SMT Neuro

Question 1

What symptoms would help you determine a patient is experiencing an “Entrapped Facet Joint Inclusion” AKA trapped meniscoid

Answer 1

Unilateral neck/back pain with/without hx of mechanical trauma or positioning strain
Paraspinal tonus, IL capsular pattern; positive joint compression tests
Resisted lateral flexion is more painful on the CL side
Neuro features: nociceptive joint pain, reflex muscle splinting, myofascial pain spots

Question 2

What kind of joint dysfunction does the McKenzie protocol aim to address?

Answer 2

Internal disc derangement (mechanical derangement of disc leading to joint dysfunction - associated with aging, DDD, trauma)

Question 3

S&S of internal disc derangement

Answer 3

Muscle tenderness, spasm, reflex muscle tonus, mechanical dysfunction, nociceptive pain

Question 4

True or false: the clnical pattern for annular disc bulge without radiculopathy is aggravated by valsalva maneuver

Answer 4

True

Question 5

In radiculopathies, which usually is affected first: the motor or sensory portion? Why?

Answer 5

motor - has larger axons

Question 6

Which 4 tests are best for evaluating a nerve root lesion?

Answer 6

Light touch sensation with von frey hair monofilament
Sharp/dull testing
Joint position test
Two-point discrimination

Question 7

The sensory fiber overlap between nerve roots is greater with (touch/pain) fibres

Answer 7

Pain - this is why you should test pain (sharp/full) when evaluating for nerve lesions. Less overlap = deficits will come through sooner. Light touch testing will not reveal early radiculopathy.

Question 8

What are 6 neurological features of fibrotic tissue shortening?

Answer 8

1. Lateral entrapment (positional/nocturnal)
2. Lumbar lateral recess compression
3. Nociceptive pain with overuse
4. Muscle imbalance with reflex inhibition
5. Muscular co-contraction
6. Mechanical joint dysfunction/irritation

Question 9

What is thought to be the neurological cause of upper/lower cross syndrome?

Answer 9

Reflex activity of musculature and/or facilitation of inhibited muscle activity
Nociceptive function around motor units changes the kinematics and muscle contraction patrerns which triggers behavioural modifications, feeding into postural distortions and malalignments

Question 10

Irving Korr proposed that joint dysfunction was sustained after nociceptive input from joint receptors was gone through which part of the neural circuit?

Answer 10

Hyperactivity of the interneuron

Still recieves nociceptive input from many other receptors (ie skin receptors)

Question 11

What is the convergence theory?

Answer 11

Says that afferent sensory functions from visceral and somatic sources converge onto the same neural unit. Acitvation of other areas innervated by the same neural unit can affect other tissues.

Question 12

How does Howard Vernon describe central sensitization?

Answer 12

Progressive overflow of nociceptive funcitons at the motor unit leads to progressive changes/stresses
Causes buckling and inflammation, leading to central sensitization

Question 13

What structures make up the posterior, lateral, and anterior borders of the thoracic outlet?

Answer 13

Posterior: first thoracic vertebrae
Lateral: 1st rib
Anterior: clavicle, SC jt, manubrium of the sternum

Question 14

What are the 3 areas where constriction can occur in the thoracic outlet?

Answer 14

1. Interscalene triangle
2. Subclavicular space
3. Pec minor

Question 15

What makes up the base and sides of the interscalene triangle? What are its contents?

Answer 15

Base: first rib
Sides: anterior and middle scalene muscles
Contents: inferior trunk of plexus, subclavian artery

Question 16

Roughly ____% of patients have neurogenic TOS, while ___% have venous TOS, and ___% have arterial

Answer 16

95%; 2-3%; ~1%

Question 17

Name 6 MOI for TOS

Answer 17

Trauma
Repetitive injuries (i.e. sports)
Anatomical defects
Pregnancy
Postural faults (forward head carriage)
Overuse (abnormal pressure on shoulders due to heavy backpack, canoe, construction material)

Question 18

What are 4 anatomical anomalies which can cause TOS?

Answer 18

Cervical rib
Prolonged TVP
Muscular Abnormalities (eg. sickle-shaped middle scalene)
Fibrous CT

Question 19

What are 2 causes of arterial TOS?

Answer 19

Cervical rib
Excessively long TVP of C7
Causes arterial compression with arm movement

Question 20

What are the 2 points of impingement for venous TOS? Which soft tissue structures commonly contribute?

Answer 20

Rib & clavicle

Subclavious muscle, costoclavicular ligaments

Question 21

Compare the S&S of neurogenic and vascular TOS

Answer 21

Neurogenic:
- painless atrophy of muscles of hands (weakened grip strength)
- numbness/tingling in fingers
- pain in neck, shoulder, hand
Vascular:
- cyanosis of hands during activities (sometimes at rest)
- arm pain due to claudication and edema
- blood clot in veins or arteries in upper areas of arm due to atherosclerosis
- pallor in one or more of fingers and entire hand
- cold fingers/hands/neck
- arm/neck weakness
- throbbing lump near collarbone

Question 22

Name 5 complications of TOS

Answer 22

Frozen shoulder
CTS
Paget-Schroetter syndrome
Cerebrovascular arterial insufficienct
Loss of vision due to vertebral artery compression

Question 23

Which orthopedic test can diagnose anterior scalene syndrome?

Answer 23

Adson’s (loss of radial pulse in arm by rotating head to IL side with extended neck following deep inspiration)

Question 24

How can you test for costoclavicular syndrome?

Answer 24

Costoclavicular maneuver: find radial pulse then have patient abduct, externally rotate, and extend arm to 45degrees. Apply downward traction to arm and turn neck away from affected side.

Question 25

What did Wason & Pizzari find was the biggest flaw with classic TOS provocation tests?

Answer 25

Low specificity - up to 90% of healthy patients had pulso obliteration

Question 26

True or false: if Adson’s test is negative, TOS can be ruled out

Answer 26

False - low sensitivity

Question 27

How do you perform Wright’s test?

Answer 27

Patient’s shoulder abducted and externally rotated to 90deg, examiner takes pulse
Patient hyperabducts arm and examiner re-assesses pulse
Positive = change in pulse or symptom reproduction

Question 28

Which ortho test can be done to assess for pec minor syndrome?

Answer 28

Allen’s:
Hyperabduction of patient’s shoulder with elbow flexed 90deg
Patient rotates head CL to affected side

Question 29

What is the difference between traction test and Halstead maneuver?

Answer 29

In both, patient is seated and arm is distracted distally while examiner checks for changes in pulse or symptoms
In Halstead, perform traction test but have patient extend neck as well

Question 30

What is Paget-Schroetter syndrome?

Answer 30

Axillary-subclavian vein thrombosis resulting from repetitive strenuous upper extremity activity
AKA effort thrombosis