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What is the function of the cervical spine?
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OPP Test 3
Lectures 18-23
| Question | Answer |
|---|---|
| What is the function of the cervical spine? | to stabilize and support the head; to permit motion of the head and neck; and to provide protection and housing for the cervical spinal cord, nerve roots, and the vertebral artery |
| Is neck pain more common in women or men? | women; this may be b/c the cervical vertebrae of women are not as robust |
| When neck pain is related to a motor vehicle accident, what ages have peak incidence? | 20-40 |
| What is the peak age of neck pain in the general population? | 30-59 |
| True or false: Neck pain is the most common musculoskeletal presentation. | False; neck pain is second to lower back pain |
| What fraction of ppl have an episode of neck pain during their lifetime? | 2/3 |
| What are some factors associated with neck pain and radiculopathy? | smoking, middle age, female gender, mental stress, dental/facial problems, obesity, other MSK pains, prolonged work with the hand above shoulder level |
| What are some co-morbid conditions associated with neck pain? | autonomic failure, CV disease, digestive system disease, dizziness, headaches, low back pain, shoulder pain, TMJ syndrome, etc. |
| How many cervical vertebrae are there? | 7 |
| What type of curve is displayed by the cervical spine? | lordosis |
| What is significant about the spinous processes from C2-C6? | they are bifid |
| What is the fxn of the uncinate process on the cervical vertebrae from C3-C7? | increased support for the cervical spine and prevention of herniation |
| Why do C1-C7 have a transverse foramen? | the vertebral artery runs through the foramen |
| What are the three distinct biomechanical areas of the cervical spine? | the occipital-atlantal segment, the atlantal-axial segment, and the typical cervical vertebrae |
| What is the occipital-atlantal segment? | the articulation of the occiput and the atlas |
| What is the atlantal-axial segment? | the articulation of the atlas and the axis |
| What is the function of the cervical muscles? | They stabilize the spine and control the effects of gravity. They also integrate cervical spine movement with thoracic, rib, and upper extremity motions. |
| Cervical muscles are divided into what two major groups? | flexors and extensors |
| What motions are enabled when the cervical muscles act bilaterally? | flexion and extension |
| What motions are enabled when the cervical muscles act unilaterally? | sidebending and rotation |
| How many cervical nerves are there? | 8 |
| Where do the nerve roots of C1-C7 exit? | ABOVE the corresponding cervical vertebrae (for example: C1 nerve root exits above the C1 vertebrae) |
| Where does the nerve root of C8 exit? | below the 7th cervical vertebrae (above T1) |
| Where do the rest of the nerve roots exit? | below the corresponding vertebrae (for example: the nerve root of T4 will exit below T4) |
| Where is the most common herniation in the cervical spine? | b/w C5 and C6 (the C6 nerve root) |
| What is the primary motion of the occipital-atlantal joint? | flexion and extension |
| What percent of cervical flexion occurs at the OA? | 50% |
| Does the cervical spine obey Fryette's mechanics? | NO |
| When sidebending is induced at the OA joint, what direction will rotation occur? | in the OPPOSITE direction |
| What is the primary motion of the atlantal-axial joint? | rotation (almost entirely) |
| What percent of cervical rotation occurs at the AA? | 50% |
| What happens to the facets during flexion of the cervical spine? | they open |
| What happens to the facets during extension of the cervical spine? | they close |
| In the cervical spine (excluding the OA joint), when sidebending occurs, what direction will rotation occur? | to the same side (sidebend left = rotate left) |
| When might you observe dorsokyphosis? | in patients with depression, advanced age, etc. |
| Sluggish movement of the cervical spine may be indicative of... | fibromyalgia, osteoarthritis, and/or cervical strain |
| What is torticollis caused by? | acute muscle spasm |
| Should you assess active or passive ranges of motion in the cervical spine first? | active |
| How should passive range of motion compare to active range of motion? | Passive range of motion should be equal to or greater than active range of motion. |
| What is the most sensitive indicator to pathology intrinsic to the neck? | loss of rotation (rotation to either side should be near 90 degrees with a smooth end feel) |
| If rotation of the cervical spine is less than 90 degrees, what should you do? | perform a neuro exam of the upper extremities and consider doing an x-ray to evaluate for osteoarthritis, cervical radiculopathy, and severe cervical strain. |
| What is another strong indicator of abnormal cervical function? | diminished ability to sidebend (should be greater than or equal to 45 degrees) |
| What is the most commonly irritated neck muscle? | the trapezius (remember, this muscle attaches to all 7 spinous process and the distal acromion process) |
| Muscle tenderness in the cervical spine may be indicative of... | trauma and/or cervical strain (think reactive whiplash, fibromyalgia, poor posture, etc.) |
| The Spurling maneuver is specific for... | radiculopathy, but it is not a sensitive test |
| How do you perform the Spurling maneuver? | Press on the top of the head while extended and sidebent |
| deltoid m nerve | C5 |
| wrist extensors nerve | C6 |
| wrist flexors nerve | C7 |
| finger flexors nerve | C8 |
| interossei m nerve | T1 |
| biceps reflex nerve | C5 |
| brachioradialis reflex nerve | C6 |
| triceps reflex nerve | C7 |
| What does the Wallenberg test asses? | for vertebral artery insufficiency |
| How do you perform the Wallenberg test? | with the patient supine, hold the head in extension, flexion, extension w/rotation right, and extension w/rotation left for ten seconds each |
| What is a positive Wallenberg test? | nystagmus, dizziness, lightheadedness, visual disturbance |
| What is contraindicated by a positive Wallenberg test? | HVLA |
| What would indicate cervical radiculopathy? | paracervical tenderness, abnormal upper extremity exam, loss of full ROM (especially rotation), positive Spurlings, and relief when vertical traction is applied |
| How might you treat cervical joint somatic dysfunctions? | You would treat the muscle tension and/or tender points with soft tissue, counterstrain, or MFR |
| What tests should you perform before treating cervical somatic dysfunction? | vertebral artery challenge test, cervical compression test, and beighton hypermobility screening |
| When should you obtain an x-ray before treatment? | when there is persistent muscle spasm and restricted range of motion, when the patient is apprehensive with active motion, when there is persistent inflammation, or when there is hypermobility |
| What is the most common cause of cervical strain and sprain? | whiplash |
| What is strain? | muscular injury |
| What is sprain? | ligamentous stretch injury |
| What are common cervical flexion injuries? | posterior muscle strain, interspinous ligament sprain, anterior vertebral body compression or fracture, disc herniation, and spinal stenosis |
| What are some common extension injuries? | anterior muscle strain, anterior ligament sprain, brachial plexopathy, and fracture of the dens (atlanto-axial subluxation) |
| What is at risk when there is a contusion caused by a shearing injury? | the facet joints and the meniscus |
| What is at risk for sprain caused by shearing injury? | the anterior longitudinal ligament, the facet capsule, and the anulus fibrosis of the disc |
| What is at risk for fracture caused by shearing injury? | the articular pillar, the subchondral plate, evulsion of the endplate, and the articular surface |
| If someone is sidebent and rotated (aka looking to the side) at the onset of whiplash... | neurological symptoms are more probably; this is b/c the cranial nerves may be subjected to stretch |
| True or false: Whiplash may result in facial/sinus pain, headache, ear pain, sensory disturbances, back pain, and/or pain in the extremities. | True |
| Victims of whiplash have a worse prognosis if... | they are older in age, are female, had initial neck pain, allowed time to pass b/w the accident and treatment, had high initial pain intensity, had lawyer involvement, and/or were injured while working. |
| What percent of whiplash patients have recovered at 3 months? | 56% |
| What percent of whiplash patients have recovered at 24 months? | 82% |
| Persistent restricted motion predicts... | chronic pain |
| Persistent restriction at 2 months is a good predictor of... | pain and disability at 2 years |
| Patient guarding with active ROM is a red flag for... | instability |
| Why is ROM at 3 months important? | it is a major prognostic indicator |
| How long after a whiplash injury should you wait to use direct techniques? | at least 2 weeks |
| During the first two weeks (acute stage) after injury caused by whiplash, how should you treat the patient? | indirect techniques, sympathetic normalization, and lymphatic drainage |
| If there is still pain after two weeks, you can add... | direct techniques and home flexibility |
| If there is still pain after 2 months, what can you do? | add injections and move on to multidisciplinary treatment |
| What is somatic dysfunction? | impaired or altered fxn of the related components of the somatic (body framework) system: skeletla, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements |
| What hypothesis is used to explain counterstrain and muscle energy? | the neurogenic hypothesis |
| True or false: Somatic dysfunction is, essentially, anything OMT can treat successfully if done well. | TRUE |
| The key to diagnosis of somatic dysfunction is... | making anatomic correlation with history, observation, and palpation. (Ask yourself: How and Where is the pain generated?) |
| What component of physiology are we concerned with when using counterstrain? | the neuromuscular component |
| afferent nerves | carry info from sensory receptors to the CNS |
| efferent nerves | carry info from the CNS to functional motor end organs |
| What is proprioception? | sensing of motion and position of the body in space |
| What is used for proprioception? | sight, hearing, the vestibular system, golgi tendon organs, and muscle spindle afferents |
| Nociception is carried out via... | nerve ending of unmyelinated C fibers that sense noxious stimuli and interpret them as pain |
| alpha motor nerves | activate muscle (outside of the muscle spindle) |
| gamma motor nerves | changes the base length of the muscle spindle (within the muscle spindle) |
| What do muscle spindles sense? | stretch, rate of stretch, and relative/absolute position in space |
| counterstrain hypothesis | trauma/sudden strain causes proprioceptive dysregulation; spindle afferents send inaccurate info to the muscle which maintains spasm at rest; lack of coordination of agonist/antagonist; dysfunctional hypertonia causes tenderness |
| counterstrain treatment allows... | alpha/gamma resetting |
| What is the competing model to the counterstrain model? | the nociceptive model |
| counterstrain/gamma gain hypothesis order of events: | postural imbalance - strain - NEURAL IMBALANCE - muscle spasm - tenderness - pain |
| nociceptive hypothesis order of events: | postural imbalance - strain - PAIN - neural imbalance - muscle spasm - tenderness |
| What are we trying to fix in the counterstrain/gamma gain hypothesis? | the neural imbalance b/c this is the cause |
| What are we trying to fix in the nociceptive hypothesis? | pain b/c this is the cause |
| Who developed the concept of osteopathy in the cranial field and the theory of the primary respiratory mechanism? | William G. Sutherland |
| What are the five components of the primary respiratory mechanism theory? | 1. motility of the brain and spinal cord 2. fluctuation of CSF 3. mobility of the intracranial and intraspinal membranes 4. mobility of cranial bones 5. involuntary mobility of the sacrum between the ilium |
| Cranial rhythm corresponds to... | pulse pressure fluctuation |
| Palpation of cranial mobility is termed... | cranial rhythmic impulse (CRI) |
| Cranial motion is described relative to... | the sphenobasilar synchondrosis |
| How does the SBS move in extension? | the SBS moves inferiorly; the examiner would feel the head getting longer and thinner |
| How does the SBS move in flexion? | the SBS move superiorly; the examiner would feel the head getting wider and fatter |
| What is the typical CRI rate? | 10-14 cycles/minute (Note: rate is determined from flexion to flexion...NOT flexion to extension) |
| amplitude of CRI measurement is the distance from... | flexion to extension |
| To diagnose cranial somatic dysfunction, check... | CRI rate, amplitude, and symmetry |
| What is a normal CRI amplitude? | 4-5 |
| True or false: Sacral motion is linked to cranial motion. | TRUE |
| The CRI can be palpated over the entire body as... | inherent motion (external rotation vs internal rotation) |
| coronal suture | articulation b/w the frontal and parietal bones |
| sagittal suture | articulation b/w the parietal bones |
| lambdoidal suture | articulation b/w the occipital and parietal bones |
| squamosal suture | articulation b/w the parietal and temporal bones |
| pterion | articulatory spot where the frontal, parietal, sphenoid, and temporal bones all meet |
| asterion | articulatory spot where the temporal, parietal, and occipital bones all meet |
| occipitomastoid suture | articulation b/w the occiput and temporal bones |
| bregma | where the coronal and sagittal sutures touch |
| lambda | where the lambdoidal and sagittal sutures touch |
| Indications for cranial manipulative therapy | headaches, sinus congestion, URI, CN entrapments, TMJ dysfxn/facial pain, cervical pain, mood disorders, otitis media, tinnitus, vertigo, colic, torticollis, feeding disorders, and plagiocephaly |
| Contraindications for cranial manipulative therapy | intracranial bleed, subdural/epidural hematomas, skull/facial fracture, infection of the brain/dura/meninges (during the acute phase of infection), seizure disorders, and CNS malignancies |
| What is the cranial base? | the portion of the skull made up of the sphenoid and occiput that is formed in cartilagenous bone rather than membranous bone |
| What is a synchondrosis? | a union of two bones formed by hyaline cartilage or fibrocartilage (allows for slight movement) |
| True or false: Most cranial base strain patterns are named in relation to what the SBS is doing. | FALSE...ALL cranial base strain patterns are named in relation to what the SBS is doing. |
| What axes are involved in flexion? | there are 2 parallel TRANSVERSE axes; during flexion the sphenoid and occiput rotate in opposite directions around the axes so that the SBS moves superiorly |
| What axes are involved in extension? | 2 parallel TRANSVERSE axes; the sphenoid and occiput rotate in opposite directions so that the SBS moves inferiorly |
| What are the physiologic cranial base strain patterns? | flexion/extension, torsion, and sidebending rotation |
| What are the non-physiologic cranial base strain patterns? | vertical strains (inferior and superior), lateral strains (right and left), and SBS compression |
| Which strain patterns (physiologic or non-physiologic) are usually caused by trauma to the head? | non-physiologic; physiologic strain patterns can be normal cranial motion and are not usually related to trauma |
| SBS torsion | the sphenoid and occiput rotate in OPPOSITE directions around a single ANTERIOR-POSTERIOR AXIS |
| How is SBS torsion named? | it is named for the greater wing of the sphenoid that is superior |
| SBS sidebending rotation | 1 ANTERIOR POSTERIOR AXIS (the sphenoid and occiput rotate in the same direction) and 2 VERTICAL AXES (occiput and sphenoid sidebend in opposite directions) |
| How is SBS sidebending rotation named? | for the side of convexity |
| What would cause an SBS vertical strain? | shearing forces at the SBS (such as a helmet to helmet hit at the top of the head) |
| Describe the movement associated with a vertical strain: | the sphenoid and occiput rotate in the same direction around parallel TRANSVERSE AXES; this rotation causes the sphenoid to shift either superior or inferior to the occiput |
| How is vertical strain named? | named for relative position of the sphenoid base to the occipital base. b/c we are monitoring the greater wing of the sphenoid, naming is opposite to what is felt. if you feel the sphenoid move superiorly, it is an inferior vertical strain. |
| What might cause an SBS lateral strain pattern? | a shearing force applied just anterior or posterior to the SBS (for example: a bat hitting someone on the side of the head) |
| Describe the movement associated with a lateral strain: | the sphenoid and the occiput rotate in the same direction (either clockwise or counterclockwise) around 2 parallel VERTICAL AXES |
| How would lateral strain feel to the practitioner? | While in the vault hold, both index fingers would point in one direction while the pinkies point in the opposite direction |
| How is lateral strain named? | for the position of the basi-sphenoid in relation to the basi-occiput. (if your index fingers move left, it is a right lateral strain. if your index fingers move right, it is a left lateral strain.) |
| What might cause SBS compression? | a severe blow to the head, fever, or a metabolic problem |
| How is SBS compression classically described? | as a "bowling ball head" or as a "bag of worms" |
| Describe the developmental difference b/w the cranial vault and the cranial base: | Embryologically, the cranial base is derived from cartilagenous bone while the cranial vault develops from membranous bone. |
| What bones make up the cranial vault? | frontal, parietals, the squamous portion of the occipital bone, the greater wings of the sphenoid, and the temporals |
| Which of the bones composing the cranial vault are 'paired'? | frontal (due to the meitopic suturea), parietals, and temporals |
| Which of the bones composing the cranial vault are 'unpaired'? | the occiput and sphenoid (greater wings) |
| What are the midline bones and how do they move during CRI? | the sphenoid and occiput; they move through flexion and extension |
| How do the paired bones move during each CRI? | They move through internal and external rotation |
| How do the midline bones and paired bones move in unison during the CRI? | When the midline bones are in FLEXION, the paired bones are in EXTERNAL ROTATION. When the midline bones are in extension, the paired bones are in internal rotation. |
| Articulations of the occiput include... | the atlas, the sphenoid, the parietal bones, and the temporal bones |
| Articulations of the sphenoid include... | the occiput, the temporal bones, the ethmoid, the palatine bones, the frontal bone, and the vomer |
| dysfunctions of the sphenoid... | trauma with forceps delivery, endocrine problems can result from sphenoid dysfuncion, and there may be problems with CN I-VI if there is sphenoid dysfunction |
| articulations of the frontal bone: | parietals, ethmoid, sphenoid, lacrimals, nasals, zygomae, and maxillae |
| The frontal bone has an inferior attachment site for what important cranial structure? | the falx cerebri (this structure is also attached to the ethmoid) |
| What brain region is housed in the frontal bone? | the frontal lobes |
| How is the frontal bone related to the eyes? | the frontal bone forms the roof of the orbit and the floor of the anterior cranial fossa |
| Indications for frontal lift (a cranial vault technique): | frontal headache, congestion of the frontal sinuses, sutural restrictions, and/or when mobilization of the frontal bone is needed (sometimes the frontal bone is restricted by the falx cerebri) |
| The parietal bone encloses the anterior and posterior division of... | the middle meningeal artery |
| What brain structure is protected by the parietal bones? | the parietal lobes of the cerebrum (the site of the motor cortex) |
| Dural reflections from the parietal bone form what sinus? | the superior sagittal sinus |
| articulations of the parietal bones: | sphenoid, temporal, occipital, and frontal |
| Indications for parietal lift (a cranial vault technique) include... | hypertensive headaches, impulsivity, headache, idiopathic epilepsy, and local pain along the cranial suture. This technique enhances drainage along the superior sagittal sinus and can help relieve dural tension |
| articulations of the temporal bones: | sphenoid, occiput, parietal, zygoma, and mandible |
| important osteological features of the temporal bones: | mastoid process that connects the SCM, petrous portion that connects to the sphenoid, long protruding column that connects to the zygoma, fan-shaped squama that attaches to the parietals superiorly |
| Where is the axis of rotation for the temporal bones? | it is parallel to the external auditory canal within the petrous portion of the bone |
| What is contained within the petrous portion of the temporal bones? | the organs of hearing and balance as well as the openings of several foramen for cranial nerves and the fossa for the trigeminal ganglion |
| The most common clinical problems involving temporal bone dysfunction relate to... | hearing, balance, pain, and vagatonia |
| Why might strabismus improve with temporal balancing? | b/c the motor nerves to the eye pass b/w the layers of the tentorium cerebelli whose tension is influenced by the temporal bones |
| Temporal balancing is good for children with... | dyslexia and/or difficulty with reading skills |
| Important structures associated with the temporal bone include: | CN VII and VIII, the trigeminal ganglion, the jugular vein, the carotid artery, TMJ, and the Eustachian tube |
| Indications for temporal balancing through temporal decompression: | vertigo, nausea, chronic headaches, hearing problems, recurrent ear infections, tinnitus, optical difficulties, Bell's palsy, and trigeminal neuralgia |
| What is significant about the pterion? | it overlies the anterior branch of the middle meningeal artery and is the thinnest region of the cranial vault; restrictions at the PRM can shut down the entire PRM |
| What is significant about the occipitomastoid suture? | it is commonly tender and restricted by tightness of the SCM and can cause focal sutural pain or retro-orbital headache |
| Hypertonus or contracture of the temporalis muscle, as in conditions of emotional stress, dental malocclusion, and/or temporomandibular joint dysfunction can restrict... | the squamosal or temporoparietal suture and cause sutural pain or temporal headache |
| The V-Spread technique is used for... | sutural tenderness or cranial bone restriction associated with headache, cranial nerve entrapment, or other problems |
| How are viscerosomatic reflexes mediated? | through the general visceral afferent neurons of the autonomic nervous system |
| Rather than manifesting a distinctive barrier, viscerosomatic reflex somatic dysfunction often demonstrates... | ambiguity at the barrier |
| True or false: The intensity of the palpatory findings is often not a good indicator of the severity of the causative visceral pathology: | FALSE; The intensity of the palpatory findings directly mirrors the severity of the causative visceral pathology. |
| What are Chapman's points? | small (2-3 mm) firm nodular masses, palpable in soft tissue, that demonstrate sharp pinpoint nonradiating tenderness; Chapman's reflexes provide another method of recognizing viscerosomatic effects. |
| To diagnose viscerosomatic reflexes, it is recommended that special palpatroy attention be directed toward to costotransverse area in the thoracic spine. Viscerosomatic reflexes may be differentiated from primary somatic dyfxn by... | the involvement of two or more adjacent spinal segments |
| What are some signs of acute viscerosomatic reflex? | increased skin temp, red reflex, increased sweating, increased skin drag, cutaneous and subcutaneous tissue texture change, and active spasm of the deep paravertebral musculature (multifidi and rotatores) |
| What are some signs of chronic viscerosomatic reflex? | local vasospasm with resultant decreased skin temperature, decreased skin drag, decreased sweating, subcutaneous fibrosis, hypersensitivity of the deep paravertebral muscles to palpation |
| Viscerosomatic reflexes classified as sympathetic are found... | from the first thoracic segment through the mid lumbar region |
| Viscerosomatic reflexes classified as parasympathetic are found... | in association with the vagus with manifestations in the high cervical region; there may also be manifestation in the pelvic region |
| Somatic dysfunction that is the reflex result of primary visceral pathology is treated by employing... | the medical treatment specifically indicated for the underlying pathology responsible for the reflex |
| True or false: Manipulative treatment may be directed at the somatic dysfunction to decrease the facilitated state, even if it is of viscerosomatic reflex origin. This results in a beneficial effect upon the site of pathology. | TRUE |
| When treating the somatic component of a viscerosomatic reflex to induce a somatovisceral reflex, what is often the treatment of choice? | inhibitory pressure procedures |
| Stimulatory procedures are appropriate when treating... | congested states (such as pneumonia) or hypoactive conditions (such as constipation) |
| Somatic dysfunction that resists manipulative treatment should cause concern about... | the presence of a possible viscerosomatic reflex |
| How does OMT of viscerosomatic reflexes work? | it interrupts the reflex arc |
| How are Chapman's points treated? | massage of the point for 10-30 seconds |
| head and neck | T1-T4 |
| cardiovascular | T1-T5 |
| Respiratory | T2-T7 |
| Stomach, liver, gallbladder | T5-T9 |
| Small intestines | T9-T11 |
| Ovaries/testicles | T9-T10 |
| Kidney, ureters, and bladder | T10-T11 |
| Large intestines, rectum | T8-L2 |
| uterus | T10-T11 |
| Prostate | L1-L2 |
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smuncy