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For this practical exam we may be asked to demonstrate assessments of VertebroBasilar Artery sufficiency, the Transverse Atlantal Ligament, the Alar Ligament and Lateral Flexion of the entire C-spine by segment. We are also covering strain/counterstrain of the cervical extensors, anterior and middle scalenes, SCM, upper trapezius, levator scapula, masseter and lateral pterygoid. We may have to demonstrate Positional Isometric Relaxation technique on the extensors, scalenes, SCM and traps, levator and masseter.

FOUR CARDINAL SX OF UPPER CERVICAL INSTABILITY
balance: loss of balance with head movement, may use a cane
proximal paresthesias: face/lip paresthesia reproduced by neck mvt (active or passive)(rare)
paired distal paresthesias: bi- or quadrilateral limb paresthesias, constant or agg by neck mvt
nystagmus: nystagmus reproduced by neck mvt (active or passive)

OTHER SX
flushing/pallor, diaphoresis, pupil size change are signs of acute, watch for these during assessments
neck pain
limitation of neck movements
torticollis (SCM spasm)
neuro sx: headache, dizzy, buzzing in ears, dysphagia
neuro sx: hyperreflexia, gait disturbances, spasticity, paresis
tests: Hoffman's, Babinski's

VBI, VERTEBROBASILAR ARTERY INSUFFICIENCY TEST
the vertebrobasilar artery may become occluded or insufficient
etio: atherosclerosis, compression at C6 by ant scalenes or longus colli
etio: compression in transverse foramen between C6 and C2, or at level of C2
runs inside the C spine transverse foramina until C2 when it comes out, is loose for mvt
one feeder on each side to the arterial loop at the base of the brain
supplies approximately 20% of blood to brain
you put the person's neck in a kink to close off one side, and if the other side is insuff they'll have sx: syncope or near, nystagmus, vertigo, cognitive disturbance/disorientation
SX: 5D's And 3N's: diplopia, dizziness, drop attacks, dysarthria,dysphagia ataxia of gait, nausea, numbness, nystagmus
HX to ask: stroke or MI, smoker, HTN, OCPs, PVD, syncope or light headedness with head movement, connective tissue disorders (Marfans, Ehler-danlos, RA)
pt is supine, doc takes head passively into
the position: 1. side bend 2. rotate to same side 3. extend 4. hold at least 20 secs then 4. have patient look at your forehead and 5. start asking questions: person, place, time, evaluate their LOC
if this position is impossible an alternative 1. extension for 30 seconds 2. monitoring for signs in neutral 3. extension and rotation for 30 seconds 4. monitoring, 5. repeat on other side

TRANSVERSE ATLANTAL LIGAMENT STRESS TEST
holds the dens of C2 inside the arch of C1
may be congenitally absent in Down's, Marphan's
pt sits, doc stands at side
put index finger on SP and pinch C2 lateral bodies with thumb and midfinger
other hand or crook of arm arm (alternative grip) on forehead to move head posteriorly
flex pts head forward
push C2 forward and skull backward, hold at least 5 sec and monitor for sx
should have no more than a few mm movement, should feel springy resistance of ligament
positive test: sx are reduced or there is palpable hypermotility of CO-C1 on C2

ALAR LIGAMENT STRESS TEST
this ligament goes from the top of the dens to the anterior arch of C1
test rotation in neutral position only, then proceed to lateral flexion in neutral
test lateral flexion also with pts neck flexed, and extended (approximately 5 degrees)
posterior hand blocks C2 as above
anterior hand to top of pt's head, passively moving head while sensing with hand on C2
move head while feeling for contact of C1 or lig on C2
normal movement 3-5mm before bone moves
positive if: onset of sx, excessive sidebending in all positions
positive suggests alar ligament tear or instability at CO-C1 joint
alar tear if rotation greater than 30 degrees
at upper cerical segments same side as lateral flexion instability
CO-C1 instability if found on the opposite site as lateral flexion instability
???

SOFT TISSUE TECHNIQUE AKA STRAIN/COUNTERSTRAIN
identify tender point in muscle
get rating
5+ is tender enough to merit working on it
keep fingers on tender point and "cave in" pts body around point
shorten muscle involved
be a minimalist: move only enough to get reduced pain
get rating again, looking for substantial reduction in pain
if no reduction readjust, shorten muscle more
get new rating
once lowered pain is reported (want 3 or lower)
hold
lighten pressure, sense tissue with fingers, wait for release
release may feel like spasm, throbbing, warming up, softening
wait 1-2 minutes
after release is sensed, passively move body back to neutral
keep hand on tender point
reapply original pressure and ask for rating of pain

CERV EXT
id point
extend neck
hold point

ANT SCAL
point anterior to SCM
on anterior surface of cervical pillar
flex using headrest, sidebend to cave

MID SCAL
lateral aspect of cervical pillar
mostly sidebend to cave
no flex/ext unless no release from sidebending

SCM
pinch muscle
mostly rotate head away, flex, a little side bend
use headrest to support in shortened position
return to neutral passively using leg to adjust headrest

UPPER TRAP
help elbow to shorten
abduct if needed to reduce sensitivity
use my leg to support my elbow so I can be relaxed while holding pt in position

LEV SCAP
passive shrug (hold elbow) & abduct
max is throwing position
compress scap to back if needed to stabilize

MASSETER
sit at head
find point in TMJ area, hold from outside or pinch through cheek
have pt lat deviate jaw, passively close
hold hot spot and jaw

LAT PTERYGOID
glove up: intra-oral
use L hand for L side
behind upper molar


PIR aka POSITIONAL ISOMETRIC RELEASE
contracting tightest muscles from stretched position
uses reciprocal inhibition, fatigues muscle
pt may sit or lie supine
locate muscle indicated
position pts body so as to stretch the muscle maximally
anchor insertion point (clavicle for SCM, mid scal)(acromion for upper trap)
place other hand on head to resist contraction of muscle in question
good stretch first
ask pt to exert to tighten muscle vs my hold
exert at 25-75% (for scalenes ear to shoulder, for trap shrug1 ear to shoulder2)
breathe: "hold your muscle not your breath"
relax
stretch (don't overstretch, stop if late pain)
return to neutral between cycles
repeat 3-4x
finish with stretch

CERV EXTENSORS
pt supine
pt help tuck chin and head lift
while doc at head flexes neck fwd
hold head while pt exerts to straighten neck, keeping chin tuck

ANT SCAL
pt sitting
side bend 1st, extend 2nd to lengthen
hold clavicle down with heel of hand, hold forehead with palm

MID SCAL
supine
side bend away to lengthen
hold clavicle down
hold head above ear
x hands or not
do good stretch first
have pt "shrug"

SCM
pt supine
lengthen with rot twd, ext, hold occiput to stretch
hold clavicle down
exert vs hand on TMJ "push into my hand"

UPPER TRAP
pt sitting, hold elbow to side (contract serratus anterior) and side bend away
passive stretch 1st
hold acromion down using forearm, stabilize head with arm
1 shrug 2 ear to shoulder
3 both

LEVATOR SCAP
sitting
drop head twd opp thigh
hold shoulder down with forearm
hold head
shrug

MASSETER
bilateral stretch
jaw open, hold mandible with thumb pads
have pt gently resist hold, steady isometric, don't close

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