physical therapists only rarely or occasionally perform a cranial nerve examination, so this is an area in need of improvement. Self-Assessment Quiz Question #31 Which two cranial nerves are involved in smell and hearing? a. Vagus and hypoglossal nerves.
Cranial nerve X, vagus nerve: Ask the patient to open their mouth and say “aaaaahhhhhh” while you observe for symmetrical eleva- tion of the soft palate and central ascent of the uvula. Cranial nerve XII, hypoglossal nerve: Ask the client to stick out their tongue, and move it side to side. Head, neck, and shoulder Cranial nerve XI, accessory nerve: Ask the client to resist shrug- ging of the shoulder. When examination reveals side-to-side differences or abnormal responses, this may be an indication to refer the patient to an- other healthcare provider for further examination or appropriate imaging/testing. The urgency of referral depends on the full clini- cal picture in terms of the client’s status and symptoms. Accord- ing to Taylor et al. (2021), the diagnostic accuracy of a complete cranial nerve examination is moderate at best. However, cranial nerve dysfunction may link to a wide variety and combination of potential pathologies, and a thorough medical screening during physical therapy examination for neck pain and headaches should include this element. At present, Mourad et al. (2021) report that Differential diagnosis cervical conditions When systemic and viscerogenic sources of neck pain have been ruled out, the task facing the assessing clinician is to determine what cervical structure(s) are causing the client’s presenting symp- toms. This is absolutely necessary for determining an effect treat- ment plan. Facet joint pain Facet (or zygapophyseal) joint dysfunction is a possible source of neck pain. According to Hurley et al. (2022), the facet joints are considered the primary source of pain in 26%–70% of patients with chronic neck pain and 54%–60% of neck pain following whip- lash injury. The C2–C3 and C5–C6 joints are most commonly im- plicated in neck pain, with C2–C3, C3–C4, and C4–C5 being the most radiologically involved (Hurley et al., 2022). Healthcare consideration: Since research shows that the facet joints are frequently involved in both acute and chronic neck pain, physical therapists must be skilled at differentiating wheth- er the facet joints are involved. Three ways to assess facet joint function are (1) looking at deficits in neck flexion, side bend, and rotation as each of the facet joints contributes their part to overall cervical motion; (2) observing the neck during flexion, rotation, and side bend to see if there is a visible restriction in motion at any particular level; and (3) providing posteroanterior pressure to each level of the cervical spine on both sides to determine if there is stiffness/decreased motion or pain at any level. AO and AA joints and neck pain The anatomy of atlantooccipital (AO) and atlantoaxial (AA) is uniquely different in the cervical spine. The AO joint is a synovial articulation between the convex occipital condyles of the skull and C1. The AA joint consists of the lateral articulations between C1 and C2 and the median articulation between the odontoid process and the posterior surface of the anterior arch of the atlas anteriorly and the transverse ligament posteriorly. The AO and AA joints provide mechanical stability between the head and cervical spine while allowing for significant movement. Approximately 33% of cervical spine flexion and extension comes from the AO joint. Over 50% of cervical spine rotation occurs at the AA joint. Pain related to AO or C0–C1 dysfunction tends to occur at the occipito-cervical region, in the retro-mastoid region, and in the upper cervical area. Pain related to dysfunction in C1–C2 most often occurs in the suboccipital area with radiation up to the back and head and down into the upper neck (Hurley et al., 2022).
b. Facial and glossopharyngeal nerves. c. Olfactory and vestibulocochlear nerves. d. Trigeminal and oculomotor nerves.
Self-Assessment Quiz Question #32 The cranial nerve that can be tested by resisting the client’s abil- ity to shrug the shoulders is:
a. Cranial nerve X, the hypoglossal nerve. b. Cranial nerve XI, the accessory nerve. c. Cranial nerve V, the trigeminal nerve. d. Cranial nerve XII, the hypoglossal nerve.
Self-Assessment Quiz Question #33 Another name for the articulation between the occipital con- dyles of the skull and C1 is: a. Atlanto-axial joint. b. Atlanto-occipital joint. c. Axial-occipital joint. d. C1-C2. Self-Assessment Quiz Question #34 The structure that runs posterior to the dens and provides sta - bility to the C1/C2 articulation via the den is:: a. Transverse ligament. b. Atlas ligament. Case Study: Ben Barnes Mr. Barnes presents to physical therapy with complaints of neck pain. When asked to show you where the pain is, he puts his hand on the upper cervical spine and says, “Right here.” Based on this basic information, it seems that upper cervical dysfunction may explain his symptoms. Question What tests can you use to determine if upper cervical spine dys - function is present? What symptom might accompany the pres - ence of upper cervical spine dysfunction if it is present? Discussion Tests that can be used to determine if upper cervical dysfunction is present include (1) the head nod test, which isolates motion at the C0/C1 joints; (2) the flexion rotation test, which isolates mo - tion at the C1/C2 joints; and (3) palpation of the upper cervical facet joints to determine if they are painful and/or demonstrate restricted motion, which can indicate involvement of these joints. C2 to C7 facet joints and neck pain Specific physical examination findings can be used to confirm a differential diagnosis of neck pain originating from the cervical spine. Hurley et al. (2022) identified the following exam findings as useful for diagnosing facet joint pain in the cervical spine: ● Cervical spine range of motion . Assessment of cervical flex- ion and extension, bilateral lateral flexion or side bend, and rotation can identify facet joint restrictions. Gross motion of the cervical spine is accomplished via the segmental contribu- tions of each facet joint. Limitations in cervical range of motion c. Atlantis ligament. d. Vertebral ligament.
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