Week 2 Cervical Physmed 2024 Asynchronous .pdf

Orthopedic Conditions & Assessment C o n d i t i o n s o f t h e C e r v i ca l S p i n e Dr. Albert Iarz, ND, RMT BMS 150 Lab The Clinical Encounter - OHIPMNRS Observe History LO DR FICARA Inspection Palpation Motion Neurovascular Referred Pain (screening adjacent areas) Special Tests Observe...

Orthopedic Conditions & Assessment C o n d i t i o n s o f t h e C e r v i ca l S p i n e Dr. Albert Iarz, ND, RMT BMS 150 Lab The Clinical Encounter - OHIPMNRS Observe History LO DR FICARA Inspection Palpation Motion Neurovascular Referred Pain (screening adjacent areas) Special Tests Observe Patient’s general appearance, posture & gait (how do they walk into the office? Emotional status (happy, sad) – are they comfortable? History (Basic Considerations) Where is the problem? Point to it exactly. When did it start? What makes it better or worse? Prior treatment or injuries? Quality of issue? (numbness, tingling, sharp, ache) Severity (scale from 0-10)? Gradual or sudden onset? LoDrFicara Inspection (Visual) Posture, gait, bony deformity, trouble with activities of daily living (ADLs) Obvious discomfort (painful expression, unable to sit comfortably, limp) Bony & soft tissues (deformity, bruising, swelling, colour, sweat/dry, scars, calluses, bunions, atrophy, ulcers) Foot wear (supportive, wear patterns on shoes, assisting devices such as orthotics or braces) Palpation (360 Degrees Around Joint/Painful Area) Please NOTE: Temperature, Texture, Tone, Tenderness (4 Ts) 360 Degrees around the joint A bit above and a bit below the site of injury/ complaint Apply enough pressure to feel deeper tissues and recreate pain Anatomy review (bone, tendons, ligaments, fascia, blood vessels, nerves, lymph, viscera) Motion: AROM/PROM/RROM Start with AROM - Full Ranges (Note any issues) Move to PROM - Full Ranges with Over Pressure at the end for End Feel Move to RROM - Full Strength but fully isometric (neutral/relaxed position) Neurovascular Screen Dermatomes Myotomes Deep Tendon Reflexes Pulses, Capillary Refill, Temperature Referred Pain (screen adjacent areas) Is there pain in other areas Special Tests (Orthopedic Tests) Start with tests for the specific area of pain/ concern Keep in mind nerve referral pathways. So, if appropriate, perform specials tests above and below the site of pain/concern. CERVICAL SPINE ANATOMY Joints of the Cervical Spine Atlanto-occipital joints (C0-C1) Atlanto-axial joints (C1-C2) Facet joints (14 in total) Intervertebral discs CERVICAL SPINE ANATOMY Atlanto-occipital joints (C0-C1) Principle motion = flexion/extension (15-20 degrees) Rotation is negligible stabilized by several ligaments CERVICAL SPINE ANATOMY Atlanto-axial joints (C1-C2) Most mobile articulation of the spine main supporting ligament is the transverse ligament holding the dens of the axis against the anterior arch of the atlas this ligament weakens or ruptures in rheumatoid arthritis two projections of the ligament go superior to the occiput and inferior to the axis, together with the transverse is know as the cruciform ligament movements Flexion Extension Lateral Flexion Rotation CERVICAL SPINE ANATOMY Facet joints (14 in total) Facilitates flexion and extension Limited rotation or side flexion Greatest flex/ext occurs at C5-C6 and next between C4-C5 and C6-C7 Because of this mobility degeneration is more likely to be seen at these levels CERVICAL SPINE ANATOMY Intervertebral discs Make up 25% of the height of the C/S No disc between C0-C1 and C1-C2 Nucleus pulposus buffers axial compression Annulus fibrosis withstands tension within the disc CERVICAL SPINE ANATOMY Although there are 7 cervical vertebrae there are 8 cervical nerve roots, each is named for the vertebrae ABOVE it Ex. C5 nerve root is between C4 and C5, rest of the spine the root is named for the vertebrae BELOW, eg: L4 nerve root is between L4 and L5 Cervical Spine Assessment Bony Palpation Anterior aspect Thyroid cartilage (C4-C5) Cricoid Cartilage(C6) Posterior aspect Occiput Inion (EOP) Mastoid process SP of the cervical vertebrae (C2-7) Facet joints Cervical Spine Assessment Soft tissue palpation Anterior SCM Involved in torticollis Note discrepancies in size, tone\damaged Hyperextension damages May cause torticollis Lymph Node Chain Along medial border of SCM Enlarged nodes in SCM region indicate URTI Supraclavicular fossa Palpate for unusual swellings or lumps Swelling in the fossa might be secondary to trauma Small lumps may be due to enlarged lymph nodes Cervical Spine Assessment Soft tissue palpation Posterior Trapezius Muscle Origin = Inion to T12 Insertion = clavicle, acromion, spine of scapula Action = elevate retract, and depress shoulders Lymph Nodes Anterolateral aspect of traps Enlarged with infection Levator Scapulae Origin = Upper cervical TVP’s Insertion = Superior angle of the scapulae Action = Shrug shoulders Splenius and semispinalis capitus (Deep Muscles) Scalenes (Anterior, Middle, Posterior) Multiple attachments including ribs 1 and 2 RANGE OF MOTION (CERVICAL SPINE/MUSCLES/JOINTS) Active ROM (AROM) - Patient copies movement of practitioner or is told to move in particular direction Movements should be done in an order such that expected painful ones are done last and no residual pain is carried over from the previous movement. If very acute, some movements may be left out to avoid exacerbation of symptoms. RANGE OF MOTION (CERVICAL SPINE/MUSCLES/JOINTS) Flexion = 45-50 Degrees Bring the chin to the chest can divide the flexion into two parts C0-C2 gives nodding, C2-C7 gives flexion if problem with nodding is upper restriction for lower normal can be chin touching chest with mouth closed or up to 2 finger width space between chest and chin RANGE OF MOTION (CERVICAL SPINE/MUSCLES/JOINTS) Extension = 70 Degrees Bend the head backwards, lift the chin up without moving the neck normally the nose and forehead can go nearly horizontal tingling, loss of balance etc.. suggest serious complication of cord compression RANGE OF MOTION (CERVICAL SPINE/MUSCLES/JOINTS) Rotation = 70-90 Degrees Look over your left and right shoulders usually the chin does not quite reach the plane of the shoulder RANGE OF MOTION (CERVICAL SPINE/MUSCLES/JOINTS) Lateral flexion = 20 - 45 Degrees Bring each ear to the shoulder Be sure ear is moving to shoulder and not the reverse Neurological Testing Dermatomes Myotomes DTR’s Dermatomes MYOTOMES (UPPER LIMBS) Must be held for 5 seconds Spinal level Resisted action C1-C2 Neck flexion • Head slightly flexed • Pressure to forehead with stabilizing hand between the scapula • Be sure neck does not extend when applying pressure C3 Neck side flexion • One hand above patients ear • Stabilize with other hand on opposite shoulder C4 Shoulder elevation • Bring shoulders up to about half of full elevation • Apply a downward force while patient tries to keep in place • If done seated have patient push up on thighs C5 C6 Shoulder abduction • Elevate arms to 70-80 degrees, elbows at 90 degrees • Apply downward force on humerus • To prevent rotation place examiners forearms over the patients forearms Elbow flexion • Arm at the side, elbow at 90 degrees • Forearm neutral • Apply downward force C7 Elbow extension • Arm at the side, elbow at 90 degrees • Forearm neutral • Apply upward force C8 Thumb extension • Extend the thumb to just short of full range • Apply pressure to bring into flexion T1 Squeeze patients abducted fingers together T2 Pull patients adducted fingers apart MYOTOMES (LOWER LIMBS) Must be held for 5 seconds Spinal level Resisted action L2 Hip flexion • With Knee Bent • Pressure to thigh while patient tries to resist downward pressure L3 Knee Extension • With Knee Bent • Hand on Tibia and patient will resist knee flexion L4 Ankle Dorsiflexion • With Knee bent • Hand on dorsal of foot and patient resists dorsiflexion L5 Great Toe Extension • Patient resists big toe extension S1 Hip Extension but also Ankle Plantar Flexion and Eversion • Patient can stand on toes and hold or, while sitting, plantar flex into examiners hand • This also adds hip extension, so get patient to lie prone with knee bent and resist hip extension S2 Knee Flexion • With knee bent patient resists knee flexion DTR’s Reflex Site of Stimulis Spinal level Biceps Biceps Tendon C5-C6 Brachioradialis Brachioradialis tendon or just distal to the musculotendinous junction C5-C6 Triceps Distal triceps tendon above the olecranon process C7-C8 Patellar Patellar Tendon L3-L4 Achilles Achilles Tendon S1-S2 Cervical Degenerative Joint Disease (DJD) Definition: Cervical facet (zygapophyseal joint) irritation or damage that may cause cranial, cervical or upper shoulder & back pain referral; often difficult to differentiate from other neck issues Differential Diagnosis: Discogenic pain syndrome or sprain/strain Cervical radiculopathy Fibromyalgia, myofascial pain syndrome Infection, neoplasm, aneurysm Cervical Degenerative Joint Disease (DJD) History: Dull, achy localized pain, although may be sharp during acute episodes, headaches and limited ROM – patient will often have pinpoint pain, neck muscle spasm/ torticollis Sometimes radiates to the shoulder or mid back regions, although does not often radiate beyond the elbow or upper thoracic spine Patient may report a history of whiplash injury Pain is reduced when supine Cervical Degenerative Joint Disease (DJD) Physical: Increased pain on extension & rotation (due to facet approximation) Antalgia is typically away from the facet in acute patients resulting in slight flexion and lateral flexion position (torticollis like position) Possible muscle splinting and guarded ROM No neurological deficit (DTRs, motor, sensation) Cervical Degenerative Joint Disease (DJD) Special Tests: Cervical Compression Test (+) local pain with compression Cervical Distraction Test (+) DECREASED pain with distraction Spurlings or Maximal Compression Test (+) Local pain with compression Cervical Radiculopathy Definition: Neurocompressive disorder of the cervical nerve roots resulting in various neurologic findings (7 vertebrae & 8 nerve root) Pathogenesis occurs from the inflammatory process initiated by nerve root compression Differential Diagnosis: Peripheral Neuropathy Facet syndrome, meniscoid, instability Myofascial pain syndrome, trigger point referral Cervical myelopathy, CNS lesions Infection, neoplasm, fracture, rotator cuff injury Cervical Radiculopathy History: Patient describeas deep aching to burning neck pain & radicular arm pain (“numbness, tingling, sharp, shooting, electrical”) that may follow a neck injury or be of insidious onset May be a history of multiple episodes of previous neck pain. Possible muscle weakness in the arm/hands or sensory changes along the involved nerve Patient may state symptom relief when shoulder is abducted with hand held behind head (shoulder abduction test). Observation: Head tilt & neck posture; head tilt away from the side of injury & holds neck stiffly Cervical Radiculopathy Physical: AROM: Limitations: extension, rotation & lateral bending either away or towards the affected nerve root (increase pain, numbness, tingling or electrical pain) Pain away from the affected side = disc herniation Pain towards affected side = impingement of nerve root at site of IVF Palpation: Tenderness along cervical paraspinals Muscle tenderness along muscles where symptoms are referred (medial scapula, proximal arm, lateral elbow) and associated hypertonicity/spasm Motor weakness: Grip and pinch weakness Cervical Radiculopathy Physical: Sensory changes Decreased sensation to pain and light touch (dermatomal distribution) Burners or Stingers DTRs: Hyporeflexia indicates peripheral neuropathy, hyperreflexia indicates CNS lesion Cervical Radiculopathy Special Tests: Valsalva Test (+) Reproduction of neck or radicular pain in case of disc herniation or SOL Cervical Compression Test (+) Reproduction of neck or radicular pain due to nerve root compression Cervical Distraction Test (+) DECREASED radicular symptoms Brachial Stretch Test (+) reproduction of dermatomal pain referral TMJ Syndrome Definition: Pain & tenderness due to a dysfunction of the TMJ or surrounding musculature & soft tissue. 3 Subtypes: Myofascial pain dysfunction Internal derangement Degenerative Joint Disease Differential Diagnosis: Headache (cluster, migraine, tension) Temporal/Giant Cell arteritis, trigeminal neuralgia Dental infections, parotiditis TMJ Syndrome History Jaw or facial pain (80%), pain with mastication (chewing) Locking or clicking or catching with motion, limited ROM, grinding & popping Headache, earache (30%) & neck pain History of neck or facial trauma (whiplash) TMJ Syndrome Physical Observation: asymmetry, muscle hypertrophy, abnormal dental wear Palpation: tender (80%) over the muscles of mastication, can feel crepitus in the joint in late stages ROM: decreased jaw opening Normal = 40mm or at least 3 knuckles inserted between upper and lower incisors Clicking or popping of TMJ, crepitus over joint (may indicate disc damage) Abnormal mandibular tracking (gait): lateral deviation of mandible, non-uniform pattern TMJ Syndrome Special Tests: Rule out DDXs Often special tests are done to rule out other conditions you are considering to make TMJ syndrome your most likely working diagnosis. Benign Paroxysmal Positional Vertigo (BPPV) Definition: A disorder arising from a problem in the inner ear where the underlying mechanism typically involves small calcified otolith moving around loose in the inner ear A type of balance disorder Differential Diagnosis: Labyrinthinitis Meniere’s Disease Benign Paroxysmal Positional Vertigo (BPPV) History Any Nausea Any head injury What is patient’s age What are symptoms: Spinning sensation (vertigo) Nausea/Vomitting Symptoms worsen with movement of head Is it paroxysmal (Suddenly and short duration) Per-Syncope or syncope Benign Paroxysmal Positional Vertigo (BPPV) Special Tests: Rule out DDXs Dix-Hallpike Test Is nystagmus observed Treatment Usually involves simple movements such as the Epley Maneuver or other maneuvers based on direction of nystagmus. Prescription drugs to help with nausea Whiplash • Injury to the neck due to sudden acceleration or deceleration • Results in a flexion or extension deformation of the spine • 2 common scenarios for whiplash • A body at rest suddenly put in motion (E.g. quarterback being hit from behind) • A moving body suddenly stopped (E.g. hockey player absorbing a hit in open ice) Whiplash 4 types of whiplash •Posteroanterior (back to front) •Anteroposterior (front to back) •Lateral (right to left) •Lateral (left to right) Whiplash Symptoms • Neck pain • Onset can be immediate or hours later • Soreness, stiffness, fatigue • Nausea Symptoms if structural damage is found • Sharper pain • Quicker onset • Pain may radiate anywhere • ROM can be severely limited Special Orthopaedic Tests Cervical Distraction Test (Pain Relief Test) Spurling’s or Foraminal compression test Maximal foraminal compression test Valsalva Shoulder Depression Test Vertebral Artery Test Jaw Reflex Chvostek’s Test Soto-Hal Test Brachial Stretch Tests/Upper Limb Tension Tests Median Nerve Dominant Radial Nerve Dominant Ulnar Nerve Dominant THE END