MSK III Study Guide Pt.2 Lec 3, 4, 5

Cervical radiculopathy

clinical condition where motor, reflex, and/or sensory changes such as radicular arm pain, paresthesia or numbness may be present & may be provoked by neck postures and/or movements.

Radiculopathy:

weakness, numbness (loss of function) caused by problem at the nerve root

Radicular pain:

weakness, numbness (loss of function) caused by problem at the nerve root

Note: Radicular pain + radiculopathy = Painful Radiculopathy but they always don’t go

together

What are the primary causes of cervical radiculopathy?

Nerve root compression from herniated nucleus pulposus (HNP),

spondylotic/degenerative changes, or both

What are the differences between an asymmetrical disc bulge and a symmetrical disc

bulge?

Asymmetrical:

counter of outer annulus extends in horizontal (axial) plane beyond the edges of

the disc space, usually greater than 25% of the circumference of the disc

What are the differences between an asymmetrical disc bulge and a symmetrical disc

bulge?

symmetrical:

less than 3 mm beyond the edges of the vertebral body apophysis

How is disc herniation defined and categorized?

Localized (<25% circumference) displacement of disc material beyond disc space;

types include protrusion, extrusion, and sequestration

Protrusion =

annulus is still in tact

Extrusion =

annulus fibrosis is compromised; disc material extrudes through

Sequestration =

pieces of disc have broken/separated off

- How does cervical HNP affect nerve roots compared with lumbar HNP?

Cervical HNP of C5-C6 affects the nerve root at the C6 nerve root; lumbar HNP of

L4-L5 impacts L4 nerve root

What pathophysiological processes produce radiculopathy symptoms, and which cause loss vs gain of nerve function?

Mechanisms Leading to LOSS of Function (Negative Neurologic Signs):

• Mechanical compression → ischemia

• Impaired axonal transport

• Demyelination

• Axonal degeneration

• Clinical findings:

  • Weakness (myotomal)

  • Numbness (dermatomal sensory loss)

  • Hyporeflexia or areflexia

What pathophysiological processes produce radiculopathy symptoms, and which cause loss vs gain of nerve function?

Mechanisms Leading to GAIN of Function (Positive Neurologic Signs):

• Chemical irritation/inflammation of the nerve root

• Increased neural sensitivity and ectopic firing

• Clinical findings:

  • Radicular pain (sharp, shooting, electric)

  • Paresthesia/tingling

  • Hyperesthesia/allodynia

*Note: Both mechanisms often coexist in cervical radiculopathy. *

True or False: Radicular symptoms can occur without evident compression?

True because chemical irritation/inflammation alone can produce symptoms

- How does radiculopathy differ from myelopathy?

Radiculopathy = nerve root compression (LMN signs)

Myelopathy = spinal cord compression (UMN signs). However, in lumbar spine

myelopathy is a LMN issue

- What condition is a differential diagnosis of cervical radiculopathy and why?

Thoracic Outlet Syndrome due to compression of neurovascular structures at the

interscalene triangle, costoclavicular space, or subcoracoid space

*Note: Can use ROOS test or Adson’s test to assess if there is a vascular change. SPECIAL TESTS that may show up as positive are Spurling’s Test, Cervical Traction. Neurodynamic tests may show up as negative*

- What pathoanatomical diagnoses are associated with radiating neck pain?

Cervical radiculopathy, nerve root impingement, herniated disc, cervical stenosis,

stinger/burners

- What are the common symptoms of cervical radiculopathy?

Neck pain radiating pain in the involved extremity, UE dermatomal

paresthesia/numbness, and myotomal weakness. If scapular pain, then think Cloward’s sign

- How reliable are dermatomes for radicular pain?

Pain is non‑dermatomal in ~70% of cases, but numbness/tingling usually follow

dermatomal patterns

- What did Cloward’s study demonstrate?

Cervical disc pathology can produce referred pain patterns into the neck and upper

extremity.

- What do discogenic referral patterns indicate clinically?

Pain referral may not match dermatomal distributions.

- How do facet referral patterns differ from trigger point referral?

Facet joints refer pain segmentally; trigger points produce muscular referral unrelated

to nerve root patterns.

What exam findings are expected in radicular neck pain?

Symptom reproduction/relief with radiculopathy tests (ULTT1a i.e. Median N.,

Spurling’s 7kg, Cervical distraction 14kg), decreased cervical ROM, possible sensory, strength, or reflex deficits

- What is the clinical prediction rule for cervical radiculopathy?

Positive ULTT1a, (+) Spurling’s (~7 kg), (+) Cervical distraction (~14 kg), and cervical

ipsilateral rotation <60°

• 3 positives → ~65% probability

  4 positives → ~90% probability.

- What is the role and limitation of imaging for cervical radiculopathy?

CT/MRI show good sensitivity but high false positives due to common asymptomatic

abnormalities; EMG is accurate but only detects axonal damage.

- What are intervention strategies of neck pain with radiating pain by irritability level?

Acute/high:

mobility/stability exercise, low‑level laser, short‑term collar. (level C)

- What are intervention strategies of neck pain with radiating pain by irritability level?

Subacute/moderate:

CPG has not updated yet

- What are intervention strategies of neck pain with radiating pain by irritability level?

Chronic/low:

intermittent traction + strengthening & stretching + cervical & thoracic

mobilization/manipulation + education. (level B)

- What are the three core managements of neck pain with radiating pain?

Education, address the container (tissues surrounding the structures where nerve

tissue runs), address neurodynamics (can be assessed with nerve glides).

How should clinicians address patient beliefs and concerns regarding severe radicular

pain, compression mechanisms, and the need for surgery?

Validate Pain Severity & Provide Reassurance:

● Acknowledge that radicular pain can be severe, distressing, and functionally limiting

● Listen empathetically to the patient’s experience

● Explain that seriousness of pain is common and is not necessarily dangerous

● Offer short‑term relief strategies to help manage symptoms

How should clinicians address patient beliefs and concerns regarding severe radicular

pain, compression mechanisms, and the need for surgery?

Correct the “Pure Compression” Belief:

● Educate that symptoms are typically due to both compression and inflammation

● Emphasize that reducing inflammation can decrease pain and reduce the effects of

compression

● Reinforce that improvement does not always require structural changes

How should clinicians address patient beliefs and concerns regarding severe radicular

pain, compression mechanisms, and the need for surgery?

Address Concerns About Surgery:

• Explain the two components: compression and inflammation and natural history

• Discuss evidence that:

  • Surgery may provide faster short‑term relief in some cases, however long‑term outcomes are often similar to conservative management when no red flags are present

  • Help patients understand that surgery is not automatically required

- What does “address the container” mean?

Optimize cervical movement, mobility, and surrounding soft tissues to reduce

mechanical stress on the nerve root

- What does “If the pump doesn’t work…open it up!” imply clinically?

Use traction to increase space and reduce nerve root compression when movement

alone is insufficient. Can also use patient‑performed manual traction techniques to relieve

symptoms.

- What medical and supportive treatments may be used for high irritability/acute cervical radiculopathy

• Short‑term soft cervical collar (for acute symptom relief only)

• Pharmacological agents that may be prescribed:

  • Membrane stabilizers(usually chronic conditions)

  • Sodium channel–blocking anticonvulsant: phenytoin, carbamazepine, oxacarbaepine, valproic acid

  • Sodium Channel blockers/Local Anesthetics: lidocaine, mexiltine, lamotrigine

  • Calcium channel blockers: Gabapentin, pregablin, zonisamide, ziconitide, magnesium

• Steroid dose pack (usually tapered over 1 week)

• Transforaminal or epidural steroid injection to help extremity symptoms

When is a soft collar appropriate?

Short‑term use only for acute symptom relief.

- What are principles of neurodynamic management?

Active before passive, sliders before tensioners, avoid excessive stress due to neural

sensitivity.

- How can the container be addressed mechanically?

Through manual therapy, exercises, traction, and mobility interventions to improve the

nerve’s environment

- Why is cardiovascular exercise important?

Nerves require adequate blood supply (“nerves are blood‑thirsty”); aerobic activity

supports neural health and recovery

What is the typical recovery pattern and chronicity risk for Whiplash Associated Disorder (WAD)?

• Most individuals do not experience symptoms or seek care

• Of those who do seek care:

  • About 1/2 recover within 3 months

  • About 1/3 develop chronic symptoms

  • Of those with chronic symptoms, about 1/3 are severe

• Some individuals continue disability even at 1 year

What is the main takeaway regarding upper cervical ligamentous disruption in a patient with persistent whiplash associated disorders?

deep upper cervical injuries (alar, transverse, tectorial membrane) may be underdiagnosed contributors to persistent whiplash symptoms. Imaging and assessment is supported when someone has pain lasting years after whiplash, persistent instability or “clunk” sensations, and dizziness or non-specific neurologic ℅

- What are the common symptoms associated with WAD?

• Mechanism of onset linked to trauma or whiplash

• Referred scapular or upper extremity pain

• Varied nonspecific concussive signs & symptoms:

  • Dizziness

  • Nausea

  • Headache

  • Concentration difficulties

  • Memory difficulties

  • Confusion

• Hypersensitivity to stimuli:

  • Mechanical

  • Thermal

  • Acoustic

  • Odor

  • Light

Heightened affective distress (i.e. ersonality changes & conflicts between external stressors of life and internal needs)

- What is the Quebec Task Force (QTF) Classification for WAD?

Grade 0:

● No neck pain

● No mechanical signs

- What is the Quebec Task Force (QTF) Classification for WAD?

Grade 1:

● Neck pain, stiffness, or tenderness only

● No mechanical signs

- What is the Quebec Task Force (QTF) Classification for WAD?

Grade 2:

● Neck pain AND mechanical signs

- What is the Quebec Task Force (QTF) Classification for WAD?

Grade 3:

● Neck pain AND mechanical signs AND neurological signs

- What is the Quebec Task Force (QTF) Classification for WAD?

Grade 4:

● Neck pain AND fracture or dislocation

What prognostic indicators are NOT related, related to worse outcomes, or have

conflicting evidence in WAD?

NOT related to outcome:

● Speed of impact

● Direction of impact

● Head restraint

● MRI findings

What prognostic indicators are NOT related, related to worse outcomes, or have

conflicting evidence in WAD?

Related to worse outcome:

● Prior neck trauma

● Higher initial pain (> 5.5/10)

● Anxiety

What prognostic indicators are NOT related, related to worse outcomes, or have

conflicting evidence in WAD?

Conflicting evidence:

● Preinjury psychological factors

● Preinjury pain

● Age

● Gender

● Education level

What cervical examination tests are recommended for each neck pain classification, and which are specific to movement coordination impairments?

Mobility Deficits:

● AROM

● Cervical Flexion-Rotation Test

● Cervical & thoracic segmental mobility

What cervical examination tests are recommended for each neck pain classification, and which are specific to movement coordination impairments?

Radiating Pain:

● Neurodynamic tests

● Spurling’s test

● Distraction test

● Valsalva test

What cervical examination tests are recommended for each neck pain classification, and which are specific to movement coordination impairments?

Headache:

● AROM

● Cervical Flexion-Rotation Test

● Upper cervical segmental mobility

What cervical examination tests are recommended for each neck pain classification, and which are specific to movement coordination impairments?

Movement Coordination Impairments (WAD):

● Cranial Cervical Flexion Test

● Neck Flexor Endurance Test

What outcome measures are recommended for neck pain, and what might additionally be considered for WAD?

Recommended for neck pain:

● Neck Disability Index (NDI); MCID = 7

● Patient-Specific Functional Scale (PSFS); MCID = 2

What outcome measures are recommended for neck pain, and what might additionally be considered for WAD?

Additional considerations for WAD:

● Measures addressing psychosocial factors

● Tools for individual functional limitations

What are the expected examination findings for neck pain with movement coordination

impairments?

● Positive cranial cervical flexion test

● Positive neck flexor endurance test

● Positive pressure algometry (tests pain pressure threshold)

● Decreased neck muscle strength and endurance

● Neck pain during mid-range motion that worsens at end range

● Soft tissue tenderness and trigger points

● Altered muscle activation patterns

● Proprioceptive deficits

● Postural balance/control impairments

● Segmental joint assessment produces neck and referred pain

What intervention strategies are recommended based on irritability/prognosis stages (2017 CPG)?

Acute / Quick Recovery:

● Education: remain active

● Reassurance: recovery expected within 2–3 months (Level B)

● HEP: pain-free cervical ROM + postural exercises (Level B)

● Monitor progress for need of pain education (Level F)

● Minimize soft collar use (Level B)

What intervention strategies are recommended based on irritability/prognosis stages (2017 CPG)?

Subacute / Prolonged Recovery:

• Education: activation & counseling

• Combined exercises:

  • Cervical AROM

  • Low-load isometric strengthening

• Manual therapy (mobilization/manipulation; consider waiting > 4 weeks)

• Physical agents: ice, heat, TENS

• Supervised exercise:

  • AROM

  • Stretching

  • Strengthening

  • Movement coordination exercises

What intervention strategies are recommended based on irritability/prognosis stages (2017 CPG)?

Chronic:

• Education: prognosis, encouragement, reassurance, pain management (Level C)

• Cervical mobilization + individualized progressive exercise:

  • Low-load cervicoscapulothoracic strengthening

  • Endurance

  • Flexibility

  • Functional training using CBT principles

  • Vestibular rehabilitation

  • Eye-head-neck coordination

• TENS (Level C)

What MDT/McKenzie acute-stage recommendations are provided for neck pain with

movement coordination impairments?

Acute stage:

● Education on role of movement in healing

● Posture correction

● Exercises every 1–2 hours, progressing ROM

● Regular movement is more important than order

What MDT/McKenzie acute-stage recommendations are provided for neck pain with

movement coordination impairments?

Suggested movement order:

1. Retraction & Rotation

2. Lateral flexion

3. Extension (general)

4. Flexion (general)

What MDT/McKenzie acute-stage recommendations are provided for neck pain with

movement coordination impairments?

Chronic stage:

● Traditional MDT using graded exposure

- What specific movement is emphasized for MDT acute-stage treatment?

● Cervical rotation with retraction exercises (supine, seated, C1-C2 snags, open books)

● Multisegmental movement patterns may be used

- What movement is emphasized next in MDT acute-stage progression?

 Lateral flexion exercises (think trap stretch movements)

What movement and stretching components are emphasized next for MDT acute-stage progression?

● Cervical extension exercises (thoracic extension, bird dogs, etc.)

● SCM stretching

- What final movement direction is included in MDT acute-stage exercises?

● Cervical flexion exercises (chin tucks, rock backs with chin tucks)

● Levator scapulae stretch

● Upper trapezius stretch

- What types of exercises are included under force/load training?

prone bilateral/unilateral I’s, T’s, Y’s, planks, unilateral/bilateral rows, ½ kneeling trunk

rotations, seated farmer carry

- What additional components must not be overlooked in rehabilitation?

● Cardio / aerobic conditioning

● Examples include treadmill, elliptical, cycling

- What is Thoracic Outlet Syndrome (TOS) and where can compression occur?

● TOS involves compression of neurovascular structures: nerve, artery, vein

● Three potential compression sites:

1. Interscalene triangle

2. Costoclavicular space

3. Pectoralis minor (subcoracoid) space

Compression of the interscalene triangle can be due to:

- Hypertrophy of scalenes

- Elevated, depressed, or broken 1st rib

- stiff/shortened pec minor

- Fracture or depression of clavicle

- What tests can be performed for Thoracic Outlet Syndrome (TOS)?

ROOS, Adson, Wright, Allen’s, and Eden’s Test. Most of these tests are vascular,but

there are limitations

ROOS, Adson, Wright, Allen’s, and Eden’s Test. Most of these tests are vascular,but

there are limitations Limitations include:

○ Only 1–2% of TOS is arterial

○ 2–3% is venous

○ MRI is not helpful

○ EMG has a high false-negative rate

Important Note: Testing should NOT be used as a stand-alone diagnostic tool

- If vascular tests are limited, how should TOS be evaluated clinically?

• First rule out cervical radiculopathy

• Use Upper Limb Tension Tests (ULTT) for:

  • Median nerve

  • Radial nerve

  • Ulnar nerve

• In TOS:

  • Opening/traction movements often worsen symptoms

- What mobility-focused management strategies are recommended for TOS?

Goal:

Improve the neurovascular container

- What mobility-focused management strategies are recommended for TOS?

interventions:

• Mobilize the upper thoracic spine & ribs, especially the first rib

  • Use a narrow strap if performing self-mobilization (example = 1st rib stretch)

  • Avoid excessive scapular depression

• Address tight structures:

  • Pectoralis minor release/stretch

  • Scalene release

• Perform Neurodynamic techniques

What types of muscle activation/movement coordination is focused on for the

management of TOS?

muscle activation/ movement coordination of the deep cervical flexors, upper and lower trapezius, serratus anterior, diaphragmatic breathing, and promoting UPWARD rotation of the scapula; do not instruct the patient to put the scapula “down and back”

- How should force load intolerance be managed in patients with TOS?

through unloading and reloading-graded exposure

Unloading phase:

a. b. Support UE in scapula elevation

Inform patient that tingling is good

Reload-Graded Exposure:

a. Increase brachial plexus tolerance

b. Incorporate the LE

- What multidimensional factors contribute to persistent TOS symptoms?

● Central / nociplastic mechanisms

● Nociceptive mechanisms

● Neuropathic mechanisms

● Cognitive/emotional factors

● Contextual factors

● Comorbidities

Patients may present with chronic symptoms influenced by multiple systems.

- What are the statistics regarding surgery in those with THOS?

70% resolve with conservative management, but surgery is needed if there is no improvement after 6 months. Surgical interventions are performed through a supraclavicular or transaxillary approach and includes:

● Resection of the 1st rib

● Resection of the cervical rib

● Resection of the fibrous bands

● Resection of the scalenes

- What are the characteristics of thoracic compression fractures?

• Wedge-shaped vertebral deformity

• Common in:

  • Older females

  • Osteopenia or osteoporosis

• May be asymptomatic

• Pain typically reduces within 2–12 weeks

- How are thoracic compression fractures managed conservatively?

1. Patient education:

● Avoid thoracic flexion

● Importance of activity

- How are thoracic compression fractures managed conservatively?

2. Exercise:

● Postural training

● Strengthening

● Balance exercises

● Encourage thoracic extension

● Encourage weight-bearing

- How are thoracic compression fractures managed conservatively?

3. Other interventions:

● TLSO brace for 4–6 weeks if needed

● Vertebroplasty/kyphoplasty in ~15% of patients

How is scoliosis named?

based upon the location of curve (lumbar/thoracic) and direction/side of convexity

- What are the types of scoliosis?

thoracic scoliosis, lumbar scoliosis, thoracolumbar scoliosis, combined scoliosis

Thoracolumbar scoliosis = 

both going in same direction

Combined scoliosis

going in opposite directions

- What are the major age-related types of scoliosis?

- Idiopathic Adolescent Scoliosis (IAS)

- Adult Scoliosis

- What 3 types can scoliosis be classified as?

1. Congenital

2. Neuromuscular

3. Idiopathic

- What degree % indicates scoliosis and what is the most common?

> 10 degrees, right side more common than left

- How is scoliosis measured using the Cobb method?

• Draw lines parallel to end plates of:

  • Uppermost tilted vertebra

  • Lowermost tilted vertebra

• Angle between lines = Cobb angle

What test is used to identify idiopathic adolescent scoliosis (IAS) and how is it

conducted?

Forward Bend Test:

a.Patient performs full trunk flexion

b. Positive tests indicates a posterior rib hump or lumbar bulge on the side of convexity

- How is IAS managed based on Cobb angle severity?

● 10–25° → Mild

● <30° → Conservative care

● 25–29° → Possible orthosis (bracing)

● 40° → May require spinal fusion

Severe curves may:

● Impair breathing

● Lead to restrictive pulmonary issues

- What are the effects and recommendations for bracing in IAS?

● Prevents curve progression (does NOT correct curve)

● Can reduce pulmonary function and trunk muscle endurance

● Some recommend up to 23 hours/day (not always necessary)

IMPORTANT NOTE: Bracing doesn’t correct IAS, it only limits the rate of progression

- What exercises can be performed for IAS management?

● Strengthening the convex side if asymmetrical

● Stretching the concave side if asymmetrical

● Movement coordination

● Functional training

What is the Postural Restoration Institute (PRI) theory?

Asymmetries of thoracic organs and diaphragm produce asymmetric spinal and pelvic

forces

Exercises emphasize activation of:

● Left abdominal obliques

● Left adductors

● Right gluteus maximus

● Diaphragm

Important note: Currently no supporting evidence