MSK 4- Final: Endgame

Ulnar-meniscal - triquetral volar glide procedure?

pt: seated with elbow supported at 90 degrees with table. Dorsal wrist facing therapist stabilizing hand: lumbrical/golfers grip on radial side wrist manipulating hand: key grip with thumb on ulnar head and pointer finger on pisiform. Squeeze key grip

Anterior and posterior glide of lunate on capitate procedure?

pt: seated with hand hand resting palm down on the table Stabilizing hand: capitate manipulating hand: lunate, moving dorsally or palmary

Anterior and posterior glide of lunate on scaphoid procedure?

pt: seated with hand resting palm down on table Stabilizing hand: scaphoid Manipulating hand: hamate, moving dorsally or palmary

Anterior and posterior glide of lunate on triquetrum procedure?

pt: seated with hand resting palm down on table Stabilizing hand: triquetrum Manipulating hand: lunate moving dorsally or palmarly

Distraction of MCP, PIP, or DIP procedure?

pt: seated with proximal phalanx on wedge-hand in pronation Stabilizing hand: grasps proximal phalanx of joint Manipulating hand: Grasps distal phalanx of joint and pulls apart

Elbow ulnar distraction procedure

pt: supine with arm in SCHNECK Stabilizing hand: distal humeraus, hold down against table Manipulating hand: grasping proximal ulna only, grasping flexor group, exerting inferior force on ulna in plan of humerus

Posterior radial head glide procedure?

pt: supine with pillow or wedge supporting forearm Stabilizing hand: distal humerus, holding it down Manipulating hand: grasp head of radius with thumb and digging into extensor group with fingers push with fingers

Anterior radial head glide procedure?

pt: supine with pillow under forearm Stabilizing hand: distal humerus, holding it down Manipulating hand: grasp head of radius with thumb and digging into extensor group with fingers. Push with thumb

What nerves innervate the facet joints?

recurrent sinuvertebral mixed spinal posterior primary ramus

Mid-Cervical Multifidus isometric

relieving an impacted facet capsule resists the following motions -extension -ispilateral side bending -contralateral rotation

Posterior Lumbar Interbody Fusion (PLIF)

removing disc tissue pressing on the lower spine area, inserting a piece of bone between the vertebrae, and fusing this area with plates and screws. Skeletal System

Clinical signs of instability during AROM assessment

shaking "juddering" while forward bending more difficulty in coming up from forward bending than going into forward bending

Neurogenic Claudication

shooting, sharp, burning pain results from narrowing of spinal canal

Shoulder anterior glide improves?

shoulder abd, ER, and extension

C5 myotome

shoulder abduction

Ectomorph

shoulder and hip width the same (hypo/hyper mobile tendencies)

C4 myotome

shoulder elevation

Shoulder inferior glide improves?

shoulder flexion and abduction

Shoulder posterior glide improves?

shoulder horizontal add, IR, and flexion

Mesomorphs

shoulders broader than hips (hypomobile tendencies)

Lumbar and thoracic functional sidebending

side bending causes rotation to the same side ex. picking up a penny in front of right toe

Describe the osteokinematics and associated arthrokinematics in the lumbar spine for side bending (non functional left)

side bending produces rotation to the opposite side due to ribs and lordosis Right facet upglide Left facet down glide

Pt presents with lateral foraminal stenosis with radiulopathy. What is likely direction of preference to centralize symptoms?

sidebend away

Upward and downward rotation of the scapula

sidelying joint play for all movements of the shoulder

Cephalic and Caudal movement of scapula

sidelying joint play for classical movements of the shoulder

Red flags for manipulation

significant trauma weight loss hx of cancer fever intravenous drug use steroid use severe unremitting night time pain pain that worsens on lying down

Manipulation is

skilled passive movement to a joint with therapeutic intent

T or F: A hallux valgus could be caused by a hypomobility and a hypermobility?

true

What dictates the treatment of a torn mensicus?

type of tear and symptoms

Mid Thoracic Tilt Manipulation

type: graded or progressive oscillation forward and backward bending

Joint play that improves elbow flexion and extension

ulna distraction

T10 dermatome

umbilicus

Which side does a heel lift go on when dealing with stenosis?

unaffected side

Idiopathic scoliosis

unknown cause 90% female early detection/screening key 20-40 degree curves hard braces are used curves can be reduced 50% by bracing >40% harrington rods surgery

Tx of a tendonitis

unload area slow return

Forward bending PIVM (sitting)

upper thoracic pt seated examiner stands on the side of the pt. one hand on the forehead the other palpates spinous processes as head is flexed

Describe the osteokinematics and associated arthrokinematics in the lumbar spine for forward bending

upslide of both facets

Describe the osteokinematics and associated arthrokinematics in the mid thoracic region for forward bending

upslide of both facets limited by posterior ligament, disc and MF

Painful Entrapment

Caused by an awkward movement in eccentric range S/S unable to slide inferior articular processes down Head held away from painful side No Neurological signs management Cervical -multifidus isometric Lumbar -Multifidus isometric -rotational manipulation over a bolster

Functional sidebending in the C Spine

Causes rotation to the same side in the mid/lower cervical spine and subcranial spine

Bunnel Littler

Checks for: intrinsic muscle tightness or capsular problem Procedure: 1. MCP Extension with passive PIP flexion (if unable to flex PIP progress to step 2) 2. MCP flexion with passive PIP flexion. Positive: If PIP flexes then tight intrinsics If PIP does not flex then problem with PIP joint/capsule

Cozen's Test

Checks for: lateral epicondylitis Procedure: patient is stabilized, patient makes a fist, pronates and radially deviates, extends the wrist while the examiner resists the motion. Examiner will also have a thumb over the common extensor tendon Positive: pain

Describe the osteokinematics and associated arthrokinematics in mid cervical backbending

facets are at 45 degrees facets translate down and back at the end range the facet tilts and gaps superiorly lateral interbody joints translate posteriorly spinal canal has narrowed and shortened annulus and ligamentum flava bulge in the spinal canal

Describe the osteokinematics and associated arthrokinematics in upper thoracic back bending

facets at 45 degrees similar movement to the cervical but limited by large spinous process and rib attachments both facets glide down and back nucleus shifts anteriorly annulus bulges posteriorly

Lumbar rotation PIVM: prone lying with rolling legs

evaluates passive rotation in L5/S1 to T12/L1 Leg direction indicates the side of rotation being tested (ex. Rolling legs to L = Left rotation) *rule of the leg*

Lumbar rotation PIVM: Spring Test through the transverse processes

evaluates passive rotation of lumbar segments L5/S1 to T12/L1 ex TP of L3 spring test = Rotation of L3/L4 segment Pushing on L side = Right rotation

Upper Thoracic Forward bending PIVM (seated)

evaluates the passive forward bending of segments C7/T1 to T3/T4

Lateral arc glide of the calcaneus improves

eversion and pronation (frontal plane)

Hip Anteversion

excessive = pigeon toed appears to have increased IR and lack ER Normal cartilage end feel

A patient with excessive hip anteversion will appear to have?

excessive IR and limited ER for PROMclass

Potential causes of plantar fascitis

excessive hindfoot pronation or supination weakness or tightness of surrounding muscles Poor footwear Excessive time on feet Decreased dorsiflexion heel spur

Alar ligament

extends from sides of the dens to lateral margins of foramen magnum

Multifidus action

extends, laterally flexes and rotates vertebral column to opposite side stabilizes vertebral column

MSTT Extension of Index finger

extensor carpi radialis longus

MSTT Extension of ring finger

extensor digitorum

Trochanteric fx

extra-capsular severely comminuted position: ER and shortened Swelling Tx: ORIF - good union F>M

What determines the spinal plane of arthrokinematic movement?

facet joints

Describe the osteokinematics and associated arthrokinematics in upper thoracic (T1-T4) forward bending

facets at 45 degrees similar movement to the cervical but limited by large spinous process and rib attachments both facets glide up and forward nucleus shifts posteriorly annulus bulges anteriorly

BB Lumbar spine

facets slide down bilat facets fulcrum on the lamina facet joints open up cephalically (tilt) Annulus bulges posteriorly and flattens anteriorly nucleus deforms anteriorly

BB Thoracic spine

facets slide down bilat ribs rotate

FB in lumbar spine

facets slide up bilat disc bugles anteriorly and flattens posteriorly nucleus deforms posteriorly

Forward bending in the thoracic spine

facets slide up bilat ribs rotate on their long axis

Mid/Lower C Spine BB

facets translate down and back At end range the facet tilts and gaps superiorly Lateral interbody joints translate posteriorly Spinal canal is narrowed and shortened Disc and ligamentum flava bulge into spinal canal IV forament is narrowed

Mid/Lower Cervical Forward Bending what happens?

facets translate up and forward (40%) Lateral interbody articulations translate anteriorly *IV disc bulge anteriorly and flatten posteriorly* Spinal canal lengthens and narrows (no change in volume) IV foramen open

If the knee is in genu valgus in what position is the femur?

femoral IR

Other muscle states

fibromyalgia

T1 myotome

finger abduction

T1 myotome

finger abduction/adduction

Dorsal glide of MCP, PIP, DIP improves?

finger extension

Palmar glide of MCP, PIP, DIP improves?

finger flexion

Finklestein's test

flex thumb across palm and bend fingers over top- pt then ulnarly deviates wrist + = pain in thumb extensors

Empty Can Test

flexion and internal rotation of the shoulder followed by resistance to observe for weakening of the supraspinatus muscle

What is the capsular pattern at the elbow?

flexion is more restricted than extension

When is a tight capsule at the elbow more likely to occur?

following immobilization (bracing, splinting)

Press Test

for TFCC injury. Sn 100%, pt sits in chair, grasps both sides of seat & presses body up. (+) ulnar sided wrist pain

If the hindfoot is supinating

forefoot pronating midfoot supinating

If the hind foot is pronating

forefoot supinating midfoot pronating

Still

founded Osteopathy 1874

Palmer

founded chiropractic 1895

Spondylolysis

fracture of pars interarticularis

Spondylolisthesis

fracture of the pars interarticularis with forward slipping of one vertebra over another

The greatest amount of motion at the subtalar joint is in what plane of motion?

frontal

Closed packed position of the hip

full extension medial rotation abduction

Neurophysiological effects of manipulation

gate control - type I & II centralization of pain muscle inhibition (type III) joint nutrition & lubrication

How does BB relieve pain?

gate control theory Increase H2O in disc mobilizes the facet joints promotes circulation relieve the fear of movement neural tension decrease protruded nucleus pulposus begins to shrink *good for everything but an annular tear*

Hypermobility causes of PFS

genuvalgum, small lateral femoral condyle, patella alta

In the LE what muscles typically get weak?

glutes, quads, posterior tib, anterior tib

Clinical signs of instability PROM assessment

grade 5 or 6 on passive motion palpation

prone rib manipulation

graded or progressive oscillation used for help with exhalation follows scapula -superior glide after scapula -superior glide costovertebral -inferior glide costotransverse

Synovitis S/S

gradual onset (6-12 hours) Warm Joint Min/mod limited joint ROM Usually dull ache in the joint with joint disteneded

L5 myotome

great toe extension

L1 dermatome

groin

Cyriax Capsular Pattern

gross limitation of: (FAME) -flexion -abduction -medial rotation and extension -slight limitation of lateral rotation

What muscle weakness could lead to ACL injuries?

hamstring, glude mead and min

In the LE what muscles typically get tight?

hamstrings, hip flexors, adductors, gastrocs

Forward bending at OA joint

head rolls anteriorly and glides posteriorly

O/A Joint Mechanics for FB

head rolls anteriorly and glides posteriorly

O/A joint mechanics for for SBL

head rolls left and glides right

Sidebend left at OA joint

head rolls left and glides right

Backward bending at OA joint

head rolls posteriorly and glides anteriorly

O/A joint mechanics for BB

head rolls posteriorly and glides anteriorly

Chronic SOC

healing almost complete if not complete 12-15 weeks post injury pain behaviors begin

Endomorphs

hips broader than shoulders hypermobile tendencies

Clunk Test

identifies a glenoid labrum tear

Slump Test

identifies dysfunction of neurological structures supplying the lower limb

Drop arm test

identifies tear and/or full rupture of rotator cuff

Lateral distraction of humeral head with long lever arm

joint play for classical GH motions pt - sitting PT - at pt side Stabilizing hand - placed under pt axilla (acts as fulcrum Manipulating hand - grasps the lateral distal side of humerus Force applied towards the pt trunk with an inferior pull

Lateral distraction of humeral head (short lever arm)

joint play for classical movements at GH joint pt supine PT - standing at pt side stabilizing hand - lateral/distal humerus while providing a slight inferior force on humerus manipulating hand - grasps mid humerus Force applied away from trunk of pt

Distraction of the Ulna

joint play for flexion and extension pt - supine. elbow flexed hand resting on PT PT - standing to side of pt Stabilizing hand - hand grasps distal upper arm Manipulating hand - hand wraps around proximal ulna fingers on anterior side Movement - manipulating hand pulls downward

Tx of a tendonosis

load area progressively eccentrically

Side bending - side lying - raising legs

located L5 pt flexes hip and knee to 90 pt legs are supported by examiners thigh examiner controls legs by grasping lower ankle (up or downward motion) other hand palpates near interspinous space Upward motion = concavity Downward motion = convexity

Coccyx manipulation

long axis distraction

Deep neck Flexors

longus capitis and longus colli Chin Tucks deep neck flexor endurance training

How do you differentiate between a popliteus and semimembranosus tendinopathy?

look at hip

MSTT GH Adduction

loose pack position of the shoulder about 20 degrees from the trunk (scaption) - patient is sitting - PT: standing, cradles elbow into the palm to maintain loose pack position and to avoid patient having to hold arm in the position - Muscles: teres minor, teres major, latissimus dorsi, pectoralis major - Contact: medial mid humerus to apply resistance

MSTT GH Abduction

loose pack position of the shoulder about 20 degrees from the trunk (scaption) - patient is sitting. - PT: standing, cradles elbow into the palm to maintain loose pack position and to avoid patient having to hold arm in the position - Muscles: deltoid, supraspinatus - Contact: lateral mid humerus to apply resistance

Injury to median nerve can cause

loss of pronation ape hand deformity benediction sign sensory : loss of 3 1/2 lateral digits

What is the articular discs responsibility in the TMJ?

maintain joint integrity and alignment distribute forces guide movement shock absorption

Mechanoreceptor influence in pain modulation

manipulation influences *type 1* and *type 2* mechanoreceptors modulation = the exertion of a controlling influence on something

Mechanoreceptor influence on muscle inhibition

manipulation influences *type III* mechanoreceptors

TX: Settled stage of condition

progress strengthening to more aggressive forms of strengthening, stretch any tight muscles; progress with manipulations as needed for joint restrictions, 80% (8-12 reps) 1 RM for strengthening

Distraction of proximal row of carpals on radius procedure?

pt: seated in pronation with wrist slightly hanging over wedge Stabilizing hand: hold down distal radius and ulna against wedge "kiss hands" Manipulating hand: grasp proximal row of carpals, including thumb. pull apart in direction of loose packed

Volar (palmar/anterior) glide of carpals on radius procedure?

pt: seated in pronation with wrist slightly hanging over wedge Stabilizing hand: hold down distal radius and ulna against wedge "kiss hands" Manipulating hand: grasp proximal row of carpals. Push down in direction of loose packed

Dorsal (posterior) glide of carpals on radius procedure?

pt: seated in supination with wrist slightly hanging over wedge stabilizing hand: hold down distal radius and ulna against wedge "kiss hands" manipulating hands: grasp proximal row of carpals, including thumb. push down in direction of loose pack

Pisiform glides (medial/lateral/superior/inferior) procedure?

pt: seated with elbow supported at 90 degrees palmar wrist facing therapist grasp pisiform with thumb and pointer finger and move in direction indicated

External rotation Lag sign

(infraspinatus, teres minor) -Arm at side w/ elbow 90 degrees flexion -arm max ER w/ 20 degrees abduction - (+) test Inability to hold arm in ER - or hold against resistance

What will likely occur after an intracapsular humeral neck fracture?

* Hemarthrosis within the capsule - can lead to early adhasion formation and joint degeneration * this type of fracture is often malaligned once healing is complete

Z-Deformity of the thumb

* deformity due to laxity of the IP joint secondary to RA - MCP joint is positioned into flexion - IP joint is positioned into hyperextension

MOI for humeral shaft fracture? how is it treated?

* result of direct trauma to the arm without FOOSH * tend to heal with with good blood supply *treatment: closed reduction with cast or splint if fractured bones are still aligned * ORIF if there is malalignment with fractures surfaces

How are nerve entrapments between the median nerve and its anterior interosseous branch different?

* the anterior interosseous nerve is ONLY motor, no sensory component * median is both motor and sensory

Hypertonic states

- spasm - hypertrophy - involuntary muscle holding - chemical muscle holding - voluntary muscle holding

What role does joint play motion play in movement?

Allows joints to absorb outside forces in order to decrease chances of injury

What is a loose pack position?

Angular position All tissues on most amount of slack

How do we determine the stage of healing?

Based on our examination

MOIs for humeral neck fractures (2)

1. FOOSH injury 2. compressive force into the glenoid - common in patients with osteoporosis

Scaphoid Fracture 1. What is the MOI? 2. How can it be medically treated? 3. What is unique to the scaphoid that can cause additional complications post-fracture?

1. FOOSH injury to the radial side of the wrist when it is in close-packed position - scaphoid and lunate are in rigid contact with radial articular surface 2. casting, surgery, bone stimulation - can take up to 3 months to heal 3. scaphoid has limited blood supply due to little periosteum surrounding it. can lead to: - avascular necrosis - delaye healing and non-unions

Grade II manipulation

Beginning of range to middle range, large amplitude

Grade I manipulation

Beginning of range, small amplitude

Where do thoracic and lumbar nerves exit?

Below the vertebrae ex. T3 nerve - T3/T4 segment L2 nerve - L2/L3 segment

What two tests can differentiate between a neurogenic and vascular claudication?

Bike test and treadmill test

Cervical Central Stenosis S/S

Bilat UE symptoms Vague transient neuro signs in arms and maybe leg UMN signs -babinski -clonus

What is a swelling end feel?

Boggy or soft

Phase III of Osteocondrosis

Bone healing -bone resoprtion stops -bone deposition continues -biological plasticity still present -final shape of epiphysis is forming

Bennett's Fracture 1. What anatomical area is it specific to? 2. What is the MOI? 3. What are common characteristics of this injury (3)

1. Fracture of the base of the 1st CMC 2. Axial force to the thumb (usually in a slightly flexed position) driving CMC into the carpal bones 3. - fracture tends to be more anterior - fractured segment remains intact w/ trapezium due to strong volar oblique ligament - 1st metacarpal susceptible to dislocation in radial direction

Supraspinatus tendinitis vs calcific tendinitis

Calcific tendinitis results from local areas of necrosis within the tendon. Causes calcium deposits (toothpaste consistency) requires radiography to confirm

What is a tissue specific impairment that can cause altered joint alignment?

Capsule or ligament laxity/instability/hypermobility

Etiology

Cause of disease

disuse atrophy

Cause: underused muscle, immobilization, stiffness Signs and Symptoms -Loss of bulk on MRI, CT, US, Palpation Management Manipulate stiffness Exercise the muscle

Fibromyalgia

Cause: unknown (sleep disturbances, neurobiological abnormalities, loss of SNS control, local tissue factors, trauma/virus, psychological Signs and Symptoms -Primary: aches and pains (swelling, stiffness, weakness, tender points) -Secondary: excessive fatigue, non-restorative sleep, chronic tension migraine, HA, bowel and bladder irritability (11/18 specific spots for greater than 3 months) Management Multidisciplinary approach PT: posture, low load exercise, low reps, low impact

SIJ Sprain/Strain

Cause; trauma Signs and Symptoms Pain, well localized over SI joint (unilateral in nature) Management Strengthen multifidus and other core IFC stim Heat or Ice

Central spine stenosis

Caused by DDD and DJD Pressure on spinal cord Can lead to saddle paresthesia and loss of bowel or bladder control

Restriction

Caused by a resolved synovitis or hemarthrosis not symptomatic S/S: limited ROM (capsular pattern), pain, lowered tolerance to insult Clinical pres: capsular pattern Management: manipulation -grade dependent on pt reactivity

Biomechanical Effects of manipulation

1. Restore mobility and ROM 2. Restore Restricted connective tissue 3. Stretch/Snap capsular adhesions 4. Release capsule/meniscoid entrapment 5. correction of a positional fault

What two things can happen to the humeral head if laxity or instability is present

1. The humeral head is already in an incorrect position prior to movement. Movement then results in earlier encroachment of the humeral head to the coracoacromial arch. 2. The humeral head is in the correct position prior to movement, but once movement occurs the humeral head may move excessively in one arthrokinematic motion thus resulting in encroachment of the humeral head to the coracoacromial arch.

1. what is the MOI for a redial head fracture 2. what are the surgical treatment options?

1. compression of radial head into capitullum as a result of a FOOSH - can be comminuted or non-comminuted - malunions are likely 2. - closed reduction w/ cast - open reduction w/ early motion - ORIF - replacement or resection of radial head

T5 dermatome

1/2 between nipples and xiphoid process

Mid-Cervical joints

10 8 are synovial

Ankle dorsiflexion (with knee extended)

10 (end-feel: muscular, ligamentous, or capsular)

Dorsal (posterior) glide of carpals on radius loose packed?

10 degrees flex neutral 10 degrees ext

Anterior and posterior glide of hamate on triquetrum loose packed position?

10 flex neutral 10 ext

Anterior and posterior glide of lunate on capitate loose packed position?

10 flex neutral 10 ext

Anterior and posterior glide of lunate on scaphoid loose packed position?

10 flex neutral 10 ext

Anterior and posterior glide of lunate on triquetrum loose packed?

10 flex neutral 10 ext

Scoliosis

10-20 degrees - mild 20-40- moderate 40-50 severe (structural changes, tx needed) 60-70 cardiopulmonary changes - decreased life expectancy

Loose packed position of the MCP joint

10-20 degrees flexion

PIP/DIP loose packed

10-20 degrees flexion

What are steps 10-12 of the 18 steps of the extremity examination?

10. MMT 11. Special Test 12. Movement Analysis

Finger PIP flexion

100 (end-feel: boney, tissue approximation, capsular, or ligamentous)

Thoracic joints

12 10 are synovial

Chronic

12-15 weeks Pain behaviors begin to develop Smaller noxious stimuli will cause the same amount of pain despite healing considered finished Pt despondent is possible to to the chronicity of the condition

Hip flexion

120 (end-feel: tissue approximation, capsular, or muscular)

What are steps 13-15 of the 18 steps of the extremity examination?

13. Palpating for tenderness 14. Neuromuscular 15. Diagnostic imaging

Knee flexion

135 (end-feel: tissue approximation or muscular)

Ankle eversion

15 (end-feel: boney, ligamentous, or capsular)

Thumb CMC flexion

15 (end-feel: tissue approximation, capsular, or muscular)

Elbow flexion

150 (end-feel: tissue approximation, boney, capsular, or muscular)

What are steps 16-18 of the 18 steps of the extremity examination?

16. Evaluation 17. Dx and prognosis 18. Intervention

Shoulder abduction

180 (end-feel: ligamentous, capsular, or muscular)

Proliferation healing (sub acute)

2 weeks - 1-2 months

Thumb CMC extension

20-80 (end-feel: capsular or muscular)

What is needed for functional opening of the mouth?

25-35 mm or at least 2 knuckles between teeth

Inflammatory healing (acute)

3-14 days

Cervical Myelopathy causes

Cervical spondylosis (80%) Cervical stenosis Large central or paracentral disc herniation Lig Flavum PLL Ostephytes

Neer's Test

Checks for: supraspinatus or bicepts tendon injury (impingement) Procedure: Elbow extended, IR, PT passively elevates arm into scapular plane flexion Positive Test: pain in face or verbalized due to greater tuberosity jamming into the acromion

Tinel's Sign at elbow

Checks for: ulnar nerve problem at the cubital tunnel Procedure: tap ulnar nerve in cubital tunnel Positive: pain or tingling

Wartenburg's sign

Checks for: ulnar neuropathy Procedure: the examiner passively spreads the fingers and asks the patient to bring them together again Positive: unable to adduct digits 4 and 5

Scapular assistance test

Checks for: weak scapular stabilizers Procedure: 1. patient lifts arm into scaption. 2. patient lifts arm into scapiton with therapist upwardly rotating at superior angle and inferior angle Positive: decrease in pain

Scapular Retraction Test

Checks for: weak scapular stabilizers (rotator cuff/labrum) Procedure: 1. patient lifts arm into scaption. 2. patient lifts arm into scaption with therapist supporting medial border and clavicle/spine of scapula in retraction Positive: if decrease in pain

Empty Can Test

Checks for:Supraspinatus or suprascapular nerve injury Procedure: pt's arm is abducted to 90 degrees, thumb down. told to resist PT. Positive Test: Pain or verbal complaints. Inability to resist

CPR Thoracic Manipulation for Neck Pain

Cleland (FSTEPS86) FABQ less than 12 Symptoms dont pass the shoulder T3-T5 diminished kyphosis Ext <30 Painless BB Symptoms < 30 days 3/6 = 86%

What is the stage of condition?

Clinical appearance/presentation of dysfunction

What should be included in pt position during a manipulation?

Comfortable Relaxed Joint supported

What should be included in therapist position during a manipulation?

Comfortable Relaxed Body mechanics

Myelopathy cluster

Cook HIGAB +Hoffman;s +Inverted Supinator Gait deviations Age over 45 +Babinski 3/5 LR = 30.9 Tx: DNF strengthening, posture education, cervical stabilization

Tx of TMD

Correct forward head posture anterior cranial rotation exercises -chin nods Nasal breathing Self-Distraction/mobilizations Rocabado's 6x6

Functional Limitation

Difficulty with ADL

What are the types of manipulations?

Direction Glide Distraction Tilt

Physical Therapy is....

Disability oriented

Lumbar discectomy

Disc removal

What are the precautions for manipulations?

Disease states Hemarthrosis Hypermobility/instability Muscle holding Acute inflammation Joint Replacements Anti-coagulant therapy

Standing: PSIS unequal GT are equal Seated: PSIS and GT equal Causes?

Femoral joint angle DJD Perthe's Disease SCFE trauma

A normal capsule end feel will be?

Firm arrest with creep

A normal ligament end feel will be

Firm with no creep

Cervical Myelopathy CPR (Cook)

Hoffman's inverted supinator gait deviations Age over 45 Babinski

Major and Minor Muscle States

Hypertonic states Hypotonic states Normal tone/shortened Other

What grades of manipulation are used to examine capsular restrictions?

III and IV

TSI or tissue specific impairments

Identifies a tissue and the dysfunction or impairment and tells us what is wrong with it

CPR for SIJ

Laslett Rule: -No centralization of pain w/ McKenzie Evaluation -Reproduce pain w/ 3+ provocation tests Specificity: 0.78 Sensitivity: 0.91 Tx: SIJ manipu and lumbosacral stabilization

Superficial layer of back muscles

Last, traps, rhomboids, levator, glut max

What types of amplitude can you use with manipulations?

Non-Thrust Thrust - small amplitude high velocity Oscillations

Relative contraindications/precautions

Osteoporosis Herniated disc with radiculopathy signs of spinal instability RA w/ Upper cervical instability Pregnancy Local infection inflammatory disease active cancer hx of cancer long term steroid use systemically unwell hypermobility syndrome CT disease Cervical anomalies throat infection in children recent manipulation by another healthcare professional

TSI: Bursitis Best exam step? Best Tissue reactivity

P4C P4T

TSI: Edema Best exam step? Best Tissue reactivity

P4C P4T

What are the two best examinations to confirm synovitis?

P4C and PROMacc

Supination consists of:

PF Inversion IR

Anterior glide of the talus improves

PF and Supination (sagittal plane)

Best Exam Findings for Bursitis?

PFC and PFT

Compared to a MD what does a PT focus on during treatment?

PTs focus on the dysfunction or impairments MD = the condition

18 steps

Pain Assessment Initial Observation History Structural Inspection PFC AROM PROM MSTT MLT MMT Special Test Movement analysis PFT Neurovascular Evaluation Imaging Dx Tx

Thoracic Outlet Syndrome (TOS) S/S

Pain and paresthesia in UE Deep aching ill defined pain intermittent claudication Raynaud's phenomena Intermittent edema, venous engorgement, cyanoses Dorsal scapula pain

Posteroanterior (PA) Forward Bending PIVM

Peace sign fingers are placed on TP's and other hand provides a PA pressure Assess passive forward bending motion and the level of reactivity of thoracic segments T3/T4 to T11/12 (Spinous Process of T2 between fingers = T3 Transverse Processes)

Clinical Presentation of WAD

Postural muscle imbalance Limited or guarded ROM Muscle weakness as well as decreased endurance and motor control Muscle tightness Limited joint mobility Tenderness and increased muscle tone

Management of Cervical central stenosis

Posture-axial extension Stabilize cervical spine - deep ant. Muscles Avoid backward bending - sleeping postures, cycling, basketball, breastroke Manipulate upper thoracic region to help reduce MC stress Surgery - remove impingements and then fusion

Stages of disc injury (Paris)

Pre-Prolapse Immediate injury (tear or herniation) Acute and Sub Acute Prolapse Settled Prolapse Chronic Disc Disease

Preparatory

Prepares he tissue for the corrective treatment Ex. Warm up

Lumbar Side Bending PIVM test prone position

Purpose: evaluates passive side bending L5/S1-T12/L1 feeling same side lateral interspinous space and should feel it move into your fingers Knee can be extended or flexed

T4/T5 to L5/S1 SB L

R facet upglide L facet down glide

Biomechanical effect: restore mobility and ROM

ROM and mobility improved with: Upper Cervical - thrust Cervical thrust and non-thrust manipulation Thoracic thrust manipulation Lumbar thrust manipulation Isometric muscle contraction: muscle energy

Hemarthrosis S/S

Rapid onset (1-2 hours) Hot joint Mod/severe limited joint ROM with inability to assess due to pain more severe pain because knee is very inflammed

Clinically, at the talocrural joint we examine for what 2 planes of motion using what 2 manipulations/glides?

Sagittal (A/P glide of talus) Frontal (M/L glide of talus)

In what direction will roll and glide be if a concave surface is moving on a convex surface?

Same direction

Why should PT do an examination?

Screening process Provides a starting point for intervention Additional interventions needed?

Maitland Grade IV

Small amplitude movement at the end of the range last 10% of range

Maitland Grade V

Small amplitude, quick thrust manipulation at the end of the range. Within the anatomical range

What nerves innervate the intervertebral disc?

grey ramus communicans recurrent sinuvertebral mixed spinal anterior primary ramus

SIJ Syndromes

Sprain/Strain Hypermobility Displacement

What is a displaced meniscus end feel?

Springy rebound/bouncing back

Symptom

Subjectively manifested Consciously affecting the pt and likely verbalized by them Can only be felt by the pt

Lumbar segment

T12/L1 - L5/S1

Mid-Thoracic segment

T3/4 - T12/L1

Anterior Apprehension Test

TESTING: Anterior instability POSITION: Supine, 90˚ shoulder abduction, and take into ER (+) TEST Apprehension (Not pain)

supination lift test

TFCC pathology

Yergason's Test

Tests for the integrity of transvere ligament and may also identify bicipital tendonitis

Rib Exhalation PIVM

Tests the costotransverse and costovertebral joints of targeted rib Ribs around scapula = inferior glide Ribs below scapula = Costovertebral - superior glide and Costotransverse - inferior glide

gate control theory of pain

a theory of pain perception based on the idea that signals arriving from pain receptors in the body can be stopped, or gated, by interneurons in the spinal cord via feedback from two directions

Inferior glide of humeral head without scapula stabilization

component motion of elevation pt - seated PT standing above shoulder Stabilizing hand - grasps distal surface of humerus Manipulating hand - superior surface of the humerus Inferior force applied

Anterior radial head glide type of motion?

component or joint play

Acute SOC

condition is worsening cardinal signs of inflammation

anterior longitudinal ligament

connects anterior surfaces of adjacent vertebral bodies prevents hyperextension

MidCarpo Wrist extension

dorsal glide

Weakness of what muscles at the hip can lead to genu valgus?

hip abductors and ER

L1 myotome

hip flexion

L2 myotome

hip flexion

Unicondylar glides

dude just do it

Cruciform ligament

transverse ligament of atlas and vertical ligament from skull; holds body of C2 and dens to the inside of the skull

management of thoracic outlet syndrome

treat the cause manipulate hypomobility stretch myofascia - pec minor, scalenes postural exercise scapular neuromuscular control diaphragmatic breathing HEP - self stretching & mobilization

Psychological effects of manipulation

therapeutic touch and intelligent hands induced skilled movement in presence of fear jt pop/snap/cavitation placebo nocebo pt expectations Therapeutic alliance

A capsular pattern indicates?

whole joint capsule is restricted

1. What are the nerve roots for the ulnar nerve? 2. What muscles are innervated by the ulnar nerve? 3. What is the sensory distribution of the ulnar nerve?

woof

1. What nerve roots contribute to the median nerve? 2. What muscles are innervated by the median nerve? 3. What muscles are innervated by the anterior interosseous nerve? 4. What is the sensory distribution of the median nerve?

woof

Side lying raising legs manipulation

stretch or progressive oscillation for side bending

Painful Arc Test

subacromial impingement

L1 dermatome

inguinal ligament

L3 myotome

knee extension

S2 myotome

knee flexion

What is the key to success with manipulation?

knowing when and how to manipulate

Spring test for thoracic rotation

peace sign with one finger higher than the other (TPs of different vert) same as PA glide but rotation occurs towards the lower finger *rule of the lower finger*

Anterior and posterior glide of hamate on triquetrum procedure?

pt: seated with hand resting palm down on table stabilizing hand: triquetrum manipulating hand: hamate, move dorsally or palmaryl

Shoulder posterior glide procedure

pt: supine with wedge under scapula PT opposite side of the table Stabilizing hand: on table Manipulating hand: grasp humeral head with C grip and push posterior/lateral with heel of hand

sacrotuberous ligament

sacrum to ischial tuberosity

Edema

swelling outside of a joint

What spinal level does the L4 nerve root exit?

L4/L5

What nerve does the L5/S1 disc impinge on?

L5

What nerve does the L4/L5 disc impinge on?

L5 nerve root

Cyriax

"end feel"

Where does manipulation fit in the 18 steps?

#7 PROM

Why is the supraspinatus more susceptible to tendonous pathology?

*With the arm along the side of the body, the tendon is pulled down and over the greater tuberosity of the humerus * The tuberosity compresses against the tendon, creating a zone of avascularity

hypomobility risk factors for shoulder impingement

*adhesions - most specifically in inferior aspect of capsule - prevenst inferior glide of humeral head during osteokinematic flexion, preventing greater tuberosity from clearing the acromion

MSTT ECRL

- Position: elbow extension, forearm pronation, wrist in 10 degrees of extension, fingers in neutral - Contact: dorsum of the index finger between the MCP and PIP to apply resistance

MSTT Forearm supination

-- loose pack position at the elbow about 70 degrees of elbow flexion and neutral between pronation and supination. - Patient is sitting - PT: standing, hand cradles the posterior elbow to maintain loose pack position and to avoid patient having to hold arm in position - Muscles: supinator and biceps - Contact: distal 1/3 dorsum of forearm on radius to apply reisstance

What motion does the convex-concave rules apply to?

Component motions

Hoffman's reflex (sign)

-Upper extremity equivalent to Babinski reflex (sign) -Reflex test which verifies the presence or absence of problems in the corticospinal tract; also known as the finger flexor reflex -Involves tapping the nail or flicking the terminal phalanx of the third or fourth finger *-Positive response is seen with flexion of index finger to the thumb* -Sign of UMN damage, spinal cord compression (myelopathy)

Hoffman's reflex (sign)

-Upper extremity equivalent to Babinski reflex (sign) -Reflex test which verifies the presence or absence of problems in the corticospinal tract; also known as the finger flexor reflex -Involves tapping the nail or flicking the terminal phalanx of the third or fourth finger -Positive response is seen with flexion of index finger to the thumb -Sign of UMN damage, spinal cord compression (myelopathy)

Prone Knee Bend Test

-assesses upper lumbar (L1-L3) nerve root lesion, femoral nerve tension -pt. is prone and flexes knee, PT hyperextends hip -"+" = pain in lateral hip, upper lumbar spine, or anterior thigh

Prone Knee bend TEst

-assesses upper lumbar (L1-L3) nerve root lesion, femoral nerve tension -pt. is prone and flexes knee, PT hyperextends hip -"+" = pain in lateral hip, upper lumbar spine, or anterior thigh

Elbow extension

0 (end-feel: boney)

Finger DIP extension

0 (end-feel: capsular or ligamentous)

Finger PIP extension

0 (end-feel: capsular or ligamentous)

Knee extension

0 (end-feel: capsular or ligamentous)

Thumb CMC adduction

0 (end-feel: capsular or ligamentous)

Thumb MCP extension

0 (end-feel: capsular, ligamentous, or muscular)

PIVM grading

0: Ankylosed: fused joint primarily caused by ankylosing spondylitis 0 manipulation technique performed → can break fusion 1: Considerable restriction 0 thrust performed → when too tight, thrust can tear joint capsule 2: Slight restriction Thrust or non-thrust (for pain, ect.) ok 3: Normal 4: Slight increase in motion Stabilize? Unless increased ROM is normal to the individual 5: Considerable increase in motion Stabilize c supporting musculature around spine (TA, mult, obliques) 6: Unstable Need external support (brace, tape) Take care when using this term, can infer pt is surgical candidate

Cervical radiculopathy: 1. Spondylitic changes of what bony landmark contribute to this? 2. what population does CR affect most? 3. What type of sensations are reported? 4. impairments?

1. * joint of Von Lushka (uncinate process) acts as a barrier between the disc and nerve root in C-spine - spondylitic changes include osteophyte formation at this joint * vertebral bodies decrease in size due to osteoporosis, but not facet joints of T1/T2 - high will decrease anteriorly, but not posteriorly, causing hyperextension in lower cervical spine 2. Affects more women in 4th or 5th decade - C6/C7 most commonly affected 3. gradual onset of pain in neck and upper trap that spreads to arm - parasthesias in UE - symptoms worse by looking up or sidebending to side of symptoms 4. Foward head/shoulders' - limited SB toward involved side and BB w/ pain radiating into UE - neurological signs postiive in corresponding dermatome/myotome - distraction decreases symptoms - compression and quadrant test all increase symptoms in UE - tenderness on involved side in upper trap/levator/paraspinal/interscap muscles

Muscular Torticolis 1. What is it 2. what corrects it

1. Congenital tightness/restriction in sternocleidomastoid muscle - weeks after birth, a firm swelling develops in the SCM, leaving behind a contracture once resolved 2. daily stretching for the first year

Benefit of the POP

1. Continued stretch on the capsule (gas) 2. Increased joint mobility increased joint space 3. Stimulate type III mechanoreceptors 4. Decrease pain from endorphin release

Dupuytren's Contracture 1. What anatomical region is it specific to? 2. what is the MOI?

1. Contracture of palmar fascia with flexion deformity of MCP and PIP joints - most often affects digits 4 and 5 2. formation of nodules of unknown etiology on palmar aspect of hand - eventually leads to thickening and shortening of palmar fascia

Galeazzi Fracture 1. What anatomical region is it specific to? 2. What is the MOI?

1. Distal radius fracture with dislocation of distal radioulnar joint 2. MOI not given

Potential risks of the pop

1. Muscle inhibition = joint not as protected as well 2. ROM increases which could cause instability over time 3. fosters dependency on the POP and relief it brings 4. Inflicts stress and trauma on the disc

What are the first three steps of the 18 steps of the extremity examination?

1. Pain assessment 2. Initial observation 3. History

CRPS 1. what is it? 2. what are some possible causes?

1. Painful and intolerable hypersensitivity that ins't proportional to any specific event - most commonly in upper extremities 2. direct trauma to sympathetic nerves - direct trauma to a peripheral nerve - immobilization - immobilization in the presence of edema - psychological predisposition

Supine examination of C-spine 1. MLT 2. Palpation

1. Pec Minor - Pec Major - SCM - Upper Trap 2. SC joints - Clavicles - Subclavius - AC joints - Scapular spines - levator scap - upper trap - cervical paraspinals - SCOM - Scalenes - Articular PIllars/facet joint capusles - Spinous processes

Boutonniere Deformity 1. What causes it? 2. What is its appearance? 3. What is it often a consequence of? (5)

1. Volar displacement of the lateral bands of the PIP joints 2. PIP joint is pulled into flexion while the MCP and DIP joints are pulled into extension 3. RA - inflammatory arthritis - traumatic tendon avulsions - contractures - nerve injuries

In reflex testing: 1. What grade would you expect from a nerve irritation? 2. what grade would you expect from a nerve compression?

1. a +3 or +4, indicating hyperactivity (hyperreflexive) 2. +1 indicating a diminished reflex

Potential causes of scapular dyskinesis (5)

1. abnormality in bony posture or injury: excessive scapular protraction and acromial depression - excessive resting kyphosis - forward head posture 2. AC joint injuries or instabilities: can alter center of rotation of scapula, leading to faulty mechanics 3. muscle function alterations: involving serrature anterior and lower trap most common - microtrauma due to excessive strain in muscles, fatigue, and inhibition due to pain 4. nerve damage: rare cause 5. contractures: especially to anterior musculature that attaches to the coracoid process (pec minor, short biceps) - causes anterior tilt and forward scapular lean - also tightness to posterior capsule and latissimus

What types of surgery are done for carpal tunnel syndrome? (2)

1. endoscopic - like arthroscopic, but in a tunnel rather than a joint 2. open * both aim to cut flexor retinaculum pr remove lesions to increase amount of space available to median nerve

Shoulder posterior glide loose packed position?

20 flex 20 abd

Hip adduction

30 (end-feel: capsular, ligamentous, or muscular)

Ulnar deviation

30 (end-feel: ligamentous, capsular, or muscular)

Ankle inversion

35 (end-feel: muscular, ligamentous, or capsular)

What is the normal for mouth opening?

35-50mm

What are steps 4-6 of the 18 steps of the extremity examination?

4. Structural inspection 5. Palpating for condition 6. Joint Active Range

MSTT Biceps

: GH internal rotation, GH flexion, elbow flexion, forearm supination

Finger MCP extension

45 (end-feel: capsular or ligamentous)

First metatarsophalangeal flexion

45 (end-feel: capsular or ligamentous)

Hip external rotation

45 (end-feel: capsular, ligamentous, or muscular)

Hip internal rotation

45 (end-feel: capsular, ligamentous, or muscular)

C1 joints

5 5 are synovial

What is an abnormal muscle end feel?

A don real contractile resistance

Damage to which ligaments will result in joint effusion?

ACL and MCL

Best steps to identify a capsular pattern of the shoulder

AROM - patient's active movements are decreased with ER>ABD>IR PROM CLASSICAL (quantity) - decreased passive classical ROM with limitations of ER>ABD>IR PROM CLASSICAL (quality) - tight capsule end-feel in all directions PROM ACCESSORY (quantity) - decreased P/A>inferior>A/P PROM ACCESSORY (quality) - tight capsule end-feel in all directions

cervical radiculopathy werrners

AROM <60 ULTT + Spurling Distraction relieves symptoms

Provocation Tests for SIJ

ASIS distraction test Gaenslen's Thigh Thrust ASIS compression Sacral thrust test Drop Test

S1 reflex

Achilles

Pathology

Actual problem or disease that is occurring at the cellular level

MSTT GH Flexion

All positions same as above - Muscles: deltoid, biceps, coracobrachialis - Contact: mid humerus anteriorly to apply resistance

MSTT GH Ext

All positions same as above - Muscles: lat dorsi, triceps - Contact: mid humerus posteriorly to apply resistance

A tissue specific impairment is best described as?

An impairment of an identifiable tissue or structure in the body that is contributing to the patients complaints and functional loss

Backward bend lumbar spine

Annulus bulges posteriorly Facets move back and down Nucleus deforms slightly anterior Foramen close

Lateral flexion or sidebending of the lumbar spine

Annulus bulges to side of sidebending Annulus flattens on opposite side Facet slides up on opposite side Facet slides down on same side

Spine ligaments ant to post

Ant Long ->IV disc ->Post Long -> facet capsules ->flavum->interspinous->supraspinous

C6 Dermatome

Anterior arm, radial side of hand to thumb and index finger

What is traction?

Application of force such as joint play assessment and treatments that are directed along the axis of the long bones

What is distraction?

Application of force where there is joint surface separation; the force is perpendicular to the treatment plane (joint separation)

T4/T5 to L5/S1 Rotation Left

L facet gap/distract R facet compresses

L2 dermatome

Back, front of thigh to knee

L3 dermatome

Back, upper buttock, anterior thigh and knee, medial lower leg

Chronic SOC

At ~12-15 weeks post injury primary healing is considered finished. Pain behaviors begin to develop A smaller noxious stimuli will cause the same amount of pain despite healing considered finished Patient despondent is possible due to the chronicity of the condition

SIJ CPR

Author Laslett No peripheralization or centralization with BB or ext 3+ provocation tests -Gaenslens -FABERS -Sacral Thrust -Thigh Thrust -ASIS Compression/distraction 2/2 = 91%

Thoracic Manipulation for Neck Pain CPR

Author: Cleland FABQ <12 Shoulder up symptoms T3-T5 decreased kyphosis Extension of cervical spine less than 30 degrees Painless BB Symptoms <30 days 3/6 =86% probability of success

Cervical Myelopathy CPR

Author: Cook +Hoffman's +Inverted Supinator Gait deviations Age >45 +Babinski 3/5 = high likelihood

Lumbopelvic Manipulation CPR

Author: Flynn FABQ <19 Lumbar Hypomobility IR >35 degrees in at least one hip Knee up symptoms Symptoms <16 days 4/5=95% chance of success

Unhealthy disc mechanics

BB will NOT centralize an extruded nucleus, but will keep any further extrusion from occuring McKenzie extension routine has been shown to centralize PAIN Protruded NP will shrink d/t loss of proteoglycans over time

S2 Dermatome

Buttock, thigh, and posterior leg

What is occurring in the cervical spine during forward head posture

C1-C2 extension C3-T1 flexion

Forward head posture (need more info)

C1-C2 extension C3-T1 flexion Tight lower cervical extensors and upper cervical flexors Tight pectorals and SCOM Lengthened erector spinae, scapula retractors,

What is being assessed with an open mouth radiograph?

C1/C2 articulation

Mid-Cervical segment

C2/3 - C7/T1

What spinal level does the C4 nerve root exit?

C3/C4

Provide the areas corresponding to the following myotomes: C4 C5 C6 C7 C8 T1

C4 = upper trap C5 = biceps (elbow flexion/supination) C6 = wrist extensors C7 = triceps, wrist flexors C8 = thumb extensors T1 = intrinsics (finger add/abd)

Provide the areas corresponding to the following reflexes: C5 C6 C7

C5 = biceps C6 = brachioradialis C7 = triceps

Apprehension Test

Checks for: Anterior GH instability Procedure: patient is supine and the arm is abducted to 90 degrees then ER Positive Test: Apprehension or pain

Pinch grip

Checks for: Anterior interosseous nerve Procedure: patient makes and "O" sign with thumb and index fingers Positive: unable to make "O" pad to pad

Phalen's

Checks for: CTS Procedure: pt pushes dorsum of hands together Positive: pain/tingling

Reverse phalen's

Checks for: CTS Procedure: Patient pushes palms of hands together Positive: pain/tingling

Anterior radial head glide improves

Component = elbow flexion Joint play = pronation/supination

Posterior radial head glide type of motion?

Component and joint play

What are the two types of accessory motion?

Component motion and joint play motion

Anterior glide humeral head

Component motion for -GH ER -GH ext -Coronal abd -Horizontal abd WEDGE USED Stabilizing hand - anterior surface of the AC joint Manipulating hand - proximal surface of humeral neck Force applied anteriorly "GANGSTA LEAN"

Posterior glide of humeral head

Component motion for GH IR, GH sagittal flex, horizontal adduction WEDGE used

Radial Glide of Base of Phalanx of the Hand

Component motion for MCP abduction (index) MCP adduction (ring and little fingers) Pt seated with forearm pronated and supported on the table PT - sitting Stabilizing hand - ulna side proximal aspect of the proximal joint Manipulating hand - ulna side of the distal joint surface MCP in 20 degrees of flexion force applied by manipulating hand in radial direction

Settled

Condition has stabilized Tissue is not fragile Swelling may or may not be present No warmth

Sub-acute

Condition is beginning to improve Tissue is fragile and must be cared for delicately as to not cause re-injury Warmth and swelling is commonly present

Sub-Acute SOC

Condition is starting to improve Tissue is fragile warmth and swelling present Goal: Continue to facilitate healing

Acute Stage of conditioning

Condition is worsening cardinal signs of inflammation Goal: Prevent worsening

Acute

Condition is worsening cardinal signs of inflammation Goal: prevent the condition from worsening

Outward roll of radius and ulna

Connective tissue extensibility for all wrist movements pt - seated with forearm in supination supported on table PT - standing facing forearm Manipulating HANDS - grasps the volar radius and ulna with thenar eminences and fingers wrap around to dorsal side Movement - volar skin is bunched between thenar eminences. Fingers push radius and ulna volarly and thenar eminences exert and outward force from the midline of the forearm

posterior longitudinal ligament

Connects all the posterior surfaces of the vertebral bodies limits flexion

PIVM grade 5

Considerable increased movement (hypermobile) Stabilize (conservative first)

Chronic stage of healing

Continued complaints beyond perceived healing Abnormal pain perception Likely to function but expresses continued complaints

Settled stage of healing

Continued state of healing but not resolved No redness Unlikely warmth Unlikely swelling Low pain Decrease in pain complaints

ligamentum nuchae

Continues supraspinous ligament (C7 to skull)

The Triplane motion of the pronation consists of what 3 classical ROM?

DF Eversion ER

Posterior glide of the talus improves

DF and pronation (sagittal plane)

RadioCarpo Wrist abduction

Distraction Ulnar glide (proximal row) medial tilt

CarpoMetacarpo

Distraction dorsal glide volar glide

What are the principles of tx?

Do no harm Base treatment on accurate dx and prognosis Select treatment with specific aims Cooperate with laws of nature Be realistic and practical in tx Select tx for your patient as an individual

Hx questions specific to lumbar spine

Do you have tingling in the saddle region Do you have any loss of bowel or bladder control Any change in symptoms during valsalva

Evaluation

Dynamic process in which the physical therapist makes clinical judgements based on data gathered during the examination

What is the tissue specific impairment?

Dysfunction found during examination

What is the capsular pattern for decreased ROM within the glenohumeral joint?

ER is most limited, followed by abduction, follwed by internal rotation - ER>ABD>IR

Management of WAD

Early muscle strength training re-education for coordination and endurance Manual PT to address restricted joints and tight muscles Balance and coordination exercises Paris vs Quebec Task force -Paris: collar up to 6 weeks and rehab in easy stages -Quebec: Avoid collar, maintain normal activity, early intervention as tolerated

A normal muscle end feel will be?

Elastic and slow

Grade IV manipulation

End of range, small amplitude

C3 dermatome

Entire neck, posterior cheek, temporal area, prolongation forward under mandible

What is clinical management?

Entire process of treating our patients. Starts with exam Analysis of the information gained during physical exam, evaluation, dx and prognosis

Cervical Downglide PIVM Test

Evaluates passive downglide of cervical segments C2/C3-C7/T1 force is in the direction of the opposite axilla

Thoracic PA rotation PIVM

Evaluates passive rotation and level of reactivity of T3/T4 - T11/T12 Peace sign is staggered (one finger higher than the other) Rule of lower finger = rotation towards lower finger

Medial glide of the talus improves

Eversion and pronation (frontal plane)

What two things provide the PT accountability to treat patients?

Examination and evaluation

Why would you use manipulation?

Examination and treatment of accessory motion Restore normal motion Improves function and performance Decrease pain Improves tolerance to insult Aides nutrition and repair

Hip Retroversion

Excessive - toes point out appears to have increased ER and lack IR

What are functional goals?

Expected outcome from our chosen treatment intervention

apical ligament

Extends from apex of dens to anterior aspect of foramen magnum

A normal cartilage/bone end feel will be?

Hard/rigid

Cross-Body adduction test

Flex shoulder to 90 degrees, pull arm across body; Pain at AC indicates AC pathology/arthritis

What are the manipulation variables?

Force Duration Type of manipulation Temperature Amplitude Velocity

MSTT Supraspinatus

GH abduction, GH external rotation

MSTT Deltoid

GH abduction, GH flexion

MSTT Pec Major

GH adduction, GH internal rotation

MSTT Teres Major

GH adduction, GH internal rotation

MSTT Lat Dorsi

GH adduction, GH internal rotation, GH extension

MSTT Teres Minor

GH adduction, external rotation

MSTT Triceps

GH extension, elbow extension

MSTT Infraspinatus

GH external rotation

MSTT Coracobrachialis

GH flexion

What are the neurophysiological effects of manipulation?

Gate control theory biopsychosocial theory of pain centralization of pain mechanoreceptor neurological influence movement fosters nutrition

Sub Acute stages of healing

Getting better No redness Maybe some warmth Decreased pain level Improving function

Acute stage of healing

Getting worse Redness Warmth Swelling High pain Limited function

What is the prognosis?

Goals and outlook for treatment

The patient has a tight joint capsule in the anterior direction at the tibiofemoral joint. The best choice of treatment to have a mechanical effect is?

Grade III anterior glide

Maitland

Graded Oscillations I-IV Oscllations work by increasing mobility as well as modulating pain through neurophysiological effects

Lateral foramenal stenosis

Gradual onset Pain in lumbar spine, buttocks, or LE Increased with backward bending and or side bending to the side affected

CPR for lumbar stabilization

Hicks and Rabin Hicks (FPAALS) FABQ >8 +prone instability test Aberrant movement Age under 40 Lumbar spring test (hypermobile) SLR over 91 Rabin (2/4 useful) aberrant movement +prone instability test Likelyhood Ratio 3+/4 = +4.0 *3/4 = 67%* success Tx: Stabilization and strengthening (QL, TA, Multi)

Thrust manipulation

High velocity, low amplitude therapeutic movements within or at end range of motion

Degenerative spondylolisthesis

The entire vertebrae "slips" forward at the level that is involved. Slippage is felt at the level of the fracture

Intermediate layer of back muscles

Iliocostalis, longissimus, spinalis

Upper thoracic and mid cervical upslide in prone

Improves rotation to the opposite side -sidebending to opposite side and forward bending as well PT thumb contact with TP with other thumb ontop. avoid grade III graded oscillation

What is an examination finding?

Information directly identified during an examination test

Nerve Root Injury

Injury to a nerve at the level of the spinal cord. Radicular symptoms myotome/dermatome/reflex

Biopsychosocial theory of pain

Interaction of biological, psychological, and cultural factors influence the intensity and duration of pain

Where can lumbar stenosis occur?

Intervertebral foramen Central canal

If the L4/L5 foremen is stenoic then what nerve root is affected?

L4

Patella reflex

L4

What is the tissue reactivity?

Irritability of the tissue when a stress is applied to it

What three things need to be r/o when examining the spine?

Is there a non-mechanical problem? (Cancer) Are there neurological signs? (Myotome/dermatome) Are there psychosocial issues? (Waddell's behavior signs)

Manipulations that occur in the same row

Joint play

Long Axis Rotation (radial direction) of base of phalanx of hand

Joint play pt - seated with left forearm pronated and supported on table PT - sitting to either side of left finger Stabilizing hand - grasps proximal joint surface Manipulating hand - distal joint surface MCP in 20 degrees of flexion grade 2 distraction force applied with a force of rotation in the radial direction

Long Axis Rotation (ulnar direction) of base of phalanx of hand

Joint play pt - seated with left forearm pronated and supported on table PT - sitting to either side of left finger Stabilizing hand - grasps proximal joint surface Manipulating hand - distal joint surface MCP in 20 degrees of flexion grade 2 distraction force applied with a force of rotation in the ulnar direction

Metacarpal heads - dorsal and volar movements

Joint play sitting with elbow flexed and posterior aspect of elbow on table PT - facing dorsal aspect of hand stabilizing hand - grasps head next to manipulating head Manipulating hand - grasps head to manipulate and move in either a dorsal or volar direction Performed on 2-4 heads (4th stabilized on 3, 3 on 2)

Dorsal Glide of Radius on Ulna

Joint play pt - seated or supine with left forearm supported on table in neutral position PT - seated facing volar aspect of forearm Stabilizing hand - grasps dorsal and volar surface of the distal ulna and lateral side of carpals (Golfers Grip) Manipulating hand - pal placed on volar surface of the radius and fingers wrap around to dorsal side Movement: manipulating hand exerts a dorsal force through palm contact

Maitland Grade III

Large amplitude movement at the end of the range 50-100% of the range

Maitland Grade II

Large amplitude movement. Within the midrange of the joint range between 10 and 90% (50% ROM)

Distraction of proximal row of carpals on radius loose packed position?

determine: 10 degrees flexion neutral 10 degrees ext

Lumbar Lateral Foraminal Stenosis

Lateral symptoms -Pain -Subjective numbness -Hyper neurological responses True neurological signs -paresis>skin sensation>reflexes>neural tension (SLR) Management -Posture education -Stabilization -Stretch myofascia -Manipulate stiff joints -Positional distraction -Possible heel lift on unaffected side

Anterior radial head glide end feel?

Ligament end feel

Palmar glide of MCP, PIP, DIP end feel?

Ligament end feel

Kaltenborn Capsular Pattern

Limitation in: (MEAL) Medial rotation Extension abduction Flexion with slight limitation in lateral rotation

Supraspinous ligament function

Limits flexion of the spine

Forward bending sidelying double knee flexion (pt on right side)

Locate L5 (moves away with leg ext) Hand placements R: hand and forearm grasp both the pt legs L: middle finger palpates interspinous spaces pt legs balanced on operators thigh (right) legs are flexed and movement is felt

Impairments for lateral foraminal stenosis

Lordotic posture Limited backward bending Dermatome and myotome issues Tight hamstring and piriformis Limited neural mobility

T8 dermatome

Lower costal margine

Anterior primary Ramos proceeds where?

Lumbar and sacral plexus

TSI: Partial Tear Best exam step? Best Tissue reactivity

MSTT Defer

TSI: Partial Tear Best exam step? Best Tissue reactivity

MSTT Defer

TSI: Complete Tendon Tear Best exam step? Best Tissue reactivity

MSTT MLT

What does a goal need to be?

Measurable Objective Applicable Realistic

Which meniscus is injured more frequently?

Medial

C8 Dermatome

Medial arm and forearm to long, ring, and little fingers

T1 Dermatome

Medial side of forearm to base of little finger

Grade III manipulation

Middle of range to end range, large amplitude

What are some examples of interventions?

Modalities, stretching, manipulation, strengthening, etc

Compared to the examination of a medical doctor the examination of a physical therapist is?

More detailed

Manipulating hand vs the stabilizing hand

Most often the stabilizing hand will be on the proximal part of the joint and the manipulation hand will be distal

What is joint play motion?

Motions not under voluntary control. They need outside forces in order for the motion to occur

What is component motion?

Motions that take place at a joint surface in order to facilitate a particular movement

What is accessory motion?

Movements that accompany classical motion

S/S of WAD

Muscle guarding Generalized non specific pain Vague visual, hearing and swallowing issues Fatigue Dizziness, unsteadiness, visual disturbances Altered postural stability Decreased control of head and eye movements

Wrist Loose Packed

Must determine 0 degrees 20 degrees ext or flexion

Management of lumbar central stenosis

Myofascial manipulation and stretching -psoas, low back muscles Increase physical fitness (pool or unweighted TM) Lifestyle changes (smoking obesity, posture)

Phase I of Osteocondrosis

Necrosis -0 blood supply -osteocytes and bone marrow die -Imaging negative -Quiet Period -Symptomless

Radiculopathy

Nerve root issue S/S -sensory and/or motor dysfunction -Neurogenic pain (deep radiating) -Follows dermatomal and myotomal pattern -LMN signs (hyporeflexia, areflexia, hypotonia, muscle atrophy) Management -traction, joint and myofascial manipulation, pt education

Does every Functional limitation lead to a disability?

No

Abdominal reflex

Normal response is the ipsilateral contraction of the abdominal muscles with an observed deviation of the umbilicus towards the stroke.

Forward bend lumbar spine

Nucleus deforms posteriorly Facets slide up and forward Foramen opens

Clinical Presentation of TOS

Numbness and paresthesia usually follows ulnar nerve Tight scalenes, elevation of first rib, shortened pectorals

What is the only joint to follow the convex concave rule in the spine?

OA joint

Sign

Objectively measured Not always known by the pt but observed by others Must be seen or read by the examiner

Sub-cranial Spine segment

Occ/C1/C2

What are the three main types of spina bifida?

Occulta, meningocele, myelocele

In what direction will roll and glide be if a convex surface is moving on a concave surface?

Opposite directions

Multifidus origin and insertion

Origin: PSIS, dorsal surface of sacrum, mammillary processes of lumbar vertebrae, TPs of thoracic vertebrae, articular processes of cervical vert. Insertion: SPs of all vertebrae

What step can tell you the tissue reactivity?

PROM

Ligament Adhesion Best exam step? Best Tissue reactivity

PROM ACC PROM ACC

TSI: Adhesion capsule Best exam step? Best Tissue reactivity

PROM ACC PROM ACC

TSI: Capsule Laxity Best exam step? Best Tissue reactivity

PROM ACC PROM ACC

TSI: Capsule Tightness Best exam step? Best Tissue reactivity

PROM ACC PROM ACC

TSI: Cartilage tear Best exam step? Best Tissue reactivity

PROM ACC PROM ACC

TSI: Effusion Best exam step? Best Tissue reactivity

PROM ACC PROM ACC

TSI: Ligament laxity Best exam step? Best Tissue reactivity

PROM ACC PROM ACC

What is the best examination to use to determine the tissue reactivity of a joint capsule adhesion?

PROM accessory

How can you tell the difference between a structural hallux valgus and a functional hallux valgus?

PROM classical - passively re-alight jt it is positional. if you cannot it is structural

What are the three best examinations steps and findings to differentiate an ATFL sprain from an peroneal strain?

PROMacc MSTT PFT

what direction does a disc typically bulge?

Posteriorlateral direction

Allodynia

Pain due to a stimulus that does not normally provoke pain

Moderate tissue reactivity

Pain is reported at the point the tissue is taken to its restriction, or rather, at the point the therapist does determine the end feel

Moderate Tissue Reactivity

Pain is reported at the point the tissue is taken to its restriction, or rather, at the point the therapist does determine the end-feel. This means you were able to feel the end-feel or the resistance of the tissue and the patient complained of pain.

High tissue reactivity

Pain is reported before tissue can be taken to its restriction or rather enforce the therapist can determine the end feel

At the radiocarpal joint, when the joint is in neutral flexion/extension and the forearm is probated, where is the therapist forearm placement to indicate direction of force for a GLIDE?

Parallel to the distal end of the radius (concave)

Cervical upglide PIVM

Passive upglide of cervical segments C2/C3-C7/T1 force is in the direction of opposite eye

L4 dermatome

Patella, medial lower leg, and medial malleolus

L3/L4 reflex

Patellar

pathogenesis

Pathological process of disease

What direction do the menisci move during knee flexion?

Posteriorly

Tinel's sign (wrist)

Percuss over the flexor retinaculum of the wrist and the tunnel of Guyon. Positive with tingling into the lateral 3 fingers or medial 2 fingers indicating carpal tunnel syndrome or ulnar nerve impingement

At the radiocarpal joint, when the joint is in neutral flexion/extension and the forearm is probated, where is the therapist forearm placement to indicate direction of force for a distraction?

Perpendicular to the distal end of he radius (concave)

Aspects of pain

Physical: actual physical causes of the pain Emotional: pt's concern about intensity, duration, effects of the condition on their lifestyle Rational: pt's ability to understand the self-limiting nature of the condition

What is the intervention?

Plan of care. Purposeful and skilled interaction of the pt with the patient/client

Cervical Central Stenosis Clinical presentation

Poor posture-forward head Cervical stress, strain, sports, MVA Compensatory hypermobility to UT kyphosis/stiffness Instability at C2/3 and C5/6

What is the closed packed position?

Position of most congruency in the joints. Statically stable

MSTT Extensor Digitorum

Position: elbow extension, forearm pronation, wrist in 10 degrees of extension, fingers in neutral Contact: dorsum of the ring finger between MCP and PIP to apply resistance

MSTT ECRB

Position: elbow extension, forearm pronation, wrist in 10 degrees of extension, fingers in neutral - Contact: dorsum of the middle finger between MCP and PIP to apply resistance

Dysfunction/impairment

Problem that is causing a decrease in function

Examination

Process of obtaining a history, performing relevant systems reviews and selecting and administering specific tests and measures

Lumbar Forward-Bending Passive Intervertebral motion test: Sidelying with single leg flexion

Purpose: evaluates passive forward bending motion of L5/S1 to T12/L1

What are impairments that a person with a disc dysfunction may have?

Protective scoliosis Limited AROM Dermatome and myotome issues Limited neural mobility Tight hamstrings and piriformis Distraction decreases symptoms Compression increases symptoms Tenderness in the lumbar paraspinals, QL, and posterior lateral hip muscles on side involved Decreased function and endurance

nucleus propulsus

Proteoglycans and Type II Collagen (resists compression) Centrally located in cervical (children and young adults) and thoracic discs, more posterior in lumbar discs Functions -Imbibition: holding fluid against mechanical pressures -Nutrition: attracts nutrients from vertebral bodies -Force Transmission -Stress Equalization: equally transmits forces across annulus -Movement: ball-bearing like "rocking"

Cartilaginous End Plate

Proteoglycans, hyaline cartilage Contains Sharpey's fibers that connect the disc into the rim of the vertebral bodies Avascular after 10 years following birth Functions -Protect bone -Transmit weight -Fluid exchange: between disc and vertebral body

What are the effects of manipulation?

Psychological Neurophysiological Mechanical

What effect will a grade II manipulation have?

Psychological and neurophysiological effect

What effect will a grade IV manipulation have?

Psychological, neurophysiological, and mechanical

Low Subject Reactivity

Pt can carry out functional activities as expected without complaints during the activity

Moderate subject reavitivity

Pt can carry out the functional activity as expected bu expressed complaints during that activity Post activity complaints

Inverted Supinator Sign

Purpose: Cervical myelopathy Method: PT support pt's forearm and taps the dista brachioradialis with a reflex hammer. Positive Test: Finger flexion or slight elbow extension

Cervicogenic Headache

Referred headache pain that originates from the neck, often due to muscle tension or cervical degenerative arthritis. Also referred to as occipital neuralgia. management -Impairment based approach (manual therapy and exercise) -DNF training -Postural education -Cervical mobilization

What are the indications for manipulation?

Relief of pain increase range of motion improve function impairment-based evidence informed approach

Phase IV of Osteocondrosis

Residual deformity -bone healing complete -shape of epiphysis is fixed -jt function limited -DJD may ensue

Hemarthrosis Tx

Rest Support Aspiration by MD PRICE

Synovitis Tx

Rest from provoking activities PRICE

What are outcomes?

Results of the patient/client management

Phase II of osteocondrosis

Revascularization -blood supply returns -bone deposition occurs -pathologic fracture -symptoms present -imaging shows fragmentation -dx -biological plasticity - TX = splinting or bracing

Examination of scoliosis (structure)

Rib hump - on side of convexity S curve typically L lumbar/R thoracic Unlevel shoulders Scapula prominent on the side of the convexity Pelvic obliquely may appear as a leg length

C2/C3 to T3/T4 rotation to left

Right glides up and forward Left glides down and back

Non-Functional sidebending in the C spine

Rotation to the same side in the mid/lower C Spine Rotation to the opposite side in the upper/subcranial C spine (keeps eyes level)

What is an abnormal cartilage end feel?

Rough and grating

Achilles tendon reflex

S1-S2

What muscle is associated with torticollis?

SCOM

Standing: PSIS and GT unequal Seated: PSIS and GT unequal causes?

SI disfunction scoliosis inominates asymentrical

Straight leg raise tension test

SID - sural TED - tibial PIP - peroneal

Biceps Load Test II

SLAP lesion

How would you differentiate between a lateral shift caused by the disc or instability?

SLR if + = disc if - = instability

Median N. Tension test

Shoulder ABD External Rotation Supination Wrist/finger/elbow extension Shoulder depression Cervical contralateral lateral flexion

Ulnar N. tension test

Shoulder ABD & ER Supination Wrist/finger/elbow extension Shoulder depression Cervical contralateral lateral flexion

Radial N. Tension Test

Shoulder ADD & IR Pronation Wrist/thumb/index flexion Elbow extension Shoulder depression Cervical contralateral lateral flexion

Examination of scoliosis (Active movements)

Side bending limited to side of convexity erector spinae prominent on convex side of lumbar spine

What two words are important when providing a definition of intervention?

Skilled and purposeful

What is a manipulation?

Skilled passive movement to a joint

Passive Compression test

Slap lesion

PIVM grade 2

Slight restriction (hypomobile) non thrust/thrust progression

A normal muscle/soft tissue approximation end feel will be?

Soft and spongy

What is a pannus end feel?

Soft with crunchy feeling

What is the best examination to determine tissue reactivity of the medial mensicus injury?

Special test

What is an examination test?

Specific test related to one of the 18 steps

Spina bifida myelocele

Spinal cord and nerve roots are completely exposed/infection may result in death

Settled SOC

Stabilized condition Goal restore tissue back to normal

In what steps can you find TSI's?

Step 5 P4C Step 7 PROM Step 8 MSTT Step 9 MLT Step 10 MMT Step 11 Special Tests (some) Step 13 P4T Step 14 Neuromuscular/vascular

What should happen if a patient suffers adverse reactions to manipulation?

Step back, re-examine, critically reflect upon what happened and analyze in order to correct

Lumbar Roll (Lumbar rotation/stretch)

Stretch Contraindicated for disc involvement and spondys Pt right side lying -L rotation -Gapping L -Upper hand pushes down on vert (pt R) -Lower hand pulls up on vert (pt L) Locking-facet distraction

Which manipulations engage the plastic region of the stress strain curve?

Stretch Thrust Progressive oscillation Grade III and IV

What mechanical effects do you get from manipulation?

Stretching a restriction Snapping an adhesion Change in positional relationships

What is a bony block end feel?

Sudden hard/rigid stop

What is joint adhesions end feel?

Sudden sharp arrest in one direction

CPR for spinal stenosis

Sugioka (FBASICS65) FB improves symptoms +2 BB improves symptoms -2 Age >70 +3 Standing symptoms worse +2 Incontinence +1 Claudication +1 Symptoms >6 months +1 score of 7+ = 65% validity

What position will a person with a disc dysfunction prefer?

Supine

Supportive

Supports previous treatments Ex home exercise program

Straight Leg Raise Test (SID, TED, PIP)

Sural -inversion and dorsiflexion Tibial - eversion and DF Peroneal - inversion and PF

Effusion

Swelling inside a joint

Which words are clues that it is not a tissue specific impairment?

Syndrome or pain

Facet Syndromes

Synovitis/Hemarthrosis (sprain) Restriction Painful Entrapment (capsular) Mechanical Block Chronic Facet Arthrosis

C2 dermatome

Temple, forehead, occiput

What is the difference between tendonitis and tendonosis and tendonopathy?

Tendonitis implies that there is an inflammatory process occurring within the tendon; tendonosis refers to tendon degeneration; tendonopathy is the pathology of at tendon and includes tendonosis and tendonitis

What are 3 causes of scapular dyskinesis?

Type I - SICK scapula -malposition of scapula - interiormedial border prominence -coracoid pain -kinesis abnormality Type II - Portuded medial border Type III -Superior translation

Settled SOC

The condition has stabilized The tissue is no longer fragile and corrective treatments are well tolerated Swelling may or may not be present, but warmth is likely absent

Sub-acute SOC

The condition is beginning to improve The tissue is fragile and must be cared for delicately as to not cause re-injury Warmth and swelling is commonly present

Lytic spondylolisthesis

This usually occurs in a younger population due to trauma or excessive/repetitive backward bending as seen in gymnastics. The pars interarticularis is where the fracture occurs. Slippage is at that level of the fracture but felt at the level below L4 lytic = L5 step felt

Indication for manipulation: Acute neck pain and mobility deficits?

Thoracic Manipulation

Indication for manipulation: Sub Acute neck pain and mobility deficits

Thoracic and cervical manipulation and mobilization

Indication for manipulation: Chronic neck pain and mobility

Thoracic manipulation Cervical: manipulation and mobilization

Indication for manipulation: Chronic neck pain and radiating pain

Thoracic manipulation and mobilization

What are the 4 possible end-feels for classical DF following immobilization?

Tight capsule Tight muscle adhesion Swelling

What is the purpose for the 9 abnormal end feels?

To assist with identifying the structure that is limiting joint movement

What are component motions used for?

To detect joint dysfunctions that may be interfering with active range of motion

The purpose of STT (muscle selective tissue tension testing) is?

To identify dysfunction within the musculotendinous unit

What is the purpose of the evaluation and the diagnosis?

To make a clinical judgement based on the data from the tests and measures that results in a diagnostic label for the patient

What are the psychological effects of manipulation?

Touch=caring Induced skilled movement in presence of fear (decreases pt fear) pop or snap cavitation placebo and nocebo effect Impact of pt expectations (keep it positive) therapeutic alliance: relationships (TRUST)

A disc bulge that is medial to the nerve root will cause a pt to shift or lean which way?

Towards the side of pain

Deep layer of back muscles

Transverse spinalis, multifidus, rotators

Peripheral Nerve Injury

Traumatic injury (lacerations, fractures, crush injury), nerve entrapment neuropathy (external compression by fibrous band, median nerve commonly involved, may require surgical release if unresponsive to conservative treatment)

Corrective

Treatment that actually tries to correct or fix the impariment

Palliative

Treatments to ease symptoms and complaints Ex. Electric stim

C7 reflex

Triceps

T or F a patient with SCFE may complain of pain into the knee and thigh?

True

T or F manipulation is both an examination and a treatment?

True

types of mechanoreceptors

Type I Type II Type III Type IV

Annulus Fibrosis

Type I collagen (resists tension) Fibers at oblique orientation of 30-70° arranged in opposite directions Inner layers more gelatinous, less organized Outer 1-2 layers innervated by Ventral Ramus, Sinuvertebral n, Gray Ramus Communicans Blood supply from Segmental aa Functions -Contain nucleus -Stabilization: limits excessive motion of each segment -Movement: wide range permitted

SI forward torsion manipulation

Type: Strong stretch, sustained stretch, progressive oscillation, impulse

PIVM grade 6

Unstable (loss of ligament and osseous control) Stabilize/fusion surgery candidate be careful grading 6-d/t surgery need

C2 myotome

Upper cervical extension/ Neck Rotation

C1 myotome

Upper cervical flexion

Lumbar sidebending prone lying abducting the leg

Used to stretch the opposite side facet joint in an upslide Thumb is used to block the vert above the segment being treated (L3/4 segment = block of L3) progressive oscillation or stretch

Ulnar collateral ligament test (thumb)

Valgus stress test to thumb

Cluster to rule in radiculopathy

Wainner SUD60 +Sprulings +ULTT Distraction improves >60 degrees of cervical rot to involved side Specificity 4/4 = 90% likely 3/4 = 65% Sensitivity 4/4 0.24

Disability

a physical or mental condition that limits a person's movements, senses, or activities.

What is manipulation founded on?

anatomy and biomechanics

What does the ALL become?

anterior A/A membrane and the anterior A/O membrane

C3 myotome

cervical lateral flexion

The AA joint is

convex on convex

MSTT Anconeus

elbow extension

C7 myotome

elbow extension, wrist flexion

MSTT SUpinator

forearm supination

Imbibition

how the discs get nutrition

L4 dermatome

includes kneecaps

What causes TMD?

injury to jaw, TMJ, muscles of the head and neck teeth grinding or clenching injury to the disc

Femoral Neck Fx

intracapsular problematic - 95% displaced no obvious swelling even tho swelling in joint poor bone healing due to low blood supply

Mennell

joint play

C8 Dermatome

little finger

T1 dermatome

medial forearm

Forefoot

metatarsals and phalanges

What is the primary segmental stabilizer of the lumbar spine?

multifidus

What 3 structures prevent facet capsule from getting pinched

multifidus meniscus ligamentum flavum

14 steps to spinal examinations

pain assessment initial observation hx and interview structural inspection AROM Neurovascular P4C Palpation for position PIVM Upper and lower quadrant assessment radiologic summary of findings tx plan prognosis

T6 dermatome

passes over xiphoid process

PIVM

passive intervertebral motion

Ankylosed

permanently immobile

Neurochemical Effects

plausible release of endorphins

High Subject Reactivity

pt cannot carry out activity

Manipulation

skilled passive movement to a joint with a therapeutic intent (paris)

McKenzie

spinal extension for LBP

T3 dermatome

third intercostal space

PA Glide Supine

thrust

What nerve innervates the TMJ?

trigeminal nerve

What are some factors that could lead to impingement?

• Structure (osseous) • Instability and/or laxity • Hypomobility • Muscle imbalance (tightness, weakness) • Extrinsic factors: postural - functional, nerve, trauma, disease

A/A joint mechanics for FB

atlas glides anteriorly on both sides

A/A joint mechanics for BB

atlas glides posteriorly on both sides

RadioCarpo Wrist Flexion

distraction dorsal glide dorsal tilt

CarpoMetacarpo Wrist adduction

distraction dorsal glide volar glide

CarpoMetacarpo Wrist extension

distraction dorsal glide volar glide

CarpoMetacarpo Wrist flexion

distraction dorsal glide volar glide

RadioCarpo Wrist adduction

distraction radial glide (proximal row) lateral tilt

TSI: Complete tear Best exam step? Best Tissue reactivity

MSTT MLT

TSI: Strain Best exam step? Best Tissue reactivity

MSTT MLT

TSI: Tendonitis/osis Best exam step? Best Tissue reactivity

MSTT MLT

At the AA joint with forward bending what direction does atlas move?

anteriorly on both sides

A/A joint mechanics for rotation to L

atlas right facet glides anteriorly left facet glides posteriorly

At the AA joint with rotation left what direction does atlas move?

atlas right facet glides anteriorly and left facet glides posteriorly

A patient with a left lumbar disc bulge that protrudes lateral to the nerve root will shift what direction?

away from pain

Joint play motions of MCP joint

distraction radial tilt ulnar tilt long axis rotation

PIP/DIP joint plays

distraction radial tilt ulnar tilt unicondylar glides

Radio Carpo wrist extension

distraction volar glide volar tilt

A/A Joint (C1/C2)

convex on convex - planar/pivot joint in transverse plane motions: rotation, some sidebending 50% of rotation

Kaltenborn

convex/concave rule

Joint play that improves pronation and supination

distraction radius from capitulum

Reverse Phalen's Test

TESTING: Carpal tunnel syndrome POSITION: Prayer position with palms together and fingers pointed upward (+) TEST: If symptoms worsen

Crank Test

TESTING: Inferior labrum tear POSITION: 160˚ flexion load through the elbow and move in a IR/ER motion (+) TEST: Clicking or popping with loaded movement

Lift-off test

TESTING: Subscapularis tear POSITION: Patients hand behind their back and ask them to pull it away from their back (+) TEST: Inability to perform the movement

Settled Prolapse

(3-4 weeks) slow improvement Signs:sensory and motor dysfunction, neurogenic pain Clinical Presentation: flex or shifted posture Management -Commence positional distraction with caution (HEP) -Stabilization -Lifestyle and healthy back regime -Goal is to prevent chronicity by encouraging activity and managing any fear avoidance behaviors

Malunion:

* a fracture that has healed but incorrectly, leading to significant deformity

Scapular dyskinesis

* any alteration in the position or motion of the scapula * 3 main types - type 1 "sick": malposition of scapula, ineriormedial border prominence, coracoid pain and malposition, kinesis abnormality - type 2: protruded medial border - type 3: superior translation * treatment: restoring normal position and motion to allow proper scapulohumeral rhythm

Codman's exercise (pendulum)

* bend forward at waste - puts GH join in slide flexion and ABD * move trunk in forward/backward, lateral, an circle movements - allows for pain reduction and joint separation NEUROPHYSIOLOGICAL EFFECT

What is different about a calcific tendonitis than traditional tendinitis? What muscle tendon is this unique to?

* calcific results from local necrosis within the tendon - the necrosis causes calcium deposits to occur within the tendon - has a "toothpaste" like consistency - can be laid down fast (acute) or more slowly (chronic) - requires radiography to identify * specific to supraspinatus

Muscle imbalance risk factors for shoulder impingement

* common pattern - anterior muscular tightness (pec major + minor, subscapularis) - posterior weakness (mid and low trap, rhomboids, serratus anterior, supraspinatus, infraspinatus, teres minor) * tight anterior muscle causes anterior tilt of scapula, closing subacromial space

What is a non union

* failure of fracture to heal with bone * i.e fibrous union, fracture healed by fibrous tissue rather than bone

Delayed union:

* fracture heals much slower than expected

Greenstick fracture:

* fracture on convex side of bone * only bending on concave side

What is impingement syndrome a reference to?

* greater tuberosity of the humerus coming into closer proximity to the underside of the caraco-acromial arch - soft tissues i.e supraspinatus, long head of biceps become impinged between humerus and coracoacromial arch

MOI for clavicular fractures

* most often a fall directly onto outside of the shoulder * can also be a FOOSH * most often affected: middle 1/3 of the bone *greenstick fracture most common: cancaveity on one side of bone, convecity with bone splintering on other side * figure 8 brace to treat

CRPS is a pathology of the communication between the ANS and the brain. - what does this mean?

* the response to injury through the sympathetic NS is impaired - redness, swelling, vasodilation, which are normal responses to injury, occur in CRPS without an injury

Why is the glenohumeral joint slightly abducted post surgery?

* to promote blood flow for the supraspinatus tendon * if the shoulder is adducted, the tendon is "wrung" out over the head of the humerus, decreasing blood flow

Pseudoarthrosis:

* type of nonunion that occurs due to continual movement at fracture site * a "false joint" starts to form

Chemical muscle holding

- Occurs when muscles have been overused - Muscles will ache and feel "doughy" and tender to touch - May also occur as result of sustained involuntary guarding Management: heat and massage

Hypotonic states

- disuse atrophy - wasting and fibrosus

Benediction sign

- have patient make a fist - if they can only flex the 4th and 5th digits, loss of median nerve is indicated

MSTT Elbow Flex

- loose pack position at the elbow about 70 degrees of elbow flexion and neutral between pronation and supination. - Patient is sitting - PT: standing, hand cradles the posterior elbow to maintain loose pack position and to avoid patient having to hold arm in position - Muscles: biceps, brachialis, brachioradialis - Contact: mid forearm of radius to apply resistance

MSTT Forearm pronation

- loose pack position at the elbow about 70 degrees of elbow flexion and neutral between pronation and supination. - Patient is sitting - PT: standing, hand cradles the posterior elbow to maintain loose pack position and to avoid patient having to hold arm in position - Muscles: pronator teres - Contact: distal 1/3 volar forearm on radius apply resistance

MSTT Elbow Ext

- loose pack position at the elbow about 70 degrees of elbow flexion and neutral between pronation and supination. - Patient is sitting - PT: standing, hand cradles the posterior elbow to maintain loose pack position and to avoid patient having to hold arm in position - Muscles: triceps and anconeus - Contact: mid forearm of ulna to apply resistance

Subcranial instability 1. how can it occur 2. what is it caused by? 3. what should you do when you encounter it?

1. - can occur in those with rheumatoid arthritis - ankylosing spondylitis - down's syndrome - those on corticodsteroids - post trauma 2. excessive anterior translation of the atlas on the axis - greater than 3mm in adults and 4mm in children - can cause compression of medulla, spinal cord, vertebral arteries - superior sympathetic ganglion - nasopharynx 3. REFER TO MD IMMEDIATELY

Posture related neck ache 1. where is it usually located? 2. what is the source?

1. - neck - upper trap region -interscapular region -suboccipital region 2. facet joint capsule or cartilage

Prognosis of CRPS

1. 80% have complete spontaneous relief of signs + symptoms within 18 months 2. no criteria established to predict outcome 3. 50-80% disability secondary to pain or limited ROM 4. long duration of symptoms - presence of tropic changes - presence of cold (reflex sympathetic dystrophy (RSD)

Capsular pattern at the elbow (5)

1. AROM flexion more limited than extenson 2. PROM classical flexion more limited than extension 3. tight capsular end feel with PROM classical 4. PROM accessory P/A glide more limited than A/P glide of radial head 5. tight capsule end feel with PROM accessory

Best Examination findings to confirm a capsular pattern of restriction at the GH joint (4)

1. AROM: active movements decreased with ER>ABD>IR 2. PROM classical (quantity): decreased passive ROM with ER>ABD>IR 3. PROM classical (quality): tight capsule end-feel in all direction 4. PROM accessory (quantity): decreased P/A> inferior> A/P

Carpal Tunnel Syndrome 1. What is it? 2. What are the primary signs and symptoms?

1. Crompression of the median nerve in the carpal tunnel 2. paretheisias within the median nerve distribution and motor weakness within the muscles innervated by the median nerve

What are the three best examination findings to confirm carpal tunnel syndrome?

1. history - night pain 2. MMT: weakness in hand muscles innervated by median nerve 3. neurovascular: decreased sensation in median nerve distribution in the hand

1. What would be the positive exam findings for supraspinatus calcific tendonitis with the following steps. - PFC -AROM -PROM -MSTT -MLT -PFT -DI 2. out of these steps, what are the BEST ones to rely on

1. FFC: warmth and swelling over tendon -AROM: painful arc -PROM- painful in opposite direction that muscle contracts - MSTT: strong and painful with ER and abduction - MLT: pain with lengthening of the supraspinatus -PFT: painful over tendon - imaging: "brightness" noted within supraspinatus tendon location 2.- MSTT -MLT -PFT -Imaging: will be positive but it is not a clinical exam since PTs can't order images

Monteggia Fracture-dislocation 1. what anatomical region is it specific to?

1. Fracture of the proximal 1/3 of the ulna with dislocation of proximal radioulnar joint 2. radius is displace and angled anterior

Instability risk factors for shoulder impingement (3)

1. humeral head is in incorrect position before movement. Movement then causes earlier encroachment of humeral head to coracoacromial arch 2. humeral head is in normal position prior to movement, but movement causes excess arthrokinematic movement that encroaches humeral head to coracoacromial arch 3. increased muscular effort due to laxity can pull humeral head up too much, closing off the subacromial space.

1. What is the MOI for a supracondylar fracture of the elbow? 2. what complications can this injury present? 3. how can this injury be treated (outside of pt)

1. hyperextension or fall on flexed elbow? 2. Comminution, jaggest ends of bone being driven into the anterior periosteal tissue and brachialis - could cause neurovascular damage to median nerve and brachial artery 3. immobilization if no displacement or neurovascular damage. if the former occured, closed reduction. If the latter occured, ORIF

1. What is the most common location for the ulnar nerve to become entrapped at the elbow 2. What can cause this entrapment?

1. in the cubital tunnel behind the medial epicondyle 2. larger carrying angle * larger forearm flexor mass

USA Clinical Philosophy

1. Injuries to the joints such as osteoarthritis, instability, and the effects of sprains and strains are considered impairments or dysfunctions and fall under the scope of physical therapy 2. Impairments are considered abnormal movements that either increase or decrease the amount of motion from normal. 3. If the impairment results in limited motion the treatment should focus on increasing motion by use of manipulation (joint structure), stretching (muscles and fascia), and activities that focus on full range of motion. 4. If the impairment results in increased movement the treatment should focus on decreasing motion by using stabilization and not manipulation. Stabilization includes correct posture, stabilization exercises, and correction of limitations in movement in surrounding areas. 5. Timely physical therapy is key in preventing adverse effects from impairments or dysfunctions 6. The role of the physical therapist is to deal with impairments and dysfunctions of the neuromusculoskeletal system and the physicians role is to diagnose and treat diseases. Different roles that are complementary to each other. 7. Physical therapy should focus on correcting the impairment rather than just pain. Unless pain prevents treatment of the impairment 8. Anatomy and biomechanics are the foundation to physical therapy so an understanding and continual study in these areas is essential to providing quality care for our patients. 9. Physical therapy is now at the level where it should be the primary care for movement dysfunctions and impairments not dependent on referrals from other healthcare professionals 10. The responsibility to get better lies with the patient because if they do not follow the education, example, or direction of the physical therapist they will not benefit from physical therapy.

USA Philosophy

1. Injuries to the joints such as osteoarthritis, instability, and the effects of sprains and strains are considered impairments or dysfunctions and fall under the scope of physical therapy 2. Impairments are considered abnormal movements that either increase or decrease the amount of motion from normal. 3. If the impairment results in limited motion the treatment should focus on increasing motion by use of manipulation (joint structure), stretching (muscles and fascia), and activities that focus on full range of motion. 4. If the impairment results in increased movement the treatment should focus on decreasing motion by using stabilization and not manipulation. Stabilization includes correct posture, stabilization exercises, and correction of limitations in movement in surrounding areas. 5. Timely physical therapy is key in preventing adverse effects from impairments or dysfunctions 6. The role of the physical therapist is to deal with impairments and dysfunctions of the neuromusculoskeletal system and the physicians role is to diagnose and treat diseases. Different roles that are complementary to each other. 7. Physical therapy should focus on correcting the impairment rather than just pain. Unless pain prevents treatment of the impairment 8. Anatomy and biomechanics are the foundation to physical therapy so an understanding and continual study in these areas is essential to providing quality care for our patients. 9. Physical therapy is now at the level where it should be the primary care for movement dysfunctions and impairments not dependent on referrals from other healthcare professionals 10. The responsibility to get better lies with the patient because if they do not follow the education, example, or direction of the physical therapist they will not benefit from physical therapy.

Hypermobility risk factors for shoulder impingement

1. congenital capular and ligamentous laxity - there are people born with "stretched out" ligaments -AMBRII: atraumatic multidirectional bilateral rehab inferior interval 2. some type of trauma to GH joint that results in tearing or stretching of the capsule, ligaments, or labrum - SLAP tear: tear of superior labrum from anterior to posterior direction 3. dislocation: most often happens in anterior direction

What tendons may be used to surgically fix trauma to the elbow MCL?

1. palmaris longus tendon 2. plantaris tendon 2. toe extensor tendons

What are the 10 muscles responsible for gripping?

1. flexor pollicis longus 2. flexor digitorum profundus 3. flexor digitorum superficialis 4. opponens pollicis 5. opponens digiti minimi 6. flexor digiti minimi 7. flexor pollicis brevis 8. adductor pollicis 9. dorsal interossei 10. palmar interossei

bicycle test

1. Pt in erect posture rides bike 2. Time noted at onset of symptoms 3. Pt rests until symptoms resolve 4. Pt leans forward and repeats 5. Time of symptom onset recorded *Vascular claudication if symptoms come on at same time as erect posture trial*

Bicycle Test for intermittent claudication

1. Pt in erect posture rides bike 2. time noted at onset of symptoms 3. pt rests until symptoms resolve 4. pt leans forward and repeats 5. time of symptom onset noted *Indicates vascular claudication if symptoms come on at same time as erect posture trial*

Treadmill Test

1. Pt walks on 0% incline 2. Time of symptom onset recorded 3. Pt rests until symptoms resolve 4. Pt walks on inclined treadmill 5. Time of symptom onset recorded *Symptom onset quicker if due to vascular claudication*

C/S Disc - posterior annular tear exam What is the painful movement pattern?

1. forward flexion 2. bilateral rotation 3. possible extension * pain can be unilateral or bilateral

How would you differentiate facet joint tightness vs muscular tightness, such as upper trap?

1. have patient side bend with arms at their side and observe range 2. support patient's arms in elevation to slack upper traps and reobserve side bend * if range improves with slacked traps, then tightness is in facet joint

"No Man's Land" 1. where is it? 2. What's important about it? 3. why is it difficult to heal an injury to it?

1. part of flexor zone 2 - from distal palmar crease to mid portion of middle phalanx 2. This is where the tendons of the flexor digitorum profundus and flexor digitorum superificalis tendons pass through their fibrous tunnels 4. surgery is always required but adhesions are likely due to low blood supply

Physiology of the pop

1. Thrust manipulation to the joint 2. Increased Joint Space 3. Vacuum of negative pressure is created 4. "POP" formation of the CO2 gas bubble 5. POP is more than gas in the joint 6. Joint capsule is distracted by the gas like a balloon 7. Mechanoreceptor III is stimulated causing muscle inhibition 8. Local relaxation is experienced *PAIN RELIEF* 9. Has biomechanical effect as the synovial capsule is stretched and adhesions may be snapped

extrinsic risk factors for shoulder impingement (2)

1. postural: increased kyphosis, forward head, rounded shoulders - all cause anterior tilt of scapula and internal rotation of humerus, increasing risk of impingement 2. nerve damange - suprascapular nerve - axillary nerve - long thoracic - dorsal scapular

Treadmill Test for Intermittent claudication

1. pt walks on 0% incline 2. time of symptom onset recorded 3. pt rests until symptoms resolved 4. pt walks on inclined treadmill 5. time of symptom onset recorded *symptom onset quicker if due to vascular claudication*

Sprain/strain/synovitis of C-spine 1. cause? 2. location? 3. key factor? 4. impairments?

1. an overstretch of the facet capsule - sore on onset, with worse pain over the following days 2. location can ary from centered in upper trap/levator region to the interscapular region or cervical/subcranial regions 3. no neurological signs 4. forward head and rounded shoulders - limited AROM: side-bending and rotation is one direction more limited than other - upper trap and levator tighter on more involved side - tenderness and increased ton in cervical/thoracic paraspinals, suboccipital muscles, upper trap, levator and interscapular muscles

SC joint 1. most common MOI? 2. treatment?

1. anterior or posterior dislocation - posterior more rare, but more severe 2. immobilization followed by PT for normal motion, strength, stability, and function

How would an MD treat olecranon bursitis?

1. aspirin, cortisone, antibiotics 2. sling

What are the associated signs and symptoms of CRPS? (11)

1. atrophy of hair, nails, other soft tissue 2. alterations of hair growth 3. loss of joint mobility 4. impaired motor function (weakness, tremor) 5. sympathetically maintained pain 6. pain described as burning throbbing, shotting, or aching 7. hyperalgesia 8. allodynia (feeling pain from things you normally shouldn't) 9. abnormal sweating or anhydrosis 10. redness of bluish discoloration 11. heat of cold sensitivity

Areas of median nerve entrapment

1. bicipital aponeurosis 2. ligament of struthers - anatomical anomaly 3. area between the two heads of pronator teres - hypertrophy/tightness/swelling can cause this

Acceleration/Deceleration injuryies/whiplash 1. What anatomical structures can be effected (12) 2. impairments? 3. Interventions?

1. bone - ligaments - discs - facet joints - anterior/posterior cervical musculature - esophagus - trachea - pharynx - sympathetic chain - brainstem - spinal cord - blood vessels 2. Guarded posture - AROM markedly limited and guarded - no neurological signs - muscle tightness - joint overstretch/hypermobility - weak anterior neck musculature - tenderness and increased muscle tone 3. stabilization of C-spine - treat muscle gurading and pain - 50% 1 RM exercise - isometrics - ROM 1st, then resistance

1. Heterotropic ossification vs 2. myositis ossificans

1. bone formation in location other than bone 2. bone formation in inflamed muscle

Heberden's and Bouchard's nodes 1. What do both signify the presence of? 2. How do they differ? 3. what are the hallmark findings of these nodes?

1. both represent swelling or appearance of thickned bone 2. - Heberden's are located at the DIP joint and associated with OA - Bouchards are located at PIP joint, and associated with both OA and RA 3. - decreased joint space - sclerosis of subchondral bone - osteophytes at articular margins - joint deformities

Headaches 1. when is it warranted to be treated by a PT? 2. what segments are typically involve? 3. impairments? 4. interventions?

1. can be treated by a PT when pain begins in cervical, suboccipital or thoracic regions and radiates to the head - headache must be affected by change in position or movement 2. Occ/C1 or C1/C2 3. Forward head posture - poor postural awareness - upper trap/levator tightness - increased tone/tenderness - no neurological signs 4. treat tight cervical flexion - soft tissue mob - postural exercises

cervical radiculopathy exam 1. What type of stress would increase pain? 2. What type of manual technique would decrease pain? 3. Where would you experience tissue tenderness? 4. what movements will be compromised? 5. Where will neurological signs be observed?

1. compression 2. distraction 3. tenderness experienced on the side of involvement 4. ipsilateral side bending, and back bending 5. In dermotome and myotome

What areas are important to be touched upon during the subjective evaluation? (6)

1. demographic/ vitals 2. symptom location/type/intensity 3. what makes it better/worse 4. past medical/surgical history 5. functional limitations 6. Red flegs (screen for non musculoskeletal origin of symptoms

Olecranon Bursitis 1. etiology? 2. Clinical presentation? 3. differential diagnosis? 4. PT treatment?

1. direct trauma - repetitive weight bearing 2. warmth and swelling on posterior elbow - pain with ARM extension - pain with PROM flexion or MLT 3. Infection - RA - gout - Fracture 4. Modalities to decreased inflammation and pain - education for repetitive stress - stretch/strengthen as indicated by exam

Tribonucleation

1. distraction force is applied to the joint 2. Increase tension to a joint cavity = increase in joint space 3. A vacuum of negative pressure is created 4. Tribonuleation -opposing surfaces resist separation until a critical point where they separate rapidly *POP* -synovial fluid converts to gas -80% CO2 -joint space increases 5. 15-20 mins until joint can pop again (refractory period)

History Questions specific to C-spine (7_

1. do you have trouble bringing your head upright when you look downwards or bend your neck forward? 2. do you ever experience episodes of dizziness? 3. do you have difficulty swallowing or speaking? 4. have you noticed an increased incidence of gagging? 5. do you have any difficulty walking or balancing? 6. do you note a change in symptoms if you hold your breath and strain?

Swan neck Deformity 1. what causes it? 2. What is it's appearance? 3. what is it often a consequence of? (5)

1. dorsal displacement of the lateral bands of the PIP joints 2. PIP joint is pulled into extension while MCP and DIP joints are pulled into flexion 3. RA - inflammatory arthritis - traumatic tendon avulsions - contractures - nerve injuries

How can CRPS be medically treated? (4)

1. drugs 2. sympathetic blocks 3. psychotherapy 4. surgery - spinal cord stimulator - intrathecal infusion - baclofen pump - morphine pump - sympathectomy - radiofrequency

Subcranial instability: what are the signs of compression for the : 1. lower brain stem 2. vertebral arteries 3. spinal cord (upper cervical spine) 4. sympathetic ganglion

1. dysarthria: difficulty with speak due to dysfunctin of the tongue - dyphagia: inability or difficulty swallowing - lingual deviation - cariac or respiratory distress 2. dysarthria (difficult speech) - dysphagia (difficult swallowing) - staggering gait - vertigo - hypotonia - incoordination of movement - nystagmus (abnormal reflex in eyes) 3. bilateral or quadrilateral parasthesia - hypoesthesia 4. Ptosis (drooping eyelid) - Miosis (contraction of the pupil) - Anhydrosis (absence of sweating) - Enopthalmos (recession of the eyball within the socket)

AC joint 1. most common MOI? 2. tests? (18 steps) 3. treatment?

1. fall on the shoulder with GH joint adducted 2. -PFC -PFT 3. immobilization followed by PT for ROM, strength, stability, and function - for grades 1-3

DeQuervain's Tenosynovitis 1. What region is it specific to? - what type of injury is it considered to be? 2. What are the clinical features? 3. What are the positive exam findings? 4. How can it be treated in PT?

1. inflammation within the tendons and tendon sheath of the 1st extensor tunnel - considered an overuse injury 2. pain on radial side of wrist and area of first extensor tunnel - pain with active abduction and extension of thumb, pain with active ulnar deviation 3. PFC: warmth, swelling, thickening over APL EPB - AROM: pain with active abduction and extension of thumb - PROM: pain with classical flexion and adduction - MSTT: strong and painful for abduction and extension of theumb - MLT: pain with lengthening of abductors and extensors - Special tests: positive Finklesteins 4. treat hypo-hypermobilities - stretching tight muscles - strengthen weak muscles -address ergonomics - splinting to decrease stress place on tendons

1. Characteristics of Axonotmesis 2. signs and symptoms

1. injury damages axons but not nerve body - axons, myelin, internal structures are all disrupted - corresponds with 2nd, 3rd, 4th degree injury to a nerve - axons are disrupted and must regenerate while the epineurium is intact - typically occurs with traction type injuries - regeneration occurs in intact neural tubes, but slowly 2. pain - evident muscular atrophy - diminished motor, sensory, and sympathetic function - recovery sensations return before motor function

1. Characteristics of Neurotmesis 2. signs and symptoms

1. internal structural framework and enclosed axons are destroyed - corresponds to a 5th-degree injury to a nerve - results from a disruption in continuity of both axons and all supporting structures, including epineurium - losing the neural tubes negates potential for normal regeneration - neurofibrils can grow out from the divided ends to produce a neuroma 2. no pain - muscle wasting - complete motor, sensory, and sympathetic function loss

Smith's fracture 1. how is it similar to a Colle's Fracture? 2. How is it different?

1. it's also a FOOSH- induced transverse fracture to the distal radius 2. FOOSH occurs in a pronated position rather than supinated position - distal segment has a volar displacement rather than a posterior displacement in Colle's - wrist tends to be flexed rather than extended

Post traumatic DJD what can cause it?

1. joint disruption associated with: - intra articular fractures - dislocation - fracture/dislocations 2. malunion

Opera glove anesthesia 1. what is it 2. what individuals will primarily present with this?

1. lack of sensation or numbness from the wrist down to the fingers - NOT due to pathology of radial, median, or ulnar nerves - therefore, no neurological cause 2. individuals with hysteria, leprosy, diabetes, CRPS

Cervical facet entrapment 1. what structures prevent this? (3) 2. When would pain be reported by the patient? 3. what are the impairments? 4. Internvention?

1. ligamentum flavum - multifidus - menisci all 3 attach to the capsule 2. A "painful catch" reported while turning the head or returning from an eccentric movement - often at first thing in the morning - pain is unilateral - no neurological signs - pain with any activity involving downsliding of involved facet joint 3. - postural shift of head/neck away from painful side in order to open up involved facet more - AROM markedly limited and painful w/ rotation and SB to involved side - backward bending also painful and limited - swollen facet joint capsule with tenderness and guarding in paraspinals and levator scapula 4. Multifius Isometric - if right sided pain, PT stands on left side - left hand wraps around head to contact posteriorlateral aspect of head - right hand stabilizes right shoulder - left hand exerts a submaximal force (similar to that of MSTT) to bring head down on a diagonal to opposite knee for 5-6 seconds - patient resists pull, initiating isometric constraction - perform 2-3 reps for 2-3 sets

Shoulder bursitis: 1. bursa most commonly effected? 2. clinical features? 3. positive exam findings (18 steps) 4. treatment?

1. subacromial, subdeltoid, subscapular bursa 2. pain over lateral brachial region of shoulder - gradual onset with previous history of tendinopathy (possibly) - patient supports arm in loose pack position 3. PFC: warmth and swelling - AROM: pain in any direction that compresses bursa - PROM: pain in any direction that lengthens muscle over the bursa or directions that compress the bursa - PTF ** best findings are the two palpations 4. *decrease swelling within bursa - massage - temporary lifestyle modifications * avoid movements that may cause greater compression * retrain function movement after bursa has healed

Movement (manipulation) fosters nutrition

1. moves articular surfaces -improves cartilage nutrition 2. moves articular capsules -secretes synovial fluid to the joints (motion is lotion) 3. improves ROM -facilitates circulatory system and nerve nutrition

What are six TSI that can cause anterior knee pain?

1. muscle weakness 2. muscle tightness 3. edema/effusion 4. tendinitis/osis 5. hypermobility 6. hypomobility make specific by specifying muscle, location or tissue

Boxer's Fracture 1. What anatomical area is it specific to? 2. what is the MOI? 3. how can it be medically treated?

1. neck of the 5th metacarpal 2. a ulnar striking force or a "unskilled" punch - 4th and 5th metacarpals are more mobile and less rigid than the other 3 3. - closed fixation - ORIF to plate 5th metacarpal

Kienbock's disease 1. what is it

1. osteochondrosis of the lunate bone

Scheurmann's Disease 1. What is it 2. When does it effect humans 3. What does it result in 4. How is it treated

1. osteochondrosis of the spine (juvenile kyphosis) 2. begins at puberty and progresses until growth is complete. Occurs more in males than females 3. results in projections of the disc into the vertebral body and to decreased growth of the anterior aspect of the vertebral bodies - wedge shaped vertebral bodies and marked kyphosis in 3-4 levels 4. bracing and postural exercise

Osseous risk factors for shoulder impingement

1. osteophyte formation - generally form under acromion and underside of AC joint 2. acromion shape - flat: least likely to cause - curve or hook: more likely to cause 3. a larger than average greater tuberosity

Central spine stenosis and myelopathy: 1. How is it caused? 2. what complaints are reported? 3. What are the impairments? 4. how can it be managed/treated?

1. osteophyte formation on posterior aspect of vertebral body - disc protrusion - ligamentum flavum - combo of DJD and DDD in c-spine 2. complaints of aching in neck and shoulders - occasional radiation into the arms - paresthesias noted in hands and/or feet - weakness in legs - problems with balance 3. forward head posture with thoracic kyphosis - generall limited ROM - permanent or transient neurological signs - general weakness of extremities - muscle tightness/weakness associated with posture - tenderness and increased tone in upper traps, cervical regions 4. work on tightness/weakness - strengthen extremities - work on balance activities - local treatment for muscle soreness - chin tucks performed with head resting on 2 pillow

Medial collateral ligament 1. etiology? 2. clinical presentation? 3. Treatment?

1. overhead athlete (throwing) - trauma 2. - pain on medial elbow - warmth/swelling - pain and increased mobility with valgus stress test - pain with PFT 3. Rest, ice, protect - gentle increase ROM and strenght - strengthen/stabilize above and below - supervised throwing progression

C/S right facet cartilage exam: What is the painful movement pattern? (3)

1. pain w/ bilateral extension 2. pain w/ ipsilateral sidebending and rotation * pain is experienced on the right side of the neck

Laslett's Cluster for SIJ

1. reproduction of pain with 3+ provocation tests a. distraction test b. thigh thrust c. gaenslen d. compression e. sacral thrust f. drop test 2. no centralization with MDT

1. MOI for an avulsion fracture of an olecranon? 2. potential complications post surgery? 3. Treatment options?

1. result of a sudden passive flexion with a powerful contraction of the triceps - causes triceps to avulse the olecranon process 2. non-union - post-traumatic DJD 3. immobilization with elbow flexed to 90 if minimal or no displacement - otherweise ORIF followed by immobilization

How can CRPS be treated in physical therapy?

1. sensory training 2. pain science education 3. ROM and muscular maintenance 4. massage for edema 5. muscle pumping exercises

1. MOI of elbow dislocation 2. complications (9)

1. severe hyperextension of a fall on hand with elbow slightly flexed 2. capsular damage - brachialis damage - collateral ligament damage - median nerve damage - brachial artery damage - fractures - myositis ossificans - post traumatic DJD - tight muscles/capsule

1. Charcteristics of Neuropraxia 2. signs and symptoms

1. slight damage to the nerve with transient loss of conductivity - corresponds to a 1st degree nerve injury - demyelination with restoration in weeks - complete recovery is expected within ~ 12 weeks 2. pain - none or minimal muscle wasting - some muscle weakness - numbness - loss of proprioception

Volkman's Ischemic Contracture 1. What region is it specific to? 2. How does it occur? 3. What pressure is associated with 70% decrease in compartmental blood flow?

1. specific to the compartments of the forearm 2. a build up of pressure in the compartment (from trauma or casting too tight) leading to increased pressure on neurovascular tissue - increased pressure leads to decreased blood flow - decreased blood flow leads to ischemia - ischemia leads to necrotic damage and fibrosis of muscles and surrounding ST - fibrosis leads to contractures which can further impinge a nerve 3. 50mmHg

Mallet Finger 1. What anatomical area is it specific to? 2. What is the MOI? 3. what is the appearance?

1. specific to the extensor tendon @ DIP being ruptured or bone at the attachment being ruptured 2. heavy eccentric load applied to extensor tendon results in the injury 3. DIP joint is held in flexion

Potential factors leading to an impingement syndrome (5)

1. structure (osseous) 2. instability or laxity 3. hypomobility 4. muscle imbalance (tightness, weakness) 5. extrinsic factors - postural - nerve - trauma - disease

Rotator cuff 1. muscle most/least often involved? 2. MOI for youth/elderly? 3. positive exam findings( 7 of 18 steps)? 4. treatment?

1. supraspinatus/supscapularis 2. youth: trauma elderly: degeneration 3. PFC: warmth and swelling (if acute) - AROM: painful in direction that muscle contracts - PROM classical - MSTT: strong and painful if tendinopathy or minor tear, weak and painful if partial tear, weak and painless if complete tear - MLT: painful with lenghetning of involved muscle if not deferred due to MSTT finding - MMT: weakness of involved muscle if not deferred due to MSTT finding - special test: combo of painful arc, drop arm sign and infraspinatus muscle test has highest probability of a full thickness tear 4. treatment depends on SOC and other impairments present

What are common symptoms of Volkmann's ischemic contracture?

1. swelling and tightness 2. diminished pulses and capillary refill

Trigger finger 1. What causes it?

1. swelling around flexor tendons - and/ or formation of a nodule within the flexor tendon - and/ or thickening of the fibrous sheath of the flexor tendons

What impairments are typical of of a forward head and shoulders posture

1. tightnes off upper traps, levator scap, suboccipital muscles, pec major, pec minor 2. weakness of mid traps, low traps, deep neck flexor

Rocobado 6x6

1. tongue clicking -correct resting position 2. Controlled TMJ rotation on opening -keep tongue in position and work on opening 3. Mandibular rhythmic stabilization -pt resists opening, closing, lateral deviation in resting pos. 4. Upper Cervical distraction -UC flex while stabilizing cervical spine "hand collar" 5. Axial Extension of Cervical Spine - opposite of FHP 6. Shoulder girdle retraction -retraction and depression of scapulae to fix posture

Colles fracture 1. What anatomical region is the specific to? 2. what is the MOI 3. Who is more predisposed to this type of injury? 4. What are some complications (7)

1. transverse fracture through distal radius 2. FOOSH with wrist in extension, the force traveling dorsally through distal radius - forearm usually in supination 3. - people over 50 - women - people w/ osteoporosis 4. radioulnar or radiocarpal instability - median and ulnar nerve injury - malnunion: "dinner force deformity": proximal portion of fracture posteriorly dispalced - post-traumatic arthritis - soft tissue adhesions - RSD - shortening or lengthening of radius

Myositic ossificans 1. etiology? 2. clinical presentation? 3. treatment?

1. trauma - burns - genetic disorders - typically within muscles located close to periosteum (brachialis, quadriceps) 2. AROM/PROM limited in flexion and extension - PROM accessory should be normal - decreased length of muscles - decreased strength of muscles - imaging: as early as 2 weeks post injury 3. Maintain ROM - don't be too aggressive

What are the possible causes of Carpal Tunnel? (9)

1. trauma - disease process or space-occupying lesion 2. ergonomics resulting in compression of carpal tunnel - overuse injury 3. displaced lunate volarly taking up space within carpal tunnel 4. edema within carpal tunnel 5. effusion within the wrist 6. retinaculum tightness causing compression 7. tight flexors preventing neural gliding 8. pronator teres syndrome mimicking carpal syndrome 9. C5-T1 nerve root pathology mimicking a carpal tunnel syndrome

1. Where can the deep branch of the radial nerve get entrapped 2. Where can the superficial branch of the radial nerve get entrapped

1. within the belly of the supinator 2. at the fibrous edge of the ECRB - main complaint = pain over dorsal aspect of 1st CMC joint

Shoulder flexion

180 (end-feel: ligamentous, capsular, or muscular)

What are the three best examinations to confrim patellar tendonopathy?

MSTT, MLT, P4T

What are the best examinations for tendinopathies?

MSTT, MLT, and P4T

Rabin's review of Hicks CPR

2/4 useful Aberrant movement +prone instability test

Radial deviation

20 (end-feel: boney, ligametnous, capsular, or muscular)

Thumb IP extension

20 (end-feel: capsular or ligamentous)

Hip extension

20 (end-feel: capsular, ligamentous, or muscular)

Ankle dorsiflexion (with knee flexed)

20 (end-feel: muscular, ligamentous, or capsular)

Loose packed position for shoulder

20 degrees scapulohumeral abduction from 20 degrees horizontal abduction

Shoulder inferior glide loose packed position?

20 flex 20 abd

Shoulder anterior glide loose packed position?

20 flex, 20 abd

The 3 best examination findings to confirm an achilles tendon rupture are:

MSTT, MMT, P4C

Hip abduction

45 (end-feel: capsular, ligametnous, or muscular)

Cervical Arterial Dysfunction

5 D's and 3 N's Refer

How far should the mandible be able to protrude?

5 mm

Reflex grading

5+ - sustained clonus 4+ - very brisk, hyperreflexive with clonus 3+ - brisker or more reflexive than normal 2+ - Normal 1+ - Low Normal, diminished 0 - No Response

Thumb MCP flexion

50 (end-feel: boney, capsular, ligamentous, or muscular)

Ankle plantarflexion

50 (end-feel: muscular, ligamentous, or capsular)

Ideal healing rate

50% first 2 weeks 80% in first 6 weeks 100% by 12th week

The ideal healing rate

50% first 2 weeks 80% in first 6 weeks 100% in 12 weeks

Shoulder extension

60 (end-feel: ligamentous, capsular, or muscular)

Lumbar Joints

6: 2 saf, 2 iaf, 2 ib 4 are synovial

Sacrum Joints

6: 2 sup art facets, 2 infer, 2 interbody 5 are synovial

What are steps 7-9 of the 18 steps of the extremity examination?

7. Joint Passive Range (quantity and quality) 8. Muscle selective tissue tension 9. MLT (including myocardial)

Shoulder internal rotation

70 (end-feel: capsular or muscular)

First metatarsophalangeal extension

70 (end-feel: capsular, cartilaginous, or muscular)

Thumb CMC abduction

70 (end-feel: ligamentous or muscular)

Wrist extension

70 (end-feel: ligamentous, capsular, muscular, or boney)

Anterior radial head glide loose packed position?

70 degrees flexion

Elbow ulnar distraction loose packed position

70 degrees flexion

Posterior radial head glide loose packed position?

70 degrees flexion

Ulnar-meniscal - triquetral volar glide loose packed position?

70 degrees flexion

Loose packed radio humeral joint

70 degrees flexion and 35 degrees supination

Loose packed radio ulna joint

70 degrees flexion and 35 degrees supination

Loose packed position ulna humeral joint

70-90 degrees flexion

Waddell's Behavior signs

8 signs 3-4 -yellow flag Overreaction Axial compression Rotation Regional weakness or disturbances Regional sensory disturbance Distracted SLR Superficial tenderness to palpating Non-anatomic tenderness to palpation

normal lateral deviation of the mandible?

8-10mm

Forearm pronation

80 (end-feel: boney or ligamentous)

Forearm supination

80 (end-feel: ligamentous or muscular)

Wrist flexion

80 (end-feel: ligamentous, capsular, or muscular)

Thumb IP flexion

80 (end-feel: ligametnous, capsular, or boney)

C2 joints

9 8 are synovial

Finger MCP flexion

90 (end-feel: boney, capsular, or ligamentous)

Finger DIP flexion

90 (end-feel: capsular or ligamentous)

Shoulder external rotation

90 (end-feel: capsular, ligamentous, or muscular)

MSTT Subscapualris

: GH internal rotation

MSTT Extension of middle finger

: extensor carpi radialis brevis

MSTT Pronator Teres

: forearm pronation

Remodeling phase (chronic)

>1-2 months

Coxa Valga

>125 degrees Genu varus

Biopsychosocial model

A model of illness that holds that physical illness is caused by a complex interaction of biological, psychological, and sociocultural factors.

Sprengel's deformity

A scapular that sits too high on the thorax - congenital in nature *typically smaller and more internally rotated than than conralateral scapula * overhead function commonly limited * possible brachial plexus and muscular imbalance dysfunctions

When performing a joint manipulation on a hypomobile joint capsule the expected abnormal end feel is?

Abnormal tight capsule

MSTT GH ER

All positions same as above - Muscles: teres minor, infraspinatus, supraspinatus - Contact: ulna on mid dorsum of the forearm to apply resistance

MSTT GH IR

All positions same as above - Muscles: teres minor, infraspinatus, supraspinatus - Contact: ulna on mid dorsum of the forearm to apply resistance

Based on the convex-concave rule what is the component motion for glen oh unreal joint ER?

Anterior glide

What direction do the menisci move during knee extension?

Anteriorly

With backward bending which direction does the nucleus deform?

Anteriorly

CPR for regional lumbopelvic manipulation

Author: Flynn FLICKS FABQ <19 Lumbar Spine hypomobility IR >35 degrees on at least one hip Knee-up symptoms Symptoms <16 days 4/5 = 95% chance of favorable response 0/4 = 45% Tx - manipulation

Lumbar Traction CPR

Author: Fritz +Nerve Root Symptoms Peripheralization with extension +Crossed SLR (45) Centralization with traction 4/4 high likelyhood

Lumbar Stabilization CPR

Author: Hicks Age <41 SLR >91 degrees Aberrant Motion + Prone instability test 3/4= 67% Author: Rabin +Prone instability test Aberrant Motion

Cervical Traction CPR

Author: Raney +ULTTA +Shoulder Abd Test Age >55 Peripheralization with PAVIM +Cervical Distractions 4/5=95%

Spinal Stenosis CPR

Author: Sugioka FB +2 BB -2 Age >70 +3 Standing worsens +2 Incontinence +1 Claudication +1 Symptoms > 6 months 7+ = 65.5%

Cervical Radiculopathy CPR

Author: Wainner +Spurlings Test +ULTTA Distraction Test decreases symptoms <60 degrees cervical rotation towards affected side 4/4 = 90%

A disc bulge that is lateral to the nerve root will cause a pt to shift or lean which way?

Away from the side of pain

Coxa Valga at the hip will result in which of the following at the knee? A. Genu Valga B. Genu Vara C. Genu Recurvata D. Nothing

B

What examination steps and findings would indicate a complete tear of the achilles tendon?

MSTT: weak and painless plantarflexion

The etiology of Legg Calve Perthes disease is thought to be A. Largely unknown B. Related to the vascular supply C. Due to trauma

B

How do we know if a patient needs a specific intervention?

Based on the data from the tests and measures and the list of tissue specific impairments

L5 dermatome

Buttock, posterior and lateral thigh, lateral aspect of leg, dorsum of foot, medial half of sole, first, second, and third toes

S2 dermatome

Buttock, thigh, and posterior leg

The 2 most common MOI for an anterior labral tear are? A. Older person with OA/DJD B. young person with repetitive use into flexion C. older person with hx of hip dysplasia due to repeated pivoting and twisting D. Young person with a twisting injury to the hip (ER and hyperextension)

C and D

Indication for manipulation: Chronic neck pain and headaches

C or C/T manipulation/mobilization

Chronic Facet Arthrosis

Cause: poor posture, trauma, overuse S/S: dull ache, local pain, stiffness Management: Decompress by: -posture education -mobilize joints if stiff and neighboring joints if hypermobile -address muscular impairments

Ulnar Upper Limb Tension Test

Depress the shoulder ER shoulder elbow flexion forearm pronation wrist and fingers extended "waiter"

Mechanical Block

Cause: idiopathic, loose body, impaction S/S: Sudden onset, block to motion, relatively pain free Clinical presentation: extension, SB towards, and rotation away (limited downglide) Management: Cervical: Strong manual traction w/SB away and rotation to blocked side (gap) Lumbar: Rotational manipulation over a bolster to further open affected side (gap)

Wasting Fibrosis

Cause: neurological (paresis disc prolapse), spinal cord tumor, surgical Signs and Symptoms -Rapid loss of muscle bulk -Fibrous nature of muscle Management Exercise as innervation returns Myofascial release to fascia of muscle

Provide the areas corresponding to the following dermatomes: C4 C5 C6 C7 C8 T1 T2

C4 = upper trap C5 = lateral delt C6 = thumb C7 = middle finger C8 = ulnar border of hand/pinky T1 = medial forearm T2 = medial arm

biceps reflex

C5-C6

Brachioradialis reflex

C6

Patient has decreased sensation around thumb and index finger with weakness in wrist ext. Also a diminished biceps reflex what nerve root is involved?

C6

Tricep reflex

C7

Upper Thoracic segment

C7/T1 --> T3/4

Involuntary muscle holding

Cause: Injury or dysfunction Signs and Symptoms -Hypertonicity -Protective muscle guarding -Elevated resting tone -Abnormal elastic response to touch Management Treat the cause of the impairment

synovitis / hemarthrosis (strain)

Cause: Trauma, overstretch, awkward movement S/S: guarded movement, involuntary/voluntary muscle holding Management: Lumbar: rest, soft corset, careful movement Cervical: rest, soft collar, careful movement Codman principles to an acute neck Diaphragmatic breathing Slow circumduction circles within circles

Adaptive Shortening

Cause: chemical holding, slouching posture (uhoh) Signs and Symptoms -Normal tone -Shortened length and loss of ROM -Altered posture (increased lordosis secondary to psoas shortening) Management Myofascia stretching

SIJ Displacement

Cause: hypermobile joint overrides articular prominences, severe force to joint, pubis rupture Signs and Symptoms Constant or nearly constant low grade pain Raised or lowered iliac crest Restrictive PROM Positive supine to sit test Management Manipulative reduction

Voluntary muscle holding

Cause: pain or fear of pain (can follow involuntary or chemical) Signs and Symptoms -Slow and guarded movements -Trunk moves as a whole Management R/O more serious (fx) Ignore give reassurance Repetitive motion

Tinel's Sign at wrist

Checks for: Carpal tunnel/ median neuropathy Procedure: PT taps supinated wrist at carpal tunnel Positive: tingling or pain

Finkelstein's Test

Checks for: DeQuervian's Syndrome Procedure: pt makes a fist with the thumb inside the fingers. The examiner stabilizes the forearm and deviates the wrist towards the ulnar side Positive: APL, EPB pain

Sulcus Test

Checks for: Inferior instability Procedure: patient stands with arm by their side and shoulders relaxed. Examiner grasps the patient's forearm below the elbow and pulls down Positive Test: presence of a sulcus sign

Mills Test

Checks for: Lateral epicondylitis Procedure: while palpating the lateral epicondyle the examiner passively takes the patient into pronation then flexes the wrist fully, then extends the elbow Positive: pain

Posterior apprehension Test

Checks for: Posterior GH instability Procedure: Patient supine and examiner elevates the arm to 90 degrees in the scapular plane and applies a posterior force to the elbow Positive Test: apprehension or pain

Scapular Slide Test (lateral slide)

Checks for: Scapular dyskinesis/rhythm Procedure: Patient standing with arm at the side. Examiner measures the distance from the base of the spine of the scapula to the spinous process T2 -same test with hands on hips -same test with arms at 90 Positive: measurements shouldnt vary more than 1-1.5 cm from test 1

TFCC Load Test

Checks for: TFCC tear Procedure: examiner compresses carpals into ulnar side of wrist and ulnarly deviates Positive: pain in TFCC location/ulnar side of the wrist

Supination Lift Test

Checks for: TFCC tear Procedure: pt is seated with elbows flexed to 90 degrees and forearms supinated. The pt is asked to place the palms flat on the underside of the table and asked to lift table Positive: pain on ulnar side of the wrist

Yergason's Test

Checks for: Tests for transverse humeral ligament to hold biceps tendon Procedure: patient's elbow is flexed to 90 degrees and stabilized against the thorax with the forearm pronated. The examiner resists supination and external rotation while palpating the bicipital groove Positive: biceps tendon pops out of groove or pain

Valgus Test

Checks for: UCL or MCL Procedure: pressure on lateral proximal humerus and opposing pressure at distal medial forearm Positive: laxity

Milking Maneuver

Checks for: UCL/MCL Procedure: Holding patients arm in 90 abduction, examiner grabs patients thumb and moves in painful arc Positive: laxity

Moving Valgus Test

Checks for: UCL/MCL Procedure: Holding patients arm in 90 abduction, move at distal forearm into elbow flexion at an arc of ER Positive: laxity

Froment's Sign

Checks for: Ulnar Nerve Palsy Procedure: Patient attempts to grasp a piece of paper between their thumb and index finger. When the examiner tries to pull away the piece of paper and terminal phalanx of the thumb flexes or patient cannot hold Positive: finger flexes up or unable to hold paper

Allen's Test

Checks for: blood flow to the hand Procedure: patient pumps hand, Examiner occludes radial and ulnar artery and lets 1 go to test that side and repeats with other Positive: no refill of 1 side

Load and Shift Test

Checks for: position of humerus in the glenoid fossa and instability Procedure: Patient sits with no back support with the hand of the test arm relaxed on the thigh. Examiner stands slightly behind the patient and stabilizes the shoulder with one hand over the clavicle and scapula. With the other hand the examiner grasps the head of the humerus with the thumb over the posterior humeral head and fingers over the anterior humeral head. Examiner runs the fingers along the anterior humerus and thumb along the posterior humerus to feel where humerus is seated relative to the glenoid. Positive Test: If the fingers dip in anteriorly, the humeral head is seated anteriorly. Humerus is then pushed anterioly or posteriorly in the glenoid to seat it properly. The examiner then pushed anteriorly or posteriorly to see the amount of translation and end feel.

Drop arm test

Checks for: rotator cuff tear Procedure: examiner abducts the arm to 90 degrees and asks the patient to slowly lower the arm to the side in the same arc of movement Positive: Patient drops arm instead of slowly lowering, indicating RC tear

Lift Off Sign

Checks for: subscapularis weakness or dysfunction Procedure: patient stands with hand behind their back, the dorsum of their hand resting on the back pocket or midlumbar area. The patient then tries to actively lift their hand away from their back Positive: abnormal/no scapular motion

Hawkins-Kennedy Test

Checks for:supraspinatus tendonitis or impingement Procedure: patient stands while examiner forward flexes the arm to 90 degrees then forcibly internally rotates the shoulder Positive Test: pain

Lumbar central stenosis S/S

Chronic dull LBP Leg pain on walking any distance (neurogenic claudication) LMN symptoms (LLTT, myotome, dermatome)

Ulnar Glide of the base of phalanx of hand

Component motion for MCP adduction (index) MCP abduction (ring and little fingers) Pt seated with forearm pronated and supported on the table PT - sitting Stabilizing hand - radial side proximal aspect of the proximal joint Manipulating hand - radial side of the distal joint surface MCP in 20 degrees of flexion force applied by manipulating hand in ulnar direction

Dorsal (posterior glide) of 1st MCP

Component motion for abduction pt - seated with forearm semi supinated and supported on table PT - standing at right angle to palm stabilizing hand - volar and dorsal side of trapezium manipulating hand - first metacarpal Movement - into palm Volar glide is opposite and for adduction

Medial (ulnar) glide of first MCP

Component motion for flexion pt - seated with arm in neutral rotation and supported on table PT - standing stabilizing hand on dorsal and volar surface of trapezium Manipulating hand - proximal surface of 1st metacarpal. Movement towards palm of hand Lateral Radial glide is opposite (movement should be 1:1)

Medial Glide of Proximal Carpal Row (Ulna glide)

Component motion for wrist abduction (radial deviation) NO SPACE BETWEEN STABILIZING AND MANIPULATING HAND

Volar Glide of proximal carpal row

Component motion for wrist extension pt - seated with forearm pronated on table or wedge PT - standing on ulna side Stabilizing hand on wrist Manipulating hand - on proximal hand dorsal side movement - volar direction force by manipulating hand

Volar Glide of Capitate and Hamate on proximal carpal row

Component motion for wrist flexion

Cephalic movement of radius

Component motion necessary for elbow flexion and wrist extension pt - standing or supine PT - standing radial side of pt and holding left humerus in approximately 20 degrees of abduction Stabilizing hand - grasps the distal humerus and posterior proximal aspect of the ulna Manipulating Hand - thenar eminence contacts pt thenar eminence. Thumb hooks pt thumb Examination movement - manipulating hand exerts a cephalic motion through hand Treatment - above is maintained with small rotary oscillatory motion of forearm and moved towards end-range (10 degrees of flexion)

Hypertrophy

Increase in bulk from the normal. Normal response to exercise (can overload joints and limit ROM)

CCFT

Cranial Cervical Flexion Testing Local neck muscles -suboccipitals -multifidus -semispinalis cervicis -longus capitus -longus colli Assesses the firing of local muscles Cuff placed at C3/4 chin nod starting 20mmHg progressing to 30mmHg in 2 mmHg intervals Hold 10s x10

Joint manipulation is defined as: A. A grade V (thrust) movement B. Passive movement to a joint that does not include thrust C. Forceful movement of a joint D. Skilled passive movement to a joint

D

Osgood Schlatters disease A. osteochondrosis of the tibial tubercle B. Requires a period of rest from activity C. May be associated with muscle tightness D. All of the above

D

The 18 steps are organized such that A. They go from least aggressive to most aggressive b. The start off with superficial touch and examination C. Systems are grouped together D. All of the above

D

What is the purpose of the concave convex rule? A. Provide clinical rationale for direction of manipulations B. Allows the therapist to use biomechanics to predict movement C. Assist with clinical examination and evaluation D. All of the above

D

Lumbar central stenosis clinical presentation

Degeneration, wear and tear, poor posture, abdominal protrusion/lordosis, tight iliopsoas, tight lumbar spine myofascia Disc protrusion, prolapse

C5 dermatome

Deltoid area, anterior aspect of entire arm to base of thumb

Your patient with foraminal stenosis with radicular symptoms in the L4 distribution. What else would you expect to find in your neruovascular exam?

DF weakness Medial lower leg decreased sensation patella reflex hypo +neural tension

What data would indicate the need to perform manipulation as a treatment?

Decreased accessory motion with an abnormal end feel or pain with accessory motion

What is in the anterior compartment of the lower leg?

Deep peroneal N Anterior tibial A and V ankle dorsiflexors

Low back pain CPR (flynn)

FABQ < 19 Lumbar hypomobile IR <35 degrees Knee (prox symptoms) Symptoms <16 days *0 to 4 = 45% success rate with spinal manipulation* *4 to 5 = 95% success rate*

LBP (Hicks) prediction of stabilization exercise success

FABQ >8 Aberrant movement Prone instability test hypermobile lumbar spring test *3/4=best success*

Lumbar spine L facet limited pattern

FB - deviation to the L BB - deviation to the R SBR - limited RL - Limited SBL - free RR - free

Lumbar L Capsular Pattern

FB deviation L SBR limited RL limited SBL free RR free

Lumbar spinal stenosis CPR (Sugioka)

FB improves (+2) BB worsens (-2) Age over 70 (+3) Standing worsens (+2) Incontinence (+1) Claudication (+1) Symptoms >6 months (+1) *Score >3 = LSS*

Lumbar Myofascial Patterns

FB limited with inability to reverse lumbar lordosis

Cervical spine L facet limited pattern

FB possible deviation to the L BB possible deviation to the R SBR - Restricted RR - *most restricted* SBL - relatively free RL - Relatively free

Cervical L Capsular pattern

FB some deviation L SBR limited RL free SBL free RR most restricted

Upper Thoracic Joints (C7/T1 to T3/4)

Facet Joints -60 degrees from transverse plane movement limited by spinous processes and rib attachments

The posterior ramps provides innervation where?

Facet joints, ligaments and muscle posterior

Lumbar Joints (T12/L2-L5/S1)

Facets -Planar/synovial -90 degrees to transverse plane -2/3 in the sagittal plane -1/3 in the frontal plane Motion -flex/ext/SB/Rot

Mid Thoracic Joints (T3/4-T12/L1)

Facets -planar synovial joints -60-90 degrees to the transverse plane -20 degree to frontal plane Motion -Rotation (gapping same side) -Sidebending (greatest movement) -flex and ext

Describe the osteokinematics and associated arthrokinematics in mid cervical forward bending

Facets are at 45 degrees facets translate up and forward (40% displacement) Lateral interbody articulations translate anteriorly Intervertebral discs bulge anteriorly, flatten posteriorly Spinal canal lengthens and narrows (constant volume)

Rotation of the lumbar spine

Facets gap on side rotating toward Facets compress on side rotation away from

FOOSH injury

Fall on and Out Stretch Hand

Describe the osteokinematics and associated arthrokinematics of the TMJ during opening

First 12 mm of opening -rotational motion of the condyle moving anteriorly and the disc moving posteriorly Greater than 12 mm of opening -ligaments tighten -anterior translation of the condyles begins Terminal phase of opening -downward and forward translation (lateral translation occurs for chewing)

CPR for traction

Fritz Cervical -peripheralization with P/A PIVM -+shoulder abduction test (decreases radicular therapy) -Age >55 -+ULTT -+cervical distraction test Positive response to traction 3/5 = 79% 4/5 = 95% Lumbar -+Nerve root signs Peripheralization of leg pain with lumbar extension -+crossed SLR (45 degrees) -LE pain that centralizes with traction

Lumbar Traction CPR

Fritz NPCC +Nerve Root signs Peripheralization of leg pain with lumbar ext + Crossed SLR (45) LE pain centralizes with traction 4/4 high likelihood

In which direction is the manipulation applied in order to improve the specific classical motion?

Glide direction

What is classical/physiological motion?

Gross, general motion that you can see at a joint

Impairments of a lumbar sprain/strain/synovitis

Guarded posture Limited ROM in all directions QL and posterior lateral muscles tight on involved side tender and increased tone over lumbar paraspinals, QL, post-lat hip muscles Decreased strength and endurance No neurological signs

What is a capsule tightness end feel?

Harsh resistance with reduced or absent creep

Examination of scoliosis (MLT and Strength)

Hip flexors and lumbar myofascia Muscles weak on convex side Weak abdominals Trunk extensors weak

S1 dermatome

Lateral and plantar aspect of foot

What is the difference between a MD dx and an PT dx?

MD = disease or pathology PT = tissue and movement impairments

TSI: Muscle Tightness Best exam step? Best Tissue reactivity

MLT MLT

What is a capsule/ligament laxity end feel?

Increased movement with out firm arrest

What are the 3 phases of healing?

Inflammatory Proliferation Remodeling

TSI: Muscle Weakness Best exam step? Best Tissue reactivity

MMT MLT

Distraction of base of phalanx of hand

Joint play pt seated with forearm supported on table PT - perpendicular to pt Stabilizing hand - grasps the proximal joint surface Manipulating hand grasps the distal joint surface Joint held in 20 degrees of flexion "looking at quality or creep movement"

Dorsal - volar sweep stretch of syndesmosis at MC heads

Joint play necessary for closing and opening hand pt - seated with elbow flexed and posterior aspect of elbow on table PT - sitting facing dorsal aspect of hand Manipulating hand - both thumbs placed on dorsal surface of the MC shafts. Other fingers are placed on the volar surface Arch is either increased or flattened

Describe the osteokinematics and associated arthrokinematics in the mid thoracic region for rotation (left)

L facets gap R facets compress rotation and sidebending occur opposite to each other

Patellar reflex

L4

Your pt has a severe lateral disc bulge affecting the L5 nerve root. What spinal level is involved?

L5/S1

Maitland's Grades of Movement

MOBILIZATION (all based on available range - goal to reach anatomical limit) Size, speed and location Grade I - Small amplitude, low velocity, beginning of range Grade II - Large amplitude, low velocity, beginning to mid range (I&II only for pain) Grade III - Large amplitude, low velocity, mid to end range Grade IV - Small amplitude, low velocity, end of range THRUST/MANIPULATION (hear pop/crunch - more damaging to tissues) Grade V - small amplitude, HIGH velocity, end of range

Forward and backward Bending single leg sidelying PIVM (pt on right side)

Located L5 (moves away with leg ext) Hand placements R: support at the ankle L: middle finger palpates interspinous spaces Pt shin is placed on R thigh pt leg is flexed or extended and movement is felt

Cervical Myofascial patterns

Lumpiness or painful bump in trapezius or paraspinals Radiating pain referred from trigger points Dizziness Nausea Disturbed sleep due to night pains *Limited SB improves with shoulder girdle support*

An unhappy triad injury consists of injury to what structures?

MCL, ACL, Medial Mensicus

Injury to what tissues at the knee will result in synovitis?

MCL, Meniscus, anteriormedial fibers of ACL

Sequaelae of forward head posture

Mid and lower cervical spine (C2-T1) is in flexion Leads to hypermobility in lower cervical spine Upper cervical (AA and OA) is in extension Leads to hypomobility in upper cervical spine Compensation Excessive thoracic kyphosis Leads to hypomobility of thoracic spine Excessive lumbar lordosis Excessive facet compression Tight anterior muscles (pectorals, scalenes, scm, etc) Weakened/lengthened posterior muscles (longus colli and capitius) Scapular stabilizers too

Types of braces for scoliosis

Milwaukee - 23-24 hours a day Boston brace - molded plastic jacket Electrical stimulation - midaxillary line of the convex side at night time

Type II mechanoreceptors

Name: Dynamic Location: joint capsule Fired by: oscillations and progressive stretch When are they fired? changes in direction and velocity (rapidly adapting)

Type II mechanoreceptors: type, location, fired by, adapt?

Name: Dynamic Location: capsule Fired By: Oscillations, Progressive-stretch When are they Fired? How do they adapt?: Change in direction and velocity/rapidly adapting

Type III mechanoreceptors

Name: Inhibitive Location: Capsule/ligament Fired by: stretch, sustained pressure, thrust When are they fired? joint pop, stretched capsule, (very slow adapting)

Type III mechanoreceptors: type, location, fired by, adapt?

Name: Inhibitive Location: Capsule Ligament Fired By: Stretch, Sustained pressure, Thrust When are they Fired? How do they adapt?: joint pop, stretched capsule, very slow adapting

Type IV mechanoreceptors

Name: Nociceptive Location: most tissues Fired by: injury or inflammation When are they fired? with damage (Non Adapting) *just respond*

Type IV mechanoreceptors: type, location, fired by, adapt?

Name: Nociceptive Location: Most Tissues Fired By: Injury/inflammation When are they Fired? How do they adapt?: With damage/Non Adapting

type I mechanoreceptors

Name: Postural Location: Joint capsule Fired by: oscillations and progressive stretch When are they fired? Constantly (slow adapting)

type I mechanoreceptors: type, location, fired by

Name: Postural Location: Capsule Fired By: oscillations, progressive-stretch When are they Fired? How do they adapt?: constantly firing, slow adapting

3 N's

Nausea Numbness Nystagmus

Can PTs make the dx of osteoarthritis and degenerative joint disease?

No

Is every disability permanent?

No

What are the contraindications to manipulation?

No absolute contraindications

spina bifida occulta

No external manifestation Least serious 10% of population Rarely associated with neurological deficit

Does time frame alone define how well the tissue is healing?

No it is general guideline

Low tissue reactivity

No pain is reported at the point of the tissue resistance (end feel)

Low Tissue Reactivity

No pain is reported at the point of the tissues resistance (end-feel). This means you were able to determine the end-feel but the patient did not report any pain.

Healthy Disc Mechanics

No real displacement of nucleus with FB or BB, only deformation BB causes anterior fibers of the annulus to become taut, and a radial bulge posteriorly

High Tissue Reactivity

Pain is reported before the tissue can be taken to its restriction, or rather, before the therapist can determine the end-feel. This is before you feel an end-feel, or resistance of the tissue, the patient complains of pain.

What neurophysiological effects do you get from manipulation?

Pain relief and decreased muscle guarding

What are the treatment categories of intervention?

Palliative Preparatory Corrective Supportive

Based on the convex concave rule, what is the component motion for the MCP joint flexion?

Palmar glide

Sulcus Sign Test

Positive Test: Increased translation of humeral head from glenoid fossa and/or sulcus below acromion process. Indication: Inferior glenohumeral joint instability.

what is a positive babinski?

Positive= toes fan out, hallux extends upwards. Negative=toes curl down, plantar flexion [gas pedal] a positive Babinski = UMN lesion (brain/SCI)

Ligamentum Flavum becomes

Posterior atlanto-occipital membrane and posterior A/A membrane

What nerve innervates the multifidus

Posterior primary ramus

What is in the posterior compartment of the lower leg?

Posterior tibial N Posterior tibial A and V Peroneal A and V Ankle plantar flexors

With forward bending which direction does the nucleus deform?

Posteriorly

High Subject Reactivity

Pt cannot carry our their functional activity as expected of them because of thei compliants

subject reactivity

Pt limitations as they may relate to work, home, leisure, etc. the pt limitations as they may relate to work home leisure, etc

MSTT Brachialis

elbow flexion

Varus stress test (elbow)

Purpose: Lateral collateral ligament sprain Method: Pt is sitting with elbow flexed between 20-30 degrees. PT places one hand on elbow and the other proximal to pt's wrist. PT applies varus force while palpating joint line. Positive Test: Increased laxity, apprehension, or pain.

Valgus stress test (elbow)

Purpose: Medial Collateral Ligament Sprain Method: Pt is sitting with elbow flexed between 20-30 degrees. PT places one hand on elbow and the other proximal to pt's wrist. PT applies valgus force while palpating joint line. Positive Test: Increased laxity, apprehension, or pain.

Lumbar Forward-Bending Passive Intervertebral motion test: Sidelying with double/bilat leg flexion

Purpose: evaluates passive forward bending motion of L5/S1 to T12/L1

Cervical traction CPR

Raney (USAPC95) +ULTTA +Shoulder abduction test Age >55 Peripheralization with Ext +cervical distraction test 4/5 = 95%

MSTT Brachioradialis

elbow flexion

Elbow ulnar distraction improves?

elbow flexion and extension

C6 myotome

elbow flexion, wrist extension

Spinal Cord Injury signs

pathological reflex gait deviations transient bilateral symptoms

Fibro adipose meniscoids

present in the AA and mid-cervical joints

C4 dermatome

Shoulder area, clavicular area, upper scapular area

Median Upper Limb Tension Test

Shoulder depression shoulder ER and abduction elbow extension forearm supination wrist and fingers extended flex head away

What is the difference between a sign and a symptom?

Sign - something you can see Symptom - something pt tells you

Red Flags

Significant trauma Weight loss History of cancer Fever IV drug use Steroid use Severe unremitting nightime pain Pain that worsens on lying down

Pre Prolapse

Signs - no frank neurological signs, signs of instability -Grade 5 or 6 PIVM Symptoms - Dull muscular ache on sitting (need to get up and move around) -occasional LBP w/radiating into buttock -Hx of self cracking Management -Stabilization - decrease load, increase endurance -Back school - educate: posture, ergonomics, work, etc -Manipulation - joint and myofascia impairments -First Aid Ed - should injury occur go into lordosis and maintain it

Immediate Injury (tear or herniation)

Signs - Hx of pre prolapse -sudden and deep pain -may refer pain to butt -very guarded motions Symptoms - "it tore, ripped, gave out" Clinical presentation - sudden unguarded motion resulting in acute but deep pain, usually from flexion and perhaps with a torque. -Neurological will be negative for first 30 minutes Management -Lordosis position for 2 weeks (3-4 preferred) -Support and reinforce behavior (corset) -Try to gain lordosis if not in it -Back school principles -Stabilization exercises - gently with spine in muscular fusion -Myofascial techniques

Acute and Sub Acute Prolapse

Signs - classic neurological signs Symptoms - fatigue and disability Management Acute (day 1-4) Try to gain lordosis Minimal bed rest as disc swells with rest Try backward bending but probably too late Medical palliative measures Education - move, dont rest too long, laxatives Sub-Acute (Day 4 and improving) Initiate movement Myofascia manipulations Corset Stabilization Avoid aggravating prolapse

Lateral Foraminal Stenosis Cervical

Signs and Symptoms Radiculopathy Neck and arm pain and parethesia Frank neurological S/S + ULTT Positive spurling Management -Joint and myofascia release -Posture -Positional distraction

lumbar laminectomy

The excision of a vertebral posterior arch in the part of the back between the thorax and pelvis. Takes pressure off nerve root

Crossed Straight Leg Raise

also known as *well leg raise* Inclinometer is placed on tibia to measure the onset or change in symptoms Examiner *raises the unaffected limb* until pain (symptoms) is produced or reaches 90 degrees Positive findings: Increase in radicular pain on affected leg *(ex. you raise the L leg because it doesn't hurt and you get pain in the R leg)* Indications: Probable posteromedial disc protrusion involving L4, L5, S1, S2 or S3 roots (most likely L5 or S1)

Coxa Vara

angle of the neck of the femur and the shaft of the femur is <125 degrees Genu Valgus

L4 myotome

ankle dorsiflexion

PIVM grade 0

ankylosis - fused/no movement No manipulation

Component motions that improve supination

anterior and posterior glide of radial head

Load and Shift Test

anterior and posterior instability

Component motions that improve pronation

anterior glide radial head posterior glide radial head

hindfoot pronation effect up the kinetic chain

tibia - IR Genu valgum Femur - add and IR

Tx:Acute stage of condition

prevent condition from worsening, decrease inflammation, PRICE principles, gentle PROM in pain free ROM to preserve ROM, 50% 1 RM exercise (31+reps without fatigue) for vascularity/pain

Hindfoot supination effect up the kinetic chain

tibia ER Genu varum Femur - abd and ER

What are the symptoms of PFS?

anterior knee pain, pain with sitting, pain with descending stairs, and gradual onset of pain dull achy pain

Centralization of pain

process of where the pain experience moves from a peripheral location to a more central location repetitive motion produces centralization of pain Mckenzie method (MDT)

Rib manipulation

assists with exhalation and free costo-verterbral articulations graded or progressive oscillation follows scapula

Cervical Myelopathy

compression of the spinal cord in the neck. S/S -Bilat UE symptoms -UMN signs (hyper reflexive, pathological reflexes) -Hypertonia -gait deviation and poor balance Management -refer -stabilize -pt education/posture -manipulate UT

Hawkins-Kennedy Test

compression of the supraspinatus tendon against the coracoacromial ligament to assess the possibility of impingement of the subacromial bursa

prone instability test

also called Segmental Instability Test ___Instruct patient to *lie prone on the table with legs off* the end and feet on the floor ___Apply pressure to the lumbar spine & ask if it provokes symptoms ___*If pain is found* proceed to the next step, if pain is not found then the test is over ___Ask patient to actively lift legs off the ground (active lumbar & hip extension) ___Apply pressure to the spine again while the legs are elevated ___Positive finding: pain decreases or disappears when pressure legs are up (muscular contraction is contributing to stability ___Indication: Lumbar instability

A/A joint make up

atlas and axis inferior articular facets of C1 (convex) on superior articular facets of C2 (convex) 50% of cervical rotation

Where do cervical nerves exit?

above the vertebrae ex. C6 nerve - C5/C6 segment

Lumbar Lateral Shift

active or reflexive avoidance of a spinal nerve root compression or irritation

Normal tone/shortened

adaptive shortening

Difference between capsular tightness and adhesion?

adhesion is tight in one direction

what causes hypomobility?

adhesion or tight capsule

Anterior and posterior glide of lunate on triquetrum improves?

all motions of the wrist

Distraction of MCP, PIP, or DIP improves?

all movements of the finger

Anterior and posterior glide of hamate on triquetrum improves?

all movements of the wrist

Anterior and posterior glide of lunate on capitate improves?

all movements of the wrist

Anterior and posterior glide of lunate on scaphoid improves?

all movements of the wrist

Distraction of proximal row of carpals on radius improves?

all movements of the wrist

Tx for degenerative tendonopathy should include which of the following? Functional Strengthening Modalities as needed Stretching Eccentric Exercise

all of the above

Prone Instability Test

also called Segmental Instability Test ___Instruct patient to *lie prone on the table with legs off* the end and feet on the floor ___Apply pressure to the lumbar spine & ask if it provokes symptoms ___*If pain is found* proceed to the next step, if pain is not found then the test is over ___Ask patient to actively lift legs off the ground (active lumbar & hip extension) ___Apply pressure to the spine again while the legs are elevated ___Positive finding: pain decreases or disappears when pressure legs are up (muscular contraction is contributing to stability ___Indication: Lumbar instability

Caudal movement of radius

component motion for elbow extension and wrist flexion pt - supine PT - standing at side of pt Stabilizing hand - distal humerus and palpating joint line Manipulating hand - distal radius (golfers grip) Movement for Exam - caudal force applied to radius Movement for tx - exam step maintained and combined with small oscillatory rotary motion and forearm is moved towards end range of extension

Anterior and posterior Glide of the radial head

component motion for elbow flexion and extension joint play for supination and pronation Anterior force through thumb Posterior force through fingers

Inferior glide of clavicle head

component motion for shoulder elevation pt supine PT at pt head Manipulating hand - thumb pad contacts the most superior/proximal surface of the clavicle Movement - inferior force applied through thumb

Posterior glide of clavicular head

component motion for shoulder retraction pt supine PT - at head of pt thumb pad contacts anterior/proximal surface of the clavicle. movement - posterior force applied through thumb

Volar glide of trapezium on proximal carpal row

component motion for wrist flexion

Posterior radial head glide improves?

component: elbow ext joint play: pronation/supination

iliolumbar ligament

connects the transverse process of L5 with the ala of the sacrum

PIVM grade 1

considerate restriction (hypomobile) Non-thrust manipulation (could tear capsule)

C2/C3 to T3/T4 backward bending

both facets glide down and back

T4/T5 to L5/S1 forward bending

both facets glide up

C2/C3 to T3/T4 forward bending

both facets glide up and forward

C6 reflex

brachioradialis

Chronic compartment syndrome

secondary to overuse (exercise induced)

Mid to lower C spine combined motion

bends and rotates in same direction when the motion occurs either in the frontal plane or horizontal plane

Lumbar spine combined motion

bends and rotates in the opposite direction when motion occurs in the frontal plane

C5/6 reflex

biceps reflex

Speed's test

bicipital tendinitis

Are the cruciate ligaments extracapsular or intraarticular?

both

T4/T5 to L5/S1 backward bending

both facets glide down

Acute Compartment syndrome

secondary to trauma

O/A Joint (C0/C1)

convex (condyles) on concave (facets of C1) Ellipsoid/condular type synovial joint Accounts for 50% of cervical flexion and extension Motions: nodding, sidebending and minimal rotation

Anterior and posterior glide of hamate on triquetrum type of movement?

component motion

Anterior and posterior glide of lunate on capitate type of motion?

component motion

Anterior and posterior glide of lunate on scaphoid type of motion?

component motion

Anterior and posterior glide of lunate on triquetrum type of motion?

component motion

Dorsal (posterior) glide of carpals on radius type of motion?

component motion

Dorsal glide of MCP, PIP, DIP type of motion?

component motion

Manipulations that occur in different row

component motion

Palmar glide of MCP, PIP, DIP type of motion?

component motion

Pisiform glides (medial/lateral/superior/inferior) type of movement?

component motion

Shoulder Inferior Glide type of motion?

component motion

Shoulder anterior glide type of motion?

component motion

Shoulder posterior glide type of motion?

component motion

Ulnar-meniscal - triquetral volar glide type of motion?

component motion

Volar (palmar/anterior) glide of carpals on radius type of motion?

component motion

Inferior glide of humeral head with scapula stabilization

component motion stabilizing hand in armpit downward force applied to distal humerus

Dorsal glide of base of phalanx of hand

component motion for MCP extension pt - seated with forearm supinated and supported on table PT - STANDING at side stabilizing hand - grasps the dorsal aspect of the proximal joint surface Manipulating hand - grasps the distal joint surface Joint held in 20 degrees of flexion posterior force applied by manipulating hand

Volar glide of base of phalanx of hand

component motion for MCP flexion pt - seated with forearm pronated and supported on table PT - standing at side stabilizing hand - grasps the dorsal aspect of the proximal joint surface Manipulating hand - grasps the distal joint surface Joint held in 20 degrees of flexion Anterior force applied by manipulating hand

Hindfoot

calcaneus and talus

Shoulder inferior glide end feel?

capsular

Shoulder anterior glide end feel?

capsular end feel

Shoulder posterior glide end feel?

capsular end feel

Elbow ulnar distraction end feel?

capuslar or ligament end feel

Phalen's test

carpal tunnel syndrome

Component motions that improve elbow extension

caudal movement of radius posterior glide of radial head

Distal Radio Ulnar wrist flexion

caudal movement radius dorsal glide volar glide

SIJ Hypermobility

cause: repetitive minor trauma, one legged standing, sex, childbirth Signs and Symptoms Dull ache on backward torsion (prolonged positioning) Reference possibly posterior leg Lowered iliac crest on standing Hypermobile symphysis pubis Positive spring test Management Support (belt) Postural instruction Hip manipulation if restricted Stabilization exercise (glutes, multifidus, abdominals) Sclerosing for pain reduction Surgical fusion

LBP and improvement with traction (Fritz)

centralization of sx with ext - shows greater improvement and no need for traction I peripheralization w/ extension movements II. + crossed SLR test

Distal radio-Ulnar wrist extension

cephalic motion of radius dorsal glide volar glide

Component motions that improve elbow flexion

cephalic movement of radius outward roll anterior glide of radial head

Indication for manipulation: sub acute neck pain and head aches

cervical manipulation and mobilization

Why is a capsular pattern considered?

characteristic of shrinking of the joint

A/A joint mechanics for SBL

clinical insignificant

O/A joint mechanics for for RotL

clinically insignificant motion

How would you treat a lateral shift?

correct lateral shift extension program Stabilize posture education

Elbow flexion test

cubital tunnel syndrome. Passive elbow flexion held for 3 mins + if symptoms recreated

Lumbar rotation using progressive oscillations

done on TP's pressure on one side improves rotation in opposite direction (R side pressure = L rotation)

Distal radio ulnar pronation

dorsal glide volar glide

Distal radio ulnar supination

dorsal glide volar glide

MidCarpo WRist abduction

dorsal glide volar glide

MidCarpo wrist adduction

dorsal glide volar glide

PIP/DIP component motions

dorsal glide volar glide

Component motions of the MCP joint

dorsal glide volar glide radial glide ulnar glide dorsal tilt with flexion beyond approximately 65 degrees

Pronation consists of:

dorsiflexion eversion ER

L5 dermatome

dorsum of foot

Describe the osteokinematics and associated arthrokinematics in the lumbar spine for backward bending

downslide of both facets

What are possible end feels for accessory motion following immobilization?

tight capsule, effusion, bony block

Hypomobility causes of PFS

tight lateral retinaculum, tight ITB and tight quads

Describe the osteokinematics and associated arthrokinematics in the mid thoracic region for backward bending

downslide of facets on both sides

Developmental dysplasia of hip

due to repetitive dislocation F> M Birth to infancy

What are possible end feels for classical motion following immobilization?

tight muscle, tight capsule, edema, bony block

a pt will shift towards leg pain if it is caused by

disc bulge is medial to the nerve root

a pt will shift away from leg pain if it is caused by

disc bulge that is lateral to nerve root

Chronic Disc Disease

discogenic back pain: no great solutions. life style education, stabilization, posn distraction if neuro signs, fitness training, counseling

Posterior Fx dislocation

dashboard injury occurs in loose packed Medical emergency Complications -AVN -Sciatic N -Post DJD

hypoalgesia

decreased pain sensation

DDD

degenerative disc disease. Will narrow the central canal and intervertebral foramen

DJD

degenerative joint disease

What does excessive and repititive shoulder impingement lead to?

degenerative tendonopathy of rotator cuff musculature and potentially rotator cuff tears

Radial Upper Limb Tension Test

depress shoulder 10 degrees abduction elbow extension internally rotate shoulder pronate forearm flex wrist and fingers flex head away

Volar (palmar/anterior) glide of carpals on radius loose packed position?

determine 10 degrees flex neutral 10 degrees ext

Craig's Test

determines amount of anteversion or retorversion 15-18 anteversion 5-8 retroversion Normal 8-15 degrees

5 D's

diplopia, dizziness, drop attacks, dysarthria, and dysphagia

Neer Test

impingment test of subscalpular n/supraspinatus

Mid-Thoracic Tilt on Spinous process

improves forward bending and backward bending (costo-vertebral restrictions) Pressure is applied to spinous process with hand (distal to pisiform) Graded or progressive oscillations

Clinical signs of instability during HX

inability to stay in one posture for a prolonged period of time pain relieved with rest and change of position

spina bifida meningocele

incomplete fusion with neural tissue/meninges protruding

Clinical signs of instability during structural assessment

increase muscle tone with standing presence of a step indicates spondylolisthesis *disappearance of muscle tone and step during prone lying*

hyperalgesia

increased sensitivity to pain

Upper Thoracic rotation in prone

increasing movement here will cause: -decreased stress on cervical spine -gate cervical discomfort -enable improved posture -reduce associated swelling pt head turned towards direction to be manipulated ex R rotation - pt head to R. PT R hand higher than L Stretch

Upper thoracic rotation prone

increasing movement here will cause: -decreased stress on cervical spine -gate cervical discomfort -enable improved posture -reduce associated swelling pt head turned towards direction to be manipulated ex R rotation - pt head to R. PT R hand higher than L Stretch

Lateral glide of the talus improves

inversion and supination (frontal plane)

Medial arc glide of the calcaneus improves

inversion and supination (frontal plane)

Distraction of MCP, PIP, or DIP type of motion?

joint play

Distraction of proximal row of carpals on radius type of motion?

joint play

Elbow ulnar distraction type of motion?

joint play

Distraction of Proximal Carpal Row

joint play pt - seated with forearm in pronation and supported on the table. CAN USE WEDGE DETERMINE CLOSED PACKED PT - seated on radial side of forearm Stabilizing hand - grasps distal radius and ulna Manipulating hand - web space contacts the dorsal surface of proximal carpal bones. Thumb wraps around to scaphoid other fingers contact triquetrium Movement - manipulating hand pulls away

Ulno-menisco-triquetral (volar glide of ulna)

joint play for supination pt - seated with elbow flexed and in a neutral position. Elbow on table PT- sitting and facing ulna side Stabilizing hand - hand grasps the radial side of the hand, wrist, and distal radius Manipulating hand - thumb placed on distal dorsal ulna. PIP flexed and contacts pisiform to stabilize Movement: thumb exerts a volar glide on ulna while PIP stabilizes pisiform and other hand stabilizes radial side

Posterior-superior and anterior - inferior glide of clavicle on the acromion

joint play motion for all shoulder movements pt - supine PT standing facing pt Stabilizing hand - anterior surface of the humerus while palpating the AC joint line Manipulating Hand - index finger contact the posterior/lateral surface of clavicle. Thumb contacts the anterior/lateral surface of clavicle Force is directed either through thumb or index finger

Modified relocation

labral pathology or anterior instability

What are absolute contraindications of manipulation?

lack of indications poor integrity of ligmamentous or bony structures from recent injury or disease process Unstable fractures bone tumors infectious disease osteomyelitis upper cervical instability cervical arterial dysfunction (CAD) vascular: aortic aneurism multilevel nerve root pathology worsening neurological function unremitting, severe, non mechanical pain unremitting night pain UMNL Spinal cord damage

C7 Dermatome

lateral arm and forearm to index, long, and ring fingers

Cozen's Test

lateral epicondylitis

Passive Tennis Elbow Test

lateral epicondylitis

S1 dermatome

lateral foot

Pisiform glides (medial/lateral/superior/inferior) improves?

lateral glide-stretches retinaculum

standing: PSIS and GT unequal seated: PSIS and GT Equal what is the cause?

leg length structural or functional

Where can the median nerve be entrapped?

lig of struthers bicpital aponerurosis pronator teres carpal tunnel

Anterior and posterior glide of hamate on triquetrum end feel?

ligament end feel

Anterior and posterior glide of lunate on capitate end feel?

ligament end feel

Anterior and posterior glide of lunate on scaphoid end feel?

ligament end feel

Anterior and posterior glide of lunate on triquetrum end feel?

ligament end feel

Distraction of MCP, PIP, or DIP end feel?

ligament end feel

Distraction of proximal row of carpals on radius end feel?

ligament end feel

Dorsal (posterior) glide of carpals on radius end feel?

ligament end feel

Dorsal glide of MCP, PIP, DIP end feel?

ligament end feel

Pisiform glides (medial/lateral/superior/inferior) end feel?

ligament end feel

Posterior radial head glide end feel?

ligament end feel

Ulnar-meniscal - triquetral volar glide end feel?

ligament end feel

Volar (palmar/anterior) glide of carpals on radius end feel?

ligament end feel

Characteristics of abnormal spinal motion

limited range unwillingness to move pain during or at end range painful arc compensatory or trick movement signs of instability

What are the effects of manipulation?

mechanical neurophysiological psychological Chemical

L3 dermatome

medial knee

T2 Dermatome

medial side of upper arm to medial elbow, pectoral and midscapular areas

What injury do plica's imitate?

mensical lesions

L2 dermatome

mid anterior thigh

What is the difference between C1 and mid-cervical vertebrae?

mid-cervical: has uncinate processes, spinous processes, and bodies C1 does not

C7 dermatome

middle finger

Mulligan

mobilization with movement

C3 dermatome

neck

C2 myotome

neck flexion

What is the best examination step to identify compartment syndrome?

neurovascular

T4 dermatome

nipple line

Finger MCP abduction

no normal (end-feel: ligamentous or muscular)

Finger MCP adduction

no normal (end-feel: ligamentous or muscular)

PIVM grade 3

normal

Lumbar instability/hypermobility

normal integrity of spinal lig's are insufficient to prevent normal Fs from producing aberrant motions; from chronic misuse, poor posture, self adjusting Signs: Hx: Inability to sit for prolonged period Pain worse later in day-- relieved by movement or rest Frequent "catches" or "twinges" Increased m. tone in standing Disappearance of m. tone, step or rotation in prone lying Juddering in FB More difficulty coming up from FB than going into Grade 5-6 on motion palpation Rad evidence of motion studies of FB & BB showing translation

Sensitization

normal pain with abnormal response

Osteochondrosis

not specific to the hip alone Children 3-10 M>F Ex: Legg-Calve Perthes - hip femoral head - most common Osgood-Schlatter's disease - knee Severs disease - foot

interverterbral disc

nucleus annulus cartilage endplate

What are the 3 components of the disc?

nucleus pulposis annulus fibrosis cartilaginous end plate

O/A joint make up

occipital condyles (convex) on superior articular facets of C1 (concave) 50% of cervical flexion occurs here only joint in the spine to follow concave convex rule

Describe the osteokinematics and associated arthrokinematics Rib depression

occurs with exhalation costovertebral joint- upglide costotransverse joint - downglide

Describe the osteokinematics and associated arthrokinematics of rib elevation

occurs with inhalation costovertebral joint -downglide Costotransverse joint - upglide

Anterior interosseous nerve entrapped at

off the median nerve and motor only pronator teres

intermittent claudication

pain in the leg muscles that occurs during exercise and is relieved by rest

Claudication

pain, tension, and weakness in a leg after walking has begun, but absence of pain at rest

S/S of TMD

pain/tenderness in face, jaw, joint area, neck, shoulders, in and around the ear problems with opening Stuck or locked jaw clicking, popping, grating sounds with movement trouble chewing facial pain, chronic ear aches

Bishop's deformity

patient holds their hand with the 4th and 5th digits flexed due to loss of the ulnar nerve and medial two lumbricals that assist with PIP extension - patient is unable to extend digits fully

Slump Tension Special Test

patient seated at the end of examining table patient slumps back to flex thoracic/lumbar spine examiner maintains head in neutral position and applies overpressure to the cervical spine to maintain flexion with the other hand the examiner holds patient's foot in dorsiflexion patient is asked to extend knee as far as possible POSITIVE TEST: unable to fully extend knee

PA glide spring test (PIVM)

peace sign over TP other hand is placed over the two fingers and a downward force is applied feeling for PA movement

Medial Tibial Stress syndrome

periosteitis at attachment of posterior tibialis and medial attachment of soleus

Mid-Cervical Joints C2/3-C7/T1

planar joint 45 degrees from transverse plane move up and forward in sagittal plane

S1 myotome

plantarflexion

At the AA joint with backward bending what direction does atlas move?

posterior on both sides

multifidus innervation

posterior rami of spinal nerves

PA glide supine

precautions: osteoporosis and shoulder strain

Tx: Subacute stage of condition

progress to AAROM as tolerated and then to AROM as tolerated to preserve ROM and stress the tendon more; manipulations as needed to address any joint restrictions (if present); gentle PRE may begin to allow for strength progressions at the end of subacute, 60% (25-30 reps) 1 RM for coordination; eccentrics for tendon healing

Treatment Triangle Manipulation

progressive oscillations

If the knee is in genu valgus in what position are the hindfoot and ankle joint?

pronation

Distraction of scapula

prone or sidelying joint play for all shoulder movements

What are the effects of manipulation?

psychological mechanical neurophysiological chemical

Moving Valgus Stress Test

pt arm is abducted to 90 and elbow fully flexed. PT maintain valgus force and quickly extend pt's elbow. (+) reproduction of pain between 120-70 of flexion (partial tear of MCL

Low subject reactivity

pt can carry out functional activities without issues possible post activity pain

Moderate subject reactivity

pt can carry out functional activity but complaints during activity

Side bending - prone lying abducting the leg

pt is prone located L5 pt knee flexed to 90(if they can) Examiner reaches around flexed knee and lifts it off table slightly upper hand is placed near the side of the interspinous space spinous processes should move into hand as leg is abducted

Rotation - prone lying raising pelvis

pt lying prone upper hand is placed on the spinous processes lower hand grasps the opposite side ASIS and raises it off the table caudal SP is graded relative tot he cephalid process

Rotation - prone lying rolling the legs

pt lying prone with knees bent to 90 upper hand palpates with thumb between spinous processes lower hand grasps the ankles and rotates either left or right *rule of the leg = rotation occurs in the direction of leg roll*

Rotation prone lying - impulse over transverse processes (treatment triangle)

pt lying prone with support upper hand (thumb to bum) downward force is applied to the TP that you are testing (spring) Typically start at L2 opposite side L2-L4 same side L5 rotation occurs to the opposite side of the force

Palmar glide of MCP, PIP, DIP procedure?

pt position: seated with proximal phalanx on wedge- hand in pronation Stabilizing hand: grasps proximal phalanx of joint Manipulating hand: grasps distal phalanx of joint and pushes down /palmarly

Dorsal glide of MCP, PIP, DIP procedure?

pt position: seated with proximal phalanx on wedge-hand in supination stabilizing hand: grasps proximal phalanx of joint manipulating hand: grasps distal phalanx of joint and pushes down/dorsally

Rib PIVM spring test

pt prone examiner at the top of the table done in time with breathing (if time allows) downward force is applied with medial palm follows scapula

Spring Test mid thoracic (PIVM)

pt prone with pillow support upper hand (thumb to bum) force is generated downward on the spinous process (tilting)

Babinski Reflex

pt relaxed seated or supine coarsly run end of reflex hammer up the lateral aspect of foot from heel curve across metatarsal heads from 5th digit to hallux normal: toe flexion abnormal: splaying of toes with hallux flexion

Babinski reflex

pt relaxed seated or supine coarsly run end of reflex hammer up the lateral aspect of foot from heel curve across metatarsal heads from 5th digit to hallux normal: toe flexion abnormal: splaying of toes with hallux flexion

Inverse Supinator Sign

pt relaxed w forearm supported in neutral perform brachioradialis reflex test observe for abnormal *inverted supinator and digit flexion (repetitive) UMN involvement

Inverse supinator sign

pt relaxed w forearm supported in neutral perform brachioradialis reflex test observe for abnormal *inverted supinator and digit flexion (repetitive) UMN involvement

Tinel's sign (elbow)

pt seated, place elbow in a position where examiner can percuss the cubital tunnel (+) reproduction or aggravation of parasthesia down the arm = ulnar nerve neuritis

Side bending - side lying -rocking the pelvis

pt sidelying locate L5 lower hand is placed on the greater trochanter upper hand is placed near the spinous processes force is generated upwards with the lower hand causing pelvis movement and side bending of the spine

Cervical side bending

pt supine tests downslide of the facets in the cervical spine pt head is cradled in examiners hands in slight flexion force is in the direction of the pts opposite arm pit

Shoulder anterior glide procedure?

pt supine with wedge under scapula Cris-cross method Stabilizing hand: outside arm on coracoid/clavicle, elbow bent and underneath Manipulating hand: inside arm grasp proximal humerus and exert medial/anterior force, arm on top of stabilizing arm with elbow bent

C1 dermatome

top of head

PA glide of Mid-Thoracic (manipulation) prone

restores forward bending TP's level below spinous process between fingers (T6 Tp's/T5 SP) graded or progressive oscillation

PA glide mid thoracic

restores forward bending graded or progressive oscillation TPs level below ex. T6 TPS/T5 SP

Mid Thoracic Rotation manipulation

restores rotation graded or progressive oscillation rule of lower finger - rotation in direction of lower finger

Mid-Thoracic Rotation via TP's

restores rotation rule of lower finger peace sign Graded or progressive oscillation

winging scapula can be a disguise for

reverse thoracic curve

clonus reflex

rhythmic muscle contraction and relaxation during stretch reflex

T11 dermatome

right above groin line

T9 dermatome

right above the belly button

C2/C3 to T3/T4 SB L

right glides up and forward Left glides down and back

Describe the osteokinematics and associated arthrokinematics in upper thoracic SBL

right glides up and forward left glides down and back

Describe the osteokinematics and associated arthrokinematics in mid cervical rotation (left)

right glides up and forward left glides down and back SB to same side occurs in mid cervical

Describe the osteokinematics and associated arthrokinematics in mid cervical functional side bending

right glides up and forward left glides down and back rotation occurs to the same side in mid cervical

Describe the osteokinematics and associated arthrokinematics in mid cervical non-functional side bending (left)

right glides up and forward left glides down and back rotation occurs to the same side in mid cervical upper cervical rotation is to the opposite side

Describe the osteokinematics and associated arthrokinematics in the sacroiliac joint during nutation/counter-nutation

rotary moment of sacrum on the ilium

Describe the osteokinematics and associated arthrokinematics in the sacroiliac joint during rotation/torsion

rotary moment of the ilium on the sacrum

How does atlas move on axis when the head rotates to the right?

rotates to the right

Rotation rules for lumbar and thoracic spine

rotation and SB occur to the opposite side

Cervical Spine rotation rule

rotation and SB occur to the same side

Describe the osteokinematics and associated arthrokinematics mid thoracic region for side bending (non functional left)

rotation is to the opposite side due to ribs and lordosis left side downslide Right facet upslide

Describe the osteokinematics and associated arthrokinematics in the lumbar spine for Side bending (functional Left)

rotation occurs to the same side (ex picking up a penny in front of you) right facet up glide left facet down glide

Rule of the lower finger

rotation occurs towards lower finger

Subcranial spine rotation rule

rotation produces SB to the opposite side

Subcranial rotation rule

rotation produces side bending to the opposite side

Lumbar and thoracic non functional sidebending

rotation to the opposite side due to crowding of the ribs and the lordosis (T6-S3 lordosis increase)

Describe the osteokinematics and associated arthrokinematics in the mid thoracic region for side bending (functional left)

rotation to the same side left side downslide right facet upglide

Atlas moves in what direction in comparison to the occiput?

same direction

Sidebending rules for subcranial spine

same side rotation for functional non Functional - opposite side (to keep eyes level)

scaphoid compression test

scaphoid fracture

Progressive oscillation

slack is taken up and then a series of short and sharp impulses are delivered at ever increasing depths with the goal of using the oscillations to "gate" any discomfort while the fourth and final impulse being up against the end of range will increase range

How does atlas move on axis when the head rolls backward

slides backward

How does atlas move on axis when the head rolls forward?

slides forward

How does atlas move on axis when the head bends right

slides right

Distraction of MCP, PIP, or DIP loose packed position?

slight flexion

Dorsal glide of MCP, PIP, DIP loose packed position?

slight flexion

Palmar glide of MCP, PIP, DIP loose packed position?

slight flexion

PIVM grade 4

slight increase in movement (hypermobile) could be normal depending on pt possibly stabilize

Maitland Grade I

small amplitude movement at the beginning of the range first 10% of the range

Characteristics of normal spinal motion?

smooth motion regardless of speed adequate relation of antagonists range is full according to body type pain free muscles are of normal strength PROM > AROM

Paris

spinal manipulation progressive osscilation

Hippocrates

spinal traction

Shoulder inferior glide procedure?

stabilizing hand: inside arm stabilizing arm with pillowcase Manipulating hand: grasp humerus above elbow and pulls inferior in scapular plane

Lumbar Roll Manipulation

stretch or thrust PIVM performed to locate restricted movement pt upper body is rotated away lower body is rotated towards

Lumbar Sidebending prone abducting the leg manipulation

stretch/progressive oscillation less likely to injure the disc

Internal rotation lag sign

subscapularis tear . Pt unable to keep hand off lower back

Spasm

sudden, involuntary muscle contraction indicates impairment nothing more

What is in the lateral compartment of the lower leg?

superficial peroneal n Peroneal M

Ulnar-meniscal - triquetral volar glide improves?

supination

First rib manipulation

supine pressure downward on 1st rib used for thoracic outlet or respiratory problems pt instructed on breathing and PT holds hand in position

Common injuries that affect the median nerve

supracondylar humerus fracture Pronator teres syndrome tight casts/forearm fx wrist laceration

T12 dermatome

suprapubic region

Hoffman's sign

tapping/downward flicking distal phalanx of long or ringer finger elicits flexion of the distal thumb; associated with corticospinal tract lesions

Midfoot

tarsal bones

What does the PLL become from C2 to occiput?

tectorial membrane

Upper thoracic rotation PIVM

tests rotation of C7/T1 to T3/T4

Gate Control Theory

the theory that the spinal cord contains a neurological "gate" that blocks pain signals or allows them to pass on to the brain. The "gate" is opened by the activity of pain signals traveling up small nerve fibers and is closed by activity in larger fibers or by information coming from the brain.

Indication for manipulation: Chronic neck pain and movement coordination impairments

thoracic and cervical mobilization

Indication for manipulation: Acute neck pain and movement coordination impairments

thoracic and cervical mobilization and manipulation

Neurovascular claudication

throbbing, pulsing, pounding pain caused by insufficient blood flow artherosclerosis

C6 dermatome

thumb

C8 myotome

thumb extension

Lumbar sidebending - sidelying

used for upslide stretch Thumb is used to block vert above the segment being treated (L3/4 segment = block of L3) Stretch or progressive oscillations

1st rib manipulation

used for: thoracic outlet and respiratory problems graded or progressive oscillation

SI backward torsion

used to correct a displacement

Proximal Row movements

volar - extension dorsal - flexion

MidCarpo Wrist flexion

volar glide

Ulno-menisco-triquetral supination

volar glide of ulna

1. What are the nerve roots for the radial nerve? 2. What muscles are innervated by the radial nerve? 3. What is the sensory distribution of the radial nerve?

woof

Volar (palmar/anterior) glide of carpals on radius improves?

wrist extension

Pisiform glides (medial/lateral/superior/inferior) loose packed?

wrist flexed, ulnar deviation to put flexor carpi ulnaris on slack

Dorsal (posterior) glide of carpals on radius improves

wrist flexion

T7 dermatome

xiphoid process

What are some complications to elbow dislocations?

• Capsular damage • Injury to brachialis muscle • Damage to the collateral ligaments • Median nerve injury • Brachial artery damage • Fractures • Myositis ossificans • Post traumatic DJD • Tight muscles/capsule

Chemical effects of manipulation?

• Release of endorphins following multiple level thrust manipulations o these act as pain killers o the muscle reflexively relax from Type III mechanorecptor or GTO response o this approach is more representative of traditional chiropractic

Mechanical effects of manipulation

• Restore normal joint play • Stretch tight capsules • Stretch adhesions • Rupture adhesions • Alter relative positions of articular surfaces