Level 1 Manual Therapy

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List 5 L-spine Scan Mandatory Questions: 1. Medications? (steroids, NSAIDS, anti-coags)
2. Special Investigations/Tests? (Xrays, MRIs, etc)
3. Pain or Paraesthesia in saddle region?
4. Change in bladder, bowel, genital function?
5. Groin or inner thigh pain?
When do you add overpressure?: If range (active or passive) is pain free
List the key movements tested for the neurological exam of the L-spine scan (L1-S2): L1-2 = hip flexion
L3 = knee ext
L4 = ankle DF
L5 = big toe ext/hip abd
S1 = PF/eversion/knee flexion
S2 = hip extension
What two types of tests are performed for dermatome testing in the L-spine scan?: 1. Light touch (use cotton ball - spinothalamic tract)
2. Sharp/Dull (paper clip = spinothalamic tract)
What reflexes are tested in the Lspine scan?: L3 = Patellar/Quads

L5 = Hamstrings

S1 = Achilles
What 3 tests are used to detect cord and UMNLs?: 1. Plantar Response (Babinksi sign = UMNL)
2. Clonus (UMNL)
3. Oppenheimer's sign (+ is stroke med tibia = upward great toe = UMNL)
What articular tests are conducted as part of the L-spine scan?: 1. P/A to SPs
2. SIJ stress tests (ant and post distraction)
What neural mobility tests are conducted as part of the L spine Scan?: 1. SLR
2. Slump
3. PKB
What pulses can be checked in the Lspine scan?: Femoral, popliteal, dorsal pedal, post tib
What level are the iliac crests for most patients?: l4-l5 interspace
What level are the PSIS at?: S2
What joint specific questions would you ask about the hip (5)?: 1. Clicking or giving way?
2. Morning stiffness and duration?
3. Pain on squat, stairs?
4. History of W sitting, in-toeing?
5. Footwear?
Name 3 joint stability tests for the hip?: 1. Torque
2. Compression
3. Distraction
Name joint stability tests for the knee.: 1. Lachmann's
2. Anterior and posterior Drawer
3. Valgus and Varus stress
4. Appley's
5. McMurrays
6. Compression
7. Distraction
8. Patellar Apprehension
Mandatory C-Spine Scan questions (12): 1. Bilateral or Quadrilateral paraesthesia
2. Hemiparasthesia (w/ contralat facial parasthesia)
3. Facial Paraesthes
4. Bowel or bladder dysfx
5. 5Ds: Dizziness/vertigo, drop attacks, dysphagia, dysarthria, diplopia
5. Peri oral numbness
6. URTI
7. Traumatic MOI, immediate onset of pain?
8. Periodic LOC
9. Effect of cough on pain?
10. Headaches
11. Meds (steroids, NSAIDs, anticoags)
12. Special Tests/Investigations
List the key movement patterns tested for myotomes C1-T1: C1/2 = short neck extensors
C3/4= shoulder elevation
C5 = shoulder abduction
C6 = Elbow flexion/Wrist extension
C7 = Elbow extension/Wrist flexion
C8 = thumb extension
T1 = 5th digit abduction
What reflexes are tested in the C-spine scan?: C4-C7

But most often:
C5-6 = Biceps
C6 = Brachioradialis
C7 = Triceps
What 3 Neural Mobility Tests can be performed for Cspine scan?: 1. Upper limb tension tests (Ulnar, median, radial biases)
2. Slump
3. Shoulder retraction (C8-T1)
When should vertebral artery testing be done? (3) When should it NOT?: SHOULD
1. History of dizziness
2. Prior to any rotational, extension or traction techniques on C-spine
3. As C-spine ROM increases

NOT
If S & S indicate medical referral
Describe the process of testing vertebral artery sufficiency: 1. Sustained 10 sec R rotation
2. Sustained 10 sec L rotation
3. Sustained 10 sec combined rotation and extension (L & R)

*Wait 10 sec between each position.
*If no symptoms, go straight to rot + ext test
Describe the entire vertebral artery testing procedure (8): 1. Subjective Hx
2. Neuro exam (Myotomes, Dermatomes, Reflexes, Clonus/Plantar/Hoffmans)
3. AROM
4. CV Stability Tests (Alar/kinetic test, Sharp-Purser, Anterior)
5. Vert Artery Testing
6. Hautards and other Vestibular tests
7. Provoking position described by patient
8. Pre mob/manip hold
List Vertebral Artery symptoms (9): Dysphagia, Dysarthria, Diplopia, Dizziness or Vertigo, Drop Attacks, Ataxia, Peri-oral numbness, Nystagmus
List cord signs (4): Ataxia, Quad Paraesthesia, HYPERtonicity, Bowel & Bladder dysfx
Describe vertebral artery testing (Active, passive, Hautards): AROM (sitting)
1. Cspine Flexion
2. Cspine rotation
3. Cspine extension
4. Cspine rot + ext

PROM (supine)
1. Cspine flexion
2. Cspine rotation
3. Cspine extension
4. Cspine traction
5. Cspine rot + ext
6. Cspine traction + rot + ext

Hautards
List mandatory Tspine Questions (6): 1. Bilat or Quadrilat Paraesthesia (Cord)
2. Effect of physical exertion
3. Effect of eating
4. Effect of breathing
5. Effect of flex or twisting posture
6. Severity (hyperacute cardiac or disc prolapse)
Define myotome & dermatome: Myotome - muscles supplied primarily by one nerve root

Dermatome - skin supplied primarily by one nerve root
What functions are the following lobes responsible for? Frontal, Parietal, Occipital, Temporal: Frontal - motor fx, speech, thought/exec planning

Parietal - Touch, proprioception

Temporal - hearing + other senses, memory

Occipital - vision
What are the following lobe functional areas responsible for? Motor Cortex Pre-motor cortex Broca's area Somasthetic Cortex Wernicke's Area Pre-Frontal Area: Motor Cortex - discrete muscle movements

Pre-motor cortex - patterns of movements

Broca's - (generating) Speech

Wernicke's - (understanding) speech

Somesthetic - detects tactile and proprioceptive sensations

Pre-frontal Area - 'elaborates thought'
What 3 components make up the diencephalon and limbic system and what are their functions: 1. Thalamus - Relays sensory signals to cortex (to be able to make sense of sensory input)

2. Hypothalamus - Integration of ANS (regulation of hormonal secretion thru pituitary)

3. Subthalamus - Controls planning and programming of movement (w/ basal ganglia)
What are the structures in the PONS and their functions?: 1. relay info from cerebral hemispheres --> Cerebellum--> spinal cord

2. CN 5,6,7,8 = eye and facial mvmts, sensory input for balance, auditory systems, skin of face

3. Medial lemniscus - sensory signals to thalamus
What is are important structures and functions of the MEDULLA OBLONGATA?: Pyramids decuss = crossover of corticospinal tract

Medial lemniscus decuss = cross over of med lemniscus

CNs 9-12: motor signals to larymx, tongue, neck mms, parasympathetic system, sensory from viscera
What is the important structure and function of the RETICULAR FORMATION?: 1. Vasomotor centere - controls vasotone, arterial pressure, heart articity

2. Respiratory centere - controls inspiration and expiration
What is the importance of the CEREBELLUM?: Coordination and integration of sensory and motor information (smoothness of mvmt, balance)
What tracts run through white matter of the SC? (8) What are their functions?: 1. Propriospinal - signals btwn spinal segments

2,3. Lateral & Ventral corticospinal - MOTOR signals from CORTEX --> cord

4. Dorsal Column (ascending, sensory - detects vibration and touch)

5,6. Ventral & Lateral SPINOTHALAMIC (ascending, sensory - crude touch, pain, temperature signals to brain stem and thalamus)

7,8. Ventral and Dorsal SPINOCEREBELLAR - proprioceptor signals to cerebellum (SC --> Cerebellum)
Explain why nerve roots are more susceptible to injury than peripheral nerves: 1. Funiculi are straighter in nerve roots (less ability to stretch/traction)

2. Nerve roots have minimal epineurium and no perineurium (less tensile strength, less resistance to compression, less ability to cope w/ edema)

**Nerve roots have fewer protective/nourishing layers and are already quite straight so less ability to cope with traction or compression or edema)**

Peripheral nerves
1. have some slack and arranged in plexi (allow movement/stretch/glide)
2. Have 3 layers of protective covering (endo, peri, epineurium = tensile strength, resistance to compression and edema (perineurium allows fibroblasts, macrophages, mast cells to infiltrate to nourish during edema)
How is blood supply well designed to nourish nervous system? 4 (requires more vascular supply than muscles and joints!!): 1. Multiple segmental supply
2.Plexus and branching formation
3.Feeder arteries at tension points
4.Plasticity in vasc system allows axial vessels to straighten and transverse vessels to fold

*Note - nerve roots have more limited blood supply and more vulnerable to ischemia. Also rely on CSF for nourishment**
Describe the 3 meningeal layers of neural connective tissue: 1. Pia mater - innermost layer, highly vascular, thin membrane, intimate w/ SC and nerve rootlets,denticulate ligament btwn pia --> dorsal/ventral rootlets

Subarachnoid space (btwn pia and arachnoid, contains CSF and blood vessels)

2. Arachnoid Mater - Delicate, thin, AVASCULAR membrane, invests ventral and dorsal nerve roots but not with spinal nerve

3. Dura - tough, dense outermost, loose sheath. Continuous with intracranial dura! Attached to circumference of foramen magnum and post bodies of C2-C3,PLL via Hoffman's ligs. Invests all spinal nerves in a sleeve and attaches to IVF.

Epidural space - contains fat and veins

**All layers end at S2/filum terminale and attaching to coccyx**
Describe the 3 layers of peripheral connective tissue: Endoneurium: Blood - nerve barrier, no lymphatics, maintains positive fluid pressure

Perineurium: surrounds bundles of nerves, mechanical barrier to external force, most resistant to tensile force, storage area for fibroblasts, macrophages, mast cells d/t blood supply. Forms a 'diffusion barrier' to prevent epineurial edema from reaching perinerium

Epineurium - THICK, Irregular, dense, surrounds group of funiculi (nerve trunk), provides tracks for blood vessels and lymphatics. Provides cushioning to resist compression
How do neural CT coverings allow for movement and protection?: - Attached to surrounding tissues (mms, joints) to help restrict excessive motion and dispersing pression from external pressure

-Epineurium/Perineurium (outer): Strong, thick and oriented to allow for TENSILE strength, protection vs edema and COMPRESSION

-Endoneurium: Small ability to resist compressive forces
What happens when there is an interruption of axoplasmic flow d/t compression, angulation, torsion or traction? 4: 1. Pain

2. Paraesthesia

3. Paresis

4. Hypoasthesia

5. ??Painless, fatiguable weakness = insufficient replenishment of neurotransmitters.
Typically, is one point of compression sufficient to impede flow above the critical level?: NO. Usually 'double crush syndrome' - requires a secondary compression of same nerve to raise above critical level.

Note - impairment of protein flow (transportation) occurs more readily than electrical conduction impairment
What are common sites of compression? 4: 1. IVF

2. Btwn muscle or facial layers

3. Bony canals

4. over moving bone

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Number of cards 42

Created By sastroh