Module 6 part 2

Question 1

Neck Pain with Mobility Deficits: What are 10 Key exam findings?

Answer 1

1. Recent onset of symptoms due to unguarded/awkward movement or position
2. Unilateral/local neck symptom with or without referred symptoms in the upper quarter (NO RADICULAR SYMPTOMS)
3. No peripheralization with active/repeated movements
4. Limited cervical ROM
5. Pain at end-ranges of AROM/PROM
6. Restricted cervical and thoracic segmental mobility
7. Symptoms provoked with cervical and/or thoracic PAIVM and/or PPIVM
8. Regional Impairments
   
   • mobility
   • muscle performance/length
9. No sign of nerve root compression
10. Altered neurodynamics

Question 2

Neck Pain with Mobility Deficits: What are 7 Interventions?

Answer 2

1. Thoracic mobs or manips
2. Cervical mobs or manips
3. AROM/PROM to augment mobilization/manipulation
4. Muscle lengthening exercises
5. Muscle performance: endurance, coordination, strengthening exercise
6. neural mobilization
7. Address regional and functional/activity limitations

Question 3

What is a simulated manipulation position and why and how is it used?

Answer 3

Before performing a cervical thrust manipulation, a simulated manipulation position (SMP) may be used to screen for patient tolerance to procedure.

SMP is a pre-manipulative hold of the C-spine in the intended HVLA thrust position for 10-15 sec. This may result in reduced blood flow through the ICA or VA and produce symptoms suggestive of diminished cerebral perfusion. So it’s cool cause it can help us identify people at risk of neurovascular compromise after a cervical manip. So if we see symptoms during or right after the SMP, we’ll say “Hell no” to the manip. “Lady you are contraindicated for this!”

That said diagnostic accuracy of SMP is unknown. There is a study in the book but nothing that sets this in stone.

VA = Vertebral Artery

SMP = Simulated Manipulation Position

ICA = Internal Carotid Artery

Question 4

What is the role of thoracic spine mobilization in the treatment of neck pain?

Answer 4

Several authors report improved outcomes with thoracic spine manipulation in patients with MNP with or without radiculopathy. TSM is effective in decreasing neck pain and disability, improving neck posture, and ROM for patients with chronic MNP.

TSM = Thoracic Spine Manipulation

MNP = Mechanical Neck Pain

Question 5

Neck Pain with Radiating Pain: What are 10 key findings?

Answer 5

1. Neck pain with associated radiating or referred pain in the involved UE that may be somatic, neuropathic in origin, or both
2. UE paresthesia, numbness, and weakness may be present
3. Centralization or peripheralization with active/repeated movements
4. Neck and neck-related radiating pain reproduced with
   
   1. Cervical extension, Lateral flexion, and rotation towards the involved side (Spurling’s test)
   2. ULNDT
5. Neck and neck-related radiating pain with neck compression
6. May have UE sensory, strength, or reflex impairments associated with the involved nerve(s)
7. Symptoms provoked with cervical and/or thoracic PAIVM and/or PPIVM
8. Regional impairments
   
   1. Mobility
   2. Muscle Performance/Length
9. Signs of nerve root compression
10. Altered neurodynamics

Question 6

Neck Pain with Radiating Pain: What are 10 Inerventions?

Answer 6

1. Thoracic mobilization or manipulation
2. ICT (intermittent cervical traction)
3. Cervical mob or manip,
4. cervical MET
5. Repeated movements that centralize symptoms
6. AROM/PROM to augment mobilization/manipulation
7. Muscle lengthening exercises
8. Muscle performance: endurance, coordination, and strengthening exercise
9. Gentle neural mobilization
10. Address regional and functional/activity limitations.

Question 7

Apply the sagittal progression of direction specific exercise for extension direction specific exercise.

(4 in sitting and 4 in supine, and why you would use them)

Answer 7

1. retraction in sitting
2. retraction in sitting with patient overpressure
3. retraction in sitting with clinician overpressure
4. retraction and extension in sitting and postural correction and education

(if symptoms peripheralize with those or patient is unable to perform))

1. retraction in supine with pillow as needed
2. retraction in supine with pt. overpressure
3. retraction in supine off of table
4. retraction off of table with clinician overpressure

(exercises to be performed 10-15 reps every 2-3 hours as long as symptoms do not peripheralize)

*****This answer differs from the sheet Dr. Mincer gave us. #3 and #4 in sitting should be switched

Supine: #3 retraction w/ pt. OP and extension, #4 retraction w/ PT OP, #5 retraction w/ PT OP and extension.

Also corresponds with what I saw in the clinic (MB)*****

Thanks MB! I got confused, so I just pasted in the progressions from the hand out below:

Sitting:

1. Retraction in sitting
2. Retraction in sitting with self overpressure
3. Retraction in sitting with self overpressure and extension
4. Retraction in sitting with therapist overpressure

Supine

1. Retraction in supine
2. Retraction in supine with self overpressure
3. Retraction in supine with self overpressure and extension
4. Retraction in supine with therapist overpressure
5. Retraction and extension in supine with therapist overpressure

Question 8

What are three categories included in the classification: Neck Pain With Radiating Pain?

Answer 8

1. Cervicobrachial pain with Cervical Radiculopathy
2. Cervicobrachial pain with Repeated Motions (responds to DSE)
3. Cervicobrachial pain with Neuropathic pain (Neurodynamics mostly)

Question 9

What is the CPR for Cervical Radiculopathy and how do you interpret it?

Answer 9

CPR for Cervical Radiculopathy (3 positive has 0.94 specificity, 4 positive is even more suggestive; additional testing should be used as well because of wide confidence interval)

1. ULTT/ULNDT 1/A (most useful test when used alone for ruling out cervical radiculopathy)
2. Cervical rotation less than 60* to involved side
3. Distraction test
4. Spurling test A

Question 10

What is the CPR to help identify pts with neck pain likely to benefit from cervical mechanical traction with exercise?

Answer 10

CPR to help identify pts with neck pain likely to benefit from cervical mechanical traction + exercise

1. Age > 55
2. Positive shoulder abduction sign
3. Relief of symptoms with manual distraction (symptoms decrease or centralize)
4. Peripheralization with lower c-spine (C4-C7) mobility testing
5. Positive ULNDT using the median nerve bias with shoulder to 90 abd

Question 11

What are some treatments for Cervical Radiculopathy? (4 points, summarize)

Answer 11

Treatments

1. Neck pain clinical practice guideline recommends consideration of mechanical intermittent cervical traction (ICT) combined with manual therapy and exercise
2. Overall, literature supports a multimodal, nonsurgical approach, consisting of manual therapy, Intermittent cervical traction, and exercise for pts with cervical radiculopathy
3. Neural mobilization was included successfully in one of the studies
4. Traction may not be needed in all cases, but it is often used.

Question 12

What are the two main subgroups of Cervicobrachial pain that responds to Repeated Movements (DSE)?

What is another approach?

Answer 12

• Extension Exercise Subgroup
• Flexion Exercise Subgroup
• Lateral Flexion/Rotation can be used if sagittal motions do not work (but we did not learn)

Question 13

In addition to the specific exercise, what are some other points (2 ish), summarizing some treatment for Cervicobrachial pain that responds to Repeated Movements (DSE)?

Answer 13

Treatment

• While further research is needed to determine the effectiveness of repeated movements in this classification, a multimodal strategy incorporating this concept may result in better outcomes.
• Based on a directional preference and a goal of centralization, repeated movements were used in combination with exercises for cervical spine stabilization and neural mobilization.

Question 14

What is Cervicobrachial pain with Neuropathic Pain (Neurodynamics sort of), and how does it compare to something we learned to use in the lumbar spine?

Answer 14

• More about distinguishing between pain from neural source vs. somatic
  
  • so can include cervical radiculopathy, but that is addressed more in the cervical radiculopathy section
• Appears we can use similar guidelines to what we learned in lumbar to make distinction.
  
  • Check LANSS score suggests central sensitization if > = 12
  • Hard Neuro Signs suggest Radiculopathy/”Denervation” (which is included as a type of Neuropathic Pain, but is addressed more specifically above)
  • s/s nerve trunk mechanosensitivity suggests Neurodynamics/Neuropathic/sensitized peripheral nervous tissue source
  • Lack of all the above suggests somatic/MSK source

Question 15

What are 7 subjective complaints/pain descriptors suggesting neural involvement?

Answer 15

1. Burning pain
2. Electric shocks
3. Cold pain
4. Itching
5. Paresthesia
6. Numbness
7. Tingling

Question 16

What are 4 objective findings sugessting neural involvement?

Answer 16

1. An antalgic posture to protect or de-tension sensitized nervous tissue, such as shoulder girdle elevation, adduction, and elbow flexion
2. Active and passive movements that lengthen neural tissue, such as cervical lateral flexion away from the painful side [will be provocative]
3. Mechanical allodynia to palpation of neural tissue
4. Provocative tests that suggest a local cause of the irritated neural tissue such as the ULNDT

Question 17

What are 3ish exam techniuqes that could be helpful in identifying neural involvement?

Answer 17

1. The self reported version of the LANSS should be utilized
2. Clinical neurological examination including manual muscle testing, reflexes, sensibility to pinprick, light touch, vibration, and neural tissue palpation
3. Electromyography and nerve conduction studies may be useful

Question 18

Summarize treatment for pts with Cervicobrachial pain with Neuropathic Pain (Neurodynamics sort of)

Answer 18

Treatment

• See cervical radiculopathy section for treatment specific to radiculopathy
• Positive outcomes with
  
  • Cervical mobs helped
  • Neural tissue techniques helped more than manual therapy
    
    • Lateral glides in various ULNDT positions
    • Nerve glide exercises
    • Sliding and tensioning techniques
  • In pts with chronic nerve-related neck and arm pain, preliminary evidence supports a 2-week, specific neural tissue management approach as effective compared to advice to “stay active.”
  • Basically Manual therapy (mobs and glides), nerve glides, and exercise seemed to help.
  • Doing nothing and ultrasound did not help.

Question 19

Some advice about the subcategories of the Neck Pain with Radiating Pain Classification

Answer 19

All of the categories and treatment reccomendations seem a lot less clear cut than in lumbar, but with striking similarities. When in doubt, go with what you know about lumbar, but include a more multi-modal approach to treatment. Manual therapy and exercise seemed to be very common in producing good outcomes. Traction was also commonly thrown in a lot more than in lumbar (especially for cervical radiculopathy). Nerve glides (sliders and tensioners) were used with neuropathic pain, but not as much as you would think (mostly it seemed there was a lack of evidence on what to do for these patients).

Can probably apply the same algorithm using LANSS we learned in Lumbar for Neuropathic Pain

Question 20

Neck Pain with Movement Coordination Impairments: What are 11 Key exam findings?

Answer 20

1. Neck pain and neck-related (referred) UE pain
2. Symptoms may be linked to, or precipitated by, trauma or whiplash and may be of longer duration (>12 weeks)
3. No centralization or peripheralization
4. Absence of nerve root compression
5. Neck pain with mid-range motion that worsens with end range movements or positions
6. DNF and upper quarter strength, endurance, and coordination deficits
7. Neck and neck related UE pain reproduced with provocation of the involved cervical segments
8. Poor performance of the CCFT and DNF endurance test
9. Upper quarter muscle flexibility deficits
10. Difficulty with repetitive activities
11. Somatosensory dysfunction

Question 21

Neck Pain with Movement Coordination Impairments: What are 6 interventions?

Answer 21

1. Specific motor control exercises
2. General exercises for upper quarter impairments of strength and endurance
3. Spinal posture education
4. Muscle lengthening exercises
5. Task-specific training for endurance, coordination, and strengthening to address activity limitations
6. Sensorimotor control exercises

Question 22

Contrast and describe the use of the high and low load exercise approaches to treatment.

Answer 22

From Class Notes:

• High load- activates superficial muscles, lifting head off the table- don’t start with high load, use low load first
• Low load- chin nod, activates deep muscles - really important for coordination and control and building endurance for DNF

pg 454

• Low load- training deep neck flexors through low load increases muscle activation, improves speed of activation, and aids in maintenance of upright sitting posture.
• High load- does not produce similar outcomes, but still important to reduce deficits in strength and endurance.

pg 549

• Two exercise regimes: general strengthening exercises or head lift and a low-load program designed to focus on motor control and coordination between the superficial and DNF muscles and the quality of the craniocervical flexion movement.
• low load aims to improve DNF activation of longus capitis and longus colli with min activation of SCM and anterior scalene.
• general strengthening or high load exercises emphasizes activation of all muscles to produce head lift.
• both high and low have similar EMG activation of the DNF with isometric testing, but the high load bring in activation of SCM and anterior scalene too.
• In a study comparing both approaches only the low load group showed significant improvement in ability to maintain an upright C-spine posture

Should be able to perform low-load exercise before progressing to high load. Train coordination with the DNF/low load, then progress to higher load and add superficial coordination on top of deep muscle coordination (like in lumbar spine)

pg 552

• low load exercises are pain-free and can be introduced early in the plan of care incorporating principles of motor learning and progression to functional exercises

Question 23

Neck Pain with Headache Classification: What are 10 key exam findings?

Answer 23

Key Exam Findings (Table 6-2 on pg 450)

1. Unilateral headache associated with neck/suboccipital area symptoms aggravated by neck movements or positions
2. HA produced or aggravated with provocation of the ipsilateral/involved posterior cervical soft tissue and motion segments
3. Restricted cervical ROM
4. Upper cervical motion segment dysfunction above C4 (PAIVM, PPIVM)
5. DNF and upper quarter strength, endurance, and coordination deficits
6. (+) Cervical flexion rotation test
7. Poor performance of the CCFT
8. Upper quarter muscle flexibility deficits
9. Active trigger points
10. Altered neurodynamics

Question 24

Neck Pain with Headache Classification: What are 7 interventions?

Answer 24

Interventions

1. C-spine manipulation or mobilization
2. Specific motor control exercises
3. Strengthening exercises for upper quarter impairments of strength and endurance
4. Spinal posture education
5. Muscle lengthening or soft tissue procedures
6. Trigger point therapy
7. Muscle energy techniques (MET)

Question 25

when is referral is indicated for headache symptoms? (14 red flags)

Answer 25

Red Flags that may require referral to a medical specialist for additional testing include the following: 1. Sudden-onset HA (ie, thunderclap) 2. Worsening pattern of HA 3. Change in pattern of previous HA 4. Fixed laterality 5. Triggered by cough, exertion, or postural change 6. Nocturnal or early morning onset 7. New onset after age 50 8. Systemic s/s (ie, fever, rash, and stiff neck) 9. Seizures 10. Papilledema or optic disc swelling 11. Focal neuralgic symptoms or signs other than typical visual or sensory migraine aura 12. New pain level, especially when described as the worst ever 13. Personality change or cognitive impairment 14. No response to seemingly appropriate treatment

Question 26

What usually causes Whiplash-associated disorder?

Answer 26

Due to potential for acceleration and deceleration MOI, whiplash associated disorders WAD usually occur during MVC, but are also known to occur during sporting events such as skiing.

Question 27

What are the clinical findings in the basic classifications of WAD based on the Quebec Task Force Classification?

Answer 27

* 0 = No complaints bout the neck; no physical signs * I = No complaint of neck pain, stiffness or tenderness only; no physical signs * II = Neck complaint; MSK signs including decreased ROM; point tenderness; no neurological signs (this category has 3 subcategories) * III = Neck complaint; MSK signs; neurological signs includincreased/absent DTRs, muscle weakness, and sensory deficits * IV = neck complaint and fracture or dislocation

Question 28

How many classifications are there in the Quebec Task Force Classification (of WAD)?

Answer 28

5 (0-IV) Classification II has three sub categories (A-C)

Question 29

Quebeck Task Force WAD II Classification: Describe the clinical findings in the three proposed sub-categories of classification II:

Answer 29

II = Neck complaint; MSK signs including decreased ROM; point tenderness; no neurological signs IIA * Neck Pain; no neurological signs * Decreased ROM and altered muscle recruitment on the craniocervical flexion test * Local cervical mechanical hyperalgesia IIB * same as WAD IIA * Psychological impairment with elevated psychological distress as demonstrated on the General Health Questionnaire - 28 and the Tampa Scale of Kinesiophobia IIC * Everything in IIB * Increased joint position error * Generalized sensory hypersensitivity (mechanical, thermal, and neural tissue) * Some sympathetic nervous system disturbances * Symptoms of acute posttraumatic stress as identified by the Impact of Event Scale

Question 30

What is the role of exercise in acute WAD?

Answer 30

Active exercise results in reduced pain intensity and may improve ROM (pg 564)

Question 31

Quebeck Task Force WAD II Classification: What are the clinical findings in IIA?

Answer 31

II = Neck complaint; MSK signs including decreased ROM; point tenderness; no neurological signs IIA * Neck Pain; no neurological signs * Decreased ROM and altered muscle recruitment on the craniocervical flexion test * Local cervical mechanical hyperalgesia

Question 32

Quebeck Task Force WAD II Classification: What are the clinical findings in IIB?

Answer 32

II = Neck complaint; MSK signs including decreased ROM; point tenderness; no neurological signs IIB * same as WAD IIA * Psychological impairment with elevated psychological distress as demonstrated on the General Health Questionnaire - 28 and the Tampa Scale of Kinesiophobia

Question 33

Quebeck Task Force WAD II Classification: What are the clinical findings in IIC?

Answer 33

II = Neck complaint; MSK signs including decreased ROM; point tenderness; no neurological signs IIC * Everything in IIB * Increased joint position error * Generalized sensory hypersensitivity (mechanical, thermal, and neural tissue) * Some sympathetic nervous system disturbances * Symptoms of acute posttraumatic stress as identified by the Impact of Event Scale

Question 34

What is the role of multidisciplinary care in the treatment of WAD?

Answer 34

Best practice recommendations for noninvasive interventions during the chronic WAD stage include- the majority of studies support interdisiplinary intervention of PT and psychological counseling intervention… Gestalt therapy, Rosen method bodywork, and craniosacral therapy are not supported.

Question 35

What is the role of neurophysiology education in the treatment of WAD?

Answer 35

Neurophysiology education appears to be a promising strategy to affect motor performance, disability levels, pain behavior, and pain thresholds-- at least in the short term.

Question 36

In general, how do the outcomes of surgery compare to conservative treatment of neck pain?

Answer 36

Conservative care usually results in successful outcomes with surgical management reserved for patients with progressive neurological deficit and intractable pain. According to the Cochran review study- “ Surgically treated patients had better outcomes related to sensory loss at 4 months, but at 16 months there were no significant differences”. These results confirm a short term benefit from surgery compared physiotherapy in terms of pain relief with an apparent lack of treatment benefit at one year.

Question 37

What are two classifications that we have for neck pain that do not correspond to any classifications in the lumbar spine?

Answer 37

headaches and whiplash

Question 38

What is a role of the coordination deficits classification in relationship to other classifications?

Answer 38

Most patients with neck pain, regardless of the initial classification, require assessment and intervention or muscle performance deficits for optimal recovery

Question 39

Coordination Imparment treatment: Describe appropriate AROM

Answer 39

* Low-load exercises are initiated early in rehabilitation in non-weightbearing or supine, with pillow support if needed. * Begin with setting DNF prior to controlling motion into rotation * Rotation and lat flex can be performed in standing with the head in contact with the wall as feedback to maintain the plane of motion and cervical spine neutral * Segmental flexion and extension control were discussed previously in sitting and prone (the initial movement control exercises from other cards)

Question 40

Coordination Imparment treatment: Describe appropriate postural education

Answer 40

patients are not instructed to sit up straight. Postural correction begins in sitting by first positioning the pelvis anteriorly to create a normal lumbar lordosis. Thoracic and cervical postures are then corrected as needed by a gentle lift of the sternum to reduce and increase thoracic kyphosis, or by gentle depression of the sternum to relax and extended thoracic spine. Cervical postural correction may be guided by asking the pt to lengthen the back of the neck by imaging a gentle occipital lift or lifting the occiput 1mm off the atlas. A gentle occipital lift facilitates activation of the longus coli.

Question 41

Coordination Imparment treatment: Describe appropriate extension control

Answer 41

The pt is asked to look to the ceiling and follow it backward to slowly extend past the plane of the shoulder, staying in a pain-free range with good control and return to neutral. Cervical extension is initiated by cervical extensors and requires early eccentric control of the cervical flexors; movement on return to neutral trains concentric flexor control and is initiated by craniocervical flexors to facilitate activation of the DNF. also looking at functional activity of deep neck flexors - if you see them initiate with cervical flexors rather than the craniocervical flexors, then there are weak deep neck flexors present

Question 42

Coordination Imparment treatment: Describe appropriate stabilization with arm movement

Answer 42

Task-specific exercises, such as working at a computer or daily home activities, are started using a small range of arm elevation. The pt maintains neutral upright posture and optimal scapular positioning during the task. Progression adds speed of movement or resistance to the arm movement and increases range of elevation based on the demands of the task can increase speed, arm ROM, or resistance

Question 43

Control Impairments: Describe the appropriate approach to strength and endurance training.

Answer 43

* higher load progression strategies facilitate more superficial muscle activation and are not initially indicated for pts with high pain and disability levels or with long-standing bracing strategies * Pt symptoms should be mild and stable prior to adding higher loads with age, gender, and functional requirements considered prior to initiation and slow progression to higher muscles forces to the c-spine. * Start with Flexion Training * Train cervical flexor strength, beginning in supine with pillows * Pt sets the DNF prior to just lifting the head from the surface and holds for 1-2 seconds for 5 reps * Repetitions, sets and hold time are used to progress * Pillows are removed so that pt has to lift from a flat surface * An inclined surface is also used to gradually moved toward horizontal * Extrension strength training * in craniocervical neutral with resistance band performed in sitting, standing or quadruped * Patients who participate in general exercise and fitness programs should be observed for cervical spine control during these activities and adjustments made as needed

Question 44

Movement control impairments: Basic principles for a specific exercise approach: (5)

Answer 44

1. Exercise begins early in the process and should not provoke pain 2. Exercises should address specific changes in muscle and sensorimotor function with emphasis on precision in the motor learning process 3. Training should be functional and task-specific 4. Repetition is necessary for appropriate movement and control 5. Pt education and adherence are vital components

Question 45

Movement Control Deficits tx: How to initiate and progress supine exercises

Answer 45

DNF * master movement * CCF through activation of the longus capitis and longus colli without excessive activation fo the superficial flexors * CCF is performed pain-free and slowly with precision and control * Endurance training * Train short of fatigue * Work toward 10 reps 10 seconds at 30 mmHG * Practice with eyes open then closed * Move to CCF in sitting or standing (See posture)

Question 46

Movement Control Deficits tx: How to initiate and progress extension exercises

Answer 46

Deep Neck Extensors (semispinalis cervicis and mulifidus) * start in supine and press isometrically into table (learn the movement) * progress to sustain holds in supine pressing into table * Move to prone/quadruped with head in cervicocranial neutral (CCN) * To work deep neck extensors, keep neutral upper c-spine and flex lower c-spine and come back to neutral (prone on forearms or in quadruped) * To add superficial neck extensors (plenius capitis; semispinalis capitis), perform craniocervical extension * can progress to seated extension exercises and exercises with a band

Question 47

what are the two deep neck flexor muscles?

Answer 47

longus capitis longus colli

Question 48

what are the two deep neck extensor muscles?

Answer 48

semispinalis cervicis mulifidus

Question 49

what are two superficial neck extensor muscles?

Answer 49

plenius capitis; semispinalis capitis

Question 50

Two sets of criteria of Cervicogenic HA (Just be able to distinguish between this vs tension type vs migraine type)

Answer 50

Just be able to distinguish between this vs tension type vs migraine type Criteria 1: * A. Pain referred from the neck and perceived in 1 or more head regions and/or face, fulfilling C and D * B. Clinical, lab and/or imaging evidence of a c-spine disorder known or accepted as a valid cause of HA * C. Evidence that pain is due to a neck disorder based on at least 1 of the following * Clinical signs that implicate a source of neck pain * Abolition of HA after diagnostic blockade * D. Pain resolves within 3 months of successful treatment of the causative disorder Criteria 2 * Signs & Symptoms of neck involvement: * Precipitation of the head pain similar to the usual occurring one: * By neck movement and/or sustained awkward head posture * By external pressure over the upper cervical or occipital region on the symptomatic side * Restriction of neck ROM * Ipsilateral neck, shoulder, or arm pain of vague nonradicular or occasionally radicular nature * Confirmatory Evidence by diagnostic anesthetic blockades * Unilaterality of the head pain without side shift. For CGH diagnosis one or more aspects of Point 1 must be present with la sufficient to serve as a sole criterion for positivity or Ib and Ic combined

Question 51

Recognize Tension-Type Headache (Episodic, Frequent episodic, Chronic - do not have to know the difference) (Just be able to distinguish between this vs tension type vs migraine type)

Answer 51

Episodic: * At least 10 episodes occurring \< 1 day/month on average (\<12 days/year) and fullfilling criteria 2-4 Frequent episodic: 1. At least 10 episodes occurring on \>/=1 but \< 15 days/month for at least 3 months 2. HA last from 30 min to 7 days 3. HA has at least 2 of the following * Bilateral location * Pressing/tightening (non-pulsating) quality * Mild or moderate intensity * Not aggravated by routine activity (walking or stairs) 4. Both of the following * No Nausea or vomiting * No more than 1 of photophobia or phonophobia 5. 5. Not attributed to another disorder Chronic (basically the same as episodic except) * HA occurring on \>15 days/month on average for \>3 months per year and fulfilling criteria 2 to 4 (from episodic I think) * HA lasts for hours or may be continuous * Replace "both of the following" with: * No more than 1 of photophobia, phonophobia, or **mild nausea** * Neither moderate or severe nausea or vomiting

Question 52

Recognize Migraine Headache (with and without aura) (Just be able to distinguish between this vs tension type vs migraine type)

Answer 52

Migraine without Aura * B. HA attacks lasting 4-72 hours (untreated or unsuccessfully treated) * C. HA has at least 2 of the following * Unilateral location * Pulsating quality * Moderate or severe intensity * Aggravations by or causing avoidance of routine activity (walking or stairs) * D. During HA at least 1 of the following * Nausea and/or vomiting * Photophobia and phonophobia * Not attributed to another disorder * Having had at least 5 attacks of HA fulfilling these criteria Migraine With Aura * At least 2 attacks of criteria B to D * Aura with at least 1 of the following but no motor weakness * Fully reversible visual symptoms (flickering lights or loss of vision) * Fully reversible sensory symptoms (pins/needles, or numbness) * Fully reversible speech disturbance * At least 2 of the following * Homonymous visual and/or unilateral sensory symptoms * At least 1 aura symptom develops over \>/=5 minutes and/or different aura symptoms in succession over \>/=5 minutes * Each symptom lasts \>/=5 or \>/=60 minutes * HA fulfilling B to D for migraine without aura begins during aura or follows aura within 60 minutes * Not due to another disorder

Question 53

What is WAD? What are some categories of clinical presentation? (4)

Answer 53

WAD is characterized as a complex and heterogeneous condition with a variety of clinical presentations related to * motor deficits, * sensorimotor deficits * sensory deficits and * psychological distress

Question 54

WAD: when is onset of symptoms?

Answer 54

Immediate onset of symptoms is common, but often symptoms are delayed up to 12-15 hours

Question 55

WAD: what is the primary complaint?

Answer 55

Primary complaint is neck pain that may refer to the head or extremities, interscapular, thoracic, or low back regions.

Question 56

WAD: What are some additional s/s (besides neck pain that refers)? (8)

Answer 56

* Additional symptoms may include 1. headache 2. visual disturbances 3. parestheisa 4. anestheisa 5. weakness 6. poor balance 7. poor concentration 8. poor memory

Question 57

WAD: what are some more specific things to look for? (4 ish)

Answer 57

1. reduced cervical ROM 2. cold hyperalgesia 3. Neuropathic pain, Use S-LANSS to figure out if neuropathic or not * burning pain in the neck * hyperalgesia to manual pressure * electrical shock-like pain 4. Look for neurological/sensitization-type s/s and instability! (also more general stuff in the book I think)

Question 58

WAD: what is an outcome measurement that should be used?

Answer 58

IES (Impact of Event Scale) should be included as a measure of posttraumatic stress. A score of more than 26 at 6 weeks postinjury may indicate the need for a psychological referral.

Question 59

WAD: how are the acute, subacute, and chronic stages defined?

Answer 59

* acute (less than 2 weeks), * subacute (2-12 weeks), and * chronic (longer than 12 weeks) stages

Question 60

does current evidence provide support for early interventions over natural recover in the acute phase of WAD?

Answer 60

Current evidence does not provide support for early intervention over natural recovery in the acute phase since no early management approach has been shown to lessen the incidence of transition to present symptoms. However in some patients, a delay between onset of injury and the start of therapy presents an increase risk to develop chronic symptoms.

Question 61

WAD: What are best practice intervention reccomendations for the acute stage? (5 points)

Answer 61

1. Education alone does not provide a significant benefit, but oral and video info may be more effective than pamphlets 2. Immobilization with a soft collar is less effective than active exercise and no more effective than advice to act as usual 3. Active exercise results in reduced pain intensity and may improve ROM 4. the use of pulsed electromagnetic field therapy and acupuncture are not supported 5. some evidence supports mythylprednisone infusion but no firm conclusions are possible

Question 62

WAD: What are best practice intervention reccomendations for the subacute stage? (7 points)

Answer 62

1. supervised exercise my be more effective than unsupervised exercise in the short term 2. earlier therapy appears more effective than later therapy 3. fitness and aggressive work-hardening programs may be counterproductive or detrimental to recovery 4. An interdisciplinary approach of psychological counseling and exercise may be more effective in reducing pain and sick leave than passive therapy modalities 5. Interdisciplinary treatment may result in an earlier return to work 6. some evidence supports thoracic and cervical joint manips in the short-term for pain relief and improved motion, but definitive conclusions cannot be made 7. Botulinum toxin injections do not appear to be more effective than placebo

Question 63

WAD: What are best practice intervention reccomendations for the chronic stage? (7 points)

Answer 63

1. Exercise programs are effective in reducing pain but not in the long term 2. Specific exercise protocols (as discussed on pg 565 in book) appear to be effective, but more research is needed 3. The majority of studies support interdisciplinary intervention of PT and psychological counseling intervention 4. Evidence to support joint manip is insufficient 5. limited evidence supports myofeedback training 6. Gestalt therapy, Rosen method bodywork, and craniosacral therapy are not supported 7. considering a review of surgical and injection-based interventions for chronic WAD, the strongest research supports radiofrequency neurotomy for whiplash-related pain, although the relief is not permanent.

Question 64

Cervical Exam: Upper Quarter Neuro Screen Practice/Describe/Think it through (basically what we learned last year)

Answer 64

MYOTOMES: * C1/2- Neck flexion * C3- Neck lateral flexion * C4- Shoulder elevation * C5- Shoulder abduction * C6- Elbow flexion and wrist extension * C7- Elbow extension and wrist flexion * C8- Thumb extension * T1- Hand intrinsics (finger abduction) DERMATOMES: 1. C1- Top of the head 2. C2- Side of the head 3. C3/4- **Lateral neck** and top of the shoulder 4. C5- **Lateral** shoulder and **arm** 5. C6- Lateral forearm, **thumb**, index finger 6. C7- **Middle** and ring fingers 7. C8- Ring and **little fingers** 8. T1/2- **Medial forearm** and arm DEEP TENDON REFLEXES: * C5- Biceps * C6- Brachioradialis * C7- Triceps UPPER MOTOR NEURON SCREEN: * Hoffmann’s Sign: ‘flick’ distal phalanx of middle finger; (+) if thumb flexes in response * Babinski: stroke lateral sole of foot firmly proximal to distal; (+) if great toe extends and other toes ‘splay’ * Clonus: with patient relaxed, quickly dorsiflex ankle to end range; (+) if ankle ‘beats’ repeatedly toward plantar flexion

Question 65

Cervical Traction Indicaations (from last year) (5)

Answer 65

**_Indications:_** 1. Nerve impingement 2. Hypomobility of joints from degeneration changes 3. Joint pain from facet joint impingements 4. Muscle guarding/spasms 5. Herniated disc

Question 66

Effects of cervical traction (2 points from last year)

Answer 66

**_Effects:_** * Reduces pain and paresthesia form nerve root impingement * Reduces amount of pressure on nerve roots, assists in circulation, and decrease muscle guarding and spasm

Question 67

Clinical Guidelines for Cervical Traction from last year (HNP and Joint dysfunction DDD) * position * weight * angle of pull * ON:OFF * Duration * Steps Other note

Answer 67

**Cervical Spine - HNP:** * 7% patient body weight – supine * No more than 30lbs * Angle of pull: supine - 20 degrees * ON:OFF time: 60:20 * Duration: Begin with 3-5 minutes progress to 15 minutes * Steps: 1^st time begin with 3 steps, if tolerated 2 steps **Cervical Spine – Joint Dysfunction DDD:** * 7% patient body weight – supine * No more than 30lbs * Angle of pull: supine \> 20 degrees * ON:OFF time: 30:10 (intermittent) * Duration: Begin with 10-12 minutes progress to 20 minutes * Steps: 1-2 steps per patient comfort/tolerance Note: PT/PTA need to remain by patient for one full cycle

Question 68

Steps to Setting up Cervical Traction from last year

Answer 68

**_Steps to Setting up Cervical Traction_** 1. Head Position * Occiput halter: at base of skull - occiput 2. Tighten: * Head strap * Occiput halter 3. Turn on unit and set: * Duration * ON/OFF time * Choose steps 4. Give patient Alarm/Safety switch 5. Remain by patient for one full cycle **\*\*\*If patient s/s increase discontinue and reassess parameters\*\*\***