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Clinical Disorders and the Sensory System
The Chiro.Org Blog
We would all like to thank Dr. Richard C. Schafer, DC, PhD, FICC for his lifetime commitment to the profession. In the future we will continue to add materials from RC’s copyrighted books for your use.
This is Chapter 4 from RC’s best-selling book:
“Basic Principles of Chiropractic Neuroscience”
These materials are provided as a service to our profession. There is no charge for individuals to copy and file these materials. However, they cannot be sold or used in any group or commercial venture without written permission from ACAPress.
Chapter 8: Clinical Disorders and the Sensory System
This chapter describes those sensory mechanisms, joint signals, and abnormal sensations (eg, pain, thermal abnormalities) that have particular significance within clinical diagnosis. The basis and differentiation of pain are described, as are the related subjects of trigger points and paresthesia. The chapter concludes with a description of the neurologic basis for the evaluation of the sensory system and the sensory fibers of the cranial nerves.
THE ANALYSIS OF PAIN IN THE CLINICAL SETTING
Although all pain does not have organic causes, there is no such thing as “imagined” pain. Pain that can be purely isolated as a structural, functional, or an emotional effect is rare. More likely, all three are superimposed upon and interlaced with each other in various degrees of status. This is also true for neural, vascular, lymphatic, and hormonal mechanisms.
Common Causes of Pain and Paresthesia
The common causes of pain and paresthesia are:
(1) obvious direct trauma or injury;
(2) reflex origins in musculoskeletal lesions, which deep pressure often exaggerates, such as trigger areas;
(3) peripheral nerve injury (eg, causalgia), which results in an intense burning superficial pain;
(4) the presence of nerve inflammations and degeneration of the peripheral or CNS, which frequently cause other changes indicative of such lesions;
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The Horizontal Neurologic Levels
The Chiro.Org Blog
We would all like to thank Dr. Richard C. Schafer, DC, PhD, FICC for his lifetime commitment to the profession. In the future we will continue to add materials from RC’s copyrighted books for your use.
This is Chapter 4 from RC’s best-selling book:
“Basic Principles of Chiropractic Neuroscience”
These materials are provided as a service to our profession. There is no charge for individuals to copy and file these materials. However, they cannot be sold or used in any group or commercial venture without written permission from ACAPress.
Chapter 4: The Horizontal Neurologic Levels
and Related Clinical Concerns
This chapter describes the basic functional anatomy and clinical considerations of the horizontal aspects of the supratentorial, posterior fossa, spinal, and peripheral levels of the nervous system.
OVERVIEW
The reader should keep in mind that the various aspects of the nervous system as described in this manual (eg, longitudinal and horizontal systems) are only reference guides that are visualizations of a patient’s nervous system in the upright position. They can be likened to the lines of longitude and latitude on a globe of the earth.
Such systems do not exist physically, but they do serve as excellent mental grid-like tools (viewpoints) during localization and areas in which and from which relationships can be described. For example, although the longitudinal systems take a general vertical course within the spinal column there are numerous alterations and they actually become horizontal when decussating. While the horizontal levels are spatially placed in and extend from the CNS in a general segmental manner, they soon take a widely diffuse course as they project toward their destinations. Thus, references to longitudinal and horizontal levels are just general viewpoints.
It is helpful for study purposes to isolate the body into certain systems, as described above, organize systems into organs, organs into tissues, tissues into cells, and cells into their components. However, we should keep in mind that, physically and functionally, there is only one integrated body and it is more than the sum of its parts. And even the body cannot be thought of as truly separate from its external environment. Although we may do this for study purposes, it is a limited viewpoint.
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The Longitudinal Neurologic Systems
The Chiro.Org Blog
We would all like to thank Dr. Richard C. Schafer, DC, PhD, FICC for his lifetime commitment to the profession. In the future we will continue to add materials from RC’s copyrighted books for your use.
This is Chapter 3 from RC’s best-selling book:
“Basic Principles of Chiropractic Neuroscience”
These materials are provided as a service to our profession. There is no charge for individuals to copy and file these materials. However, they cannot be sold or used in any group or commercial venture without written permission from ACAPress.
Chapter 3: The Longitudinal Neurologic Systems
This chapter succinctly describes the basic structure and function of the six major longitudinal systems; viz, the sensory, motor, visceral, vascular, consciousness, and cerebrospinal fluid systems.
As we begin this chapter, it might be well for the reader to subjectively grasp the significance of the motor and sensory systems as far as possible. One exercise in this is to imagine that you had become unconscious and someone has placed you in a remote dark empty cellar, far beyond any source of environmental sound. The first thing you realize is that you are a total sensory and motor paralytic from the neck caudad. You are unable to move even a fingertip because your motor system is not functioning. Because there is no feeling, you do not know whether you are recumbent or tied in a chair. Your vision is normal, but there is no light. Your hearing is normal, but there is no sound. Your taste buds are functional, but there is nothing to eat or drink. Your olfactory organs are functional, but there are no detectable odors. There is little left except thought and memory.
After a time in this predicament, thoughts undoubtedly arise such as, “I wish I had really looked at the beauty of the world when I had a chance. I wish I had listened to the music of the masters and even the birds in my backyard when I had a chance. I gulped down so many delicious meals. I had a beautiful garden, but I rarely took time to appreciate its design and fragrance. I even failed to take time to appreciate the texture of my own clothes. I was in such a hurry to go nowhere that was more important. I missed so much.”
OVERVIEW
The human nervous system is a marvel in organizing and adapting to internal and external environmental changes:
(1) The receptors and afferent neurons of the visceral and somatic input systems are necessary to detect internal and external environmental changes.
(2) The visceral efferent neurons and the muscles of the motor output system must be stimulated if action is to be taken.
(3) The integrative system serves as intermediary stations via a complex arrangement of interneurons whose synapses control impulse strength and signal direction from the sensory system to the motor system.
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 By Frank M. Painter, D.C. in Chiropractic Care on January 6th, 2013 at 1:54 pm
Clinical Biomechanics: Mechanical Concepts and Terms
The Chiro.Org Blog
We would all like to thank Dr. Richard C. Schafer, DC, PhD, FICC for his lifetime commitment to the profession. In the future we will continue to add materials from RC’s copyrighted books for your use.
This is Chapter 2 from RC’s best-selling book:
“Clinical Biomechanics:
Musculoskeletal Actions and Reactions”
Second Edition ~ Wiliams & Wilkins
These materials are provided as a service to our profession. There is no charge for individuals to copy and file these materials. However, they cannot be sold or used in any group or commercial venture without written permission from ACAPress.
Chapter 2: Mechanical Concepts and Terms
All motor activities such as walking, running, jumping, squatting, pushing, pulling, lifting, and throwing are examples of dynamic musculoskeletal mechanics. To better appreciate the sometimes simple and often complex factors involved, this chapter reviews the basic concepts and terms involved in maintaining static equilibrium. Static equilibrium is the starting point for all dynamic activities.
Energy and Mass
Biomechanics is constantly concerned with a quantity of matter (whatever occupies space, a mass) to which a force has been applied. Such a mass is often the body as a whole, a part of the body such as a limb or segment, or an object such as a load to be lifted or an exercise weight. By the same token, the word “body” refers to any mass; ie, the human body, a body part, or any object.
Energy
Energy is the power to work or to act. Body energy is that force which enables it to overcome resistance to motion, to produce a physical effect, and to accomplish work. The body’s kinetic energy, the energy level of the body due to its motion, is reflected solely in its velocity, and its potential energy is reflected solely in its position. Mathematically, kinetic energy is half the mass times the square of the velocity: m/2 X V524. In a closed system where there are no external forces being applied, the law of conservation of mechanical energy states that the sum of kinetic energy and potential energy is equal to a constant for that system.
Potential energy (PE), measured in newton meters or joules, is also stored in the body as a result of tissue displacement or deformation, like a wound spring or a stretched bowstring or tendon. It is expressed mathematically in the equation PE = mass X gravitational acceleration X height of the mass relative to a chosen reference level (eg, the earth’s surface). Thus, a 100-lb upper body balanced on L5 of a 6-ft person has a potential energy of about 300 ft-lb relative the ground.
The Center of Mass
The exact center of an object’s mass is sometimes referred to as the object’s center of gravity. When an object’s mass is evenly distributed throughout, the center of mass is located at the object’s geometric center. In the human body, however, this is infrequently true, and the center of mass is located towards the heavier, often larger, aspect. When considering the body as a whole, the center of mass in the anatomic position, for instance, is constantly shifted during activity when weight is shifted from one area to another during locomotion or when weight is added to or subtracted from the body.
The term weight is not synonymous with the word mass. Body weight refers to the pull of gravity on body mass. Mass is the quotient obtained by dividing the weight of a body by the acceleration due to gravity (32 ft/sec524). Each of these terms has a different unit of measurement. Weight is measured in pounds or kilograms, while mass is measured by a body’s weight divided by the gravitational constant. The potential energy of gravity can be simply visualized as an invisible spring attached between the body’s center of mass and the center of the earth. The pull is always straight downward so that more work is required to move the body upward than horizontally (Fig. 2.1).
Newton’s Laws of Mechanics
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By Frank M. Painter, D.C. in Diagnosis on August 6th, 2012 at 12:08 pm
Multiple Myeloma Presenting as Sacroiliac Joint Pain: A Case Report
The Chiro.Org Blog
SOURCE: J Can Chiropr Assoc. 2012 (Jun); 56 (2):94-101
Danielle Southerst, BScH, DC, John Dufton, DC, MSc, MD, Paula Stern, BSc, DC, FCCS(C)
Canadian Memorial Chiropractic College, Division of Graduate Studies, 6100 Leslie Street, Toronto, ON, M2H 3J1, (416) 482-2344 x 287; dsoutherst@cmcc.ca.
Multiple Myeloma (MM) is the most common primary cancer of bone in adults. The clinical presentation of MM is varied and depends on the sites and extent of involvement. Most importantly for chiropractors, the leading clinical symptoms of MM are related to bone neoplasm and may mimic pain of musculoskeletal origin. The following is the case of a 56 year old male chiropractic patient presenting with a 6 month history of sacroiliac joint pain previously diagnosed and managed unsuccessfully as a hematoma by multiple providers. Physical examination, imaging, and laboratory investigations confirmed a diagnosis of MM. The case report describes relevant pathophysiology, clinical presentation, imaging, and management for MM, while illustrating key issues in patient management as they relate to chiropractic practice and the recognition of pathology in the context of musculoskeletal pain.
From the FULL TEXT Article
Introduction:
Multiple Myeloma (MM) is a primary malignancy of bone marrow characterized by clonal proliferation of plasma cells and production of monoclonal immunoglobulin. It is the most common primary bone cancer in adults [1,2] contributing to 1.3% of new cancer cases in Canada and 1.9% of cancer deaths. [3] In 2008, an estimated 6000 Canadians were living with the disease, including 2100 newly diagnosed. [3] Myeloma is slightly more prevalent in males [4-6] and blacks. [4,5,7] The median age at diagnosis is 66, with the majority diagnosed over the age of 60; [8,9] however in a review of 1027 patients diagnosed with MM, 30% were under the age of 60 and the age of diagnosis ranged from 20–92. [8] The most common symptoms reported are those related to bone neoplasm including unexplained backache that is often severe and precipitated by movement. [8,11] These symptoms may motivate a patient to seek conservative care for what is assumed to be a complaint of musculoskeletal origin. This case emphasizes key components of patient management as they relate to chiropractic practice and the recognition of pathology in the context of a patient presenting with pain of presumed musculoskeletal origin.
Discussion:
Pathophysiology
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A Practical Guide to Avoiding Drug-Induced Nutrient Depletion
The Chiro.Org Blog
SOURCE: Nutrition Review ~ October 2011
By Hyla Cass, MD
A little known, but potentially life-saving fact is that common medications deplete your body of a host of vital nutrients essential to your health. This practical guide will show you how to avoid drug-induced nutrient depletion and discuss options for replacing nutrient-robbing medications with natural supplements.
America has been called a pill-popping society, and the statistics bear this out. Nearly 50 percent of all American adults regularly take at least one prescription drug, and 20 percent take three or more. [1] Our increasing reliance on prescription medications has contributed to the growing problem with nutrient depletion. The truth is that every medication, including over-the-counter drugs, depletes your body of specific, vital nutrients. This is especially concerning when you consider that most Americans are already suffering from nutrient depletion. Additionally, many of the conditions physicians see in their everyday practice may actually be related to nutrient depletion. The good news is that, armed with information and the right supplements, you can avoid the side effects of nutrient depletion, and even better, you may be able to control and prevent chronic diseases, such as diabetes, cardiovascular disease and osteoporosis.
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A Common Scenario
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By Frank M. Painter, D.C. in Announcement on June 14th, 2012 at 10:16 pm
The Subluxation Complex Saves Diagnosis for Texas Chiropractors
The Chiro.Org Blog
SOURCE: Dynamic Chiropractic
By James Edwards, DC
On April 5, 2012, the Third Court of Appeals of Texas issued a 58-page opinion in Cause No. 03-10-673-CV – the Texas Board of Chiropractic Examiners (TBCE) and the Texas Chiropractic Association (TCA) vs. the Texas Medical Association (TMA), the Texas Medical Board (TMB) and the State of Texas.
According to an April 6, 2012 communication by the Texas Chiropractic Association [1], the case presented three questions for the court:
1) Are the two TBCE rules that allow chiropractors to make certain “diagnoses” valid?
2) Can chiropractors perform MUA?
3) Can chiropractors perform needle EMG?
Here’s what the Court of Appeals had to say in the matter:
Diagnosis
On the two most important issues presented by the TCA, the Court of Appeals upheld the validity of TBCE’s Rules 75.17(d)(1)(A) and (B) (“the scope of practice rules”). The first rule, 75.17(d)(1)(A), permits chiropractors to render diagnoses “regarding the biomechanical condition of the spine and musculoskeletal system,” and lists six typical diagnostic areas as examples of what is within the scope of practice. At the district court level, Judge Yelenosky had struck down that rule, stating that it created an unlimited authorization to diagnose any disease or condition, which, he said, exceeded chiropractors’ scope of practice.
The Court of Appeals disagreed and reversed Judge Yelenosky’s decision. The court found that the TBCE rule does not exceed the scope of practice because the rule limits chiropractors to making diagnoses of the biomechanical condition of the spine and musculoskeletal system.
The second rule, 75.17(d)(1)(B), permits chiropractors to diagnose subluxation complexes of the spine or musculoskeletal system, and lists three examples of what is within the scope of practice. The Texas Medical Association and Texas Medical Board had challenged that rule, claiming that the rule allowed chiropractors to diagnose neurological conditions, and pathological and neurophysiological consequences that affect the spine and musculoskeletal system. At the district court level, Judge Yelenosky agreed and struck down the rule because he found that it expanded the scope of chiropractic beyond what was allowed in the Chiropractic Act.
Again, the Court of Appeals disagreed with District Court Judge Yelenosky. The appeals court acknowledged that a subluxation complex could have functional or pathological consequences that affect essentially every part of the body. But the court found that the rule itself only allowed chiropractors to render a diagnosis regarding a subluxation complex of the spine or musculoskeletal system. That authority, the appeals court held, was consistent with the Chiropractic Act.
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TMJ Trauma and Its Rehabilitation
The Chiro.Org Blog
Clinical Monograph 13
By R. C. Schafer, DC, PhD, FICC
TEMPOROMANDIBULAR JOINT DYSFUNCTION
Proper treatment of TMJ dysfunction must be based on a thorough case history, a complete physical workup, an evaluation of the cranial respiratory impulse and craniosacral mechanisms, and a detailed examination of the TMJ, cranium, and cervical spine. Unfortunately, radiographs to determine abnormal joint space are rarely successful unless over 30% of the bone has been destroyed.
A blow to the jaw is easily transmitted to the temporal bones. As mentioned previously, osteopathic research suggests that a subluxated temporal bone is often the focal fault. This is reported to be grossly indicated by flattening (temporal internal rotation) or protrusion (temporal external rotation) of an ear from the skull.
Symptomatology
The major symptoms of TMJ dysfunction are masticator muscle fatigue and pain, which are usually described as a severe, unilateral (rarely bilateral), dull facial ache that is often fairly localized to an area just anterior to the tragus of the ear. The onset of pain is gradual, progressively increasing over several days or months. It is aggravated by chewing and opening and closing the mouth. Precipitation is often made by eating an apple, a wide yawn, snorkeling, prolonged dental work, playing a wind instrument, prolonged chewing, a bump or pressure on the mandible, sleeping in the prone position, or a cervical whiplash.
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and our:
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Forearm and Wrist Trauma
The Chiro.Org Blog
Clinical Monograph 18
By R. C. Schafer, DC, PhD, FICC
As with most parts of the body, traumatic effects in the forearm or wrist may occur abruptly (eg, fracture, strain, sprain) or be the result of long-term microtrauma (eg, tunnel syndromes, arthritis, entrapment by scar tissue).
BACKGROUND
Screening injuries of the forearm and wrist
Joint Motion Restriction
Restriction in pronation suggests a disorder at the elbow, radioulnar articulation of the wrist, or within the forearm. Restriction in supination is associated with a disorder of the elbow or radioulnar articulation of the wrist. Thickened tissues may cause compression symptoms. A palpable nontender ganglion may be found on either the dorsal or volar aspect of the wrist, perceived as a pea-size or slightly larger jelly-like cyst.
Significance of Tenderness
Tenderness over the medial collateral ligament, which rises from the medial epicondyle, is a sign of valgus sprain. Muscle tenderness in the wrist flexor-extensor group is characteristic of flexor-pronator strain (eg, tennis, screwdriving motions). Tender, possibly taut, wrist extensors on the lateral aspect are often associated with tennis elbow. Tenderness in the first tunnel on the radial side is a common site for stenosing tenosynovitis associated with a positive Finkelstein’s sign.
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Arm and Elbow Trauma
The Chiro.Org Blog
Clinical Monograph 17
By R. C. Schafer, DC, PhD, FICC
The shoulder girdle is a multiaxial intricately synchronized joint complex that has considerable power and an extreme range of motion. The anterior, superior, and posterior shoulder muscles provide the great power, and the collateral ligaments do not appreciably limit motion in any plane. Thus, stability must be provided by muscles: essentially the rotator cuff and subscapularis muscles of the arm, which are aided slightly by the glenohumeral ligaments.
BACKGROUND
The proximal ulna forms the most important articulation in the elbow area, while the distal radius forms the most important articulation in the wrist.
Elbow area injuries are commonly the result of direct blows or falls. Avulsion-type injuries of the elbow are often seen as a result of acute or chronic strain at a site of tendon or ligament attachment. As in all traumatic injuries, the sooner the patient is examined after injury, the more accurate the diagnosis. Swelling, spasm, tenderness, and motion limitations rapidly cloud the picture. A list of common elbow injury syndromes is shown in Table 1.
Table 1. Common Elbow Injuries
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Initial Case Management Following Trauma
The Chiro.Org Blog
Clinical Monograph 2
By R. C. Schafer, DC, PhD, FICC
Without a doubt, no other health-care approach equals the efficacy of chiropractic in the general field of conservative neuromusculoskeletal rehabilitation.
For many centuries, therapeutic rehabilitation was a product of personal experience passed on from clinician to clinician. In the last 20 years, however, it has become an applied science. In its application, of course, much empiricism remains that can be called an intuitive art –and this is true for all forms of professional health care.
INTRODUCTION
The word trauma means more than the injuries so common with falls, accidents, and contact sports. Taber [1] defines it as “A physical injury or wound often caused by an external force or violence” or “an emotional or psychologic shock that may produce disordered feelings or behavior.” This is an extremely narrow definition for trauma can also be caused by intrinsic forces as seen in common strain. In addition to its cause being extrinsic or intrinsic, with a physical and emotional aspect, it also can be the result of either a strong overt force or repetitive microforces. This latter factor, so important in treating a unique patient’s specific pathophysiology, is too often neglected outside the chiropractic profession.
Taber [1] states rehabilitation is “The process of treatment and education that lead the disabled individual to attainment of maximum function, a sense of well being, and a personally satisfying level of independence. The person requiring rehabilitation may be disabled from a birth defect or from an illness. The combined effects of the individual, family, friends, medical, nursing, allied health personnel, and community resources make rehabilitation possible.” It is surprising that Taber excludes trauma as a prerequisite for rehabilitation for it is the most common factor involved.
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Upper Back and Thoracic Spine Trauma
The Chiro.Org Blog
Clinical Monograph 23
By R. C. Schafer, DC, PhD, FICC
Upper-thoracic spasms and trigger points are common within the milder complaints heard in a chiropractic office. Typical posttraumatic injuries of the posterior thorax involve the large posterior musculature, thoracic spine, spinocostal joints, and tissues supporting and mobilizing the scapula (especially the rhomboids). Upper right abdominal quadrant ailments (eg, gallbladder, liver) commonly refer pain and sometimes tenderness to the right scapular area.
BACKGROUND
Severe biomechanical lesions of the thoracic spine are seen less frequently than those of the cervical or lumbar spine. But when they occur, they may be serious if related to disc protrusion or a dynamic facet defect. Shoulder girdle, rib cage, spinal cord, cerebrospinal fluid flow, and autonomic visceral problems originating in the thoracic spine are far from being scarce. Common biomechanical concerns are the prevention of thoracic hyperkyphosis, flattening, or twisting, as each can be suspected to contribute to both local and distal, acute and chronic possibly health-threatening manifestations.
Thoracic Fixations
The study of the thoracic spine is often perplexing. It was Gillet’s opinion that many fixations found in the thoracic spine were secondary (compensatory) to focal lesions in either the upper cervical spine or the sacroiliac joints. Thus, a maze of potential variables exists. Empiric evidence has suggested that many thoracic problems have their origin in its base, the lumbar spine or lower, while others are reflections of cervical reflexes. Also, a thoracic lesion may manifest symptoms in either the cervical or the lumbar spine. Foremost in an examiner’s thoughts should be the recognition that the thoracic spine is the structural support and sympathetic source for the esophagus, heart, bronchi, lungs, diaphragm, stomach, liver, gallbladder, pancreas, spleen, kidneys, and much of the pelvic contents. Referred pain and tenderness from these organs to the spine are common.
Screening Thoracic Vertebral Fractures
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A Basic Rehabilitative Template
The Chiro.Org Blog
Clinical Monograph 1
By R. C. Schafer, DC, PhD, FICC
INTRODUCTION
Injuries can be classified into 13 types: abrasions, contusions, strains, ruptures, sprains, subluxations, dislocations, fractures, incisions, lacerations, penetrations, perforations, and punctures. This paper will not detail the management of burns or injuries requiring referral for operative correction, suturing, or restricted chemotherapy.
Objectives
Except for the most minor injuries, traumatized neuromusculoskeletal tissues are benefited by alert restorative procedures. The more serious the injury, the more prolonged is and the greater the need for professionally guided rehabilitation. The first step in rehabilitation is to explain to the patient that rehabilitation is just as important as the initial care of the injury. The goal is not only to restore the injured part to normal activity or as near normal as possible in the shortest possible time but also to prevent posttraumatic deterioration. It is an individualized process that requires patient dedication. The author recognizes that it is easier to write about comprehensive planning than to motivate some patients to follow prescriptions after pain has subsided.
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Most authorities would agree with Harrelson when he lists the goals of rehabilitation as:
- decreased pain;
- decreased inflammatory response to trauma;
- return of full pain-free active joint ROM;
- decreased effusion;
- return of muscle strength, power, and endurance; and
- regain of full asymptomatic functional activities at the preinjury level (or better).
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Joint Trauma:
Perspectives of a Chiropractic Family Physician
The Chiro.Org Blog
Clinical Monograph 8
By R. C. Schafer, DC, PhD, FICC
INTRODUCTION
The general stability of synovial joints is established by action of surrounding muscles. Excessive joint stress results in strained muscles and tendons and sprained or ruptured ligaments and capsules. When stress is chronic, degenerative changes occur.
The lining of synovial joints is slightly phagocytic, is regenerative if damaged, and secretes synovial fluid that is a nutritive lubricant having bacteriostatic and anticoagulant characteristics. This anticoagulant effect may result in poor callus formation in intra-articular fractures where the fracture line is exposed to synovial fluid. Synovial versus mechanical causes of joint pain are shown in Table 1.
Table 1. Synovial vs Mechanical Causes of Joint Pain
| Feature |
Synovitic
Lesions |
Mechanical
Lesions |
| Onset |
Symptoms fairly consistent, during use and at rest. |
Symptoms arise chiefly during use |
| Location |
Any joint may be involved. |
Primarily involves weight-bearing joints. |
| Course |
Usually fluctuates. Episodic flares are common. |
Persistently worsening progression. No acute exacerbations. |
| Stiffness |
Prolonged in the morning. |
Little morning stiffness. |
| Anti-inflammatory effect |
Aided by cold and other anti-inflammatory therapies. |
Anti-inflammatory therapy of only minimum value. |
| Major pathologic features |
Negative radiographic signs or diffuse cartilage loss, marginal bony erosions, but no osteophytes. |
Radiographic signs of cartilage loss and osteophyte developments |
Periarticular Lesions
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Shoulder Girdle Trauma
The Chiro.Org Blog
Clinical Monograph 16
By R. C. Schafer, DC, PhD, FICC
The articulations of the scapula, clavicle, and the humerus function as a biomechanical unit. Only when certain multiple segments are completely fixed can these parts possibly function independently in mechanical roles. Forces generated from or on one of the three segments influence the other two segments. Thus, they will be described here as a functional unit. Please underscore this point in your mind as you read this paper.
BACKGROUND
Shoulder pain can arise from either local or systemic causes. Jaquet points out that about 95% of all shoulder disorders are due to four conditions:
- adhesive capsulitis
- simple tendinitis,
- tendinous perforation and rupture, and
- hyperalgesic calcareous tendinitis.
Note that three of these four conditions are tendinous in origin, but tendon inflammation is not as common in the shoulder as it is in the elbow and wrist. However, because all tendons are relatively avascular, all are subject to chronic trauma, microtears, slow repair, and aging degeneration.
As in so many musculoskeletal disorders, thorough investigation of the history of shoulder pain may reveal that trauma did not initiate the first attack or an injury was just a precipitating event that revealed an underlying degenerative disorder. Besides direct injury, shoulder pain may have an inflammatory, a neurologic, a psychologic, a vascular, a metabolic, a neoplastic, a degenerative, a congenital, an autoimmune, or a toxic origin.
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Deciphering Shoulder Complaints
Shoulder pain has a high incidence. Cailliet says that it ranks third to low-back and neck pain. Despite its prevalence, posttraumatic shoulder pain can be deceiving. Accurate diagnosis is not an easy task. For example, there may be unavoidable occupational stress in the clinical picture that is aggravating the condition and delaying healing. How should the patient react when a doctor says “avoid overhead work” and the patient makes his living as a painter or pipe fitter of ceiling sprinkler systems? Temporary rest can be provided but not permanent relief from such occupational stress. It may have taken the patient many years of effort to reach his present status. This is not easily put aside. Counsel the patient thoroughly — from his or her viewpoint.
Normal mobility is extensive. The glenohumeral joint alone expresses abduction, adduction, elevation, extension, external rotation, flexion, horizontal abduction, horizontal adduction, and internal rotation. Thus, a thorough knowledge of shoulder kinematics, neurology, angiology, myology, and kinesiology is required for proper treatment to be applied.
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By Frank M. Painter, D.C. in Cervical Spine on May 15th, 2012 at 1:36 pm
Cervical Spine Trauma
The Chiro.Org Blog
Clinical Monograph 22
By R. C. Schafer, DC, PhD, FICC
The cervical spine provides structural stability and support for the cranium, and a flexible and protective column for movement and balance adaptation, along with housing of the spinal cord and vertebral arteries. It also allows for directional orientation of the eyes and ears. Nowhere in the spine is the relationship between the osseous structures and the surrounding neurologic and vascular beds as intimate or subject to disturbance as it is in the cervical region.
BACKGROUND
Whether induced by trauma or not, cervical subluxation syndromes may be reflected in total body habitus. IVF insults, and the effects of articular fixations can manifest throughout the motor, sensory, and autonomic nervous systems. Many peripheral nerve symptoms in the shoulder, arm, and hand will find their origin in the cervical spine, as may numerous brainstem disorders.
Common Injuries and Disorders of the Cervical Spine
Cervical spine injuries can be classified as:
- Mild (eg, contusions, strains);
- Moderate (eg, subluxations, sprains, occult fractures, nerve contusions, neurapraxias);
- Severe (eg, axonotmesis, dislocation, stable fracture without neurologic deficit); and
- Dangerous (eg, unstable fracture-dislocation, spinal cord or nerve root injury).
Spasm of the sternocleidomastoideus and trapezius can be due to strain or irritation of the sensory fibers of the spinal accessory nerves as they exit with the C2–C4 spinal nerves. The C1 and C2 nerves are especially vulnerable because they do not have the protection of an IVF. Radicular symptoms are rarely evident unless an IVD protrusion or rupture is present.
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Prevalence
Because of its great mobility, relatively small structures, and weight-bearing role, the cervical spine is a frequent site of severe spinal nerve injury and subluxation/fixations. A large variety of cervical contusions, Grade 1–3 strains and sprains, subluxations, disc syndromes, dislocations, and fractures will be seen as the result of trauma.
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Soft-Tissue Neck Trauma
The Chiro.Org Blog
Clinical Monograph 15
By R. C. Schafer, DC, PhD, FICC
The mechanical relationship between the head and neck has been crudely compared to a brick attached to a flexible rod. As the structural mass of the head is so much greater than that of the neck, it is no wonder that injuries of the neck are so prevalent. Even the person with a short neck and well-developed neck muscles and ligaments is not free of potential injury.
BACKGROUND
The viscera of the neck serve as a channel for vital vessels and nerves, the trachea, esophagus, and spinal cord, and as a site for lymph and endocrine glands. When the head is in balance, a line drawn through the nasal spine and the superior border of the external auditory meatus will be perpendicular to the ground.
Anterior injuries are more common to the head and chest as they project further forward, but a blunt blow from the front on the head or chest may cause an indirect extension or flexion injury of the cervical spine and soft tissues of the neck. In any neck injury, the injury may not be the product of a single force. For example, while extension, flexion, and lateral flexion injuries are often described separately, rotational, compressive, tensile, and shearing forces are invariably part of the picture.
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Chronic Neck Pain and Chiropractic Page
The anterior and lateral aspects of the neck contain a variety of vital structures that have no bony protection. Partial protection is provided by the cervical muscles, the mandible, and the shoulder girdle.
After neck injury, a careful neurologic evaluation must be conducted, and every examination should begin with a thorough case history. See Table 1. Note any signs of impaired consciousness, inequality of pupils, or nystagmus. Do outstretched arms drift unilaterally when the eyes are closed? Standard coordination tests such as finger-to-nose, heel-to-toe, heel-to-knee, and for Romberg s sign should be conducted, along with superficial and tendon reflex tests.
Table 1 Typical Questions Asked During the Investigation of Joint Pain
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The Foundation of Biomechanical Evaluation Following Injury
The Chiro.Org Blog
Clinical Monograph 9
By R. C. Schafer, DC, PhD, FICC
INTRODUCTION
The study of human biomechanics includes the mechanical principles involved, the physiologic considerations of muscle length-tension relations, and an understanding of the controlling neuromotor mechanisms and the sensory feedback apparatus, reflecting both locomotor activity and cerebral function. Applied biomechanics is the application of the practical principles of mechanics (the study of forces and their effects) to the body in movement and at rest.
The more biomechanics are understood, the better musculoskeletal disorders in sports and the workplace can be appreciated. The same can be said of physical work and recreational activities. The athlete is constantly attempting to improve performance by applying biomechanical principles to specific movements. The same is true for ergonomics in the workplace. From the viewpoint of the doctor, knowledge of the mechanisms involved in an injury is necessary to evaluate an injury accurately.
PERTINENT BIOMECHANICS
From a pure musculoskeletal standpoint, the human body is a mechanical device. All mechanical devices are subject to wear during use that reflects their history of destructive forces. Unique to living tissue is its ability to heal, adapt, and strengthen, which provides a dialogue between catabolic and anabolic forces. While machines convert thermal or chemical energy into mechanical energy, muscle tissue transforms nutrients directly into mechanical energy without a thermal intermediary. Body energy enables it to overcome resistance to motion, to produce a physical effect, and to accomplish work.
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Chiropractic Rehabilitation
Practical Concepts
The body’s kinetic energy is reflected in its velocity, and its potential energy is reflected in its position. Work is the result of a force acting through a distance. Power relates to the time element and the work accomplished. There is a close association in the same unit of time between the work accomplished by a weight lifter and that of a sprinter.
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How To Use the Evaluation & Management (E&M) Codes Properly: Part III
The Chiro.Org Blog
Part III: Mastering the
Evaluation & Management (E&M) Guidelines
Jump to: Part 1 or Part 2
FROM: Chiropractic Economics
By Kathy Mills Chang, MCS-P
The medical decision making component ties it all together.
Welcome to part three this focus series on the evaluation and management (E/M) guidelines. This will wrap up what you need to know to stay compliant with E/M coding for the Centers for Medicare and Medicaid Services (CMS).
In the last installment, the elements of your patient’s examination were reviewed and you learned how it is the second of the three key elements of the patient’s E/M service. Now, the third part of this E/M documentation series will unravel the final component of the E/M code: medical decision making (MDM). For chiropractors, this is usually the diagnosis and treatment plan.
Three key components of the E/M guidelines:
- Patient history
- Examination
- Medical Decision Making (MDM)
Remember that your patient’s medical record should establish a chronological record of exams, tests and results, and treatments and treatment plans (including the diagnosis and prognosis of the illness or disease). The medical record should corroborate the reimbursement request and is requisitioned by most payers for adjudication of claims when reimbursement is in question.
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How To Use the Evaluation & Management (E&M) Codes Properly: Part II
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Part II: A Closer Look at Evaluation & Management (E&M) Guidelines
Jump to: Part 1 or Part 3
FROM: Chiropractic Economics
By Kathy Mills Chang, MCS-P
Make sure you know how to fulfill the “examination” component. In part one of this series, the components of a patient’s history were reviewed, and you learned how it is the first of three elements that help you justify and document your evaluation and management (E/M) service. In the second part of this series, you’ll learn about the objective information required to properly document the examination.
Remember, the medical record establishes a chronological record of exams; tests and results; treatments; and treatment plans, including the diagnosis and prognosis of the illness or disease. Its job is to corroborate the reimbursement request and is requisitioned by most payers for adjudication of claims when reimbursement is in question.
For this reason, your medical record is a vital piece of the reimbursement puzzle, too. Understanding all the requirements, including those of the examination, is critical.
There are four levels of E/M services that are based on four types of examinations:
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How To Use the Evaluation & Management (E&M) Codes Properly: Part I
The Chiro.Org Blog
In order to document your history, diagnosis, and treatment of patients in accord with rules set out by the Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG), your patient record should address: (1) Patient history, (2) Examination, and (3) Medical decision-making (MDM). These three components are addressed in the following three articles, which also make reference to the Sample Worksheet included with Part III
Part I: The 3 Key Components of the Evaluation & Management (E&M) Guidelines
Jump to: Part 2 or Part 3
Chiropractic Economics
By Kathy Mills Chang, MCS-P
As regulatory and insurance guidelines tighten, the quality of your evaluation and management documentation is more important than ever before.
Just like a great story, the patient’s notes for an episode of care must have a beginning, middle, and end. This article is a review of the first of three parts of evaluation and management (E/M) documentation, and its focus is on the beginning of the patient’s story — the history. More information on the next two key E/M components will be presented in future issues of this magazine.
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