Physical Medicine 204 Final
What is the main motion from C0 to C1 of the cervicocranial region?
Flexion to extension = nodding 15 - 20o
What is the main motion from C1 to C2 of the cervicocranial region?
Injuries to the cervicocranial region (C0 to C2) can affect?
The spinal cord, brainstem, and brain
Injuries to the cervicocranial region (C0 to C2) can cause the following symptoms?
headaches, fatigue, vertigo, poor concentration, hypertonia of sympathetic nervous system, and irritability
Which artery supplies nearly 20% of the blood to the brain?
At what level does the vertebral artery enter the transverse processes?
Injuries to the vertebral artery can be from the following:
Osteophytes of the facet joint, injury to the facet joint, compression by extension, rotation, or traction
Where is the greatest stress on the vertebral artery?
At the level of C1 - C2 where it enters the occiput
What are some main symptoms of vertebral-basilar artery insufficiency?
Vertigo, nausea, tinnitus, drop attacks, and visual disturbances
Where can an injury to the cervicobrachial region (C3 - C7) refer pain to?
What are some main symptoms to an injury of the cervicobrachial region (C3 - C7)?
Arm and/or neck pain, paresthesia, headache, restricted ROM, altered dermatomes and myotomes, sympathetic dysfunction, and cranial nerve and cognitive dysfunction are possible
A history of radiating symptoms with coughing/sneezing/straining can indicate:
Increased intrathoracic pressure (space occupying lesion)
What are the red flag clinical characteristics of a serious cervical spine disorder related to a fracture?
- clinically relevant trauma in adolescent or adult
- minor trauma in elderly patient
- ankylosing spondylitis
What are the red flag clinical characteristics of a serious cervical spine disorder related to a neoplasm?
- pain worse at night
- unexplained weight loss
- history of neoplasm
- age of more then 50 or less than 20 years
- previous history of cancer
- constant pain, no relief with bed rest
What are the red flag clinical characteristics of a serious cervical spine disorder related to an infection?
- fever, chills, night sweats
- unexplained weight loss
- history of recent systemic infection
- recent invasion procedure
- intravenous drug use
What are the red flag clinical characteristics of a serious cervical spine disorder related to a neurologic injury?
- progressive neurological deficit
- upper and lower extremity symptoms
- bowel or bladder dysfunction
What are the red flag clinical characteristics of a serious cervical spine disorder related to a cervical myelopathy?
- sensory disturbance of the hands
- muscle wasting of hand intrinsic muscles
- unstable gait
- Hoffman reflex
- bowel and bladder disturbances
- multisegmental weakness and/or sensory changes
What are the red flag clinical characteristics of a serious cervical spine disorder related to an upper cervical ligamentous instability?
- occipital headache and numbness
- severe limitations during neck active ROM in all directions
- signs of cervical myelopathy
What are the red flag clinical characteristics of a serious cervical spine disorder related to a vertebral artery insufficiency?
- drop attacks
- dizziness or lightheadedness related to neck movement
- positive cranial nerve signs
What are the red flag clinical characteristics of a serious cervical spine disorder related to an inflammatory or systemic disease?
- temperature more than 37 degrees Celsius
- blood pressure more than 160/95 mmHg
- resting pulse more then 100bpm
- resting respiration more then 25bpm
When doing AROM of the cervical spine, what extreme caution do you need to be aware about?
Bulging of C2 spinous process - C1 subluxating forward
What nerve root supplies the biceps deep tendon reflex?
What nerve root supplies the brachioradialis deep tendon reflex?
What nerve root supplies the triceps deep tendon reflex?
What is the pathological reflex seen in cervical myelopathy?
What does a positive Hoffmann's sign suggest?
An upper motor neuron lesion
What is are Burners/Stingers?
Burners and stingers are injuries that occur when nerves in the neck (brachial plexus - usually C5 -C6) and shoulder are stretched or compressed after an impact (usually via lateral flexion)
What are the symptoms of burners/stingers?
- Lightning-like, thenheaviness/weakness of the arm
- Transient dermatomal symptoms
- Usually mild, transient (minutes) symptoms
Examination of burners/stingers:
- Weakness or sensory deficit may be delayed, important to
re-evaluate patient 1-week post injury
- Most common finding: weakness of shoulder abduction, lateral rotation and flexion
- No long tract signs: bowel/bladder, lower extremity DTR, gait, pathological reflex – all negative
- Persistent symptoms may need x-ray and/or EMG
What is the management of burners/stingers?
- Treat any cervical sprain/strain (rest ice)
- Avoid same direction of injury
- Strengthen cervical spine when safe to do so (start with gentle isometric cervical exercises, and progress)
- Proper protective gear for athlete - repeat trauma can cause further damage
Characteristics of facet joint syndrome?
- Irritation of the facet joint, now compression of the joint causes pain
- Often a mild (turning head) or moderate (MVA) trauma;
- can be insidious (waking up with it)
- Often accompanied by myofascial pain
Can have referred pain from facetjoint
Examination of facet syndrome:
- Perform standard orthopedic/neurologic exam of neck and upper extremity
- Subjective numbness a possibility, but no objective numbness
- Cervical compression: negative, but local pain as facets are irritated
- Pain: with extension, and with ipsilateral rotation to the side of pain
- Search for trigger points: including supraspinatus and infraspinatus
- Rule out: Cervical stenosis – hard neurologic findings (DTRs, myotomes, dermatomes)
What is the management of facet syndrome?
- Adjusting is the treatment of choice!
- Cervical traction
- For associated myofascial pain: trigger-point therapy, or myofascial release techniques, etc
- Long term: general stretching, strengthening, and postural exercises
What is radiculopathy?
Commonly known as a pinched nerve
Characteristics of cervical radiculopathy:
- Acute – usually disc herniation (severe neck pain that radiates to the shoulder, scapular and or arm; worse with straining/jarring/sneezing/coughing)
- Less likely after age 40+ because of dessication of nucleus pulposus
- Chronic – usually secondary to spondylosis
Signs and symptoms of cervical radiculopathy:
- Often insidious onset
- Often a history of previous neck pain
- But disc herniation could also be from trauma without prior history
- Deep ache, unilateral symptoms
- Myotomal muscle weakness,
- Dermatomal sensory alteration
- Shoulder Abduction Relief (Bakody’s Sign) - decrease in symptoms
- Painful AROM and PROM, usually more to one side (especially extension plus rotation or lateral flexion)
- Cervical Compression: may reproduce the neck and arm pain, but radiation to medial scapula is also a possibility
- Cervical Distraction: may relieve the pain
- Shoulder Depression: may reproduce the symptoms on the side of head deviation
- Associated radicular signs: DTR, Myotome, and dermatome
- Gait, bowl/bladder, pathological reflexes - normal
Management of cervical radiculopathy:
- No cervical spinal manipulation
- Mild mobilization can
be used but use “provocation testing”:
- Try a gentle mobilization maneuver
- If increase in symptoms that maneuver is contraindicated
- If not increase in symptoms that maneuver is not contraindicated
- Cervical traction and physiotherapy may also be incorporated
- Home traction of 15 minutes twice a day benefits some patients. Improvement should be noticed after a few days
- Patients with severe pain or are unresponsive to care should be referred for medical comanagement
- Exercise: Axial retraction – try to centralize (not peripheralize) symptoms
- Long term prevention: postural exercise, stretch & strengthen muscle imbalances, avoid causative postures
Characteristics of cervicogenic headaches:
- Occipital or suboccipital pain
- Abnormal posture
- Cervical AROM: limited and alters headache
- Abnormal movement at C0-C1 (C1 joint dysfunction-pain in the occiput or top of the head; C2 joint dysfunction-pain in temporal area)
- Tenderness in the suboccipital and nuchal area
Management of cervicogenic headaches:
- Manual manipulation/mobilization
- Stretching, trigger point therapy
- Physical therapy such as TENS
- Long term: postural exercises, stretching & strengthening muscle imbalances
What is Myelopathy?
An injury to the spinal cord due to severe compression that may result from trauma, congenital stenosis, degenerative disease or disc herniation
Characteristics of cervical myelopathy:
- Injury to the spinal cord; Many possible causes: tumour, trauma, spondylosis
- Presentation differs with degree and location of the compression
- Spastic weakness, paresthesia (hands or legs), incoordination of one or both lower extremity with alteration of balance, proprioception and/or sphincter function
- If cervical nerve roots are also involved, lower motor neuron symptoms will also be found
Neurological examinations for cervical myelopathy:
- Pathologic reflexes (Hoffman’s, Tromner’s, Babinski’s),
- Decreased proprioception (finger position with eyes closed)
- Lhermitt’s test
Neurological examinations for cervical myelopathy can also include tests for cerebellar function which are:
- Dysmetria (finger to nose to Dr’s moving finger),
- Dysdiadocokinesis (dysfunction of paired cooperative movement-repetitive pronation/supination),
- Dysergia (decomposition of movement-running heel of foot down shin of opposite leg repetitively and fluidly)
Cervical fracture information:
- Usually high energy trauma
- Point tenderness at the location of injury
- Possible deformity
- May have neurological deficit, sensation of instability
- If suspected fracture, refer for x-ray
- If fracture, in most cases referral to physician warranted
Vertebral artery injury information:
- Head and/or neck pain – unlike any experienced before
- Syncope, presyncope, drop attacks (falling without provocation and no loss of consciousness), visual changes
- Referral to medical doctor
What type of breathing uses scalene and SCM muscles less than if moving the ribcage to ventilate?
Information about trigger points:
- “A hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle’s fascia, that is painful on compression and that can give rise to characteristic referred pain, tenderness and autonomic phenomena.”
- Weakness and greater fatigability (without atrophy)
- Active trigger points (painful), Latent trigger points (present, but not painful until compressed)
- Have a characteristic referral pain pattern for each muscle group
- Caused by injury, overload, fatigue and cold
- Can be treated with cold & stretch, stretching, ischemic compression, etc.