Syndromes Flashcards
Altered Muscle States
- Spasm
- Hypertrophy
- Involuntary Muscle Holding
- Chemical Muscle Holding
- Voluntary Muscle Holding
- Disuse atrophy
- Wasting and Fibrosus
- Adaptive Shortening (normal tone)
- Fibrositis:
- Myalgia
Involuntary Guarding
Caused by injury or dysfunction
S/S include hypertonicity, protective muscle guarding with loss of “free” motion, elevated resting tone and abnormal elastic response to stretch
Treat the cause of the impairment
Chemical Muscle Holding
Caused by sustained involuntary guarding and could lead to a compartmental syndrome
S/S include doughy to touch, limited ROM
Treat with heat and massage to promote circulation to remove irritants and waste; exercise; think compartmental syndrome multifidus
Voluntary Muscle Guarding
Caused by pain or fear of pain and often follows involuntary or chemical muscle states
S/S include slow and guarded motions, can see trunk move as a whole
Treat once more serious pathologies, such as a fracture is ruled out; give reassurance and encourage movement
Adaptive Shortening
Caused by chemical muscle holding or slouched posture
S/S include NORMAL tone*, shortened length, loss of ROM, altered posture with increased lordosis secondary to psoas shortening
Treat with myofascia stretching
Facet Dysfunction
(1) Synovitis/Hemarthrosis (Strain)
(2) Stiffness
(3) Painful entrapment
(4) Mechanical block
(5) Chronic facet arthrosis
Synovitis/Hemarthrosis (Sprain)
Caused by awkward movement of catch or gross trauma
S/S: good but guarded movement, involuntary and voluntary muscle holding
Treatment:
- Lumbar: rest, soft corset, careful movement
- Cervical: rest, soft collar, careful movement - circular, interferential for swelling
- Codman principles to acute neck = diaphragmatic breathing, slow circumduction, circles within circles
Restriction/Stiffness
Caused by resolved synovitis hemarthrosis, not symptomatic
S/S: NONE, stiffness does not hurt; lowered tolerance to insult hence strain & associated pain if from current strain of the joint or neighboring hypermobile joints may become symptomatic if unstable
Treat with manipulation
Painful entrapment
Caused by an awkward movement in an eccentric range
S/S: unstable to slide inferior articular process down, head held away from painful side
Treatment:
- cervical: multifidus isometric manipulation
- lumbar: multifidus isometric manipulation or rotational manipulation over bolster
Mechanical block
Cause can be idiopathic, loose body or impaction
S/S: sudden onset, block to motion, relatively pain free
Treatment:
- cervical: strong manual traction with SB away and ROT to the blocked side
- lumbar: rotational manipulation over a bolster to further open up affected side
Chronic facet arthrosis
Caused by poor posture, trauma or overuse
S/S: dull ache, local pain, stiffness
Treat with posture, mobilize adjacent areas
Sacroiliac dysfunction
(1) Sprain strain
(2) Hypermobility
(3) Displacement
(4) Ligamentous weakness
(5) Instability
(6) Disc dysfunction
Ligamentous weakness
Caused by repeated minor strains, obesity, poor posture, vibration
S/S: pain on assuming fixed position, pain relieved by changing position, relieved by “cracking back” increasing weakness, supraspinous and S/! ligaments sensitive to touch
Treatment:
- early: exercise, stabilization, posture, back school
- later: pre discal rest/controlled activity, corset, braces, taping, instruction in first aid (ex: BB if injury was to occur)
Instability
Definition: instability is where the osseo-ligamentous structures and the neuromuscular control systems are unable to hold a spine in neutral and during motion against buckling and slippage/shear.
Caused by ligamentous stress and strain from sports and poor posture, lack of NM training and exercise, surgical such as laminectomy or fusion (above), and medical/surgical such as with cymopapain
Characterized by ligamentous weakness/laxity, muscle weakness and neuromotor atrophy, fatigue, poor posture, pain on assuming fixed position and chronic pain
Treatment:
- ensure slow continuous improvement
- muscle endurance, body awareness with motor control, diet and nutrition, motivation, frequent rest for disc nutrition, education on stability/overload and on movement/exercise
- exercises: abdominal setting with TA, multifidus, quadratus lumborum, quads, glutes
- MT to joints and myofascia
Cervical Spine Stabilization
Posture: atlas moves posterior with forward head
- keep all ROM activities within range
Avoid BB, neck rolling, isometrics as they can cause translation/slippage and aggravate instability
Treat by strengthening longus coli and multifidus strengthening
Disc dysfunction - Paris Tx Classification
(1) Pre-prolapse - instability
(2) Immediate injury - tear/herniation
(3) Acute & Sub-acute Prolapse
(4) Settled prolapse
(5) Chronic disc disease
Pre-prolapse
Hx: dull muscular ache on sitting (chemical muscle holding), has need to get up and move around, hx of self cracking, LBP occasionally radiating into buttock, no frank neuro signs
Physical: many instability signs, Grade 5/6 PIVM
Tx: stabilization, back school, manipulation, instruction for first aid
Immediate injury - tear/herniation
Hx: hx of pre-prolapse, sudden unguarded motion resulting in acute/deep pain usually from flexion and maybe with torque, patient may report “tearing” or “giving out”
S/S: sudden deep pain, can refer to buttocks, very guarded movements
Physical: avoid FWB and rotations, neuro signs will be negative for first 30 min, usually happens outside clinical setting
Tx: GOAL to heal outer annulus
- immediately into lordosis & stay for min 2 weeks; prefer 3-4
- support & reinforce behavior with taping or corset
- tx as acute prolapse if lordosis cannot be achieved without causing peripheralization
- gentle stabilization exercises
- myofascial techniques
Acute & Subacute prolapse
S/S: classic neurological signs, fatigue, disability Acute: days 1-4 - aim for lordosis - minimal bed rest to avoid disc swelling - attempt BB - medical palliative measures - education Subacute - day 4 and improving - initiate movement - myofascia manipulation - corset, stabilization - avoid aggravating prolapse
Settled prolapse
3 - 4 weeks, slow improvement, ambulatory
- Begin positional distraction with caution, treat as a home program WITHOUT rotational component
- Stabilization
- Lifestyle, healthy back regime
GOAL: prevent chronicity by encouraging activity and managing any fear avoidance behaviors
Chronic discogenic back pain
Hx: serious debilitating back pain with history of neuro signs and possibly failed surgery or other treatments
Physical: sad, depressed patient on meds; often obese, unfit, unhealthy, ROM restricted secondary to pain, PIVM combo restrictions and instability, myofascial restrictions with poor tone/condition
Tx: lifestyle education, stabilization, positional distraction if neuro signs, “careful” neuro mobs, manipulation, fitness training/work hardening, counseling
Spondylolisthesis - Type I
Fatigue fracture of pars-articularis - spondylolisis
S/S: step on standing (appears one level higher than defect), if unstable it will disappear when lying, hypertonicity at affected level, ligamentous dull ache, rotational component if one sided that can be palpated in standing
Caused by repeated overload, combo torque motion that involves extension and rotation
Common in weightlifters, gymnasts, divers
Tx: stabilization, manipulation to joints above and myofascia to psoas
Spondylolisthesis - Type II
Degenerative - facet arthrosis and tropism
Caused by congenital tropism which is the alteration of facet planes from mostly coronal to sagittal, degeneration process leading to facet arthrosis and overload in these conditions.
S/S: step will appear at the level of the slip, x-ray must be in standing and loaded at the end of the day
Treatment: same as type I, stabilization and manipulations to usually joint above and myofascia to psoas
*lordotic posture can make spondy worse, therefore look for tight hip flexors and stretch in prone or supine with leg off table
Spondylolisthesis - Type III
Isthmic spondylolisthesis Pars interarticularis (isthmis) lengthens allowing vertebra to slip forward, precipitating factors include childhood obesity S/S: x-ray may show elongated pars/isthmus or show fracture of pars therefore the stretch of pars (initial cause) is often missed Treatment: same as types I and II as well as weight control
Spinal Stenosis
Definition: narrowing of an opening, lumen, etc.
Main concern is the affect of narrowing on the spinal cord and nerve roots
Lumbar spine - central spine stenosis
Collapse of disc into central spinal canal -> enlarged facet -> loss of disc height -> thickens LF -> very narrow spinal canal
Caused by degeneration, wear/tear, poor posture, abdominal protrustion/lordosis, tight iliopsoas, tight lumbar spine myofascia, disc protrustion/prolapse
S/S: chronic dull LBP, leg pain on walking any distance**have to distinguish neurogenic claudication from vascular claudication
Treatment: myofascial manipulation and stretching of psoas and LB musculature, increase physical fitness, lifestyle changes, surgery
*surgery LAST option for patients who are older, diabetic, overweight, poorly motivated, basically unhealthy
Lumbar spine - lateral foraminal stenosis
Caused by lateral disc protrusion, loss of disc height, and degenerate changes to LF and facets
S/S: lateral symptoms including pain, subjective numbness, hyper neurological responses (pre-prolapse NR irritation), true neurological signs such as paresis, skin sensation, reflexes and neural tension (SLR)
Treatment: posture and movement education, stabilization, stretch myofascia, manipulate stiff joints, positional distraction, possible heel lift on unaffected side to open affected foramen
Cervical spine - central stenosis and myelopathy
Caused by congenital narrowing of the cervical spinal canal, hypermobility/instability, resultant bosses and bars into spinal canal and enfolding of LF
Bosses and bars = ridges; osteophytes are one of the causes of narrowing and cord pressure
Contributing factors include poor posture with forward head, cervical stress/strain/sports/MVA, compensatory hypermobility and UT kyphosis/stiffness, and instability mostly at C2/3 and C5/6
S/S: BUE s/s (central), vague/transient neuro signs arms and maybe legs, test LE for UMN signs (Babinski, Clonus)
PT: posture, stabilize cervical spine, avoid BB with sleeping and activities, manipulate UT region to reduce MC stress
last option surgery to remove impingements and then fusion
Lateral foraminal stenosis (radiculopathy)
Caused by degenerative changes, osteophytes from lateral interbody articulations (such as uncinated processes, von luschka joints), thickening of LF, arthrosis of facet joints
Contributing factors include U/T slouch and stiffness which causes MC hypermobility and instability
S/S: neck/arm pain and paresthesia, frank neuro s/s of muscle/skin/reflex, positive ULTT, positive spurling
Treatment includes joint and myofascia release, posture and positional distraction
*surgery would include foraminectomy
Lumbar vs. Cervical neurological signs
Lumbar: usually discogenic, young age 28-50, male more than female
Cervical: spondylogenic degenerative arthrosis, older age group 50+
Whiplash Acceleration/Deceleration Injuries
Caused by motor vehicle accidents, fall down stairs, hit by yacht boom (trauma)
S/S: very unreliable, often minimal initially, minor to bizarre, sympathetics
Horner’s syndrome
interruption of the sympathetic nerve supply to the eye
S/S: ipsilateral loss of sweating, ptosis, pupil constriction
check cranial nerves
Treatment Protocol for WAD
Rigid immobilization for 2 weeks
Plastic collar at 1 week if symptom free
Soft collar at 4 weeks if symptom free
NO traction ever until after 8 weeks
- also - minimal movement first 2 weeks, no exercise for 4 weeks, no resisted exercises for 8 weeks
- early rehab can use submax CCFT, treat thoracic spine and use eye movements to contract deep neck/suboccipital muscles
Signs of odontoid fracture
Nausea, Nystagmus, Numbness
Distress, Distal paresthesia, Dysarthria, Dysphagia, Diplopia, Dilation of pupils, Dizziness, Drop Attacks
Thoracic outlet syndrome
Definition: compromise of the neurovascular structures of the UE
Functional causes include hypertrophy or adaptive shortening of the anterior scalenes, elevation of the first rib, hypertrophy of the subclavius, and adaptive shortening of the pec minor
Congenital causes include broad insertion or 2-banded insertion of anterior scalene, fibrous slip running from anterior scalene to mid scalene and presence of a cervical rib or fibrous band from C7
Other causes include bony exostosis of the first rib (old fx) or tight clavi pectoral fascia
S/S: most commonly affects inferior trunk/ulnar N
pain, paresthesia in UE, can be deep aching usually in medial arm/forearm, intermittent claudication, Raynaud’s phenomena, intermittent edema/venous engorgement/cyanoses, dorsal scapular pain
Treatment: depends on what was found
Manip restricted joints including first rib and T spine, myofasical manip for tight muscles, postural re-ed, instruction in diaphragmatic breathing, HEP for self-stretch and mobilization, special tx for release phenomenon
Headaches
Principal indicators:
- pain begins in the cervical or thoracic spine
- headache can be affected by a change in posture or movement
- a history of trauma preceded the headaches
- physical or emotional stress brings on headaches
Red flags:
- very short history
- new headache that they have not had before
- headache is worse than ever before
- behavioral and mood changes
Lesion changes
More than one syndrome/structure
Paris 1965 - The “lesion complex” refers to the fact that while one entity may predominate, others will soon be present. “degenerative cascade”
Treatment for each syndrome:
(1) soft tissue restriction -> myofascia techniques
(2) limited facet motion -> manipulation
(3) restricted hip function -> manipulation
(4) instability -> stabilization routines
(5) poor general condition -> general conditioning exercises
Kissing SP - Baastrups disease
Arthritic “joint” forms between SPs in lumbar spine
Commonly a source of LBP in short stocky middle aged men
Caused by SP rubbing in posterior midline and inflammatory reaction as a source of pain
Contributing factors include poor posture, pot belly with excessive lordosis, short stocky males
Treat with pelvic tilt, stretch psoas and myofascia, weight loss, healthy back living
Kissing lamina
A condition of friction between the lamina or vertebra at 1 or more cervical levels
S/S: central neck pain
Contributing factors: excessive M/C lordosis, stiff U/T, M/C hypermobility/instability, loss of disc height, collapse of lateral interbody joints
Treatment: posture and stabilization, avoid BB and circumduction, manipulate U/T
Thoraco-lumbar syndrome
aka Maigne syndrome
Description: pain over the ant/lat and occasional giving away of the leg, often confused for hip impairment
Caused by instability of the T/L junction involving the lateral cutaneous N to the thigh
S/S: pain over lateral thigh, spontaneous giving way of the leg, tenderness of iliac crest laterally
Treat with stabilization of the T/L junction with multifidus exercises
