MDDR

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What displacement is common with RA patients?

Anterior antlanto-axial subluxation

What is Spondylosis? and where does it occur?

Degeneration of the IVD, C5, C6, C7

What are the symptoms of Spondylosis?

Neck pain, stiffness, possible headache

What are the 3 symptoms of ligament instablity?

Parasthesia (numbness) of lips, face & tongue. Signs of vertabral artery compromise & cord signs

What are the 3 clincal signs of instability?

Empty end feel, reproduction of symptoms of instability & production of lateral nystagmus

What does the tectorial membrane limit?

Flexion & rotation

2 ways to define Schuermans

Multilpe vertabral end plate irregularites & Osteochondrosis of spine

What are the symptoms of schuermans?

Pain in thoracic region
↑ kyphosis

What will X-rays show? - schuermans

Wedged vertabrae, Irregularity of end plate & narrowing of disc space

Define Ankylosing Spondylitis?

Systemic rheumatic disease with
progressive ossification of the spine

What does Ankylosing Sponylitis affect? and in what order

Starts in SIJ, affects spine & peripheral joints

What are the symptoms of Ankylosing spondylitis?

Inflammatory pain, pain in spine & pelvis, ↓ ROM in spine & fatigue

What is fibrosed & ossifced in Ankylosing spondylitis?

Insertional points of ligaments, tendons, fascia & capsule

What are the less common symptoms of Ankylosing spondylitis?

Inflammation or uveitis (middle layer of eye, heel pain, swelling/pain in Joint shoulders, knees, and ankles, fever

What are the two most commonn symptoms of whiplash?

Decreased range of motion and stiffness

Define spondylolysis?

Defect of pars interarticularis at L5, L4

What are the symptoms of sponylolysis?

Focal low back which may radiate into the buttock or proximal lower extremities

What causes radiculopathy?

Space occuping lesion such as, Disc herniation, Spondylosis ie osteophytes, trauma/ fracture & Tumour

What are the signs and symptoms of mylepoapthy

Clumsy ness, gait disturbances & upper motor neuron signs

Longus Colli Superior oblique fibers

O: Anterior tubercle of C3- C5 Transverse processes
I: Anetriorlateral surface of anterior tubercle of Atlas

Longus Colli - Inferior oblique fibers

O: Anterior aspect of T1- T3 Vertabrae
I: Anterior tubercle C5-C6 Transverse Process

Longus Colli - Vertical fibers

O: Anterior aspect of C5, C6, C7, T1, T2, T3 vertabrae
I: Anterior aspect C2,C3,C4 vertabrae

Which ligaments connect Dens to occiput

Alar
Tectorial membrane
Cruciform (comes off transverse)

Longus Capitus

O: Anterior tubercles of the transverse processes
C3, C4, C5, C6
I: Basilar part of the occipital bone
Flexion at OA joint

When to test integrity of ligaments

RA + Down sydrome & non recent trauma

Coupled movement

Lateral flexion right
Occipital condyles translate left &
Left occipital condyle posterior (flexion)
Right occipital condyle anterior(extension)
C1 rotates left
C2 rotates right

Pancoast tumour - signs and symptoms

Severe pain in the shoulder or the shoulder blade (scapula)
Pain in the arm and weakness of the hand on the affected side

Diagnosis for thoracic outlet sydrome

Adson test- reduction of radial pulse with cervical extension & rotation
Roos test - elevated arm stress test , hold for 3 mins and look for change in extremity colour
Watson et al Manual therapy 2009

Thoracic outlet syndrome pins & needles distribution

C8/T1 distribution
(Ring & little fingers, medial forearm & medial arm)

Differential diagnosis for radiating arm

thoracic outlet syndrome

Radial motor and sensory test

Motor - Wrist extension
Sensory - Dorsal webspace between thumb & index finger

Ulnar motor and sensory

Motor Abduction - little finger
Sensory - Distal ulnar aspect little finger

Median sensory and motor

Motor - Opposition of thumb
Sensory - Distal radial aspect index finger

Axillary motor and sensory

Motor - Deltoid
Sensory - Lateral arm

Musculoscutaneous motor and sensory

Motor - Biceps
Sensory - Lateral foream

Serratus anterior

Origin: External surface of the lateral aspect of ribs 1- 8
Insertion: Costal surface of the medial border of the scapula and costal surface of the inferior angle

Rectus abdominus

Origin: Pubic crest and pubic symphysis
Insertion: Costal cartilages of ribs 5 - 7

6 SIgns/symptoms of minor cervical instability

Neck pain, catching locking, weakness, altered ROM, potenial headache (from upper cervical pattern)

VBI testing sen or sp?

More specific Kerry 2003

Thoracic spine - common causes of pain

Facet, Costotransverse, costvertrabral, Paraspinal muscle strain, schuermanns

Facet joint sprain movements

Injury during rotating, bending, lifting, arching and twisting

Facet symptoms -2

Hypomobility & local tenderness

Costvertabral/costotransverse joint symptoms 4

Hypomobility & local tenderness, +/- pain on inspiration, local or referred pain to chest wall

If IVD protusion happens (alhtough it is rare) which thoracic disc will it affect and why

T11-12 beause the discs are larger

Role of physio in the osteoporosis in older patients, Bennell 2000

Conserve bone mass, reduce the risk of falls, promote extended posture, reduce pain, and improve mobility and function.`

Signs and symtpoms of OA

Increase thoracic kyphosis and dowagers hump

Is pain present with OA

No unless fractured

Where is the primary site for neoplasm in the thoracic spine

Bronchial tumour and pancoasts (lung apex)

Symtpoms of bone cancer in thoracic spine

Severe pain in central thoracic region, Limited ROM, swelling, tenderness, fatigue, weighloss & un-remitting night pain

What is T4 syndrome

Sponylitic/osteochodritic lesions from T4, 5, 6

What does Sponylitic/osteochodritic lesions mean ( T4 syndrome)

Inflammation of bone and joint surfaces

What does it result from ( T4 syndrome)

Trauma, RA or infection

What are the T4 clinical features

Diffuse arm pain in helmut glove distribution, distal pain worse at night, increase thoracic kyphosis, tight pectorals, foward head posture, local thoracic tenderness wit marked stiffness in PAIVM

Where does some one with MI have pain

retrosternal/paraspinal, jaw, neck and inside arm

What is the pain like with MI

vice like

What aggravateds MI symptoms

exercise and stress

MI confirmed with ?

ECG

Is degeneration of the cervical discs common

Yes

When does coupled movement of OA AA happen

with side flexion

AO movements

flexion/extension and some rotation and side flexion`

AA joint movements

Rotation as well as some flexion and extension

Degrees of movement up and down slope in cervical spine

8

Signs on instablity of cervical spine 3

Parasthesia of lips, face and tongue. VBI signs and cord signs

Signs of instability on testing cervical spine 3

empty end feel on testing, reproduction of lateral nystagmus, reproduction of signs of instability

When to test ligaments in cervical spine

Upper cervical pain post trauma, congenital abnormalities ie downs, degenerative such as RA

Clinical features of artery dissection

Pain like no other, acute, neck stiffness but no decrease in ROM, pain in head and neck

PART means

Pain provocation, asymetry, range of motion and tissue texture changes

Red flags for lumbar spine

tumour, spinal osteomyletis, fracture and cauda equina

Tumour signs

pain at rest, might pain, upper lumbar radiculopathy in the young, UEWL,age above 50 below 17, family or previous history of cancer

Spinal osteomyletis 7

fever, chills, night sweats, IV drug user, immunosuprresent disorder history of surgery or recent infection

Fracture

Trauma, long term sterioid, age above 70 menopause or amenmhorhea

What can be narrowed in lumbar spine stenosis

vertabral canal, nerve root canal or intervertabral foramin

SIgns of vascular intermittent claudication (which is secondary to peripheral arterial disease)

Pain ache in calf, associated with cramps, cyanosis, atrophic changes, decreased pulse, regular pattern and worse up hill

SIgns of neurogenic intermittent claudication

Deterioating pattern and better up hill

What releives neurogenic intermittent claudication

flexing and lying down

SIgns of derangement

Repeated movements centralises or peripheralises, decreased ROM or movement obstruction and shift possible

What produces Postural sydnrome symptoms

Sustained EROM

Who said that directional preference was highly prognostic of disc pain and associated with good outcome

Aina 2004

Effect of manipulation

Local tissue effect, neuromodulation of pain and short term ROM changes

Name the SIJ tests

Distraction, thight thrust, compression, sacral thrust and gaenslens

Laslett 2005 said what

2/4 or 3/6

How many tests have to be negative to rule out SIJ

All

What attaches to the TCF

...

Where does biceps femoris attach

...

Who said that instability tests correspond moderately well with MRI in patients with WAD

Kaale 2008

Who said that McKenize assesment for centralisation has 74% accuracy

Donelson 1997 ( I think!)

Management for derangement (after treatment)

Avoid flexion in morning. Gym programme for core stabilisers

Nuation is what

sacrum anterior, ilium posterior

Nuation causes tension in what ligaments

Interosseus, short dorsal and sacrotuberous

Which muscles cause relative nuation

biceps femoris and gluteals

Pain pattern of SIJ - young and april

Unilateral, dull ache in buttock, subjective heavyness of limb

Mechanism of injury for SIJ

Jarring through one leg, fall onto buttocks and preganancy

Two other tests for SIJ

SLR and SKE

with 100% sensitivity the test will be always negative or positive if some has the condition

positive

with 100% specificity the test will have no

there will be no false positives

Global muscles of the spine 4

Iliocostalis, longissimus, quadratus lumborum, rectus abdominus

Local muscles

Multifidus, TA, IO (posterior), QL (medial), intertransversarri, spinales

Quadratus lumborum O and I

Origin iliac crest and iliolumbar ligament
Insertion Last rib and transverse processes of lumbar vertebrae

Lat D

Origin: spinous processes of thoracic T7-L5, thoracolumbar fascia, iliac crest and inferior 3 or 4 ribs, inferior angle of scapula
Insertion: floor of intertubercular groove of the humerus

Validity of PAIVMs and PIVMs in lumbar spine for instabilit

Specific but not sensitive Abbot 2005

Dysfunction location

LBP w+/- referred pain with dominat symptoms above the gluteal fold

Treat dysfunction with

TERT, low load prolonged stretching

With radiculopathy is the numbness & weakness dermatonal.myotomal

Yes (Bogduk) 2009

Active straight leg raise tests what

Form and force closure of the pelvis

Which sling should you activate when doing the SLR

Anterior

What makes up the anterior sling

TA, IO & EO (Vleeming 1995)

If a patient had right sided pain turning left and you thought they had an upslope problem on the left at the CT junction, would you place the blocking hand on the same or opposite side as you

Opposite (and you try and grip the spinous process above with your pinkie

When assesing physiological movement at the CT junction where should you fingers be

between the spinous process or on the articular pillar

To test OA joint physiological movements which directions do you test

Flexion, extension, side flexion and flexion in side flexionq

How do you test the tectorial membrane

Fix C2 and grip occiput, distract

When testing alar ligaments how much movement are you expecting

10 degree

Test Alar ligaments in what position

neutral, if positive, flexion and extension

WHen testing the alar ligs with left lateral flexion which bands are tight

right uppper and left lower

When testing left flexion alar what happens to C1/C2`

Altlas (C1) moves to the right and C2 rotates right

What do you need to determine about pain before proceeding with repeated movements

site, intensity, nature & any other symptoms

When performing test determine what about pain

Symptoms better, worse or the same, are they only at end rom

What must happen with each movement

PRogressively further into rom

Do you apply over pressure with repeated movements

If it is required, if there is a poor response

How long do you hold sustained movements for

1-2 minutes an document change

What do patients with disc bulges need to be educated about

Gettting up of bed, how to sit and stand with lumbar spine extended, (tense abdominals before movement) to avoid flexion in the morning, then progress to strengthening programme

For a left sided disc bulge which side against the wall

RIght

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