•

Cervical pain / Brachial neuralgia

Seated faut Yatra
• Observation • Neuro Status
• __ Head posture /Antalgia • ___DTR, Sensation, Motor strength – Upper
extremity / Lower extremity
• __ Shoulder Cross syndrome
•
• Elbow
• ROM:Flexion__ Extension__Rotation Rt.__/Left_ Lateral
Flexion Right__ Left___ • __ Tinnel’s Elbow cubitaltunnelsyn
• __ Pronator Teressyndrome
• Palpatory tenderness • Wrist
• ___Cervical spine • ___ Tinnel’s Wrist carpal
• ___Upper thoracics • ___ Phalen’s / Reverse Phalen’s tunnel
• ___Costotransverse Margins – T4 syndromegougers.FI
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• ___Myo spasm • Supine (If not already done)

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• ___Trigger pts: muscles • __Axial distraction
• • __ Palpation cervical spine for listings and
• __ Motion palpation: upper thoracics & cervicals
tenderness
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• ___Cervical Axial Distraction
• ___Cervical Compression test • Prone (If not already done)
• ___Spurling’s test (If indicated) • __Palpate upper thoracic spine / Ribs
• TOS tests • for listings and tenderness
___ East's • __Palpate dorsal spasm
• Adson’s
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___ Eden’s (Costoclavicular) •
•
Also TP’s if not done prior
• ___ Hyperabduction
• ___
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East’s
Upper Cross Syndrome

Images

Tight Weak
Muscles Muscles
Pectoralis Major Rhomboids
Anterior Deltoid Posterior Deltoid
Levator Scapulae Serratus Anterior
Upper Trap Lower Trap

Subscapularis, Longus Coli &

Latissimus Dorsi, Capitus
SCM, Scalenes
Myofascial Pain Syndrome

• Associated with postural

faults
• Ex: Cross syndromes
• Characterized by Trigger
points.
• Local twitch response
(Jump sign)
• Typical referral patterns.
• Chronic pain characterized by widespread ache, and
stiffness. Fibromyalgia
• Most commonly neck, back, shoulders, pelvic girdle, &
hands.
• Characterized by Multiple Tender Points (11 out of 18)
• Deep muscular ache, throbbing
• Numbness, tingling, & burning
• Often worse in morning.
• Cold/Humid conditions
Irritable Bowel Syndrome
• Irritable Bladder
• Headache
• Anxiety / Stress
• Depression
• • Impaired memory
• Sleep Disturbances: /Non-restorative sleep
Distinctive abnormalities in Stage 4 sleep
Fatigue: all encompassing exhaustion
 New Criteria for Fibromyalgia
s
American College of Rheumatology (ACR) classification criteria,
developed in 1990. Required presence of widespread pain and 11 or
more of 18 specific tender point sites.

The 1990 ACR criteria required tender point examination—found to be a

barrier for primary care setting. Also, they created the erroneous
impression that FMS is a peripheral musculoskeletal disease with the
pathology centered on the tender points.

The 2010 ACR criteria were aimed at simplifying the diagnosis of FMS
and being suitable for use in primary care practice without requiring a
tender point examination. Another objective was to recognize the
importance of the numerous nonpain symptoms of FMS, such as
perceived cognitive impairment (“fibrofog”), fatigue, and sleep
disturbance, in making the diagnosis
 Determining Your Widespread Pain Index (WPI)
The WPI Index score from Part 1 is between 0 and 19.

• Area have felt pain in past

week.
• Shoulder girdle, left • Lower leg left
• Shoulder girdle, right • Lower leg right
• Upper arm, left • Jaw left
• Upper arm, right • Jaw right
• Lower arm, left • Chest
• Lower arm, right • Abdomen
• Hip (buttock) left • Neck
• Hip (buttock) right • Upper back
• Upper leg left • Lower back
• Upper leg right • None of these areas
 Symptom Severity Score : Had any of following in last week.
• Muscle pain • Wheezing
• Irritable bowel syndrome • Raynauld’s
• Fatigue/tiredness • Hives/welts
• Thinking or remembering problem • Ringing in ears
• Muscle Weakness • Vomiting
• Headache • Heartburn
• Pain/cramps in abdomen • Oral ulcers
• Numbness/tingling • Loss/change in taste
• Dizziness • Seizures
• Insomnia • Dry eyes
• Depression • Shortness of breath
• Constipation • Loss of appetite
• Pain in upper abdomen • Rash
• Nausea • Sun sensitivity
• Nervousness • Hearing difficulties
• Chest pain • Easy bruising
• Blurred vision • Hair loss
• Fever • Frequent urination
• Diarrhea • Painful urination
• Dry mouth • Bladder spasms
 for3T no reason
Criteria for fibromyalgia syrup other path
I no the
if the following 3 conditions are met: for
• 1a. The WPI score (Part 1) is greater than or equal to 7
• AND the SS score (Part 2a & b) is greater than or equal to 5
• OR
• 1b. The WPI score (Part 1) is from 3 to 6 AND the SS
• score (Part 2a & b) is greater than or equal to 9.
• 2. Symptoms have been present at a similar level for at
• least 3 months.
• 3. You do not have a disorder that would otherwise
• explain the pain.
TABLE
CLINICAL PRESENTATION OF CERVICAL SPONDYLOTIC MYELOPATHY

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Common symptoms
Clumsy or weak hands
Leg weakness or stiffness
Neck stiffness
Pain in shoulders or arms
Unsteady gait
Common signs
Atrophy of the hand musculature
Hyperreflexia
down
rsMfar back
Lhermitte's signsie FW
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w mid
Sensory loss extreprodoltme
si
Cervical Spondylotic Myelopathy
Cervical Spondolytic Myelopathy (aafp sept 2000)
of
ref6 r MM
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Biceps & supinator reflexes (C5 and C6) may be absent
Brisk triceps reflex (C7). This pattern is almost pathognomonic of cord
compression because of cervical spondylosis at the C5-C6 interspace
Ankle clonus and Babinski's sign: Present
Hoffmann's sign (a reflex contraction of the thumb and index finger after
nipping the middle finger) is a subtle indicator of spinal cord dysfunction.
Stiff or spastic gait is also characteristic of CSM in its later stages.
 Polymalgia
Rheumatica
• Musculoskeletal findings
• Morning stiffness for more than 1
hour, often more prolonged
• Muscle stiffness after prolonged
inactivity
• Carpal tunnel syndrome (in about 15%
of patients)
• Distal extremity swelling (uncommon)
• Possible development of arthralgia
and myalgia up to 6 months after
onset of systemic symptoms
Blindness in sm
• Patient seated
Cervical Axial
• Examiner applies downward
compression on patients head. Compression
•Positive: Cervical pain or
brachial radiation

•Significance:
• Disc herniation
• Foraminal Encroachment
• Facet Irritation
• Cervical spine extended and head
rotated ipsilateral. Axial load placed
on head Spurling’s Test
• Positive: Reproduction of (Maximal Cervical Compression test)

the( patient's shoulder or arm

•Significance:
• Foraminal encroachment
• Cervical disc Herniation
• Facet irritation
Distraction

• Traction under chin and occiput.

• Positive: Relief of symptoms

• Significance:
• 1) foramen encroachment
• 2) facet irritation
• 3) disc herniation
• Will aggravate
• 1) ligamentous pain.
Thoracic Outlet Syndrome
EXAMPLES
• Palpate radial pulse
• Move upper extremity in abduction, Adson’s test
extension, and external rotation. Scalenes Anticus
• Rotate head ipsilateral
• Deep breath and hold it.
• Positive:
• Diminished / absent radial pulse
• Reduplication of symptoms

• Indications:
• Scalenes
• Cervical rib
• Locate radial pulse
• Draw patient's shoulder Costoclavicular Maneuver
down and back as they lift
their chest in an
exaggerated "at attention"
posture.
• Examiners hand depresses
shoulder
• Positive: test by an
absence of a pulse.
• Reproduction of
symptoms
• Significance:
• TOS
Wright’s test
Hyperabduction
• Palpate radial pulse with arm at side.
• Arm fully abducted in external
rotation

• Positive:
• Reduction in pulse
• Significance:
• TOS
• Hyperabduction syndrome
• Hold both elbows at shoulder ) Ross stress test
height while pushing shoulders (East’s
back.
• Repeatedly open and close fist
for up to 3 minutes
•Positive: Reproduction of
Symptoms
•Significance:
• TOS
• Elevate hand and makes fist
• Pressure applied over radial and / ulnar arteries Allen’s Test
• Hand lowered and hand opened.
• Examiner releases ulnar compression
• Repeat by releasing radial artery

•Normal: Hand color flushes within 5 to 7 seconds

•Significance: Partial or complete obstruction of
vasculature
Lhermitte’s Sign
• Maximal neck flexion

•Positive:
• shooting, electric-like pain in the
lower extremities.

• Significance:
• Cervical Myelopathy
 Soto-Hall Test
• Patient Supine
• Examiner exerts pressure on sternum
• Examiner’s other hand under the
patient's occiput and flexes neck
toward sternum.

•Positive: Pain in cervical

area

•Significance:
• Vertebral bony injuries
• Patient abducts arm to put hand on top
of head.
Bakody’s Sign
•Positive: Arm abduction sign
• Relief of pain

• Significance:
• Cervical disc
• Forminal encroachment
 T4 Syndrome
• Symptoms:
• Paresthesias, numbness, / upper extremity pains associated
with or without upper back stiffness.
• No hard neurological signs are present.
• Upper thoracic joint dysfunction, especially in the region of the
T4 segment, appeared to be the major cause.
• A nontraumatic onset is common and the peculiar glove-like
distribution of hand or forearm pain
• Joint manipulation, stretching, and strengthening exercises
directed at the upper thoracic dysfunctional segments were used
with good results.

• The T4 syndrome. De Franca GG, Levine LJ Journal of Manipulative and Physiological

Therapeutics, Jan 1995, 18(1) p34-7