NYCC Loia Exam 3 Evi. Based Clin Case Mgmt Sp2012
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| Abducts and externally rotates thigh | piriformis
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| piriformis syndrome PAIN from sciatic n. irritation | DEEP in buttocks, worse by SITTING, CLIMBING, SQUATS
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| Patient presentation = PIRFORMIS syndrome | (+) LASAGUES, INTERNAL rotation pain, HYPESTHESIA over S1/2 dermatomes, diffuse MOTOR WEAKNESS = pain in the SACRAL or GLUTEAL region is MOST CONSTANT SYMPTOM
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| Medical mgmt of piriformis syndrome | Stretch – Ice/heat – PT – Meds – Injections – Electrotherapy
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| PT for piriformis syndrome | Deep massage, ROM exercises
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| CHIRO treatment options for piriformis syndrome | Ischemic compress – Spray n stretch – Active myofascial release – manip/adj of associated joint dysfunction – Exercise
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| Claudication | 'limping' – can be neurogenic from stenosis or vascular from atherosclerosis
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| Will all patients with spinal stenosis (ss) or foraminal encroach have neuro sx? | No. Only have symptoms when there is IRRITATION
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| Leading PRE-OPERATIVE DX for adults >65 | LUMBAR SPINAL STENOSIS [LSS] = neurogenic claudication
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| Why is LSS more frequent in lower lumbar area | Increased DORSAL ROOT GANGLION DIAMETER then decreased foramen
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| Younger population has disc herniation and congenital... | canal STENOSIS (young = LDH + SS)
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| Structure which presses on DORSAL COLUMNS in lumbar ss: | Hypertrophied LIGAMENTUM FLAVUM
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| When should SURGERY for LSS be considered? | UNREMITTING pain or PROGRESSIVE NEURO defect = CAUDA EQUINA
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| Non-surgically, ______ management for LSS is encouraged. | Conservative – intention is to reduce inflammation
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| Conservative mgmt for LSS medically | Anti-inflammatory meds, pain relievers, steroid injections, laminectomy
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| Complications of LSS (3) | Injury from LACK OF SENSATION, INFECTIONS, CHANGES from nerve compression
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| Ligamentum flavum hypertrophy in LSS affects the | DORSAL COLUMNS = less proprioreception, wide based gait, loss of sense of vibration
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| TESTS for LSS | REFLEXES (asymmetry of lower), NEUROLOGIC (hypesthesia and leg WEAKNESS), X-RAY/CT (degeneration and stenosis), MRI (stenosis and ligamentum flavum hypertrophy), EMG
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| What will you see on LSS imaging? | Disc space NARROWING, Prominent OSTEOPHYTES, Hypertrophied LIGAMENTUM FLAVUM, Facet ARTHROSIS
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| Who should decide if chiropractic manipulation should be applied to LSS patient? | The chiropractor!
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| What kind of spinal manipulation does KIRKALDY-WILLIS rec. for LSS | FLEXION & ROTATION
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| Flaccid weakness and hyporeflexive... | Lumbar RADIC!
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| Why is LSS relieved by FLEXION? | Creates a tensile pull on the ligamentum flavum, instead of buckling it
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| Prominent sx of BOTH neurogenic and vascular claudication | LEG pain on WALKING
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| Claudication RELIEVED BY FLEXION | NEUROGENIC
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| NEUROGENIC claudication big 3: | RELIEVED by FLEXION, Walking UPHILL EASIER, Riding a BICYCLE EASIER (all flexed postures)
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| Claudication WORSENED by STANDING | VASCULAR (severe cramp due to back up of fluid)
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| PAIN of vascular claudication | SEVERE CRAMP (versus tingling and numbness of neurogenic claudication)
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| PAIN of neurogenic claud | TINGLING, NUMBNESS
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| CLASSIC presentation of Lumbar Spinal Stenosis LSS | BILATERAL NEUROGENIC claudication
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| Kind of stenosis that causes unilateral neurogenic claudication | Lateral recess stenosis or foraminal stenosis
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| INTERMITTENT, DIFFUSE radiating thigh or leg pain w/ assoc parasthesias | NEUROGENIC claudication
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| Affects 90% of patients with LSS | LEG PAIN
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| ALLEVIATES neurogenic claudication (LSS) | Lying SUPINE, SITTING, SQUATTING, FLEXION lumbar
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| Neurogenic claudication (LSS) 80% pain diminution with... | SITTING and 75% relief w/ forward BENDING/FLEXION
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| Physical EXAM findings in LSS | Often NORMAL – WIDE BASED GAIT, EXTENSION causes thigh pain, RHOMBERG test (+), loss of lumbar LORDOSIS, MRS abnormalities L4-L5 MOST COMMON
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| ASYMMETRIC muscle stretch and focal myotomal weakness | LATERAL recess stenosis
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| These symptoms are NEGATIVE for neurogenic LSS | VASCULAR (skin color/temp/turgor, bruits, pulses) & Lumbar segment MOBILIZATION fails to reproduce pain. NO mftp's.
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| Can you ADJUST a pt w/ neurogenic claudication LSS | Yes, even elderly. Just reduce the flexion and pre-load.
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| Describe sx of CAUDA EQUINA syndrome | SADDLE, BLADDER, NEURO DEFICIT lower ex
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| LONG TERM effects of cauda equina syndrome | Bladder infection – Decubitis ulcer – Venous thromboemboli
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| CAUSES of vascular claudication | ATHEROSCLEROSIS + HEART disease
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| EXACERBATED by PHYSICAL activity, RELIEVED by REST | VASCULAR claudication – no positional component
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| If the dorsal pedal pulse is patent, then … | no vascular component. OKAY. Helps d/dx vascular from neuro lesion
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| 3 arteries of lower extremity | Femoral – Popliteal – Dorsalis pedis (most impt)
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| TESTS for vascular claudication | DORSALIS PEDIS PULSE – CAPILLARY REFILL – BRUGGER'S dorsi/plantar flex
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| Bifurcation level of abdominal aorta into common iliac a. | L4
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| Average diameter of aorta? Evaluation diameter of aorta? | Normal 2.0-2.5 cm, EVALUATE if 3.5 cm or greater!
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| More than 90% of AAA are associated with? | ATHEROSCLEROSIS and can cause CLAUDICATION as LEG: PAIN - NUMBNESS - FATIGUE
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| An artery may be sclerosed but if the lumen isn't altered, | there is NO aneurysm.
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| CHIEF SIGNS of AAA (when there are any): | 1. PULSATING MASS 2. BRUIT 3. symptoms from continuous PRESSURE (ie, abdominal and back pain)
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| Most AAA do NOT produce symptoms but the pt can feel a | pulsating sensation in abdominal
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| AAA on CT | Calcium is bright/white on CT
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| How can PULSATIONS of AAA cause a spinal problem? | EROSION of vertebrae, LOW BACK PAIN due to pounding on vertebral endplate (nociceptors), also THINS aorta (rupture)
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| How to PALPATE an AAA | Hooklying position, relaxed abs, pulsation to RIGHT of midline = surgical eval
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| Renal artery aneurysm causing hypertension | NOSEBLEED relieves the headache
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| D/dx AAA | PSOAS SPASM will angulate spine, RENAL A. aneurysm will cause HIGH b.p.
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| INNER THIGH PAIN can be triggered by |
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| TESTS for AAA | KIDNEY PUNCH, LABS (inflammation/infection/stones + kidney fcn) =but there is NO LAB TEST for AAA
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| 90% chance of AAA rupture if what 2 comorbidities | HYPERTENSION & COPD
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| Is there a lab test for AAA? | No.
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| IMAGING for AAA | FILMS, ULTRASOUND, MRI, CT, ANGIOGRAPHY
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| Hemothorax | ruptured AAA on xray as cloudy (full of blood)
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| Sx of RUPTURE of AAA | PULSATING, PAIN, RIGIDITY,LBP, PALE, RAPID pulse, DRY, THIRST, cannot concentrate!!, TACHYCARDIA
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| Plethysmography | BP CUFFS on ankles -recorded by pulse volume
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| Visible signs of AAA on LEGS | HAIR LOSS patches
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| Imaging technique to measure abmormal arterial blood flow | DOPPLER ultrasound
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| When NOT to use b.p. Cuff on ankles to detect AAA | THROMBOPHLEBITIS – possible embolus
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| RED flags of LBP | Severe MORNING stiffness as CC – Pain Unrelieved by posture and unchanged over 2-4 wks – Bowel/bladder dysfcn – Failed back surgery
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| LBP w/ bilateral leg pain. Difficult to stand or walk up stairs. Biking good. | Neurogenic claudication LSS
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| #1 cause of disability in America | ARTHRITIS
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| Chronic dz causing break down of JOINT CARTILAGE and sclerosis | Osteoarthritis
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| OA occurs in | Athletes and more Women after age 55
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| Primary CAUSE of OA | MECHANICAL
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| Labs for OA | none. Can use them to monitor tx
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| X-RAYS of OA | LOSS of cartilage and NARROWING of joint space
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| CHIRO OFFICE mgmt for OA | ADJUST & MODALITIES to control pain + reduce inflammation
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| CHIRO HOME mgmt for OA | Weight loss, Nutrition, Heat/Cold, EXERCISE (water)
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| MOST common form of INFLAMMATORY ARTHRITIS | RHEUMATOID = most debilitating
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| 3 stages of RA | 1. SWELL 2. PANNUS 3. DEFORMITY/misalignment
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| Who gets RA (excepting JRA) | Women b/w ages 20 – 50
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| 22 yo male LBP getting progressively worse. Rough in morning, better, then stiff/achy | Ankylosing spondylitis
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| D/dx for 22 yo male w/ progressive LBP worse in morning + night | AS and Reiter's
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| LABS for AS and REITER REACTIVE | HLA-B27 (both)
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| LABS for LUPUS (SLE) | ANA
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| LABS for GOUT | URIC acid
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| LABS for PSORIATIC arthritis | ESR and Rf+
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| LABS for RA and Sjogren syndrome | ANA and Rf+
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| When is adjustment for RA contraindicated? | ACUTE inflammatory stage or wherever there is ankylosis
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| Spinal FUSION terms for AS | SYNDESMOPHYTES >> BAMBOO SPINE
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| Difference b/w AS and Reiter's reactive arthritis EYE | AS – no conjunctivitis, just uveitis. No exudate.
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| MOST common SYMPTOMS of AS | Ages 17-35, males: STIFF lower back & buttocks, GRADUAL onset, DULL/DIFFUSE, worse in MORNING & NIGHT
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| HALLMARK feature of AS | SACROILIAC involvement
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| GASTROINTESTINAL feature of AS | Bowel inflammation, assoc w/ Crohn's or Ulcerative colitis
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| PERIPHERAL JOINT involvement is more common in ______ w/ AS. | JUVENILES
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| AS often accompanied by | IRITIS or UEVITIS (non-exudative) will see injection, watery
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| D/Dx AS | PHYSICAL EXAM, RADIOGRAPHS, HISTORY, FAMILY hx of AS, LAB = include HLA-B27
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| Radiograph finding of AS | SACROILITIS (can take 7-10 years to show so not best imaging choice)
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| 3 predisposing factors for AS: | 1. FAMILY HX 2. Freqent GI INFECTION 3. HLA-B27 (+) marker
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| CHIRO mgmt of AS | EXERCISE – ADJUST – LIFESTYLE chg.
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| MD mgmt of AS | PT and Meds
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| Causes of FATIGUE in AS | ANEMIA, inflammation (exercise may increase fatigue)
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| 3 sx of REITER'S/REACTIVE arthritis | 1. ARTHRITIS 2. UEVITIS (redness) 3. URINARY TRACT infection
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| Name the SERONEGATIVE spondyloarthropathies | REITERS – PSORIATIC – ANKYLOSING SPONDYLITIS – INFLAMMATORY BOWEL syndrome
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| Why is Reiter's called REACTIVE | Apart from Dr. Reiter being a known Nazi, REACTIVE implies an etiology due to infection elsewhere in the body
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| 2 modes of infectious transmission in REITER/REACTIVE | 1. SEXUAL (genitourinary) 2. GI/ENTERIC (food ingest that is tainted by bacteria)
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| #1 cause of REITERs/REACTIVE arthritis | CHLAMYDIA trachomatis (sex), then CAMPYLOBACTER (food), salmonella, shigella, yersinia
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| GENETIC factor for reactive arthritis | HLA-B27 (*80% of people w/ Reiter's have the HLA-B27 factor)
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| MOST common type of ARTHRITIS to affect young men (20-40) | REITER'S /REACTIVE arthritis because of sexual transmission
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| JOINT sx of reactive arthritis | knees, ankles, feet = ENTHESOPHYTES leading to HEEL SPUR (can't dance with me)
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| SPINAL effects of reactive arthritis | SPONDYLITIS (inflammation of vertebrae) & SACROILITIS
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| EYE effects of reactive arthritis | CONJUNCTIVITIS (exudative uevitis)
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| What 2 tests are NORMAL in reactive arthritis | 1. ANA 2. Rf factor {both negative in Reiters/Reactive}
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| 2 tests that are normally positive in Reiter's/Reactive arthritis | CHALMYDIA & HLA-B27
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| LAB for temporal arteritis or polymyalgia rheumatica | ESR
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| LAB for Inflammatory Bowel disease |
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| Defining characteristics of SLE for d/dx | malar rash, thrombocytopenia, arthritis, and (+) ANA test
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| LAB for scleroderma, Sjogren's, and Raynaud syndrome (not dz) | ANA
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| Characteristics for RA d/dx | nodules and (+) RF and ANA and CRP
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| Stiffness in joints in morning, nodules, swelling, xray joint capsule evidence | RA = RF+
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| characteristics for Sjogren's syndrome | Xerostomia (dry mouth) and Kertoconjunctivitis sicca (dry eye) due to lymphocyte infiltration = RF +
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| Why would there be a connection b/w Sjogren's and lymphoma | Sjogren's is due to lymphocyte infiltration of glands, caused by genetics and exposure to virus or bacteria
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| NEGATIVE Rf can mean: | NO RA, too early in dz to diagnose, patient in remission phase
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| Arthritis char by sudden, severe attacks of pain, red, tender joints | GOUT
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| Chronic gouty arthritis due to | Overproduction of URIC acid or reduced ability to ELIMINATE it via kidneys
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| Populations at highest risk for gout | Men and post-menopausal women (Diabetes II, Sickle cell, Kidney dz)
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| TEST for GOUT | Best: aspiration SYNOVIAL fluid analysis, URIC acid, KIDNEY FCN, X-RAY affected jts
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| DRUG tx for GOUT | Allopurinol, cholchicine, Probenecid, and increasing fluid
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| TREATMENT for Inflammatory arthritides | MOVEMENT THERAPY (gentle – tai chi, yoga), WEIGHT LOSS & STRENGTH (pain reduction), RELAXATION therapy (meditation, biofeedback, guided viz)
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