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The upper quarter screen is appropriate when the diagnosis is unclear or when there is potential for referred pain from more proximal structures.
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The purpose of the upper quarter screen is to determine which anatomic region of the upper quarter is contributing to the patient’s symptoms and to rule out gross sensory or motor neurologic deficits.
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The examiner should observe for reproduction of the patient’s chief complaint of pain or symptoms, and, when identified, a more thorough examination of that region is necessary.
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The screening examination is performed bilaterally. This is especially true for reflex testing since results in normals can vary widely.
Anatomically, the upper quarter includes the cervical spine, upper thoracic spine, and the upper extremity. Because the source of a patient’s symptoms is often unclear, a screening examination can be helpful in providing an efficient mechanism for determining more precisely which region(s) may be contributing to the symptoms. The upper quarter screening examination is designed to achieve two basic purposes: (1) determine which anatomic region of the upper quarter is contributing to the patient’s symptoms and therefore needs to be examined in greater detail, and (2) rule out gross sensory or motor neurologic deficits consistent with a cervical radiculopathy or other source. ,
A screening examination is often unnecessary when the source of a patient’s symptoms or dysfunction is very clear from the history, such as with postsurgical problems or when some isolated traumatic injury has occurred to the upper extremity. The screening examination is most appropriate when the diagnosis is unclear or when there is a potential for referred pain, typically emanating from more proximal structures.
Referred pain can be simply defined as pain perceived in an area other than its source. A complete discussion of referred pain is beyond the scope of this chapter, but understanding some general characteristics of referred pain can be very helpful clinically. First, deeper, more proximal structures are most likely to refer pain. , Therefore, the majority of the upper quarter screening examination focuses on the cervical spine and shoulder. These areas are known to be potential sources able to refer pain to multiple sites in the upper extremity. However, it is rare that distal structures in the upper extremity refer pain proximally. Referred pain is also typically described as a poorly localized, dull aching sensation. , Therefore, the patient who rubs the entire lateral aspect of the arm while describing a dull aching pain is more likely to have referred pain than a patient who, for example, complains of a sharp localized pain on the lateral aspect of the elbow.
While performing the examination, the goal is to reproduce the patient’s chief complaint of pain or other symptoms. Occasionally, patients have mild restrictions in cervical range of motion (ROM) or complaints of discomfort or pulling sensations during cervical spine testing. Painless restrictions in motion or symptoms that are not part of the patient’s chief complaint should not be interpreted as positive tests but more likely represent normal variations.
What is included in the screening examination varies greatly; however, a suggested format is given in the form shown as Figure 10-1 . As a general rule, the vigor and extent of the examination should be based on the patient’s history. The goal is to gain enough information to proceed intelligently without exacerbating the patient’s symptoms unnecessarily. Therefore, for patients with very severe symptoms the exam should be more limited. Also, tests or motions that are anticipated to most likely provoke symptoms should be saved for the end of the examination whenever possible so as to avoid clouding the remaining tests.
The screening examination includes inspection, progressively vigorous cervical spine testing, a brief systematic scan of the peripheral joints, myotome testing for motor weakness, sensory testing for diminished light touch sensation, reflex testing, and special tests related to neural tension and palpation of common entrapment sites.
Inspection
Inspection includes observation from the side as well as anterior and posterior views. Any asymmetry should be noted as well as gross postural abnormalities. Careful attention should be given to normal soft tissue contours to observe for muscle wasting in key areas such as the supra- and infraspinous fossa (rotator cuff atrophy), and the upper trapezius and deltoid musculature ( Fig. 10-2A ). Anteriorly, the supraclavicular area should be inspected for any swelling (loss of normal concavity), which could represent swelling associated with brachial plexus injury as well as the potential for an upper lung tumor ( Fig. 10-2B ). Asymmetrical shoulder heights are somewhat common, with the dominant side being lower than the nondominant side. However, an elevated shoulder girdle could represent protective guarding associated with a cervical spine or neural tension problem, and a low shoulder may provoke neural tension problems.
Cervical Spine
The cervical spine is probably the most common source of referred pain to the upper extremity. If the problem is from direct compression of a nerve root or spinal nerve (cervical radiculopathy), the symptoms will include either sensory disturbances or motor weakness. , More commonly, the cervical somatic tissues (ligaments, facet joints, disk, muscle) can refer pain to the upper extremity without direct neural compression. In either case, the goal of the examination is to reproduce the chief complaint symptoms with ROM tests or special tests. ROM testing is done in each direction, first actively, then with passive overpressure applied at the end range if the active motion was pain-free ( Fig. 10-3 ). Generally, cervical extension is the most provocative motion and should be performed last. If standard motions do not provoke symptoms, special tests can be performed. These include cervical distraction, the Spurling test, shoulder abduction test, and the upper limb tension test ( Figs. 10-4 to 10-7 ). For cervical distraction (see Fig. 10-4A, B ), patients must be relaxed, which is best accomplished by having them supine and applying traction by pulling on the occiput and mandible. A positive test is diminished symptoms during distraction. Distraction may also be accomplished with the patient seated while leaning back slightly on the chair or directly on the examiner. , Spurling’s maneuver as originally described involves passive sidebending with overpressure and axial loading (see Fig. 10-5 ); although, several authors have described the test to include ipsilateral rotation and extension. A positive test requires reproduction of the patient’s chief complaint symptoms, because many patients feel some local neck discomfort during the maneuver that is not part of their symptom complex. The basis for this test is that this position maximally narrows the intervertebral foramina on the side being tested. The shoulder abduction test is performed by the patient resting the hand on top of the head for approximately 30 seconds, and a positive test is when the chief complaint symptoms are reduced or eliminated (see Fig. 10-6 ). The upper limb tension test has many variations, but all utilize a combination of extremity movements performed sequentially to produce tension in the neural tissues. Specific tests for adverse neural tension within the upper quarter are discussed more completely in Chapter 118 . A simple screening maneuver for the upper quarter is the combined active motions of full shoulder abduction in the frontal plane plus elbow, wrist, and finger extension. Generally, the elbow, wrist, and fingers are extended first, and shoulder abduction is the final motion. If the chief complaint symptoms are reproduced, or shoulder abduction is appreciably reduced when combined with elbow, wrist, and finger extension, the possibility of adverse neural tension must be more fully evaluated. Wainner and colleagues studied the upper limb tension test (ULTT, part A), which was performed passively with the patient supine in a sequential fashion as follows: (1) scapular depression, (2) shoulder abduction, (3) forearm supination with wrist and finger extension, (4) shoulder lateral rotation, (5) elbow extension, and (6) contralateral and ipsilateral cervical sidebending. The patient is questioned regarding reproduction of chief complaint symptoms during the entire procedure. The criteria for a positive response were any of the following: (1) reproduction of the chief complaint symptom, (2) greater than a 10-degree difference between sides with elbow extension, (3) chief complaint symptoms increased with contralateral sidebending and decreased with ipsilateral sidebending.
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