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Critical Rule Outs Upper cervical instability Fractures Vertebral artery injury Scanning Clearing Upper Quadrant Upper Quadrant Tspine PAVCP’s (Upper: T1-6) Cl...

Critical Rule Outs Upper cervical instability Fractures Vertebral artery injury Scanning Clearing Upper Quadrant Upper Quadrant Tspine PAVCP’s (Upper: T1-6) Clear joint above & below Cervical Peripheral Joint Scan TMJ TMJ (open, close, side to side) Open, close, side to side Shoulder (AROM/OP) T spine Elbow (AROM/OP) PACVPs (T1-6) Wrist (AROM/OP) Shoulder AROM/OP Myotomes C3-T1 Thoracic C spine PAVCPs Dermatomes L spine PACVPs C1-T2 Shoulder AROM/OP Reflexes Biceps tendon: Brachioradialis: Triceps tendon: Lower Quadrant Lower Quadrant Tspine PACVPs (Lower: T7-12) Tspine Quick Test - Squat PACVPs (T7-12) SI Joint Peripheral Joint Scan Gillets SI Joint (Gillet’s) Hip Hip (AROM/OP) AROM/OP Knee (AROM/OP) Ankle (AROM/OP) Myotomes L1-S2 Dermatomes L1-S2 Reflexes  Patellar tendon Achilles tendon Hamstring tendons Bony Conditions of the Spine Bone Pain Characteristics: Deep, nagging Aching Sharp Localized Fractures Acute Insidious More common in the cervical spine Infrequent but more common than traumatic 1. Compression (osteoporosis) fractures 2. Avulsion 1. Stress May involve: Most common in lumbar spine Spinous process (spondylolysis and Transverse process spondylolisthesis) Vertebral arch 2. Fragility Vertebral body Most common in thoracic spine (osteoporosis) May Involve: Pars interarticularis Vertebral end plate Acute Fracture Rule-Out Mechanism of Injury ○ Axial compression ○ MVA and other traumatic forces Associated symptomatology ○ Central, local pain ○ Bilateral paresthesia ○ In the neck: 5 D’s Headaches Tinnitus Nausea Cranial nerve symptoms Patient profile - Osteoporosis  Canadian C spine Rules Observation: Rusts sign ○ Self stabilization with hands ○ Patient has bought a cervical collar ○ When asking patient to go from supine to seated they grab their neck for support Muscle spasm/other guarding postures Unable or unwilling to move neck Examine: Palpation Vibration/tap - Tuning fork Spondylopathies Inflammatory Non-Inflammatory Ankylosing Spondylitis Spondylosis Spinal stenosis Spondylolysis Spondylolisthesis Ankylosing Spondylitis Characteristics: Progressive inflammatory disease with gradual fusion of vertebral joints/bony structures (can extend to peripheral joints) More common in males 40 years - Degeneration starts in 20s 3 Stages: 1. Dysfunction 2. Instability 3. Stabilization Signs/Symptoms: Can be asymptomatic (especially at beginning) Stiffness (SIJ) Pain generally worse at the beginning and at the end of the day ○ Can improve with movement but too much movement is aggravating Decreased ROM N/T or other neurological S/S in later stages Spondylolysis Characteristics: Defect of pars interarticularis - Unilateral or bilateral Predominantely in lumbar spine No displacement of vertebral body Often coincides with adolescent growth spurt - Sometimes associated with trauma 10-25 years of age ○ Can occur in older populations Athletes in sports with repetitive spinal extension Spondylolisthesis Characteristics: Bilateral defect of pars interarticularis Predominantly seen in lumbar spine - Most common at L5 Forward slippage of a superior vertebrae over the inferior vertebrae (traumatic or chronic) S/S mimic spondylolysis - Difference found in accessory motions Females more likely to transition from lysis to lithesis Patient Profile: Adolescent female who participates in a sport requiring repetitive/excessive extension Anterolisthesis = Forward slippage Retrolisthesis = Vertebrae slides posteriorly Spondylolysis/Spondylolisthesis Observations: Increased lordosis Step deformity of vertebrae (superior vertebrae translates anteriorly which makes the inferior vertebrae or SP feel more palpable) Muscle spasm (erectors or tightness in hamstrings) Aberrant movement (most prevalent moving from flexion to neutral) Signs/Symptoms: Lumbar pain aggravated by extension and sustained standing Catching, clicking or clunking sensation with movement from flexion to extension Potential radicular symptoms Can be asymptomatic in earlier stages Motion Assessment in Spondylolysis/Spondylolisthesis AROM May be painful Restricted in extension and quadrant positions Instability jog (aberrant motions) PPIVMs: Increased segmental mobility PAIVMs: Increased segmental mobility with pain RIM: May reduce pain in neutral positioning Stenosis Narrowing of a canal Secondary to a facet (or other bony structures), arthritis, disc degeneration, ligament remodeling/degeneration, tumors, spondylolisthesis Seen in individuals >50 years Can also be congenital Central Stenosis Foraminal Stenosis Narrowing of spinal canal Narrowing of intervertebral foramina Signs/Symptoms: Signs/Symptoms: Pain ( bilateral) Radicular pain/paresthesia (unilateral) Paresthesia (bilateral) Weakness (unilateral)  Cramping or weakness Pain with movements that reduce Pain with walking and standing foraminal space (extension) ○ Pain improves when seated or Weakness, fatigability flexion Hyporeflexive DTR Weakness or spasticity (jerky Atrophy movements) Hypomobility in Hyperreflexive DTR physiological/accessory motion Bowel/bladder dysfunction Coordination/balance difficulties If treatment for disc pathology is not working it may be stenosis Aggravating Factors: Movements that close the foramen (extension - standing/walking) Axial compression Observations: Forward flexed and/or side flexed posture Doesn't hurt going up stairs (due to flexion) S/S relieved by flexion, sitting or side bending away from affected side (foraminal) Examination: Motion assessment (physiological and accessory) DTR, clonus, pathological reflex testing Neurodynamic tests Foraminal tests (compression + opening) Claudication tests (blood vs nerve pathology) Osteoporosis Osteoporosis: A progressive structural deterioration of bone tissue resulting in low bone density and increased porosity Condition results in increased risk of fragility fractures Patient Information Age Older (>50) patients at greater risk Gender Females > males Occupation/Sport/ADL Caucasian and asian at greater risk Anthropometrics Thin - small frame more at risk (low BMI) Female athlete triad Smoker Greater risk Pregnancy/Menses N/A MVA’s Fracture risk Pain Aggravates Movement Pressure/compression Breathing (inspiration/expiration) Lifting Possibly coughing, sneezing or bearing down Alleviates Rest Radiating (N/T or COS) Possibly Observation Forward head posture Increased kyphosis Dowager’s hump Scoliosis Protuberant abdomen Consider using: Flexicurve ruler or picture Testing AROM: Typically not assessed due to risk PROM: Typically not assessed due to risk PAIVMs: Typically not assessed due to risk RIM: Typically not assessed due to risk Special Tests: Rib-pelvic distance Wall-occiput distance Balance Functional tasks Generally tests/tasks that require spinal flexion, rotation or sidebending or “heavy lifting” are contraindicated Imaging: Xray or DEXA  Sprains/Strains Patient Information Age Gender Occupation/Sport/ADL Shoveling, gardening, bending, forceful twisting or push/pull, sudden acceleration/decelleration, contact sports (strains) Anthropometrics Smoker Can increased risk due to decreased tissue/vascular health Pregnancy/Menses Not related but may have an effect on ligamentous stability MVA’s Yes Rheumatoid Arthritis Increased risk of serious ligament injury Pain Location Dependent on tissue structure involved More common in posterior/lateral muscle groups Quality Dull, aching, stiff, tight Severity Variable Aggravates AROM contraction PROM stretch Sustained posture Alleviates Supine or neutral/unloaded position Ice or heat Medications for pain, spasm or inflammation Morning or Night Stiffness in AM Radiating Not typically Sleeping Position Yes with positions out of neutral alignment Caution with S/S:  Lump in throat Difficulty swallowing Unwillingness to move head Lip/facial paresthesia 5 D’s and 3 N’s Observation Posture: Head posture, postural deviation, shoulder levels, pelvic tilt, spinal curve Rust’s sign Muscle spasm SHARD PPIVMS Strains: Hypomobile Sprains: Hypomobile or hypermobile depending on guarding and compensation PAIVMs Strains: Hypomobile Sprains: Hypermobile Special Tests SHARP-Purser Transverse Ligament Stress Test Lateral Flexion or Rotational Alar Ligament Stress Test Pettman’s Distraction Test Torticollis Frequently associated with whiplash and cervical strains Whiplash Sprain/strain occurring due to high velocity/traumatic forces Whiplash Associated Disorder Classification (WAD) - MVA and WCB Grade Clinical Presentation 0 No complaints of neck pain No physical signs  1 Pain, stiffness or tenderness in neck No physical signs 2 Pain, stiffness or tenderness in neck MSK Signs: Decreased ROM Point tenderness 3 Pain, stiffness or tenderness in neck Neurological Signs: Decreased or absent DTR Muscular weakness Sensory deficits 4 Pain, stiffness or tenderness in neck Fracture or dislocation Symptoms and disorders can also include deafness, dizziness, tinnitus, headache, memory loss, dysphagia and TMJ pain Facet Joint Dysfunction Mechanism of Injury Sustained or repeated spinal extension and/or rotation Sudden or unusual movement Habitual posture (chin poke, slouch) Poor sleeping positioning Degenerative/cumulative trauma Often insidious onset Positional Faults Misalignment of vertebrae Comparing position of bony landmarks with the same landmarks on the opposite side If a suspected positional fault is identified examine whether the perceived alignment is a positional fault or simply a bony abnormality by palpating adjacent bony landmarks ○ Joint should be hypomobile and painful with accessory motion testing Pain Location Posterolateral Unilateral - Localized (Patient can often point to specific facet) Quality Dull, aching, stiff, can be pinching, sharp Often pain-free until certain ROM Severity Variable Aggravates Closing patterns of joint (ext, SF to same side, rotation) Alleviates Opening patterns of joint (SF to opposite side) Static Morning or Night N/A Radiating N/A Sleeping Position Sleeping position of in closing pattern Observation Forward head posture Possible chin tilt Habitual poor posture Overt abnormalities may be lacking PPIVMS Hypomobile Adjacent segments may be hypermobile Often pain-free PAIVMs Painful Hypomobile or hypermobile (adjacent segments) Special Tests Quadrant Cervical compression Spurling’s Jackson’s Rib Joint Dysfunction Mechanism of Injury Sustained or repeated thoracic movements Traumatic twisting/torsional movements Direct blow/trauma Exertional Habitual postures/muscular imbalances Insidious onset  Pain Location Localized Quality Sharp, stabbing Severity Typically high Aggravates Rotation - Side bending Cough, sneeze, laugh Exertion Breathing Trunk rotation Holding heavy items Alleviates Static or certain positions Morning or Night N/A Radiating N/A Sleeping Position Yes Observation Forward head posture Possible chin tilt Habitual poor posture Excessive coughing Chest deformities Special Tests Rib motion/breathing Costovertebral expansion Joint play (P-A, A-P, lateral-medial) 1st rib mobility Disc Pathologies Disc Pathology: Localized, graded herniation of the nucleus pulposus against or through the wall of the intervertebral disc  4 Categories: 1. Protrusion 2. Prolapse 3. Extrusion 4. Sequestration Schmorl’s Nodes: Herniation of the NP into the vertebral end plate Patient Information Age 25-55 Gender Males slightly > females Occupation/Sport/ADL Those requiring sustained or repeated spinal flexion and/or compression Anthropometrics Obesity may be a risk due to increased load on spine Smoker Increased risk due to decreased vascular health Pregnancy/Menses N/A MVA’s N/A Mechanism of Injury Repetitive movements Habitual postures Repetitive microtrauma - “wear and tear” Degenerative/cumulative trauma Compressive/hyperflexion forces - Possibly combined with twisting/torsion Pain Location May be localized to area of pathology or diffuse - May have radicular pain - May not have back pain but pain everywhere else Centralization: Pain moving towards the spine Ex. Pain in both the back and the knee but certain movements take away knee pain and pain is only in back Peripheralization: As assessment goes on, pain spreads Quality Dull, aching, stiff Sharp, shooting or burning Severity Variable Aggravates Prolonged sitting Cough/sneeze Certain spinal movements Alleviates Supine lying Medications for pain and/or inflammation Certain C spine movements Morning or Night Pain may increase in the morning due to fluid repletion overnight - This increases the pressure on the discs Radiating Possibly - Only if disc is impinging on nervous tissue Sleeping Position Yes with postures/cervical positions out of neutral Caution “Cord Signs” - Myelopathies Bilateral/quadrilateral paresthesia Ataxic gait Hyperreflexia Hypertonia Non-dermatomal reference of pain Bowel/bladder dysfunction Coordination difficulties Pathological reflexes Observation Muscle spasm Muscle wasting (depending on how long patient has had condition) Lateral shift (most often shift is away from the side of pain) Flatback Overt abnormalities may be lacking (more so in cervical spine) AROM Both opening and closing the segment likely aggravates Repeated Movements Mackenzie technique Pain/Symptoms During Movements ○ Does it increase/decrease? ○ Does it produce/abolish? ○ Are symptoms centralizing/peripheralizing?  ○ Is it during the movement (which part, when)? ○ Is it at end range? Pain/Symptoms After Movements? ○ Worse/better ○ Not worse/better ○ Centralized/peripheralized ○ No effect PPIVMs & PAIVMs PPIVMs: Hypomobile and painful PAIVMs: Hypomobile and painful Special Tests Cervical compression Spurling’s Cervical distraction Shoulder abduction Valsalva Dermatomes Reflexes Myotomes Neurodynamic Tests ○ Slump ○ SLR ○ Upper limb tension test Adverse Neurodynamics Neurodynamics: The mechanics and physiology of nerves Mechanically ○ Longitudinal sliding ○ Transverse sliding Physiologically ○ Blood flow Elongation Compression ○ Inflammation ○ Sensitivity Interface: Any structure adjacent to a nerve Example: Bone, muscle, connective tissue Spinal Cord and Nerve Movement: Nerve takes up the slack, then slides towards the pull and eventually elongates (stretches) Nerve slides towards the point where tension is applied Downward movement of the spinal cord doubles when you add the contralateral side (bilateral) but the transverse movement is negated If the dura becomes adherent, excessive stress may be produced in the areas of adhesion, increasing the length of the dura beyond its normal imit of tension ○ Naturally occurring convergence points C6, T6 and L4 Elbow, shoulder and knee Structural Differentiation: hy Sensitizing Movements: th Mechanism of Injury Traction/vibration injuries Disc pathology Space occupying lesions Poor posture Inflammation Injections Compression/ischemia Surgery Electrical injury Scarring Immobilization Poor muscular flexibility Observation Poor posture Muscle atrophy in affected nerve (motor) distribution Overt abnormalities may be lacking Special Tests Slump test Upper limb tissue tension tests Straight leg raise Less Common: Tinel’s  Brachial plexus traction test First thoracic nerve root stretch Prone knee bend (femoral nerve stretch test) Bowstring test Miscellaneous Conditions Scoliosis 2 Categories: 1. Functional Develops secondary to injury, habitual postures and movements, muscular imbalances, leg length discrepancies and/or other malalignment at the pelvis and/or lower extremity AT can treat - Find the cause and treat this rather than trying to manage symptoms 2. Structural Develops secondary to problems during the development or degeneration of the spine AT cannot treat Patient Information Age Structural can be younger (development) or older (degenerative) Functional any age Gender Females > males (structural) Observation Shoulder levels Rib prominence/humping Trace fingers down the length of the spine Flexicurve, markers, stickers Pelvic levels Leg length Muscle spasm Breathing  Vertebrobasilar Artery Insufficiency (VBI) Vertebrobasilar Artery Insufficiency: Localized or diffuse disruption of the circulation that supplies the (posterior) brain and brainstem Most frequently injured site is at C1-C2 Patient Information Age Older patients more at risk Gender Men > women Occupation/Sport/ADL Those requiring sustained or repeated cervical rotation and/or extension Anthropometrics N/A Smoker Increased risk due to poor vascular health Pregnancy/Menses N/A MVA’s MOI Mechanism of Injury  MVA - Whiplash Cervical rotation, extension or both Contributing Factors Increased age Smoking Diabetes Hypertension Rheumatoid arthritis Hyperlipidemia, atherosclerosis Heart disease Clotting disorders Upper cervical instability Sickle cell disease Pain Pain is not a primary symptom of VBI If the onset was secondary to a traumatic MOI, it may be associated with the symptoms of cervical strain and is often accompanied by occipital headache and/or posterior neck pain Signs/Symptoms Primary Symptoms Secondary Symptoms Dizziness Slurred speech Headache Nystagmus Loss of consciousness Diplopia Visual disturbances Drop attacks Gait disturbances Dysphasia UE paresthesia Tinnitus Nausea/vomiting Facial paresthesia Symptoms tend to be provoked by cervical rotation and/or extension, arising too quickly and vigorous exercise Observation Observe for gait disturbances, nystagmus, loss of coordination Overt abnormalities may be lacking Special Tests Other Testing: Cranial nerve examination Blood pressure Eye examination AROM: Observe for cervical rotation and/or extension to be provocative for symptoms Special tests: Cervical rotation in sitting Body on head rotation When doing RIM movements may induce the valsalva maneuver so prompt patient to exhale Thoracic Outlet Syndrome Thoracic Outlet Syndrome: Obstruction of emerging structures outside of the superior thoracic aperture, specifically the: Trunks and medial cord of brachial plexus Subclavian artery Subclavian vein 3 Types: 1. Neural 2. Vascular 3. Non-specific/mixed Patient Information Age Variable - Vascular often younger Gender Women > men Occupation/Sport/ADL Those requiring repetitive or sustained overhead positions and desk jobs Anthropometrics N/A Smoker Yes - Due to decreased vascular health Pregnancy/Menses N/A MVA’s Often related Mechanism of Injury Acute Chronic Congenital  Clavicle fracture Poor posture Cervical rib Muscle Backpacks, purses, Decreased space strain/whiplash bags between first rib and Repetitive overhead clavicle activities Adaptive shortening of anterior and/or middle scalenes, pec minor and UFT Pain Location May involve head, neck, scapula, chest, shoulder, arm, hand Neuro: Typically follows affected nerve distribution Vascular: hand and/or arm Quality Aching, throbbing, burning Severity Variable Aggravates Overhead activities Sustained postures Heavy backpacks/bags Sleep Neck rotation and/or side flexion away from affected side Alleviates Rest Shoulder/arm support Morning or Night Yes Radiating Yes Sleeping Position Yes Vascular S/S Swelling and discolouration Feeling of heaviness in arm Fatigue and/or loss of strength in arm/hand Cramping Pallor or cyanosis Decreased skin temperature Edema Distended veins Observation  Forward head posture Spinal curve Rounded shoulders Pallor or cyanosis Decreased skin temperature Edema Distended veins Diminished pulse Atrophy Breathing Special Tests Consider 1st rib mobility PAIVMs may be hypomobile Neurological Testing Neurodynamic Testing ○ UQ ○ Tinel’s ○ Brachial plexus traction test Vascular Tests ○ Adson’s ○ Allen’s ○ Military brace ○ Roos PAVIMs PPIVMs T5/6 decreased SRL - PAUVP left on T5 and PAUVP right on T6 C5/6 traction - Flex and traction C5 stabilize C6 T1/2 Decreased flexion - PACVP with cranial direction on T1