Exam 1 - Musculo lecture & lab

If a patient has nerve root signs you figure you can treat them unless you notice which of the following? a. Pain b. Numbness c. 2/5 MMT d. None of the above

C - if a patient has < 3/5 you need to refer out to a neurologist (progressive neurologic deficits) (note: n. root signs are a contraindication to manipulation and precaution to mobilization but if it is clearly getting worse always refer out)

Which of the following is not a yellow flag a. emotional distress b. fear avoidance c. AAA d. pain catastrophizing e. None of the above

C --> this is a red flag

Pain with forced exhalation would indicate which of the following? a. cardiac concern b. neuropathic pain which should be referred out for c. rib is stuck in elevated position and cannot depress d. the patient has a rib that is depressed and presenting like thoracic pain e. T4 syndrome

C --> to fix push rib down!

Cervical arterial dysfunction includes: a. Vertebral basilar insufficiency b. Carotid artery dissections c. Can present with mechanical NP early d. Most common etiology is trauma or whiplash e. All the above

E

Choose the true facts about cervical mobilizations that have been validated through research. a. CPA decrease pain for mechanical neck pain b. mechanisms have a biochemical and mechanical effect c. mechanisms may be explained by neurophysiological effect d. A + B e. A + C

E

Inidications for mobilization of the thoracic spine/ribs includes: a. Pain that "mimics" Thoracic mechanical derangement b. "Mimics" Derangement #3 c. Mechanical neck pain d. Shoulder pain e. All the above

E

Shoulder pain interventions include a. manual therapy to the shoulder b. therapeutic exercises c. manual therapy to the thoracic spine d. a+b e. all the above

E

Spinal mobilization with leg movement is used on a patient with... a. positive SLR b. derangement number 5 c. low back pain with radiating pain d. patient has pain below the knee e. all the above

E

We are not concerned with the pop but we are absolutely concerned about the: a. snap, crackle b. running start prior to manipulating c. education post manipulation d. patient compliance e. quick stretch

E

What are the indications for Mulligan SNAGS? a. mechanical neck pain (including chronic pain) b. Cervicogenic HA c. Cervicogenic dizziness d. To increase ROM and decrease pain e. All the above

E

Which of the following is an indication to using Maitland physiological rotation mobilization techniques? a. unilateral pain b. McKenzie D3 derangement c. McKenzie D4 derangement d. physiological signs (lumbar ROM) are more positive than accessory signs (CPA) e. All the above

E

Which of the following is false about rib articulation? a. true ribs 1-7 articulate with the sternum and is a synovial joint b. false ribs 8-10 attach with costochondral cartilage from the rib cage c. floating ribs 11-12 have fibrous attachments to costochrondral cartilage d. A + B e. none of the above

E

Which of the following is true about SNAGs principles a. must be in weight bearing b. articular signs need to be checked in standing and sitting c. patient is moving throughout the motion while the technique is being completed d. need passive overpressure e. All the above

E - note: clear sitting articular signs first, and gravity acts as overpressure except in rotation when PT has to apply the pressure

You are unable to take your patient to end range during CPA testing. You articulate until about 50%. What is the likely end feel

Empty

The L5-S1 myotome tests:

Eversion (completed in supine)

What are the clinical prediction rules for lumbar manipulation?

durations < 16 days, no symptoms distal to knee, FABQ (fear avoidance) <19, segemental mobility > 1 hypomobile segement, and hip IR RIN > 1 hip > 35 degrees (if you have 4/5 of these then you have a +LR) Note: CPR are just guidelines

Put the following in order from lowest quality of evidence to highest: a. case studies b. large RCT c. small RCT d. expert opinion e. systematic reviews

expert opinion, case studies, (uncontrolled studies which was not an option but would go next), small RCT, large RCT, systematic reviews

Your pt. states they have pain while driving long distances and have pain bending over. The pain feels better with standing and laying down flat. This patient is known to have a _____________ most likely caused by a disc herniation

extension directional preference

The patient presents with pain on deep inspiration what muscle is impaired?

external intercostals

The L2 myotome tests:

hip flexion (completed in supine)

If a patient comes in to the clinic complaining of low back pain and the first thing you notice on observation is their increased lordosis you immediately want to stretch their _______ as part of treatment as you know this muscle is tight.

hip flexors (psoas or rectus)

Screening your patient prior to completing a manipulation is important. What part of your exam would you most likely get this information from?

history --> need to ask the right questions

Explain a grade 1 mobilization?

0-25% of the range of motion

what is a grade 2 mobilization?

0-50% of the ROM *

What is a 2+ mobilization?

0-75% ROM (note: compared to a grade 2 which is just 0-50%)

What are the 5 biggest benefits of manual therapy?

1. provide immediate pain relief 2. decrease anxiety and fear of movement --> chronic pain 3. motivation to perform pain reliving movement 4. provide a window of opportunity to relearn pain free movement memories 5. active involvement in rehab

What is the explanation of the biomechanical mechanism for thoracic manipulation?

1. reduction of discs 2. prevent disruption of adhesions 3. unbuckling of motion segments 4. release entrapped synovial fluids (remember: DASS to remembers Disc, Adhesions, Segments, Synovial)

What are the CPRs for thoracic manipulations with neck pain?

1. symptom duration <38 days 2. + expectation that manip will help 3. side-side difference in c. rotation >10 degrees 4. pain w/ CPA middle c. spine

What are the CPR's for thoracic manipulation for neck pain?

1. symptoms < 30 days 2. no symptoms distal to shoulder 3. looking up does not aggravate symptoms 4. FABQ score <12 5. diminished upper thoracic spine 6. cervical extension ROM < 30 degrees

What are the clinical prediction rules for thoracic manipulation?

1. symptoms less than 30 days 2. no symptoms distal to the shoulder 3. looking up does not aggravate symptoms 4. FABQ score < 12 5. diminished upper thoracic spine kyphosis 6. cervical extension ROM < 30 degrees

With TOS you often get compression between first rib and the clavicle. What manual technqiue (therapist generated) can be used to treat this issue?

1st rib mobilization

What would ROM look like if a patient have a vertebral Fx?

limited to almost NO ROM with an empty end feel (note: lumbar vertebral fx are not as common as the cervical spine)

To complete UPA/CPA you need to have the patient in the ______ position

loose pack/ closed pack

Cancer of the spine most likely presents as a musculoskeletal way in what area of the spine?

lower thoracic, upper lumbar (most commonly note fatigue, constant/unrelenting, weight loss, night sweats, night pain)

________ is described as a single, quick and decisive movement of small amplitude

manipulation

You do not manipulate through an empty end feel or normal joint barrier but you CAN manipulate through a ________

manufactured joint barrier (note: this is created by the therapist prior to manipulation)

Pt. is a 30 yo w/ gradual onset of R neck/scapular pain. Pain gets worse with sitting. Moderate painful and limited R rotation and R side bending (spasm EF), mildly limited extension with from EF. CPA at C4 was positive and painful. Is this mechanical or non mechanical?

mechanical - bc asymmetrical pattern of motion loss, sitting makes it worse and pain w/ CPA

Scalenus anticus Syndrome is compression between the anterior and __________ scalene

middle scalene (note this first involvement for TOS)

What is the "crossed hands" technqiue for?

mobility testing of ribs 2-10 --> left hand mobilizes and right hand stabilized

Fill in the blanks regarding lateral glides for the cervical spine: when used as treatment, the ________ hand contacts the contralateral lamina of the desired segment with radial aspect of ______ phalanx of your index finger

mobilizing; proximal

A diminished or absent deep tendon reflex is indicative of ______ whereas hyperreflexia is indicative of _________

n. root lesion; spinal cord compression

Thoracic manipulation was effective in reducing neck pain, improving dysfunction and ____________ and also improves ROM

neck posture

A lateral glide is indicated for:

nerve root pathology / neck pain with radicular symptoms

Fill in the blanks: PT maintains transverse mobilization during SMWLM with thumbs _______ as the patient performs ________ SLR. The assistant with apply gentle _______ overpressure at end range then ________ brings leg back to starting position.

overlapping; active; passive; passively (note: this is done 3x then re-evaluate w/ SLR)

Which hip is faced up with a grade 1 rotation when completing a maitland physiological mob technique

painful hip UP

In your history if you are suspecting CAD which motion would you avoid during the cervical exam?

passive cervical end range rotation (and passive end range provacative tests in general) ***

Interventions need to be based on what 3 things regardless of diagnosis?

patient concerns best evidence clinical expert *******

when completing SNAGs in the cervical spine your thumbs have to be in what position?

perpendicular

If a patient as increased lumbar lordosis when you position then in prone prior to completing CPA/UPA add ______ to decrease lordosis and open ______ joints

pillow; lumbar facet

If the snag is not sustained and the bone comes back this could ________

pinch a disc again and increase the pain "the SNAG along the joint surface must be sustained throughout the motion"

What is a positive sharp purser test?

posititve = cervical instability --> sliding motion of head posterior occurs aka C1 reduces (and this can often reduce symptoms)

What is the force of mobilizing the costvertebral joint of ribs 2-12?

posterior to anterior

Fill in the blanks regarding lateral glides for the cervical spine: when used as treatment, the ________ hand contacts the ipsilateral lamina of the desired segment with radial aspect of ______ phalanx of your index finger

stabilizing; proximal

The costotransverse joint is the most ______ joint therefore you should ________ a. distal; treat first b. distal; treat last c. superficial; treat first d. superficial; treat last e. none of the above

superficial; treat first (note: costotransverse is superficial and costovertebral is deep)

The costovertebral joints articulate how?

superior facet of the lower vert. articulates with the inf. facet of upper vert (note: covex head of rib with concave vert body)

What is the force for mobilizing the costotransverse joint of ribs 2-12

superior, anterior, lateral

What manipulation should be used to also treat SIJ?

supine lumbo-pelvic manipulation

SNAGS stands for....

sustained natural apophyseal glide

What is the purpose of myotome testing?

tests for possible muscle weakness which suggests nerve root involvement such as a disc pressing on a n. root

The cervical rotation lateral flexion test is to test for:

the 1st rib involvement (Note: pt. is sitting, passively rotate away from side to be tested, gently side flex head towards chest)

What is the main treatment for neck pain with headaches?

they'd have a positive flexion rotation test, can use SNAGs

To reduce risk with cervical manipulation consider _______ manipulation for management for neck pain

thoracic

The _____ spine is by far the most commonly manipulated region

thoracic (and its often done with people with neck pain, there is a biomechanical advantage)

For someone who has pain in their neck they are most likely to get a ________ manipulation and the neurophysiological mechanism behind this is that pain is modulated through ______ and ________ pathways

thoracic; central and peripheral

Combination of upper cervical and upper ______ manipulation has greater short term effects than ____ for neck pain

thoracic; mobilization

When assessing the costotransverse joint of ribs 2-12 note it has a little bit of an angle so make sure the force is:

toward table slightly laterally, also anteriorly and superiorly is a given based on hand placement

Regarding a 3D axial separation manipulation. Choose any that apply. a. advised to be used with a patient who has a directional preference b. Is a global technique c. should be used with stiffnedd and empty end feel d. Patient is placed in same position as Maitland mobilization e. Patient will only feel pop is manipulation was successful

A + B + D

Which of the following muscle would be appropriate to assess if a pt. is having back pain? (choose any that apply) a. gluts b. hamstrings c. supraspinatus d. hip abductors e. rectus and psoas

A + B + D + E

With an intercostal muscle strain you'd notice which of the following on exam? Choose any that apply. a. pain with palpation would be most painful b. pain with end range rotation c. pain with inhalation or exhalation d. mobility testing does not reproduce pain bc its muscle e. pain with gentle massage therapy

A - D

Which of the following is true about thoracic outlet syndrome: a. does not following a dermatone b. is more common in males c. occurs due to old age and osteoporosis d. pt will always need surgery

A is true B - no females C - trauma, pregnancy, backpacks D- no think mobilization of neck, tspine and 1st rib in CLINIC

Which of the following is NOT result from a spinal manipulation? a. dizziness b. headache c. syncope d. fatigue e. paraesthesia

C (these risks are simply transient meaning they go away after a certain period of time aka 4-24 hrs... others include discomfort, tired, pain, nausea)

Rib 6 will articulate with Inferior Costovertebal facets of _______, Superior Costovertebral facets of ____, and Costotransverse facet of ____

- Inferior Costovertebal facets of T5 - Superior Costovertebral facets of T6 −Costotransverse facet of T6

Indications for manipulations would be:

- mobility deficit with or without directional preference - D1/D3 - unilateral pain - noncapsular/asymmetrical pain

For each of the following choose either: a. costochondritis or b. tietze syndome - multiple ribs involved: - caused by trauma: - can be treated with mobilizations:

- multiple ribs involved: A - caused by trauma: B - can be treated with mobilizations: A

What are the 4 indications to using Mulligan spinal mobilizations with leg movement (SMWLM)

1. LBP w/ radiating pain i.e D5 2. Positive SLR 3. Best if L5/S1 level 4. McKenzie D3 w/ positive SLR

What are the 10 contraindications for manipulation and precautions for mobilization?

1. active inflammatory process 2. metabolic bone disease 3. if technique increases or peripheralize pain 4. spinal instability/ spondy 5. neurogenic bladder 6. spinal cord signs 7. nerve root signs 8. prolonged use of steroids/anti-coagulants 9. emotional problems 10. patient DOES NOT want to be manipulated

What are 2 theories for spinal manipulation effects?

1. biomechanical (repositioning) 2. neurophysiological (elicit stretch reflex, reduces muscle guarding, and reduced pain, central sensitization)

What are red flags to consider in the CERVICAL spine?

1. cervical arterial dysfunction 2. cervical hyper mobility (due to instability or fracture) 3. vertebral fracture

What is the step-wise process for evaluating the ribs?

1. clear c. spine 2. thoracic spin eval 3. mobility testing of ribs 4. the test becomes the treatment

What are the 3 ways manipulation can have a huge neurophysiological influence?

1. decrease pain 2. decrease muscle guarding 3. wakes up muscles

What are the 3 steps for making clinical predication rules?

1. derivation of the rule 2. validate the rule 3. evaluate the impact

What are the 5 D's And 3 N's of cervical arterial dysfunction?

1. diplopia 2. dizziness 3. dysarthria 4. dysphasia 5. drop attacks ---- 1. ataxia ---- 1. nausea 2. numbness 3. nystagmus (note: these only occur in the late stages)

The purpose of the SLR test is to test for what 3 things?

1. dural mobility 2. sciatic n. irritation 3. L4-S2 n. root irritation

What are the 2 peripheral effects of thoracic manipulation?

1. increased skin conductance 2. decreased skin temperature

Although there are not many contraindications to treating thoracic spine and ribs we need to be cautious for what 2 things?

1. osteoporosis 2. potential for ribs / vertebral fx

What are the 2 likely reasons for an intercostal muscle strain?

1. overuse 2. trauma --> pain at end range trunk rotation

What are the 3 things mobilizations in general assess

1. pain - makes it better or worse? 2. hypo mobility 3. end feel

When performing lumbar mobilization for stiffness which quadrants do you work in?

3 and 4

How do you find a transverse process of T4-T9

3 fingers up, 2 across

How long do you complete a rhythmic mobilization for?

30-60 seconds (and this is the big difference between a mob and manip)

With a grade 1 rotation when completing a maitland physiological mob technique you need to flex the hips and knee to ____ degrees, the PT is standing in a stride standing perpendicular and the patients top hand is placed ________

45; flat on the mat (blocks movement at the UE)

what is a grade 3 mobilization?

50 - end of the ROM

In the cervical exam why are there 6 active motions but only 5 passive motions?

6 actives = flexion, extension, side flexion L, R, and rotation L, R BUT there is no passive flexion = 5 passive motions

what is a grade 4 mobilization?

75% - tissue end feel within the ROM

If the rib is stuck down and won't elevate the patient has pain with: a. inhalation b. exhaltion c. pain with rotation d. pain with flexion e. all the above

A

Neurophysiological effects from thoracic manipulation help: a. decrease pain and calm the system down b. put the train back on the tracks. c. increases sympathetic NS output d. decrease red flags in the history

A

Which of the following is true about cervical arterial dysfunction a. rotation puts the greatest amount of tension on cervical arteries b. as a PT you can rely on one clinical test to base conclusions c. cervical manipulations are the biggest cause d. refer to MD doesnt have to happen until one month of still having passive end range rotation provocation

A B- is false bc you CANNOT rely on one clinical test to base conclusions C - is false bc you would never take a pt. to end range for manipulations D - refer right away

The quad reflex is: a. L1 b. L2 c. L3 d. S1-S2

C

What is a non-thrust manipulation?

Another term for mobilization

With regards to the costovertebral joint, placement for rib 1 the force is:

Anterior, Medial, slightly INF (toward the opposite ASIS) **

The purpose of testing for Babinski is:

Assess for spinal cord compression (myelopathy)

Which of the following is a high velocity technique used by physical therapists? a. Manual Massage b. Plyometric therex for athletes c. Manipulation d. Mobilization e. C + D

C

The purpose of completing prone knee flexion during the lumbar exam is for:

Assessment of dural mobility and neural tissue irritation of L2,3,4 (femoral n.)

A CPA is indicated for _____ pain and a UPA is indicated for ______ pain a. central; central b. central; unilateral c. unilateral; unilateral d. unilateral; central e. none of the above

B

After the prone press up progression which of the following is a good progression to alleviate tension? a. cat/cow pose b. child/lion pose c. happy baby pose d. single leg lunge

B

Research shows hypo-mobility at C7 and T1-T2 shows: a. + CPA/UPA and manipulation b. Signification predictor os shoulder and neck pain c. Positive cervical rotation, lateral flexion test d. Increased muscle spasm will occur e. All the above

B

Which of the following is not a spinal cord sign a. babinski b. pain c. hyperreflexia d. spasticity e. none of the above

B

Which of the following is not an indication to using mulligan SNAGS a. mechanical neck pain b. non mechanical neck pain c. cervicogenic HA d. cervicogenic dizziness

B (goal is to increase ROM and decrease pain)

Why is rib 1 different? a. it is larger than the rest b. it only attached to T1 c. it is elevated more d. there is most often pain here

B (note: anatomy within 1st rib there are scalenes, traps, subclavian a. v.)

What are the CPRs for cervical manipulation? Choose any that apply. a. symptoms < 28 days b. + expectation that manipulation will help c. side to side difference in cervical rotation ROM > 10 deg d. FABQ < 19 e. Pain w/ CPA at middle cervical spine

B + C + E + symptom duration < 38 days

Which of the following is NOT a patient generated lumbar technique? a. Mulligan self traction b. Mulligan Mobilization with leg Movement c. Lion "childs pose" d. McKenzie extension progression e. None of the above

B - this is patient, therapist and assistant generated

A spinal manipulation is not necessarily energetic and is completed _______ the patient can stop it

Before

Anyone with D4 has a lateral shift what do you do first a. stretch b. manipulations c. fix the lateral shift d. balance work e. mobilization to the femur

C

If central pain is more painful how would you treat? a. traction b. distraction c. CPA d. UPA e. all the above

C

Non capsular pattern of motion at the lumbar spine MOST likely indicates which of the following? a. vertebral Fx b. SIJ dysfunction c. mechanical derangement such as a disc or facet d. spondylolithesis e. osteoarthrtis

C

Resisted cervical testing is completed within the cervical exam to assess for possible muscle strain and resisted rotation assesses for _____ nerve root

C1

Resisted scap elevation assesses ________ nerve root(S)

C2, 3, 4

Someone comes in with unilateral suboccipital head and neck pain and says 4 days ago he had the worse headache of his life. This pt. has never had neck pain before, is morbidly obese and is a retired teacher. What is the likely differential dx?

CAD (cervical arterial dysfunction)

What are accessory motions in the lumbar spine?

CPA, UPA --> motions that pt. does not do but PT does

During cervical CPA testing how is hand placement different than in the lumbar spine?

Cervical - thumb over thumb with rest of fingers by pt. neck starting at C2 then once you reach C5/6 move hands to patients upper back

Someone with a slipped/sublux rib would report which of the following? Choose any that apply. a. grinding feeling / sound b. intense 9/10 pain c. pt says he got a blow to the side which brought on pain d. limited raising of arm on that side in abduction, limited side bending e. pain with deep breath

Choose all

Costoclavicular Syndrome is compression between the first rib and the ________

Clavicle (note this first involvement for TOS)

Which of the following is NOT a red flag for spinal manipulation? a. Infection within disc or vertebra b. Vertebral Fx c. Triple A d. Emotional distress e. None of the above

D --> this is a yellow flag Red flags include all of the following: AAA, vertebral fx, serious medical condition, cancer, infection

Fill in the blank: for evidence poor areas we as PTs really rely on _____ a. small RCTs b. newspaper clippings c. hierarchy of evidence d. expert opinion e. clinical decision making

D expert opinion

If a patient has acute or irritable cervical conditions such as whiplash or radiculopathy consider _______ as treatment: a. thoracic active ROM b. thoracic resisted MMT c. thoracic mobilization d. thoracic manipulation e. none of the above

D

If a patient presents with kyphosis or decreased lumbar lordosis which of the following is most likely? a. disc protrusion b. iliac crest asymmetry c. SIJ dysfunction d. spinal stenosis e. lumbar spinal infection

D

If unilateral pain is more painful how would you treat? a. traction b. distraction c. CPA d. UPA e. all the above

D

The achilles reflex is: a. L1 b. L2 c. L3 d. S1-S2

D

When do you choose Maitland mobilization technique a. pt in Mckenzie D3 derangement b. pt has physiological pain c. pt has unilateral pain d. all the above

D

Which of the following is false about rib pain a. mimics unilateral pain in the thoracic area b. mimics a thoracic derangement #3 c. pt. with more pain with rotation is actually a thoracic spine issue d. will radiate bilaterally e. pain with side bending is more commonly a rib issue not a thoracic spine dysfunction

D

Which of the following is false about spinal mobilization? a. its a therapist generated procedure b. its a skilled passive movement to a joint c. examples include CPA, UPA d. most commonly done in a thrusting maneuver e. grading should be documented

D

_______ is intended to restore optimal motion, function, and can reduce pain a. manipulation b. mobilization c. massage d. A + B e. All the above

D

Evidence based medicine includes all of the following except? a. patient concerns b. best research evidence c. clinical experience d. none of the above

D (note: balancing the 3 pillars of EBP aka patient values, clinical expertise and relevant research is critical)

What is being manipulated in the lumbar spine? a. facet joints b. discs c. muscles d. facet capsules e. all the above

D (note: the facet capsule has mechanoreceptors)

Cervical distraction/ axial separation would be for: a. young patient b. pt. with disc issue c. D1 or D3 d. all the above

D - and note you pull moderate to heavy, neck is in slight extension, must have stabilization from second operator unlike mechanical traction which is used for older populations

Mechanical traction is commonly used for: a. young patient b. pt. with disc issue c. D1 or D3 d. someone who has closed up joints e. none of the above

D - becuase its for older patient, narrowing of neck, technique is in slight flexion and pull is light to medium, pt. is D5 and stabilization is not required bc not pulling hard

For a cervical extension SNGAG the therapist is _______ and the patient is _______ a. sitting; standing b. sitting; sitting c. standing; standing d. standing; sitting e. none of the above

D - standing; sitting (need to maintain 45 degree plane)

What patient would need core strengthening? a. immobility b. low back pain patient c. postpartum female d. all the above

D - you can honestly work on core work with everyone

The L4 myotome tests:

DF (completed in supine)

Your patient circles YES on the patient questionnaire to having night pain. What is the most important follow up question

Does any position relieve this night pain? If they can change position and it feels better its more likely mechanical but if its unrelieving it could be cancer or something more serious

True or False: During a maitland grade 1 rotation you want to see the patient move in a log roll like position

FALSE - this means the patient is stiff and the technique is not effective

What is the patient position for mulligans mobilization with movement technique?

Facing PT (belly to belly), pt. is side lying w/ affected leg up, close to edge of tx table, unaffected hip and knee is flexed to 45 deg, affected leg is extended w/ slight knee flexion and abduction at the hip supported by assistant

True or False: A spinal manipulation must always be localized in the way its applied.

False - it is localized or globally applied (and most are actually global especially in the lumbar spine)

True or False: If your pt. tells you they have pain with taking a deep breath it has to be a rib dysfunction

False- this doesnt tell you thoracic vs. rib you have to check articular signs and accessory motion testing

True or False: "When you manipulate a patient tell them they will feel a pop so they dont get anxious"

False- you wont always get a pop and there is not correlation with pop and success

True or False: Rib movement happens before thoracic movement

False: "Thoracic motion does NOT occur independent of Rib motion" -Thoracic spine extends --> Ribs elevate -Thoracic spine flexed --> Rib depress

What are 4 other ways to say spinal Manipulations....

HVLA (high velocity low amplitude thrust), HVT (high velocity thrust), thrust manipulation, grade 5 mobilization

The L5 myotome tests:

Hallux (completed in supine)

Passive cervical extension has a ______ end feel

Hard

ITS A FREE BE!

PASS GO

What is being explained below? Simultaneously pull patient's pelvis toward you & push patient's thorax away, Hold 1 sec, repeat 10x...DO NOT over correct into pain! Will take multiple sessions to fully correct lateral shift Once corrected with therapist assistance then perform standing extensions... (stand on the concave side to pull pelvis toward you)

McKenzie D4 Lateral Shift correction

What is one most common way to treat someone with a extension directional preference?

Mckenzie method (extension) Note: - If D2: start w/ pillow under abd. - D3 & D5: trial this first if not go straight to D3 progression - D4: must perform lateral shift correction 1st

If you have left side pain with limited left rotation would you prescribe a self SNAGs technique?

No - it wont work if its on the same side

Use the patients ______ as a guide when completing active cervical rotation in the cervical exam

Nose

The cervical distraction is a therapist generated technqiue - how is it performed?

PT cups chin with one hand and occiput with the other standing with chin side leg behind & distract by leaning back --> hold 20-30 sec up to 10x

Which patients are best for manipulations? What are the indications?

Pain in low back, central or unilateral that doesn't cross the knee; directional preference pt; McKenzie D1/D3

________ is performed by placing one hand on the frontal bone with your elbow behind the patients shoulder while the other hand is on the occiput with that elbow in the front of shoulder.

Passive cervical rotation

If articular or physiological reproduce pts. pain what technique would you use?

Physiological technique

With regards to the costotransverse joint plane for rib 1 the force is:

Posterior to Anterior **

Explain the McKenzie Extension Progression:

Prone 5 min --> prone on elbows 5 min --> prone press ups 10x --> standing extension 10x (Note: if D3 progress pelvic shift AWAY from side of pain and go through prone progression until pain is centralized (D1/D2)

If iliac crest palpation appears uneven standing this could be indicative of 3 dysfunctions. When compared in a seated posture the patients iliac crests become symmetrical what is the most likely cause of this change?

Pt. most likely has leg length discrepancy (if it was still asymmetrical it would be indicative of scoliosis or SIJ dysfunction)

Which UMN tests are completed in the cervical exam and how are these completed?

Quad relfex - tested in seated Hoffman - flick 3rd finger... positive if thumb flexes Babinski - can be done in a seated posture

Fill in the blank in regards to myotome testing in the cervical exam: Resisted abduction: C___ Resisted adduction: C___ Resisted rotations: C___ Resisted elbow flexion: C___ Resisted elbow extension: C___ Resisted wrist flexion: C___ Resisted wrist extension: C___ Resisted thumb extension: C___

Resisted abduction: C5 Resisted adduction: C7 Resisted rotations: C5,6 Resisted elbow flexion: C6 Resisted elbow extension: C7 Resisted wrist flexion: C7 Resisted wrist extension: C6 Resisted thumb extension: C8

The purpose of completing 5 heel raises (resisted plantarflexion) during the standing portion of the lumbar exam is to assess:

S1-S2 n. root

Main intervention with neck pain with movement coordination deficits would be?

Stabilization training --> activate stabilizers --> supine utilizing gravity, the pillow and biofeedback --> to train deep neck flexors --> can also incorporate neck flexor endurance test later on

What is the sharp-purser test?

Stabilize C2 and flex head --> if pt. had instability they might c/o lump in throat and dizziness --> C1 is sliding in C2 --> after test is completed positive test would either be a clunk or symptom relief

According to Mulligan SNAGs technqiue if you find that T6 is the painful level during bilateral PA's complete the technqiue on _____ level

T5 - always complete SNAGS on the level above ***

In prone the inferior angle of the scap is in line with T___ and in T___ in sitting

T6; T7

First rib might be a contributing factor for ____, neck pain or headaches

TOS

________ is characterized by pins and needles, pain, weakness or vascular symptoms in the upper limbs

TOS (note: its mostly compression of brachial plexus and vasculature)

If physiological signs are more positive/painful on exam than accessory motions what would a PT treat?

TREAT the physiological signs first!

Your pt. is a 55yo w/ 3 month hx of neck pain and R arm pain, R thumb numbness. Pt. has painful and limited neck extension, R rotation and R side bending. There are weak R triceps and R flexor carpi, C7 dermatome sensory loss, decreased R tricep reflex. What could be interventions for this patient?

Tensioners and gliders, address posture (kyphosis and forward head), ULT position

Lower ribs ________ & move in a lateral direction aka coronal/fontal plane which occurs on a ______ axis

WIDEN; sagittal

The rib "swivels/rotates" in what 2 joint types?

The costotransverse and costovertebral joints.

For cervical extension SNAGS what is the overpressure? Is it necessary?

The overpressure is through gravity (not the therapist) so yes necessary

The overpressure component in a rotational SNAGs in the C spine is done how?

The pt. does it using opposite hand than the direction theyre going

You are working in a subacute in the pulmonary unit. Your COPD patient tells you every time they sigh they get a sharp shooting pain. You ask them to inhale and they have no pain. When you ask the patient if any other motions increase the pain they say yes "extension and side bending to the opposite side increase the pain". What do you think is going on with this patient?

There is an intercostal muscle strain - specifically internal intercostals (note: this makes sense becuase the patient has COPD... intercostal strains are most commonly caused by trauma or OVERUSE and its best treated with transverse deep friction massage)

Passive cervical side flexion L/R has a _______ end feel

Tissue stretch end feel

What is the most common etiology for CAD (cervical arterial dysfunction)?

Trauma such as whiplash

True or False: Both costovertebral joints and costotransverse joint have convex rib articulate with concave vertebrae

True

True or False: Mulligan SNAGS and Maitland Mobs provide short term relief of dizziness

True

True or False: Shoulder pain can be treated with thoracic manipulation

True

True or False: The Mulligan SNAG principle needs to always be painless and communication with your patient is essential

True

True or False: The treatment Philosophy for spinal mobilizations is "As gentle as possible but as strong as necessary"

True

True or False: There is good quality evidence which suggests the use of thoracic manipulation plus exercise

True

True or False: To test the right 1st rib rotate to the left passively and side bend/flex to the right

True

True or False: When we do mobilizations in the cervical spine movement doesn't only happen at the one single bone but occurs in the segment above and below

True

True or False: Yellow flags in the cervical spine are the same as yellow flags in the lumbar spine?

True

True or False: in a study, patients with neck pain who met CPR for thoracic HVT did better with cervical HVT and had fewer side-effects

True

True or False: A vertebral fracture could create cervical hyper-mobility

True (note: prolonged use of corticosteroids, mild trauma > 50yo, age >70, Hx of osteoporosis, recent major trauma would all lead you to believe pt could have vert fx)

True or False: Posterior thoracic pain of the costotransverse/costovertebral joint is most common

True (there are 3 types: posterior, lateral, anterior)

True or False: Side effects and risks associated with manip techniques are rare in the cervical spine

True --> Note: Although rare, side effects in the cervical spine may be severe and prohibit their use by the novice practitioner

True or False: Choosing an intervention must be based on the balance of evidence for risk and therapeutic efficacy.

True!

True or False: SNAGs has to be pain free

True!

Your pt. comes in complaining of a painful left side, unilateral pain. You decide to complete a grade 1 UPA but are unsuccessful due to pain. What is the next step?

Try the UPA on the opposite side. If that is unsuccessful then try to complete UPAs on the segment above or below

For SNAGs extension, rotation, and side bending in the thoracic spine the front hand must be ______ and the back hand is ______

above! ; below

If a patient presents with lump in throat, nausea, dizziness you begin to think they might be suffering a whiplash injury. What ligaments need to be tested?

alar (for cervical instability) and transverse (sharp purser)

During the _____ test of the cervical exam you would state to the patient "I am going to test the ligaments in the upper portion of the neck to confirm that these ligaments are intact & therefore not contributing to the neck pain you came in with"

alar ligament test

After completing resisted testing in the cervical exam the next step is to check for alternate signs of pancoast tumor and then assess for_____

alternate signs for should pathology aka have patient complete shoulder elevation "can you please raise your arms overhead"

Scapular retraction, upward rotation, posterior tilting + humeral head depression will lead to......

an increase in available subacromial space (scapular + rotator cuff strengthening)

Complete an _____ glide for self SNAGS extension/sidebending/rotation

anterior cranial glide

The cervical SNAG for rotation and sidebending is done at the ______ of the vertebrae

articular pillar --> which is right off of the spinous process

What does the assistant do during cervical distraction/axial separation?

assistance stabilizes shoulders by bringing them down and holds here for 1 minute until PT releases the distraction!! Note PT position: PT will support head which is off table, PT one hand on neck and other hand has chin cradled --> whatever hand is on chin that leg steps back (Stride stance), elbows bend close to body --> sit back and down so arms automatically extend

Your pt. is a 55yo w/ 3 month hx of neck pain and R arm pain, R thumb numbness. Pt. has painful and limited neck extension, R rotation and R side bending. Is this symmetrical or asymmetrical and is it capsular or non-capsular?

asymmetrical; non-capsular

If the patient has right side pain but is limited to the left explain how to complete cervical SNAGS?

do SNAG on the painful side (right) and have patient use left hand to rotate to the left

Once you refer a pt. to MD for CAD (cervical artery dysfunction) based on history what diagnostic exams might the MD complete to confirm?

doppler US or CT scan

A positive alar ligament test is:

delay in movement of the ligament

With a rib 1 issue we would think to complete the ______ and also assess the 1st rib using ________, a special test

cervical exam; cervical rotation lateral flexion test

What is the difference between costochondritits and tietze syndrome?

costo has multiple rib involved vs. 2nd/3rd ribs in T syndrome, costo has no swelling vs. T syndrome has swelling, costo is caused by inflammatory response vs. T syndrome which is caused by trauma or infection, costo you can treat with mobilization, T you can only treat with cortisone injection

What one simple question can be asked to help rule out vertebral fracture?

did you get an X-ray or image taken (especially if they went to ER)

Research in general on thoracic manipulation shows it ____ pain, ______ ROM, and ____ function Choose either: a. increase b. decrease

decreases, increases, increases

pelvic floor are _____ muscles important for postpartum females, dancers, young females who can turn these muscles on but have instability issues

deep

Passive cirvical rotation has a _____ end feel

firm/capsular

For Maitland rotation principles position of the bottom leg is very important. For grade III & IV, the patient's top knee must be __________, and the patient is placed in ________ on the treatment table.

free to extend over the edge of the table; diagonal/oblique

The S1-S2 myotome tests what 3 muscle groups?

gastroc, prone knee flexion, gluts

For a pain dominant patient which CPA mobilization would you complete?

grade 1 and 2

In states that do not allow manipulation, therapists often complete a ______ mobilization

grade 5

The only difference between grade 1 and grade 2 maitland physiological mobilization is:

hand position has to be on lateral rib cage

What is the most important aspect at the end of cervical distraction/axial separation?

help pt. come to seated position so in case they get dizzy

During the cervical exam the PT stands in front of patient instructed them to stand with elbows bent to 90 and forearms pronated and fingers extended. PT places index fingers between 4th 5th digits to test _____ which assess ____ nerve root

resisted finger adduction; T1

The L3 myotome tests:

resisted knee extension

When performing cervical lateral glides it should be performed in the direction of ______

restriction

If ribs 2, 3, 4 are hypo-mobile and not moving what would this mean for the proximal and distal structures?

ribs 2,3,4 articular directly w/ scap therefore scap and shoulders subsequently cant move as well and --> would need mobilization of ribs

To test the left alar ligament the PT should put their ____ thumb on the left side of their C___ spinous process & ____ hand on top of the patients head. You would then sidebend the patients head to the right ___ - ___ degrees and you'd feel for the spinous process to mov into thumb indicating C2 has rotated to the right meaning the ligament is intact

right, left, 5-10 (note: the test is only positive if there is a delay or no movement indicating ligament insufficiency)

Middle ribs moved in the ____ and ____ planes and this is commonly referred to as pump handle and ________

sagittal & coronal; bucket handle

Upper ribs move in the _____ plane on a _______ axis and this is commonly referred to as the pump handle

sagittal plane (anterior/posterior diameter) ;coronal/frontal

The _____ bone sits above ribs 2 and 3 which is why its very important to treat the ribs and spine

scapula (want to prevent dysfunction) - rib dysfunction may be a contributing factor in patients with shoulder pain bc rib dysfxn can alter scapular position and could lead to shoulder impingement

Therapeutic exercises for scapular and rotator cuff strengthening include:

scapular retraction, upward rotation, posterior tilting plus humeral head depression which will increase subacromial space

Upper rib dysfunction may alter _____ position and _______ motion

scapular; thoracic

Rib Tip syndrome is also called:

slipped/sublux rib (Note: Mechanism: After an injury to the anterior chest wall, involvement of anterior cartilage of 8th-10th, Ribs subluxes INFERIOPOSTERIORLY, Resultant contact with intercostal nerves, PAIN)

What is spinal manipulative therapy (SML)?

spinal mobilization combined with spinal manipulation (note: evidence supports the use of SML early in combination with exercise)

For thoracic SNAG extension technique fill in the blanks regarding therapist contact: Primary mobilizing contact hypothenar eminence just distal to pisiform either on _______ or transverse process of bone ___ level ____ painful segment. Elbow of mobilizing hand is tucked into PT side

spinous process; 1; above

D3 is _______ pain

unilateral

Someone with cervical arterial dysfunction would present with subtle symptoms when taking history. What is this symptoms the pt. would c/o ?

unilateral suboccipital head and neck pain (dont confuse with cervicogenic HA) --> may also say theyre having the worst HA of their life

Etiology for cervicogenic dizziness includes:

upper cervical degeneration, whiplash, trauma

Explain normal inspiration vs. expiration

− Normal Inspiration: Trunk and rib cage expands Thoracic spine extends Posterior aspect of ribs roll posterior and glide anteriorly Anterior aspect of ribs elevate − Normal Expiration: Trunk and rib cage condenses Thoracic Spine flexes Posterior aspect of ribs roll anteriorly and glide posteriorly Anterior aspect of ribs depress