MS 1: Parts 1-3

RLQ pain/worse hip movements/McBurney point/Rovsing sign is related to what condition?

Appendicitis

Once we discover the mechanism of injury (MOI) we move on to the Dimensions of pain, and we look at 7. symptom location, 8. symptom (pain) quantity, and 9. symptom quality, what should you have the patient do for symptom location?

Have patient point precisely to symptom location(s) (and trace the regions)

True or False: By the end of the history you should be able to hypothesize 1 or more diagnosis

True

Whats the differences between a sudden onset, gradual onset, and recurrent onset?

- Sudden onset = usually a trauma - want to gather the MOI - Gradual onsets = microtrauma, degenerative conditions - Recurrent = problem that was never solved /fixed

When would we conduct a functional screening for AROM?

Acute care, screening assessment of multiple body parts

What are some of the advantages and disadvantages with a Self-Report Medical History Questionnaire?

Adv: fill out themselves reducing the liability, may be quick Disadv: Can take 30 minutes to fill out and can capture this in 15 mins., less likley to commit, libaility is only as good as the form

If a patient presents with severe or prolonged compression from foraminal spinal stenosis they may have _____ signs. In this case what may they develop?

LMN's Neuropraxia

A Bancroft sign is when there is pain when the calf is pushed into the tibia but not when you push the calf...?

From side to side

What is HCTZ used for?

Thiazide Diuretic prevents body from absorbing too much salt / fluid retention / treats fluid retention on CHF, liver, kidney disorders ... also treats hypertension

An annulus can tear and chemically irritate the nerve root this may produce ______ symptoms. If the disc swells when we sleep overnight, and it feels worse in the morning this is due to...?

Constant related Nocturnal Inhibition

Whats the difference between a strain and pain? Do we want to produce a strain?

Strain: hurts at the end range than goes away when we stop, no damage is created Pain: hurts at the end range than persists longer (created damage or chemical inflammation) Want to produce strain (as long as discomfort stops) can push as hard as you can Ex: 9/10 hurting back off and it goes away than explain that no tissue damage is taking place

Although, end-feels can be very shady it helps us identify...?

The etiology of a motion loss. End-feels are determined by applying overpressure at the end of PROM (still try and make a go at it)

Special tests are used to confirm a tentative diagnosis or assist w/differential dx, some examples include...? How long do you hold these tests for?

Spurling, Cervical distraction, Bakody -30 seconds or until they have pain than stop

A ganglion cyst can form due to the tearing of...?

Tearing of ligaments or lunate triquetrium ligament (ganglion)

At the end of your interview and systems review you should be able to generate a preliminary....?

Testable hypothesis Helps steer test & measures

If an UMN lesion is present what special tests can be done to confirm or reject this hypothesis? What is the cause of etiology of UMN signs?

Tests: 1. Babinski 2. Hoffman 3. Clonus -Central stenosis (cord compressed), CVA, tumor, TBI, disc hernia

What are some other system specific risk factors for Musculoskeletal/Neurological (risk factors for red flags)?

• Unrelenting night pain unrelieved by positional change • Symptoms independent of mechanical stimulus • Joint pain & swelling/heat with no apparent reason onset • Bone tenderness • Rash w/pain (lime disease, shingles) •Saddle anesthesia and/or loss of bowel or bladder function* •Undiagnosed! -Dysarthria, dysphasia, or dysphagia -Acute loss hearing, vision or diplopia -UMN signs & symptoms -Progressive or sudden LMN signs

Palpation: What are the 7 possible reasons a patient may have swelling...?

•Bleeding: immediate (tear or fracture) - ↑ temperature -Ecchymosis*may be delayed (ham/calf) •Synovial: delayed ≈ 24 hours thick/boggy -Acute or chronic •Serous fluid: fluctuates, loose -fluid wave •Pitting: indentation •Diffuse: systemic - lymphedema, sodium, HTN, CHF •Chronic: thick/leathery/brawny •Hard: bone, callus after fracture, exostosis

Is weakness more pronounced w/peripheral nerve branch or myotome?

Peripheral nerve branch weakness is much more pronounced Overlapping with myotomes

You should never HAND calculate BMI yourself plug their height and weight into a program. What is considered normal?

- 18.5-24.9 normal Medicare age tend to live a little bit longer (a little bit more meat on their bones) BMI of 23 less than 30 is considered normal in some studies

Someone who is alert, awake, and oriented (AAO) can be x 0,1,2,3, or 4. What does this exactly mean?

- AAO x 4: the person, themselves, the place, the time, and the event (he listed 5 but just be aware of them all)

Whats the difference between the Grading scale for pitting edema and the edema scale that uses (1+)-(4+)?

- Graded from 0-4 (second or timed grading scale cleaner) - Grade 0: If you press in on someone's skin and does not leave an imprint - Grade 1: if it leaves an imprint and there is an immediate rebound - Grade 2: if imprint stays for up to 15 seconds - Grade 3: 16-30 seconds - Grade 4: greater than 30 seconds 1+: mild pitting slight indentation 2+: indentation subsides rapidly 3+: indentation remains for short period of time 4+: considered more of a deep pitting (subjective but be familiar with both scales)

Palpation: Use back of hand or volar wrist to check for temperature bilaterally: What causes increased temp vs decreased temperature?

- Increased temperature • Bleeding • Infection • Inflammation (acute) • Post exercise • Venous stasis • Stage 1 CRPS - Decreased temperature • Chronic • Decreased circulation

Non-Mechanical Conditions that Mimic MS Disorders: What are some conditions from the kidney that may mimic MS disorders?

- Pain from renal calculus (will likely have a period of hematuria, once stone passes into bladder unlikely to cause pain): pain with percussion over kidney*, hematuria, periods of intense pain F/B absence of pain, thoracic flank region and/or right lower abdominal quadrant pain**, Flank pain or percussion pain only when there is a hydronephrosis - *may be delayed **Stone pain based on geographics

Non-Mechanical Conditions that Mimic MS Disorders: What are some conditions from the Appendix that may mimic MS disorders?

- Pain/tenderness lower right quadrant, severe, sudden, anorexia, constitutional signs, MAY worsen with hip movements, visceral pain, McBurney point (decrease appetite in the McBurneys point 1/3 the way of the right ASIS and the umbilicus), Rovsing sign: press into the LLQ increase pain in RLQ nice example of the poorly experience visceral system or neurological system that the lack of understanding it has over visceral pain

Non-Mechanical Conditions that Mimic MS Disorders: What are some conditions from the Gallbladder that may mimic MS disorders?

- Pain/tenderness right upper abdominal quadrant, rebound tenderness, scapular/acromion right shoulder pain referral, fatty foods may worsen the symptoms, Murphy sign: have the person lay supine you identify the mid clavicle region and you draw a line straight down to the lower aspect of the ribs anteriorly than you hook your fingers under trying to dig your fingers under that rib cage have that person take a deep breath (can't take a deep breath or have severe pain considered positive

What is the scale for documenting DTR, if you can't get a reflex on the third attempt what should you do next?

-0=Absent -1+=Diminished -2+=Normal -3+-Exaggerated -4+=Pathological -Jendrassik: hold breath & squeeze hands or feet together (tips: make sure patient is releaxed, tap no more than 3X, use long lever technique, speed not force!!)

If a patient only has 5 deg of DF how much do they need to walk, what about stairs, run?

-10 deg DF walk -15 deg DF stairs -20 deg DF run

Whats considered normal: -Combing your hair you need ____ deg of scaption or abduction, _____ deg of ER to wash our hair -To "reach up our backs" we need _____ deg of shoulder extension -We need ______ deg of supination of forearm and wrist to use telephone or place it to our ear -You need ______ deg of hip flexion to tie a shoe lace

-119, 89 -69 -60 -120

Whats considered normal: -Functional Squat, you need ____ deg of lumbar flexion, _____ deg of knee flexion, and _____ deg of hip flexion -Walk you need ____ deg of DF, and _____ deg of hip extension for terminal stance -To descend stairs you need ______ deg of DF, ____ deg of knee extension for lead foot and ___ deg of knee flexion trailing leg -To Run you need ____ deg of DF -To back up your car you need _____ deg of cervical rotation

-48, 117, 120 -10, 10 -15, 0, 107 -20 -68

If a patient injured themselves in the 9090 High 5 position may suggest...? Lateral blow to the knee may suggest? Inversion ankle injury? Bench Press Injury?

-Anterior dislocation, subluxation, labral tear -MCL tear -ATFL injury -Pec Major Tear

• Height/Weight: BMI • Circumference: tape measure (cm) • Body composition: body impedance, skin fold • Volume: immersion These are all examples of...?

-Anthropometrics=body dimensions & composition

A patient may have hypomobility (limited) due to PostOp, injury,-repair, dissues, joint pathology (OA), but what treatment would be best? With Hypermobility (excessive) the causes are typically due to instability, ligament disorders, and generalized hyperlaxity, what treatment would be best?

-Arthrokinematics -May have good muscular control but want to make sure they are stabilized during interventions

If positive myotomal weakness what would be assessed next? If sensory loss assess dermatome vs. cutaneous branch, than whats the next step?

-Assess remaining actions of myotome vs. peripheral branch -Determine protective & disciminative, confirm if they have hyposthesia (inability to perceive sharp) may want to avoid thermal modalities ALL dermatomes have an origin at the proximal spine

Joint Specific Questions: When discussing the Hip area, what kind of joint specific questions should we ask or relating too?

-Audible -WB pain -Groin Pain -LBP (with hip, knee, ankle/foot) OA: WB Pain Audible sounds: labral tear instability popping clicking Grinding-degenerative

Joint Specific Questions: When discussing the Shoulder, what kind of joint specific questions should we ask or relating too?

-Audible sounds -Night/Sleep (SN. 88) -Painful arc (RTC pathology and subacromial impingement) -90/90 (anterior instability) -Dom. arm overuse

In the ICF Impairments are also called_______, what about functional limitations?

-Body function/structure -Activity limitations

Normal End Feels: If an end-feel feels hard unyielding painless this is a...? If an end-feel yields, mushy this would be a...? Tissue Stretch: Whats the difference between a Ligament/Capsular end-feel and a Muscular end-feel?

-Bone to Bone -Soft Tissue Approximation - Ligament/Capsule: slight yielding then an abrupt stop, sensation of stretching leather, will cause discomfort* if taken beyond end-range but no worse as result (wrist flexion with elbow flexed, fingers relaxed=inert tissue) - Muscle: elasticity at first (not abrupt), resistance directly correlates with range! May produce discomfort* beyond end-range but no worse as a result (wrist flexion with elbow extended flex fingers=muscle)

With Statin Induced Myalgia we will have lower ______ or _______ production and the body begins using the muscle (gluconeogenesis) worse with activity (requires bioneurogenics)

-COQ10 -Ubiquinol

When speaking about symptom prevalence (frequency) we want to know whether the pain is constant or intermittent. Whats the difference between chemical and mechanical pain? What type of injury may have both?

-Chemical: inflammatory symptoms are usually constant -Chemical MS pain should change decrease= w/meds (corticosteroid), ice, or rest, more complicated until symptoms resolve -Mechanical: symptoms (pain) are usually intermittent (times of day they have no pain), can abolish increase or decrease w/activity or position changes Less likely to benefit from ICE, NSAIDS, corticosteroids Acute injury may have both

This test can be performed at the ankle or wrist and involves quick DF of the foot & hold observe and count the oscillations, for the wrist quickly extend the wrist and observe the oscillations what is this test called and what is a normal vs. abnormal response?

-Clonus Test Ankle: support knee in a partly flexed position. With the patient relaxed, quickly dorsiflex foot & hold. Observe for rhythmic oscillations (> 0 = +sign). COUNT BEATS for documentation (>5 = sustained). Wrist: support the elbow in a partly flexed position. With the patient relaxed, quickly extend the wrist. Observe for rhythmic oscillations (+sign). COUNT BEATS for documentation

How does a nerve (root/branch) get compressed or stretched? What are some other ways nerves can be damaged?

-Compression • Stenosis or space occupying lesion (disc, osteophyte, tumor) • Trauma (fracture, dislocation, or swelling) -Stretch • Injury (trauma, exercise, dislocation, surgical) -Other: burn, scar tissue adherence (more likely not to have signs), laceration

Central stenosis may be either _______ or _______, often times does this condition produce a symptomatic patient?

-Congenital -Acquired -It depends where the compression of the cord is located Cervical (upper thoracic)- yes Lumbar (lower thoracic): does not produce symptoms, below the conus medularis (L2 will produce LMN sign)

•Pain differential: -AROM is WNL & painful (anterior knee) with knee extension, however, PROM knee extension is pain-free, what type of tissue lesion? •AROM loss differential: -AROM shoulder abduction painful & limited to 90°, PROM abduction 95° & painful, is it due to weakness of stiffness?

-Contractile -Stiffness as opposed to weakness (determine what is the etiology of stiffness)

- Pain w/AROM that is absent (pain free) w/PROM is likely ________ tissue - Pain with AROM that persists w/PROM is likely _______ tissue, and is not painful with RIMT *Caveat: AROM may not be sufficient to reproduce pain with all contractile tissue lesions

-Contractile (Partial tear or tendon, or acute tendonitis, or partial tendon tear will cause pain with AROM) -Inert •Caution: contractile may be stretched/compressed at end-range • Caution: PROM may be hypermobile ( > normative values)

Pain differential: Describe Contractile vs. Inert Lesions (think AROM, PROM, and RIMT) Note: pain differential also will include special tests & palpation Note: Contractile tissue may be stretch/compressed when applying overpressure to determine end-feel. Consider pain location & test position

-Contractile lesion: -AROM: pain when tendon acutely inflamed or > grade 1 muscle strain (in most instance may not be enough produce pain) -PROM: no pain (True PROM=no stretch) -RIMT: reproduces pain (limitation may be tester strength) -Inert lesion: -AROM: pain -PROM: pain -RIMT: no pain (unless testing is so aggressive it induces movement of joint or joint is positioned incorrectly end-range)

RIMT Interpretation: With a False+ painful or weak but etiology is not _______ or _______.

-Contractile or Neural (joint stress from test, fracture, neoplasm, infection)

Weakness is identified as the source of AROM loss (PROM is normal) the next step is to determine the source of weakness which can be two options...?

-Contractile tissue (if suspected source of pain next you should perform RIMT & palpation) -Neural (myotome versus peripheral branch) *If neural: all muscles innervated by nerve affected

Joint Specific Questions: When discussing the Lumbar region, what kind of joint specific questions should we ask or relating too?

-Flex (sit/bend) -Ext (stand/walk): discogenic patients -Sit-to-stand -Static positions: instability -Audible: degenerative or instability sounds -Walking -Diurnal cycle (disc and SI): how they feel throughout the day, worst in AM -Bowel/bladder change: Cauda Equina Syndrome -Driving, -Pain sneeze -Symptom referral to LE, paresthesia/hypoesthesia

Neurological testing is performed for patients with extremity diagnosis referral when: -Radicular signs or sensory alteration is reported -Suspected involvement of cervical or lumbar spine -Long tract signs are present -Suspected multiple dimensions of pain and/or unknown etiology of joint complaint with lack of clear presentation -When suspected nerve lesion is found during RIMT • Weak & pain-free lesion What does a long tract sign mean?

-Cord compression signs, potential ataxia

Symptom Quality: If we detect audible sounds such as grinding or grating this is caused by what condition? What about popping or clicking?

-Degenerative -Instability

When testing dermatomes you should have the patient close their eyes, test light touch first and if the patient is hypoesthesia what should you do next? The other stages are Normal (intact) and Hyperesthesia

-Determine protective & discriminative (use paper clip for sharp dull) Pain and temp follow lateral spinothalamic tract

Repetitive Motion & Static Positioning will help guide treatments & may provide insight into diagnosis. If we have centralization with extension and peripherlization with flexion what type of pathology is this?

-Discogenic Pathology It would be Foraminal Stenosis if the patient centralized with flexion and peripheralized with extension Peripheralize with both flexion & extension= disc extrusion or large protrusion that is nonnevetable to conservative care (don't abandon them treat with traction

Joint Specific Questions: When discussing the neck, what kind of joint specific questions should we ask or relating too?

-Discuss their balance (effected by cervical stenosis), headache, UE or LE referral, directional preference flex vs ext, static positions; instability (feel worse in a still position), audible, paresthesia

Joint Specific Questions: When discussing the Thoracic area, what kind of joint specific questions should we ask or relating too?

-Discuss their chest pain (usually referred from neck or visceral source, thoracic pain travels around the chest circumferentially, balance, recent falls, respiration (displaced ribs), flank= hydronephrosis from renal calculi or abdominal pain RUQ=Liver/gall... LUQ=Spleen RLQ=Appendix LLQ=Diverticulosis

With Central Stenosis a patient may develop ataxia due to the ______ tract being compressed. (responsible for proprioception)

-Dorsal Column Medial Meniscal Tract

During palpation we notice that patient A has dry skin compared to patient B who has moist skin. What can cause this for both patients?

-Dry: -Lack of circulation -Gout -Stage 2 CRPS -Moist: -Septic joint -Draining Tophi Gout -Stage 1 CRPS

Hip ER AROM/PROM loss: unable to distinguish endfeel. RIMT strong and pain-free. How could you determine if ROM loss is inert or contractile stiffness?

-Due to stiffness, strong RIMT not due to weakness -Would do an anterior glide of the femur on the acetabulum if that was normal than we would make the assumption that the motion loss would be contractile if its hypomobile than we know its an inert tissue contribution

Special Tests: Tests that are more aggressive will have a lot more ______ positives Tests that are not so aggressive will have a lot of _______ Most are graded based on a _______

-False -Misses -Dichotomy (positive or negative)

-Shoulder flexion & extension RIMT or knee flexion & extension RIMT? -Abduction and external rotation RIMT of shoulder Would both of these examples be considered false positives? (Think RIMT Interpretation)

-False+: no shared function -Abduction and ER does have a shared function (conjoin tendon work together)

Additional questionnaires (instruments) may be deemed necessary after history or during tests & measures when more "specific" information is available What are some examples of these additional ones? What does the phrase Kinesiophobia mean?

-General: Tampa Scale of Kinesiophobia (can be used for any part of the body) -Spine: Fear Avoidance Beliefs Questionaire (FABQ) -Knee (ligament or meniscus): Tegner Lysholm questionnaire -UE Injury work/sports: Optional QuickDash work or sports modules Kinesiophobia-fear of movement, or fear avoidance beliefs are similar

What are the different grades with a muscle strain? With a strain we should have MOI, when would it feel better and worse?

-Grade 1: Few fibers torn (minor) -Grade 2: 50% fibers torn -Grade 3: all fibers torn (may not have pain) -Better at rest without tension -Pain w/contraction-stretch-tension

This test (supine or seated) involves tapping the nail on the second, third or fourth finger (stabilize at the middle phalanx) what is this test called? What is a normal vs abnormal response?

-Hoffman Sign • A + Hoffman sign is the involuntary flexing of the thumb and/or index finger •Normally, there should be no reflex response or may have digit extension.

We know that AROM is volitional movement, where as PROM is passive movement to the anatomical barrier, when would you apply overpressure to this barrier and why?

-In order to move the patient further, and the purpose is to capture an end-feel Stretching=Overpressure

With a ligament rupture/instability what should we see at the following joints? Knee Shoulder Ankle

-Knee: buckling and/or loss of control (hyperextension) -Shoulder: apprehension, feeling of subluxation "going out" -Ankle: often recurrent inversion

You detect ROM loss if indeed stiffness is determined to be the etiology of an AROM loss the following will be present: 1. PROM is limited 2. End-feel is captured Do we know cause of stiffness from end-feel alone, is other data needed?

-Know its hypomobile but still not sure if muscular or inert Can always treat both (ex: sustained stretching foam rolling instrumental soft stretching of the calf, arthrokinematic glides) -Arthokinematic assessment

Valgus deformity develops over a long period of time (some people at a very young age), Varus deformity (not as common) If someone has OA etiology in the lateral compartment of their knee (unicondylar OA) this will likely cause... (Varus or Valgus), what about the medial compartment?

-Lateral compartment Unicondylar OA: Valgus -Medial compartment Unicondylar OA: Varus

Cardiopulmonary: Vitals should always be taken before, during, and after (especially during exertion if indicated) if a patient has a cardiorespiratory history. What is considered a normal capillary refill: Nail bed?

-Less than 3 seconds on the finger, 5 seconds or less seconds on the big toe it may be slow if perfusion issue or if there is dehydration If there is dehydration you would see delayed skin integer (when you lift skin it will tent if someone is dehydrated) normal hydration instant recoil) peripheral vascular disease, dehydration or hyperthermia can cause this

Contractile tissue is considered muscle & tendon, while Inert tissue (non-contractile tissue) would be...?

-Ligament, capsule, vessel, dura, bursa, skin, & cartilage

Fibrocartilage (knee) we can see degenerative and/or traumatic (micro or macro), flexion with rotation mechanism of injury (macro), and pain w/weight-bearing or end-range loading (often flexion). Why may we feel a springy block end feel at the knee? *(if acute & traumatic we will have swelling)

-Locking/buckling/catching -May be periodic Better unloaded (may report motion block)

How do you differentiate between loss between a dermatome and a cutaneous branch?

-Look at general pattern & consider clustered findings from exam -Ex: Hyposthesia at the web space between the great toe and second toe L5 or deep peroneal N. (if only deep peroneal N. ONLY that web space will have hypoesthesia) but if L5 will have anterior and lateral leg and dorsum of the foot and web space will have hypoesthesia (sometimes its just sensory sometimes just motor or both)

Whats the difference between someone who has a capsular pattern vs. noncapsular pattern?

-Loss of AROM and PROM in every direction -Cause: present from total capsular contraction or other total joint reactions such as OA, RA, adhesive capsulitis, arthrofibrosis -Very specific mobility loss -Cause: ligament adhesion, internal derangement (intracapsular fragment or structure interferes with movement. i.e. impingement from torn meniscus, cyclops lesion, or osteochondral fragment in knee), impingement, extra-articular, muscle, tendon

Which region specific instrument/questionnaire would work best for LE? What about for Global Function?

-Lower Extremity Functional Scale (LEFS) *not scored with percentage HIGHER score=better, pts make a mistake and score backwards -Patient Specific Functional Scale (PSFS)

Spinal stenosis can be unilateral or bilateral, and have a directional preference, we know that symptoms increase with extension and decrease with flexion or contralteral flexion but what position provocation would make the lumbar spine and cervical spine worse?

-Lumbar-worse: standing, walking -Cervical-worse: looking up overhead, sleeping supine without a pillow -Lumbar-better sitting or walking w/shopping cart

A discogenic pathology can happen for NAR, gradual, sudden, or recurrent. What is the MOI, when does the patient feel better and worse?

-MOI: flexion or flexion/rotation mechanism -Worse: flexion, cough/sneezing, bending, lifting, A.M. hours -Better: extension, walking, standing, corrected posture (lordosis), Doesn't feel good at first during walking (especially after sitting for long periods of time) but can walk it off

What is the common MOI of a ligament sprain-rupture-instability? At what position would the ligament feel the worst or best?

-Macrotrauma or hx of repetitive undesirable loading (microtrauma) -Worse: end range -Best: mid-range or resting/loose pack position (no tension on that ligament) -Better w/support/bracing

What is the next step for these four scenarios: • AROM is full (WNL) & pain-free • AROM is full (WNL) & painful • AROM is limited & pain-free • AROM is limited & painful (remember if their is pain determine what tissue is causing pain)

-Move on to next motion -The other three are all PROM

Which region specific instrument/questionnaire would work best for the Neck (cervical/upper TS) and Back (lumbar/low TS)?

-Neck Disability Index (NDI) -Oswestry Disability Questionnaire (ODI)

How can Neurogenic Claudication be defined? What about Arterial Claudication?

-Neurogenic Claudication: another name for the radiculopathy that we experience, lower extremity symptoms radicular symptoms that are coming from foraminal stenosis -Arterial Claudication: those that are coming from the arteries, will report that they feel worse with continue walking as well, similar to foraminal stenosis (no relief)

Any time there is a spine condition you want to perform...? Cervical spine problem you would perform a...? Lumbar spine problem you would perform a...?

-Neurological testing and the reason is because of close proximity of the spine at minimum myotomes, dermatomes and DTRs -Upper quarter neurological testing routine -Lower quarter neurological testing routine

Referral/Prescription Questions: -Patient is s/p ACL reconstruction with medial meniscal repair. Referral from family practitioner (M.D./D.O) for WBAT? (can we perform WBAT) -Patient (above) has pacemaker & referral from surgeon requests electrical stimulation for edema? (do we deliver the treatment) -Referral for massage, however, examination reveals no muscle guarding, no trigger points or tenderness, and normal mobility? (do we still need to deliver the treatment) -Hip weakness w/chondromalasia patella dx on referral? Can you treat hip?

-No, the family practioner did not do the surgery have to get WB precautions from surgeon -No not required to deliver a treatment that is a contraindication or precaution -No massage, no tight muscle or guarding indicated -Yes, can treat the hip due to regional interdependence

The purpose of the systems review is to determine or confirm the general health status of client guided by "history," need for medical referral or implementation of precautions. Is a complete systems review necessary? What are some systems that may require additional considerations?

-No...let history guide, standard MS exam covers many systems -Cardiorespiratory -GI/GU

Myotome: If weakness found test remaining myotome actions to confirm or reject impression (if reject myotome then search ________ branch) How many movements should be checked out?

-Peripheral branch -When possible, 2+ movements (ideally from different peripheral branches) should be checked to confirm culprit nerve root -Hold 6-10 seconds & grade similar to MMT

Most activities involve putting anterior pressure on the disc which is why most disc herniation are ______ or ______ in nature. What is the age predilection for discogenic patient?

-Posterior, Posterior lateral -20-55

Typically a patient is given an entry paperwork/data (forms) prior to interview. What is typically contained in these forms?

-Prescription/referral -Demographics -Age -Gender -Occupation -Medical history questionnaire -Region specific questionnaires & instruments

What is the standard procedure for a Babinski Sign? What is the normal and abnormal response?

-Procedure: Stroke outside sole from heel to toe with a pointed object.(video on Canvas) - Normal response = nothing or flexion of toes. -Abnormal response= upward (extensor) movement of great toe and/or abduction of the toes.

Proximal enlargements of PIP Bouchards Nodes: is only present with OA but can be present with...? Swelling of DIP is called?

-RA as well -Heberdens Nodes (OA)

-Limited AROM that is WNL on PROM suggests ________ -Limited AROM that remains limited w/PROM = ________ -Etiology of stiffness determined in part by _________ (adding that overpressure to PROM)

-Weakness -Stiffness -End-feel

What does reactivity level mean, and describe each level; low, moderate and high

-Reactivity level: symptom (not sign) severity associated with the patient's sensitivity is assessed during the range of motion component of the exam in conjunction with the clinician's overall impression of the patient. -Low reactivity: No pain, green-light can handle tough interventions -Moderate reactivity: painful response evoked at the end-available range during ROM assessment (clinician proceeds with caution) -High reactivity: painful stimulus evoked prior to end range (proceed with extreme caution)

Most likley the cervical distraction test can be done for someone who has radiculopathy. We apply distraction in supine or seated (10-15 kg) what is considered a positive test?

-Relieves Symptoms: If the patients symptoms were relieved than we can make the assumption that their symptoms are coming from their neck because we are only distracting the neck and or the cervical spine ,stenosis and discogenic pain -Reproduces pain: case where this may increase pain may be cervical instability because than by applying an axial stretch it would make the patient worse, annulus tear or extrusion would feel worse

Whats the position of the cervical spine during retraction and protrusion? What is considered upper cervical spine and mid-lower cervical spine?

-Retraction: upper cervical flex & mid-lower cervical ext -Protrusion: upper cervical ext & mid-lower cervical flex -Upper cervical spine=occiput to C2 -Mid-lower cervical spine=C2 to C7-T1

With OA/DJD what are some factors related to these conditions? With mobility loss in the hip & shoulder what motion do we lose? What about the spine?

-Risk factor age -Gradual -Symptoms: WB/loading -Audible: creptius or grating -Morning stiffness knee=30 min, hip=60 min -Loss of joint space -Hip & shoulder loss of IR & spine decrease ext.

Tendon injury can be micro or macro-trauma, may present as tendiopathy or rupture, whats the difference between the two?

-Rupture: similar to presentation to a muscle rupture -Teninopathy: -Tendonitis (reactive tendinopathy): chemical component or more acute constant -Tendinosis: break down of tendon matrix overtime leads to more of a degenerative presentation (sub acute chronic intermittent symptoms)

Besides physiological what are the other dimension of pain and describe each one.

-Sensory: intensity, frequency (what they rate their pain, subjective) -Affective: influence of emotions, negative and optimistic, someone crying as they describe, monotone=flat affect, crying to smiling=labile effect -Cognitive: influence of beliefs and understanding of condition, self-efficacy & locus of control (kinesiphobia, internal locus of control "i can help myself=better, external locus: "you help me"= worse -Behavioral: response to stressors (refuse to move or facial expression) -Social & Cultural: influenced by Both patient & practitioner)

What are the Nerve root SIGNS and SYMPTOMS if damaged?

-Signs: loss of reflex, hypoesthesia, weakness -Symptoms: pain, burning, shooting paresthesia

List the 8 abnormal end-feels, and briefly describe each one

-Spasm: sudden arrest of movement with pain -Early range: Highly reactive or fracture Late range: instability -Empty: no resistance-painful (highly reactive, acute chemical) -Capsular/Ligament-tissue stretch: -Hard (full capsule/ligament): abrupt non-yielding, sensation of leather stretching (frozen shoulder) Key: ↓ motion all planes -Soft (part of capsule or ligament): slight yielding then abrupt stop with restricted ROM. Key is specific ROM loss & discomfort -Muscle: rubber band w/↓ ROM. (How is this different than normal?) -Springy Block: rebound effect (meniscus tear/ loose body) -Bone to Bone: felt where another end feel should be felt •e.g. Supination after Colles fracture or cervical DDD with DJD -Boggy End-Feel: edema

Upper Quarter Myotomes: C5: Abduction of shoulder (ortho), when would we test bicep? C6: Elbow flexion (ortho) -What would we test if the patient had a spinal cord injury?

-Spinal Cord Injury (SCI) -Wrist extension

A ligament _______ is causative and associated with instability. Describe the three ligament sprain grades.

-Sprain-Rupture-Insufficiency -Grade 1: few fibers torn -Grade 2: 50% MRI to know this (stretch reproduces that pain) -Grade 3: complete tear (guarantee instability, connection is gone=less likely to experience pain)

After someone completes a course of antibiotics we tend to be more conservative to avoid _____ tears. What class of antibiotics is being referred here? (Kolber tore his tendon taking this class of antibiotics)

-Tendon -Fluoroquinolones such as levaquin, cipro, avelox (responsible for tendinopathy & ruptures)

If a patient is taking a actonel, boniva tablets or fosamax (most common bisphosphonates) what can you expect, and what questions may you ask?

-That they have decreased BMD, probably have osteoporosis/osteopenia Need to know WHEN can't lay supine or bend forward for 1 HOUR

Slipped Capital Femoral Epiphysis occurs in males between ages 10-16 what causes this to occur? Lupus is an autoimmune disease most common in...? If people are out of work due to their injury are they more likely to have a better or worse prognosis compared to someone who continues to work?

-The epiphysis of proximal femur is displaced from metaphysis -Women of childbearing age -Poorer prognosis compared to those who continue to work

If a patient has physiological pain what are some characteristics they may show?

-They understand the actual tissue at fault, there is a very predicatble pattern and location of pain (the ONLY DIMENSION of pain that diagnostic utility and can help determine exactly what is going on)

What coupling motion is required to achieve full knee extension in OKC, in CKC?

-Tibial ER -Femoral IR

Central stenosis cord compression may produce what type of signs, UMN or LMN? What kinds of signs would we see with this patient?

-UMN signs unless below the conus medularis (L2) than it would be LMN signs -Brisk DTRs, + pathological reflexes (Babinski, Hoffman), clonus, gait abnormality (ataxia), stocking/glove paresthesis

If a patient has a stent what kind of medications would we expect to see? If on Coumadian ask their Coumadin level (PT INR), what does it need to be between for us to see the patient?

-Usually on anticoagulant/blood thinner for 1 year. -Expect Coumadin, Warfarin, etc but a pt can bruise easy on these. -Normal is 1 or 1.1, if need anticoagulation therapy they are at a 2 or 3 to prevent clotting. If >3 they may bleed too easily

Pain (symptom) quantity: Describe the differences between Verbal Rating Scale (VRS)/ Numerical pain rating scale (NPRS) and Visual Analog Scale (VAS)?

-VRS/NPRS: most used option where you rate your pain from a 0-10, MDC: 2 points, MCID: 2 points -VAS: Using a 10 cm line graph from no pain, to most severe pain (don't like this because we have to use a ruler and can be error) *remember scales need anchors (clarification of scale)

Symptom Quality: What are some qualitative descriptors of pain or symptoms of the following: -Vascular -Non fracture bone pain -Nerve -Muscular -Inert -Fracture (Acute)

-Vascular: diffuse-non-focal, throbbing, pulsating, cramping -Non fracture bone pain: dull, deep, nagging -Nerve: sensory alteration, paresthesia, sharp, shooting, burning (if nerve root/branch will present with specific distribution) -Muscular: dull, ache, or cramping -Inert: Dull, ache -Fracture (Acute): sharp, severe, intolerable, deep-dull

Joint Specific Questions: When discussing the Knee area, what kind of joint specific questions should we ask or relating too?

-WB -Locking-buckling -Audible -Swelling -Stairs (Chondromalegia patella will hurt with stairs and squatting, and degenerative conditions) -Squat

Joint Specific Questions: When discussing the Ankle/foot area, what kind of joint specific questions should we ask or relating too?

-WB pain -A.M. Pain -Footwear change or wear patterns -Ankle/foot: plantar fasciosis hurt first thing in the morning in the arch but you can walk it off

Joint Specific Questions: When discussing the Wrist/elbow/hand, what kind of joint specific questions should we ask or relating too?

-Work tasks -Night/sleep; Carpal tunnel parethesia while they sleep, can shake the hand out (flick sign) to make paresthesia go away -Computer -Gripping -FOOSH injury -dom. arm -Paresthesia/hypoesthesia

What positions is instability worse in, what kind of sounds will we hear?

-Worse w/end-range or instability induced positions (90/90, ankle inversion/supination) -Symptoms w/prolonged (static) unsupported positions -Audible sounds: clicking popping NOT grating

Common Clinical Conundrums: -Cervical radiculopathy and/or thoracic outlet where should the thoracic radiculopthy wrap around?

-Wrap around the front of the chest and its going to follow a thoracic dermatome T10 around the umbilicus T4 mid chest -Thoracic outlet syndrome is more likely to effect your C8-T1 nerves so sort of that lower trump like presentation. If it coming from the costoclavicular or the pec minor they will report symptoms with sustained overhead arm position or upright posture where as people with cervical radiculopathy are going to report symptoms with cervical motions mostly

What helps relieve OA/DJD, list some meds? Advanced OA/DJD in the spine leads too?

-anti-inflammatories such as glucosamine chondroitin at the knee (OA) NSAIDS Celebrix, Mobic COX-2 or CAM examples, non steroidal that are easier on the stomach, heat -Spinal stenosis

Palpation: Describe the cheatham wolfe scale for tenderness (Only use tenderness once we know the tissue etiology to determine the EXTENT of the LESION and CONFIRM the diagnosis this scale has a reliability of 0.88 pretty good)

0-no tenderness 1-report of tenderness 2-report w/grimace-flinch 3-withdrawal upon tissue contact 4-withdrawal prior to contact Grade 2=cut point

Neural Tension/Mobility Tests: Describe the procedures of an Upper Limb Tension Test #1, and what nerve bias does it have?

1. Depress/Block shoulder then abduction to=90 (or 80) 2. Wrist ext-supination-finger ext (using pistol grip) & ER shoulder 3. Elbow extension (slowly) 4. Sensitize motion (lateral flexion away=worse, lateral flexion towards=better) Nerve Bias: C5-C7 nerve roots & median Nerve

What are the 5 elements of Patient/Client Management?

1. Examination: -History -Systems Review -Test & Measures 2. Evaluation: synthesis of examination (look for clusters with all the info) 3. Diagnosis: based on clusters from exam 4. Prognosis: predicted optimal level of improvement, time frame, goals & plan of care 5. Intervention diagnosis, impairments, functional limitations, clinical predictive rules, directional preference (spine), & outcome studies

For the Bakody Test why is that your pain is decreased if you place your hand on your head?

1. Intraneural microcirculation: the microcirculation pressure decreases about 8-9 mm of mercury, (nerve compression symptoms are symptoms of that intraneural microcirculation), by decreasing pressure would alone would decrease symptoms of radiculopathy 2. The nerve root resides right in the center of the foramen; due to dural ligament of hoffman that suspend that nerve root, if that nerve root was compressed and inflamed whatever it may be tension on that ligament in a sense may translate tension to that nerve root, when we raise our arm overhead the nerve root kind of lift up as well and puts those dural ligaments of hoffman on slack which no longer tugs on the nerve root. As we reach our arm over head the nerve moves superior so we are lifting that nerve root off the herniation, pressure is elevated during compression

During the interview process what should be said or done during the intro before moving on too symptom location

1. Introduction: Name & discipline (ask the patient how they would like to be addressed) Confirm region to be examined (R vs. L) 2. Clarify or gather PMH/PSH 3. Chief Complaint ("Tell me about the problem that brought you here today" patients are typically interrupted within 18 seconds of explaining problem) 4. Onset date (or if recurrent need initial onset & recent exacerbation) 5. Type of onset: gradual, sudden, recurrent 6. MOI: How it happened, FOOSH, fall, lifting, repetitive activity

The Spurling Compression test is used to investigate the etiology of neural symptoms. A Positive test is caused by...? Describe the sequence as well This test gives a good ______validity

1. Laterally flex the patients head 30-45 deg towards the side of involvement 2. Than apply an axial compression (7kg) where you feel your gaining some resistance 3. Perform bilaterally -Positive test=reproduces concordant symptoms -Diagnostic Validity (only)

What are the MDC and MCID values for the following instruments/questionnaires: 1.Oswestry Disability Index 2.Neck Disability Index 3.Quick DASH (disorders of the 4.Arm, Shoulder & Hand) 5.Shoulder Pain & Disability Index (SPADI) 6.Lower Extremity Functional Scale (LEFS) 7.Patient Specific Functional Scale (PSFS)

1. MDC: 11% (percent points) MCID: 30% (percent change) 2. MDC: 3% (3.3%) MCID: 7% 3. MDC: 11% MCID: 8% 4. MDC: 13% MCID: 8% 5. MDC: 9 raw points MCID: 9 raw points 6. MDC: 2 raw point MCID: 2 raw points

End-feel importance: (nature of limitation and intervention) 1. An empty end-feel typically indicates that a patient will have poor...? 2. Are goals for ROM reasonable for someone with a bone to bone end-feel? 3. How should we stretch muscle vs inert tissue, what about spasms?

1. Poor pain tolerance, reactivity/yellow flag 2. Goals for ROM not reasonable (ex: HO can be made worse) 3. Muscle-longer duration stretching Inert-repeated short duration stretch/joint mobilization Spasm-no stretch/stabilization needed

What types/region of cancer most commonly metastasize to bone? (hematogenous type of movement PTBLK)

1. Prostate 2. Thyroid 3. Breast 4. Lung 5. Kidney

Special Test: The Purpose of the Thomas test is to look at the hip flexor flexibility (one joint), describe the sequence of this test. What is considered a positive versus a negative

1.Patient: supine & flexes non-tested leg to chest & holds position 2.Tested leg is assessed while non-tested leg is flexed to chest 3.Tested leg should remain flat if adequate hip flexor flexibility (since the heel is on the table it does NOT assess the rectus femoris)

What are 4 reasons you would use the region specific instruments/questionnaires? Why use them prior to interview/ T & M?

1. Required 2. Helps get a baseline score of somebody's perceived function, classify use over and over to determine change, very specific questions help us establish goals 3. Functional limitations are hard to track while taking a history, prevents cross examination 4. Help give insight towards diagnosis Helps steer our questions (helps us understand what we are walking into)

Describe an example of repetitive motions & static positioning for a patient who has right side lumbar LBP

1. Standing flexion 5x pain peripheralized to gluteal region 2. Standing extension 5x no change 3. Standing extension 5 more times R LBP only 4. Standing extension 5 more times central pain: centralized Intervention: Extension based program Diagnosis: Discogenic pathology

Neural Tension/Mobility Tests: Describe the procedures of a Straight Leg Raise Test, and what is the nerve bias for this test? What is a Drehmann Sign, and what it is suggestive of?

1. Supine relaxed w/consistent head position 2. Examiner passively raises LE until end-range restriction or pain 3. Hip flexion w/adduction & knee extension & neurtal ankle DF 4. If positive (pain 30-70 deg) then perform: sensitizing component (ankle DF=worse, PF=better OR if no DF then hip IR=worse, hip ER=better) -Nerve Bias: Sciatic Nerve (L4-S3) L4; Furcal n (supplies both femoral and sciatic nerve) -Obligatory shift into ABD/ER in child, suggestive of LCPD or SCFE

Describe an example of repetitive motions & static positioning for a patient who has cervical spine pain right sided into arm/elbow

1. Sustained(static) flexion: pain abolished 2. Sustained extension: symptoms peripheralized to elbow into lateral forearm/thumb Intervention: Flexion based program (C5-C6) Diagnosis: Spinal stenosis C6 nerve root

Any patient that presents with N.A.R. onset plus...? They would be at risk for a red flag.

1. Unaffected by position-meds 2. Constant, truly worsening

After discussing the patients joint specific questions, we move on to their 12. Limitations: function (activities), sport, job, recreation, 13. May query re: red flags or illness (review of systems) 14. Treatments & diagnostic tests for this condition (current & prior), and what are the last two points to discuss with the patient during the interview?

15. Patient's goals & expectations 16. Is there something else you would like to tell me before I proceed?

Well Clinical Score (CPR): DVT 2 or more ___% may have a DVT, if 3 or more may have a ____%. 1 or less highly unlikely; however any suspicion will send out not worth the risk. What are some factors listed on the Well Clinical Score for a DVT?

17% 75%

Discogenic pathology most common age ____? Postmenopausal women are more likely to have _______? Legg Calve Perthes Disease is a hip condition in preadolescent _______ associated with AVN

20-55 Osteoporosis Males

______% of the asymptomatic population >60 has spinal stenosis _____% adults have a disc bulge, ____% over 60 have a RTC tear

21% 81% 40%

DOMS (delayed onset muscle soreness) typically resolve in _______ hours. Is Statin Induced Myalgia better or worse with activity? Can it be relieved with rest? What kind of Statins are commonly used?

24-72 hours -Worse with activity the reason being statin effect the bodies ubiquinol production (need this for the electron transport chain to function appropriately) why we recommend people take supplementary ubiquinol or COQ10 -Not relieved w/rest (contractile conditions are relieved with rest) -Crestor, Lipitor, Zocor

With instability it can effect all ages, but younger more likely in spine especially at what age? What are the three common etiologies of instability?

<37 Born loose: people with congenital hyperlaxity Torn loose: trauma, microtrauma renders someone as being unstable such as a dislocation Worn loose: compuslitaory activity such as a thrower or overhead athlete or swimmer (microtrauma that they make their joints susceptible too ends up over stretching the tissue)

The cervical distraction test determines if symptoms are of cervical origin. This test provides not only a diagnostic validity but a ______ validity.

A prescriptive validity meaning if the patient has relief of symptoms with the distraction test it makes sense that the distraction treatment or traction will be something of benefit here

What is the apprehension test? If this person has pain during this test what is done next?

Apprehension test: where you passively put someone in the 90, 90 position abduction and ER at the shoulder used for anterior instability. The specificity of that test is 90%, we do a relocation test: when that person has pain in the apprehension test we push the humeral head posterior and the pain goes away. If both the apprehension test and relocation test are positive well than the specificity increases to 100%, test in clusters will be most valuable for us

Ruptures should have a MOI as well, however, when would we see a muscle rupture without a mechanism of injury? What will signs will be reported with a rupture?

As we get into our 60's we begin to have these rotator cuff tears that are age induced from pathology -Report of weakness, pain, ecchymosis

The Apley Position is where a patient places their hand behind their...?

Back see how far up the spine they go (use third digit or thumb) patient can reach to back pocket, patient can reach to T8-T9 inferior angle, mark spinal level (make assumptions about function)

Abnormal End Feel: With a soft capsular/ligament-tissue stretch we experience a slight yielding then abrupt stop with restricted ROM. This is due to Obligate translation, so if you IR someone's shoulder you'd be stretching their posterior capsule (posterior inferior GH ligaments). What can occur next?

Based on the angular motion and the fact that we posteriorly glide when we internally rotate(head goes post on glenoid). You'll get to a point where you can't post glide anymore bc you reached the point of tissue stretch. If you continue to push beyond that, the glide changes course and the humeral head will move the opposite way. The tight capsule you put stress on will push that humeral head anterior. It gives you a yield in the end feel. (cannot have if hard feel)

Which myotome regions are seldom weak & may indicate non-mechanical problem (yellow or red flag) S2-4(5) loss of function is a red flag as it may suggest...?

C1-C3, T1 (apical lung tumor, or thoracic outlet syndrome), L2 (psoas cyst) -Caudal equina syndrome (saddle anesthesia as well) If Cauda Equina is compressed and causing problems in those sacral nerves (they are not really mylinated not a good blood supply like the lumbar nerves) than we need immediate decompression a medical emergency

With Foraminal Stenosis we may produce a specific dermatomal paresthesia or hypoesthesia pattern, how does that differ from Central Stenosis?

Central stenosis: stocking/glove paresthesia pattern- cervical spine paresthesia in a pattern that covers the whole hand and distal forearm (compressing the vascular supply at the neck producing a gross pattern of paresthesia)

Whats the difference between chemical guarding and involuntary guarding?

Chemical Guarding: muscle is in a state of hypertonicity, and that state of hypertonicity does not change when that joint or region of the body is supported Involuntary Guarding: is when there is guarding when that joint per say or region of the body needs stability but when its supported it goes away

Right shoulder pain/worse after meals/Murphy Sign; palpate underneath lower ribs and have that person take a deep breath (liver gallbladder drops in the fingers and person stops taking a deep breath will report pain) this condition is most likely from...?

Cholecystitis/Cholelithiasis

All forms must have...?

Date and Therapist signature (who scores it)

During the Observation/Structural Inspection we look for Constitutional signs or acute distress such as diaphoresis, pallor, etc. What do these two terms mean?

Diaphoresis: pallor with sweating looking for general pallor Pallor (pale): is best by looking at the conjunctiva or nail beds

With a neural disorder the root or branch could be effected. If we have weak eversion what are the possible reasons?

Eversion weak: S1 myotome or could be Superficial Peroneal N, if PF is weak it is the Tibial N. Than you know its coming from S1 as opposed to Superficial Peroneal N. If its just the superficial peroneal N. it will be JUST EVERSION

True or False: PROM and AROM are both indicative of function

False; AROM is, but not PROM

True or False; Osteokinematic function is an absolute necessity for normal joint mechanics & prerequisite for full arthrokinematic function

False; Arthrokinematic function is an absolute necessity for normal joint mechanics & prerequisite for full osteokinematic function

True or False: You will always have signs of neuropraxia with nerve root compression, nerve root iritation, and stretch.

False; The signs will only be present if there is a neuropraxia just because they have symptoms of sharp-shooting-burning doesn't mean they will have a loss of sensation, or motor weakness

True or False: Insurance companies will cover a patient without a referral

False; although we have direct access many insurance companies will not pay without a referral from a physician

True or False; You have to have a diagnosis to treat the patient

False; no you do not always have to have one (but you need to have an understanding of what their impairments are their functional limitations or activity restrictions depending on the nomeclature you want to use)

A patient with instability will have poor quality movement with acceleration/deceleration. They may have improved symptoms w/bracing or changing positions but how do we tell the difference between stenosis and instability?

Feel worse when your standing too long (could be instability or foraminal stenosis) take it to the next level, How does it feel when your sitting for too long (forminal stenosis- sitting is generally fine) instability worse in any position that they are in for too long

When would the Shoulder Pain & Disability Index (SPADI) be used?

For people at lower functioning levels (medicare, Post-OP)

Secondary gain is described as financial insensitive not to give full effort or not wanting to harm yourself. Inconsistent effort leads to ______ dimension (s) of pain

Heightened other dimensions of pain (sensory dimensions)

Whats the difference between hematemesis and hematuria?

Hematemesis: vomiting blood, ulcer (over zealous use of NSAIDS) Hematuria: blood in the urine

Describe the Homan & Lowenberg test when diagnosing a DVT

Homan test: patient receives a forceful DF effort and that forceful DF produces a forceful stretch of the posterior tibial vein that is thought to cause pain in someone who has a DVT; problem research shows that it is really not that accurate, 8-56% accuracy. Do it with pressure pushing into the calf as they are going into DF Lowenberg test: blood pressure around calf up to 80 mm of mercury, average person should be able to tolerate without pain if they have pain= DVT

Vytorin (lipitor, Zocor, Crestor) are some common statins seen used to treat...?

Hypercholesterolemia (high cholesterol) Be aware of statin induced myalgia • atorvastatin (Lipitor) • fluvastatin. • lovastatin (Mevacor, Altoprev) • pitavastatin (Livalo, Nikita) • pravastatin (Pravachol) • rosuvastatin (Crestor) simvastatin (Zocor)

While grading arthrokinematic/segmental mobility we do not use the Ordinal grading scale 0-6 due to poor reliability (it does address broad spectrum such as ankylosed to instability) Instead what scale do we use?

Hypomobile-Normal-Hypermobile Scale -Reliable & Valid -Does not encompass broad spectrum of findings

Would you scan? Yes/No? Why & what? Diagnosis: Hamstring strain (pain proximal) -No apparent reason 3-week onset, no ecchymosis, walking better

If there is going to be a muscle strain their needs to be a reason something would have had to happen, if you do AROM and muscle testing and its unremarkable you would do a screening of the lumbar spine, lumbar ROM all planes, repeated motion and lower quarter screening lumbar and sacral myotomes, dermatomes and DTRs.

What are the most common areas of discogenic pathology? If a patient has an MRI and it looks like the have a disc bulge, would this always cause symptoms?

L4-L5, L5-S1 Don't make assumption that's always causing the symptoms, 81% of asymptomatic patients have a disc bulge

How do Fluoroquinolones work?

Inhibiting bacterial DNA and because they inhibit bacterial DNA it inhibits that DNA replication cell division (effect on bacterial cell lines share very little homology with human cell lines) never the less it does effect cell division to some degree

In cases where you tap C6 Deep Tendon Reflex (brachioradialis) and you see the hand go into flexion or wrist flexion that is what they consider a...?

Inverted Supinator Sign which is suggestive of UMN pathology

What does irritability refer to and what are the components to it?

Irritability: determining how vigorous or gentle the clinician should be during physical exam and interventions Components: 1. Activity threshold: level required to produce or worsen symptoms 2.Duration of symptoms provocation (seconds vs min vs hours) *heightened pain dimensions may compliment the decision-making process

If we examine a shoulder and start to realize this may be coming from the cervical spine we can do what...?

Jump to upper quarter scanning

What type of presentation would someone have if they have a mallet finger, swan neck, and a bouitneire?

Left: Mallet finger hyper flexion of DIP (just the distal tip cannot extend; ovulsion of the extensor tendon, slight hyperflexion of the distal phalange) passively extend can't hold it there Bottom right: Swan neck pronounced hyperextension of the PIP, hyperflexion of the DIP (over stretching of the volar plates common in RA or extrinsic muscle contractures) Upper right: Bouitneire- hyperflexion of the PIP and Hyperextension of the DIP (rupture of the extensor slip)

What is the difference between MDC and MCID?

MCD: Minimum detectable change.. the error threshold within the scale MCID: Minimum clinically important difference ... a statistic that is calculated that determines how much change is needed to exceed the threshold of error

Common Clinical Conundrums: -Kidney (renal calculus) or thoracic disorder can give us more of a...? -Shoulder and/or neck (example: "medial" scapular pain, should hurt with movements from the neck not from the shoulder)

MS presentation, causes a hydronephrosis (flail pain) generally posterior lateral and lower thoracic pain

Scheuermann's Disease occurs more often in adolescent ______ Teen girls with anterior knee pain may have ________ Fibromyalgia is a chronic MS disorder associated with widespread soft tissue pain, tenderness (tactile allodynia), fatigue. Common in what gender and what ages?

Males Chrondromalcia Patella Women Ages 30-55

A patient presents with spasm/cramping reported or visible spasm w/movement in the knee they are likely to have...?

Meniscal tear, ACL, or labral tear may report giving way or locking symptoms as well

Muscle group innervated by the same nerve root this is called a...? Represents sensory integrity of specific nerve root this is called a...?

Myotome Dermatome

A discogenic patient only has somatic pain you can be confident that the disc is not...? If the patient does have clearly distributed dermatomal symptoms you can be confident that there is some level of...?

NOT Compressing the nerve root Nerve root Compression

What is the clinical triad of appendicitis?

Nausea, abdominal pain, loss of appetite and in 90% of cases fever 100.4 (hypothermia)

What does the phrase Regional interdependence mean?

Neighboring joints are often associated with the one involved, ex: knee diagnosis and see something wrong with the hip, thoracic spine needs to function well so the shoulder can function well -Always document this and doc will sign off

Pain location may change (internal damage and bleeding), dysuria/hematuria/percussion pain (pain is due to hydronephrosis) this condition is most likely?

Nephro/Ureterolithiasis

If a patient has radicular symptoms then they have _____ root pathology. If only somatic then probably no ______ pathology

Nerve Root (for both)

What are the major differences between Neurogenic and Arterial Claudication?

Neurogenic: -Bilateral or unilateral -No relief w/simply "rest" -Relieved w/flexion -Increased by extension -Bike Vs. TDM (unless inclined) -Walk w/shopping cart stooping forward Arterial: -Usually bilateral -Relief w/rest (exertion induced) -No change w/flexion -No increase w/extension -Bike vs TDM (won't make a difference) -Shopping cart no relief -Worse w/elevation (leg elevation to 60 deg, norm circulation least a min without symptoms -Common complaint is calf pain (forminal stenosis (S1 or S2)

AROM we would test bilaterally and the uninvolved side first, if AROM is WNL & pain-free is PROM necessary?

No it is not necessary, but if incomplete (↓) or painful note range & if pain is concordant then - Proceed to next step: PROM & possibly overpressure (end-feel)

What is considered normal and abnormal halux valgus of the great toe?

Norm: less than 20 Abnormal: greater than 20

When should you consider the medical history complete?

Once you have reviewed medical history form, clarified queries with patient, and completed the physical examination (so we can see old scars and incisions)

Whats the difference between RIMT and MMT?

Only difference from isometric MMT is that outcome is used to posit etiology of weakness/pain RIMT (ordinal qualitative values)

With saddle anesthesia there is a loss of sensation at the perianal region at the proximal inner thigh region (suggestive of cauda equina syndnrome) why is this a medical emergency?

Only have a short window before experiencing improvement in their symptoms (medical emergency surgery) most common reasons is a disc herniation cauda equina is just a nerve root

When doing an interview you should start with more ______ questions and than move on to more direct.

Open-ended

ROM loss may be due to arthrokinematic range of motion loss or _________ ROM loss (in addition to tissue stiffness), may be the result of restricted coupling motions.

Osteokinematic *These motions take place to facilitate complete active movement: (e.g. ER required for GH abduction & IR required for GH flexion)

If disc puts pressure on the dura matter where would pain be experienced?

Pain on glute and posterior thigh

With steri strips generally we don't take these off, put we can assist by pealing off some of the edges, generally will fall of on their own This type of method following an arthroscopy does not involve a lot of suturing, tend to use a fibrin type glue easier to heal, this is called?

Portals

Are there any indication to test PROM instead of AROM?

Post-OP AROM constrictions, generally when tendon or muscle is repaired we generally don't do AROM for 6 weeks, Post-Op cases PROM is our go to test

The most common vein we may experience a DVT is...? Here we will experience, redness, heat, and tenderness

Posterior Tibial Vein

When would it be okay to proceed with care despite LMN signs?

Previously diagnosed, if you see a patient through direct access who has not seen a physician and identify UMN signs or symptoms or LMN signs and is not previously diagnosed need to get under the care of the physician (can progress worse)

A positive ludington's test is a sign of...?

Proximal bicep tendon tear (gives that pop-eye appearance) - Check the other side to see if that's normal or not - Long head tendon ruptures that connection is no longer there to cause pain - Partial tear of long head bicep pretty obvious pain (when it does finally tear will say pain is gone)

For a cardiopulmonary systems review we look at the RR (what is considered normal?), Pulse rate (what is considered normal), BP, and other. Describe the Pulse Quality grades from 0-4+

RR: 12-20 normal PR: radial pulse graded based on quality, or based on rate average resting PR is a 79 and anything less than 60 bradycardia over 100 tachycardia BP: capture in someone who is hypertensive even it is under control 0= Absent 1+=Diminished/weak 2+=Normal 3+=Bounding 4+=Aneurysmal

If a patient has gallbladder pain (typically worse after pain) or cholecystitis (stones in the gallbladder) they would experience right shoulder pain but where in the abdomen would they experience pain? Why might someone have pain in their RLQ, LLQ, and LUQ?

RUQ: Gallbladder (experience jaundice as well obstruction interferes with trying to get bilirubin out of there), liver RLQ: appendix, utera, calculous kidney stone stuck in distal ureter LLQ: diverticulosis LUQ: spleen

For the Achilles reflex if the tibialis anterior is activated what should be done next?

Put the thumb around tib anterior and put constant pressure to suppress (tibialis anterior is contracting it will shut down that reflex arc of the achilles via reciprocal inhibition)

Which region specific instrument/questionnaire would work best for disabilities of the arm, shoulder, & hand? This questionnaire is optimal performing arts/ athletic/ occupational items you can add, can be used for a highly functioning person

QuickDASH (11-item)

When observing the integumentary system on a patient you look at their color (erythema, icterus, ecchymosis, pallor), wounds, trophic changes, skin lesions, & scars. What are the ABCDE of skin lesions?

Skin lesions: A (asymetrical) B (irregular edges blur) C (multipigmented) D (diameter large) E (evolution is it changing)

A gunstock deformity occurs from an improperly healed...?

Supracondylar fracture) cast people in some degree of flexion (not evident that they have it until they extend their elbow) Not casted in extension

In order to reduce stiffness we need to determine...?

The source of stiffness (End-feels, arthrokinematics, muscle length testing)

When performing the shoulder abduction/Bakody test how do you differentiate between the shoulder vs. cervical radiculopathy?

UE pain abolished w/hand to head = cervical radiculopathy Lateral shoulder pain produced or worsened w/hand to head = SIS

Some common "errors" in history include selective listening (patient has pain when walking) and prescription bias (radiographs indicated that patient has spinal stenosis) 21% of the asymptomatic over the age of 60 have some degree of foraminal stenosis, but if they feel worse with extension and better with flexion what should you do?

Treat based upon what makes them better

True or False: If arthrokinematics are normal we can move on from capsule or ligamentous end-feel focus on soft tissue mobilization

True

True or False: Neurological examinations are always done for someone with a spine condition or nerve related diagnosis

True

If reflex is sluggish or absent document & compare other neurological measures. Bilateral absence is common in elderly, unless

Unilateral -Spinal cord compression of cervical spine you would expect upper and lower extremity reflexes to be hyperactive, if spinal cord compression at the thoracic spine then you'd only expect lower extremity to be hyper active -UMN signs from cord compression, than they would have ataxia as well, some spasticity they may have clonus, positive babinski

If you see that your patient had a lumpectomy what should you ask next? What are the 5 most common causes of cancer?

What did the lumpectomy biopsy show? Was there cancer Prostate Thyroid Breast Liver Kidney 5 most common cancers that metastasize to the skeletal spine

After the identifying the symptom location, symptom (pain) quantity, and symptom quality. The next question that could be asked would be?

What makes your symptoms better or worse, is there a position that its best at or worst at? Than you'd ask joint specific questions

You have a patient with a spine diagnosis that it may be an extremity problem (or they come in with the diagnosis of an extremity problem). During course of extremity examination it may be related to spinal etiology. Hip, knee, or ankle foot problem during course of examination- AROM/PROM and RIMT are all unremarkable than what should be the next step?

You'd believe that its a lumbar spine etiology (that's when you would do a scanning of the lumbar spine)

With a tendon injury we will see pain with contraction & potentially weakness, tenderness (to touch), and worse with...?

Worse w/resisted activity or when stretched/compressed

You conduct an RIMT to differential diagnosis of pain and/or weakness for contractile, neural, and inert tissue. The procedure is similar to MMT (6-10 sec, do not let me move you, or meet my resistance, avoid break test if possible) When would we not document or perform RIMT?

Would not necessarily document RIMT in acute or sub-acute post-operative patient or patient with SCI as goal in these individuals is to alleviate impairment, functional limitations, and potential disability NOT to postulate a diagnosis •Traditional MMT and/or myotomal screen is more appropriate

Would you scan? Yes/No? Why & what? Diagnosis: Lumbar Strain (pain location gluteal & groin) -Full pain-free lumbar AROM, painful hip crepitus with WB

Yes, going after hip and doing a hip screening. May have concurrent problems meaning may have concurrent lumbar and hip problems may find yourself examining multiple areas

40% of patients who centralize will report an increase in central pain, is this okay compared to peripherlization?

Yes, peripherlization is worse although the central pain will feel better

If a prescription is old can we still see the patient?

Yes, the prescription is never to old, most times insurance companies want a prescription that is more current

Would you scan? Yes/No? Why & what? Diagnosis: Shoulder impingement -No pain with shoulder AROM & shoulder RIMT strong-pain-free

Yes, there is no shoulder conditions that should not have some symptoms with AROM and RIMT (scan would include cervical AROM throughout the planes of movement) repetitive motions at our static position, and upper quarter neurological screening which consists of the cervical dermatomes, cervical myotomes and reflexes

What are some other system specific risk factors for Gastrointestinal/Genitourinary/Hepatic/Biliary (risk factors for red flags)?

• Abdominal or flank pain (hydronephrosis) • Persistent heartburn/indigestion correlating to sx onset • Pain associated with feeding or pain worse supine • Unexplained nausea & vomiting • Bladder or bowel dysfunction • Icterus • Hematemesis or hematuria • Constipation (opiods in elderly) may lead to small bowel obstruction - Be aware of patients taking pain medication

DTR's what type of lesion would a Hypoactive reflex represent what about a Hyperactive?

• Hypoactive may signify an interruption of reflex arc (LMN) (root compression from a disc herniation) • Hyperactive signifies loss of cortical inhibition (UMN) (TBI, spinal cord compression) • Asymmetry has more significance than actual value for LMN

Neural Tension/Mobility Tests is used to identify adverse neural tension and/or ↓ neural mobility. What are the indications for these tests? A positive test occurs when we have Concordant symptoms which means what?

• Indications: neural symptom pattern* + testing may result from nerve inflammation, scar tissue (aberrant), traction injury, and compression -Symptoms that they came in, that are reproduced with the test (radiculopathy)

What are some specific risk factors for cancer?

• Previous history of cancer & family history (55% of people will have a prior history of cancer) • Constant unrelenting night pain (48% will be over the age of 65 and report night pain) • Unexplained weight loss (23% weight loss or loss of appetite) • Unexplained loss of appetite • Age > 65 • N.A.R. onset of pain coupled with other variables (Good to keep in mind from a statistical considerably less than 1% with low back pain will have cancer as the cause)

What are some risk factors for a DVT? How do we diagnosis a DVT?

• Risk factors -Recent immobilization/surgery -Age > 40 (75) -Oral contraceptives/postpartum -Malignancy or Previous DVT -Diagnosis of calf pain PostOp -Surgery up to 12 weeks -Bed ridden greater than 3 days • Diagnosis -Duplex US (unable to compress/flatten US head into vein=DVT) -IV contrast = gold standard (but invasive test so no done often) -Labs -Homan & Lowenberg test -Wells screening tool (CPR) -D-dimer tests: breakdown products of the fibrin mesh, most valid lab test for a DVT

With a nerve (root/branch) injury what are some common symptoms and signs that can occur?

• Symptoms: location =nerve distribution -Sharp-Shooting-Burning-Tingling (paresthesias) • Signs (dependent upon degree of injury-may be symptoms only) -Weakness: muscles innervated by affected n. root/peripheral branch -Sensory loss: distribution of n. root/cutaneous branch -Other: Atrophy, ↓DTRs, ↓ tone, fasciculation, ↓ sweat, ↓ pilomotor

What are the specific risk factors for fracture?

• Trauma • Age > 70 • Osteoporosis - Check for screening (DEXA) if: • Post menopausal • Cancer • Long-term catabolic steroid use • Clinical - All movement aggravates - Unable to load (weight-bear) - Bone tenderness - Joint deformity

RIMT Documentation-Interpretation: •Strong* & pain free...? • Strong* & painful Grade__ strain, tendinopathy • Weak* & painful Grade _strain, significant incomplete tear or severe tendinopathy. May be reactive lesion or partial tear/avulsion • Weak* & pain-free (consider MOI) Rupture of muscle or tendon = grade_____ strain OR__________

•Strong* & pain free: Normal contractile tissue and peripheral nerve innervation •Strong* & painful Grade 1 strain, tendinopathy (if greater or equal to 2 muscles no shared action may be false+, same for Weak & painful) •Weak* & painful Grade 2 strain, significant incomplete tear or severe tendinopathy. May be reactive lesion or partial tear/avulsion •Weak* & pain-free (consider MOI) Rupture of muscle or tendon = grade 3 strain OR Neurological