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586 Cards in this Set
- Front
- Back
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What type of mechanics are in the lumbar region?
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Typical Fryette mechanics
Type I or Neutral - Rotation/Sidebending coupled to opposite sides Type 2 or Non-neutral - Rotation/Sidebending coupled to same side |
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What region in the lumbar spine does not follow the typical mechanics of the area?
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L5/S1
site of more spinal anomalies than anywhere in the spinal column Anomalous facings of the facet joints negate Fryette mechanics Trauma common at this segment with loss of stability due to ligamentous or disc injury |
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Lumbar motion permitted by?
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Bones and joints
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Lumbar motion restrained by?
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Ligaments
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Lumbar motion produced and stabilized by?
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Muscles
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Anatomical/Functional areas of the lumbar spine?
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Anatomical: L1-L5
Functional T11-L5 |
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Curve of lumbar spine?
Designed for? |
Lordotic curve
For weightbearing |
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Orientation of the facets in the lumbar spine?
Allows for? |
In sagittal plane
Superior articular facet - faces posteromedially Inferior articular facet - faces anterolaterally Allow for good FB, BB Limits Rotation, SB |
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Degrees of flexion/extension in lumbar spine?
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L1 on L2: 9-16
L2 on L3: 11-18 L3 on L4: 12-18 L4 on L5: 14-21 L5 on S1: 18-22 |
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Degrees of sidebending in lumbar spine?
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~10
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Degrees of rotation in lumbar spine
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L1 to L3: ~2
L4 and L5: ~3-4 |
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Where are lumbar discs thicker? Why?
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Anteriorly, contributes to shapes of lumbar lordosis
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Where are lumbar discs attached?
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To hyaline cartilage at vertebral endplates
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Vascularity of IV discs?
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Avascular and receive nutrients via diffusion (Except on periphery)
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What does motion loss impair for the IV disc?
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Nutrition
Leads to premature disc degeneration |
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How much of the vertebral column do IV discs make up?
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1/5 of length
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What does the fiber arrangement of the annulus fibrosus check?
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Checks rotary motion
Screws down the disc |
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Which part of the IV disc is the NP closer to?
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Posterior surface of disc
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What fractures first when compressive forces are applied to spine?
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Vertebrae fracture before discs give away
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When does disc degeneration begin?
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11-20 in men
21-30 in women 97% of lumbar discs show degeneration at age 50 |
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Where does the most common disc herniation occur?
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L5-S1
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What does the posterior longitudinal ligament do?
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Reinforces strength of disc posteriorly in the mid-line
Becomes smaller and weaker as you descend spine This predisposes lower discs to herniation |
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Describe the function of ligaments
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To allow adequate physiologic motion and fixed postural attitudes between vertebrae with a minimum expenditure of muscular energy
To provide stability to the spine within physiologic ranges of motion (shares this task with the musculature) To protect the spinal cord and cauda equine by restricting motions within well-defined limits To protect the spinal cord in traumatic situations in which high loads are applied at fast speeds All requires the absorption and dissipation of large amounts of energy |
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Types of ligaments
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Check ligaments (forward bending, backward bending, lateral bending, rotation)
Kinetic ligaments |
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What eight ligaments are in the lumbar spine?
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Anterior longitudinal lig
Posterior longitudinal lig Intertransverse lig Capsular lig Ligamenta flava Interspinous lig Supraspinous lig Iliolumbar lig |
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What are the forward bending check ligaments in the lumbar spine?
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Supraspinous lig
Interspinous lig Posterior longitudinal lig Capsular ligaments (fibers oriented at right angles to facet joint surface; provide increasing stability with increasing flexion of the spine) |
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What are the kinetic ligaments of the lumbar spine?
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Ligamentum flavum (packed w/ elastic fibers, purest form of elastic tissue in human body, in forward bending it stores kinetic energy to assist the musculature in returning the spine to the upright position)
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What are the sidebending check ligaments in the lumbar spine?
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Intertransverse check lig (thickening of the anterior layer of lumbodorsal fascia... enclose the intertransverse musculature in lumbar region; one subset is the lumbosacral ligaments (L5-S1)
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What are the rotational check ligaments in the lumbar spine?
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Iliolumbar ligaments (blend continuously w/ superior end of the sacroiliac lig; these lig are the ones injured in classic lumbosacral strain/sprain)
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Discs check what motion?
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Alternating direction of fibers in adjacent lamina of disc serve to check rotational movement
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What are the backbending check ligaments in the lumbar spine?
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Anterior longitudinal lig (reinforces disc anteriorly; roughly twice as strong as the posterior longitudinal lig)
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What occurs w/ traction on the vertebral attachments of the anterior longitudinal ligament?
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Osteophyte formation
"anterior lipping" seen in lateral lumbar radiographs |
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The biomechanical properties of the anterior longitudinal ligament decrease with?
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Increasing age
Ligament weakens, loses elasticity, and ruptures at lower force loads |
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The thoracolumbar fascia is critical for?
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Lumbar stability
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What keeps the thoracolumbar fascia taut?
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Positive pressure on abdomen
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Instability in thoracolumbar fascia generated by?
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Weakness
Hernias Incisions Pregnancy |
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What do the short muscles of the lumbar spine do?
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Stabilize the column (ensures efficient action of long muscles)
Needed as vertebral column would otherwise buckle with compression |
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Short muscles are:
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Involuntary
Stabilize/Balance spine |
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Long muscles are:
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Voluntary
Move the spine |
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What are the deep paraspinal muscles of the lumbar spine (aka involuntary mm)?
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Intertransverse mm, Interspinalis mm, Rotatores brevis, rotatores longus
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What do the deep paraspinal musculature respond to?
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Viscero-somatic and somato-somatic reflexes
These are what CAUSE and MAINTAIN segmental somatic dysfunction |
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What causes and maintains segmental somatic dysfunction?
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The deep paraspinal musculature via viscero-somatic and somato-somatic reflexes
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Attachments of the intertransverse mm
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Between lumbar TP
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Action of intertransverse mm
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Segmental sidebending/stabilization
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Innervation of intertransverse mm
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Posterior primary division of the spinal nerves
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Attachments of the interspinalis mm
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T11-L5
One on either side of interspinous lig |
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Action of interspinalis mm
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Segmental extension/Stabilization
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Innervation of interspinalis mm
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Posterior primary division of the spinal nerves
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Attachments of rotatores brevis
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TP to SP one segment above
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Attachments of rotatores longus
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TP to SP two segments above
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Action of rotatores brevis
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Rotates segment(s) to the opposite side
Aka right rotatores will rotate vertebra to the left Also: segmental stabilization |
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Innervation of rotatores brevis
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Posterior primary division of spinal nerve
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What initiates flexion of the trunk?
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Rectus abdominis muscle
Then gravity will take over Further control provided by erector spinae mm |
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When are spinal muscles at rest?
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Full flexion
Passive posture maintained by check ligaments and resistance to disc deformation |
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What are the extenders of the spine?
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Iliocostalis lumborum
Longissimus thoracis Spinalis thoracis Multifidus |
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Actions of the voluntary muscles of the lumbar spine
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When acting unilaterally - sidebending
When acting bilaterally w/ pull of internal oblique mm - rotators |
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Attachments of diaphragm
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Crura attach to anterior surface of bodies of L1-L3 (Right to L1-L3 and left to L1 and L2)
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What will diaphragmatic overuse (d/t asthma) or chronic hypertonicity (d/t COPD) lead to?
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Creates flexed dysfunctions of the upper lumbar segments
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What does upper lumbar somatic dysfunction mechanically interfere with?
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Function of the diaphragm
Results in dyspnea |
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When does the psoas major become active?
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Silent when standing
Active as part of balance in seated position |
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What happens to the psoas major with prolonged sitting?
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Shortens psoas mm with anterior tilt of pelvis and increase in lumbar lordosis
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How are the lumbar nerve roots vulnerable when around the psoas major?
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After leaving neural foramina, they pass anteriorly between the proximal attachments of the psoas mm
Vulnerable to compression and irritation w/ hypertonicity or spasm of psoas major |
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Acute psoas spasm sidebends the trunk WHERE?
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To the side of the spasm
Also flexes trunk forward at the waist |
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Net effect of acute psoas spasm on the lumbar segments?
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Fryette Type II dysfunction
Typically affects L1, 2, or 3 with the segment flexed; rotated and sidebent to side of psoas spasm |
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What do extended dysfunctions of L1-L3 tend to cause?
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Somato-somatic reflex resulting in acute psoas spasm
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Where would hypertonicity of the quadratus lumborum tend to deviate the body?
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Sidebends body towards side of hypertonicity
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Significance of attachments of quadratus lumborum in relation to its hypertonicity
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Muscle attachments nearly on line w/ neutral mechanics
Tends to Produce a group curve (L1-5NRLSR) |
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What does the lat. dorsi commonly do in terms of its dysfunction?
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Transfers lumbar and lower thoracic problems to shoulder
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What does the lat. dorsi do when fixation of the arm (when the lat. dorsi is dysfunctional)
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contraction of this muscle can influence the lower thoracics, all lumbar semgnets, and the pelvis
Depends on which portions of the muscle are firing at time of injury |
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Fx of serratus posterior inferior?
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Accessory muscle for forced expiration
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What occurs with unilateral contraction of the serratus posterior inferior when ribs are held in fixed inhalation posture (d/t COPD)?
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Rotates L1-L3 away from side of muscle contraction
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What do air trapping diseases tend to cause in relation to the thorax and lumbar areas?
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Create flexed posture to thorax w/ compensatory increase in lumbar lordosis
May be enough to provoke Type II dsfunction |
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What are the veins of the spine also called?
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Batson's plexus
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Where do the veins of the spine allow for infections to go?
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From bladder or pelvis to vertebrae or epidural space w/ osteomyelitis of epidural abscess formation
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What do the veins of the spine also supply in children?
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the discs
May result in infectious discitis |
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Veins of the spine are principal route for metastasis of?
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Pelvic cancers to spinal column
Especially from prostate |
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How long is the L1 nerve root? S1?
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L1 - 60 mm
S1 - 170 mm Axons from S1 level of spinal cord to final destination in foot may exceed 100 cm |
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What are nerve roots limited in motion by?
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Fibrosis, intraspinal or extraspinal entrapement
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Why must nerve root complexes be extremely mobile
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To accommodate lumbar flexion, sidebending, and rotation
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When would blood flow in the vasa nervorum be significantly reduced?
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When nerve root is stretched just 8% of total length
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When would blood flow in the vasa nervorum cease?
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when the nerve is stretched 15% of its entire length
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Causes of low back pain?
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Fracture
Strain Disc Herniation Infection "Referred pain" |
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How many Americans will need health care professional assistance w/ low back pain at some point in their lives?
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4 out of 5
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90% of all low back and/or sciatica will resolve within?
99% within? |
6 weeks without any intervention
99% within 12 weeks |
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What is the goal of treatment in low back pain?
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Hasten recovery
Control pain Facilitate rehabilitation |
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First question to ask when evaluating lower back pain
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What is the most serious thing this could be
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What would compose "an ominous history" for onset of lower back pain?
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Bilateral radicular pain
Saddle area anesthesia Urinary incontinence Urinary retention Increased urinary frequency Overflow urinary incontinence May indicate: Acute cauda equina syndrome Massive multi-nerve compression Large central disc herniation Hemorrhage into spinal canal Swelling of rapidly growing tumor |
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Within how many hours of onset must you treat cauda equina syndrome?
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Within 24-48 hours
Or permanent neurologic impairment may result |
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History for possible fracture
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Major trauma
Fall from a height Female over 50 years, or other risk factor for osteoporosis |
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History for possible infection
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Age over 50 or under 20
Fever or chills Pain worse supine Recent UTI IV drug abuse Immune suppression |
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PEX suspicious for infection
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Feels hot
SP percussive pain |
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History for tumor
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Age over 50, under 20
Unexplained weight loss Pain worse when supine Severe nocturnal pain |
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On PEX, if temp high, you rule out what?
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Infectious etiology
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On PEX, if pulse is weak and rapid, you rule out what?
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Retroperitoneal hemorrhage
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On PEX, if blood pressure is low, you rule out what?
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Retroperitoneal hemorrhea (dissecting AA)
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How would you have a patient localize their pain?
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One finger test
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Markings of Shober Test are where?
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One between PSIS
5 cm down 10 cm up should be minimum of 20 cm with trunk flexed |
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What does a positive Tredelenberg Test indicate?
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Weakness of gluteus medius muscle
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What innervates the gluteus medius muscle?
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L5
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Etiology for positive Trendelenberg test?
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Disc herniation
Spinal tumor Intraspinal abscess |
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What is straight leg raising a test for?
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Stretch test for sciatic nerve
Also does stretch hamstrings, so hamstring tightness/pain may cause false positive |
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What does flank percussion with pain indicate
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Lloyd sign
Possible renal pathology |
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How would you test SP percussion in lumbar spine?
Indications? |
Use reflex hammer
Three causes - fracture, tumor, infection (osteomyelitis or abscess) |
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Reflex grading scale
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0 - absent
1 - decreased 2 - normal 3 - increased 4 - clonus |
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What is clonus?
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Alternating muscle contraction in relaxation in rapid succession
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What is clonus indicative of?
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Disconnect between upper and lower motor neurons
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How do you test reflexes of L1, 2, and 3
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No reflexes to test
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How do you test reflex of L4?
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Patellar test
(also some from L3 though..) |
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How do you test reflex of L5?
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No reflex to test
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How do you test reflex of S1?
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Achilles reflex
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How do you test reflexes for S2, 3, and 4?
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Superficial anal reflex
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Presence of Babinski sign indicates what?
Causes? |
Disconnect between upper and lower motor neurons
Indications: MS, ALS Also could mean destruction of upper motor neuron Indications: CVA, brain tumor |
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Grades of muscle strength
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0 - flaccid paralysis
1 - palpate muscle contraction, but muscle cannot move affected body part 2 - only move body part with gravity eliminated 3 - can only move body part against gravity 4 - in between 3 and 5 5 - full strength against full resistance |
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What does peripheral muscle weakness in context of lower back pain almost always indicate?
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Presence of neural compression
If Grade 3-4+: Spinal cord Nerve root Peripheral nerve |
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What does grade 0-2 muscle weakness indicate usually?
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Central nervous system problem
CVA, Guillain-Barre, MS, etc. |
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How do you test L1-L3?
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Iliopsoas
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How do you test L2-L4?
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Quadriceps, Hip adductors
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How do you test L4?
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Tibialis anterior
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How do you test L5?
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Extensor hallucis longus, extensor digitorum longus and brevis, and gluteus medius
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How do you test S1?
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Fibularis longus and brevis, gluteus maximus
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How do you test S1-S2?
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Gastrocnemius and soleus
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What is the most overlooked dysfunctional muscle in causes of LBP?
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Dysfunctional quadratus lumborum
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OMM for L-spine somatic dysfunction?
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Counterstrain for TPs
ME/HVLA restrictions Decrease restrictions in other areas |
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Where does most back pain problems occur?
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Multifidus triangle
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What does exacerbation of low back pain during iliopsoas strength testing (L1-3) often indicate?
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Presence of discogenic pain
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What is psoas syndrome?
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Flexed contracture of iliopsoas
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What is the pathogenesis of psoas syndrome?
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Prolonged positions with shortened psoas
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What are the organic etiologies of psoas syndrome?
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Appendicitis
Sigmoid colon dysfunction Ureteral calculi or dysfunction Prostate CA metastasis Salpingitis |
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Pain location of psoas syndrome?
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Low back radiating to groin
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Signs and symptoms of psoas syndrome
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increased pain with standing or walking
Positive Thomas test Positive TP medial to ASIS NN SD L1/L2 Positive pelvic shift test contralaterally Sacral SD on oblique axis Piriformis spasm contralaterally |
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Treatment of psoas syndrome?
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Acute: Ice (decreases pain and edema)
Do NOT initially use heat OMT: Indirect followed by direct (counterstrain then ME/HVLA) Chronic: Stretching |
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Where would you test sensation for L1-3?
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anterior thigh
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Where would you test sensation for L4?
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Medial side of foot
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Where would you test sensation for L5?
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Web space between great toe and second toe
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Where would you test sensation for S1?
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Lateral side of foot
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Where would you test sensation for S2-5?
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Perianal skin
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What sensations do you test?
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Pain (pin prick) w/ sterile needle
Light touch w/ wisp of gauze or cotton Vibration w/ tuning fork |
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What etiology in abdomen could cause referred pain in back
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Retroperitoneal viscera
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How do you evaluate abdomen for presence of intra-abdominal dysfunctions causing referred lower back pain?
What are you looking for? |
auscultate for bruits
Would indicate abdominal aneurysm, renal artery stenosis |
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What would you palpate abdomen for when evaluating the pt w/ lower back pain?
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Guarding response
Masses Presence of abdominal aneurysm |
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Positive valsalva indicates?
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Space occupying lesion in spinal canal
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What is the Naffziger test?
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Pressure on the jugular vein results in increased cerebrospinal fluid pressure and may cause pain in the case of a herniated disc
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What is the Soto Hall Test?
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Pt supine
Restrain sternum Passively flex neck Pain elicited at site of spinal disorder |
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How do you test sacroiliac joint pain?
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Pelvic Rock Test
Gaenslen Test Patrick Test |
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Patrick test is for:
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Sacroiliitis
Also hip joint disease |
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Motions involved in Patrick test
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FABERE
Flexion, Abduction, External Rotation, and Extension |
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What testing do you perform in the prone position on lower back?
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Nachalas test
Palpation Strength testing |
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What is the Nachalas test?
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Pt prone
Leg flexed at knee Pain radiating down anterior thigh implies femoral nerve entrapment or disease |
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How do you test truncal strength??
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While pt prone have them raise shoulders and hold for 10 secs
Also have them raise both legs for 10 secs |
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What do you palpate while evaluating lower back?
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SP (Spina bifida occulta, spondylolisthesis)
Supraspinous lig Intraspinous lig Iliolumbar lig Ischial tuberosity and bursa PSIS Iliac crests (episacroiliac lipomas, cluneal nerves) Sciatic nerves Paravertebral soft tissues (Layer by layer palpation) |
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What is layered on top of the orthopedic/neurologic/functional evaluations?
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Osteopathic structural exam
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Pathogenesis of spinal stenosis
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Degenerative changes in L-spine including:
Hypertrophy of facet joints Ca2+ deposits in ligamentum flavum/posterior longitudinal lig Loss of IV disc height |
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Pain assc w/ spinal stenosis
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Achy, shooting pain
Paresthesias |
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Pain location in spinal stenosis
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Low back to lower legs
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Sx of spinal stenosis
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Worsened by extension (Standing, walking, lying supine)
Osteophytes and decreased IV space on imaging |
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Tx of spinal stenosis
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OMT (decrease restrictions, increase ROM)
PT, NSAIDs, low dose tapering steroids Epidural steroid injection Surgical laminectomy w/ decompression |
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Pathogenesis of herniated NP
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Narrowing of posterior longitudinal lig
95% at L4-L5 or L5-S1 exerts pressure on nerve root of vertebra below |
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Quality of pain w/ HNP
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Numbness, paresthesias, sharp burning, shooting pain that worsens w/ flexion
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Sx of HNP
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Weakness, decreased reflexes
Sensory deficit in corresponding dermatome Positive straight leg test |
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Gold standard diagnostic for HNP?
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MRI
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Tx of HNP
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<5% are surgical candidates
Bed rest no more than 2 days OMT: Indirect followed by gentle direct (HVLA relatively contraindicated) Medical management of pain control (watch narcotic abuse) Therapeutic exercise |
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Indications for OMT in the patient with lower back pain
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pain, somatic dysfunctions w/ secondary sx
Prevent/treat complications d/t immobility Increase ROM |
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Contraindications for OMT in patient with lower back pain
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HVLA in cases of spondylolisthesis and HNP (relative contraindication)
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Summary of tx for pt w/ lower back pain
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Initial phase --> relief of sx
Second phase --> return to activity OMT useful to decrease sx and improve quality of life Individualize tx |
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Definition of lordosis
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Abnormal extension deformity of the spine
Concavity in the curvature of the lumbar and cervical spine as viewed from the side is increased Term used to refer to abnormally increased curvature... not the normally lordotic lumbar or cervical curvature |
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What other terms are synonymous with lordosis?
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Hollow back
Saddle back Sway back |
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What somatic dysfunctions can cause increased lordosis?
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Cervical extended segments
Thoracic flexed segments Lumbar extended segments Anterior innominate rotation Sacral flexed dysfunctions (bilaterally flexed sacrum, unilaterally flexed sacrum, and anterior sacral torsion) |
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What would you do if you decided the lordosis was severe enough upon physical examination?
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Perform a standing radiographic analysis
For purposes of both quantification of the curve and determination of etiology |
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Where should the lateral mid-gravity line fall in relation to lumbar region?
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Extended downward from mid-body of L3, it should fall at the sacral promontory
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What is Fergusen's Angle, and what is the normal range?
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Compares angle between plane of the superior surface of S1 and the horizontal plane
Normally 30-40 degrees |
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What is Mitchell's angle, and what is the normal range?
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Mid bodies of lumbar vertebrae through middle of sacrum on lateral view
Normal range is 125-145 degrees |
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What is the lumbosacral lordotic angle, and what is the normal range?
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Cobb Angle from superior endplate of S1 to superior endplate of L2
Normal is 40-60 degrees |
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What is the lumbo-lumbar lordotic angle, and what is the normal range?
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Cobb angle from superior endplate of L2 to inferior endplate of L5
Normal range is 35-55 degrees |
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What is Jungman's pelvic index dependent on?
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Age
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How do you calculate Jungman's pelvic index?
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Ratio of measurements representing the position of the sacrum relative to the innominates
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When does Jungman's pelvic index increase?
What are the typically seen ranges? |
When gravity overcome's body's homeostatic ability to resist it
Age 20 = 0.55 Age 50 = 0.65 Chronic lower back pain = 0.65-0.75 |
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What are the consequences of increased lumbar lordosis?
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Increased weight bearing on the facets and facet joint pain
Narrowing of the intervertebral foramina with neural entrapment Approximation of the spinous processes (Kissing spines - Baastrup syndrome) Visceroptosis Lumbar vertebral wedging Fixed flexion of the sacrum Anterior rotation of the pelvis Increased anterior concavity of the sacrum (remember Wolff's Law) |
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What is visceroptosis?
What can it result in? |
Descent of the viscera from their normal position
Can result n visceral ischemia syndrome |
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Symptoms of visceral ischemia syndrome?
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Postprandial pain
Anorexia (from fear of eating Weight loss Diarrhea |
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Physical findings with visceral ischemia syndrome?
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Occasionally occult fecal blood
Short systolic bruit in the epigastrium or umbilical region |
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Cause of symptoms with visceral ischemia syndrome?
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Celiac artery compression is main
Others: Atherosclerosis Fibromuscular hyperplasia neoplasia embolism polyarteritis nodosa thromboangiitis obliterans carcinoid |
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Etiologies of increased lumbar lordosis
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Poor posture (weakness of rectus abdominis/obliques, shortening of psoas mm)
Block vertebrae High heels (shortening of Achilles tendon... sudden discontinuation may increase lordosis... may have to do lift regression) Spondylolisthesis Obesity (abdominal binders/lumbar supports must be wide enough at back to provide broad support, if binder is too narrow, it will increase lordosis) Pregnancy Increased thoracic kyphosis Hip disorders (Congenital dislocation of the hip, coxa vara, flexion contracture d/t arthritis) Muscle contracture Development Rickets Cretinism |
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|
What is the normal angle from the femoral shaft to neck angle
|
120-160 degrees
Normal adult = 127 Angle greater in children |
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|
What is the angle from the femoral shaft to neck angle in coxa vara?
|
Below 120 degrees
|
|
|
What does coxa vara alter?
|
The pattern of muscle attachment with subsequent anterior rotation of the pelvis and increase in the lumbar lordosis
|
|
|
Describe a muscle contracture
|
Fibrosis of a muscle producing permanent shortening
Muscle reduced to hard cord, smaller in diameter than normal Muscle does not permit full ROM of a joint |
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|
Etiologies of muscle contracture
|
Congenital
Muscle disease Prolonged ischemia Inflammatory myositis |
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|
How would you test a hip flexion contracture?
|
Thomas test
|
|
|
What muscles would cause a positive Thomas test?
|
Psoas
Iliacus Rectus femoris |
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|
How would developmental problems cause increases lordosis?
|
Larger than normal erector spinae musculature
Often assc w/ massive gluteal and thigh mm Lifetime yoga participants |
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|
What is rickets, and what might is cause?
|
Vitamin D deficiency
Causes deformity of lumbar vertebrae |
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|
What is cretinism, and what could it cause
|
Neonatal hypothyroidism
Could cause lumbar lordosis |
|
|
What is Stiffman syndrome?
|
Insidious onset with hypertonicity and rigidity of paravertebral mm
Episodic spasm caused by sudden movement, jarring, noise, or emotional upset |
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|
Findings with Stiffman syndrome?
|
Motor and sensory exam normal
Intellect normal EMG: Abnormal (shows continuous motor activity at rest) |
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|
Treatment for Stiffman syndrome?
|
Diazepam 20-300 mg QD
Lumbar flexion exercises ROM exercises for extremities OMT: Soft tissue, muscle energy, HVLA |
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|
What can cause decreased lumbar lordosis?
|
Cervical flexed segments
Thoracic extended segments Lumbar flexed segments Posterior innominate rotation Sacral extended dysfunctions (bilaterally extended sacrum, unilaterally extended sacrum, posterior sacral torsion) |
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|
Consequences of decreased lumbar lordosis?
|
Increased weight bearing load on discs w/ increased risk of HNP
|
|
|
Etiologies of decreased lumbar lordosis
|
Lumbar sprain/strain
Acute lumbar HNP Lumbar spondylosis (OA of spine) Ankylosing spondylitis Psoas contracture |
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|
How would you describe decreased lumbar lordosis?
|
Flat back syndrome
|
|
|
What is flat back syndrome?
|
Loss of all AP curves
|
|
|
How do you treat flat back syndrome?
|
Heel lifts bilaterally
Lumbar extension exercises |
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|
What is assc w/ flat back syndrome?
|
Symptomatic MVP
Occurs in 27% of women w/ MAC |
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|
What does cervical lordosis cause?
|
Increased weight bearing on facet joints
Narrowing of intervertebral foramina Kissing spinous processes (Michotte syndrome) |
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|
Etiologies for increased cervical lordosis?
|
Increased thoracic kyphosis
Osteoporosis Poor posture, slouch shoulder variety Ill-fitting bifocals |
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Etiologies for decreased cervical lordosis?
|
Cervical sprain/strain
Cervical disc herniation Cervical spondylosis Flat back syndrome |
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Describe the management of abnormal lordoses
|
Determined by etiology
Some curve abnormalities are self-limited and recover w/ time --Sprain/strain Some will correct when underlying disorder is corrected --Somatic dysfunction, psoas contracture Some are irreversible and care becomes largely symptomatic --Ankylosing spondylitis, osteoporosis |
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|
What type of mechanics does the thoracic spine follow?
|
Typical Fryettes...
One - opposite Two - together Three - Altered motion in one plane is affecting motion in ALL planes |
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|
What biomechanics are unique within the thoracic region?
|
Dysfunction can occur in only one plane
Usually either flexion or extension Little or no sidebending or rotation |
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|
What indicates somatic dysfunction in the thoracic region?
|
Sites of tenderness
Typically they are just lateral to tips of transverse processes Also may be on the tip of the spinous processes |
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|
How are facets arranged in the thoracic region?
What does this allow? |
Facets have a coronal orientation
This allows for the greatest permitted movement to be in rotation |
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|
What do the presence of ribs in the thoracic region restrict?
|
Ribs restrict rotation
|
|
|
Which ribs allow for greatest motion?
|
Floating rib segments have greatest motion
False rib segments have moderate motion True rib segments have least motion |
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|
What are the degrees of motion in the sagittal plane (flexion/extension) for the thoracic spine?
|
T1-5: 4 degrees
T6-10: 6 degrees T11-L1: 12 degrees |
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|
What are the degrees of motion in the coronal plane (sidebending) for the thoracic spine?
|
T1-10: 6 degrees
T11-12: 8-9 degrees |
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|
What are the degrees of motion in the horizontal plane (rotation) for the thoracic spine?
|
T1-T9: 8-9 degrees
T10: 10 degrees T11: 12 degrees T12: 14 degrees |
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|
How were degrees of motion measured in the thoracic spine?
|
1967
Gregerson and Lucas inserted Steinman pins in to the SP of the thoracic vertebrae of six medical students They left these pins protruding through the skin Then measured the available motion |
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|
What are the role of the ribs in relation to the thoracic spine?
|
Ribs and sternum stiffen the thoracic spine
In comparison to thoracic spine w/o ribs (but w/ discs/ligs/etc.): Flexion stiffened by 27% Extension stiffened by 132% Sidebending stiffened by 45% Rotation stiffened by 31% |
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|
Describe orientation of T12
|
T12 is a transitional segment
Upper facet joints are coronal Lower facet joints are sagittal NOTE: this change in facet orientation is somewhat variable, and it has been recorded to occur anywhere from T9 to T12 |
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|
What thoracic segment is very vulnerable to mechanical influences or trauma?
|
T12 due to sudden change in mechanical characteristics - upper facets = coronal, lower facets = sagittal
NOTE: this change in facet orientation is somewhat variable, and it has been recorded to occur anywhere from T9 to T12 |
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|
What is the rule of threes in the thoracic spine?
|
T1-3: TP at same level as SP
T4-T6: TP one half level above SP T7-T9: TP one full level above SP T10: Like T7-T9 T11: Like T4-T6 T12: Like T1-T3 |
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|
Describe the ligaments in thoracic spine
|
Same configuration as lumbar spine
Also have the COSTAL ligaments... These costal ligaments stiffen the thoracic spine |
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|
Function of costal ligaments?
|
To stiffen the thoracic spine
|
|
|
Function of rib cage in relation to musculature in thoracic spine
|
Serves as an anchor for muscles that move the shoulder, neck, and lower back
|
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|
Attachments of the Trapezius
|
SP of T1-T12
|
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|
Actions of the Trapezius
|
Scapular retraction and depression
|
|
|
Innervation of the Trapezius
|
Spinal accessory (C1-C6), ascends through the foramen magnum and exits via Jugular foramen in the petrosqamous suture
|
|
|
What does motion loss from trapezius hypertonicity cause?
|
loss of scapular protrusion and elevation
|
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|
Symptoms with hypertonic trapezius
|
Interscapular pain
Shoulder pain Pectoral region pain Lateral rib cage pain |
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|
Attachments of the latissimus dorsi
|
Lower 6 thoracic spinous processes
Lumbar and sacral spinous processes Supraspinous ligament Iliac crest via lumbodorsal fascia |
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|
Action of the latissimus dorsi
|
Humeral adduction, medial rotation, extension
|
|
|
Innervation of the latissimus dorsi
|
C6, C7, and C8
|
|
|
What occurs with thoracic dysfunction d/t lat. dorsi?
|
typically T7 and T8
Results in limited humeral external rotation and flexion (reaching) |
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|
Symptoms with thoracic dysfunction d/t lat. dorsi?
|
Infrascapular mid-thoracic backache
Pectoral pain |
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|
Attachments for Rhomboideus major and minor
|
Major - T2-T5 and supraspinous lig
Minor - C7 and T1 |
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Action of rhomboideus major and minor
|
scapular retraction
|
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|
Innervation of rhomboideus major and minor
|
C4 and C5
|
|
|
Thoracic dysfunction from rhomboideus major and minor
|
Scapular protrusion is limited and painful
|
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|
Symptoms with thoracic dysfunction d/t rhomboideus major and minor
|
Pain along vertebral border of the scapula extending into the supraspinous fossa of scapula
Muscle tends to ache at rest (postural pain) Look for tense, shortened pectoralis muscles |
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|
Attachments of the erector spinae to thoracic spine
|
Longissimus thoracis: lumbar TP to all of thoracic TP and lower 9-10 ribs just lateral to costotransverse articulation
Longissimus cervicis: T1-T5 TP to C2-C6 Longissimus capitis: TP of C4-T5, extends up to mastoid process |
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|
Actions of the longissimus mm
|
Longissimus thoracis and cervicis: Backbend and sidebend vertebral column
Longissimus capitis: Extends the neck and rotates the head to the same side |
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|
Innervation of erector spinae
|
Dorsal rami of thoracic, upper lumbar, and lower cervical nerve roots
|
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|
What does a hypertonic longissimus cause?
|
Thoracic segmental dysfunctions, typically with restricted flexion and sidebending
Neck motion would be limited contralateral rotation |
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|
Symptoms with dysfunctional longissimus thoracis
|
Muscle tenderness and pain, extending over approximately 4 thoracic segments
|
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|
Where would a dysfunctional longissimus thoracis radiate if present in the T10-T12 range?
|
Down to lower portion of buttock
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|
Where would a dysfunctional longissimus thoracis radiate if present in the upper lumbar fibers?
|
To the mid-lumbar region, causing lumbago
|
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|
If longissimus mm involved bilaterally at thoracolumbar junction?
|
Pain can be disabling
Pt cannot arise from a chair, and climbing stairs can be extremely painful |
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|
Action of rotatores
|
Mostly in sidebending and extension of the thoracic segments, contrary to their name
Attachment is too close to the base of the SP to affect much rotation |
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|
What would hypertonicity/spasm of the rotatores cause?
|
Develop and maintain a Type II segmental dysfunction
|
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|
When would the levator costae cause segmental sidebending?
|
If rib is anchored
|
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|
For a patient in a neutral seated posture, how long would it take for an EMG to recognize activity?
|
Within one half hour or sooner
Repositioning temporarily quieted this activity EMG activity built progressively in everyone, some sooner than others, some more intensely than others |
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|
Top reasons for adult visits to office-based physicians
|
1. HTN
2. Pregnancy care 3. Checkups, well care 4. URIs 5. Low back pain 6. Depression/anxiety 7. DM |
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|
How many times more back surgeries occur in the US than England?
|
5x
|
|
|
Seven myths about low back pain
|
1. If you have slipped disc, you must have surgery, and surgeons agree about exactly who should have surgery
2. XR/CT/MRI can always identify the cause of pain 3. If your back hurts, you should take it easy until the pain goes away 4. Most back pain is caused by injuries or heavy lifting 5. Back pain is usually disabling 6. Everyone w/ back pain should have spine XR 7. Bed rest is the mainstay of therapy |
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|
What is a sprain?
|
Damage to LIGAMENTOUS tissue
|
|
|
What is a strain?
|
Damage to MUSCULAR tissue
|
|
|
What is the grading scale for sprains?
|
Zero - Minimal overstretching of the ligament
Grade I - microtearing Grade II - partial tearing of ligament Grade III - complete rupture of ligament |
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|
Which sprain grades are tender to palpation?
|
All of them
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|
Describe the clinical features of a grade I sprain
|
Moderate pain with tension
Visible swelling Overstretching or minor tearing of muscle or ligament No visible bruising |
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|
Describe the clinical features of a grade II sprain
|
Maximal pain with tension
Easily visible edema Macrohemorrhage with visible bruising Muscle or ligament partially torn but still intact |
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|
Describe the clinical features of a grade III sprain
|
May be painless under tension
Significant edema Macrohemorrhage with visible bruising Muscle or ligament completely ruptured Joint instability |
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|
Nerve roots of the sciatic nerve?
|
L4-S3
|
|
|
Initial management of lumbar sprain
|
Pt education
Pain management Physical methods Activity alteration Work activities |
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|
What would your patient education involve in case of lumbar sprain?
|
Reassurance
Tell pt no hint of serious condition Rapid recovery expected 80% pts recover in 4 weeks 95% of pts recover in 6 weeks 99% of pts recover in 12 weeks If coexisting sciatica --> longer recovery period, probable ~12 weeks |
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|
What is usually sufficient in pain management for a lumbar sprain?
|
Non-prescription analgesics
Acetaminophen Ibuprofen (Motrin, Advil) Naproxen (Aleve) Avoid NSAIDs |
|
|
Examples of making sure analgesics are properly taken in pt with lumbar sprain
|
One 200mg Ibuprofen will not provide relief
Pts afraid of Acetaminophen d/t liver failure (take up to 4g in normal pt) |
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|
What are some examples of topical analgeics for lumbar sprains?
|
Lidocaine patches
Salicylate creams (some systemic absorption, usually combined w/ menthol to give warm feeling) Effectiveness of salicylate creams is UNPROVEN in low back pain |
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|
Describe opiates and their relation to addiction
|
Much safer than previously believed
Less than 1% of chronic opiate analgesic users become drug abusers |
|
|
Define drug abuse
|
Use of medication for other than its intended purpose
|
|
|
Define drug addiction
|
Physiologic response of the body to the presence of a controlled substance
|
|
|
describe drug withdrawal syndrome
|
Physiologic response of the body to removal of ANY medication
|
|
|
When do oral pain medications typically show onset, peak, and how long do they last?
|
Onset: 20-30 min
Peak: 1-2 hours Duration 3-6 hours |
|
|
When do IM injections of pain medications show onset, peak, and how long do they last?
|
Onset: 20-30 min
Peak: 30-60 min Duration: 3-4 hours |
|
|
When do IV injections of pain medications show onset, peak, and how long do they last?
|
Onset: 10-15 seconds
Peak: 15-30 minutes Duration: 1-2 hours |
|
|
Describe muscle relaxants in lumbar sprain therapy
|
No more effective than NSAIDs for lumbago
No advantage when used in combo w/ NSAIDs |
|
|
When are muscle relaxants typically used in lumbar sprains?
|
At night as they cause drowsiness
Designed for use as an adjunct to bedrest for acute muscular injury |
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|
Physical methods for treating pt w/ lumbago
|
Manipulation
Traction Physical modalities |
|
|
Define radiculopathy
|
Neurologic deficits in the distribution of a nerve root
See reflex loss, sensory loss, muscle weakness |
|
|
Define radiculitis
|
Inflammation of a nerve root
usually pt will have radicular pain, muscle spasm, and hyperreflexia |
|
|
Sx of patients with radiculitis
|
Radicular pain, muscle spasm, and hyperreflexia
|
|
|
What exists with every sprain and strain injury?
|
Somatic dysfunction
|
|
|
When would you typically do manipulation in a pt with sprains/strains?
|
Safe and effective in first month of acute low back pain symptoms without radiculopathy
|
|
|
Would you use manipulation in pt w/ lumbar sprain for over one month?
|
Probably safe, but unproven
|
|
|
What if a patient is unimproved after four weeks of manipulation in lumbar sprain/strain?
|
Treatment should be discontinued
Pt should be reevaluated |
|
|
Would you use manipulation in the presence of radiculopathy or radiculitis when due to degenerative disc disease?
What must you know? |
Yes
Must know etiology of radicular symptoms prior to undertaking manipulation |
|
|
Would you use traction in lower back pain?
|
Ineffective for most lumbago
Transient relief obtained in pts w/ radicular pain Traction with lumbar extension may be effective in reducing disc protrusion |
|
|
What are physical modalities for acute lumbago?
Are they effective? |
massage: NO
diathermy: NO Ultrasound: NO Cutaneous laser treatment: NO Biofeedback: NO Transcutaneous electrical nerve stimulation (TENS): NO |
|
|
Is the self application of heat and cold in lumbar back pain effective?
|
Not contraindicated
Unproven efficacy If patient is too mentally focused on their injury, it gives them something to do |
|
|
Are low back corsets/belts effective in management of acute lower back pain?
|
No
|
|
|
Bed rest in lower back pain
|
Flat on back w/ legs elevated
Not for more than 2-4 days Most pts won't last more than two days |
|
|
What should you actively avoid when having lower back pain?
|
undue back irritation
Avoid activities and positions that aggravate the lower back pain Sitting will aggravate the pain of disc injury Bending forward (over a sink) in a Cantilevered position is very bed (high muscle and ligament stress and highest intradiscal pressures) |
|
|
Suggestions for activity alterations when experiencing lower back pain
|
Change position often
When sitting, use a soft pillow as a lumbar support to maintain the lordotic curve Sit in a chair w/ arm rests so arms can support some of the body weight This also makes it easier to stand up again Get into a position of maximal comfort for at least 10-15 minutes each hour while awake (even when done with bed rest) |
|
|
When should a pt with lower back pain return to some aerobic activity?
|
As soon as possible
Includes: pool walking, swimming, walking, elliptical trainer, stationary bicycle |
|
|
How would you avoid debilitation when having lower back pain?
|
Incrementally increase activity up to 20-30 min per day by end of first two weeks
This conditioning is no more stressful on lower back than sitting on side of bed for same time period As sx improve, add core strengthening exercises for the trunk No evidence that back-specific exercise machines are effective for acute low back pain No evidence that stretching exercises are effective for low back pain |
|
|
Are back-specific exercise machines or stretching exercises effective in reducing lower back pain?
|
No evidence of it
|
|
|
Max activity work restrictions for pt w/ lumbago?
|
Max of three months
|
|
|
During work, what is the recommendation for sitting time periods for pt w/ lower back pain?
|
No pain: 50 min
Mild pain: 40 min Moderate pain: 30 min Severe pain: 20 min |
|
|
During work, what is the recommendation for lifting objects for pt w/ lower back pain?
|
Men:
No pain: 80 lbs Mild pain: 60 lbs Moderate pain: 20 lbs Severe pain: 20 lbs Women: No pain: 40 lbs Mild pain: 35 lbs Moderate pain: 20 lbs Severe pain: 20 lbs |
|
|
What routine testing (Blood work, XR, EMG, MRI) should you do for a patient w/ lower back pain upon presentation
|
None during first month of activity limitation unless one of the red flags shows up on PEX
If pt fails to improve in four weeks, reassess the situation |
|
|
80% of patients with lumbago recover in how long?
|
Four weeks
|
|
|
Why should you wait before doing imaging of lower back in pt w/ lumbar pain?
|
Reduces potential of labeling asymptomatic age-related (over 30) changes in the lower back as being responsible for the symptoms
|
|
|
Imaging studies of lower back have a high rate of what?
|
False positives
Up to 30% of population by age 30 has asymptomatic pathology on imaging studies One must combine knowledge of patient's physical condition, location of pain, etc. with imaging findings |
|
|
What do you perform if there is a suspicion for spinal tumor, infection, or occult fracture?
|
Radionuclide bone scan
|
|
|
What will a radionuclide bone scan do?
|
Light up areas of high bone turnover
Responds to severe inflammation such as very bad arthritic changes Bone scan remains positive for up to two years after pathology as resolved Must be interpreted in conjunction with XR, CT, or MRI |
|
|
Imaging of choice when back pain predominates?
|
Plain XR
Cheap and have chance of identifying any anatomic defect that may exist MRI is second choice |
|
|
What do you perform If there is unresolved radicular pain or a question of muscle weakness in a patient with lower back pain?
|
Electromyography/Nerve Conduction Velocity (EMG/NCV)
|
|
|
When would you use an electromyography/nerve conduction velocity study?
|
Not useful in absence of radicular symptoms
Will not be positive in some cases for 4-6 weeks Study is uncomfortable enough that most people will not do two of them |
|
|
What does EMG/NCV do?
|
Differentiates between nerve root damage vs. a peripheral nerve lesion
|
|
|
what will an EMG/NCV not discover?
|
CNS etiologies of muscle weakness (EMG/NCV would come back as normal)
|
|
|
What tests do you perform if sensory loss predominates in a pt w/ lower back pain?
|
Somatosensory evoked potentials (SSEP)
Dermatomal evoked potentials (DEP) |
|
|
What nerves would an EMG/NCV evaluate?
|
Motor system and peripheral nerve function
|
|
|
What nerves do the SSEP and DEPs evaluate?
|
sensory system
|
|
|
What must the SSEP and DEP be used in conjunction with?
|
At least NCV to differentiate peripheral nerve from spinal cord or cortical dysfunction
|
|
|
What would you do if the EMG/NCV or SSEP/DEP returned POSITIVE?
|
Use nervous system electrodiagnostic evaluation to guide MRI imaging of involved neural structures
|
|
|
What is MRI best at demonstrating?
|
Soft tissue pathology
Includes: HNP, spinal tumor, abscesses, etc. |
|
|
What is CT best at identifying
|
Best at delineating bone pathology such as small fracture fragments
Not good when used alone to demonstrate soft tissue abnormalities |
|
|
CT when used with what is the "gold standard" (99% accurate) for diagnosing intraspinal etiology in the patient with lower back pain?
|
Myelogram
|
|
|
With what imaging studies are complications highest with?
|
CT/Myelogram
second with myelogram alone Then drops for Bone scan, CT, XR Lowest for MRI (excluding claustrophobia...) Even w/ open MRI, claustrophobia requires termination of 1-4% of all MRI procedures |
|
|
Describe the open MRI, including when it would preferably be used
|
0.2-0.3 Tesla
Better for peripheral joints which can be positioned in the magneto-center of the imaging device Peripheral joints may be placed in any position desired |
|
|
Describe the closed MRI, including when it would preferably be used
|
1.5-3.0 Tesla
Probably better for spinal imaging Clearer image due to high field magnet strength |
|
|
When is vertical MRI useful?
|
Done in seated position
Useful for patients who have negative standard MRI, but who have persistent radicular symptoms WORSE IN THE SEATED OR ERECT POSTURE |
|
|
What laboratory studies would you use in the patient with a lumbar sprain?
|
CBC
Sed rate Urinalysis |
|
|
What are you looking for with a CBC in the pt. w/ lower back pain?
|
WBC - indicators of infection or leukemia
RBC - indicators for anemia due to marrow replacement by tumor |
|
|
What are you looking for with a urinalysis in the pt. w/ lower back pain?
|
RBCs - evidence of kidney stones, bladder/renal cancer
WBCs - evidence of UTI Nitrates - evidence of UTI Crystals - indicates propensity for stone formation |
|
|
What is the Erythrocyte sedimentation rate?
Normal values? |
Indicates presence and intensity of inflammatory process
Men: Age divided by two Women: Age plus 10 divided by two Reported in mm/hr |
|
|
What is ESR specifically diagnostic for?
|
Nothing
Westergren method preferred |
|
|
What would normal ESR exclude?
what does it not exclude? |
Excludes diagnosis of polymyalgia rheumatic or temporal arteritis
Does not exclude malignancy or other serious disease |
|
|
What is ESR useful to detect?
|
Occult disease
|
|
|
How would an ESR aid in differential diagnoses?
|
MI vs. angina (Increased in MI)
Acute appendicitis vs ruptured ectopic pregnancy (increased in appendicitis) Rheumatoid arthritis vs. osteoarthritis (increased in RA) |
|
|
In what percent of cases is ESR elevated for unknown reasons?
|
<3%
|
|
|
What causes extreme elevations in ESR?
|
malignancy (lymphoma, colon cancer, breast cancer)
Hematologic disease (multiple myeloma) Collagen diseases (RA, SLE) Renal diseases Serious systemic infections |
|
|
What does an ESR of over 100 mm/hr indicate?
|
Presence of metastatic cancer
Osteomyelitis Subacute bacterial endocarditis Giant cell arteritis Polymyalgia rheumatica |
|
|
What supportive care do you provide to pt w/ lower back pain?
|
Medical management of pain control (Narcotic abuse a concern in chronic LBP population)
Therapeutic exercise OMT |
|
|
Indications for OMT in the patient with lower back pain?
|
Pain, somatic dysfunctions w/ secondary sx
Prevent/treat complications d/t immobility Increase ROM |
|
|
What are contraindications for OMT in pt w/ lower back pain?
|
HVLA in cases of spondylolisthesis and HNP
Relative contraindications... |
|
|
Describe the overall process in treating the patient with lower back pain
|
Initial phase --> relief of symptoms
Second phase --> Return to activity OMT useful to decrease sx and improve quality of life Individualize your treatment... |
|
|
What is the second leading cause of death in the US?
|
Cancer
|
|
|
What are the traditional allopathic approaches for cancer?
|
Surgery
Radiation therapy Chemotherapy |
|
|
What do you do if you cannot treat the disease of cancer?
|
Treat the patient
End-of-life and palliative care |
|
|
Percentage of renal cell cancers?
|
2-3% of all cancers
|
|
|
What is the classic triad for renal cell cancer?
|
Hematuria
Flank pain Abdominal mass |
|
|
What do 34% of patients with renal cell cancer have at diagnosis?
|
Metastasis
|
|
|
Systemic manifestations of renal cell cancer?
|
Anemia or erythrocytosis
FUO Weight loss Hypercalcemia |
|
|
Metastasis of non-skin melanoma?
|
Spine (causes back pain)
Soft tissue (with a mass) Compression of spinal cord/nerve root (peripheral neuropathic symptoms) Direct metastasis (CNS symptoms) |
|
|
How do you diagnose renal cell cancer?
|
CT, MRI, IVP, and US
|
|
|
Treatment of renal cell cancer?
|
Surgery most effective when localized
Radiation and chemotherapy is palliative |
|
|
Most common cancer?
|
Lung cancer
|
|
|
Most common cancer death in males + females?
|
Lung cancer
|
|
|
What is the relationship between tobacco products and cancer?
|
30% cancer deaths
80-85% of lung and pharyngeal cancers |
|
|
What are the types of lung cancer?
|
Small cell (oat cell)
Squamous cell (epidermoid) Adenocarcinoma Large cell |
|
|
What is the most aggressive form of lung cancer?
|
Small cell (oat cell)
70% present with regional lymph node involvement |
|
|
What could bronchogenic carcinoma present with?
|
Pain in the:
Neck axilla anterior lower ribs scapular region thoracic paraspinal muscle spasm paresthesia in upper extremity |
|
|
What are the paraneoplastic syndromes associated with lung cancer?
|
Cushing syndrome
SIADH Hypercalcemia (nonmetastatic) Subacute cerebellar degeneration Dementia syndromes Peripheral neuropathies Polymiositis Dermatomyositis |
|
|
What additional problems could you see with lung cancer?
|
Altered CNS function
Hypertrophic pulmonary osteoarthropathy (w/ frequent musculoskeletal paraneoplastic symptoms) Endocrine syndromes (except nonmets hypercalcemia)-->small cell CA Osteoarthropathy --> Adenocarcinoma |
|
|
What is in the differential diagnosis when you find paraneoplastic syndromes?
|
Lung CA
|
|
|
What does a formal diagnosis of lung cancer require?
|
Tissue confirmation (biopsy, surgical resection, sputum cytology, bronchial washings)
|
|
|
What therapy do you give for lung cancer?
|
Varies
Comvination of surgery, radiation, and chemo |
|
|
What is the 5 year survival rate of lung cancer s/p surgical resection?
|
30-80%
Negligible with small cell carcinoma, but it is improving |
|
|
What is multiple myeloma?
|
Neoplasm of B-lymphocytes of monoclonal origin
|
|
|
What is the most common primary tumor of medullary bone?
|
multiple myeloma
|
|
|
What is often overlooked in patients with back pain?
|
Multiple myeloma
|
|
|
Multiple myeloma is often overlooked in the patient with what?
|
Back pain
|
|
|
What are the symptoms with multiple myeloma?
|
Vague and nonspecific
|
|
|
What would an XR show with multiple myeloma?
|
Lytic, punched out lesions are absent
Diffuse osteoporosis pattern may be seen |
|
|
What is the incidence rate in the patient with multiple myeloma?
|
2-4 per 100,000
|
|
|
In what organ would a multiple myeloma tumor originate?
|
In any organ
The nasal sinuses, nose, nasopharynx, and tonsil are the most common extramedullary sites |
|
|
What do 2/3 of patients with multiple myeloma complain of?
|
Bone pain (esp. in spine, ribs)
|
|
|
What is common in the patient with multiple myeloma?
|
Spinal cord and nerve root compression (will lead to radicular pain)
Pathologic fractures |
|
|
What is a common complication in the patient with multiple myeloma?
|
Hypercalcemia
GI sxs (N/V/C) + polyuria --> hypercalcemia |
|
|
What CNS problems are associated with multiple myeloma?
|
Progressive confusion, drowsiness
Hyperviscosity syndrome HA, visual problems, fatigue, vertigo, nystagmus, paresis --> confusion, coma All this resembles a CNS metastasis |
|
|
How do you treat hyperviscosity syndrome in the patient with multiple myeloma?
|
Plasmapheresis
Chemo (steroids and alkylating agents) |
|
|
What is the chronic phase of multiple myeloma responsive to?
|
Steroids and alkylating agents
|
|
|
How do you treat pathologic fractures in the patient with multiple myeloma?
|
pins
|
|
|
How do you treat impending fractures and spinal cord/nerve root compression in the patient with multiple myeloma?
|
Irradiation
|
|
|
What is essential in the treatment of the patient with multiple myeloma?
|
Activity and ambulation
|
|
|
What are you preventing by hydrating the patient with multiple myeloma?
|
Renal complications and hyperviscosity
|
|
|
How do you treat the acute phase of a patient with multiple myeloma?
|
pack marrow with plasma cells --> infection
|
|
|
What terminal events are in the patient with multiple myeloma?
|
Infection and renal failure
|
|
|
Where does breast tissue actually occur?
|
Tissues of the breast
Ductal and lobular carcinoma |
|
|
Incidence of BRCA?
|
F --> 192,370 in 2009
M --> 1910 in 2009 |
|
|
Prevalence of BRCA?
|
>2.5 million
|
|
|
Deaths d/t BRCA in 2009
|
F --> 40,170
M --> 440 |
|
|
Where is BRCA typically diagnosed, site-wise?
|
Primary site --> 60%
Regional nodes --> 33% Distant metatasis --> 5% |
|
|
Treatment for BRCA
|
Surgery
Radiation Chemotherapy |
|
|
What is lymphedema?
|
Protein-rich interstitial fluid in the skin/subcutaneous tissue
|
|
|
How do you get lymphedema?
|
secondary to radiation
removal of axillary lymph nodes Present in 15-35% of women with mastectomies |
|
|
What does chronic lymphedema cause?
|
Tissue fibrosis
Infections (cellulitis) |
|
|
What are some OMT considerations in the patient with lymphedema?
|
Soft tissue techniques to regions proximal to site of edema
Effleurage to extremity Thoracic inlet/outlet Scalene spasm --> Cervical SD at C3-4 1st rib (usually elevated) |
|
|
MSK sx in pt w/ BRCA?
|
Back pain
Arthralgias Muscle and skin sx |
|
|
CNS sx in pt w/ BRCA
|
Direct cerevral malignancy
Indirect paraneoplastic |
|
|
Lymphatic sx in pt w/ BRCA
|
Lymphedema
|
|
|
Peripheral nervous system sx in pt w/ BRCA
|
peripheral manifestations
spinal cord compression |
|
|
Viscero-somatic type response in pt w/ BRCA?
|
TNF--> enhanced cytolysis (tissue destruction), infection, tumor vascular damage, inflammatory responses (fever induction)
|
|
|
Characteristic onset of pediatric cancer?
|
Insidious (gradual)
|
|
|
What sx should provide high index of suspicion for pediatric cancer?
|
Disproportionate pain levels
Atypical arthritis (not characteristic of specific rheumatologic disease) |
|
|
Ethical considerations when presenting options to patient with cancer?
|
tell the truth
offer optimism and reassurance Cure vs. control of disease Give opportunity to think and ask questions TREAT THE PATIENT |
|
|
What is supportive care for the patient with cancer?
|
Medical management of pain control
Nutrition Infection control and treatment Psych and emotional support OMT |
|
|
In end of life care, what pain should you be considering?
|
Physical pain (acute, chronic, somatic, visceral, neuropathic)
Anxiety |
|
|
Indications for OMT in pt w/ cancer?
|
Pain, somatic dysfunctions secondary to surgery, viscerosomatic reflexes
Prevent/treat complications d/t immobility Atelectasis --> pneumonia or constipation Lymphedema |
|
|
Contraindications for OMT in pt w/ cancer?
|
Area immediately surrounding cancer
HVLA could lead to a pathologic fracture of bone weakened by primary/metastatic tumor Lymphatic pumps/effleurage due to lymphogenous spread (controversial) |
|
|
When would you use indirect techniques in pt w/ cancer?
|
For acute/severe illness or advancing age
Inc. myofascial release or counterstrain |
|
|
When would you use direct techniques in pt w cancer?
|
stable pt
When metastasis to area has been ruled out Inc. HVLA, ME |
|
|
When would you use rib-raising/thoracolumbar soft tissues techniques in the patient with cancer?
|
Prevent/treat atelectasis or constipation
|
|
|
When would you treat the lymphatic pumps in the patient with cancer?
|
Lymphedema
Treat the fascial diaphragms Should RULE OUT METASTASIS |
|
|
What cancers commonly metastasize to the vertebrae?
|
Breast
Prostate Lung Kidney Thyroid |
|
|
What cancers commonly metastasize to the spinal cord?
|
Lung
Breast Colon Sarcoma |
|
|
Which are the atypical ribs?
|
1 and 2
|
|
|
Which are the true ribs?
|
1-7
|
|
|
Which are the false ribs?
|
8-12
|
|
|
Which are the floating ribs?
|
11-12
|
|
|
What type of joints do all ribs have, and what motions do they permit?
|
Costovertebral joint - allow gliding rotary motion
Costotransverse joint - allow gliding arcuate motion |
|
|
What is the axis of motion of a rib through?
|
The neck of the rib
|
|
|
What do the position and mobility of the thoracic vertebrae influence?
What is this due to? |
Influences rib motion
due to ligamentous attachments |
|
|
What does thoracic segmental dysfunction alter?
|
the mechanics of attached ribs
|
|
|
What are the types of rib motion?
|
Bucket handle
Pump handle Caliper |
|
|
What are the axes for the upper and lower ribs (for motion)?
|
Upper ribs - axis is in coronal (lateral) plane
Lower ribs - axis is in sagittal (anterior-posterior) plane |
|
|
What is the attachment of rib one to the sternum?
|
A synchrondrosis
|
|
|
What passes over the superior surface of rib one?
|
Subclavian artery and brachial plexus
|
|
|
What muscles attach to rib one?
|
scalenes and serratus anterior, as well as the subclavius
|
|
|
Does rib one have an attachment to the iliocostalis cervicis muscles?
|
No
|
|
|
Normal mechanics at rib one?
|
Pump handle motion predominates
Very little bucket handle motion |
|
|
What would hold rib one in inhalation?
|
Hypertonic scalene muscles (anterior and middle)
|
|
|
What are the symptoms of a rib one dysfunction held in inhalation (restricted in exhalation)?
|
Tenderness over angle of rib posteriorly
Ulnar distribution pain and paresthesias Arm swelling (compression of subclavian vein against clavicle) |
|
|
What would hold rib one in exhalation?
|
Hypertonic serratus anterior
|
|
|
What are the symptoms of a dysfunctional rib one held in exhalation (restricted in inhalation)?
|
Tenderness at costochondral junction anteriorly
Ulnar distribution pain and paresthesias Arm muscle claudication due to subclavian artery compression |
|
|
What cervical dysfunctions could an exhaled rib one cause?
|
Mid-cervical dysfunction sidebent and rotates to the side of the dysfunctional rib
Flexed occipito-atlantal dysfunction, sidebent to the side of the dysfunctional rib |
|
|
What type of attachment does rib two have to the sternum?
|
Bicompartmental synovial joint at manubrio-sternal junction
|
|
|
What muscles attach to rib two?
|
Posterior scalene and serratus anterior
|
|
|
Does the ilicostalis cervicis attach to rib two?
|
No
|
|
|
Motion at rib two?
|
pump handle
|
|
|
What would hold rib two in inhalation?
|
Hypertonic posterior scalene muscle
|
|
|
What would the symptom be for a rib two held in inhalation (restricted in exhalation)?
|
Tenderness over angle of rib posteriorly
|
|
|
What would hold rib two in exhalation?
|
Hypertonic serratus anterior muscle
|
|
|
What are the symptoms for a rib two held in exhalat
|
Tenderness at costochondral junction anteriorly
Neck pain and stiffness from passive traction on posterior scalene muscle |
|
|
How do ribs 3-7 attach to the sternum?
|
synovial joints
|
|
|
What muscle attachments are associated with ribs 3-7?
|
Iliocostalis cervicis and thoracis muscles posteriorly
Pectoralis minor anteriorly to ribs 3, 4, and 5 Serratus anterior laterally |
|
|
Mechanics of ribs 3-7?
|
Pump handle mostly, especially at superior ribs
Progressive increase in bucket handle motion as you descend to rib 7 |
|
|
What could hold ribs 3-5 in inhalation?
|
Hypertonic pectoralis minor muscle
|
|
|
What could hold ribs 3-7 in inhalation?
|
Hypertonic iliocostalis thoracis muscles
|
|
|
What are the symptoms associated with ribs 3-7 that are held in inhalation (restricted in exhalation)?
|
Tenderness at angle of rib posteriorly
Reduced thoracic sidebending due to hypertonic iliocostalis thoracis muscles |
|
|
What would hold ribs 3-7 in exhalation?
|
Hypertonic iliocostalis cervicis muscles
|
|
|
What are the symptoms associated with ribs 3-7 being held in exhalation (restricted in inhalation)?
|
Tenderness at costochondral junction anteriorly
Restricted cervical sidebending contralaterally due to hypertonicity of iliocostalis cervicis muscles |
|
|
How do ribs 8-10 attach to the sternum?
|
Synovial joint to costal cartilage above
|
|
|
What are the muscle attachments to ribs 8-10?
|
Diaphragm
Serratus anterior Iliocostalis thoracis and lumborum |
|
|
Mechanics of ribs 8-10?
|
Bucket handle
|
|
|
What would hold ribs 8-10 in inhalation?
|
Hypertonic serrates anterior muscle
Hypertonic iliocostalis lumborum muscles |
|
|
What are the symptoms associated with ribs 8-10 being held in inhalation (restricted in exhalation)?
|
Rib angle tenderness posteriorly
Restricted lumbar sidebending from hypertonic iliocostalis lumborum muscles |
|
|
What would hold ribs 8-10 in exhalation?
|
Hypertonic iliocostalis thoracis muscles
|
|
|
What are the symptoms associated with ribs 8-10 being held in exhalation (restricted in inhalation)?
|
Tenderness over costochondral junctions anterolaterally
|
|
|
What type of joint do ribs 11 and 12 make with the sternum?
|
They do not have any sternal attachments
|
|
|
Do ribs 11 and 12 have a costotransverse articulation?
|
No
|
|
|
What muscles do ribs 11 and 12 attach to?
|
Respiratory diaphragm
Quadratus lumborum |
|
|
What are normal mechanics for ribs 11 and 12?
|
Caliper motion
Inhalation pulls ribs downward and posteriorly quadratus lumborum anchors the ribs for more effective diaphragmatic contraction Exhalation draws the ribs upward and anteriorly |
|
|
What anchors ribs 11 and 12 for more effective diaphragmatic contraction during inhalation?
|
Quadratus lumborum
|
|
|
What would cause ribs 11 and 12 to be held in inhalation?
In what patient does this typically occur? |
Pull of quadratus lumborum overpowering the pull of the diaphragm
Common occurrence in patients with lower back pain and quadratus lumborum trigger points |
|
|
What are the symptoms associated with ribs 11 and 12 being held in inhalation (restricted in exhalation)?
|
Tenderness over angle of rib posteriorly
Low back pain |
|
|
What causes ribs 11 and 12 to be held in exhalation?
|
Often traumatic in origin, especially in MVAs from shoulder harness
|
|
|
What are the symptoms associated with ribs 11 and 12 being held in exhalation (restricted in inhalation)?
|
Tenderness over tip of rib laterally
Flank pain |
|
|
What structural rib dysfunctions are associated with an anterior subluxation?
|
decreased posterior prominence
increased anterior prominence |
|
|
What structural rib dysfunctions are associated with a posterior rib dysfunction?
|
Increased posterior prominence
Decreased anterior prominence |
|
|
What structural rib dysfunctions are associated with rib torsion?
|
Superior border of rib is more prominent
Inferior border of rib is less prominent Wider intercostal space above and narrow intercostal space below |
|
|
What would you see in an anterior rib structural dysfunction?
Is this an inhaled or exhaled dysfunction? Does it have an anterior or posterior tenderpoint? |
Depression posteriorly lateral to TP, near rib angle
Prominence anteriorly Usually inhaled dysfunction Posterior tenderpoint |
|
|
What would you see in an posterior rib structural dysfunction?
Is this an inhaled or exhaled dysfunction? Does it have an anterior or posterior tenderpoint? |
Prominence posteriorly lateral to the TP, at rib angle
Depression anteriorly Usually exhaled dysfunction Anterior tenderpoint |
|
|
What would you see with anteroposterior compression (structural rib dysfunction)?
|
Less prominence anteriorly and posteriorly
Increased prominence in mid-axillary line Intercostal space above and below tender and hypertonic |
|
|
What would you see with lateral compression (structural rib dysfunction)?
|
increased prominence both anteriorly and posteriorly
Decreased prominence in mid-axillary line Intercostal spaces above and below tender and hypertonic |
|
|
What would you see with a laterally flexed rib (structural rib dysfunction)?
|
Prominence of the involved rib in the mid-axillary line
Narrow intercostal space above and wider intercostal space below Marked tenderness in intercostal space above rib |
|
|
Which rib is most commonly seen with a laterally flexed dysfunction?
|
second rib
|
|
|
What branches do the intercostal nerves give off?
What do they provide? |
Three cutaneous branches anteriorly, posteriorly, and laterally
Give maximal tenderness at these sites with neuritis generated by severe or long standing rib dysfunction |
|
|
What binds the sympathetic chain ganglia to the anterior surface of the costal heads of the ribs?
|
parietal pleura
|
|
|
What gives the blood supply and venous drainage to the sympathetic chain ganglia?
|
Intercostal vessels
|
|
|
What do each sympathetic chain ganglia communicate with?
|
every thoracic spinal nerve
|
|
|
What percentage of patients with MI have concomitant chest wall pain?
|
15% - don't ignore potential visceral sources of pain!
|
|
|
What is the coin test?
|
assistant places coin flat on anterior chest wall
Strikes coin with second coin Examiner places chest piece of stethoscope to back of same hemithorax In pneumothorax, note is transmitted as a clear ringing sound called bell tympany |
|
|
What is the most important XR to obtain in the patient with rib pain/dyspnea?
|
chest XR
not rib XR |
|
|
What is one of the most important questions to ask when a patient has a new injury?
|
Did this arise spontaneously or as a result of the injury
|
|
|
Etiologies of pneumothorax?
|
Asthma
Esophageal perforation Exercise induced Manipulative treatment Rib fracture Spontaneous Thoracic or cervical surgery Tracheobronchial perforation Ventilator |
|
|
Symptoms with rib fracture
|
Well-localized, "lancinating" pain
|
|
|
What approach would you use in the patient with possible rib fracture?
|
layer by layer approach
|
|
|
Where would you auscultate when evaluating the patient with a possible rib fracture, and what might you be specifically listening for?
|
Heart - pericardial friction rub if pericardium is involved
Lungs - pneumo Chest wall - pleural friction rub, fracture crepitance |
|
|
What PEX findings would you have with a pneumothorax?
|
Inaudible breath sounds
inaudible spoken voice Bell tympany |
|
|
What might you heart with auscultation at potential site of rib fracture?
|
crepitance
|
|
|
What might you feel at site of possible rib fracture
|
Palpable crepitance
|
|
|
What would motion induction cause in the patient with rib fracture
|
pain at fracture site with remote pressure on rib cage
|
|
|
Appropriate tests for the patient with rib fracture?
|
CXR - look for pneumothorax
Rib XR - look for fracture |
|
|
Manipulative treatment for the patient with rib fracture
|
none to fracture side of chest wall
Treat opposite side and diaphragm to maximize remaining pulmonary function Treat C3-C5 dysfunctions if present |
|
|
Describe the role of bracing in the patient with a rib fracture
|
rib belts unnecessary for fracture healing
Rib belt maybe used to help control pain Rib belt further compromises respiratory function which may be significant in patients with preexisting pulmonary disease |
|
|
Medication used for the patient with a rib fracture?
|
Analgesic
May require an opiate, but remember that opiates further suppress respiratory function on initiation and dose increases |
|
|
Role of injections in the patient with a rib fracture
|
CONTRAINDICATED
puncturing skin turns a closed fracture into an open fracture... increases risk for osteomyelitis and causes failure to heal |
|
|
What would trauma to thorax potentially cause
|
rib fracture
fracture costal cartilage separated costal cartilage subperiosteal hematoma rib tip syndrome cough fracture |
|
|
When would you find a fractured costal cartilage
|
Common in MVAs from the shoulder harness
|
|
|
Physical findings associated with fractured costal cartilage
|
Possible pneumo (inaudible breath sounds)
Crepitance at site of pain Check abdomen for hepatic or splenic enlargement/tenderness d/t rupture Pain with motion induction |
|
|
Imaging for fractured costal cartilage
|
CXR
no need for rib XR Bone scan - increased uptake of radionuclide at fracture site Peritoneal lavage - only if suspicion of hepatic or splenic injury (if MRI is available on emergent basis... do this first) |
|
|
Osteopathic manipulation for fractured costal cartilage?
|
None to fracture side of chest wall
Treat opposite side and diaphragm to maximize remaining pulmonary function |
|
|
Role of bracing for fractured costal cartilage?
|
Rib belts unnecessary for fracture healing
Rib belt may be used to help control pain Rib belt further compromises respiratory function which may be significant in patients with preexisting pulmonary disease |
|
|
History associated with a cough fracture
|
Bronchitis or pneumonia
|
|
|
Symptoms with cough fracture
|
Persistent pain at level of lower ribs posteriorly
(really though any rib can be affected) |
|
|
Vital signs with cough fracture?
|
Fever
Tachypnea |
|
|
What would you see upon inspection of a patient with a cough fracture?
|
Decreased diaphragmatic breathing
|
|
|
What would you hear with auscultation of the patient with a cough fracture
|
Pneumonia (early--suppressed breath sounds, late-- bronchial breathing and crepitant rales)
Bronchitis (sibilant, sonorous or moist rales) |
|
|
Most common ribs associated with cough fracture?
|
11 and 12
|
|
|
What would you hear with percussion in the patient with a cough fracture?
|
pneumonia (area of dullness over consolidated lung)
bronchitis (NO dullness) |
|
|
What would you see with motion induction in the patient with a cough fracture?
|
Loss of local thoracic and rib motion
Pain with deep inhalation/cough Restricted diaphragmatic breathing |
|
|
Testing done in the patient with a cough fracture?
|
CXR - look for pneumonia
Rib XR NOT INDICATED!! (stress fracture wouldn't show) Bone scan - clearly demonstrates stress fracture... MRI will also show stress fracture, but floating ribs difficult to MRI |
|
|
Manipulation for the patient with cough fracture
|
Indirect myofascial release technique ONLY
Counterstrain technique cannot be used here due to bone pain |
|
|
How would you treat the patient with a cough fracture?
|
Manipulation (indirect myofascial release0
Treatment of underlying condition (abx, mucolytic, cough suppressant) analgesic |
|
|
What do compression fractures of the thoracic spine often cause?
|
acute angulation of the kyphosis
|
|
|
How much does the average adult chest expand with deep inhalation (when measuring below the pectoral region, at level of xiphoid process)?
|
3 inches
|
|
|
What are painful or painless conditions associated with loss of motion?
|
Cicatrix (scarring)
Calcification of the costal cartilages Atrophy or myopathy Connective tissue disease Osteoarthritis Spondyloarthropathies Scheuermann disease Somatic dysfunction |
|
|
What is cicatrix?
|
burns
surgical scars adhesions lacerations If problematic, will cause all tissues around it to be less mobile |
|
|
Describe post-polio syndrome
|
insidious onset
weakness, fatigue, muscle fasciculations, and pain with additional atrophy of the muscle group involved during the initial paralytic disease 2-30 years earlier |
|
|
What is scleroderma associated with?
|
Skin becomes thickened, and bound to underlying fascia
Skin becomes taut and shiny Raynaud's Puffy fingers Edema often accompanied by erythema |
|
|
Describe the musculoskeletal features associated with scleroderma
|
Pain, swelling, and stiffness of fingers and knees
Symmetric polyarthritis similar to RA thickening of tendon sheaths leads to carpal tunnel syndrome resorption of bone |
|
|
Where does the resorption of bone occur in pt with scleroderma?
|
RIBS, CLAVICLE, angle of mandible, terminal phalanges
|
|
|
Pulmonary features seen in the patient with scleroderma
|
RESTRICTION OF CHEST MOVEMENT BY SKIN INVOLVEMENT
exertional dyspnea dry, nonproductive cough pulmonary fibrosis bibasilar rales |
|
|
cardiac features seen in the patient with scleroderma
|
PERICARDITIS
CHF cardiomyopathy |
|
|
Renal manifestations in the patient with scleroderma
|
MALIGNANT HTN
RENAL FAILURE hematuria proteinuria oliguria |
|
|
Where does OA occur in thoracic spine?
|
DDD
Zygapophyseal joint disease |
|
|
Where does OA occur in the ribs?
|
Costotransverse joint
Chondrosternal joint Chondrochondral joints |
|
|
What are the spondyloarthropathies?
|
Ankylosing spondylitis
Psoriatic arthritis Reactive arthritis associated with IBS (Crohn's, UC) |
|
|
What is seen with Scheuermann disease?
What about on XR? |
INCREASED KYPHOSIS
RIGID THORACIC SPINE XR: irregular endplates, vertebral wedging |
|
|
Causes of atraumatic respiratory pain?
|
chest wall syndrome
inflammation infection |
|
|
Causes of chest wall syndrome (AKA precordial catch)?
|
Intercostal muscle spasm
Intercostal myositis Costochondral pain Costal somatic dysfunction Shoulder girdle disorder |
|
|
Physical findings with chest wall syndrome?
|
Diffuse pain with pressure over the sternum
Pain with should motion Pain with cervical spine motion and nerve root impingement tests |
|
|
Pain type with intercostal muscle spasm
|
sharp pain that lasts for 1-3 minutes
|
|
|
what would you find with palpation of an intercostal muscle spasm
|
intercostal tenderness and firmness
may be associated rib dysfunction often tenderness at serratus anterior attachments |
|
|
Treatment of intercostal muscle spasm?
|
Manipulation
Intercostal nerve block Trigger point injection Medications (analgesic, muscle relaxant) |
|
|
Symptom with intercostal myositis?
|
Pain with inspiration
|
|
|
Findings with palpation in patient with intercostal myositis?
|
tender intercostal space
Induration fascial nodularity |
|
|
Treatment of intercostal myositis?
|
Manipulation (indirect technique)
Anti-inflammatory meds (NSAIDs or corticosteroids) Can give corticosteroid injection if pain is localized to small area |
|
|
Describe shoulder girdle disorders in the patient with thoracic pain
|
Pain may be referred from any shoulder girdle muscle attachment sites
Trigger points within the shoulder muscles may refer pain to the rib cage |
|
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For costochondritis,
what is the character of pain? What aggravates the pain? Where does it typically present? |
Localized Dull pain
Aggravated by shoulder motion Typically symmetric and affects 3rd, 4th, and 5th costochondral joints |
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Main symptom with costochondral pain?
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Pain in anterior chest wall
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Physical findings with costochondral pain
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Tenderness at costochondral junction
May have associated rib dysfunction |
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Manipulation for costochondritis
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Anterior cartilages may be site of multiple counterstrain tenderpoints
This may be attempted, but it would be unsuccessful in true costochondritis Treat any rib dysfunction present |
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What analgesic would you give for costochondritis?
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Lidocaine patch
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For Tietze syndrome,
What does it present as? Where is it usually? When do most people get it? |
palpable fusiform swelling of costal cartilage
usually asymmetric often involves 2nd and 3rd costal cartilages often get prior to age 40 |
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After what type of infection might you get Tietze syndrome?
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Post-viral syndrome (Parvovirus B19)
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Manipulation for Tietze syndrome
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Correct any accompanying costal and thoracic segmental dysfunctions
May use thoracic pump and splenic stimulation to boost the immune response |
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What treatments for Tietze syndrome
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Analgesic (lidocaine patch)
NSAIDs Oral corticosteroids Inject corticosteroids |
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Infectious origins of respiratory pain?
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Herpes zoster
pleurisy Epidemic pleurodynia Osteomyelitis Epidural abscess Infectious chondritis Periostitis |
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What is the classic finding in herpes zoster?
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dermatomal rash that typically does not cross the midline
May be preceded by intercostal neuralgia for several days before rash emerges |
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What is a possible complication with herpes zoster infection?
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post-herpetic neuralgia
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Where does tenderness from intercostal neuralgia typically occur?
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At the cutaneous branches of the intercostal nerve (paraspinal, parasternal, and mid-axillary)
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When are you most likely to have a shingles outbreak?
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6th-8th decades of life
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What dermatomes are you most likely to get shingles?
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T3-L3
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Describe the timelike of manifestations for shingles
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Pain may precede onset of lesions by 48-72 hours
Vesicles form for 3-5 days Entire disease lasts 7-10 days Skin may take 2-4 weeks to return to normal Rarely, people have intercostal neuralgia, serologic evidence of disease, but no rash |
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Manipulation for herpes zoster outbreak?
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Treat segmental and costal dysfunctions at the levels of the rash
While painful to do, it prevents post-herpetic neuralgia Use thoracic pump and splenic stimulation to enhance the immune response |
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Medications for herpes zoster
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Acyclovir
Valacyclovir Famcyclovir all shown to diminish pain and reduce incidence of post-herpetic neuralgia if given within 72 hours of onset of rash OTW: Analgesics (Opiates, Lidocaine 5% patch), Tricyclic antidepressants (Nortriptyline... SSRIs not as effective for pain control), and a tapering dose of glucocorticoids |
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What medications for post-herpetic neuralgia?
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Antiseizure medications (gabapentin, topiramate, and lamotrigine)
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Describe the presentation of a patient with pleuritis
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knife-like shooting pain
fever, leukocytosis pleural friction rub |
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Which pleura is sensitive in pleurisy?
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Parietal
Innervated by overlying intercostal nerves pain sense in thoracic wall |
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How do you treat pleurisy?
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Treat the underlying cause
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Manipulation for pleurisy?
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depends on underlying disease
Treat isolated areas Improve costal motion (helps prevent formation of pleural adhesions) |
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What is the periphery of the diaphragm innervated by?
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T6 and T7
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What innervates the central tendon region of the diaphragm?
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Phrenic nerve (C3, C4, and C5)
The phrenic nerve innervates both the thoracic side of the diaphragm as well as the abdominal side oft the diaphragm |
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Which side of the diaphragm does the phrenic nerve innervate?
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Both thoracic and abdominal sides
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Where do you sense pain with diaphragmatic pleurisy?
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in addition to T6 level...
Pain in lateral neck and shoulder |
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Other names for epidemic pleurodynia?
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Bornholme disease
Devil's grip The grip |
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Findings with epidemic pleurodynia?
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Severe paroxysms of thoracic and abdominal pain
Fever Headache Mild pharyngitis No leukocytosis |
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Etiology of epidemic pleurodynia?
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coxsackie virus group B
Echo virus |
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complications of epidemic pleurodynia?
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Pericarditis
Orchitis |
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What would diagnose epidemic pleurodynia?
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rising viral titers
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What might you have to do to a patient with epidemic pleurodynia?
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put on ventilator due to hypoxia (hurts too much to breathe)
pain is severe enough that the patients often end up in CCU with Dx of rule out MI or dissecting aneurysm |
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Causes of intercostal neuralgia?
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Tabes dorsalis (neurosyphilis)
Neoplasm Pott disease (tuberculosis of the spine) Neurofibromatosis Fracture callous |
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Most common cause of osteomyelitis?
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staph aureus
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What is nostalgia paresthetica?
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sensory neuropathy involving one of the dorsal cutaneous rami of the upper thoracic region
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symptoms of nostalgia paresthetica
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Pruritis
Local dysesthesia Local hyperesthesia Local skin hyperpigmentation |
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Treatment for nostalgia paresthetica?
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OMT
Licocaine patch Paravertebral nerve block Botulinum toxin injection Anticonvulsant medications Transcutaneous electrical nerve stimulation |
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Referred pain from what areas would present in the thorax?
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myocardium
pericardium aorta pulmonary artery mediastinum esophagus gall bladder pancreas duodenum stomach |
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Describe referred pain
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Pain sensed deep in tissues, not skin surface
Not consistently reproducible by musculoskeletal maneuvers |
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What would you do in presence of possible referred pain?
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Look for somatic dysfunction at spinal levels associated with the various viscera
Look for presence of chapman's reflexes |
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What is xiphalgia?
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painful, prominent xiphoid
Xiphisternal arthritis (synchondrosis) |
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What is dercum disease?
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Adipose dolorosa
Painful obesity (Michelin tire man) Peripheral nerve stretch neuropathy from weight of rolls of hanging fat |
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What is mondor disease?
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Thrombophlebitis of the thoracoepigastric vein
This vein runs in the anterior lateral abdomen and thorax (runs from femoral vein to the axillary vein) |
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what do you find with mondor disease
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tender palpable cord, sometimes visible when the skin is stretched
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What may mondor disease result from?
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potential complication of mastitis, breast and abdominal surgeries
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What are some chest wall deformities?
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Rachitic rosary
Pectus excavatum Pectus carinatum Harrison grooves Barrel chest Lumps, bumps, and depressions |
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Etiology of rachitic rosary?
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Rickets
Healing obliterates the costochondral knobs |
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Other names for pectus excavatum?
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funnel breast
Trichterbrust |
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Etiology of pectus excavatum
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Genetic
Rickets Marfan syndrome Cobbler chest |
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Explain the associations/complications with pectus excavatum
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Assc w/ coexisting MVP
Found in 27% of women with Mycobacterium avium complex Very severe type can cause cardiopulmonary compromise |
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What is the other name for pectus carinatum?
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pigeon breast
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Etiology for pectus carinatum?
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Genetic
Rickets Marfan syndrome Congenital heart disease Severe kyphoscoliosis |
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Etiology for Harrison's grooves?
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Genetic
Rickets Young pregnancy Prune belly syndrome |
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Etiology for barrel chest?
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Genetic
Kyphosis Pulmonary emphysema |
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What might you see with cardiac enlargement?
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Bulging precordium
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What do you associate with lumps, bumps, and depressions?
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Malnutrition (anorexia, bulimia)
Cardiac enlargement Rickets Aortic aneurysm Neoplasm Abscess |
