Vestibular Disorders Host: Jimmy McKay, PT, DPT Featured Guest; Alicia Flach, PT, DPT, NCS Notes by Alexis Lancaster Vestibular Disorders   What is it? Disruption that can occur from vestibular apparatus (inner ear) through the cranial nerve to the CNS where the information is processed Any disruption along this path will cause a vestibular disorder   Anatomy Peripheral vestibular system BPPV: problems within the vestibular apparatus, specifically semicircular canal Creates sensation of moving, pt feels dizzy Problem with cranial nerve 8 (before synapse in brain stem) Problem here= peripheral problem Central vestibular system After cranial nerve 8 synapses in brainstem Travels different pathways to locations within the brain Problem here= central problem   Differential diagnosis Dizziness can be due to different things Vertigo: room spinning, could be peripheral or central vestibular problem Feeling of imbalance or disequilibrium, pt doesnt feel steady on their feet. Could be peripheral or central vestibular problem Unrelated to vestibular system Polypharmacy Orthostatic hypotension (pt complains of feeling light-headed, passing out, fainting) Low blood sugar (hypoglycemia) Migraines Get to the root of how the patient describes their dizziness   Special Tests Subjective interview: try to understand when it happens, how long it has been going on, how long it lasts when it happens, does it come and go or is it constant, is it related to positional changes? Rule out/in peripheral condition, BPPV: Dix Hallpike, head thrust test, dynamic visual acuity test Look for central signs throughout exam Hypermetria with saccades Abnormal changes in the ability to perform Vestibulo-occular reflex cancellation: being able to follow a moving object with your eyes and head moving in the same direction Rule in the vestibular system overall, rule in/out peripheral vs. central   Treatment Common encounter: BPPV Managed through canalith repositioning maneuvers (otoconia getting stuck in canal): Epley and BBQ Roll Dysfunction of peripheral nerve/hypofunction Gaze stabilization Tx Movement sensitivity/central component Habituation Exercise Graded exposure   Sample Question A physical therapist evaluates a patient who reports dizziness when getting out of bed. The physical therapist suspects the pt is experiencing symptoms related to BPPV. Which of the following would be the most appropriate assessment to confirm the presence of BPPV Head thrust test Dynamic visual acuity testing Dix Hallpike maneuver Clock drawing test   Answer: C. Dix Hallpike: it is an assessment in which an individual is moved into a position and is intended to elicit a response from the presence of otoconia in the semicircular canal. Position the patient and look for the presence of nystagmus to rule in BPPV.   Why the others are wrong: A: Head thrust test looks at the ability of a patient to perform VOR (vestibulo-ocular reflex)--> specifically looks for hypofunction B: Dynamic visual acuity testing tests for peripheral hypofunction. Perform eye chart and look at visual acuity in static position and then pt will move head side to side to see visual acuity dynamically. D: Clock drawing test identifies the presence of unilateral neglect

Episode 20: Cauda Equina Syndrome Host Jimmy McKay Featured guest Bridget Ripa Notes Alexis Lancaster Cauda equina: “horse’s tail”   What is it? Injury to lumbar and sacral spinal nerve roots within the canal   Presentation Variable lower extremity paralysis Sensory loss Bowel and bladder dysfunction   Causes Trauma, pelvic crush (MVA), child birth could precede it   Differential diagnosis Other spinal cord syndromes Transverse myelitis MS Spinal infarct Spinal tumor   Special tests CT, MRI Clinical presentation & mechanism of injury   Treatment Make sure they are managed medically first Bowel/bladder program Motor learning Task-specific training ICF model Weight-bearing Neuromuscular re-education Tone management FES Aerobic training Positioning Bracing/splinting Locomotion if applicable Keeping an eye on shoulder pain Allow compensation in this population when they need to How will it look on the test? Mechanism of injury and clinical presentation Bowel and bladder dysfunction will be present with cauda equina!

Episode 19: Central Cord Syndrome Host Jimmy McKay Featured guest Bridget Ripa Notes Alexis Lancaster What is it? Damage to the central portion of the spinal cord   How does it happen? Hyperextension of the cervical spine is the typical cause Inflammation or pressure on the cord centrally   Anatomy/Presentation Tricky Damages spinothalamic, corticospinal, and dorsal columns Upper extremities weaker than lower extremities Greater motor deficits than sensory deficits The sensation of the sacral region is present   Differential diagnosis The other spinal cord syndromes Rely on clinical presentation Imaging (CT/MRI)   Special tests CT/MRI Clinical presentations (UE deficits>LE)   Treatment Medically stable first Bowel/bladder program Motor learning Task-specific training Weight-bearing Neuromuscular re-education Strengthening Tone management FES Aerobic training Positioning Bracing/splinting Locomotion if applicable LE stronger than UE! So you will probably be walking Keeping an eye on shoulder pain Allow compensation in this population   How it will look on the NPTE Upper involved more than lower (hallmark sign) Mechanism of injury→ hyperextension injury

Episode 18: Brown Sequard Syndrome Notes by Alexis Lancaster, SPT What is it? Damage to one side of the spinal cord   Mechanism of injury: MVA, gunshot wound, stab wound   Impairments/presentation: Ipsilateral losses: proprioception, vibration, deep touch, discriminative touch, and voluntary motor control Contralateral losses: pain, temperature, crude touch   Differential diagnosis: Other spinal cord injuries (see above impairments list and differentiate this way) MS Spinal infarct Spinal tumor Transverse myelitis   Special tests: CT, MRI Clinical presentation   Treatment: Medically stable/managed Bowel/bladder program Task-specific training Motor learning Neuromuscular re-education Weight-bearing Tone management FES Aerobic training Positioning, splinting, bracing Keep an eye on shoulder pain   Allow for compensation!! (This is different, usually with the neurological population you want to use less compensation and aim for recovery of function, but these patients will need to compensate some)     How it will appear on the test: Know how it presents clinically Know the type of injury that may result in Brown-Sequard

Episode17: Posterior Cord Syndrome Notes by Alexis Lancaster, SPT What is it? Damage to the posterior cord itself Occlusion of posterior spinal artery Very rare   Differential diagnosis Any of the other spinal cord syndromes (anterior/brown sequard/central cord)   Clinical presentation Isolated loss of proprioception, vibration, & discriminative touch   Special tests Clinical presentation stated above CT/MRI for confirmation   Treatment ICF model Medical management Bowel/bladder program Motor learning Task-specific training Weight-bearing Neuromuscular re-education Tone management FES Aerobic training Positioning Bracing/splinting Locomotion Keeping an eye on shoulder pain Allow compensation in this population   Sample question Identification of the mechanism of injury related to this condition Identification of clinical presentation

Episode 15- Autonomic Dysreflexia   What is it? Excessive autonomic nervous system activity triggered by afferent stimuli below the level of the spinal cord injury (usually level T6 and above) The stimulus can be noxious or non-noxious Usually it is a noxious stimulus Example: kinked catheter, tight clothing, overheating, UTI, bowel impaction, skin irritation Need to realize that the patient does not have sensation at this level, so their body is telling them that something is wrong via AD/excessive ANS activity and you as the PT need to figure out what is causing this response   Anatomy Know what level it can occur at (T6 level of injury and above) Noxious/non-noxious stimuli   Differential Diagnosis Orthostatic hypotension: presents similarly, check BP! OH: BP drops, AD: BP stays the same or is rising Migraine: a lot of reports from patients involve a pounding headache Essential hypertension: a person is becoming hypertensive with a certain activity Anxiety Withdrawal from pharmacologic drugs   Special tests BP Clinical diagnosis: look at the signs & symptoms Signs: very rapid increase in BP (doesn’t always increase, but if it does, it will be rapid), decreased heart rate, goosebumps, diaphoresis, flushed skin above the level of the injury Symptoms: pounding headache, chills, anxiety, nausea   How it will look on the test: Incorporating a patient with a SCI and identifying AD and knowing how to manage it, what level injuries it may occur with How to manage: sit the patient up! (the direct opposite of orthostatic hypotension), quickly identify what the irritant is Fun way to remember how to treat immediately: AD: BP up, sit the patient up OH: BP down, lay patient down

Episode 14: Huntington’s Disease Host Jimmy McKay Featured guest Bridget Ripa Notes by Alexis Lancaster What is it? Inherited, an autosomal dominant trait Causes degeneration to specific brain regions Huntington’s disease gene is on chromosome 4 and it produces the Huntington protein that’s found throughout the body   Signs/Symptoms Symptoms can present at any age Symptoms can include physical, cognitive, and psychiatric signs & symptoms   The disease is divided into 5 stages Preclinical, early, middle, late, end of life   Anatomy/Presentation Mechanism unclear Hallmark sign: atrophy of striatum that later involves cerebral cortex and subcortical structures Leads to severe loss of neurons in caudate and putamen Also affects basal ganglia pathways, the indirect pathway is affected before direct pathway (important)   Differential diagnosis Lupus, chorea, ataxia, generalized neurodegenerative disorder R/O with genetic testing   Treatment PT will see patients in middle/later stages (95% of pts) Check medications→ should have meds for abnormal movements and psychiatric disorders Specific to individual Family training Management of falls and decreased mobility   On the NPTE Medications will be important (drastically changes function) Know meds they may be on Antipsychotics Antidepressants disorder. Side effects may include nausea, diarrhea, drowsiness and low blood pressure. Mood stabilizing drugs Know the PT management of disease progression (family education, etc.)

Episode 12: Orthostatic Hypotension NPTE Studycast Featured Expert Bridget Ripa, PT, DPT, NCS, CBIS, CSRS Notes by Alexis Lancaster, SPT What is it   A decrease in blood pressure by ≥20mmHg systolic and ≥10mmHg diastolic when moving from a supine to upright position   Causes   Cardiovascular system, BP, blood supply to the brain   Signs & Symptoms:   Physical signs: pallor, diaphoresis, loss of consciousness (potentially) Symptoms pt will report: dizziness, light-headedness, faintness, nausea   Differential Diagnosis:   Autonomic dysreflexia Look at the blood pressure: AD will have ↑ in BP, OH will have ↓ in BP Vertigo, BPPV: b/c of dizziness and light-headedness symptoms Generalized nausea from infection, etc.   Special tests   Orthostatic testing: monitor BP with position changes   Treatment examples:   Immediately: lay the person down, elevate legs to prevent loss of consciousness After: talk to the team about BP treatment medications Encourage fluids with pt Progress upright tolerance with a hospital bed, tilt table to decrease the number of OH episodes/frequency & duration of OH episodes Abdominal binders, ace wraps on legs to keep BP up   How can it look on the test?   The important part: recognizing OH and manage it Emergent scenario: decide that it’s OH and what you would do about it May need to differentiate between OH and more emergent conditions, such as AD

TIA – Transient Ischemic Attack Notes by Nick O'Hanlon, SPT What is it? The same underlying mechanism as an ischemic stroke; with the main difference being the duration of symptoms is significantly less In other words, a brief episode of neurological dysfunction caused by ischemia (lack of blood supply) to the brain No tissue death occurs Signs and Symptoms Clinically presents like a stroke, but can also look like: a seizure disorder, tumor, migraines, or hypoglycemia Stroke symptoms – slurred speech, paralysis, overactive reflexes, balance and coordination issues, reduced sensation A complete resolution of symptoms occurs within 24 hours   Anatomy Dependent on an area of the brain the ischemic attack occurs, but any part of the brain Crescendo TIAs – having more than one TIA within a specified time period 2 within 24 hours 3 within 3 days 4 within 2 weeks   Special Tests Imaging – CT/MRI Clinical Exam – ABCDD2 prediction rule, which can predict risk of stroke after a TIA Age, >60 years BP, >140/90 Clinical presentation: unilateral weakness with or without speech impairment Duration of symptoms Diabetes Above a certain point threshold for the rule, patient is at increased risk for a stroke Differential Diagnosis Can present similarly to stroke, but the duration of symptoms for a stroke is much longer Causes Risk factors for TIA include: smoking, high blood pressure, high cholesterol, diabetes, and family history Treatment examples Treating the person as they present with their impairments There is a good possibility the duration of symptoms is too short for us to see them during the dysfunctional window before resolution of symptoms Education about risk factors and crescendo TIAs How does it look on the test? ABCDD prediction rule is important to know Be able to differentiate between TIA and stroke

Episode 9: Heterotopic ossification (HO) featured guest Bridget Ripa Notes by Alexis Lancaster What is it? The formation of bone inside soft tissue structures, where it’s not supposed to be It is extra-articular, so it occurs outside of the joint capsule   What is involved? How does it happen? Exact pathophysiology is unknown Usually comes from a period of immobilization or traumatic injury to that bone or to the affected area of the body   Presentation Swelling, redness, warm to the touch Similar to a DVT presentation Presents similarly to an infection within that area, such as thrombophlebitis, osteomyelitis, cellulitis, sepsis, septic arthritis Can present as a fracture, trauma, bruise, hematoma   Special tests XRay (gold standard) Bone scan   Treatment examples As the PT you can’t change the bone formation once it occurs Maintain ROM of the joint/area Maintain strength Prophylaxis is important: before HO occurs, you want to make sure you are paying attention to maintaining ROM with positioning, splinting/bracing early on to avoid HO development   On the NPTE Might be integrated into a question “During an initial evaluation of a patient s/p MVA with a complete lesion at C7, the PT notes redness, swelling, and warmth at the posterior knee joint. Which of the following conditions would most likely be present? Dependent on answers if HO is an answer, you can go with that Could be DVT, as well Consider answers that are available on the test!

Episode 8: Spasticity Featured expert Bridget Ripa, PT, DPT, NCS, CBIS, CSRS Notes by Alexis Lancaster, SPT What is it   A type of tone Two types of tone exist: hypotonic and hypertonic Spasticity is a velocity-dependent resistance to stretch: this is the biggest difference between “tone” in general and “spasticity” Can lead to synergistic movement patterns   Anatomy   You won’t see spasticity unless there has been an injury to the CNS or the motor neuron Typical presentation of synergies when you see spasticity: Flexor synergies in the upper extremities Proximal extensors of the lower extremities Distal flexors of the lower extremities   Differential Diagnosis   Differentiate “tone” from “spasticity” What may present like spasticity: Decreased muscle flexibility Multi-trauma/anxious patients & muscle guarding Red flag to know it is spasticity: velocity dependent!   Special tests   Modified Ashworth (gold standard for measuring spasticity): grades spasticity, scale= 0-4   Treatment examples:   Early intervention is very important As soon as you notice spasticity, focus should shift to positioning, splinting if necessary, bracing, PROM, serial casting could be an option for more serious cases Medications: Botox, baclofen pump Surgery can be an option if ROM is significantly impaired   How can it look on the test?   Questions will be about identifying spasticity or the best way to treat it Example: Patient incurred a right CVA, he is a month out and demonstrating moderate spasticity in the left upper extremity, showing increased flexor tone. The major problem at this point is the lack of voluntary movement control. There is active movement but it is minimal and the patient has a ¼ inch separation of the shoulder. The initial treatment activity of greatest benefit would be with the patient sitting, weight-bearing on the extended affected upper extremity. Need to think about what the best option would be, go with the evidence and gold standard

Featured instructor Bridget Ripa, PT, DPT, NCS, CBIS, CSRS

Thoracic Outlet Syndrome Host Jimmy McKay, PT, DPT Featured professor:  Skye Donovan | PT, PhD, OCS Notes by Lauren Knasel What is it? Entrapment disorder of the nerves or the vascular that occurs inside the “thoracic outlet” → space between the collarbone and the first rib Three types Neurogenic Vascular Nonspecific Signs and Symptoms Shoulder pain: over the AC joint or biceps area→ could be a continuous burning, lame feeling in the shoulder and down the arm Tingling down the arm into the hand→ could lead to loss of control of the hand with the dropping objects Heaviness in the extremity Pain present at rest (when driving or watching tv) Pain radiating into the neck, trapezius musculature, shoulder blade, jaw, head, and chest Traction downwards on the arm when carrying shopping bags Pain often present during activities such as swimming, throwing, overhead activities→ could cause a feeling of fatigue and burning and having to bring the arm down due to not being able to maintain that position Anatomy Many bones, muscles, nerves, and blood vessels that course through the thoracic outlet Structures most commonly affected include: Clavicle 1st rib Scalene muscles (anterior and middle) →  more neurological s/s Pectoralis minor→ vascular s/s Subclavian artery and vein Upper and lower brachial plexus Special Tests The different tests are used to elicit symptoms of TOS with positions that would compress the nerves within the anterior scalene muscle Common Tests: Roos “Chicken Dance Test” (or commonly called Elevated Arm Stress Test or “EAST”) → nonspecific; doesn’t specify a location A positive test would result in usual TOS symptoms such as a gradual increase in pain in the neck and shoulder, aching progressing down the arm, and paresthesias Normally, a person can perform this test for 3 minutes with only minimal distress Adson’s → test for the scalenes “Reverse Dab” A positive test would result in peripheral radial pulse disappearing once the patient was put into the test position Allen’s A positive test would result in peripheral radial pulse disappearing once the patient was put into the test position Military Test → compression of costoclavicular space Hyperabduction Test or Wright’s Test→ for pec minor Recommended to use a combination of tests in order to come to clear diagnosis Differential Diagnosis Disc herniation in the cervical spine Peripheral nerve entrapment CRPS Inflammatory condition Causes Posture Forward head Tight pectoralis musculature Tight scalenes Repetitive overuse with poor posture Heavy backpacks Acute trauma Anatomic predispositions Treatment Examples Therapeutic Exercise Relaxing the shoulder girdle and upper trapezius musculature Stretching the scalenes and pectoralis muscles Strengthening the cervical extensors, scapular adductors, and shoulder retractors Manual Therapy Nerve Glides Posture Re-education Ergonomics NSAIDs Surgery (Rare) Modalities How can it look on the test? Just remember your anatomy! Postural Re-education is going to be your best answer

Featured professor:  Skye Donovan | PT, PhD, OCS Episode 2: Elbow Differential Diagnosis Notes by Alexis Lancaster, SPT General information Tennis elbow: lateral epicondylitis “Thumb side” Golfers elbow: medial epicondylitis “Pinky side” Country club elbow: both medial & lateral epicondylitis Symptoms Pain on medial or lateral side Causes Does not need to be tennis or golf Grip usually causes these conditions Driving & gripping steering wheel too tight Weight lifting with too much gripping Swimmers can be affected (pointing their fingers) Differential diagnosis Bursitis: bursa sits under olecranon Pronator teres syndrome: painful/achy on lateral side Osteoarthritis of elbow joint Rheumatoid arthritis C-spine radiculopathy (especially C6-C7) Ulnar nerve pathology What does the pain feel like? Nerve pain? Think nerve injury/problem Tendinopathy Overuse Lateral epicondylitis: usually due to excessive grip, excessive wrist extension→ seen in racquet sports, occupation and work-related tasks that have a lot of vibration (jack-hammering) Medial epocondylitis: usually due to excessive grip while in pronation, or excessive wrist flexion Anatomy Lateral: wrist extensors (common extensor origin) Usually associated with extensor carpi radialis brevis (ECRB) involvement. ECRB attaches to 3rd digit Extensor carpi radialis longus inserts on 2nd digit It could be any muscle that shares the common extensor origin that is involved (ex. brachioradialis and extensor digitorum) The radial nerve supplies extensor carpi ulnaris, radialis brevis & longus Medial: wrist flexors (common flexor origin) “Pass/fail/pass/fail”: pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris Not everyone has a palmaris longus Median nerve: pronator teres, flexor carpi radialis, palmaris longus Ulnar nerve: flexor carpi ulnaris Deep to these= flexor digitorum profundus and superficialis “Medial side of forearm” Special tests Lateral epicondylitis “Tennis elbow test”: MMT for wrist extensors Can add some radial deviation Can lift the third finger to see if it is ECRB Look for provocation of pain at the lateral epicondyle   Medial epicondylitis “Golfer’s elbow test: MMT for wrist flexion Look for provocation of pain at the medial epicondyle Cervical spine testing to rule out the spine Grip testing (will be weak) Treatment examples Modalities Corticosteroid injections TherEx: Loosen grip Eccentrics Take pressure off the origin, start with forearm supported to shorten lever arm Don’t have pt exercise into pain Bracing More common with lateral epicondylitis compared to medial Education/prevention: pts don’t understand their grip may be the problem Sample question: If your patient comes to you with lateral epicondylitis, where is the best position that you would put their brace? Superior to the elbow Inferior to the elbow Superior to the wrist At the wrist Answer: Inferior to the elbow Why: You can have a brace that is giving compression, so you put it at the joint. However, in this case, if you are bracing to decrease the force that is coming through something, you need to cheat the body into thinking that the muscle’s origin is coming from a different place so it is not getting pull where it is getting damaged. You can place a brace here because the part of the muscle that is inflamed is a tendon, not contractile tissue. If you put the brace superior to the elbow, it would likely increase pain. You’re putting compression on the damaged part, so you aren’t changing the lever arm. If you had an answer of “at the elbow”, the compression will be great, but it won’t be the best answer if “inferior to the elbow” is also a choice, Superior to the wrist/at the wrist: missing the point of the brace for the condition

Episode 1: Biceps Tendonopathy Featured professor:  Skye Donovan | PT, PhD, OCS Notes by Alexis Lancaster, SPT What is it A strain of the muscle can be damage to the muscle belly but is usually damage to the tendon Tendon can be ruptured, varying in severity from only a few fibers being interrupted all the way to a complete tendon rupture Signs and symptoms Pt may come in with pain, can also be weak Pain could limit strength depending on the amount of muscle damage With a lot of muscle damage/tendon damage they will be unable to fire the biceps muscle Point tenderness in the bicipital groove could be the pt’s only symptom More people have proximal pain rather than distal pain (this will be pain at the origin of the muscle Complete rupture: the “Popeye’s Sign”—the muscle will have detached from the bicipital groove and will be balled up in the middle of the upper arm. Pt will say they heard a “ripping” noise, and that they now have a ball in their arm that didn’t used to be there Anatomy 2 heads The short head of the biceps Origin: coracoid process, Insertion: short head and long head tendons come together and insert into the bicipital aponeurosis on the radius Long head of the biceps Origin: superior glenoid, superior portion of the labrum*, Insertion: short head and long head tendons come together and insert into the bicipital aponeurosis on the radius *Key for differential diagnosis, labrum may be the problem Can be thought of as the 5th muscle of the rotator cuff due to origin anatomy Biceps’ main action is supination, as well as elbow flexion The “wine bottle” muscle: powerful supination (wine opening), elbow flexion (pull the cork out) Innervation: musculocutaneous nerve (C5, C6, C7) Reflex testing: C5 Special tests Speed’s Test (gold standard) Patient in shoulder flexion, some external rotation, elbow extended, full supination PT applies resistance into shoulder extension, patient will resist by flexing shoulder Positive test: pt complains of pain (at the groove or at origin), pt may be weak Supination requires pt to use biceps instead of brachialis or brachioradialis Yergason’s sign Put patient into 90 degrees elbow flexion, in supination PT will try to pull pt into elbow flexion and pronation while patient resists by flexing elbow and supinating forearm Positive: pain Obrien’s test (to differentiate biceps tendinopathy from a SLAP tear) Patient in 90 degrees shoulder flexion, slight horizontal adduction, pronation, internal rotation PT applies resistance downward Positive: pain, possibly a click After: Place patient in supination and apply resistance downward, patient should feel better Pt will have less pain when in neutral forearm position compared to when they are fully pronated, as well Differential Diagnosis Pain is usually at the origin, so you have to rule out rotator cuff tendons Palpate for bicipital groove between greater and lesser tubercles Biceps sits here Could also be palpating some of supraspinatus at this location Impingement Biomechanics Supraspinatus impingement Subacromial bursa impingement Remember: many pts don’t have a great sense of pain within centimeters, so they may be having subacromial pain (hard to localize) Labral tear Long head of biceps inserts into the superior labrum Gallbladder Referred pain to right shoulder (opposite of heart attack, which is left) Coracoid process will always hurt when palpated 3 muscles attach here: short head of the biceps, coracobrachialis, pec minor MMT’s, ROM for these muscles to determine if it is one of these three muscles   Causes: Overhead sports Eccentric phase for pitchers Lifting too-heavy of weights Multiple corticosteroid injections in shoulder Treatment examples: Treat like any other tendinopathy Strengthening Restoration of ROM