Exam 1 Flashcards
rare but serious health conditions
Neoplasm
Infection
Ankylosing Spondylitis
Rheumatoid Arthritis (RA)
Klippel Feil Syndrome
Cervical Arterial Dysfunction (CAD)
Lead Kettle (PB KTL)
prostate, breast, kidney, thyroid, lung
Rheumatoid arthritis
synovial hypertension, destruction of articular cartilage and bone, synovial cysts and ligamentous laxity
likely develops prior to 6th decade
women> men
ankylosing spondylitis
Ossification ligaments of spine, IV discs/ end-plates, facet structures
men>women
observed in 3rd decade
improves with activity, worse at night
klippel feil syndrome
congenital; failed C spine segmentation
fusion of C2-C3 is most common
<50% have short neck, low posterior hairline, and limited ROM
>50% have scoliosis
cervical arterial dysfunction
intimal (inner) tear with penetration of circulating blood into the vessel wall and formation of intramural hematoma
consequences of cervical arterial dysfunction
Retinal or brain ischemia
Compression or stretching causes local symptoms
Subarachnoid or intra-cerebral hemorrhage
underlying abnormality of the vessel wall for CAD
vertebral arteries
internal carotid arteries
symptomology of cervical arterial dysfunction
neck pain
face pain
headache
pain is severe
extremity dysesthesia, motor dysfunction, pain
pulsatile tinnitus
Ds and Ns of CAD
dizziness
dysarthria
dysphagia
diplopia
drop attack
nystagmus
nausea
numbness
horners syndrome
Ptosis (dropping of upper eyelid)
Miosis (constriction of pupil)
Enophthalmos (sinking of the orbit)
Anhydrosis (dry eyes)
symptomology of cervical myelopathy
Neck pain/ stiffness
Shoulder pain
Imbalance/ fall Hx
(UE) Dysesthesia
May involve LEs first (gait, weakness)
clinical prediction rule for cervical myelopathy
Gait Deviation
Hoffmann’s Sign
Inverted Supinator Sign
Babinski Sign
Patient age >45 years old
upper cervical instability has an increased risk associated with
history of trauma
throat infection
congential collagenous compromise
inflammatory arthritides
recent neck.head/dental surgery
common special tests for upper cervical instability
Modified / Sharp-Purser Test
Alar Ligament Stability Test
Lateral Shear Test
Tectorial Membrane Test
Posterior A-O Membrane Test
jefferson fracture of C1
atlas fracture
4 part burst fracture of atlas
2 fractures at each arch
spondylolysis
defect of pars interarticularis
spondylolysthesis
anterior displacement of vertebral body
degenerative process that is most common at C3/4 and C4/5
3 factors of canadian C spine rule
- Any high risk factor that mandates radiography?
- Any low risk factor that allows safe assessment of range of motion?
- Able to rotate neck actively?
NEXUS low risk rule
5 criteria in order to be classified as having a LOW probability of injury
no midline cervical tenderness
no focal neurologic deficit
normal alertness
no intoxication
no painful, distracting injury
spondylosis
affects vertebral bodies and discs
degenerative process where osteophyte complexes form around margin of bodies
osteoarthrosis
zygapophysial joint and AA joints
osteophytes can cause joint narrowing
stenosis
narrowing of a vertebral canal
locations:
- central
- lateral
lateral canal stenosis can cause
radicular pain or radiculopathy
central canal stenosis can cause
myelopathy
somatic referred pain
pain from an anatomic structure
radicular pain
pain in a spinal nerve (dermatome) distribution due to irritation
radiculopathy
conduction block, motor and sensory affected
pancoast tumor
Tumor at the apex of the lung
May involve C8 and first thoracic nerve structures
symptomology of pancoast tumor
Chronic cough
Bloody sputum
Unexplained weight loss
Malaise
Dyspnea
will examine fever and wheezing
classification of TLICS
Morphology
Integrity of PLC
- Supraspinous ligament
- Interspinous ligament
- Ligamentum flavum
-Z-joint capsules
Neurologic Status
traditional compression fractures
Stable injury
Anterior column affected
Spinal canal intact
Common mechanism: axial loading in flexed position
Traumatic
High Energy
Osteoporotic
burst fracture
Anterior and Middle columns
15-20% of all major vertebral body fractures
Most common at T/L junction (T12, L1)
Potential neural involvement; fragments may be found in canal
Vertebral segment subjected to high force axial (and/or flexion load)
- MVC
- Falls from heights
- High-speed sport injury
rotation/translation fracture
Associated with fall from a height or heavy object falling on body with bent trunk
Torsion & Shear forces
Horizontal displacement of one T/L vertebral body on another
Dislocation: facet joints intact, but dislocated
distraction fracture
Separation in the vertical axis
Anterior & posterior ligaments, anterior & posterior bony structures, both
Potential Frx to posterior elements
red flags for vertebral fracture
Older age
Significant trauma
Corticosteroid use
Contusion/ abrasion
recommendation for clustered findings with a vertebral fracture
Henschke
Age > 70 years
Significant trauma
Prolonged corticosteroid use
Sensory alterations from the trunk down
Roman CPR for identifying vertebral compression fracture
quadas score?
QUADAS = 8
A cluster of findings to aid in identifying the presence of an osteoporotic vertebral compression fracture includes the following:
Age > 52 years
No presence of leg pain
Body mass index </= 22
Does not exercise regularly
Female gender
scheuermann’s disease
Defective growth of vertebral endplate
Poor diffusion of nutrients to un-vascularized disc
Proposed Etiology
- Genetics
- Excessive stress on pre-disposed (weak) endplate
scheuermann’s disease risk is increased among
Manual workers who begin at early age
High intensity athletes?
High BMI?
“Short sternum”?
criteria for Scheuermann’s disease diagnosis
Thoracic kyphosis > 45 deg
Wedging x 3 adjacent vertebrae > 5 deg
Thoracolumbar kyphosis > 30 deg
symptomology/exam findings of Scheuermann’s disease
Thoracic pain, commonly apex of curvature (muscular tension, IV disc bulging/ spondylosis)
exam:
- Scoliosis (15% and 20%)
- Excessive thoracic kyphosis (Compensatory hyperlordosis, rounded shoulders/ forward head, pelvic rotation)
- Vertebral wedging, Schmorl’s nodes (16-48%), disc space narrowing
- Limited thoracic ROM
- Neurologic Complications (less common)
disc disease of thoracic spine
symptomology
Back or chest pain
- Radicular: band-like pain in affected level’s dermatome, paresthesia/ anesthesia, leg pain
-Back pain at midline
Progressive/ insidious (months to years)
thoracic spine myelopathy
sympotomology and exam findings
Symptomology:
Sexual dysfunction
Bowel and bladder dysfunction
Physical Examination:
Sensory/ motor impairments
UMN signs LEs
etiologies of intercostal neuralgia
Traumatic Injury
Infection (e.g. herpes zoster)
Mechanical Compression (disc protrusion, osteophyte complex, neuroma, Frx)
Following thoracic Sx
symptomolgy of intercostal neuralgia
Burning pain/ paresthesia/ anesthesia along intercostal nerve path
exam findings with intercostal neuralgia
Focal tenderness of intercostal area
Herpes zoster: dermatomal distribution of rash with grouped vesicles and pustules
T4 syndrome
Women > Men (4:1)
Etiology unknown
Theory: sympathetic reaction with hypomobile segment
Can affect T2-T7
Primary pain generators
Thoracic IV disks and
Thoracic zygapophyseal joints
T4 syndrome
symptomology
Glove-like paresthesias unilateral/ bilateral UEs
Neck/ scapular/ bilateral upper extremity pain (constant or intermittent)
Worsens with side-lying or supine positioning
Generalized headache
T4 syndrome
exam positive tests
Tender spinous process
+ Thoracic Slump Test
+ Upper Quarter Neurodynamic Tension Tests
Hypomobile thoracic segment
scoliosis is named for the
convexity
etiology of scoliosis
congenital or acquired
zygapophysial arthropathy exam
Painful movement with closing of z-joints (AROM/ PROM)
Painful spring testing/ Hypomobility with joint mobility testing
zygapophysial arthropathy symptomology
local and/or referred pain
rib fracture concern over stability
Brachial plexus/ vascular structures (3-15% of upper rib fractures associated with this)
Laceration of pleura, lungs, abdominal organs
rib fracture symptomolgy
Focal pain, radiating pain
Pain with inspiration
Pain with coughing/ sneezing
rib fracture exam findings
Focal tenderness
Possible palpable defect
costochondritis
symptomology
Pain and local tenderness at costochondral or chondrosternal articulations
- At rest
- Trunk movement
- Respiration
costochondritis
what is it, when does it resolve
May be related to upward of 30% of ED visits related to chest pain
Involves >/= 1 rib
Proposed Pathophysiology:
Repetitive stress
Typically resolves within a year
rib dysfunction (structural, torsional, and respiratory)
Structural: subluxation of joint (anterior or posterior)
Torsional: Rib held in rotated position
Respiratory: related to posture, may affect respiration
rib dysfunction symptomology
Aggravated with deep inspiration, trunk rotation, sneezing/ coughing
rib dysfunction exam findings
Diminished rib mobility (structural)
Pain/ hypomobility with joint mobility testing
Limited/ painful thoracic spine motion
Thoracic outlet syndrome
compression
subclavian artery
subclavian vein
brachial plexus
thoracic outlet syndrome
symptomology
UE pain, paresthesia, anesthesia/ weakness (Glove-like vs. particular distribution consistent with area of compression)
Chest/ anterior shoulder pain
Typically progressive/ insidious onset
potential areas of compression TOS
scalenes
cervical rib
pec minor
first rib
clavicle
thoracic outlet syndrome clinical presentation/history
history of neck trauma
cervical rib
raynaud’s phenomenon
positive special tests for thoracic outlet syndrome
Roo’s Test
Hyperabduction Test
Adison’s Test
Cervical Rotation Lateral Flexion Test: Restricted 1st Rib
First Rib Spring Test: Restricted 1st Rib
pectoralis strain
MOI
Direct trauma
- Direct blow
- Forced horizontal abduction with extension or ER mechanism (e.g., bench press gone wrong)
Indirect trauma:
- Increased tensile stress on lengthened muscle, especially eccentric loading
- Common athletic injury (e.g., rugby); can be non-athletic(e.g., catching oneself when falling)
common history of pec strain
traumatic event with sudden onset of shoulder/ chest/ arm pain with audible “pop”
pec strain can be confirmed via
MRI
ultrasound imaging
intercostal strain
MOI
commonly excessive exertion of untrained muscle
serratus anterior strain
who does it happen in and what do they feel
More likely with rowing and weightlifting
Pain at medial scapular border, possible radiation to anterior chest
Pain/ weakness with resisted scapular protraction
internal/external oblique strain
MOI and what they feel
MOI: traumatic; eccentric contraction when muscle is lengthened
Uncommon, though more likely with cricket (bowlers), javelin, rowing, swimming, or hockey
Pain & TTP over lower 4 costal cartilages
Resisted ipsilateral lateral flexion painful
SCHEUERMANN’S DISEASE
interventions
Postural control muscle performance
Modification of aggravating activities
Strengthening and stretching of the trunk
- Seated rotation
- Extension in lying (prone press up, prone on elbows, etc.)
- Thoracic extensor strengthening
- Scapular abductor strengthening
Bracing
ANKYLOSING SPONDYLITIS
interventions
Spine extension & peripheral joint exercises
Breathing exercises
Prone lying several times/ day for spine/ hip extension
Sleeping on firm mattress & avoidance of SL position
Swimming
Adolescent Idiopathic Scoliosis
thoracolumbar bracing
Prevention of curvature progression
Correction of abnormal curvature
goal with exercise for scoliosis conservative management
Strengthen postural muscle
Address muscle length impairments/ strength impairments of extremity musculature
Maintain/ Improve respiration & chest mobility
Address back pain impairments
Resume functional tasks
Strengthen abdominals
T4 Syndrome considerations
Thoracic manual therapy techniques (mobilization, thrust manipulation)
Scapulothoracic motor performance
Thoracic extensor strengthening
DISC LESIONS
interventions
traction
Continuous or intermittent
Intermittent: twice as much separation proposed
Pt positioned sitting or supine
Duration recommendation 2 min – 24 hours
Generally 20-30 min recommended
contraindications for traction with disc lesions
acute lumbago, instability, respiratory or cardiac insufficiency, respiratory irritation, painful reactions, large [disc] extrusion, medial disc herniation, altered mental state; this includes inability of the patient to relax
ZYGAPOPHYSEAL JOINT PAIN:
interventions
Manual therapy interventions
- Mobilizations
- Oscillations
- Stretch mobilizations
Manipulation
Exercise
- Pain & guarding inhibition
- Neuro re-education (postural stabilizers, osteokinematic mobilizers into painful planes
ZYGAPOPHYSEAL JOINT PAIN
common impairments
Muscle Guarding
Joint Hypomobility
Acute irritation/ dysfunction
Pain
ROM: commonly motions that close joint (extension, ipsilateral flexion, rotation)
RIB DYSFUNCTION
interventions
Manual therapy interventions
- Rib mobilizations
–> Oscillations
–>Static stretch mobilizations
- Rib manipulation
- Soft tissue mobilization
THORACIC OUTLET SYNDROME
considerations
- Work/ activity modification
- Nerve glides
- Shoulder, upper rib/ thoracic manual therapy techniques
- Scapulothoracic motor performance
- Address tissue extensibility anterior trunk musculature
mid trap exercises
Prone row
Prone horizontal abduction with 90 deg shoulder abduction & ER
lower trap exercises
Prone full can
Prone shoulder ER at 90 deg of shoulder abduction
Prone horizontal abduction with 90 deg shoulder abduction & ER
Bilateral shoulder ER in shoulder neutral
rhomboids and levator scap exercises
Prone Extension with shoulder ER
Prone row
Prone horizontal abduction with 90 deg shoulder abduction & ER
