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LCCW Student Clinic 1 - Lab Midterm
Terms in this set (85)
What is the normal ROM for cervical flexion, extension, lateral flexion, and rotation?
Flexion - 50
Extension - 60
Lat flexion - 40
Rotation - 80
With normal cervical flexion, the chin should approach within _________ of the chest.
2 fingers breaths.
With normal cervical extension, the plane of the face does not become horizontal, however a line between the ________ and the ________ does become parallel to the floor.
Forehead and the tip of the nose.
With normal cervical lateral flexion, the head moves approximately ________ to the shoulder.
With normal cervical rotation, the chin ________ the ________, but does not quite become parallel to it.
Approximates the shoulder.
Thoracic outlet syndrome (TOS) includes what syndromes?
-Cervical rib syndrome.
-Scalenus anticus syndrome.
-Pectoralis minor syndrome (hyperabduction syndrome).
What is the purpose of the cervical compression test and its variations?
To see if increased pressure on the cervical spine structures creates or exacerbates pain.
What are the exam findings and indications for the cervical compression test?
-Creation or exacerbation of local cervical spine pain suggests
(subluxation, DJD, trauma, etc.). Ill-defined, diffuse pain into the shoulder, or arm, and may be present due to sclerogenic referral.
-Creation or exacerbation of pain, tingling, and numbness in the upper extremity (especially in a dermatomal distribution) suggests
(which can result from disc herniation or IVF stenosis).
What are the variations of the cervical compression test?
-Lateral flexion (Jackson's test).
What is the maximum cervical compression maneuver?
This is an active motion test utilizing a combination of 2 head positions to narrow the IVF. With the patient seated, the examiner instructs the patient to rotate and extend their head (compression is not applied).
What are the possible findings for the maximum cervical compression maneuver?
-Local cervical spine pain suggests
(subluxation, DJD, trauma, etc). Ill-defined, diffuse pain into the shoulder or arm may be present due to sclerogenic referral.
-Pain, tingling, and numbness in the upper extremity (especially in a dermatomal distribution) suggests
What is the Spurling test and modified Spurling test?
These are compression tests with the head in the maximal cervical compression maneuver position. The modified version is preferred because a more controlled force is utilized.
What is the Spurling test?
The examiner places one hand on top of the patient's head and delivers a vertical blow to the top of the patient's head with the other hand.
What are the exam findings for a modified Spurling's test?
-Creation or exacerbation of
local cervical spine pain
suggests joint involvement (subluxation, DJD, trauma, etc.). Ill-defined, diffuse pain into the shoulder or arm may be present due to sclerogenic referral.
-Creation or exacerbation of pain, tingling, and numbness in the upper extremity (especially in a dermatomal distribution) suggests
What is the cervical distraction test?
The main purpose of this test is to see if decreased pressure on cervical spiine structures reduce pain.
-With the patient seated, the examiner stands at the side of the patient and places one hand under the patient's chin and the other under the base of the occiput (or one hand on either side of the head without pressing in on ears). With gradually increasing force, lift the patient's heat to remove it's weight from the neck. Hold for 30-60 seconds.
What are the exam findings and significance for the cervical distraction test?
suggests joint involvement (subluxation, DJD).
pain, tingling, & numbness in the upper extremity
suggests cervical radiculopathy (due to IVF stenosis or IVD P/P).
Discomfort or pain may be produced by this procedure as a result of soft tissue injury
What is the Valsalva maneuver?
increases intrathecal (CSF) pressure
and helps to identify radiculopathy caused by a space-occupying lesion.
-With the patient seated, the examiner instructs the patient to take a deep breath, hold it, and "bear down" as if trying to move their bowels.
-Be cautious, because the patient may become lightheaded or pass out during, or shortly after this test.
What are the findings and significance of the Valsalva maneuver?
-Production or exacerbation of radiation into the upper extremity, especially in a dermatomal pattern.
-A positive finding suggests that a radiculopathy due to compression by a space occupying mass (disc protrusion/prolapse, tumor, osteophytes) is present.
What is the shoulder depression test?
This test is primarily known as a test for nerve root dural sleeve adhesions, however, it also causes stretching of muscles, and ligaments.
-With the patient seated, the examiner stands behind the patient and laterally flexes the patient's head away and then depresses the shoulder.
-This procedure causes stretching of muscles/tendons, ligaments, and spinal nerves on the side of shoulder depression.
What are the findings and significance of the shoulder depression test?
-Creation or aggravation of pain & paresthesia in the upper extremity, especially in a dermatomal distribution, suggests
nerve root dural sleeve adhesions
-More commonly, neck and shoulder pain is created or aggravated by this test, when
muscle spasm, strain, or ligament sprain
-Depression of the shoulder may cause depression of the clavicle and narrowing of the costoclavicular space causing upper extremity pain if
What is Lhermitte's sign?
(spinal cord disorder) of the cervical spinal cord.
-With the patient seated, passively flex the patient's head toward their chest.
What is a positive Lhermitte's sign?
Sharp pain down the spine and into the upper or lower extremities.
What is the significance of Lhermitte's sign?
A positive sign suggests cervical myelopathy.
Lhermitte's sign is NOT diagnostic for MS. Some people say that it is pathognomonic. You can have MS without Lhermitte's sign and vice versa.
What may cause a positive Lhermitte's sign?
-Myelopathy associated with cervical spondylosis and spinal canal stenosis.
-Central disc protrusion/prolapse.
Lhermitte's sign should be reported whenever flexion of the neck produces pain radiating down the spine regardless of position.
Ex// During the Soto-Hall or Brudzinski tests.
What is Soto-Hall test?
This test is often noted as a test for fracture, however pain and restriction is more commonly due to cervical joint disorder or posterior soft tissue involvement.
-If fracture is suspected, the radiographic exam should be done prior to ROM and orthopedic exams.
-With the patient supine, the examiner places their caudal hand on the patient's sternum and exerts slight pressure to prevent the thoracic spne from flexing during the test. The examiner's cephalad hand is placed under the occiput and passively flexes the patient's head to their chest.
What is the mechanism associated with the Soto-Hall test?
-It compresses the vertebral bodies anteriorly.
-It posteriorly tractions the nuchal ligament and pulls on the spinous processes. Posterior musculature is stretched.
What are the findings/significance of the Soto-Hall test?
-Cervical joint disorder (subluxation, DJD, trauma).
-Posterior cervical muscle spasm or strain.
-Posterior cervical ligament sprain.
-Fracture of the vertebral bodies (compression) or spinous process.
-If cervical myelopathy is present, pain may radiate down the spine and into the upper or lower extemities (see Lhermitte's sign).
-If meningitis is present, the hips and knees may flex (see Brudzinski's sign).
What is Brudzinski sign?
Flexion of the head causes stretching of the dural sac and spinal cord.
-With the patient supine, the examiner flexes the patient's head to their chest (without sternal stabilization).
-Positive sign is flexion of the hips and knees.
What is the significance of a positive Brudzinski sign?
What are the Adson and modified Adson tests?
-With the patient seated, the examiner palpates the radial pulse noting its strength, and then slightly abducts, extends, and externally rotates the patient's arm.
-The patient is instructed to rotate their head
, extend their head, and take a deep breath and hold for 10 seconds.
-For modified, the patient rotates their head
-The examiner checks the radial pulse for decreased intensity and questions the patient aboud creation or aggravation of symptoms of arm pain or paresthesia.
What are the findings for the Adson and modified Adson tests?
-Creation or exacerbation of the patient's complaint of pain and paresthesia in the upper extremity (often in lower trunk, C8-T1 distribution).
-Decreased intensity of the radial pulse.
What is the significance of the Adson and modified Adson tests?
TOS, most likely either cervical rib or scalenus anticus subgroups.
-Does not differentiate between the two.
-Presence of a cervical rib on x-ray will support a diagnosis of cervical rib syndrome, while absence will support scalenus anticus syndrome.
What is the costoclavicular test?
-With the patient seated and hands resting at their sides, the examiner stands behind the patient and reaches forward to palpate the radial pulse, noting its strength.
-The examiner brings the patient's arms back and then instructs the patient to bring their shoulders "back and down" and the "flex their chin to their chest."
-Note if amplitude of the radial pulse has decreased, and question the patient about creation or exacerbation of arm pain or paresthesia.
What is Eden's test?
With the patient seated, the examiner palpates the radial pulse and then depresses the patient's shoulder unilaterally. Associated with the costoclavicular test.
What do the costoclavicular and Eden's test do?
decrease the space between the clavicle and the 1st rib
(costoclavicular space) and may cause compression of the neurovascular bundle.
What are the positive findings and significance of the costoclavicular and Eden's tests?
-Creation or exacerbation of the patient's upper extremity pain, tingling, and numbness.
-Decreased amplitude of the radial pulse.
-Indicates TOS, most likely costoclavicular syndrome.
What is Wright's test? Aka?
-Aka hyperabduction test.
-Tests for Pectoralis Minor Syndrome.
-With the patient seated, palpate the radial pulse noting its intensity and then slowly abduct the patient's arm to 180 degrees while monitoring the radial pulse for decreased amplitude.
What are the positive findings and significance for Wright's (hyperabduction) test?
-Creation or exacerbation of the patient's complaint of pain and paresthesia in the upper extremity (often in a lower trunk, C8-T1 distribution).
-Decreased intensity of the radial pulse.
-Significance is TOS, most likely Pectoralis Minor syndrome.
What follow-up tests should be performed after a positive Wright's (hyperabduction) test?
Other TOS tests (Adson's, modified Adson's, costoclavicular, Eden's, EAST, etc.)
What is the upper limb tension test (ULTT)? Akas?
-Aka the SLR of the upper extremity.
-Aka the upper limb neurodynamic test (ULNT).
-The procedure tensions peripheral nerves in the upper extremity (possibly with a median nerve bias), the brachial plexus, and cervical spinal nerves.
-With the patient supine or seated and the patient's elbow bent, the examiner abducts the patient's upper extremity to slightly above 90 degrees and then externally rotates the extremity. The examiner then extends the patient's wrist and slowly extends the elbow. If the patient's UE symptoms have not been created or exacerbated, then instruct the patient to laterally flex the head away from the side being examined.
What are the abnormal findings and significance of the upper limb tension test (ULTT)?
-Creation/exacerbation of P/T/N in the upper extremity.
-Significance is not specific, but is sensitive to possible peripheral nerve disorder (median nerve bias), possible brachial plexus irritation, or possible cervical radiculopathy.
What are the lumbar ROMs?
-Everything else: 30
What is Kemp's test?
This low back test is similar in mechanism to the modified Spurling test in the cervical spine.
-With the patient seated or standing, bend the patient obliquely backward. If the patient is standing, it is necessary to stabilize the pelvis.
-Creation or exacerbation of radicular pain in the lower extremity indicates radiculopathy.
-Creation or exacerbation of low back pain indicates local joint involvement.
How is Kemp's test sensitive to antalgic lean?
Since a lateral disc protrusion may cause the patient to lean away from the side of leg pain, Kemp's test may exacerbate the radicular pain when bending the patient toward the side of leg pain. Since a medial protrusion may cause the patient to lean toward the side of leg pain, Kemp's test may exacerbate the radicular pain when bending the patient away from the leg pain.
What is the supported forward bending test (Belt test)?
This test helps differentiate lumbar and sacroiliac disorders.
-Part 1: Unsupported lumbar flexion. Patient standing. Ask the patient to bend forward at the waist. Note pain in the lumbar or SI region.
-Part 2: Supported lumbar flexion. Stabilize the patient's sacrum with your hip and support the ilia with your hands. Ask the patient to bend forward again. Note pain.
-Pain elicited upon unsupported flexion, but reduced upon supported flexion (which stabilizes the SI joint) indicates a
-Pain elicited upon both unsupported & supported flexion indicates a
What is the Straight Leg Raise?
-The SLR is primarily known as a test for lumbosacral radiculopathy, sciatic neuropathy, and their causes (IVD protrusion and IVF stenosis, and piriformis syndrome).
-The doctor stands facing the supine patient on the side of involvement. Place one hand under the heel and the other on the knee. Slowly flex the hip while maintaining the knee extension. Estimate the angle at which pain or restriction occurs.
-The test may also be painful and/or restricted due to tight hamstrings, hip joint, SI joint, or lumbar joint disorders. - So it is NOT diagnostic for LS Radiculopathy.
What is the mechanism of the straight leg raise?
-As the leg is raised, movement occurs at the hip joint, followed by the SI joint, and then the lumbar joints.
-Tension is first developed in the sciatic nerve, and then as the leg is raised higher, in the contributing nerve roots (particularly L5, S1, and S2).
-The first 35 degrees of hip flexion takes up the slack in the sciatic nerve, and there is no dural movement. Between 35-70 degrees, the contributing nerve roots tense over the intervertebral disc. The nerve roots are essentially fully stretched by approximately 70 degrees, and little further deformation of the roots occurs above this level.
What are the normal and abnormal findings for the straight leg raise?
-Normal is 70-80 degrees without pain.
-Abnormal is any restriction, and/or pain in the back or the leg. With regard to sciatica and radiculopathy, P/T/N below the knee would be a more specific positive finding. Dull posterior thigh pain suggests tight hamstrings.
What is the significance of the straight leg raise?
-Significance is relative to the angle at which pain is elicited or exacerbated.
-Between 0-35 degrees of hip flexion may be due to: SI joint disorder, or sciatic neuropathy (Piriformis syndrome, etc.)
-Between 35-70 degrees of hip flexion may be due to radiculopathy associated with IVD protrusion, or IVF stenosis.
-Above 70 degrees of hip flexion suggests lumbar joint pain.
What is the Braggard test used for?
This test is performed as a follow-up to an abnormal SLR in order to help differentiate pain of nerve etiology (sciatic neuropathy, or radiculopathy) from that of other causes (SI or lumbar joint disorder, or tight hamstrings).
The leg is lowered slightly to reduce strain
on all the structures possible responsible for the increased pain on SLR (hamstrings, hip joint, SI joint, lumbar joints, and sciatic nerve).
The foot is then dorsiflexed in order to recreate the tenson on the nerve structures
-When the test recreates the pain that the SLR previously created, it
indicates that the origin of the pain is neural
(sciatic neuropathy or radiculopathy).
What is Bonnet's test?
SLR with adduction and internal rotation.
-The hip motions cause stretching of the piriformis muscle and may exacerbate sciatic pain due to entrapment in the piriformis muscle (piriformis syndrome).
-Indicates sciatic neuropathy due to entrapment in the piriformis muscle (piriformis syndrome).
What is Sitting Laseque test?
It is a seates sciatic nerve - spinal nerve tension test. (Seated version of the SLR).
-With the patient seated and with no backrest, the examineer slowly extends the patient's leg at the knee.
-If the knee extension creates or exacerbates the back or leg P/T/N (especially below the knee, and in a dermatome distribution), sciatic neuropathy, or radiculopathy is indicated.
How can the Sitting Laseque test be used to see if someone is faking injury?
It can be performed under the guise of checking curculation, or the feet in order to try to identify false reporting during the SLR.
What is the Slump test?
Perform the sitting Laseque test. If negative for radicular symptomatology, dorsiflex the patient's foot (increases sciatic nerve tension). If still negative for radicular symptomatology, have the patient slump, flexing their head and thoracic spine (adds cord/meningeal contraction). If still negative, you may have the patient bear down as if straining to move their bowels.
-Indicates lumbosacral radiculopathy.
What is the Well Leg Raise test?
The WLR test is a SLR on the unaffected side. Slowly raise the unaffected leg with the knee straight.
-Positive finding is production/exacerbation of back and leg pain on the uninvolved side (contralateral to the leg being raised).
-This is one of the
best clinical indicators of radiculopathy due to IVD syndrome
, especially medial herniations.
High specificity, but low sensitivity
What is the mechanism of the well leg raise?
Raising the unaffected leg tractions the sciatic nerve and lumbar nerve roots on that side, and causes the contralateral nerve roots to be pulled toward the midline.
What is Fajersztajn's test?
It is a Braggard test performed after a positive WLR.
-With the patient supine, the unaffected leg is raised until pain is created or exacerbated on the contralateral side. The leg is lowered slightly to ease the pain on the contralateral side and the foot is dorsiflexed.
-Increase in radicular symptomatology indicates disc protrusion/prolapse, usually medial to the nerve root.
What is the Belt test?
With the patient standing, ask them to bend forward at the waist and note any pain in the lumbar or SI region. Then stabilize the patient's sacrum with your hip and support the ilia with your hands. Ask the patient to bend forward again and note any pain.
-Pain with unsupported flexion and not on supported flexion indicates SI lesion.
-Pain with both indicates a lumbar lesion.
What is the Fabere Patrick test?
This examination stresses the SI joint via the hip joint.
-With the patient supine, flex the knee on the side being tested, then abduct and externally rotate the hip, bringing the foot across the opposite knee. Stabilize the opposite ASIS and exert downward pressure on the knee (hip extension).
-Pain in the SI region indicates SI disorder. Restricted motion of the hip, or pain in the hip or inguinal region may indicate a hip disorder.
What is Gaenslen's test?
With the patient supine and the affected side close to the edge of the table, have the patient draw the knee on the unaffected side toward their chest. Slowly lower the involved extremity over the edge of the table and press downward on the extended leg while pushing the patient's knee into their chest.
-Pain in the SI joint indicates SI joint lesion.
What is the Nachlas test?
This test stresses the SI joint and the lumbar spine.
-With the patient prone, apply pressure to the sacrum and flex the heel to the ipsilateral buttock.
-Pain in the region of the SI joint indicates SI involvement. Lumbar pain indicates lumbar involvement. Aching, pulling sensation in the anterior thigh indicates tight quadriceps. Sciatic-like sensation down the anterior thigh indicates femoral neuropathy or upper lumbar radiculopathy.
What is Ely's sign?
Similar to Nachlas test, but without pelvic stabilization.
-With the patient prone, the examiner flexes the patient's knee, bringing the heel toward the ipsilateral buttock.
-Positive sign is when the pelvis on the side being tested lifts off the table. It is indicative of tight rectus femoris.
What is Yeoman's test?
Tests SI joint and lumbar spine.
-With the patient prone, apply pressure to the suspected SI joint and flex the heel to the ipsilateral buttock while extending the hip by lifting the knee off the table.
-Pain in the region of the SI joint indicates SI joint lesion. Also stresses the lumbar spine, can have tight quads, and may elicit sciatic-like sensation down anterior thigh.
What is Hibb's test?
SI joint test, but also stresses the hip joint and stretches the piriformis muscle.
-With the patient prone, stand on the side opposite to that being tested. Stabilize the pelvis by placing a hand on the sacrum and then flex the knee to 90 degrees and rotate the foot outward.
-SI pain indicates lesion. Hip pain indicates a hip disorder.
-Moving the foot laterally causes internal rotation on the hip. Piriformis spasm would cause restriction of the hip rotation.
What is the Trendelenburg test?
It assesses the ability of the gluteus
to stabilize the pelvis on the femur.
-With the patient standing and holding onto a support for balance if necessary, the examiner observes from behind and instructs the patient to raise one foot off the floor. The examiner observes the level of the iliac crest, sacral dimples, or gluteal folds.
-Drooping of the pelvis on the unsupported side indicates weakness of the gluteus medius on the supported side.
What is Schepelman's test?
With the patient seated, they laterally bend to each side.
-Pain on the side of lateral flexion (concave side) indicates intercostal neuritis.
-Pain on the opposite side (convex side) indicates intercostal myofascitis, or possible pleural inflammation,
Muscle strength grading scale.
-5: Full ROM against gravity and normal resistance.
-4: Full ROM against gravity and some resistance.
-3: Full ROM against gravity.
-2: Full ROM with gravity removed.
-1: No motion, but slight contractility.
-0: No motion, no contractility.
DTR grading scale.
-4+: Markedly hyperactive; may be associated with clonus.
-3+: Brisker than average.
-1+: Present, but diminished.
-1+(R): Only present with reinforcement.
-O(R): Absent (areflexia).
C5 muscle strength testing.
Deltoid (axillary n).
C5 reflex testing.
Biceps (musculocutaneous n.)
C5 sensory testing.
C6 muscle testing.
-Biceps (musculocutaneous n.)
-Wrist extensors (radial n.)
C6 reflex testing.
Brachioradialis (radial n.)
C6 sensory testing.
C7 muscle testing.
-Triceps (radial n.)
-Wrist flexors (median + ulnar nn.)
-Finger extensors (radial n.)
C7 reflex testing.
Triceps (radial n.)
C7 sensory testing.
L4 muscle testing.
Anterior tibialis (peroneal nerve deep branch).
-Dorsiflexion and inversion.
L4 reflex testing.
Quadriceps (patella) reflex (femoral n.)
L4 sensory testing.
L5 muscle testing.
-Dorsiflexors (deep branch peroneal n.)
-EHL (deep branch peroneal n.)
L5 reflex testing.
Medial hamstring (sciatic n.)
L5 sensory testing.
S1 muscle testing.
-Plantarflexors (tibial n.)
-Evertors (superficial branch peroneal n.)
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