5-1-98



DTR Grading 2

Goniometry 3

Dermatomes 3

Muscle Grading 3

VBAI: patients who stroke out under cervical adjustments have an underlying problem 4

George's Test: 4

Whiplash 6

Contra coup 6

Post concussive syndrome 6

Orthopedic Tests 6

O' Donohughes (Differential Tension Testing) p53 E 6

Spinal Percussion 6

Distraction p34 6

Foraminal Compression Test 6

Muscle Strain Grading 7

Sprains (Ligaments) 7

Post Concussive Syndrome 7

Proprioceptive Neuromuscular Facilitation (Voss) 8

Thyroid Damage 8

Thoracic Outlet Syndrome 8

Scalenius Anticus Syndrome 8

Cervical Rib Syndrome 8

Costoclavicular syndrome 9

Hyperabduction Syndrome 9

TMJ 9

Shoulder 9

Apley's Scratch Test 9

Dawbarn's 9

Ludington's Test sp??? 10

Codman's Sign 10

Impingement Sign 10

Tendonitis 10

Bursitis 10

Shoulder Dislocation 10

Calloway's Test 10

Dugas Test ??? Hard to Read page 44 of Linda's Notes 10

Mazion Shoulder Maneuver 11

Apprehension Test 11

Adhesive Capsulitis 11

Codman's Pendular Exercises 11

Rotator Cuff Tears 11

Luddington's 11

Rheumatoid Arthritis 11

Supraspinatus Press Test 130 12

Abbot-Saunders 12

Elbow 12

Varus 13

Tinel sign of elbow 13

Tendonitis of the Elbow 13

Common Extensor Tendotinits 13

Flexor Tendinitis 13

Ligamentous Instability Test 154 13

Elbow Flex Test 148 14

Cozen's Test *** standard elbow test ***** 14

Mill's *****standard elbow test ****** 14

Golfer's Elbow Test 14

Stenosing Tenosinivitis 14

Dequervain's disease 14

Finkelstein's Maneuver 14

Trigger Finger 15

Ganglion of the Wrist 15

Dupuytren's contracture 15

5-1-98

The information for the 1st day is the same stuff we are going over in Phys Dx. Such as Hx and review of systems, VAS,

5-4-98

DTR Grading

+4 very brisk; hyperactive; indicative of disease ; associated with clonus

+3 brisker than avg.; could be indicative of a problem

+2 normal

+1 somewhat decreased

0. no response

Other Scales

+5 sustained clonus (must be stopped by force

+4 transient clonus (stops on own)

Reflexes

← Biceps (C5)

← Triceps (C6)

← Brachioradialis (C7)

Goniometry

← Flexion

← Use body of C5 as point of intersection (axis)

← Place 2 dots on ear

← Move base of goniometer to adjust for flexion of thoracics and lumbar

← Extension

← Have goniometer below the ear but parallel to vertical axis of the ear

← Lateral bending

← Axis at base of T1

← Rotation

← Pt. Supine

← Axis above odontoid

← Follow nose

← Standard goniometer procedure

← 3 measurements in a row

← should all be within 5 degrees or 10%

← average then round to the nearest 5 degrees

← if ROM decreases as you take more measurements, indicates pain syndrome

← if ROM increases as you take more measurements, indicative of soft tissue injury that doesn't involve splinting of mm.

← Passive ROM with overpressure is normal for a healthy joint

← If passive ROM = active ROM and overall ROM is reduced ==Ex. Sholder adhesive casulitis

← Normal values are the functional values (minimal value for function

5-5-98

Dermatomes

← C5 upper lateral arm

← C6 lower lateral arm and thumb

← C7 middle finger

← C8 little finger and lower medial arm

← T1 upper medial arm

← T2 axilla

← Run 6-8 " at a time

5-6-98

Muscle Grading

+5 Normal complete ROM against gravity with full resistance

+4 Good complete ROM against gravity with some resistance

+3 Fair complete ROM against gravity

+2 Poor Complete ROM without gravity

+1 Trace slight contractility but no joint mvmt

0 none no evidence of contractility

|Level |Motor |Reflex |Sensory |

|C5 |Deltoid |Biceps tendon |Upper lateral arm and axillary |

| | | |nerve (over insertion of deltoid |

| | | |{epaulette} ) |

|C6 |Wrist extensors |Brachioradialis |Lateral forearm and thumb |

|C7 |Wrist flexors and digit extensors |Tricep tendon |Middle finger |

|C8 |Finger flexion; flexor dig. Superficialis and |No reflex |Medial forearm |

| |profundus | | |

|T1 |Adduction of digits |No reflex |Medial arm |

Review

Illiopsoas: hip flexion: T12-L3

Quads: L2-4( femoral n

Hip adductors: L2-4 ( obturator n.

L5 ( extensor digitorum longus and extensor hallucis longus

Hip abduction ( g. medius ( L5

** separate L4 and L5 dermatome with the tibial crest

S1 ( peroneus longus and brevis; gastroc. And soleus; g. max; acchiles reflex; lat foot dermatome

5-8-98 Today's info comes directly from Terrett

VBAI: patients who stroke out under cervical adjustments have an underlying problem

George's Test:

• not specific i.e a (+) George's does not always indicate an at risk patient (what they need is an adjustment)

• not sensitive : doesn't catch all VBAI's

VBAI signs and symptoms

• dizziness, vertigo, light headedness (most common symptom = dizziness)

• drop attacks( loss of consciousness

• diplopia

• dysarthria

• dysphagia

• ataxia

• nausea

• numbness

• nystagmus

TIA's ( up to 12 - 24 hours return to normal function after the attack

In george's test, you are testing the ipsilateral artery, because it is normal for the contralateral artery's blood supply to diminish during rotation of the head

Proposed mechanisms

1. narrowing of the artery as a result of trauma with a hematoma developing ; bruit sometimes produced

2. thrombus ( embolus

3. dissecting aneurysm

5-11-98

George's Test

1. History

• Arteriosclerosis

• Hypertension

• May appear normal but may be taking meds to decrease it

• C-spine spondylosis

• Hx of neck sprain injury

• Want to make sure vertebral artery not injured before adjusting

• Former TIA's

• CV disease

• Diabetes

• Family HX of stroke

• Stroke

• Medications

• Oral contraceptives

• Aspirin ( if taking a lot in a short period) is an anticoagulant and can cause GI bleeds (I thought aspirin was a safe drug????)

• Coumarin or heparin (derivatives of the main ingredient in rat poison) That's nice

• Strong anticoagulant given in heart valve replacement or deep vein thrombosis

5-13-98

Terrett p 42 and 19

Whiplash

• Rear end collision usually

• Acceleration/deceleration

• Hyperextension yields a reflex muscular contraction which throws head into hyperflexion

• Headreast at level of EOP (should be)

• Too high ( catapult)]

• Too low (fulcrum)

Contra coup

• Head comes back suddenly

• Brain in fluid

• Frontal bones slam into brain

• Brain moves back while skull is moving and occiput hits brain

Post concussive syndrome

• Loss of consciousness not a prerequisite

5/15/98( Guest Speaker--no testable material

5/18/98

Orthopedic Tests

O' Donohughes (Differential Tension Testing) p53 E

• Compares resisted motion(isometric) with passive motion

• If muscle damaged will hurt when doing work

• If ligament problem pain should not be significantly different between passive and resisted ROM

Spinal Percussion

• Not a good way to diagnose spinal fracture

• Gives information about location of pain

• Percuss spinouses and paravertebral mm

Distraction p34

• Bimanual contact and lift head

• General pain across back of neck indicated ligaments

• Localized pain indicates capsular problem

Foraminal Compression Test

• Ivf involved

• Pt presents with myotomal and or dermatomal involvement with possible parasthesia

• Locate area of c/c

• With head in neutral position, press down on top of head and look for increase in radicular pn

• Then laterally bend pt and compress

• Then laterally bend and rotate and then compress

• If problem in compression, distraction provides relief

5/20/98

Muscle Strain Grading

1. Mild

• May be only microscopic damage or can be macroscopic but damage is small

• May heal completely

2. Moderate

• Capillary damage

• Longer to heal

• More scar tissue (stiffer ) decr ROM

3. severe (rupture: tearing of at least part of the tendon)

• surgical repair often necessary

Sprains (Ligaments)

1. mild

2. moderate

3. severe (separation/rupture or avulsion fracture)

• see rubor, calor, dolar, tumor in sprain

• damage to proprioceptors (can lose functional aspects of ligaments)

• usually take longer to heal than muscle

• more movement allowed which can lead to secondary injury, but less pain

• poor vascular supply

5/22/98

Post Concussive Syndrome

• symptoms

• light headedness

• vertigo/dizziness

• headache

• neck pain

• photophobia (aversion to light)

• phonophobia (aversion to loud sounds)

• tinnitus

• impaired memory

• easily distracted

• impaired comprehension

• forgetfulness

• insomnia

• fatigues easily

• outbursts of anger

• mood swings

• depression

• loss of sexual drive

• intolerance to alcohol

• hard to document that the symptoms are from the accident

• PET scan of brain (be sure insurance will pay)

Proprioceptive Neuromuscular Facilitation (Voss)

• Stroke rehab

Thyroid Damage

• Symptoms take a while to develop

• Fatigue

• Decr labido

• Weight gain

• Forgetfulness

• Often attributed to malingering

5/27/98 ( Video on whiplash

Thoracic Outlet Syndrome

Scalenius Anticus Syndrome

• Compression of the neurovascular bundle as it exits between anterior and middle scalenes

• Usually secondary to cervical injury

• Hypertonic scalenes

• Post stenotic dilitation of the subclavian artery

• May hear bruit

• Neurologic and vascular symptoms

• Main test: Adson's

Cervical Rib Syndrome

• May be bone or cartilage

• Forms a ridge that takes up space in scalene triangle

Costoclavicular syndrome

• Carrying backpack, suitcase, etc.

• Shoulder injuries

• Clavicular and 1st rib fixations

• Eden's test

Hyperabduction Syndrome

• Abduction of the arm increases

• Hypertonicity of the pec minor

• Rib fixation

• Shoulder injuries

• Can compress axial artery and brachial plexus

• People who work overhead a lot can develop this

• Aka Pec Minor coracoid syndrome or P. minor compression syndrome

5/29/98

TMJ

• Hinge jt with anterior translation

• When opening jaw, rotation 1st then anterior translation

• Often injured in whiplash

• Review anatomy

• When palpation check for differences in timing and degree of opening

• Check whether teeth fit together well

6/1/98

Shoulder

Apley's Scratch Test

• Have pt reach above their shoulder with one hand and touch shoulder blade and other hand under shoulder and try to approximate the hands

• Look for lack of pain ???

• Look for assymmetry

• If you see a problem it is probably rotator cuff mm

• Same as deep knee bend (lower ext)

Dawbarn's

• P104

• Subacromial bursa involved

• Bring arm into extension and palpate the bursa

• Pt presents with history of shoulder pain

• Abduction of the arm relieves the pain

Ludington's Test sp???

• Pts hands behind head

• Palpate biceps mm for symmetry

• If long head of biceps tendon ruptures, initially looks bigger then atrophies

Codman's Sign

• Passive abduction of pt shoulder

• Dr drops arm and pt tries to stop

• Dr feels for contraction of the delts

• Pain with rupture of the supraspinatus or joint capsule

• Modified codman's: abduction against resistance

Impingement Sign

• Supraspinatus tendinitis

• Supraspinatus or biceps tendon

• Palpate at site of supraspinatus insertion

Tendonitis

• Can get calcium deposits

• Body stablilizing area

Bursitis

• Usually secondary to something else (tendonitis)

• With acute tendonitis and bursitis, area get real red

Shoulder Dislocation

• Usually anterior and inferior

Calloway's Test

• Measure from axilla to acromion process

• The larger side is the dislocated side due to neck of humerus dropping down

Dugas Test ??? Hard to Read page 44 of Linda's Notes

• With affected side, have pt grab other shoulder then push elbow into chest

• Pt will deck you if shoulder dislocated

Mazion Shoulder Maneuver

• Same as Dugas but try to raise elbow up

• If dislocated pain in front of acromion

Apprehension Test

• Abduct shoulder to 90 deg. And flex elbow

• Look for apprehension on pt face

6/3/98

Adhesive Capsulitis

• Frozen shoulder - aka

• Usually secondary to tendonitis or bursitis

• Pt uses less which allows for adhesions to form

Codman's Pendular Exercises

• Use pendular motion and go into painful ROM and to often each day

6/5/98

Rotator Cuff Tears

Luddington's

• Check for symmetry of the biceps (rupture of tendons)

Rheumatoid Arthritis

• Inflammatory condition

• Hot swollen painful red joints

• Synovial hypertrophy

• Pannus formation

• Erosion of menisci

• Instability

• Later on get complete loss of joint function due to ankylosis

• Stages

1. acute

2. proliferation of pannus

3. fibrotic ankylosis

4. bony ankylosis

• 2-3 X more common in females

• *** symmetrical in presentation ****

• check for stability especially in C1/C2 area

• if too much space between ant. Arch of the atlas and dens can get cord compression

• autoimmune in nature

• ulnar deviation of fingers

• carpal bones become hard to identify

• flexion deformity of thumb (boutonniere)

• swan neck deformity of fingers

• rheumatoid nodules appear in connective tissue near jt.

• Baker's cysts: synovial outcroppings popliteal region

Supraspinatus Press Test 130

• Abduct shoulder to 90 degrees and resist abduction

Abbot-Saunders

• Abduct and extern rotate

• Bring arm down

• Listen for click or pop of bicipital tendon

• Instability of transverse humeral ligament

Elbow

Valgus: lateral deviation

Vlagus stress test : tests medial collateral ligament

ditd

distal body part to the joint is in the more lateral position

Varus

Distal part to the joint is in the more medial position

Varus Stress Test is aducting the distal part and testing lateral collateral

Tinel sign of elbow

• Huge % of false positives

• Tests ulnar and radial nerves

• Lateral side of olecranon ( radial n

• Medial side ( ulnar n

Tendonitis of the Elbow

Common Extensor Tendotinits

• Tennis Elbow

• Lateral epiconylitis

• Pain more commonly in forearm just distal to elbow

Flexor Tendinitis

• Golfer's elbow

• Medial epicondylitis

Ligamentous Instability Test 154

• Elbow slightly flexed to 20 deg

• Hand in supination

• Stabilize arm

• Abduct forearm to test medial collateral (valgus)

• Adduct forearm to test lateral collateral (varus)

• If grade III sprain expect hypermobility

Elbow Flex Test 148

• Maintain forced flexion for > 5 min

Cozen's Test *** standard elbow test *****

• Flex elbow

• Pronate forearm

• Wrist extended

• Pt resists wrist flexion from Dr.

Mill's *****standard elbow test ******

• Elbow in flexion

• .flex wrist, then fingers

• bring elbow into extension and pronation with wrist and fingers still flexed

Cabil Test ?????? check spelling

• have pt squeeze sphyg bulb

• place band around extensors and do again

• should be stronger with band if tennis elbow

Golfer's Elbow Test

• elbow flexed, supinated forearm and extended wrist

• pt. Tries to flex

6/10/1998

Stenosing Tenosinivitis

• synovial sleeve inflamed around tendon

Dequervain's disease

• affects tendons of

• abductor pollicus longus

• extensor pollicus brevis

• pain in the anatomical snuffbox

Finkelstein's Maneuver

• pt makes fist and dr pushes fist into ulnar deviation at the wrist

• pos sign is pain at the distal radius or anatomical sn box

• don't immobilize; maintain motion

Trigger Finger

• affects flexor tendons proximal to the metacarpal-phalangeal ??? jt.

• Finger stuck in partial flexion and can't extend completely

Ganglion of the Wrist

• Herniation of the joint capsule or synovial sheaths filled with synovial fluid

• Benign

• If surgically removed, tend to recur

• Most common in the hand and wrist

Dupuytren's contracture

Contracture: permanent shortening of muscle or connective tissue

• Contracture of palmar aponeurosis

• Limited extension ; flexion OK

• Ripples on palmar side

• 4th and 5th digit m/c

• hypertrophy of the palmar fascia

A

Abbot-Saunders, 13

abductor pollicus longus, 15

Adhesive Capsulitis, 12

anatomical snuffbox, 15

Apley's Scratch Test, 10

Apprehension Test, 11

B

Baker's cysts, 13

Bursitis, 11

C

Cabil Test ?????? check spelling, 15

Calloway's Test, 11

Cervical Rib Syndrome, 9

Codman's Pendular Exercises, 12

Codman's Sign, 10

Common Extensor Tendotinits, 14

Contra coup, 6

Contracture, 16

Costoclavicular syndrome, 9

Cozen's Test, 15

D

Dawbarn's, 10

Dequervain's disease, 15

Dermatomes, 4

Distraction, 7

DTR Grading, 3

Dugas Test ??? Hard to Read page 44 of Linda's Notes, 11

Dupuytren's contracture, 16

E

Elbow, 13

Elbow Flex Test 148, 15

extensor pollicus brevis, 15

F

Finkelstein's Maneuver, 15

flexion deformity of thumb (boutonniere), 12

Flexor Tendinitis, 14

Foraminal Compression Test, 7

Frozen shoulder - aka, 12

G

Ganglion, 16

George's Test:. See VBAI

Golfer's elbow, 14

Golfer's Elbow Test, 15

Goniometry, 3

H

Hyperabduction Syndrome, 9

I

Impingement Sign, 11

L

lateral collateral, 13

Lateral epiconylitis, 14

Ligamentous Instability Test 154, 14

Luddington's, 12

Ludington's Test sp???, 10

M

Mazion Shoulder Maneuver, 11

medial collateral ligament, 13

Medial epicondylitis, 14

Mill', 15

Muscle Grading, 4

Muscle Strain Grading, 7

O

O' Donohughes, 7

P

palmar aponeurosis, 16

Pannus formation, 12

Post concussive syndrome, 6

Post Concussive Syndrome, 8

R

radial n, 14

Reflexes, 3

Rheumatoid Arthritis, 12

S

Scalenius Anticus Syndrome, 9

Shoulder Dislocation, 11

Spinal Percussion, 7

Sprains (Ligaments), 8

Stenosing Tenosinivitis, 15

Supraspinatus Press Test 130, 13

Supraspinatus tendinitis, 11

swan neck deformity of fingers, 13

T

Tendonitis, 11

Tennis Elbow, 14

Thoracic Outlet Syndrome, 9

Cervical Rib Syndrome, 9

Scalenius Anticus, 9

Tinel sign of elbow, 14

TMJ, 10

transverse humeral ligament, 13

Trigger Finger, 16

U

ulnar deviation of fingers, 12

ulnar n, 14

V

Valgus, 13

Varus, 13

VBAI, 5

W

Whiplash, 6

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