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Cervical-spine manipulation: RELATIVE contraindications:
- Recent trauma without workup
- Fracture or suspected fracture
- open wounds
- Skin infections
- Rheumatoid arthiritis
- Down Syndrome
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When does cervical lordotic curve become most noticeable?
As a child begins to lift head (3-4 months)
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Most mobile region of the spine and has the most mms
Cervical spines
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Typical ribs: vertebral
C2-7
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SB and R to SAME side
N, F, or E
~50% of Rotation of C-spine from these levels
C2-C7
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Atypical cervical spine
OA and AA
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Atypical C-spine that makes up ~50% of F and E of c-spine by primarily gliding on condyles
OA
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At this level, SD always have a F or E component with SB and R to OPPOSITE sides
OA
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C-Spine level that is purely rotational (~50% of Cervical rotation)
AA
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C-spine with the LONGEST transverse processes
Atlas
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Where can you feel the TP of C1
Between Angle of mandible and mastoid process (behind ear lobe)
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Where the occiput glides on the ATLAS
- Superior Articular Facets
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Where the atlas rotates on axis
- Inferior Articular processes
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Dens articulate with which part of the atlas
part behind the anterior tubercle at the articular facent for odontoid process
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What goes thru the transverse foramen?
- Vertebral A
- Vertebral V
- Vertebral Sympathetic plexus
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This structure wraps around and hides the dens
- Tectorial membrane
- Te
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Origin of the dens
- Body of C1, it dissociated from atlas and fused with body of C2
- C1- has NO body
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Ligament that gives integrity to the AA joint and if torn can lead to sudden death
- Cruciform ligament holds the dens against the atlas and keeps it from compressing the spinal cord
- Cr
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What passes thru the intervertebral foramen?
- Spinal nerve
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This can lead to Osteophytes (bony outgrowths) which can compress the nerve and artery leading to Chronic neck pain
- Unconvertebral arthrosis
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This a load-bearing structure of the IV disc
Anterior aspect is stronger
Pain sensitive
Annulus fibrosus
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Most common area for Annulus fibrosus herniation
Posterior-lateral
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Thickest in lumbar
2nd thickest in cervical
Thinnest in thoracic
Centrally placed in cervical
Gelatinous substance (absorbs majority of fluid)
Nucleus Pulposus
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Attached to IVD and 2 vertebral bodies
Cartilaginous end plate
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Prevent vertebral bodies from undergoing pressure atrophy
Cartilaginous end plate
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Keep annulus fibrosus and nucleus pulposus within anatomic borders
Cartilaginous end plate
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Most common causes of nerve root compression in C-spine
- Degeneration of joints of Lushka (uncovertebral joints) ANTERIORLY
- Hypertrophic osteo-arthritis of synovial joints POSTERIORLY at IV foramen
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Position that pt prefer with cervical nerve root compression
Front bending (Flexion)
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Position that pt dislike with cervical nerve root compression
BB, SB, or R Ipsilateral to side of compression b/c these motions decrease size of IV foramen
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Position pt prefers if have cervical disc herniation
BB and slight SB TOWARD side of herniation to keep nucleus pulposus away from neural structures
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What are the 3 components of suboccipital triangle?
- Occipital bone
- Tip of the TP of the Atlas
- Ligamentum nuchae and SP of the axis
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Nerves on the posterior part of the head that if they get squeezed, you'll have sx of tension at the posterior part of head
Greater and lesser occipital nerves
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mm Origin: external occipital protuberance, ligamentum nuchae, SP of C7-T12
Trapezius
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mm insertion: Lateral 1/3 of clavical, spine of scapula, base of scapular spine
Trapezius
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mm function: elevate shoulder, depress and retract scapula, and steady scapula and thorax
EXTEND, laterally FLEX, and contralaterally rotate head
Trapezius
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mm O: SP of C1-C4
Levator Scapulae
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mm I:Superior angle of scapula
Levator scapulae
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mm Fxn: Elevates Scapula
Levator scapulae
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O: SP of C7-T3
I: lateral aspect of nuchal line on rough area of occipital bone and mastoid
Fxn: Extend, laterally flex, and rotate head to same side
Splenius capitus
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mm Fxn: Laterally flex and rotate neck to same side
O: SP of T3-T6
Splenius cervicis
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O: TP of C7-T6
I: Occiput
Fxn: Extend head
Semispinalis capitis
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O: vertebral bodies of lower cervicals and upper thoracics; TP of lower cervicals
Fxn: Flexion of spine, some lateral flexion
- Longus coli
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Order for Dx C-Spine
- Observe, Palpate, ROM
- ALWAYS palpate PRIOR to ROM
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ROM: SB of C-spine
30-45 deg
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ROM: Rotation of C-spine
- 70-90 deg
- 50% from AA and 50% from C2-C7
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SD of AA joint: Motion testing
- Passively FLEX C-spine to lock-out lower vertebrae - if paintful, consider meningitis
- Rotate to barriers
- Compare, assess, and Dx
- Assess OA dx as well
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Name this method: Px finger pads of caudad hand touch cervical paravertebral mm on side of neck opposite of Px
gently draw PV mm VENTRALLY to produce min EXTENSION of c-spine in Rhythmic, kneading fashion
Contralateral Traction (supine)
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Type of traction created by Cradling with Traction, supine
Longitudinal traction
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Type of pressure created with Suboccipital release
Constant Inhibitoriy pressure
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C2-C7 ME and HVLA emphasis:
Directed at closed Zygapophyseal joint to de-rotate segment back to neutral
ROTATIONAL
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C2-C7 ME and HVLA emphasis:
Treating hand is ON side of the CLOSED joint
Rotational
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C2-C7 ME and HVLA emphasis:
Rotate into Barrier before SB
Rotational
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C2-C7 ME and HVLA emphasis:
SB into ease to get into the plane of Zygapophyeal joint
Rotational
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C2-C7 ME and HVLA emphasis:
Tx is directed at closed zygapophyseal joint by SB segment back to neutral
SB emphasis
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C2-C7 ME and HVLA emphasis:
Treating hand on side of OPEN joint
SB
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C2-C7 ME and HVLA emphasis:
Flex down to level being treated
SB
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C2-C7 ME and HVLA emphasis:
Rotate into ease to localize SD and get into plane of zygapophyseal joint
SB
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Glide head on condyle into F or E barrier
SB to barrier
R to barrier
Exert continuous traction
Short Rotational thrust thru barrier in direction of IPSILATERAL eye
- HVLA for OA
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HVLA: Short rotational thrust thru barrier in direction IPSILATERAL eye
OA
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ME: Flatten AP curve, rotate to barrier while pt rotate to ease
AA
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Cervical Dx: Change in gait or balance, paresthesia, loss of agility in hands
Cervical myelopathy
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Cervical Dx: Profound UMN sx; combination of arm and leg sx and gait disorder
Cervical Myelopathy
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Cervical Dx: causes due to compression of spinal cord and or nerve roots in cervical canal
Cervical myelopathy
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Cervical Dx: OMT by INdirect tx and avoid cervical extension and rotation
Cervical myelopathy
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Cervical Dx: Nerve-related sx such as pain, numbness, or mm weakness in specific nerve distribution
Cervical radiculopathy
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Cervical Dx: distal parenthesias, sensory loss, motor weakness, decreased DTRs
Cervical radiculopathy
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Cervical Dx: Caused by compression (oteophyte or disc protrusion) of cervical nerve root
Cervical radiculopathy
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Cervical Dx: OMT by avoid HVLA at site of herniation; ME and SCS are good
Cervical Radiculopathy
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Red flags include:
- Fever (infection)
- Wt. loss (tumor)
- Acute localized bone pain (fracture/expansion of bone)
- Morning stiffness of neck (Spondylo-arthropathies/RA)
- Visceral causes (angina, esophageal dz, TOS)
- Neck pain and fever (meningitis)
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Neurological Motor testing: C5
Deltoid abduction at shoulder
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Neurological Motor testing:C6
Elbow/bicepts flexion at forearm or Wrist extension (ECR)
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Neurological Motor testing:C7
Wrist Flexion or Elbow extension
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Neurological Motor testing:C8
Finger flexion, middle finger (FDP)
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Neurological Motor testing: T1
Small finger abductors (ADM) or sperad fingers (interossei)
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Contraindications to provocative tests:
- Inability to tolerate position
- Paralysis
- Increase or significant alteration of sx
- Localized path. tissue conditions (infections, tumors, congenital defects of bone/tissue)
- Fracture
- Vertebral artery compromise
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Provocative tests:
Test for vertebral artery insufficiency
Supine, Extend, R, and WAIT for 30 S
- Underburg Test
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Provocative tests:
Positive test
Dizziness, nausea, lightheadedness
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Provocative tests:
Flex pt's neck and hips until sx reproduced or end of ROM
- Lhermitte's sign
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Provocative tests:
LHermitte's Sing Positive
- Electrical shock sensation down spine or both arms or legs
- suggests a lesion or dorsal columns of cervical cord or of caudal medulla
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Provocative tests:
Lhermitte's sign causes
Most often by multiple sclerosis or a large disc herniation impinging on anterior spinal cord (cervical myelopathy)
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Provocative tests:
Extend Pt's neck and SB it to ONE side with coresponding axial compression of pt's head
Spurling's Test
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Provocative tests:
Positive sign of Spurling's Test
Pain elicited down ipsilateral arm from neck
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Provocative tests:
Postive sx of this test indicates cervical disc dz; STINGER
Spurling's Test
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Provocative tests:
Palpates radial pulse on affected arm with arm at pt's side
As pulse is monitored, Px moves pt's arm into abduction and exteral rotation
Pt. takes deep breath and turns head toward raised arm
Adson's Test
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Provocative tests:
Positive test marked diminution or loss of pulse
Adson's test
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Provocative tests:
Positive test indicates Subclavian artery compression by cervical rib and/or scalene mm
Vascular thoracic outlet syndrome
Adson's test
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Conditions that should not be missed due to morbidity/mortality
- Fracture/dislocation
- AO ligament disruption
- Herniated Cervical disc
- Stingers/burners/neurapraxia
- Transient quadrilegia
- Tumors
- Arnold-chiari malforation
- Neurolofic injury causing neurapraxia/paralysis
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Q: Neck pain
C4 prefers to SB to R
Feels better in F
Dx?
C4 F SBrRr
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Q: Neck/back/shoulder pain
head is bent backwards (E) and SB to one side
- Cervical disc herniation
- E and SB toward side of herniation to keep nucleus pulposus from impinging on nerve
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Q:
Headache
Neck stiffness
AA joint testing shows pt has to raise shoulders off table
Dx?
Meningitis
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Q:
Neck/shoulder/back pain
(+) Adson's test
Subclavian A. compression secondary to cervical rib
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Q:
As brachial Plexus if forming, which mm does it pass directly posterior to?
- Anterior Scalene
- Brachial plexus passes between A and M scalenes
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Q:
MM with dural attachment
- Rectus capitus posterior minor
- has fibers that penetrate between occiput and atlas that penetrate into the dura
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Q:
Unilateral contraction of SCM
Torticolis
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Q:
Attachments of SCM are posterior to line of gravity, so when they contract, occiput glides forwards into extension, causing___
NEED REVIEW
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Q:
Bilateral contraction of SCM will cause _________
NEED REVIEW
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Q:
Minor MVA where car was tapped from behind while he was stopped at a toll booth
No pain immediately to accident
Woke up with neck stiffness and pain
Dx: Jolt syndrome in which the force of impact was low, but driver's seat back acted as a spring catapult
PE: SD at OA level
HVLA at OA causes diplopia and visions of flashing lights, vertigo follows along with dysarthria
This indicates what?
Positional vertebral basilar insufficiency, abort the technique
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Q:
Rheumatoid arthiritis
Stiff neck
Incredible headache
OMT for headach should be ______
- Indirect method - using inherent force
- B/c Rheumatoid arthiritis is a relative CI to OMT, so you dont want to do anythin direct
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Upper part of Typical C-spine favors what motion?
More R and Less SB
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Lower part of Typical C-Spine favors what motion?
More SB and less R
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C-vertebral with longest TP
C-7
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C-vertebral:
Greater AP diameter for vertebral foramen
Long TP
Atlas
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Ligament that was a portion of NOTOCHORD that normally becomes nucleus pulposus
Connects the dens with occiput
Apical Dental ligament (suspensory lig)
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C-vertebral that develops from 3 primary centers of ossification: 2 lateral masses and 1 anterior arch
Atlas
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C-vertebral:
Thick pedicles
Small TP
Axis
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Vertibrobasilar insufficiency test
E, SB, R ipsilaterally to assess fxn vascular adequacy
Underberg or Wallenburg test
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Cervical Dx:
Secondary to compression of spinal cord and/or nerve roots
Numbness, tingling, burning
Cervical Myelopathy
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Acute Radicular (in younger pts) is due to:
Sprain, Strain, and HNP
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Chronic Radicular Pain (older pt) is due to:
Compression of nerve due to facet or uncovertebral joint hypertrophy
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Provocative test:
Test Supraspinatus
90 deg ABduction and 30 deg ADduction
Test to detect unilateral weakness
- Full can test
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Provocative test:
Positive test indicates Spacy occupying lesion
Lhermitte's
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Provocative test:
Positive Adson's test indicates:
Thoracic Outlet Syndrome
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Provocative test:
3 major causes of Adson's Sign
- Anatomic
- Trauma/repetitive activities
- Neurovascular entrapment at costoclavicular space
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Provocative test:
Positive Adson's: Anatomic problem due to____
- Cervical ribs
- Congenital fibromuscular bands
- TP of C7 elongated
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Provocative test:
TOS tx for Adson's
- OMT: tx ribs, scalenes, cervical and thoracic vertebrae
- Surgery: Decompress depending on cause
- Often 1st rib removed
- Cervical rib removed
- Release A and M scalenes
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Q:
Types of head pain that will likely have SD
Migrane headache
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Q:
What is NOT a CI using OMT in head pain
Hx of cervical vertebral fusion
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Q:
SD of the following region is involved in headache
Cranium, cervical spine, ribs, and sacral
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Common patient complaint for MCA
Neck pain
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Q:
Neck pain 8 hours after MVA
Struck from behind while stopped at a light
No airbag restrained
All Anterior structures are stretched
- Whiplash leading to headaches, neck pain, thoracic pain, back pain
- Hyperextension leading to stretch of all anterior mm
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Q:
If pushed on Scalene and pain doesn't go anywhere
Tenderpoint
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Q:
If pushed in scalene and pain radiates down the arm
Trigger point
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Q:
MVA by hitting a patch of ice on road and struck a tree head on at 25 mph
Neck pain
Headache
No trauma
restrained by seatbelt only
Hyperflexion
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Q:
L. arm pain with parasthesias after dog pulled her off balance
Brachial plexus impigement
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Q:
Moderate headache
Post-menopausal
hx: Acute GI bleed from gastric ulcer, transfusion of 4 units of PRBC
Steady dull pain and pressure extending across back of head
Vitals: Afebrile
OSE: OA ESBrRl, C2 ESRr, pain on palpation of C2-C3 radiates to area of right orbit, SBS strain pattern
DDX:?
- Muscle tension type headache
- Migrain heachache
- SD of head, cervical, thoracics, Ribs, ...
- Aneurysm, subarachnoid hemorrhage
- Tumor
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Vascular Headache from cranial Dysfunction can be due to dysfunction in:
Venous sinuses, Internal Jugular Foramen, Occiput, Temporalis, Frontal
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Headaches from visceral origin referral from:
Eyes, ears, Nose, Sinuses, Cardiac, Upper GI
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Headaches from visceral origin: common innervations
Autonomics Parasympathetics
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OMT for Tension-type headaches:
- Remove facilitation/ SD
- Reduce stressors
- Increase relaxation
- Tx T1-T4 via HVLA, ME, MFR, CS, ST
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OMT Contraindications for Tension-type headache:
Acute Neurological event: Ruptured berry aneurysm or Arteriovenous malformation
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