You are on page 1of 101


Section 1. Differential Diagnosis: General Principles................................................2 Section 2 The Subjective Examination....................................................................... Section ! "bservation..............................................................................................2# Section The $usculos%eletal Examination............................................................ & Section & The 'eurological Tests............................................................................() Section ( The Special Tests......................................................................................(& Section * +ancer an, the "rthope,ic Therapist.......................................................*) Section # Summar- of Previous Sections................................................................#

Section 1. Differential Diagnosis: General Principles

The clinical ,ifferential ,iagnosis is al.a-s provisional an, subject to change either as further information from more objective stu,ies such as bloo, tests an, imaging comes available / for their sensitivit- or lac% thereof0 or from the results of the selecte, treatment. Spinal con,itions that ,o not have overt neural or ,ural signs or s-mptoms are ,ifficult to ,iagnose except on the provisional basis that the selecte, treatment has its pre,icte, outcome. 1or example bac% pain .ith somatic pain ra,iating into the buttoc% that is not accompanie, b- neural or ,ural signs or s-mptoms coul, be cause, b- a number of pathologies. These inclu,e a containe, ,isc lesion2 a 3-gopoph-seal joint ,-sfunction or inflammation2 ligamentous or muscle tearing2 injur- to the outer anulus fibrosis2 compression or other fracture2 bacterial infection or neoplasm. +ertainl- some of these pathologies are much more common than are others an, b- the la. of probabilities alone -ou .oul, probablbe right more often than .rong if -ou generate, t.o or three ,iagnosis base, on fre4uenc- of inci,ence. Even ta%ing into account the clinical fin,ings inclu,ing other aspects of the histor- an, other objective cues2 the ,iagnosis cannot be consi,ere, as having 1))5 vali,it-. The best -ou can ,o is to generate a ,ifferential ,iagnosis in .hich -ou have the best confi,ence. Even imaging stu,ies onl- help confirm a clinical ,iagnosis given the rate false positives an, negatives of $67s an, 89ra-s. The orthope,ic manual therap- examination consists of t.o parts2 a ,ifferential ,iagnostic examination an, a biomechanical examination. "f the t.o2 the former is the more important as it confirms that the patient is appropriate for ph-sical therap-. The latter is vital if specific manual therap- or specific exercise is to be a,ministere,. 1or the most part2 the ,ifferential ,iagnosis is provisional on further2 more objective testing or2 on retrospect2 .ith the patient recovering .ith specific treatment. $an- therapists loo% onl- for re, flags on the ,ifferential ,iagnosis examination rather than a specific ,iagnosis an, .hile this approach is 4uite goo, for preclu,ing inappropriate patients from treatment2 it is of little value in the generation of a specific treatment plan.

:n overvie. of the examinations .oul, loo% li%e this:

Differential Diagnostic (Scan) Examination

;istor"bservation /7nspection0 6outine Selective Tissue Tension Tests Special Tests Peripheral Differential Screening Examination

Neurophysiological Examination
$uscle <ul% $uscle :ctivatabilitStrength 6esponse to Proprioceptive 7nput

Biomechanical Examination
<iomechanical Screening Tests Passive Ph-siological $ovements Passive :ccessor- $ovements 'on9=igamentous :rticular or Segmental Stabilit- Tests This boo% .ill mainl- concern itself .ith the ,ifferential ,iagnosis> biomechanical evaluation is too comprehensive a subject to inclu,e here in an-thing other than principle. The ,ifferential ,iagnostic examination can be ,ivi,e, up as follo.s:

Subjective "bservation :ctive $ovements Passive $ovements 6esiste, $ovements Stress Dural Dermatome $-otome 6eflexes Special Tests ?ertebral arter@pper limb tension Aua,rant PhalanBs TinnelBs Etc

Section 2 The Subjective Examination

The histor- is perhaps the most important part of the clinical examination of the patient. : careful subjective examination .ill be the tool most li%el- to uncover re, an, -ello. flags. 7t .ill provi,e the examiner .ith important information regar,ing the patientBs problem. Disabilities2 s-mptoms2 s-mptom behavior2 irritabilit-2 exacerbating2 provo%ing an, relieving factors can onl- be ascertaine, from the subjective examination. : past histor- of similar s-mptoms or non9musculos%eletal con,itions can be important in the examiner becoming suspicious that the patientBs problem ma- not be benign in nature or musculos%eletal in origin. Past treatments an, the results of these treatments ma- in,icate the best route to follo. for management an, as importantl- .hat treatments to avoi,. 7t .ill affor, information regar,ing the patientBs personalit-2 attitu,e to his or her problem an, the li%elihoo, of compliance .ith the therapistBs instructions regar,ing exercises2 rest2 activities etc. The section .ill loo% at information generate, from the subjective examination of the patient an, possible interpretations that can be put upon it especiall- .hen combine, .ith information garnere, from the objective examinations. Ce .ill loo% first at 4uestions that pertain to all regions2 spinal an, peripheral2 an, then .e .ill ,iscuss region specific histor- ta%ing. The purpose of ta%ing a histor- is to ,etermine: The patientBs profile :ge gen,er "ccupation =eisure activities 1amil- status Past me,ical histor +urrent an, past me,ications The patientBs s-mptomatolog-2 inclu,ing: The onset The s-mptoms nature The s-mptoms severit The level of irritabilit Exacerbating an, relieving factors :ssociate, factors /,iet2 posture2 activit-2 etc0 The patientBs level of ,isabilit The stresses the patient must be able to tolerate in ,ail- activities :n- other previous or current me,ical con,itions that .ill impact on the assessment or treatment


:n- current me,ications that might impact on the assessment or treatment :nother past histor- of t-pe :n- other ph-sical treatments for this or other similar con,itions an, the results of the treatment "pening communication channels .ith the patient Establishing a .or%ing relationship .ith the patient Gaining an appreciation of the patientBs li%el- compliance .ith programs Gaining an appreciation of the patientBs attitu,e,s his or problem The lists the main 4uestions that nee, to be as%e, most patients. Some are region specific. 1or example there is little point in as%ing about ,i33iness .hen the patient is atten,ing for lo. bac% pain. The 4uestions on the list .ill be ,iscusse, in ,etail either in the general principles section of histor- ta%ing or in the region specific examination section of this section. A. Patient Profile :ge /ol,D-oung0 Gen,er "ccupation an, ,escription of ,uties =eisure activities an, their fre4uenc- an, intensit 1amil- status Past me,ical histor- /cancer2 ,iabetes2 s-stemic arthritis2 congenital collagen ,isor,er0 +urrent an, past me,ications /steroi,s2 'S:7Ds2 insulin2 ,i33iness provo%ing0 Past surgeries /cancer2 spinal2 neurological0 B. Pain and Paresthesia "nset /traumaticD non9traumatic imme,iateD,ela-e,2 insi,iousDsu,,en2 causeDno cause0 =ocation /stea,-D changing2 localDextensive2 segmentalDnon9segmental2 continuousD,issociate,2 shiftingDexpan,ing0 T-pe /somatic2 neurological0 Severit- /scale of 1)0 7rritabilit- /ho. much stress to irritate an, ho. much time for relief0 :ggravatingDabating factors /activitiesDpostures2 eatingD,iet2 generalDemotional stress0 'octurnal /aching or su,,en sharp pain0 Cor% relate, or not +onstant2 continuous2 intermittent Episo,icDnon9episo,ic C. ther Symptoms and !hat Pro"o#es $hem Di33iness /t-pe 12 2 or !0 ?isual ,isturbances /scotoma2 hemiD4ua,ranopia2 floaters2 scintillations2 blurring2 tunnel0

Taste or smell ,isturbances D-sphagia /painfulDpainless0 :mnesia /traumaticDnon9traumatic0 ?omiting +ough changes /non9pro,uctive to pro,uctive0 Sputum changes /clear to -ello. or green2 fresh or ol, bloo,0 Cea%ness +lumsiness Gait ,isturbances /ataxia2 staggering2 tripping0 Drop attac%s S-ncope /fre4uenc-0 Photophobia Phonophobia ;-poacusia ;-peracusia Tinnitus /highDlo. fre4uenc-2 unilateralDbilateral2 pulsatileDnon9pulsatile0 7ntellectual impairment /,ro.siness2 concentration ,ifficulties0 <la,,er changes /retentionDincontinence2 color changes2 o,or changes0 <o.el changes /unable to expel2 ,iarrhea2 constipation2 bloo,0 7ncrease, s.eating Distal color changes /re,,ening2 bluing2 .hitening0 +hanges in facial appearance /,rooping2 ptosis2 re,,ening2 enopthalamus2 exopthalamus0 D-sarthria /slurring0 D-sphonia h-poesthesia or anesthesia /unusual in the histor-0 ;-peresthesia 7n,igestion 6ecent fever

D. %andatory &uestions Di33iness +ranial nerve s-mptoms =ong tract s-mptoms <la,,er2 bo.el or genital ,-sfunction "steoporosis ?ertebral arter- s-mptoms E. Past Episodes and $reatments 1re4uenc- /increasing2 stea,- or ,ecreasing0 S-mptom intensit- /increasing2 stea,- or ,ecreasing0 S-mptom location /stea,- changing /sprea,ing2 shifting or expan,ing0 Severit- /increasing2 stea,- or ,ecreasing0 7rritabilit- /increasing2 stea,- or ,ecreasing0 Past treatment /t-pe2 helpe,D.orsene,Dunchange,0


ther (n"estigations and )esults 89ra-s $67 $6: +T scans <one scans Scintillographs PET scans E'G EEG EEG E$G 'erve con,uction stu,ies

A. Patient Profile The patient profile inclu,es gen,er2 age2 occupation2 famil- status leisure activities an, past an, present me,ical con,itions an, current me,ications. :ge +hil,ren .ho are in enough pain to .arrant ph-sical therap- shoul, al.a-s be vie.e, .ith suspicion. 1or the most part2 minor injuries in chil,ren recover 4uic%l-. The- ten, not to have the chronic problems that a,ults suffer from2 as the- have not -et ha, the opportunit- for cumulative stress or ,egeneration to ta%e their toll. 'either ,o the- normall- have the ps-chological or financial baggage that goes .ith a,ults an, is capable of complicating an other.ise uncomplicate, injur-. So that a chil, complaining of ongoing pain ma- have a more severe injur- than the trauma .oul, suggest or be suffering from a serious ,isease. ;o.ever2 to,a- .here chil,ren are being pushe, har,er an, har,er into various forms of competitive sports2 .e are seeing more a,ult t-pes of ,-sfunction in chil,ren than previousl-. +onse4uentl- a ,etaile, histor- must be ta%en not onl- of the imme,iate precursor but also of ho. involve, the chil, is in sports an, .hat if an- previous injuries have occurre, an, ho. the- progresse, .ith treatment. The ol,er patient is2 of course2 more ,ispose, to ,egenerative con,itions2 not onlof the musculos%eletal s-stem but of other s-stems also. +ancer2 coronar- an, cerebral an, brainstem infarcts ma- all be factors in the assessment an, treatment of the ol,er patient. The age of the patient .ill also give an i,ea of .hat the range of motion shoul, be .hen the results of movement tests are consi,ere,. The ol,er patient can be expecte, to be a little stiffer than the -ounger2 as ,egeneration increasingl- becomes a factor. : -oung person .ho is stiff has either ver- high muscle tone or possibl- a s-stemic joint con,ition.

: mi,,le9age, to el,erl- .oman is more li%el- to have breast cancer than a -oung one or a man /the me,ian age at ,iagnosis is &* -ears an, is less than 1 per 1))2))) before 2& -ears of age as compare, to !F* per 1))2))) at age #)0i. Gen,er This .ill give some in,ication as to pre,isposition. "steoporosis an, g-necological con,itions are either more prevalent in or exclusive to the female. Chile prostatitis2 testicular cancer an, so forth are exclusive to the male. =ung cancer is about t.o an, half times more common amongst men than .omen an, has a higher inci,ence in those .ith previous pulmonar- pathologies such as sclero,erma an, +"PDii. <reast cancer is about 1 ( times more common in .omen than men!. : combination of gen,er an, age .ill often sensiti3e the therapist more than either alone. There is less li%el- hoo, of a thirt-9-ear9ol, man .ith lo. bac% pain having prostate cancer than a sixt-9-ear9ol,. : mi,,le age or el,erl- female is more li%elto have osteoporosis than other groups ,ue to the hormonal ,eficiencies of menopause. "ccupational an, =eisure :ctivities Chile this ma- give some clues as to the un,erl-ing cause of the patientBs problems2 the nee, to %no. exactl- .hat the patient ,oes for a living is more important in prognostication an, post9rehabilitation training. Chen can the patient go bac% to .or% an, for ho. long /that is full or part time02 .ill mo,ifications have to be ma,e in either the patientBs job ,escription or the .or% environmentG Cill retraining be necessar- an, if so .hen can it begin safel-G To these 4uestions2 in mancases at least2 a simple H.hat ,o -ou ,o for a livingGH .ill not suffice especiall- in jobs that are a little more unusual than are those normall- encountere, b- the therapist. Similarl-2 leisure activities re4uire a ,etaile, ,escription as to t-pe an, intensit-. 7s this activit- li%el- to have an a,verse effect on the patientBs progress or coul, it be use, as a rehabilitation tool. 7f the patient insists on continuing .ith the activiteven though the therapist believes it .ill li%el- cause problems2 then an accommo,ation must be reache,. Dela-ing the resumption of the activit- ma- help especiall- .hen there is an- ,egree of inflammation present. 6e,uction in its intensit- ma- also be useful. 1or example2 a golfer .ith thoracic or lo. bac% pain can be as%e, to not ,rive the ball but to pla- the shorter shots. Chile this ma- not be .hat the patient .ants to hear2 it at least allo.s him or her to pursue the activiteven if in a severel- mo,ifie, fashion. 1amil- Status Does the patient have support at home the necessar- rest or time to exercise at homeG +an the patient avoi, a,verse activities at home b- having

somebo,- else ,o themG 7s this a perio, of stress at home2 .hen little if ancooperation is to be foun,. +an the patient get somebo,- to help .ith the exercises if this is necessar- or .ill -ou have to mo,if- themG Chat are the ages of the chil,ren an, ho. much care must the patient give to them. 7f re4uire,2 the therapist must teach the patient ho. to mo,if- positions for nursing or changing infants2 ,ressing smaller chil,ren an, recruiting ol,er chil,ren to ta%e over some of the chores. Past an, Present $e,ical +on,itions $ost of the patientBs me,ical histor- .ill be of no relevance to us an, on recogni3ing this2 4uestioning shoul, be ,iscontinue, on that subject as this is simplan invasion of the patientBs privac- .ithout there being an- clinical necessit-. ;o.ever .e shoul, listen for a histor- of s-stemic arthritis2 s%in rashes2 cancer2 ,iabetes2 coronar- con,itions2 cerebral stro%es. :s%ing about cancer can be a problem. :n- mention of the ,isease to some people generates panic .ith the patient believing that -ou are as%ing because -ou thin% that the- have it. To avoi, this2 the 4uestion can be put on a 4uestionnaire that the patient fills out before seeing the therapist. : past histor- of cancer shoul, al.a-s ,eman, that the therapist as% 4uestions about previous screening for metastases preferabl- from the ph-sician rather than the patient unless the patient volunteers the information. There is no point in .orr-ing the patient about something that ma- not be an issue. <ut if screenings have not be ,one in at least the previous six months2 the therapist shoul, be concerne, an, more than a little critical of the results of the objective examination. 7f cancer is a factor as% the patient if the- are receiving ra,iation therap- or have receive, it recentl-. "ften ra,iation therap- patients are put onto s-stemic steroi,s for the ,uration of the therap- an, of course this .ill alter collagen strength. Diabetes ma- cause arthropathiesiii an, neuropathiesiv as .ell as ,ela-ing recover-. +oronar- or cerebral vascular con,itions shoul, lea, the therapist to be especiallcareful .hen treating cervical patients as these con,itions are evi,ence of s-stemic atherosclerosis an, the vertebral arter- ma- be similarl- affecte,. 7n a,,ition2 anexercise program nee,s to be planne, .ith the con,ition in min,. S-stemic arthritis2 particularl- rheumatoi, arthritis or an%-losing spon,-litis shoul, ma%e the therapist cautious especiall- .hen treating the nec%. <oth of these con,itions are intimatellin%e, .ith atlanto9axial instabilit- an, subluxationv2vi2vii. 7f a chil,Bs nec% is to be treate, as% about an- histor- of recurrent chest infections as this can lea, to GriselBsviii s-n,rome .ith its accompan-ing transverse ligament laxit-. There is the possibilit- that a heart con,ition is pro,ucing the s-mptoms of .hich the patient is complains. "ften heart patholog- .ill ma%e itself felt through an ache ,o.n the ,o.n the ,eltoi, an, lateral bor,er of the upper arm mimic%ing shoul,er joint pain. 7t is2 of course2 vital that provo%ing or exacerbating activities be ,iscusse, in ,etail.


7t is also .orth noting .hat the patient has to sa-2 if an-thing2 about congenital anomalies as these in,icate the presence of anomalies in other s-stems as almost all congenital anomalies are associate, .ith others ,erive, from the same affecte, embr-ological bloc%ix. :gain this is of particular importance in the cervical region .here a cervical rib or SprengleBs ,eformit- or pol-,act-l-2 as examples2 coul, also in,icate an anomal- or anomalies of the vertebral arter-. +urrent $e,ications "ften the patient forgets to mention me,ical con,itions but .ill tell -ou that theare ta%ing such an, such a ,rug. This naturall- lea,s -ou bac% to the reason for ta%ing the me,ication. 7n a,,ition2 certain me,ications .ill affect -our treatments. 1or example it is probabl- not the best i,ea in the .orl, to appl- ,eep frictions or give strong exercises to a ten,on or ligament that has recentl- /sa- the last three .ee%s0 been injecte, .ith steroi,. +ortisone injections into the tissue .ill .ea%en the collagen injecte, an, ma- result in rupturex2xi2xii. S-stemic steroi,s .ill cause generali3e, collagen .ea%ness2 .ater retention an, generali3e, .ea%ness an, ten,erness all of .hich can affect the results of the -our examination an, the outcome of the -our treatment. :nticoagulants are a contrain,ication to manipulation an, ,eep transverse frictions for obvious reasons. There are about four hun,re, me,ications %no.n to cause ,i33iness as an a,verse effect2 these inclu,e aspirin an, other 'S:7DBs2 s-stemic steroi,s2 amminogl-cosi,ic antibiotics2 ,iuretics an, anti9anginalsxiii2xiv. "bviousl- these must be consi,ere, .hen assessing a patientBs ,i33iness. B. Pain and Paresthesia Pain is the most common complaint bringing the patient in to the generalist orthope,ic therapist. Pain is a ver- subjective s-mptom an, varies not onl- from patient to patient for the same stimulus but from hour to hour an, from context to context. : trauma that .ill ,isable one person .ill leave another in,ifferent. :s a conse4uence it is not vulnerable to objectification an, the patientBs ,escription is the onl- source that the therapist has .hen ,etermining its 4ualities. Therefore ,escriptions of its t-pe2 location2 behavior2 intensit- etc are extremel- important in ma%ing a ,ifferential ,iagnosis. "nset 7s the pain relate, to traumaG 7f so .as it imme,iate or ,ela-e,. :n imme,iate onset of severe pain often in,icates profoun, tissue ,amage such as ligamentous or muscular tearing or fracture. 1or example2 the imme,iate onset of cervical pain motor vehicle acci,ents is recogni3e, from a number of retrospective an, prospective stu,ies to in,icate a poor prognosisxv. : ,ela-e, onset is more commonl- encountere, an, is often ,ue to the inflammator- process .hich ta%es time to ma%e itself felt. 7n a,,ition to pain2 ,i, the patient hear an- noises at the time of the injur-G +rac%ing2 tearing or popping noises coul, in,icate su,,en


,amage. Cas there s.elling an, .hen ,i, it occur. 7mme,iate severe s.elling is strongl- suggestive of hemarthrosis. Significant articular trauma causing pain but no s.elling coul, mean that there is a rent in the capsule through .hich the inflammator- exu,ate or bloo, is lea%ing 7f the pain is not relate, to overt trauma .as there a particular activit- that cause, it. "ccasionall- the patient .ill relate that it .as traumatic in origin2 but on further 4uestioning the amount of trauma .as ver- minor compare, .ith the ,egree of pain an, ,isabilit- that the patient is experiencing. 7n this case2 the trauma ma- simpl- be the final stra. put on the camelBs bac%. Iou ma- nee, to search for the factors that stresse, the faile, area to the point .here a minor stress finishe, it off. The categorinto .hich most patients fall in the general orthope,ic practice is non9traumatic. The patient can relate no over9stressful activit- or posture that either starte, or provo%e, the problem. The cause ma- have simpl- been lifting a mo,erate loa,2 su,,enl- turning the hea,2 .a%ing up .ith a Hcric%H in the nec% or something as e4uall- innocuous. There are more inci,ents of lo. bac% injur- from lifting objects out of the bac% of the car than putting them in. Ch-G Probabl- because usuall- the lifter has ,riven an, so pre,ispose, the spine to injur-. =ife is li%e that2 .e spen, our -outh an, -oung a,ulthoo, pre,isposing our bo,ies to failure from injuries that on less abuse, musculos%eletal s-stems .oul, be insignificant but on the person a fe. -ears ol,er ,isaster stri%es. The overuse, term Hoveruse s-n,romeH is an example of non9traumatic pain. 7t suggests that simple overuse .as the cause of the patientBs s-mptoms an, ,isabilities. 7n some cases2 this is accurate an, the term is being use, as it shoul, be. <ut in a substantial number of instances /7 .oul, suggest the majorit-02 it is not an accurate ,escriptor. Tennis elbo. is an excellent example of this. The patient atten,s .ith an epicon,-lar /or an- other t-pe0 tennis elbo. that is confirme, on clinical examination. The patient is then as%e, about his job. "n being tol, that he is a carpenter an, spen,s a large part of his ,a- hammering nails into boar,s2 the therapist is happ- to la- the blame here an, treat it as a primar- tennis elbo.. The fact that the patient ha, been ,oing the same job in the same .a- for fifteen -ears ,oes not enter into the e4uation. 7f -ou are hammering all ,a- then that is overuse. 7t is not overuse for that person. Perhaps if he ha, onl- been ,oing the job for six months2 or if he ha, just come bac% from a month on vacation or if he ha, change, his hammer or the position he .as hammering in2 this might have been a reasonable ,e,uction. <ut it is not a goo, i,ea to assume that the most obvious is the correct one. :lmost certainl- something ha, change,2 if it .as not the job then it .as something else. Some of the factors mentione, above ma- obtain or perhaps his nec% .as ,-sfunctional. 7n the absence of a clear9cut case of unfamiliar overuse2 the therapist nee,s to loo% for other reasons. : patient complaining of posterior thigh pain atten,e, an orthope,ic surgeon2 .ho tol, her that she suffere, from a torn hamstring. She sai, -es2 she %ne. that but .h- ,i, it tear. ;e sai, it .as because she .as a runner. To .hich she replie, J<ut 7 run on both legs.K Simplistic explanations li%e that offere, to this -oung la,- are the root cause of failure to improve or failure to maintain improvement. 7n a,,ition2 be careful of those cases


.here there is no apparent cause. Chile the vast majorit- of these patients .ill be, musculos%eletal problems2 it is from this group that the s-stemic arthritic an, cancer patients .ill be ,ra.n. Pain AualitThe nature or t-pe of pain the patient is experiencing is vital in assessing the con,ition. There are a number of ,ifferent classifications for pain but for the purposes of ,ifferential ,iagnosis the is as goo, as an- an, better then most. Pain can be classifie, as neuropathic /neurological0 or somatic /non9neurological0. Experiments have ,emonstrate, that simple compression of an uninjure, spinal nerve or spinal nerve root /.ith the exception of the ,orsal root ganglion0 ,oes not result in pain. The result of simple compression experimentall- is paresthesia2 numbness2 neurological ,eficit or all three but not painxvi2 xvii. ;o.ever it has been ,emonstrate, that compression or other forms of irritation of previousl- injure, spinal nerves or nerve roots can cause pain of a ver- particular t-pe. 7n a,,ition2 it has been postulate, that intraneural or perineural oe,ema ma- pro,uce nerve root ischemia2 .hich in turn ma- cause ra,icular s-mptomsxviii. This ra,icular pain is lancinating or shooting an, encompasses less than one an, a half inches in .i,th a running ,o.n the limb or aroun, the trun%xix2 xx. :s a conse4uence2 the recognition of ra,icular s-mptoms is ver- eas-. 7t is lancinating pain2 paresthetic2 causalgic or numb. :n- s-mptoms other than these cannot be ascribe, to spinal nerve or root compression or inflammation. 1or an excellent short ,iscourse on this subject rea, <og,u% an, T.ome-1#. The non9neuropathic or somatic pain is generall- ,escribe, as aching. 7t can be versevere or ver- mil, but it is not shooting in 4ualit-. @nfortunatel- this t-pe of pain2 .hen felt in the leg or arm is inaccuratel- ,escribe, as root pain. <ase, on experimental ,ata2 it is not. The non9neurological structures2 the ,ura2 the external aspect of the ,isc2 the ligaments2 periosteum2 bone an, so on are nociceptive an, can generate this pain1#2xxi. 7t ,oes not have the electric 4ualit- commonl- ,escribe, .hen true ra,icular pain is experience,. The argument has been ma,e that root pain ma- not be as ,escribe, above an, points to ,iabetic neuropath- an, chronic root pain .here the patient ha, E$G or clinical evi,ence that there .as a neuropathpresent but experience, Jnon9neurologicalK pain. ;o.ever2 there is no evi,ence that the pain .as in fact coming from the root2 it ma- have arisen from some other compromise, somatic structure. T-picall- if the orthope,ic patient is experiencing lancinating root pain2 there is also somatic pain present as the compressing tissue2 usuall- the ,isc2 is also compressing the ,ural sleeve of the nerve root1#. Somatic JsciaticaK is felt either continuousl- or .ith postures such as sitting .hile the 3inging pain is ver- intermittent coming on su,,enl- ,uring trun% flexion for example. :t other times2 the lancinating pain is t-picall- absent. +linicall-2 it seems that it .oul, be pru,ent to accept current experimental ,ata an, reserve the term root pain for those patients presenting .ith


lancinating pain or causalgia as this .ill re,uce the over fre4uent ,iagnosis of root compression an, the a,ministration of inappropriate treatments. "n the other han,2 it is not beneficial to the patient to mis,iagnose a ,isc lesion that might onl- be either compressing the ,ural sheath of the root or spinal nerve or appl-ing pressure to the un,amage, nerve tissue .ithout causing inflammation. The ris% no. is that inappropriate treatment ma- ,amage the ,isc further causing fran% compression .ith neurological ,eficit. The absence of lancinating pain or other neurological s-mptoms ,oes not preclu,e a ,isc herniation as the cause of the patientLs ,isabilit-. :s al.a-s2 the to the 4uan,ar- lies .ith the rest of the examination. : ,iagnosis is not base, solel- on the histor- but on anal-sis of the total examination ,ata. "ther neurological con,itions causing pain have to be consi,ere, .hen ta%ing a histor-. Thalamic pain s-n,romes2 herpes 3oster /shingles02 ,iabetic an, other neuropathies2 pol-neuropathies2 arachnoi,itis ma- all be erroneousl- referre, to the ph-sical therapist in their earl- stages. The ,escription of pain from neurological sources such as these ten, to be more vivi, than it is from orthope,ic sources even those causing spinal nerve or root compression. Descriptors inclu,e stabbing2 %nifeli%e2 a storm or shoc%2 burning2 ban,9li%e2 flesh tearing an, in,escribable. 7t is believe, that the reason for this ,ifference in ,escriptors bet.een neurological an, somatic cause ma- be that ,-sesthesia confuses the patient .ho ,oes not %no. ho. to ,escribe this totall- unfamiliar sensationxxii. ?isceral referral of pain to the s%in is believe, to occur as a result of the s-napsing of primar- somatic sensor- neurons an, visceral sensor- neurons onto common secon,ar- neurons of the ,orsal horn of the spinal cor,xxiii. <ecause of the ,istribution of nociceptors an, pain fibers2 visceral pain is generall- felt to be ,ifferent from musculos%eletal pain. Cith the exception of the parietal linings of the cavities /pleural2 peritoneal an, pericar,ial02 nociceptors2 are sparingl- ,istribute, in the viscera an, fast pain fibers are to all intents an, purposes absentxxiv. :s a conse4uence2 the fast pain associate, .ith the musculos%eletal s-stem is not common in visceral ,isor,ers unless the cavit- linings are involve, as the- ma- be .ith a,vance, ,isease. ?isceral non9cavit- pain is fre4uentl- ,escribe, as ,eep2 ,iffuse an, .aveli%exxv but also often in the same .a- as that ,escribe, for musculos%eletal pain. +onse4uentl-2 it becomes ,ifficult to rel- on the 4ualit- of pain to ,iscriminate bet.een that arising from the viscera an, that coming from a musculos%eletal problem .hen it is ,escribe, as musculos%eletal. 7t is therefore ver- important that no ,efinite conclusion is reache, one .a- or the other until further information is obtaine,. This information ma- .ell be forthcoming as the histor- progresses. The patient .ho relates that the pain is associate, .ith ,iet2 eating or the position assume, .hile eating is probabl- telling -ou that a gastric ,isor,er exists. +hol-c-stitis2 gastric or ,uo,enal ulcer ma- all present in this manner. ;o.ever remember that the patient is sitting .hen eating so ma%e sure that -ou as% about the chair an, .hether sitting in this chair or one li%e it .hen not eating causes the same problem.

+hest or shoul,er pain on generali3e, exertion such as running for a bus or .al%ing upstairs or non9ph-sical stress has a high potential for being cause, b- car,iac problems. "n the other han,2 pleural pain from a,hesions or pleuritis can be extremel- ,ifficult to ,ifferentiate from a thoracic spine or rib ,-sfunction as the structure is innervate, b- fast pain fibers an, so can pro,uce musculos%eletal t-pe pain. 7t is also attache, to the ribs2 .hich complicates the objective examination picture2 as trun% motion .ill probabl- repro,uce the patientLs pain. =ocation The location of the pain is usuall- of little value in the exact locali3ation of the source of the pain2 ,ue to the multiplicit- of the levels innervating most tissues2 an, the number of tissues that might be the source. ;o.ever2 the site of the pain ma- be useful in obtaining an, i,ea of the embr-ological levels from .hich the affecte, is ,erive,. 'either ra,icular nor somatic pains are consistent in their areas of sprea,. The referre, areas of both neurological an, somatic sources of pain var- bet.een in,ivi,uals as .ell as .ithin the same in,ivi,ual the latter seemingl- a function of the intensit- of the stimulus. ;o.ever2 neurological s-mptom sites are a better in,ication of source than are somatic pain sites. The ,egree of ra,iation is ,irectl- relate, to three factors: Stimulus intensit- /the higher the intensit- the more referral0 Stimulus centralit- /the more central the more ra,iation0 Stimulus superficialit- /the more superficial the less ra,iation0 +onse4uentl-2 the greater the ,egree of ra,iation the more li%el- is the chance that the problem is acute an,Dor proximal. <ut2 even .ith the ,iagnostic limitations place, on us b- the vagaries of pain2 often useful information can be gaine, form the location of pain. ?er- local pain is ver- li%el- to be from a structure un,er the pain area an, referre, pain that is not ,iffuse ma- in,icate the spinal segment from .hich it is ,erive,. 7t is the therapistBs job to use ju,gement about ho. reliable the pain site is li%el- to be in a particular case an, to integrate that information .ith other ,ata generate, from the histor- an, objective examinations to pro,uce a .or%ing h-pothesis as to its source. Grievexxvi ma,e the conclusions on pain 4ualit-: 1. :ll root pain is referre, pain but not all referre, pain is root pain. 2. Severe referre, pain is not necessaril- ,ue to root compromise from inflammation or other forms of irritation !. 6eferre, pain2 .hich is ,ue to root involvement2 is not necessaril- severe. . Simple root compression ,oes not cause pain an, ma- not cause neurological ,eficit.


&. The imprecise terminolog-2 concerning referre, pain2 at present reflects tra,itional assumptions /often unproven0 about its cause rather than its true nature. (. The topograph- an, nature of referre, pain in an- one patient is ina,e4uate as a single factor in ,ifferential ,iagnosis of both the tissue involve, an, the segmental level. 7 .oul, a,, one more to the list. =ancinating /ra,icular0 pain is cause, b- nerve root or ,orsal ganglion involvement an, is pro,uce, b- more than simple compression. <e careful of ,issociate, pains. @pper lumbar pain associate, .ith shoul,er pain is ver- ,ifficult to reconcile .ith a single musculos%eletal ,isor,er but eas- to associate .ith a visceral ,isease irritating the ,iaphragm. Gall bla,,er2 liver2 basal lung2 spleen2 esophageal an, stomach con,itions can all cause shoul,er pain. 7n general ab,ominal visceral ,isease ten,s to cause lo. bac% an,Dor pelvic pain .hile intra9thoracic problems ten, to cause shoul,er pain. Chile isolate, anterior thoracic an, ab,ominal pain ma- be cause, bmusculos%eletal problems2 there is a ver- real possibilit- that the pain ma- be visceral in source. @suall- spinal con,itions .ill cause local pain in a,,ition to anreferre, pain> therefore2 an- isolate, anterior pain is an o,,it- an, shoul, be treate, .ith suspicion. "n the other han,2 visceral referral can easil- be posterior mimic%ing spinal musculos%eletal ,isor,ers. Perhaps the most urgent con,ition that causes trun% pain that ma- be inappropriatel- referre, is a ,issecting aortic aneur-sm. The pain is often felt onl- in the lumbar an, groin regions sometimes referring pain into the testicle just before it ruptures. Goo,man an, Sn-,erLs Differential Diagnosis in Ph-sical Therap-2 gives excellent ,iagrams of .hich organ refers to .here. ;o.ever2 the role of the therapist in the i,entification of visceral problems la-s not in i,entif-ing .hich organ is causing the pain but in ,etermining that the pain is not musculos%eletal in origin. ;o.ever2 the are the main viscera2 their segmental innervation levelxxvii an, most li%elcutaneous referral area2 2xxviii2xxix. The phar-nx is innervate, b- the maxillar- branch of the trigeminal2 the glossophar-ngeal an, the vagus nerve an, the superior cervical ganglion giving its most common pain areas as the throat an, ear an, conse4uentl- not usuall- mista%en for a musculos%eletal problem. The sensor- suppl- of the esophagus is from the vagus nerve an, the upper five s-mpathetic ganglia. This gives the pattern of referral as the anterior nec% if the superior part of the esophagus is involve,2 substernal if the lesion affects the mi,,le levels an, from the xiphoi, aroun, the chest to the posterior mi, thoracic region.


Tracheobronchial lesions are felt in the throat an, anterior upper chest near the suprasternal notch. The vagal nerve an, me,ial branches of the s-mpathetic nerves from the upper five thoracic ganglia suppl- the trachea an, bronchi. The vagus nerve an, the 29& thoracic s-mpathetic ganglia together .ith the cervical s-mpathetic trun% suppl- the lung but this tissue is essentiall- painless unless the parietal pleura is affecte,. The me,iastinal an, central ,iaphragmatic parietal pleura is innervate, b- the phrenic nerve .hile the costal M the intercostal nerves suppllateral ,iaphragmatic pleura. The pattern of pain ra,iation can inclu,e the nec% an, upper trape3ius if the apical pleura is involve,. 7f the costal pleura is affecte,2 the pain can be felt anterior2 posterior or lateral at the level of the lesion. 7f the basal pleura is affecte, an, irritates the ,iaphragm2 then shoul,er pain can result. 7f metastases sprea, craniall- from the apical pleura2 the brachial plexus an, inferior cervical /stellate0 ganglion can be affecte, resulting in Pancoast s-n,rome. The heart is autonomicall- supplie, b- the cervical an, upper thoracic s-mpathetic ganglia an, from the vagus an, recurrent lar-ngeal nerves. <ecause of common segmental levels in the thorax an, nec% /inclu,ing the cervicotrigeminal nucleus02 referre, pain from car,iac con,itions ma- be felt in anterior or posterior chest2 throat2 ja. teeth an, even inexplicabl-2 the ab,omen. The common area of reference is the left ,eltoi, area an, the left inner arm an, han, although the right shoul,er ma- be affecte,. The ,iaphragm is supplie, b- the phrenic nerve /cervical !2 2&0 for its motor innervation but carries also fibers from cervical to suppl- sensation to the more central parts of the muscle. The six intercostal nerves suppl- the peripheral ,iaphragm. +entral ,iaphragmatic pain is generall- felt through the fourth cervical root at the shoul,er .hile peripheral lesions ma- cause pain in the thoraco9 ab,ominal junction area anteriorl-2 posteriorl- or laterall- ,epen,ing on the site of the lesion. The peritoneum encloses all of the ab,ominal an, pelvic organs an, is the largest serous membrane in the bo,-. The visceral peritoneum receives the same autonomic suppl- as the organ it is associate, .ith an, is insensible to pressure2 cutting2 chemicals or heat. The ,iaphragmatic parietal peritoneum is supplie, in the same manner as the ,iaphragm. That is2 the central part is supplie, b- the fourth cervical segment an, the peripheral part b- the thoracic intercostal nerves. The remain,er of the parietal peritoneum is supplie, b- the overl-ing s%in an, trun% musculature. Cith this in min,2 the pain ,istribution of the specific organs is actuall- the pain ,istribution of the organLs peritoneum. The stomach an, ,uo,enum refers pain to the upper ab,omen just belo. the xiphoi, .ith ra,iation to the posterior trun% level .ith the lesion bet.een the (th thoracic an, the 1)th thoracic levels. 7f the ,iaphragmatic peritoneum is affecte,2 the pain can be felt in the right shoul,er an, upper trape3ius.


The small intestine pro,uces umbilical pain an,2 if severe2 in the mi, to lo. lumbar region. The large intestine can pro,uce pain that is felt in the ab,omen an, sacrum =iver an, gall bla,,er ,isease is usuall- felt in the right upper 4ua,rant or epigastrum .ith referral potential to the right shoul,er2 mi, thoracic an, right inferior scapular regions. $i,line or left to mi,line pain ma- be pancreatic in origin an, ma- ra,iate to the lumbar region or if the ,iaphragmatic peritoneum is affecte, to the left shoul,er. The appen,ix is generall- felt in the right ab,ominal 4ua,rant .ith referral into the epigastrum an, then the right groin an, hip an, occasionall- to the right testicle. Spleen pain ma- be felt in the right shoul,er if it affects the ,iaphragmatic peritoneum of the left upper 4ua,rant2 epigastric or umbilical region. The prostate in ol,er men is one of the more sinister causes of lo. bac% pain. @suall- bla,,er problems in the form of hesitanc- follo.e, b- retention are the normal onset of prostatitis from an- cause but occasionall-2 the onset ma- be lo. bac% pelvic an, hip pain. The %i,ne- an, ureters2 unli%e most of the ab,ominal viscera2 ,o appear2 at least in part2 to be pain sensitive. Cith laceration2 puncture an, pressure pain signals being transmitte, b- the s-mpathetic suppl- from the thoracic an, upper lumbar plexi. :s a conse4uence2 %i,ne- pain can be extreme an, ver- musculos%eletal in its 4ualit-. The pain is mainl- felt in the posterior flan% but can refer aroun, the trun% to the ab,ominal 4ua,rant an, then to the ipsilateral groin an, testicle an, if the ,iaphragm or its pleura is affecte, to the ipsilateral shoul,er. The bla,,er an, urethra are felt primaril- anteriorl- in the suprapubic an, ab,omen .ith referral to the lumbar region. G-necological con,itions inclu,ing pelvic inflammator- ,isease2 cancer of the uterus etc ten, to cause ab,ominal pain .ith ra,iation into the anterior an, or me,ial thigh/s0 more than posterior trun% pain. Cith all of these visceral con,itions2 the pain ,istribution patterns b- themselves .ill not ma%e the ,iagnosis. Pa- attention to the 4ualit- of the pain. +ramp li%e2 vice t-pe2 gna.ing2 .aveli%e2 ,iffuse an, ill ,efine, etc. :lso listen an, loo% for evi,ence of ,-sfunction of the viscera itself such as nausea2 vomiting2 jaun,ice2 changes in coughing habits2 changes in sputum appearance etc. :,,itionall- loo% for s-mpathetic signs or s-mptoms such as increase, s.eating nausea etc. The


,-sfunction of the viscera ma- also sho. up in the .a- the pain behaves. Pain onset or relief after eating2 or onset before eating .oul, suggest a gastrointestinal source. +utaneous areas are associate, .ith the viscera via their nerve suppl-. ;ea,xxx gave the ;eart <ronchi an, =ung Esophagus Stomach =iver an, Gall <la,,er Spleen Ei,ne@reter Pain <ehavior 7s the pain constant2 continuous or intermittentG 7s it felt onl- ,uring the ,a- or ,oes it ,isturb sleep. Does it feel better or .orse at an- particular time of the ,a-. 7s it relate, to particular activities or posturesG ;o. much activit- or time in a given posture ,oes it ta%e to evo%e the pain an, ho. long ,oes it ta%e to rece,e .hen reste,. The ans.ers to these 4uestions can often give information concerning the painLs source2 its acuteness2 an, irritabilit-. +onstant pain is generall- accepte, as suggestive of chemical irritation2 bone cancer or some visceral lesions. The ,etermination that the pain is constant is ma,e bun,erstan,ing that at rest neither the patient nor the therapist can fin, an- position that re,uces the pain. That is2 rest ,oes not ease the pain. Cith most musculos%eletal inflammator- con,itions it is al.a-s eas- to exacerbate the pain .ith testing so it cannot accuratel- be ,escribe, as constant as it ,oes change2 but for clinical purposes2 the term is a goo, one. ;o.ever2 the main criterion is that the short term relief of stress ,oes not re,uce the constant pain. 7f the therapist is unable to exacerbate the pain b- selective tissue tension testing2 it suggests that the source of the pain ,oes not la- in a tissue vulnerable to such testing. This site ma- be in the viscera or in bone2 .hich ,oes not have a ligament or muscle l-ing close enough to pull on the painful area ,uring testing. 7nabilit- to increase the constant pain .ith normal testing proce,ures is not a goo, sign. 7f there is bon- point ten,erness associate, .ith this inabilit-2 there is a real possibilit- that the patient as serious bone ,isease. 6egar,less of the .here -ou thin% the source of the pain lies2 the presence of constant pain re4uires either referral bac% to the ph-sician if serious ,isease is suspecte, or2 if a non9serious musculos%eletal con,ition is present2 anti9 inflammator- treatments rather than biomechanical ones. :ggressive treatment that T19& T29 T&9( T(91) T*9F T(9T1) T1)9=1 T11912


exacerbates the patients constant pain ten,s to aggravate the con,ition but ice2 rest2 painfree exercises an, electroph-sical agents ten, to improve it if its source is musculos%eletal. 7ntermittent pain is pain that ,uring a particular episo,e is either completel- absent or present accor,ing to the presence of stress factors. This is mechanical pain /assuming its source is the musculos%eletal s-stem0 an, is generall- benign although there have been some notable exceptions to this /see the cases0. The mechanical stressing of a nociceptive structure causes this pain behavior. :ll things being e4ual2 pain of this t-pe generall- bo,es .ell for fairl- aggressive therapinclu,ing manual therap- an, exercises. +ontinuous pain is pain that is al.a-s there but varies in intensit- over the short an, long term. There is al.a-s a more or less intense level of bac%groun, pain that is exacerbate, or relieve, b- posture2 activit- or time of ,a-. This t-pe of behavior suggests a certain level of chemical pain associate, .ith a level of mechanical pain. The therapist must ,etermine just ho. irritable this con,ition ma- be an, this can best be ,one b- estimating ho. severe the bac%groun, pain is2 ho. easil- it is exacerbate,2 ho. long it lasts an, ho. eas- is it relieve,. The more severe the bac%groun, pain2 the more chemical involvement /inflammation0 there is. The more easil- exacerbate,2 the more irritable an, the longer it lasts an, the more ,ifficult it is to relieve2 the more inflame, it gets. The patient .ith this t-pe of pain can be more of a treatment problem than the patient .ho complains of constant pain as the treatment for the latter is prett- much preset. 7t is eas- to misju,ge an, appl- a little too aggressive a treatment an, flare the patient. :l.a-s remembering the complexit- of the nature of pain in its ,epen,ence on context2 the in,ivi,ual as .ell as the source an, level of stimulation2 the table ma- help to ,istinguish the t-pe of pain encountere,. ;o.ever also remember that pure chemical or pure mechanical pains are rarities an, some ,egree of overlap is usuall- present. +;E$7+:= P:7' +onstant or continuous nocturnal $orning stiffness lasting more than t.o hours @naffecte, b- rest 'ight pain ma- ,isturb sleep $E+;:'7+:= P:7' intermittent morning stiffness lasting less than a fe. minutes relieve, .ith rest an, appropriate activitrest eases it sleeps .ithout .a%ing from pain

The presence of episo,ic pain over a long perio,ic re,uces the ris% that the patient is suffering from some serious patholog- but also re,uces the chances of an excellent outcome. "ften episo,ic pain follo.s ver- ,efinite provocation. :n example is .here a .or%er once or a -ear has to ,o an unfamiliar job. Each time that job is ,one2 the pain re9intro,uces itself. This t-pe of episo,ic behavior is


an excellent ,iagnostic in,icator giving the cause of the patient s-mptoms an, usuall- a solution to the problem even if that is onl- counseling the patient that it .ill recover .ith cessation of the job /although not al.a-s true2 it is a goo, bet0. =ess useful is the pain that recurs perio,icall- .ithout a,e4uate provocation or on an activit- that the patient can carr- out successfull- numerous consecutive times but on one occasion pro,uces s-mptoms an, ,-sfunction. These completelunpre,ictable episo,es affor, ver- little ,iagnostic2 prognostic or therapeutic information. "ften the un,erl-ing cause is instabilit- in .hich case the patient .ill often tell the therapist that provi,ing an exercise or activit- program is maintaine,2 there is no problem but stopping it for a fe. ,a-s results in recurrence of pain. +areful 4uestioning of the progress of each episo,e compare, .ith previous ones .ill often give information on the general progress of the con,ition. : t-pical histor- given b- patients is an original onset of lo. bac% pain five -ears previousl-> this .as treate, successfull- an, 4uic%l- /t.o or three sessions0 .ith chiropractic. The pain recurre, perhaps a -ear later .ith some ,efinite provocation such as ,riving a long ,istance. +hiropractic again helpe,. The pain recurre, again .ith minor provocation /perhaps the grass0 six months later. This time chiropractic too% a ,o3en treatments an, ,i, not completel- eliminate the patientBs s-mptoms. : month or so later the bac% pain recurre, .ith no apparent provocation an, chiropractic ,i, not affor, an- relief an, no. -ou have them in -our clinic. This is a case of increasing instabilit- in the con,ition an, probabl- in the spinal segment an, as such it becomes increasingl- ,ifficult to manage. 7s the pain expan,ing2 shifting or remaining stable. Shifting pain suggest that .hatever the cause of the pain is2 it is not but moving. :n unstable ,isc herniation ma- ,o this. Expan,ing pain though is in,icative of a lesion such as bone cancer or infectionxxxi. :n example of expan,ing pain .oul, be pain that starts in the right lo. bac% then sprea,s to the buttoc% an, ,o.n the leg2 the pain might then also be felt sprea,ing to the other limb. 7s the con,ition progressing2 this .as partl- a,,resse, above .hen episo,ic pain .as ,iscusse,. :ssessing pain to see if the con,ition is .orsening is mainl- base, on three factors. 1irst is the 4ualit- of the pain changing. =ancinating pain that changes to somatic pain is evi,ence of ,ecreasing pressure on neurological tissues an, so .oul, generall- be consi,ere, an improvement. Secon, is the pain centrali3ing or peripherali3ing. +entrali3ing pain .oul, suggest that the intensit- of the stimulus has ,ecrease, or that it has shifte, to a tissue that is less able to refer pain. "n the other han,2 the centrali3ation coul, be apparent. ;-poesthesia or anesthesia ma- have replace, the pain> the objective examination .ill ,etermine .hich has occurre,. Peripherali3ation of the pain is generall- not a goo, s-mptom2 it ten,s to in,icate that there is an increase in stimulus intensit- or that a structure more able to refer pain is no. involve, or involve, to a greater extentxxxii. Disc herniations often behave this .a-2 starting of as a small herniation an, progressing to the point of extrusion. 6elate, to centrali3ation an, peripherali3ation is the concept of shifting an, expan,ing pain. The patient .ho relates that the pain starte, in the lo. bac% /for example02 .hich .orsene, an, then sprea, to the right buttoc%


an, then ,o.n the leg an, finall- across to the other leg is ,escribing expan,ing pain. This is an enlarging lesion2 it ma- be an increasing herniation or it ma- be something less benign such as an infection or a neoplasm!1. The opposite of this .oul, be the patient .ho tells -ou that it starte, in the lumbar spine an, then shifte, to the right buttoc%. This .oul, suggest something moving rather than enlarging an, is a better prognostic in,icator. Thir, is the severit- of the pain lessening if so .e can assume that the pain stimulus is abating. ;o.ever2 this bitself ma- not be an in,ication of an improving con,ition. The ,ecrease in pain masimpl- be the result of goo, compliance .ith the instruction to rest the area so that on resuming normal or even increase, activities2 the pain returns. <oth function an, pain must ,ecrease for optimal resolution of the patientBs con,ition. Severit- an, DisabilitThe severit- of the pain can be ver- ,ifficult to establish. The therapist cannot feel the patientLs pains nor is there a vali, or reliable .a- to objectivel- 4uantif- pain. +onse4uentl-2 the therapist must rel- on the patientLs o.n assessment of ho. ba, the pain is. :s pain is ver- personal2 the amount of tissue ,amage cannot be ,etermine, .ith an- ,egree of confi,ence if severit- is the onl- measure use, bthe therapist. Some patients are extremel- stoic .hile others are not an, .hile severe pain is severe pain2 as far as the patient is concerne,2 the patientLs inabilit- to tolerate pain ma- obscure the ,egree of stimulus causing the pain. The stan,ar, metho, of assessing pain levels is to as% the patient to put the current pain on a scale of 1 to 1) .here 1) is the .orse pain that this problem has pro,uce, or that the patient has ever felt. :nother metho, that can be use, either in isolation or complementar- to the pain scale is to as% about ,isabilit-. ;o.ever2 care must be ta%en here also. The compulsive .or%aholic personalit- .ill continue to .or% even in the most severe pain but .ill give up leisure activities. "f course %no.le,ge of the patientLs level of ,isabilit- is vital in an, of itself. This an, pain is .hat has brought the patient in to see -ou. The therapist nee,s to be full- a.are of .hat ,eman,s the patient ma%es on their bo,-. <ut heav- .or%ers ma- actuall- be easier to ,eal .ith in this respect than are se,entar- .or%ers. The patient .ith mo,erate lo. bac% pain .or%ing as a carpenter on a buil,ing site mabe able to get b- nicel- b- having a laborer ,o the lifting an, heavier .or% .hile the se,entar- .or%er ma- not be able to sit for prolonge, perio,s even .ith ergonomic mo,ifications. Chile the issue of ,isabilit- is obviousl- important to the therapist an, the patient from a rehabilitation an, re9training perspective2 it offers little information for ,iagnostic purposes other than alrea,- ,iscusse, concerning ,isc herniations2 clau,ication an, stenosis. Paresthesia This is a more reliable in,icator of source. Paresthesia /,efine, as a pins an, nee,les sensation0 is felt .hen a neuropath- is presentxxxiii. The most common neuropath- that the orthope,ic therapist .ill come across is compression from a


,isc herniation2 but other more serious causes .ill probabl- be encountere, ,uring a career. Patterns of paresthesia .ill affor, information as to .here the lesion lies. The is a rough in,ication of the level of the lesion from the ,istribution of the paresthesia: Peripheral Segmental <ilateral Aua,rilateral ;emilateral 1acial Perioral Stoc%ing9Glove peripheral nerve spinal nerve or root spinal cor, spinal cor, brainstem or cortex trigeminal brainstem or thalamus neurological or ps-chiatric or vascular ,isease

$ost ,istributions of paresthesia that the general orthope,ic therapist .ill encounter .ill be segmental2 arising from compression or ischemia of the nerve root or spinal nerve. Chile this ,istribution of paresthesia often in,icates strong compression an, a real problem for the patient2 it usuall- ,oes not suggest ,angerous patholog-. Possible spinal cor, an, neurovascular ,istributions are potentiall- health or life threatening if inappropriate treatment is given an, it is for these that the therapist must be alert. ;emilateral parasthesia in the orthope,ic patients suggests that one or both spinothalamic tracts are compromise, usuall- in the brain stem as part of the lateral me,ullar- /CallenbergLs0 s-n,rome possibl- cause, b- vertebral arterproblemsxxxiv2xxxv. Perioral paresthesia is 4uite .ell un,erstoo, to be a s-mptom of vertebrobasilar ischemiaxxxvi2xxxvii. :lthough the exact mechanism is not un,erstoo, its is believe, that the ,isturbance la-s in the centrome,ian part of the trigeminothalamic tract in the thalamus itselfxxxviii. This is one of the fe. tracts that is represente, bilaterall- an, receives sensation from the mouth2 gums an, teeth an, as such2 a lesion on one si,e .oul, give bilateral s-mptoms. 1acial paresthesia main,icate ,eficit in the trigeminal nerve. This must be carefull- ,istinguishe, from ,-sesthesia .here pinpric% testing provo%es paresthesia as .ell as h-persensitivit-. The latter case might in,icate trigeminal facilitation from a craniovertebral or temperoman,ibular joint ,-sfunction> the former ma- be cause, b- vertebrobasilar ischemia. 7n an- event2 the presence of paresthesia2 provo%e, or unprovo%e,2 ,eman,s cranial nerve testing an, vertebrobasilar s-stem testing. Specific patterns of paresthesia .ill be ,iscusse, in the regional sections an, in the case stu,ies. :ggravating an, :bating 1actors Chat2 if an-thing2 ma%es the s-mptoms .orse or betterG 7,eall- the therapist is loo%ing for intermittent pain of an episo,ic nature that is aggravate, b- a particular mechanical stress an, relieve, b- the avoi,ance of that stress. This case is verunli%el- to be cause, b- an-thing other than a benign musculos%eletal s-stem


,-sfunction. Cith acute inflammation2 the patient cannot fin, a position of ease an, so nothing ma%es it better. 7f nothing mechanical ma%es it .orse2 then the chances are that the problem la-s in the viscera or in some part of the musculos%eletal s-stem that is not vulnerable to mechanical stress. <one ,istant from muscle attachment is a goo, can,i,ate an, earl- neoplastic ,isease affecting these regions often present as such a musculos%eletal con,ition. 7n an- event2 constant pain that is not ma,e .orse b- mechanical stress is a potentiall- severe ,isease. 7n those patients .ho relate s-mptom changes that are associate, .ith altering mechanical stress2 a better outloo% is affor,e,. =umbar pain that is aggravate, b- .al%ing or other extension activities or postures is less li%el- to be cause, b- ,isc herniation than .here the pain is aggravate, b- sitting or other flexion activities an, postures. The effects of central spinal stenosis ma- .ell cause pain on .al%ing set ,istances that is ease, b- flexion. Chile pain that is cause, b- .al%ing set ,istances that is no relieve, b- flexion but b- time2 ma- be ,ue to intermittent clau,ication. Pain relate, to eating or ,ietar- inta%e is almost certainl- not ,ue to musculos%eletal problems regar,less of .here the pain ma- be felt. General ph-sical or emotion stress causing chest or arm pain must be suspecte, to be from car,iac origin. 'ight pain can be a major issue. 7t is of t.o main t-pes2 su,,en sharp pains that .a%e the patient usuall- as he or she turns in be,. This is the more benign t-pe an, if it accompanies sacroiliac area pain often in,icates sacroiliitis. The more sinister t-pe is the ache that often gives the patient trouble getting to sleep an, then .a%es him or her after a fe. hours. This t-pe of pain usuall- in,icates inflammation or increasing pressure. $ost patients .ith this .ill have, inflammatorproblems but a small percentage .ill prove to have cancer. ;o.ever2 from experience2 m- o.n an, others2 an, from rea,ing cases in the literature2 the relentless progressive nocturnal pain that is often taught as being s-mptomatic of cancer is not its normal presentation. This t-pe of presentation ten,s to occur in a,vance, cancer2 especiall- metastases but in the earl- case2 night pain ma- be onlminimal or it ma- not even be a feature. The point is that the absence of night pain ,oes not exclu,e serious patholog- as being a cause of the s-mptoms. C. ther Symptoms

=isten for s-mptoms that are at-pical especiall- if the- are of recent onset. +ranial nerve s-mptoms are often ,ifficult for the patient to sense an,Dor relate2 so ,irect 4uestioning might be necessar-. The presence of cranial nerve s-mptoms .ill ,eman, a cranial nerve examination2 .hich ma- clarif- the urgenc- an,Dor the inappropriateness of the problem. 7f signs an, s-mptoms are present then a brainstem lesion must be suspecte, an, follo. up testing of the long tracts is re4uire,. The potential presence of a brainstem lesion ,eman,s that the patient be imme,iatel- referre, to a ph-sician before an- further treatment is un,erta%en. The presence of cranial nerve signs an, s-mptoms coul, in,icate brainstem concussion2 petechial hemorrhaging2 neoplastic ,isease2 neurological ,isease or vertebrobasilar compromise. "bviousl- some of these con,itions are more urgent than others but the ph-sician shoul, be ma,e a.are of -our concerns. These signs an, s-mptoms

together .ith testing proce,ures .ill be ,iscusse, in the examination of the cervical region. Potential spinal cor, an, cau,a e4uina s-mptoms must be carefull- evaluate, an, if the- prove to be from these structures2 the patient must be referre, to the ph-sician. <ilateral or 4ua,rilateral paresthesia .ith or .ithout trun% s-mptoms is probablthe most common complaint in those patients suffering minor /if that .or, can be use, in this connection0 spinal cor, compression or ischemia. ;emilateral paresthesia ma- in,icate cerebral or brainstem compromise. :n- patient complaining of a ,istribution of paresthesia that ,oes not conform to a segmental or peripheral nerve origin must be objectivel- evaluate, for signs of compromise. The therapist ma- start the ball rolling .ith clinical neurological testing of the cranial nerves an,D or long tracts. ;o.ever2 this shoul, not be carrie, out if he or she believes that there is no ris% to the patient /that is there is no possibilit- of ligamentous rupture2 further neurovascular ,amage2 craniovertebral ,islocation or further migration of ,iscal material0. 7n practice2 the mere presence of such s-mptoms shoul, be sufficient to refer the patient to the ph-sician. +au,a e4uina compression is usuall- associate, .ith severe bilateral sciatic an, paresthesia although some case reports have ,ocumente, clinicall- significant compression .ithout the patient reporting an- pain. :n almost pathognomic s-mptom is perineal paresthesia .ith or .ithout h-poDanesthesia in,icating th sacral nerve pals-. =isten for s-mptoms of bla,,er2 bo.el or genital ,-sfunction. These inclu,e urinar- retention or incontinence2 lac% of expulsive bo.el function2 impotence2 frigi,it- an, penile ,eviation. :n- of these s-mptoms shoul, cause -ou to refer the patient out. Potential motor ,isturbances inclu,e ataxia2 ,rop attac%s2 clumsiness an, .ea%ness. The patient ,oes not al.a-s recogni3e them for .hat the- are. 1or example2 a colleague tol, me of a patient .ho felt that he ha, magnets in his poc%ets that .ere causing him to be attracte, to furniture. :s sill- as that soun,s2 it merits evaluation. Chat this patient ultimatel- turne, out to be ,escribing .as lateral ataxia> he .as in the mi,,le of a cerebellar infarct. $- father ha, trouble hol,ing a fol,e, ne.spaper un,er his arm .hen .al%ing> it %ept ,ropping to the floor. ;e .as having transient ischemic cerebral attac%s. JDi33iness2 ,iplopia /vertical or hori3ontal02 ,-sarthria2 bifacial numbness2 ataxia2 an, .ea%ness or numbness of part or all of one or both si,es of the bo,- /i.e.2 a ,isturbance of the long motor or sensortracts bilaterall-0 are the hallmar%s of vertebral9basilar involvement.Kxxxix Drop attac%s occur .hen the patient su,,enl- an, .ithout an- .arning falls2 almost invariabl-,s2 .hile remaining conscious. The fall is extremel- rapi, an, not in the least li%e a faint. The causes of this are numerous an, inclu,e vestibular


,-sfunction2 brain tumor2 ,iseases of the cerebellum an, posterior tract an, less commonl- vertebrobasilar ischemia!F. Tripping over minor objects or even non9 existent objects ma- in,icate foot ,rop from an- of its causes. Post9traumatic amnesia is an integral part of concussion. 7t is usuall- consistent in its effect2 being aroun, the time of the trauma for a greater or lesser perio, ,epen,ing on the severit- of the concussion. 7n fact amnesia is a better metho, of establishing that the patient .as concusse, than is as%ing about being %noc%e, unconscious as the perio, of unconsciousness can be so brief that the patient is una.are of it occurring. The length of time covere, b- the amnesia can be use, to evaluate the severit- of the concussion!F. "ther forms of amnesia are less benign in nature an, ma- in,icate neurological ,isease processes or more serious ,egrees of traumatic brain injur-. Short an, long term memor- loss must be reporte, to the ph-sician for evaluation. "ther forms of intellectual impairment inclu,e ,ro.siness2 concentration problems2 an, comprehension ,ifficulties an, so forth. These .ill be ,iscusse, in more ,etail in the region specific examination of the nec%. 7f the patient is complaining of col,ness in the han,s as% about color changes. <lueness ma- in,icate venous congestion2 .hiteness2 s-mpathetic ,isturbance an, re,ness certain s-stemic arthriti,es or infection. : feeling of heat in an area ma- be ,ue to inflammation or ma- be causalgia. 7f causalgia2 the sensation .ill run ,o.n the limb or aroun, the thorax. 7f the heat sensation is inflammator- in origin2 it .ill be aroun, the joint or over its superficial aspects. Patients .ho sa- the- feel unstable or that their hea, is going to ,rop off if themove ma- be right on the mone-. 7 have hear, reports from other therapists .here posttraumatic patients have ,ie, on moving their hea,s .hen as%e, to ,o so b- the ph-sician. These people ha, un,isplace, fractures of the ,ens that became ,isplace, on relaxing their protective guar,ing. =ess serious is the person .ho tells -ou that the spine feels unstable an, the- can feel it moving about or that it consistentlclic%s. "ften on subse4uent testing2 their feeling is correct an, there is a segmental instabilit- present. "n a s-stemic level as% about changes in s.eating2 coughing2 the pro,uct of coughing2 unexplaine, .eight loss2 recent fever2 changes in bla,,er or bo.el habits an,D or the pro,ucts of those functions2 recurrent infections2 in,igestion an, ,-sphagia. :n- alterations in the above ma- in,icate the presence of a s-stemic ,isease or cancer an, if the ph-sician is not a.are of these changes2 he or she shoul, be ma,e a.are. :gain2 it is possible to capture this information on a 4uestionnaire fille, in b- the patient on the first visit. "f course not all of these 4uestions nee, to be as%e, of ever- patient2 just those .ith unusual presentations. D. %andatory &uestions These are region specific an, .ill be ,iscusse, in more ,etail in their pertinent section. The- are 4uestions that must be ans.ere, b- the patient either


spontaneousl- or on ,irect 4uestioning. The- relate to serious pathologies such as vertebrobasilar compromise2 spinal cor, involvement an, cau,a e4uina compression that the therapist coul, easil- ma%e much .orse .ith inappropriate treatment. E. Pre"ious $reatments and )esults 7f the con,ition that the patient is atten,ing for has been experience, in the past2 valuable information can be gaine, from the histor-. 7s the pain 4ualit-2 location2 behavior an, irritabilit- similar to those previous episo,es. <- assessing the ans.ers .e can obtain an i,ea as to .hether the problem is generall- improving2 .orsening or sta-ing much the same. H;ave -ou ha, an- other treatment inclu,ing chiropractic2 other ph-sical therap-2 osteopath-2 acupuncture2 me,ication or an-thing else.H The purpose of this 4uestion is to see if -ou can learn from other practitionerLs experiences. "ften ho.ever2 the patient can mislea, -ou. 7 have a frien, an, colleague .ho is an excellent manual therapist2 probabl- one of the best in the .orl,2 near .hom 7 use, to live. "ccasionall- 7 .oul, get patients that he ha, seen either for that con,ition or for another previousl-. The 4uestion have -ou have ha, other treatments an, if so .hat2 .oul, often be ans.ere, -es from $r. 8 but he onl- put hot pac%s on me. the therapist2 7 also %ne. that this .as not something that he .oul, ,o. Sure enough .ith a little more pro,,ing such as ,i, he touch -ou the- .oul, H-esH. Di, he clic% -our jointG HIesH2 ,i, he use anelectrical treatmentsG HIesH. Di, he give -ou exercisesG HIesH. PatientBs memories are interesting an, often ,o not recall .hat actuall- happene,2 an, -ou nee, to as% further an, more ,irect 4uestions .hen the patientBs ans.ers ,o not seem li%el-. '. ther (n"estigations

7 ,o not loo% at the results of imaging tests until after 7 have examine, the patient. There are t.o reasons for this. 1irst2 the imaging results ten, to bias minterpretation of the results of the clinical examination. 7f the 89ra- sa-s there is ,egeneration present2 7 usuall- fin, it clinicall-. Secon,l-2 if on loo%ing at the imaging results or the image itself2 it agrees .ith m- clinical ,iagnosis2 then 7 am consi,erabl- more confi,ent of m- conclusion. "n the other han,2 the specificitan, sensitivit- of man- of the tests are not full- un,erstoo, -et. Ce %no. that 89 ra-s fail to ,emonstrate about !)5 of spinal fractures on first rea,ing but usuallsho. them on a subse4uent rea, .hen a better i,ea of the ,iagnosis is presentxl2xli. :bout !)5 of lumbar $67s ,emonstrate ,isc prolapse on as-mptomatic patientsxlii. 7t is .ell un,erstoo, that there in the lumbar spine there is an inverse relationship bet.een the presence of ra,iographic ,egeneration an, pain. Degeneration .orsens as the patient ages .hile the inci,ence of significant pain ,ecreases. The pea% age for lumbar pain is consi,erabl- than the pea% age for ,egeneration. "ften2 the therapist after examining the patient .ill re4uest the ph-sician to or,er imaging for a specific problem that is being postulate, b- the therapist from information gaine, from the examination. This is the better .a- of ,oing it. The


ra,iologists have a better chance of seeing the lesion on the image if the- %no. .hat the- are loo%ing for before loo%ing for it. @nfortunatel-2 no. ,a-s2 imaging an, other lab tests are being use, to ,iagnose the problem rather than confirm the clinical ,iagnosis an, .hen these tests turn out to be negative2 the patient is veroften labele, as h-sterical or a secon,ar- gainer. Potential S-stemic 7n,icators from the ;istor

initial onset over & -ears of age nocturnal pain pain that causes .rithing constitutional signs or s-mptoms /nausea2 vomiting2 ,iarrhea2 fever0 previous histor- of cancer bac% an, ab,ominal pain at same level pain unrelieve, b- recumbencunvar-ing pain severe an, persistent pain .ith painfree bac% movement severe bac% an, limb .ea%ness .ithout pain bac% pain associate, .ith eating or ,iet




: more ,etaile, ,iscussion of .hat to loo% for in each region .ill be foun, in the region specific examination sections. 7n general2 the observe, phenomenon shoul, be rea,il- apparent> if -ou cannot see it .ithin a ver- fe. secon,s it is probabl- not significant for this part of the examination. =oo% for the Gait :ntalgic limp ?ertical limp =ateral limp 'eurological gaits :taxia /.i,e base, or lateral0 Tren,elenberg ;igh stepping 1oot ,rop Etc 6e,uce, or absent arm 6e,uce, or absent trun% rotation Static Posture "bvious postural anteroposterior ,eviations /h-perlor,osisDh-per%-phosis0 "bvious postural transverse ,eviations /lateral shifts0 "bvious postural rotator- ,eviations /rotoscoliosis0 Torticollis =ateral lean :troph;-pertrophSurgical scars S%in creases /anterior an, posterior0 ?ertebral .e,ging ?ertebral le,ging E,ema <ruising +ongenital anomalies SprengleBs Elippel91eil s-n,rome Pol- or s-n or a,act-lD.arfism Do.nBs s-n,rome <irth mar%s Etc for a more complete list see page x


General :ppearance Pupil aniscoria Ptosis ;ornerBs signs Gra-ness or -ello.ness '-stagmus 1acial ,rooping Strabismus +-anosis Speech2 language2 voice D-sphasia D-sarthria D-sphonia Gait The are a number of problems .ith assessing gait. There are too man- areas to observe at one time. "ften there is not enough space available to allo. the patient to get up to normal .al%ing spee,s. The patent is conscious that he or she is being .atche, an, artificial gait ma- be execute,. Chat aspect of the patientBs bo,- -ou observe ,epen,s on .hat -ou are loo%ing forG 6emember that -ou are not in a gait lab but in a clinic tr-ing to ma%e sure that the patient has been appropriatel- referre, an, if he has2 -ou .ill give the correct treatment. Gait is a ver- secon,ar- issue at this point in the examination an, ta%es on more importance .hen assessing non9routine patients .ith non9orthope,ic manual therap- con,itions such as neurological ,isease2 amputees2 ,iabetes etc. The t-pes of gait ,eviation ,iscusse, in this section are those more commonl- seen in neurological con,itions an, those use, to assess possible causes of the orthope,ic problem. :n antalgic limp is one .here there is a shortene, stri,e length of the affecte, limp .ith the foot usuall- turne,,s. "f course this ,oes not al.a-s obtain2 .ith an :chilles ten,onitis for example the patient .ill .al% on their toes to avoi, stretching the injure, area. Similarl- .ith a %nee injur- cause a flexion posture2 toe .al%ing is necessar- to get the foot to the groun,. : lateral limp is recogni3e, b.atching the patientBs shoul,ers ,uring gait. The shoul,ers ten, to ,rop ,o.n to one si,e as the patient steps onto that leg. This ma- in,icate a short leg on that si,e. : vertical limp can best be seen b- .atching the hea, bob up an, ,o.n more than is usual. This fre4uentl- suggests a long leg on that si,e as the bo,- vaults over it. The Tren,elenberg limp is a lateral limp an, again can best be observe, b- loo%ing at the shoul,ers. ;o.ever2 it is ,ifferent from the lateral limp cause, b- leg length ,iscrepanc- in that the limp occurs once the patient is on the leg at mi,9stance rather than at heel stri%e. Generall- a Tren,elenberg gait suggests .ea%ness of the hip ab,uctors of the .eight bearing leg for .hatever reason. :taxia ta%es manforms> the most significant for the orthope,ic therapist is lateral an, .i,e base,


ataxia. =ateral ataxia ma- be cause, b- vertebrobasilar ischemia /among other neurological con,itions0 .hile .i,e base, ataxia is fre4uentl- cause, b- vestibular ,isor,ers. The high stepping gait is often cause, b- neurological ,iseases that re,uce proprioception2 perhaps the most notorious is neuros-ph-lis .ith the tabetic gait. ;o.ever2 one patient 7 sa. ha, a unilateral high stepping gait that ha, laste, for fifteen -ears an, ,isappeare, almost imme,iatel- .ith some simple exercises. Go figureN 1oot ,rop is often hear, before it is seen an, is a result of paresis or paral-sis of the ,orsiflexors cause, b- peripheral nerve or spinal nerve pals- or a stro%e. Posture @suall- .hat is meant b- posture is the position ta%en up b- the subject in 4uiet stan,ing2 the lor,oses an, %-phoses. "f course posture actuall- means much more than this an, is basicall- an- .eight bearing static position2 sitting2 stan,ing2 ben,ing an, leaning. <ut if .e ta%e it as it is usuall- meant2 static 4uiet stan,ing then a number of consi,erations have to be given. 7f .e are going to assess posture have .e an a,e4uate -ar,stic% to measure our patient against. +ertainl- optimal or i,eal postures have been a,vance,> perhaps 1lorence Een,all has been the most influential in this areaxliii2xliv. The i,ea of axial extension .here the subject attempts to line up2 as much as possible2 the vertebrae so has to minimi3e shearing forces2 muscle activit- an, ligamentous stress is the most usual ,efinition of goo, posture. <ut is this a goo, gol, stan,ar,G E$G stu,ies have consistentl- ,emonstrate, that a freel- a,opte, posture re4uires minimum an, consistent muscle activit- bet.een subjectsxlv2xlvi2xlvii2xlviii2xlix2l. ;ave a loo% at the general population2 an, at -ourself. ;o. man- people ,o -ou see maintaining this postureG 7t might be optimal but it is certainl- not normal in the statisticall- or clinical senses. <ut even if -ou ,o subscribe to this i,eal2 is there a normal variation an, is this normal variation the same for all bo,- t-pes. The examination of posture2 .hich on the surface seems,2 is an-thing but. To complicate this further it is extremel- unli%elthat the patient .hose posture -ou are observing is in their habitual state. The- are in pain an, the- are ,-sfunctional an, an- alteration in posture ma- .ell be occurring to relieve some of their pain. 7t is not reasonable to assume that the patientBs posture is habitual until -ou have returne, them to their habitual con,ition. 7t .oul, be better to note the patientBs posture an, loo% for changes as the patientBs con,ition improves. 7n a,,ition2 be a little more active in -our assessment of posture> as% the patient to move through the range of posture from axial extension to axial flexion. 7f the- are able to ,o so then -ou can presume that the- are ,oing so2 at least ever- no. an, then an, that at least the- ,o not have a fixe, postural ,eficit. =ater2 once the imme,iate problem that has brought the patient to -ou has been a,,resse, then the results of the postural assessment can be ,one in the %no.le,ge that it has more relevance. These results can be compare, .ith -our initial results. 7f there has been a ,ramatic change2 it is reasonable to assume that the initial posture .as more probabl- a result of the patientBs s-mptoms rather than their cause. Even if -ou believe that there is a postural ,eficit2 are the patientBs s-mptoms being cause,


or aggravate, b- that ,eficit. Oust because there is a postural ,-sfunction2 it ma- be completel- irrelevant to that patient. =ateral shifting is a form of postural ,eficit but in this case it is more li%el- to be ,irectl- relate, to the patientBs complaints. 6obin $cEen3ie populari3e, the significance of the lateral shift. $cEen3ie maintains that about &)5 of lo. bac% patients exhibit a lateral shift an, gives a number of reasons for this inclu,ing2 congenital anomal-2 remote mechanical cause2 alteration of nucleus position an, abnormal joint configurationli. 7t is .orth bearing in min, .hen figures such as this are use,2 that the authorBs caseloa, ma- be entirel- ,ifferent from -ours2 so ,o not get to upset .hen -ou fin, -ourself at variance .ith such an author. 7f -ou fin, a lateral shift2 is there an element of rotation involve,2 this is a rotoscoliosis2 or ,oes the spine just reach out laterall- .ithout an- obvious rotation. The former ma- .ell be part of a congenital or ,evelopmental scoliosis. E4uall- it ma- be ,ue to a 3-gopoph-seal joint ,-sfunction or a ,isc lesion> the rest of the exam .ill in,icate .hich. The straight shift is more li%el- to be cause, b- mechanical ,-sfunctions. 7f it corrects easil- an, has a normal en, feel2 the cause is li%el- to be remote. 7f spasm intervenes then this ma- .ell be a ,isc lesion or an acute 3-gopoph-seal joint problem. Spasm an, referre, pain particularl- if ra,icular in nature is li%el- to be cause, b- a ,isc herniation compressing either the ,ural sleeve an,Dor the spinal nerve root. 6esistance in the form of a spring- en, feel ma- in,icate some form of transverse ,iscal instabilit- an, ma- be fairl- easil- correcte,. : lateral lean is recogni3e, b- the .hole bo,- leaning to one si,e from the legs not just from the pelvis as in the case of the lateral shift. The usual cause of this is an ipsilateral short leg. Torticollis means t.iste, nec%2 it ma- be painful or painfree2 fixe, or correctable. The most common torticollis seen b- the orthope,ic therapist is fixe, an, painful an, re4uires treatment. Painless an, correctable torticollis are often the result of visual ,isturbances /,iplopia in particular0 an, hearing problemslii2 but ma- be cause, b- h-steria. 7nfantile torticollis ma- be cause, b- a number of things inclu,ing ,ifficult labor2 breech ,eliveries2 caesarian ,eliveries2 sternomastoi, tumor2 simple postural an, muscle shortening. The vast majorit- of cases respon, to simple stretching an, positioning .ith onl- a ver- lo. percentage re4uiring surger-. $ost benign infantile torticollises are congenitalliii2 be more careful of ac4uire, torticollis as this coul, be the result of some more serious ,isease process. +hil,hoo, torticollis usuall- affects chil,ren bet.een the ages of t.o an, 1). Chile in some there is an orthope,ic cause in a substantial number the cause ma- be infection .ith inflammation of the cervical glan,s irritating the sternomastoi,2 neurological ,isease an, neoplasm. Palpate the subman,ibular area for ten,erness an, enlargement of the glan,s an, if one or both are foun, return the patient to the ph-sician. Similarl-2 if no ver- obvious biomechanical ,-sfunction is apparent .ith testing again refer out. :,olescent torticollis is the most common t-pe usuallaffecting chil,ren bet.een the ages of F91 liv. This is a ver- painful con,ition an,


non9correctable on testing. "ften there is a biomechanical ,-sfunction in the upper part of the nec%. 7f this is left untreate, the acute pain an, range ,isturbance lasts about ten ,a-s. 7f treate,2 it lasts about a .ee% an, a halfN <ut .ith careful treatment2 7 use heat2 manual cervical traction2 a soft collar an, lots of reclining2 about #)5 of the pain .ill ,isappear in less than t.ent- four hours. 7f an a,olescent presents .ith torticollis that has laste, much more than ten ,a-s or .hich is not improving2 there is an increase, possibilit- of more sinister un,erl-ing patholog-lv. :,ult torticollis are usuall- cause, b-, mechanical problems although occasionall- a presumptive ,isc protrusion large enough to cause mechanical problems but big enough to cause neural signs .ill give a spring- en, feel an, be ver- ,ifficult to treat. $uscle :troph- an, ;-pertrophProfoun, atroph- in the absence of other obvious longstan,ing neurological signs is generall- suggestive of motor neuron ,isease or peripheral nerve pals-. Going along .ith atroph- there is often fasciculation. motor neuron palsies ten, to pro,uce coarse fasciculation .hile upper motor neuron problems pro,uce fine atroph-lvi. @pper motor neuron con,itions ten, to ta%e much longer to pro,uce atroph- .hile nerve root compression pro,uces onl- ver- slight atroph- because of the multisegmental nature of the innervation to most muscles. :troph- can also seem occur ,ue to inhibition from painful joint lesions. Aua,riceps .asting .ith meniscal injuries is an example. +onsi,er the ,istribution of the .asting2 ,oes it conform to a peripheral nerve ,istribution2 to a spinal segment or is it multisegmental or non9segmentalG The last t.o are particularl- .orrisome as the- coul, in,icate an upper or motor neuron ,isease. :troph- is of particular significance if it occurs in the intrinsic muscles of the han, or han,s. 7t ma- be the first in,ication of a motor neuron ,isease as lo. cervical ,isc lesions rarel- pro,uce palsies of these muscles12. @nilateral atroph- of the han, intrinsics ma- occur as part of the thoracic outlet s-n,rome or Pancoast s-n,rome. This is ,ue to trauma2 breast or apical lung cancer ,isrupting the s-mpathetic transmission at the stellate ganglion an, the brachial plexus. :troph- of the sternomastoi, or2 more usuall-2 the trape3ius muscles .oul, suggest an 11th cranial nerve pals-2 .hich in turn ma- be ,ue to a neuroma2 occipital metastases or fracture. This certainl- ,eman,s a cranial nerve examination. 7f other cranial nerve signs are evi,ent then a brain stem injur- or ischemia is possible. 7f it is isolate, then consi,eration must be given to a lesion of the nerve itself. 7f it follo.s trauma2 an occipital fracture shoul, be rule, out in .hich case2 the nerve ma- have been stretche, b- the mechanics of the injur-. 7f there is no trauma then the possibilities are a neuroma or metastatic cancer of the occiput. 7solate, h-pertroph- coul, be ,ue to overuse in a muscle or muscles tr-ing to support an unstable region. This is particularl- common in the tibialis posterior an,


anterior as the- tr- to support an unstable foot. "f course the h-pertroph- ma- be more apparent than real as it is in DuchenneBs muscular ,-stroph-lvii. Surgical Scars an, +reases Surgical scars .ill re9,irect the patientBs attention to previous me,ical con,itions an, their treatment thereb- jogging the memor-. $ost scars are not relevant to the patientBs complaints but some2 even though far remove, from the s-mptomatic region2 .ill be. These are scars from cancer surger-. "bviousl- if -ou are treating the lo. bac% an, the patient is exhibiting surgical scars this .ill have a bearing on the patientBs con,ition but more from a treatment perspective than a ,iagnostic one. S%in creases offer information on h-permobilit- an, instabilit- especiall- .hen these appear on movement. The- are most commonl- seen in the cervicothoracic junction an, in the lumbar spine on extension. The- are usuall- unilateral or if bilateral are seen at ,ifferent levels an, generall- ,epict extension h-permobilit- or rotator- instabilit-. =o. ab,ominal anterior creases can onl- be seen if the un,erpants are lo.ere, in front. This crease is almost pathognomic of spon,-lolithesis. <e a.are though that the mere presence of a crease ,oes not necessaril- mean that instabilit- is present an, even if it ,oes2 it ,oes not help us ,etermine if the instabilit- or h-permobilit- is clinicall- relevant. =ocal <on- +hanges : local %-phus is .e,ging. 7t generall- occurs .ith a compression fracture of the bo,- of he vertebra. "ften the patient cannot remember the injur- as it ma- have occurre, in chil,hoo, an, be nothing more than a vague memor- of lo. bac% pain. 7f the %-phus is painful to palpation2 percussion an, the application of a lo. fre4uenc- tuning for%2 then be careful. 7f there .as no overt trauma this ma- be a pathological fracture ,ue to osteoporosis2 bone cancer or some other bone ,isease. =e,ging is a little ,ifferent. ;ere the therapist can run their finger ,o.n the spinous process an, come to one that stic%s out as it ,oes .ith the .e,ge, vertebra. <ut on continuing ,o.n the spine2 the other spinous processes are level. This .oul, suggest the presence of a ,egenerative t-pe of spon,-lolithesis .here the entire vertebra has shifte,,s on those belo.. Chere there is a ,efect in the pars articularis2 this le,ge ma- not be seen as the neural arch is left behin, an, remains level .ith the spinous processes belo.. : retrospon,-lolisthesis .oul, appear in the opposite .a- .ith the ,ip coming un,erneath an, continuing ,o.n the spine. <ruising an, S.elling 'ot commonl- seen in spinal trauma but significant .hen it ,oes occur. <ruising over the mastoi, is calle, <attle sign an, fre4uentl- in,icates fractures of the temporal or occipital bones. 6accoon mas% bruising is bilateral blac% e-es similar to the features on a raccoonBs face an, is a companion of facial fractureslviii. <ruising

over the erector spinae in the thoracic or lumbar spine ma- in,icate tearing of these muscles most usuall- be ,irect impact. Shoul,er injuries resulting in bruising running ,o.n the arm generall- means that there has been a capsular tear or a major muscle such as pectoralis major2 biceps or brachialis is torn in its bell-. <ruising .ith an%le inversion injuries can often in,icate ho. severe the ,amage. Extreme bruising ma- be cause, b- a fracture. <ruising on the me,ial si,e of the an%le .ith inversion injuries means that consi,erable inversion has occurre, to allo. compression of the me,ial tissues to occur. . Generall- the more extensive the bruising the more severe the injur-. There are man- t-pes of s.elling an, some are ,ifficult to see especiall- those aroun, the spine an, the shoul,er. 7n the nec% after trauma -ou ma- see s.elling in the clavicular triangle or -ou ma- have to palpate for it. 7n m- experience2 these patients ta%e a goo, ,eal longer to recover. The shoul,er because it is so ,eep rarel,emonstrates s.elling after trauma but again .hen it ,oes2 recover- is ,ifficult. =umbar an, thoracic e,ema is extremel- rare an, ,ifficult to ju,ge2 but in %eeping .ith the motto Hif its unusual2 it must have an unusual etiolog-H be careful. S.elling of the buttoc% is not a goo, sign especiall- in the absence of severe trauma. 7t is one of the signs of the buttoc% an, ma- in,icate infection2 neoplastic ,isease2 fracture etc. 7n the presence of s.elling as% the patient ho. long after the trauma ,i, it come on. 7f it .as imme,iate2 -ou are probabl- loo%ing at a hemarthrosis if ,ela-e,2 simple effusion. 7f an entire region is e,ematous the cause is re,uce, venous return. 7f this follo.e, trauma2 it ma- simpl- be ,isuse an, a ,epen,ent position. 7f there .as no trauma other more serious causes coul, inclu,e congestive car,iac failure an, ,eep vein thrombosis. +ongenital :nomalies Name of Defect *enerali+ed "steogenesis imperfecta Diaph-sial aclasis /multiple exostosis0 :chon,roplasia "steopetrosis Gargo-lism /;urlerBs s-n,rome0 +ranioclei,o ,-stosis :rthrogr-posis multiplex congenita Clinical 'eatures 1ragile soft bones easil- fracture, or ,eforme,2 joint laxit+artilage cappe, metaph-sial exostosis .ith ,eficient remo,eling an, stunte, Defective long bone .ith short limbs2 ,.arfing an, a large hea, ;ar, ,ense bone .ith increase, ris% of fracture D.arfism .ith %-phosis ,ue to ,eforme, vertebrae2 mental ,eficienc-2 large liver an, spleen 7mpaire, ossification of the s%ull .ith ,eficient clavicles Defective ,evelopment of the muscles


/am-oplasia congenita0 Pseu,oh-pertrophic muscular ,-stroph1ibroplasia ossificans progressiva 1amilial h-pohosphataemia +-stinosis /renal tubular ric%ets0 'eurofibromatosis /6ec%linghausenBs s-n,rome0 ;emophilia GaucherBs ,isease Do.nBs s-n,rome Central Ner"ous System $run# and Spine Elippel91eil s-n,rome SprengelBs ,eformit+ervical rib ;emivertebra Spina bifi,a /spinal ,-sraphism0

resulting in stiff ,eforme, joints. Progressive muscular .ea%ness bet.een the ages of !9( -ears Extopic ossification in the trun% an, limbs2 short big toe +ongenital rac%its /bone .ea%ness0 6arifie, bones .ith ,eformit+afP au lait spots2 cutaneous fibromata an, cranial or peripheral nerve palsies Prolonge, clotting times lea,ing to hemarthrosis an, soft tissue blee,ing +-st li%e appearance of bones .ith large liver an, spleen $ental an, ph-sical impairment2 micro or a ,ensia Short stiff nec% an, lo. hair line ,ue to fuse, or ,eforme, cervical vertebrae @nilateral /usuall-0 tethere, an, high scapular2 no nec% appearance @suall- as-mptomatic but ma- result in vascular or neurological thoracic outlet s-n,rome @nilateral vertebral ,efect lea,ing to scoliosis Spina bifi,a occulta2 menigocele or m-elocele ma- be as-mptomatic or cause leg ,eformities an, incontinence ,ue to neurological involvement. 7f ma- be associate, .ith h-,rocephalus. Elongation of the cerebellum an, me,ulla into the spinal canal .ith the potential ,evelopment of central neurological signs .ith nec% extension or manipulation in a,ulthoo,. ?ar-ing in si3e the- can occur in the cranium. 7f large enough the- .ill cause pressure signs an, s-mptoms. Thema- enlarge or rupture causing chil,hoo, or a,ult s-mptoms usuall- bet.een the ages of 1)9!1 but it can be ,ela-e, to &) -ears. $a- suffer from pulsatile tinnitus. Severe interscapular an,Dor chest an,Dor lumbar pain

:rnol,9+hiari malformation

+ongenital intracranial arteriovenous fistulae2 an, hemangioma2

Dissecting aortic aneur-sm ,im-s


+ongenital amputation Phocomelia +onstriction rings :bsence of ra,ius :bsence of proximal arm muscles $a,elungBs ,eformit- /,-schon,rosteosis0 S-n,act-lPol-,act-lExtro,act-l+ongenital ,islocation of the hip +oxa vara +ongenital short femur +lub foot +urle, toe

Part or all of a limb missing :plasia of the proximal part of the limb .ith the ,istal part present =imb or ,igit constriction as if b- a purse string2 it ma- be associate, .ith s-n,act-l;an, ,eviate, laterall- ,ue to lac% of support Trape3ius2 ,eltoi,2 sternomastoi, an,Dor pectoralis major @lna hea, ,islocate, from the ra,ius .hich is bo.e, 1use, or .ebbing of t.o or more fingers $ore than five ,igits =obster cla. han, 'eonatal ,islocation .ith possible flattene, femoral hea, in a,ulthoo, Defective femoral nec% ossification .ith re,uce, nec% angle 1oot small an, everte, an, lateral t.o ,igits together .ith their metacarpals mabe absent 1oot inverte, an, plantaflexe, or everte, an, ,orsiflexe, =ateral angulation of one or more toes

+ongenital anomalies are important to recogni3e because in a,,ition to their ,irect effect on the ,iagnosis an, treatment2 the- can also in,icate other more serious ,eficits. The tables are ma,e from information from an article that loo%e, at subjects .ith %no.n vertebral malformations for associate, anomalies. 7t .as more the rule than other.ise that the presence of a vertebral malformation .as associate, .ith other anomalies usuall- from the same embr-ological bloc%. 7t is important because .hile the presence of sa-2 s-n,act-l- it might not affect the patientBs nec% problem ma- be associate, .ith vertebral arter- anomalies. 7n a revie. of 21# subjects .ith %no.n vertebral malformations <ealslix foun, that most malformations .ere associate, .ith other anomalies /!#( vertebral an, !22 other anomalies0 .ith (15 of the subjects multiple anomalies. The s-stems affecte, .ere:

$usculos%eletal 'eurological Genitourinar"tolar-ngeal Gastointestinal +ar,iac Pulmonar-


The stu,- foun, a prevalence of thoracic an, lumbar anomalies /&&.&5 an, 215 respectivel-0 .ith the cervical spine having about 1&5 an, the sacrum about #5 giving an average of 1.** anomalies per patient. :nomalies :ssociate, .ith ?ertebral $alformation /from <eals0 're.uency of Diagnosis +ranial nerve pals@pper limb h-poplasia +lub feet limb h-poplasia Dislocate, hip SprengelBs ,eformit;emifacial microsomia 6enal anomal+ar,iac anomal'eurogenic incontinence 7nguinal hernia motor neuron lesion of limb Sei3ures General :ppearance Pupils :niscoria is the term for as-mmetrical pupils either in si,e to si,e si3e or in shape. The pupils shoul, be .ithin 1&5 of the same si3e as each other an, roun, an, shoul, react e4uall- to light2 convergence an, surprise.lx +onstriction of the pupils is a paras-mpathetic function in relation to increasing light levels. The constrictor muscles are controlle, b- the E,inger9Cestphal nucleus /part of the !r, cranial nucleus0 via the oculomotor nerve .hile the ,ilator muscles are s-mpatheticall- innervate, b- fibers from the superior cervical ganglion. The control of pupil ,iameter is a coor,inate, effort bet.een the s-mpathetic an, paras-mpathetic s-stems2 .ith the paras-mpathetic s-stem ,ominant so that un,er ambient light an, environmental levels2 the pupils ten, to constrict. 7f there is a s-mpathetic paral-sis2 the paras-mpathetic tone is unoppose, an, the constrictor muscles close the pupil. =ight reaction ma- absent2 sluggish or oscillating. Pathologies causing ;ornerBs s-n,rome are the most common cause of this con,ition that the "$T is li%el- to encounter. +onstriction of the pupils also occurs ,uring convergence of the e-es via <ro,manLs area in the frontal an, the E,inger9Cestphal nucleus lobe although the exact mechanism is not .ell un,erstoo,. Num-er of Patients 2 21 2) 1F 1# 1# 1# 1* 1( 1& 1 11 & 115 1)5 1)5 F5 #5 #5 #5 #5 (5 *5 (5 &5 25


Dilation of the pupils occurs2 either as a result of re,uce, paras-mpathetic tone in re,ucing light con,itions or from increasing s-mpathetic tone in threat con,itions. :bnormal ,ilation of the pupil is ,ue to unoppose, s-mpathetic tone. This is generall- ,ue to oculomotor paral-sis or paresis. 7n these cases2 the pupil fails to respon, normall- to the absence or re,uction of light in the initial part of the consensual reflex test or if the flashlight is move, a.a- from the e-es. Pupil ,ilation .ith ptosis is almost pathognomic of oculomotor lesions. :,,ieBs pupil is a tonic pupil .hose si3e ,epen,s on its last light environment. 7t ,oes not react normall- to light reflex testing but .ill change its shape over time in ,ifferent light con,itions an, once change, maintains that ,iameter. 7t respon,s better ,uring converges than it ,oes to light stimulation2 although still abnormallslo.l-2 to near target testing. 7t is often associate, .ith s-mmetrical or as-mmetrical ,eep ten,on h-poreflexia an, appears to be a mil, benign pol-neuropath-. 7t has no significance for the orthope,ic therapist. The :rg-le96obertson pupil is an irregular pupil that ,oes not constrict to light but ,oes constrict on convergence or near vision. 7t is specific to neuros-philis. The near vision an, light reflex ,iscrepanc- .ith regular pupils is foun, .ith con,itions other than s-philisQ. Ptosis Ptosis is pathological ,epression of the superior e-eli, to the point .here it covers part of the pupil. The muscles responsible for opening the e-e an, maintaining it opene, position are the levator palpebrae an, $ullerBs muscle. The levator palpabrae is innervate, b- the thir, cranial nerve /oculomotor0 as this nerve causes elevation of the e-eball. 7t is efficient then that the same impulses that result in orbit elevation also cause superior e-e li, elevation. The small s-mpatheticallinnervate, $ullerBs muscles are attache, to the inferior an, superior tarsals /fibrocartilaginous plates in the e-eli,s0. Chen the muscle contracts2 it pulls on the plate an, causes the e-eli, to raise. Paral-sis or paresis of one or both of these muscles causes ptosis. 7f an oculomotor paresisDparal-sis is present2 the ptosis is generall- not capable of correction beffort2 as the levator palpabrae is the larger of the t.o muscles. 7f a s-mpathetic paral-sis is present /;ornerBs s-n,rome0 the patient is usuall- able to elevate the e-eli, on comman, an, the ptosis is most noticeable at rest. :s s-mpathetic paral-sis lea,s to miosis an, oculomotor to m-,riasis2 loo%ing for these as associate, signs .ill further help ,ifferentiate the source of the ptosis1#. 1rom an orthope,ic perspective2 ptosis ma- mean a neurovascular compromise. 7f the thalamus2 reticular formation or the ,escen,ing s-mpathetic nerve are affecte,2 ;ornerBs s-n,rome results an, the ptosis .ill be accompanie, b- miosis2 facial re,,ening2 anh-,rosis an, Enophthalamos2 as .ell as other neighborhoo, signs.


"ther possible sites for ,amage that coul, cause ;ornerBs s-n,rome are the thoracic outflo.2 the inferior or the superior cervical ganglion or along the s-mpathetic chain in the nec%. 7f the !r, nerve is impaire, the ptosis .ill be associate, .ith pupil ,ilation an, extra9ocular paresis or paral-sis. ;ornerBs Signs1# These are cause, b- s-mpathetic paral-sis or paresis ,ue to a lesion affecting one of the structures:

Thalamus 6eticular formation Descen,ing s-mpathetic nerve +ervicothoracic outflo. 7nferior cervical ganglion $i,,le cervical ganglion Superior cervical ganglion

Preganglionic /rostral to the inferior cervical ganglion0 are the most serious but for the therapist there is no .a- of clinicall- ,etermining if it is pre or postganglionic2 so all patients presenting .ith ;ornerBs s-n,rome must be consi,ere, as suffering from serious patholog- until proven other.ise. The ph-sician can ,etermine .hether this is pre or postganglionic b- infusing the e-e .ith cocaine an, amphetamine solutions an, .atching for ,ilation. The clinical signs of ;ornerBs s-n,rome are:

Ptosis /small ,ue to paral-sis of $ullerBs muscle0 :nh-,rosis /lac% of s.eating0 $iosis /constricte, pupil0 1acial flushing :pparent enopthalamus /retraction of the e-eball0

There are a number of causes inclu,ing:

cervical l-mph no,e inflammation or tumor posterior fossa tumors trauma to one of the cervical ganglion ,issection of the caroti, arterapical lung cancer inva,ing the brachial plexus an, ganglion /Pancoast s-n,rome0 breast cancer inva,ing the brachial plexus an, ganglion /Pancoast s-n,rome0 s-ringom-elia an, s-ringobulbia trauma of the cervicothoracic outflo. vertebrobasilar compromise lateral me,ullar- /CallenbergBs0 s-n,rome i,iopathic

here,itar- /the iris is usuall- a ,ifferent color blue from the other si,e0

'-stagmus1#2lxi '-stagmus is non9volitional rh-thmic motion of the e-es. '-stagmus sorte, into t.o main t-pes2 jer% an, non9jer% /an alternative metho, is spontaneous2 ga3e evo%e, an, ga3e suppresse,0. Oer% n-stagmus2 the most common is .here there is a fast component /sacca,es0 in one ,irection an, a slo. recover- to mi,line. 'on9jer% n-stagmus is pen,ular2 that is there is no fast component an, generall- an, e4ual ,isplacement on each si,e of mi,line. 'on9jer% n-stagmus ma- be congenital2 part of albinism or is fre4uentl- associate, .ith visual problems so that the e-es move to fin, the most sensitive spot on the fovea. Oer% n-stagmus is cause, b- ,isturbances in the cerebellum2 vestibular s-stem2 inclu,ing the lab-rinth2 nuclei2 neural projections an, mechanoreceptors in the cervical spine. : sub,ivision of jer% n-stagmus is central an, peripheral. +entral n-stagmus is n-stagmus of central neurological origin an, is the more serious of the t.o being cause, b- brainstem ischemia2 neurological ,isease an, posterior fossa tumors. Oer% n-stagmus is name, after the ,irection of the fast component an, can be lateral /the most common02 vertical /upbeat an, ,o.nbeat02 converging2 retracting2 combination of the above an, seesa. .here one e-e moves up an, the other ,o.n. +entral n-stagmus has characteristics that ,ifferentiate it from peripheral n-stagmus .hose commonest cause is lab-rinthine ,-sfunction. The table belo. lists some of the easier to i,entif- on clinical examination. Th e table belo. compares n-stagmus of central origin to that of peripheral. CEN$)A, <rainstem neighbor hoo, signs2 possiblCallenbergBs s-n,rome if ?<7 ?ertigo intensit- mil, to mo,erate ?ertigo ,uration long /ma- be in,efinite0 ?ertigo M oscillopsia ma- be relate, to the n-stagmus an, not hea, movement '-stagmus is hori3ontal or vertical an, ma- not have a torsional element2 but ma- be pureltorsional Positional n-stagmus usuall- static an, ,irection changing Ga3e evo%e, PE)(P/E)A, RD9 sensorineural or con,uction h-poacusiaDtinnitus ,epen,ing on the cause ?ertigo intensit- mil, to severe ?ertigo ,uration short /)92 minutes ?ertigo M oscillopsia relate, to hea, movement @suall- hori3ontal al.a-s has a torsional element combine, .ith the linear ,isplacement Positional n-stagmus is usuall- parox-smal an, ma- be ,irection fixe, or changing Ga3e suppresse, after short perio, /S one .ee%0

There are numerous causes of n-stagmus most of .hich are relativel- benign but the orthope,ic therapist ,oes not usuall- have the %no.le,ge2 training2 s%ills or tools re4uire, to ,etermine if a particular case falls into this categor-. So in the

event of meeting a previousl- un,iagnose, case of n-stagmus it is pru,ent to refer the patient to a ph-sician for further investigation. The table belo. loo%s at the various t-pes of n-stagmus an, it causes. $0PE 1. SP"'T:'E"@S C/A)AC$E)(S$(CS not ,epen,ent on ga3e of hea, position although ma- be .orsene,2 ease, or altere, bga3e ,irection spontaneous fixation ,epen,ent ma- be monocular /latent0 high fre4uenc- /29( bps0 ma- be pen,ular non9jer% high fre4uencperio,icall- changes ,irection .ith change of hea, or e-e position c-cles CA1SES



Pen,ular Perio,ic :lternating /P:'0



2. G:TE E?"EED


combine, torsional9hori3ontal but mainl- hori3ontal inhibite, b- fixation "be-s :lexan,erBs =a. pure vertical2 hori3ontal2 torsional or combine, not ,epen,ent on fixation ga3e ,irecte, into ,irection increases fre4uencga3e ,irecte, a.a- from ,irection changes ,irection unable to maintain stable e-e ,eviation a.a- from central position an, corrective sacca,es reset ga3e position al.a-s in ,irection of the ga3e e4ual left9right amplitu,e

congenital multiple sclerosis retinopathies congenital brainstem ischaemia /?<70 multiple sclerosis s-philis s-ringobulbia trauma peripheral vestibular ,-sfunction Gcervical ,-sfunction #th. nucleus cerebellar atroph?<7 :rnol,9+hiari multiple sclerosis me,ullar- tumors an, infarcts

me,ication /phenobarbital2


une4ual left9right amplitu,e ma- be combine, .ith peripheral spontaneous n-stagmus .ith #th neuromas changes ,irection .ith fatigue or resetting of primar- position overshoots the ab,ucte, position the non9affecte, e-e a,,ucts more slo.l- than the affecte, ab,ucts

6eboun, Dissociate,

phen-toin2 ,ia3epam2 alcohol0 m-asthenia gravis multiple sclerosis cerebellar atrophcerebellopontine tumors acoustic neuromas recover- from ga3e paral-sis cerebellar ,isease M atrophme,ial longitu,inal fasciculus lesions /,em-elinating ,iseases /bilateral0 ?<7 /unilateral0 m-asthenia gravis /.orsens as ga3e is maintaine,0 hea, injurlab-rinthitis internal au,itor- arterinsufficienc- /?<70

!. P"S7T7"':= Peripheral Parox-smal

+entral Parox-smal

provo%e, b- hea, positioning provo%e, b- ;allpi%e9Dix maneuver associate, .ith vertigo commonl- has a !91) secon, latenc- perio, onset of high fre4uenc- but rapi,l- ,issipates an, rarel- last U !) secon,s often ,isappears .ith repeate, testing combine, torsional9hori3ontal usuall- provo%e, in one ,irection onl- .ith recoverpro,ucing opposite ,irection n-stagmus ,oes not have latenc- perio, ,oes not ,isappear .ith repeate, testing lasts longer than !) secon,s provo%e, b- man- ,irections of movement an, ,irection of n-stagmus ma- change .ith ,irection of test often vertical

brainstem lesions cerebellar lesions


ma- or ma- not be associate, .ith vertigo remains as long as the position is hel, ma- fluctuate in fre4uenc- an, amplitu,e ma- be uni,irectional or change .ith position ma- be apparent after parox-smal positional n-stagmus has ,isappeare, comes on .ith slo. an, fast positioning

peripheral vestibular ,isor,ers /most common causes0 central lesions /non9 suppressible .ith fixation0

1acial an, E-e :s-mmetr-1#2lxii =oo% at the e-e position. Strabismus /s4uint0 ma- either be paral-tic or non9 paral-tic. 'on9paral-tic is a non9neurological con,ition that occurs in chil,hoo, an, persists if not correcte,2 it is the la3- e-e. Paral-tic strabismus occurs .hen one or more extra9ocular muscles are paral-3e, or paretic an, the unoppose, pull of the antagonists cause mal9positioning of the e-e. The trac%ing tests ,iscusse, in the section on cranial nerve testing .ill ,etermine .hich is .hich. Paral-tic strabismus is associate, .ith brain stem function compromise an, nee,s to be referre, bac% to the ph-sician. 1acial ,roop is cause, b- either an upper motor neuron lesion above the facial nucleus or from a facial nerve pals-. 7f the muscles above the e-e are involve,2 it is a peripheral pals- such as a <ellBs pals- if there are not the lesion la-s above the nucleus as there is a partial ,ecussation of the corticobulbar tract fiberslxiii. +olor +hanges Gra-ness often in,icates s-stemic ,isease an, ma%es the patient loo% ill. Iello.ness ma- be ,ue to jaun,ice2 especiall- if the conjunctiva are also -ello.. +auses of jaun,ice inclu,e2 <ile ,uct stenosis2 gallstones2 pancreatic stones2 pancreatitis2 hepatitis2 liver cancer2 pancreatic cancer2 gallbla,,er cancer2 hemol-tic anemia. :ll con,itions that ,eman, the patient is further assesse, b- a ph-sician. 1acial flushing ma- be part of ;ornerBs s-n,rome an, can accompan- caroti, arter,isease. Speech2 =anguage an, ?oice +hangeslxiv =isten for:


D-sarthria D-sphonia

D-sphasia is .here the abilit- to sa- a .or, is unaffecte, but the abilit- to use the .or, appropriatel- is lost. "utsi,e of mi,,le cerebral arter- stro%es2 the most serious con,ition causing ,-sarthria that the therapist .ill li%el- come across .ill be ,ue to vertebrobasilar ischemia. Cerni%eBs area is vasculari3e, b- the temporal branch of the posterior cerebral arter- the terminating branch of the basilar so an embolus coul, cause ,-sphasia. :s obvious stro%es .ill never get to the therapist2 the signs an, s-mptoms .ill be transient an, ma- onl- sho. up on turning or exten,ing the hea,. +onse4uentl-2 ,-sphasia ma- onl- become apparent on testing the nec% or vertebral arter- or .hile appl-ing treatment an, then onl- if the patient is tal%ing. =isten for .or, substitutions2 .or, omissions an, neologisms /ne. .or,s that ,o not exist0 or the patient ma- tal% aroun, the subject to avoi, a .or, that cannot be brought to min,. :phasia2 the complete loss of the spo%en .or, is cause, b- an infarct in <rocaBs area .hich is supplie, b- mi,,le cerebral arter- a branch of the internal caroti,. 7n ,-sarthria2 the correct .or, is chosen but it is announce, incorrectl-. 7n cerebellar ,-sfunction2 .hich ma- be the result of vertebrobasilar ischemia2 the speech is slo. an, slurre, an, it loo%s as if the patient has to .or% har,. : similar soun, is hear, if the control of the mechanics of speech2 the tongue an, phar-nx is affecte, in me,ullar- problems again possibl- ,ue to vertebrobasilar problems. D-sphonia is a voice aberration .here the .or,s are pronounce, an, use, correctlbut the voice is usuall- lo. an, rasping soun,ing li%e lar-ngitis but .ithout the pain. This is cause, b- paresis or paral-sis of the lar-ngeal muscle .hich ma- result from ischemia of the vagal nucleus2 .hich is supplie, b- the vertebral arter-.


Section " The #usculos$eletal Examination

The ,ifferential examination that .ill be outline, in this boo% is a mo,ification of Oames +-riaxBs an, is base, on his concepts of selective tissue tension testinglxv. 1or the most part2 the +-riax examination is base, on anatom- an, patholog-. The examination .or%s on the principle of isolating the function2 as much as possible2 of a tissue an, ma%ing it perform its action in that isolation. 1or example having the patient perform an isometric contraction .oul, test for a tear in a muscle bell- or for a ten,onitis. The nature of the contraction .oul, minimi3e joint movement an, the stress put through non9contractile tissues. ;o.ever2 it is apparent that some stress .oul, be present in these non9contracting tissues2 compression an, translation .oul, still occur to some extent. :s a conse4uence2 the examiner must un,erstan, that no single test is capable of generating a ,iagnosis. 6ather it is the integration an, anal-sis of all of the ,ata2 both positive an, negative2 that allo.s the therapist to come to a rational ,etermination of the patientBs problem. +-riax ,ivi,e, the musculos%eletal s-stem into four parts:

7nert tissues /capsule2 ligaments2 bone2 bursa2 fascia2 ,ura2 nerve tissue0 +ontractile tissues /muscle2 ten,on2 tenoperiosteal junctions2 near muscle bone2 compresse, bursa0 'eurological tissues /afferent2 efferent an, inhibitor- functions0 ?ascular tissues /arteries an, veins0

These are teste, respectivel- .ith: 1. 2. !. . &. :ctive Passive 6esiste, $-otomal2 ,ermatomal2 reflexes 6epeate, or sustaine, contractions

2. Acti"e %o"ements :ctive motion testing non9,ifferentiall- tests the contractile an, inert tissues of the musculos%eletal s-stem an, also the motor aspect of the neurological s-stem in cases of profoun, .ea%ness an, patient motivation an, anxiet-. 7t ,oes this b,emonstrating the

6ange of motion Pattern of restriction Aualit- of the movement "nset an, t-pe of the s-mptoms The patientBs .illingness to move

T-picall-2 the movements teste, are the major movements /the car,inal movements02 flexion2 extension2 rotation2 ab,uction2 a,,uction an, si,e flexion. The combine, movements /4ua,rants0 are generall- not teste, initiall- in the ,ifferential ,iagnostic examination for goo, reason. 7f the car,inal movements are positive in that the- repro,uce s-mptoms or ,emonstrate re,uce, movements2 the combine, tests usuall- a,, little if an- further information an, become re,un,ant an, potentiall- a source of confusion. 1or example2 if cervical extension2 right si,e flexion an, right rotation repro,uce pain2 then 7 can be ver- confi,ent that the right posterior 4ua,rant test that combines these movements .ill also repro,uce the patientBs s-mptoms. There are situations .here the combine, movement tests become ver- useful if not in,ispensable. The spinal 4ua,rants are: 6ight :nterior: =eft :nterior: 6ight Posterior: =eft Posterior: flexion2 right si,e flexion2 right rotation flexion2 left si,e flexion2 left rotation extension2 right si,e flexion2 right rotation extension2 left si,e flexion2 left rotation

These 4ua,rant tests can help ,ifferentiate the cause of lancinating pain. ;er .e %no. that the pain is ,ue to neurological tissue insult but .e cannot be sure of .hat is causing the insult. 7f the problem is stenosis on an inflame, spinal nerve then the pain shoul, be repro,uce, .ith extension an,Dor unilateral extension to that si,e .ith the posterior 4ua,rant tests. 7f a small ,isc bulge is compressing an inflame, spinal nerve then flexion or unilateral flexion a.a- from the si,e /contralateral anterior 4ua,rant test0 ma- .ell pro,uce the s-mptoms. : large herniation .oul, probabl- cause lancinating pain .ith both the contralateral anterior an, the ipsilateral posterior 4ua,rants. The 4ua,rants ma- also ,emonstrate pain an, restricte, movement .hen the car,inal tests ,o not. This is because the- are at the full extreme of range. @suall-ou cannot attain this .ith car,inal movements. To ,emonstrate tr- this exercises. Exten, -ou hea, as far as possible. 'o. si,e flex it. Iou have just exten,e, it past full range because the initial full range .as s-mmetrical that is both si,es of the segment un,er.ent the same movement. Iou cannot simultaneousl- flex or exten, both 3-gopoph-sial joints. "ne joint or si,e of the segment has to unflex or unexten, for the other to reach its full excursion of motion. The same happens in the peripher-2 at least in those joints that have less than three ,egrees of motion. @nless the conjunct rotation /see section on biomechanical examination0 is inclu,e, in the movement2 the motion being teste, cannot reach its full range. The 4ua,rant test inclu,es that rotation. =astl-2 the 4ua,rant test is a more functional test than is the car,inal motion test an, is better at ,etermining the functional abilit- of the patient.

The active range of motion is normall- a little less than that of the passive range an, these t.o ranges shoul, be compare,. 7s there severe2 mo,erate2 mil, or no restrictionG The last shoul, be assesse, ver- criticall- as .hat is often ta%en for full range is slightl- limite, or slightl- increase,. 7n a,,ition2 in the spine in particular remember that -ou are assessing multiple joints an, if one is h-pomobile2 there is an excellent chance that one or more of the others have been h-permobili3e, an, are compensating an, giving a false impression of full range. Painful h-permobilitan,Dor instabilit- can also fool -ou. The motion ma- automaticall- stop before the affecte, tissues become s-mptomatic again giving an impression of full range rather than excessive range. 7f the range is restricte, .hat is the pattern of the restriction2 is it capsular or non9capsularG 6ecentl-2 +-riaxBs capsular patterns have been calle, to 4uestion2 at least in the %neelxvi. +-riaxBs capsular patterns .ere often base, on rheumatoi, arthritic patients ,uring 4uiescent perio,s an, sometimes on acute s-stemic or posttraumatic arthritislxvii. This ma%es interpreting the pattern of restriction ,ifficult. ;e ,i, not al.a-s use ever- motion available at a given joint2 the shoul,er is a prime example of this .here flexion an, extension .ere ignore,. 7t is also ,ifficult to ju,ge sometimes ho. he measure, the restriction an, from .hich neutral point. The hip ,emonstrates this clearl-. +-riaxBs pattern is gross limitation of flexion2 ab,uction an, me,ial rotation2 relativel- slight limitation of extension an, minimal if an- loss of lateral rotation an, a,,uction. ;o.ever2 if -ou fix the ischium rather than the ilium2 thereb- better restricting the pelvisB abilit- to rotate anteriorl- as -ou exten, the femur a ,ifferent pattern is foun,. 'o. extension an, me,ial rotation are the most limite, movements. 7n the earl- case2 the pattern is again often ,ifferent .ith extension an, me,ial rotation being limite, but painless an, flexion especiall.hen combine, .ith a,,uction an, me,ial rotation being painful. Perhaps a better .a- of ,etermining the presence of an arthrosis or arthritis is to loo% for t.o or movements that are not couple, to pro,uce combine, movements to be restricte, an, or painful. 1or example in the .rist2 flexion an, extension shoul, be affecte, rather than just extension an, ra,ial ,eviation as these movements couple ph-siologicall-. :lternativel-2 flexion an, ra,ial ,eviation ma- in,icate a capsular pattern of limitation. The en, feels shoul, either be har, capsular or spasm or a combination of both in ,ifferent ranges. 'on9capsular restrictions are cause, b- non9arthritic or non9arthrotic con,itions. Chile .e ma- not be able to be certain about a capsular pattern is2 it seems li%elthat .e can %no. .hat a non9capsular pattern shoul, loo% li%e. Chen onl- on motion is restricte,2 it is safe to sa- that this cannot be ,ue to a lesion affecting the entire joint as a capsular pattern must. 7f onl- t.o movements that are functionallcouple,2 that is normal functional ph-siological movements emplo-s these movements2 the restriction is probabl- non9capsular. 7f the movement,s the close pac% position is not at least painful then it is probabl- a non9capsular pattern of restriction. There shoul, be a capsular or spasm en, feel /,epen,ing on the acuteness of the arthritis0 at the en, of at least one range. 7t is clear from the above that an- ,etermination from the active movement tests that there is a capsular

pattern present is extremel- tentative an, has to be confirme, .ith passive movement testing an, the appreciation of the en, feels. The 4ualit- of motion is an important observation to ma%e. 7s it a smooth practice, motion or are there glitches. Painful arcs are evi,ence of abnormal motion an, mabe avoi,e, b- ,eviating the limb or trun% out of the optimal path of motion. 'ec% an, trun% ,eviation also occur ,ue to mechanical bloc%s2 these .ill be ,iscusse, in the region specific examination sections. 6ecover- from a motion shoul, be the same as the motion itself. :n example of .here this is not the case is in the lumbar spine2 .hen after trun% flexion2 the patient has to .al% themselves up their thighs .ith their han,s to come bac% to erect stan,ing. :bnormal recover- movement patterns often in,icate instabilities. The inabilit- to manage smooth coor,inate, motion ma- be one of the first in,icators of cerebellar problems from .hatever causes. This fin,ing ,eman,s a fairl- ,etaile, neurological examination of the patient inclu,ing cranial nerve an, cerebellar tests. Chen .atching spinal movements2 the trun% ma- appear to more fairl- normall- but ,oes the spine> loo% for segmental motion as .ell as trun% motion. 7n some cases2 active movement .ill not repro,uce s-mptoms. The patient mahave learne, .hen to stop the movement before the pain starts or2 the car,inal movements /uncombine, movements0 ma- not be sufficientl- sensitive to repro,uce the pain. 7n the more usual case .here the car,inal movements ,o repro,uce s-mptoms2 .hat are the-2 .hen ,o the- start in the range an, ,o the- get .orse as the patient pushes further into the rangeG The repro,uction of lancinating pain or paresthesia .ith active movement in,icates that a neurological tissue is being compresse,2 tractione, or irritate, in some other .a-. Generall- if this is allo.e, to continue2 the patient stan,s little chance of 4uic% recover- an, so steps must be ta%en to limit these occurrences. The further referre, pain is experience, ,istall- the more intractable is the con,ition li%el- to be an, again the less often the patient repro,uces this pain2 the better. 7s there a painful arc in the rangeG 7f this occurs .ith trun% flexion2 a small ,isc protrusion ma- be catching the spinal nerve at this part of the range. This is fre4uentl- associate, .ith a painful arc in the straight leg raise especiall- if the si3e of the bulge is not .eight ,epen,ent to an- great ,egree. 3. Passi"e $ests ((nert $issues) These inclu,e:

Ph-siological movements =igamentous stress tests 'on9specific stress tests such as axial compression an, traction Dural tests @pper limb neural tensionDprovocation tests

7nert tissues are those that ,o not have an inherent abilit- to contract2 or transmit bloo, or neurological impulses an, inclu,e the joint surfaces2 bone2 joint capsule2 ligament2 bursa an, ,ura. 7nert tissues are teste, .ith full range passive movements. These movements inclu,e ph-siological movements2 ligament stress tests2 ,ural mobilit- tests /straight leg raise2 prone %nee flexion or femoral nerve stretch2 scapular retraction02 spinal compression an, traction2 vertebral postero9anterior pressures. "f course passive movements .ill also appl- stress to non9inert tissues such as the muscle9ten,on unit2 bloo, vessels2 nerves2 spinal cor, an, even2 to a small extent2 the me,ulla. 7n fact this attribute is sometimes exploite, .hen testing some of these structures. ?ertebral arter- testing is base, on active or passive positioning of the nec% an, upper limb tension testing .hich2 among other things2 tests the mobilit- an, tension tolerance of those tissues comprising the brachial plexus an, its continuations into the arm an, han,. <ut for the main part an- effect on the non9inert tissues is consi,ere, complicating an, is un.ante,. <ut it cannot be eliminate, entirel- an, so the therapist must again use ju,gement .hen interpreting the results of the passive movement tests.

En, feel Pain an, other s-mptoms 6ange of motion Pattern of restriction :ssociation bet.een the onset of s-mptoms an, the onset of tissue resistance

1rom these an, their integration .ithin themselves an, .ith the rest of the examination2 a fairl- accurate picture of the state of the inert tissues can be built up. En, 1eel This is ,efine, as the sensation imparte, to the examiner at the en, of the available range of motion. 7t affor,s information about the restrictor of the movement. 7s it normal or abnormal an, if abnormal .hat is it. 7 believe that the en, feel is a more vali, .a- of assessing movement especiall- .ith spinal segmental motion .here objective measurement is all but impossible. The assessment of en, feel rather than range of motion preclu,es the man- problems associate, .ith measuring actual motion an, comparing it to normative ,ate. The main problem is .ith the normative ,ata. 1rom .hat population .as the sample ta%enG Cere the- men or .omen2 ol,2 -oung or mi,,le age,G Cere the- en,omorphs2 mesomorphs or ectomorphs or .ere the- a mixture of ages2 sexes an, bo,- t-pesG Chat si3e .as the sample2 .as it large enoughG Cas the normal figure arrive, at the average or .as a range of normal obtaine,2 an, if a range .as given2 .hat is it. Chat .as the stan,ar, ,eviationG 7s the patient2 .hose range of motion that -ou have just teste,2 in the same population from .hich the sample .as ,ra.nG 7s the ,ifference in range enough to measureG 7n large joints .ith a gross loss of range2 the to this last 4uestion is -esN <ut if the range of motion loss is small or the joint has a ver- small range of motion /the spinal joints spring to min,0 then goniometric error ma-


prevent -ou from measuring the ,ifference. 7n orthope,ic manual therap- the range of motion loss is usuall- ver- small2 fre4uentl- less than five ,egrees. 7f the spine is being assesse, biomechanicall-2 then .e are loo%ing at segmental ranges of motion that are commonl- less than five ,egrees. 7f there is a restriction of &)5 of range this means that the therapist has to be able to pic% up motion ,ifferences of less than three ,egrees. 'o. some /or ma-be all0 ph-sical therapists ma- be able to ,o this2 but 7 cannot therefore 7 have to assess movement ,ifferentl-. 7 believe that the properl- traine, therapist can recogni3e the ,ifferences in en, feel in both normal an, ,-sfunctional joints. Does the joint feel stiff2 jamme,2 reactive2 s4uish-2 ,evoi, of en, feel. These are all ever- ,a- terms for en, feels an, .hen put into these terms most therapists can tell the ,ifference .ith practice. The is a list of en, feels2 mo,ifie, from +-riax2 together .ith their major i,entif-ing characteristics an, a normal example of each. End 'eel +apsular Characteristics Stretchable to a variable extent Normal Example Crist flexion /soft0 Crist extension /me,ium0 Enee extension /har,0 Elbo. extension in pronation :n%le ,orsiflexion .ith the %nee exten,e, 'o normal example in ph-siological movements but compression testing of the cervical spine pro,uces it 'o normal example Enee flexion. Elbo. flexion is capsular unless the elbo. flexors are massivel- ,evelope, 'o normal example 'o normal example 'o normal example

<onElastic Spring<oggSoft tissue interposition Patho9 mechanical Spasm Empt.

:brupt an, un-iel,ing 6ecoil 6eboun, S4uish'o resistance Oamme, 6eactive response in the opposite ,irection to the movement =imite, onl- be severe pain the examinerBs reluctance to continue the test


The table lists the en, feels an, their implications both normal an, abnormal. End 'eel 'ormal +apsular ;ar, +apsular /stiff0 Soft +apsular /loose0 <one in elbo. extension <ogg- /s4uish- an, limite,0 Earl- spasm /reactive earl- in the range0 =ate spasm /reactive at the en, of the expecte, range0 Soft tissue interposition /s4uishan, unlimite,0 Elastic /recoil0 Possi-le (mplication 'ormal range of motion Pericapsular tissue h-pomobilit- ,ue to arthrosis2 a,hesions or scarring. 6e4uires some t-pe of stretching2 usuall- joint mobili3ations 'on9irritable h-permobilit- or instabilit-. 6e4uires mechanical stress re,uction .ith rest an,Dor mobili3ation techni4ues an,Dor orthoses 'ormal range of motion .ith elbo. extension in pronation. "r juxtapositioning from osteoph-tosis2 fracture fragment angulation in an- other range. 'o further movement is obtainable ;emarthrosis. 6e4uires aspiration Deal .ith the source of the spasm not the spasm itself. "ften ,ue to arthritis2 gra,e 2 muscle tear2 fracture near a muscle insertion2 ,ural sleeve or other meningeal compression an,Dor inflammation Due to irritable h-permobilit-. :voi, irritating the over9stretche, tissues an, remove stress .ith mobili3ation an,Dor orthoses 'ormall- foun, onl- on %nee flexion other causes are massive ,evelopment of muscles or obesit-. 'o treatment $uscle tone. @suall- muscle can be stretche, through but the gastrocnemius is ,esigne, not to allo. the capsule to be reache, so that an%le ,orsiflexion .ith the %nee exten,e, shoul, give a this muscle tone en, feel. 7n other cases of this en, feel suspect h-pertonicit-. This ma- be ,ue to segmental facilitation. This is not normal .ith ph-siological movements an, is present .ith internal ,erangements such as meniscal injuries an, loose bo,ies. :l.a-s abnormal it can be ver- har, similar to bone or more spring- li%e the internal ,erangement. 7t in,icates a biomechanical ,-sfunction re4uiring manipulation or non9 rh-thmic mobili3ations. 'o en, feel is reache,. The therapist stops the test ,ue to the extreme pain an, ,istress the patient is exhibiting. This is almost al.a-s ,ue to serious patholog- in structures that are incapable of provo%ing spasm.

Spring- /reboun,0 Pathomechanical /jamme,0 Empt-

7 can remember learning to appreciate en, feels2 or at least tr-ing to. 7 can also remember thin%ing that the instructor .as tal%ing out of the top his hea, because ever-thing 7 felt2 felt the same. 7 eventuall- came to reali3e that the first resistance


that is met on passivel- moving a joint is muscle an, if this is not stretche, sufficientl-2 the un,erl-ing en, feel cannot be appreciate,. 7n or,er to obtain the en, feel of the ultimate2 rather than the initial2 restrictor in joints .ith minimal movement loss2 the force applie, has to be sufficient to stretch the muscle enough to reach the restrictor. Cith more ,ramatic range loss2 this is not a problem because the range ,oes not reach the point .here muscle is capable of acting as a passive barrier. +onse4uentl-2 spasm2 severe arthrosis2 subluxation2 fibrosis an, an- other cause of severe tissue shortening can be felt .ithout the application of the same magnitu,e of force necessar- in normal or minimall- re,uce, ranges. : 4uestion that al.a-s arises is .hether the therapist shoul, appl- over9pressure in the presence of pain. "ften the teaching is to not ,o this as it might ,amage the patient further. ;o.ever2 almost all relevant en, feels .ill be experience, in the painful range. The empt- en, feel can onl- be felt in the painful range an, earlspasm invariabl- ,oes so. +onse4uentl-2 if the en, feel is not sought in the painful range2 there is no point in ,oing an- passive movements to the patient2 as no relevant information .ill be forthcoming. 7n a,,ition to evaluating the restrictor of the movement2 the acuteness of the con,ition can be assesse,. <- comparing the onset of tissue resistance to the onset of pain2 a pseu,o94uantifiable estimate of acuteness can be arrive, at. Pain4)esistance )elationship Pain an, no resistance +onstant pain Acuteness Empt- en, feel ;-peracute Possi-le Pathology @suall- serious patholog?er- acute arthritis2 s-stem arthritic flare up2 overt fracture2 cancer2 visceral problems T-pical after injur-2 acute traumatic arthritis Sub9acute traumatic arthritis2 @sual coupling seen2 usuall- mechanical ,-sfunction @nusual to have a patient present this .a- as the main complaint but ,uring treatment2 the coupling can go from pain after resistance to resistance an, no pain

Pain felt before resistance Pain .ith resistance Pain felt after resistance 6esistance .ithout pain

:cute /mainl- inflammation0 Sub9acute /chemomechanical0 +hronic or non9acute /mechanochemical0 Stiff /mechanical0

6ange of $otion an, Pattern of 6estriction


7n a,,ition to the en, feel being assesse,2 the passive movement shoul, also loo% at the angular ,isplacement that the joint un,ergoes ,uring testing. This .ill affor, an i,ea of the range of motion /given the limitations alrea,- ,iscusse, above0 an, the pattern of restriction. The passive range of motion shoul, also be compare, to the active range. 'ormallthe passive range is a little greater than the active. 7f it is greatl- increase,2 the possibilities are that the patient is: a. "ver anxious b. :mplif-ing c. 1abricating 7f the movement at a joint is restricte,2 assess the pattern of restriction. This can be more easil- ,one .ith passive movements than .ith active as the patientBs anxietor gain issues are minimi3e,. 7s the restriction capsular or non9capsularG 7n the light of some of the concerns regar,ing the vali,it- of capsular patterns2 care shoul, be ta%en .hen coming to the conclusion that there is one present an, a more flexible approach ta%en to the ,efinition of capsular patterns /see the ,iscussion un,er active movements0. ;o.ever2 for those of -ou .ho .oul, be more comfortable .ith establishe, patterns /an, onl- the %nee has been ,emonstrate, experimentall- to be suspect0 the lists the capsular patterns as ,escribe, b- +-riax. )egion or 5oint 'ec% Sternoclavicular :cromioclavicular Glenohumeral Elbo. 7nferior ra,io9ulnar 1st carpometacarpal 7nterphalangeal Thoracic =umbar Sacroiliac Capsular Pattern of )estriction Si,e flexion an, rotation are e4ualllimite, bilaterall-2 flexion is full or near full an, extension limite,. Pain at the extremes of shoul,er range Pain at the extremes of shoul,er range =ateral rotation most limite,2 ab,uction next limite, an, me,ial rotation least limite, $ore limitation of flexion than extension .ith pronation an, supination onl- being affecte, in more severe arthritis 1ull ranges .ith pains at extremes =imitation of extension an, ab,uction2 full flexion 1lexion more than extension :lmost impossible to ,etermine except in gross arthritis. :lmost impossible to ,etermine except in gross arthritis. Pain .hen stress falls on the joint


S-mph-sis pubis an, sacrococc-geal ;ip


Superior Tibiofibular 7nferior Tibiofibular :n%le Talocalcaneal $i,9tarsal 1st metatarsophalangeal "ther metatarsophalangeals

Pain .hen stress falls on the joint Gross limitation of flexion2 ab,uction an, me,ial rotation2 slight limitation of extension an, minimal or no limitation of a,,uction an, lateral rotation Gross limitation of %nee flexion2 slight limitation of extension .ith rotation remaining unaffecte, except in gross arthritis Pain .hen biceps contraction stresses the upper joint. Pain .hen mortise is stresse, Plantaflexion more than ,orsiflexion if the muscles are of normal length =imitation of varus /inversion0 until in gross arthritis it fixes in valgus =imitation of ,orsiflexion2 plantaflexion2 a,,uction2 an, me,ial rotation .ith ab,uction an, lateral rotation full range Gross limitation of extension an, slight limitation of flexion ?ariable2 the- usuall- ten, to fix in extension .ith the interphalangeal joints flexe, /cla. toes0

<- assessing the en, feel2 its association .ith the s-mptoms an, the range of motion2 a ,etermination of the range of motion2 acuteness an, seriousness of the con,ition can be provisionall- ma,e. The proviso .ill be the remain,er of the examination. : potentiall- serious sign is the patient .ith continuous or constant pain .ho has full range painfree movement. 7t is reasonable to expect that musculos%eletal con,itions causing constant or continuous pain .ill have significant signs. ?arious t-pes of bone cancer have been reporte, to appear in this .a- an, visceral con,itions .ill for the most part be unaffecte, b- ph-sical stress. =igament Stress Tests Partial or complete rupture of the ligaments or gra,ual over9stretching of ligaments is a cause of one t-pe of instabilit-2 the ligamentous instabilit-. The secon, t-pe of instabilit-2 articular or segmental instabilit-2 for the peripheral an, spinal joints respectivel- .ill be ,iscusse, in a later section. =igaments .ith prevent movements that shoul, not ta%e place at all such as ab,uction of the exten,e, %nee or limit movements that shoul, occur such as inversion of the foot. 7nsufficienc- of a ligament lea,s to instabilit- of the joint2 ho. fast this instabilit- occurs ,epen,s on the presence an, thic%ness of secon,ar- restraints an, the stress that the joint is


ma,e to tolerate. :nother factor to consi,er is .hether the instabilit- is clinical or functional. That is2 ,oes it interfere .ith the patientBs function or is it simpl- a clinical fin,ingG The implications for treatment are ,ifferent for each. Determining .hich can be ,ifficult. The are the criteria that ma- be consi,ere, provisional in,ications for beginning a course of stabili3ation therap-:

Su,,en mo,erate to severe trauma Episo,ic pains @npre,ictable behavior of the problem to treatment or ever- ,a- stresses S-mptom relate, clic%s or clun%s S-mptom relate, feeling of instabilit;-permobilit6ecurrent subluxations =oc%ing Giving .a-

The initiation of stabilit- therap- is in part ,epen,ent on fin,ing the instabilit- but more importantl- having one or more of the above characteristics present. 7nstabilit- is not al.a-s ,etectable clinicall-. =igament stress tests are carrie, out b- fixing one bone to .hich the ligament is attache, an, moving the other bone a.a- from it such that the connecting ligament is stretche, maximall-. "bviousl- in or,er to avoi, ,oing further ,amage2 the stress must be gra,uall- progressive until a positive test is obtaine, or until the therapist is satisfie, that the test is negative. There is no set time to hol, the stress. Some teach that the stress must be hel, for five2 1) or !) secon,s so that creep can be ta%en out. +reep cannot be ta%en out in this length of timelxviii. Even if it coul,2 is the perio, suggeste, in a thic% ligament or a thin ligament2 in an a,ult or a chil,2 in a .oman or a man2 in an ectomorph or an en,omorph2 in an athlete or non9athleteG Each of these people .oul, have a ,ifferent thic%ness for the same ligament an, so each .oul, ,eman, a ,ifferent perio, of stressing. <etter is to hol, the stress until a normal en, feel is felt2 at .hich point2 -ou have ta%en out the crimp2 .hich is about all -ou can expect to ,o in this si,e of fifteen minutes. : positive ligamentous stress test is one .here there is:

Pain Excessive movement : softer en, feel than shoul, be present

Positive tests can be classifie, as follo.s:


G6:DE 1 minimal tear 2 partial tear ! complete tear

+;:6:+TE67ST7+S Pain .ith no excessive movement an, normal capsular en, feel Pain .ith mo,erate excessive movement an, abnormall- soft capsular en, feel 'o pain .ith severel- excessive movement an, ver- soft capsular en, feel

The classification s-stem can be confuse, .ith an ol, gra,e 2 tear that is no longer irritable but still allo.s excessive movement. This can appear to be a gra,e ! tear. +areful evaluation of the histor- an, en, feel must be ma,e to ,etermine .hich it is. 7n the peripheral joints the nee, for ligamentous stress testing is obvious. 7n the spine2 it is less so. The transverse ligament an, alar ligament are t.o ligaments routinel- teste, .hile the iliolumbar ligament is less commonl- evaluate,. These tests .ill be ,iscusse, in a later section. The ,ifferential ,iagnostic stress tests in the spine an, pelvis are:

Transverse ligament :lar ligament +ompression Traction :nteroposterior Torsional /rotational0 Sacroiliac primar- /compression an, gapping0

+ompression an, traction ma- both be use, as stress tests in all areas of the spine. +ompression .ill stress the ,isc2 the vertebral bo,- an, the en, plate. @nfortunatel-2 acute 3-gopoph-seal joint problems .ill also become painful .hen this stress is applie, to the region in .hich the- la-. Traction has been postulate, to stress the anulus fibrosis2 the 3-gopoph-seal joint capsules2 the long ligaments an, the interspinous ligaments. Pain is the positive for traction as a stress test .hile relief of pain ma- be use, as an in,icator of relief of stress from ,isc or stenotic compression. Postero9anterior pressures over the vertebrae are also a form of stress test although not a ver- goo, one as the- ,o pro,uce a goo, ,eal of ph-siological motion. 7t is therefore ,ifficult to sa- .ith an- ,egree of certaint- that an- repro,uce, pain is ,ue to ligamentous ,amage. Pressure over =! for example .ill pro,uce an anterior shear at =!D but a posterior shear effect at = D&. :t the same time =2 .ill exten, .hile = flexes both resulting in extension at =2D! an, =!D . 7f the inferior vertebra of the segment to be teste, .ith a postero9anterior pressure can be stabili3e,2 the test becomes more useful as a stress tests as it pro,uces a little more of a purer anterior shear an, exten,s onl- one segment. General torsion can be teste, in the


lumbar spine b- stabili3ing T12 an, pulling ,irectl- bac% on the anterior superior iliac spine. This results in contralateral axial rotation of the spine. 7f this repro,uces pain2 each segment can be teste, in,ivi,uall- b- stabili3ing the superior bone an, pulling through the innominate. 7n all of the above tests2 the therapist loo%s for excessive movement2 spasm en, feel an, pain. ;o.ever2 as there are so mancauses of these signs an, s-mptoms other than instabilit-2 the ,iagnosis is verprovisional an, biomechanical segmental stabilit- tests shoul, be carrie, out an, correlate, .ith the patientBs histor-. The sacroiliac joints are stress teste,2 but for inflammation rather than instabilit-. +ommonl- calle, anterior gapping an, posterior compression the tests see% to repro,uce the patientBs sacroiliac pain. 7f positive2 inflammation is suggeste,. Dural /'euromeningeal0 $obilit- Tests12lxix2lxx The ,ura is teste, both centrall- an, peripherall-. The ,ural sheath is not stretch sensitive but ,oes seem to be sensitive to compression an, is certainl- versensitive to inflammation> meningitis ,emonstrates that ver- nicel-. The ,ural sleeve is innervate, b- the sinuvertebral /recurrent meningeal0 nerve from its o.n level an, the a,jacent levels. +onse4uentl-2 the pain experience, .hen this tissue is pro,ucing pain is multisegmental rather than segmental an, has no ,efine, boun,aries in the .a- that a ,ermatome ,oes. 1or example2 the straight leg raise test .hen it ,oes pro,uce ,ural pain ma- be positive for pain felt in the leg or the bac% or the buttoc% or all three. "f course2 the ,ural sleeve cannot be teste, in isolation2 the neural tissue containe, .ithin it must also move to some ,egree. The pain pro,uce, b- the ,ura is somatic> that is an ache2 not the lancinating pain or paresthesia of neurological tissue. 7f paresthesia or lancinating pain is felt2 then tissues other than or in a,,ition to the ,ura are being irritate, an, the con,ition must be consi,ere, more serious. The ,ural tests are: TEST 'ec% flexion /central0 +oughing /central0 7nspiration /peripheral0 Scapular retraction /peripheral0 Trun% flexion /central0 Trun% extension /central0 Slump /central an, peripheral0 Straight leg raise an, a,junct tests /peripheral0 Prone %nee flexion /femoral nerve0 /peripheral0 D@6:= S=EE?E TESTED 'on9specific 'on9specific Thoracic levels 1st thoracic non9specific =22! 'on9specific = 9S2 =22!

'ec% flexion moves the ,ura centrall- b- elongating the spinal column. +onse4uentl-2 it cannot be assigne, a particular level or levels as it moves the entire


spinal ,ura. +oughing raises the intrathecal pressure an, again can onl- be consi,ere, as non9specific. Trun% flexion is a%in to cervical flexion but can be isolate, from the nec% b- having the patient %eep the nec% in neutral or extension. 7n fact this is not unnecessar-2 as the ,-sfunctional point .ill i,entif- its region of location b- the site of the pain. Trun% extension moves the femoral nerve ,ural sleeve as this passes anterior to the hip2 it can be ,istinguishe, from pain from the lumbar joints b- having the patient ben, from the .aist rather than from the hips. The slump test moves the ,ural both centrall- an, peripherall- ,epen,ing on the se4uence that the test is carrie, out an, moves all of the spinal ,ura. Straight leg raise moves the th lumbar to the 2n, sacral ,ural sleeves an, is peripheral. Prone %nee flexion tests the mobilit- of the femoral nerve ,ura b- pulling it ,uring %nee extension. The region specific tests .ill be ,iscusse, in a later section. 6. )esisted (Contractile $issues) These mainl- comprise of the muscles> ten,ons2 tenoperiosteal junctions an, the un,erl-ing bone. ;o.ever2 other structures ma- be substantiall- affecte, b- the contraction of the muscles an, become painful .hen this occurs. ;ol,ing sometimes honorar- memberships in the contractile tissue club because of this are bursae an, bone in particular. The contractile tissues are teste, b- isometric contraction. Despite2 .hat .as to m- min,2 a some.hat fla.e, /there .as no evi,ence that the t-pe of muscle injur- susceptible to selective tissue tension testing ha, occurre,0 the contrar-lxxi2 there is no reason to ,oubt the original observations ma,e b- +-riax concerning the response of injure, contractile units. =esions of the contractile an, non9contractile tissues that .oul, sho. up positive for pain or .ea%ness on isometric testing inclu,e the

gra,e one through three tears of the bell- or ten,on ten,onitisB /often consi,ere, as a gra,e one tear0 tenoperiostiitis bursitis fractures near a ten,on insertion acute arthritis particularl- rheumatoi, an, infective arthritis bone cancer near a ten,on insertion

+-riax a,vocate, that these tests be carrie, out in the resting position of the joint so as to minimi3e articular stress ,uring the test an, false positives. ;o.ever2 a more efficient .a- is to carr- out the isometric contraction in the stretche, position of the muscle if that position is attainable. Chen this positioning is combine, .ith a maximum force contraction2 the contractile tissue has been stresse, as full- as possible. This saves re9testing all of the negative tests in the resting position. <ut +-riax .as correct in his feelings of false positives. :n- significant inflammation of the joint or irritation of the joint capsule .ill be painful .hen teste, using this techni4ue. Perhaps the best marriage of specificit- an, efficienc- occurs .hen a


minimal progressing to maximal contraction is carrie, out in the stretche, position. 7f this ,oes not prove to be positive nothing further nee,s to be ,one in the assessment for contractile lesions. ;o.ever2 if there is pain or .ea%ness2 the contraction is repeate, from minimal to maximal in the resting position of the muscle. 1rom these t.o tests2 the placement of the KpositivenessH of the test on a spectrum can be ma,e. Chen a minimal contraction in the rest position of the muscle of the muscle is painful2 the test can be consi,ere, strongl- positive for a contractile lesion. ;o.ever2 if it ta%es a maximal contraction in the stretche, position to repro,uce pain2 the test is .ea%l- positive for a contractile lesion an, other explanations are as li%el- or more li%el-. There are t.o variables to be consi,ere, .hen carr-ing out contractile tests2 pain an, .ea%ness. Extensibilit-2 .hile important for other reasons2 .ill pla- no role in assessing for contractile lesions. Each test .ill generate information about these lea,ing to four variables:

Painless an, strong Painless an, .ea% Painful an, strong Painful an, .ea%

: test resulting in a maximum contraction that in the stretche, position .as painless an, strong .oul, suggest that there is little if an-thing .rong .ith the contractile tissues being teste,. Painless an, .ea% on testing might suggest a neurological pals-2 segmental facilitation2 a gra,e three /complete0 tear .here there .as no tissue to irritate2 ,e9con,itioning an, painless inhibition from an articular problem /4ua,riceps inhibition from a meniscus tear .oul, be one example0. : painful an, strong contraction coul, in,icate the presence of a minor contractile lesion such as a ten,onitis2 a gra,e one tear2 or a bursitis. The final combination is the most .orrisome as it can be a gra,e t.o tear but ma- also be acute arthritis2 bone cancer or a fracture. 1in,ing painful .ea%ness ,eman,s a ver- careful examination of the patient.


Section % The &eurological Tests

The neurological tests inclu,e the function of the:

central nervous s-stem /cortex2 cerebellum2 brainstem an, spinal cor,0 spinal nerve an, root /afferent an, efferent functions0 peripheral nerve /afferent an, efferent functions0

The ,o this b- investigating the integrit- of the m-otome /%e- muscles02 ,ermatome an, reflexes. The stan,ar, neurological tests in the ,ifferential ,iagnostic examination loo% at strength2 fatigabilit-2 sensation ,eep ten,on reflexes an, the inhibition of those an, other reflexes b- the central nervous s-stem. 7t is .orth noting that one surgical stu,- comparing neuroph-siological tests /inclu,ing ,ermatomal evo%e, potentials0 .ith the level of ,isc lesion foun, on surger-2 conclu,e, that: J...neuroph-siolog- is not useful to ,iagnose the exact level of a nerve root lesion2 but ma- reveal .hether it is present.Klxxii $-otome Tests The efferent s-stem is teste, .ith resiste, tests to muscles that are most representative of the motor innervation from a given spinal segment. Ce use the .or% m-otome incorrectl- in this regar, as m-otome is actuall- an, embr-ological term that means a muscle or group of muscles innervate, exclusivel- from one segment. There are ver- fe. of those muscles in the bo,-. Cith the possible exceptions of the multifi,ous2 rotatores an, the suboccipital muscles2 multiple segments suppl- all others. The term %e- muscle is more precise but the m-otome is in such common misusage that it .ill almost certainl- continue. Evaluating the strength an, fatigabilit- of the muscles innervate, primaril- from its segment tests the m-otome. : %e- muscle2 that is one that is most representative of the suppl- from a particular segment2 is selecte, an, it is ma,e to un,erta%e a maximum contraction. To ensure that the contraction is maximal2 the therapist must brea% the contraction2 if this is not ,one2 there is no guarantee that the patient has ma,e maximum effort an, that -ou are assessing the full of the muscle. 7f the muscle is felt to be .ea% t.o follo. up tests are carrie, out. :nother muscle innervate, mainl- from the same segment2 the alternate2 is assesse, for strength. 7f a segmental ,istribution is establishe, then the possibilit- that this is a nerve root paresis is strengthene,. 6epeate, contractions or a sustaine, contraction then assess fatigabilit-. Chile there is no experimental evi,ence for it2 the combine, clinical experience of numerous +ana,ian an, :merican orthope,ic therapists over man-ears suggests that spinal nerve paresis causes abnormall- fast fatiguing of the


affecte, muscles. 7f a segmental ,istribution of abnormall- fatigable .ea%ness is foun,2 then spinal nerve or nerve root paresis is assume,. ;oppenfel, state, that H6epetitive muscle testing against resistance helps ,etermine .hether the muscle fatigues easil-2 impl-ing .ea%ness an, neurologic involvement.Hlxxiii This assumption .ill be reinforce, if a segmental ,istribution of h-poesthesia an,Dor ,eep ten,on h-poreflexia is later foun,. 7f non9fatigable segmentall,istribute, .ea%ness is ,iscovere,2 then other signs of segmental facilitation are searche, for. Segmental facilitation an, its effects .ill be ,iscusse, later. :lternativel-2 a non9fatigable segmental .ea%ness ma- be cause, b- an ol, root pals- that has not full- recovere, its strength. 7f paral-sis rather than paresis is foun, a ,iagnosis of spinal nerve pals- shoul, not be ma,e regar,less of the ,istribution of the paral-sis. <ecause multiple segments innervate muscles2 paral-sis is not an effect of compression of a single spinal nerve or root an, the culprit must be loo%e, for :s these culprits inclu,e serious neoplastic an, neurological ,iseases an, severe injuries to the brachial plexus2 the therapist shoul, eliminate the peripheral nerve as a possible cause an, then refer the patient bac% to the ph-sician. Dermatome Due to the overlap of the segmental innervation of the s%inlxxiv2 onl- a small area .ithin .hat .e thin% of as the ,ermatome is exclusivel- or almost exclusivelsupplie, b- that segment. This is the autogenous area an, comprises of a small region2 usuall- at or near the ,istal portion of the ,ermatome. This area varies not onl- bet.een in,ivi,uals but also .ithin the same in,ivi,ual from ,a- to ,a- an, possibl- from hour to hour. The inter an, intra9subject variation is confine, mainlto the si3e of the area rather than to its location. Grieve put it .ell .hen he sai, that: HVthe experimentall-9observe, si3e of an isolate, ,ermatome is a variable 4uantit-2 an, at an- one moment is more of an in,ex of the efficienc- of sensortransmission in the same an, neighbouring segments of the spinal cor,2 than an anatomicall- fixe, cutaneous territor-.H lxxv 1igure 1. illustrates one ,epiction of the ,ermatomes. This is a fairl- stan,ar, ,epiction but the variabilit- of the ,istribution of the ,ermatomes must be remembere,. The ,etermination of s%in sensitivit- is a major %e- in the pu33le of neurological tissue involvement. There are man- causes of sensor- changes in the s%in an, man,ifferent t-pes of change /an, man- ,ifferent ,efinitions ,epen,ing on .hom -ou rea,0. These inclu,e:

;-poesthesia: ,ecrease, light touch2 pain or heat sensation


:nesthesia: complete loss of light touch2 pain or heat D-sesthesia: the substitution of one sensation /usuall- pain0 for another ;-peresthesia: increase, non9nociceptive sensation :llo,-nia: the sensation of pain .ith a non9noxious stimulus

Each of these can occur .ith a multitu,e of insults or ,isease processes. The pathologies inclu,e ischemia2 infarction2 compression2 traction2 neuromas2 +'S neoplasms an, neuritislxxvi. The tissues that can lea, to sensor- changes if so affecte, inclu,e:

Spinal nerve or posterior root or posterior root ganglion Spinal cor, /anterior an, lateral spinothalamic tracts0 +au,a e4uina Peripheral nerve <rainstem /spinothalamic tracts an, trigeminal nucleus0 Thalamus 7nternal capsule Posterior sensor- cortical g-rus

7n orthope,ic manual therap-2 the most common lesion that .e see affecting sensation is compression of the spinal nerve or root b- a ,isc herniation. So the most common presentation that .e see is one reflecting that patholog-. :s there is so much overlap in the ,ermatome2 it usuall- results in h-poesthesia rather than anesthesia in the bul% of the ,ermatome but anesthesia or near anesthesia in the autogenous area. ;o. much sensor- loss is ,epen,ent on the ,egree of pressure exerte, on the neural tissue if it is a compression phenomenon or ho. much ischemia if that is the cause an, ho. long or ho. much contact .ith the nucleus if this is a factor. =arge9scale anesthesia is not a sign of spinal nerve insult for the same reason that paral-sis is not. There is too much overlap to allo. an-thing other than autogenous area anesthesia. ;o. -ou test is ver- ,epen,ent on .hat -ou are loo%ing for. 7f a spinothalamic tract problem is suspecte, or has to be eliminate,2 the limbs must be teste, .ith both light touch an, pinpric% /temperature sensation ,oes not nee, to be teste, separatelas it is carrie, through the lateral spinothalamic tract together .ith pain0. 7f2 though2 a spinal nerve or nerve root compression is being teste, for2 there is no nee, to test both as .e are simpl- intereste, in .hether or not2 sensation impulses can pass through these tissues to reach the conscious level. Pinpric% is generall- regar,e, bneurologists as more sensitive than light touch for testing h-poesthesia as there is greater ,ermatomal overlap .ith vibration an, light touch than there is for pain an, temperaturelxxvii. 7f light touch is to be emplo-e, for sensation testing2 stro%ing the s%in .ith the fingers ,oes not ,o it. This is the least sensitive metho, for sensation testing as it is easil- felt even in h-poesthesia. <etter is the use of a monofilament but still useful in orthope,ic patients are the neurological brush or soft tissue paper. 7f segmental h-poesthesia to pinpric% is being teste, for2 then it is best if the ,ermatome being teste, is compare, to the same ,ermatome on the other si,e of the


bo,-. The patient is as%e, if this is the same as that. This an, that being the pin.heel s.eep on the affecte, an, unaffecte, limbs or si,es of the trun%. Disposable pin.heels are best as these easil- maintain the same amount of pressure an, the entire ,ermatome can be teste, in one s.eep of the .heel. 7f light touch is teste,2 then the patient is as%e, to close their e-es an, in,icate .henever the- feel the ,ab of the instrument or tissue paper. The areas of re,uce, or absent sensation are mappe, out for the autogenous area an, then the presume, ,ermatome is teste, .ith pinpric% to map out the .hole of the h-poesthetic area. :s .ith paresis2 the ,istribution of the sensor- changes must be carefull- evaluate,. Does it conform to a segmental pattern2 is it hemilateral2 bilateral or 4ua,rilateral. The are t-pical ,istributions an, the tissues that cause those ,istributions. Segmental: ;emilateral: <ilateral: Aua,rilateral: Deep Ten,on 6eflexes The value of reflex testing .as ,iscovere, b- Erb in 1#*& .ho use, clinical observation an, his %no.le,ge of neuroph-siolog- to ,evelop the principles of ,eep ten,on reflex testinglxxviii. :n- muscle .ith a spin,le has the potential to be reflexive .hen its intrafusal fibers are su,,enl- stretche,. Stri%ing the ten,on or the bell- of the muscle sharpl- .ith a reflex hammer .ill test the afferent an, efferent function of the peripheral nerve2 spinal nerve an, the cor, path.a-s. 7n a,,ition2 it also tests the abilit- of the central nervous s-stem to inhibit the reflex. Chile in neurolog- it is useful to gra,e the response2 this is not as important in orthope,ic manual therap-. 1or our purposes the reflex can be classifie, much more simpl- as:

spinal nerve or ,orsal root brainstem2 thalamus2 internal capsule or cerebrum spinal cor, or bilateral spinal nerve or root spinal cor,

:reflexic ;-poreflexic <ris% ;-perreflexic

Generali3e, h-poreflexia or even areflexia can have man- causes inclu,ing neurological ,isease particularl- affecting the cerebellum2 chromosomal metabolic con,itions2 anxiet-2 h-poth-roi,ism an, schi3ophrenialxxix. Peripheral neuropath-2 spinal nerve or spinal root compression an, cau,a e4uina s-n,rome ma- cause non9 generali3e, h-poreflexia. 7t is the latter group that orthope,ic therapists run into more commonl-. :gain it is important to test more than one reflex if there is a possibilit- it is re,uce, or absent. This .ill allo. the therapist to establish if the re,uce, reflex is part of a segmental or peripheral nerve pattern. 7f the reflexes are re,uce, or absent in a generali3e, ,istribution2 one of the above causes ma- be at pla- but it ma- also simpl- be that patientBs ma%e up. 7f the- are not suffering from an- s-mptoms other than pain then that assumption ma- be ma,e. ;o.ever2 if the-

are complaining of s-mptoms that appear to be generate, from the central nervous s-stem or if an- other central nervous s-stem signs are foun,2 the patient shoul, be referre, to the ph-sician. True h-perreflexia .ill have some ,egree of reverberation /clonus .ithin it0 that .ill ,istinguish it from an overl- bris% reflex. ;o.ever2 the reverberation cannot be felt in most positive tests because of the .a- the reflex is teste,. @nless the stretch is maintaine, ,uring the test2 the clonus .ill not2 of course2 occur an, the reflex .ill simpl- loo% bris%. The exception to this is the :chilles ten,on reflex. ;ere2 the tester ,oes hol, the an%le in some amount of ,orsiflexion ,uring the test an, clonus can be elicite,. $- suggestion is that if a reflex or reflexes appear bris%2 re,o the test but this time maintain a stretch. 7n a,,ition loo% for recruitment of other muscles ,uring the reflex contraction of the target. Simple increase in bris%ness mabe cause, b- segmental facilitation2 some ps-chiatric con,itions2 an, h-perth-roi,ism an, in people .ith high muscle tone. ;aving ,etermine, that there is a change in the reflex2 loo% at the ,istribution pattern of the change an, an- coexistent neurological signs. :re the changes segmental2 bilateral2 hemilateral or 4ua,rilateralG 7f all reflexes are absent or re,uce,2 consi,er that this ma- be part of s-stemic con,ition2 neurological ,isease or simpl- the patientBs ma%e up. Segmental h-poreflexia coul, be part of a spinal nerve pals-. ;emilateral h-perreflexia ma- be a sign of a brainstem or cerebral lesion. Aua,rilateral h-perreflexia ma- be ,ue to spinal cor, compression2 multiple sclerosis or some other neurological ,isease. Aua,rilateral or hemilateral h-poreflexia ma- be ,ue to cerebellar ,isease. "ther signs an, s-mptoms are important in putting the reflexes into perspective. 7f there is re,uce, or absent reflexes2 are there also .ea%ness2 h-potonia an, or sensor- changes. ;-perreflexia shoul, be associate, .ith a <abins%i response to the extensor9plantar test2 clonus an,Dor spasticit-. 7f there is spinal cor, compression2 there shoul, also be some paresthesia an, if there is ,isc prolapse there shoul, be pain an, articular signs to support the ,iagnosis. :s .ith all else .e ,o2 each test that proves positive shoul, be part of an overall picture that generates the provisional clinical ,iagnosis. 'o single test .ill provi,e this.


Section ' The Special Tests

Special tests are non9routine tests that are carrie, out onl- .hen there is an in,ication to ,o so either from something in the histor- or previous objective examination or from ,eci,ing on a particular treatment that re4uires some %in, of pretest before it is carrie, out. 1or example2 the presence of paresthesia in the arm ma- lea, -ou to carr- out an upper limb tension /provocation0 test2 or -ou ma,eci,e to mobili3e a cervical segment in .hich case2 vertebrobasilar sufficienctesting .oul, be appropriate. :mong the special tests in this ,ifferential ,iagnostic examination are:

Di33inessD?ertebrobasilar sufficienc- tests E4uilibrium tests ?estibular screening tests +ranial nerve tests Selective long tract tests Spinal 4ua,rant tests ; M 7 tests @pper limb tension /provocation0 tests ?ascular tests 1racture tests =ocal speciali3e, tests /TinnelBs 1in%lesteinBs2 PhalenBs etc0

There are numerous tests for both the spinal an, peripheral joints for various pathologies an, s-mptoms. So man- in fact2 that the clinician can get lost among them .ith the man- ,ifferent .a-s of ,oing the same test an, the conflicting interpretations place, upon positive tests. Davi, $agee has .ritten an excellent boo% that revie.s almost ever- special orthope,ic text %no.n to manlxxx. 7n principle2 it is best if a particular test is onl- carrie, out .hen there is a specific in,ication for it. 7n a,,ition2 ,o not ,o more than one test for each suspecte, con,ition2 as ,uplication is inefficient an, can be confusing. $ost of the tests liste, in the table belo. .ill be ,ealt .ith in more ,etail in the region specific examination.


The table integrates the test .ith its in,ication. $ES$ Di33inessD vertebral artersufficienc(ND(CA$( N +omplaints of ,i33iness2 Post9trauma2 Pre9manipulative or pre9 mobili3ation2 Pre9an- treatment li%el- to stress the vertebral arter+omplaints of ,i33iness or ,ise4uilibrium "bserve, ,ise4uilibrium or ataxia +omplaints of ,i33iness2 Post9trauma +omplaints of ,i33iness Post9trauma +entral neurological s-mptoms or signs $ES$ P) $ C , +aroti, pulses2 repro,uction an, ,ifferentiation tests +ranial nerve tests


?estibular screens +ranial nerve tests

Selecte, long tract

Positive cranial nerve tests =ong tract s-mptoms or signs

Spinal 4ua,rant

6a,icular s-mptoms 1ull range an,Dor painfree spinal movements


7n,ications of segmental instabilit-

6hombergBs2 sharpene, 6hombergBs2 single leg stance2 e-es close, stance an, single leg stance ;allpi%e9Dix /once the vertebral arter- is cleare, +onfrontation +onsensual Trac%ingD convergence 1acial sensation Oa. reflex Oa. clonus SmileD fro.n <o,-Dhea, tilting 1inger rustlingD hum @vular9phonation 6esiste, shoul, elevation Tongue protrusion Strength Pain sensation =ight touch sensation Proprioception Spasticit?ibration Graphagnosis 1lexion right rotationDsi,e flexion 1lexion left rotationDsi,e flexion Extension right rotationDsi,e flexion Extension left rotationDsi,e flexion Aua,rant tests ,one .ith care on se4uencing the si,e flexion an, rotation in each 4ua,rant


@pper limb tension provocation

@pper limb paresthesia @pper limb pain .here the obvious cause cannot be foun, Chere a ,ouble crush s-n,rome is suspecte, 7ntermittent clau,ication s-mptoms +omplaints of col,ness or color changes in the peripherSu,,en onset of posttraumatic pain 'oises hear, ,uring trauma 1ailure to recover :ngulation Suspecte, specific patholog- such as nerve compression2 DeAuervainBs2 carpal tunnel s-n,rome


:pplie, constant length phenomenon .here the position of the elbo. an, .rist ,etermine .hich main brachial nerve is moving2 tensing an,D or being provo%e, Pulses Sustaine, or repeate, exercisesDcontractions +ompression Shearing Percussion Tuning for% application @ltrasoun, :s the test ,ictates


=ocali3e, speciali3e,

Spinal Aua,rant Tests These are combine, movement tests an, can be use, in an- part of the spine. The patient is instructe, to flex2 si,e flex an, rotate to the same si,e in both ,irections an, exten,2 si,e flex an, rotate to the same si,e in both ,irections. This test is particularl- useful .hen the car,inal movements of flexion2 extension2 si,e flexion an, rotation are full range an, painfree. "nl- the 4ua,rants can ta%e the 3-gopoph-seal joints to their extreme ranges an, if onl- this part of the range is ,-sfunctional onl- this movement ma- repro,uce the patientBs pain. The- are also useful in those cases exhibiting neurological pain /lancinating or causalgia0. Chile the tester %no.s .hat tissue is causing the s-mptoms2 he or she ma- not %no. .hat structure or tissue is aggravating the inflame, or scare, neural tissue nor ho. severe the problem is. 7f .e assume right leg pain for example2 the patterns of 4ua,rant pain ma- in,icate ,isc prolapse2 extrusion or lateral stenosis. 7f onl- the anterior 4ua,rant repro,uces the pain2 the problem is unli%el- to be ,ue to stenosis2 as flexion ten,s to open the intervertebral foramen. :n extrusion or large prolapse is more li%el- to be problematic into flexion an, extension rather than just flexion. Therefore an anterior 4ua,rant position provo%ing lancinating pain is probabl- the result of a ,isc prolapse.


7f onl- the posterior 4ua,rant is positive for neurological pain then the li%eliest cause is lateral stenosis closing on an irritate, spinal nerve or nerve root as it closes the foramen. 7f both 4ua,rants cause neurological pain2 then there is either a verlarge prolapse or an extrusion. Peripheral Differential Screening Examination The purpose of a screening examination is to focus the examinerBs attention on a particular area or movement2 not to ma%e a specific ,iagnosis. 1urther2 screening tests can onl- screen in2 the- cannot screen out. This is because even the best screening tests are not as comprehensive as the full examination. This must be remembere, other.ise patients .ill be consi,ere, clear .hen if fact the- are not. : screening examination must be 4uic% an, as comprehensive as possible .ithout ma%ing the examination so long that it is just as 4uic% to carr- out the full examination. "n the other han,2 some of the 4uic%er screens are not comprehensive enough an, are not .orth ,oing. : goo, screening examination then2 is comprehensive enough to allo. the examiner fair confi,ence that little has been misse, an, is able to be carrie, out fast enough to ma%e ,oing it .orth .hile. There are various .a-s of screening for this part of the examination. The commonest screening examination for the upper limb is to have the patient attempt to clench the han,s behin, the upper bac%. This is ,one b- having the patient activel- elevating an, laterall- rotating one arm an, exten,ing an, me,iallrotating the other so that the- meet /or nearl- meet0 each other at the level of the scapula. The movement is then reverse,. This test certainl- meets one criterion2 it is fast. <ut it is not ver- comprehensive2 it ,oes not test elbo. extension or .rist motion. 1or the limb2 the most usual .a- of screening is to have the patient s4uat. :gain ver- fast but it ,oes not test hip or %nee extension nor ,oes it test an%le plantaflexion or eversion of the foot. 7n both the upper an, limb screening tests2 the examiner can have onl- the most mo,est confi,ence that the test has inclu,e, most pathologies. : better test2 although a little longer2 is to have the patient ta%e the joint being teste, through its full active range in each of the major movements2 the therapist then applies overpressure an, then resists recover- of the movement pro,ucing an isometric contraction. This gives the therapist an i,ea of the function of the neurological2 inert an, contractile tissues. 7t ,oes miss the stress tests but no screening test is 1))5 inclusive. The test ta%es about a minute per limb so it is longer than the other screening tests but its inclusivit- more than ma%es up for that. The bigger 4uestion than ho. to ,o the test is .hat are -ou going to ,o .ith the results. 1or example2 a patient presents .ith nec% pain2 -our examination ,etermines that there is a biomechanical ,-sfunction present that -ou are going to treat .ith manual therap- an, exercises. Iou have inclu,e, the peripheral screening tests in the examination an, these tell -ou that the patient has an as-mptomatic restriction of lateral rotation of the right shoul,er. 'o. .hatG "E2 -ou ,o .hat the screening examination ,eman,s2 a full examination of the shoul,er an, -ou fin,


that there is a specific restriction of lateral rotation of the glenohumeral joint2 probabl- ,ue to posttraumatic a,hesions or scarring. :re -ou going to treat this or ignore itG 7f -ou treat it2 -ou run the ris% of pro,ucing s-mptoms .here none existe, before. The counter argument is that b- not treating the h-pomobilit- the patient has increase, pre,isposition to shoul,er problems. There is no evi,ence to support this h-pothesis an, there is little ,efense against a la.suit un,er these circumstances. 7 .oul, suggest that the screening examination is not carrie, out unless -ou are loo%ing for something specific. :n example of this .oul, be .here a tennis elbo. has been ,iagnose, but there is no a,e4uate explanation as to cause. 'o. screening the upper 4ua,rant for a causal or contributing factor ma%es sense an, .ith a,e4uate explanation to the patient an, sometimes to the ph-sician2 treating the ,emonstrate, problem is legitimate.


Section ( )ancer an* the !rthope*ic Therapist

The is a broa, an, ver- shallo. overvie. of cancer> for more information there are numerous oncolog- texts available2 t.o of .hich are pre,ominantl- use, in this textlxxxi2lxxxii. 7t is not necessar- for the therapist to un,erstan, the ,etails of cancer or of its treatment. Chat is nee,e, is a general %no.le,ge of its inci,ence an, its presentation to the orthope,ic therapist> that is .hat re, flags it flies. 7n a,,ition to the more specific fin,ings from the usual neurological an, orthope,ic examination2 that .oul, alert the therapist to the nee, for referral to a ph-sician the ma- sho. up in the general chat .ith the patient: 1. 2. !. . &. (. *. +hange in bla,,er or bo.el habits : sore that ,oes not heal @nusual blee,ing or ,ischarge Thic%ening or a lump in the breast or Prolonge, in,igestion or ,ifficult- in "bvious changes in a .art or mole 'agging cough or hoarseness

7nci,ence of +ancerlxxxiii 7n the @S:2 after heart ,isease /! 50 cancer is the secon, lea,ing cause of ,eath /2!50. "ne out of three people .ill2 at some point in their lives2 ,evelop a life threatening malignanc-. Chile stomach an, uterine cancers have ,ecrease, over the last !) -ears other t-pes have remaine, stea,- or even increase, /lung cancer has increase, 1(). The five9-ear survival rate for all cancers is no. &)5. S7TE S%in /melanoma0 "ral =ung <reast Stomach Pancreas +olon M rectum Prostate @rinar"varian @terine =eu%emia M =-mphomas "thers $:=E 5 ! ! 1* 'egligible ! 2 1! 2# F 9 9 # 1 1E$:=E 5 ! 2 12 !2 2 1! 9 # ( 1


The table is a,apte, from the :merican +ancer Societ-Bs boo%lxxxi" an, is inten,e, to ma%e -ou a little more familiar than -ou might be at present .ith terminolog- for various cancers. riginating $issue S4uamous cells <asal cells Glan,ular or ,uctal epithelium Transitional cells <ile ,uct =iver S%in glan,s Sebaceous glan,s 6enal epithelium Testes an, ovaries <loo,Dl-mph Benign S4uamous cell papilloma :,enoma +-sta,enoma Transitional cell papilloma <ile ,uct a,enoma ;epatocelluar a,enoma 'evus Seat glan, a,enoma Sebaceous glan, a,enoma 6enal tubular a,enoma %alignant S4uamous cell carcinoma <asal cell carcinoma :,enocarcinoma +-sta,enocarcinoma Transitional cell carcinoma <ile ,uct carcinoma ;epatocelluar carcinoma $alignant melanoma glan, carcinoma Sebaceous glan, carcinoma 6enal cell carcinoma Embr-onal carcinoma Iol% sac carcinoma =eu%emia =-mphoma ;o,g%inBs ,isease $ultiple m-eloma $alignant peripheral nerve sheath tumor 'euroblastoma 6etinoblastoma 1ibrosarcoma =iposarcoma "steogenic carcinoma +hon,rosarcoma =eiom-osarcoma 6hab,om-osarcoma :ngiosarcoma EaposiBs sarcoma S-novial sarcoma $alignant mesothelioma $alignant meningioma E.ingBs tumor

'erve sheath 'erve cells 6etinal cells +onnective tissue 9fibrous tissue 9fat 9bone 9cartilage $uscle 9smooth muscle 9striate, muscle <loo, vessels =-mph vessels S-novium $esothelium $eninges @ncertain origin

'eurilemmoma Ganglioneuroma 1ibromatosis =ipoma "setoma +hon,roma =eiom-oma 6hab,om-oma ;emangioma =-mphangioma $eningioma


+ancer Pain S-n,romes The inci,ence of pain .ith cancer varies .ith the authorit- but seems to lie bet.een !)lxxxv9F)lxxxvi5 of all cancer patients experiencing pain at some point in their illness. Pain ma- occur as a ,irect effect of the tumor2 as a result of treatment or it ma- not be relate, to the ,isease or the therap-. Somatic pain is usuall- poorl- locali3e, an, ,escribe, as a ,ull aching that2 .hen it arises from the musculos%eletal or cutaneous s-stem is .ell locali3e,. ;o.ever2 visceral pain is poorl- locali3e, an, is often referre, to the ,ermatome ,erive, from the visceraBs segment. Pleural2 peritoneal an, pericar,ial pain can be ver- similar to musculo9s%eletal pain. 'eurological pain is felt as ra,icular or causalgic an, is often accompanie, bparesthesia an, ,-sesthesia. Somatic pain respon,s to normal analgesics but neurological pain ,oes not. This t-pe of pain respon,s better to anticonvulsant an, anti,epressants(. The three major causes of pain associate, .ith cancer are: 1. 2. !. Direct tumor involvement 7atrogenic @nrelate,

Direct tumor involvement accounts for (25 of pain in outpatient cancer patients an, results from metastatic bone ,isease2 nerve compressionDinfiltration or hollo. viscus involvement. <one 7nvasion is the most common cause of pain. The pain is believe, to be from both the osteoclastic an, osteoblastic activit- from prostaglan,in s-nthesis. Pain ma- also arise from pathological fractures2 local nociceptor activation2 an, compression of nerves an, vascular structures. 2&5 of pain in outpatient patients results from ra,iotherap-2 chemotherap- or surger-. :bout 1)5 of outpatient patients have pain unrelate, to their cancer or their therap-. "rthope,ic +linical Presentation of 'eoplastic Disease The presentations2 liste, belo.2 ma- be foun, on the orthope,ic examination an, ma- in,icate the presence of a neoplastic ,isor,erlxxxvii2 lxxxviii2lxxxix2 xc2xci. ;o.ever2 it shoul, be note, that in the majorit- of cases2 these clinical features are of benign origin. $an- neoplastic con,itions .ill not ,emonstrate an- of these features an, .ill appear just li%e a run of the mill biomechanical ,-sfunction. 7f a mechanical lesion ,oes not respon, rapi,l- to a mechanical treatment the therapist nee,s to reconsi,er the ,ifferential ,iagnosis.


constant unrelenting or continuous pain /al.a-s some ,egree of bac%groun, pain but varies in intensit-0 nocturnal pain .aves of pain severe spasm expan,ing pain empt- en, feel signs .orse than the s-mptoms upper limb ra,icular pain .ith coughing 1st or 2n, lumbar root palst.o or more cervical or three or more lumbar roots affecte, bilateral neurological signs .ea%ness an,Dor atroph- of the han, intrinsic muscles non9traumatic thoracic pain in the el,erlforbi,,en area pain ;ornerBs or Pancoast s-n,rome nontraumatic central nervous s-stem /inclu,ing cranial nerve0 signs or s-mptoms bone point ten,erness especiall- in the absence of articular signs sign of the buttoc% a. limite, trun% flexion b. limite, hip flexion c. limite, straight leg raise ,. non9capsular pattern of restriction at the hip e. painful .ea%ness of hip extension f. s.ollen buttoc% g. empt- en, feel on flexion

Paraneoplastic S-n,romesxcii These result from the in,irect effect of the tumor or its metastases an, are remote s-mptom complexes. 7t is suspecte, that the s-n,rome is cause, b- an autoimmune mechanism. The s-n,romes inclu,e neurological /cerebral2 cerebellar2 spinal cor,2 peripheral neuropathies an, autonomic0 associate, .ith lung2 ovarian2 renal2 breast2 gastrointestinal cancer2 l-mphoma an, ;o,g%inBs ,isease. +ar,iovascular s-n,romes ten, to result from cutaneous2 urogenital2 metabolic an, gastrointestinal cancers. "f those s-n,romes of most relevant to the therapist2 peripheral neuropathies are the most common an, present in the usual .a- .ith atroph-2 .ea%ness2 areflexia2 h-po or anesthesia2 parasthesia2 proprioception loss an, paral-sis. Neurological Syndromes +erebral s-n,romes are mainl- associate, .ith lung cancer an, ;o,g%inBs ,isease .ith the patient suffering ,ementia2 cranial nerve ,eficits2 sei3ures2 ,epression2 motor poliom-elitis2 optic neuritis .ith bilateral scotomas an, ,ecrease, acuit-.

+erebellar paraneoplastic s-n,romes are mainl- cause, b- lung2 cervix2 ovar-2 prostate an, colorectal cancer. The s-n,rome inclu,es bilateral ataxia2 n-stagmus2 ,-sarthria an, ,ementia. Spinal cor, s-n,romes shoul, not be a problem for the orthope,ic therapist as it involves rapi, an, progressive upper an, motor neuron an, sensor- affects. =ung an, renal cancer an, l-mphoma cause it. Peripheral neuropathies are the most common neurological paraneoplastic s-n,rome an, the one most li%el- to get through to the orthope,ic therapist as it most mimics orthope,ic con,itions .ith neurological involvement. 7t is associate, .ith breast2 lung2 gastrointestinal an, thoracic cancers an, l-mphoma. Paresthesia2 pain2 areflexia2 atroph-2 .ea%ness2 proprioception an, sensor- loss2 an, paral-sis ma- all be part of the s-n,rome. Autonomic Neuropathies +ause, b- small cell lung carcinoma axonal an, neuronal ,egeneration occurs an, presents .ith orthostatic h-potension2 neurogenic bla,,er an, altere, peristalsis. Neuromuscular syndromes These cause m-asthenia gravis or similar ,isease. The- are associate, .ith th-moma an, cause .ea%ness an, excessive fatigabilit- although one con,ition /Eaton9=ambert0 actuall- cause, the patientBs strength to increase .ith repeate, testing. The .ea%ness of the hip an, thigh muscles an, because the areas are painful2 the patient ma- en, up in the therapistBs office. ther Syndromes These inclu,e2 car,iovascular2 cutaneous2 urological2 repro,uctive2 gastrointestinal an, metabolic. Bone %etastases Patholog:lmost all malignant cancers have the potential for metastasi3ing to bone .ith &)9 #)5 of breast2 lung2 %i,ne-2 prostate2 gastrointestinal an, th-roi, cancers pro,ucing metastases. These metastases are usuall- not life threatening unless affecting the upper cervical spine2 but the- are painful an, liable to allo. fractures to occur as a result of .hat .oul, other.ise be none threatening stresses. The inci,ence of bone metastasis has increase, as improve, therap- has increase, survival rates in cancer patients. Pain is often cause, b- pathological fractures2 but joint pain an, ,irect


bone pain from the presence of the tumor are also factors. Purel- osteoblastic lesions ma- be as-mptomatic until fracturing occurs. +linical Presentation The metastasis ma- be first s-mptoms of cancer2 pre9,ating signs or s-mptoms from the primar- tumor. S.elling ma- be seen if the joint is superficial or the patient thin2 there is usuall- point ten,erness2 ,ecrease, 6"$2 spasm2 painful .ea%ness2 parasthesia an, paresis if the fracture affects neurological tissue an, this can inclu,e spinal cor, signs an, s-mptoms. The pain is generall- relate, to increase, activitbut is also relentless in nature being present at rest an, fre4uentl- .orse at night. The effects of a paraneoplastic s-n,rome ma- be perceive, an,Dor s-stemic effects such as .eight loss> fever2 malaise etc ma- be present. 7nvestigations 896a-s: Shoul, be ,one in at least t.o planes inclu,ing obli4ue vie.s of the spine if involve,. ;o.ever2 often more than &)5 of the bone ,ensit- must be lost before the 89ra- ,emonstrates the presence of the metastasis. <one Scan: Technetium9F)m is effective for ,emonstration of bone metastases but has a 1)5 false positive rate. $67D+T Scan: 6e4uire, onl- in the presence of neurological signs from spinal problems. $anagement: Peripheral fractures are treate, .ith rest> internal an, external fixation .ith immobili3ation times 29! times longer than are conventional ,ue to the slo.ness of bone healing .hen ra,iation therap- is being a,ministere,. Periarticular fractures are generall- treate, b- joint replacement. 7mpen,ing fractures /more than &)5 cortex ,estruction or cortical lesions larger than 2.& centimeters or one inch0 ma- be proph-lactical- fixe,. Spinal compression fractures are stable but painful an, ,o not re4uire surgical intervention. +ervical fractures are fre4uentl- unstable an, re4uire surger- if so. S%ull <ase $etastases Pain prece,es neurological signs b- .ee%s. Plain ra,iographs are usuall- useless .ith $67 an, +T scans being more helpful. Ougular 1oramen S-n,rome


"ccipital pain .ith reference to the vertex an, the ipsilateral shoul,er an, arm. ;ea, movement repro,uces pain an, there is occipital ten,erness over the occipital con,-le. There is variable cranial nerve /those that exit through the occiput0 involvement .hich ma- inclu,e ,-sphonia2 ,-sarthria2 ,-sphasia2 nec% rotation an, shoul,er elevation .ea%ness an, ptosis2 ;ornerBs s-n,rome. +livus $etastasis ?ertex hea,ache increase, .ith nec% flexion. There is (912 cranial nerve involvement 7nitiall- the signs an, s-mptoms are felt an, observe, unilaterall- but progress to become bilateral. Sphenoi, Sinus <ifrontal hea,aches .ith ra,iation to both to temporal regions an, intermittent retro9orbital pain are experience,. There is often nasal stuffiness an, fullness of the hea,2 associate, .ith ,iplopia an, bilateral sixth cranial nerve pals-. ?ertebral <o,Pain is earl- an, prece,es neurological signs an, if not earl- ,etecte, irreversible neurological ,eficits such as paraplegia or 4ua,riplegia ma- ,evelop. 7n more than #&5 of cor, compression patients2 metastases are present an, in1)5 of patients .ith cor, compression the onl- complaint .as of pain. Dens 1racture Pain results from the fracture itself an,Dor the secon,ar- subluxation. There is often resultant cor, or brainstem compression. The pain is felt to ra,iate over the occiput an, into the vertex an, is exacerbate, b- nec% flexion. Progressive sensor- an, motor signs are foun, initiall- in the upper limbs an, are associate, .ith autonomic changes. $anipulationDmobili3ation is extremel- ,angerous. $67 is the most useful imaging techni4ue. +*9T1 $etastases This is a common site for lung an, breast cancer an, l-mphoma. The sprea, ma- be via the vascular s-stem or more ,irectl- from involvement of the brachial plexus or the paravertebral space. The pain is usuall- locali3e, the a,jacent paraspinal region an, is characteristicall- a ,ull aching2 constant pain ra,iating bilaterall- to both shoul,er. Percussion ten,erness is generall- present over the spinous process of the involve, vertebra. 7f there is nerve root compression2 there is ra,icular pain2 usuallunilaterall-2 in the +*2 +# an, T1 ,istributions. 'eurological fin,ings inclu,e numbness an, parasthesia in these ,istributions .ith .ea%ness of the intrinsic


muscles2 triceps an, the .rist flexors. ;ornerBs s-n,rome ma- be present if the paraspinal ganglion has been affecte,. +T scanning is the best imaging techni4ue. =umbar $etastases $ainl- affects =1. Dull aching mi, bac% pain ra,iating to the S7 area an, iliac crest an, ma- be unilateral or bilateral. The pain is exacerbate, b- la-ing or sitting an, relieve, b- stan,ing is characteristic. $ovement increases the pain particularlmovement from la-ing to stan,ing. =1 or 2 motor or sensor- pals- shoul, al.a-s ma%e the therapist concerne, as ,isc lesions at these levels are rare. Sacral $etastases :ching pain felt in the sacrum2 cocc-x an,D or lo. bac% is characteristic. The pain is .orsene, b- l-ing or sitting an, relieve, b- .al%ing. There ma- be neurological signs that inclu,e perianal sensor- ,eficit2 bo.el2 an, bla,,er an, genital ,-sfunction. The greater sciatic notch area ma- be ten,er an, there ma- be sciatic ra,icular pain if there is compression of the nerve. +T scanning is the choice imaging techni4ue. Neurological %etastases Tumor infiltration an, su,,en or progressive compression ,ue to pathological fractures cause the signs an, s-mptoms. The tissues affecte, inclu,e the peripheral nerve2 root2 plexus2 spinal cor, or meninges an, the pain can be somatic or ra,icular. Peripheral 'erve T-picall-2 the patient complains of constant causalgia2 ,-sesthesia an, h-poesthesia. There is commonl- ra,icular pain. The most common area affecte, is the intercostal nerve from infiltration b- a rib tumor. +T scan images the con,ition best. <rachial Plexus The plexus is the most common site /+*9T10 although breast cancer an, l-phoma ma- .ell involve the +&9( roots. Pain patterns .ill var- .ith the levels involve, an, ma- reach paraspinall- ,o.n to the T region from the upper plexus an, infra9scapularl- from the Pain t-picall- prece,es motor signs an, these procee, sensor-. Sprea, along the nerve root to the cor, is common an, &)5 of these patients .ill eventuall- present cor, signs an, s-mptoms. ;ornerBs s-n,rome ma- be present. +T scan is the best imaging techni4ue.


=umbosacral Plexus $ost common infiltration occurs from g-necological2 genitourinar- an, colon cancers. Pain .as the presenting s-mptom in F)5 of these patients2 .ith .ea%ness secon, at ()5 an, numbness in )5. T.o t-pes of pain are t-pical> local pain in the sacrum2 S7 joint2 lo. bac% or groin an, the secon, t-pe2 ra,icular pain in the lateral2 anterior an, posterior leg. +T scanning is the best imaging techni4ue although $67 has not been fullevaluate, for its sensitivit-. =eptomeningeal This is infiltration of the cerebrospinal flui, .ith or .ithout neurological invasion. )5 of these patients present .ith pain of one or t.o t-pes. +onstant hea,aches .ith or .ithout nec% stiffness or lo. bac% an, buttoc% pain. The pain results from traction on the tumor infiltrate, nerves an, meninges. =umbar puncture ,emonstrates the +S1 changes an, m-elograph- images the no,es on the nerves. $ultiple level neurological signs an, s-mptoms strongl- suggest this con,ition. Epi,ural +or, +ompression Severe nec% an, bac% pain is characteristic an, is the presenting s-mptom in F&5 of these patients an, occurs from either local bone or root compression. 7t is of t.o t-pes.: 1. =ocal pain over the involve, vertebral bo,- or ra,icular pain in the root ,istribution unilaterall- in the cervical an, lumbar regions2 bilaterall- in the thoracic spine. 2. 'eurological s-mptoms that .ill var- .ith the level of the lesion an, #&5 of patients .ith neurological signs have accompan-ing vertebral bo,- lesions. 2. %ultiple %yeloma This con,ition comprises 1 .&5 of all hematological malignancies an, 1.15 of all malignancies. .(D1))2))) males an, !.1D1))2))) in females .ith !.& an, 2. ,eaths D1))2))) respectivel-. PathologThis is a plasma cell carcinoma /P+'0 plasma cell ,-scrasia /P+D0 that has multiple foci an, mainl- affects the bone2 bone marro. an, extra9osseous sites. The proliferation of monoclonal plasma cells resulting in osteoclastic activit- an, conse4uent fractures an, bone pain. 6is% 1actors:


:ge: me,ian age at ,iagnosis (# .ith S1D1))2))) un,er ) an, 2#.2D1))2))) b- #). Sex: $ales 1.& times ris%ier. 6ace: <lac%s 1.# times at ris%. Genetic: 1irst ,egree relatives at greater ris%. Previous Patholog-: S-stemic inflammator- ,iseases such as 6:2 s-stemic lupus2 sclero,erma patients are at greater ris%. "ccupation: 7ncrease, ris% in .or%ers in printing2 plastics2 leather2 .oo,.or%ing2 rubber an, petrochemical inci,ences an, those expose, to arsenic2 asbestos an, lea,. +linical Presentation Some patients are as-mptomatic an, ,iscovere, inci,entall- ,uring a .or%9up for an unrelate, con,ition. $ost present .ith a combination of local an, s-stemic signs an, s-mptoms. 1. =ocal These result from bone lesions. Severe intractable pain2 ten,erness an, s.elling Particularl- lo. bac% pain occurs in the majorit- of patients. <one pain /()502 fractures /2)50 an, spinal cor, compression signs an, s-mptoms2 from vertebral compression fractures /1&50. =o. bac% pain is a common s-mptom. 2. S-stemic :nemia2 h-percalcemia2 fatigue2 .ea%ness2 renal insufficienc-2 6e-nau,Bs2 intellectual ,-sfunction2 hea,aches2 mucosal blee,ing2 urinar- tract infection2 mixe, sensor-Dmotor peripheral neuropath-. Prostate Cancer This is the most common male malignanc- M secon, lea,ing cause of ,eath from cancer. #&.&D1))2))) .ith 2!.& ,eaths. ;igher inci,ence in 'orth.estern Europe an, 'orth :merica in Scan,inavia an, the "rient. 6is% 1actors: :ge: me,ian age for ,iagnosis *) -ears M *)5 of males over F) -ears have a focus 6ace: blac%s 1.& times greater than .hites .ith a onset age Genetic: slightl- higher in first ,egree relatives Diet: high fat ,iets implicate, Previous genitourinar- infections: increase, sexual activit- possibl- ,ue to venereal ,isease


+linical Presentation Earl- cancer ma- have no signs or s-mptoms. 1. =ocal <la,,er irritation .ith hesitanc-2 nocturia2 retention2 fre4uenc- an, uncommonl- hematuria2 2. S-stemic <ac% an, hip pain2 fatigue2 an, malaise an, .eight loss. 'o paraneoplastic s-n,romes associate, .ith prostate cancer. :n- el,erl- patient presenting .ith a2 for them2 unusual bac% pain shoul, have their prostate examine, b- the ph-sician before an- treatment is initiate,. Screening Programs 6ectal examination an, prostate serum antigen /PS:0 bet.een &)9*) routinel- or ) in those patients .ith a famil- histor-. CNS %alignancy +omprise 1.*5 of all cancers .ith *.&D1))2))) males an, &.1D1))2))) females .ith .F an, !.! ,eaths respectivel-. 6is% 1actors :ge: +hil,ren at higher ris%. Sex: $ales 1. * times at ris%. 6ace: +aucasians 1.& times more at ris% than blac%s. Previous +'S Patholog-: 'one +linical Presentation =ocal These manifestations ,epen, of the localit- of the tumor an, inclu,e sei3ures2 .ea%ness2 sensor- changes2 hea,ache2 nausea an, vomiting2 personalit- changes2 intellectual changes. Gait ,isturbances such as ataxia2 .ith cranial nerve ,-sfunction as the brainstem is affecte,.. ;emiplegia2 ,ecrease, consciousness levels2 hemianopia2 ,ecorticate an, ,ecerebrate posturing ,ung Cancer


This is the secon, most common malignant cancer in men an, the thir, most in .omen /after breast0 an, the lea,ing cause of ,eath from cancer in both sexes. The inci,ence is #!D1))2))) in men an, !&D1))2))) in .omen2 resulting in * an, 2( ,eaths respectivel-. 6is% 1actors :ge: 7ncreases .ith age .ith the inci,ence going from 1 per 1))2))) at !) -ears to !!) per 1))2))) at *)9* . The average age at ,iagnosis is () -ears. Sex: $ales are 2. times ris%ier than .omen are chiefl- ,ue to cigarette smo%ing habits. 6ace: <lac%s are 1. more times more li%el- to ,evelop lung cancer than .hites. Genetic: 1irst ,egree relatives are 2. times more li%el- to ,evelop lung cancer. Diet: ?itamin :2 E an, beta9carotene ,eficient ,iets have been ,emonstrate, to increase the ris% of lung cancer. Smo%ing: :ccounts for #&5 of all lung cancers an, the ris% is ,irectl- proportional to the amount smo%e,. +igarette2 cigar an, pipe smo%ing each have a ,ecreasing ris%. "n stopping smo%ing2 the ris% ,ecreases after &9( -ears an, approaches that of non9smo%ers after 1& -ears. Passive smo%ing increases the ris% in non9smo%ers b29! times an, accounts for 2&5 of cancers in non9smo%ers. Previous PulmonarPatholog-: "ther benign lung con,itions seriousl- increase the ris% of lung cancer. F5 of +"PD patients .ill ,evelop lung cancer .ithin 1) -ears. Environmental: :ir pollution an, occupational exposures /asbestos2 arsenic2 chromium2 ca,mium2 formal,eh-,e2 chlorometh-l ether0 +linical Presentation (5 of patients .ith lung cancer are as-mptomatic. $ost alrea,- being smo%ers have a habitual cough. <ut this .ill change as the cancer starts to pro,uce effects. 1. =ocal

S-mptoms from the primar- tumor .ill ,epen, on its location. +entral tumors pro,uce a cough2 hemopt-sis2 .hee3ing2 stri,or2 ,-spnea2 pain an, pneumonia. Peripheral lesions cause a cough2 chest .all pain2 shoul,er an, arm pain2 pleural effusion2 ,-spnea2 an, ;ornerBs s-n,rome. 2. 6egional


Extension of the primar- tumor to the l-mph no,es2 nerves2 esophagus2 superior vena cava2 pericar,ium an, ribs ma- all cause pain or other s-mptoms such as ,-sphagia2 phrenic nerve pals-2 superior vena cava s-n,rome2 voice hoarseness2 pericar,ial rub2 ,isten,e, nec% veins an, tach-car,ia. !. S-stemic

$etastases ma- cause pathological fractures2 jaun,ice2 ab,ominal pain an, masses2 neurological ,eficits2 intellectual ,eterioration2 .eight loss2 anorexia2 .ea%ness an, malaise. =ung cancer paraneoplastic s-n,rome is associate, .ith man- of these s-n,romes that affect the car,iovascular2 neurological2 renal2 gastrointestinal2 hematological2 metabolic2 s%eletal2 an, ,ermatological s-stems. Signs an, s-mptoms ma- inclu,e fever2 ,ementia2 increase, strength .ith repeate, contractions /m-asthenic s-n,rome02 er-throc-tosis2 h-percalcaemia2 arthropath-2 autonomic an, peripheral neuropathies2 anorexia. Examination ;istor-: changes in cough2 hemopt-sis2 smo%ing histor-2 alterations in mental status2 .eight loss an, anorexia. "bservation: gauntness2 s%in coloration /anemia2 jaun,ice2 gra-ness2 an, ,ermatitis02 re,uce, energ- levels2 mental processing2 miosis2 ptosis2 anh-,rosis2 hemifacial flushing2 voice hoarseness an, finger clubbing. Pancoast Syndrome Superior sulcus tumors an, breast cancers fre4uentl- inva,e the upper chest .all an, brachial plexus giving rise to PancoastBs s-n,rome. The cancer .ill usuallinva,e the upper t.o ribs lea,ing to scapular2 shoul,er an, arm pain together .ith the neurological s-mptoms arising from the brachial plexus effects. These inclu,e ra,icular an, somatic pain2 an, parasthesia2 in the +*2 +# an, T1 ,istributions. The stellate ganglion is often affecte, causing ;ornerBs s-n,rome /ipsilateral miosis2 anh-,rosis2 ptosis an, facial flushing0. 89ra-s an, sputum anal-sis .ill usuall- generate the ,iagnosis although often the anteroposterior 89ra- .ill not sho. the lesion an, special obli4ue vie.s have to be ta%en. 7f the ribs have been affecte,2 passive nec% si,e flexion a.a- from the painful si,e ma- be limite, an, painful .ith a spasm en, feel an, isometric si,e flexion,s the si,e is painfull- .ea%. There is sensation loss in the brachial plexus ,istribution usuall- ulnar along .ith intrinsic han, .ea%ness an, .rist flexor an, finger flexor paresis. The presence of ;ornerBs s-n,rome is a complete contra9 in,ication to an- treatment until this has been ,iagnose,.


Breast Cancer The most common cancer accounting for !)5 of all malignancies an, 1#5 of all cancer relate, ,eaths. The lifetime ris% of cancer in .omen is about 1)5 an, increasing .ith the rate in .omen being 1)2D1))2))) in females an, ).*D1))2))) in males .ith 2* an, o.! ,eaths respectivel-. 6is% 1actors :ge: 1D1))2))) before 2& -ears to ))D1))2))) at #). The me,ian age at ,iagnosis is &*. Sex: 1emales more at ris% than males b- 1 (:1. 6ace: 1.2 times higher in .hite females than blac%. Genetics: @ncertain in first9,egree relatives but 1.& times higher in secon, ,egree. Previous Patholog-: 'o increase .ith fibroc-stic changes. unilateral cancer2 there is a 9& times increase, ris% of ,eveloping it in the contralateral breast. En,ocrinal: Earl- menarche /before 12 -ears0 increases the lifetime ris% of cancer. Prolonge, estrogen stimulation for post9menopausal problems increases the ris%. There is no ,emonstrate, relationship bet.een oral contraceptives an, breast cancer. There is an increase, ris% .ith late menopause /after & 0 an, earlmenopause lo.ering it. 1irst parit- after !) increases the ris%2 earl- first parit/before 1#0 lo.ers it an, not having chil,ren increases it further. +linical Presentation The primar- tumor presentation .ill almost certainl- not be a presentation problem for the therapist as this is usuall- a painless palpable breast mass. ;o.ever2 it is possible that the patient has misse, its ,evelopment an, presents .ith s-mptoms of extension of the tumor into the brachial plexus or upper ribs /Pancoast s-n,rome0 or bone or neurological metastases have ,evelope, an, brought the patient to the therapist.

Section + Summar, of Previous Sections

The ,ifferential ,iagnostic examination is a vital precursor to an- biomechanical examination2 it must be carrie, out to ensure that the ph-sician has referre, appropriate patholog- or2 in the case of ,irect contact2 the patient has .al%e, into the appropriate setting. 7n a,,ition2 the examination is necessar- to pinpoint the patholog-. Diagnoses such as shoul,er pain2 lo. bac% pain2 internal ,erangement an, rotator cuff s-n,rome are of no value in ,etermining .hich treatment is re4uire,. The routine examination of the patient must inclu,e an examination that .ill pro,uce a ,ifferential ,iagnosis or in,icate the nee, for a biomechanical examination .hen a ,ifferential ,iagnosis is not attainable from the information generate, from the examination. The examination outline, in this chapter is that a,vocate, b- Oames +-riax $D2 an, base, on selective tissue tension testing. The routine ,ifferential ,iagnostic examination involves the stressing of a specific tissue .hile that tissueBs function is as isolate, as possible from the other tissues of the musculos%eletal s-stem. 1or the purposes of this examination2 the tissues .ere classifie, as inert2 contractile2 neurological an, vascular each of .hich .as teste, accor,ing to the principles of selective tissue tension testing. Special tests an, peripheral screening tests are emplo-e, .hen there are specific in,ications for them. The tests are routinel- carrie, out in the ,ifferential ,iagnostic examination:

;istor"bservation $usculo9articular /active2 passive resiste,2 stress0 Dural 'eurological /m-otome2 ,ermatome2 reflexes0 Special


+"$P:67S"' "1 SISTE$7+ M $@S+@="SEE=ET:= P:7' SISTE$7+


,isturbs sleep ,eep aching or throbbing re,uce, b- pressure constant or .aves of pain an, spasm is not aggravate, b- mechanical stress associate, .ith : jaun,ice migrator- arthralgias s%in rash fatigue .eight loss lo. gra,e fever generali3e, .ea%ness c-clic M progressive s-mptoms histor- of infection

generall- lessens at night sharp or superficial ache usuall- ,ecreases .ith cessation of activitusuall- continuous or intermittent is aggravate, b- mechanical stress associate, .ith: usuall- nothing specific

The ,iagnosis is arrive, at onl- after all of the routine an, in,icate, special tests have been carrie, out an, all the information processe,. Generall- a number of provisional ,iagnoses are generate, /the more experience, -ou are the less there are0 an, the most probable is selecte, for treatment. 7f this ,oes not turn out to be the correct one /the treatment ,oes not .or%02 the next most li%el- is treate, an, so on. @suall-2 ho.ever2 the ,ifferential ,iagnosis examination is negative2 in that it ,oes not generate a ,iagnosis. 7n this case2 more information is re4uire,. The best metho, of ac4uiring this is .ith the biomechanical examination that .ill generate a joint pathomechanical ,iagnosis. 7f the therapist is not familiar .ith a biomechanical examination2 then treatment .ill have to be base, on the best information from the ,ifferential examination. This treatment .ill usuall- be an exercise program ,esigne, to increase range of motion in the ,ecreases ranges. To ,o this2 secon,ar- examination techni4ues can be utili3e, such as repeate, movements to assess the potential effects of an exercise program over a short perio,.


The table loo%s at some potential implications of certain characteristics gaine, from the subjective examination an, the observation of the patient in ,ifferent t-pes of con,itions an, patients. +;:6:+TE67ST7+ :ppearance Pain areas Pain behavior SE67"@S P:T;"="GI Tire, an, often ill loo%ing =ocal an,Dor ra,iating +onstant an, manot be affecte, bmechanical stress @suall- reasonable although patient ma- be ,epresse, 'one or objective 'one or over bone Corrie,2 angr- or ,epresse, 'o response or ver- short term2 the patient is concerne, .ith the lac% of results Corrie, +;6"'7+ P:7' SI'D6"$E $a- loo% tire, but not ill $ultiple unassociate, areas Exacerbations on an-thing but particularl- to emotional stress 'on9specific an, concentrates on his or her suffering Ci,esprea,2 non9 objective an, h-peresthetic Ci,esprea, Egocentric2 misun,erstoo, an, either hostile or apathetic "ften ver- prou, of the lac% of results SE+"'D:6I G:7' 'ormal =ocal sometimes .ith extensive ra,iation Exacerbate, b.or% t-pe activities or postures $atter of fact an, unconcerne, 'one or if claime,2 it is non9objective =ocal an, inconsistent if patient is ,istracte, $ainl- concerne, that -ou believe him or her @nconcerne, .ith the lac% or results more intereste, n ma%ing sure that ever-thing is ,ocumente, :nno-e,

Pain ,escription 'umbness Ten,erness :ttitu,e

Previous treatment results

Iou are



The tabulates general signs2 from the objective examination that are potentiallserious particularl- .hen foun, in combinations : +=7'7+:= S7G' 1ull range of motion .ith normal en, feels in patients .ith significant pain 'o range of motion $ulti,irectional movements .ith spasm en, feels $ulti,irectional painful .ea%ness $ultisegmental paresis an,D or h-poesthesia :nesthesia Paral-sis Empt- en, feel Progressive pain Signs are .orse than the s-mptoms 'ight pain <on- point ten,erness Expan,ing pain P"TE'T7:= SE67"@S +:@SE ?isceral con,itions <one cancer Possible fracture Possible fractures 1racture <one cancer 'eurological cancer +au,a e4uina s-n,rome 'eurological ,isease +entral nervous s-stem patholog'euroma +entral nervous s-stem patholog'euroma Serious pathologies that affect tissues that cannot cause spasm +ancer 7nfection 'eurological ,isease +ancer 7nfections <one cancer <one infection <one or neurological cancer 7nfections P6"<:<=E <E'7G' P:T;"="GI Therapist error :mplification or fabrication :nxiet'one ;-peracute arthritis +entral stenosis $ultiple level lateral stenosis Peripheral neuropathPeripheral neuropathSub9,eltoi, bursitis 7nflammation 'one :cute inflammation 6eferre, ten,erness 7ncreasing ,isc herniation


7f there is an- cause for concern about the patientBs general health2 the can be sought either from the histor- or from the objective examination: ;istor

1ever @nexplaine, .eight loss $alaise S.eating especiall- at night +hanges in coughing habits or its pro,uct 1atigue +hanges in urination habits /hesitanc-2 retention2 incontinence0 +hanges in the urine /bloo,2 pus0 Sleep ,isturbances Drop attac%s Episo,ic s-ncope 6epeate, ,ropping of objects or stumbling "ther joint problems Pathological fractures Diabetes "steoporosis 6ecurrent infections


Oaun,ice Gra-ness +-anosis E,ema ;ornerBs signs '-stagmus D-sarthria D-sphasia 1acial ,rooping Potosis :niscoria :taxia

Pulse ate an, rh-thm

D-srh-thmia Tach-car,ia <ra,-car,ia


6espiration rate an, ,epth

6api, Shallo. =abore,

<loo, pressure

;-potension ;-pertension

;-potension than 1)) than () +onsult -our ,octor 'ormal range bet.een 1)) an, 1 ) bet.een () an, F) Self9chec% $il, h-pertension bet.een 1 ) an, 1() bet.een F) an, 1)) +onsult -our ,octor $o,erate h-pertension bet.een 1() an, 1#) bet.een 1)) an, 11) +onsult -our ,octor Severe h-pertension higher than 1#) higher than 11) +onsult -our ,octor imme,iatel:b,omen

:scites $asses Ten,erness :ortic pulsatile mass

Differential Diagnostic Examination The lists the ver- significant fin,ings of the general ,ifferential ,iagnostic examination together .ith an in,ication of .h- the- are significant. N <e careful .ith this patient an, .atch ho. his or her progress carefull-. 7f therap- .orsens matters or ,oes not help 4uic%l- refer the patient bac% to the ph-sician. Q The patient potentiall- has a problem that is outsi,e of our scope of practice either as the presenting complaint or coinci,ental .ith it2 or the musculos%eletal problem .ill li%el- re4uire prolonge, treatment or specialist intervention. 7t is as .ell to ,iscuss this patient .ith the ph-sician so that arrangements can be ma,e for specialist referral or time of .or%2 me,ication etc. 7t is not necessar- to ,iscontinue treatment if the problem is of musculos%eletal origin. QQ This has all the ma%ings of a ver- nast- con,ition an, shoul, be examine, .ith extreme caution if foun, in the histor-. 7t shoul, almost certainl- be referre, to the ph-sician for further testing.


;istor Trauma N 'o previous histor- of t-pe N Corsene, .ith treatment N 'o ,ifference .ith treatment N +ancer QQ

S-mptoms Pain 6a,icular /lancinating0 N +ausalgia N +onstant .orsene, b- activit- or position N +onstant not .orsene, b- activit- or position QQ Exacerbate, b- eating or ,iet QQ Strongl- exacerbate, b- emotional stress QQ +lau,icational N Corsening N 'octurnal QQ Deep an, ,iffuseQ 6epro,ucible b- ph-sical posture or activit'ot repro,ucible b- ph-sical posture or activit-QQ 7mme,iate Q ?er- extensive N 'on9segmental @nilateral an, segmental <ilateral an, segmental N <ilateral an, multi or non9segmental Q ;emilateral N Sa,,le area Q 1orbi,,en area /s%in across the bac% at =1 or =2 level0Q =1 or 2 ,ermatome Q <ilateral face QQ ;emifacial if not T$O ,isor,er Q ;emifacial an, contralateral bo,-9limb QQ

:nesthesia an, Paresthesia :nesthesia QQ /unless peripheral neuropath- ,iagnose,0


@nilateral an, segmental paresthesia N <ilateral segmental paresthesia N <ilateral multisegmental QQ Aua,rilateral QQ <isegmental upper limb paresthesia NQ Tri9segmental limb paresthesia NQ Sa,,le area paresthesia QQ ;emifacial QQ 1ull face QQ

"ther +omplaints <la,,er2 bo.el or genital ,-sfunction QQ D-smenorrhea QQ ?ertigo Q Di33iness N +entral neurological /car,inal0 NQQ

"bservation +entral neurological signs /car,inal signs0 QQ Patch- or hemifacial s.eating QQ ;emilateral s.eating QQ @nilateral segmental atroph- N <ilateral segmental atroph- Q :cutel- painful angular ,eformit- QQ Severe bruising Q 'on9traumatic s.elling over bone QQ 'on9traumatic effusion N 6e,,ening QQ

:ctive 6ange of $ovement Severel- restricte, or no movement QQ 'on9traumatic capsular pattern N 'o restriction an, no pain repro,uce, at en, range QQ 6epro,uces lancinating painN 6epro,uces paresthesia N 6epro,uces central nervous s-stem signs or s-mptoms QQ

Passive $ovement


Empt- en, feel QQ /acute sub9,eltoi, busitis is the exception0 $ulti,irectional spasm QQ =arge increase over active range N +og .heeling movement Q Painful crepitus Q

7sometric 6esiste, /contractile0 Painful .ea%ness N

Stress Test +raniovertebral instabilt- QQ "ther ligamentous instabilit- Q

$-otome /%e- muscles0 $ore than one level .ea%ness in the upper limb Q $ore than three level .ea%ness in the limbQ <ilateral .ea%ness Q Aua,rilateral .ea%ness QQ Paral-sis QQ /unless a peripheral neuropath- is ,iagnose,0

Dermatome $ore than one level h-poesthesia in the upper limb Q $ore than three level h-poesthesia in the limbQ <ilateral h-poesthesia Q Aua,rilateral h-poesthesia QQ 1acial QQ :nesthesia QQ /unless a peripheral neuropath- is ,iagnose,0

6eflexes Deep ten,on ;-poreflexia N Deep ten,on ;-perreflexia QQ +lonus QQ <abins%i response QQ ;offmanBs strongl- positive QQ D-namic ;offmanBs QQ


Dural Severel- limite, N Pro,uces lancinating pain N Pro,uces paresthesia N <ilateral N +rosse, N Special Tests 1racture tests QQ ?ertebral arter- QQ +ranial nerve test in neutral hea, position Q +ranial nerve tests in altere, hea, position QQ =ong tract tests QQ

$an- of the above items nee, to be consi,ere, in context rather than as absolutes. +ranial nerve an, long tract congenital anomalies ,o exist as isolate, non9significant entities2 but if the- are associate, .ith s-mptoms or other signs2 ,o not assume this. 7t is better to be over cautious than cavalier2 the .orse that happens if -ou are .rong is that the patient has further tests.

?7S+E6"GE'7+ +:@SES "1 SP7':= P:7' +E6?7+:= T;"6:+7+ =@$<:6 tracheobronchial pleuropulmonarmetastatic lesions irritation ,isor,ers cervical bone peptic ulcer renal ,isor,ers tumors cervical cor, pancreatitis or prostatitisDcancer tumors cancer Pancoast tumors chol-c-stitis testicular cancer vertebral renal ,isor,ers ab,ominal aortic osteom-elitis aneur-sm

S:+6"97=7:+ prostatitisDcancer g-necological ,isor,ers bo.el ,isor,ers en,ocar,itis Spon,-lo9 arthropathis an%-losing spon,-litis 6eiterBs s-n,rome psoriatic arthritis +rohnBs ,iseasae PagetBs ,isease sign of the buttoc% causes

me,iastinal tumors

en,ocar,itis aortic aneur-sm en,ocar,itis acute pancreatitis small intestine obstruction +rohnBs ,isease g-necological ,isor,ers tuberculosis


:ppropriate 1in,ings an, General Treatment Gui,elines C ND($( NS D7S+ =ES7"'S Small Protrusion "thers /large protrusion2 prolapse2 extrusion SEG$E'T:= S@<=@8:T7"' :nteroposterior Transverse '(ND(N*S ipsilateral extension 4ua,rant limite, .ith spring- en, feel all movements severel- re,uce, .ith severe pain $)EA$%EN$ P) $ C , extension or unilateral extension neutral to extension /gentle manual traction0

flexion an, extension verrestricte, an, painful2 rotation minimall- affecte, "ne rotation maximall- affecte, flexion an, extension minimallso. Cill sho. mainl- on the biomechanical examination .ith transverse mobilit- test. +apsular pattern /ipsilateral extension 4ua,rant SS contralateral flexion 4ua,rant0 .ith spasm en, feel on extension 4ua,rant +apsular pattern /ipsilateral extension 4ua,rant SS contralateral flexion 4ua,rant0 .ith har, capsular en, feel on extension 4ua,rant an, less so on flexion 4ua,rant. 7psilateral extension 4ua,rant ,ecrease W contralateral flexion 4ua,rant .ith ver- har, capsular en, feel on both 4ua,rants 1lexion "6 extension 4ua,rant limite, .ith pathomechanical en, feel

extension /manual traction an, traction manipulation in extension0 'eutral /manual traction an, traction manipulation0

1:+ET =ES7"'S :rthritis

67+E until the spasm is absent2 then pain mo,alities inclu,ing gra,e 1 an, 2 mobili3ations. 1lexion an, extension mobili3ations



1lexion an, extension mobili3ations


1lexion or extension mobili3ations or manipulation


+ameron2 6<. Practical "ncolog- page 1*. :ppleton M =ange ' +onnecticut2 1FF +ameron2 6<. Practical "ncolog- pp 1#F91F). :ppleton M =ange ' +onnecticut2 1FF



Schumacher Or.2 ;6. e,itor. Primer on the 6heumatic Diseases 1)th E,ition pp 1F1 an, 2 !. :rthritis 1oun,ation :tlanta 1FF!

Ceiner2 CO. Goet32 +G. 'eurolog- for the non9neurologist !r, e,ition pages 1((91(* 1FF

Sharp2 O. Purser2 DC. Spontaneous atlantoaxial ,islocation in an%-losing spoin,-litis an, rhematoi, arthritis. :nn 6hem Dis 1F(1> 2): *9**

Stevens2 Oc. Et al. :talantoaxial subluxation an, cervial m-elopath- in rheumatoi, arthritis. A O $e, 1F*1> ):!F19 )#

<o-le2 :+. The rheumatoi, nec%. Proc 6 Soc $e, ( :11(19(& 1F*1


Par%2 CC. 6othman2 6;. <ro.n2 $D. The phar-ngovetebral veins: an anatomic rationale for GriselLs s-n,rome. O <one Ooint Surg /:m0 ((/ 0:&(#9&* 1F#

<eals2 6E. Et al. :nomalies associate, .ith vertebral malformations. Spine 1#/1)0:1!2F91!!2 1FF!

Ciggins2 $E. etal. ;ealing characteristics of a t-pe 1 collagenous structure teate, .ith corticosteroi,s. :m O Sports $e, 22/20:2*F92##2 1FF

"xlun,2 ;. The influence of a local injection of cortisol on the mechanical properties of ten,ons an, ligaments an, the in,irect effect on the s%in. :cta "rthop Scan,2 &1/20:2!192!#2 1F#)

Calsh2 C6. etal. Effects of a ,ela-e, steroi, injection on ligament healing using a rabbit me,ial collateral ligament mo,el. <iomaterials 1(/120:F)&9F1)2 1FF&

Sev-2 6C. Drugs as a cause of ,i33iness an, vertigo.pp #19F*7n 1inestone2 :O. E,itor. Di33iness an, vertigo. Oohn Cright2 <oston. 1F#2

<allant-ne2 O. :jo,hia2 O. 7atrogenic ,i33iness. 7n Dix2 $6. ;oo,2 OD. E,it ors. ?ertigo. Pp!2F9!!*. Oohn Cile-2 +hichester. 1F#

Stur33enegger2 $. 6a,anov2 <P. Di Stefano. The effect of acci,ent mechanisms an, initial fin,ings on the long9term course of .hiplash injur-. O 'eurol2 2: !9 F 1FF&

$c'ab2 7. The mechanism of spon,-logenic pain. 7n: ;isch2 +. Totterman2 I. E,itors. +ervical pain. Pages #F9F&. Permagon2 "xfor,. 1F*2

;o.e2 O1. etal $echanosensitivit- of the ,orsal root ganglia an, chronicall- injure, axons: a ph-siological basis for the ra,icular pain of nerve root compression. Pain !:2&91 1F**

<og,u%2 '. T.ome-2 =T. +linical anatom- of the lumbar spine 2n, e,ition pages 1&191&F 1FF1


Sm-th2 $O. Cright2 ?. Sciatica an, the intervertebral ,isc. :n experimental stu,-. O <one Ooint Sur /:m0 )::1 )191 1# 1F&F


$c+ulloch2 O:. Ca,,ell2 G. ?ariation in of the lumbosacral m-otomes .ith bon- segmental anomalies. O <one Ooint Surg /<r0 (2/<0: *&9 #) 1F#)

El $ah,i2 $: etal. The spinal nerve root innervation2 an, a ne. concept of the clinicopathological interrelations in bac% pain an, sciatica. 'eurochirugia 2 :1!*91 1 1F#1

:,ams2 6D. ?ictor2 $?. 6opper2 :;. Principles of 'eurolog- (th E,ition /+D96"$ version0. $cGra.9;ill2 'I. 1FF#

Cilson9Pau.els2 =. et al. :utonomic 'erves pp 29 !. <+ Dec%er 7nc. ;amilton 1FF*


Goo,man2 ++. Sn-,er2 TE. Differential Diagnosis in Ph-sical Therap- 2n, E,ition pages (9* C< Saun,ers +ompan-2 Phila,elphia2 1FF&

;olleb2 :7. 1in%2 DO. $urph-2 GP. Textboo% of +linical "ncolog- page &&&. :merican +ancer Societ-2 :tlanta2 1FF1

Grieve2 GP. 6eferre, pain an, other clinical features. 7n GrieveLs $o,ern $anual Therap- 2n,. E,ition. <o-ling2 OD. Palastanga2 '. E,itors. +hurchill =ivingston2 E,inburgh 2*19 2F2 1FF

Cilliams2 P=. Car.ic%2 6. Gra-Ls :ntom- !(th e,ition. +hurchill =ivingston2 E,inburgh 1F#) +ameron2 6<. Practical "ncolog- page. :ppleton M =ange ' +onnecticut2 1FF



;olleb2 :7. 1in%2 DO. $urph-2 GP. Textboo% of +linical "ncolog- page. :merican +ancer Societ-2 :tlanta2 1FF1

;ea,2 ;. Stu,ies in neurolog- pp (&!. "xfor, $e,ical Publications2 =on,on2 1F2)


+-riax2 O. Textboo% of "rthope,ic $e,icine2 ?ol #th. E,ition. <alliere Tin,all M +assell2 =on,on 1F#2

$cEen3ie2 6:. The lumbar Spine: mechanical ,iagnosis an, therap-. Spinal Publications =t,. 'e. Tealan, 1F#1


Ceiner2 CO. Goet32 +G. 'eurolog- for the non9neurologist !r,. E,ition. pp1&&. O< =ippincott +ompan-. Phila,elphia 1FF

George2 <. =aurian2 +. The vertebral arter-: patholog- an, surger-. Springer9?erlag2 'I 1F#*


:,ams2 6D. ?ictor2 $?. 6opper2 :;. Principles of 'eurolog- (th E,ition /+D96"$ version0. $cGra.9;ill2 'I. 1FF# :usman2 O7. etal Posterior circulation revasculari3ation. Superficial temporal arter- to superior cerebellar arter- anastamosis. O 'eurosurg &(/(0:*((9**( 1F#2

Pessin2 $s. Etal. <asilar arter- stenosis: mi,,le an, ,istal segments. 'eurol !*/110:1* 291* ( 1F#*

Ean,al2 E6. S.art3e2 O;. Prinicples of 'eural Science 2n, E,ition. Pp&(*9&(F. Elsevier2 'e. Ior%


:,ams2 6D. ?ictor2 $?. 6opper2 :;. Principles of 'eurolog- (th E,ition Part /+D96"$ version0. $cGra.9;ill2 'I. 1FF#

Dalin%a2 $E et al. The ra,iographic evaluation of spinal trauma. Emerg $e, +lin ' :mer. !:!: *&9 F)

6ei,2 D+. et al. Etiolog- an, clinical course of misse, spinal fractures. O Trauma ?ol. 2*:F: F#)9 F#&
xli xlii

;u2 SS. etal. Disor,ers2 ,iseases an, injuries of the spine. 7n: S%inner2 ;<. E,itor. +urrent ,iagnosis an, treatment in orthope,ics. pp1#&. :ppletone an, =ange ' +T. 1FF&

Een,all2 ;o. Een,all2 1P. <o-nton2 =:. Posture an, pain. Cilliams an, Cil%ins2 <altimore. 1F&2


Een,all2 ;o. Een,all2 1P Ca,s.orth2 GE. $uscles: testing an, function. 2n, E,ition. Cilliams an, Cil%ins2 <altimore 1F*1

=un,ervol,2 :OS. Electrom-ographic investigations of positions an, manner of .or%ing in t-pe.riting. C. <roggers2 <o%tr-%%eri :DS. "slo 1F&1

+arlsoo2 S. The static muscle loa, in ,ifferent .or% positions: an electrom-ographic stu,-. Ergonomics :1F!9211 1F(1 <asmajian2 O?. De=uca2 +O. $uscles alive: their functions reveale, b- electrom-ograph- &th E,ition. Pp 2&292( 1F#&

xlvii X


Portno-2 ;. $orrin2 1. Electrom-ographic stu,- of postural muscles in various positions an, movements. :m O Ph-siol 1#(:122912( 1F&(

Portno-2 ;. $orrin2 1. Electrom-ographic stu,- of postural muscles in various positions an, movements. :m O Ph-siol 1#(:122912( 1F&(

$urra-2 $P. etal. 'ormal postural stabilit- an, stea,iness: a 4uantitative assessment. O <one Ooint Surg &*/:0:&1)9&1& 1F*&

$cEen3ie2 6:. The lumbar spine: mechanical ,iagnosis an, therap-. Pp!&9!( Spinal Publications2 Cai%anae 'T 1F#1

:,ams2 6D. ?ictor2 $?. 6opper2 :;. Principles of 'eurolog- (th E,ition /+D96"$ version0. $cGra.9;ill2 'I. 1FF#

+heng O+> :u :C. 7nfantile torticollis: a revie. of (2 cases. O Pe,iatr "rthop2 1 /(0:#)29# 1FF 'ov9Dec

+-riax2 O. Textboo% of "rthope,ic $e,icine2 ?ol #th. E,ition. <alliere Tin,all M +assell2 =on,on 1F#2

Stern2 PO. et al. +ervical spine osteoblastoma presenting as mechanical pain: a case report. O++: !#/!0:1 (91&1 1FF


Gilman2 S. Cinans 'e.man2 S. $anter an, Gat3Ls Essentials of clinical neurolog- an, neuroph-siolog-. * th E,ition. Pp &F9(2 1: Davis +ompan-2 Phila,elphia. 1F#*

:,ams2 6D. ?ictor2 $?. 6opper2 :;. Principles of 'eurolog- (th E,ition Part & /+D96"$ version0. $cGra.9;ill2 'I. 1FF#


:,ams2 6D. ?ictor2 $?. 6opper2 :;. Principles of 'eurolog- (th E,ition Part /+D96"$ version0. $cGra.9;ill2 'I. 1FF#

<eals2 6E. Et al. :nomalies associate, .ith vertebral malformations. Spine 1#/1)0:1!2F9!2 1FF!


Ceiner2 CO. Goet32 +G. 'eurolog- for the non9neurologist !r, e,ition. !1&9!1# O< =ippincott +ompan-. Phila,elphia 1FF 1*291*#

;er,man2 SO. E,itor. ?estibular 6ehabilitation. pp &#2 11&91( 2 21!922F2 2&192&*. 1: Davis +ompan-2 Phila,elphia. 1FF

:,ams2 6D. ?ictor2 $?. 6opper2 :;. Principles of 'eurolog- (th E,ition Part 2. /+D96"$ version0. $cGra.9;ill2 'I. 1FF#

Cilson9Pau.els2 =. et al. +ranial 'erves pp #29F&. <+ Dec%er 7nc. Toronto. 1F##


:,ams2 6D. ?ictor2 $?. 6opper2 :;. Principles of 'eurolog- (th E,ition Parts 1 an, 2 /+D96"$ version0. $cGra.9 ;ill2 'I. 1FF#

+-riax2 O. Textboo% of "rthope,ic $e,icine2 ?ol #th. E,ition. <alliere Tin,all M +assell2 =on,on 1F#2 ;a-nes2 EC. Et al. :n examination of +-riaxLs passive motion tests .ith patients having osteoarthritis of the %nee. Ph-s Ther * /)#0:(F*9*)* 1FF
lxvi lxvii

+-riax2 O. Personal communication. 1F*2

<og,u%2 '. T.ome-2 =T. +linical anatom- of the lumbar spine 2n, e,ition pages &!9( 2 1FF1



Slater2 ;. et al. The ,-namic central nervous s-stem: examination an, assessment using tension tests. 7n GrieveLs $o,ern $anual Therap- 2n,. E,ition. <o-ling2 OD. Palastanga2 '. E,itors. +hurchill =ivingston2 E,inburgh &#*9()( 1FF

<utler2 DS. $obili3ation of the nervous s-stem. +hurchill =ivingston2 E,inburgh 1FF1

1ran%lin2 $E. et al. :ssessment of exercise in,uce, minor muscle lesions: the accurac- of +-riaxLs ,iagnosis b- selective tissue tension para,igm. O "rthop Sports Ph-s Ther 2 /!0:122912F 1FF(


Tullberg T2 Svanborg E2 7saccsson O2 Grane P Spine 1#:#!*9 22 1FF!

;oppenfel,2 S. "rthope,ic neurolog-: a ,iagnostic gui,e to neurologic levels pp. 19!.O< =ippincott +ompan-2 Phila,elphia. 1F**
lxxiii lxxiv

Denn-9<ro.n2 D. et al. The tract of =issauer in relation to sensor- transmission in the ,orsal horn of the spinal cor, of the maca4ue . O +omp 'eurol 1&1:1*&92))2 1F*!

Grieve2 GP. Thoracic musculos%eletal problems. 7n GrieveLs $o,ern $anual Therap- 2n,. E,ition. <o-ling2 OD. Palastanga2 '. E,itors. +hurchill =ivingston2 E,inburgh )19 2# 1FF

:,ams2 6D. ?ictor2 $?. 6opper2 :;. Principles of 'eurolog- (th E,ition2 Part 2 /+D96"$ version0. $cGra.9;ill2 'I. 1FF#

Oara,eh2 S. +au,a e4uina s-n,rome: a neurologistLs perspective. 6eg :nesth 1#: * 9 #)2 1FF!


=ouis ED2 Eaufmann P. ErbBs explanation for the ten,on reflexes. =in%s bet.een science an, the clinic.

:,ams2 6D. ?ictor2 $?. 6opper2 :;. Principles of 'eurolog- (th E,ition2 Part & /+D96"$ version0. $cGra.9;ill2 'I. 1FF#

$agee2 D. "rthope,ic Ph-sical :ssessment2 C< Saun,ers2 Phila,elphia2 1FF2


+ameron2 6<. Practical "ncolog-. :ppleton M =ange. ' +' 1FF ;olleb2 :7. et al.+linical "ncolog-2 :merican +ancer Societ-2 :tlanta 1FF1
+ameron2 6<. 7ntro,uction to the cancer patient. 7n +ameron2



6<. Practical "ncolog- pp 19 . :ppleton M

=ange. ' +' 1FF


Pfeifer2 OD. Cic%2 $6. The pathological evaluation of neoplastic ,isease. 7n ;olleb2 :7. Et al. Textboo% of +linical "ncolog- *92 2 :mercian +ancer Societ-2 :tlanata2 1FF1

1ol-2 E$. Diagnosis an, treatment of cancer pain. 7n ;olleb2 :7. et al.+linical "ncolog- pp &&&9 &*&2 :merican +ancer Societ-2 :tlanta 1FF1
Ceissman2 DE. Principles of pain management. 7n +ameron2


6<. Practical "ncolog- pp !!9!F :ppleton M

=ange. ' +' 1FF


Textboo% of "rthope,ic $e,icine ?ol 1. +-riax2 O. <alliere Tin,all M +assell =on,on Crist pain in a !2 -ear ol, man. ;oro.it32 S$. +lin "rthop 6el 6es !)*:2#)92#* 1FF



Tumors of the :tlas: ! inci,ental cases of osteochon,roma2 benign osteoblastoma an, at-pical E.ingBs sarcoma. =ope39<area2 1. +lin "rthop 6el 6es !)*:1#291## 1FF

$etastatic bone ,isease Secon,ar- to breast cancer: an all too common cause of lo. bac% pain. Gro,2 OP. +ro.ther2 E6. O++: !#:!:1!F91 & 1FF +ervical spine osteoblastoma presenting as mechanical nec% pain: a case report. Stern2 PO et al. O++: !#:!:1 (91&1 1FF 6oth2 P. 'eurologic Problems an, Emergencies. 7n +ameron2 6<. Practical "ncolog- pp &*9&F. :ppleton M =ange. ' +' 1FF