Methods 5-Midterm Flashcards
New Patient CPT Code: Problem focused, straightforward MDM, minimal severity, average 10 minute face-to-face visit
99201
Adjustment CPT Code: Spinal, 1-2 regions
98940
Adjustment CPT Codes: Spinal, 5 regions
98942
CPT adjustment codes: Spinal, 3-4 regions
98941
CPT Adjustment Codes: Extraspinal, 1 or more regions
98943
M99.00
Occiput
M99.01
Cervical
M99.02
Thoracic
M99.05
Pelvis
M99.06
Lower Extremity
M99.08
Rib
M99.07
Upper Extremity
M99.06
Lower Extremity
Radiculopathy involves _________ compression ; Myelopathy involves ________ compression
Nerve root; Spinal cord
Radiculopathy involves _______ stenosis; Myelopathy involves ______ stenosis
Foraminal (IVF) ; Spinal
Bone spur, osteoarthritis, growth, infection, ossification, trauma, inflammation, and degeneration are all causes of:
Radiculopathy
Cyst, hematoma, tumor, infection, autoimmune disorders, injury, inflammation and degeneration are all causes of:
Myelopathy
Symptoms of Radiculopathy
-Sharp Pain
-Numbness: Pins/Needles Paresthesia
-Loss of Reflexes
-Weakness in extremities
-Follow nerve root distribution
Symptoms of Myelopathy
-Pain
-Tingling, Numbness, weakness
-Difficulty with fine motor
-Increased reflexes
-Difficulty walking (hunched posture)
-Loss of bladder/bowel
-Issues w/ Balance
-Issues w/ Coordination
Peripheral Neuropathy
-Damage to the nerves located outside the brain and spinal cord
-Damage to the PNS, may overlap radiculopathy symptoms
-Ex. Carpal tunnel syndrome/Diabetics (neuropathy of feet/legs)
Regardless if its a lateral disc or central disc, the cervical nerve affected will be ______ the segment.
Above
Lumbar: _____ disc lesion is going to affect the segment below; (Ie. L5/S1=Affects S1). Whereas a _____ disc will affect the same segment.
Central; Lateral
Structure can cause chemical response with an extruded disc
Nucleus puposis
Stages of Disc Herniation
Stage 1: Disc bulging
Stage 2: Disc protrusion: Annular fibers push out but NP is contained; Can affect central spinal nerve
Stage 3: Disc extrusion: NP breaks through annulus
Stage 4: Disc sequestration: Pain can move side to side due to NP material being able to move (May be bilateral)
Disc Herniation Development Factors
-Genetic
-Changes in Hydrogen/Collagen
-Environment: Repetitive motions
Disc Herniation Risk Factors
-30-50yo
-Overweight*
-Improper lifting*
-Frequent driving
-Sedentary Lifestyle
Saddle anethesia is common in:
Cauda equina syndrome
Disc Injury is aggravated by _________ and relieved by _________
-Aggravated by sitting and bending
-Relieved with standing and recumbent positions
Sprain/strain injury is aggravated by __________ and relieved by _________
-aggravated with standing and twisting
-relieved by sitting
L1-2 Central Disc Radiculopathy (NR, Motor deficit, pain dist.)
-Nerve Root compressed: L2
-Motor deficit: Iliopsoas
-Pain distribution: Anterior medial thigh
L3-4 Central Disc Radiculopathy
-Nerve Root Compressed: L4
-Motor Deficit: Quadriceps/Tibialis anterior
-Reflex: Diminished/Absent Patellar Reflex
-Sensory Loss: Medial Ankle
-Pain Distribution: Post. Lat thigh, and anterior tibia
L4-5 Central Disc Radiculopathy
-Nerve Root Compressed: L5
-Motor Deficit: Extensor Hallucus longus
-Reflexes: Possibly medial hamstring
-Sensory loss: Greater toe
-Pain distribution: Dorsum of foot
L5-S1 Disc
-Nerve Root Compressed: S1
-Motor Deficit: Gastrocnemius and peroneus longus
-Reflex: Diminished/absent achilles
-Sensory loss: Lateral foot/heel
-Pain distribution: Lateral Foot
Orthopedic Tests w/ Disc Herniation
Straight leg raise, Femoral stretch test, slump test, Bechterew’s, Strength: Heel/Toe Walk
Nonorganic Physical Signs with disc herniation
-Malingering (“Faking”): Superficial tenderness, positive results for simulated tests, distraction tests, disturbances do not correlate, overreaction during the examination
Disc Herniation Treatment
-Active Care: Core stabilization, 30 mins/day (walking), McKenzie Exercises
-Home Care: Rest 24-48 hours from onset
Co-Management: Acupuncture, Massage, Steroid injection, PT, Surgical-Discectomy (Last resort)
-Passive Care: Mechanical traction, ultrasound, moist heat, cryotherapy
Categories of Acquired Spinal Stenosis
- Degenerative
- Combined: Congenital and degenerative stenosis
- Spondylolytic/spondylolisthetic
- Iatrogenic: After medical intervention/treatment
- Post traumatic
- Metabolic: Padget’s, Acromegaly, Pseudogout
3 Classifications of Lumbar Facet Syndrome
- Traumatic: Facet joint inflammation to the joint capsule
- Pathologic: Degenerative arthrosis of the facet joint/Generally associated with DDD
- Postural (Chronic): Weight, occupation, increased stress on facets
Orthopedics for spinal stenosis
SLR: Typically negative
-Bicycle test: Positive
-Walking Test: Positive
Orthopedics for Lumbar Facet Syndrome
Absence of + valsalva, Kemps, Spring Test of the affected facets will reproduce pain
Types of Iliosacral motion
1)ANTERIOR & POSTERIOR TILT
• EXTENSION (ANT, SUP, LAT)
• FLEXION (POST, INF, MED)
2) CALIPER (FLARING)
• INTERNAL OR EXTERNAL
ROTATION
• 3) SUPERIOR & INFERIOR SHEARING
2 TYPES OF SACROILIAC MOTION:
• NUTATION
• COUNTERNUTATION
Sacroiliac Dysfunction
-PAIN IN THE SI REGION UNRELATED TO TRAUMA,
INFLAMMATORY DISORDERS ORSYSTEMIC ILLNESS
• ABNORMAL MOTION OF THE SI
• COULD BE RESTRICTED OR HYPERMOBILE!
SI Dysfunction: Cause/Risk
- LEG LENGTH DISCREPANCY
- SCOLIOSIS
3.PREGNANCY
SI Dysfunction: Signs/Symptoms
DULL TO SHARP PAIN WITHIN THE BUTTOCKS, THIGH OR LOWER BACK
• UNILATERAL OR BILATERAL
• PAIN IS WORSE UPON WAKING AND DECREASED WITH MOVEMENT OR EXERCISE
• PAIN IS EXACERBATED WITH PROLONGED SITTING OR TORSO ROTATION
Sacroiliac Dysfunction: Diagnosis
• OBSERVATION: DIFFICULTY RISING FROM CHAIR, ASYMMETRICAL HEIGHT OF ILIAC CRESTS
• GILLET TEST - ASYMMETRICAL MOTION NOTED
• LEG LENGTH INEQUALITY
• ROM – NO CHANGES
• FLEXION MAY BE PAINFUL
SI Dysfunction Tests
Cluster of Laslette
-SI Stretch Test
-Gaenslen’s Test
-Iliac Compression Test
-Thigh Thrust
-Sacral Thrust
SI Dysfunction: MSR/PARTS
MSR
• ALL SHOULD BE WITHIN NORMAL LIMITS
PARTS
• LOCAL PAIN PALPATED OVER THE PSIS
• ASYMMETRY OF THE PSIS; NUTATION/COUNTERNUTATION OF SACRUM!
• LOSS OF FLEXION OR EXTENSION
• LOCAL GUARDING OF MUSCULATURE.
• SHORTENED HIP FLEXORS, HAMSTRINGS, TFL, AND RECTUS
FEMORIS. WEAKENED GLUTS AND ABDOMINAL MUSCLES.
SI Dysfunction: Treatment (Active/Home)
ACTIVE
• STRETCHES TO ELONGATE HIP FLEXORS, HAMSTRINGS, TFL, RECTUS FEMORIS.
• STRENGTHEN GLUTES AND ABDOMINAL MUSCLES.
HOME
• AVOID ACTIVITIES THAT AGGRAVATE THE CONDITION
• ICE WITH TRANSITION TO HEAT
• CUSTOMIZED ORTHOTICS TO EQUALIZE LEG LENGTH
SI Dysfunction: Treatment (Co-Management/Passive)
CO-MANAGEMENT
• MEDICAL RX OF NSAIDS OR INTRA-ARTICULAR INJECTION
• MASSAGE THERAPY
• PASSIVE
• ULTRASOUND, MYOFASCIAL RELEASE, CRYOTHERAPY, MOIST HEAT
• RELEASE OF SACRAL AND PELVIC LIGAMENTS
• ADJUST PER THE PARTS FINDINGS
Sacroiliac Sprain
-CLASSIC PRESENTATION: PAIN OVER ONE SI JOINT AFTER STRAIGHTENING FROM STOOPED POSITION, MAY RADIATE INTO BACK OF LEG, SHARP/STABBING, RELIEVED SLIGHTLY WITH LYING OR SITTING
-ACUTE TRAUMATIC* MODE OF ONSET (OFTEN FROM LIFTING)
-INCREASED SEVERITY OF DISCOMFORT
-EXAMINATION FINDINGS ARE OTHERWISE THE SAME AS SACROILIAC DYSFUNCTION
-TREATMENT MAY ALSO INCLUDE SI BRACING, STABILITY
SI Sprain: Tests
Iliac Gapping, Gaenslen’s Test, Iliac Compression Test
Piriformis Syndrome : Signs/Symptoms
-BUTTOCK AND POSTERIOR LEG PAIN UNRELATED TO TRAUMA
-PAIN THAT WORSENS WITH:WALKING, ADDUCTION AND INTERNAL ROTATION
-PAIN EXACERBATED BY PROLONGED SITTING
-SEQUELA OF TRAUMA: CHRONIC COMPLICATION OF AN ACUTE CONDITION
*DON’T LET THIS CONDITION FOOL YOU, IT MAY ACTUALLY BE A LUMBAR RADICULOPATHY!
Piriformis Syndrome: Diagnosis
OBSERVATION
► PELVIC OBLIQUITY – MISALIGNMENT OF THE PELVIS
ROM
► PAIN REPRODUCED WITH FLEXION, ADDUCTION AND INTERNAL ROTATION OF THE HIP
ORTHO
► BONNETS TEST – SCIATIC NERVE PAIN FROM PIRIFORMIS
► RESISTED ABDUCTION OF THE THIGH (PACE SIGN) ELICITS PAIN
► PASSIVE, INTERNAL ROTATION OF EXTENDED THIGH (FREIBERG SIGN) ELICITS PAIN
Piriformis Syndrome Exam (MSR/Parts/Imaging)
MSR
► WNL – CLINICAL KEY IN DIFFERENTIATING BETWEEN SCIATICA AND PIRIFORMIS SYNDROME
► WEAK RESISTED HIP ABDUCTION AND EXTERNAL ROTATION
PARTS
► PAIN PALPATED OVER THE GLUTEAL REGION
► GLUTEAL ATROPHY IN CHRONIC CASES
IMAGING
► CT OR MRI FOR SOFT TISSUE: SEVERE CASES
Piriformis Syndrome Treatment: Active/Home
ACTIVE
► STRETCH PRIOR TO GETTING OUT OF BED
► KNEE BENDS
HOME
► AVOID EXACERBATING ACTIVITIES
► AVOID SITTING FOR LONGER THAN 20 MINUTES
► ICE OR MOIST HEAT
Piriformis Syndrome: Co-Management/Passive
CO-MANAGEMENT
► DIAGNOSTIC INJECTION OF THE PIRIFORMIS SYNDROME TRIGGER POINTS WITH LIDOCAINE
► NSAIDS
► MASSAGE THERAPY
PASSIVE
► MOIST HEAT
► ULTRASOUND
► PASSIVE STRETCHING OF THE PIRIFORMIS (FLEXION, ADDUCTION AND INTERNAL ROTATION)
► SOFT TISSUE RELEASE OF HIP ROTATORS
► ADJUST THE SI JOINTS AVOIDING DIRECT CONTACT OVER THE PIRIFORMIS MUSCLE
► CHECK HIP ROM AND ADJUST
Reactive Arthritis (Reiter’s Syndrome)
YOUNG MALE WITH LBP
• ONSET AFTER URETHRITIS, CONJUNCTIVITIS, AND SKIN LESIONS ON SOLES OR PALMS
• CAUSE: D/T INFECTION OFTEN CHLAMYDIA, CAMPYLOBACTER, SALMONELLA, SHIGELLA
• SI JOINT MOST COMMON SYMPTOMATIC JOINT
• MANAGEMENT: ANTIBIOTICS
• MANIPULATION MAY AGGRAVATE!
What are common signs and symptoms of sacroiliac dysfunction?
A) Dull to sharp pain within the buttocks, thigh, or lower back, usually bilateral
B) Pain is worse upon waking and decreases with movement or exercise
C) Exacerbated pain with prolonged sitting or torso rotation
D) All of the above
D) All of the above
Migranes are more prevalent in:
Females (3x more)
Migrane Symptoms
EPISODIC PERIODS OF SEVERE THROBBING HEADACHE PAIN
• VISUAL DISTURBANCES
• NAUSEA
• VOMITING ‘
• HYPERSENSITIVITY TO LIGHT, SOUND, SMELL, TOUCH
• FACIAL TINGLING OR NUMBNESS
Migraine w/o Aura typically involves _____ per month and attacks can last between _____ hours
> 5, 4-72 hours
Migraine w/o Aura will have at least two of the following:
- UNILATERAL LOCATION
- PULSATING QUALITY
- MODERATE-SEVERE PAIN INTENSITY
- AGGRAVATION BY OR AVOIDING ROUTINE ACTIVITY
“PUMA”
During Migraine w/ Aura have one of the following:
- NAUSEA AND/OR VOMITING
- PHOTOPHOBIA AND PHONOPHOBIA
Migraine w/ auro will have atleast ___ attacks
2
Hemliplegic Migraine
MIGRAINE WITH AURA, INCLUDING FULLY REVERSIBLE MOTOR WEAKNESS
• BEGINS WITH TEMPORARY MOTOR PARALYSIS, SENSORY DISTURBANCES AND/OR SPEECH/LANGUAGE SYMPTOMS
• ONE SIDE OF THE BODY
• GENERALLY LAST < 72 HOURS
Opthalamoplegic Headache
PAIN THAT SURROUNDS THE ORBIT
• LASTS FROM A FEW DAYS TO A FEW MONTHS.
• THERE MAY BE PARALYSIS IN THE MUSCLES SURROUNDING THE EYE.
• PT SHOULD SEEK IMMEDIATE MEDICAL ATTENTION BECAUSE THE SYMPTOMS CAN BE CAUSED BY PRESSURE ON THE NERVES BEHIND THE EYE.
Retinal Migraine
TEMPORARY, PARTIAL, OR COMPLETE LOSS OF VISION IN ONE EYE
• FOLLOWED BY A DULL, ACHE BEHIND THAT EYE THAT MAY SPREAD TO THE REST OF THE HEAD
Migraine w/ Brainstem Aura (Basilar Artery Migraine)
• SUDDEN ONSET DIZZINESS, CONFUSION OR LACK OF BALANCE.
• SHORT TERM VISUAL DISTURBANCES (DIPLOPIA)
• ALTERATION TO SPEECH
• RINGING IN THE EARS
• VOMITING
• ATAXIA
• STRONGLY RELATED TO HORMONAL INFLUENCES (PRIMARILY STRIKES YOUNG ADULT WOMEN/ADOLESCENT GIRLS)
Abdominal Migraine
• IDIOPATHIC DISORDER SEEN MAINLY IN CHILDREN
• ATTACKS OF MODERATE TO SEVERE MIDLINE ABDOMINAL PAIN
• DULL TO SORE QUALITY
• NAUSEA, VOMITING
• LASTS 2-72 HOURS
• NO HEADACHE WITH THESE EPISODES!!
Cluster Headaches
• SUDDEN ONSET OF FREQUENT, SEVERE HEADACHES THAT OCCUR IN GROUPS (CLUSTERS)
• SEVERE UNILATERAL, ORBITAL, SUPRAORBITAL OR TEMPORAL PX
• SHARP, PULSATING, PRESSURE, BURNING,
• PEAKS IN 10-15 MINUTES
• LASTS 15-180 MINUTES
• PAIN RESOLVES RAPIDLY
• TEND TO OCCUR AT NIGHT
• CYLCES CAN LAST WEEKS-YEARS WITH 1-8 ATTACKS PER DAY
Cluster headaches are associated with:
TEARING, RHINORRHEA, PTOSIS, FACIAL SWEATING, EDEMA OF EYELID
Sunct Headache
• SHORT LASTING, UNILATERAL, NEURALGIFORM HEADACHE WITH CONJUNCTIVAL INJECTION AND TEARING (SUNCT)
• MOD-SEVERE BURNING, PIERCING, THROBBING PAIN
• AROUND ONE SIDE OF HEAD AND EYE/TEMPLE
• PAIN PEAKS WITHIN SECONDS
• USUALLY DURING THE DAY
• LASTS 5 SECONDS TO 4 MINUTES PER EPISODES
• USUALLY 5-6 ATTACKS PER HOUR
• WATERY BLOOD SHOT EYES, EYELID SWELLING
• NASAL CONGESTION, RUNNY NOSE, SWEATY FOREHEAD
• TX: SOFT TISSUE TECHNIQUES, TRY GENTLE ADJUSTING, PT, INJECTIONS,
Tension Headaches
• FREQUENT OCCURRENCE
• WORSE IN AFTERNOON/EVENING
• USUALLY BILATERAL DULL/ACHY PAIN
• TIGHTNESS ACROSS FOREHEAD
• SUBOCIPPITAL OR SUPRAORBITAL
• LAST DAYS-WEEKS
• MAY BEGIN WITH MIGRAINES GOING TO LESS SEVERE TENSION HA
• RESPOND WELL TO ST TECHNIQUES AND ADJUSTING
Treatment of Tension Headaches
Passive: Adjust!, Manual or instrument assistant muscle work Modalities
Active: Post isometric stretching, Deep neck flexors
Home care: Postural awareness, Heat, Stress management
Co-Management: Acupuncture, Massage
Sinus Headaches
ASSOCIATED WITH INFLAMMATION OF THE SINUS CAVITIES
• FACIAL PAIN WORSE FIRST THING IN THE MORNING, IMPROVES AS THE DAY PROGRESSES
• WORSE WITH SUDDEN HEAD MOVEMENT AND BENDING FORWARD
• FEVER, CORYZA, YELLOW OR GREEN MUCUS, FOCAL FACIAL PAIN
• RISK FACTORS INCLUDE ALLERGIES, HIGH ALTITUDES, NASAL POLYPS, SWIMMING OR DIVING
Types of Headache Characteristics: Sinus, Cluster, Tension, Migraine
-Sinus: Behind browbone and/or cheekbones
-Cluster: Pain is in and around the eye
-Tension: Pain is like a band squeezing the head
-Migraine: Pain, nausea, and visual changes
Cervical Facet Syndrome: Presentation
Point tenderness over facet, stiff achy neck, limited ROM
• May radiate into skull, neck, shoulders, upper back
• Pain with extension, Possible HA
• Possible trauma, sometimes insidious
People with cervical facet syndrome often report:
They “Just woke up with it”
Cervical Facet Syndrome: Cause/Risk
• Trauma due to an injury to the facet joint
• Degenerative disc disease
• Stress or strain in a prolonged posture.
Cervical Facet Syndrome Examination
Observation: Antalgia, Anterior Head Carriage
MSR: Rarely Weakness and Sensory Changes (UE)
ROM: Limited ROM
Cervical Facet Syndrome: Orthopedic Tests
Foraminal Compression, Jacksons, Shoulder Depression Test,
C5 Radiculopathy
• Weakness: deltoid and biceps
weak – shoulder abduction
• Sensory: Anterior lateral arm along
the deltoid
• Reflex: Diminished biceps
C6 Radiculopathy
• Weakness: biceps and wrist
extensors
• Sensory: radial aspect of
antebrachium, thumb and index
• Reflex: diminished brachioradiali
C7 Radiculopathy
• Weakness: triceps and wrist
flexion
• Sensory: anterior
antebrachium, middle finger
• Reflex: diminished triceps
C8 Radiculopathy
• Weakness: finger flexors
• Sensory: Ulnar aspect of
antebrachium, ring and little finger
• Reflex: Finger flexors
T1 Radiculopathy
• Weakness: Finger
abduction/adduction
• Sensory: medial biceps
• Reflex: N/A
Lower Cervical Disc w/ Radiculopathy: Signs/Symptoms
In the older patient, cervical radiculopathy is often
a result of foraminal narrowing from:
• osteophyte formation
• decreased disc height
• degenerative changes of the uncovertebral joints anteriorly/facet joints posteriorly.
Lower Cervical Disc w/ Radiculopathy Examination
-Observation: Antalgia, Cervical Flexion
-MSR: Changes in Motor, Reflex and Sensation
-ROM: Limited ROM
LOWER CERVICAL DISC W/
RADICULOPATHY: ORTHOPEDIC TEST
• Foraminal compression test – neg do Spurling’s
• Jackson’s and Spurling’s test is considered the best
• Shoulder depression test reproduces neck and arm symptoms on the side of head deviation
-Valsalva and Soto Hall
• Manual cervical distraction can be used as a physical examination test which will greatly reduce the neck and limb symptoms in patients with radiculopathy.
• Bakody’s sign will decrease discomfort – C5-C6
Cervical Sprain/Strain: Examination
Observation: Antalgia, Outward injuries, Confusion
MSR: Changes in Motor, Reflex and Sensation
ROM: Limited
Cervical Sprain/Strain Orthopedic Tests
O’ Donoghues, Shoulder Depression, Rusts, Soto Hall, Naffzinger’s, Jackson’s, Foraminal Compression, Valsalva, Maximum Cerivcal compression
