CLASS 2&3 2024 Fall Lab 4 - Cervical PDF

Cervical Assessment Day 1 & Day 2 Magee: Chapter 3 (cervical) Chapter 4 (TMJ) Fiona: various, based on condition/test RANGE OF MOTION TESTING  ACTIVE RANGE OF MOTION While the patient performs the active movements, the examiner looks for: limitation of movement rea...

Cervical Assessment Day 1 & Day 2 Magee: Chapter 3 (cervical) Chapter 4 (TMJ) Fiona: various, based on condition/test RANGE OF MOTION TESTING  ACTIVE RANGE OF MOTION While the patient performs the active movements, the examiner looks for: limitation of movement reasons for pain, spasm, stiffness, or blocking As the patient reaches the full range of active movement, passive overpressure may be applied very carefully, but only if the movement appears to be full and does not cause pain  PASSIVE RANGE OF MOTION Passive Movements of the cervical spine Flexion, Extension, Side Flexion, Rotation  The passive ROM with the patient supine is normally greater than the passive ROM with the patient sitting  If passive range of motion with overpressure is normal and pain free continue to test individual segments as stated below Passive Intervertebral Movements of the cervical spine: In addition to the passive movements of the cervical spine, physiological movements between each pair of vertebrae may be performed. By stabilizing or blocking the movement of one vertebra (usually the distal one) and then passively moving the head through the different physiological movements (e.g., flexion, extension, side flexion, rotation), each segment can be tested  the amount of movement of each segment will be considerably less than the whole  Ex. Atlanto-Occipital Range of motion  Ex. Atlanto-Axial Range of motion  RESISTED RANGE OF MOTION Resisted ROM tests myotomes and Strength of muscles Review actions of muscles: – SCM – Rec cap anterior – Splenius capitis – Semispinalis capitis – Trapezius – Longissimus capitis – Scalene group – Levatore scapulae  GENERAL ASSESSENT: POSTURE Sagittal plane: chin in line with sternum? Frontal plane: ear in line with shoulder? Is poker chin or military neck evident? Protraction or retraction of the cranium? (forward head carriage?) Torticollis? Head shifted, tilted or rotated? Level at the neck line? (upper traps) Muscle bulk from one side to the other BONES ANATOMY- BONES  GENERAL TESTING: JOINT PLAY ASSESSMENT Use both motion and static joint play to assess: Tenderness Quality of movement Quantity of movement **Start more broadly and move to specific levels JOINT PLAY MOVEMENTS at each segment (start at T1 and move UP) Anterior glides of each segment (anterior spinous challenge) Lateral glides on TP’s (lateral spinous challenge) Unilateral anterior glide on TP (to assess rotation) AO/AA mobility (see below) Compression (Cervical compression test - see below) Distraction (cervical distraction test – see below)  Atlas (C1) C1 is the atlas C1 lacks a body and spinous process Supports the skull – Superior articular facets receive the occipital condyles Allows flexion and extension of neck – Nodding the head “yes” Figure 7.22a The first and second cervical vertebrae. C1 Posterior Posterior tubercle Posterior arch Transverse foramen Lateral masses Superior articular facet Anterior arch Anterior tubercle Superior view of atlas (C1)  Axis (C2) Has a body and spinous process Dens (odontoid process) projects superiorly – Is formed from fusion of the body of the atlas with the axis – Acts as a pivot for rotation of the atlas and skull – Participates in rotating the head from side to side “No”  Figure 7.22c The first and second cervical vertebrae. C2 Posterior Spinous process Inferior articular Lamina process Pedicle Superior articular Transverse facet process Dens Body Superior view of axis (C2)  ATLANTO-OCCIPITAL ARTICULATION – Passive Range of Motion PURPOSE: To determine if there is a restriction at the C0 and C1 articulation in both flexion and extension combined with lateral flexion PROCEDURE: Patient is supine Grasping patient near base of skull, put patient into full flexion Using small movements, apply lateral pressure moving head from right to left and then left to right Repeat test with patient in slight cervical spine extension (head not off end of table) POSITIVE: Slight leathery end feel either to the right or left Test may be positive in flexion AND/OR extension  ATLANTO-AXIAL ARTICULATION – Passive Range of Motion PURPOSE: To determine if there is a restriction at the C1 and C2 articulation in rotation PROCEDURE: Patient is supine Grasping patient near base of skull, put patient into full flexion Rotate head to end range in both directions POSITIVE: Slight leathery end feel either to the right or left AO & AA ARTICULATION A: AO joint B: AA joint  FIRST RIB MOBILITY TEST PURPOSE: Assess the mobility of the first rib PROCEDURE: Variation A: Place the patient in a supine position Palpate the first rib bilaterally (posterior to clavicles and in line with T1) Note movement of 1st rib upon client palpation Next, palpate one rib while side flexing the neck contralaterally. Note range Variation B: Place the patient in prone position Place reinforced thumbs on the first rib Push the first rib inferiorly to assess for end feel and presence of pain Variation C: physiotutors video on next slide. POSITIVE: Hypomobility, decreased range, pain Magee, D. J. (2014). FIRST RIB MOBILITY TEST CONT.  ANTERIOR SPINOUS CHALLENGE PURPOSE: To determine the location of minor vertebral derangement. Either hypermobility or hypomobility of the vertebral segment of the cervical spine in the sagittal plane. PROCEDURE: Place the patient in a supine position (to assess cervical spine) Lean your elbows on the table, hands supinated Use the fingertips to anteriorly challenge the spinous processes. Count the vertebrae to determine the location of the dysfunction, using T1 as a reference point. POSITIVE: Patient reports local mild pain with pressure at a specific vertebral level Hypomobility- one segment has less mobility than segments above and/or below Hypermobility – one segment has more mobility than segments above and/or below  LATERAL SPINOUS CHALLENGE PURPOSE: To determine the location of minor vertebral derangement. Either hypomobility or hypermobility of a vertebral segment of the cervical spine on the coronal/frontal plane PROCEDURE: Place the patient in a supine position (to assess cervical spine) Use the fingertips to laterally challenge the spinous processes. Count the vertebrae to determine the location of the dysfunction, using T1 as a reference point POSITIVE: Patient reports local mild pain with pressure at a specific vertebral level ANATOMY- MUSCLES https://painneck.com/neck-anatomy/  GENERAL TESTING: PALPATION Use both motion and static palpation of the spine Examine for: Tone Tension Temperature Tenderness (confer with client) muscle spasm presence of trigger points ** follow principles of massage (general  specific; superficial  deep  GENERAL TESTING: PALPATION The following are cervical palpation landmarks: Suboccipitals SCM Scalenes (ant vs mid vs posterior) Erector Spinae of cervical spine Masseter Frontalis Suprahyoid muscles *you should be able to landmark bony structures such as SP’s, TP’s, bony protuberances, etc* Palpation assessment can move directly into….  ANTERIOR NECK FLEXORS STRENGTH TEST PURPOSE: To assess strength or pathology of SCM, Anterior scalenes, Suprahyoids, Infrahyoids, Longus capitis, Longus colli, Rectus capitis anterior PROCEDURE: Patient lies in supine with arms abducted to 90 degrees, elbows flexed and hands resting on table Instruct patient to tuck in chin and then lift head off table If patient can hold position against gravity (grade 3), apply gentle posterior pressure to forehead and instruct patient to resist POSITIVE: Muscle pain or weakness (unable to hold position) Cnx.org ANTEROLATERAL NECK FLEXORS STRENGTH TEST (SCM, Scalenes) PURPOSE: To assess strength or pathology of SCM and scalenes PROCEDURE: Patient lies in supine with arms abducted to 90 degrees, elbows flexed and hands resting on table Stabilize shoulder on side to be tested Instruct patient to turn head away from side to be tested Instruct patient to lift head off table, into slight flexion, and hold against gravity If patient can hold position against gravity (grade 3), apply gentle posterior/oblique pressure to temporal region and instruct patient to resist POSITIVE: Muscle pain or weakness (unable to hold position) http://www.med-health.net/images/10415815/image002.jpg  POSTEROLATERAL NECK EXTENSORS STRENGTH TEST, Active Resisted PURPOSE: To assess strength or pathlogy of Splenius capitis, Splenius cervicis, Semispinalis capitis, Semispinalis cervicis, Erector spinae PROCEDURE: Patient lies in prone with arms abducted to 90 degrees, elbows flexed and hands resting on table Instruct patient to extend the neck, rotate the head towards the side being tested and hold head in position against gravity If patient can hold position against gravity (grade 3), apply gentle anterior/oblique pressure to posterolateral region of head and instruct patient to resist POSITIVE: Muscle pain or weakness (unable to hold position) http://www.med-health.net/images/10415815/image002.jpg ANATOMY- VASCULARIZATION Magee, D. J. (2014). Orthopedic Physical Assessment (6th ed.). St. Louis, Missouri: Elsevier Saunders Inc.  VERTEBRAL ARTERY TESTING/CERVICAL QUADRANT The vertebral artery is important to assess prior to using end range mobilization and manipulation that involves rotation to the upper cervical spine as it is vulnerable to injury Signs and symptoms of vertebral artery problems: – Dizziness/vertigo – Dysphagia (difficulty swallowing) – Drop attacks – Malaise and nausea – Vomiting – Unsteadiness in walking, incoordination – Visual disturbances – Severe headaches – Weakness in extremities – Sensory changes in face or body – Dysarthria (difficulty with speech) – Unconsciousness, disorientation, lightheadedness – Hearing difficulties – Facial paralysis Magee, D. J. (2014). Orthopedic Physical Assessment (6th ed.). St. Louis, Missouri: Elsevier Saunders Inc. PURPOSE: test for vertebral artery compression VERTEBRAL ARTERY TEST/CERVICAL QUADRANT CONT. PROCEDURE: Variation 1 (preliminary/ACTIVE) Variation 2 (standard, PASSIVE) Patient position: Patient Position: Seated with feet hanging over Supine edge head is passively placed in Client rotates head to one side extension and lateral flexion then extends patients head is then rotated to Hold for 30 seconds same side as lateral flexion and Repeat on other side holding for 30 seconds. POSITIVE: Feelings of dizziness Nystagmus Nausea If test is positive, discontinue test and REFER IMMEDIATELY VERTEBRAL ARTERYPROCEDURE: TEST/CERVICAL QUADRANT CONT. NERVOUS TISSUE  Recap: CERVICAL MYOTOMES Neck flexion: C1 to C2 Neck side flexion: C3 and cranial nerve XI Shoulder elevation: C4 and cranial nerve XI Shoulder abduction/shoulder lateral rotation: C5 Elbow flexion and/or wrist extension: C6 Elbow extension and/or wrist flexion: C7 Thumb extension and/or ulnar deviation: C8 Abduction and/or adduction of hand intrinsics: T1 PROCEDURE: Hold contraction for a least 5 seconds Recap: DERMATOMES  Recap: CERVICAL REFLEXES A: Jaw, B: Ignore C: Brachioradialis D: Biceps E: Triceps  CERVICAL COMPRESSION TEST PURPOSE: Assess nerve root compression when patient cannot rotate or extend cervical spine PROCEDURE: ** stage one of Spurlings Test Patient is in seated position Examiner stands behind patient Apply pressure to top of head inferiorly with head in neutral POSITIVE: Radiating pain or neurological symptoms in the affected arm  CERVICAL DISTRACTION TEST PURPOSE: To assess nerve root compression PROCEDURE: Hands placed under chin and occipital bone of skull, slowly lift the head in a superior direction POSITIVE: Relief of pain If pain is produced, indicates possible muscle strain CERVICAL DISTRACTION TEST  SPURLINGS TEST/ Foraminal Compression Test/Maximal Cervical Compression Test PURPOSE: To assess nerve root compression when patient is able to rotate and extend cervical spine PROCEDURE: Patient is in seated position Examiner stands behind patient Apply pressure inferiorly with patients head in 3 STAGES: 1. Neutral (aka Cervical Compression Test) 2. Extension 3. Extension and Rotation (unaffected side first) ** DO NOT PROGRESS TO NEXT POSITION IF THERE IS PAIN AT ANY POINT POSITIVE: Radiating pain or neurological symptoms into same side arm. The combined action of the client’s head position and the downward pressure compresses the intervertebral foramen, the nerve root and the facet joints on that side Pain remaining local to the neck or shoulder indicates cervical facet joint irritation on the side experiencing pain SPURLINGS TEST/ Foraminal Compression Test/Maximal Cervical Compression Test  ORBICULARIS OCULI STRENGTH TEST PURPOSE: To confirm/rule out Bell’s Palsy (Cranial Nerve VII) PROCEDURE: WASH HANDS BEFORE YOU PERFORM THIS TEST The patient is in either seated or supine Instruct the patient to keep her eyes closed The examiner gently tries to open the eyes. POSITIVE: https://classconnection.s3.amazonaws.co Patient is unable to resist the action and the eye m/520/flashcards/2373520/png/orbicularis -oculi1354586192771.png on the affected side is opened. TRIGGER POINTS  SCALENE CRAMP TEST PURPOSE: Assess trigger points in scalenes or assess thoracic outlet syndrome (TOS) PROCEDURE: Patient is in seated position Patient rotates the head to the affected side and pulls the chin down into the hollow above the clavicle by flexing the cervical spine POSITIVE: Pain (trigger points in scalenes) Radicular signs (Plexopathy or TOS)  SCALENE CRAMP TEST ANATOMY: http://groundupstrength.wdfiles.com/local--files/muscles%3Ascalene-muscles-location-actions- trigger-points/scalene-triggers.jpg http://en.wikipedia.org/wiki/Scalene_muscles  SCALENE RELIEF TEST PURPOSE: Assess for active trigger points in scalenes PROCEDURE: Patient is in a seated position Ask patient to place the forearm of the affected side across the forehead, as close to the elbow as possible Ask the patient to elevate and protract the shoulder. This will lift the clavicle, relieving any compression of the scalenes. POSITIVE: Reduction of pain after a few minutes due to active trigger points in the anterior scalene  SWALLOWING TEST PURPOSE: If there is pain while swallowing, test assesses whether pain is due to trigger points in SCM PROCEDURE: Patient is in a seated position Palpate the SCM in a pincer grasp. When the most tender point in the muscle is found, maintain a firm pressure on the muscle belly while the patient swallows. POSITIVE: Pain diminishes while swallowing If pain is still experienced on swallowing with the SCM being compressed, the pain may be due to throat infection, hematoma, space occupying lesion of the cervical spine or tumour. SPACE OCCUPYING LESION  VALSALVA PURPOSE: Assesses the effect of increased pressure on the spinal cord. Tests for space occupying lesion, herniated disc, tumors, stenosis, or osteophytes PROCEDURE: Patient takes a deep breath, holds, and bears down as if to have a bowel movement (or ask your client to put their thumb to their lips and mimic blowing up a balloon, without actually expelling any air) POSITIVE: Pain Indicates increased pressure on the spinal cord from intrathecal pressure  DAY 2 CERVICAL SPINE ORTHOPEDIC TESTS Magee: Chapter 5 (shoulder ) chapter 4 (TMJ) Rattray: varies based on condition/test  THORACIC OUTLET SYNDROME (TOS) A condition that involves the compression of the brachial plexus and it’s accompanying artery SYMPTOMS: Unilateral or bilateral Neurological compression – Numbness, tingling (C8 to T1 distribution) – Pain (upper limb, shoulder, forearm and hand) – TPs for motor weakness of the hand – Atrophy (hypothenar and interossei muscles) Vascular Compression – Pain – Pallor – Cyanosis – Sense of coldness in the limb – Blood vessel distention  THORACIC OUTLET SYNDROME (TOS) CAUSES: Internal or external compression Prolonged poor positioning Poor posture Disorders Trauma Joint subluxation Pregnancy  TOS Anatomy Branches http://www.miamivascular.com/images/dynamic/V57a.jpg http://upload.wikimedia.org/wikipedia/commons/thumb/0/0e/Brachial_plexus_2.svg/750px- Brachial_plexus_2.svg.png  THORACIC OUTLET SYNDROME 1. Anterior Scalene Syndrome compression at the intrascalene triangle (anterior and middle scalene) 2. Cervical Rib Syndrome compression at a cervical rib at C7 3. Costoclavicular Syndrome compression between the clavicle and first rib 4. Pectoralis Minor Syndrome (aka hyperabduction syndrome) compression between the coracoid Magee, D. J. (2014). process and the pectoralis minor muscle  ANTERIOR SCALENE SYNDROME Intrascalene triangle consists of the: – anterior scalene – middle scalene – first rib Anterior scalene syndrome compresses the brachial plexus (C5-T1) and the subclavian artery. The subclavian vein is not compressed at this level Symptoms include neurological S/S in the 4th and 5th digits Magee, D. J. (2014). THORACIC OUTLET SYNDROME  ADSON’S MANEUVER PURPOSE: To test for Thoracic Outlet Syndrome involving the anterior scalene muscle PROCEDURE: Locate client’s radial pulse Have client rotate the head towards the test shoulder The client then extends the head slightly, and the therapist laterally rotates and extends the client’s shoulder Instruct the client to take a deep breath and hold it for at least 15-20 seconds. POSITIVE: https://www.orthobullets.com Disappearance of the radial pulse /shoulder-and- Reproduction of signs and symptoms elbow/3064/thoracic-outlet- syndrome ADSON’S MANEUVER  ROOS TEST /ELEVATED ARM STRESS TEST (EAST) PURPOSE: To test for Thoracic Outlet Syndrome (TOS) PROCEDURE: Client is standing or sitting Ask client to abduct the arms to 90°, https://chloemassagespa.com/2018/03/19/ externally rotate shoulders, and flex elbows to 90°. stretches-for-thoracic-outlet-syndrome-tso/ Elbows should be slightly behind the frontal plane. Have client slowly open & close the hands for 3 minutes POSITIVE: Client is unable to keep arms in the starting position for 3 minutes Ischemic pain, heaviness, or profound weakness of the arm. Numbness and tingling of the hand during the 3 minutes.  Minor fatigue and distress are considered negative tests. ROOS TEST /ELEVATED ARM STRESS TEST (EAST)  TRAVELLS VARIATION ON ADSON’s/Reverse Adson’s/ Halstead maneuver PURPOSE: To test for Thoracic Outlet Syndrome (TOS) Involving the middle scalene muscle PROCEDURE: Locate client’s radial pulse The client’s head is rotated to face away from the test shoulder The client then extends the head, while the therapist laterally rotates and extends the client’s shoulder Instruct the client to take a deep breath and hold it for at least 15-20 seconds POSITIVE: Disappearance of the radial pulse Magee, D. J. (2014). Reproduction of symptoms  CERVICAL RIB SYNDROME Additional rib that forms at C7 Compression of the neurovascular bundle can result  COSTOCLAVICULAR SYNDROME Space between the clavicle and first rib Compression of the neurovascular bundle may result Costoclavicular syndrome compresses the brachial plexus (C5-T1) and the subclavian artery and vein Symptoms include neurological S/S in the 4th and 5th digits, and venous congestion (edema, pallor, cyanosis)  COSTOCLAVICULAR SYNDROME TEST/Military Brace Test/Eden Test PURPOSE: To assess for Thoracic Outlet Syndrome (TOS) involving compression of the neurovascular bundle between the clavicle and the first rib PROCEDURE: Locate client’s radial pulse Passively depress and extend the client’s shoulder Monitor the radial pulse POSITIVE: Disappearance of the radial pulse Magee, D. J. (2014). Reproduction of symptoms COSTOCLAVICULAR SYNDROME TEST/Military Brace Test  PECTORALIS MINOR SYNDROME/ Hyperabduction Syndrome Space between the clavicle and the pectoralis muscle The neurovascular bundle is compressed under the pectoralis minor muscle Pectoralis minor syndrome compresses the brachial plexus (C5-T1) and the subclavian artery and vein Symptoms include neurological S/S in the 4th and 5th digits, and venous congestion (edema, pallor, cyanosis) When the arm is extended and abducted, neurovascular structures are compressed between: – pectoralis minor tendon and the coracoid process – the clavicle and first rib  WRIGHT’S HYPERABDUCTION TEST/Allen Maneuver PURPOSE: To test for Thoracic Outlet Syndrome (TOS) Involving the pectoralis minor muscle PROCEDURE: Variation #1 (Allen Maneuver): Abduct client’s shoulder to 90°, laterally rotate the arm, and flex the elbow to 90° Client rotates head away from the test side Monitor radial pulse Variation #2 (Wright Hyperabduction): Locate client’s radial pulse. Arm is brought over the head in the coronal plane with the shoulder hyperabducted and laterally rotated Monitor radial pulse POSITIVE: Disappearance of the radial pulse Reproduction of symptoms WRIGHT’S HYPERABDUCTION TEST/Allen Maneuver  NEUROLOGICAL TESTING TINEL’S SIGN PURPOSE: neuroma and indicates a disruption of the continuity of the nerve PROCEDURE: Client sits with neck slightly side flexed Tap along the brachial plexes at the location of the trunks POSITIVE: Tingling sensation in the nerve distribution  NEUROLOGICAL TESTING UPPER LIMB TENSION TESTS 1-4 PURPOSE: To assess whether cervical nerve roots or peripheral nerve roots are the source of the client’s shoulder or arm pain. PROCEDURE: Place the client in a supine position for all four tests, with the side to be tested close to the edge of the table. With one hand grasp the client’s shoulder and apply a constant depressive force to it. With other hand, hold the client’s wrist and move the arm into the various positions described on the next slide. SENSITIZATION TEST: If the position does not produce pain, laterally flex the client’s head to the opposite side. The neck position places further stretch on the nerve root. POSITIVE: Reproduction of the client’s symptoms. ULTT 1-4 puts tension on the upper limb neurological tissues even in normal individuals. It is important to differentiate between normal and pathological symptoms. Note: If the symptoms are reproduced, laterally flex the patient’s head back towards the side being test. The symptoms should diminish at this point.  NEUROLOGICAL TESTING UPPER LIMB TENSION TESTS 1-4 UPPER LIMB TENSION TEST TEST 1 TEST 2 TEST 3 TEST 4 Shoulder Depression & Abduction (110°) Depression & Abduction (10°) Depression & Abduction (10°) Depression & Abduction (90°) Elbow 90° -> Extension 90° -> Extension 90° -> Extension 90° -> Flexion Forearm Supination Supination Pronation Supination or Pronation Wrist Extension Extension Flexion & Ulnar Deviation Extension & Radial Deviation Fingers & Thumb Extension Extension Flexion Extension Shoulder --- Lateral Rotation Medial Rotation Lateral Rotation Cervical Spine Contralateral Side Flexion Contralateral Side Flexion Contralateral Side Flexion Contralateral Side Flexion Nerve Bias Median Nerve Median Nerve Radial Nerve Ulnar Nerve Anterior Interosseous Nerve Musculocutaneous Nerve Nerve Roots C8 & T1 Nerve Roots C5, C6, C7 Axillary Nerve How to Video https://www.youtube.com/watch?v=rir6x6Iiqc4 NEUROLOGICAL TESTING- UPPER LIMB TENSION TEST 1  OTHER CERVICAL CONDITIONS TORTICOLLIS HEADACHES & MIGRAINES WHIPLASH/ WHIPLASH ASSOCIATED DISORDER  Chvostek TORTICOLLIS test (Magee p.240) An abnormal position of the head and neck relative to the body Magee, D. J. (2014). Acute acquired Torticollis: painful, unilateral, shortening or spasm of neck muscles resulting in an abnormal head Cause: trp, C1C2 articulation, facet joint, infection, DDD Congenital torticollis: contracture of one sternocleidomastoid muscle resulting in an abnormal head position Cause: idiopathic Spasmodic Torticollis: localized dystonia resulting in an involuntary spasm of cervical muscles and an abnormal head position Cause: idiopathic Associated with: Unilateral shortening or spasm of neck muscles (SCM) Facet joint irritation Latent trigger points Congenital Torticollis (right-SCM)  TORTICOLLIS- Chvostek TESTING CONSIDERATIONS test (Magee p.240) Range of Motion: Active & Passive- may reveal pain and restriction of out torticollis position Resisted- may reveal weakness on contralateral anterior & lateral neck muscles. May reveal weakness on ipsilateral posterior lateral neck muscles. Orthopedic tests: Compression Test Distraction Test Vertebral artery Test Spurlings Test  Consider how the presence of a spasm will impact your testing  TENSION HEADACHES Chvostek & MIGRAINES test (Magee p.240) Tension Headache: A muscle-contraction-type headache Migraines: A neurological disorder with various signs and symptoms Signs of a headache having a cervical origin: Occipital or suboccipital component to headache Neck movement alters headache Painful limitation of neck movements Abnormal head or neck posture Suboccipital or nuchal tenderness Abnormal mobility at C0–C1 Sensory abnormalities in the occipital and suboccipital areas  TENSION HEADACHES & MIGRAINES- Chvostek TESTINGtest (Magee p.240) CONSIDERATIONS Range of Motion: Active and Passive- cervical spine, thoracic spine as well as mandible and shoulder should be tested Resisted- possible weakness on the affected side Orthopedic tests: Consider taking blood pressure Motion and static palpation AO articulation AA articulation Anterior and lateral spinous challenge First rib mobility Spurlings Cervical compression Cervical distraction Vertebral Artery Test  WHIPLASH/WHIPLASH ASSOCIATED DISORDER Chvostek test (Magee (WAD) p.240) An acceleration- deceleration injury to the head and neck resulting from: Contact sports Diving accidents Motor vehicle accidents (MVA) – Rear impact – Front impact – Side impact Classification system – Grade 0- no neck complaints – Grade 1- neck pain, stiffness or tenderness only – Grade 2- neck pain, stiffness, or tenderness and decreased ROM https://www.physio-pedia.com/Whiplash_Associated_Disorders – Grade 3- neck pain, stiffness, or tenderness and decreased ROM, and neurological signs – Grade 4- neck complaints with fracture or dislocation  WHIPLASH/WHIPLASH ASSOCIATED DISORDER Chvostek test (Magee (WAD) p.240) Tissues involved in a whiplash (direction of injury directly influences the structures involved) Cervical vertebrae Disc, facets, capsules, ligaments TMJ Muscles: – Posterior cervical muscles (suboccipitals, upper traps, levator scapulae, splenius cap, cerv) – Anterior cervical muscles (SCM, hyoids, longus capitis/colli) https://www.physio- – Lateral cervical muscles (scalenes) pedia.com/Whiplash_Associated_Disorders – Muscles of mastication (masseter, lateral and medial pterygoid)  WHIPLASH/WHIPLASH ASSOCIATED DISORDER Chvostek test (Magee (WAD) p.240) Range of Motion Active- potentially painful and restricted Passive- potentially painful with a tissue stretch end feel Restricted- decreased strength Orthopedic tests: Vertebral artery test Dermatomal testing Reflex testing Upper limb tension tests Spurlings Compression test Distraction test Rib mobility Passive range to the spine TOS testing as appropriate TMJ testing as appropriate Scalene testing TEMPORAL MANDIBULAR JOINT (TMJ)  TEMPORAL MANDIBULAR JOINT DYSFUNCTION (TMJD) A disorder of the muscles of mastication including their joint and associated structures Magee, D. J. (2014).  RANGE OF MOTION Active: – Depression (opening) –tissue stretch end feel – Occlusion (closing)- bone to bone Passive: not typically performed Resisted:  Have client keep jaw in resting position for testing. Apply a firm but gentle resistance using “don’t let me move you” as your cueing – Depression (opening) ex. A – Occlusion (closing) ex. B and C – Lateral deviation (left and right) ex. D Magee, D. J. (2014).  ACTIVE FREE ROM – Visual Cues POSITIVE: Asymmetrical motion, hesitation in motion, lateral deviation, and/or wobble in the movement of the mandible An S shape wobble indicates A MUSCULAR SOURCE of the dysfunction. A C shaped wobble indicates a CAPSULAR SOURCE, with the mandible deviating to the side that has the capsular restriction. Magee, D. J. (2014).  GENERAL TESTING: PALPATION Examine for presence of trigger points, tenderness, or muscle spasm The following are palpation landmarks for the jaw: Mandible Masseter Med pterygoid Lateral pterygoid Temporalis Mastoid process Magee, D. J. (2014).  ACTIVE FREE ROM – with Palpation PURPOSE: To assess for the motion of the mandible at the temporomandibular joint. TMJ dysfunction or pathology PROCEDURE: Place the index finger pads of both hands just anterior to each of the patient's external auditory meatus (just posterior to the mandibular condyles) allowing the motion of both of the TMJ's to be palpated simultaneously. Instruct the client to open and close the mandible slowly and fully. Assess the quality of motion of the condyles as they should be bilaterally symmetrical and smooth POSITIVE: Clicking, crepitus, asymmetry of motion, pain  JAW REFLEX PURPOSE: Testing cranial nerve 5 (CN V – Trigeminal) PROCEDURE: Examiner's thumb is placed on the chin of the patient with the patient's mouth relaxed and open in the resting position. Patient is then asked to close the eyes (if not done, the patient will usually tense when they see the reflex hammer swung towards the examiners thumb). The examiner then taps the thumbnail with the hammer POSITIVE: The reflex closes the mouth The jaw jerk is exaggerated. Possibly cervical myelopathy (spinal cord injury) or upper motor neuron lesion. Magee, D. J. (2014).  KNUCKLE TEST/ 3 FINGER TEST PURPOSE: Functional movement of the jaw PROCEDURE: Ask the patient to try to place 2 or 3 flexed proximal interphalangeal joints within the mouth opening. The opening should be approximately 35- 55 mm. Normally, only about 25-35 mm of opening is needed for everyday activity POSITIVE: If the patient has pain on opening, the examiner should measure the amount of opening to the point of pain and compare to functional opening. If the space is less than 25 mm, the TMJ is Magee, D. J. (2014). hypomobile.  ChvostekCHVOSTEK TEST p.240) test (Magee PURPOSE: Pathology of cranial nerve 7 (CN VII - facial nerve) PROCEDURE: Examiner taps the parotid gland overlying the masseter muscle POSITIVE: Facial muscle twitch Positive Chvostek https://www.youtube.com/watch?v=ep6IEqnyxJU&feature=player_embedded https://www.pinterest.ca/pin/510947520193861663/?lp=true  REFERENCES Magee, D. J. (2014). Orthopedic Physical Assessment (6th ed.). St. Louis, Missouri: Elsevier Saunders Inc. Rattray, F., Ludwig, L. (2000). Clinical Massage Therapy: Understanding, Assessing and Treating Over 70 Conditions. Toronto, Ontario, Canada: Talus Incorporated