Clinical Assessment of Neck and Cervical Spine
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Questions and Answers

What should a clinician observe during vertebral artery testing?

  • Decreased heart rate
  • Nystagmus and slurring of speech (correct)
  • Improved range of motion
  • Increased muscle strength
  • Which of the following is considered a contraindication to neck traction and manipulation?

  • Dizziness after testing the vertebral arteries (correct)
  • A history of neck pain
  • Mild headaches
  • Patient age under 30 years
  • Which condition does not fall under red flags for serious pathology in neck-related issues?

  • Muscle strain (correct)
  • Cervical myelopathy
  • Neoplastic conditions
  • Vertebral artery insufficiency
  • What age criterion is mentioned as a red flag for serious pathology in patients?

    <p>Age &gt;50 years (A)</p> Signup and view all the answers

    Which of the following symptoms could indicate vertebral artery insufficiency?

    <p>Dysphasia (A)</p> Signup and view all the answers

    After ruling out serious pathology, how is neck pain often classified?

    <p>Neurological or non-specific (A)</p> Signup and view all the answers

    Which vital sign is identified as a red flag when assessed?

    <p>Blood pressure &gt;160/95 mm Hg (A)</p> Signup and view all the answers

    Which symptom is specifically mentioned as a warning sign during vertebral artery testing?

    <p>Blurring of vision (B)</p> Signup and view all the answers

    What unique feature do the transverse processes of the upper six cervical vertebrae possess?

    <p>Foramen transversarium (C)</p> Signup and view all the answers

    What is the orientation of the articular facet joints in the middle and lower cervical spine?

    <p>Sagittal plane inclined upward and forward (A)</p> Signup and view all the answers

    Which cervical segment is known to allow the greatest amount of rotation?

    <p>C1-C2 (D)</p> Signup and view all the answers

    What type of motion coupling occurs during lateral flexion in the upper cervical spine?

    <p>Opposite side axial rotation (B)</p> Signup and view all the answers

    What anatomical structures limit the movements of spinal segments?

    <p>Ligaments, intervertebral discs, and facets (C)</p> Signup and view all the answers

    What is the shape of the occipital condyles in relation to the superior articular surfaces of the atlas?

    <p>Convex and concave respectively (A)</p> Signup and view all the answers

    What does the performance index measure in cervical spine assessment?

    <p>The ability to maintain a pressure level through repetitions (A)</p> Signup and view all the answers

    What type of movement occurs simultaneously due to anatomical structures in the cervical spine?

    <p>Lateral bending and axial rotation (A)</p> Signup and view all the answers

    What characteristic describes the spinous process of a typical cervical vertebra?

    <p>Short and bifid (D)</p> Signup and view all the answers

    Which of the following is a subjective feature of clinical cervical instability?

    <p>Fatigue and inability to hold the head up (C)</p> Signup and view all the answers

    What is the purpose of strengthening stabilizing muscles in the cervical spine?

    <p>To enable better control of movement within the neutral zone (A)</p> Signup and view all the answers

    What is the most common surgical treatment for severe cervical spine instability?

    <p>Anterior cervical fusion (C)</p> Signup and view all the answers

    Which characteristic is NOT typically associated with poor neuromuscular control in cervical instability?

    <p>Absolute range of motion increases in standing (D)</p> Signup and view all the answers

    What is a key goal of non-surgical treatment in managing cervical instability?

    <p>Improvement of controlled motion quality (A)</p> Signup and view all the answers

    Which of the following is a possible objective feature of clinical cervical instability?

    <p>Hypomobility of the upper thoracic spine (C)</p> Signup and view all the answers

    What type of exercises are beneficial for improving proprioception in the context of cervical instability?

    <p>Balance and coordination exercises (A)</p> Signup and view all the answers

    What cervical spine position is most effective in provoking arm symptoms during Spurling's test?

    <p>Neck in extension, lateral flexion and axial compression (C)</p> Signup and view all the answers

    Which condition is characterized by neck pain, irradiating arm pain, and a decrease in cervical spine range of motion?

    <p>Cervical radiculopathy (C)</p> Signup and view all the answers

    What is a common symptom exacerbated by lateral flexion toward the affected side in cervical radiculopathy?

    <p>Decreased muscle strength (C)</p> Signup and view all the answers

    What does the pathoanatomical model primarily focus on in understanding clinical conditions?

    <p>Structure that is dysfunctional within the body (C)</p> Signup and view all the answers

    In treating cervical radiculopathy, which of the following is NOT a proposed intervention?

    <p>High-impact aerobic exercises (A)</p> Signup and view all the answers

    What is defined as the inability of the spine to maintain its pattern of displacement under physiological loads?

    <p>Cervical instability (B)</p> Signup and view all the answers

    Which classification is NOT included in the treatment-based classification for managing neck pain?

    <p>Chronic tension-type headache (A)</p> Signup and view all the answers

    Which of the following is NOT a typical symptom of cervical radiculopathy?

    <p>Joint stiffness in the lumbar region (A)</p> Signup and view all the answers

    What was the main purpose of the approach suggested by Werneke et al regarding acute spinal pain syndromes?

    <p>To enhance the identification of patients with improved treatment outcomes (B)</p> Signup and view all the answers

    Which aspect has been emphasized with the shift towards a cost-effective model for diagnosis?

    <p>Separating patients into treatment-oriented subgroups (D)</p> Signup and view all the answers

    Which intervention involves manual or mechanical methods to relieve symptoms of cervical radiculopathy?

    <p>Cervical traction (B)</p> Signup and view all the answers

    How is clinical instability primarily characterized?

    <p>Increased size of the neutral zone (C)</p> Signup and view all the answers

    In the context of neck pain management, what does 'WAD' stand for?

    <p>Whiplash Associated Disorders (D)</p> Signup and view all the answers

    What does the treatment-based classification model emphasize for therapists?

    <p>Matching interventions to specific patient subgroups (C)</p> Signup and view all the answers

    Which of the following is a characteristic of the symptom response-based approach known as centralization?

    <p>It assesses how movement impacts symptom location (A)</p> Signup and view all the answers

    What was updated in 2008 as part of the APTA Orthopedic section ICF Guidelines?

    <p>The classification categories for neck pain (D)</p> Signup and view all the answers

    What is the purpose of the Sharp-Purser test in relation to the Transverse Ligament Stress Test?

    <p>To reproduce symptoms before reducing them (D)</p> Signup and view all the answers

    Which of the following is NOT a sign of a positive test result for the procedure involving the C1 vertebra?

    <p>Increased neck strength (D)</p> Signup and view all the answers

    During the Neck Flexor Muscle Endurance Test, which position does the patient assume?

    <p>Supine in hook lying (C)</p> Signup and view all the answers

    What defines the activation score in the Craniocervical Flexion Test (CCFT)?

    <p>The activation of deep cervical flexor musculature (B)</p> Signup and view all the answers

    What is a normal endurance time for men during the Neck Flexor Muscle Endurance Test?

    <p>38.9 seconds (B)</p> Signup and view all the answers

    What commonly occurs in patients with neck pain due to clinical instability during deep neck flexor activation?

    <p>Altered neuro-motor control strategy (C)</p> Signup and view all the answers

    Which aspect of the Neck Flexor Muscle Endurance Test is MOST critical for its termination?

    <p>Separation of skin folds due to loss of chin tuck (D)</p> Signup and view all the answers

    What is indicated by soft end-feel during the examination of the C1 vertebra?

    <p>Potential ligamentous laxity or instability (C)</p> Signup and view all the answers

    Flashcards

    Cervical Vertebrae Body Shape

    The superior surface of the cervical vertebra curves upwards at the sides, while the inferior surface is sloped downwards.

    Foramen Transversarium

    The cervical vertebrae have an opening in the transverse process, except the seventh cervical vertebra.

    Cervical Vertebrae Spinous Process

    The spinous process is short and divided into two, except the seventh spinous process.

    Cervical Facet Joint Orientation

    The facet joints in the middle and lower cervical spine (C2-C3 to C7-T1) are oriented in the sagittal plane, angled upwards and forwards.

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    C1-C2 Facet Joint Orientation

    The facet joints in the upper cervical spine (C1-C2) are more horizontal than the middle and lower regions.

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    Cervical Spine Motions

    The cervical spine allows flexion, extension, rotation, side-bending and translation.

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    Coupling of Motions

    Movement in one direction often causes a coupled movement in another direction due to anatomical structures.

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    Occiput-C1 Joint Movement

    The movement of the joint follows the convex/concave rule, where the convex surface glides in the opposite direction to the motion.

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    Treatment-based classification

    A system of classifying neck pain patients based on the type of treatment provided, rather than the underlying pathology or symptom distribution.

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    Cervical hypomobility

    A classification of neck pain characterized by restricted movement in the neck, often involving stiffness and pain with turning the head.

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    Cervical radiculopathy

    A type of neck pain with radiating pain into the arm, caused by compressed nerves in the neck.

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    Clinical instability

    A classification of neck pain involving instability and difficulty coordinating movement, often associated with whiplash or previous injury.

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    Acute pain/Whiplash

    A classification of neck pain that includes acute pain and whiplash, characterized by movement coordination impairments.

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    Cervicogenic headache

    A type of neck pain that causes headaches originating from the neck itself.

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    Clinical Condition

    A medical model that organizes neck pain based on symptoms like discomfort, restricted movement, and pain referral.

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    Pathoanatomical

    A medical model that classifies neck pain based on the affected structures, such as the facet joint or intervertebral disc.

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    Vertebral Artery Test

    A test to assess the health of the vertebral arteries, which supply blood to the brain. It involves rotating, extending, and laterally flexing the neck to each side for 1 minute while observing for signs of compromised blood flow, such as dizziness, nystagmus, slurring of speech, blurred vision, or unconsciousness.

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    Red Flags (Cervical Spine)

    A collection of warning signs and symptoms associated with conditions that require immediate attention. It helps guide clinicians in determining the urgency of further investigations and referrals.

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    Upper Cervical Ligamentous Instability

    A specific red flag indicating a possible serious issue, often associated with conditions such as tumors, inflammation, or nerve compression in the cervical spine. It involves symptoms in the upper cervical region and should be carefully assessed by a health professional.

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    Cervical Myelopathy

    A group of conditions characterized by compression of the spinal cord in the neck region, often leading to sensory and motor disturbances in the hands, arms, and legs. It is a red flag requiring prompt attention and further investigation.

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    Non-Specific Neck Pain

    A type of neck pain with no clear neurological cause. It is often referred to as 'mechanical' neck pain, suggesting a musculoskeletal origin rather than a nervous system involvement.

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    Neurological Neck Pain

    A type of neck pain with noticeable involvement of the nervous system, potentially arising from nerve compression or other neurological issues. It often presents with symptoms like numbness, weakness, or tingling.

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    Vertebral Artery Insufficiency

    A potential complication of cervical traction and manipulation. It occurs when the vertebral arteries are compressed, leading to reduced blood flow to the brain, resulting in symptoms like dizziness, nystagmus, slurring, blurred vision, and even unconsciousness.

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    Neck Pain Red Flags

    Symptoms that indicate potential serious conditions in the neck. These require prompt assessment and investigation by a qualified health professional.

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    Sharp-Purser Test

    A manual test used to assess the integrity of the transverse ligament of the atlas (C1 vertebra). It involves lifting the patient's head and C1 vertebra anteriorly, while maintaining a neutral position of the neck.

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    Transverse Ligament Stress Test

    A manual test designed to assess the stability of the transverse ligament by applying stress to it. It is performed by extending the patient's neck to simulate a movement that could potentially damage the ligament.

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    Neck Flexor Muscle Endurance Test

    A test that measures the endurance of the deep neck flexors. It involves the patient holding their head up against gravity for as long as possible.

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    Deep Neck Flexor Activation Score

    The ability of the deep cervical flexor muscles to activate and maintain a stable position of the head and neck.

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    Craniocervical Flexion Test (CCFT)

    A test that evaluates the strength and endurance of the deep cervical flexor muscles, typically used to assess neck stability and function.

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    Cervical Instability

    A clinical condition in which the cervical spine loses stability, leading to discomfort and potential pain.

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    Deep Neck Flexor Muscles

    Muscles that are located under the superficial muscles and play a crucial role in maintaining posture and stability.

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    Postural Endurance

    A measure of the time a person can maintain a certain posture, such as holding their head up.

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    Spurling's Test

    A diagnostic test that assesses nerve function and is typically used to diagnose cervical radiculopathy. It involves applying pressure to the nerve roots, causing pain and symptoms if nerve compression is present.

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    Parasthesia

    The sensation of tingling, numbness, or prickling that can radiate to the arm and hand, often following a dermatomal pattern.

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    Myotomal Pattern

    A pattern of weakness affecting specific muscles innervated by a certain nerve root, often caused by nerve compression.

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    Secondary Musculoskeletal Issues

    Weakness, stiffness, and postural defects that can arise as a secondary complication of cervical radiculopathy, affecting muscles such as the upper trapezius, scalenes, and levator scapulae.

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    Cervical Traction

    A treatment technique involving gentle traction applied to the neck to create space for the spinal nerve roots, aimed at reducing nerve compression and relieving symptoms.

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    Cervical Range of Motion Exercises

    A series of exercises designed to improve neck movement and reduce stiffness, involving both active and passive movements of the cervical spine.

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    Deep Neck Flexor & Scapular Strengthening Exercises

    Exercises that focus on strengthening the deep neck flexors and scapular muscles, aimed at stabilizing the cervical spine and improving posture.

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    What is the Performance Index?

    A measure of how many times someone can maintain a specific muscle pressure, out of a maximum of 10 repetitions.

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    What is the Activation Score?

    The highest force a person can generate and hold for 10 seconds.

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    What is a symptom of clinical cervical instability?

    A condition where the neck muscles are weak, making it difficult to hold the head upright or maintain certain postures.

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    Describe hypermobility.

    The ability to move beyond normal limits, often with a loose feeling.

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    What is an example of physical therapy for cervical instability?

    Involves strengthening the muscles that support and stabilize the neck.

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    Explain proprioception exercises.

    Improving the body's awareness of its position and movement.

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    What is an anterior cervical fusion?

    An operation that fuses neck vertebrae together.

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    When is surgery considered for cervical instability?

    A surgical procedure is usually recommended when there is significant nerve involvement.

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    Study Notes

    Cervical Spine Disorders

    • Objectives: Students should be able to memorize clinical anatomy and biomechanics, identify red flags of the cervical spine, and understand classifications and treatments for cervical disorders.

    Cervical Vertebrae Special Characteristics

    • Cervical vertebrae have transverse processes with foramina (foramen transversarium) in the upper six.
    • Typical cervical vertebrae have anterior and posterior tubercles for muscle attachment.
    • The body's superior surface projects upward, while the inferior surface is beveled.
    • The spinous process is short and bifid, except for the seventh spinous process.

    Joints of the Cervical Spine

    • Craniovertebral Joints: Include the atlanto-occipital and atlanto-axial joints.
    • Zygapophyseal Joints: Also known as facet joints, comprised of the superior articular process of one vertebral body and the inferior articular process of the adjacent vertebra.
    • Uncovertebral Joints: Unique to the cervical spine (C3-C7), these joints are formed by the uncinate processes.
    • Intervertebral Joints: Joints between adjacent vertebral bodies of the spine.

    Uncovertebral Joint

    • Located between C3 and C7.
    • These joints are formed by the projections of the superior surfaces of the vertebral bodies called the uncinate processes.

    Facet Joints Orientation

    • Articular facet joints of the middle and lower cervical spine (C2-C7 to T1) are situated in the sagittal plane, angled upward and forward approximately 45°.
    • C1-C2 facet joints are oriented more horizontally to allow for increased mobility.
    • C1-C2 also allows for the greatest amount of rotation (approximately 50%).

    Motions Available

    • Motions in the spine, including flexion, extension, translation, axial rotation, and lateral bending, occur simultaneously.
    • The exact pattern of coupling depends on regional anatomical variations.
    • In the cervical and upper thoracic spine, side bending is coupled with axial rotation in the same direction.

    Occiput-C1 Joints

    • Formed by the occipital condyles and the concave-shaped superior articular surfaces of the atlas.
    • Occipital condyles glide in the opposite direction of the motion, following the convex/concave rule.

    Ligaments

    • Ligaments of the upper cervical spine: Include the transverse ligament, alar ligament, and apical ligament.
    • The transverse ligament encloses the dens and provides lubrication as the atlas rotates around the dens.
    • The alar ligament is a major portion of the stabilization system of the upper cervical spine.
    • The apical ligament becomes taut when traction is applied to the head.

    Important Considerations

    • Upper cervical spine ligaments can be damaged in high-velocity accidents, weakened by rheumatoid arthritis, or congenitally absent.
    • Before any mechanical treatment, the integrity of the upper cervical ligaments should be tested. Tests include the Sharp-Purser test, lateral flexion alar ligament stress test, and transverse ligament stress test.

    Vertebral Artery

    • The vertebral arteries supply blood to the posterior brain stem and cerebellum.
    • Occlusion of the vertebral artery can cause a reduction in blood flow to the brain stem leading to dizziness, nystagmus, slurring of speech, and loss of consciousness.
    • Before any traction or manipulation techniques on the upper cervical spine, carefully test the vertebral arteries by placing and holding the neck in rotation, extension, and lateral flexion for approximately 1 minute.
    • Clinicians should observe the patient for potential warning signs, including dizziness, nystagmus, slurring of speech, and loss of consciousness, during vertebral artery testing.

    Red Flags (Features for Further Investigation)

    • Cervical Myelopathy: Sensory disturbance of hands, muscle wasting of hand intrinsic muscles, unsteady gait, hyperreflexia, bowel and bladder disturbances, and night pain.
    • Neoplastic Conditions: Age >50 years, history of cancer, unexplained weight loss, constant pain.
    • Upper Cervical Ligamentous Instability: Post-trauma, RA, Down Syndrome, occipital headache, and numbness.
    • Inflammatory or Systemic Disease: Temperature >37°C, drop attacks, blood pressure >160/95 mmHg.
    • Vertebral Artery Insufficiency: Dizziness, lightheadedness related to head movements, resting pulse >100 bpm, and resting respiration >25 bpm.

    Classification Types

    • Neurological or non-specific: Pain often described as having neurological involvement or being non-specific.
    • Clinical condition: Classifies based on signs and symptoms, such as cervicogenic headaches.
    • Pathoanatomical: Categorized based on the dysfunctional structure, such as facet joints or intervertebral discs.

    Response to Movement (Centralisation)

    • This classification system is based on how movement changes symptoms.
    • It allows for improved treatment outcomes and planning of conservative treatment.

    Treatment-Based Classification

    • 1-Cervical Hypomobility: Neck pain with mobility deficits.
    • 2-Cervical Radiculopathy: Neck pain with radiating pain.
    • 3-Clinical Instability: Neck pain with movement coordination impairments.
    • 4-Acute Pain (including whiplash): Neck pain with movement coordination impairments.
    • 5-Cervicogenic Headache: Neck pain with headache.

    Cervical Hypomobility

    • Stiffness as a primary dysfunction, noted during active, passive, and passive intervertebral motion testing.
    • No symptoms beyond shoulder.
    • Examination findings include:
      • Restricted AROM, PROM.
      • Restricted PIVM testing cervical or upper thoracic.
      • No UE radicular symptoms.
      • Sudden or gradual onset.
      • Deficient in cervicosaculothoracic strength and motor control

    Cervical Radiculopathy

    • Disorder of the spinal nerve root, often caused by foraminal encroachment, decreased disc height, and/or degenerative changes in the uncovertebral and zygapophysial joints.
    • Characterized by unilateral pain in the neck and arm, loss of motor function, and/or reflex changes in the distribution.
    • Can be caused by herniation of the intervertebral disc.

    Whiplash Associated Disorders (WAD)

    • Injury resulting from sudden acceleration and deceleration forces on the neck.
    • Includes several issues affecting muscles, joints, bones, ligaments, discs, and nerves.

    Quebec Task Force Classification for Whiplash-Associated Disorders

    • Classification system for whiplash-associated disorders based on clinical presentation (0-4).
    • Grade 0: No complaint or signs.
    • Grade 4: Complaints and fracture/dislocation.
    • Note: Musculoskeletal signs include decreased range of motion and point tenderness. Neurological signs include decreased or absent deep tendon reflexes, weakness, and sensory deficits.

    Physical examination Tests for Cervical Instability

    • Sharp-Purser test, Transverse Ligament Stress Test, Neck Flexor Muscle Endurance Test, C-R Flexion Test.

    Acute Pain and Whiplash Associated Disorders

    • This is a complex condition with various disturbances that impact motor, sensorimotor, and sensory functions, and psychological distress.

    Cervicogenic Headaches

    • Headaches originating from musculoskeletal dysfunction of the cervical spine.
    • Common clinical tests include CCFT, a test of the deep flexors of the cervical spine, and the CFRT, used to identify movement impairment.

    Special Tests

    • Cervical Flexion-Rotation Test: Assess cervical spine rotation.

    Clinical Presentation (Cervical Disorders)

    • General presentation: Symptoms, including pain, radiating pain, muscle weakness, paresthesia, headaches, and potentially referred symptoms to the upper body.
    • Cervical Radiculopathy: Pain in the neck and one arm, along with other symptoms.
    • Cervical Instability: Poor coordination, aberrant movements, pain relief through non-weight-bearing, fatigue, and external support.

    Physical Therapy Management

    • Proper posture, spinal manipulation (on hypomobile segments below the level of instability), strength to deep flexor muscles, strengthening the stabilizing muscles, proprioception exercises, and ergonomic corrections for managing cervical disorders

    Treatment Considerations

    • Surgical interventions (anterior cervical fusion) may be necessary.
    • Post-surgical rehabilitation involves low-level strengthening exercises for anterior cervical and parascapular muscles.
    • Avoid any lifting greater than 4 kg for at least 6 weeks post-surgery.
    • Avoid any cervical dynamic strengthening or ranges of motion exercises for the first 6 months.

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    Description

    This quiz focuses on key observations and assessments related to vertebral artery testing, contraindications to neck manipulation, and red flags in neck-related conditions. It is essential for clinicians to understand these critical aspects to ensure patient safety and effective treatment. Test your knowledge on cervical anatomy and clinical signs relevant to neck pain.

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