesia •Non-mechanical patterns or sx •Emerging evidence suggests a central neurogenic component in the presence of such signs and symptoms. Mechanical hyperalgesia (local and distal) is warranted.

Characteristics of WAD:

•There is consistent strong-level evidence to support early active intervention. •Depending on how it's measured, recovery rates range from 20-80% after 12 months, leaving a significant number with persistent problems. •It is the most common outcome of non-catastrophic road traffic collision. •Course of Action: Rule out serious pathology, explore variable to help estimate recovery trajectory, establish patient goals, establish a baseline for tracing and quantifying progress towards recovery goals on a patient by patient basis.

Cervicogenic Headache

•Unilateral headache with neck/suboccipital area symptoms aggravated by movements or sustained postures is a hallmark sign of cervicogenic headache •Cervicogenic headaches can be seen in both genders, but females are more likely to have cervicogenic headaches. They also will be more likely to have migraine or tension headaches