posture & muscle length
You suspect a cervical extension movement coordination disorder is the cause of your patients underlying pain and weakness. What postures, sustained motions and repetitive motions do you want to assess?
Seated posture
Standing posture
Sleeping posture
Quadruped
Quadruped rock back
Posture with chin tuck cue
Supine and prone head lifts
Shoulder elevation and loading
Your patient reports neck pain after sitting at her desk working on her computer all day. What test could you use to assess her deep neck flexor endurance? Demonstrate it.
Cranio-cervical flexion test (CCFT)
Use of biofeedback cuff under cervical lordosis
Inflate to 20 mmHg
Increase 2 mmHg and hold 10 seconds
Goal: at least 26 mmHg
Your patient reports difficulty looking turning to look at cars when they are driving, and pain with looking up at the ceiling. What are your top priorities for testing ROM? What are the normal values?
Priorities = extension and rotation
Extension = 60
Rotation = 80
Your patient complains of numbness and tingling from their neck down their R arm. You suspect that it is coming from the C4-C5 nerve root. Perform the dermatome test for C-C5.
Dermatome - sensory
C4 = superior shoulder
C5 = lateral deltoid
Your patient reports numbness and tingling along the 4th and 5th digits, as well as the medial forearm. What ULNT would be most appropriate to perform? Demonstrate it.
ULNT 3 = ulnar
Pt supine with legs extended
PT stand facing pt head
Kuckled hand at superior shoulder to prevent shoulder elevation
GH ER
GH abd 90-100 deg
Elbow flexion
Forearm pronation
Wrist and finger ext
Add elbow flexion
Your patient is demonstrating excessive cervical extension in all postures. What influences down the chain would you observe? What ICF category would you classify the patient?
PPT = lumbar flexion = thoracic flexion = cervical extension
Cervical extension movement coordination syndrome
You predict weakness of cervical neck extensors. Demonstrate neck extensor MMT for capital vs cervical extensors.
Capital
Prone w/ arms flat
Pt looks up
PT grab occiput and try to bend head down
Cervical
Prone w/ arms flat
Pt perform posterior/upward translation of head
PT stabilize thoracic spine and apply inferior force to occiput
You perform cervical ROM testing in all directions. They had pain with extension and rotation. However, flexion and lateral side bending did not provoke symptoms. Perform overpressure ROM testing as appropriate.
No overpressure to extension or rotation b/c they caused pain
Overpressure to flexion and lateral flexion
Flexion: stabilize T spine and apply pressure on posterior head
Side bend = stabilize opposite side and apply pressure on side of head
As of recent, your patient reports dropping coffee mugs and has had difficulty writing with pens. Which myotomes are a priority to assess? Demonstrate them.
UE myotomes = strength
C6 = elbow flex/wrist ext
C7 = elbow ext/wrist flex
C8 = thumb ext
T1 = finger ABD/ADD
Your patient c/o sharp burning along the anterior forearm, in addition to their middle fingers. What ULNT would be most appropriate to perform? Demonstrate it.
ULNT 1 = median nerve
Pt supine with legs extended
PT stand facing pt head
Kuckled hand at superior shoulder to prevent shoulder elevation
GH abduction 90-100 deg
Wrist and finger ext & forearm supination
GH external rotation
Elbow extension
ULNT 2 = median nerve
Pt at diagonal with legs extended
PT stand facing pt feet
Use thigh to depress scapula
GH abd 10 deg
Elbow extension, ER of arm
Wrist and finger extension
GH abduction
Your patient presents with rounded shoulders. Social hx includes hitting chest 5 days a week at the gym and working on computer all day for IT. What posture are you predicting? Perform 1 appropriate muscle length test.
Forward head posture, thoracic kyphosis
Muscle length: pec minor, pec major,
How would you grade a neck flexor MMT if the patient was only able to flex their neck through the partial ROM? What is the grading scale for cervical MMTs?
Grading
5 = max pressure
4 = mod pressure
3 = full ROM
2 = partial ROM
1 = palpation
0 = no movement
You suspect that your patient will have limited flexion mobility at C5. What type of joint mob would be most appropriate to assess? Demonstrate it and explain how you are finding the appropriate vertebrae?
CPA at C5
Your patient loves to watch medical shows, and asks if you can do the “test where you hit their knee to make them kick”. You realize that you forgot to assess UE DTRs. Perform them now! How would you score them?
C6 = biceps
C5-6 = brachioradialis
C7 = triceps
Grades: 2+ = normal, 1+ = diminished, 0 = absent, 3+ = brisk, 4+ = hyperreflexive
Your patient presents to the clinic with [gasp] wrist drop with tinlging along the back of the hand and thumb! You suspect that the ___ nerve may be involved, and perform the most appropriate ULNT. Demonstrate it.
ULNT 2b = radial nerve
Pt at diagonal with legs extended
PT stand facing pt feet
Use thigh to depress scapula
GH abd 10 deg
Elbow extension, IR of arm n
Wrist and finger flexion, add ulnar deviation and thumb flexion
GH abduction
Your patient presents to the clinic with forward head posture, and complains of tightness in their neck and shoulders are a long day of work. What muscles of the neck are you predicting to influence this posture? Demonstrate palpation of these muscles.
Upper trap
Levator scapula
Anterior, middle, posterior scalenes
SCM
Suboccipitals
When assessing posture and movement patterns, you notice that your patient has excessive forward head posture. What test could you use to assess her deep neck flexor endurance (other then CCFT)? Demonstrate it. What value are you looking for?
Neck flexor endurance test - deep neck flexors (longus colli/capitis)
Hooklying
Chin maximally retracted and held isometrically
Lift head and neck 1 inch off table
Maintain chin tuck
Observe for skin folds
Mean time = 38.95 seconds
You decide to test upglides and downglides on your patient. Which PPIVM is related to opening of the facet? What about closing? Demonstrate both.
PPIVM = passive physiological intervertebral motion
Upglide = opening of facet
Supine w/ head supported
Articular pillar
Upward rotation force towards eyes
Downglide = closing of facet
Supine w/ head supported
Articular pillar
Downward glide towards opposite shoulder
You are concerned that your patient has an UMN issue. What are 2 tests that you can do to rule this out? Demonstrate them.
Hoffman’s
Babinski
You suspect that your patient is experiencing radiating pain due to a nerve root compression. You want to confirm this hypothesis by performing the Spurling’s and Distraction tests. In which order should you perform these and why? Demonstrate it.
Spurling first bc it provokes symptoms, followed by distraction to relieve symptoms
Nerve root (radicular s/s)
Spurlings = symptom provocation…SPIN = 0.86
Seated
Apply axial loading in neutral
If no s/s, repeat in lateral flexion
+ = pain radiates into arm
Reverse spurling = pain felt on opposite side = muscle spasm
Distraction = symptom alleviation..SPIN = 0.90
Seated or supine
One hand under pt chin, and the other around occiput
Apply traction (2X as much force as spurling)
+ = pain is relieved
Your patient presents with forward head posture. How would you measure this? What are normal values. Demonstrate.
Craniovertebral angle
Line connecting C7 and tragus in relation to horizontal w/ a goniometer
Normal = 48.8 (standing) or 42.8 (sitting)
Your patient presents to PT with c/o neck pain. After testing MMTs, they present with strength deficits. You suspect that they have strength deficits down the chain at the shoulder. Demonstrate 2 shoulder MMTs you predict to be weak.
Lower trap = prone with arm abd ~130 deg
Middle trap = prone with shoulder abd 90 deg and elbow slightly flexed
Rhomboid = prone with shoulder IR and hand resting on lower back
Supraspinatus = seated shoulder ABD 90 deg
Infraspinatus = seated shoulder ER w/ arm by side of body
Your patient has been complaining of tight upper traps. They say that no matter how many massages they get, it still feels firm. You palpate and realize that “oh no!” it is their 1st rib. Demonstrate an assessment 1st rib mobility.
Supine
Cervical spine slightly flexed, ipsilateral SB and ipsilateral rotation
Apply inferior, medial and anterior force towards opposite ASIS
Seated
Pt arm draped over knee
Use webspace of hand to apply inferior, medial and anterior force aimed towards opposite knee
My favorite number is 7! Perform the dermatome and myotome testing for C7!
Dermatome = distal 3rd digit
Myotome = elbow ext/wrist flex
Your patient reports pain, numbness and tingling down their R arm when they wake up in the morning. You suspect thoracic outlet syndrome. What is one test you can perform to confirm this hypothesis? Demonstrate it.
Thoracic outlet syndrome
ULTT of Elvey
Seated w/ arms out to side
Flex wrist
Move head into Lr and R lateral flexion
+ = provoke s/s
90 deg ABD, ER stress test (EAST)
90 deg abd
90 deg ER
Pump hands (make fist)
+ = provoke s/s
Cyriax release test….SPIN = 0.97
Elevate pt shoulder girdles by lifting forearms
Lean pt trunk posteriorly by 15 deg
Hold up to 3 min
+ = release phenomenon occurs = provoke symptoms