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    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................................................................#

    1

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    Section 1. Differential Diagnosis: General Principles

    The clinical ,ifferential ,iagnosis is ala-s provisional an, subject to change either

    as further information from more objective stu,ies such as bloo, tests an, imagingcomes available /alloing 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 signsor s-mptoms are ,ifficult to ,iagnose except on the provisional basis that the

    selecte, treatment has its pre,icte, outcome. or example bac% pain ith somatic

    pain ra,iating into the buttoc% that is not accompanie, b- neural or ,ural signs ors-mptoms coul, be cause, b- a number of pathologies. These inclu,e a containe,

    ,isc lesion a 3-gopoph-seal joint ,-sfunction or inflammation ligamentous or

    muscle tearing injur- to the outer anulus fibrosis compression or other fracturebacterial infection or neoplasm. +ertainl- some of these pathologies are much more

    common than are others an, b- the la of probabilities alone -ou oul, probabl-

    be right more often than rong if -ou generate, to or three ,iagnosis base, onfre4uenc- of inci,ence. Even ta%ing into account the clinical fin,ings inclu,ing

    other aspects of the histor- an, other objective cues 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- helpconfirm a clinical ,iagnosis given the rate false positives an, negatives of $67s an,

    89ra-s.

    The orthope,ic manual therap- examination consists of to parts a ,ifferential

    ,iagnostic examination an, a biomechanical examination. "f the to 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 bea,ministere,. or the most part the ,ifferential ,iagnosis is provisional on further

    more objective testing or on retrospect ith the patient recovering ith specific

    treatment. $an- therapists loo% onl- for re, flags on the ,ifferential ,iagnosisexamination rather than a specific ,iagnosis an, hile this approach is 4uite goo,

    for preclu,ing inappropriate patients from treatment it is of little value in the

    generation of a specific treatment plan.

    2

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

    Differential Diagnostic (Scan) Examination;istor-

    "bservation /7nspection06outine Selective Tissue Tension Tests

    Special Tests

    Peripheral Differential Screening Examination

    Neurophysiological Examination$uscle

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    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. Disabilities s-mptoms s-mptom behavior irritabilit-exacerbating 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 patientBsproblem 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, informationregar,ing the patientBs personalit- attitu,e to his or her problem an, the li%elihoo,

    of compliance ith the therapistBs instructions regar,ing exercises rest activities

    etc.

    The folloing 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 objectiveexaminations. Ce ill loo% first at 4uestions that pertain to all regions spinal an,

    peripheral 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

    amil- status Past me,ical histor- +urrent an, past me,ications

    The patientBs s-mptomatolog- inclu,ing:

    The onset The s-mptoms nature

    The s-mptoms severit- The level of irritabilit- Exacerbating an, relieving factors ssociate, factors /,iet posture activit- 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

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    n- current me,ications that might impact on the assessment or treatment n-

    other 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 toar,s his or problem

    The folloing lists the main 4uestions that nee, to be as%e, most patients. Some are

    region specific. or 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,-oung0

    Gen,er "ccupation an, ,escription of ,uties =eisure activities an, their fre4uenc- an, intensit-

    amil- status Past me,ical histor- /cancer ,iabetes s-stemic arthritis congenital collagen

    ,isor,er0

    +urrent an, past me,ications /steroi,s 'S7Ds insulin ,i33iness

    provo%ing0 Past surgeries /cancer spinal neurological0

    B. Pain and Paresthesia

    "nset /traumatic non9traumatic imme,iate,ela-e, insi,ioussu,,en

    causeno cause0

    =ocation /stea,- changing localextensive segmentalnon9segmental

    continuous,issociate, shiftingexpan,ing0 T-pe /somatic neurological0

    Severit- /scale of 1)0 7rritabilit- /ho much stress to irritate an, ho much time for relief0 ggravatingabating factors /activitiespostures eating,iet

    generalemotional stress0 'octurnal /aching or su,,en sharp pain0 Cor% relate, or not

    +onstant continuous intermittent

    Episo,icnon9episo,ic

    C. ther Symptoms and !hat Pro"o#es $hem

    Di33iness /t-pe 1 2 or !0 ?isual ,isturbances /scotoma hemi4ua,ranopia floaters scintillations

    blurring tunnel0

    &

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    Taste or smell ,isturbances

    D-sphagia /painfulpainless0 mnesia /traumaticnon9traumatic0 ?omiting

    +ough changes /non9pro,uctive to pro,uctive0

    Sputum changes /clear to -ello or green fresh or ol, bloo,0 Cea%ness

    +lumsiness Gait ,isturbances /ataxia staggering tripping0 Drop attac%s

    S-ncope /fre4uenc-0

    Photophobia Phonophobia ;-poacusia

    ;-peracusia Tinnitus /highlo fre4uenc- unilateralbilateral pulsatilenon9pulsatile0

    7ntellectual impairment /,rosiness concentration ,ifficulties0

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    '. ther n"estigations and esults

    89ra-s $67 $6

    +T scans

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    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)))))

    before 2& -ears of age as compare, to !F* per 1))))) at age #)0 i.

    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 prostatitis

    testicular cancer an, so forth are exclusive to the male. =ung cancer is about toan, 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.

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    somebo,- else ,o them 7s this a perio, of stress at home hen little if an-

    cooperation 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- them Chat are the ages of thechil,ren an, ho much care must the patient give to them. 7f re4uire, the therapist

    must teach the patient ho to mo,if- positions for nursing or changing infants

    ,ressing smaller chil,ren an, recruiting ol,er chil,ren to ta%e over some of thechores.

    Past an, Present $e,ical +on,itions

    $ost of the patientBs me,ical histor- ill be of no relevance to us an, on

    recogni3ing this 4uestioning shoul, be ,iscontinue, on that subject as this is simpl-

    an invasion of the patientBs privac- ithout there being an- clinical necessit-.;oever e shoul, listen for a histor- of s-stemic arthritis s%in rashes cancer

    ,iabetes coronar- con,itions 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,this the 4uestion can be put on a 4uestionnaire that the patient fills out before

    seeing the therapist. past histor- of cancer shoul, ala-s ,eman, that thetherapist 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.

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    7t is also orth noting hat the patient has to sa- if an-thing 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- as examples 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 the-

    are ta%ing such an, such a ,rug. This naturall- lea,s -ou bac% to the reason for

    ta%ing the me,ication. 7n a,,ition certain me,ications ill affect -our treatments.

    or example it is probabl- not the best i,ea in the orl, to appl- ,eep frictions orgive 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 rupturexxixii. S-stemic steroi,s ill cause

    generali3e, collagen ea%ness 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 tomanipulation an, ,eep transverse frictions for obvious reasons. There are about four

    hun,re, me,ications %non to cause ,i33iness as an a,verse effect these inclu,e

    aspirin an, other 'S7DBs s-stemic steroi,s amminogl-cosi,ic antibiotics,iuretics an, anti9anginalsxiiixiv. "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 generalistorthope,ic therapist. Pain is a ver- subjective s-mptom an, varies not onl- frompatient 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 theonl- source that the therapist has hen ,etermining its 4ualities. Therefore

    ,escriptions of its t-pe location behavior intensit- etc are extremel- important in

    ma%ing a ,ifferential ,iagnosis.

    "nset

    7s the pain relate, to trauma 7f so as it imme,iate or ,ela-e,. n imme,iate onsetof severe pain often in,icates profoun, tissue ,amage such as ligamentous or

    muscular tearing or fracture. or example the imme,iate onset of cervical pain

    folloing 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 pain ,i, the patient hear an- noises at the

    time of the injur- +rac%ing tearing or popping noises coul, in,icate su,,en

    1)

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    ,amage. Cas there selling an, hen ,i, it occur. 7mme,iate severe selling is

    strongl- suggestive of hemarthrosis. Significant articular trauma causing pain but no

    selling coul, mean that there is a rent in the capsule through hich theinflammator- 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 origin 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 case the trauma ma- simpl- bethe 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 categor-

    into hich most patients fall in the general orthope,ic practice is non9traumatic.

    The patient can relate no over9stressful activit- or posture that either starte, orprovo%e, the problem. The cause ma- have simpl- been lifting a mo,erate loa,

    su,,enl- turning the hea, 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- Probabl- because usuall- thelifter has ,riven somehere an, so pre,ispose, the spine to injur-. =ife is li%e that

    e spen, our -outh an, -oung a,ulthoo, pre,isposing our bo,ies to failure frominjuries 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 cases this is accurate an, the term is being use, as it shoul, be.

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    here there is no apparent cause. Chile the vast majorit- of these patients ill be

    straightforar, musculos%eletal problems it is from this group that the s-stemic

    arthritic an, cancer patients ill be ,ran.

    Pain Aualit-

    The 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 folloing 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 notresult in pain. The result of simple compression experimentall- is paresthesia

    numbness neurological ,eficit or all three but not painxvi xvii. ;oever 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,,ition ithas been postulate, that intraneural or perineural oe,ema ma- pro,uce nerve root

    ischemia hich in turn ma- cause ra,icular s-mptomsxviii. This ra,icular pain islancinating or shooting an, encompasses less than one an, a half inches in i,th a

    running ,on the limb or aroun, the trun%xix xx. s a conse4uence the recognition

    of ra,icular s-mptoms is ver- eas-. 7t is lancinating pain paresthetic causalgic or

    numb. n- s-mptoms other than these cannot be ascribe, to spinal nerve or rootcompression or inflammation. or an excellent short ,iscourse on this subject rea,

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    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,

    it is not beneficial to the patient to mis,iagnose a ,isc lesion that might onl- beeither 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% compressionith 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 ala-s the anser 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 ahistor-. Thalamic pain s-n,romes herpes 3oster /shingles0 ,iabetic an, other

    neuropathies pol-neuropathies 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 eventhose causing spinal nerve or root compression. Descriptors inclu,e stabbing

    %nifeli%e a storm or shoc% burning ban,9li%e flesh tearing an, in,escribable. 7t isbelieve, that the reason for this ,ifference in ,escriptors beteen 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.

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    +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, pleural pain from a,hesions or pleuritis can beextremel- ,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 ribs hich complicates the objective examinationpicture 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 pain ,ue to the multiplicit- of the levels innervating most tissues an,

    the number of tissues that might be the source. ;oever the site of the pain ma- beuseful 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- beteen

    in,ivi,uals as ell as ithin the same in,ivi,ual the latter seemingl- a function ofthe intensit- of the stimulus. ;oever 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- the greater the ,egree of ra,iation the more li%el- is the chance that

    the problem is acute an,or proximal.

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    &. The imprecise terminolog- concerning referre, pain 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 simplecompression.

    therefore an- isolate, anterior pain is an o,,it- an, shoul, be treate,ith suspicion. "n the other han, 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 sometimesreferring 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. ;oever 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. ;oever thefolloing are the main viscera their segmental innervation levelxxviian, most li%el-

    cutaneous referral area2xxviiixxix.

    The phar-nx is innervate, b- the maxillar- branch of the trigeminal theglossophar-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 thesuperior part of the esophagus is involve, substernal if the lesion affects the mi,,le

    levels an, from the xiphoi, aroun, the chest to the loer posterior mi, thoracic

    region.

    1&

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    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 theparietal pleura is affecte,. The me,iastinal an, central ,iaphragmatic parietal pleura

    is innervate, b- the phrenic nerve hile the costal M the intercostal nerves suppl-

    lateral ,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, the

    pain can be felt anterior posterior or lateral at the level of the lesion. 7f the basal

    pleura is affecte, an, irritates the ,iaphragm then shoul,er pain can result. 7f

    metastases sprea, craniall- from the apical pleura the loer 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.

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    The small intestine pro,uces umbilical pain an, if severe in the mi, to lo lumbar

    region.

    The large intestine can pro,uce pain that is felt in the loer ab,omen an, sacrum

    =iver an, gall bla,,er ,isease is usuall- felt in the right upper 4ua,rant orepigastrum ith referral potential to the right shoul,er 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 loer 4ua,rant ith referralinto 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 ,iaphragmaticperitoneum of the left upper 4ua,rant 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- folloe, b- retention are the

    normal onset of prostatitis from an- cause but occasionall- the onset ma- be lobac% pelvic an, hip pain.

    The %i,ne- an, ureters unli%e most of the ab,ominal viscera ,o appear at least in

    part to be pain sensitive. Cith laceration puncture an, pressure pain signals beingtransmitte, b- the s-mpathetic suppl- from the loer thoracic an, upper lumbar

    plexi. s a conse4uence %i,ne- pain can be extreme an, ver- musculos%eletal in its4ualit-. The pain is mainl- felt in the posterior flan% but can refer aroun, the trun%to the loer 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, loer

    ab,omen ith referral to the lumbar region.

    G-necological con,itions inclu,ing pelvic inflammator- ,isease cancer of theuterus 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,itions the pain ,istribution patterns b- themselves

    ill not ma%e the ,iagnosis. Pa- attention to the 4ualit- of the pain. +ramp li%e

    vice t-pe gnaing aveli%e ,iffuse an, ill ,efine, etc. lso listen an, loo% forevi,ence of ,-sfunction of the viscera itself such as nausea vomiting jaun,ice

    changes in coughing habits changes in sputum appearance etc. ,,itionall- loo%

    for s-mpathetic signs or s-mptoms such as increase, seating nausea etc. The

    1*

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    ,-sfunction of the viscera ma- also sho up in the a- the pain behaves. Pain onset

    or relief after eating or onset before eating oul, suggest a gastrointestinal source.

    +utaneous areas are associate, ith the viscera via their nerve suppl-. ;ea,xxxgave

    the folloing:

    ;eart T19&

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    exacerbates the patients constant pain ten,s to aggravate the con,ition but ice rest

    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 thingsbeing e4ual pain of this t-pe generall- bo,es ell for fairl- aggressive therap-

    inclu,ing manual therap- an, exercises.

    +ontinuous pain is pain that is ala-s there but varies in intensit- over the short an,long term. There is ala-s a more or less intense level of bac%groun, pain that is

    exacerbate, or relieve, b- posture 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 canbest be ,one b- estimating ho severe the bac%groun, pain is ho easil- it is

    exacerbate, ho long it lasts an, ho eas- is it relieve,. The more severe thebac%groun, pain the more chemical involvement /inflammation0 there is. The more

    easil- exacerbate, the more irritable an, the longer it lasts an, the more ,ifficult it

    is to relieve the more inflame, it gets. The patient ith this t-pe of pain can bemore 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.

    la-s remembering the complexit- of the nature of pain in its ,epen,ence on

    context the in,ivi,ual as ell as the source an, level of stimulation the folloingtable ma- help to ,istinguish the t-pe of pain encountere,. ;oever also rememberthat pure chemical or pure mechanical pains are rarities an, some ,egree of overlap

    is usuall- present.

    +;E$7+= P7' $E+;'7+= P7'

    +onstant or continuous

    nocturnal

    $orning stiffness lasting more than

    to hours

    @naffecte, b- rest

    'ight pain ma- ,isturbsleep

    intermittent

    morning stiffness lasting less than a

    fe minutes relieve, ith rest an,

    appropriate activit-

    rest 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 follos ver- ,efinite provocation. nexample is here a or%er once or tice a -ear has to ,o an unfamiliar job. Each

    time that job is ,one the pain re9intro,uces itself. This t-pe of episo,ic behavior is

    1F

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    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 ala-s true 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 completel-unpre,ictable episo,es affor, ver- little ,iagnostic 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,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- /to 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 moing the grass0 six months later. This timechiropractic too% a ,o3en treatments an, ,i, not completel- eliminate the patientBs

    s-mptoms. month or so later the bac% pain recurre, ith no apparent provocationan, 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,ing shifting or remaining stable. Shifting pain suggest that

    hatever the cause of the pain is it is not groing but moving. n unstable ,isc

    herniation ma- ,o this. Expan,ing pain though is in,icative of a groing lesionsuch 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, ,on the leg thepain might then also be felt sprea,ing to the other limb.

    7s the con,ition progressing 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. irst 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- ofthe stimulus has ,ecrease, or that it has shifte, to a tissue that is less able to refer

    pain. "n the other han, the centrali3ation coul, be apparent. ;-poesthesia or

    anesthesia ma- have replace, the pain> the objective examination ill ,eterminehich has occurre,. Peripherali3ation of the pain is generall- not a goo, s-mptom

    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. Discherniations often behave this a- 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 example0 hich orsene, an, then sprea, to the right buttoc%

    2)

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    an, then ,on the leg an, finall- across to the other leg is ,escribing expan,ing

    pain. This is an enlarging lesion it ma- be an increasing herniation or it ma- be

    something less benign such as an infection or a groing neoplasm!1. The oppositeof 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 painlessening if so e can assume that the pain stimulus is abating. ;oever this b-

    itself ma- not be an in,ication of an improving con,ition. The ,ecrease in pain ma-

    simpl- be the result of goo, compliance ith the instruction to rest the area so thaton resuming normal or even increase, activities the pain returns.

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    ,isc herniation 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 folloing is a rough in,ication of the level of the lesion from the ,istribution ofthe paresthesia:

    Peripheral peripheral nerve

    Segmental spinal nerve or root

    the former ma- be cause, b- vertebrobasilarischemia. 7n an- event the presence of paresthesia provo%e, or unprovo%e,

    ,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 actors

    Chat if an-thing ma%es the s-mptoms orse or better 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 ver-

    unli%el- to be cause, b- an-thing other than a benign musculos%eletal s-stem

    22

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    ,-sfunction. Cith acute inflammation the patient cannot fin, a position of ease an,

    so nothing ma%es it better. 7f nothing mechanical ma%es it orse then the chances

    are that the problem la-s in the viscera or in some part of the musculos%eletals-stem that is not vulnerable to mechanical stress.

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    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 structures the patient must be referre, to the ph-sician.

    he as inthe mi,,le of a cerebellar infarct. $- father ha, trouble hol,ing a fol,e, nespaper

    un,er his arm hen al%ing> it %ept ,ropping to the floor. ;e as having transient

    ischemic cerebral attac%s.

    JDi33iness ,iplopia /vertical or hori3ontal0 ,-sarthria bifacial

    numbness ataxia an, ea%ness or numbness of part or all of one or

    both si,es of the bo,- /i.e. a ,isturbance of the long motor or sensor-tracts bilaterall-0 are the hallmar%s of vertebral9basilar

    involvement.Kxxxix

    Drop attac%s occur hen the patient su,,enl- an, ithout an- arning falls almost

    invariabl- forar,s 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

    2

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    ,-sfunction brain tumor ,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 effect 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 isunaare 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 theph-sician for evaluation. "ther forms of intellectual impairment inclu,e ,rosiness

    concentration problems 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.

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    spontaneousl- or on ,irect 4uestioning. The- relate to serious pathologies such as

    vertebrobasilar compromise spinal cor, involvement an, cau,a e4uina

    compression that the therapist coul, easil- ma%e much orse ith inappropriatetreatment.

    E. Pre"ious $reatments and esults

    7f the con,ition that the patient is atten,ing for has been experience, in the past

    valuable information can be gaine, from the histor-. 7s the pain 4ualit- locationbehavior an, irritabilit- similar to those previous episo,es.

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    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- no ,a-s imaging

    an, other lab tests are being use, to ,iagnose the problem rather than confirm theclinical ,iagnosis an, hen these tests turn out to be negative the patient is ver-

    often 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 /nausea vomiting ,iarrhea fever0 previous histor- of cancer bac% an, ab,ominal pain at same level

    pain unrelieve, b- recumbenc- unvar-ing pain

    severe an, persistent pain ith painfree bac% movement severe bac% an, loer limb ea%ness ithout pain bac% pain associate, ith eating or ,iet

    2*

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    Section !bservation

    more ,etaile, ,iscussion of hat to loo% for in each region ill be foun, in the

    region specific examination sections. 7n general 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 folloing:

    Gait

    ntalgic limp?ertical limp

    =ateral limp

    'eurological gaitstaxia /i,e base, or lateral0

    Tren,elenberg

    ;igh steppingoot ,rop

    Etc

    6e,uce, or absent arm sing

    6e,uce, or absent trun% rotationStatic

    Posture

    "bvious postural anteroposterior ,eviations/h-perlor,osish-per%-phosis0

    "bvious postural transverse ,eviations /lateral shifts0

    "bvious postural rotator- ,eviations /rotoscoliosis0

    Torticollis =ateral lean

    troph-

    ;-pertroph-Surgical scars

    S%in creases /anterior an, posterior0

    ?ertebral e,ging?ertebral le,ging

    E,ema

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    General ppearance

    Pupil aniscoria

    Ptosis;ornerBs signs

    Gra-ness or -elloness

    '-stagmusacial ,rooping

    Strabismus

    +-anosisSpeech language voice

    D-sphasia

    D-sarthria

    D-sphonia

    Gait

    The are a number of problems ith assessing gait. There are too man- areas toobserve 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 beingatche, an, artificial gait ma- be execute,.

    Chat aspect of the patientBs bo,- -ou observe ,epen,s on hat -ou are loo%ing for6emember 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 has -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,icmanual therap- con,itions such as neurological ,isease amputees ,iabetes etc. The

    t-pes of gait ,eviation ,iscusse, in this section are those more commonl- seen inneurological con,itions an, those use, to assess possible causes of the orthope,icproblem.

    n antalgic limp is one here there is a shortene, stri,e length of the affecte, limpith the foot usuall- turne, outar,s. "f course this ,oes not ala-s obtain 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 posture 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 ,on 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, ,on more than isusual. 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. ;oever 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 man-

    forms> the most significant for the orthope,ic therapist is lateral an, i,e base,

    2F

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    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 thatre,uce proprioception perhaps the most notorious is neuros-ph-lis ith the tabetic

    gait. ;oever 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 oot ,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 4uietstan,ing the lor,oses an, %-phoses. "f course posture actuall- means much more

    than this an, is basicall- an- eight bearing static position sitting stan,ing

    ben,ing an, leaning. perhaps lorence en,all has been the mostinfluential in this areaxliiixliv. The i,ea of axial extension here the subject attempts

    to line up as much as possible the vertebrae so has to minimi3e shearing forces

    muscle activit- an, ligamentous stress is the most usual ,efinition of goo, posture.

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    or aggravate, b- that ,eficit. Oust because there is a postural ,-sfunction 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 $cen3ie populari3e, the

    significance of the lateral shift. $cen3ie maintains that about &)5 of lo bac%patients exhibit a lateral shift an, gives a number of reasons for this inclu,ing

    congenital anomal- remote mechanical cause alteration of nucleus position an,

    abnormal joint configurationli. 7t is orth bearing in min, hen figures such as thisare use, that the authorBs caseloa, ma- be entirel- ,ifferent from -ours so ,o not

    get to upset hen -ou fin, -ourself at variance ith such an author. 7f -ou fin, a

    lateral shift is there an element of rotation involve, this is a rotoscoliosis or ,oes

    the spine just reach out laterall- ithout an- obvious rotation. The former ma- ellbe 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, feel the cause is li%el- to be remote. 7fspasm 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 because, b- a ,isc herniation compressing either the ,ural sleeve an,or 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 isrecogni3e, 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 tiste, nec% it ma- be painful or painfree fixe, or correctable.

    The most common torticollis seen b- the orthope,ic therapist is fixe, an, painfulan, re4uires treatment. Painless an, correctable torticollis are often the result ofvisual ,isturbances /,iplopia in particular0 an, hearing problems lii but ma- be

    cause, b- h-steria.

    7nfantile torticollis ma- be cause, b- a number of things inclu,ing ,ifficult labor

    breech ,eliveries caesarian ,eliveries sternomastoi, tumor 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 benigninfantile torticollises are congenitalliii 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 beteen the ages of to an, 1). Chile in some there is anorthope,ic cause in a substantial number the cause ma- be infection ith

    inflammation of the cervical glan,s irritating the sternomastoi, 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- if no ver- obvious biomechanical ,-sfunction is apparent ith

    testing again refer out. ,olescent torticollis is the most common t-pe usuall-

    affecting chil,ren beteen the ages of F91liv. This is a ver- painful con,ition an,

    !1

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    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, it lasts about a ee% an, a halfN

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    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 some even though far remove, from the s-mptomaticregion 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- orrotator- instabilit-. =o ab,ominal anterior creases can onl- be seen if the

    un,erpants are loere, in front. This crease is almost pathognomic ofspon,-lolithesis.

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    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 ,on the arm generall- means that there has been a capsular tear or a majormuscle such as pectoralis major biceps or brachialis is torn in its bell-.

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    /am-oplasia congenita0 resulting in stiff ,eforme, joints.

    Pseu,oh-pertrophic muscular ,-stroph- Progressive muscular ea%ness beteen

    the ages of !9( -ears

    ibroplasia ossificans progressiva Extopic ossification in the trun% an, limbs

    short big toe

    amilial h-pohosphataemia +ongenital rac%its /bone ea%ness0+-stinosis /renal tubular ric%ets0 6arifie, bones ith ,eformit-

    'eurofibromatosis /6ec%linghausenBs

    s-n,rome0

    +af au lait spots cutaneous fibromata an,

    cranial or peripheral nerve palsies

    ;emophilia Prolonge, clotting times lea,ing to

    hemarthrosis an, soft tissue blee,ing

    GaucherBs ,isease +-st li%e appearance of bones ith large

    liver an, spleen

    DonBs s-n,rome $ental an, ph-sical impairment micro or a

    ,ensia

    Central Ner"ous System $run# and

    Spinelippel9eil s-n,rome Short stiff nec% an, lo hair line ,ue to

    fuse, or ,eforme, cervical vertebrae

    SprengelBs ,eformit- @nilateral /usuall-0 tethere, an, highscapular no nec% appearance

    +ervical rib @suall- as-mptomatic but ma- result invascular or neurological thoracic outlet

    s-n,rome

    ;emivertebra @nilateral vertebral ,efect lea,ing to

    scoliosis

    Spina bifi,a /spinal ,-sraphism0 Spina bifi,a occulta menigocele or

    m-elocele ma- be as-mptomatic or causeleg ,eformities an, incontinence ,ue to

    neurological involvement. 7f ma- beassociate, ith h-,rocephalus.

    rnol,9+hiari malformation Elongation of the cerebellum an, me,ullainto the spinal canal ith the potential

    ,evelopment of central neurological signs

    ith nec% extension or manipulation ina,ulthoo,.

    +ongenital intracranial arteriovenous

    fistulae an, hemangioma

    ?ar-ing in si3e the- can occur an-here in

    the cranium. 7f large enough the- ill

    cause pressure signs an, s-mptoms. The-ma- enlarge or rupture causing chil,hoo,

    or a,ult s-mptoms usuall- beteen theages of 1)9!1 but it can be ,ela-e, to &)

    -ears. $a- suffer from pulsatile tinnitus.

    Dissecting aortic aneur-sm Severe interscapular an,or chest an,or

    lumbar pain

    ,im-s

    !&

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    +ongenital amputation Part or all of a limb missing

    Phocomelia plasia of the proximal part of the limb

    ith the ,istal part present

    +onstriction rings =imb or ,igit constriction as if b- a purse

    string it ma- be associate, ith s-n,act-l-

    bsence of ra,ius ;an, ,eviate, laterall- ,ue to lac% ofsupport

    bsence of proximal arm muscles Trape3ius ,eltoi, sternomastoi, an,or

    pectoralis major

    $a,elungBs ,eformit- /,-schon,rosteosis0 @lna hea, ,islocate, from the ra,ius hichis boe,

    S-n,act-l- use, or ebbing of to or more fingers

    Pol-,act-l- $ore than five ,igits

    Extro,act-l- =obster cla han,

    +ongenital ,islocation of the hip 'eonatal ,islocation ith possible flattene,femoral hea, in a,ulthoo,

    +oxa vara Defective femoral nec% ossification ithre,uce, nec% angle

    +ongenital short femur oot small an, everte, an, lateral to

    ,igits together ith their metacarpals ma-be absent

    +lub foot oot inverte, an, plantaflexe, or everte,an, ,orsiflexe,

    +urle, toe =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, treatment the- can also in,icate other more serious

    ,eficits. The folloing tables are ma,e from information from an article that loo%e,at subjects ith %non vertebral malformations for associate, anomalies. 7t as

    more the rule than otherise that the presence of a vertebral malformation asassociate, ith other anomalies usuall- from the same embr-ological bloc%. 7t is

    important because hile the presence of sa- 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 %non vertebral malformations

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    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 #5giving an average of 1.** anomalies per patient.

    nomalies ssociate, ith ?ertebral $alformation /from

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    Dilation of the pupils occurs 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 isgenerall- ,ue to oculomotor paral-sis or paresis. 7n these cases 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, aa- 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 stimulation although still abnormall-

    slol- to near target testing. 7t is often associate, ith s-mmetrical oras-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,itionsother 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 levatorpalpabrae 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 orbitelevation also cause superior e-e li, elevation. The small s-mpatheticall-innervate, $ullerBs muscles are attache, to the inferior an, superior tarsals

    /fibrocartilaginous plates in the e-eli,s0. Chen the muscle contracts 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

    paresisparal-sis is present the ptosis is generall- not capable of correction b-

    effort as the levator palpabrae is the larger of the to muscles. 7f a s-mpatheticparal-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-,riasis loo%ing for these asassociate, signs ill further help ,ifferentiate the source of the ptosis1#.

    rom an orthope,ic perspective ptosis ma- mean a neurovascular compromise. 7fthe thalamus reticular formation or the ,escen,ing s-mpathetic nerve are affecte,

    ;ornerBs s-n,rome results an, the ptosis ill be accompanie, b- miosis facial

    re,,ening anh-,rosis an, Enophthalamos as ell as other neighborhoo, signs.

    Q

    !#

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    "ther possible sites for ,amage that coul, cause ;ornerBs s-n,rome are the thoracic

    outflo the inferior or the superior cervical ganglion or an-here along the

    s-mpathetic chain in the nec%. 7f the !r,nerve is impaire, the ptosis ill beassociate, 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 folloing 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 postganglionicso all patients presenting ith ;ornerBs s-n,rome must be consi,ere, as suffering

    from serious patholog- until proven otherise. 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 seating0 $iosis /constricte, pupil0 acial 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, arter-

    apical lung cancer inva,ing the loer brachial plexus an, ganglion/Pancoast s-n,rome0

    breast cancer inva,ing the loer 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

    !F

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

    '-stagmus1#lxi

    '-stagmus is non9volitional rh-thmic motion of the e-es. '-stagmus sorte, into

    to main t-pes jer% an, non9jer% /an alternative metho, is spontaneous ga3eevo%e, an, ga3e suppresse,0. Oer% n-stagmus 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,ular that is there is no fast component an, generall- an, e4ual,isplacement on each si,e of mi,line. 'on9jer% n-stagmus ma- be congenital 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 cerebellum vestibular s-stem inclu,ing the lab-rinth nuclei neuralprojections 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 to being cause, b- brainstem

    ischemia neurological ,isease an, posterior fossa tumors. Oer% n-stagmus is name,after the ,irection of the fast component an, can be lateral /the most common0

    vertical /upbeat an, ,onbeat0 converging retracting combination of the abovean, seesa here one e-e moves up an, the other ,on. +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 toi,entif- on clinical examination.

    Th e table belo compares n-stagmus of central origin to that of peripheral.

    CEN$A, PEP/EA,

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    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.

    $0PE C/AAC$ES$CS CA1SES1. SP"'T'E"@S not ,epen,ent on ga3e of hea,

    position although ma- be

    orsene, ease, or altere, b-

    ga3e ,irection

    +ongenital spontaneous

    fixation ,epen,ent

    ma- be monocular /latent0

    high fre4uenc- /29( bps0

    ma- be pen,ular

    congenital

    Pen,ular non9jer%

    high fre4uenc-

    congenital

    multiple sclerosis

    retinopathies

    Perio,ic lternating

    /P'0

    perio,icall- changes ,irection

    ith change of hea, or e-eposition

    c-cles

    congenital

    brainstem ischaemia

    /?

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    phen-toin ,ia3epam

    alcohol0 m-asthenia gravis

    multiple sclerosis

    cerebellar atroph-

    s-mmetrical une4ual left9right amplitu,e ma- be combine, ith

    peripheral spontaneous

    n-stagmus ith #th neuromas

    cerebellopontinetumors

    acoustic neuromas

    recover- from ga3e

    paral-sis

    6eboun, changes ,irection ith fatigue or

    resetting of primar- position

    cerebellar ,isease M

    atroph-

    Dissociate, overshoots the ab,ucte, position

    the non9affecte, e-e a,,ucts

    more slol- than the affecte,ab,ucts

    me,ial longitu,inal

    fasciculus lesions

    /,em-elinating,iseases /bilateral0

    ?

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    ma- or ma- not be associate,

    ith vertigo

    Static 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-stagmushas ,isappeare,

    comes on ith slo an, fast

    positioning

    peripheral vestibular

    ,isor,ers /most

    common causes0

    central lesions /non9suppressible ithfixation0

    acial an, E-e s-mmetr-1#lxii

    =oo% at the e-e position. Strabismus /s4uint0 ma- either be paral-tic or non9paral-tic. 'on9paral-tic is a non9neurological con,ition that occurs in chil,hoo,

    an, persists if not correcte, 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 theantagonists 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% tothe ph-sician.

    acial ,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, it isa peripheral pals- such as a

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    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%es 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 therapistthe signs an, s-mptoms ill be transient an, ma- onl- sho up on turning or

    exten,ing the hea,. +onse4uentl- ,-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, substitutions or, omissions an, neologisms /neor,s that ,o not exist0 or the patient ma- tal% aroun, the subject to avoi, a or,

    that cannot be brought to min,. phasia the complete loss of the spo%en or, is

    cause, b- an infarct in

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    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. orthe most part the +-riax examination is base, on anatom- an, patholog-. The

    examination or%s on the principle of isolating the function as much as possible ofa tissue an, ma%ing it perform its action in that isolation. or 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. ;oever it is apparent that some

    stress oul, be present in these non9contracting tissues compression an,

    translation oul, still occur to some extent. s a conse4uence the examiner mustun,erstan, that no single test is capable of generating a ,iagnosis. 6ather it is the

    integration an, anal-sis of all of the ,ata both positive an, negative that allos 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 /capsule ligaments bone bursa fascia ,ura nerve tissue0 +ontractile tissues /muscle ten,on tenoperiosteal junctions near muscle

    bone compresse, bursa0 'eurological tissues /afferent efferent an, inhibitor- functions0 ?ascular tissues /arteries an, veins0

    These are teste, respectivel- ith:

    1. ctive

    2. Passive

    !. 6esiste,. $-otomal ,ermatomal reflexes

    &. 6epeate, or sustaine, contractions

    2. Acti"e %o"ements

    ctive motion testing non9,ifferentiall- tests the contractile an, inert tissues of themusculos%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 folloing:

    6ange of motion

    Pattern of restriction Aualit- of the movement "nset an, t-pe of the s-mptoms

    The patientBs illingness to move

    &

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    T-picall- the movements teste, are the major movements /the car,inal

    movements0 flexion extension rotation ab,uction a,,uction an, si,e flexion. Thecombine, 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, movements the combine,tests usuall- a,, little if an- further information an, become re,un,ant an,

    potentiall- a source of confusion. or example if cervical extension right si,e

    flexion an, right rotation repro,uce pain then 7 can be ver- confi,ent that the rightposterior 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 notin,ispensable. The spinal 4ua,rants are:

    6ight nterior: flexion right si,e flexion right rotation

    =eft nterior: flexion left si,e flexion left rotation6ight Posterior: extension right si,e flexion right rotation

    =eft Posterior: extension left si,e flexion 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 hatis causing the insult. 7f the problem is stenosis on an inflame, spinal nerve then the

    pain shoul, be repro,uce, ith extension an,or 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 aa- from the si,e /contralateralanterior 4ua,rant test0 ma- ell pro,uce the s-mptoms. large herniation oul,

    probabl- cause lancinating pain ith both the contralateral anterior an, theipsilateral 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,erent 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- at least in those joints that have less than three ,egrees of motion. @nlessthe conjunct rotation /see section on biomechanical examination0 is inclu,e, in the

    movement the motion being teste, cannot reach its full range. The 4ua,rant test

    inclu,es that rotation.

    =astl- 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.

    (

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    The active range of motion is normall- a little less than that of the passive range an,

    these to ranges shoul, be compare,. 7s there severe mo,erate mil, or no

    restriction The last shoul, be assesse, ver- criticall- as hat is often ta%en for fullrange is slightl- limite, or slightl- increase,. 7n a,,ition in the spine in particular

    remember that -ou are assessing multiple joints an, if one is h-pomobile 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-permobilit-

    an,or instabilit- can also fool -ou. The motion ma- automaticall- stop before the

    affecte, tissues become s-mptomatic again giving an impression of full range ratherthan excessive range. 7f the range is restricte, hat is the pattern of the restriction

    is it capsular or non9capsular

    6ecentl- +-riaxBs capsular patterns have been calle, to 4uestion 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

    ala-s use ever- motion available at a given joint the shoul,er is a prime exampleof 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 flexion ab,uction

    an, me,ial rotation relativel- slight limitation of extension an, minimal if an- loss

    of lateral rotation an, a,,uction. ;oever if -ou fix the ischium rather than theilium 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- case 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 to ormovements that are not couple, to pro,uce combine, movements to be restricte,an, or painful. or example in the rist flexion an, extension shoul, be affecte,

    rather than just extension an, ra,ial ,eviation as these movements couple

    ph-siologicall-. lternativel- flexion an, ra,ial ,eviation ma- in,icate a capsularpattern 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 is it seems li%el-

    that e can %no hat a non9capsular pattern shoul, loo% li%e. Chen onl- on

    motion is restricte, it is safe to sa- that this cannot be ,ue to a lesion affecting theentire joint as a capsular pattern must. 7f onl- to movements that are functionall-

    couple, that is normal functional ph-siological movements emplo-s these

    movements the restriction is probabl- non9capsular. 7f the movement toar,s theclose 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

    *

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    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, ma-

    be 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%s 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 lumbarspine hen after trun% flexion 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 hatevercauses. This fin,ing ,eman,s a fairl- ,etaile, neurological examination of the

    patient inclu,ing cranial nerve an, cerebellar tests. Chen atching spinal

    movements the trun% ma- appear to more fairl- normall- but ,oes the spine> loo%

    for segmental motion as ell as trun% motion.

    7n some cases active movement ill not repro,uce s-mptoms. The patient ma-have learne, hen to stop the movement before the pain starts or 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 ,orepro,uce s-mptoms hat are the- hen ,o the- start in the range an, ,o the- get

    orse as the patient pushes further into the range The repro,uction of lancinating

    pain or paresthesia ith active movement in,icates that a neurological tissue is

    being compresse, tractione, or irritate, in some other a-. Generall- if this isalloe, to continue 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 thepatient repro,uces this pain the better.

    7s there a painful arc in the range 7f this occurs ith trun% flexion a small ,iscprotrusion 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 tensionprovocation tests

    #

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    7nert tissues are those that ,o not have an inherent abilit- to contract or transmit

    bloo, or neurological impulses an, inclu,e the joint surfaces bone joint capsule

    ligament bursa an, ,ura. 7nert tissues are teste, ith full range passive movements.These movements inclu,e ph-siological movements ligament stress tests ,ural

    mobilit- tests /straight leg raise prone %nee flexion or femoral nerve stretch

    scapular retraction0 spinal compression an, traction vertebral postero9anteriorpressures. "f course passive movements ill also appl- stress to non9inert tissues

    such as the muscle9ten,on unit bloo, vessels nerves spinal cor, an, even to a

    small extent the me,ulla. 7n fact this attribute is sometimes exploite, hen testingsome of these structures. ?ertebral arter- testing is base, on active or passive

    positioning of the nec% an, upper limb tension testing hich among other things

    tests the mobilit- an, tension tolerance of those tissues comprising the brachial

    plexus an, its continuations into the arm an, han,.

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    prevent -ou from measuring the ,ifference. 7n orthope,ic manual therap- the range

    of motion loss is usuall- ver- small fre4uentl- less than five ,egrees. 7f the spine is

    being assesse, biomechanicall- then e are loo%ing at segmental ranges of motionthat 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 thisbut 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 stiff jamme, reactive s4uish- ,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 folloing is a list of en, feels mo,ifie, from +-riax together ith their majori,entif-ing characteristics an, a normal example of each.

    End 'eel Characteristics Normal Example

    +apsular Stretchable to a variable extent Crist flexion /soft0Crist extension /me,ium0

    nee extension /har,0

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    The folloing table lists the en, feels an, their implications both normal an,

    abnormal.

    End 'eel Possi-le mplication

    'ormal +apsular 'ormal range of motion

    ;ar, +apsular /stiff0 Pericapsular tissue h-pomobilit- ,ue to arthrosis a,hesions orscarring. 6e4uires some t-pe of stretching usuall- joint

    mobili3ations

    Soft +apsular /loose0 'on9irritable h-permobilit- or instabilit-. 6e4uires mechanical

    stress re,uction ith rest an,or mobili3ation techni4ues an,or

    orthoses

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    that is met on passivel- moving a joint is muscle an, if this is not stretche,

    sufficientl- the un,erl-ing en, feel cannot be appreciate,. 7n or,er to obtain the

    en, feel of the ultimate rather than the initial restrictor in joints ith minimalmovement loss the force applie, has to be sufficient to stretch the muscle enough to

    reach the restrictor. Cith more ,ramatic range loss this is not a problem because

    the range ,oes not reach the point here muscle is capable of acting as a passivebarrier. +onse4uentl- spasm severe arthrosis subluxation 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 ala-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. ;oever almost all relevant en, feels ill be experience, in thepainful range. The empt- en, feel can onl- be felt in the painful range an, earl-

    spasm invariabl- ,oes so. +onse4uentl- if the en, feel is not sought in the painful

    range there is no point in ,oing an- passive movements to the patient as no

    relevant information ill be forthcoming.

    7n a,,ition to evaluating the restrictor of the movement the acuteness of thecon,ition can be assesse,.

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    7n a,,ition to the en, feel being assesse, 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, thepattern of restriction.

    The passive range of motion shoul, also be compare, to the active range. 'ormall-the passive range is a little greater than the active. 7f it is greatl- increase, the

    possibilities are that the patient is:

    a. "ver anxious

    b. mplif-ing

    c. abricating

    7f the movement at a joint is restricte, assess the pattern of restriction. This can be

    more easil- ,one ith passive movements than ith active as the patientBs anxiet-

    or gain issues are minimi3e,. 7s the restriction capsular or non9capsular 7n the light

    of some of the concerns regar,ing the vali,it- of capsular patterns care shoul, beta%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 activemovements0.

    ;oever for those of -ou ho oul, be more comfortable ith establishe,patterns /an, onl- the %nee has been ,emonstrate, experimentall- to be suspect0 the

    folloing lists the capsular patterns as ,escribe, b- +-riax.

    egion or 5oint Capsular Pattern of estriction

    'ec% Si,e flexion an, rotation are e4uall-

    limite, bilaterall- flexion is full or nearfull an, extension limite,.

    Sternoclavicular Pain at the extremes of shoul,er range

    cromioclavicular Pain at the extremes of shoul,er range

    Glenohumeral =ateral rotation most limite, ab,uction

    next limite, an, me,ial rotation least

    limite,

    Elbo $ore limitation of flexion than extension

    ith pronation an, supination onl- beingaffecte, in more severe arthritis

    7nferior ra,io9ulnar ull ranges ith pains at extremes

    1st

    carpometacarpal =imitation of extension an, ab,uction fullflexion

    7nterphalangeal lexion more than extension

    Thoracic lmost impossible to ,etermine except ingross arthritis.

    =umbar lmost impossible to ,etermine except ingross arthritis.

    Sacroiliac Pain hen stress falls on the joint

    &!

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    S-mph-sis pubis an, sacrococc-geal Pain hen stress falls on the joint

    ;ip Gross limitation of flexion ab,uction an,

    me,ial rotation slight limitation of

    extension an, minimal or no limitation ofa,,uction an, lateral rotation

    nee Gross limitation of %nee flexion slightlimitation of extension ith rotation

    remaining unaffecte, except in gross

    arthritis

    Superior Tibiofibular Pain hen biceps contraction stresses the

    upper joint.

    7nferior Tibiofibular Pain hen mortise is stresse,

    n%le Plantaflexion more than ,orsiflexion if themuscles are of normal length

    Talocalcaneal =imitation of varus /inversion0 until ingross arthritis it fixes in valgus

    $i,9tarsal =imitation of ,orsiflexion plantaflexiona,,uction an, me,ial rotation ith

    ab,uction an, lateral rotation full range

    1stmetatarsophalangeal Gross limitation of extension an, slightlimitation of flexion

    "ther metatarsophalangeals ?ariable the- usuall- ten, to fix inextension ith the interphalangeal joints

    flexe, /cla toes0

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    ma,e to tolerate. nother factor to consi,er is hether the instabilit- is clinical or

    functional. That is ,oes it interfere ith the patientBs function or is it simpl- a

    clinical fin,ing The implications for treatment are ,ifferent for each. Determininghich can be ,ifficult. The folloing 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-

    ;-permobilit- 6ecurrent subluxations =oc%ing

    Giving a-

    The initiation of stabilit- therap- is in part ,epen,ent on fin,ing the instabilit- butmore importantl- having one or more of the above characteristics present.

    7nstabilit- is not ala-s ,etectable clinicall-.

    =igament stress tests are carrie, out b- fixing one bone to hich the ligament is

    attache, an, moving the other bone aa- from it such that the connecting ligamentis stretche, maximall-. "bviousl- in or,er to avoi, ,oing further ,amage 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