PT 606-608 FINAL

The percentage of patients who report ongoing pain and disability 12 months post-whiplash injury is:

50%

Common sxs of WAD

- MOI linked to trauma or whiplash

- referred shoulder girdle/UE pain

- nonspecific concussive sxs

- dizziness and nausea

- headache, concentration, memory difficulties, confusion

Exam findings for WAD

- (+) cranial cervical flexion test

- (+) neck flexor endurance

- (+) pressure algometry

- strength/endurance deficits

- neck pain w mid range and worsens w/ end range

- postural balance/control/proprioceptive deficit

Early evidence suggests that factors associated with poor recovery post-WAD include:

a. Pain catastrophizing

b. Poor coping strategies

c. Fear avoidance behavior

d. All of the above

All of the above!

The following factors have no impact on prognosis

a. Direction of impact

b. Presence of a headrest

c. Awareness of impending collision

d. All of the above

d. All of the above

(this is stupid. and i disagree.)

(T/F) Positive expectations of recovery are associated with less pain and disability

True

Which of the 6 red flags are most relevant after MVA?

Fracture

Cervical instability

CAD

What changes might we expect to see on the radiograph post-whiplash injury

- loss of lordosis (muscle guarding, large/uncontrollable ROM, muscles spasm)

- Hyperflex/extend

- Abnormal Alignment

- Soft tissue swelling

After pain, the most common complaint(s) associated with chronic whiplash is/are:

Dizziness and Unsteadiness

Pt reports dizziness with R Cx rot. R rot with eyes closed improves the patient symptoms. This finding strengthens the case for which system(s)?

Visual system

The movement coordination impairment classification is diagnosed by

history and subjective information

examining osteo and arthrokinematics

Whiplash-associated disorders (WAD)

- Sxs arising from rear or side impact (predominantly MVA)

- Acceleration-deceleration mechanism for energy transfer to the neck

- 50% fully recover, other half have persistent symptoms

Cervicogenic dizziness defined as:

c/o lightheaded, unsteady, off balance

Impact MVCs

Factors that DO NOT affect prognosis

- Angular deformities of the neck

- Impact direction

seating position in the vehicle

- awareness of impending collision

- headrest in place at the time of the collision

- stationary or moving when hit

- older age

Quebec task force grades of WAD

Grade I (least)

Grade II

Grade III

Grade IV (severe)

Grade I Quebec task force WAD

no physical neck.upper back signs

Grade II Quebec task force WAD

Neck/upper back musculoskeletal signs

- decreased ROM

- point tenderness

Grade III Quebec task force WAD

Neck/upper back neurological signs:

- decreased reflexes

- decreased sensation

- decreased strength

Grade IV Quebec task force WAD

Neck/upper back fracture/dislocation

What Quebec grade is most common

WAD II is most common

- subgroup is very broad

Sterling 2004 classification

Differences in physical and psychological impairments (recovered v persistent pain/disability)

- accounts for motion, sensory, and psychological dysfunction

Recovery trajectories classifications

Mild

Moderate

Severe Disability

Yellow flags in WAD

headache

arm pain / paresthesia

head injury

neck OA

prior affective/poor coping strategies, catastrophizing

job, family, finances

RIsk factors for persistent problems

- High pain intensity

- High self-report disability

(greatest prognostic value)

Alar ligament and upper cervical instability

Hx: trauma, RA, down's

AROM: cord sx (worse in flex)

Tests: alleviate/provoke

Neuro: cord signs

Alar ligament Origin and Insertion

O: lateral side of Upper part of dens

I: medial side of occipital condyles

Transverse ligament Origin and Insertion

O: medial aspect of the lateral masses of C1

I: dens of axis (C2)

Spinal cord compression (due to upper cervical (structural) instability

- Clumsy gait, loss of dexterity

- paresthesia worsens w/ AROM flexion

- neuro signs of myelopathy

- sensory disturbance b/l

- b/l UE weakness

- hyper- DTR

- incontinence

Cervicogenic dizziness (swivel stool test)

- Seated on stool, swivel back and forth => dizzy?

- eyes closed, improves = visual

- remains the same, hold head, rotate body = vestibular

- if closing/open eyes, head held/not does not improve sxs, test for cervical afference (proprioceptive)

rule in/our swivel test

- Visual = close eyes (eliminate)

Visual out, still dizzy = rule out

- Vestibular = keep head still

Vestibular out, still dizzy = rule out

- Cervical = separate test (laser)

true vertigo

patient reports self spinning or environment spinning

cervicogenic dizziness (vs vertigo)

- onset soon after trauma

- Pt. c/o disorientation or vague dizziness

- exacerbated by neck movement or pain

- relief associated with relief of neck pain

Cervical position sense training

- head-mounted laser

- outside target = altered cervical proprioception

- overshoot neutral

Determination of stage: acute, subacute, chronic

acute: high irritable, pain at rest or w initial movement

subacute: mod. irritability, pain with mid-range, worse w/ end range

chronic: low degree of irritability, pain worsens with end range (sustained) or overpressure into resistance

what do we do for each stage- acute

- Education

- HEP

- monitor progress

- minimize collar use

what do we do for each stage- subacute

- education

- exercise (add manual + physical agents)

- supervised exercise (postural coordination+ stabilize)

what do we do for each stage- chronic

- education

- manual therapy + exercise

Exercise! towel snags

cross your arms across your chest and grab the towel

- stabilize with one hand, mobilize and twist with the other

what else could cause WAD

bicycle, skiing, etc (trauma)

- Most common: rapid deceleration and what the spine does in response

Alar ligament test

passive bending of upper cervical spine

- pulling alar ligament forward

- when taut = palpate C2, can feel it move to the other side

Sxs of Instability

- Intolerance to prolonged static postures

- fatigue and inability to hold head up

- better w/ external support

- need for self-manip

- feeling of instability/lack of control

- acute attacks

- sharp w/ sudden movement

neck skin crease

hypermobility @ creases

hypomobility above and below

aberrant motion

movement that deviates from the typical or expected movement pattern

- associated with low back dysfunction or instability

myofascial pain

chronic

tension

prolonged posture

tenderness of muscle

trigger points

pain with stretch

Upper crossed syndrome

stabilizers: weak, hypOtonic, inhibited

Movers: tight, hypERtonic, facilitated

Upper crossed syndrome pic

Common muscles (upper crossed) shortened/tight/overactive

Upper Trapezius

Levator Scapulae

Sternocleidomastoid (SCM)

Pectoralis Major & Minor

Suboccipitals

Common muscles (upper crossed) lengthened/weak/inhibitied

Deep Cervical Flexors (longus colli and longus capitis)

Lower Trapezius

Serratus Anterior

Rhomboids

Middle Trapezius

neck flexor muscle endurance test

maximal cervical retraction (chin tuck)

- raise head 1-2 inch. off bed and hold

W/o neck pain: 39s

W neck pain: 24s

cranial cervical flexion test

cuff under upper cervical spine, inflate to 20 mmhg

- tongue to roof of mouth, lips together, teeth apart

STAGE I

- nod to 22,24,26...30 w/ 2-3 second hold (ensure pt. can perform test)

STAGE II

- repeat each lvl. with 10 second hold, 3 reps at each level, 10 s rest between each level

What is the baseline for the cranial cervical flexion test

the highest level that the patient can hold for 3x10 seconds

cervical position sense training (JPE)

head-mounted laser

- pt stands/sits 35 inches from the target

(+) impairment = any error in the test (red or off the paper)

*ONLY 1 ERROR NEEDED TO FAIL THE TEST*

Functional Instability is Diagnosed by

A. History and subjective information

B. Examining osteo- and arthrokinematics

C. Radiographs

D. A and B

E. All of the Above

A and B

history and subjective information and examining osteo/arthrokinematics

Aberrant motion describes

a. Sudden accelerations with movement

b. Sudden decelerations with movement

c. Motion that is outside of the intended plane

d. All of the above

All of the above

progression for JPE (laser)

progression: standing, foam pads under feet

Regression: smaller ROM (dont turn to max rotation), eyes opened then eyes closed (alt. sets)

progression to deep neck flexor endurance test and exercise

progress: add conjunctive exercise, chest on yoga ball + chin tuck, chin tuck + ITY, chin tuck + row

regression to deep neck flexor endurance test and exercise

raise head of bed (less distance to travel)

Disability index in relation to outcomes

Lower = get better sooner (3-6 months)

Higher (+ older, + fearful) = progress into chronic pain

Integration of primitive reflexes, such as the Asymmetrical Tonic Neck Reflex, is essential for the emergence of head control. (T/F)

TRUE

Plagiocephaly could be best described as:

a. Unilateral shortening of the sternocleidomastoid

b. Cranial flattening due to mechanical forces

c. Premature closure of cranial sutures

B- cranial flattening due to mechanical forces

(A= CMT, C= cranial stenosis)

Cranial Stenosis

premature fusion of fontanelles and cranial sutures can lead to cranial vault abnormalities

CMT

unilateral shortening of the SCM

ex: left-sided shortening, the child shows lateral flexion toward the shortened side and rotation to the opposite

All of the following are associated with a higher risk of CMT, except:

a. Cephalic position (Head first)

b. Longer birth body length

c. Primiparity (1st time giving brith)

d. Family history

a- cephalic position (head first is typical)

The physical therapy intervention for CMT is should primarily focus on the stretching and strengthening of the sternocleidomastoid muscle. (T/F)

False

- should focus on stretching and parent education, not strengthening

Current evidence for CMT management is primarily derived from clinical expertise or opinions rather than actual research. (T/F)

False

Asymmetrical tonic reflex (ATNR)

*Primitive reflex*

- fencers position

- onset ~ 37 wk

- integrated ~4-6 mo.

Extension of the arm and leg on the "face" side

Flexion of the arm and leg on the skull side

Craniosynostosis

Premature closure of cranial structures or fontanelles

- cranial asymmetry

Fontanelle closure (A,P,AL, PL)

Anterior: 12-26 month

Posterior: 1-2 month

Anterolateral (sphenoidal): 2-3 month

Posterolateral (mastoid): 12-18 month

Clinical relevance of fontanelle closure

- they are soft and flexible, allow for easy delivery

- can put infant at risk for skull fracture

ex: forceps used during deliver, head trauma post birth (MVA, mishandling)

Head control development, birth-6 months

Birth: limited capacity

2 month: hold head in midline

3 month: can hold neck vertically for long periods, can visually track

4-6 month: head in line w body when moved from supine to sit (pull-to-sit task)

Pull-to-sit test

Newborn: complete head lag

3 months: slight lag

4-6 months: no lag

> 6 months: lift head spontaneously and repeatedly in anticipation

Congenital muscular torticollis (CMT)

wry neck, twisted neck

- unilateral shortening of SCM

- lateral neck flexion to one side and rotation to others

Congenital muscular torticollis (CMT) accompanied by other conditions:

cranial deformity

developmental

dysplasia (hips)

Brachial plexus injury

Etiology of CMT

excessive fibrosis, hyperplasia, and atrophy of SCM

(some have palpable fibrotic nodule = more severe than w/o)

Risk factors for CMT

prenatal: intrauterine crowding, malposition, ineffective myositis

perinatal: breech, forceps used during delivery

postnatal: positional preference, cranial deformity

*history of CMT in family, primiparity, longer birth length

Prognosis CMT

PT before 3 month = excellent prognosis = greater tolerance to stretching before voluntary head control development

Positive prognostic factors CMT

- participation in PT

younger @ initiation

- decrease difference in PROM b/w L and R sides

- decreased difference in SCM thickness b/w L and R

- caregivers adherence to HEP

Negative prognostic factors for CMT

- motor asymmetry

- older age at initiation

- restriction of PROM or increased severity of head tilt

- increased thick/stiff SCM

- SCM mass

- low birth weight, breech

PT Exam for CMT

- infants posture: supine, sit, prone, stand

- look @ asymmetries

- positional preference

- PROM

- AROM

- strength + endurance

PT intervention for CMT

- manual stretching

- AROM neck and trunk

tummy time (assisted or independent)

- parent education

Discharge/discontinue PT CMT

- passive neck ROM within 5 degrees of the non-affected side

- no visible head tilt

- age-appropriate motor development

- symmetrical active movement patterns

- caregivers understanding/monitor adherence to exercise

Measurement of infant strength and motor control of the head and neck using MFS

trigger points

hyperirritable spots in skeletal muscle that are associated w/ palpable nodules and taut bands of muscle fibers

latent trigger point

non-constant, provoked w/ palpation

active trigger points:

provoked when touched, compressed, etc.

can be spontaneous

referred pain

characteristic of trigger points

tender spot in muscle

tense band of muscle

decreased stretch

referred pain w palpate

sweating, vasoconstrict

interventions for trigger points

direct pressure application w/w/o PROM,AROM,stretch

- enough pressure to reproduce sxs

- 10 sec-1 min of pressure

- release, add passive stretch, active contraction

- ice/heat

-dry needling

- injection

which of the following anterior muscles is commonly inhibited in persons presenting with neck pain

Longus coli

longus capitus

which of the following muscles are commonly tight in persons with neck pain

pectoralis major and minor

Providing equitable care begins with using the correct terminology. Gender identity is:

a) The patient's internal sense of who they are

b) Is assigned at birth

c) Is aligned with gender expression

d) All of the above

A- the patient's internal sense of who they are

While many have different feelings about the term microaggression, this term is commonly used to describe:

a) verbal, behavioral, and environmental indignities

b) can be overt or subtle

c) Are consistently intentional slights that target a person or group

d) All of the above

e) A & B

A and B

- verbal, behavioral, and environmental indignities that can be overt or subtle

If you commit a microaggression, you should

a) Identify the harmful behavior

b) Focus on the intent of the behavior rather than the impact

c) Create a plan to change behavior

d) All of the above

e) A & C

A and C

- identify the harmful behavior and create a plan to change

To manually stretch the R upper trapezius, the therapist would position the patient's neck in slight flexion, L SB and ...

a) Slight L rotation with overpressure on the acromion

b) Slight R rotation with overpressure on the acromion

c) Slight L rotation with overpressure on the spine of the scapular

d) Slight R rotation with overpressure on the spine of the scapular

b) Slight R rotation with overpressure on the acromion

Acting unilaterally, contraction of the right sternocleidomastoid results in:

a) Right cervical side bending and left rotation

b) Left cervical side bending and left rotation

c) Right cervical side bending and right rotation

d) Left cervical side bending and right rotation

a) Right cervical side bending and left rotation

Which prominent muscle of the anterolateral neck attaches to the mastoid process?

a. upper trap

b. lev. scap

c. sternocleidomastoid

d. mylohyoid

c. sternocleidomastoid

Patients categorized as having non-traumatic neck pain with movement coordination impairments often present with a pattern of muscle imbalance known as "upper crossed syndrome". All of the following is characteristic of upper crossed syndrome, EXCEPT:

a) Shortened, hypertonic suboccipital muscles with weakened, hypotonic longus coli muscles.

b) Shortened, hypertonic upper trapezius muscles with weakened, hypotonic levator scapula muscles

c) Shortened, hypertonic pectoralis major and minor muscles with weakened, hypotonic serratus anterior muscles

d) Shortened, hypertonic sternocleidomastoid muscles with weakened, hypotonic lower trapezius muscles

b) Shortened, hypertonic upper trapezius muscles with weakened, hypotonic levator scapula muscles

According to Childs et al (2004), all of the following statements are true of patients in the "Conditioning and Increased Exercise Tolerance" category, EXCEPT:

a. While strengthening and endurance training for some upper trunk muscles is often helpful for patients in this category, clinical experience suggests that there is no additional benefit from specific stretching of shortened muscles in the upper trunk or shoulder girdle.

b. Patients in this category are often characterized by lower disability and pain scores and a longer history of neck symptoms.

c. Patients in this category often do not present with significant limitations during examination of active range of motion.

d. Many patients in this category are regarded as having ''clinical instability'', meaning that they may have segmental hypermobility and poorly controlled or aberrant patterns of movement

a. While strengthening and endurance training for some upper trunk muscles is often helpful for patients in this category, clinical experience suggests that there is no additional benefit from specific stretching of shortened muscles in the upper trunk or shoulder girdle.

Based on Rebbek (2017) therapists should select exercises for patients with whiplash and associated disorders absed on

a. the presence of a specific impairment

b. symptom responsiveness

c. the absence of pain

d. A and C

e. A and B

A and B

- presence of a specific impairment and the symptom responsiveness

After pain, the most common complaint(s) associated with chronic whiplash is/are:

a. loss of active ROM of the cervical spine

b. dizziness

c. unsteadiness

d. B and C

B and C

- dizziness and unsteadiness