NMS 1 - Exam 2 Part 2: Cervical & Upper Extremity ROM

When we report findings, do we as chiropractors report impairment or disability?

Impairment!

NOTE: disability is their ability to perform their "work", we assess their "function"

What tool is used to test cervical ROM (Flexion, Extension, Lateral Flexion, Rotation)?

Inclinometer ONLY

How do you perform the CROM Flexion? (5)

1) Place Inclinometer on top of head and 0 it out

2) Patient flexes cervical spine & read degrees

3) Place Inclinometer at C7/T1 interval and 0 it out

4) Patient flexes cervical spine & read degrees

5) Subtract the reading from C7/T1 from the reading of top of the head

What is the average degree for CROM Flexion?

60 degrees

How do you perform the CROM Extension? (5)

1) Place Inclinometer on top of head and 0 it out

2) Patient extension cervical spine & read degrees

3) Place Inclinometer at C7/T1 interval and 0 it out

4) Patient extension cervical spine & read degrees

5) Subtract the reading from C7/T1 from the reading of top of the head

What is the average degree for CROM Extension?

75 degrees

How do you perform the CROM Lateral Flexion? (5)

1) Place Inclinometer on top of head and 0 it out

2) Patient lateral flexes cervical spine (R or L) & read degrees

3) Place Inclinometer at C7/T1 interval and 0 it out

4) Patient laterally flexes cervical spine (same as above) & read degrees

5) Subtract the reading from C7/T1 from the reading of top of the head

REPEAT w/ other side lateral bend

What is the average degree for CROM L or R Lateral Flexion?

45 degrees

How do you perform the CROM Rotation? (3)

1) Patient lies SUPINE

2) Place one Inclinometer on forehead and 0 it out

3) Patient rotates cervical spine (R & L) & read degrees

What is the average degree for CROM L & R Rotation?

80 degrees

What is the average degree of Shoulder Flexion & Extension ROM?

Flexion = 180

Extension = 50

How do you perform the Shoulder Flexion & Extension ROM? (4)

1) Patient seated w/ arms in anatomical position

2) Place inclinometer on upper arm and 0 it

3) Patient flex arm; Read degrees

4) Return to starting position, then have patient extend arm and read degrees

What is the average degree of Shoulder Abduction & Adduction ROM?

Abduction = 180

Adduction = 50

How do you perform the Shoulder Abduction & Adduction ROM? (4)

1) Patient seated with arm in anatomical position

2) Place on upper arm and 0 out

3) Have patient abduct arm and read degrees

4) Return to starting position, then have patient adduct arm an dread degree

What is the average degree of Shoulder Internal & External Rotation ROM?

Internal & External = 90 degrees

How do you perform the Shoulder Internal & External Rotation ROM? (4)

1) Seated w/ arm abducted to 90 and elbow flexed to 90

2) Place on upper arm and 0 out

3) Have patient externally rotate the arm and read degrees

4) Return to starting position then have patient internally rotate the arm and read degrees

What is the average degree of Elbow Flexion & Extension ROM?

Flexion = 140-150

Extension = 0-10

How do you perform the Elbow Flexion & Extension ROM? (4)

1) Patient seated with arm in anatomical position

2) Place inclinometer on forearm and 0 it out

3) Patient flex forearm and read degree

4) Return to start, then have patient extend forearm and read degree

NOTE: you can place arm on table supported to the elbow

What is the average degree of Elbow Supination & Pronation ROM?

Supination & Pronation = 90

How do you perform the Elbow Supination & Pronation ROM? (4)

1) Patient seated w/ forearm flexed to 90 thumb up

2) Patient holds inclinometer w/ thumb up and 0 it out

3) Have patient supinate the forearm and read degree

4) Patient pronate the forearm and read degree

What is the average degree of Wrist Flexion & Extension ROM?

Flexion = 90

Extension = 70

How do you perform the Wrist Flexion & Extension ROM?

1) Patient seated w/ elbow at 90 and wrist in neutral position

2) Place on dorsal aspect of hand and 0 out

3) Have patient flex wrist and read degree

4) Return to start, then have patient extend wrist & read degree

NOTE: forearm can be placed on a tabletop supported up to the wrist

What is the average degree of Wrist Radial & Ulnar Deviation ROM?

Radial = 20

Ulnar = 55

How do you perform the Wrist Radial & Ulnar Deviation ROM? (4)

1) Patient seated w/ elbow fully flexed

2) Inclinometer in fingers pointing up and 0 it out

3) Have patient ulnar deviate the wrist and read degree

4) Return to starting position and have patient radially deviate wrist & read degree

What is Rusts sign?

Patient spontaneously grasps head w/ both hands

(POSITIVE sign)

What does Rust's Sign suggest?

Severe upper cervical (atlantoaxial) instability'

(X-ray patient before any other tests)

What procedure is when the examiner applies thumb pressure to the mastoid process until it becomes noticeably uncomfortable?

Libman's Sign

What does Libman's Sign demonstrate?

Threshold for pain

(Unusually low or normal)

NOTE: Useful for interpretation of palpation findings in later exams

What test is placing the palms on the top of the head and seeing if there are any increase or decrease in symptoms?

Bakody Sign

What Bakody Sign is when the radiating pain is lessened or disappears? What does this indicate?

Positive Bakody

Indicates nerve root encroachment

What Bakody Sign is when the pain is exacerbated? What does this indicate?

Positive Reverse Bakody

Indicates thoracic outlet syndrome from interscalene compression

What Bakody Sign is no change in the pain?

Negative Bakody

What sign is when you abduct the shoulder to 90 degrees then extend the elbow? What does this stress and what can this indicate?

Bikele's Sign

Stresses brachial plexus

-- pain will be radicular in nature if brachial plexus is irritated

How do you perform the Brachial Plexus Tension Test? (2)

1) Abduct both shoulders to 90 degrees & place hands behind head

2) Pull elbows back

The Brachial Plexus Tension Test will stress the brachial plexus, and can result in what response if there is irritation of the brachial plexus?

Radicular pain

What is the Valsalva Maneuver?

Ask patient to take a deep breath in and hold while bearing down (like a bowel movement)

What is an abnormal result for Valsalva Maneuver? What may this be due to?

Increased in pain

-- Increased intrathecal pressure & caused by space occupying lesions

What sign is when the procedure, coughing, sneezing, and straining during defecation may cause aggravation of the radiculitis symptoms?

Dejerine's Sign (Triad)

What can Dejerine's Sign be due to?

Mechanical obstruction (space-occupying lesion; SOL)

How do you perform the swallowing test? What is a positive result for this test?

Instruct the patient to swallow some water

-- Pain or difficulty swallowing

If the patient has pain/difficulty swallowing during the swallowing test, what could this indicate? (3)

SOL (space occupying lesion)

Ligamentous sprain

Muscular Strain

How do you perform the Naffziger test?

1) Occlude external jugular vein for 10-15 seconds

2) Ask patient to cough

With the Naffziger test, there is an increase in the intra-thecal pressure, and you may have a sharp pain at the level of what?

The level of the lesion

What are the 5 red flag symptoms of Cerebral Vascular Ischemia?

1) Neck pain/stiffness

2) Headaches

3) Dizziness/Vertigo

4) Nausea/Vomiting

5) Diplopia

T/F: If symptoms are present, regardless of examination findings, assume VBI and refer out.

TRUE

-- refer for possible pending strokes

-- manipulation should NOT be performed until vascular tests have been investigated

How do you perform the Barre-Lieou Sign?

Patient slowly rotates head from side to side (compresses vertebral arteries)

NOTE: symptoms of vertigo, dizziness, visual disturbances, nausea, syncope, nystagmus = positive

How do you perform the VBI Functional Maneuver?

1) Palpate & auscultate carotid & subclavian arteries for pulsations/bruits

2) Instruct patient to rotate & hyperextend head to one side, hold/count for 20 seconds. & observe for nystagmus. Repeat on other side

NOTE: symptoms of vertigo, dizziness, visual disturbances, nausea, syncope, nystagmus = positive & indicates ischemia

How do you perform the Deklyn's Test?

1) Supine w/ head off table

2) Pt rotates & hyperextends head to one side (15-45s) observing eyes for nystagmus or until symptoms

3) Repeat

NOTE: symptoms of vertigo, dizziness, visual disturbances, nausea, syncope, nystagmus = positive & indicates ischemia

What test is an exerted upward pressure on the patients head, lasting for 30-60 seconds?

Distraction Test

An increase in pain during distraction test indicates what?

Muscle spasm

A decrease in pain during distraction test indicates what?

Intervertebral foraminal encroachment or facet capsulitis

An initial decrease in pain but then an increase in pain during distraction test indicates what?

Facet capsulitis

What are the 6 tests included in the Cervical Foraminal Compression Test?

1) Active ROM (impairment rating)

2) Passive ROM (most important)

3) Foraminal Compression Test

4) Jackson Compression Test

5) Maximum Cervical Compression Test

6) Spurling's Test

How do you perform the Foraminal Compression Test?

1) Actively rotates head from side to side

2) Exert strong downward pressure w/ head in neutral position

3) Rotate neck while exerting strong downward pressure on head

If during the Foraminal Compression Test radicular pain is present, what does this indicate?

Pressure on the nerve root

How do you perform the Jackson Compression test?

1) Laterally flex head from side to side (noting pain)

2) Laterally flex neck while exerting strong downward pressure on head (pressure should be maintained 30-60 seconds)

When performing the Jackson Compression test, if there is pain on the side opposite of flexion, what does this suggest? How about pain that is on the side of flexion?

Opposite = Muscular strain

Same side = facet/nerve root involvement

(interpret pain location)

How do you perform the Maximum Cervical Compression Test?

Chin to shoulder (fully rotating head), laterally flex & extend neck

When performing the Maximum Cervical Compression Test, if there is pain on the concave side, what is involved? How about pain on the convex side?

Concave = nerve root or facet involvement (interpret pain location)

Convex = muscular strain

How do you perform the Spurling's Test?

1) Chin to shoulder , laterally flex & extend neck

2) Exert strong downward pressure on the head for 30-60 seconds. Perform bilaterally

3) If no pain, deliver a vertical blow to the uppermost portion of cranium

When performing the Spurling's Test, if the pain is on the concave sign, what does this mean? How about the pain on the convex side?

Concave = nerve root or facet involvement (interpret pain location)

Convex = muscular strain

How do you perform the Lhermitte's Sign? What is a positive result?

1) Patient seated

2) Flex the patients head

Positive = sharp pain down the spine and into the upper or lower limbs

What does a positive Lhermitte's Sign (sharp pain down spine & into upper & lower limbs) indicate?

Dural irritation of the spine

-- suggests myelopathy of cervical spine

What test can be done at any joint where the patient attempts to actively move through a range of motion with the doctor resisting and maintaining the joint in a neutral position, not allowing the joint to reach the end range (resisted active range of motion)?

O'Donoghue Maneuver

What is a positive test for O'Donoghue Maneuver and what does this indicate?

Pain during resisted ROM or isometric contraction

Indicates muscle strain

What sign is when the patient is supine and you passively flex the head? What is a positive for this test?

Brudzinski Sign

Positive = nuchal rigidity w/ increased headaches --> POSITIVE sign for Meningitis

What may occur with meningitis to decrease the dural traction during the Brudzinski Sign?

Flexion of both knees

What sign is the patient is supine, flex the hip and knee to 90 degrees and then attempt to extend the leg? What is a positive for this test?

Kernig Sign

Positive = increased headaces --> POSITIVE for Meningitis

What may occur with meningitis to decrease the dural traction during the Kernig Sign?

Involuntary flexion of opposite knee & hip

How do you perform the Shoulder Depression test?

1) Examiner depresses patient shoulder on affected side

2) Laterally flex cervical spine away from that shoulder

What does a positive sign indicate for the Shoulder Depression Test?

Positive = Dural sleeve adhesions, spinal nerve roots, or adjacent structures of joint capsule of the shoulder

How do you perform the Soto-Hall Sign?

1) Patient Supine w/ examiner placing one hand on sternum of patient and exerting slight pressure

2) Other hand under occiput and flexes head towards the chest

If Soto-Hall (febrile) sign is positive with Kernig's or Brudzinski's sign, this would suggest what?

Meningeal irritation or Inflammation