clinical patterns: conditions, pathologies, syndromes and presentations · clinician looks at your...

Clinical Patterns: Conditions, pathologies, syndromes and presentations

BSc(Hons) Physiotherapy BSc(Hons) Sports Therapy and rehabilitation

Name:……………………………………………………………………….

University of the West of England, Bristol. School of Allied Health Professions

Condition Staff sig/date Enter the name of the condition/pathology that you have completed in this book.

From time-to-time staff will ask you to present a condition/pathology that you have studied and made notes about.

When a member of staff or clinician looks at your book they will sign alongside the last entry in the list alongside this box.

The book is for use in all modules in levels1, 2 and 3. The Patterns may form the basis for work and reflection in seminars and practicals at levels 2 and 3.

Make good use of this book and keep up to date.On clinical placement continue to complete the book as you encounter conditions and pathologies.

More formatted sheets can be obtained from module online sites ie DCRP and RSP.

ConditionCERVICO-GENIC HEADACHES

Definition / DescriptionHeadache due to a disorder of the neck associated with movement abnormality in the intervertebral segments. It may arise from the joints and surrounding soft tissues. The movement abnormality is manifested during either active or passive examination of the movement. (Bogduk et al 1995) NB: Differential diagnosis between other factors which cause headaches is vital.

Populations / Risk FactorsHypo-mobility lesions of the upper cervical spine Cervical spondylosis Post whiplash Symptoms - (Distribution, description, daily pattern, etc)

Hypo-mobility of the upper Cx Spine - unilateral pain in the occiput radiating to one side of the head, eyes and face. Distribution fairly constant. Dull, aching or soreness. Worse in am, raising head from supine. Agg by activity, jolting, cough / sneeze, sustained postures e.g. reversing car

Clinical Signs - (Reliable measures)Movements of the upper cervical joints (contra or ipsilateral) will reproduce pain. Most likely on PPIVM and PAIVM.

HistoryPresence of risk factors. Gradual onset. Frequently preceded by neck pain or stiffness New glasses / bi-focals or vari-focals

Investigations - (Radiology, haematoloty etc)

X-Ray usually NAD, unless spondylitic or arthritic changes present. Atypical Presentations

Vertigo, nausea, depression, feeling generally unwell. All make differential diagnosis difficult.

Management Options and Levels of Evidence

Useful Resources

ConditionWHIPLASH, Whiplash Associated Disorders (WAD)

Cervical Acceleration / Deceleration Injuries (CAD) Definition / DescriptionUmbrella term for wide range of disorders of varying severity. Frequently associated with collisions (often RTAs), where the cervical spine is involved in high velocity hyperextension &/or hyperflexion movements. Damage can occur to bony, ligamentous, muscular, vascular and nervous tissue and probably results from rapid unguarded stretching and compression forces, which elongate tissue beyond its normal limits. Quebec classification = 0 - 4. Populations / Risk FactorsCar Drivers, passengers. Injury mechanism influences structures which are damaged e.g. direction of collision force, position of head, anticipation of impact, restraints. Anticipation of impact, properly fitted headrest can reduce degree of damage. Underlying pathology may affect recovery. Symptoms - (Distribution, description, daily pattern, etc)Miriad of symptoms depending on structures damaged, and emotional and psychological impact of the accident. Acute phaseCan be localised to neck, but frequently pain, stiffness and tenderness are felt in lumbar spine, with radicular symptoms radiating into one or both arms. Headaches, hoarseness, difficulty swallowing or speaking. TMJ pain. Vertebral artery damage may result in symptoms affecting the eye and ear. (vertigo) Late or Chronic Whiplash SyndromeMay exhibit pain, stiffness, loss of function as above. Pain may be due to central sensitisation of CNS. Clinical Signs - (Reliable measures)Variable presentation depending on extent of injury and early management AROM reduced. Functional activity reduced. Difficulty finding comfortable positions Fear of movement, ADL Muscle weakness - neck, shoulder girdle, upper limbs Joint tenderness - neck, thoracic and lumbar spines, shoulders Neurology +ve Positive neurodynamic signs. TAKE CARE+++. HistoryCollision in RTA Sporting injuries, e.g. contact sports, gymnastics Investigations - (Radiology, haematoloty etc)X-Ray will detect bony damage. Should be carried out if RTA sever. Atypical PresentationsAll presentations will be different and individual Popping in the ear has been described as spasm in Sterno-cleido- mastoid. (Travell and Symons)


Useful Resources

ConditionOsteopenia /Osteoporosis

Definition / Description

Populations / Risk Factors

Symptoms - (Distribution, description, daily pattern, etc)

Clinical Signs - Reliable measures


Atypical Presentations


Useful Resources

Condition Intervertebral Disc Herniation Disc Prolapse (Occurs at L4/L5 or L5/S1 in 95% cases) Disc Sequestration Definition / Description

Escape of the nuclear material from the confines of the annulus in an anterior, posterior, postero-lateral or inferior direction. Sequestration occurs when the nuclear material separates from the rest of the disc and is sequestered into the spinal canal. Populations / Risk Factors

20 - 50 years, peak = 40 years Not common <16 years or >50years (consider other diagnoses) Affects men and women Presentation

will depend on inter-relationship between the size and direction of prolapse, the features of the spinal canal and neural elements


Pain in low back, sudden onset, severe (deep, dull, knife-like) Central, unilateral radiation to buttock May worsen and radiate into dermatomal distribution if nerve root affected Paraesthesia, hyperalgesia and muscle weakness if nerve root affected May be intermittent but become more frequent Worse, sitting, straining, cough & sneeze, movements that stress disc Better - lying, moving around Night - variable, turning may be painful. AM - No pain waking, worse on WB Disappearance of back pain as leg pain appears may indicate sequestered disc Clinical Signs - (Reliable measures)

Posture - Loss of lumbar lordosis, difficulty standing fully upright, lateral shift / scoliosis (contra-lateral in 85% cases). Difficulty FWB on painful leg, stands with hip and knee in flexion, antalgic gait Palpation - Paravertebral muscle spasm. AROM - Painful and limited - Flexion worse +/- pain and spasm, +/- deviation. Limitation of Extension - may be blocked rather than painful Lateral flexion may be limited to painful side PPIVMs limited due to pain and muscle spasm Neurological - Reduced sensation, muscle power and reflex response in relation to a single nerve root Neurodynamic - Reduced SLR. All tests may be positive - TAKE CARE ++

History - HPC / PMH

May have history of low grade lumbar ache after specific activity. Onset of pain frequently related to a minor incident or familiar activity such as bending or lifting. May describe a tearing sensation or say "I was stuck", "it just locked" etc. May describe episodic pain. Investigations - (Radiology, haematoloty etc)

X-Ray not indicated. May show postural deviation and in some cases loss of disc height. MRI scanning not freely available, can detect direction, level and extent of prolapse - used when surgery is indicated i.e. in the presence of severe or worsening neurolog signs. Atypical Presentations

Many variations in presentation can occur, but usually involves the absence of one or more of the above symptoms or clinical signs. Prognosis

High chance of recovery in 90% Nerve root irritation will take 6 - 8 weeks to settle in most cases Spontaneous absorbtion of disc material can occur Reoccurrence may occur, but less likely if rehab is complete and patient returns to full functional activity and has good understanding of condition Chronic pain and illness behaviour may result if not managed well by patient or health care professionals. Management Options and Levels of EvidenceINITIALLY Pain relief, drugs, electro-physical modalities Maximum 2 days bed rest, early activity is encouraged Advice and education as to best management approach

Management Options and Levels of Evidence (cont'd)

Useful Resources

ConditionSpondylosis








Useful Resources

ConditionSpondylolysis and Spondylolythesis


Spondyloslysis is a fracture of the pars interarticularis of the lumbar spine without forward displacement of one vertebra on another. Described as a stress fracture which occurs due to a hereditary disposition. Most common at L5. Can be bilateral. More common in males than females. Black races have the lowest incidence, inuits the highest Spondylolythesis is the forward displacement of a vertebral body on its lower neighbour, classified in relation to the degree of slippage. Most common at L4/5 and L5/S1. Can be spondylitic, dysplastic or degenerative. Rarely traumatic. Populations / Risk Factors

S'lysis = most common overuse sporting injury of lower back. Occurs contralaterally e.g. right arm fast bowlers sustain # of the L pars interarticularis. Can occur in children and adolescents. S'lysthesis = occurs secondary to bilateral spondylolysis in adolescent males. Secondary to OA in people over 50 years, not common in under 50s. Thought to be more prevalent in black women or people with exaggerated lumbar lordoses. Symptoms - (Distribution, description, daily pattern, etc)

Clinical Signs - (Reliable measures)

Investigations - Radiology, haematoloty etc


Prognosis


Useful Resources

ConditionAnkylosing Spondylitis








Useful Resources

ConditionThoracic Outlet Syndrome


Neurovascular Impingement Syndrome at various points where the brachial plexus and subclavian artery exit the spine and pass to the arm, via the thoracic outlet. Iimpingement may occur due to presence of cervical rib or fibrous band, due to over-activity in muscle interfaces such as Pec Minor, Scalenes, Lat Dorsi + Pec Major etc Populations / Risk Factors

Not known. Possibly more likely with repetitive tasks. Presence of congenital abnormalities e.g. cervical rib does not predispose to this syndrome - most people are asymptomatic. Probably combination of biomechanical (posture, obesity, excessive mm activity) and ergonomic (protracted and medially rotated postures) factors. Symptoms - (Distribution, description, daily pattern, etc)





Useful Resources

ConditionT4 Syndrome


Diffuse collection of symptoms in the arm - pain, paraesthesia, numbness in a non-dermatomal distribution. Associated with a hypomobility syndrome at T3 and T4. Debate as to whether condition exists. Populations / Risk Factors

Not known Probably multifactoral - biomechanical + ergonmic Symptoms - (Distribution, description, daily pattern, etc)

Diffuse pain, paraesthesia, numbness in one or both arms. Non dermatomal distribution Variable daily pattern Clinical Signs - Reliable measures

Hard to find reliable, repeatable signs Stiffness at T3 and T4 on PAIVM and PPIVM Tenderness may also be apparent May have neurological signs once condition advanced Diagnosis difficult. History - HPC & PMH

Gradual onset of symptoms over period of time. May have noticed "tiredness" or aching in Thoracic spine after sustained activity. Investigations of cervical and thoracic spine often normal. Neuro often normal. May have had different opinions offered from different practitioners Investigations - Radiology, haematoloty etc

Nil Atypical Presentations

All presentations may be different. PrognosisMay well take considerable time to improve. Likely that sub-clinical state existed for some time prior to symptoms becoming apparent and likely that sydrome will have become chronic prior to patient presenting for treatment


Check beliefs and understanding of condition Restore optimal biomechanics and assess ergonomics of workplace and ADL

Useful Resources

ConditionDiffuse Idiopathic Skeletal Hyperostosis (DISH)







Prognosis


Useful Resources

ConditionCAUDA EQUINA SYNDROME



Symptoms - Distribution, description, daily pattern, etc





Useful Resources

ConditionSPINAL STENOSIS



Symptoms - Distribution, description, daily pattern, etc





Useful Resources

ConditionHYPERMOBILITY/INSTABILITY OF S/I JOINT


Increased motion of the sacro-iliac joint. (Diane Lee 1999)


Repeated micro-trauma as a result of sporting incidents. Major trauma, leading to ligamentous strain around the joint resulting in reduced form closure, or muscular inhibition due to pain, leading to reduced force closure. Secondary to hormonal changes e.g. those associated with pregnancy. Symptoms - (Distribution, description, daily pattern, etc)

Unilateral S/I pain +/- pubic symphasis pain, +/- pain radiating into buttock, post-medial thigh, abdomen and groin. Agg: unilateral weight bearing, forward flexion, lifting, supine lying, rolling over, fast walking, prolonged activity. Eased: rest, so long as comfortable posture can be found. Clinical Signs - (Reliable measures)

With peri-articular damage, the joint may appear to be hypo-mobile due to excessive muscle spasm. The joint maybe fixed at the end of / or beyond its normal physiological range. Mobility and stability tests are blocked. Gait - exaggerated displacement of the centre of gravity - the patient attempts to compensate by reducing the shear forces at the joint (compensated Trendelenberg sign). Can also demonstrate a true Trendelenberg. Posture - unloading Sijoint. Functional Tests - Asymmetrical mobility tests - if not blocked, manual stability will immediately improve function. Mobility/Stability Tests - Asymmetric end feel and motion. Blocked (hard end feel) or soft/elastic end feel if not compressed. Pain responses highly variable and maybe inconsistent. Muscle Tests - Weak gluts ipsilaterally. Poor inner unit function. Neuro - L5 and S1 nerve roots can be affected. History

Onset often sudden e.g. an unexpected vertical load through weight-bearing limb or ischium or a load applied to the trunk in a flexed/rotated posture.


Nil



The compression of the joint must be treated first to regain the normal position and then the hypermobility will become evident and can be treated. Aim to improve form closure by……….

Patients that do not respond to conservative treatment may be offered a sclerosing injection to increase form closure.

Useful Resources

Diane Lee (1999) The pelvic girdle - an approach to the examination and treatment of the lumbo-pelvic-hip region. Churchill Livingstone.

Condition




Clinical Signs - (Reliable measures)

History




Useful Resources

clinical patterns: conditions, pathologies, syndromes and presentations · clinician looks at your...

Documents