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67 Cards in this Set
- Front
- Back
Cardinal Signs & Symptoms - Definition
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S/S indicative of CNS involvement
Require referral back to MD |
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Cardinal Signs & Symptoms - Listed
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• bowel & bladder dysfunction
• incontinence • loss of bowel control • bilateral or quadrilateral paraesthesias or anaesthesias • bilateral or quadrilateral paresis • ataxia • nystagmus • diplopia (double vision) • scotoma • miosis (pupil constriction) • +ve Babinski • clonus • hyper-reflexia • +ve Hoffman test • +ve Oppenheimer test • periodic LOC • lip anaesthesia • facial anaesthesia • facial muscle paresis • recurrent syncope • dysphasia • dysarthria • trapezius/SCM paresis • drop attacks • Horner's syndrome |
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Dizziness - Definition
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Sensation of altered orientation in space
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Dizziness - Causes
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• postural hypotension
• drug side-effect • vertebrobasilar • cervicogenic • vestibular • TMJ dysfunction • SCM trigger points |
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Vertigo - Definition
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Spinning or swirling sensation
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Frature Tests
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• Battle’s sign
• raccoon eyes • compression test |
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Cranial Nerve Dysfunction - Signs & Symptoms
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• scotoma
• ↓ pupillary reflexes • facial anaesthesia • facial muscle paresis • sensorineural hypoacusia associated with the trauma • +ve Hautard's test • SCM or trapezius weakness • dysarthria • dysphasia • tongue deviation on protrusion |
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Quick Scan CN Testing - CN I
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Olfactory Nerve - smell coffee or similar substance with eyes closed
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Quick Scan CN Testing - CN II
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Optic Nerve - read something with one eye closed
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Quick Scan CN Testing - CN III, IV, VI
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Occulomotor Nerve, Trochlear, Abducens - eye movements and note lid ptosis
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Quick Scan CN Testing - CN V
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Trigeminal Nerve - contract muscles of mastication - masseter & temporalis
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Quick Scan CN Testing - CN VII
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Facial Nerve - move eyebrows up & down, purse lips, show teeth, wink, whistle or close an eye
* most commonly injured |
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Quick Scan CN Testing - CN VIII
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Vestibulcochlear Nerve/Auditory Nerve - eyes closed - talk to patient & have him/her repeat back what you said or rub your fingers together by his/her ears – should sound the same
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Quick Scan CN Testing - CN IX & X
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Glossopharyngeal Nerve & Vagus Nerve - swallow or say “Ahhhhh”
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Quick Scan CN Testing - CN XI
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Accessory Nerve - contract SCM muscle
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Quick Scan CN Testing - CN XII
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Hypoglossal Nerve - stick out tongue & move it to the (R) & (L)
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Long Tract Spinal Cord Signs & Symptoms
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• bilateral or quadrilateral anaesthesia
• bilateral or quadrilateral weakness • spasticity/hypertonicity • hyper-reflexia • clonus • ataxia • presence of pathological reflexes |
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Types of Sensation Tested for in Long Tract Lesions
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• light touch
• hot/cold • vibration • proprioception |
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DTR in UE
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• jaw CN V
• biceps C5-6 • brachioradialis C5-6 • triceps C7 |
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How do you test for clonus?
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• the joint is rapidly taken to end range & held there
• > 3 contractions/relaxations (beats) indicates an UMNL • elicits a dynamic stretch reflex • assess how well the CNS inhibits the reflex • in the UE, one can use elbow flexion or wrist extension |
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Ataxia - Definition
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• erratic, uncontrolled UE movements - may be intention tremor
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Babinski Reflex aka extensor plantar response
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* pathological reflex
 • foot is nociceptively stimulated by stroking the lateral aspect of the side of the foot & then across to the big toe • normal response = down going and converging toes or no reaction at all • abnormal response = upgoing of the big toe and splaying toes • indicative of a corticospinal (pyramidal) traction lesion |
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Oppenheimer’s Test
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* pathological reflex
• application of a nociceptive stimulus to the ridge of the tibia • normally there is no response to this • +ve response = a Babinski response (ie. upgoing of the big toe & splaying toes) • indicative of a corticospinal (pyramidal) tract lesion |
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Hoffman’s Test
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* pathological reflex
• apply a noxious stimuli to the D3 DIP joint (eg. pinching or squeezing) • normally = no response • +ve response = reflex flexion of the DIP joint - part of a flexor withdrawal response • indicative of a pyramidal tract lesion |
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Signs & Symptoms of VBI
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• 5D’s
• facial paralysis or paresis • hemiparesis • rapid lateral nystagmus • ataxia • blurred vision • nausea • vertigo • hypoacusia • hx of LOC • Horner’s syndrome • vomiting • unsteadiness • loss of concentration • SCM & trapezius muscle atrophy |
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Tests for VBI
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• palpation of carotid pulse
• CN testing (before VA tests) • CV ligament stress tests (before VA tests) • VA tests • Hautard’s (Hautant’s) test |
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Causes of CV Instability
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• trauma
• sports related injuries • ankylosing spondylitis • rheumatoid arthritis (RA) • Grisel’s syndrome • Down’s syndrome |
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Grisel’s Syndrome
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• involves the subluxation of the AA joint from inflammatory ligamentous laxity following an infectious process – usually URTI
• rare -usually affects children but can affect adults |
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CV Instability Signs & Symptoms
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• cord findings (eg. ataxic gait, clonus, hyperreflexia, +ve Babinski)
• VA findings (5 D’s & other S/S’s described previously) • patient holding head • sub-occipital numbness • lump in throat |
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Mandatory Features of Cervicogenic Headaches
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• unilateral headache that may or may not spread to the other side
• pain is always on the same side (ie. does not change between or within headache episodes) • associated suboccipital, neck or neck-shoulder pain • pain starts in the cervical area & spreads to the frontal, retro-orbital or temporal areas • long lasting headache (ie. few hours to a few weeks) • can fluctuate in intensity • dull, deep, achy in nature • headache episodes of varying duration • mild to moderate intensity of headache • analgesics & NSAIDs offer little relief • stress or tension may aggravate a cervical headache |
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Cervicogenic Headache - Causes
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• trigeminocervical nucleus extends from the pons to C3 or C4
• receives afferent input from the upper 3 cervical spinal nerves, CN V, VII, IX & X • receives all the nociceptive afferents from the head & upper c-spine • convergence of afferent input = any structure innervated by above nerves can cause headache • may include: muscles, z-joints, capsules & ligaments of the upper 3 cervical segments, nerves, dura mater, SC or VA |
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Order of Sequencing for C-Spine Assessment
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• cardinal symptoms - ask & observe
• fracture tests • neurological tests • CV stress tests • VA tests • detailed cervical joint assessment |
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Implications of Positive C-Spine Screenings
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If any are positive, send to physician
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Cardinal S/S - Indication
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CNS involvement
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Peri-Oral Numbness - Why is it a significant neurological finding?
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• area innervated by 2 branches of trigeminal nerve (upper & lower lip)
• innervation comes from central trigeminal nucleus - not a peripheral origin |
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Ataxic Gait - How can trauma cause it?
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• cerebellum supplied by basilar artery
• concussive force can disrupt the vessels supplying the area - superior cerebellar artery - anterior inferior cerebellar artery - posterior inferior cerebellar artery |
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Blurred Vision - Cardinal Finding?
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No
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Reduced Visual Acuity - Cause (CN nerve involvement)
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Optic Nerve - CN 1
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Scotoma - What is it
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Loss of visual field in a certain area, surrounded by unaffected vision
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Miosis - What is it
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• Unequal pupil constriction (should be symmetrical)
• PNS • Due to damage of occulomotor nerve (??) |
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Significance of SCM/Trapezius Atrophy
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• CN 11 - Accessory nerve innervates them
• Indicates central involvement |
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Horners Syndrome - Presentation
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• ptosis + miosis + anhidrosis + litosis
• decreased sweating |
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Horners Syndrome - Causes
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• problem with sympathetic nervous system (autonomic nervous system )
• cervico-sympathetic chain is supplied by vertebral artery - if injured, sympathic chain may be affected |
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Dizziness/Vertigo - Cardinal Finding?
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No
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Dizziness - VA Involvement
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• VA supplies cerebellum (via vertebral/basilar artery) & vestibulocochlear system (via labyrinthine artery)
• damage results in dizziness/vertigo |
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Most Common/Least Common Causes of Dizziness
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• most common: cervicogenic
• least common: TMJ dysfunction |
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Cervicogenic Dizziness - How?
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there’s an integrated proprioceptive loop between eyes and craniovertebral region
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MOI of Vestibular System Injury
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• trauma
• flexion • extension • rotation |
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Battle Sign - Location/Cause/Implications
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• bruising behind ear
• caused by injury/fracture of temporal bone • middle meningeal artery is at risk of trauma due to location behind temple (weakest area) • at risk of subdural hematoma |
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Racoon Eyes - Causes
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• high facial fracture
• frontal bone fracture |
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CN Dysfunction - Signs & Symptoms
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• scotoma - optic nerve (CN 1)
• decreased pupillary reflexes (CN II - occulomotor) • facial anesthesia (CN V - trigeminal) • facial muscle paresis (CN V & VII - trigeminal & facial) • sensorineural hypoacusia (CN VIII - vestibulcochlear nerve) • + Huatards Test - may indicate vertebrobasillar insufficiency and loss of bloodsupply to cerebellum - lose positional sense & proprioception |
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Sensorineural Hypoacusia - What is it?
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• loss of hearing
• due to damage of vestibulocochlear nerve - CN VIII • dammage to inner ear/brain |
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Hautard's Test
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• positional test
• when positive indicates vascular compromise implicates cerebellum (positional sense, proprioception etc..) • positive test = drift on contralateral side to head turn |
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Hypoglossal Nerve Palsy
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• CN XII is affected
• tongue will be pushed to weak side (i.e., contralateral to UMN lesion, ipsilateral if LMN) |
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Muscles of Mastication - Trigeminal Nerve
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• temporalis
• masseter |
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Jaw Jerk Reflex - What CN?
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• quick stretch of masseter & temporalis
• CN test for trigeminal nerve • hyper-reflexive = snapping jaw shut |
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Most Commonly Injured CN
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• facial nerve - CN VII
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Conductory Hearing Loss
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• problem with conducting sound waves
• problem with outer hear, tympanic membrane or middle ear |
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Uvula Palsy
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• indicated problem with pharyngeal branch of vagus nerve (CN X)
• look at symmetry • will deviate to strong side (unlike hypoglossal nerve) |
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Vertebral Artery Tests - Clinical Decision Making
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• use to rule out VA compromise - not confirm
• do not use within first 6 weeks of MVA/trauma |
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Vertebrobasilar Signs & Symptoms
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• 5 d’s (dysphagia, diplopia, drop attacks, dysarthria, dizziness)
• facial paralysis • hemiparesis • lateral nystagmus • ataxia • blurred vision • nausea • vertigo • hypoacusia • LOC • Horners syndrome • vomiting • unsteadiness • loss of concentration • SCM/trapezius atrophy |
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Importance of VA Anatomy in S/S
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VA supplies the cerebellum & upper part of cord
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Downs Syndrome - Reason for CV Instability
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• during resegmentation (development) the dens doesn’t ‘become’ part of C2 like it should normally
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CV Instability - Diagnostic Investigations
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• open mouth x-rays
• dynamic flexion/extension |
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Common Trigeminal Nucleus - Innervation
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• CN nerves V, VII, IX, X
• upper cervical spinal nerves (C 1, 2, 3) • all nociceptive affarents from upper c-spine and head |
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Common Trigeminal Nucleus - Association w/ Headaches
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• common trigeminal nucleus & convergence theory
• any structure innervated by said nerves is capable of causing headache |
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Headache - Possible Structures Causing Pain
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• muscles
• z-joints • capsules • ligaments of upper 3 cervical segments • nerves • dura mater • SC • VA |