A process that differentiates when musculoskeletal conditions need further examination or consultation by a PT or when they need to be referred to another practitioner
Differentiate between Examination and Evaluation
Examination - History from background info, systems review, tests and measures
Evaluation - Make clinical judgments regarding the information gathered during the exam regarding musculoskeletal conditions
What are some red flags in the cervical spine?
1. Cancer (metastasis to the spine and ribs) 2. Fracture 3. Cardiovascular problem 4. RA 5. Meningitis 6. Cervical myelopathy 7. Vertebrobasilar artery insufficiency
What is the purpose of the screening process?
1. Differentiate neuromusculoskeletal impairments from medical conditions 2. Identify patterns that suggest origin of pain/symptoms 3. Identify signs and symptoms (yellow and red flags) that warrant attention 4. First step in making a diagnosis
Name the 5 steps in the medical screening process
1. Past medical history 2. Risk factor assessment 3. Clinical presentation 4. Associated signs and symptoms 5. Systems review
Name the red flags you are looking for in a patient's medical history
1. Family history of cancer 2. Upper respiratory infection 3. Recent history of trauma (MVA, fall, etc) 4. Osteoporosis/osteopenia
Name the red flags you are looking for when performing a risk factor assessment
1. Body mass index (BMI) 2. Tobacco use 3. Alcohol abuse 4. Age (especially >50) 5. Gender 6. Sedentary lifestyle 7. Diet 8. Occupation
Name the red flags you are looking for when you are observing the patients clinical presentation
1. No known cause, etiology, insidious onset 2. Symptoms that are unrelieved by PT intervention 3. Gradual, progressive, or cyclical presentation of symptoms (worse, better, worse) 4. Unrelieved by rest or change in position 5. Symptoms seem out of proportion to the injury
Name the red flags you are looking for when observing the patients pain pattern
1. Upper back or shoulder pain (metastasis) 2. Pain accompanied by full and painless ROM 3. Pain not consistent with emotion or psychologi overlay 4. Night pain
Name the red flags for pain pattern with a cardiac origin
Upper quadrant pain with the use of the lower extremities while upper extremities are inactive
1. Increased temperature 2. HR > 100 3. Persistent fatigue 4. BP > 160/95
1. Where do the intervertebral discs begin? 2. What is the orientation of the AA facet joints? Why? 3. What is the orientation of the midcervical facet joints? Why?
1. C2/C3 2. Horizontal to allow for rotation 3. 45 degrees, posterior to anterior to allow for flexion/extension
What two structure limit extension?
1. Anterior longitudinal ligament
2. Approximation of the facet joints
What motions occur @ C0/C1?
1. Where does the vertebral artery normally enter the vertebral column? 2. Where is the vertebral artery most vulnerable?
1. Usually enters around C6
2. Most vulnerable in the upper cervical spine
1. What cervical vertebrae has the largest spinous process? 2. What cervical vertebrae has a bifid spinous process?
Why do you normally lose lateral flexion as you age?
Due to degeneration of the oncovertebral joints
1. What motions does the Alar ligament prevent? 2. What are symptoms that would lead you to believe the Alar ligament may be compromised?
1. Excessive ipsilateral rotation and contralateral sidebending
2. Chronic pain, HA, vertebrobasilar symptoms
Name and describe the 4 types of disc lesions
1. Protrusion - Bulging of the nucleus pulposus 2. Prolapse - Spinal disc and the associated ligaments remain in tact, but form an outpouching that can press against the nerves 3. Extrusion - Annular fibers disrupted and nucleus is bulging 4. Sequestration - Free nuclear material
What is the purpose of the intervertebral disc? What happens when it ruptures?
1. Control movement and shock absorption
2. If the annular fibers tear you have increased segmental motion
What disc lesions cause local pain? Radicular pain?
1. Protrusion and Prolapse
2. Extrusion and Sequestration
What signs and symptoms are associated with cervical myelopathy
1. Expanding symptoms 2. Multi-segmental symptoms 3. Changes in walking/balance 4. Changes in handwriting 5. Changes in bowel/bladder function 6. Parathesias (can be UE, LE, or both) 7. Falls 8. Difficulty swallowing
What are signs and symptoms of radiographic cervical instability
1. (+) Alar ligament, Sharp-purser, vertebral artery 2. HA in occipital region/numbness 3. Difficulty with prolonged positions (esp sitting) 4. Difficulty/reluctance to rotate head 5. Bilateral parathesias 6. Any sign of myelopathy 7. Supporting head on hands
What are signs and symptoms of clinical instability (CCSI)?
1. Head feels heavy **2. Abhorrent motion (poor quality) **3. Difficulty with prolonged positions (esp sitting) 4. Recurrent attacks of pain
What is clinical cervical instability? How do you treat?
Instability that can occur anywhere in the cervical spine, but is not picked up on x-ray.
There is no major structural damage
Treat with stabilization exercises
What are the risk factors for fractures?
1. Age (65+) 2. Osteoporosis
What are the clinical indicators for fracture?
1. Active rotation <45 degrees 2. Parathesias 3. Proximal weakness of arms 4. Immediate, worsening, unrelenting pain 5. Midline tenderness
What are red flags for neoplasm?
1. Age (>50) 2. Personal history (NOT family hx) 3. Night pain 4. Pain unrelieved with position change 5. Unexplained weight loss 6. Multisegmental, expanding pain 7. Increased sed rate
What are red flags for systemic disease?
1. Increased temperature (>37 C) 2. Change in vital signs - BP >160/95 - HR >100 - RR >25 3. Fatigue 4. Multiregion involvement
What was wrong with the original Quebec Task Force Classification of Grades of WAD?
They didn't consider the psychological components, so there were proposed adaptations
What is hyperalgesia?
Increased sensitivity to normally non-painful stimuli
When do you want to begin strengthening exercises after someone comes to you with decreased mobility?
Don't start strengthening until mobility is restored
What factors influence prognosis in patients with WAD neck pain?
1. High baseline pain (>7) 2. Presence of pain @ intake (>52 on NDI) 3. WAD 2 or 3 (not 4 because of immobilization and they can rationalize pain) 4. Female 5. Lower education level 6. History of previous neck pain 7. Catastrophizing 8. Didn't use seat belt
What treatments would you want to perform on a WAD patient?
Would you want to perform a sensory and proprioception test on WAD patients?
Yes on all patients
What are signs and symptoms of Cervicogenic Headache
1. Unilateral HA associated with neck/suboccipital location 2. Aggravated by neck movements 3. Aggravated by provocation of facet joints 4. Aggravated by provocation of cervical myofascia 5. Restricted/painful cervical ROM 6. Restricted cervical segmental hypomobility (esp upper cervical) 7. Substandard performance on the CCFT
What are signs and symptoms of TMD?
1. Pain on palpation of TMJ 2. Clicking/popping with opening/closing 3. Restricted ROM in opening 4. Crepitus 5. HA
What is the prediction rule for thoracic manipulation
1. Symptom duration <30 days 2. No symptoms distal to the shoulder **3. Subjective reports that looking up does not aggravate symptoms 4. Fear Avoidance score <12 5. Diminished upper thoracic kyphosis (T3-T5) 6. Cervical extension <30 degrees
Name the precautions/contraindications for mobilization/manipulation
1. Hypermobility 2. Fracture 3. Increased Fear Avoidance beliefs 4. Collagen Disorder 5. Pregnancy 6. Cancer 7. Inflammation and pain
What is more effective: Manipulation/mobilization or manipulation/mobilization with exercise
Manipulation/Mobilization with exercise
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