Download The Upper Quarter Screen - Oklahoma Physical Therapy Association

3/19/16
TheUpper
QuarterScreen
DaleBorenJr.,PT,MPT,OCS
PhysicalTherapyCentral
OfElkCity
UpperQuarter
Screen
•  Appropriateforupperthoracic,upper
extremity,andcervicalproblems
•  Posturalassessment:observedfromfront,
backandsidelookingforasymmetry
•  RangeofmoGon:AcGvecervicalandUE
ROMwithoverpressureifnopainisfelt
•  ResisGveTesGng:tesGngatvarious
innervaGonlevelsfromC1-T1
•  ReflexTesGng:Biceps(C5),brachioradialis
(C6),andtriceps(C7)
•  Dermatomes:dermatomesatvarious
innervaGonlevelsfromC2-T1
ObjecGves
•  Understandtheimportanceoftheupperquarter
(UQ)screenandfollowtheUQSkillList
•  IncorporatetheUQScreeninarouGne,
systemaGcpaGentExaminaGonProcess
•  RecognizefindingsimportanttoaVainthe
PrimaryDiagnosisandensureappropriateness
forPTtreatment
•  ExaminaGonofMyotomes(C1-T1)
–  CervicalNerveRootLesionvsPeripheralneural
involvement
Neuromotor
Sensory
Screening
•  SensoryExaminaGon:
–  SegmentalNerveRootLevel
–  PeripheralNerveFields
•  UpperExtremiGes–Hypo/Hyperreflexia
–  LowerMotorNeuronReflexes
•  CervicalReflexes
–  UpperMotorNeuronReflexes
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ExaminaGonof
Myotomes
Myotomes
•  C1-2:CervicalFlexion
• 
Amyotomeisthegroupofmusclesthatasinglespinal
nerverootinnervates.(ie.C6=ElbowFlexors/Wrist
Extensors)
• 
DuringmyotometesGng,theclinicianislookingfor
muscleweaknessofaparGculargroupofmusclesorina
peripheralnerve.
• 
•  C3:CervicalSidebending
•  C4:UpperTrapezius
•  C5:Deltoids/Infraspinatus
–  FaGguablevsNon-FaGguableWeakness
•  C6:BicepsandExtensorCarpiRadialisBrevisand
Longus
–  TesGngmorethan1musclegrouppermyotomeis
important.
•  C7:TricepsandFlexorCarpiRadialis
•  C8:AbductorPollicisBrevis/ExtensorCarpiUlnaris
Resultsmayindicatelesiontothespinalcordnerveroot,
orintervertebraldischerniaGonpressingonthespinal
nerveroot.
•  T1:FirstDorsalInterosseiossei
SegmentalNerve
RootLevel
• 
C1:Nodermatome/meninges
• 
C2:Posteriorocciput
SegmentalNerve
RootLevel
• 
Musculocutaneous:
• 
Axillary:
• 
Radial:
• 
Median:
• 
Ulnar:
• 
• 
C3:Posteriorcervicalspine
• 
C4:UpperTrapezius
• 
• 
C5:Mid-Deltoid/Lateralforearm
• 
C6:Thumb
• 
• 
C7:Dorsalaspect3rddigit
• 
C8:Ulnaraspect5thMCP
• 
• 
T1:MedialforearmMedialforearm
• 
Radialborderofforearm
Lateraldeltoid
Dorsumofradialsideofwrist
Palmarsurfaceoffirst3digitsandradialhalfofdigit4
Palmarsurfaceofdigit5andulnarhalfofdigit4
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Reflexes:MSR/DTR
•  BicepsBrachii(C5)
•  Brachioradialis(C6)
•  Triceps(C7)
•  PosiGveFinding:Reflexesfoundtobe
diminishedorabsentcanbecorrelated
withthedermatomeandmyotome
assessmentstodeterminethepresence
ofnerverootpathology.HyperacGvity
mayindicateuppermotorneuron(UMN)
pathology
•  BabinskiSign:
–  PosiGveisgreattoeextensionwith
fanningoftoes
UpperMotor
Neuron
(UMN)
Reflexes
•  Clonus:
–  PosiGveisreflexivetwitchingofplantar
flexors(needstobe2-3beatforpos)
•  HoffmanTest:
–  Flick/forcedDIPjointflexionofthirddigit
withclonicflexionofassociatedindex/
thumbIPorwristsupinaGonwitchof
thumband2nddigit
Clearingthe
Cervical&Thoracic
Spine
ClearingtheCervical&Thoracic
Spine
•  WithpaGentsijng,assessAROMnoGngqualityandquanGtyofmoGonand
changeinsymptoms.
•  AkerAROMassessment,theexaminerpassivelymovesthecervicalspinethrough
maximalend-ROM(astoleratedbypaGent),appliesoverpressure,andnotes
ROM,painreproducGon,andend-feel.
•  ClearingtheCervical&ThoracicspinebeginswithsubjecGve
history.
Motions Assessed:
•  KeyquesGons:
Flexion
Extension
–  Traumatocervicalspineorhistoryof?
Sidebending
–  MechanismofInjury?
RotaGon
–  AggravaGng/Easingfactors?
Additional Tests:
1stribpalpaGon
–  NatureofSymptoms?
CRLF
–  Sleepaffected?
–  SleepposiGons?
Spurling’sTest
IdenGfyAComparableSign:
DidIreproducetheirUEsymptom?
CompressionTest
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1stRib
PalpaGon
CervicalRotaGonLateralFlexionTest
•  Sijng
•  Purpose:Totestforpresenceof1st
ribhypomobility
•  1stribarGculaGonfromT1
posteriortojustinferiortoclavicle
atSCjoint
•  Sijng,passivelyrotatethenlateral
(forward)flex.
•  TestisconsideredposiGvewhen
thelateralflexionmovementis
decreased.
•  Heightof1strib
•  MuscletonicityatT1inserGon
•  ContralateraltorotaGondirecGon
Spurling’s
Test
•  Purpose:Testsforpresenceof
cervicallateralstenosis/radiculopathy
•  PaGentseated.
•  PTsidebendsthecervicalspine
towardstheaffectedsideandapplies
approximately7kgofcompression
force
•  PosiGvetestisreproducGonof
comparableaffectedUEsymptoms
onsamesidebeingtested.
Symptomstothescapularoratleast
toshoulderlevel.
Cervical
Radiculopathy
•  Whatisradiculopathyvsneuropathic
pain??
–  Neuropathicpain:characterizedby
painthatseemstoradiatefromthe
spine,extendingoutwardtocause
symptomsawayfromthesourceofthe
spinalnerverootirritaGon.(burning,
electriclike,zinging)
–  Radiculopathy–neuropathicpainwith
signsofnerverootcompromise
(hyporeflexia,hypoesthesiainnerve
root,andmyotomalweakness)
•  It’simportanttodifferenGalbetween
neuropathicpainwithorwithout
radiculopathy
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Cervical
Radiculopathy
•  ClinicalPredicGonRuleforCervical
Radiculopathy(Wainneretal,
2003)
–  (+)ULTTa(Mediannervebias)
–  CervicalrotaGonipsilateral<60deg
Cervical
Radiculopathy-CPR
Numberof
SensiGvity Specificity PosLR
PosiGveCriteria
NegLR*
Two 0.39
0.56
0.88
1.09
Three 0.39
0.94
6.1
0.65
Four 0.24
0.99
30.3
0.77
–  (+)DistracGontest
–  (+)Spurling’stestA
–  ***hVp://www.physio-pedia.com/
CPR_for_Cervical_Radiculopathy
•  Wainneretal,Spine,2003
•  Sijng
•  Placehandsclaspedbehindhead
orinfrontofchestifnecessary
•  MoGonstested:
–  thoracicflexion/ext
–  thoracicrotaGon
–  thoracicsidebending
Clearing
Thoracic
Spine
TheShoulder
•  Posture&PalpaGon
•  FuncGonalQuickScreen
•  ResistedMuscleTests
–  AROMthenOP
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Shoulder
ClearingExam
ShoulderAROM/
OP(sijng)
•  Flexionw/OP
•  flexion
•  AbducGonw/OP
•  abducGon
•  Handbehindback(HBB)w/OP
•  internalrotaGon
•  StaGcresistedER/IR
•  externalrotaGon
•  Shoulderquadrant
•  PalpaGon
FuncGonal
Screens
ShoulderResisted
MuscleTests
•  Apleyscratchtestt
•  Shoulderflexion
•  Fan/Fold
•  ShoulderAbducGon
•  ShoulderExternalRotaGon
•  ShoulderInternalRotaGon
•  DetecGonofcontracGlelesions
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•  PalpaGon
Shoulder
PalpaGon
•  IdenGfylandmarks
•  PalpateupperquadrantstarGng
superficiallyandprogressingto
deeperstructures.
•  ObservaGon:WiththepaGent
seated,thePTobservesforany
asymmetriesinanyofthesok
Gssuesorbonylandmarks
Elbow&Forearm:
ObservaGonand
PalpaGon
•  PalpaGon:ThePTpalpatesthe
elbow,forearmandsurrounding
sokGssueandbonystructures
starGngsuperficiallyand
progressingtodeeperstructures
forthepresenceofany
temperaturechanges,moisture,
swelling,andGssuetexture
abnormaliGes
•  Palpateforthepresenceofany
temperaturechanges,moisture,
swelling,andGssuetexture
abnormaliGes.
Note:DependingonthepaGentpresentaGon,thepalpaGonexammaybeperformedearlierorlaterintheexaminaGonprocess
BasicElbow&
ForearmSeated
ROM
•  ElbowFlexion&Extension:
–  ThepaGentisaskedtoacGvely
flextheelbowasfaraspossible.
Ifnosymptomsareelicited,the
PTappliesOPwhileassessing
qualityofmoGon,symptom
response,andendfeel
–  Repeatforextension.
•  ForearmSupinaGon&PronaGon
BasicElbow&
ForearmSeated
ROM
–  ThepaGentisaskedto
maintain90degofelbow
flexionandtoacGvely
supinatetheforearmasfaras
possible.Ifnosymptomsare
elicited,thePTappliesOP
whileassessingqualityof
moGon,symptomresponse,
andendfeel.
–  RepeatindirecGonof
pronaGon.
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Elbow&Forearm
SeatedResisted
MuscleTests
•  ElbowFlexion:
WristRangeof
MoGonScreen
•  AskthepaGenttoflex,extend,and
radially/ulnarlydeviatethewristasfaras
possible
•  AddOPasindicated
•  ElbowExtension
•  Assessquality,ROM,pain(0-10),symptom
locaGon
•  ForearmSupinaGon
•  DifferenGatejointversussokGssue
restricGonbymodifyingposiGonofelbow
•  ForearmPronaGon
–  ElbowextensionposiGon:moGon
limitaGonsuggestssokGssuerestricGon
–  ElbowflexionposiGon:moGonlimitaGon
suggestsjointrestricGon
WristResisted
MuscleTests
DigitalRangeof
MoGonScreen
•  DigitAbducGon&AdducGon
•  WristFlexion
•  WristExtension
•  WristRadialDeviaGon
•  WristUlnarDeviaGon
•  PTaskspaGenttoabductandadduct
thedigits.Observeabilityofthedigit
tocompleterangeofmoGon
•  OpposiGon
•  PTasksthepaGenttoopposethe
thumbtoeachdigit.Observethe
abilityofthedigitstoflexateachjoint.
AskpaGenttotouchasfardownthe
baseofthesmallfingeraspossible
andobservetheamountofflexionat
theCMC,MCP,andIPthumbjoints
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Cervical
DistracGon
Test
SupinePorGon
•  Purpose:Totestforthepresence
ofcervicalradiculopathy.
•  CervicalPROM
–  RotaGon,lateralflexion,
flexion
•  Supine
•  PTgraspsunderthechinand
occiputwhileslightlyflexingthe
paGent’sneckandappliesa
distracGonforceof14lbs.
•  CervicalDistracGonTest
•  ULTTTests
•  PosiGvetestifpaGentsymptoms
arereduced
NeuralDynamics:
ExaminaGon&
IntervenGon
•  Purpose:NeurodynamictestforsensiGveneuralGssue;tests
fornerveimpingementorradiculopathy
•  DescripGon:PaGentissupine.
•  Scapulardepression
Neural Dynamic Slider & Tensioner Concepts
MedianNerveBias
UlnarNerveBias
UpperLimb
TensionTestA
(MedianNerve
Bias)
•  ShoulderabducGon
•  ForearmsupinaGon,wristandfingerextension
•  ShoulderlateraldeviaGon
•  Elbowextension
•  Contralateral/Ipsilateralcervicalsidebending
•  PosiGveTest:
•  Symptomsreproduced:Comparable?
RadialNerveBias
•  Sidetosidedifferenceinelbowextensiongreaterthan
10degrees
•  Contralateralcervicalsidebendingincreasessymptoms
oripsilateralsidebendingdecreasessymptoms
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Normal
Response
•  Purpose:NeurodynamictestforsensiGveneuralGssue;tests
fornerveimpingementorradiculopathy
•  DescripGon:PaGentissupineangledonmattoexpose
shoulder.
•  Adeepstretchoracheincubital
fossa
•  Scapulardepression
UpperLimb
TensionTestB
(RadialNerve
Bias)
•  Elbowextension
•  ShoulderinternalrotaGonandforearmpronaGon
•  AGnglingsensaGoninthefirst
threefingers
•  Fingerflexionaroundthumb,wristflexion,andradial
deviaGon
•  Shoulder/armabducGon
•  Cervicallateralflexionaway
increasesresponsein90%
•  Contralateral/Ipsilateralcervicalsidebending
•  PosiGveTest:
•  Symptomsreproduced:Comparable?
•  Cervicallateralflexiontowards
decreasesresponsein70%
•  SidetosidedifferenceinmoGonavailable
•  Contralateralcervicalsidebendingincreasessymptomsor
ipsilateralsidebendingdecreasessymptoms
Normal
Response
•  Strongpainfulstretchoverradial
aspectoftheproximalforearmand
elbow
•  Okenaccompaniedbyastretch
paininthedorsumofthehand,
lateralupperarm,andbiceps
brachii
•  Purpose:NeurodynamictestforsensiGveneuralGssue;tests
fornerveimpingementorradiculopathy
•  DescripGon:PaGentissupineangledonmattoexpose
shoulder.
•  Scapulardepression
UpperLimb
TensionTestB
(UlnarNerve
Bias)
•  Wristandfingerextension
•  ForearmpronaGon
•  ShoulderexternalrotaGon
•  ElbowflexionandshoulderabducGon,bringingpaGent’s
handtowardtheear
•  Contralateral/Ipsilateralcervicalsidebending
•  PosiGveTest:
•  Symptomsreproduced:Comparable?
•  SidetosidedifferenceinmoGonavailable
•  Contralateralcervicalsidebendingincreasessymptomsor
ipsilateralsidebendingdecreasessymptoms
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Normal
Response
ProneCervical/
Thoracic
Segmental
AccessoryMobility
•  PaGentprone
•  CentralPA
•  UnilateralPA
•  TherehavebeennonormaGve
studiesdocumenGngtheresponses
toULTT3(Ulnar)
•  PTcontactsthespinousprocesswiththe
thumbs.Thelateralneckmusculatureisgently
pulledposteriorlywiththefingers.PTshould
bedirectlyoverthecontactareakeeping
elbowsextended.PTusestheuppertrunkto
impartaposteriortoanterior(PA)forceina
progressiveandoscillatoryfashionthroughthe
spinousprocess.Repeatforremainingcervical
segments.
•  PainduringsegmentaltesGngassociatedwith
reportsofneckpain:
•  SensiGvity:.82
•  Specificity:.79
UQScreenWrap-Up
•  Purpose:TheUpperQuarterScreenisperformedtoquicklyassessforimpairment
orpathologyoftheUpperQuarterforareasoffurtherexaminaGon.CriGcally
importantnowthatwehaveDirectAccessinOklahoma.
•  Whatnow?
–  ANegaGveUQScreenisaGOODthing!Nowyoucanjumprightintothe
BiomechanicalExaminaGon.
Thankyou!
Any
QuesGons?
–  APosiGvefindingontheUQScreenwillnecessitatefurtherexaminaGonand
evaluaGonorreferraltophysician/specialist
•  QuesGonsoverthisporGon?
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