History: any trauma before having musculoskeletal problems

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  • any trauma before having musculoskeletal problems

  • any changes in behavior

  • ask questions

  • bone problems, take an x-ray

  • x-rays are also needed if suspect fracture, tumor (usually metastasis, 2°), osteoporosis, infxn (mostly spread hematogenously first, then minor trauma aggravates the area)

  • ms. problems- tumor is rare, usually cyst

  • tendon problems

  • ligament problems- 1°, 2°, 3°- bursitis- ligament problems heal slower

  • fascia problems- involves sclerotogenous pain- not very elastic and when damage surrounding tissues, the fascia is also damaged

  • joint problems- subluxations (major), arthritis (trauma, wear and tear, DJD), synovial, infxn, dislocation

  • onset- insidious, don’t remember when it started

  • aching = ms.

  • burning, stinging, numbness, tingling = nerve

  • location- pt. point to it

  • referred pain

  • check dermatome pattern, peripheral nerve pattern, trigger point pattern

  • sore ms., weak ms., could be due to over exercising the ms., neurological problems, or due to decrease nerve supply

  • instability due to ligament laxity, could be either genetic or b/c of being an athlete

  • surface of skin- look for blisters, bruises, lyme dz

  • passive ROM vs. active ROM- if have pain during both ROM, then ligament and joint problems- if pain on active ROM, then ms. problem

  • pain scale = 10-0- what is 10 to you?- i.e., can you sleep at night, if you can, then ok

  • send pt. for special study or imaging if necessary


Chapter 17

HA (p.453)

  • HA, HTN, nosebleed = all are serious problems

  • neurologic

  • migraine HA

  • can get HA if skip breakfast, caffeine addiction, too much to drink

  • hurt face with HA leads to sinus problems when standing up after awakening

  • hematoma = HA getting worse, check with ophthalmoscope

  • meningitis = HA gets worse, nuchal rigidity, cannot flex neck, dural irritation, +valsalva test

  • brain tumor = may or may not get worse, depends on the location of the brain tumor- there is pain if tumor is around or close to the meninges- neurosympathetic without HA can also be a tumor

  • stroke = doesn’t care about age, i.e. TIA involves many small episodes

  • temporal artery = associated with polymyalgia rheumatica

  • nuchal rigidity with fever = bacterial

  • nuchal rigidity without fever = viral

Migraines (p.458)

  • cluster (special type II), tension, cervicogenic

  • metabolic, toxic (hang over due to alcohol)

  • eye strain can cause HA, CSF changes can cause HA

  • migraine with aura- (a sensory input that they feel that the HA is coming) usually vision and auditory problems are most common- flash, temporary loss of vision, inc. sound, dec. sense of taste or smell

  • migraine HA: unilateral, pulsating, throbbing, prohibit ADL, aggravated, family Hx involved, photophobia, assoc nausea, stress, lack of sleep/fatigue, alcohol, food triggers it, nitrate

  • cervicogenic HA: unilateral, location is to the neck or suboccipital region around the orbitals, hurts with neck movement

  • cluster HA: trigeminal autonomic parasympathetic, seen in males, comes back then ceases, myosis (constricted pupils), assoc with runny nose, Lacrimation, sweating, ptosis. Painful, feels like someone is poking your eye, red eye, due to smoking or drinking

  • sinus HA: worst headache, due to pressure changes when getting upright posture, can also be related to tooth problems

  • tension HA: feels like band around the head, bilateral, mild to moderate intensity, no nausea or vomiting

  • temporal arteritis: unilateral pain in temporal region, pt experiences double vision, assoc to polymyalgia rheumatica, affects medium and small sized arteries, need to refer to ER, treated with corticosteroids

Management for HA:

  • modify lifestyle factors, good diet, exercise

  • treat with Chiropractic manipulation

  • refer to medical management

Chapter 18


  • obtain a more complete description of pt’s complaint of dizziness

  • differentiate between vertigo and other dizziness complaints

  • determine onset and length of attack

  • determine if pt senses hearing loss

  • ask about any neurologic or systemic complaints

  • ask about current medication

  • differentiate between peripheral and central causes

Positional vertigo

  • vertigo occurs with certain head positions

  • vertigo lasts for second to a couple of minutes

  • head movement or change in position can cause it, i.e. head ext, rotation, bending over and then straightening back up, rolling over in bed

  • it is caused by degenerative debris floating in the posterior semicircular canal

  • trauma and age can also be an important factor

  • it is the main cause for vertigo

  • treatment can include habituation exercises and otoconia repositioning maneuvers

Meniere’s Disease

  • pt complains of paroxysmal attacks of severe vertigo accompanied by a low-tone hearing loss

  • the episodes last for several hours to a day

  • considered to be the 4th leading cause of vertigo

  • hearing loss is progressive while the vertigo attacks decrease

  • it is caused by distention from either overproduction or retention of endolymph (immune processing area)

  • pregnant females are more prone for an attack

  • sudden onset of vertigo with associated hearing loss or tinnitus is fairly a diagnosis

  • hearing loss is usually low tone

  • primary approach for treatment is diuretic therapy and salt restriction in diet


  • patient complains of severe vertigo that occurs suddenly and lasts for day or weeks

  • there is associated nausea and vomiting, but no hearing loss

  • the cause is unknown, however, could be from a viral infection of vestibular nerve

  • DDX for neuritis are labyrinthitis, or infarction of the inferior cerebellum

  • Need to differentiate between the two (finger to nose test)

  • Treatment is usually done by central compensation and the condition resolves over time


  • Pt. complains of an acute onset of vertigo with bacterial or viral hearing loss

  • It is believed that bacteria (worse) or virus causes damage to the inner ear

  • Bacterial infection can lead to otitis media infection and cause complete destruction

  • Finding are the same with hearing loss

  • Treatment may include antibiotic therapy

  • Bacterial infection can lead to otitis media infection and cause complete destruction

  • Finding are the same with hearing loss

  • Treatment may include antibiotic therapy

Cervicogenic vertigo

  • pt complaining of vertigo due to certain head positions

  • also may be complaints of neck or suboccipital pain

  • trauma (whiplash) is common in 1/3 of pts

  • can also be caused by over stimulation of neck muscles

  • finding of upper cervical restricted movements

  • treatment may include CMT

Acoustic neuroma

  • is tumor growth of a benign schwannoma of the vestibular nerve that causes brain stem compression

  • pt presents with a complaint of mild but constant hearing loss and dizziness or tinnitus

  • with neuroma, hearing loss is unilateral (usually bilateral is due to ageing)

  • treatment is usually surgery

Chapter 2

Neck and Neck/Arm Complaints

  • with recent trauma, the first step after the Hx is x-ray

  • The c/s acts like a lever so the demands on the post. muscles are dramatically increased by the weight of the head as it moves forward of the body

  • c/s is involved in complaints of the head and upper extremities

  • the upper c/s nerves and the trigeminal nerve results in complaints of HA, facial pain, or ear pain

  • upper extremity complaints affects the spine, nerve roots, or brachial plexus

    • common pt. presentations include the following:

- Acute injury neck and/or arm pain, i.e., whiplash, cervical “stingers” (stingers occur secondary to whiplash), etc.

- acute, pseudotorticollis (not a true torticollis but a painful limitation of all neck mvmts.)

- postural pain or stiffness due to poor ergonomics in the work environment

- osteoarthritis associated stiffness or pain- OA is due to normal wear and tear, age of the pt. (>40)- also should ask how long it has been since they badly injured their neck (for whiplash)- ask about family members with OA- if pain changes with mvmt. it may be a nerve problem

- headaches- could be related to c/s subluxation or also due to injury


  • screen the pt. for “red flags” that indicated the need for either immediate x-rays or referral to or consultation with a specialist, including severe trauma, direct head trauma with loss of consciousness, nuchal rigidity, bladder dysfunction associated with onset of neck pain (could be a myelopathy), associated dysphasia, associated CN or CNS signs and sx, onset of a “new” HA, and preexisting conditions such as RA, cancer, Down syndrome, alcoholism, drug abuse, or an immunocompromised state- metastasis will affect the pedicles first causing a “halo” sign on x-ray- alcohol and drugs leads to poor nutrition, osteoporosis- need an informed consent taken from a sober pt., not alcoholics or drug addicts (need to write in the chart “i smell alcohol on the pt.’s breath”)

  • if there is a Hx of trauma, determine the mechanism and the severity

  • for pts. involved in a MVA, take a thorough Hx with regard to the angle of the collision, speed, use of brakes, seat belt, shoulder harness, air bag, position of the pt. in the car, subsequent legal concerns with regard to police reports, etc.

  • determine whether the complaint is one of pain, stiffness, weakness, or a combo of complaints

  • determine whether the complaint is limited to the neck or is radiating to the head or upper extremity unilat. or bilat.

  • determine the level of pain and functional capacity with a questionnaire such as the Neck Disability Index with a pain scale (visual analog scale)

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