E2- TOS- Stenosis Flashcards
what is the general management of HA
HA with other suspicious S&S require urgent or emergency referral
all other HA complaints can be investigated with MSK scan
what are the types of HA
primary and secondary
what are primary HA
tension, migraine, cluster
what are secondary HA
cervicogenic
what is a tension HA
Bilateral band - like tightness
Anxiety/stress cause
No migraine S&S - milder
Dull pressure
what can cause a tension HA
anxiety/stress
commonly confused with cervicogenic HA because of muscle tension
what is the PT Rx for tension HA
address stress/anxiety
MET
oscillations or manipulations
what is a migraine
Pulsating
Out of commission
Unilateral
N & V
Drome’s
Sensational auras with visual and auditory sensitivity
what causes migraines
temporal artery vasodilation
trigeminal n nociplastic pain with CV dysfunction
what is the PT Rx for migraines
address CV dysfunction
vasoconstriction of temporal arteries - ice and caffeine
increase water intake 1.5 L
2-3 mg of melatonin
nociplastic pain MET
what is a cluster HA
Comes and goes
Retro-orbital and temporal region
Unilateral
Sudden and severe pain
Horners syndrome
INtense
Grumpy
what causes cluster HA
abnormal hypothalamus
genetic
sleep dysfunction
medication side effects
what is the prevalence for primary HA
- Tension
- migraine
- cluster
what are S&S cervicogenic HA
unilateral
starting in neck/occipital region
PROVOKED by neck motion
mild to moderate pain
non throbbing/pulsating
what can cause cervicogenic HA
C2/3 jt dysfunction
what can find in a scan for cervicogenic HA
limited and painful A/PROM
possible + with combined motion
neuro- possible + hypersensitivity
hypomobility and/or hypermobility with + linear stress test
+ cervical Flx/RT test
+ TTP in O-C3 region
what is the Rx for cervicogenic HA
address cervical dysfunction
what does the research say about dry needling with HA
no better than other modalities
should be paired with more MT and MET
what is TOS
compression of subclavian a and possibly brachial plexus
what can cause TOS
FHP
scalenes compress
trauma
differential diagnosis
what is the mechanism of FHP in TOS
upper thoracic jt hypomobility into extension
increase tension of subclavian fascia on axillary a
the floor or roof compresses the nerve
why would scalene compression cause TOS
chest breather with respiratory dysfunction and excessive use of accessory respiratory muscles
why can trauma cause TOS
WAD
protective muscle guarding
adhesions and scarring if torn
what are some differential diagnosis that can cause TOS
cervical rib
pancoast tumor compressing medial cord of brachial plexus
carpal tunnel
spinal n impingement
neurovascular disease
what are symptoms of TOS
UE glove/sleeve-like paresthesia
coldness and swelling with vascular compromise
what are the symptoms of peripheral n damage
nonsegmental paresthesia - short/intermittent duration, fast progression to well defined area of numbness
coldness and swelling with vascular compromise
what can increase symptoms of TOS
raising arms, prolong period
sleeping
poor sitting posture
what can we find in the scan for TOS
ob- FHP, possible UE discoloration
A/PROM- possible upper thoracic restriction
Resisted/MMT- decreased strength/endurance in post sh/scap muscles due to FHP
Neuro - only dural mobility +
what is dural tension restriction
paresthesia increased from both end
due to decreased elasticity or inflammation
how would you treat acute dural tension
paresthesia at rest
POLICED
motion without resistance or symptoms
STM over segmental
how would you treat persistent dural tension
paresthesia with resistance
motion with resistance
neural mobilizations with resistance at END range once acuity settles
what is gliding dural restriction
paresthesia increased from one end but relieved from other
due to adhesion
how do we treat acute gliding dural restriction
same as neural tension
how do we treat persistent gliding dural restriction
same as neural tension but neural mobilizations at MID range
what rep range do we do with neural mobilization
10-20 reps a day
what would we find in biomechanical exam for TOS
more often a upper thoracic hypomobility
less often - limited 1st rib inferior glide (guarded scalenes, sublaxation due to WAD)
use gilliard’s cluster
how do we treat TOS
posture/ergonomic
diaphragmatic breathing
MT/MET- improve mobility, strength and endurance of sh/scapular muscles
what MSK changes happen due to FHP
diaphragm actively insufficient/overworked
thoracic extensors and accessory muscles overworked with respiration
what is Dowager’s hump
fat pad over upper C/T junction develops with atrophy and shearing
what are most common thoracic restrictions with FHP
bilateral upper thoracic extension leads to lower cervical instability
can contribute to TOS and shoulder conditions
how can we treat FHP
MT/MET- more upright posture
postural education
ergonomic improvements
breathing training
what are the statistics for gillards cluster for TOS
5/5 LR+ =5.3
<5/5 LR- =.19
meaning if a pt has all 5 they have TOS bc it is so good at picking up - if + they got it and vice versa
describe tinels test
tap supraclavicular fossa - tenderness
describe adson’s test
15 degrees abd, inhale and hold breath for 10-20 sec with neck ext and ipsi RT - parethesia or descreased radial pulse
describe hyperabd test
90 degrees sh abd/er up to 1 min - paresthesia or decreased radial pulse
describe roo’s test
90 degrees sh abd/er while rapidly opening and closing fist for 1 min - symptoms
describe wright test
90 degrees sh abd/er with contra RT up to 1-2 min - paresthesia or decreased radial pulse
What is acute IDD
Annulus and end plate tear
Acute herniation (least common)
What is persistent IDD
Disc changes due to numerous variable allow herniation to happen gradually
Most prevalent
Describe the outer annulus
Type 1 collagen- resist tension- trigger multifidus to contract
Like a ligament- proprioceptive
Describe the inner annulus
Type 2 collagen - resist compression
Describe the anatomy of the annulus
Avascular
Concentric rings 15-25 fibers
Both compression and distraction can cause pain
Embedded into end plate
Describe the nucleus pulposa
Resist compression- type 2 collagen
High number of GAG
Dense connective tissue
Avascular, depends on motion
How does the annulus and nucleus move
Move as a unit
Describe the end plate
High innervate and vascularized
Nutrient diffusion for disc
Articular cartilage towards bone
Fibrocartilage towards disc
Weak link
May calcify and limit diffusion
What is the prevalence of IDD
Persistent over acute
Rare in thoracic- greater risk if so
Where on the disc is IDD most likely to occur and why
Posterolateral portion of disc
Weak,thinner,more vertical
Transition of annulus into endplate
What response can happen once a disc structure gets damaged
Immunoreactive
Large auto immune inflammatory- excessive osmotic pressure, n gets sensitized due to chemicals, no drainage, extends inflammatory phase
What would a pt report with postlat acute IDD
Dull achy spinal pain - referred pain
Radiculopathy
What is the worse situation with acute postlat IDD
Presence of radiculopathy
Presence of coldness indicating circulatory compromise
What are influencing behaviors with acute postlat IDD
Decrease pain with unloading
Increase pain and paresthesia with looking down
Increased pain in AM and worsening through day
How is ROM in a scan affected from acute postlat IDD
All may increase pain
FLX and contra SB/RT - limited and increase spinal pain (pressure on spinal n and tension on annulus)
EXT and ipsi SB/RT - decrease spinal pain (centralization) but could increase spinal pain due to hydrostatic pressure
What do symptoms do as they centralize
Decrease distal and/or spinal pain in a distal to proximal direction because of motion or position
What can be found in a scan for acute postlat IDD
Resisted/MMT- varies
Stress- possible +
Neuro- possible + (dural mobility always positive)
Stability test - +
Why can stress test be positive with all stress tests
Annulus irritated with distraction
Nucleus irritated with compression
Finding the segment irritated with PA pressure
What are the central IDD symptoms and what would we do
Cord S&S
Immobilize and emergency referral
what does research say about Mckenzie method with cervical IDD
weak evidence
no more beneficial vs general exercise
what is the aggressive nonsurgical Rx for acute IDD
intermittent traction
specific therapeutic exercise
oral anti-inflammatory meds
patient education
what is the Rx for acute IDD
POLICED
intermittent traction - may help if no centralization
neural mobilizations
MET
what is the ultimate Rx goal with MET for acute IDD
why
tissue proliferation and stabilization
if non-contractile tissue is the issue for instability, motion and strengthening of local muscles can help stabilize the jt
what is persistent IDD
degenerative disc disease
age related disc changes
what region is the most common persistent IDD
lumbar
if cervical, C6 spinal n is most effected bc it is largest in diameter
what can cause persistent IDD
acute IDD
sedentary lifestyle
genetics
if pt has persistent IDD with persistent inflammation, what can happen
the persistent inflammation brings excessive and destructive proteins and a low-grade infection likely enters disc
what is the snowball affect of persistent IDD
less GAGs so more fibrotic and dehydrated nucleus
more acidic disc
annular disorganization
thinning/loss of cartilage at end plates
increase inflammation and fatty deposits (Modic)
what are the categories of disc herniation
protrusion (bulge)
extrusion
free sequestration
what can happen due to persistent IDD
narrowing of:
disc - instability develops
increased load on facet - age related jt changes can develop
foramen - stenosis may develop
how are symptoms affected with persistent IDD
slow change allows tissue to adapt
how do we treat persistent IDD
what structure is the symptom driver??
disc?
jt hyper?
jt hypo?
nerve?
combo???
what is the prognosis of acute and persistent IDD
mostly good
what are the predictors of negative prognosis in acute IDD
peripheralization
pt attitude is negative
tumor
what are the possible MD Rx for acute/persistent IDD
antibiotics
laminectomy - paired with fusion because you are making the jt unstable
partial discectomy
total disc replacement
what is the axis of the jt maintained by
passive structures
active structures
neural control
what is the result of abnormal motion in a spinal segment under a load
in P! and instability that changes instantaneous axis of motion
what is functional instability
instability that can be stabilized with m activation or positioning
what is mechanical instability
instability that cannot be completely stabilized with muscle activity
what segments have the most instability
C5-7
what can cause of instability
trauma
age related disc changes - narrowing
repetitive activities
creep
adjacent hypomobility
connective tissue disorder
you can have BJHS if….
2 major criteria
1 major and 2 minor criteria
4 minor criteria
what are functional instability symptoms
predictable pain
decrease pain with position changes or support
increase pain with prolong position
catching
easy self manip
what can we find in a scan for functional instability
ROM- aberrant (acute), inconsistent WB and NWB findings, PROM > AROM
CM- inconsistent block
RST- most often strong/painless
neuro- (-)
ST- (+) PA pressure
Linear Stability test= (+)
what are the symptoms of mechanical instability
unpredictable pattern
worsening symptoms and more often
increase pain with less stress
symptoms dont get better as quick
what can be found in a scan for mechanical instability
same as functional BUT
ST- (+) wont stabilize fully
what can you do in a linear stability test to further test for mechanical instability
neck FLX tightens posterior ligament (closed pack postion)
functional = jt tighten
mechanical = still lax
what is the Rx for instability
POLICED
postural education
JM- increase adjacant hypo jts (C2 or thoracic)
bracing/taping
MET= stabilization, local muscles
why is EXT limited/painful with acute functional instability
increased ant vertebral shearing
why is FLX better than EXT with acute functional instability
large posterior lig/fascia tighten to help stabilize
what can be the MD Rx in severe/rare cases of mechanical instability
prolotherapy (injection) for stabilize along with PT
fusion surgery
what is the culprit tissue of age related jt changes
articular cartilage
what are the common diagnosis of age related jt changes
Degenerative joint disease
OA
spondylosis at multiple levels
what are the most common regions for age related jt changes
C5-7
L4-S1
why does age related jt changes progress along with age related disc changes
facets could bear more load due to disc narrowing causing facets to have more wear
what can protect against age related jt changes
physical activity
what is the leading cause of disability
age related jt changes
describe articular cartilage
covers ends of long bone, 2-4 mm thick
chondrocytes
frictionless
aneural/alymphatic/avascular
If articular cartilage is aneural/alymphatic/avascular, what causes the inflammatory response
arthritis - everything in the jt but articular cartilage can become inflammed
mostly the bone takes on more compression causing the pain and initiating the inflammatory response of the repair phase — more fibrotic tissue
what pressures does articular cartilage like
compression and decompression
why is full ROM beneficial for our jts in the healing process
synovial fluid fully diffuses into cartilage
inflammatory agents fully exit cartilage
how does viscoelasticity work in articular cartilage
rigid with more load
flexible with less load
what can cause age related jt changes
gradual onset
trauma
sedentary lifestyle - underloading
genetics
other disease- RA
age
what is the patho of age related jt changes
progressive
articular cartilage - fray, blisters, tearing
subchondral bone penetrated and overloaded
spurs
degenerative
acute tears
why can the articular cartilage become degenerative in age related jt changes
- thins and the jt space narrows - synovial fluid does not fully fill
- fibrous capsule slackens then becomes more fibrotic - inflammatory response on overdrive (repair phase never stops)
- synovial membrane produces less synovial fluid - nutrients not there and increase friction
what symptoms can be found with cervical ARJC
gradual onset
pain with prolong positions
morning stiffness < 30 minutes
pain and limitation with RT (looking in blind spot)
some movement helps, too much hurts
why would a pt have pain and limitation with RT with cervical ARJC
IMP or compression on facets
why might someone have paresthesias with cervical ARJC
compressed spinal n - narrowing or spurs
based on the cervical symptoms, what can be found in a scan for ARJC
ROM- painful and limited (EXT, RT, SB) capsular pattern of restriction
CM- consistent block or opposing quadrant block
RST- depends on acuity
ST- (+) compression, EXT, RT, SB, PA pressure
neuro- (-) unless spurs can cause stenosis on spinal n
what can show in a BE of cervical ARJC
accessory- hypomobility due to fixated hypermobile jts or hypomobile adjacent jts (C2-3 or thoracic)
special tests - spurlings may be (+) due to stressing the tissue in multiple positions (EXT, RT, SB)
why would compression be (+)for cervical ARJC
more stress directly on the jt
why would neuro tests be (+) with cervical ARJC
spurs can develop near the intervertebral foramina and compress the spinal n
what are the 2 patho of stenosis
narrowing and fibrotic
what can cause narrowing stenosis
compressed from outside in
IDD
ARDC
instability
enfolding of lig flavum (older people)
describe fibrotic spinal n patho
due to persistent inflammation associated with instability
nerve wont expand, compression from inside out
circulation compromise
what are the symptoms of lateral stenosis
unilateral UE P!, segmental paresthesias and gripping type pain
decrease pain with looking down, standind/walking, AM
increase pain with sitting, looking up, turning one side
what would we find in a scan for lateral stenosis
ob- increase lordosis
ROM- FLX, contra SB/RT decreases pain, EXT ipsi SB/RT increases pain
ST- (+) compression, (+) PA pressure due to translation of vb
neuro- possible (+) = radiculopathy
what can we do in BE for lateral stenosis
AM- jt hypomobility
MMT- local muscle inhibited
Spec. test- (+) spurlings, wainers CPR, stability= possible shear
what is our Rx for stenosis
pt education for posture
MT with MET- improve thoracic ext, neural mobilizations
mechanical traction
what is our Rx directed towards with stenosis
foraminal opening
what is the MET for stenosis
aerobic- increase circulation
local muscle stabilization
what is the MD Rx for stenosis
Sx- constant or worsening symptoms
laminectomy with or without fusion
how does radiculopathy surgery compare to PT
surgery has a more rapid and greater improvement in P!, but the two groups were no different with symptoms after 2 years
