Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
81 Cards in this Set
- Front
- Back
|
Signs and Symptoms of VBI |
-Dizziness, Diplopia, Dysarthria, Dysphagia, and Drop attacks ("5 D's") -Diminished pupillary light reflex, Devaition of the tongue with protrusion, Nystagmus, and impaired sensation of the face may also be present |
|
|
Testing for VBI |
-Sensitivity and specificity of tests are poor. -Having Pt move with AROM toward test position and then into manipulation position is encouraged -Hold/observe end position x10 seconds -Suggestion is to test prior to every manipulation; most common insult occurs on 2nd or 3rd manipulation not the first -Think of the 5 D's |
|
|
Cook, Brismee, Fleming, Sizer. Identifiers suggestive of clinical cervical spine instability: Delphi study of physical therapists by |
-Most identifiers involved intricate palpation and visual assessment skills, poor tolerance to certain postures, and movement-related similarities. -Appropriate clinical reasoning is required for distinctive assessment. |
|
|
What causes harm to the Vertebral Artery? |
-Most injuries occur with rotational movements when techniques associated with injury -VA can stretch 139-162% before failure -Force of manipulation is about 12% of strain at failure -"VA dissection after neck movement, trauma, or manipulation should be considered rare, random, and unpredictable complication associated with these activities." -Haldeman, Spine, 1999 |
|
|
Contraindications to Cervical Manipulation |
-Pt undergoing anti-coagulant therapy -Downs Syndrome -Fracture/Dislocations -Disease processes that thrust would affect adversely |
|
|
Thoracic Arthrokinematics |
-Sibending and rotation occur opposite -Apophysial joints are oriented in the frontal plan -With flexion superior articular surfaces glide up and forward -With extension superior surfaces glide down and back -During SB & Rotation superior articular surfaces glide down and back -Rotation gaps facet on same side of rotation |
|
|
Thoracic Biomechanics |
-Flexion, extension, and rotation are observed in sitting -Rotation is the primary motion tested with ~60 degrees to each side |
|
|
Thoracic Repeated Movements |
-If upper thoracic: start with cervical retraction with extension -If lower thoracic: prone press up with hands at level of head |
|
|
Types of Thoracic Derangements |
#1 Central/Symmetrical- no deformity #2 Unilateral/Asymmetrical- acute Kyphosis #3 Unilateral Asymmetrical- symptoms may radiate around ribs |
|
|
Rib biomechanics |
-Forward flexion/rotation of the superior vertebrae coupled with anterior translation "pulls" the superior aspect of the rib forward at the costovertebral joint resulting in anterior rotation of the rib. -Anterior rotation of the neck of the rib results in superior glide of tubercle at costotransverse joint. Superior glide of tubercle results in anterior rotation of the neck of the rib. -With backward sagittal rotation superior vertebra "pushes" superior aspect of head of rib backward. |
|
|
Cauda Equina Syndrome |
-Urinary retention -Fecal incontinence -Widespread neurological signs & symptoms of LE -Gait abnormality -Saddle area numbness -Lax anal sphincter *medical emergency and requires urgent hospital referral |
|
|
Spinal Manipulation CPR for patients with low bak pain who demonstrate short-term improvement with spinal manipulation |
- Symptoms <16 days - No symptoms distal to the knee - FABQWK <19 - Lumbar stiffness - Hip IR >35 degrees |
|
|
Bialosky, Bishop, et al. 2009. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy. |
-Model suggests that a mechanical force from MT initiates a cascade of neurophysiological responses from the peripheral and central nervous system which are then responsible for outcomes. |
|
|
Absolute Contraindications of Manipulation |
Malignancy Tuberculosis Osteomyelitis Osteoporosis Fracture Ligamentous rupture Diisc prolapse w/ nerve root compression Influenza with fever |
|
|
Relative Contraindications of Manipulation |
Lumbar disc herniation, osteoarthritis, hyper mobility, severe scoliosis, depleted general health, Pt unable to relax, pregnancy |
|
|
Regional Contraindications of Manipulation |
VBI, traumatized transverse ligament of C1, Cauda equina syndrome, suspected spinal aneurism, post surgery, RA (cervical) |
|
|
Alqarni, Schneiders, and Hendrick. 2011. Clinical Tests to Diagnoses lumbar Segmental Instability: A systematic Review |
-Majority of test to treat LSI demonstrated limited ability to do so -Passive Lumbar Extension Test may be useful to Dx LSI (further research needed on application to a variety of populations though) -Most LSI tests have high specificity and low sensitivity -"PLE" Passive Lumbar Extension Tests performed in prone with both LE's passively elevated ~30cm high |
|
|
Hutting, Scholten-Peeters, et al. 2013 Diagnostic accuracy of Upper Cervical Spine Instability Tests: A systematic Review. |
Conclusions: Overall, the studies suffered from various types of potential bias, and the sensitivity varied. Therefore, we conclude that screening for upper cervical instability cannot be done accurately at the moment. |
|
|
Haldeman, Kohlbeck, and McGregor. 2002. Unpredictability of Cerebrovascular Ischemia Associated With Cervical Spine Manipulation TherapyA Review of Sixty-Four Cases After Cervical Spine Manipulation |
Conclusion: Cerebrovascular accidents after manipulation appear to be unpredictable and should be consideredan inherent, idiosyncratic, and rare complication ofthis treatment approach. |
|
|
Flynn, Fritz, Wainner, and Whitman. 2003. The Audible Pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with LBP. |
Conclusion: There is no relationship between an audible pop during SI manipulation and improvement in ROM, pain, or disability with nonradicular LBP. |
|
|
Laslett, Young, et al. 2003. Diagnosing painful sacroiliac joints: A validity study ofa McKenzie evaluation and sacroiliac provocation tests. |
Purpose was to assess diagnostic accuracy of a The centralisation and peripheralisation phenomena were used to identity possible discogenic pain and the results from provocation sacroiliac joint tests were used as part of the clinical reasoning process. sensitivity, specificityand positive likelihood ratio (95% confidence intervals) of the clinicai evaluation were 91% (62 to 98), 83% (68 to 98) and 6.97(2.70 to 20.27) respectively. The diagnostic accuracy of the clinical examination and clinical reasoning process was superior to the sacroiliac joint pain provocation tests alone. A specific clinical examination and reasoning process can differentiatebetween symptomatic and asymptomatic sacroiliac joints. |
|
|
Dunning, Butts, Mourad, Young, Cleland, et al. 2016. Upper cervical and upper thoracicmanipulation versus mobilization and exercise in patients with cervicogenicheadache: a multi-center randomizedclinical trial |
Results: Individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001)than those who received mobilization and exercise at a 3-month follow-up. Conclusions: 6-8 sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months. |
|
|
Mechanical Change |
Its important to measure the change in motion/change in function as much or more importantly than the pain #. |
|
|
Yellow Flags |
Obstacles from thoughts, feelings and behaviours. Some common examples include:Catastrophising – thinking the worst Finding painful experiences unbearable, reporting extreme pain disproportionate to the condition Having unhelpful beliefs about pain and work |
|
|
Red Flags |
Clinical findings that increase level of suspicion that a serious medical condition is present that my cause disability or untimely death. Often includes: -Constant pain -Thoracic pain -Severe night pain -Abdominal pain and changed bowel habits but with no change of medication -Cauda Equina -Systemically unwell -Pts with quick relapses of pain/intermittent response to PT |
|
|
FABQ |
The *** measures patients' fear of pain and consequent avoidance of physical activity because of their fear. This questionnaire consists of 16 items, with each item scored from 0-6. Higher scores on the *** are indicative of greater fear and avoidance beliefs. |
|
|
Main effects of Mobilization |
-Stretching/rupturing joint lesions -Relaxation of reflexively contracted muscles (often from MET's effecting GTO's/m. spindles) -Activation of Type III mechanoreceptors -Release impacted tissues -Altering of positional relationships -Removing pressure from sensitive structure -Stimulating fast conducting fibers -Psychological |
|
|
Joint Dysfunction |
Loss of involuntary movement or joint play and may be result of: resistance imposed by muscle activity or lack of movement in joint itself. |
|
|
Principles of Mobilization |
-Pt is in maximally relaxed position -Start articulation in resting position or as close to this as possible -User ideal body mechanics -Stabilize with belt, stirrup, or hand -Articulate with other hand -No pain (Articulate below the point of pain) |
|
|
Indications for Mobilization |
-Presence of dysfunction -Neurological effects to reduce pain and guarding -Mechanical effects to overcome restriction barriers |
|
|
Two further descriptions of Derangements are now made:
|
-Severity indicator, which, relates to the location of the symptoms. These are divided into threesub-groups - Central and symmetrical Symptoms - Unilateral and asymmetrical symptoms tothe knee - Unilateral and asymmetrical symptoms to below knee. Again the location ofsymptoms will change in response to mechanical forces so is a description not aclassification.- Directional preference or treatment principle. These include extension, flexion, lateral orcombination. Again this may change during the course of treatment and hence is not part ofthe classification. |
|
|
Cervical Classifications of Derangement |
D1 – Central, symmetrical - 35% D2 – Central, symmetrical (kyphotic deformity) - 3% D3- Asymmetrical, above elbow – 39% D4 – As per D3 with wry neck – 2% D5 – Asymmetrical below elbow – 15% D6 – As per D5 with deformity – 6% D7 – Anterior derangement, symmetrical, possible “choking” feeling – 4% |
|
|
Canadian C-spine rules |
1. High-risk factors mandating XR: >65 yrs., dangerous mechanism of injury, paresthesia 2. Low risk factors which allows safe assessment of ROM: simple MVA, sitting in ER, ambulatory, delayed onset of neck pain, absence of midline c-spine tenderness 3. Rotation: able to actively rotate 45 degrees B. |
|
|
Mid to lower C-spine examination flow: |
-Protraction -Retraction -Retraction-extension (*baseline established prior to each movement) Repeated movements: -Retraction -Retraction-extension -If not tolerating position them move to supine and perform continued saggital plane movements -If no effect, then perform repeated side bending and rotation in sitting |
|
|
Normal AO ROM |
10 degrees flexion, 20 degrees extension 8-10 degrees of SB bilaterally 5-7 degrees of rotation |
|
|
Normal AA ROM |
~45-50 degrees of rotation (a majority in the neck) d10 degrees of F/E 5 degrees of SB |
|
|
Cranial Nerves |
CN I: Smell CN II (Optic): see with 1 eye closed CN III, IV, VI: Look around CN V (Trigeminal): Contract mastification muscles CN VII (Fascial): Move eyebrows, smile CN VIII (auditory): Hear! CN IX: Swallow CN X (vagus): Pt can say ahh.... CN XI (Spinal Accessory): Pt shrugs CN XII: Stick tongue out |
|
|
UE Reflexes |
C5/6: Biceps C6: Brachioradialis C7/8: Tricpes |
|
|
LE Reflexes |
L3/L4: Patellar S1/S2: Achilles |
|
|
Mytomes |
C1/2 cervical flexion C3 Cervical SB C4 Scapula elevation C5 Shoulder abduction C6 Elbow F/ wrist E C7 Elbow E/ wrist F C8 Thumb extension T1 Finger Abd L1/2 Hip F L3 Knee Ext L4 Ankle DF L5 Great toe Ext S1 Ankle PF S2 Knee flexion |
|
|
Shaffer, Brismee, Sizer, Courtney. 2014. Temporomandibular disorders. Part 2. conservative management. JMMT. |
Joint mobilization should be applied when a movement restriction is evident but should be avoided if joint hypermobility is suspected. While many patients with TMD will require joint mobilization, hypermobility may be present in the joint so caution is advised. |
|
|
Furto, Cleland, Whitman, Olson. 2006 Manual physical therapy interventions and exercise for patients with temporomandibular disorders. Cranio. |
Patients with TMD treated with manual physical therapy interventions plus exercise, with or without iontophoresis with dexamethasone, can demonstrate clinically meaningful improvements in disability and overall perceived change in a relatively short period of time. |
|
|
Hutting, Scholten-Peeters, et al. 2013. Diagnostic Accuracy of Upper Cervical Spine Instability Tests: A systematic Review. |
Sensitivity is highly variable and upper cervical instability testing cannot be done accurately at this time. The Atlanto-adial membrane test and tectorial membrane test showed best diagnostic accuracy. |
|
|
Lee and Lee, March 2017. Effect of maitland mobilization in cervical and thoracic spine and therapeutic exercise on functional impairment in individuals with chronic neck pain |
Mobilization + exercise gropu improved significantly more on right lateral flexion and rightward rotation. Muscle tone improved significantly in the upper trapezius in both groups. [Conclusion] The joint mobilization and therapeutic exercise for functional impairments caused by chronic neck pain had a significant effect on several types of functional impairment. |
|
|
Dunning, Butts, Mourad, Young, Cleland, et al. 2016. Upper cervical and upper thoracicmanipulation versus mobilization and exercise in patients with cervicogenicheadache: a multi-center randomizedclinical trial.
|
Conclusions: 6-8 sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months. |
|
|
Cross, Kuenze, Grindstaff, Hertal. 2011. Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: A systematic review. |
Thoracic spine thrust manipulation may provide short-term improvement in patients with acute or subacute mechanical neck pain. However, the body of literature is weak and the results may not be generalizable. |
|
|
Flynn, Fritz, Whitman, Wainner, et al. 2002. A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who Demonstrate Short-Term Improvement With Spinal Manipulation. |
A clinical prediction rule with five variables (symptom duration, fear–avoidance beliefs, lumbar hypomobility, hip internal rotation range of motion, and no symptoms distal to the knee) was identified. The presence of four of five of these variables (positive likelihood ratio 24.38) increased the probability of success with manipulation from 45% to 95%. Conclusion. It appears that patients with low back pain likely to respond to manipulation can be accurately identified before treatment. |
|
|
Da Silva, Mills, et al. May 2017. Risk of Recurrence of Low Back Pain: A Systematic Review Authors: |
The available research does not provide robust estimates of the risk of LBP recurrence and provides little information about factors that predict recurrence in people recently recovered from an episode of LBP. |
|
|
Ron Schenk, Dionne, Simon, Johnson. 2012. Effectiveness of mechanical diagnosis and therapy in patients with back pain who meet a clinical prediction rule for spinal manipulation |
purpose of this study was to compare the effectiveness of Spinal Thrust Manipulation and mechanical diagnosis and therapy (MDT) in patients who are positive for the STM CPR. Both groups exhibited statistically significant improvements in ODI and NPRS scores Mechanical diagnosis and therapy was an equally viable choice for these patients. |
|
|
Aqarni, Schneiders, Hendrick. 2011. Clinical Tests to diagnose lumbar segmental instability: A systematic review |
Conclusion: Limited ability of most tests to diagnose structural lumbar segmental instability. However, the Passive Lumbar Extension Test may be useful with 84% sensitivity and 90% specificity. Most of the 11 tests examined had high specificity but low sensitivity. Test is done by having Pt in prone and passively raising legs up to ~30 cm with knees straight. |
|
|
Bang & Deyle. JOSPT 2003. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. |
Results- significant improved in the MT group, significantly less pain in the MT group. Conclusion: MT and exercise is superior to exercise alone for improving strength, function and pain. |
|
|
Michener et al. J Hand Ther. 2004. Effectiveness of Rehabilitation for Patients with Impingement Syndrome: A systematic review. |
Results- Therapeutic exercise is more effective in reducing pain and increasing function. Adding manual therapy in addition to exercise provides favorable outcomes compared to thera/ex alone. |
|
|
Abbott, Patla, Jensen. 2001. The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia. Man Ther. |
Study indicates the proportion of patients with lateral epicondylalgia that demonstrate a favorable initial response to a manual therapy technique - the mobilization with movement (MWM) for tennis elbow. Study indicate that MWM was effective in allowing 92% of subjects to perform previously painful movements pain-free, and improving grip strength immediately afterwards. MWM is a promising intervention modality for the treatment of patients with Lateral Epicondylalgia. |
|
|
Heiser, O'brien, Schwartz. 2013. The use of joint mobilization to improve clinical outcomes in hand therapy: a systematic review of the literature. J Hand Ther. |
“In summary, joint mobilization reduces pain in patients with wrist fractures, with a moderate effect on ROM using both MWM and A-P glides.” |
|
|
MarFernández-de-Las-Peñas, Cleland, et al. 2017. The Effectiveness of Manual Therapy Versus Surgery on Self-reported Function, Cervical Range of Motion, and Pinch Grip Force in Carpal Tunnel Syndrome: A Randomized Clinical Trial. J Orthop Sports Phys Ther. |
RCT w/ 100 women with Capel Tunnel Syndrome allocated to either MT or Surgery Analyses showed statistically significant differences in favor of manual therapy at 1 month for self-reported function and pinch-tip grip force Conclusion MT and surgery had similar effectiveness for improving self-reported function, symptom severity, and pinch-tip grip force on the symptomatic hand in women with CTS. |
|
|
Hoeksma, Dekker, Ronday, et al. 2004. Comparison of Manual Therapy and Exercise Therapy in Osteoarthritis of the Hip: A Randomized Clinical Trial. Arthritis Car and Research. |
Compared a group receiving spinal and hip mobilization and manipulation to a group which received exercise only for a treatment period of 5 weeks. MT group had a success rate of 81% compared to the exercise groups 50%. Furthermore, the MT group had greater improvement in pain, hip function, and ROM which was sustained at 29 weeks. |
|
|
Cliborne, Wainner, Rhon, et al. 2004. Clinical hip tests and a functional squat test in patients with knee osteoarthritis: Reliability, prevalence of positive test findings, and short-term response to hip mobilization. JOSPT. |
Article found that hip mobilization does have a short-term effect including the reduction of individual test pain scores and improving ROM significantly. The study found that those who received hip mobilization had a reduction in pain for all tests performed except for the hip flexion test. |
|
|
Gross et al. 2004. A Cochrane review of manipulation and mobilization for mechanical neck disorders. |
"Strong evidence" of benefit favoring mobilization and/or manipulation with exercise for pain relief, restoration of function, and global perceived effect. -Mob/manipulation when used w/ exercise is beneficial for persistent mechanical neck disorders with or without headache -Inadequate evidence is available to determine effects of mob/manip for neck disorders with radicular symptoms |
|
|
Isaacs & Bookhout Book on Spinal Manipulation 2002 |
"The belief shared by some patients that if there is no joint noise associated with the manipulation procedure then nothing has happened is incorrect." |
|
|
Pt consent question prior to manipulation |
"I think you're a candidate for the following technique based on XXXXX, you don't have any negative or limiting factors such as XXXXX, so I think you would do well with a similar technique with a little more speed. Is that OK with you to proceed?" |
|
|
Assessment component of OSCE: Screening process, Indications, contraindications, evidence for assessment/technique |
Indications: based on the patients history of XXXX pain without specific MOI and movement or activity that exacerbates it, a screening of the spine with repeated end range movement examination is warranted. This would then be followed by extremity examination pending findings... given no other body systems involved (sig past medical history) I believe this to be primarily musculoskeletal. This patients relative/regional/absolute/or no contraindications have any contraindications suggest that we move forward with (further examination or limited evaluation, outside referral..etc.) The evidence: the active and passive motions were limited and painful at end range . This would suggest the need for further assessment of joint play. The resisted movements were strong and not painful. This would suggest the possibility of an articular joint dysfunction or derangement. |
|
|
Deep neck extensors |
-Longus Capitis -LongusCcolli -Rectus Capitis post major/minor -Semispinalis Cervices -Multifidis |
|
|
Upper cervical ligament reinforcements |
-Posterior atlantoaxial ligament which is continuation from Ligament Flavum -anterior atlantoaxial continuation from ALL -Techtorial membrane continuation from PLL -Ligamentum nuchae (CO to C7) continuation from supra spinous ligament |
|
|
Cervical Spine Special Tests |
1. Sharp-purser test 2. Transverse Ligament test 3. Aspinall's test 4. Test for odontoid fracture 5. Alar ligament test 6. Vertebral Artery test 7. Rotatory Nystagmus test |
|
|
Sharp Purser test |
Tests atlanto-axial stability: Assesses the integrity of the Atlanto-Axial joint and more notably the stabilizers of the dens on the Atlas. This test specifically assesses the integrity of the Transverse Ligament. If the transverse ligament that maintains the position of the odontoid process relative to C1 is torn, C1 will translate forwards on C2 in flexion. 96% specificity and 88% sensitivity found in RA patients |
|
|
Transverse Ligament test |
Performed in supine with thumbs up and fingers under the posterior arch of C1. Apply PA translation through arch of C1 and monitor for a negative response |
|
|
Aspinalls test |
In supine with cradle grip of Its head, pull heads upward and look for negative response |
|
|
Test for Odontoid Fracture |
in supine, apply lateral translation to the arch of C1 |
|
|
Alar Ligament test |
In sitting, perform small side bending to cervical spine and feel for C2 spinous process kick opposite direction as tension on the Alar ligament pulls the process on the opposite side of the SB. |
|
|
Rotary Nystagmus test |
Pt moves body only, keeping head still which stabilizes the vestibular system. If Pt has a negative response with unusual symptoms then VBI is likely involved since vestibular system has been taken out. |
|
|
Vertebral artery test |
May be done in various ways but most commonly performed in supine with full end range rotation followed by Pt counting to 10 and assessing for a negative response as well as 5D's. |
|
|
Spinal Coupling patterns |
When performed from neutral: -SB and rotation opposite in upper cervical, thoracic, and lumbar-SB and rotation to same side in cervical When performed from slight flexion, SB and Rotation occur same side |
|
|
SI joint Test Cluster |
-Distraction -Compression -Thigh thrust -Sacral thrust -Gaenslens |
|
|
Werneke, Hart. Spine 2001. Centralization phenomenon as a prognostic factor for chronic low back pain and disability. |
Pain pattern classification (noncentralization) and leg pain at intake were the strongest predictive variables of chronicity. CONCLUSION:Dynamic assessment of change in anatomic pain location during treatment and leg pain at intake were predictors of developing chronic pain and disability. |
|
|
Long, Donelson, Fung. Spine 2001.Does it matter which exercise? A randomized control trial of exercise for low back pain. |
A standardized MDT assessment identified a large subgroup of LBP patients with a DP. Regardless of subjects' direction of preference, DP significantly and rapidly decreased pain and medication use and improved in all other outcomes.
|
|
|
Su, Lim. 2016. Does Evidence Support the Use of Neural Tissue Management to Reduce Pain and Disability in Nerve-related ChronicMusculoskeletal Pain? A Systematic Review With Meta-Analysis. Clin J Pain. |
When compared with minimal intervention, neural mobilization provided superior pain relief, and reduction in disability. No signicant dierences were found when comparing neural mobilization with other treatment approaches for pain. |
|
|
Michel Coppieters et al.2008 & 2009. Do 'sliders' slide and 'tensioners' tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. Different nerve-gliding exercises induce different magnitudes of median nerve longitudinal excursion: an in vivo study using dynamic ultrasound imaging. |
A series of experiments that sliders have greater nerve excursion and less strain on the nerve compared to tensioners.
|
|
|
Deep neck flexors |
-Longus capitis -Longus Colli -Rectus capitis post major/minor -Semispinalis cervicis -Multifidis |
|
|
Collins, Teys, Vicenzino. 2004 Man Ther. The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains.
|
Results indicate that the MWM treatment for ankle dorsiflexion has a mechanical rather than hypoalgesic effect in subacute ankle sprains.
|
|
|
Kaminksi, Hertel, Amendola, et al. 2013 J Athl Train. National Athletic Trainers’ Association Position Statement: Conservative management and prevention of ankle sprains in athletes.
|
Passive joint mobilizations and mobilizations with movement should be used to increase ankle dorsiflexion and improve function.
|
|
|
Rons preferred informed consent |
"all of the tests and measures we have done, beginning with your history of localized pain, no acute structural deformity, and limitation and pain with active, repeated end range and passive tests and palpatory findings, combined with a negative neurological exam indicate that you are a very good candidate for this procedure. In addition, we have done some screening tests for any unusual adverse response and held your joint at end range both of which you tolerated well. There may be some soreness from this technique but it should be mild and temporary. Is it ok if we proceed with the technique"?
|
