Vertebral artery test

Approximately one‐quarter of ischaemic strokes involve the posterior or vertebrobasilar circulation. Stenosis of the vertebral artery can occur in either its extra‐ or intracranial portions, and may account for up to 20% of posterior circulation ischaemic strokes. Stenotic lesions, particularly at the origin of the vertebral artery, are not uncommon. In an angiographic study of 4748 patients with ischaemic stroke, some degree of proximal extracranial vertebral artery stenosis was seen in 18% of cases on the right and 22.3% on the left. This was the second most common site of stenosis after internal carotid artery stenosis at the carotid bifurcation. Such stenotic lesions are now potentially treatable by endovascular techniques.

In marked contrast with carotid artery stenosis, the optimal management of vertebral artery stenosis has received limited attention, and is poorly understood. This partly reflects difficulties in imaging the vertebral artery adequately, and limited surgical treatment options. Recent improvements in imaging and the arrival of vertebral artery angioplasty, however, have opened up new opportunities for intervention in this disease.

Read the rest "Diagnosis and management of vertebral artery stenosis" @ http://www.oxfordjournals.org/en/.

The treatment in such cases is purely medical. However, a Physical Therapist should be aware of this problem, the vertebral artery disease or  vertebrobasilar ischaemia, and should know the basic anatomy, symptoms and assessment test in his everyday practise.

A very nice article on Physiopedia explains these issues clearly.

What to keep in mind:

To test the blood flow in the vertebral artery, one should put the patient on his back and perform an passive extension, followed by a passive rotation of the neck. The rotation should be performed in both directions. The manoeuvre causes a reduction of the lumen at the third division of the vertebral artery, resulting in de decreased blood flow of the intracranial vertebral artery of the contralateral side. It causes an ischemia due to blood loss in the pons and the medulla oblongata of the brain. This results in dizziness, nausea, syncope, dysarthria, dysphagia, and disturbances of the hearing or vision, paresis or paralysis of patients with vertebrobasilar ischaemia.

Below is an alternate vertebral artery test, presented by http://www.thestudentphysicaltherapist.com/.

http://www.patient.co.uk/ offers an extended overview of the Vertebrobasilar Occlusion and Vertebral Artery Syndrome, including treatment and management options.

Scapular dyskinesis guidelines

Abnormal movement of the shoulder blade (scapula) is known as scapular dyskinesis. This occurs in a variety of shoulder problems. It is an important sign of an underlying shoulder disorder and a guide to shoulder rehabilitation.

Based on PhysioPedia, intervention is aimed at reducing posterior capsule and pectoralis minor restriction and restoring periscapular mm balance through exercises promoting early and increased serratus anterior, lower, and middle trapezius activation while minimizing upper trapezius activity.

• Manual gr 4 mobilization to reduce posterior capsule tension, cross-body stretch.
• Manual stretching and soft tissue mobilization to decrease pec minor tension (cadaveric studies imply that a position of 150 degrees elevation with 30 degrees scapular retraction is optimal).
• Exercises of sidelying forward flexion, external rotation, prone extension, and prone horizontal abduction to strengthen middle and lower trapezius over upper trapezius.
• Quadruped and variable push-up positions to activate serratus anterior.

Here is a very nice guideline for treating scapular dyskinesis, offered by the Beth Israel Deaconess Center (a Harvard Medical School teaching hospital).

Online interactive tutorial in Radiology

A very interesting online interactive tutorial in radiology offered by University of Virginia.

Scapulohumeral rhythm

In the healthy shoulder, a natural kinematics rhythm/timing exists between glenohumeral ABD and scapulothoracic lateral rotation. After 30 degrees of abduction this rhythm is 2:1, meaning that for each 3 degrees of abduction, 2 degrees occur in the glenohumeral joint and 1 degree occurs in the scapulothoracic joint.

This very nice video and article by Physio-Pedia makes it very clear.

The myth of core stability?!

A very famous subject in all schools of Physical Therapy. Is it true or not? Is it something that can be applied in practise or not? The myth of core stability is a very interesting work by Professor Eyal Lederman. Whether you agree or not, it worths reading it since it stimulates your brain.

SaveYourSelf.ca - Your Back Is Not “Out” and Your Leg Length is Fine

The story of the obsession with crookedness in physical therapy and treatment for chronic pain. A must read for every healthcare professional (and everyone in general).

“Structuralism” is the excessive focus in the physical therapies on crookedness or “mechanical” problems in the body — what I call the biomechanical bogeymen. It is the source of much bogus diagnosis — things like tilted pelvises, short legs, abnormal spinal curvatures, or “misaligned” anything — and the cause of much therapeutic barking up the wrong tree. Such factors are much less important than many people still believe.

Read the rest.

Preventing and treating orthostatic hypotension: As easy as A, B, C

Orthostatic hypotension is a chronic, debilitating illness that is difficult to treat. The therapeutic goal is to improve postural symptoms, standing time, and function rather than to achieve upright normotension, which can lead to supine hypertension. Drug therapy alone is never adequate. Because orthostatic stress varies with circumstances during the day, a patient-oriented approach that emphasizes education and nonpharmacologic strategies is critical. We provide easy-to-remember management recommendations, using a combination of drug and non-drug treatments that have proven efficacious.

Read the rest of The National Center for Biotechnology Information website.

Wheeless' Textbook of Orthopaedics

Orthopaedics References and Discussions for Physicians

Editor-in-Chief: Clifford R. Wheeless III, MD

Managing Editors: James A. Nunley, II, MD and James R. Urbaniak, MD

Our online textbook, presented by Duke University Medical Center’s Division of Orthopaedic Surgery, in conjunction with Data Trace Internet Publishing, LLC, is a true head to toe, comprehensive discussion of orthopaedic topics.

With thousands of pages in an easy-to-read outline format, accompanied by countless explanatory photos, drawings, radiological images, and videos, Wheeless’ Textbook of Orthopaedics is the premier website for the industrious orthopaedic physician.

This dynamic website is continually updated by experts in their fields. Links to pertinent journal article abstracts and additional, helpful websites provide students, educators, practicing orthopaedists, and patients with valuable medical information.

Simply click on a particular section of the skeleton (to the right) for easy access to our compendium of information, or find specific topics through alphabetical or keyword searches (see search box above).

Regional interdependence in treatment of the elbow

Regional Interdependence

• Treatment directed at one area of the body to elicit changes in another.
• In addition to treatment directed at the elbow, patients with elbow pain may benefit from treatment directed at the cervical or thoracic spines, and/or wrist.

Examination 

• Differential diagnosis for Lateral Epicondylalgia can be done through Elbow Examination
• Prior to performing interventions directed at the spine, appropriate examination and safety screens should be performed.

• Cervical Examination and screen for Red Flags
• Vertebral Artery Test
• Transverse Ligament Stress Test
• Tests for Cervical Instability
• Thoracic Examination 

Read more here for intervention methods and techniques.

Clinical Bottom Line 

Incorporating manual therapy directed at the cervical spine, thoracic spine, cervico-thoracic junction, wrist, and carpals appear to provide benefits for patients with lateral epicondylalgia, cubital tunnel syndrome, and nerve entrapment. Clinicians may consider these interventions in addition to treatment directed only at the elbow. More specific information can be found in the references below.

Sport rehabilitation

A very nice website from some ESP students - very useful and with clear instructions: https://sites.google.com/site/sportsinjuriesandpt.

MRC Muscle Strength testing

One more very useful video from PhysioTutors YouTube channel.

Physical Therapy EBP videos, advices, ideas - Physical Therapy Nation

Physical Therapy Nation is platform which facilitates the sharing of evidence based information worldwide among both physical therapy students and active clinicians. PT Nation is also a completely free evidence based video database of over 1,000 internally filmed videos. The video library is free to all student PTs and licensed clinicians. It includes instruction covering manual therapy techniques, examinations, special tests, and many specialty areas like vestibular therapy and orthotic casting and fabrication.

The goal of Physical Therapy Nation is to promote, enhance, and move the profession of PT forward by providing a free video focused resource to all clinicians.

www.PhysicalTherapyNation.com

Applied anatomy YouTube channel

A wonderful YouTube channel with detailed videos on applied anatomy. These videos were originally filmed for some students DPT class, but its become so popular.

NeuroLogic examination videos and descriptions

The "NEUROLOGIC EXAM VIDEOS AND DESCRIPTIONS: AN ANATOMICAL APPROACH" uses over 250 video demonstrations with narrative descriptions in an online tutorial. It presents the anatomical foundations of the neurologic exam and provides examples of both normal and abnormal conditions as exhibited by patients. Use the Table of Contents on the left to access these tutorials, organized by type of exam.

The website combines the use of anatomical diagrams, live patient exams, video patient cases and self-evaluation tools to accomplish its educational goals. It utilizes clinical video patient cases as digital movie files that can be viewed online or freely downloaded for local repurposing.

This "Clinical Dissection of the Nervous System: An Internet Accessible Tutorial" for Medical Neuroscience is authored by the University of Nebraska Medical Center (Paul D. Larsen, MD) and the University of Utah School of Medicine (Suzanne S. Stensaas, PhD), with some section movies contributed by the Fundación Stern, Buenos Aires, Argentina (Alejandro Stern).

The presentations interweave the neurological examination with neuroanatomy, laying the foundation for clinical problem solving by...

first, establishing the anatomical concept;

second, demonstrating the problem solving method;

then third, allowing active participation in applying the method.

Anatomy and pathology of the nervous system is understood by directly visualizing it. This is best accomplished by handling the brain (or model of the brain as the case may be) and dissecting or taking it apart for direct examination. The purpose (for the clinician) of understanding neuroanatomy and neurophysiology is to be able to use that knowledge to solve clinical problems.

The first step in solving a clinical problem is anatomical localization. So, if one cannot directly inspect the patient's brain, how is this localization accomplished? The "WINDOW TO THE PATIENT'S BRAIN" is the neurological examination. A neuro exam is a series of tests and observations that reflects the function of various parts of the brain. If the exam is approached in a systematic and logical fashion that is organized in terms of anatomical levels and systems, then the clinician is lead to the anatomical location of the patient's problem.

SaveYourself.ca

What works for stubborn aches, pains, and injuries? What doesn’t? Why? SaveYourself.ca reviews your treatment options: hundreds of detailed, free self-help articles and several e-books about common pain problems, constantly updated, and readable enough for anyone but heavily referenced for professionals. (There’s also a giant bibliography.) I serve up the science with some sass — I try to have fun taking this subject seriously. The salamander? More mascot than logo, he’s a symbol for regeneration and unsolved mysteries of biology. ~ Paul Ingraham, publisher

Examination of the Cranial Nerves

Published on Apr 29, 2012

This is a detailed explanation of the examination of the Cranial Nerves illustrating technique and patient interaction.

The film was produced by practising clinicians to aid the teaching of clinical examination skills. It starts at the point when the clinician has finished taking the medical history and begins the clinical examination.

Presented by Dr Richard Abbott MD FRCP Consultant Neurologist. Produced and Directed by Dr Irene Peat FRCR FRCP, Dr Nicholas Port MBChB BSc and Jon Shears.

More Clinical Examination materials can be found at: http://www2.le.ac.uk/departments/msce/existing/clinical-exam

PhysioTutors: Assessment - Posture Analysis

In this video Andreas from PhysioTutors talks about basic posture analysis for your assessment!

PhysioTutors: Patient History and RPS-Form

In this video Andreas from PhysioTutors explains you a way of how to use the RPS-Form of the ICF framework in your patient history taking.

Restoring the Body (Fitness, Health and Nutrition)

Series: Fitness, Health and Nutrition

Hardcover: 144 pages

Publisher: Time Life Education (January 1988)

Language: English

ISBN-10: 0809461870

ISBN-13: 978-0809461875

A great book suggested to me by an Orthopeadic surgeon.

Foot analysis for runners

It is of extreme importance to have comfortable and ergonomic shoes if you are a city runner. I recently went to the Asics store in Amsterdam in order to buy a pair of running shoes. They offered me a free foot analysis before buying my runners, which I enjoyed very much. They have really good knowledge of gait analysis, especially when it has to do with city runners.

I am pointing out the major parts of the manual they gave me after my foot analysis and I add some of my knowledge in order to give you useful information on this matter:

1. Foot length

The length of your foot is measured from the end of your heel to the end of your longest toe, along an imaginary line running from the center of your heel to the end of your longest toe. For sport shoes, you should choose a size approximately 8-10 mm larger than your base foot length. This is because your feet become slightly longer in the propulsion phase o the gait cycle.

2. Ball girth (or circumference)

"Ball girth" measures around the foot, from the ball of the big toe to the ball of the little toe. Ball girth is different from foot width, which is a simple two-dimensional measurement. It is a very important measure for correct shoe fitting.

3. Heel breadth

Heel breadth is measured from the inside to the outside of the hell, at 18% of the distance of the whole foot, measuring from the back of the heel. If your heel is very narrow, you will have to place it more firmly into the heel of your shoes by tightening your laces a little more. If your heel is wide, there is no problem.

4. Instep height

Because it is related to the ball girth, instep height has a subtle effect on fitting. The place to measure the instep is roughly equal to three fingers from the base of the ankle. For example, a narrow ball girth and a high instep may not fit slim shoes.

5. Arch height

Arch height is measured by the height of the navicular bone and is directly linked to the type of arch and instep height. If your feet have low arches and your footprint shows dropped arches, you may have flat feet. Losing the basic shape of arch tends to cause more tiredness and pain.

6. Heel angle

The hell angle is the angle between the vertical line that passes through the heel and the vertical line that passes through your body center of gravity. There are two possibilities regarding the heel angle: pronation (eversion) or supination (inversion). The average is 1.5 degrees of eversion. Excessive eversion increases loading on the inner side of the foot and tiredness around the big toe. Excessive inversion increases loading on the outside of the foot decreasing stability and flexibility.

7. Toe angle

Toe angle shows the inclination of your big toe. In pathologies, it can be either valgus (outward point of the big toe) or varus (inward pointing of the big toe). Both cases have negative effects on your gait.

8. Footprints

There are two main archs in your foot, the transverse and the longitundinal arch. Depending on their height, three deformities can be distinguished:

a. Increased height of the longitundinal arch (pes cavus) - runners with high arched foot choose shoes in the under-pronator to neutral categories.

b. Loss of the longitundinal arch (flatfoot, or pes planus) - runners with flat feet should select shoes in the overpronator to severe over-pronator categories

c. Loss of the transverse arch (splayfoot, or pes tranversoplanus) - same as flatfoot runners

9. Running styles

Depending on the degree of pronation (outward movement of the foot) during running, you can be categorized in one of the three major running styles (the picture above show the right foot from behind):

a. Overpronation

 - excessive outward movement of the foot

 - more load is put on the inside part of the foot, which is transferred to the knee, hip and lower back

 - waste of energy and early fatigue

 - higher risk of injury

b. Neutral

 - balanced gait

 - efficient sock absoprtion

 - more biomechanically efficient

 - low risk of injury

c. Underpronation (or supination)

 - excessive inward movement of the foot

 - more load is put on the outside of the foot, which is transferred to the knee, hip and lower back

 - high foot arch

 - rigid foot

 - high risk of injury but very rare case