What causes piriformis syndrome?
Anomaly of sciatic/pirformis relationship, local trauma, hip or SI injury, Forcefull or prolonged external rotation of hip, twisting of foot with foot planted.
How will a patient with piriformis syndrome present?
buttock pain with possible diffuse referral to leg. Paresthesias in lower extermity. Pain with external rotation activities of hip.
What will sensory and motor loss be like with piriformis syndrome?
possible but usually not a single neurological level.
What is piriformis sign?
Persistent relative external rotation of involved hip due to piriformis contracture.
What will palpation be like for piriformis syndrome?
local tenderness and hypertonicity/contracture to palpation. Tendon over greater trochanter may be especially tender.
Name the ortho and neuro tests done for piriformis syndrome?
SLR, Lasegue’s, bonets, bragards, patrick’s faber, hibbs, Ely’s, sign of the buttock, knee to shoulder, trendelenburg, rhomberg.
Name 3 goals for treating piriformis syndrome?
- relieve local inflammation and congestion around piriformis and sciatic nerve. 2. Restore length to contractued muscle and treat myofacial trigger point components. 3. Reduce any complicating or predisopsing dysfunction.
How can you releive local inflammation and congestion around piriformis and sciatic nerve?
Cryotherapy, ice massage, alternating hot/cold, deep tissue massage, stretching, vibrator, ultrasound, electrotherapy, contract/relax techniques.
How can you restore length to contractured muscles and treat myofascial trigger point components?
digital (or elbow) compression. Stretching techniques, contract/relax techniques, specific exercise, heat, postural advice.
How can you reduce complicating or predisoping dysfunctions seen with piriformis sydnrome?
Treat SI, lumbosacral, hip, lower extremity, leg length problems. Beware side-posture manipulations that may aggravate the piriformis.
IVD syndrome is what?
How will IVD syndrome develop?
acute trauma; unexpected or forcefull load producing annular fissuring and minor protrusion. Repetitive; abnormal rotation or shear stress producing fissuring and minor protrusion.
IVD syndrome is similar to what?
Posterior joint syndrome (facet syndrome).
Disc derangement is aka?
Internal disc disruption.
What % of low back pain is from injured lumbar discs?
What will take longer to heal strain/sprain or disc syndromes?
What will pain be like with disc derangement?
chronic low back pain, buttock pain. Pain is deep in lumbar region. If leg pain is present it is a late finding and is not dermatomal.
Disc derangement might be associated with what?
trauma like heavey lifting.
What might aggravate the pain with disc derangement?
Rotation, flexion, and or side bending.
What is the primary complaint with disc derangement?
What might centralize a disc derangement patients pain?
Repetitive end range loading usually in extension.
What will paraspinal muscles be like with disc derangement?
Tenderness may be absent.
What is the disc thining like with disc derangement?
there is no disc thining.
What will CT, X-ray and MRI’s be like with disc derangements?
CT, and X-ray’s are normal but MRI will show annular tears.
What are the pertinent negatives with disc derangement?
no radiculopathy, no positive tension signs, no neurological deficits, IF the MRI is normal it completely rules out this condition.
What are some conservative treatment considerations for disc derangments?
a trial of manual therapy, flexion distraction therapy, aggressive lumbar stabilization program with strict activity modification. Emphasize extension oriented Tx.
What are some aggressive treatment options for disc derangments?
spinal fusion, intradiscal electrothermal therapy.
Lumbar disc herniations will most commonly occur to who?
age 20-40 and twice as common in males.
What is the most common level for a Lumbar disc herniation?
L4-5 and L5-S1 levels.
Lumbar disc herniations are a common source of what disability?
Social security disability and has a significant economic impact.
What are some risk factors for Lumbar disc herniation?
smoking, sitting professions, vibration, and bending/twisting activities, obesity. Also genetic and auto-immune factors.
How will Lumbar disc herniation first start?
gradual long-term breakdown of annular fibers often seen with progressive episodes of low back pain.
How often will a lumbar disc herniation be from a single sudden traumatic event?
What usually will happen when a Lumbar disc herniation is first noticed?
Usually noticed after a trivial event like bending/twisting unguarder movement.
What will the pain be like for a lumbar disc herniation?
Deep low back pain and leg pain (if radicular symptoms are present). Increased when sitting, dejerine’s triad, activity. Relieved by recumbency.
What is a medial herniation?
It is one that is medial to the nerve root.
What will leg pains be like with a lumbar disc herniation?
Sclerotomal and dermatomal and may take several days to develop and may last longer than the back pain.
What is a classical antalgic positions for a patient with a posterolateral lumbar disc herniation?
Flexion and lateral bending away from the herniation and radicular pain.
What is a classical antalgic positions for a patient with a posteromedial lumbar disc herniation?
Flexion and lateral bending toward herniation and radicular pain.
What things are favorable factors when seen with a lumbar disc herniation?
Large extrusion or sequesteration, absence of spinal stenosis, >50% reduction in leg pain in the first 6 weeks, motivated to recover, good fitness level.
What things are unfavorable factors when seen with a lumbar disc herniation?
Positive crossed SLR, Leg pain produced by spinal extension.
What will the posture of a patient with lumbar disc herniation be like?
antalgic posture if acute.
What will an exam be like for a patient with lumbar disc herniation?
Neurologicla deficits (diminished DTRs, Dermatomal sensory and motor loss), Reduced Lumbar lordosis.
What are the goals with treatment of a lumbar disc herniation?
reduce pain, inflammation and intradiscal pressure. Decompress, retract, or reposition disc hernation if possible. Alleviate associated posterior joint locking and segmental muscle spasms. Promote healing, Surgical removal.
How can we get pain, inflammation and intradiscal pressure to be reduced when treating a patient with Lumbar disc herniation?
Cryotherapy, ultrasound, electrotherapies, traction, NSAIDS, lumbosacral support, crutches.
How can we decompress, retract or reposition a disc herniation (If possible)?
Flexion/distraction mobilization (COX therapy). Extension mobilization (McKenzie therapy). Side posture rotation mobilization or manipulation.
What is the important part of flexion/ distraction mobilization for disc herniation?
Flexion is so the distraction can be localized to the problem, but distraction is the key.
When would extension mobilization be helpful for disc herniation?
More effective in less severe cases.
How can we alleviate associated posterior joint locking and segmental muscle spasms seen with disc herniations?
Flexion mobilization, side posture adjusting.
How can we promote healing of a herniated disc?
Nutritional support, Rest and controlled activites. PROM.
What is the standard surgical treatment for a herniated disc?
Microsurgical removal of nucleus.
In general with all treatment plans for disc herniations how should they be done?
Monitor patients tolerance and response carefully.
What is discogenic spondylosis?
DJD without herniation.
What would X-ray findings of discogenic spondylosis be?
disc thinning, endplate sclerosis, vacuum phenomenon, hypertrophic changes, spondyloarthrosis (facets).
What vectors should CMT be done in for a disc herniation?
Reproduce antalgic or centralizing vectors.
Cauda equina syndrome is typically caused by what?
midline lumbar disc herniation.
What are some signs that a patient has cauda equina syndrome?
Incontinence, diminished sexual function, saddle paresthisa, diminished anal spincter tone, uni- or bilateral sciatica, altered SLR, sensory or motor deficits.
A central spinal stenosis is aka?
intermittent neurogenic claudication.
What can cause a central spinal stenosis?
Spondylosis (vertebral fusion), spondyloarthrosis, midline disc herniation or bulge, proliferation of ligamentum flavum, congenital factors.
What will a patient with central spinal stenosis present like?
Inconsistent pattern of leg pain and other symtoms with possible back pain.
What will leg pain be like central spinal stenosis?
Increased with activity and may resemble vascular claudication.
Central spinal stenosis exams may only be evident after what?
What will palpation be like for central spinal stenosis?
local to minimal pain and may be increased with deep joint play.
What will ROM be like for central spinal stenosis?
possible limited Extension, with increased symptoms during sustained extension (30 seconds).
What will SLR test be like for central spinal stenosis?
usually negative unless symptoms are active.
What is the normal age for a patient with central spinal stenosis?
over 55 or more commonly over 65.
What will the gait be like for central spinal stenosis?
Will there be pain while sitting with central spinal stenosis?
What walking be like with central spinal stenosis?
Leg symptoms aggravated by walking, bu It will be improved with spinal flexion.
Central spinal stenosis diagnosis can only be made after what?
Confirmed by a CT or MRI.
What is the normal size of the spinal cannal like?
Large in cervicals, smaller in thoracics, large in lumbar and sacrum.
What size will the spinal cannal be for it to be considered a stenosis?
less than or equal to 10 mm.
The normal thoracic spinal cannal will be on average how wide?
around 14 mm at the smallest part.
The next few questions will ask if things will be present with neuro and/or vascular claudication?
Neuro- proximal. Vascular- distal.
neuro- variable. Vascular- fixed.
Neuro- increased extension. Vascular- no change.
Bloop pressure, pulse?
Name the types of treatment for spinal stenosis?
flexion/distraction mobilization (COX therapy), flexion CMT, improve segmental motion as needed, Traction, Williams exercises, abdominal exercises, aerobic exercise, Improve vasular health, weight loss, Yoga, Tai Chi.
How will improveing vascular health help with spinal stenosis?
reduce edema and fluid retention.
What are some ways to improve vascular health?
Fish oils, primrose oil, vitamin E and C, L-carnitine, garlic, ginko, glucosamine/ chondroition sulfate.
What will surgery be like for spinal stenosis?
Epidural steroid injection, surgical decompression.
What can cause a lateral stenosis and what is it aka?
aka lateral recess syndrome. Spondylosis, joint subluxation, congenital factors.
What will a patients history be like that has lateral stenosis aka lateral recess syndrome?
variable and inconsistent pattern. Leg pain is typically unilateral and aggravated by weight bearing.
What is a clue that a patient might have lateral stenosis aka lateral recess syndrome?
Radiculopathy in older patients with DJD.
What is palpation like for a patient with lateral stenosis aka lateral recess syndrome?
local pain increased with joint play and deep pressure.
What is ROM like for a patient with lateral stenosis?
Painful and limited in extension and lateral flexion and rotation towards involved side.
What are some orthopedic tests we can do for lateral stenosis?
SLR, Bragards, bowstrings, kemps, valsalva.
What will treatment be like for lateral stenosis?
CMT in pain-free direction, emphasize flexion, stabilization tracts.
What are transitional segments?
Extra vertebrae like L6.
What is tropism?
Where is tropism most common?
What is Baastrup’s disease?
Lumbar Sp’s rest on eachother.
What is spina bifida occulta?
A minor lack of a neural arch.
What is spondylolisthesis?
Congenital defect at posterior facets or neural arch.
Name 5 types of spondylolisthesis?
- spondylolysis. 2. Isthmic. 3. Degenerative. 4. Post traumatic. 5. Pathologic.
What is Isthmic?
Spondylolysis- degeneration of articular part of vertebrae.
What are the 3 types of isthmic aka spondylolysis?
- Lytic- most common. 2. Elongation- pars. 3. Acute- rare trauma leading to fracture of the pars.
What will a patient be like that has spondylolisthesis?
Acute antalgia to asymptomatic. Back pain usually predominated with occasional sclerogenic or radicular leg pain. Symptoms often associated with te adjacent superior segment.
What will posture be like for a patient with spondylolisthesis?
What will ROM be like for a patient with spondylolisthesis?
Limited and painful into extension.
What will the treatment goals be for treating spondlyolisthesis?
Improve dynamics, pain control in acute exacerbations, increase musclar fitness and local regional muscular support.
What would CMT be like for spondylolisthesis?
Side posture, Knee-chest, prone, supine.
When should surgery be done with spondylolisthesis?
What is scoliosis?
A lateral curvature of the spine with rotational component as well.
What are the 2 types of scoliosis?
Structural (rigid), functional (non-rigid).
What will be some things to ask in a history of a patient with scoliosis?
Was it associated with trauma. When was onset. What is the progression like since onset. Sex, age. Family history.
How should an observation examination be done on a patient with scoliosis?
Plumb line evaluation. Record any asymetries. Adams test. Leg length evaluation.
What is Adams test?
Have patient flex down and measure scoliosis and a scoliometer may be used, 7 degrees is threshold for referral at school screenings.
What are 3 types of non-structureal scoliosis?
- Compensatory. 2. Postural. 3. Transient.
What will a compensatory scoliosis be like?
Leg length inequality, Pelvic subluxation with pelvic unleveling, anatomical symmetry.
What will a postural scoliosis be like?
Musclar imbalance, handedness,habitual, physiological (stress increases muscle spasms and increases scoliosis).
What will a transient scoliosis be like?
antalgic, inflammatory, traumatic, psychogenic, radiculopathy.
How is a scoliosis named?
By the convex side.
What type of scoliosis could be found with an iliac crest that is low on the left side?
a right scoliosis.
What is lovett positive? What is Lovett negative?
Positive- Right scoliosis where Sp’s deviate on concavity side of scoliosis. Negative- right scoliosis where SP’s deviate on the convexity side.
What is Lovetts static?
A right scoliosis where SP’s do not deviate.
What is Lovetts failure?
No scoliosis and no SP deviation, but the sacral base is not level.
What is Lovett Excess?
A lovett positive (SP’s deviate to concavity), but 40 degrees instead of the normal 20 degrees.
What is lovetts reverse?
A left scoliosis with no SP deviation.
What causes a loevett failure?
Left Quadratus lumborum spasm.
What causes a lovett excess?
Left psoas spasm/instability.
What is the ideal Scoliosis posture?
What causes a loevett negative?
Severe Right psoas spasm.
With a right scoliosis what will the adams test be like?
A posterior bulge of the right ribs.
Name 8 types of stuctural scoliosis?
- Idiopathic. 2. Congenital. 3. neuromuscular. 4. Neurofibromatosis. 5. Mesenchymal disorders. 6. Trauma. 7. Vertebral neoplasm. 8. Metabolic.
What is the normal scoliosis curve for a idiopathic (genetic scoliosis)?
Right throacic curve if it is a left curve this is a red flag.
What could be a cause of a left scoliosis?
What % of idiopathic scoliosis will start at infant, juvenilie (3-10), or adolescent (10- skeletal maturaty)?
Infant- 1%. Juvenile- 9%. Adolescent- 90%.
What causes congenital scoliosis?
Vertebral and extravertebral abnormalities. PROBABLY NOT GENTIC (don’t tell Kaminski).
What are the 2 types of vertebral abnormalites that can lead to congenital scoliosis?
- Closed- No posterior element defect. 2. Open- posterior element defect. Both of these include things like spina bifida and hemivertebrae.
What Are some extravertebral abnormalities that can lead to a congenital scoliosis?
Congenital rib fusion. Sprengel’s deformity. Klippel feil.
What are things that are neuromuscluar causes of congenital scoliosis?
neuropathic- UMNL and LMNL, spinal cord trauma. Myopathic- progressive and static.
What is neurofibromatosis?
AKA von recklinghausen’s disease and is a cause of congenital scoliosis.
What are some mesenchymal disorders that can lead to congenital scoliosis?
Congenital diseases like Marfans, ehlers-danlos dwarfism. Aquired mesenchymal disorders like RA. Other mesenchymal disorders like scheurmanns, and osteogenesis imperfecta.
What are some metabolic disorders that can lead to congenital scoliosis?
Rickets, Osteogenesis imperfecta.
What is the most common type of congenital scoliosis?
What type of people are most likely to get infantile (<3) idiopathic scoliosis?
Common in England and Northern Europe. Rare in America. Males > females.
What type of scoliosis is most common with infantile idiopatic scoliosis?
Left thoracic curve.
What is the typical outcome of infantile idiopathic scoliosis?
80-90% resolve spontaneously without treatment.
Who is most likely to get Juvenile (3-10) idiopathic scoliosis?
What is the type of scoliotic curve is most common with juvenile idiopathic scoliosis?
A right thoracic curve- very progressive.
What is the teatment like for juvenile idiopathic scoliosis?
Milwaukee brace (30-60 degree curve) 1-2 years and then part time and this has excellent results.
Who is most likely to get Adolescent (age 10 - skeletal maturaty) idiopathic scoliosis?
10 degree curve- females > males by 6:1.
How many females with adolescent idiopathic scoliosis will have a persistent curve?
How will one get adolescent idiopathic scoliosis?
Genetic autosomal dominant pattern. Multifactorial.
Who will pass adolescent idiopathic scoliosis to the kids?
Mother- to son or daughter. Father- passes to daughter.
What % of people with 1 parent who has adolescent idiopathic scoliosis will get the same disease? What about 2 parents?
1- 30%. 2- 40%.
What will the first, second, thrid and fourth most common curve be like for adolescent idiopathic scoliosis?
Right thoracic curve T5-12 is most common. 2nd most common is a left lumbar and right thoracic. 3rd most common is thoracolumbar. 4th- right lower thoracic and left upper thoracic.
A curve of less than what will a large majority of the time not progresses with adolescent idiopathic scoliosis?
Less than 30 degrees.
What makes a curve the primary scoliotic curve Vs. a secondary?
Primary is most rigid and longest and earliest onset.
What is a Risser sign and what will it show?
A grading system of the epiphysis of the ASIS and will be from 0-5+. It gives you an idea of skeletal maturaty.
What is a COBB angle?
Measure the superior end plate of the upper vertebrae in a scoliosis and then measure the inferior end plate of the lower vertebrae in a scoliosis and get the angle of these lines.
How will a COBB angle change throughout the day?
10-20 degrees difference in A.M. vs. P.M.
Besides geneticaly inheriting idiopathic scoliosis what causes it?
MRI’s have shown brainstem abnormalities, abnormal vestibular funciton, altered proprioception, learning disabilities have been seen. Greater vascularity in left breast and costosternal junction, increased EMG activity on convex side, muscle fiber differences, altered collagen, A LOT OF CNS PROBLEMS.
What is the Barge theory of scoliosis etiology?
Shift of nucleus (disc block subluxation) and sacral plateau is in lateral flexion.
With the barge theory what % will be male and female?
Male- 49%. Female- 92%.
What is the goodheart chiropractic theory of scoliosis etiology?
reflex muscular imbalance.
What are the logan, Illi, B.J. Palmer, and De Jarnette’s chiropractic theories of scoliosis etiology?
Logan- sacral unleveling. Illi- sacroiliac and pelvic disfunciton. B.J.- proprioceptive or motor disturbances originating in the upper cervical spine. De jarnette- imbalance myosensory input.
What will the risk of having progressive idiopathic scolosis with different risser signs?
0- 38%. 1+- 25%. 2+- 12%. 3+- 11%. 4+- 10%.
What is one of the most important risk factors for females with adolescent idiopathic scoliosis?
onset before menarche- 50% risk of progression. Onset after menarche- less than 20 % risk of progression.
Will a lumbar scoliosis seen with adolescent idiopathic scoliosis be a risk factor for progression?
No it will decrease the risk.
What risser sign will show a decreased risk of progression of adolescent idiopathic scoliosis?
Greater than or equal to 2.
What curve degree seen with adolescent idiopathic scoliosis will increase and decrease the risk of progression?
> 20 degree will increase. <20 degrees will decrease the risk.
Will maternal age be a factor in progression of adolescent idiopathic scoliosis?
yes maternal age over 30 will increase risk. Maternal age under 30 will decrease risk.
What should treatment be like for adolescent Idiopathic scoliosis (AIS) with a curve less than 10 degrees?
evaluate risk factors and monitor every 6 months until skeletal maturity is reached. Rule out and treat functional components, sympotmatic treatment and patient education.
What should treatment be like for adolescent Idiopathic scoliosis (AIS) with a curve of 10-20 degrees?
Evaluate risk factors and monitor every 3-6 months until skeletal maturity is reached. Should do a orthopedic and neurological examination, motorized flexion-distraction, proprioception rehab exercises, daily stretching, possible lift therapy, electospinal stimulation.
What should treatment be like for AIS with a curve of 20-25 degrees?
evaluate risk factors and monitor as warranted. Same treatments as 10-20 degree curve, but maybe with increased frequency and intensify exercise regime. Radiographic evaluation every 3-6 months as clinically indicated. Continue to monitor 1-2 years after skeletal maturity.
What should treatment be like for AIS with a curve of 25-40 degrees?
Evaluate risk factors and moniotr as warranted. Same treatments as 20-25 degree curve and increase as needed. Refer for brace therapy if >5 degree progression in one year and at least one year of growth remains. Monitor for progression as adult.
When should you refer out for a brace with AIS?
A curve greater than or equal to 30 degrees.
What should treatment be ike for AIS with a curve of 40-50 degrees?
Similar to 25-40 degree treatment, but this is considered to be a gray zone of treatment and braces and other conservative care is usually not effective and surgery is usually necessary. Referral and co-treatment is wise.
What should treatment be like for AIS with a curve greater than 50 degrees?
Surgery may be necessary and shoulld refer or consult with an orthopedic surgeon. Chiropractic treatment may facilitate success of surgery or relieve symptoms and improve function of patient who has not had surgery. Progression is likely even as an adult. Respiration difficulty is possible.
What brace has a pelvic attachment and a chin support?
How many hours a day should a milwaukee brace be worn?
What is the primary goal of a milwaukee brace?
stop progression of scoliosis not undo scoliosis.
What is a boston brace used for?
Scoliosis and primarily used for lower thoracics and thoracolumbar and lumbar curves and has better patient acceptance because there is not chin support.
What brace will have air-injected pneumatic force vector units?
What is the goal of a cope brace?
TO correct the curvature not merely halting the progression.
What are the goals of exercise therapy for AIS?
improve ROM, reduce contractual changes in soft tissue, correct vestibular and postural imbalances, normalize weight bearing in lower extermities and spine, neuromuscular re-education, normalize postural reflexes, re-educate CNS.
What type of stretching should be done for AIS?
Stretch concave side of a curve.
What muscles should be strengthened with exercise for AIS?
convex side muscles, and trunk muscles.
What type of rotary torso exercises should be done for AIS?
Rotary torso exercises to the left (if it is a normal right curve).
Why would a heel lift be used for people with AIS?
Not just for pelvic leveling, but up to 5mm to balance weight bearing and to re-educate the CNS.
How should a patient with a Right sided AIS sleep?
laying on right side with pillow under ribs.
What are the goals of electrospinal stimulation for a AIS patient?
upper motor neuron re-education, proprioceptive re-education, re-establish balance of function between concave muscles and convex side.
How should electrospinal stimulation be done for a patient with AIS?
identify muscle imbalance by surface EMG and lateral bending x-rays to determine optimal electrode placement. Use blocks and wedges to minimze curve. Use 2500 Hz russian stim. Concave (A fibers) treat 10:50 stim:rest cycle for 13-15 minutes. Convex side (B fibers) treat 10:10 stim:rest cycle for 15-18 minutes.
What is scheuermann’s disease?
disorder in calcification of vertebral epiphyses characterized by notching and wedging of vertebral endplates.
Scheuermanns disease is aka?
What is the typical onset for scheuermanns disease?
puberty (13-17). More common in males than females.
What part of the spine is typically affected with scheuermanns disease?
75% thoracic. 25% thoracolumbar.
What is commonly seen with scheuermanns disease?
30-40% have associated scoliosis.
What are the theories about what causes scheuermanns disease?
trauma to end plate will cause a growth arrest. This could be followed by the Heuter-Volkmann effect. Malnutrion, aseptic necrosis, disc herniation, osteoporosis.
How is scheuermanns diseas diagnosed?
Irregular endplates, apparent disc narrowing, vertebral body wedging, increased kyphosis, possible limbus bone.
What is limbus bone?
a piece of bone that is separated from end plate that will be on the edge.
What is the normal thoracic kyphotic curve?
What will the treatment be like for Scheuermanns disease?
If curve is over 50 degrees and skeletal maturity is not reached consider a brace. CMT to promote extension. In acute phase limit weight bearing activity and contact sports, postural training, home care exercise (for extension), Stretch abs and pecs, STM, heat, traction or hanging for a bar.
How will a patient present with a collapsed vertebra or compression fracture?
Local pain and muscle spasm, may recall recent trauma with sudden pain even snapping sound (may not recall trauma in osteoportic), tenderness to palpation or percussion over involved segments, ROM decreased and painfull especially in flexion, hyperesthesia to pinwheel in involved dermatome
What will lumbodorosal fractures be like?
may refer pain into low back that may radiate into the buttock and greater trochanter and even into the legs.
What is the definitive diagnosis of a collapsed vertebra?
How should a collapsed vertebra be managed?
If there is a fresh fracture referr to orthopedic surgeon for medicolegal reasons, treat for subsequent subluxations and myospasms, Neurological evaluation should be done, a stable fracutre does not require immobilization in plaster inless it is a rotary fracture, rest in be for 2 weeks.
What % of collapsed vertebra respond to conservative care and what % need surgical care?
50% for both.
What is Thoracic outlet syndrome?
Compression of the neurovascular bundle within the thoracic outlet.
What are the different areas of compromise in the thoracic outlet?
- Supraclavicular. 2. Costoclavicular. 3. Infra calvicular.
What are the general symptoms of thoracic outlet syndrome?
pain and paresthesias.
What will neuro compression cause with thoracic outlet syndrome?
Intermittent pain/paresthesias, and Trophic changes.
What will vascular compression cause with thoracic outlet syndrome?
Pain, cyanosis (loss of blood supply), Edema, decreased pulses, gangrene (ulcerations)- only in severe cases.
What are things that can cause thoracic outlet syndrome (TOS) in the supraclavicular area?
Cervical rib, congenital defects, post traumatic myofibrosis, postural distortions, joint dysfunctions of the cervicals and upper rib.
TOS from the supraclavicular region will be like what?
Neuro over vascular, pain and paresthesias.
What are things that can cause TOS in the costoclavicular area?
Trauma, congenital defects, postural defects, joint dysfunction- first rib and SC and AC.
TOS from the costoclavicular region will be like what?
More vascular in origin, pulsating burining pain, cyanosis, trophic.
What are things that can cause TOS in the Infraclavicular area?
Occupational or recreational, muscle hypertophic, congenital, post traumatic myofibrosis, postural distortions.
TOS from the infraclaviclar region will be like what?
More neurologic in origin, pain and paresthesias.
What orthopedic test would be best for Supraclavicular, costoclavicular and infraclavicular TOS?
Supraclavicular- Adsons. Costoclavicular- Edens. Infraclavicular- Wrights.
What should treatment be like for TOS?
Moist heat- alternating hot/cold, electrotherapies, CMT, SMT, Exercises, patient education, surgery.
What should CMT be like for TOS?
cervical, 1st and 2nd rib, upper thoracic, clavical, shoulder.
What should STM be like for TOS?
Scalenes, Pec. Minor, subclavius.
What exercises should be done to treat TOS?
intrascapular, cut stretch, doorway stretch, shoulder rolling, cervical neck-ups.
What should patient education be like for TOS?
Postural exercises, sleep and support.
What is complex regional pain syndrome (CRPS)?
dysfunction sympathetic nervous system leads to pain and altered temperature regulation, edema, and possible trophic degeneration. It is a cluster of symptoms and signs with injury to bones, soft tissue, or nerves. A triad of autonomic, sensory, and motor dysfunctions.
What is the diagnostic criteria for CRPS?
burining pain, allodynia, temperature and color changes, hair and nail changes.
What will labs be like for CRPS?
thermography > 1 degree C.
What is the etiology of CRPS?
- Somato-autonomic reflex- soft tissue or bone injury. 2. Peripheral nerve injury.
What will the first, second and third stage of CRPS be like?
1- pain and altered temperature regulation, erythema hyperesthesia and hyperalgesia. 2- progression of soft tissue edema, thickening skin and possible muscle and articular wasting. 3- marked changes, adhesions, waxy skin, brittle and rigid nails, joint contracture.
What is Raynauds syndrome?
Peripheral vasospasm (hands, feet, nose, and ears), symptoms include numbness, tingling, burning (not necessarily pain),
How long will Raynauds syndrome’s symptoms last for?
minutes to hours.
What is the etiology of Raynauds phenomenon?
TOS, Trauma, systemic CT disease.
What will the normal raynauds phenomenon patient be like?
Perdominantly female, provoked by cold or emotional stress, discoloration of digits, numbness and tingling, Advanced stages include trophic changes.
Name 6 types of treatment for Raynauds?
- Stress management. 2. Stop smoking. 3. Chiropractic care. 4. Heat/ paraffin. 5. Circumduction. 6. nutrition- Niacin.
What is the double crush theory?
nerve compression in multiple sites usually has a larger effect than one large compression.
Will traumatic thoracic strains and sprains be common?
Where will traumatic strains and sprains be more common?
Middle and upper traps and are associated with unilateral lifting.
Sprains in the thoracic spine are most commonly found where?
Rib cage and the costovertebral and costotransverse and anterior costal cartilages.
What type of patients might present with symptoms and findings representative of thoracic paravertebral strains?
Cervical whiplash patients.
What causes thoracic myofascial syndromes?
complication of traumatic strains, chronic postural strains, joint dysfunctions, structural imbalances, emotional stress, nutritional inadequacies.
What is scapulocostal syndrome?
myofascial syndrome involving the soft tissue between the scapula and rib cage.
What causes scapulocostal syndrome?
traumatic or mechanical irritation to the soft tissues contained within the scapular interspace.
How will a patient present with scapulocostal syndrome?
Local pain along the vertebral border and deep to the scapula, commonly referred down the posterior shoulder and arm with dysesthesias in arm and forearm is common.
What is T4 syndrome?
Dysfunction in the T4 area can cause problems in the arms, but will not be dermatomal.
What is Xiphoidalgia?
Pain midline over the xiphoid.
What is rib tip syndrome?
Traumatic hypermobility of the anterior costal cartilage.
What is tietze syndrome?
Painful enlargment of the upper costochondral cartilage with unknown etiology. Firm bony enlargment usually the second costochondral junction. May persist for months or years and then spontaneously remit.
What is Schepplemans sign?
A test for a thoracic disc herniation.
How common are thoracic disc herniations?
Uncommon 0.002% of reported disc patients will have thoracic disc herniations.
What is the typical pain pattern for slipping rib/ rib tip syndrome?
Intermittent stabbing pain followed by dull ache. Reproduced by a Hooking maneuver.
What is pain like with costochondritis/ Tietze’s syndrome?
Localized to costochondral or costoternal junction.
What is the swelling like with constochondritis/ Tietze’s syndrome?
Usually no swelling with costochondritis, but Tietze’s syndrome implies there is swelling and pain.
What is visceral pain like?
Not easily localized and often first noticed midline of abdomen. Not made worse by movement, coughing, palpation. Underlying muscle is not tense or painful.
What sympathetic afferent levels are associated with the stomach?
Will there be pain with passive ROM with a strain or a sprain?
Pain only with a sprain.
Will there be pain with active ROM with a strain or a sprain?
Pain with both strains and sprains.
Will there be pain with isometic contractiosn with a strain or a sprain?
Pain only with a strain.
What will lead to strains in the cervical region?
overuse fatigue, overstretching, excessive contaction, postural strain, direct blow, unguarded movement.
With a strain what would the antalgia be like?
usually toward involved state.
What will posture be like for a cervical strain?
probable reduction of cervical lordosis.
What will AROM be like for a cervical strain?
Painful and decreased flexion. Lateral flexion is painful away from involved side. Rotation- often painful toward involved side. No pain with extension.
What will PROM be like for a cervical strain?
flexion pain. Extension will not have pain.
What are the treatment goals for a cervical strain?
- Control pain and inflammation. 2. Prevent further injury. 3. promote flexible healing and remodeling.
How can we control pain and inflammation with a cervical strain?
Cryotherapy, electrotherapy, rest, hot/cold, effleurage, CMT.
How can we prevent further injury while treating a cervical strain?
Rest, possible soft collar, cervical pillow.
How can we promote flexible healing and remodeling with a cervical strain?
Pain-free ROM exercises, massage, stretching and Active exercises as patient reaches remodeling stage, CMT.
What is myofibrosis?
Fibrous repair following muscular injury.
What would a history be like for someone with myofibrosis?
Past trauma followed by persistent stiffness and soreness and possible development of Trigger point and referred pain.
What will palpation of a myofibrosis patient be like?
muscular tenderness, inelasticity, TT or TP.
What are the treatment goals for myofibrosis?
Restoration of movement and flexibility, alleviate pain.
How can we restore movement and flexibility with a myofibrosis patient?
Muscle stretching techniques, CMT, Moist heat, electrotherapies which produce deep heat, home care stretching and aerobic conditioning.
How can we alleviate pain with myofibrosis?
What is another name for cervical posterior joint syndrome?
aka Facet syndrome.
What can cause cervical posterior joint syndrome?
Interarticular- intrasical block, articular strain (spasm), segmental muscle imbalance and in-coordination, joint dysfunction as complication of associated soft tissue injury.
How will a patient with cervical posterior joint syndrome present?
Pain will be mild to marked unilateral and increased with movement and may refer to arm. Antalgia will typically bw away in acute patients torticollis may result.
What will ROM be like with cervical posterior joint syndrome?
decreased globally and segmentally typically into extension and LF toward painful side or returning from flexion.
What are the goals of treatment for Cervical posterior joint syndrome?
control pain and inflammation, restore joint mobility restrictions that persist after acute phase, address predisposing and perpetuating factors.
How can we control pain and inflammation with cervical posterior joint syndrome?
distractive CMT, cryotherapy, electrotherapy.
What will cause chronic facet syndromes?
Previous trauma or reocurring mechanical injuries producing tissue derangement, chronic inflammation, persistent joint restrictions or vertebral instability.
What will pain be like with a chronic facet syndrome?
Dull background ache with episode of acute pain and immobility. May be uni or bi lateral.
What is spondyloarthrosis?
Osteroarthrosis aka DJD.
What causes spondyloarthrosis aka osteoarthrosis aka DJD?
acute or repetitive trauma leading to permanent joint derangement and degeneration.
What will a patient present like with spondyloarthrosis?
very similar to facet syndrome patients.
Will the degree of spondyloarthrosis correlate with the symptoms?
What are x-ray findings like for spondyloarthrosis?
joint thinning erosion sclerosis. Osteophytosis, bony remodeling.
Name 3 types of treatment for spondyloarthrosis?
CMT, STM and mobilization, patient education and home care.
What is the most common cause of serious spinal injury?
What is CAD?
Cervical acceleration-deceleration aka whiplash.
What is a diagnostic term for CAD or whiplash?
Cervical sprain or strain.
What % of the population will have residuals from CAD?
80% of motor vehicle accidents happen at what speeds?
25 mph or less.
What happens with a rear end collision?
The seat moves forward and so will the body, but not the head until inertia throughs the head back in a violent hyperextension. This will cause a hyperextension injury.
What happens in a rearend collision besides hyperextension of the neck?
Ramping- vertical lift of the head.
In a rearend collision what happens after hyperextension of the neck?
A rebound hyperflexion produced by deceleration of the auto, impact of the seat, muscle stretch reflex.
What type of stress will occur with a rear-end collision?
hyperextension phase- tensile to anterior neck, compressive to posterior structures, and shear stress anterior and posterior. Rebound or hyperflexion phase- tensile to posterior structures and compressive to anterior, and shear to anterior and posterior.
What is the deepest muscle on the anterior neck that can get very injured in a CAD?
How long will a CAD accident take?
What happens in a deceleration injury?
aka front end collision. Hyperflexion followed by a rebound component.
What are the biomechanical effects of a front end collision?
Identical to hyperextension (from a rear-end collision) but reversed.
What is the major vector for a rear end and a front end collision?
Rear-end- Hyperextension. Front-end- hyperflexion.
What can cause a lateral flexion injury from a motor vehicle accident?
Car is struck from the side, front or rear with head turned.
What are the biomechanical effects of a lateral flexion injury from a motor vehicle accident?
rotary and shear stress are produced in the sagittal or coronal plane producing compressive stress on the concave side and tensile stress of the convex side.
Ideally what should a head rest be like in a car during an accident?
As close to the back of the head as possible.
What happens to the spine in the first 50 milliseconds of a CAD accident?
The spine straightens.
What happens to the spine between 50-75 millisconds of a CAD accident?
S- shaped curve.
What happens during the 150 msec of a CAD accident?
Seatback pushes body forward and head is thrown violently backwards.
What happens during the 200 msec of a CAD accident?
Head is thrown forward.
What will the movement of the neck be like during a CAD?
An arc movement.
What ligament is importantly involved with the occiput during a CAD accident?
Name some things to ask in a history of a CAD patient?
and type of vectors, mass of vehicles involved, Major vector, speed or magnitude of trauma, patient position, head rest, police report, road conditions, where brakes applied (this is a good thing if they were), where air bags deployed, loss of consciousness or other head trauma, detailed account of symptoms and injuries at the time of the accident and subsequent to the accident, chronology about vision hearing dizziness dysphagia, detailed account of any previous examinations diagnosis or treatment related to the accident, Past history of any MVA or cervical traumas.
With MVA they need to be documented very well so what should you probably use?
An inclinometer with a physical exam.
What is the series of x-rays that should be taken with a CAD patient?
Davis series; AP, APOM, lateral, 2- obliques, 2- flexion and extension. 7 total.
What is post-concussive syndrome?
A syndrome seen after concussive trauma not just MVA and has; impaired memory, cognitive problems, difficulty concentrating, irritability, personality changes, visual changes, auditory changes, fatigue, dizziness/vertigo, headaches made worse by cough/sneeze, fatigue.
What is the natural history of recovery for post-concussive syndromes?
1 year- 70% recover. 2 years- 80% recover. 3 years- 85% recover.
What is the causes post-concussive syndrome?
Rapid acceleration- deceleration of the brain.
What will muscle spasms do to spinal curves?
What is a jefferson fracture?
Burst fracture of C1 result of axial compression.
What is a hangmen’s fracture?
C2 fracture separation of anterior and posterior elements typically at the peicles. Results from hyperextension.
C2-7 fractures/ dislocations usually result from what?
Hyperflexion injuriesw with marked ligamentous disruption.
What typically causes compression fractures?
excessive compression usually from hyperflexion. If compression is in the articular pillars it resulted from hyperextension.
What part of a vertebra will typically chip?
anterior superio body due to compression and shear stress produced in hyperflexion.
What are the signs and symptoms of myelopathy? What is Myelopathy?
Sensory and motor. It is cord trauma.
What is Horner’s syndrome?
A type of sympathetic injury disorder of the anterior sympathetics with Ptosis, anhydrosis, miosis, enopthalmus.
What is BarreLieux?
A type of sympathetic injury a disorder of the posterior sympathetics with tinitis, vertigo, vision and hearing changes, vasomotor changes, occipital headaches, bizarre symptoms.
What is cervical instability?
The loss of the ability of the spine under physiological loads to maintain relationships between vertebrae in such a way that there is neither damage nor subsequent irritation to the spinal cord or nerve roots.
What will be seen on X-rays of a patient with cervical instability?
listhesis, dislocations, subluxations, georges line problems (posterior cervical line), IVD spaces, fractures, hypertrophic changes.
What is a tetrad of clinical instability?
widening of the interspinous space, subluxation of facet joints, compression fractures of subadjacent vertebrae, loss of cervicla lordosis.
What are things that would be on the white and Panjabi check list of cervical instability and what score will indicate an unstable spine?
anterior elements destoryed, posterior elements destroyed, sagittal plane translation or rotation, positive stretch test, spinal cord or nerve root damage, abnormal disc narrowing, dangerous loading anticipated. Score of 5 or more indicates unstable.
What will soft tissue injuries from CAD be like long term?
70% of people still had symptoms 15 years later. 95% of patients over 40 years of age had symptoms 15.5 years later. Soft tissue injuries are serious and permanent.
How can we control pain, spams and inflammation for a CAD patient?
cryotherapy, PT, NSAIDS, Collar support for 2-5 days if needed.
How can we promote flexible healing and improve circulation, early restoration of function, pain control, minimize effects of fibrosis, and minimize atrophy for a CAD patient?
STM, Traction- manual or sustained, home care: active ROM stretching, CMT- progress to deeper mobilization and manipulation as tolerated and needed, cervical exercises like neck-ups, tubing, resisted ROM.
What are the 5 grades of a CAD like?
1- minimal no limitations of ROM, no ligament injury, no neurological symptoms. 2- slight limitation of ROM, no ligamentous injury, no neuro findings. 3- moderate limitation of ROM, some ligamentous injury, neurological findings present. 4- moderate to severe limitations of ROM, ligamentous instability, neurological findings, fracture or disc derangement. 5- severe requires surgical treatmetn and stabilization.
What will the characteristics of soft-tissue injury recovery be like during acute, subacute and chronic phases?
acute- pain, swelling, heat, redness, anxiety. Subacute- repair phase, collagen synthesis, collagen deposition. Chronic- rehabilitation phase, collagen hypertrophy, collagen hyperplasia.
What is the goal of treatment in the acute, remobilization, rehabilitation and lifestly adaptation phases?
Acute- no pain at rest. Remobilization- operational end point capacity to perform unstressed basic duty activities. Rehabilitation- end point capacity to perform normal activities under some constraints. Lifestyle adaptation- full recovery or functional recovery.
What are some ways to prevent injury from a CAD?
head rest at proper position, stiffer seat, shoulder harness, air bags, defensive position.
What is the most common location for a spondyloarthrosis in the cervicals?
What is torticollis?
a contracted state of the cervical muscles, producing a twisting of the neck and an unnatural position of the head.
Torticollis is aka?
Name 8 causes of torticollis?
congenital, traumatic, myositis (muscle inflammation), spasmodic, neurogenic, paralytic, infectious, facet syndrome.
What is a spasmodic cause of torticollis?
UMNL of CN XI which innervates the SCM and upper traps.
What is a neurogenic cause of torticollis?
Viral effects to CN XI (this will be similar to bells palsy).
Of the 8 causes of torticollis which one will be a non-traditional cause?
What are some treatments for torticollis?
heat, stretching, CMT, STM, reciprical inhibition, MET, electrotherapy, support immune system, Bo-tox helps with spasms.
name some causes of cervical radiculopathy?
spondylosis (vertebral fusion), disc herniations, trauma, SOL, stenosis, facet inflammation, instability, fracture, adhesions, ligamentous hypertrophy.
What will pain be like for cervical radiculopathy?
Local and dermatomal.
What will relieve pain with cervical radiculopathy?
flexion relieves pain and lateral flexion to contralateral side.
What is Bakody sign?
Hand over head to remove nerve root tension and is seen with cervical radiculopathy.
What are some treatments for cervical radiculopathy?
Traction, cervical collar (acute), CMT, cryotherapy, PT, homecare, surgery.
What will the goals of CMT be for cervical radiculopathy?
Try to open IVF, promote motion away from nerve root, try to make constant compression intermittent, improve blood supply.
What type of CMT should be done for radiculopathy?
Vectors which decrease radicular pain and AP, pure rotation- contact radicular side and rotate away. Laterally flex away from radiculopathy.
What will a patients history be like for a cervical disc herniation?
Sudden onset, possible past trauma, dejerine triad, may include radicular component.
What causes cervical stenosis?
DJD, disc herniation, SOL (space occupying lesion), Hematoma, congenital.
What are the symptoms of a cervical stenosis?
all extremities (sensory/ motor/ proprioception) lower extremities also need to be tested. Spondylitic myelopathy.
What are the normal sizes of the spinal cannal at C1, C2, C3-7?
1- 22mm. 2- 20mm. 3-7- 17mm.
What is SSEP?
Sommato, sensory, evoked potential.
What should cervicla stenosis treatment be like?
like DJD radiculopathy, traction, epidural steroid injection, flexion oriented treatment.
What general type of a headache is a migraine?
Name 6 trigger factors for migraine headaches?
Stress, rapid hormonal changes, rapid blood sugar changes, vasoactive foods, alcohol (cluster headaches), medication (oral contraceptives, exogenous estrogen, nitroglycerin, anti-hypertensive drugs, resperpine).
How do migraines happen?
Starts with a stimulating factor that leads to platelet aggregation and serotonin is released.
What will serotonin do?
What might this vasoconstricion cause?
Aura or prodrome.
What happens after vasoconstricion?
Anoxia causes local humoral response which leads to a rapid serotonin reduction and this leads to vasodiliation.
Rapid vasodiliation leads to what?
Edema, pressure, inflammation and one very nasty headache.
What gender is most likely to get migraines?
Females 3:1 or 70%.
Migraine symptoms usually start when?
What type of personality might be associated with migraines?
What is the neurovascular therories of migraines?
unstable autonomic nervous system, reduced magnesium levles destabilizes nerve membranes, electrical activity imbalance, platelet dysfunction.
What type of hormonla changes can be triggers for migraines?
menstrual, ovulation, puberty, menopause, hysterectomy.
Name some vasoactive foods that can be triggers for migraines?
Tyramine containing foods like; red wine, cheese, nuts, chocolate. Histamines; citrus food, coffee, tea, alcohol, niacin, processed foods like MSG.
What should be monitored during treatment of migraines?
Frequency, severity, and duration.
What are the 2 types of migraine treatment catagories?
preventive and abortive.
Name some nutritional stuff to use for migraines?
Magnesium, vitamin B6, tryptophan, feverfew, fish oils, valerian kava.
What type of physical treatments can be done to help with migraines?
CMT, STM, accupuncture, biofeedback, hot baths, hypnosis, hormone modifications.
How should CMT be done to treat migraines?
Based on exam findings, cervical and upper thoracic most common, treat for cervicogenic headaches that might lead to migraines.
What is a biofeedback treatment?
vasomotor and muscle relaxation.
What has the research told us about migraines and chiropractic?
Migraine sufferes demonstrate cervical abnormalities. CMT can help with migraines. Chiropractic therapy plays an important role in treating migraines, cervicogenic and tension headaches.
What will basilar headaches cause?
They also cause cerebellum problems that may lead to balance and verbal problems.
What are some things that cause vascular headaches but are not migraines?
Systemic infection, hypoglycemia, hypoxia, toxic headache, caffine withdrawl, hypertension, allergic, vasomotor changes, syncope (fainting), CVA, temporal arteritis.
Who is more likely to get a cluster headache?
Males are 90% and females are 10%.
What are the triggers of cluster headaches?
Smoking and alcohol.
What are the symptoms of cluster headaches?
temporal artery bulging, severe headache with pain behind the eye, unilateral ptosis, miosis, tearing, nasal congestion, sweating on side of face.
What are some treatments of cluster headaches?
CMT, PT, SMT, capsaician spray (stuff that makes peppers hot), light therapy, normalize daily routine, meds, O2, surgery, biofeedback, acupuncture.
What are the most common types of headaches?
Cervicogenic and tension.
What is the pain like for cervicogenic headaches?
Pain in neck and occiput region. May project to forehead and orbital region, temples, vertex or ears. Pain is precipitated or aggravated by special neck movements or sustained posture.
What is the diagnositic criteria for cervicogenic headaches?
at leaste one of the following; 1. resistance to or limitation of passive neck movements. 2. changes in neck muscle conture, texture, response to active and passive stretching and contractions. 3. Abnormal tenderness of neck muscles.
What will radiological exams of cervicogenic headaches reveal?
movement abnormalities in flexion/ extension, abnormal posture, fractures, congenital anomalies, bone tumores, RA, or other pathology (not DJD).
Cervicogenic headaches are associated with what?
movement abnormalities in the cervical intervertebral segments, and manifests during either active or passive examination of the movement.
What type of MRI is used to look at blood vessels in the brain?
Magnetic resonance angiography (MRA).
How long will tension headaches last for?
30 minutes to 7 days.
what is the diagnositic criteria for a tension headache?
at leaste 2 of the following; 1. Pressure/ tightening quality (non-pulsating). 2. Mild or moderate intensity. 3. Bilateral location. 4. No aggravationm by walking stairs or similar routine activity. AND both of these; 1. No nausea or vomiting. 2. Photophobia and phonopobia are absent or one but not the other is present. and history and physical and neurological examinations do not suggest another type of headache.
What causes tension headaches?
Tension headaches are associated with what?
one of the following muscular stresses; Unphysiological working position, long lasting tonic muscular contraction for another reason, lack of sleep or rest.
What are the treatments of cervicogenic and tension headaches?
CMT, Mobilization, manual therapy. Soft tissue therapies, exercise and streching, PT, cervical pillow, meds, biofeedback, referral, acupuncture.
What are traction headaches and they are aka?
aka inflammatory headaches. They are headaches resulting form inflammation, infection, expansile lesions, or organic diseases.
What are some general symptoms of tumors?
Personality changes, speech changes, visual changes, headaches, vomiting without nausea, fundoscopic changes, UMNL sings, Babinski.
How often will tumors cause headaches?
20% of the time headaches will be the initial symptom, but 90% of people with tumors will eventually get headaches.
Name some things that cause traction headaches?
tumors, abscess, hematoma, post-lumbar puncture (LP), meningitis, encephalitis, hydrocephalus, trigeminal neuralgia- aka tic delureaux which is nerve pain following the trigeminal nerve, herpes zoster, constipation.
What is a traumatic headache?
headaches that are post concussive or result from trauma.
What are EENT headaches?
Headaches caused by ophthalmic, otitis, sinusitis, URI, Dental problems.
What nerve would be affected with a herniated disc between L4-5 vertebra?