hi everybody welcome to the clinical examination of the cervical spine and i'm thrilled to have guests with me today these are two alumni of the msat and so they want to give back to the program and it gives me a chance to introduce two of my friends the first is dr jarrett welsh jared is a chiropractor he's a sports physician and he's a certified athletic trainer and so he works in san diego i thought how good it would be for you to get inside the mind of a spine specialist so jared welsh is going to be taking you through the clinical examination and and i'm excited to hear what dr welsh has to say dominique williams is another alumni and she will be his model his patients and i'm thrilled that both of them can teach you today so i hope you enjoy this hello everybody um i want to thank dr sullivan for letting me come in and give you guys what i do in my clinic and in my office as an evaluation of the cervical spine uh so thank you dr sullivan for letting me do that the only thing i want to kind of mention about this is this is what i would do as a examination in the clinic not on the field if someone got injured so it's going to be a little more basic and not as specific for the first part of this video um so now what i'm going to do is i'm going to bring in dominique you guys all heard her introduction she also graduated with the msat here with me um when i graduated she's also the office manager in my office so glad she can be here to help us also so when a patient first comes in um to the office one thing i want to let you guys know we're looking at is you you got to remember to look up the overall presentation of the person as they're walking in either into the office or into the door or into the athletic training room i think the one of the most important things is it's kind of like you know when you are supposed to be paying attention and you see an injury on the field you saw what happened you have a general idea of what's going on already that's what we want in this circumstance too you want to watch their presentation as they're coming to you into the office or even into the athletic training room see their presentation dr sullivan already went into this with um you know the examination and palpation of things but just look at their presentation shoulder high head tilt forward backwards laterally flags things like this just kind of look at their overall presentation so with dom here her overall presentation seems to be perfect um so we're not going to worry about the presentation but what i am going to do is just kind of guide you through what i would do if a patient came in and said hey dr j the left side of my neck hurts because i slept wrong on my neck so this is what i would do i'd say okay i'd ask her all the history questions the pertinent ones just make sure one question you ask is has this happened before that's a very important one has this happened before have you had treatment for this before if you've had treatment was it from a medical professional or not so make sure you get that little history part second i would say okay well what hurts and then she's gonna say what hurts um i would say does range's emotion hurt yes she's gonna tell me what that is now what i would do is say okay let's have you come over here sit down like dom's doing and we're gonna go through some simple range of motion stuff so first i'm gonna have her look down so i'd say yep look down for me perfect then i would have her look up and then i'd have her go back to neutral when i'm doing this in my office i'm actually in front of the patient and i am showing them so i'm doing the same thing if i say look down i look down if i say look up i look up i believe you should do this with patients because you guide them and then they kind of know what's going on by looking at you and what you say so then i'll say ear to shoulder so let's do your left ear to your left shoulder there you go right ear to your right shoulder and then we'll have you look over your shoulder look to your right look to your left boom range of motion done right next what we would do is i would tell her okay now what i'm going to do and please when you guys do special tests explain what you're going to do to the patient and possibly what they may feel so what i'm going to say is this i'm going to say okay dom i'm going to stand behind you i'm going to put my elbows on your shoulders and i'm going to put my hands on your head all those ranges of motion you just did i'm going to push down on your head let me know if there's any pain or discomfort i think that's key it's keeping the communication open you need to say let me know if there's pain or discomfort so they'll actually tell you some people like to hide these things and try to be tough guy so some people if i can tell that there's a tough guy i'm like hey guy don't be tough this isn't the point you came to me because something's bothering you so please don't be tough just let me know i can't help you if you don't tell me something's wrong so we're going to go ahead and do foraminal compression test that's what i would do next so i'm going to come behind the patient and again i'm going to instruct i'm going to tell her i'm going to put my elbows on your shoulders like so i'm going to put my hand on top of your head like so now i'm going to push down on your head in all of those range of motion first we're going to push down right here so i'm going to push down and i push down and i say any pain or discomfort yes or no then we come down and i i'm guiding your head down you see i'm not pushing it down i'm just sort of guiding her in this direction to right about here and then i'm gonna say the same thing i'm gonna push down any pain or discomfort with that then i'm going to pull her back and i'm guiding her the whole way relax then i'm going to push down same thing now we're going to go back to neutral now i'm going to turn her head to the right just a little bit and then i'm going to push down and then i'm going to come up same thing we're going to go to the left push down up ear to shoulder gonna make her shoulder come this way and i'm guiding her she can tell i'm not pushing on her head you can see my hands are loose i'm not laying on her shoulders everything is nice and loose i'm just standing here and then i'm gonna push down on her head like this this one takes a little finesse because you don't want to just take their head and slam it down that's a different test so what i want to do is have control of her head and push down and sort of in so it's kind of like a down and in type thing because these these tests what you're wanting to do is jam the joints right you're trying to figure out if this is sort of a joint thing going on so if i just laterally flex her head for most people that's going to hurt that's going to give them pain do it to yourself you're probably going to feel that so you want to really try to get the specifics of these types of tests and that is just laterally bending a little bit and then a little bit of downward pressure that is foraminal compression test so that's what i would do second range of motion foraminal compression test you can see it's because they walk into each other they just did the range of motion now i did the same thing just added a little bit of compression um next i do shoulder depression test and that would be where i come behind it and say i'm going to put my hand on your right shoulder and i'm going to put my left hand on your head and all i'm going to do is push them away from each other so i'm just going to go like this right here there's a little bit of tension i'm not going to overbear on her i'm just going to give a little bit of over pressure and that's it you can see her traps right here were popping out um so you can see that's a good amount of tension you don't want to push more than that a lot of the times people do these tests and they push really hard i have a lot of chiropractors that come in that are getting their sports designation and it's the first thing i tell them i'm like hey guy if someone's hurt they're hurt if you push hard of course it's going to hurt to me it's somewhat of a false positive so what i like to do is just get him to a position and now we're going to do the left side shoulder depression test she's going to say pain no pain i'm going to continue if she says no that hurts i'm not even going to do the test one more thing i'd like to tell you about that is if someone if you put them in a position and they say oh ow or you see him cringing or something's happening don't continue that means the test is positive that means there's pain of course if you push harder it's going to hurt more so i caution you on that um shoulder impression test now what we're going to do is i'll do adsense test so i do adsense tests no matter what even if they don't have radicular symptoms any paresthesia pain anything like that and i do this because a lot of the times you'll get that incidental finding of a decrease of pulse and i think that's important because that means something's wrong if you take someone's arm back like this and their pulse decreases their radio pulse decreases that's an issue right so although it's not a positive for the test it's an incidental finding because you're not reproducing the paresthesia or the pain it needs to be noted and it'll tell you that maybe their pecs are tight that might lead you into oh well if their pecs are tight and it's not enough to affect the nerves but it's enough to affect the artery or the flow of blood to your arm then what we need to do is maybe look into correcting her posture and maybe this neck pain is a huge posture problem also so that's kind of why i also use adsense there's a lot that kind of goes into that test so we'll do that to the next what we're going to do is i'm going to instruct the patient i'm going to tell her i'm going to grab your right arm your wrist um where your pulse is at i'm going to take your arm i'm going to pull it behind you and then i'm going to have you take a deep breath in hold it on the top and look towards me and i'm that's it i'm not going to tell them what i'm looking for because you never want to lead the patient right so i'm going to do that now i'm going to grab your wrist and you just relax relax your arm perfect and i'm going to do everything you just relax so i'm feeling for her pulse right here and i'm going to pull her arm behind her so till about tension i'm not going to over pull her right there's no need to do that just pull her to where there's a little tension my left arm up here has a slight resistance just so that i can get this hinge right here to hinge only from her shoulder boom then i'm gonna have her take a deep breath in and look to your right and i'm gonna ask her if she has reproduction of pain or paresthesia down the affected extremity so we'll do that bilaterally next we would do another test i really like is cervical distraction test this just tells me if there's compression going on most patients or clients or athletes if you lift up on their head they're gonna absolutely love it it feels good it's traction right it's pulling you up so they're most of the time gonna feel good but that's awesome to note you need to note that because you know wow okay anything i do that's going to decompress them will help them so all i'm going to do with this one is i'm going to tell her i'm going to lift up on your head from the back let me know if you feel any pain or discomfort so i'm going to grab my thumbs or on her just behind her mastoid processes on the occipital region right here and i'm not going to clamp her face i'm not going to stick my fingers in her eyes i'm not around her neck it's really my um uh thane are right here and my thumbs and i'm just going to grab her like this and i'm just going to pull straight up and ask is there any pain or discomfort and then relax so i didn't pull her really hard i tried to keep the uh pull on her head only uh and that's about it so that is the quick down and dirty that i do in my office really quick just to see and the reason i pick these four tests is because they all indicate something different if the patient says oh that hurt um or let's say i do adsense tests and they didn't have pain or paracetamol but then i do it another like yikes i do feel a little numbness or tingling or something going on in my fingers then i know okay let's go attack that or let's in dr sullivan's terms let's tease that one out so this is what i would do in my office as the quick down and dirty uh exam and we'll go through another a few of the other tests that you guys have on the packet right now what we're going to do now is we're going to go over the tests that are in your packet some of these tests i'm going to go over and i'm going to kind of give you my insight to the test kind of when i would use it or maybe i won't even use it some of these tests are kind of in infringing on the patient and yet you just really don't often have to do them there's other tests that are either equivalent or maybe you will have noticed in another test the same symptom so you don't need to do these ones the first one in your packet is spring test what we're going to do is we're going to do a pda glide on the spinous processes of the cervical spine so i have dom laying down here and i'm going to demonstrate that right now what you're going to do is you're going to take your thumbs and you're going to place them on the spinous processes they're right down the center of her spine they're pretty easy to find those little dinosaur bones sticking out right here and what you're going to do is a p to a glide so you're going to push down you can see my thumbs are side by side in the manual it has thumb over thumb i personally like side to side because when i push down if i do equal pressure i can kind of push from the right a little more or from the left a little more so i'm looking for joint mobility with this one in this one i to be honest would never do this one in my office this is a very painful test for most people no matter what especially if they come in and they're not sure what happened what if they have a clay clay shoveler's fracture well they have some sort of fracture in their spine and you're just going to sit here and push down on it obviously some other tests you would do would indicate not doing this test if you got to this test i would still be weary nobody likes being pushed down straight down on their spine but what you can do is come from the side you would come from the bottom but i'm going to show you for camera view on the top and you can just grab right along the side on those transverse processes or the lamina of the pedicles and you can just kind of go side to side like this i'm just pushing side to side and you're looking for movement you're looking for hyper mobility which means too much movement or you're looking for not enough movement which is hypomobility and these would be insufficiencies of the supporting structures all right guys now we're going to talk about the upper limb tension test this is a test for the you're going to be looking for pain or paresthesia down the affected extremity again so some neurological symptoms this could indicate a few things the biggest one that you might be concerned about is a herniated disc or some sort of space occupying lesion which would be something with the spinal cord that's encroaching on that this will test for that so what we're going to do i want to make sure you guys know that this is a passive test um and that if there's pain anywhere in the ranges of motion that we're doing this or any test that you ever do if there's pain while putting someone in the position or on their way to it that's apprehension right there's apprehension test that's actually the name of the test so with any of these tests remember that if they cringe or they have pain or symptoms while you're putting them in a position that's positive you can stop you don't have to take them to the end you don't got to yank on them just to make them say hey look that really hurts so here we go dom's right here what we're going to do is we're going to start with her arm to her side and her head we're going to passively flex this okay so i'm going to do it to the opposite side in this case we're using her left shoulder so i'm going to laterally bend her head to her right and we're going to leave it there she's going to relax and not strain that don't need to try to hold it there and then the first thing i'm going to do is i'm going to push down on her shoulder like so we're looking for recreation of pain and paresthesia down the affected extremity no all right let's get a little deeper let's kind of see is this one nerve uh the median nerve c5 c6 what's going on median or ulnar nerve or what what's exactly happening if there is anything else deeper into this so i'm going to abduct her arm and to 90 degrees and i'm going to flex her elbow to 90 degrees and i'm just going to hold it here and i'm going to ask her is there any pain or paresthesia are you okay yes awesome move to the next one you can have her if you read the piece of paper there's kind of a different ways um that should go about this to tease out the different nerves but you're gonna come up and down you can see on the tv i'm supinating her wrist and extending it and then you can also come down and in so this is important but if she feels pain while she went from here to here that's going to traction this nerve right because i went from a shortened state to elongated state i'm going to stop if i do this i'm further tractioning the nerve so if she has pain right here i'm going to stop if i go all the way and internally rotate and do this whole thing and there's no pain because basically what i did is i just traction the entire nerve and pulled it as long as it'll go that's then we're going to stop there and that's a positive test all right guys now we're going to go over the brachial plexus test this is similar to what i called earlier the shoulder depression test they're actually the same test just kind of two different names what we're looking for the main point in this is reproduction of the pain or paresthesia down the affected extremity so when you push down on the shoulder and you push the head away like this you can see the brachial plexus which is located right here which is all the nerves and vascular supply that um innervates her arm and controls everything that's going on in her arm comes out of here so when we do this we're squishing it so we're looking for provoking right something causing the problem i'm gonna push down here we're provoking it she's going to say ow the next test is shoulder abduction test this test is going to relieve the symptoms so if you go like this and you're like oh wow that's that's bad i feel the numbness i feel the tingling things like that then you can have them raise their arm above their head like so like i'm a little teapot and you can say does that make it feel better does that relieve the pain if it does again that could be because of the brachial plexus insults or something wrong with the brachial plexus all right guys now we're going to go over the vertebral artery test just want to give you a little thing to consider when you do this test to be honest i don't ever do this test i've probably never done this test in my life as the vertebral artery test this is the same thing as a few other tests in particular dick hull pikes which is going to be looking for inner ear stuff when you get vertigo so this test can provoke and maybe even cause problems so for me what i would do is i would use this test i'd put it in my toolbox and i'd have it kind of as like the last test down the road that if i'm really not sure what's going on does this really person really have some sort of vertebral or vascular problem which incidentally you're probably gonna know prior to doing this test um then i would whip this one out but other than that i would i would keep it hidden and not use too much of it so what we're going to do first is i'm going to very nicely cradle the patient what i'm going to do is take my fingers and i'm going to go like this so when i do this i'm making a little basket right and then i'm just going to hold their neck super comfortably i'm not going to be pushing in with my fingers this is the tension and now i created a basket so i don't have to squeeze so i'm going to do that under her neck dom's neck here and then what you don't want to do you want to be really really careful about is your thumbs or hands or anything coming up around someone's neck biggest thing they tell us in chiropractic school is never put your hands up or around anybody's neck you never know about their history maybe they had trauma maybe they don't like things around their neck it's pretty simple just stay away from their neck so you want to make sure your thumbs are not wrapped around their neck they're hanging out here to the side and i can still create the basket and i'm going to create that basket like this i'm going to ask dom because i didn't want to leave her head off the whole time to scoot down the table there we go and relax and then what i'm going to do is she probably feels pretty comfortable right now because her her occiput is hanging on my pinkies so she can relax because i have her whole entire neck supported with my fingers and my pinkies on her occiput so we're just gonna go back and down like this and you're gonna constantly ask them as you extend the head does this hurt do you feel symptoms what's happening are you okay if there's nothing when you get to the end then you're going to give a little bit of rotation to one side is there any provocation no provoking i'm sorry no go to the other side um the patient should have their eyes open go let's get down um should have their eyes open when they do this test because you're going to be looking for a myriad of things nystagmus for my book is a big one that's where the eyes are going nuts it's actually kind of neat if you've never seen it before but nystagmus you're going to look for pupils changing anything going on with the eyes the other thing you're going to be looking for is nausea vertigo anything where they're kind of like wow something's not right that's a big problem and if these were ever positive for me in my office to be honest it's an emergency i'm going to call 9-1-1 and i'm done touching her