Test 2

Question 1

Compression neuropathy is the process by which a nerve becomes entrapped as it passes through a narrow tunnel or passage

Epineurium -> Perineurium -> Endonerium -> Myelin sheath -> Axon

There are 3 types of nerve injuries

1) _____ is the least severe (Days to weeks recovery) and involves focal damage of the ____ around the axon but NOT the connective tissue sheath

^** AKA first degree

2) ___ is when the axon itself is injured and recovery takes months

^** AKA second degree

3) ____ is complete disruption of the axon with little recovery

^** AKA third degree (endoneurium becomes destroyed)

Answer 1

1) Neurapraxia, myelin fibers
2) Axonotmesis
3) Neurotmesis

Question 2

Cervical nerve root compression

Usually due to disc bulging or herniation and the disc usually ruptures ____ in direction causing compression on the nerve roots as it exists the intervertebral foramen

^** SO a C4-C5 disc rupture will affect the ____ nerve root

This causes cervical RADICULOPATHY that is characterized by a pinched or irritated nerve in the neck causing pain, numbness, or weakness radiating into the CHEST or ARM

To check for this, perform the ___ maneuver which is performed via placing the neck in ____, rotating ___ the side of the lesion and side bending ___ the side of the lesion and pressing down

Answer 2

Posterior-laterally

C5

Spurlings, Extension, towards, towards

Question 3

**Know the distribution of the cervical nerves for C4-T1 and their MOTOR, SENSORY, and REFLEX distributions

Everything makes sense except for motor stuff…. Realize C5 is delts and biceps, C6 does Wrist ____ and elbow ____, C7 does wrist ___ and elbow ___ and finger ____, C8 does finger ____ and T1 does finger abduction

Also know the LOWER extremity nerves for MOTOR and REFLEX

Answer 3

Page 15 - Extremity Compression Neuropathy Lecture PPT

C6-Extension, flexion
C7-flexion, extension, extension
C8- flexion

Page 44 ^** Same lecture

Question 4

The Radial nerve provides motor to the ____ and wrist ____ors and sensation to the ____ of the hand via the posterior interosseous nerve

^** Therefore if injured you will get wrist ____ (since extensors no longer work) and tricep pain/numbness/etc and weakness in ____ (which remember occurs via the ____ muscle)

The two places it can become entrapped include

1) High on the ____ from either a fracture of the bone, of compression of the nerve near the ___ groove

^**Function returns in 4-5 months

2) ___ syndrome is due to compression of the _____ branch of the radial nerve as it passes under the ____ muscle at the Arcade of Frohse

These patients will obtain their injury from repeated rowing or sports and have pain and tenderness 5cm distal to the ____ with wrist drop and pain upon resisted ____ occurring

** Note that sensory loss will be much more prominent for an injury high on the humerous compared to that of the radial tunnel since the posterior interosseous branch is mainly a MOTOT branch**

Answer 4

Triceps, extensors, dorsum

Drop, elbow flexion, brachioradialis

1) Humerous, spiral
2) Radial tunnel, Posterior interosseous, supinator

Lateral epicondyle, supination

Question 5

The Median nerve provides motor to the forearm and wrist ____ and ____nation along with thumb abduction and ____

Sensation is to the index finger

The 3 places it can become entrapped include

1) ____ syndrome occurs as the nerve passes between the superficial and deep heads of the pronator ___ muscle

^** These patients will have pain in the mid/proximal forearm and possible sensory abnormalities in the radial three and half digits

In other words, pain during resisted forearm ____ is indicative

2) Anterior interosseous syndrome is a deep ____ branch of the median nerve so you would have ONLY motor problems like not being able to flex the forearm or fingers and NO sensory problems

^** One test to determine an anterior interosseous syndrome is the ____ since the finger can’t flex

3) Median nerve entrapment aka ___ syndrome and due to compression under the ____

^** These patients will often DROP things and pain and tingling in the radial three and half digits along with wrist pain

You can use an EMG to determine if this is the problem

To diagnosis a carpal tunnel SD, perform the phalens test, tinels sign, or 2pt discrimination (unable to distinguish 2 points on a caliper if closer than 5 mm)

Answer 5

Flexion, pronation, opposition

1) Pronator, teres

Pronation

2) Motor

OK sign

3) Carpal tunnel, flexor retinaculum

Question 6

The Ulnar nerve provides motor to the ulnar side of the forearm and hand flexors

The DEEP branch provides MOTOR innervation for the ___ muscle and the ____

The SUPERFICIAL branch provides SENSORY to the ___ fingers

The 2 places it can become entrapped include the:

1) ____ syndrome between the medial epicondyle, medial trochlea, olecranon, and ulnar colalteral ligament

^** These patients will present with 4th and 5th digit parasthesia, medial elbow pain, + Tinels sign at the elbow, and pain reproduced during elbow ___ and wrist ____

Use ____ sign to diagnosis cubital tunnel syndrome

Answer 6

interosseous, adductor pollicis

4th and 5th (ring and pinkie)

1) Cubital tunnel

Flexion, extension

Froment’s sign

Question 7

_____ syndrome is the compression of the brachial plexus or the subclavian vessels

Teats include: EAST, Adson’s, wrights hyperabduction, Military/costoclavicular

EAST tests for the ____
Adsons Test looks for S.A entrapment and if looking towards = ___ and away = ___
Hyperabduction = ___
Costoclavicular = ____

Answer 7

Thoracic outlet

Subclavian A
1st rib, Tight scalenes
Pec minor
1st rib and clavicle

Question 8

Name the nerve and it distribution

1) ____ nerve presents with pain along the LATRAL aspect of the leg and FOOT DROP (with slapping gait) and plantarflexion and inversion can cause pain with L___-____
2) ____ compression nerve causes ANTERIOR TARSAL TUNNEL SYNDROME due to compression of the deep fibular nerve at the ____ with L___-___

^** Patients will have pain over the ____ aspect of the foot and pain between the 1st and 2nd toes along with weak extensor digitorum brevis (not much motor function)

3) ____ nerve compression causes TARASL TUNNEL SYNDROME due to entrapment behind the medial malleolus with the overlying _____ retinaculum with L___-____

^** Symptoms will present on the ___ aspect of the foot and toes

** DON’T CONFUSE anterior tarsal tunnel vs tarsal tunnel syndrome and note the differences between EXTENSOR and FLEXOR retinaculum

4) _____ nerve compression causes ____ paresthetica due to compression under the ___ ligament at the inguinal canal with L__-___

^** This is a ____ only innervation nerve that causes loss of sensation from the anterolateral ___ down to the knee

Answer 8

1) Common Fibular, L4-S2
2) Deep fibular, Inferior extensor retinaculum, L4-S2

Dorsomedial

3) Posterior tibial, Flexor, L4-S2

Plantar

4) Lateral femoral cutaneous, Meralgia, Inguinal, L2-L3

Sensory, thigh

Question 9

For the upper extremities, name the dermatome level

1) Superior shoulder
2) Lateral arm over deltoid
3) Lateral forearm
4) Middle finger
5) Ring/little finger and medial forearm
6) Medial arm

Also Know L1-S2 for lower extremities

Answer 9

1) C4
2) C5
3) C6
4) C7
5) C8
6) T1

Question 10

The ____ test has the patients head and neck in a neutral position and axial loading force produces pain/paresthesia/numbness in ___ and indicates nerve entrapment

Answer 10

Compression, UEs

Question 11

PTP right = Rotated R

Remember, type 1 mechanics = TONGO

^** Type One Neutral Grouped Opposite direction

Type 2 = Not-neutral, Grouped Same direction

1) OA = _____ mechanics

^** Which means there is a FLEXION and EXTENSION component (the modified part that follows type 2) but they go in OPPOSITE directions (the type 1 part)

EX: OA F Rr Sl

2) AA = _____ mechanics

^** AKA AA Rl or Rr

3) C2-C7 = _____ mechanics

^** Which means there is a FLEXION and EXTENSION component and they go in the SAME direction

^** The reason why this could be considered modified type 2 is because often the cervical vertebra are not dysfunction in groups

Answer 11

1) Modified type 1
2) Rotation only
3) Type 2

Question 12

For tests looking at thoracic outlet syndrome

1) Adsons test looks for ____ entrapment

Have patient extend and rotate TOWARDS the affected side while feeling radial pulse if pulse diminishes it’s entrapment via the ____

If patient looks away it’s entrapment via the ____

2) Wrights hyperabduction tests for compression via ____
3) Halstead test looks for entrampent via the ___ and ____

Answer 12

1) Subclavian a.

1st rib

Tight scalenes

2) Pec minor
3) Clavicle and 1st rib

Question 13

For ribs, Inhalation SDs are the most common

For a ____ handle ME treatment, contact between the 2 heads of the SCM, flex head, and encourage exhalation and resist inhalation

For a ___ handle ME, contact LATERAL to the SCM and flex head and SB ___ the SD rib, and encourage exhalation and resist inhalation

Answer 13

Pump

Bucket, towards

Question 14

____ syndrome is the second most common compression neuropathy and involves the ___ nerve, and common in ____ type of motions that involve the ____ compression on the tunnel

Test using tinnels sign or Froments sign which tests the ____ since that is weak in ulnar nerve palsy

Answer 14

Cubital tunnel, ulnar, pitching, flexor carpi ulnaris

Adductor pollicis

Question 15

Posterior glide of the radius is coupled with ____nation and ____ion and anterior glide is coupled with ____nation and ____ion

The most common SD is a ____ radial head

Note that adduction and abduction of the elbow is referenced to the wrist so an adduction of the elbow as the wrist move in and elbow out aka VARUS force and abduction is a VALGUS force

Answer 15

Prontation/extension, Supination/flexion

Posterior

Question 16

If you have compression of the common fibular nerve, it will be compressed at the ____

Checking for gastroc vs soleus tightness, you want to ___ the patients foot and if you can not while in full extension, it is a tight ___, then bring the patients knee into slight flexion and dorsiflex again, and if inability to dorsiflex then it is a tight ____

Answer 16

Fibular head

Dorsiflex, Gastroc, Soleus

Question 17

For a posterior fibular head SD, ME and HVLA asks you to place the patient into the barrier which is ____version, ____flexion, and ____ rotation and then for ME have the patient move into opposite position and for HVLA you bring knee into flexion with hand in the popliteal crease (MCP on fibular head) and apply a HYPER____ thrust to drive the fibular head anterior

Answer 17

Eversion, dorsiflexion, external, hyperFLEXION

Question 18

Remember, ANTERIOR TARSAL TUNNEL SYNDROME is due to compression of the ____ nerve

Answer 18

Deep fibular

Question 19

For navicular vs cuboid SDs, the ____ aspect of the navicular will drop plantar and the ___ portion of the cuboid will drop plantar

Treatment for anterior tarsal tunnel syndrome can be MFR to the ___ retinaculum or HVLA of a cuboidal or navicular SD, it’s called the ____ treatment so lets say it’s a cuboidal or navicular plantar SD, have the patient come to the edge of the table PRONE, contact the dysfunction with fingertips and bring foot into slight DORSIFLEXION and then come down in a whip like motion into PLANTARFLEXION with pressure in the ____ direction

Answer 19

Lateral, medial

Extensor, HISS whip, dorsal

Question 20

For a Tarsal tunnel syndrome due to compression of the posterior tibial nerve, it is often due to an ______ SD of the ankle (subtayler joint motion aka between the calcaneus and talor bone)

To treat, you can do MFR to the ___ retinaculum or ____ HVLA treatment to the calcaneus where you apply traction to the calcaneus and then a HYPER____ thrust to the ankle

Answer 20

EVERSION calcaneus

Flexor, ankle tug, inversion

Question 21

With meralgia paresthetica due to the lateral femoral cutaneous nerve compression under the inguinal ligament, it is usually due to a _____ hip joint SD

To treat, use ME or MFR

Answer 21

Flexion

Question 22

The ureters travel across the ____ muscle fascia so if you have a kidney stone, you can have psoas aka hip flexor spasms

Answer 22

Psoas Major

Question 23

The sphincter, trigone, and urethral orifice are activated by ____pathetics from ___-____ and inhibited by _____pathetics from ___-____

^** In other words, parasympathetics = Voiding

The bladder wall (detrusor muscle) is activated by ____pathetics and inhibited by _____pathetics

Answer 23

Sympathetics, T10-L2, Parasympathetics, S2-S4

Parasympathetics, sympathetics

Question 24

SYMPATHETICS:

The kidney and upper ureter comes from ___-___ and synapse in the ______

The lower ureter and bladder comes from ____-____ and synapse in the _____

PARASYMPATHETICS:

The kidney and upper ureter comes from the ___ nerve

The lower ureter and bladder comes from ___-____ and the ___ nerve

Answer 24

T10-L1, Superior Mesenteric Ganglion

T12-L2, Inferior Mesenteric Ganglion

VAGUS

S2-S4, Pelvic splanchnic nerve

Question 25

For bladder emptying, activation via parasympathetics is from the ____ nerve at ___-____ to cause emptying (Detrusor contracts)

For bladder urinary retiention, activation via sympathetics is via the ____ at ____-____ to cause retention (Internal Urethral Sphincter closes via ____ adrenergic and detrusor relaxes via ____ adrenergic innervation)

Somatic is the voluntary control of our bladder (External Urethral Sphincter) with the ___ nerve at ___-____

So to void, we activate paras, relax IUS via inhibiting sympas, and open/relaxing EUS via somatic

Answer 25

Pelvic splanchnic, S2-S4,

Hypogastric plexus, T10-L2, Beta 2 adrenergic, Alpha adrenergic

Pudendal nerve, S2-S4

Question 26

For treating a patient with a urological SD, if they have:

1) Parasympathetics involved with the PROXIMAL ureter and KIDNEY treat the ___ nerve by correcting any SD at the ____ or ____ suture or sacrum/pelvis
2) Parasympathetics involved with the DISTAL ureter and BLADDER treat the ___ nerve by correcting any SD at the ____-____
3) Sympathetics involved with the KIDNEY and BLADDER correct any SD at ____-____ to reduce stimulation to the renal arteries/reduce relaxation of bladder/reduce ureterospasm of the IUS

^** Examples could be ____ of T10-L2 and inferior mesenteric gnaglion help

You can also treat lymphatics via rib raising/lymphaitc pump/thoracic inlet etc…

Answer 26

1) Vagus, OA/AA, OM
2) Pelvic splanchnic nerve, S2-S4
3) T10-L2

Rib raising

Question 27

BPH would be seen at ___-____

If a patient has T12-L2, S2-S4 and Psoas spasm affecting hip motion with ureter involved, think _____

If you have dilated lymph channels and want to treat them for a urological SD, you can do rib raising, lymphatic pump, or thoracic inlet and diaphragms

Answer 27

T11-L1

Nephrolithiasis

Question 28

For micturition control:

1) The Corticopontine-mesencephalic pathway inhibits the parasympathetics via the frontal lobe and it will result in a ____ bladder if there is an injury above the pontine center
2) The Pontine mesencephalic sacral pathway coordinates detrusor and sphincter interaction so it will result in ____ if there is an injury below the pontine center (causes the detrusor and sphincters to ____)
3) The Pelvic and pudendal nuclei pathway mediates the sacral ____ reflex so that when the bladder is full, it causes the detrusor muscle to contract. So if this is injured, you will get an ____ bladder and urinary retention
4) The Motor cortex to pudendal center mediates ____tary control of the EUS

Answer 28

1) Hyperreflexic
2) Detrusor-sphincter dyssynergia, contract
3) Areflexic
4) Voluntary

Question 29

Pain referred to the head unilaterally from a cervical SD is called ____

Very common in patients with whiplash injury (C2-C3 joint pain) and affects ___ genders the most

The OA and AA SD commonly cause the CHA SD

The most likely muscle-referral pain pattern with this type of headache is the _____

Answer 29

CHA (Cervicogenic cephalgia)

Female

Cervical facet joint

Question 30

The suboccipital triangle muscles include the

1) ____ that ____ to the ____ side
2) ____ that ___ to the ____ side
3) _____ that has bilateral contraction causing ____ and unilateral contraction causing ____ to the ___ side

4) SCM u/l SB ____ and R ____
SCM b/l ___ion of the head and neck

5) Traps help elevate and ____duct the UEs
6) Semispinalis, splenius capitis, and longissimus capitis allow ___ when contracted

^** ____ and ____ u/l contract cause ___ to the ____ side

_____ u/l contraction causes ___ to the ____ side

**Rotatores (connects successive vertebra) and multifidi (1-3 spinal levels) allow ____ movement and u/l contraction causes ___ to the ____ side**

Also note the rectus capitis posterior minor has a fascia/tendon that attaches to the spinal dura causing a direct anatomical link between MSK and dura and this is called the ____

Answer 30

1) Obliquus capitis superior, SB, same
2) Obliquus capitis inferior, R, same
3) Rectus capitis posterior major, extension, SB/R, same

4) Towards, away
Flexion

5) Adduct
6) Extension

Splenius capitis and longissimus capitis, SB/R, same

Semispinalis capitis, R, away

Segmental, R, away

Myodural bridge

Question 31

The ______ nerve tract descends into the upper cervical spine and has sensory and motor innervation along with convergence of other pathways like the peripheral nerves afferent (vagus V and spinal accessory nerves XI)

For sympathetics the ____ ganglion is located anterior to C2 and the peripheral nerves (greater and lesser occipital nerves) C1-C3 can cause ___characterized by pain to the ___ of the head

^** So in other words, the ___ nerve and superior cervical chain ganglia are most likely maintaining the patients headache*****

^** If it’s ____ neuralgia there will be lacrimation in the ipsilateral eye and pain to the back of the head and if it’s ____ neuralgia there will be pain to the back of the head and no lacrimation

Answer 31

TNC (Trigeminal nucleus caudalis)

Superior cervical ganglia, occipital neuralgia, back

Vagus

C2, C3

Question 32

The anatomical dural attachments that allow for motion of the primary respiratory mechanisms relative to the spinal dura are ____

Answer 32

FM-232 (Foramen magnum, C2, C3, and S2)

Question 33

OA is ____ mechanics

AA is ____ mechanics

C2-C7 is ____ mechanics

For ME, place patient into barrier and tell them to go back neutral

For HVLA of OA and AA, bring patient into barrier and apply the thrust (OA you use MCP joint of your hand and grab their chin, etc and apply thrust towards patients ____)

For C2-C7 (typical cervical vertebrae), you need to determine first if you have a SB or R focus component aka which one had the harder end feel….

^** For SB if they are C5 E Rr SBr you would push down on the ____ side of the patients neck at C5 to SB them to the ____ (SB THROUGH), then rotate their head to the _____ (R TO NOT THROUGH) along with flexion of the head and then apply the thrust

^** So in other words, you are ALWAYS pushing down on the opposite transverse process from the PTP Opposite the rotational aspect**

For R if they are C5 E Rr SBr you would rotate them to the ____, SB them to the ____ and flex and apply thrust

^** ROTATE THROUGH AND SB TO

Last but not least, upper cervicals thrust towards ___, middle towards ____, and lower towards ______

Answer 33

MT1 (aka TONGO -> Type One Neutral Grouped Opposite, but the modified part means there is a flexion and extension component to it)

Rotation only

MT2 (aka Type 2 F/E Single segments Same and the modified part means sometimes instead of single segments, sometimes they can be grouped)

OA

Left, left, right

Left, right

Eyes, neck (straight across), chest (downwards)

Question 34

Direct inhibition (aka inhibitory pressure) is a subset of ____ used to treat the upper thoracic spine such as squeezing the trapezius between your fingers

*******Commonly seen in CHA headaches is the _____ tender point associated with upper thoracic cervical spine tension and you can treat this with ME via pushing with thumb on point and other fingers lie on-top of the anterior shoulder

^** Then, ___/SB/R ____ from the affected side and the patient shrugs the ____ shoulder up towards ear (superiorly)

Answer 34

Soft tissue

Levator scapulae

Flex, Away, ipsilateral

Question 35

For ME of thoracic if you are working with the ____-T spine you are involving the head and neck flexion or extension

If you are working T5 and below, you are using the HAND on the ____ side of the PTP and elbow technique

For HVLA of chin-pivot, if the patient is T3 N Rr SBl you have them rotate and SB to the ____ side aka SB LEFT and R RIGHT in this example

Answer 35

UPPER-T spine (T1-T4)

Same

Ipsilateral

Question 36

____ set and fine-tune the activity of the moment-to-moment fine adjustments of posture and locomotion

The spindle has a stretch reflex and proprioception component (that consists of an agonist and antagonist muscle aka one that relaxes with internerouron involvement and one that contracts)

So counterstrain works to bring a hypertonic muscle, whose spindles report strain where there is none, into a SHORTENED position so the physician can reverse the hyperactivity of the spindles and restore normal stretch reflexes and the normal range of motion

^** The three proposed pathways for counterstrain points are 1) Reflex mediated through gamma motor neuron pathways (strain-counterstrain) 2) Trauma via direct injury to tissues 3) Secondary to a SD

^**** If a patient has a preference for a motion, they have INCREASED gamma motor activity of THAT preference aka patient with lateral ankle pain and inversion ankle SD they have increased gamma of the INVERTERS and increased nociceptive activity of the LATERAL ankle ligmanets ****

Answer 36

Gamma motor neurons

Question 37

Frail patients CAN be treated but patients with SEVERE osteoporosis, C-spine injuries, or severely ill should NOT

The _____ is related to localized, ____athetically mediated vaso____

If multiple treat the worst one first and if area is close then treat the middle one

Answer 37

Therapeutic pulse, sympathetically, vasodilation

Question 38

Cardiac sympathetics are from the ___-____ level that synapse in the upper thoracics and _____

Fibers on the right innervate the ___ node and those on the left innervate the ___ node

Cardiac parasympathetics has the ____ nerve going to the SA node and ____ going to the AV node

^** Hyperactivity of ___ side leads to sinus bradycardia and hyperactivity of ____ side leads to AV block

If a patient ASPIRATES, it causes the pulmonary branches to affect the heart and this is a ___-____ reflex that can lead to ____ of the heart rate

^** So realize you can use other visceral-visceral reflexes to slow the heart

Answer 38

T1-T5, cervical chain ganglia

SA, AV

Right Vagus Nerve, Left vagus nerve

Right, Left

Visceral-visceral, slowing

Question 39

The heart and lungs drain to the ______ lymphatic duct

The thoracic duct which drains the left side is under ___ control

Answer 39

RIGHT

Sympathetic

Question 40

Severe scoliosis at 75 degrees thoracic curvature compresses the cardiac function and you get MSK compensation

This is a ____ model so look at ___ stressors

GAIT is a ____ model so work on optimizing gait pattern

Anterior chest wall syndrome (chest pain NOT cardiac in origin)

Answer 40

Bio-Mechanical, postural

Bio-mechanical

Question 41

**Classic cardiac and coronary patterns are seen at ___-____ for anterior wall problems and ___ for posterior and inferior wall MIs (along with bradyarrhtymias)****

____ is seen with bilateral changes at T5-L2

Answer 41

T1-T4, C2

HTN

Question 42

To treat a patient with MI, you would want to decrease the ___ activity in the ____ such as an ___ technique called ____ to discourage collateral circulation

^** So make sure it is INDIRECT, and not DIRECT

For an inferior MI, treat C2 and the cranial base for ___ stimulation

For anterior wall MI treat the ____ since remember, it’s seen at T1-T4

Answer 42

Sympathetic, upper thoracics, Indirect, paraspinal inhibition

Vagal

Upper thoracics

Question 43

To treat HTN treat the ENTIRE spine, address the kidney and adrenal areas that are hyperactive with ___pathetics and involves the respiratory/fluid, neurological, and energy models

^** SO in other words you want to DECREASE sympathetic tone aka decrease peripheral resistance

To treat CHF treat ____ and ____

To treat arrhythmias treat ____ and reduce segment facilitation in the upper thoracics (sympathetics)

Answer 43

Sympathetics

Lymph and autonomics

Vagal tone