NMS

7/15/99

· pressure at T1 IVF—Horner's Syndrome

facet—osteophytes—Luschka joints
disc bulge

· if encroachment touches parenchyma, only then will depress conduction leading to radiculopathy

· to get to nerve substance (parenchyma)

dural sleeve—adheres to sides of bones, but the nerve slides
synovium—nonfriction slide

· initially contact dural sleeve—years before it can hit nerve substance

· dural sleeve is innervated from won nerve root (recurrent meningeal nerve) off 1° posterior ramus—sensory and autonomic (sympathetics)—poorly myelinated C fiber pain patterns

· sclerotome pain—C4, C5, and C6—site of pain is b/w shoulder blades, upper trap region—Cervical spondylosis (C6 at triceps tendon area also)

· no inflammation or infection

· beginning of osteoarthritis

· can't localize

· orthopedic nerves—only reproduce achiness

· no A fibers present to produce sharp pain

· increased motion of the segment to help treatment (excite nerves which produce hypertonicity of the muscles) help reduce muscle tonicity

· inflammation

· pain at rest (physiological rest)—this is a position that should be pain free and is still painful

· all degrees of freedom are painful in an inflammatory state

· it is not inflamed if have some degrees of freedom

· capsule of shoulder inflamed has decreased ROM

· inflammation is cellular rxn to irritation

· inflammation irritates (excites) nerves

· Cyriax—capsular pain pattern—disproportionate pain pattern

· cervical facets—rotation, extension, flexion

· somatic tissues causing problems

· what exactly is it

· if don't have neuropathy, fall into this category

TOS

· compression of neurovascular bundle

· distal to problem—neurologic problem

· vascular signs—pressure difference, circulation problems

cold hands
nail beds—bluish color
fingers swell
diminished pulse—only significant if occurs at same time as numbness in arm

· numbness—compression of nerves—has nothing to do w/vascular supply)

push on nails—remains white for a time

Chart from green handout

· 3 sites of pressure on peripheral nerves

anterior scalene—brachial plexus and Subclavian artery

· turn ipsilateral and take a deep breath

· numbness is Adson's test

clavicle and 1^st rib

· more common in women

· Referred to costoclavicular or Eden's test

· Brings arms back into extension

· Press on clavicle—arm will go numb

· Numbness and loss of pulse

· open space up if lift arm over head—pain free

· More pain w/arm down esp. if carrying something—dependence

· Shrug shoulders a lot

· Rest elbows on table

· Trap exercises have helped

· Found in low shoulder

· Clavicle is the most broken bone in the body—has a lot of movement in it

Pectoralis minor and coracoid process—hyperabduction

· more common in men

· arm up, pectoralis minor pulled, numbness ensues

· ribs move nicely

· Muscle stretch of pec minor helps and trigger point therapy

· Arm is down, no symptoms

· Hyperabduction test

· Symptoms

· Nerve and vascular

· Loss of pulse means nothing

· Lose pulse and arm goes numb at same time is significant

NMS 7.15.99

· An impingement on the nerve root of T1 will cause Horner's syndrome

· This can be caused facets or osteophytes or disc bulge

· If the actual nerve substance itself, which is called parenchyma, this causes a radiculopathy by pressing on the dural sleeve.

· The dural sleeve is attached to the bone and the nerve slides inside this sleeve.

· Friction is reduced by the dural sleeve producing synovium.

· The dural sleeve can be impinged years before the nerve root is affected.

· The dural sleeve is innervated by the nerve root that runs through it called the recurrent nerve, which is a C pain fiber.

· In A fiber pain the pain centralizes, if it does not it is C fiber pain

· Sclerotome pain is seen in osteoarthritis due to the compression of the dural sleeve irritating the recurrent nerve this pain can be relieved by restoring motion to the joint and increasing proprioception

· With osteoarthritis irritating the dural sleeve via an osteophyte, the pain is not reproducible with an orthopedic test

· The disc is also innervated by the recurrent nerve; therefore disc herniation can cause scleratomal pain.

· Inflammation- is determined by pain at rest or physiological rest or when the segment is not being stressed there is still pain

· When inflammation is present than all six degrees of freedom or movement is painful, but if there are some degrees of movement that have no pain than there is no inflammation.

· Frozen shoulder is an example of inflamed joint

· Inflammation is reaction to tissue damage

· This can be treated by ice, soft collars, etc.

· Cyriax- described the capsular pain pattern or disproportionate pain pattern and described all of the things above.

· Orthopedic tests tell us the focal diagnosis, or the site of the problem not the etiology of the pain.

Tunnel syndromes

· TOS

· Compression of the neurovascular bundle

· Vascular findings are: cold hands, nail beds are blue, fingers swell, slow capillary refill

· Diminished pulse is pointless when raising the arm unless there is numbness associated with it, which is blocked conduction of nerve flow.

	Pressure on	Pressure off
Peripheral nerve	Numbness	Paresthetic tingling
Nerve root	Pain	Relief

· If the peripheral nerve is compressed and the digits are moved the tingling is this is called a Paresthetic storm

· If the compression is on the nerve root and the digits are moved than there is no change

· There is three major sites of compression

· Scalenus anticus triangle and has a syndrome

· Patient turns head to side of involvement or takes a deep breath than there is pressure in the peripheral nerve and numbness ensues Addson’s test

· Costoclavicular

· If the shoulders are brought back posterior there is numbness and tingling, but when the arm is over head the symptoms are relieved, always shrugging shoulders

· PectoralisCoracoid

· Called hyperabduction syndrome when the arm is brought up or elevated the arm goes numb