E2- TOS- Stenosis Flashcards
(130 cards)
1
Q
what is the general management of HA
A
HA with other suspicious S&S require urgent or emergency referral
all other HA complaints can be investigated with MSK scan
2
Q
what are the types of HA
A
primary and secondary
3
Q
what are primary HA
A
tension, migraine, cluster
4
Q
what are secondary HA
A
cervicogenic
5
Q
what is a tension HA
A
Bilateral band - like tightness
Anxiety/stress cause
No migraine S&S - milder
Dull pressure
6
Q
what can cause a tension HA
A
anxiety/stress
commonly confused with cervicogenic HA because of muscle tension
7
Q
what is the PT Rx for tension HA
A
address stress/anxiety
MET
oscillations or manipulations
8
Q
what is a migraine
A
Pulsating
Out of commission
Unilateral
N & V
Drome’s
Sensational auras with visual and auditory sensitivity
9
Q
what causes migraines
A
temporal artery vasodilation
trigeminal n nociplastic pain with CV dysfunction
10
Q
what is the PT Rx for migraines
A
address CV dysfunction
vasoconstriction of temporal arteries - ice and caffeine
increase water intake 1.5 L
2-3 mg of melatonin
nociplastic pain MET
11
Q
what is a cluster HA
A
Comes and goes
Retro-orbital and temporal region
Unilateral
Sudden and severe pain
Horners syndrome
INtense
Grumpy
12
Q
what causes cluster HA
A
abnormal hypothalamus
genetic
sleep dysfunction
medication side effects
13
Q
what is the prevalence for primary HA
A
- Tension
- migraine
- cluster
14
Q
what are S&S cervicogenic HA
A
unilateral
starting in neck/occipital region
PROVOKED by neck motion
mild to moderate pain
non throbbing/pulsating
15
Q
what can cause cervicogenic HA
A
C2/3 jt dysfunction
16
Q
what can find in a scan for cervicogenic HA
A
limited and painful A/PROM
possible + with combined motion
neuro- possible + hypersensitivity
hypomobility and/or hypermobility with + linear stress test
+ cervical Flx/RT test
+ TTP in O-C3 region
17
Q
what is the Rx for cervicogenic HA
A
address cervical dysfunction
18
Q
what does the research say about dry needling with HA
A
no better than other modalities
should be paired with more MT and MET
19
Q
what is TOS
A
compression of subclavian a and possibly brachial plexus
20
Q
what can cause TOS
A
FHP
scalenes compress
trauma
differential diagnosis
21
Q
what is the mechanism of FHP in TOS
A
upper thoracic jt hypomobility into extension
increase tension of subclavian fascia on axillary a
the floor or roof compresses the nerve
22
Q
why would scalene compression cause TOS
A
chest breather with respiratory dysfunction and excessive use of accessory respiratory muscles
23
Q
why can trauma cause TOS
A
WAD
protective muscle guarding
adhesions and scarring if torn
24
Q
what are some differential diagnosis that can cause TOS
A
cervical rib
pancoast tumor compressing medial cord of brachial plexus
carpal tunnel
spinal n impingement
neurovascular disease
25
what are symptoms of TOS
UE glove/sleeve-like paresthesia
coldness and swelling with vascular compromise
26
what are the symptoms of peripheral n damage
nonsegmental paresthesia - short/intermittent duration, fast progression to well defined area of numbness
coldness and swelling with vascular compromise
27
what can increase symptoms of TOS
raising arms, prolong period
sleeping
poor sitting posture
28
what can we find in the scan for TOS
ob- FHP, possible UE discoloration
A/PROM- possible upper thoracic restriction
Resisted/MMT- decreased strength/endurance in post sh/scap muscles due to FHP
Neuro - only dural mobility +
29
what is dural tension restriction
paresthesia increased from both end
due to decreased elasticity or inflammation
30
how would you treat acute dural tension
paresthesia at rest
POLICED
motion without resistance or symptoms
STM over segmental
31
how would you treat persistent dural tension
paresthesia with resistance
motion with resistance
neural mobilizations with resistance at END range once acuity settles
32
what is gliding dural restriction
paresthesia increased from one end but relieved from other
due to adhesion
33
how do we treat acute gliding dural restriction
same as neural tension
34
how do we treat persistent gliding dural restriction
same as neural tension but neural mobilizations at MID range
35
what rep range do we do with neural mobilization
10-20 reps a day
36
what would we find in biomechanical exam for TOS
more often a upper thoracic hypomobility
less often - limited 1st rib inferior glide (guarded scalenes, sublaxation due to WAD)
use gilliard's cluster
37
how do we treat TOS
posture/ergonomic
diaphragmatic breathing
MT/MET- improve mobility, strength and endurance of sh/scapular muscles
38
what MSK changes happen due to FHP
diaphragm actively insufficient/overworked
thoracic extensors and accessory muscles overworked with respiration
39
what is Dowager's hump
fat pad over upper C/T junction develops with atrophy and shearing
40
what are most common thoracic restrictions with FHP
bilateral upper thoracic extension leads to lower cervical instability
can contribute to TOS and shoulder conditions
41
how can we treat FHP
MT/MET- more upright posture
postural education
ergonomic improvements
breathing training
42
what are the statistics for gillards cluster for TOS
5/5 LR+ =5.3
<5/5 LR- =.19
meaning if a pt has all 5 they have TOS bc it is so good at picking up - if + they got it and vice versa
43
describe tinels test
tap supraclavicular fossa - tenderness
44
describe adson's test
15 degrees abd, inhale and hold breath for 10-20 sec with neck ext and ipsi RT - parethesia or descreased radial pulse
45
describe hyperabd test
90 degrees sh abd/er up to 1 min - paresthesia or decreased radial pulse
46
describe roo's test
90 degrees sh abd/er while rapidly opening and closing fist for 1 min - symptoms
47
describe wright test
90 degrees sh abd/er with contra RT up to 1-2 min - paresthesia or decreased radial pulse
48
What is acute IDD
Annulus and end plate tear
Acute herniation (least common)
49
What is persistent IDD
Disc changes due to numerous variable allow herniation to happen gradually
Most prevalent
50
Describe the outer annulus
Type 1 collagen- resist tension- trigger multifidus to contract
Like a ligament- proprioceptive
51
Describe the inner annulus
Type 2 collagen - resist compression
52
Describe the anatomy of the annulus
Avascular
Concentric rings 15-25 fibers
Both compression and distraction can cause pain
Embedded into end plate
53
Describe the nucleus pulposa
Resist compression- type 2 collagen
High number of GAG
Dense connective tissue
Avascular, depends on motion
54
How does the annulus and nucleus move
Move as a unit
55
Describe the end plate
High innervate and vascularized
Nutrient diffusion for disc
Articular cartilage towards bone
Fibrocartilage towards disc
Weak link
May calcify and limit diffusion
56
What is the prevalence of IDD
Persistent over acute
Rare in thoracic- greater risk if so
57
Where on the disc is IDD most likely to occur and why
Posterolateral portion of disc
Weak,thinner,more vertical
Transition of annulus into endplate
58
What response can happen once a disc structure gets damaged
Immunoreactive
Large auto immune inflammatory- excessive osmotic pressure, n gets sensitized due to chemicals, no drainage, extends inflammatory phase
59
What would a pt report with postlat acute IDD
Dull achy spinal pain - referred pain
Radiculopathy
60
What is the worse situation with acute postlat IDD
Presence of radiculopathy
Presence of coldness indicating circulatory compromise
61
What are influencing behaviors with acute postlat IDD
Decrease pain with unloading
Increase pain and paresthesia with looking down
Increased pain in AM and worsening through day
62
How is ROM in a scan affected from acute postlat IDD
All may increase pain
FLX and contra SB/RT - limited and increase spinal pain (pressure on spinal n and tension on annulus)
EXT and ipsi SB/RT - decrease spinal pain (centralization) but could increase spinal pain due to hydrostatic pressure
63
What do symptoms do as they centralize
Decrease distal and/or spinal pain in a distal to proximal direction because of motion or position
64
What can be found in a scan for acute postlat IDD
Resisted/MMT- varies
Stress- possible +
Neuro- possible + (dural mobility always positive)
Stability test - +
65
Why can stress test be positive with all stress tests
Annulus irritated with distraction
Nucleus irritated with compression
Finding the segment irritated with PA pressure
66
What are the central IDD symptoms and what would we do
Cord S&S
Immobilize and emergency referral
67
what does research say about Mckenzie method with cervical IDD
weak evidence
no more beneficial vs general exercise
68
what is the aggressive nonsurgical Rx for acute IDD
intermittent traction
specific therapeutic exercise
oral anti-inflammatory meds
patient education
69
what is the Rx for acute IDD
POLICED
intermittent traction - may help if no centralization
neural mobilizations
MET
70
what is the ultimate Rx goal with MET for acute IDD
why
tissue proliferation and stabilization
if non-contractile tissue is the issue for instability, motion and strengthening of local muscles can help stabilize the jt
71
what is persistent IDD
degenerative disc disease
age related disc changes
72
what region is the most common persistent IDD
lumbar
if cervical, C6 spinal n is most effected bc it is largest in diameter
73
what can cause persistent IDD
acute IDD
sedentary lifestyle
genetics
74
if pt has persistent IDD with persistent inflammation, what can happen
the persistent inflammation brings excessive and destructive proteins and a low-grade infection likely enters disc
75
what is the snowball affect of persistent IDD
less GAGs so more fibrotic and dehydrated nucleus
more acidic disc
annular disorganization
thinning/loss of cartilage at end plates
increase inflammation and fatty deposits (Modic)
76
what are the categories of disc herniation
protrusion (bulge)
extrusion
free sequestration
77
what can happen due to persistent IDD
narrowing of:
disc - instability develops
increased load on facet - age related jt changes can develop
foramen - stenosis may develop
78
how are symptoms affected with persistent IDD
slow change allows tissue to adapt
79
how do we treat persistent IDD
what structure is the symptom driver??
disc?
jt hyper?
jt hypo?
nerve?
combo???
80
what is the prognosis of acute and persistent IDD
mostly good
81
what are the predictors of negative prognosis in acute IDD
peripheralization
pt attitude is negative
tumor
82
what are the possible MD Rx for acute/persistent IDD
antibiotics
laminectomy - paired with fusion because you are making the jt unstable
partial discectomy
total disc replacement
83
what is the axis of the jt maintained by
passive structures
active structures
neural control
84
what is the result of abnormal motion in a spinal segment under a load
in P! and instability that changes instantaneous axis of motion
85
what is functional instability
instability that can be stabilized with m activation or positioning
86
what is mechanical instability
instability that cannot be completely stabilized with muscle activity
87
what segments have the most instability
C5-7
88
what can cause of instability
trauma
age related disc changes - narrowing
repetitive activities
creep
adjacent hypomobility
connective tissue disorder
89
you can have BJHS if....
2 major criteria
1 major and 2 minor criteria
4 minor criteria
90
what are functional instability symptoms
predictable pain
decrease pain with position changes or support
increase pain with prolong position
catching
easy self manip
91
what can we find in a scan for functional instability
ROM- aberrant (acute), inconsistent WB and NWB findings, PROM > AROM
CM- inconsistent block
RST- most often strong/painless
neuro- (-)
ST- (+) PA pressure
Linear Stability test= (+)
92
what are the symptoms of mechanical instability
unpredictable pattern
worsening symptoms and more often
increase pain with less stress
symptoms dont get better as quick
93
what can be found in a scan for mechanical instability
same as functional BUT
ST- (+) wont stabilize fully
94
what can you do in a linear stability test to further test for mechanical instability
neck FLX tightens posterior ligament (closed pack postion)
functional = jt tighten
mechanical = still lax
95
what is the Rx for instability
POLICED
postural education
JM- increase adjacant hypo jts (C2 or thoracic)
bracing/taping
MET= stabilization, local muscles
96
why is EXT limited/painful with acute functional instability
increased ant vertebral shearing
97
why is FLX better than EXT with acute functional instability
large posterior lig/fascia tighten to help stabilize
98
what can be the MD Rx in severe/rare cases of mechanical instability
prolotherapy (injection) for stabilize along with PT
fusion surgery
99
what is the culprit tissue of age related jt changes
articular cartilage
100
what are the common diagnosis of age related jt changes
Degenerative joint disease
OA
spondylosis at multiple levels
101
what are the most common regions for age related jt changes
C5-7
L4-S1
102
why does age related jt changes progress along with age related disc changes
facets could bear more load due to disc narrowing causing facets to have more wear
103
what can protect against age related jt changes
physical activity
104
what is the leading cause of disability
age related jt changes
105
describe articular cartilage
covers ends of long bone, 2-4 mm thick
chondrocytes
frictionless
aneural/alymphatic/avascular
106
If articular cartilage is aneural/alymphatic/avascular, what causes the inflammatory response
arthritis - everything in the jt but articular cartilage can become inflammed
mostly the bone takes on more compression causing the pain and initiating the inflammatory response of the repair phase --- more fibrotic tissue
107
what pressures does articular cartilage like
compression and decompression
108
why is full ROM beneficial for our jts in the healing process
synovial fluid fully diffuses into cartilage
inflammatory agents fully exit cartilage
109
how does viscoelasticity work in articular cartilage
rigid with more load
flexible with less load
110
what can cause age related jt changes
gradual onset
trauma
sedentary lifestyle - underloading
genetics
other disease- RA
age
111
what is the patho of age related jt changes
progressive
articular cartilage - fray, blisters, tearing
subchondral bone penetrated and overloaded
spurs
degenerative
acute tears
112
why can the articular cartilage become degenerative in age related jt changes
1. thins and the jt space narrows - synovial fluid does not fully fill
2. fibrous capsule slackens then becomes more fibrotic - inflammatory response on overdrive (repair phase never stops)
3. synovial membrane produces less synovial fluid - nutrients not there and increase friction
113
what symptoms can be found with cervical ARJC
gradual onset
pain with prolong positions
morning stiffness < 30 minutes
pain and limitation with RT (looking in blind spot)
some movement helps, too much hurts
114
why would a pt have pain and limitation with RT with cervical ARJC
IMP or compression on facets
115
why might someone have paresthesias with cervical ARJC
compressed spinal n - narrowing or spurs
116
based on the cervical symptoms, what can be found in a scan for ARJC
ROM- painful and limited (EXT, RT, SB) capsular pattern of restriction
CM- consistent block or opposing quadrant block
RST- depends on acuity
ST- (+) compression, EXT, RT, SB, PA pressure
neuro- (-) unless spurs can cause stenosis on spinal n
117
what can show in a BE of cervical ARJC
accessory- hypomobility due to fixated hypermobile jts or hypomobile adjacent jts (C2-3 or thoracic)
special tests - spurlings may be (+) due to stressing the tissue in multiple positions (EXT, RT, SB)
118
why would compression be (+)for cervical ARJC
more stress directly on the jt
119
why would neuro tests be (+) with cervical ARJC
spurs can develop near the intervertebral foramina and compress the spinal n
120
what are the 2 patho of stenosis
narrowing and fibrotic
121
what can cause narrowing stenosis
compressed from outside in
IDD
ARDC
instability
enfolding of lig flavum (older people)
122
describe fibrotic spinal n patho
due to persistent inflammation associated with instability
nerve wont expand, compression from inside out
circulation compromise
123
what are the symptoms of lateral stenosis
unilateral UE P!, segmental paresthesias and gripping type pain
decrease pain with looking down, standind/walking, AM
increase pain with sitting, looking up, turning one side
124
what would we find in a scan for lateral stenosis
ob- increase lordosis
ROM- FLX, contra SB/RT decreases pain, EXT ipsi SB/RT increases pain
ST- (+) compression, (+) PA pressure due to translation of vb
neuro- possible (+) = radiculopathy
125
what can we do in BE for lateral stenosis
AM- jt hypomobility
MMT- local muscle inhibited
Spec. test- (+) spurlings, wainers CPR, stability= possible shear
126
what is our Rx for stenosis
pt education for posture
MT with MET- improve thoracic ext, neural mobilizations
mechanical traction
127
what is our Rx directed towards with stenosis
foraminal opening
128
what is the MET for stenosis
aerobic- increase circulation
local muscle stabilization
129
what is the MD Rx for stenosis
Sx- constant or worsening symptoms
laminectomy with or without fusion
130
how does radiculopathy surgery compare to PT
surgery has a more rapid and greater improvement in P!, but the two groups were no different with symptoms after 2 years
