Musculoskeletal System: Lec.21 - Rehabilitation Medicine

Front 1

Musculoskeletal System:

Lec.21 - Rehabilitation Medicine

Back 1

Musculoskeletal System:

Lec.21 - Rehabilitation Medicine

Front 2

Q21:

50% of people with low back pain will ...

Back 2

- get better in 2 weeks

Front 3

Q21:

80% of people with low back pain will ...

Back 3

- get better in 6 weeks

Front 4

Q21:

30% of people

Back 4

will have longstanding , serious or chronic back pain

Front 5

Q21:

How much does back pain cost annually?

Back 5

7-28 billion dollars annually

Front 6

Q21:

What is a huge risk factor for back pain?

Back 6

- genetics
- smoking
- poorposture

Front 7

Q21:

how many vertebrae are there of each segment?

Back 7

- 7 cervical
- 12 thoracic
- 5 lumbar
- sacrum and pelvis

Front 8

Q21:

iliolumbar lig

Back 8

- huge sourse of low back pain, about 80%

Front 9

Q21:

Posterior sacroiliac ligament

Back 9

?

Front 10

Q21:

Sacrotuberous Ligament

Back 10

?

Front 11

Q21:

Gluteus maximus

Back 11

- posterior of proximal femoral neck

Front 12

Q21:

Gluteus medius

Back 12

- posterior superior part of the greate trocanter

Front 13

Q21:

Gluteus minimus

Back 13

?

Front 14

Q21:

What are the three types of back pain?

Back 14

- Axial
- Radicular
- Pseudoradicular

Front 15

Q21:

Axial back pain?

Back 15

- pain is only in the back, and or buttock area without radiation into the legs

- caused by non-nerve injuries shcu as muscle, tendon, ligament or disc damage, arthritis or Fx.

Front 16

Q21:

Radicular pain?

Back 16

- Pain is usually in the legs > back, often with leg numbness, tingling or weakness. Caused by nerve irritation / injury such as nerve root impingement by herniated disk or arthritis

Front 17

Q21:

Pseudoradicular pain?

Back 17

- pain usually in the back > legs, with normal neurologic exam. Caused by referred pain from injured non-nerve structures such as muscles, tendons, ligaments or joints.
- usually pain in back> pain in the legs, and usually neuro exam is (-)
- pain comes from ligament, disks, very difficult to find.

Front 18

Q21:

radicular pain vs. pseudoradicular pain?

Back 18

- radicular pain follows a classical dermatome

- pseudoradicular pain, this is a pattern of pain that may mimic radicular pain, from sacroiliac ligament dysfunctoin

Front 19

Q21:

When should a pt with back pain seek medical attention?

Back 19

- leg pain > back pain
- pain with bowel or bladder problems
- pain with unexplained weight loss or decresed appetite and hx of Ca.
- pain after a significant injury
- progressively worsening pain
- pain longer than 6 weeks

Front 20

Q21:

When is back pain a potential emergency?

Back 20

- Significant or worsening weakness in the legs with or without pain -->severe nerve or spinal cord damage.

- Acute changes in bowel or bladder function with or without pain--> conus medullaris syndrome.

-Numbness along the insides of both thighs (“saddle anesthesia”)--> cauda equina syndrome.

-Acute back pain with fever, chills, and/or night sweats --> infection of the spine.

Acute back pain with a tearing sensation and bounding pulse in the stomach area -->dissecting or ruptured aortic aneurysm

Front 21

Q21:

numbness of inner thighs and urinary incontence, what is this?

Back 21

- cauda equina syndrome

Front 22

Q21:

when to send a pt to a musculoskeletal physiatrist?

Back 22

- pain with a structural origin (e.g. arthritis, myofascial, ligamentous or tendinous dysfunction) and/or functional deficits (e.g. decreased strength, flexibility, activity tolerance, work capacity).

Front 23

Q21:

When to send pt to see an interventional pain specialist (spinal injections under fluoroscopic guidance)

Back 23

- well-localized pain generators without profound neurologic deficits (e.g. painful radiculopathy, facet arthropathy, discogenic pain), unresponsive to other conservative treatments such as physical therapy, OMT, or medications.

Front 24

Q21:

when to send a pt to see a rheumatologist?

Back 24

Localized pain with/without pain in other joint areas, particularly the hands, and associated findings such as rash (e.g. lupus, psoriatic arthritis, dermatomyositis) or lab abnormalities (e.g. elevated ESR, ANA or rheumatoid factor).

Front 25

Q21:

When to send a pt to see a neurologist?

Back 25

- peripheral neurologic deficits without an identifiable structural cause (low motor neuron lesions, e.g. peripheral neuropathy, ALS), or central nervous system deficits (upper motor neuron lesions, e.g. multiple slerosis, stroke, ALS).

Front 26

Q21:

When do you send a pt to a neurosurgeon?

Back 26

- profound and/or emergent neurologic deficits from structural causes (e.g. large disc herniation causing severe radiculopathy, spondylosis causing severe spinal stenosis), unresponsive to other treatments such as medications or spinal injections.

Front 27

Q21:

Diagnostic tests for back pain?

Back 27

- History and Physical (most important)
- Plain Radiograph - bones (lumbar with flexion and extension views, this gives you info that even a ct or mri can not give you on stability)
- MRI - bones (especially bone metabolism), disks
- CT ( excelent for boney anatomy
- Nuclear Bone Scan - excelent for bone metabolism
- SPECT - excellent for localized boney pathology
- Angiogram - great for vascular problems
- elecdiagnosic studies
- blood work

Front 28

Q21:

what are EMGs often used to diagnose?

Back 28

-cervical rediculopathy
- brachial plexopathyies
- upper extremity mononeuropathyies

Front 29

Q21:

when do you want to order a neuro muscular study?

Back 29

- when you have a disorder that causes
- pain the in limb (unexplained)
- numbness of the extremities (when not clear where its comming from)
- weakness of extremity (when not clear where its comming from)
- prognostic test for certain conditions(carpal tunnel, or to determine the need for surgical intervention)
- if the symptoms persist after the pt has undergone a surgical correction, it can be used to evaluate persistent or improving neurological symptoms

Front 30

Q21:

What is an electrodiagnostic study?

Back 30

-a functional test to evaluate the PNS and neuromuscular function

- may not provide a clinical diagnosis, but can provide information about the type of neuromuscular injury

-location, severity, prognosis

Front 31

Q21:

Nerve Conduction Study

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involves elecally stimulating peripheral nerves using surface electrodes to measure the following in sensory nerve action potentials (SNAP) and compound motor action potentials (CMAP)

Front 32

Q21:

What are the two components of electrodiagnosics studies?

Back 32

- nerve conduction studies (NCS)
- electromyography (EMG)

Front 33

Q21:

what test is is good for neuromuscular junction disorders?

Back 33

Repetitive nerve stimulation (RNS), it involves stimulating a motor nerve repetitively using surface electrodes to measure increment or decrement of CMAP (compund motor action potentials) amplitude pre and post exercise

Front 34

Q21:

Electromyography (EMG)

Back 34

- involves passively detecting peripheral nerve electrical activity (no electrical stimulation) using a needle electrode to evaluate the following;
- insertional activity
-resting activity
- recruitment
- motor unit

Front 35

Q21:

Somatosensory Evoked Potentials?

Back 35

Involves monitoring sensory pathways back to the central nervous system

- helpfful in diagnosing demyelinating injuries and diseases (ex. MS).

Front 36

Q21:

myopathic disorders show what on an EMG

Back 36

- early and increased recruitment
- decrease in motor unit size

Front 37

Q21

neuropathic disorders show what on an emg

Back 37

- increase in motor unit size

Front 38

Q21:

what to tell your pt?

Back 38

- explain to them that there is no shock that goes through the needle, necessarily
- test is uncomfortable
- explain to them that it shows things that other tests cant (but nothing can replace those)

Front 39

Q21:

if the study is normal...

Back 39

- go back to your physical exam, if your neuro exam was abnormal then you want to think about something more central (because this study tests the PNS)
- and the physical exam is also normal, then think of pseudoradicular patterns or psycosocial problem

Front 40

Q21:

What if the study is abnormal....

Back 40

with a focal localizable lesion, possibly get an MRI or other study to confirm if possible, then make the appropriate referal

- no focal sorces, multiple things going on, there are lists of things that could cause it.

Front 41

Q21:

there will be a question on ASIA

Back 41

there will be a test on ASIA

Front 42

Q21:

What is the most common cause for cervical radiculopathy?
(and what is the cause for for this in those over 50yoa?)

Back 42

- Herniated nucleus pulposis
- Spondylosis (in those above 50)

Front 43

Q21:

If the SNAP is normal what does this mean?

Back 43

the lesion is located proximal to the dorsal root ganglion.

Front 44

Q21:

What is ASIA?

Back 44

Standard Neurological Classification of Spinal Cord Injury (this is specific for radiculopathy)

Front 45

Q21:

Describe the following dermatomes:
C8, C7, C6, C5, C4

Back 45

C8- pinkey finger sensation
C7-middle finger sensation
C6- thumb sensation
C5- upper arm sensation
C4- proximal shoulder

Front 46

Q21:

Describe the following mytomes:
T1, C8, C7, C6, C5

Back 46

T1- Finger ABduction
C8- Finger Flexion
C7- Elbow Extension
C6- Wrist Extension
C5- Elbow Flexion

Front 47

Q21:

Describe Brachial Plexopathy

Back 47

- pathological process typically occurring distal to the DRG and proximal to the peripheral nerves. ABNORMALITIES CAN APPEAR DIFFUSE and will not follow any particular dermatomal or myotomal distribution

Front 48

Q21:

Erbs Palsy

Back 48

- C5-C6 or upper trunk
- Obstectrical or trauma injury
- classic "waiters tip" position, arm becomes adducted, internally rotated extender, pronated with the wrist flexed

Front 49

Q21:

Klumpke palsy

Back 49

- C8-T1 nerve roots or lower trunk
- obstetrical traction injury
- May present with claw hand (differentiate from ulnar neuropathy)
- may have waisting of the small hand muscles (claw hand deformity due to lumbrical weakness)

Front 50

Q21:

mononeuropathies

Back 50

- these are listed from the proximal to distal for each nerve.
-Median nerve
-ulnar nerve
- radial nerve
-musculocutaneous nerve
- axillary nerve

Front 51

Q21:

Median nerve mononeuropathies

Back 51

- pronator syndrome
- anterior interosseous syndrome
- carpal tunnel syndrome (CTS)
-

Front 52

Q21:

Ulnar nerve mononeuropathies?

Back 52

- tardy ulnar palsy
- cubital tunnel syndrome
- guyon's canal (bikers palsy)

Front 53

Q21:

Radial nerve mononeuropathies?

Back 53

- crutch palsy
- spiral groove (saturday night, or honeymooner's palsy)
- posterior interosseous syndrome
- superficial radial neuropathy

Front 54

Q21:

What is pronator syndrome?

Back 54

-Median nerve neuropathy
- due to compression between heads of the pronator teres muscle or the bridging fascial band of the flexor dig. superficialis muscle
- affects all the muscle innervated by the median nerve except PT.

Front 55

Q21:

What is anterior interosseous muscle?

Back 55

- median nerve mononeuropahy
- due to Fx or idiopathic neuralgic amytrophy
- pure motor syndrom affecting "the four P muscles"

Front 56

Q21:

What is Carpal tunel syndrome?

Back 56

- median nerve mononeuropathy
- may be due to thyroid issues, CHF, RF, tumor, hematoma or pregnancy
- Affects sensation to 1,2,3 radial 1/2 of 4 and LOAF muscles

Front 57

Q21:

What is Guyon's canal (Bikers Palsy)?

Back 57

- Ulnar nerve mononeuropathy
- due to cycling activitiesor RA
- Affects all ulnar innervated intrinsic muscles of the hand, but DUC is spared

Front 58

Q21:

What is Posterior interosseus syndrome (supinator or arcade of frohse syndrome)?

Back 58

- Radial nerve mononeuropathy
- Due to the compression at the arcade of Frohse of the supinator, monteggia Fx

Front 59

Q21:

What is Superficial radial neuropathy (wristwatch syndrome, handcuff palsy)?

Back 59

- Radial Nerve mononeuropathy
- due to compression at the wrist
- pure sensory syndrome with paresthesias on dorsal radial aspect of the hand

Front 60

Q21:

Where does the musculocutaneous nerve originate?

Back 60

- C5, C6, and C7 roots

Front 61

Q21:

What neuropathy is due to impropper crutch use?

Back 61

- Axillary neuropathy
- Traction or compression from a shoulder dislocation, humoral head Fx, or impropper crutch use

Front 62

Q21:

How do you differentiate between Radiculopathy, Plexopathy, and Periphereal neuropathy?

Back 62

Radiculopathy - Changes to DTR , specific myo or dermatome pattern

Plexopathy - multiradicular presentation, does not follow strict myo or dermatomal patters

Periphereal neuropathy -