cervical Exam, WAD, Cervical instability, postural and muscle imbalance

What upper muscles are tight? (3)

- upper traps

- levator scapulae

- pectoralis

what upper muscles are weak? (3)

- deep neck flexors

- lower traps

- serratus anterior

Cervical specific things included in a patient history? (4)

- posture screen

- sleeping posture

- headaches

- upper extremity pain

with cervical AROM, motion occurs down to?

T3-T4

red flags: vertebral artery insufficiency s/s? (7)

- drop attacks

- dizzy

- dysphagia

- dysarthria

- diplopia

- lightheaded with head movement

- cranial nerve signs

when should you perform a vertebral artery insufficiency test? (4)

- before manipulations

- history of trauma

- presence of signs and symptoms

- Spinal cord compression

red flag: craniovertebral instability? (2)

- excessive movement between occiput, C1, and C2

- risk to brainstem and upper spinal cord

craniovertebral instability tests? (2)

- sharp-purser

- alar ligament test

who requires a craniovertebral instability test? (7)

- recent trauma

- Rheumatologic condition

- congential for genetic conditions

- neuro signs/symptoms

- post surgery or post cancer

- multiple myeloma

- RA, down syndrome

red flags: cervical myelopathy? (7)

- encroachment on spinal cord

- upper motor neuron signs and symptoms

- sensory disturbance of hand

- hoffman reflex

- supinator sign

- age >45

- bowel and bladder disturbances

what is the supinator sign? (4)

- suggests upper motor neuron lesion at C5-C6

- distinguish between central and peripheral neuro involvement

- DTR of brachioradialis

- when elbow extends instead of flexes

red flag: upper cervical ligamentous instability? (3)

- occipital headache and numbness

- severe limitations in all directions

- s/s of cervical myelopathy

high risk factors for canadian C spine rules? (6)

- 65 or older

- dangerous MOI

- fall more than 1 meter or 5 stairs

- axial load to head

- bike collision

- paresthesia in extremities

next step if the patient answers YES to any of the high risk factors for Canadian C spine rules?

radiographs

1 multiple choice option

low risk factors for Canadian C spine rule? (4)

- simple rear-end MVA

- normal sitting position in ER

- patient can ambulate

- delayed onset neck pain

what should you do if the patient answers NO to any of low risk factors for the canadian C spine rule?

radiographs

1 multiple choice option

what should you do if the patient answers YES to any of low risk factors for the canadian C spine rule?

go to question 3

1 multiple choice option

question 3 on the Canadian C spine rule?

able to rotate the neck at least 45 degrees to left and right

what should you do if the patient can rotate their neck at least 45 degrees to the left and right according to the Canadian C spine rule?

no x ray

what should you do if the patient CANNOT rotate their neck at least 45 degrees to the left and right according to the Canadian C spine rule?

radiographs

A 28-year-old patient presents to the ER after being rear-ended while stopped at a red light. The patient is alert and oriented (GCS of 15), denies any neck pain, and has no midline cervical tenderness. They were ambulatory at the scene and currently sit comfortably in the ER. Passive neck rotation is painless. Based on the Canadian C-Spine Rule, what should you conclude?

Imaging is not required because the patient meets all low-risk factors and has full active neck rotation

3 multiple choice options

neck disability index? (5)

- self reported neck pain

- impact on daily function and activity tolerance

- higher indicates more disability

- 0 is none, 5 is complete disability

- can be doubled for percentage

MCID for the NDI?

5

pain catastrophizing scale? (3)

- degree of catastrophic thinking related to pain

- identifies psychological risk factors influencing pain experience and recovery

- total score out of 52

pain catastrophizing scale subscales? (3)

- rumination

- magnification

- helplessness

what does a score of 0-20 indicate in regards to the pain catastrophizing scale?

low risk

what does a score of 21-30 indicate in regards to the pain catastrophizing scale?

moderate risk

what does a score of >30 indicate in regards to the pain catastrophizing scale?

high risk for poor outcome

A 32-year-old female presents to physical therapy with chronic neck pain following a motor vehicle collision 4 months ago. She reports difficulty sleeping, persistent worry about her symptoms, and frequent thoughts that the pain will never improve. Her Pain Catastrophizing Scale (PCS) score is 34. Based on current evidence, what is the most accurate interpretation of this score?

A PCS score of 34 is indicative of a high level of catastrophizing, associated with increased risk for poor outcomes, and should prompt integrated psychological referral

3 multiple choice options

Whiplash associated disorders? (3)

- acceleration/deceleration from MVA mainly

- can be from falls, collision sports, skiing

- most recovery in 3-4 weeks

- has quebec task force classification

WAD quebec task force classification of 0?

no complaint

WAD quebec task force classification of 1? (2)

- stiff or tender

- non-physical signs

WAD quebec task force classification of 2? (3)

- pain

- musculoskeletal signs

- decreased ROM and point tenderness

WAD quebec task force classification of 3? (2)

- all features of previous classes

- adding neuro signs

WAD quebec task force classification of 4?

fracture or dislocation

Sterling modification for WAD?

WAD II classifiction based on specific clinical findings

WAD II A? (6)

- pain

- sensory impairment with cervical hyperalgesia

- decreased ROM

- altered muscle recruitment

- aberrant motion

- DNF dominance

WAD II B? (3)

- all factors in WAD II A

- add psychological impairments

- includes distress

WAD II C? (4)

- adds more in motor, sensory, and psychological categories

- joint positioning errors

- generalized sensory hypersensitivity

- acute post-traumatic stress

treatment for WAD II C? (5)

- avoid provoking pain

- gentle manual and active movement

- avoiding overstrainign painful structures

- early active exercise

- early psychological consultation

A 34-year-old female presents with neck pain and limited cervical range of motion two weeks post-MVC. Her NDI score is 32/50. She demonstrates signs of altered sensory processing, moderate pain levels, and mild psychological distress. According to Sterling's WAD classification system, which subgroup best fits this patient?

WAD II (B) - Moderate pain, sensory sensitivity, and psychological impact

3 multiple choice options

predictors of prognosis for WAD? (8)

- direction of initial impact

- xray evidence of DJD and neuro signs have poorer prognosis

- headache, neck, or back pain

- no seatbelt

- high school education or less

- female

- WAD 2 or 3

- high catastrophizing

poor outcomes 6 months post injury in WAD? (5)

- higher pain >5.5

- higher disability NDI >29

- older

- cold hyperalgesia

- moderate post-traumatic stress symptoms

acute stage WAD exam? (6)

- classify by state of inflammatory process

- develops stiffness over 24-48 hours

- asses for neuro deficits and neurovascular compromise

- spasm of SCM

- more PROM than AROM

- difficult to asses joint play

acute stage WAD treatment? (3)

- allow muscle to rest without becoming stiff

- AROM of C and T spine within pain tolerance

- active mobility

subacute stage of WAD exam? (6)

- larger muscles usually healed

- more detailed exam

- deep aching pain into head, interscapular region, or upper extremity

- focal tenderness in SCM, suboccipital, DNF, multifidi

- increased AROM

- restriction of facets

subacute stage of WAD treatment? (6)

- restore flexibility to muscles and facet joints

- mobilization

- rotation in tolerance every hour

- STM

- motor control for DNF

- multifidus isometrics

chronic stage of WAD exam? (9)

- large muscle groups healed, but maybe shortened and fibrotic

- deep aching pain

- reversal of lordotic curve leading to articular instability

- suboccipital headache

- SCM hypertrophy and jaw hyperactivity

- FHP with scapular depression, abduction, and/or IR

- hypermobility of C4, C5, and C6

- capsular restriction of facets

- neuro testing negative

chronic stage WAD treatment? (6)

- restore lordosis by mobilizing into extension

- segmental strengthening of multifidus

- stretching, motor control of DNF, sensorimotor

- stretch of deep posterior neck muscles

- mobilizations

- aerobic exercise and daily activity

what happens in cervical instability when the stabilizing subsystems are unable to compensate for increased ROM?

quality of motion becomes poor and uncontrolled

contributing factors to degeneration or mechanical injury? (4)

- posture

- acute trauma

- repetitive microtrauma

- muscle imbalance

exam findings of cervical instability? (6)

- signs and systems with sustained weightbearing

- hypermobility in PIVM with loose end feel

- aberrant motion

- decreased lordosis

- radiculopathy

- greater AROM in supine than standing

consensus among OMPT of signs and symptoms of instability? (7)

- intolerance to prolonged static positions

- inability and fatigue with holding head up

- better with external support

- frequent self manipulators

- lack of control

- episodes of acute attacks

- poor coordination

treatment of cervical instability? (5)

- enhance function of stabilizing subsystems and decreasing stress

- restore cervical lordosis

- mobilize hypomobile segments

- strengthen mulitfidus and DNF

- shoulder girdle posture and strength

local effects of forward head posture? (3)

- hyperextension of subcranial

- hypomobile of upper thoracic

- hypermobile of mid cervical

faulty posture has a relationship to? (3)

- TMJ disorders

- thoracic outlet syndrome

- shoulder impingement

myofascial disorders? (3)

- guarding leads to instability and hypermobility

- muscle spasm or chemical holding

- trigger points

treatment for faulty posture and muscle imbalance? (5)

- scapular position and control

- DNF strength

- address hypomobility

- stabilization

- stretch truly short muscles

A patient demonstrates forward head posture and upper crossed syndrome during a cervical examination. Which of the following muscles is MOST likely to demonstrate weakness?

longus colli

3 multiple choice options

A 34-year-old female presents to physical therapy 4 months following a rear-end motor vehicle accident. She reports chronic neck pain, suboccipital headaches that worsen throughout the day, and a sensation that her "head feels heavy." Examination reveals forward head posture, poor deep neck flexor endurance, hypermobility at C5-C6 with a loose end-feel, and greater cervical AROM in supine compared to standing. Which of the following is the MOST likely underlying clinical presentation?

Clinical cervical instability

3 multiple choice options