*A discrete, hypersensitive nodule within tight band of muscle or fascia that present with classic pattern of pain referral that does not follow

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1 A patient presents with c/o cervical spine pain and chronic headaches that radiates across the top of his head. He also experiences frequent bouts of nausea, dizziness and indigestion. The patient also as a history of TMJD: Examination reveals: Posture: FHP and rounded shoulders. 65% loss of cervical ROM bilaterally. Tenderness in the upper 3 cervical vertebrae. The patient became diaphoretic and nauseous upon palpation of the cervical spine. Upper cervical spine dysfunction contributes to TMJ dysfunction. Dizziness or vertigo from dysfunction may be 2 nd to abnormal afferents impulses that provide proprioceptive feedback to the cerebellum. Upper cervical spine (C 1-3 ) via the spinal accessory nerve is directly connected to the Vagus nerve. There is a neurological link between the upper cervical nerves and sensory fibers of the trigeminal nerve. 1

2 A discrete, hypersensitive nodule within tight band of muscle or fascia that present with classic pattern of pain referral that does not follow segmental innervation. 2

3 Sternocleidomastoid: Sore throat, Headaches and migraines Vision problems and tearing, Ear aches, and ringing in the ears Trapezius: Shoulder pain, Head aches, Vision problems Dizziness or vertigo Face,jaw and temple pain 3

4 53 y/o female with c/o radiating neck pain that travels into her left index finger. Her symptoms began after being rearended in a MVA. The burning radiating pain is made worse with S/B or rotation to the right. She has 50% expected C/S ROM and trigger points throughout the C/S musculature. What s the possible differential diagnosis What questions do you want to ask to help determine the patient s diagnosis? How can we confirm a specific diagnosis? Typical peripheralization patterns Cutaneous Innervation and Dermatomes Attempts to compress a cervical nerve root. Do NOT perform until a cervical fracture, dislocation, or instability has been ruled out. 4

5 16 y/o patient c/o severe cervical spine pain that creates burning in all 4 extremities. PMHX of asthma, PSHX tonsillectomy. C/S rotation reduced greater than 50% Exam reveals: Patient weakness and sensory loss in all 4 extremities (upper > lower) Reflexes elevated in all 4 extremities Positive Babinski, Hoffman sign and 3 beat clonus 5

6 6

7 Patient is a 60-year-old male with history of C/S pain and frequent c/o vertigo. Recently r/o CVA because patient recently experienced dysarthria and LOB. The patient also has a 20 y/o hx of DM. Examination : C/S ROM 90% of expected for age. Reports double vision when he turns his head to the right. You notice lateral nystagmus with end range cervical rotation to the right. 7

8 Vertigo with associated Neurological signs Diplopia (double vision) Ataxia Lateral nystagmus Drop attacks Dysarthria Tingling of the lips Paralysis/weakness/Numbness Risk factors (HTN, Diabetes, CAD) 1. Bogduk N. Cervical causes of headache and dizziness. In: Grieve GP. Modern Manual Therapy, Churchill-Livingstone: New York, Berthoz A, Graf W, and Vidal P, The Head-Neck Sensory Motor System. Oxford University Press: New York, Biondi, D,DO. Cervicogenic Headache: A review of Diagnostic and Treatment Strategies, J AM Ostopath Assoc April 1 st Brown JJ. Cervical contribution to balance: cervical vertigo. In: Berthoz A, Graf W, and Vidal P. The Head-Neck Sensory Motor System. Oxford University Press: New York, Bruflat, Angela K., et al. "Stress Management as an Adjunct to Physical Therapy for Chronic Neck Pain." Physical Therapy (2012): Dvorak J and Dvorak V. Manual Medicine -- Diagnosis, 2nd ed. Thieme Medical Publishers: New York, Fernández-de-las-Peñas, César, et al. "Referred pain from muscle trigger points in the masticatory and neck-shoulder musculature in women with temporomandibular disorders." The Journal of Pain (2010): Janis, Jeffrey E., et al. "The anatomy of the greater occipital nerve: Part II. Compression point topography." Plastic and reconstructive surgery (2010): Koc, F., H. Bozdemir, and S. Paydas. "440 PANCOAST TUMOR PRESENTING WITH ARM PAIN." European Journal of Pain Supplements 4.S1 (2010): Hertling D et al. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods 3 rd ed. Lippincott-Raven Makofsky, H.W. et al. A multidisciplinary approach to evaluation and treatment of TMJD and Cervical Spine Dysfunction: Journal of Craniomandibular Practice 7(3): O'Leary, S. H. A. U. N., et al. "Muscle dysfunction in cervical spine pain: implications for assessment and management." J Ortho Sports Phys Ther39.5 (2009): Stayman, Aaron, Raul G. Nogueira, and Rishi Gupta. "Diagnosis and Management of Vertebrobasilar Insufficiency." Current treatment options in cardiovascular medicine (2013): Travell JG and Simons DG. Myofascial Pain and Dysfunction -- The Trigger Point Manual. Williams and Wilkins: Baltimore,

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