ToS, WAD, Facilitated segment Flashcards
what are the three primary outlets for ToS?
scalene triangle
costoclavicular space
subcoracoid space
what is in the scalene triangle?
subclavian artery
brachial plexus - lower roots
what is in the costoclavicular space?
brachial plexus - lower trunk
subclavian artery
subclavian vein
what are the boundaries of the costoclavicular space?
first rib
clavicle
costoclavicular ligament
middle scalene
what are the boundaries of the subcoracoid space?
pec minor
coracoid process
posterior ribs
what is in the subcoracoid space?
brachial plexus - lower cords
subclavian artery
subclavian vein
name three functional causes of costoclavicular TOS
poor posture (drooping shoulders, protracted and FHP)
carrying heavy objects, backpack
repetitive overhead arm movements (sports, etc)
what are some things to rule out with TOS type symptoms?
Cx spine spondylosis -> referred pain, neuromeningeal
Cx radiculopathy
peripheral nerve entrapment
pancoast tumour
TOS can be neurological or vascular (artery or nerve), but which is the most common?
neurological, 95% of cases
what kind of symptoms would you expect in true neurological TOS?
- pain and paraesthesia in neck, chest, and U/E
- neuro exam (+) but not as pure as nerve root compression
- ULNT1 usually positive too
what kind of symptoms would you expect to see in symptomatic TOS?
- pain/paraesthesia in ulnar areas
- provoked with prolonged arm above shoulder height positions
- neuro exam (-)
- ULNT1 (+) in ulnar sometimes
how many special tests need to be positive to be indicative of symptomatic TOS?
3/5? even though we only learned 4?
Name four special tests for TOS?
Adson
Roos
Hyperabduction (for symptoms or for pulse)
Tinels at supraclavicular nerve
name some symptoms of arterial TOS?
- cold sensitivity -> Raynaud’s phenomenon
- decreased pulse and BP in arm, esp in hyperabduction or Adson position
what are some symptoms of venous TOS?
- edema, engorgement
- cyanosis
- fatiguability
- U/E stiffness
- Adson positive
what does Adson test for - neurologic or vascular TOS?
trick! tests for both - will get loss of pulse in vascular, paraesthesia in neurologic
what else should you assess when looking at TOS
posture ULNT deep neck ms breathing pattern first rib scapular postioning
your patient is positive in Adsons for neurological TOS. You repeat the test with her scapula in a corrected position, and the symptoms improve. What does this mean?
they are a good candidate for rehab
name some treatment ideas for TOS
- EDUCATION ABOUT POSTURE
- scap position, strengthening stretching taping
- spine mobs
- deep neck stabalizers
- breathing pattern
- nerve glides
what kind of disc lesion can happen in whiplash?
rim lesion - very irritable, need MRI to confirm
how long will recovery usually take with WAD?
half of people will still have pain at 3 months, 35% at 12 months…
44% people recovered after 1mo
65% after 12mo
75% 5yrs
at what grade of WAD will there be physical signs of decreased ROM and point tenderness?
grade II - separated into IIA (no psychological distress), IIB (psychological distress), and IIC (acute post-traumatic stress)
at what stage do neurological signs appear for WAD
grade III
what are some high risk factors that means you should get an xray post WAD?
over 65 fall from height over 3ft or 5 stairs axial load to head MVA over 100km/hr MVA motorcycle MVA bicycle numbness or tingling in extremities
what are some indicators of a poor prognosis?
- high initial pain intensity, catastrophizing, high self-rated injury intensity
- low self efficacy, low educational level, anxiety
- increased sensitivity to cold, reduced ROM of neck
what kind of red flags should be searched for?
- CNS
- VB
- Cranial nerve
what 5 elements should be done in a WAD exam?
- CNS
- perpheral nerves
- VB
- Cr-Vx ligaments
- concussion
your patient is complaining of dizziness post WAD injury, but you suspect a concussion. What would be some signs to look for?
- memory impairment
- depression
- fatiguability
- insomnia
- mood swings
nausea and vomiting may be from what (not vestibular)
cranial nerve involvement
what should always be done before ROM of neck in WAD?
neuro exam to rule out SC lesion
are collars recommended for WAD?
NO! if they are ever used it should be for less than 48hrs
the facilitated segment theory postulates that constant afferent input can lead to:
“central segmental excitation”
what type of pain do facilitated segments cause?
referred pain, dermatomal. can also cause hyperalgesia and hyperesthesia (increased sensitivity to deep and light touch).
other than pain, what else can a facilitated segment cause?
tenderness, hypertonicity of key muscles, and soft tissue changes
when there is a constant neural input by a facilitated segment, the synaptic resistance is ______ while neuronal transmission is ______
lowered
facilitated
name three possible causes of a facilitated segment
vertebral dysfunction (hypermobility) visceral disease peripheral joint dysfunction
name 4 possible motor changes that one may see with facilitated segment
- hypertonicity
- stiffness
- exaggerated reflexes
- fatiguability
what three autonomic changes may happen with a facilitated segment?
- vasoconstriction
- sweating
- orange peel skin
what can you do (Ax) to test for:
a) motor changes
b) sensory changes
c) autonomic changes
a) muscle stretch, palpation at rest, RISOM, reflexes
b) light touch and pinprick
c) scratch test for vasoconstriction, drag test for sudation, skin rolling test for orange peel/thicker skin
what is the most common facilitated segment level? what are 3 findings of this problem?
C5/6 hypermobility leading to C6 facilitated segment.
- pain over lateral epicondyle and ECR muscle
- resisted wrist extensor muscle -> fatiguable/painful
- wrist extensors stiff & painful
