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225 Cards in this Set
- Front
- Back
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define osteopathic medicine
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Osteopathic medicine is a complete system of medical care with a philosophy that combines the needs of the patient with the current practice of medicine, surgery, and obstetrics, that emphasizes the interrelationship between structure and function, and that has an appreciation of the body's ability to heal itself.
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principles of osteopathic philosophy
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The body is a unit; the person is a unit of body, mind, and spirit
The body is capable of self-regulation, self-healing, and health maintenance Structure and function are reciprocally interdependent Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function |
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define somatic dysfunction
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the impaired or altered function of related components of the somatic (body framework) system
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define spinal facilitation
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the maintenance of a pool of neurons in a state of partial or sub threshold excitation ; in this state, less afferent stimulation is required to trigger the discharge of impulses- “hair trigger”
Once established, facilitation can be sustained by normal central nervous system (CNS) activity |
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define OMT
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the therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction
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TART
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tissue texture abnormalities
asymmetry restriction of motion tenderness |
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anatomic vs. physiologic vs. direct motion barriers
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Anatomic: the limit of motion imposed by anatomic structure; the limit of passive motion-if you go past, things break; tested by passive range of motion
Physiologic : the limit of active motion-tested by active ROM Direct: may also see it called the restrictive barrier; a functional limit that abnormally diminishes the normal physiologic range |
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direct vs. indirect OMT
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Direct techniques are ones in which the restricted tissue is initially taken in the direction of the restriction to motion
Indirect techniques are those that initially position the tissue away from a barrier toward relative ease or freedom of motion There are techniques that are a combination of both direct and indirect |
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Fryette's law 1
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when the spine is in neutral (easy normal), sidebending and rotation are in opposite directions.
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when does fryette's type I dysfunction occur?
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neutral
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what does it mean that fryette's laws are compensatory?
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reacts to something else: type II, short leg, rotated pelvis
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fryette's law II
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when the spine is flexed or extended (non-neutral), sidebending and rotation are in the same directions.
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where are type II dysfunctions found?
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Found at apices and crossovers and/or sites of viscerosomatic reflexes
Primary somatic dysfunction Due to strain or viscerosomatic reflex |
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mechanics of the neck vertebrae
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OA: type 1-like
AA: purely rotation 2-7: type 2-like |
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fryette's law III
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Law III = when motion introduced in one plane it modifies (reduces) motion in other two planes
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Posterior transverse process and paravertebral fullness visible when spine is in neutral.
Asymmetry not significantly altered by flexion/extension. Sidebending and rotation opposite directions. |
type I somatic dysfunction
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In extension - no asymmetry
Both facets can close easily. No apparent rotation or sidebending asymmetry. Most comfortable position for the patient. |
type II extension SD
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In flexion - no asymmetry
Both facets can open easily. No apparent rotation or sidebending asymmetry. Most comfortable position for the patient. |
type II flexion dysfunction
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which type of SD has engaged facets?
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type II
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which type of SD do you treat first?
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type II
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where does the vertical line pass in a posterior static postural exam?
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halfway between the knees
along the gluteal fold through all spinous processes along the midline of the head |
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lateral static postural exam- where does the weight bearing line normally pass?
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just anterior to lateral malleolus
middle of the tibial plateau greater trochanter body of L3 (center of body mass) middle of the humeral head external auditory meatus |
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hip drop test
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ask pt to shift weight onto one leg, allowing the other knee to bend and induce lumbar sidebending toward the weight-bearing leg
observe lumbar sidebending and amount of hip drop and amount of hip drop (should be >25 degrees) hip drop less than 25 degrees indicates restricted lumbar sidebending toward the side of the weight bearing leg test is named for the bent leg side (+ right hip drop test indicates restricted left lumbar sidebending) |
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scoliosis definition
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Scoliosis is defined as: An abnormal lateral curvature of the spine in the coronal plane.
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most common cause of scoliosis
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idiopathic
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27% of children with scoliosis have ______
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abnormalities of posterior cranial fossa, spinal cord or central nervous system
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adams test
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scoliosis is characterized by both lateral curvature and vertebral rotation, giving a rib hump
structural: does not reduce with sidebending toward the rib hump functional: reduces with sidebending toward the rib hump |
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who has worse cobb angle?
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women
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in short leg syndrome, which way do the sacrum and pelvis tilt? what about the spine?
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toward the shorter leg
spine curves back in attempt to keep eyes level |
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how to name a scoliotic curve?
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a scoliotic curve is always named for the direction of the convexity
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most common pattern of scoliosis?
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double major
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how do you evaluate scoliosis?
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static postural exam
adam's test neurological exam radiographs if indicated |
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scoliotic vs. postural radiographs
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scoliotic x-ray
-erect AP from occiput to sacral base -measurement of Cobb angle postural radiographs -AP erect -lateral erect -obliques, when suspect spondylolistesis (scottie dog deformity) |
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what is the cobb angle?
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draw lines from the top of the superior vertebra and bottom of the inferior vertebra into the concavity of the curve
drop intersecting lines perpendicular to these lines and measure the acute angle "measure the most tilted at the top and the most tilted at the bottom" |
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ferguson's angle
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weight bearing line- bisect L3, drop a vertical line
it should fall on anterior 1/3 of sacral base |
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treatment based on curve severity
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mild (5-15%)
-conservative, including OMT, exercises & treatment of short leg moderate (20-45%) -above plus (bracing, electrical stimulation) severe (>50%) -surgical stablization |
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functional impairment with thoracic curves
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possible impairment with thoracic curves
-possible respiratory impairment >50% -possible cardiac impairment >75% |
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when do you refer a scoliotic patient?
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over 20 degrees
not necessarily for surgery, but for treatment only do surgery if there is functional impairment |
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prognostic factors of scoliosis
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age at diagnosis
risser sign menarche in female curve severity at diagnosis curve patterns gender |
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risser sign
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ossification of iliac crest identified w/ x-ray
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absolute contraindications to OMT
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absence of somatic dysfunction
patient refuses to have OMT performed |
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counterstrain steps
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1) find and label tender point 10/10
2) position to relieve tenderness (2/10 or less) 3) fine-tune to 0/10 if possible 4? hold position for 90 seconds (some schools teach 120 for ribs) 5) slow passive return to neutral 6) retest tender point |
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mavericks
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positioned completely opposite of what you would expect based on anatomy
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what might suggest the location of a counterstrain tender points?
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patients bend around tender points
location can also be suggested by position the patient was in when the original injury occurred |
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Usually tender
may be palpable tissue texture changes non-radiating |
counterstrain tender point point
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usually tender
that present as anterior and posterior fascial tissue texture abnormalities assumed to be visceral dysfunction or pathology (Glossary of Osteopathic Terminology) Viscerosomatic reflex Helps to know the locations! |
chapman's point
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Usually tender
a small hypersensitive site that, when stimulated, gives rise to referred pain and/or other manifestations in a consistent reference zone |
trigger point
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sherrington's law
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When a muscle receives an nerve impulse to contract, its antagonists receive, simultaneously, an impulse to relax.
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wolff's law
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Fascia will deform as a result of the lines of force to which it has been subjected.
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tensegrity
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Myofascial release (myofascial unwinding)
“Local” treatment produces changes in other parts of the body. Fascia moves as a unit in a tensegrity matrix down to the cellular level. Mechanical forces into fascia transmitted throughout the entire organism. |
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fascial continuity
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Fascial restrictions in one area will strain areas away from the restriction causing abnormal movement patterns.
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MFR steps
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Diagnose restricted motion
Slowly move into position of laxity and follow release until completed (indirect) Slowly move into restriction and stretch until tissue give completed (direct) Retest motion |
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muscle energy technique
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Diagnose restriction
Move in to restrictive barrier Isometric contraction away from the restrictive barrier 3-5 seconds Stretch until give stops Repeat 3-5 times Retest motion |
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how does muscle energy work?
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Tissue creep
constant load causes tissue give Conditioning less tissue resistance with repeated stretch Post-isometric relaxation Reciprocal inhibition reflex relaxation of antagonist |
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articulatory technique
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Diagnose restricted joint motion
Slow movement of joint to its position of laxity for all planes Slow movement of joint into its restriction for all planes 3-5 repetitions as one smooth movement Retest motion |
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HVLA technique
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Diagnose restriction
Move into restrictive barrier for all planes Short quick movement through barrier Retest motion |
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what are the 5 soft tissue techniques?
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Traction – longitudinal muscle stretch
Kneading – lateral muscle pressure Inhibition – sustained muscle pressure Effleurage – stroking pressure to move fluid Pétrissage – squeezing pressure to move fluid |
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3 types of visceral treatment
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autonomic normalization
lymphatic treatment visceral treatment |
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acute vs. chronic problem
use indirect techniques, fewer regions, lower dose, 1-2 treatment per week, 2-4 treatments |
acute/severe problem
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acute vs. chronic problem
use any technique, treat more regions and higher dose every 2-6 weeks as long as it is helpful |
chronic problem
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what are the 4 transverse fascial diaphrams?
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pelvic diaphragm (L5-S1)
thoracic diaphragm (T12-L1) thoracic inlet (T1, 1st rib) suboccipital region (OA, AA) |
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Zink's most common compensated patterns
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L R L R
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Zink's uncommon compensated patterns
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R L R L
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Zink's uncompensated patterns
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nonalternating
RRRR, LLLL RLLR, LRRL |
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where do you start when you treat Zink's patterns?
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right foot
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what area is drained by the right lymphatic duct?
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right arm, right side of her head, right chest
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what area is drained by the thoracic duct?
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everything but the right arm, right side of her head, right chest
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Drains RIGHT upper body
Crosses Thoracic Inlet Once Drains into jugulosubclavian junction |
right lymphatic duct
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Drains LEFT upper body and all LOWER body
Crosses Thoracic Inlet Twice Drains into subclavian and left brachiocephalic vein junction |
thoracic duct
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intrinsic lymphatic pumps
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lymphangions
vessels contract 6-8 times per minute affected by autonomics |
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extrinsic lymphatic pumps
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diaphragms
respiration peristalsis arteries adjacent to lymphatics body movement (vigorous exercise increases flow 15-20) external compression (bandages, water emersion, manual therapy) |
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how do you treat lymphatic system?
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proximal to distal
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what treatments normalize autonomic activity?
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rib raising
suboccipital inhibition sacral rocking |
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acute viscerosomatic reflexes
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hot
moisture, fullness, edema, tension increased or prolonged redness |
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chronic viscerosomatic reflexes
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cool
thickness, dryness, ropiness, pimples prolonged blanching |
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autonomic innervation: head and neck
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S: T1-4
P: vagus |
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autonomic innervation: cardiovascular
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S: T1-5
P: vagus |
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autonomic innervation: respiratory
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S: T2-7
P: vagus |
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autonomic innervation: stomach, liver, gall bladder
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S: T5-9
P: vagus |
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autonomic innervation: ovary, testicle
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S: T9-11
P: S2-4 |
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autonomic innervation: kidney, ureter, bladder
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S: T10-11
P: S2-4 |
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autonomic innervation: large intestine
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S: T8-L2
P: vagus, S2-4 |
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autonomic innervation: uterus
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S: T10-11
P: S2-4 |
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autonomic innervation: prostate
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S: L1-2
P: S2-4 |
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autonomic innervation: pancreas
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S: T5-11
P: vagus |
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autonomic innervation: arm
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S: T2-7
P: none |
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autonomic innervation: leg
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S: T10-L2
P: none |
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rib raising treatment
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Sympathetic chain ganglia just anterior to rib heads
Constant or repetitive lift of rib angles stimulates chain ganglia |
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how do you do ganglia treatment?
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Push posteriorly into celiac, superior mesenteric, or inferior mesenteric ganglion
Hold until tissue release, about 10-20 seconds Ganglion inhibition is contraindicated in patients with peritonitis, bowel obstruction |
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what do you do to treat the parasympathetic component of visceral disease?
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upper cervical soft tissue (SO inhibition)
sacral rocking |
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how do you treat chapman's reflexes?
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Treat posterior points
Anterior points may also be treated but often to sensitive and uncomfortable for patient Light rotatory massage with your fingertip Treat about 10-30 seconds Treat 2 or 3 times each day for best results |
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upper ankle joint
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tibiotalar (talocrural)
talus moves in the ankle mortise |
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lower ankle joint
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subtalar (talocacaneal)
major motions are dorsiflexion and plantar flexion |
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talus glides _________ with plantar flexion
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anteriorly
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talus glides __________ with dorsiflexion
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posteriorly
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ankle swing test
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Tests for talus anterior glide somatic dysfunction:
Hold feet horizontally and push them posteriorly. Tests ankle dorsiflexion and posterior talus glide Positive swing test= restricted posterior talus glide= anterior talus = plantar flexed ankle = restricted ankle dorsiflexion |
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most common somatic dysfunctions in the foot
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inversion of the navicular and cuboid bones
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minor motion of the knee
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anterior and posterior glide
medial and lateral glide internal and external rotation |
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knee flexion results in __________ glide of the tibial plateau
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anterior
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knee extension results in an __________ glide of the tibial plateau
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posterior
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restriction in knee posterior glide causes:
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restriction in knee extension
pain at the end of knee extension |
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restriction in anterior knee glide
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restriction in knee flexion
pain at the end of knee flexion |
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how do you check fibular head dysfunction?
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glide the fibular head anterolateral and posteromedial?
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tibia and fibula move __________
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together
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internal rotation of the tibia and inversion of the foot all cause __________ motion of the distal fibula and _________ of the fibular head
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anterior
posterior |
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external rotation of the tibia and eversion of the foot all cause __________ motion of the distal fibula and _________ of the fibular head
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posterior
anterior |
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distal fibula is the _____
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lateral malleolus
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most common ankle injury
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inversion
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what is lateralization of the pelvis?
what are the tests for it? |
determines the SI joint that is dysfunctional
standing flexion test (hamstrings, innominates, sacrum, spine) seated flexion test (innominates, sacrum, spine) compression test (innominates, sacrum) |
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ASIS compression test
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With the patient supine, place your palms on the anterior superior iliac spines (ASIS);
Push posteromedially on one ASIS while monitoring the other ASIS and repeat for the opposite side; Resistance to posteromedial pressure indicates sacroiliac joint restriction on that side. |
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superior innominate shear
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All of the static landmarks on the side of the dysfunction are shifted superiorly
ASIS, pubic bone, PSIS, iliac crest |
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inferior innominate shear
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All of the landmarks are inferior compared to the opposite side
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anterior or posterior innominate rotation
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all on the same side:
-positive ASIS compression -ASIS inferior (ant)/ superior (post) -PSIS superior (ant)/ inferior (post) |
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ilium inflare
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all on the same side:
-positive ASIS compression -ASIS closer to midline |
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ilium outflare
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all on the same side:
-positive ASIS compression -ASIS further from midline |
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pubic compression
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tender pubic symphysis with symmetrical pubic tubercle
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pubic shear
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tender pubic symphysis with inferior or superior pubic tubercles
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physical exam for sacral SD
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seated flexion test (positive test- last side that moves with flexion is the side of the restriction)
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sacral axis responsible for postural motion
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middle transverse axis
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sacral axis responsible for movement of ilia on sacrum
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inferior transverse axis
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sacral axis responsible for respiration and CRI
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superior transverse axis
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during inhalation and exhalation, what happens to the spine and sacral base?
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Inhale-spine elongates sacral base posterior
Exhale- spine recoils sacral base anterior |
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CRI- what happens to the sacral base?
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Cranial FlexionSacral base extends/ counternutates/posterior
Cranial Extension sacral base flexes/nutates/ anterior |
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what happens to the sacral base with forward and backward bending?
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Forward bending base posterior
Backward bending base anterior |
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what sacral axis is response is responsible for movement of the ilium on the sacrum?
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inferior transverse axis
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where do forward and backward sacral rotation occur?
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oblique axis
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forward vs. backward sacral rotation
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forward: right on right, left on left
backward: left on right, right on left |
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most important sacral axes
are important component of gait cycle |
oblique axes
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sacral motion in the gait cycle
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Right Heel strike
Left rotation on left axis Lumbar spine sidebends to the left Left Heel Strike Right rotation on right axis Lumbar spine sidebends to the right Maintenance of normal L-on-L and R-on-R sacral movement is an important therapeutic objective. |
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diagnosis of sacral somatic dysfunction requires?
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Asymmetry of paired sacral landmarks
Asymmetry of range of motion of sacroiliac joint as evidenced by: -Seated flexion test and/or ASIS compression test -Backward bending test/Lumbosacral springing test Tissue texture changes: -In deep fascia and ligaments over SI joints -Within the sacrotuberous ligaments -Gluteal and peroneal muscles |
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viscerosomatic reflexes associated with lumber spine
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Sympathetic
Location: L1 and L2 Organs innervated: distal colon, pelvic organs, and lower extremity Parasympathetic Not present in the lumbar spine |
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rule of 3's
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The Rule of Threes: the relationship of the spinous process tip to underlying bony structures
T1-T3: same level as its vertebral body T4-T6: 1/2 vertebral level down T7-T9: 1 vertebral level down T10-T12: same level as its vertebral body |
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what are the rib SD?
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Rib 1 elevation or depression
Ribs 2-10 Inhalation or exhalation Anterior or posterior subluxation Ribs 11-12 Inhalation or exhalation |
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what are the 5 articulations of the rib?
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costovertebral: 2 demifacets, except ribs 1 and 10-12
costotransverse costochondral (except ribs 8-12) chondrosternal (except ribs 8-12) |
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what are the steps of treating ribs?
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treat thoracic spine (type II and then I)
for a group of respiratory ribs, treat the key rib |
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key rib
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top rib for exhalation somatic dysfunction
bottom rib for inhalation somatic dysfunction |
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joints of the shoulder
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Scapulothoracic joint
Acromioclavicular joint Sternoclavicular joint Sternocostal joint Costovertebral joint Glenohumeral joint |
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for every 3 degrees of abduction, 2 occur in the ________ and 1 in the _______
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2: glenohumeral
1: scapulothoracic |
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restriction in scapular rotation
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shoulder girdle problem
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restriction in humeral abduction
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glenohumeral problem
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ulnohumeral somatic dysfunction
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The ulnohumeral joint passively adducts with flexion and passively abducts with extension
This cause the hand to deviate to the mouth during flexion It is also responsible for the carrying angle |
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ulnohumeral somatic dysfunction
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Ulnar Abduction
Restricted adduction (lateral glide) Patient may present with pain or restriction at endpoint of flexion Increases the carrying angle Ulnar Adduction Restricted abduction (medial glide) Patient may present with pain or restriction at endpoint of extension Decreases the carrying angle |
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medial glide of the ulnohumeral joint causes ________
lateral glide causes__________ |
abduction
adduction |
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with posterior radial head, there is restricted_____________
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anterior glide with supination
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posterior radial head somatic dysfunction is often caused by fall _____________--
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forward onto an outstretched hand
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with anterior radial head, there is restricted ____________
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posterior glide with pronation
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anterior radial head somatic dysfunction is often caused by falling ___________
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backward
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3 distinct biomechanical areas of the cervical spine
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Cervical Spine has three distinct biomechanical areas:
Occiptial-antlantal segment (C0-C1) Antlantal-Axial segment (C1-C2) Typical cervical vertebrae (C2 through C7) |
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motion in the Occiptial-antlantal segment (C0-C1):
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Primary motion is flexion and extension
When sidebending is introduced, rotation will occur in opposite direction (SLRR) |
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motion in the Antlantal-Axial segment (C1-C2):
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Primary motion is rotation
50 % of cervical rotation occurs at AA |
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motion in the typical cervicals
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(Inferior facet of C2 on C3 through C7.)
Facets oriented backward, upward, and medial. Facets articulate at 45 degree oblique plane Motion: Flexion/extension and coupled sidebending/rotation to the same side. |
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five components of the respiratory mechanism
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Motility of the brain and spinal cord.
Fluctuation of cerebrospinal fluid. Mobility of the intracranial and intraspinal membranes (later called the reciprocal tension membranes (RTM)) Mobility of cranial bones Involuntary mobility of the sacrum between the ilium. |
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mobility vs. motility
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(Motility=inherent motion Mobility=passive secondary motion)
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classifying the CRI
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Rate = cycles/min (10-14)
Amplitude = distance from flexion to extension (0- 5) Symmetry |
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unpaired cranial bones move in
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flexion and extension
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paired cranial bones and frontal bone move in
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external and internal rotation
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flexion of unpaired cranial bones goes with _________ of paired cranial bones
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external rotation
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extension of unpaired cranial bones goes with _________ of paired cranial bones
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internal rotation
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unpaired cranial bones
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ethmoid
mandible occiput sphenoid vomer frontal inferior concha lacrimal maxilla nasal |
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paired crainal bones
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palatine
parietal temporal zygoma |
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normal SBS motion in flexion
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In FLEXION when the SBS rises superiorly the sphenoid and occiput rotate in opposite directions about 2 parallel transverse axes
What you feel on the surface of the head is: the occiput expands inferiorly and widens the greater wings of the sphenoid (just behind the zygomatic arch) move inferiorly and widens. The result is that the head feels fatter and wider in FLEXION. |
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Sphenoid and occiput rotate in opposite directions about 2 parallel transverse axes. SBS rises superiorly.
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flexion
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normal SBS motion in extension
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In EXTENSION, the SBS moves inferiorly and the sphenoid and occiput rotate in opposite directions about 2 parallel transverse axes
What you feel on the surface of the head is: the occiput moves superiorly and gets thinner. the greater wings of the sphenoid move superiorly and get narrower The result is that the head feel thinner and longer in EXTENSION |
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Sphenoid and occiput rotate in opposite directions about 2 parallel transverse axes. SBS moves inferiorly.
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extension
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physiological SBS strains
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Flexion / Extension (normal physiologic motion)
Torsion Sidebending Rotation |
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non-physiological SBS strains
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SBS vertical strains
Inferior vertical strain Superior vertical strain SBS lateral strains Right lateral strain Left lateral strain SBS compression strains |
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Sphenoid and occiput rotate in opposite directions about an anterior-posterior (AP) axis
Named for the greater wing of the sphenoid that is superior (higher) i.e., if the right greater wing of the sphenoid is higher, then it’s a right torsion Using the vault hold, the right index finger moves anteriorly Feels like unscrewing a lid off a jar |
SBS torsion (right or left)
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One AP axis and 2 parallel vertical axes
AP axis (same axis around which torsion occurs but here the sphenoid and occiput rotate the same direction) Vertical axes—thru body of the sphenoid and foramen magnum and is perpendicular to the AP axis Occiput and sphenoid sidebend in opposite directions This opposite sidebending leads to a bulging of the head on one side Rotation is towards the convexity Named for side of convexity Feel a down and out sensation using the vault hold (cracking an egg) |
SBS sidebending rotation
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Caused by a shearing force at the SBS (i.e. Helmet to helmet hit to the top of the head)
Causes the sphenoid and occiput to rotate in the same direction around parallel transverse axes Rotation causes sphenoid to shift either superior or inferior to the occiput Will feel opposite motion on palpation because you are monitoring the greater wings of the sphenoid i.e., Using the vault hold, both index fingers will rise on a inferior vertical strain Named for relative position of the sphenoid base to the occipital base Superior vertical strain: sphenoid base superior Inferior vertical strain: sphenoid base inferior |
SBS vertical strain (superior or inferior)
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Caused by a shearing force applied just anterior or posterior to the SBS (i.e. a bat nailing you on the side of the head)
This forces causes the rotation of the sphenoid and occiput in the same direction (both clockwise or counterclockwise) around two parallel vertical axes Again, you will feel opposite motion on palpation using the vault hold, both index fingers shift to the right and the pinky fingers shift to the left with a left lateral strain Named for position of basi-sphenoid in relation to the basi-occiput. Right Lateral strain: sphenoid base is sheared right in relation to the occiput Left Lateral strain: sphenoid base is sheared left in relation to the occiput |
SBS lateral strain (right or left)
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The sphenoid and occiput have been forced together.
May be caused by severe blow or by fever or metabolic problem. Little or no motion at the SBS. Classically described as a “bowling ball” head or a “bag of worms”. May manifest as no established pattern (i.e., a different strain pattern every time in flexion). |
SBS compression
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how do you name a torsion cranial strain pattern?
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for the superior greater wing of sphenoid
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how do you name a sidebending rotation cranial strain pattern?
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side of head convexity
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how do you name a sphenobasilar strain pattern?
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direction of basisphenoid movement
(note: this is opposite greater wing movement) |
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what cranial nerve entrapment causes extraocular muscle dysfunction?
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III, IV, VI
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what cranial nerve entrapment causes trigeminal neuralgia?
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V
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what cranial nerve entrapment causes Bell's palsy?
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VII
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what cranial nerve entrapment causes feeding disorders?
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IX, X, XII
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what cranial nerve entrapment causes torticollis?
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XI
important: google torticollis guinea pig. |
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indications for OCF
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Congestion of respiratory system (sinusitis, otitis media)
Cranial nerve entrapment neuropathies TMJ syndrome Headache, neck pain, mood disorders Pediatric development abnormalities |
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contraindications for OCF
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Intracranial bleed
Increased CSF pressure CNS malignancy or infection Craniofacial fracture |
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beighton hypermobility screen
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Dorsiflexion of second finger to 90 degrees
Apposition of thumb to volar forearm Hyperextension of elbow by 10 degrees Hyperextension of knee by 10 degrees Hand flat on floor with knees extended Present if 4-5 are + on non-dominant side |
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red flags of low back pain: signal that there might be fracture
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Major trauma
Involvement in a motor vehicle accident Fall from a height Physical assault Minor trauma Osteoporosis Metabolic bone disease Malignancy and infection Pain is usually axial, non-radiating, and severe and disabling Pain usually begins immediately following the trauma Palpation is important to correlate any reports of pain to the radiographic level of injury |
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red flags of low back: signs of possible infection
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Risk factors for possible spinal infection:
Intravenous (IV) drug use Immunosuppression Fever and/or chills Pain that worsens when supine; severe nighttime pain |
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red flags of low back pain: signs of tumor
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Cancer risk factors:
Age less than 20 or older than 50 History of cancer Unexplained weight loss Failure to improve after four to six weeks of conservative therapy If all four of the above risk factors for cancer are absent, studies suggest that cancer can be ruled out with 100% sensitivity |
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red flags of low back pain: signs of cauda equina syndrome
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(Results from any lesion that compresses the cauda equina nerve roots)
Defined as a complex of symptoms that include: Lower back pain Unilateral or more typically bilateral sciatica Variable lower extremity motor and sensory loss Saddle sensory anesthesia Bladder and bowel dysfunction (and erectile dysfunction in men) |
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L4 neuro testing
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disc level: L3, L4
motor testing: tibialis anterior (invert foot) reflex testing: patellar tendon sensation: medial foot |
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L5 neuro testing
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disc level: L4, L5
motor testing: extensor digitorum longus (dorsiflex foot) no reflex sensation: dorsum of foot |
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S1 neuro testing
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disc level: L5, S1
motor: peroneus longus (evert foot) reflex: achilles tendon sensation: lateral portion of foot |
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iliolumbar ligament syndrome
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Pain in Multifidus triangle
Pain in sacroiliac, posterior thigh and/or inguinal region. Mimics inguinal hernia. |
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three layers of a nerve
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Epineurium
Surrounds the whole nerve. Perineurium Surrounds the nerve fascicles. Endoneurium Surrounds individual neurons. |
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piriformis syndrome is usually attributed to
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pressure on the sciatic nerve
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neurological deficits in piriformis syndrome?
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are not present.
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Patient flexed at time of injury.
Sciatic pain usually not past knee. Patient often c/o new scoliosis. Key Lesion = Type 2 at L1-2. Pelvis shift to opposite side of spasm. Piriformis spasm on opposite side of spasm. R/O herniated disc. |
iliopsoas syndrome
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inflammation of costochondral junction
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costochondritis
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posterior shoulder pain with scapular muscle trigger points
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scapulocostal syndrome
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stabbing pain and clicking at costochondral junction of rib 8, 9. 10
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rib tip syndrome
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what tests do you do for cervical radiculopathy?
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Cervical compression test
Neurological exam: DTR Motor strength testing by nerve root Sensation testing by nerve root |
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Compression of a nerve at one point renders it more susceptible to damage at another site.
Altered function is greater than the sum of the impairment caused by individual lesions. (1+1=3) |
double crush syndrome
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C5 motor exam
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deltoid muscle
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C6 motor exam
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wrist extensors
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C7 motor exam
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wrist flexors
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C8 motor exam
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finger flexors
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T1 motor exam
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interossei mm.
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C5 reflex
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biceps
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C6 reflex
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brachioradialis
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C7 reflex
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triceps
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where can thoracic outlet syndrome occur?
how do you test for it at each location? |
between the clavicle and the 1st rib; costoclavicular compression test
between the anterior and middle scalenes; Scalene compression test (Adson's maneuver) Positive test = diminished pulse and/or reproduction or exacerbation of symptoms under the pectoralis minor muscle or tendon; pectoralis compression test |
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when a patient has arm pain and paresthesia, need to rule out these dangerous causes:
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Cervical radiculopathies
Pancoast tumor Metabolic causes: hypothyroidism, type 2 diabetes mellitus, vitamin B12 deficiency |
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“…an acceleration-deceleration mechanism of energy transfer to the neck…”
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whiplash
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muscular injury
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strain
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ligamentous stretch injury
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sprain
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what can cause all of these?
Neck pain Neck stiffness Loss of ROM Headache Shoulder pain Facial or sinus pain Headache Ear pain Sensory disturbances Tinnitus/hearing loss Dizziness Visual disturbances Tongue pain Back pain Extremity pain |
whiplash
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what are the factors associated with developing chronic pain from whiplash?
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Older age
Female Initial pain in neck Increasing lag time between injury date and presentation for treatment Higher initial pain intensity Lawyer involvement Injury during work |
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after whiplash, reduced cervical range of motion is a good predictor of
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pain and disability at 2 years
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Easily mistaken for lumbar radicular pain (coughing or sneezing may increase the pain) or piriformis syndrome or hip pain
"joker of low back pain" |
quadratus lumborum
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how can you treat the quadratus lumborum?
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inhalation ME to the 12 ribs
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spasm of this muscle causes "pseudosciatica and pain in the buttocks and down the lateral portion of the leg
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gluteus minimus
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how do you treat gluteus minimus spasm?
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direct MFR to the hip
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spasm causes pain in the low back and anterior upper thigh
"hidden prankster" |
iliopsoas
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treatment for iliopsoas spasm
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Correction of somatic dysfunctions of the thoracic, lumbar, or sacral areas and avoid prolonged sitting
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trigger points of this muscle can be confused with cervical radiculopathy
Symptoms include myofascial pain or secondary sensory and motor disturbance due to neurovascular entrapment |
scalenes
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muscle most often found to have trigger points?
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trapezius
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frequently overlooked source of temporal and cervicogenic headache
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trapezius spasm
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no matter what modality you use to treat trigger points, an essential component in treatment is __________-
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home stretching
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