The first weekend in March, the 3-5th, I had the pleasure of working with Vince Cunnan, @funsocksphysio on Twitter, on a Level 2 course. This time the course was not in Vancouver, it was in Kelowna! This course was spearheaded by Vince in the fall of 2016. He sent me an email asking if I would be interested in helping him out in a course in the spring of 2017. I agree and then he set to work trying to set the course up with the BC Orthopaedic Section. It was a close call because we did not get the numbers that we needed to get the course going at first. It was postponed, then we had a couple more physiotherapists sign up for the course and it was a go!
The course started on Friday afternoon, did I mention the course was in Kelowna? Vince started off with talking about the course and where it fits into postgraduate learning. Transitioning into the upper quadrant scan. We use this type of scan to make sure that us, physiotherapists, do not miss some of the subtleties. Basically, it is a quick scan from the head down the arm and hand. We get the clients to do the basic moves to make sure that we are getting the information we need. We go through head/neck, shoulder, elbow, wrist and hand movements. We check to see if there is anything that our client did not tell us because it did not seem important to them. For example, when dealing with neck or shoulder pain, the client will almost always tell us about one or the other. In reality, they are so closely related that it is very difficult to have shoulder pain without neck pain or vice versa.
Then we go onto the neurological scan of the assessment. This is one of my favorite parts! It tests the integrity of the nervous system and the ability of the muscles to get the nerve impulses. We, as physiotherapists and doctors i.e. GP and neurologist for example, know that the nerves from the arms entangle with one another, in the brachial plexus, and come out as different nerves, with a little bit of multiple different origin nerves. For example, the C5-T1 nerves go into the brachial plexus and come out at the radial, median, ulnar and axillary nerves. The axillary nerve has components of the C5 and C6 nerve in it. Continuing on with my little story, there are certain muscles in the arm that even though they get multiple nerve inputs, there is a primary nerve going to that muscle. That is called a key muscle. Testing the nerve and muscle is called key muscle testing. It tests for weakness in the muscle that is NOT painful! The test is basically an isometric contraction of the muscle that is held for about 5-10 seconds. If the muscles do not lose strength, everything is good and move to the next muscle. If there is some weakness, the muscle should be retesting immediately, within 1 second, to see if the weakness is present and or getting worse. This can be a sign of the nerve having some pressure on it. A lot of people immediately think, it is a disc bulging, that puts the pressure on the nerve. It can be, but it does not have to be. There are many places along the path of the nerve that can add some extra pressure that may change the strength of the end muscle.
The conduction of the nerves can also be tested by doing the reflexes of the nerves. Yes, the classic sitting on the table and having the physiotherapist hit your knee with a reflex hammer and watch your leg swing forward. In fact, in the upper body we can do that down the arm. We can get reflexes in following different muscles, levator scapula (back on the shoulder blade), in the deltoid (shoulder muscle), biceps, triceps, thumb and little finger sides of the hand. Each one of those reflexes tell something to the physiotherapist or doctor about the integrity of nerve and the nerve pathway. Very cool.
Friday night was finished off with a talk on neurodynamics. I think I did another blog post about this. Neurodynamics includes the movement of the nerves and how they interact with the tissue around them. It is always interesting.
Saturday morning, I was up and we started discussing the CV region of the spine. That is the area of the body where the head sits on the neck. There are two joints up in this area, the OA and the AA joint, Occipital-atlantal and the axial-atlantal joints. The skull is known as C0, top on the cervical spine, aka the neck. The first cervical vertebrae is called C1 or the atlas. C2 vertebrae is the second cervical vertebrae aka axis.
The top joint, C0-1 or the OA joint causes the ‘yes’ chin nod motion of the head. The AA joint, causes the head turning, ‘no’ motion of the head. We went through the biomechanics with the physiotherapists, i.e. how do these joints in theory move. What muscles get them to move and what muscles, or other structures, restrict their movement. That always brings up some good conversation between the instructors and students.
Just before the morning break we started into the assessment of this area of the body. This is usually an area of the body that is not covered well in the their normal training in university. A lot of hands on training for the physiotherapists. Lots of questions and questioning their techniques. And most importantly, lots of learning and stimulation of conversation between physiotherapists and instructors. We went through stability testing in this area of the spine because this area can be injured with trauma. For example a fall or a car accident. What I tried to teach, which is more important than stability testing, is when not to stability test and send the client back to their doctor or the emergency room. It is not often that occurs, but it is really good to know when to do it.
We finished off the second day of the course, only 10 more to go, with how to treat this area when there is something wrong.
Vince discussing the C-spine
Sunday morning started off with me again, going over the anatomy of the upper and lower cervical spine. Then Vince jumped right in and started off with the biomechanics of the cervical spine, how the bones in the neck move. There are two different ways of looking at how the bones move, arthrokinematically or osteokinematically. Arthrokinematics deal with what type of movement happens that the joints, between the bones, while osteokinematics deal with the how the bones move but ignoring the joint movement. Very interesting indeed!
Vince then went on to teach assessment of the cervical spine. There are a lot of little subtleties that occur with the assessment of the neck. The younger physiotherapists did a great job with trying the different skills and adding them to their arsenal of assessment techniques.
Treatment of the cervical spine was just getting started and the day ended. One thing that Vince and I did was video some techniques for the physiotherapists taking the course. I am going to try to add them to this blog post or maybe try to embed them with YouTube.