Cervical, Thoracic, and TMJ Musculoskeletal Physiotherapy Flashcards

Clinical Anatomy of the Cervical Spine

• Vertebral Bodies and Segmental Overview

  • The cervical spine consists of $7$ vertebrae.
  • It possesses the greatest range of motion (ROM) of the entire spine, which leads to an increased risk of injury.
  • The vertebral bodies in this section are smaller compared to other spinal sections.
  • $1^{st}$ Vertebra: Atlas (C1).
  • $2^{nd}$ Vertebra: Axis (C2).
  • $C3$ to $C7$: Lower cervical vertebrae.

• The Atlas (C1)

  • The $1^{st}$ cervical vertebra is unique as it has no vertebral body and no true spinous process.
  • Key structures include the transverse process, transverse foramen, and the vertebral foramen.
  • The Atlas supports the weight of the head through the atlanto-occipital joint ($C0$-$C1$).
  • Primary movement at this level is flexion and extension.

• The Axis (C2)

  • The $2^{nd}$ cervical vertebra features a small vertebral body with a superior projection known as the Dens (Odontoid process).
  • It contains a spinous process, transverse process, and transverse foramen.
  • The atlanto-axial joint is a pivot joint formed by the articulation between the Dens and the Atlas.
  • Primary movement at this level is rotation of the skull.

• Typical Cervical Vertebrae (C3-C7)

  • Features include an anterior tubercle, posterior tubercle, vertebral body, transverse process, bifid spinous process, transverse foramen, vertebral foramen, lamina, superior articular facet, and pedicle.

• Ligamentous Structures

  • Key ligaments include the Superior Crus, Inferior Crus, and Alar ligaments.
  • Damage to alar ligaments can increase rotation by up to $30\%$, leading to frank instability.

• Vascular Supply

  • The vertebral artery follows a specific course from $C6$ to $C1$ through the bony rings of the foramina transversaria.
  • The artery makes a double U-turn between $C2$ and $C1$ and passes posteriorly around the lateral mass of the Atlas.

• Neural Anatomy

  • Cervical Nerves: The first $7$ nerves ($C1$-$C7$) exit above their corresponding vertebrae.
  • The $C8$ nerve exits below the $7^{th}$ cervical vertebra.
  • The Brachial Plexus originates from nerve roots $C5$ through $T1$.

Special Considerations and Red Flags in the Cervical Spine

• Regional Disorder Associations

  • Upper Cervical Spine: Frequently the cause of cervicogenic headaches.
  • Mid-Cervical Spine: Commonly involves zygapophyseal (facet) joint dysfunction.
  • Lower Cervical Spine: Most frequent region for discogenic disorders and spinal nerve/nerve root compromise.

• Medical Red Flags

  • Major Trauma.
  • History of cancer or neoplasm.
  • Systemic inflammatory diseases and infections.
  • Cervical myelopathy symptoms.
  • Bladder and bowel dysfunction.
  • Neurological symptoms: Upper or lower limb clumsiness, uncoordinated movements.
  • Previous neck surgery.

• Vascular Screening: The 5 D's and 3 N's

  • Dizziness.
  • Diplopia (Double vision).
  • Dysarthria (Difficulty talking).
  • Dysphagia (Difficulty swallowing).
  • Drop attacks (Collapse without loss of consciousness).
  • Nausea (Vomiting).
  • Numbness (Perioral/around mouth and nose).
  • Nystagmus (Spontaneous eye movement).

• Indications of Cervical Spine Trauma

  • Known mechanism of injury (MOI) such as a Motor Vehicle Accident (MVA), fall, or fight.
  • Consistent, severe neck pain.
  • Increase in pain and decrease of movement on examination.
  • Signs of neurological injury.
  • Requirements: Urgent MRI, CT, or radiological referral.

Craniovertebral Instability and Fractures

• Craniovertebral Instability (Upper Cervical Instability/AAI)

  • Definition: Excessive movement at $C1$-$C2$ vertebrae due to bony or ligamentous abnormality.
  • Causes: Acute trauma, degeneration, congenital conditions, and Down syndrome ($10\%$ to $20\%$ of individuals).
  • Presentation: Neck pain, wry neck posture, headache, and signs of cord compromise.
  • Cord Compromise Signs: Ataxia (walking difficulty, hand clumsiness), lack of coordination, bowel/bladder dysfunction, positive primitive reflex testing, hyperreflexia, spasticity, and vascular symptoms.

• Odontoid (Dens) Fracture Classification (Anderson and D'Alonzo)

  • Type I: Fracture of the upper part of the odontoid peg. Rare and potentially unstable.
  • Type II: Fracture at the base of the odontoid. Unstable with a high risk of non-union.
  • Type III: Fracture through the odontoid and into the lateral masses of $C2$. Best prognosis for healing.

• Hangman's Fracture

  • A fracture of both pedicles or the pars interarticularis of the Axis ($C2$).

• Jefferson's Fracture

  • A burst fracture of $C1$, typically following traumatic axial compression.

• AO Spine Classification for Lower Cervical Fractures (C3-C7)

  • Type A (Compression): A1 (Impaction), A2 (Split), A3 (Burst).
  • Type B (Distraction): B1 (Posterior injury, intact body), B2 (Posterior fracture plus Type A), B3 (Anterior distraction/hyperextension).
  • Type C (Rotation): C1 (Unilateral facet fracture-dislocation), C2 (Unilateral facet dislocation), C3 (Separation fracture of articular mass plus Type A/B).

Vascular Conditions: CAD and VBI

• Cervical Arterial Dissection (CAD)

  • A tear in the wall of the vertebral artery (or internal carotid artery) potentially resulting in a stroke.
  • Early Features: Acute onset of unfamiliar, moderate-to-severe headache or neck pain.
  • Risk Factors: Minor trauma (sporting injury, manipulation, heavy lifting), infection (recent prolonged coughing/vomiting), genetic factors, and migraines.
  • Target Population: Often younger individuals (less than $55$ years of age).
  • Action: Immediate referral to the Emergency Department via ambulance if suspected.

• Vertebrobasilar Insufficiency (VBI)

  • Decreased blood flow to the posterior brain, fed by two vertebral arteries that join to become the basilar artery.
  • Target Population: Typically older patients (greater than $65$ years of age).
  • Causes: Atherosclerosis, spondylosis (osteophyte formation), trauma, or occlusion during head/neck movements.
  • Testing: VBI positional tests (Sustained End Range Rotation) are only used if symptoms are unclear. They are not indicated if the patient already has clear symptoms. The therapist sustains rotation for $10$ seconds and waits $10$ seconds in neutral between sides.

Neurological Conditions of the Cervical Spine

• Disc Prolapse

  • Most common at $C5$-$C6$ and $C6$-$C7$.
  • Typical in the $3^{rd}$ to $5^{th}$ decade (highest in group aged $51$-$60$ years).
  • Symptoms: Neck pain, referred shoulder pain, and impaired ROM.

• Cervical Radiculopathy

  • Compression of a nerve root resulting in neurological loss (power, sensation, reflexes).
  • Causes: Disc injury (younger) or spondylosis/stenosis (older).
  • Cluster of Wainner for Diagnosis: Positive Spurling's test, positive Axial Distraction test, positive Upper Limb Tension Test ($ULTT1$), and cervical rotation less than $60^{\circ}$.

• Stinger and Burner Syndrome

  • Transient brachial plexopathy caused by traction injury, common in contact sports (Rugby, AFL).
  • Symptoms: Radicular burning, shooting pain, numbness, and weakness. Usually resolves within $24$ hours; residual weakness may last up to $6$ weeks.

• Cervical Myelopathy

  • Severe spinal cord compression from trauma or stenosis (congenital/degenerative).
  • Signs: Bilateral neurological symptoms, bladder/bowel dysfunction, and saddle anesthesia.
  • Myelomalacia: Lack of fluid signal on MRI indicating cord softening.

Whiplash-Associated Disorders (WAD)

• Mechanism and Presentation

  • Acceleration-deceleration injury causing rapid hyperextension followed by hyperflexion.
  • Symptoms: Neck pain, headache, decreased mobility, tinnitus, blurred vision, and delayed onset of symptoms.

• Grades of WAD (QTF Classification)

  • Grade 0: No complain about neck, no physical signs.
  • Grade I: Neck complaint (pain, stiffness, tenderness), no physical signs.
  • Grade II: Neck complaint and musculoskeletal signs (decreased ROM, point tenderness).
  • Grade III: Neck complaint and neurological signs (decreased reflexes, weakness, sensory deficits).
  • Grade IV: Neck complaint and fracture or dislocation.

• Prognosis and Barriers

  • Negative predictors: Initial pain intensity greater than $5/10$ on VAS or NDI score greater than $15/50$.
  • Psychosocial factors: Negative expectations of recovery or post-traumatic stress symptoms (Impact of Events Scale score greater than $25$).

Mechanical Neck Pain Disorders

• Acute Wry Neck

  • Zygapophyseal Wry Neck: Sudden onset, common in children/young adults at $C2$-$C3$. Posture is lateral flexion and slight flexion.
  • Discogenic Wry Neck: Gradual onset, often on waking, common in middle age. Affects lower cervical or upper thoracic regions. Posture includes lateral flexion, rotation, and slight flexion.

• Spondylosis

  • Age-related degeneration involves disc breakdown, joint space narrowing, and osteophyte formation.
  • May lead to foraminal stenosis (causing radiculopathy) or spinal stenosis (causing myelopathy).

Headache Disorders

• Epidemiology

  • Approx. $40\%$ of the global population ($3.1$ billion people) were affected by headache disorders in $2021$.
  • In Australia, $4.9$ million suffer from migraines, and $7$ million suffer from tension-type headaches.
  • Migraines alone cost Australia approximately $35.7$ billion AUD per year.

• Primary Headaches

  • Migraine (ICHD-3 Category 1)
    • Recurrent attacks lasting $4$ to $72$ hours.
    • Four phases: Prodrome, Aura, Migraine, Postdrome.
    • Aura: Fully reversible visual or sensory symptoms developing gradually over minutes.
  • Tension-Type Headache (TTH) (Category 2)
    • Pressing or tightening quality (band-like), bilateral, mild-to-moderate intensity.
    • Infrequent episodic: less than $1$ day/month ($12$ days/year).
    • Frequent episodic: $1$ to $14$ days/month for more than $3$ months.
    • Chronic TTH: occurs on $15$ or more days/month for more than $3$ months.
  • Trigeminal Autonomic Cephalalgias (TACs/Cluster Headaches) (Category 3)
    • Severe unilateral pain (stabbing/burning) around the eye or temple.
    • Associated with ipsilateral lacrimation, rhinorrhea, miosis, or ptosis.
    • Attacks last $15$ to $180$ minutes, occurring once every other day to $8$ times per day.

• Secondary Headaches

  • Cervicogenic Headache (CGH) (Category 11.2.1)
    • Pathophysiology: Convergence of afferents from $C1$-$C3$ nerve roots and the trigeminal nerve in the trigeminocervical nucleus.
    • Clinical Signs: Reduced cervical ROM, painful upper cervical joint dysfunction ($C0$-$C2$), and impaired muscle function in deep neck flexors/extensors.
  • Headache Attributed to TMD (Category 11.7)
    • Aggravated by jaw motion, chewing, or palpation of the temporalis.
    • Up to $44\%$ of cervical headache patients exhibit TMD signs.

Temporomandibular Disorders (TMD)

• TMJ Anatomy and Bio-mechanics

  • Joint type: Bilateral interdependent synovial joints lined with fibrocartilage.
  • Articular Disc: Fibrocartilaginous, separating the joint into the upper cavity (translation) and lower cavity (rotation).
  • Muscles of Mastication: Temporalis, Masseter, Medial Pterygoid (elevators); Lateral Pterygoid (protrusion/translation).
  • Suprahyoid Muscles: Digastric, Mylohyoid, Stylohyoid, Geniohyoid (depressors).
  • Opening Phases: $0$-$25\,mm$ (Rotation in inferior compartment); $25$-$40\,mm$ (Translation in superior compartment); and $40+\,mm$ (Secondary rotation).

• Joint Mechanics During Movement

  • Opening: Disc rotates posteriorly as condyle translates anteriorly.
  • Laterotrusion: Contralateral condyle/disc complex slides anterior, lateral, and inferior; ipsilateral complex slides posterior, medial, and superior.
  • Protrusion: Anterior, inferior, and lateral glide of both mandibular heads and discs.

• TMD Subgroup Classification (DC/TMD)

  • Pain-Related: Myalgia (muscle pain), Arthralgia (joint pain), and headaches attributed to TMD.
  • Intra-articular Disorders: Disc displacement with reduction (ADDwR - click present) and disc displacement without reduction (ADDwoR - no click, limited opening to less than $30\,mm$).
  • Hypermobility: Opening greater than $50$-$55\,mm$.

• TMD Red Flags

  • Unilateral hearing loss.
  • Facial/neck masses.
  • Occlusal changes.
  • Systemic symptoms (fever, unexplained weight loss).

Treatment Direction Techniques (TDTs)

• Framework and Definitions

  • Symptom Modification Procedure (SMP): A test to see if symptoms can change immediately.
  • Treatment Direction Technique (TDT): The specific movement strategy chosen for treatment based on SMP results.
  • Core skill: Test-Treat-Retest.

• Categories of Modification

  1. Movement Direction and Load: Repeated movements or sustained positions.
  2. Manual/External Modification: Joint repositioning, taping, or passive support.
  3. Task/Context Modification: Adjusting starting positions or breaking tasks into components.
  4. Patient-Controlled Strategies: Self-correction and awareness.

Thoracic Spine Anatomy and Conditions

• Prevalence and Red Flags

  • Thoracic spine counts for less than $15\%$ of spinal pain cases.
  • The thoracic spine is the most common site for secondary spinal metastases.
  • $70\%$ of all secondary bone metastases are in the spine ($60\%$ to $80\%$ in the thoracic region).

• Biomechanics of the Thoracic Spine

  • Global ROM: Flexion ($30^{\circ}$-$40^{\circ}$), Extension ($15^{\circ}$-$20^{\circ}$), Lateral Flexion ($25^{\circ}$-$30^{\circ}$), Rotation ($25^{\circ}$-$35^{\circ}$).
  • Stability is enhanced by the ribs and sternum, providing $3$ times more load-bearing capacity than the spine alone.

• Referral Patterns

  • Cervical Face Joints ($C5$-$C7$) and Discs ($C3$-$C7$) refer into the thoracic region.
  • Thoracic Visceral Referral: Esophagus (mid-thoracic), Pancreas (low-thoracic), Gallbladder (right inferior scapula), Spleen (left lower anterior ribs), Diaphragm (shoulder/upper trapezius).
  • Thoracic Dermatomes: $T5$ (nipple line), $T7$-$T8$ (epigastric), $T10$-$T11$ (umbilical), $T12$ (groin).

• Specific Clinical Conditions

  • Scheuermann’s Disease: Postural deformity in adolescents ($13$-$16$ years) involving vertebral wedging (greater than $5^{\circ}$ in $3$ adjacent vertebrae) and hyperkyphosis (greater than $40^{\circ}$).
  • Ankylosing Spondylitis (AS): Inflammatory arthritis linked to HLA-B27. Onset between $16$-$25$ years. Morning stiffness greater than $1$ hour and chest excursion less than $2.5\,cm$.
  • T4 Syndrome: Upper extremity paresthesia and pain arising from upper thoracic hypomobility.
  • Scoliosis: Cobb angle assessment; bracing is typically used for curves between $20^{\circ}$-$40^{\circ}$, while surgery is considered for curves greater than $60^{\circ}$.

Clinical Assessment and Conditions of the Shoulder

• Epidemiology and Facts

  • Lifetime prevalence of shoulder pain is $67\%$.
  • It is the $3^{rd}$ most common cause of MSK consultation.
  • RC tendinopathy and impingement account for greater than $60\%$ of shoulder clinical presentations.
  • Shoulder imaging has poor correlation with clinical pain symptoms.

• Shoulder Impingement Categories

  • External (Subacromial): Mechanical encroachment in the subacromial space. Painful arc between $60^{\circ}$-$120^{\circ}$ abduction.
  • Internal (Posterosuperior): Encroachment of the rotator cuff between the humeral head and glenoid rim, common in overhead athletes at end-range ER and horizontal abduction.

• Shoulder Instability

  • TUBS: Traumatic, Unidirectional, Bankart lesion, Surgery.
  • AMBRI: Atraumatic, Multidirectional, Bilateral laxity, Rehabilitation, Inferior capsular shift.
  • AIOS: Acquired sport-specific Instability Overuse Syndrome.
  • Anterior dislocation (forced Abduction + ER) accounts for $95\%$ of traumatic dislocations.

• Biceps and Labral Pathology

  • SLAP Lesions: Superior Labrum Anterior to Posterior. Subtypes range from fraying (Type 1) to detached labrum/LHB (Types 2-4).
  • Tests: O'Brien's test and Biceps Load II show moderate-to-high specificity for SLAP lesions.

• Physical Exam Statistics

  • Hawkins-Kennedy (Impingement): Sensitivity $80\%$, Specificity $56\%$.
  • Jobe’s/Empty Can (Impingement): Sensitivity $72\%$, Specificity $60\%$.
  • Apprehension Test (Instability): Sensitivity $98.3\%$, Specificity $71.6\%$.