Final Flashcards
Compression neuropathies
Ok
Biomechanical causes compression neuropathy
Space occupying-herniated disc, cyst
Degenerative causes-foraminal stenosis
Post traumatic-fracture, hematoma, compression from equipment
Mechanical-muscle spasm, pinching from external or positional forces
Systemic causes
Pregnancy, hypothyroid, diabetes
Epineureum
Fascicles, blood vessels, CT
Perineureum
Contain axons
Pathological changes
Microvascuar compression->ischemia
Thickened epineurium
Myeli thinning
Microtubules closure
Axonal degeneration
Neuropraxia nerve injuries
Focal damage of myelin fibers around axon
Least severe, days o weeks improve
Axonotmesis
Some disruption/injury to the axon itself
Myelin sheath remains intact
Regeneration is possible but months without a fill recovery
Neurotmesis
Disruption of axon and endometrium
Recover with axonal regeneration, surgery, may be no improvement
Know your dermatomes!
Want to know where the lesion is
Where will lesion be on MRI why am i ordering MRI-i think there is pinching that we will want to do something about
Person has this deficit
It’s this nerve root
Herpes in dermatome pattern
Herpes
Pain in 1 derm
Nerve
Pain down buttand leg
Not dermatomal -nothing down side of leg
Cervical nerve compression: bulging disc
Evenly bulging out gain weight lose height
Cervical comrpession: herniated disc
Protrusion-only a few cartilage rings are torn , no leakage of central material
Extrusion-cartilagerings have in a small area, nucleus purposes is able to flow out of the disc space
Most commonly the cervical disc ruptures __-___ causing compression of the nerve root as it exits the intervertebral foramen
Posterior laterally
What does cervical nerve root compression cause
Radiculopathy-pain caused y compression of the spinal nerve that radiates int he distribution of the defined nerve root
Spurring test
Extend and rotate the neck toward symptomatic side and look forexacerbation of radicularpain
CERVICAL RADICULOPATHY indicative of
Adson test
Elicited by having the patient elevate the chin and rotate the head toward the affected side while inspiring deeply; look for obliteration of radial pulse on affected side
Thoracic outlet syndrome
Hoffman test
Elicited by firmly grasping the middle finger and quickly snapping or flipping the dorsal surface, look for a quick flexion of both the thumb and index finger
Cervical myelopathy (cervical stenosis)
Purpling
High SPECIFICITY hold. Head down
Cervical compression
Comrpession test
Just push down
Cervical spine c2 what nerve root looking at
C3 bc go above vertebral body nerve root
Lumbar
Below
General treatment cervical comrpession
Anti inflammatory, Modification of activity, splinting, injections , PT OMM for 3-6 months OMM cant unpinch nerve
Surgical release is considered when non operative management fails
Cubical tunnel syndrome -operative decompression is probably ustified in all but the mildest cases to prevent nerve damage
Upper extremity compression
Radial, median, ulnar, musculocutaneous, axillary
Radial nerve entrapment : motor and sensation
Triceps brachii, anconeus, wrist extensors
Sensation to majority of dorsum of hand
Where entrap radial nerve
High on humerus
Radial tunnel
At wrist
High humerus radial
Wrist drop, weakness of elbow flexion (brachioradialis), tricep
4-5 months return
Radial tunnel radial nerve entrapment
From repetitive oratory movements like rowing, discus,racquet sports, heavy Manila labor
Pain and tenderness lateral epicondyle
Wrist drop or pain with resisted supination
At wrist
Superficial branch pinched between brachioradialis and ECRL during forearm pronation changes over posterolateral band
Why do distal neuro exam
Start distal and work proximal the figure out where it starts
46 yo pain numbness hand health no injury. What ask
Hobbies? Sports? New baby? Other symptoms?
Superficial radial nerve compression
Cheiralgia, paresthesia aka waternbergs
Numbness , tinging, burning, pain in SRN distribution, caused by compression, edema, surgical injury
Treat superficial radial nerve
Rest Avoidance of aggravating behaviors Stretching NSAIDS Counter-strain/muscle energy
Median nerve entrapment places
Ligament of struthers
Pronator syndrome
Anterior osseous syndrome
Caravan tunnel syndrome
Function median nerve
Forearm flexion and pronation
Wrist flexion and radial deviation
Thumb abduction and opposition
Index and middle finger abduction and flexion
Pronator syndrome
Occurs as the median nerve passse between the superficial and deep heads of pronating motions: pianists, fiddlers, baseball players, dentist, weight trainers
Symptoms pronator
Achy pain in the mid/proximal forearm, aggravating by repeated lifting
-may have sensory abnormality in the radial three and a half digits
-pain with resisted forearm pronation
Anterior interosseous syndrome
Deep motor branch of median n just distal to pronator teres which innervates flexors
Etiology anterior interosseous syndrome
Trauma, cast pressure, bulky tendinous origin of ulnar head of pronator teres, soft tissue masses, fibrous bands
Symptoms anterior interosseous
Ok sign, no sensory problems, weak flexion of index finger DIP and thumbs IP
Treat anterior interosseous
Elbow splinted in 90 flexion for 12 weeks
Gold standard diagnose carpal tunnel
EMG
Most common compression syndrome
Carpal tunnel
Treat carpal tunnel
NSAIDs, mfr, st, lymphatics, steroids injections if nothing working, wrist splitting in 30 extension , surgical release
Ulnar nerve where entrap
Cubical tunnel
Guy on canal
Ulnar nerve function
Innervates skin
Deep branch in hand->motor innervation for interosseous msucles and adductor pollicis
Superficial branchin hand-> sensory innervation to ring an pinky finger
Cubical tunnel syndrome
Medial elbow
Baseball pitches or elbow flexion , external compression against. Hard surface, thickened cubical tunnel retinaculum
Sx ulnar nerve entrap
Paresthesia tinea sign at elbow elbow flex and wrist ext
Froment sign
Ulnar nerve
Thoracic outlet syndrome
Brachial plexus compressed
Test for TOS
East/roos, adson, wrights hyperabduction
L1,l2
Hip flexion
Meralgia paresthetica
Lateral femoral cutaneous
Compression under inguinal ligament canal
-athletics, obesity, belt,
Symptoms lat femoral cutaneous
Numbness or burning pain on anterolateral thigh
Hyperesthesia dont wnt to put things in pocket
Asis tinel+
Common fibular nerve compression
L4-2s,
Leg hooked under rail, squatting, ankle sprain, lithotomy position during birth
Symptoms common fibular nerve compression
Pain along proximal third of lateral leg
Foot drop with a slapping gait
Exacerbated during plantarflexion and inversion of the foot
Treat fibular n compression
Posterior fibular head HVLA or ME
ME on gastroc/soleus biceps femoris
Anterior tarsal tunnel syndrome
Deep fibular nerds L4-s2
Deep fibular nerve comrpession at the inferior extensor retinuaculum
Symptoms anterior tarsal tunnel
Pain over dorsomedial aspect of foot and worse at rest
Weakness of extensor digitorum breves
Etiology anterior tarsal tunnel
Trauma, talonavicular dyssfctunion
Treat anterior tarsal
Remove compressive forces
Myofascial release or extensor retinaculum
Traction tug of talonavicular joint
Hiss whip for navicular , cuneiforms, 1st and 2nd metatarsal
Symptoms lateral femoral cutaneous
Numbness or burning pain on anterolateral thigh, hypersthesia to the point of not putting anything in pockets, tropic skin changes later on
Tinel 1cm medial and inferior to ASIS
Tarsal tunnel
Compression of posterior tibial nerve in tarsal tunnel behind the medial malleolus with flexor retinaculum
Nerve function tarsal tunnel
Pain on plantar side of foot tingling burning
Treat tarsal tunel
MFR, HVLA , NSAIDS< US< PT, acupuncture
Hoffman+
Central nervous system problem
Ok sign
Median nerve
Spinal disc disease: initial herniation
Painful, disc slowly shrivels away in few days-weeks most resolve without treatment within 2-6 weeks
9)% back to normal regardless of treatment
Spinal disc disease 10%
Have gotten chronic back pain, spasm, stiffness,
Weak back ligaments-radiating pain down legs, predisposes to further injury, change in biomechanics, accelerated osteoarthritis and stress on other joints
Treat spinal disc disease
Stretching, anti inflammatories/pain meds, muscle relaxers, PT, BLT therapy, prolotherapy to strengthen ligaments
Pt presents to FM clinic with 2 month HZ of low back and right sharp, burning hip pain that radiates down their leg. No recent injuries or MVA they can remember. Denied numbness or weakness, incontinence, no other inciting factors known/revealed
Point to pain-point right SI joint and drawl a line right lower SI joint straight down back of leg to posterior kneee
Low back pain with sciatica -nerve root in tact so not radiculopathy
Radiculopathy
Compression nerve root
Myelopathy
Compression spinal cord so bilateral symptoms
Neuropathy
Result of damage to peripheral nerves, often causes weakness numbness and pain, usually in hands and feet
Sciatica
Pain emerging from the low back felt along distribution of sciatic nerve
Symptom not a cause
Not sciatic nerve comrpession!!!!
Cause sciatica
Usually sacroiliac ligament weakness
Nerves innervation SI capsule refer pain to spinal cord segment and ay radiate, but not in ___ patter
Dermatomal
Treat sciatica
Strengthen ligaments was-DONT USE STEROIDS
Sciatica clincial
Pain with walking but long periods of sitting also
Pain when getin up from seated position, espicially if they have been sitting with their legs crossed
They tend to use the armrests or their thighs to push themselves up to the standing position from being seated
Tight muscles sciatica
Hamstring, adductor Magnus
Psoas syndrome
Ok
25 yo RLQ pain. What want to know/ nausea pain with movement, pressure on RLQ, relieved fetal position, radiates to low back, constant, standing hurts .
PSOAS syndrome
Origin insertion function psoas major
O-T12-L4 and L1-L5 TP
Insert-lesser trochanter, bursa over the lesser trochanter
Fnunction-FLEXOR
Psoas minor
Origin T12-L1
Insert-iliac fascia
Iliacus
Origin-superior 2/3 iliac crest, asis and LS ligaments
Insert-lesser trochanter, psoas major tendon
Function-flexes thigh
Iliopsoas
Psoas minor and iliacus muscle
Piriformis
Origin sacrum
Insertion-greater trochanter
Functions: major hip ER
Function psoas
Walking, flexion of femur, pelvis, lumbar spine
Maintains pelvis in erect posture
Medially rotates hip when laterally rotated
Laterally rotated hip when medially rotated
Psoas ___ rotates hip when laterally rotated
Medially
Causes / etiologies psoas syndrome
Flexion stress of lumbar spine
Sit ups
Deadlifts/squats
Quick elongation of psoas
Arthritis of the hip
Viscerosomatic reflexes (lower GI GU)
Urethral calculi/appendicitis (more viscerosomatic)
Viscosomatics appendix
T10-11
Rectum bladder uterus viscerosomatic
T12-l2
If no improve with OMT and recurrent psoas issues
Colon cancer, diverticulitis, femoral bursitis, hip arthritis, prostatis, salpingitis, urethral calculi, herniated disc
Presentation psoas syndrome
Walk flexed forward and to one sire (difficulty sitting or standing upright(
Difficulty lying prone
Walking S
Pain in thoracolumbal, SI, lumbosacral, gluteal , pain stop at knee on contralateral side, pain at belt line
What happens posture hip flexors tight
Flattened lordosis and forward flexed posture
Backward bending sacral base
Abdomen protrude
Tight hamstrings-counteract hip flexion, cervical lordosis
Thomas test
See space between posterior thigh and table
Psoas
When pull both knees to chest and then drop one
If cant flex may be tight quad
Osteopathic psoas
Hip flexion.extensoin ROM
Screen for innominate somatic dysfunction
Screen for sacral somatic dysfunction
Screen for lumbar somatic dysfunction tender pts-iliacus, low ilium, al1-5, c/l piriformis
Key dysfunctions
Tight psoas (identified through ROM testing)
L1 flexed rotated and sidebent to the side of the tight psoas
Five staged psoas: phase 1
- Both sides tight, flexed and flat lordosis, L1 flexed
Increased or flattened lordosis
Can’t stand straight, positive Thomas, pain hip extension, pain at belt line wraps around
Treat stage 1
CS, indirect ME
Passive stretch rolled towel
NSAIDs andor muscle relaxants
What not do stage 1
Direct stretching or direct ME ina cute setting
Will irritate
Don’t use eat (unique to this dysfunction)
Cs stage 1
Low ilium, iliacus, rolled passive towel stretch(towel belower lower back)
Coldpack
Stage 2
Unilateral spasm
Bent forward and to a direction (say right)
Key lesion-L2 F RR SR
Psoas spasm, r hip external rotation dysfunction
Sidebent toward and rotate away l2-4 RlSr
L5 Extended
Pain at right belt line +lateral flexion test
Treat stage 2
L2, L2-L5, psoas stretch, muscle relaxants and nsaids
Stage 3
Postural compensation
Axis on side of SD
L pelvic side shift -shifts away from side of SD, causes SB towards SD right
Pain at lumbosacral junction at side of sacral axis
Treat-treat torsion, ME, HVLA<
If chronic, possible R posterior innominate SD->posterior rotation shortening right leg
If chronic stage 2
R posterior innominate SD-> R short leg syndrome
Stage 4
L piriformis spasm (opposite side from psoas SD)
L piriformis TP
Pain. At L pelvic side shift ->eft gluteal, SI, hip bc of the piriformis
Exam-L LE external rotation Treatment-treat piriformis: CS Spray and stretch Trigger point injection *do what did before but add piriformis
Stage 5
Add sciatica
L sciatic nerve irritation can follow quickly after S2
Pain L gluteal, SI, hip, radiates down L leg to knee no neurological effects no emg issue
Straight leg +
Left leg paresthesia(stop at knee)
No neural deficits, msucle atrophy
EMG -, - nerve conduction study
+ straight leg raise>30
Treat with adding a low dose steroid
Treat stage 5
Low dose steroid
Visceral cause
Pathology go then start doing OMT
Chronic structural issue
More OMT
Stretching psoas
Psoas, piriformis (happy baby pose)
Do for psoas
Passive stretch with rolled towel 3 times a day
Supine leg lifts
Push ups
Swimming
Report any change in condition
Do not psoas
Sleep ones tomach, use heat to treat, slump/slouch when sitting bend forward, lean toward painful sidebending, perform sit ups, lean backward when standing
Narcotic
Stage 5 but off quick to muscle relaxer and nsaid
Treat pharm psoas
NSAIDs, muscle relaxant, steroids, pain management for spinal injections useful
Rep/fluid psoas
Fluid, release diaphragm fascia (thoracolumbar and pelvic) will help move lymph
Energy immune psoas
Manage pain spasm and visceral causes
Psychological psoas
Posture
Do not over treat psoas
Presentat high stage-no HVLA-do CA, MFR< MS,
If recurrent dont delay look for viscerosomatic and work up for particular organ
Short leg syndrome
Ok
What s short leg syndrome
Leg short causes signs and symptoms
Something causes short leg and results effect body and msk
Functional causes leg short
Bony-lumbar group curve, innominate rotation, sacral base unleveling
Soft tissue abnormalities-hypertonic flexors/extensors/adductors
When the patient is supine the lumbar group curve tends to pull the hemipelvis on the side of concavity of the curve ___ causing a short leg
Cephalad
Structural causes short leg
Trauma
THA-total hip arthroplasty TKA Pes planus Knock knees AO Salter Harris fracture, leg calve perches, slipped capital femoral epiphysis
Leg calve Perth’s
Often self limiting idiopathic avascular necrosis of femoral head bone withers away and dies
Younger boys progressive PAINLESS limp
Slipped capital femoral epiphysis
Ice cream falling off a cone
Associated obesity
Teen
PSINFUL limp decreased internal rotated
Need surgery
Presents LLD
Pain-back hip, knee, foot, shoulder TMJ
Foot drop
Abnormal gait
Just feels off
Many, many more
Evaluate short leg
Spine, palpatory landmarks, standing and seated, gait analysis
Weight bearing postural x rays
-femoral head height discrepancy, sacral base unleveling, anatomic leg length measurements
Gai
Forward propulsion and movement
Approx 2 inches vertical and horizontal deviation throughout normal cycle
Abnormal-> decreased efficiency, increased deviation, wasted movement, increase energy/effort to move
Innominate leg short leg
Anterior rotation
Iliac crest height short leg
Low
Sacrum shor leg
Deep (anterior) sulcus
Lumbar short leg
Convexity (SB away)
Thoracic (late) short leg
Concavity
Shoulder short leg
Early-high
Late low
Foot short leg
Supinate
Ankle, calcaneus, forefoot short leg
Plantarflexed, inverted, addicted
Femur short leg
External rotation
Knee short leg
Extended
Pelvic shift short leg
Away
;5-S1 ambulatory compensation
Stance leg engages oblique sacral axis
-wt shift results in lumbar towards
As swing leg moves forward, sacral base moved anteriorly as well around stance leg axis
- torsion-rotation around oblique axis
- forward torsion=physiologic; backward=non physiologic
L spine rotates opposite
-think as your r arm swings forward, you rotate left
Treat LLD
OMT -resolve leg discrepancy
Home stretching/therapy
Follow up
Treat structural LLD
Same as functional, plus heel lift
But only when femoral head is >5mm
Max 1/2 heel lift, then progress to whole foot
Final lift height should be1/2-3/4 of measured sicrepancy, unless recent sudden cause apparent
Heilig lift formula
Total lift needle=sacral base unleveling/duration+compensation
Duration<10 yrs =1, 10-20=2, >30=3
Compensation non=0, L spine rotation/SB=1, wedging of vertebra=2
Acute changes
Full amount recommended
Physical therapists
Movement and promote development, ameliorate activity limitations
Collaborate
Advocate for patients
Acupuncture
Points in body that are pathways for qi to flow and traditional principles
Recruiting neuroanatomical activities in segmental distributions
Acupuncture theory
Neurochemical response to the placement of a needle into body
Body thinks injured so inflammation and releases mediators of healing when removed
5 elements
Boimechanical wood, fire behavior, water resp/circ, earth metabolic, metal neurologic
Why refer to acupuncture
Need more frequent treatments
Know physical problem and lab findings are negative and omt is not lasting
What know when refer to acupuncture
Frequency, acupuncturist training, insurance: not usually covered
Chiropractor
MSK and nervous system
Back pain, neck pain, pain in the joints of the arms or legs, and headaches
Examine, diagnosis, treatment, recommend therapeutic and rehabilitative exercises as well as to provide nutritional, dietary and lifestyle counseling
-clincial exam, lab test, diagnostic imaging
Boundaries of chiropractor
State reactive acts and regulated by state licensing boards. Have a 4 year doctoral graduate school program under US department of education.
Need CE credits
Why refer to DC
Lost skills of feels unskilled in OMT
Feels that the patient needs more frequent treatments.
Specializes in another area of practice
Things consider when refer to a DC
Frequency, HVLA, insurance-many accept but maybe a few per year
Occupational therapist
ADL an dwork assessment and treatment
Site evaluation
Performance
Equipment
Social support
Habilitation and rehab services under ACA manage chronic disease and improve function
Massage therapy
Strokes, lubricants, clothing, position, duration
Why refer to a massage therapist
Feel need more frequent treatment, feels muscle hypertonicity is so severe that whole body massage on a more frequent basis is needed
For lymphedema for consider a MT or PT who specialize in lymphatic massage with wrapping
Rolfing
Often consider a deep tissue approach, Rolfing bodywork actually works with all the layers of the body to ease strain patterns in the entire
A series of ten sessions
-ten-series is like a tune up for your body. The ten series is a systematic approach to aligning your structure; each session builds upon the last a prepares the body for the next
Rolfing certification
Basic-731 hours 3 phases and high school diploma
Advanced -3 year of practice adn 18 intermediate courses completed within a 7 year period
Yoga
Physical, mental, and spiritual practice or disciplines which originated in ancient India
Most likely developed around 6th and 5th centuries
Mixed and inconclusive results
Why send to yoga
Patient needs more frequent approach
Understands that the patient is either too tight, weak or both. And that a trial of yoga may be beneficial
Yoga prescription
Frequency and duration, key is to start conservative and increase as tolerated
Feldenkrais
Gentle movement and directed attention to help ppl learn new and more effective ways of living with their bodies
Based on physics, biomechanics, and an empirical understanding of learning and human development,
Why send to feldenkrais
Feels that the patient problems are based upon too much focus on their own pain
Observe that the patient has significantly ingrained maladaptive patterns of movement and posture
Prescription feldenkrais
Frequency/duration: daily practice depending upon the patient
Patient may attend weekly classes or individual sessions with a practitioner
Common aging MSK complaint
OA
PE MSK old
Evaluate gait, assess posture, ROM for upper and lower extremities, evaluate feet for ulcers/nail care
OSE of muscles and joints for somatic evaluation
Neck pain
Discs are thicker anteriorly oposteriorly
Greatest pressure : extension of c spine
After age 50 the nucleus purposes becomes fibrocartilaginous and has characteristics similar to the annulus fibrosis
OA
Slow onset -join pain, stiffness, limitation of motion
Rapid increase>50 years of age
Common complaints OA
Night pain, interference with sleep
Tenderness over joint line-ROM reduction, bony swelling, joint deformity, instability, x ray narrowed joint spaces
Medical treatment OA treatment
Pain relief
Prevention
OA OMT research
After treatment those subjects who had received OMT demonstrated continued improvement in their ROM in the placebo group decreased
Conclusion OA
Participants in manual therapy group had significant and clinically important sustained improvements in symptoms at 1 year. Those in the exercise therapy group also had sustained benefit with respect to physical performance tests. No added benefit was found in group who underwent both therapies
Oa omt
Had resolution of the effusion within a couple days post treatment
Neurological complaints
Parkinson disease
PE reflexes parkinson
Ankle reflex may be absent in older adults!
Parkinson
Over 40 yers of age
Older
PE parkinson
Tremor, bradykinesia, rigidity, postural instability, gait
PD OMM
Those treated with OMT had significant increases in stride length, cadence, and the maximum velocities of upper and lower extremities
PD research
PD more susceptible to SD in head/cranial and cervical regions
Pulmonary
Increased perception of shortness of breath->anxiety
Cardiovascular aging
Calcification, sclerosis
Decreased hemodynamically response to inotropic agents->fatigue , decreased endurance, depression
HTN risk
Heart attack, stroke, chronic HF, kidney diseases
OMM heart
Decreased hemoconcentration, increased fibrinolytic activity, decreased fibrinogen
Heart failure study
High correlation of changes at T4 in patients with significant cardiac disease in the men and women
Pneumonia OMM
Well tolerated even in old and frail
Immobility=death
Getting out of bed shorten hospital stay
OMT in the acute care setting has potential to reverse the effects of mobility
Bed boudn patient who cant get out of bed can have body parts and fluids mobilize using lymphatic pump and other osteopathic
Conclusion omt pneumonia
Seniors with pneumonia who are very old or very ill more likely to survive if get omt, while younger seniors recover faster and leave hospital sooner
Die less
Infection old ppl
Immune senescence
PE infection
Absent or atypical
Altered febrile response in some frail
For healthy community dwelling older adults
Omm lymphatic old
Significantly reduces the number of hospitalization and decreased medication use
Short ten effect of lymphatic pump
Decrease in platelet counts
Constipation
Alarm symptoms-hematochezia+FOBT, weight loss, FHx colon ca or IBS
Os finding constipation
T10-l2
Anteriolateral thigh along it band
TP of l2-L4 extending laterally to iliac crests
OMT colonic inertia
Less invasive less costly treatment option for patients with colonic inertia
Chronic constipation omt
Improve across all 3 domains-symtpoms, discomfit and stuff
Fall risk old ppl
Leading cause of death
So test balance and ambulation
-sitting to stand, walk,
Non manipulative intervention fall
VD, PT and exercise
OMT fall
Decrease in sets taken, improved step/stride length, increase velocity
Sway was significantly reduced in omt
Depression
Higheres old white men
Treat depression
Sri snri
Ect
OMT
OMT depression
All reverted to normal by week 8
What omt depression
Cranial, treat SD, balance ans
