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