I have a new website!!

 

http://physiocharlie.vpweb.co.uk

 

 

 

 

SI jt Ax:

http://www.youtube.com/watch?v=Eu9JaM9S0Ak&feature=PlayList&p=4C3ECA6E484A19AF&playnext=1&index=1

http://www.youtube.com/watch?v=ifO9SgdEfgk

http://www.youtube.com/watch?v=sPgVu2NjVHE&feature=related

I found this on youtube about SI manip; "Chicago"

http://www.youtube.com/watch?v=y9-dRk91AXI&NR=1

Also: Taping for anterior innominate

http://www.youtube.com/watch?v=QPppVRgdORE&feature=related

Piriformis release:

http://www.youtube.com/watch?v=UFXWrYoS9ho&NR=1

http://www.youtube.com/watch?v=uuozn0i-De8

Flouroscopically guided SI injections:

http://emedicine.medscape.com/article/96054-media

 

 

 

 

 

 

My colleague has sent this to us for this weeks IST on special questions and Red flags:

Rheumatoid Arthritis

 

Disease characterized by inflammation of the synovium of joints. RA Progresses in 3 stages:

 

1. Swelling of the synovial lining causing pain, warmth stiffness and redness and swelling around the joint

    

2. Thickening of the synovium(pannus formation)

    

3. Inflamed cells release enzymes that may digest bone and cartilage. Loss of shape and alignment of joint

Symptoms include:

 

Generally occurs in a symmetrical pattern

 

Often affecting wrist and finger joints closest to hands

 

Fatigue

 

Morning stiffness

 

Weakness

 

Flu like symptoms even a low grade fever

 

Rheumatoid nodules or lumps of tissue under the skin, typically on the elbows

 

Muscle pain

 

Loss of appetite, depression, weight loss, anemia, cold/sweaty hands/feet

 

Decreased production of tears and saliva.

 

Inflammation of the blood vessels, lining of the lungs and the pericardium

 

• RA is a systemic disease

   

• Might not be one disease, but various that share common symptoms

   

 

 

 

This is an IST done by one of my colleagues re:

Cauda Equina Sydrome

Anatomy

Spinal column ends at L1 so after this the lumbar and sacral regions contain only nerve roots, which descend down to the relevant intervertebral foramen causing it to look like a horse’s tail!

NB nerve exits below the vertebrae that it is named after eg L4 exits between L4/L5. Discs named after 2 vertebrae either side of them

Nerves for bladder and bowel are called the pelvis splanchic nerves and they exit the spinal column at S 2,3 and 4.

Aetiology

Most common cause is a large disc prolapse (most common at L4/5, L5/S1 – maybe contained or a fragment

Trauma – including chiropractic manipulation!

Tumour

Degenerative stenosis

Compression at the conus – found at the bottom of the spinal cord L1 so can cause mixed picture of compression of nerve roots and spinal column

Surgery – usually due to the nerve roots being pulled during discectotomy resulting in traction on the conus – loss of function of legs and B&B.

Age

Any age but as disc prolapse is biggest cause it is more likely to be late 20’s to 40’s

Symptoms

1.Before B&B occurs sensory disturbance around the genitalia and anus occur (Saddle anaesthesia or hypoanaesthesia). May feel odd when they sit on toilet – subjective symptoms come before objective signs. Usually unilateral but will become bilateral. Sometimes as sensory disturbance becomes estabilished patients describe their leg pain decreasing but the feeling in their legs becoming abnormal – legs like jelly.

2.B&B symptoms – loss of function of sphincters.

·        Bladder – start with difficulty initiating urination and a lack of full feeling whilst passing urine, then the patient is unable to pass urine and can become incontinent as the appreciation of passing urine is lost

·        Bowel – patients normally complain of bladder problems rather than bowel problems initially but you are looking for faecal incontinence as the anal sphincter loses tone.

3.Low back pain

4.Sciatica – bilateral is more significant

5.Absent knee, ankle or bulbocavernous (a muscle that covers the bulb of the penis in the male or the bulbus vestibuli in the female) reflexes

6.Sexual dysfunction

Confusing Aspects

Some sciatic patients complain of difficulty urinating  - remember that there are other reasons for this:

Severe pain – this can inhibit the bladder functioning or disrupt normal function

Opiate analgesics  - strong painkillers (eg opiates such as morphine-type drugs) can affect the function of the bladder sphincters

Other genitourinary pathologies – large uterine fibroid pressing on the bladder, UTI.

Anxiety

The important thing to remember is that the above symptoms will be temporary or intermittent, be without saddle anaesthesia or in isolation.

Can also have unilateral sciatica but then start to develop B&B symptoms – can be due to an L5/S1 disc prolapse, a lateral but large disc prolapse or a ruptured free fragment which migrates downwards and causes compression just below the L5/S1 disc level – sparing S1.

Overall Evolution

Can be a few days to months depending on cause – eg disc Vs tumour or degenerative changes.

Increasing pain → involvement of the other leg → numbness in both legs → saddle area sensory impairment progressing to objective evidence on examination of sensory impairment → sphincter disturbance (difficulty starting to pass urine, abnormal sensation whilst passing urine progressing to decreasing sensation or appreciation of passing urine until the patient is incontinent.

Treatment

Decompression ASAP!! Done for preservation of B&B

One paper states that neurologically speaking what is lost is lost – if they present with diminished perineal sensation and sciatica they will regain B&B but may have some symptoms in the leg. If they have diminished sensation and difficulty passing urine but are still able to pass it – they will have an intact B&B but it may not “feel right” when they go to the toilet.

Another paper stated that recovery can be realised but depends on many factors:

• Time – a delay of 24 hours or more is linked to a poor outcome (but then it is difficult to pinpoint when the symptoms actually started)
• Severity of sphincter dysfunction is an independent predictor of outcome.
• Complete perineal anaesthesia
• Bilateral sciatica at presentation
• Sudden onset of CES
• No correlation with presence or absence of reflexes, motor dysfunction or level of injury.

The red flags are as follows:

Clinical Standards Advisory Group (1994). Back Pain: Report of a Clinical Standards Advisory Group on Back Pain, HMSO.

■ Age of onset up to 20 or over 55 years.

■ Violent trauma (fall from height, road traffic accident).

■ Constant progressive non-mechanical pain.

■ Thoracic pain.

■ Past medical history of carcinoma.

■ Systemic steroids.

■ Drug abuse, HIV.

■ Systemically unwell.

■ Weight loss.

■ Persistent severe restriction of lumbar flexion.

■ Widespread neurology.

■ Structural deformity.

However, the more recent New Zealand Low Back Pain guidelines list of Red Flags includes patients with spinal problems whose pain gets worse when they lie down.

http://www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm...

 

I found this recently from an IST we did a while ago, we are recapping on this in the meeting this week.  My colleague prepared this:

 

Why we ask our PMH questions

 

Heart Problems

• Is it under control? Under investigation? Any surgery performed?
• Is it a new or old problem? Is the onset related to the onset of the PC? NB shoulder pain may well be referred from the heart.
• Is it symptomatic? – NB beware or syncope (passing out)
• Also include circulatory problems in this question as this is important when investigating peripheral pain
• NB no ice on people with lots of swelling and heart problems as this will overload the heart

 

Blood Pressure

• If it is high is it under control with medication? If not beware of dizziness, sweating etc
• If it is low has the cause been investigated? Is it linked to low iron? Care with going from lying to sitting.
• Increased BP is a risk factor for VBI
• Do not use ice with people with increased BP as this will cause vasoconstriction and therefore increase the blood pressure further.
• Care with NSAIDS

 

Asthma

• Is it controlled? If so with what? Has the patient brought their inhaler with them? – know where it is yourself and watch for warning signs of an attack.
• Has the asthma been treated with oral steroids in he past? How long was the course and how often? Was the patient given supplementary calcium at the same time as this is a risk factor for osteoporosis
• Care with recommending aspirin or NSAIDS

 

Epilepsy

• Is it controlled? How many fits a year/month? When was the last one?
• Was the onset of PC linked to a fit? NB patients tend to posture – internal rotation of the arms- during a fit and probably wont be able to tell you how they fell so the method of injury will be unclear
• NB are fits set off by pain – if so take care and precautions during the ax.

 

Diabetes

• Is it controlled? With what? Blood sugar levels should be between 4-8
• If patient injects, where is the injection site? Tissue in this area will be scarred, lumpy and tender.
• If blood sugars are low patient may be vague, start mixing words or not be able to form words then will probably pass out so watch for warning signs!
• Keep in mind – diabetic neuropathy and the fact that the patient may have poor sensation so care with ice and electrotherapy.

 

Osteoarthritis/Rheumatoid arthritis

• In the family or has the patient tested +ve – RA – blood test for rheumatoid factor but this can often be –ve even if the patient has RA. OA diagnosed by xray.
• OA – is this causingthe PC – if the patient has already been diagnosed with OA in multiple joints you should suspect that the PC joint is affected too
• RA – normal care should be taken with this inflammatory disorder – for eg care during flare-ups (think carefully before using passive treatments) and take advantage of calmer times when inflammation is at bay
• NB care with C0/C1 ligaments – NO cervical mobilisations

 

Osteoporosis

• How was it diagnosed? (normally by blood test and bone density scan) But not many people have been tested so be wary of people with more than one risk factor;
  •  
    • Early menopause or total hysterectomy with no HRT
    • Long courses of steroids without supplementary calcium
    • Dieting or diet lacking in vitamin D and calcium
    • Excessive smoking
    • Excessive drinking
    • Amenorrhoea
    • Family history of OP
    • Illegal drug use
    • Over exercising esp in teenage years- NB gymnasts

 

Any concerns and you must take care with mobilisations and remember that OP can explain generalised pain.

 

Thyroid

• Can cause generalised body pain – see handout!

 

Menopause

• Are there hormonal changes occurring at present or linked with the onset of the PC? Recent changes in HRT should be included in this.
• Check age of menopause – NB osteoprosis risk

 

Major accidents, Surgeries and Illnesses

• Too broad to discuss but you are looking for anything that will make you take care during treatment or that could have effected the PC!