MSK Oral Exam

Patterns

A. Capsular (Extra-Articular): upglide & gapping a. flexion: deviate to left b. contralateral sidebending: limited c. ipsilateral rotation: limited d. ipsilateral sidebending: free e. contralateral rotation: free f. Treatment 1. lumbar roll: affected side up A. Distraction help with all motion 2. HEP: open book B. Non-Capsular (Intra-Articular): downslide & compression a. extension: deviation to the right b. contralateral sidebending: free c. ipsilateral rotation: free d. ipsilateral sidebending: limited e. contralateral rotation: limited C. Myofascial Patterns: stretching a. lumbar spine: 1. flexion limited, all other movements relatively free b. cervical spine: 1. no consistent pattern 2. depends on muscles involved c. Normal to increased lordosis on neutral standing d. Treatment 1. soft tissue mobilization, stretching 2. child's pose, DKTC, cat-cow

Bicycle Test and Treadmill Test

A. Test for Neurogenic/Vascular Claudication B. Bicycle Test a. Patient rides upright on bike until symptoms come on, record time 1. Have pt rest until symptoms alleviate b. Patient rides again in flexed position (opening for amen), record time 1. A (+) test result for neurogenic claudication: greater tolerance in FB position C. Treadmill Test a. Patient walks on a level treadmill for up to 10 minutes, followed by a 10-minutes rest period in sitting, and then another 10 minute about rest period in sitting, and then another 10 minute bout of walking on the treadmill set at a 15 degree incline 1. A (+) test result for neurogenic claudication: greater tolerance for walking in the inclined position, which places the lumbar spine in a more flexed position

Types of Mechanoreceptors

A. Type I: Postural a. Location: Capsule b. Fired By: oscillations, graded or progressive B. Type II: Dynamic a. Location: Capsule b. Fired By: oscillations, graded or progressive C. Type III: Inhibitive a. Location: Capsular, Ligaments b. Fired By: stretch or sustained pressure. Thrust D. Type IV: Nociceptive a. Location: most tissues b. Fired By: injury and inflammation

Facet Syndromes

A. Types a. Synovitis/Hemarthrosis (strain) 1. Cause: A. awkward movement or catch B. Gross trauma 2. S&S A. Guarded movement B. Involuntary & voluntary muscle holding 3. Rx: A. Lumbar: rest, careful movement, pain free ROM B. Cervical: rest, careful movement, pain free ROM, consider interferential for swelling b. Stiffness/Restriction 1. Cause: A. Resolved Synovitis/Hemarthrosis B. Not typically symptomatic 2. S&S A. Maybe none- stiffness does not hurt B. Lowered tolerance to insult hence strain & associated pain if from a. current strain of the joint b. neighboring hyper mobile joint may become symptomatic- unstable 3. Rx: Manipulation A. Cervical: massage uplift B. Thoracic: bilateral Transverse Process P/A (upglide or distraction), rotations (unilateral gap) C. Lumbar: sideband techniques, rotation techniques, combined sideband and rotation, gap/distraction; positional distraction, lumbar roll c. Painful Entrapment 1. Cause A. awkward movement in eccentric range 2. S&S A. Unable to slide inferior articular process down B. Head held away from painful side (opposite flexion quadrant) 3. Rx A. Cervical a. Multifidus isometric manipulation b. Mid-cervical facet lock gap technique B. Lumbar a. Multifidus isometric manipulstion b. Rotation manipulation over a bolster d. Mechanical Block 1. Cause A. Idiopathic B. Loose body C. Impaction 2. S&S A. Sudden onset B. Block to motion C. Relatively Pain Free 3. Rx: A. Cervical a. Positional Distraction b. Strong manual traction with side bending away & rotation to the blocked side B. Lumbar a. Positional Distraction b. Rotational manipulation over a bolster to further open up the affected side e. Chronic Facet Arthrosis 1. Cause A. Poor Posture B. Trauma C. Over use 2. S&S A. Dull ache B. Local pain C. Stiffness 3. Rx A. Posture education B. Mobilize adjacent areas C. Gentle long axis distraction B. Facet CPR a. Age >/= 50 yrs b. Symptoms best walking c. Symptoms best sitting d. Onset pain in paraspinal location e. (+) lumbar extension/rotation test (ext quadrant) f. Absence of centralization 1. 3 or more 85% SN/91% SP 2. 4 or more: 100% SN/87% SP

UMN vs. LMN

A. UMN= Myelopathy a. non-dermatomal/myotomal b. increased DTRs c. (+) Pathological reflexes d. Ataxia, Bowel/Bladder B. LMN= Peripheral Nerve, Radiculopathy a. dermatomal/myotomal pattern b. DTR lowered c. (-) Pathological reflexes

The Sequela of Forward Head Posture

A. Upper cervical extension, lower cervical flexion B. Will narrow thoracic outlets C. Forward head posture will alter mechanics of muscle movement at the TMJ -> mandible protrudes slightly D. Muscle Imbalances: a. Weaknesses: lower/middle traps, deep neck flexors (longus colli/capitals), serrated anterior b. Tightness: pec minor/major, SCM, UT, LS, scalenes E. Results a. Scapulae elevation and abduction b. Increase: UT kyphosis, MC/UT mobility c. Decrease: head flexion, cervical lordotic curve d. Shoulder dyfunction F. Intervention a. Stretching of the tight musculature (pectorals, upper trapezius, levator scapulae, scalene, SCM) b. Strengthening of Longus Colli and Capitus and scapular stabilizers for control, endurance c. Joint and soft tissue mobilization/manipulation to increase ROM and decrease symptoms d. Postural education and therapeutic exercise

SIJ Tests and Examination Findings and Interpretation

A. ASIS gap B. ASIS compression C. FABER test D. Posterior gap/shear E. Backward rotation/torsion F. Forward rotation/torsion G. Gaenslen's Test

Lumbar Lateral Shift

A. Causes- Disc Herniation a. Direction due to side of herniation 1. Shift away from the leg pain indicates disc bugs is lateral to the nerve root 2. Shift towards the leg pain indicates disc bulge is medial to the nerve root b. Instability

Cluster to Rule-In Myelopathy

A. Gait deviation B. + Hoffman's sign C. Inverted Supinator Sign D. + Babinski test E. Age >45 3/5= high positive likelihood ratio

TOS

A. Definition a. Compromise of the neuromuscular structures of the upper extremity b. Entrapment of the brachial plexus and the subclavian axillary vessels B. Common sites of entrapment a. Scalene triangle: anterior scalene, middle scalene, 1st rib b. Costoclavicular space- beneath clavicle and superior to 1st rib c. Pectoralis minor/coracoid process- as neuromuscular bundle passes underneath pec minor C. Causes a. Functional: 1. hypertrophy or adaptive shortening of the anterior/middle scalene muscles (also subclavius muscle) 2. Elevation and/or hypo mobility of the 1st rib 3. Adaptive shortening of pec minor 4. Posture: FHP, protracted scapulae, weak DNR/low trap/serratus anterior 5. Poor scapular mechanics, "dropped shoulder" b. Congenital 1. Broad insertion or two banded insertion of anterior scalene muscle 2. Presence of cervical rib D. Signs and Symptoms a. Neurogenic TOS (brachial plexus compression) 1. Pain and paresthesia in UE, mostly commonly ulnar nerve distribution (C8,T1) 2. At times, deep aching and ill-defined 3. Repetitive use of the UE and with positioning above shoulder height b. Vascular TOS (subclavian a/v compression) 1. Raynaud's phenomenon 2. Arm fatigue, parasthesias with movement and exertion 3. Decreased arm BP and radial pulse with ABD/ER positions 4. Intermittent edema, venous engorgement, cyanosis E. Differential Diagnosis a. Cervical radiculopathy b. Ulnar/median nerve peripheral nerve entrapments c. Clavicle fx d. Shoulder impingement, AC joint pathology e. Cervical myelopathy f. Pancoast tumor F. Clinical Tests a. These tests have high fast positive rate and thus a doubtful value b. Gillard et al found that a cluster of 5 (+) special tests produced a sensitivity and specificity of 84% 1. Adson's Test (ant. scalene) A. UE abducted 30°, extend; check radial pulse B. Head extend, SB away, Rotate toward C. (+): decreased strength of radial pulse D. Dutton: 15° abd, check radial pulse; inhale and hold breath; extend rotate toward 2. Allen's (cervical rib/ant scalene) A. Shoulder abducted 90°, elbow flex 90°; check radial pulse B. Head rotate away; can add deep inhalation C. (+): decreased strength radial pulse 3. Wrights Hyperabduction test (for pulse and symptoms) (pec minor) A. UE abducted & extended; alternate position 90° abd with elbow flex; can add inhalation B. (+): decreased strength radial pulse C. Dutton: same as above with addition of rotate head away 4. Roos Stress test A. UEs 90° abduction/ER in frontal plane B. Pt actively open/close hand x3 minutes C. (+): pain neck/shoulders into arms and hands; paresthesias; arm pallor, cyanosis, swelling; inability to complete test; reproduction of symptoms a. normal response= FA muscle fatigue 5. Eden's Test (costoclavicular) A. Pt assumes military posture (chest up and scar retraction), palpate radial pulse; can add inhalation B. (+): decreased strength radial pulse 6. Allen's Maneuver 7. Tinel's sign (at supraclavicular space) 8. ULTT- median and ulnar G. Treatment a. Depends on what was found b. Manipulation to 1st rib, cervical and thoracic spine, rib cage c. Myofascial manipulation to tight muscles (scalene, pecs, UT/levator snap, etc) d. Postural re-ed- carvical DNF training, scapular stabilization e. Instruction on diaphragmatic breathing f. HEP for self stretching, self mobilization of hypomobilit joints, posture g. Workplace ergonomics

CAD (Cervical Arterial Dysfunction)

A. Definition: decreased blood flow to the brain resulting in systemic symptoms B. Types of dysfunction: a. atherosclerotic events, dissection, dessel injury C. PTs should develop a high degree of clinical suspicion when a patient presents with a sudden onset of severe sharp pain in the posteriosuperior neck and sub occipital region D. History a. 5D's, 3 N's 1. Dizziness 2. Diplopia 3. Dysarthria 4. Dysphagia 5. Drop attacks 6. Nausea 7. Nystagmus 8. Numbness b. Risk Factors 1. Past history of trauma to cervical spine/ cervical vessels 2. History of migraine- type headache 3. Hypertension 4. Hypercholesterolemia/hyperlipidemia 5. Cardiac disease, vascular disease, previous cerebrovascular accident or transient ischemic attack 6. Diabetes mellitus 7. Blood clotting disorders/alterations in blood properties (hyperhomocysteinemia) 8. Anticoagulant therapy 9. Long-term use of steroids 10. History of smoking 11. Recent infection 12. Immediately post party 13. Trivial head or neck trauma 14. Absence of a plausible mechanical explanation for the patient's symptoms c. VBI Test 1. test is provocative so decide if you should refer out or defer test based on history alone 2. Perform BP testing and CN Testing 3. Proceed with AROM/PROM based on clinical judgment 4. Then do VBI Test A. Supine full active rotation/ext (sidebend) with 30/10/30 B. Have the head over the table in case the patient lose consciousness C. Explain risks ad get permission D. Place patient in position and hold a. Watch for nystagmus b. Keep them talking and listen for dysphasia c. If patient has a positive response, elevating their legs can increase blood flow back to their head E. Test is not very sensitive- blood flow may be redirected through other available arteries and symptoms not provoked d. VBI vs BPPV 1. Constancy of symptoms A. over 30 seconds do symptoms increase (BPPV) or decrease (CAD) B. Positional change relative to gravity a. Vestibular b. Orthostasis 2. Symptoms or nystagmus that are latent, fatiguable or habituate (typical with vestibular disorder) E. How often should testing be done? a. In examination if history/symptoms/objective measures lead us there. Especially if signs are unclear b. After treatment. If treatment gained more range then perhaps the patient is now at a higher risk

DTR

C5- biceps C6- Brachioradialis C7- Triceps L3/4- Patellar tendon S1- Achilles

Lumbar Instability/Hypermobility

A. Clinical signs of Instability a. History or demonstration of tissue relaxation/creep 1. inability to sit still for long periods, discomfort increases as the day wears on, relieved by movement or rest b. Increased muscle tone while standing c. Presence of a "step" or rotation (spondylolisthesis, retrolisthesis or spondylolysis) d. Disappearance of muscle tone, step or rotation on prone lying e. Shaking "juddering" while forward bending f. Grade 5 or 6 on passive motion palpation g. radiological evidence of motion studies of forward & backward bending showing both increased angulation between the vertebra and more important still- excessive translation B. Global Musculature: transfer loads between thoracic cage and pelvis during movement a. Erector Spinae b. Rectus Abdominus c. Latissimus dorsi d. External oblique C. Local Musculature: controleical stabilprovide spinemenltifidus a. Transverse abdominus b. Quadratus Lumborum c. Rotatores d. Internal Oblique e. Psoas f. Diaphragm and Pelvic Floor g. Glutes D. Potential Causes for Hypermobility a. Primary- degeneration and/or mechanical injury of spinal stabilization 1. Contributing Factors A. Poor posture B. Weakness of local lumbar musculature b. Subjective 1. Pain wise at end of day 2. Need to change positions frequently 3. Acute trauma 4. repetitive occupational trauma E. 8 Clinical Signs a. Excessive tissue creep (poor posture, change positions, pain worsens at end of day) b. Banding at level of instability or hypertonicity c. Juddering (aberrant motion) with forward bend d. Difficult returning to upright (possible Gower'sSign) e. Step in standing f. Step disappears in prone g. PIVM Gr 5-6 h. Radiograph F. Other Potential Clinical Findings a. Tenderness along lumbar region to palpation b. Referral pain in buttock and posterior thing thigh c. Muscle guarding during PIVM/PAVM testing d. Local musculature weakness G. Potential Imaging Findings a. Types of Imaging: Static X-Ray, endrange Flex/Ext X-rays b. Potential Findings 1. Ligamentous damage 2. Osteophytes 3. Vertebral fracture 4. Degenerative Disc Disease 5. Degenerative Joint Disease 6. Vertebral displacement H. Special Tests a. Passive Lumbar Extension Test b. Anterior Shear Test c. Active Straight Leg Raise Test d. Prone InstabilityTest e. Double Leg Lowering Test (MMT) I. Treatment a. Phase 1 1. Cognitive Phase of Learning 2. Goal to facilitate the control, strength, and coordination of local musculature A. Inhibit global musculatureee 3. Better phrasing should be motor control program 4. "Draw In", not posterior pelvic tilt A. activates TrA B. Hooklying- most effective way to isolate TrA b. Phase 2: 1. Exercises in les stable positions A. quadruped, standing, half kneel 2. Phase 3 A. Autonomous Phase: new situations & higher level B. Dynamic movement patterns C. Work specific & sport specific

Radiculopathy

A. Nerve Root Pathology a. Lateral Foraminal stenosis b. Posterolateral disc

Major (and Minor) Muscle States

A. Hypertonic States a. Spasm 1. A term frequently misused. Any change in muscle tone or behavior, or even the sensation of pain is enough for some to label such changes as spasm- in fact any and all changed may be incorrectly termed spasm 2. An involuntary twitch of muscle (Dorland's) as in: A. Spastic torticollis B. Reaction to a spring test C. Reaction to palpation 3. It is momentary and indicates an impairment and nothing more b. Hypertrophy 1. Increase in bulk from the normal 2. Normal physiological response to exercise 3. Secondary to muscle and body building activities 4. may be seen in some occupations 5. tends to over load joints 6. May limit range of motion 7. Ex., cashier, golfer, baseball player c. Involuntary Muscle Holding 1. Cause A. Injury B. Dysfunction 2. Signs and Symptoms A. Hypertonicity B. Protective muscle guarding- loss of "free" motion C. Elevated resting tone D. Abnormal elastic response to touch 3. Intervention: A. Treat the cause of impairment 4. Ex: odontoid fracture, MVA, Hemarthrosis, capsular entrapment, instability with lateral shift d. Chemical Muscle Holding 1. Cause A. Sustained involuntary guarding B. May possibly lead to a compartmental syndrome 2. Signs and Symptoms A. Doughy to touch B. Limited ROM 3. Intervention A. Heat and massage (deep finger kneading) B. think compartmental syndrome- the multifidus e. Voluntary Muscle Holding 1. Cause A. Pain or fear of pain B. Often follows involuntary and chemical states 2. Signs and Symptoms A. Slow and guarded motions B. trunk moves as a whole 3. Intervention A. Once sure nothing serious e.g., fracture a. ignore, give reassurance b. movement- repetitive motion B. Gentle Movement Examples a. Hip ABD/ER hook lying b. LTR hook lying tpainfree range c. Walk d. Pool e. Supine C-Spine AROM f. Psychosomatic Tension/stress 1. Cause A. Emotional stress undoubtedly gives rise to neuromuscular symptoms a. Clenching and bruxism of teeth b. Involuntary muscle hypertonicity B. Our language indicates emotional stress a. "He gives me a headache" b. She's a pain in the butt" C. Treatment a. Counseling b. Additional Intervention Strategies 1. Diaphragmatic and Relaxation Breathing 2. self Inhibition distraction 3. TMJ rest position- upper C/S 4. Medication 5. Exercise 6. Hobbies B. Hypotonic States a. Disuse atrophy 1. Cause A. Underused muscle B. Place an arm in a sling and the muscles will waste C. Place a bac in a brace and the same may happen D. Stiff joints in the spine lead to disuse atrophy 2. Signs and Symptoms A. Loss of bulk on MRI, CT, ultrasound scan, to palpation 3. Treatment A. Manipulate stiffness B. Exercise the muscles- walking etc. b. Wasting and fibrosus 1. Cause A. Neurological as in paresis from disc prolapse B. More significant when from a large disc protrusion getting two nerves C. Spinal cord tumor getting two or more nerves D. Surgical as in a. Medical branch rhyzolysis to facets and multifidus spins fusion 2. Signs and Symptoms A. Rapid loss of muscle bulk B. Fibrous nature of muscle- i.e., connective tissue is still present but with the wasting of the muscle it appears more abundant than the other limb. If muscle does not return connective tissue will also decrease 3. Treatment A. Exercise as innervation returns B. Myofascial release to fascia of muscle c. Denervated C. Normal Tone/Shortened a. Adaptive Shortening 1. Cause A. Chemical muscle holding B. Slouching posture, e.g., to sub cranial extensors 2. Signs and Symptoms A. Normal tone B. Shortened length, loss of ROM C. Altered posture- increased lordosis secondary to poses shortening 3. Intervention A. Myofascia stretching B. Adaptive Shortening Exercises a. Inhibitive Distraction b. Prayer Stretch/child's pose c. DKTC d. Hip Flexor Stretch- Thomas, 1/2 kneel e. Anterior Hip glide/stretch f. Psoas Release- MF1 D. Other a. Fibrosis 1. there is not pathological basis or evidence for this condition. Simply put the fibrosis tissues are not inflamed 2. There does exist a diffuse "muscular rheumatism" that may better be called myalgia b. Myalgia 1. A rheumatic disease of the soft tissues characterized by a history or widespread pain occurring for longer than 3 months in combination with pain in 11 or more of 18 specific bilateral tender points in muscular tissue 2. 2019 Definition A. Fibromyalgia: a condition that causes pain all over the body (also referred to as widespread pain), sleep problems, fatigue, and often emotional and mental distress. People with fibromyalgia may be more sensitive to pain than people without fibromyalgia. This is called abnormal pain perception processing B. Affects ~4 million US adults about 2% of the adult population 3. Fibromyalgia Syndrome A. Cause a. Specifically unknown b. deprivation of restorative sleep c. neurobiological abnormalities d. loss of sympathetic nervous system control e. local tissue factors f. physical trauma & viruses g. psychological factors B. S&S a. Primary: aches & pains, stiffness, swelling in soft tissues, tender points, muscle spasm & nodules, upper body weakness b. Secondary: excessive fatigue, non-restorative sleep, chronic tension migraine, headaches, bowel & bladder irritability, dysmenorrhea, paresthesia, Raynaud's phenomenon, chest pains, anxiety, depression, swelling & numbness of the extremities 4. Updated Diagnostic Criteria to Fibromyalgia A. Widespread pain lasting at least 3 months B. Presence o other symptoms such as fatigue, waking up tired and trouble thinking C. No other underlying condition that might be causing the symptoms a. Common culprits: Rheumatic diseases, mental health problems, neurological disorders 5. Treatment: approach like chronic pain patient (nutrition, restorative sleep, exercise) A. Multidisciplinary: education on coping strategies, energy conservation, time management, stress management, nutrition, preparation for sleep (relaxation, quieting) B. Medication: combination of SSRI's, tricyclic antidepressants, short term NSAID's C. Exercise: posture, low load- low repetition strengthening, low impact aerobic conditioning, biofeedback focused on lowering sympathetic tone E. Myofascial terminology a. Tone: state of rest of a muscle b. Hypertonicity: increased resting tone c. Hypotonicity: decreased resting tone d. Spasm: an uncontrolled involuntary jerk/twitch e. Fibrositis: non entity-none have been found f. Deposits: fibro-fatty & calciferous posits can be found in otherwise healthy muscle

CPR for Thoracic Manipulation for Neck Pain

A. Symptoms < 30 days B. No symptoms distal to shoulder C. No pain with cervical BB D. FABW less than 12 E. <30° cervical extension F. Diminished T3-T5 kyphosis 3/6=86% probability of success with thoracic manipulation

Myotomes LE

L1/2- hip flexion L3- knee extension L4- dorsiflexion L5- great toe extension S1- great toe flexion/ plantarflexion S2- knee flexion

Cervical Spine Red Flags: Vertebral or Internal Carotid Artery Insufficiency

1. Drop attacks (turning head & falling without LOC) 2. Dizziness 3. Dysphasia 4. Dysarthria 5. Diplopia 6. Numbness/paresthesia 7. Nystagmus 8. Nausea 9. Cranial nerve signs

Cervical Spine Red Flags: Inflammatory or Systemic Disease

1. Fever 2. Blood pressure > 160/96 mmHg 3. Resting pulse >100 bpm 4. Resting respiration > 25bpm 5. Fatigue

Cervical Spine Red Flags: Compression Fracture

1. History of trauma, fall, direct blow 2. Age > 50 years 3. Prolonged use of corticosteroids 4. Point tenderness over fracture site 5. Increased pain with weight bearing 6. History of osteoporosis

Thoracolumbar Red Flags: Compression Fracture

1. History of trauma, fall, direct blow 2. Age > 50 years 3. Prolonged use of corticosteroids 4. Point tenderness over fracture site 5. Increased pain with weight bearing 6. History of osteoporosis

USA Philosophy and Approach to Treatment

1. Joint injury, including such conditions referred to as osteoarthrosis, instability & the after effects of sprain & strains, are impairments (dysfunctions) rather than diseases 2. Impairments are manifest as either increases or decreases of motion from the expected normal or by the presence of aberrant movements. Thus, impairments are represented by abnormal movement 3. That where the impairment is detected as limited motion (hypo mobility), the treatment of choice is manipulation to joint structures, stretching to muscles and fascia and the promotion of activities that encourage a full range of motion 1. ICF Classification: LBP with Mobility Deficits 2. Results of Restricted Motion A. Contraction, binding & proliferation of collagen B. Generalized loss of segmental flexibility & function thus liability to further injury C. Nutrition of the disc reduced due to restricted osmosis & filtration D. Degeneration of synovium...pannus like in-growth of synovium E. Disuse of supporting musculature F. May create hyper mobility leading to instability at adjacent segments 3. Manipulation/Mobilization A. Synonymous terms B. Manipulation "the skilled passive movement to a joint" 1979 C. Manipulation "the skilled passive movement to a joint with a therapeutic intent" 2004 D. Manipulation/Mobilization- "a manual therapy technique comprised of a continuum of skilled passive movement to the joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small amplitude high velocity therapeutic movement" 4. That when the impairment is manifested as increased movement (hypermobility), laxity or instability, the treatment of the joint in question is NOT manipulation, but stabilization by instruction of correct posture, stabilization exercises and the correction of any limitations of movement in neighboring joints that may be contributing to the hypermobility 1. ICF Classification: L/S Insability- LBP with Movement Coordination Impairments 2. Results of Hypermobility/Instability A. Persistent strain of supporting tissues a. Increased ligamentous stress and sensitivity b. Altered neuromuscular control c. Fatigue fracture of bone- spondylolisthesis d. Weakening/Delaminating of the annulus fibrosis of the disc B. Pain a. Muscle involuntary guarding b. Muscle chemical guarding c. Muscle shortening 5. Timely Physical Therapy intervention that addresses impairments may slow or reverse the degenerative process thus negating thinned for surgery 6. That the physical therapist's primary role is in the examination and treatment of impairments (dysfunction), whereas that of the physician is the diagnosis and treatment of disease. These are two separate but complementary roles in health care 1. "Physical therapists will be doctorally prepared autonomous practitioners recognized as the primary care physicians of the musculoskeletal system" 2. Red Flags 7. Since impairment is the cause of pain, the primary goal of physical therapy should be to correct the impairment rather than the pain. When however the nature o the pain interferes with correcting the impairment, the pain will need to be addressed as part of the treatment program 1. Brain changes occur with chronic pain 8. The key to understanding impairment (dysfunction), and thus being able to examine and treat it, is understanding anatomy y and biomechanics. It therefore behooves us in physical therapy codevelop our knowledge and skills in these areas, so that we may safely assume leadership in the non-operative management of neuromuscular disorders 9. Our body of knowledge is sufficiently unique and is of sufficient volume that to depend on referral for patients is no longer morally defensible 10. It is the patient's responsibility to restore, maintain, and enhance their health. In this context, the role of the physical therapist is to serve as an educator, to be an example to the patient and to reinforce a healthy and productive lifestyle 1. if pt doesn't buy into therapy they won't get better 2. Dysfunction is Reversible By A. Restricted Motion a. Manipulation for joint restrictions b. Myofascial stretching for adaptive shortening B. Instability a. Postural correction b. Exercise to support joint instabilities c. Patient education 3. Classification of Movement Including Joint Manipulation A. Classical Movements: Active/ Passive B. Accessory Movements: Component Motion/Joint Play C. Manipulation: Distraction/Non-Thrust/Thrust

Osteokinematics and associated arthrokinematics in each of the major regions of the spine

- Subcranial - Midcervical - Upper thoracic - Mid thoracic & Ribs - Lumbar - SIJ - TMJ

Thoracolumbar Red Flags: Abdominal aneurysm

1. Back, abdominal, or groin pain 2. Presence of PVD or CAD and associated risk factors (age >50 years, smoker, hypertension, DM) 3. Non-Caucasian 4. Symptoms not related to movement 5. Presence of bruit in central epigastric area with auscultation 6. Palpation of abdominal aortic pulse

Cervical Spine Red Flags: Tumor/Neoplastic Conditions

1. Constant pain not affected by position or activity; worse at night 2. Age>50 years old 3. History of Cancer 4. Unexplained weight loss 5. No relief with bed-rest

Thoracolumbar Red Flags: Tumor

1. Constant pain not affected by position or activity; worse with WB; worse at night 2. Age >50 years 3. History of cancer 4. Failure of conservative intervention (failure to improve within 30 days) 5. Unexplained weight loss 6. No relief with bed-rest

Cervical Spine Red Flags: Upper Cervical Ligamentous Instability (test with myelopathy)

1. Occipital headache and numbness 2. Severe limitation during neck AROM in all directions 3. Signs of myelopathy

Thoracolumbar Red Flags: Infection

1. Recent infection, intravenous drug user/abuser 2. Concurrent immunosuppressive disorder 3. Deep, constant pain, increases with WB 4. Fever, malaise, and welling 5. Spine rigidity; accessory mobility may be limited 6. Fever

Cervical Spine Red Flags: Cervical Myelopathy

1. Sensory disturbance of hand 2. Muscle wasting of hand instrinsic muscles 3. Unsteady gait 4. Hoffman reflex 5. Inverted supinator sign 6. Babinski sign 7. Hyperreflexia 8. Bowel and bladder disturbances 9. multisegment weakness or sensory changes 10. Age > 45 years

Cluster for Stenosis

1. Sugioka 2008 a. >70 years old +3 points b. Onset over 6 months +1 points c. Decreased symptoms with forward bending +2 points d. Decreased symptoms during backward bending -2 points e. Increased symptoms standing +2 points f. Intermittent claudication pain +1 point g. Urinary incontinence +1 point Score >/=7=65.5% (validation study) or 77.7% (derivation study) probability of Dx 2. Cook 2011 a. Bilateral symptoms b. Leg pain > back pain c. Pain during walking/standing d. Pain relief upon sitting e. >48 years old Variables 1/5=44% 2/5=55% 3/5=63% 4/5=76% 5/5=99%

Thoracolumbar Red Flags: Cauda Equine Syndrome (often confused with myelopathy)

1. Urine retention 2. Fecal incontinence 3. Saddle anesthesia 4. Sensory or motor deficits in the feet (L4, L5, S1 areas)

8 Clinical Signs of Lumbar Instability

1.Excessive tissue creep (poor posture, change positions, pain worsens at end of day) 2.Banding at level of instability or hypertonicity 3. Juddering (aberrant motion) with forward bend 4. Difficult returning to upright (possible Gower'sSign) 5. Step in standing 6. Step disappears in prone 7. PIVM Gr 5-6 8. Radiograph

Cluster to Rule in Cervical Radiculopathy

A. (+) ULTT A B. Distraction relieves symptoms C. Cervical ipsilateral rotation < 60° D. (+) Spurling's Test A 4/4 90% probability 3/4 65% probability of the diagnosis

TMJ Mechanics and TMD

A. Capsular pattern a. limited 1. ipsilateral retrusion, protrusion, opening 2. bite deviation to limited side 3. lateral deviation limited to contralateral side B. Arthrokinematics a. First 12 mm of opening primarily rotational movement of the condyle 1. condyle moves anterior, disc moves posterior b. Greater than 12 mm the ligaments tighten and anterior translation of the condyle begins c. Terminal phase of opening causes downward and forward translation d. Lateral translation used mainly for chewing C. Disc Dysfunctions a. Faulty kinematics from micro trauma: opening mouth for dental procedures, intubations, blows to the ace, and gritting grinding b. Result in thinning or perforations and disc displacement c. Causes inflammation and joint pain- may or may not have muscle guarding d. Disc derangement with reduction: click or pop opening and smaller click during mouth closing 1. Disc forward on condyle e. Disc derangement without reduction: restricted mandibular movements without int noises 1. used to click now can't open D. Joint Pain a. Inflammation b. Structural changes to joint surfaces 1. Differentiating between dysfunctions such as synovitis, capsulitis, or retrodiscitis 2. Response can be associated with normal degeneration similar to dysfunction at the shoulder, knee, hip, etc. 3. Patient will report pain and crepitus or grating throughout entire joint movement E. Muscles of Mastication a. Overuse or tensile strain 1. Overuse can be caused from gritting, grinding, nail biting, and gum chewing, muscle guarding from inflammation due to joint dysfunction or from long dental procedures b. Indirectly through muscle guarding 1. Trigger points can result in referred pain c. Forward head posture 1. downward force on mandible 2. excessive force on muscles to keep mouth closed

Anatomy and Mechanics of the Disc

A. Cartilaginous Joint a. Discs make up 25% of total length of spine; at birth they make up 50% of the total length B. Functions a. Bind together vertebral bodies b. Permit movement within segment c. Transmit loads across the segment C. 5 Zones of the Disc a. Neurovascular Capsule 1. Innervation: A. Branches from gray rami communicans B. Recurrent Sinuvertebral n. C. Mixed spinal n. D. Anterior Primary Ramos b. Outer Annulus 1. Annulus fibrosis made up of type I collagen (more vascularization) A. resists tensile forces 2. 6-10 concentrically arranged tough fibrocartilagenous rings or lamellae 3. Run obliquely across the disc; opposite direction of adjacent rings A. Angle of rings: periphery= 30-70 degrees; inner= vertical B. Loose elastic CT fibers are between each ring 4. Permit motion in many directions c. Inner Annulus 1. Loosely arranged fibrous tissue -> type II collagen 2. Surrounds encapsulated nucleus and blend with it 3. Function of Annulus Fibrosis A. Containment of Nucleus B. Stabilization: limits motion by becoming taut on convexity and compressing on concavity due to alternating layers and binding to cartilaginous end plates via Sharpey's fibers C. Permission of movement D. Minimal shock absorption: horizontal forces on fibers with compression d. Nucleus Pulposus 1. Nucleus pulposus made up of type II collagen A. Resist compressive forces 2. Network of delicate collagen and reticular fiber mesh in much protein gel, rich in polysaccharides; 70-80% water (dries up with age) 3. Functions A. Imbibition: taking up and holding body fluid; may imbibe up to 3x its weight/swell B. Nutrition: draws nutrient fluids in from vertebral bodies and expands at rest; fluids. Then forced out into annulus when compression added (supine or sidelying with knees/hips 90/90 is best position) C. Transmission of Force: incompressible and transmits weight across the spinal segment D. Equalization of Stress: transmits weight in equal directions (hydrostatic properties) E. Movement: like a ball-bearing, permits movement with "rocking" action to it e. Cartilaginous End-Plate: 1. Between the disc and adjacent body- hyaline cartilage end plates between bony epiphyseal rims 2. Functions A. Protect bone end- pressure is continually being transmitted to vertebral bodies in varying degrees B. Transmit weight C. Permit fluid exchange between disc and vertebral body a. End-plates= semipermeable membrane

Spinal Stenosis: Lateral Foraminal vs. Central

A. Central Spinal Stenosis a. Degeneration, wear, and tear, poor posture, abdominal protrusion/lordosis, tight iliopsoas, tight lumbar spine myofascia b. Disc protrusion, prolapse (37%+ are asymptomatic) c. S&S 1. Chronic dull low back pain 2. Leg pain on walking any distance- neurogenic claudication (distinguish from vascular claudication)- bike/treadmill d. Treatment 1. Myofascial manipulation and stretching- poses, low back muscles 2. Increase physical fitness- in a poo, unweighted treadmill 3. Lifestyle changes- smoking, obesity, posture 4. Surgery-fusion with foraminectomy and/or a "360" fusion e. Physical Therapy 1. Posture- axial extension 2. Stabilize cervical spine- deep anterior muscles 3. Avoid backward bending- sleeping postures, cycling, basketball, breaststroke, etc. 4. Manipulate upper thoracic region to help reduce MC stress f. Surgery 1. removing impingements and then fusion B. Lateral Foraminal Stenosis a. Cause 1. Lateral disc protrusion 2. Loss of disc height 3. Degenerative changes to ligament flava and facets b. S&S 1. Lateral Symptoms- pain, subjective numbness, hyper neurological responses (pre prolapse nerve root irritation) 2. True neurological signs, paresis > skin sensation > reflexes > neural tension (SLR) c. Treatment 1. Posture education, healthy back living 2. Stabilization 3. Stretch myofascia (back and posts) 4. Manipulate stiff joints 5. Positional distraction- acute cases 6. Possible heel lift on unaffected side to open affected foramen d. Primary Interest 1. Take pressure off nerve root not gap facet e. Cervical Spine 1. Cause A. Degenerative changes B. Osteophytes from lateral inter body articulations (uncinate processes, Von Luschka joints) C. Thickening of ligament lava D. Arthosis of the facet joints 2. Contributing Factors A. U/T slouch and stiffness a. MC hyper mobility and instability 3. S&S A. Neck and arm pain and paresthesia B. Frank neurological signs and symptoms- muscle, skin, reflex 4. Treatment A. Joint and myofascia release B. Posture C. Positional distraction 5. Surgery A. Foraminectomy B. Most often surgeon will tel the patient they did disc surgery- which is misleading but understandable 6. Note: A. Neurological Signs arising from the lumbar spine are usually a. Discogenic b. Young group ages 28-50 c. Male more than female B. Neurological signs arising from the cervical spine are usually a. Spondylogenic degenerative arthritis- now lateral foramina stenosis b. Older age group 50+

CPR for SIJ

A. Combination of 3 or more positive provocation tests B. No centralization & peripheralization with repetitive extension is indicative of pain from SIJ origin

CCFT & DNF Training

A. Cranio-Cervical Flexion Test: Tests the pattern of activity in the deep and superficial neck flexor muscles in a staged performance of increasing range of CC- Flexion a. Purpose: determine muscle activation patterns, proprioception sense, test muscular endurance/strength for deep flexors b. Before performing tests assess neuro-tension (neural mechanism site it's), muscle length of sub-occipital group, and cranio-cervical joint mobility B. Muscles: longus capitus and coli, rectus capitus anterior and alateralis C. Set Up: a. Patient in Hooklying Position b. Neutral Cranio-Cervical Spine 1. Use proper towel support under occipital to avoid flexion or extension of the cranio-cervical spine 2. View imaginary lines through chin and posterior to the ears. THese lines should be relatively parallel c. Fold the stabilizer cuff before inflating d. Stabilizer dug should be placed under C0/C1/C2 e. Inflation cuff to 20 mmHg for baseline measurement making sure that all cells are inflated with equally distributed air f. Therapist holds the pressure gauge to read the pressure values during the exercise g. Be sure the gauge is in front of the subjects chin to maintain spinal neutral D. Phase One: Analyze a. Movement pattern (flexion not retraction) b. Motion is slow and controlled c. Avoid overuse activity of superficial flexors (global/SCM) d. Rapid motion is a compensatory response e. Proprioception: does the pt have head/neck awareness f. Assess each stage of incremental pressure from stabilizer cuff: 22, 24, 26, 28, 30 mmHg g. If abnormal or compensatory movement patterns exist then cranio-cervical flexion TRAINING must occur before testing 1. Train in supine hooklying position 2. Facilitate with eye movement 3. Facilitate with feedback from surface of bed 4. Emphasize precision and control of the rotation motion of CCF (Avoid retraction) 5. Do not focus on pushing into the cuff b it on the quality of the motion 6. Palpate the SCM to monitor global compensation 7. Correct movement pattern impairments 8. Low load exercise for tonic muscles 9. Precision (specificity) is required 10. Exercise should be pain free 11. Exercise short of fatigue (don't allow altered movement patterns) 12. Multiple quality repetitions are needed before the test E. Phase 2: Test a. Each progressive stage of the CCFT must be associated with a progressive increase in flexion NOT retraction b. Test 10 reps at 10 seconds holds at each pressure level: 22, 24, 26, 28, 30mmHg (10 sec hold x 10 reps= 100 for each level) c. Results 1. Asymptomatic subjects 26-28 mmHg 2. Symptomatic subjects= 20-26mmHg A. Aim for 30 mmHg in interventions

Aspects/Definition of Pain and Associated Terms

A. Definition of Pain a. "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" b. Suffering: when a person doesn't understand why they are in pain; most patients come to us suffering and by virtue of a thorough examination and convincing explanation, we reduce their suffering to pain c. Pain is a complex phenomenon 1. an individual and subjective experience d. Pain is a multidimensional experience 1. CNS activity 2. Involves emotions, thoughts, and beliefs simultaneously B. What Distinguishes our Examination a. We listen to the patient- physicians have too little time b. Our hands are placed on the patient c. We seek to find and reproduce the patient's "pain" d. We are not afraid to explain our finding e. We alleviate their fears for now they know they have come to someone who understands their complaint and has 'found' their problem C. Treatment a. Manipulation: emphasis of this course b. Exercises for stabilization: second emphasis c. Myofascial stretching/manipulation d. Posture training: for lessening stress e. Modalities: for preparation f. Patient education: to assist treatment D. Sensitization a. Sensitization: normal pain, but abnormal response. The brain's interpretation of nociception is inaccurate b. Allodynia: a stimuli that usually does not cause pain (light touch), or pain in the absence of nociception c. Hyperalgesia: an increased sensitivity to a painful stimulus d. Hypoalgesia: decreased sensitive to pain

CPR for Lumbar Stabilization

A. Development a. Age <41 b. Aberrant motions present c. SLR >91° d. +Prone instability test 3/4 67% probability of success with a stabilization program B. Modified a. Aberrant motions present b. +Prone instability test

CPR for Regional Lumbopelvic Manipulation

A. Duration of symptoms <16 days B. FABQ < 19 C. Hip IR >35° (at least 1 leg) D. Hypomobility of P/A lumbar mobility E. Symptoms proximal to knee F. 4/5= 95% chance of responding favorably to a LS Regional Manipulation (1-2 visits)

Neurogenic and Neurovascular Claudication

A. Neurogenic claudication a. seen with central spinal stenosis b. Pain, Paresthesia, and cramping of the lower extremities brought on by walking and relieved by sitting 1. Occurs because the foramina is closing down and getting bilateral nerve root impingement B. Vascular claudication a. Pain, Paresthesia, and cramping of the lower extremities brought on by walking but is not affected by position of spine 1. Occurs because of atherosclerosis (becoming ischemic due to vascular problem) 2. Walking increases metabolic demand

Anatomy and Mechanics of Multifidus

A. Origin: sacrum and transverse processes B. Insertion: spinous processes and mammillary process of facet a. Attaches to the posterior facet capsule to prevent pinching; each capsule has 2 multifidi inserting on to it C. Action: extension of the spine, ipsilateral SB, contralateral Rot D. Innervation: posterior primary ramus a. Local muscle of the lumbar spine 1. Side-lying bridging is good for strengthening MF and QL

Pain Theories

A. Pain a. Pain burins the patient to us when it interferes with function or causes a functional loss B. Paris's Pain vs. Suffering a. Pain is an unpleasant physical or emotional experience b. Suffering is when you don't know why you are in pain c. Most of our patients come suffering and by a virtue of a thorough examination and convincing explanation we reduce the suffering to pain C. Pain Management Philosophy a. If we accept the patient's description of pain and that it exists whenever he says it does then we not waste time determining "if" the patient is in pain but set about to determine the causes of the pain and treat those causes as best as possible to restore normal function D. Paris's Three Aspects of Pain a. Physical b. Rational c. Emotional E. Biopsychosocial Model a. Psychological: pain is subjective (reactions, thoughts, feelings) b. Social: interactions with others (family, friends, workmates) c. Biological: symptoms

WAD (MVA Injury and Treatment)

A. Patient History a. Mechanism linked to trauma/whiplash b. Associated shoulder girdle/UE pain c. Associated varied nonspecific concussive signs and symptoms d. Dizziness/nausea e. Headache, concentration, or memory difficulties; confusion; hypersensitivity to mechanical, thermal, acoustic, odor, or light stimuli, heightened affective distress f. Sensations of muscle "tightness" or "spasms" g. Intolerance to prolonged static postures h. Fatigue and inability to hold head up (better with external support) B. Red Flags a. Suspected arterial insufficiency b. Upper cervical ligamentous insufficiency c. Unexplained cranial nerve dysfunction d. Fracture C. Remember a. Severe upper cervical instability with breakdown of passive structural elements of the upper c/s can be life threatening! b. Manual therapy is contraindicated c. Further diagnostic testing is indicated - REFER OUT D. S&S a. Bilateral foot/hand paresthesia b. Feeling of lump in throat c. Metalic taste in mouth (CN VII) d. Arm and leg weakness e. Deficits in bilateral coordination f. Positive upper cervical ligament testing E. Examination Finding a. Point tenderness may include my-fasciael trigger points b. Pain at mid-range motions (increases at end range) c. P to A provocation test reproduces pain (neck and referred pain) d. Possible upper c/s ligament laxity e. Deficits in strength, endurance, and/or coordination of the deep neck flexors 1. May be demonstrated by aberrant motion f. Positive Cranio Cervical Flexion Test g. Positive Neck Flexor Muscle Endurance Test h. Positive pressure algometry F. Recovery Categories a. Quick and early recovery- 25-30% b. Moderate to slow recovery with lingering impairments (50-65%) c. Poor recovery with severe disability (10-20%) G. Prognosis a. Risk factors for persistent problems when captured in acute or subacute WAD (less than 6 weeks from injury): 1. High pain intensity 2. High self-reported disability scores (NDI) 3. High post traumatic stress symptoms 4. Strong catastrophic beliefs 5. Cold hyperalgesia H. Interventions a. Acute WAD 1. Education of the patient to A. Return to normal, non provocative pre-accident activities as soon as possible B. Minimize use of a cervical collar C. Perform postural and mobility exercises to decrease pain and increase ROM 2. Reassurance to the patient that recovery is expected to occur within the first 2-3 months 3. Patients who are low risk of progressing toward chronicity A. A single session consisting early advice, exercise instruction, and education B. A comprehensive exercise program (including strength and/or endurance with/without coordination exercises C. Transcutaneous electrical nerve stimulation (TENS) 4. Moderate to slow recovery with persistent impairments A. mobilization techniques plus exercise (e.g., strengthening, endurance, flexibility, postural, coordination, aerobic, and functional exercises) 5. Chronic A. Patient education and advice focusing on assurance, encouragement, prognosis, and pain management B. Mobilization combined with an individualized progressive sub maximal exercise program including cervicothoracic strengthening, endurance, flexibility, and coordination, using principles of cognitive behavioral therapy C. TENS Canadian C-Spine Rules

Stages of Disc Injury- Paris

A. Pre-Prolapse- unstable- pre "discal" a. History 1. dull muscular ache on sitting- (chemical muscular holding) need to get up and move around 2. Perhaps history of self cracking 3. Low back pain occasionally radiating into buttock 4. No frank neurological signs b. Physical 1. Demonstrates many signs of instability 2. Grade 5 or 6 PIVM c. Treatment 1. Stabilization- decrease load, increase endurance 2. Back School- educate as to postures, ergonomics, work, etc. 3. Manipulation- joint and myofascia 4. Instruction in first aid i.e., maintain lordosis B. Tear/Strain- Herniation: Immediate Injury a. History 1. Sudden unguarded motion resulting in acute but deep pain, usually from flexion and perhaps with a torque 2. Patient may say"it tore" "ripped" "gave out" b. Signs andSymptoms 1. Sudden and deep pain 2. May refer to buttocks 3. Very guarded motions c. Physical 1. do not do a physical such as FB and rotations 2. Neurological may show exaggerated responses i.e., facilitated d. Treatment- goal towel the outer annulus 1. Maintain the lordosis if not too late, for 4 weeks- taping to maintain spinal neutral- encourage muscular fusion 2. Stabilization exercises 3. Manipulation- no rotation- to stiff segments after 3 weeks 4. Myofascial techniques C. Complete Prolapse a. Acute- day one to approx day 4 1. try backward bending but probably too late 2. Minimal bed rest as a disc swells with rest- 3 days max 3. Education- move, don't rest too long, laxatives b. Subacute- day 4 and improving 1. Initiate movement 2. Myofascia manipulation 3. Corset 4. Stabilization c. Settled- 3-4 weeks- slow improvement- ambulatory 1. Commence positional distraction 2. stabilization 3. Possibly neural manipulation 4. Lifestyle and healthy back regime 5. S&S A. Sensory and/or motor dysfunction B. Neurogenic pain- deep radiating C. Pain distributed to back, buttock, and leg D. Posture may be flexed or shifted, decreased WB on painful leg E. Lumbar motions closing the involved foramen may increase leg pain F. Reflex, sensation, motor signs, neural tension G. Distraction relieves leg symptoms H. Limited hip ROM, hypertonic hip musculature (piriformis etc.) 6. Treatment A. Lengthening of the myofascial (piriformis) B. Neuromobilization C. Mechanical Traction/Positional Distraction a. Commence positional distraction with caution 1. Teach as a home program D. Manual Therapy- soft tissue manipulation for Gluteals, Piriformis, Multifidus, QL E. Stabilization/Conditioning F. Education on posture and proper body mechanics G. Goal is to prevent chronicity by encouraging activity and managing any fear avoidance behaviors D. Chronic a. History 1. Serious debilitating back pain with history of neurological signs and possibly failed surgery or successful surgery and later a remission b. Physical 1. Sad and depressed patient on medications 2. Often obese, smokes, very unfit, diabetic 3. ROM restricted due to pain 4. PIVM combination or restrictions and instability 5. Myofascia restrictions and poor tone/condition c. Treatment 1. Life style education- living for a healthy back 2. Stabilization 3. Positional distraction if neurological present 4. Try "carefully" neural mobilization 5. Manipulation- joint and myofascia 6. Fitness training and work hardening principles 7. Counseling, vocational, and personal

Effects of Manipulation

A. Psychological a. Touch- caring & intelligent hands b. Induced movement c. Pop or snap B. Neurophysiological a. Gate control: a & b receptors b. Centralization of pain c. Muscle inhibition- Type III 1. end range- stretch d. Movement & hence nutrition C. Biomechanical a. Stretch the restrictions within the capsule 1. restore fiber glide 2. restore ability to elongate (crimp) b. Stretch or snap adhesions between the capsule & bone ends D. Chemical a. Probable release of endorphins 1. act as pain killers b. Above may explain why multiple thrusts to non-involved joints may give best temporary relief not advocated

Prone Instability Test

A. Purpose: not a diagnostic tool! used to predict the success of a lumbar stabilization program B. Patient Position: prone with legs handing off edge fo the table, feet resting on the floor C. PT Position: standing at side of patient D. Procedure: PT applies a posterior-anterior pressure to the targeted lumbar vertebra. If pain provoked, patient lifts feed off the floor and pressure reapplied at the same vertebra E. (+) test: pain provoked in first position, and decreased in second position sensitivity 91%, specificity 57%

SIJ Syndromes

A. Strain/Sprain a. Common event from slips, falls, and intercourse b. Cause 1. Fall on asocial tuberosity 2. "Bumping" down the stairs 3. Awkward twist & reach c. S&S 1. Pain, well localized over SIJ d. Rx 1. None required 2. Interferential 3. Heat or ice e. Causes of Backward Torsion Strain 1. Persistent one leg standing 2. Fall on ischial tuberosity (snowboarding, fall in splits) 3. Vertical thrust on extended leg 4. Intercourse positions f. Causes of Forward Torsion Strain 1. Golf Swing 2. Horizontal Thrust on Flexed Knee- MVA 3. Hip Hyperextension B. Hypermobility a. Result from persistent strain/sprain b. Cause 1. Repetitive minor trauma 2. One leg standing 3. Sexual intercourse strains 4. Childbirth c. S&S 1. Dull ache on backward torsion- such during standing 2. Reference posterior leg 3. Lowered iliac crest on standing 4. Hypermobile symphysis pubis 5. Positive spring test d. Interventions 1. Postural instruction/education (microtrauma) 2. Hip manipulation if restricted 3. Stabilization 4. Support- SIJ belt 5. Sclerorisng- Prolotherapy (injection) 6. Fusion C. Displacement a. Can result from hyper mobility/instability b. Positional fault c. Cause 1. Hypermobile joint overrides articular prominences; positional fault 2. Severe force to joint- possibly hypermobile 3. Possible rupture symphysis pubis d. S&S 1. Constant or nearly constant low grade pain- even at bed rest A. but may be silent (aka tight hip) 2. Raised or lowered iliac crest 3. Restricted pass motion 4. Positive mobility tests e. Intervention 1. Manipulative reduction A. forward rotation/torsion B. backward rotation/torsion 2. Examine to see if now hyper mobile A. if hyper mobile support the hypermobility

Myotomes UE

C1/2- cervical flexion C3- lateral cervical flexion C4- shoulder shrug C5- shoulder abduction C5/6- elbow flexion C6- wrist extension C7- elbow extension/ wrist flexion C8- thumb extension T1- spread/squeeze fingers

Dermatomes UE

C2- top of head C3- lateral neck C4- top of ac joint C5- lateral side of upper arm (deltoid) C6- volar surface of 1st and 2nd digit of hand C7- volar surface of 3rd digit of hand C8- volar surface of 5th digit of hand T1- medial surface of lower forearm T2- medial surface of arm

Pathological Reflexes

Hoffman's Inverted Supinator Babinski Clonus Abdominal

Dermatomes LE

L2- lateral upper thigh/anterior mid thigh L3- medial surface of the knee L4- medial surface of calf to medial malleoli L5- lateral lower leg S1- lateral forefoot and heel

CPR for Lumbar Traction

a. +Nerve Root Signs (reflexes, numbness, weakness, +SLR) b. Periphralization of leg pain with lumbar extension c. + Crossed SLR (45°) d. LE pain that centralizes with traction

Cervicogenic Headaches

a. ICF Classification: Neck Pain with Headaches b. Originates from musculoskeletal dysfunction of the cervical spine c. Signs and Symptoms 1. Unilateral, starting in neck, "ram horn" distribution 2. HA pain elicited by pressure on posterior neck (C1-C3) 3. HA affected by neck movement or sustained head positions (FHP, upper C/S extension) 4. Facet hypo mobility of upper cervical spine 5. (+) cervical flexion-rotation test 6. Muscle length limitations (upper traps, elevator scapulae, sub occipitals, scalene) 7. Poor CCFT performance d. Differential Diagnosis 1. TMJ dysfunction 2. Cervical Arterial Dysfunction (CAD) 3. Intoacranial neoplasm (brain tumor) 4. Dizziness, BPPV 5. Trigger points in upper trapezius e. Treatment 1. Impairment based approach that combines manual therapy & exercise 2. Cervical mobilization (0-C1, C1-C2), upper thoracic mobilization 3. DNF training 4. Scapular stabilization (lower trapezius, serrates anterior) 5. Postural re-education & ergonomics 6. Stretching (sub occipitals, upper trap, elevator scapulae, pectoralis) 7. Cervical joint position sense, neuromuscular control training

Spinal Cord/Myelopathy

a. Pathology 1. Central Canal Stenosis 2. Ligamentum flavum buckling 3. Osteophytes 4. DDD/DJD 5. Instability 6. RA 7. Central Disc b. Sensory/Motor 1. Bilateral, quadrilateral Paresthesia; glove/stocking/non-dermatomes pattern; motor in non—myotomal pattern c. Reflexes 1. (+) pathological: Babinski, Hoffman's, Inverted Supinator, Clonus 2. DTRs: brisk d. Other: 1. Ataxia 2. Bowel/Bladder e. PT Interventions 1. ***Refer to MD 2. PT Education: myelopathy, red flags signs, posture, joint protection, activity modification 3. Strengthen and coordination of DNFs, and other surrounding neck and postural muscles 4. Joint mobilization of any hypomobile neighboring joints including thoracic spine t5. Gait and balance activities, ergonomic assessment, STM

Peripheral Nerve Entrapment

a. Pathology 1. Neuritis, entrapment b. Sensory/motor 1. In PN distribution for sensation and motor c. Reflexes 1. LMN DTR Reflexes: lowered 2. Initial irritation could be slightly increased temporarily d. Intervention 1. PT Education: posture, ergonomics, functional/activity modifications/protection strategies 2. Joint mobilization to hypomobile joints 3. Stabilization for hypermobile joints 4. STM, IASTM 5. Neural glides 6. Positional Distraction

Nerve Root/Radiculopathy

a. Pathology 1. lateral foraminal stenosis 2. Posterolateral disc b. Sensory/Motor 1. In nerve/root distribution for sensation and motor 2. Dermatomes and myotomes patterns c. Reflexes 1. LMN DTR Reflexes: lowered 2. Initial irritation could be slight increased temporarily d. Intervention 1. PT education: posture, ergonomics, functional/activity modifications/protection strategies 2. Joint mobilization to hypomobile joints 3. Stabilization for hypermobile joints 4. STM, IASTM 5. Neural glides 6. Traction (nerve root radiculopathy), positional distraction

CPR for Cervical Traction

a. Peripheralization with P/A (PAIVM) b. + Shoulder Abduction Test c. Age >55 d. + ULTT (A) e. + Cervical Distraction Test Will Respond to (Traction + DNF Ex + Posture Education) if: A. 3/5= 79% probability of success with Rx B. 4/5= 95% probability of success with Rx