NMS Test 3 Notes 1 of 9
Dr. Christy
Orthopedic testing people think that it is going to give the diagnosis
not 1 orthopedic test is designed to reproduce the signs of a subluxation
orthopedic tests are designed to recreate a chief complaint
+ SLR what does it really test for…it effects many things so many things
would be tested…how could it be just disc
o Subluxation with a chief complaint? Not always
Overall the orthopedic tests show a lot when they are negative too
If most subluxations are asymptomatic then what do you use to determine that there is a
subluxation.
At best the orthopedic test will tell you where the problem is, but not what the problem is.
This is only when there is a reproducible complaint that the orthopedic test will be an
identifier.
If you ask the patient to show you what they do to make the chief complaint appear the
patient will do the orthopedic test for you.
Is a sprain strain the same as a subluxation? NO, but a sprain strain can cause a
subluxation.
If someone comes in with a headache, then you do a compression test and the patient says
that there is some pain, but not severe. So, after all the tests (orthopedic and neurological
tests) you do some motion palpation, x-ray, and then after a little lateral sheering you
decided as a chiropractor that this is a subluxation. The subluxation was found not by the
orthopedic tests, but by the motion palpation or the chiropractic checks.
When looking for a subluxation, orthopedic tests will not be the main determinant in
finding them.
Disc
Discs can herniate, protrude.
Nucleus pulposes, and angular fibers make up the disc. It is innervated by the recurrent
meningeal (aka sinovertebral) also there is a post ganglionic fiber that joins the recurrent
meningeal. This nerve fiber has C-fibers (substance p) and autonomics (NE). Substance P
and NE are pro inflammatory.
Facet irritation causes the c-fibers to fire in side the cord. So glutamate is released inside
the cord and the NT is going to hit more than one nerve. This causes substance P to be
released at the disc space too. So, any thing going on outside the disc can cause disc
degradation due to the excitation in the cord causing increased release of pro
inflammatory NT to the disc.
NMS Test 3 Notes 2 of 9
Dr. Christy
Discogenic pain disc itself can become a source of pain, even if the disc works
the
normal or looks normal. There is no way to tell for sure that the disc is the problem. (no
deficits, deep dull ache, and we do not know how to figure out the problem)
If the disc herniates then there is evidence of the disc being the problem. So if a disc
protrudes lateral or medial it is determined by where the nerve root is located..
So if L5 is herniated then S1 nerve root will be affected and if the disc is a lateral disc
herniation then the lateral side of the nerve is affected.
Lateral Disc herniations have better outcomes than the medial ones.
Lateral disc buldge, you lean away from the pain.
Sclerotomal pseudoradicular pain
no neurological signs
no paresthesiae
no tension sign
SLR, Braggerts
Disc Buldge
Dural sleeve or sheeth encompases the nerve. So there should be no adherence
to the nerve or the IVF from the sheeth.
o The sinuvertebral nerve will inervate its own dural sheeth
o The dural sleeve is segmentally innervated (innervated exclusively by one
nerve)
o The recurrent (SV nerve) continues past the dural sleeve and innervates a
little above and below the area on the cord from the IVF.
If a patient had irritation from a disc buldge the C-fibers would fire and all NT
to be put onto the nerves that all overlap. So pain would be felt all over in the
area. Lumbago of dural origin (pain). (posterior or central disc buldge cause
this)
Rene Cyriax M.D. – discussed this pain pattern and coined the term…”extra
segmental pain pattern” (non-segmental)
A central disc buldge is notorious fro causing lumbago pain pattern
Dural Signs do they all need to be positive?
o Valsalva
o Neck Flexion (soto hall)
o SLR = should be called the RLR
o Well Leg Raise = should be called the LLR
In our case there is no leg involvement so where does the leg come
in
There are no A fibers in the dura
Paresthesia = neurological
if the patient was put into the Kemp’s maneuver and it was exaggerated…then
there would be some tingling in the toes
NMS Test 3 Notes 3 of 9
Dr. Christy
1. CC Burning Anterior thigh pain (burning is related to nerve normally)
a. + Ely (extension in lumbar spine going on with stretching of anterior
thigh, supposed to be for SI pain)
b. + Kemps (extension of lumbar spine, stretches ant. thigh, jams facets)
c. + Percussion (if positive…pain must be coming from the spine)
d. + Valsalva (space occupying lesion within the spinal canal if positive)
e. + Neck Flexion (similar to Soto Hall…puts stress on Dura)
f. – SLR
i. Possible Answers to this diagnosis (correct one in bold)
1. L2 disc herniation
2. Sclerotogenous referral
3. L3 IVF encroachment
4. Lumbar facet syndrome
5. Meralgia paresthetica
2. CC Generalized low back pain; spasm. No trauma. (NOT NEUROLOGICAL)
a. + RLR
b. +LLR
c. + Kemp
d. + Forward Flexion
e. – Valsalva
f. – Bechterew
i. Possible Answers to this diagnosis (correct one in bold)
1. Sciatic neuralgia (neurological?)
2. DJD (spondylosis = arthritis)
3. Lumbar sprain/strain (trauma?)
4. Central Disc ( + valsalva?)
5. Dural sheath irritation (sclerotome referral?)
3. CC Back pain and spasm associated with left buttock and upper leg pain
a. + leg raise for back pain
b. + valsalva for back pain
c. + Left Kemp for back pain
d. + Forward flexion for back pain
e. + Ely
f. – Bechterew
g. – Neck Flexion
h. – Right Kemp
i. Possible Answers for this diagnosis (answer in bold)
1. L5 Disc syndrome
2. L4/L5 osteophytic impingement
3. Facet syndrome
4. Sciatica
5. Sclerotogenous
NMS Test 3 Notes 4 of 9
Dr. Christy
4. CC right back pain associated with right SI dermatomal leg pain and paresthesiae.
Lumbar DJD: sprain injury 2 weeks ago.
a. + Milgrims (
b. + SLR
c. + Kemp
d. + Bechterew
e. + Braggard
f. – WLR
g. – Valsalva (for central space occupying lesion)
h. – Neck Flexion
i. Possible Answers for this diagnosis (answer in bold)
1. dural sheath irritation (sclerotomal)
2. Central disc (lumbago pain)
3. Sciatica
4. Osteophytic impingement (spur)
5. Posterolateral disc
Focal diagnosis is given with the orthopedic tests, but no ideological diagnosis. So, it
won’t tell you exactly what the exact thing is.
Ex: Valsalva is used for the space occupying lesion, but what is occupying the
space?
Strain- soft tissue injury to contractile tissue
Longitudinal (occult / hidden / myofascial) – intercellular injury usually
o Sometimes called spindle injury – lengthening of a hypotonic muscle,
capillary bleeding, lymph channels in area, free nerve endings
Transverse – when injury is through the muscle cells (direct trauma, excessive
resistance against contraction), pain on palpation, but not on Active movement
Concentric Vs Eccentric
Concentric – insertion and origin together (active and passive motion)
Eccentric – insertion and origin separated
Strain relating to the spindle
The nuclear chain has sarcomeres on each end called the nuclear ends and detects stretch.
This information is transported to through the 1A fiber. Then gamma is activated and
shortens the muscle, yet takes stretch off the IIA fiber while applying stretch back to the
1 A fiber. Then the flower spray aka annulofiber aka IIA fiber seems to play a role
that is not well understood, it is smaller than 1 A, slower, and multi synaptic. These
things all make up the muscle spindle.
IIA Fiber can inhibit or excite the 1 A fiber since it is multi synaptic
Group 1 flexers, int. rotators, adductors (joint closing muscles, fetal
position)
o IIa will enhance the Ia and increase tone
Group 2 extensors, external rotators, abductors (postural muscles, or joint
opening muscles)
NMS Test 3 Notes 5 of 9
Dr. Christy
o IIa inhibit Ia to reduce tone usually
o Intrinsic spinal muscles (involuntary mutifida, inter transversarii)
SOME muscles can be MIXED or have both groups
Maximal / sustained stretch this over comes the neural ends and stretch
occurs
ICA – isometric contraction of the antagonist
o If you want to reduce the tone of a spastic muscle then contract the
antagonist
Passive stretch
Contract/relax/stretch – contract – activate GTO, but stop 1a Firing.
White = fast twitch
Red = slow twitch (postural)
Thoracic Outlet Syndrome
Common Symptoms
Tingling, numbness, (most of the numbness and tingling is found in the ulnar
dermatome C7) cold digits, swollen digits, symptoms come and go with arm movement,
minimal pain, mostly achiness, bluish discoloration of nail beds, no reproduction of
symptoms on cervical examination
4 Major forms consists of nerves and vessels (neurovascular) (tingling and numness
more prevalent in TOS, lightning like pain incredibly rare
Scalenus Anticus Syndrome – there will be entrapment of the neurovascular
bundle. When patient turns towards side of dysfunction then the bundle will be
constricted (this is what usually reproduces the signs). (addisons Test)
Cervical rib – not usually the problem
Hyperabduction Syndrome – the Wrights test, bg
Costoclavicular Syndrome – entrapment between the 1st rib and the clavical
(clavicular compression will cause S&S)
Pressure on Pressure off Digital movement
Peripheral N Numbness paresthetic tingling inc tingling
Nerve Root Pain Relief no change
Paresthetic storm-peripheral nerve compressed and upon moving patient experiences
flood of tingling.
In TOS moving shoulder increases symptoms, if cervical problem then symptoms
relieved by distraction.
4/7/05
Decreased antiversion >12° - foot in
Decreased retroversion 12° - foot inward, internal rotation
Don’t use foot as indicator, use patella – it would point outward as well
Trendelenburg gait & gluteus medius limp
4/11/05
Trendelenberg gait – this is when one hip is higher than the other when the patient lifts
one leg.
NMS Test 3 Notes 7 of 9
Dr. Christy
At the hip joint the normal compressive force would be 3 X the body weight
compressive force in the acetabulum / hip joint. Over time there is a protective reflex will
cause the high hip to lower and then to keep balance they lean over the weight bearing
hip to keep the compressive force off the weight bearing hip joint.
If the patient has a cane, the cane will be on the opposite side of the effected hip.
This is like adding a leg on the opposite side. This takes off some of the compression.
10-12 bursea these can be very problematic
They can become inflamed, pain on weight bearing, flex and externally rotate hip
(pain disappears), lean over painful hip
Transient Synovitis – effects pre-adolescent boys, le cav perthes disease is what people
think it is due to symptoms at first.
Pain in anterior groin, lean over effected hip – people think that the femur head is
necrosing, yet there is increased fluid in the femoral head.
Double Crush Syndrome
Double crush syndrome was first described by Upton and McComas in 1973, and refers
to the coexistence of dual compressive lesions along the course of a nerve. The authors
suggested that a proximal compressive lesion makes the distal portion of the nerve more
vulnerable to injury or compression. This has been well supported in follow-up studies.
67 – 75% of patients studied who had carpal tunnel or ulnar neuropathy also showed
some degree of nerve root irritation in the cervico-thoracic area.
(it should be emphasized that cervical spondylosis and carpal tunnel syndrome can
coexist and relief of one may relieve the patients symptoms)
Complaints of pain and stiffness to neck
Clinical evidence of sensory abnormalities corresponding to dermatomes, rather
than peripheral nerve distribution
Proximal and distal symptomatology
Previous history of neck injuries commonly of the hyperestension “whiplash”
type as a result of a MVA
WHAT’S ON TEST #3???????
Two types of strain injuries
Transverse (tearing of actual muscle), contraction against resistance
Longitudinal (tearing of connective tissue, myofascial pain syndrome),
loss of muscle tone, hypotonia, stretching of hypotonic tissue
Different presentations
Hurts when muscle contracts, (Transverse)
NMS Test 3 Notes 8 of 9
Dr. Christy
Spindle
IIa fiber
Function – differs from text to text, but generally speaking is that it has an
inhibitory function (tones spindle activity down, and not in every muscle)
Multi synaptic
Relationship to gamma the IIa fiber sits on top of sarcomeres of the nuclear
chain, and when gamma fires and sarcomeres contract the stretch is taken off
the IIa fiber. However, it was Gamma that put the stretch on the Ia fiber.
o Gamma (keep stretch off IIa, and stretch Ia
Disc Lesions
Posterolateral
o Medial – according to the nerve root
o Lateral – according to the nerve root
Central – generally does not cause a nerve root impingement (nerve pressure)
Ligaments and Dura Sinovertebral nerve
o Dura is innervated from both side, up and down (multisegmental
innervation) if this is irritated then the pain is dull ache pain and called
lumbago and is an extrasegmental pain pattern
o What is the clue that it is dural related?
Valsalva + (someone who has lumbago with valsalva)
Two Leg raises +
Neck flexion (soto hall) +
o Meningeal irritation can be reproduced by the above tests.
o Orthopedic tests at best will reproduce a chief complaint, and shows the
area that is effected
Dermatomal pain pattern if MEDIAL or LATERAL buldge
o Dural signs will be present for both, but one will have neurological sign
(medial &lateral)
Lumbago is not segmental or sclerotogenous…it is considered
extrasegmental….Dr. Christy prefers (NON-SEGMENTAL)…it is non-
neurological
o You could get a dermatomal or sclerotogenous presentation (but its not)
Ortho Tests
o Dural signs
Valsalva, neck flexion, Two leg raises
o Braggard sign – related to neurological lesions (stretching on peripheral
nerves)
o Bechterew – sitting sciatic stretch (best mechanism to reproduce a sciatic
presentation)
o Ely’s – for femoral nerve and stretches anterior thigh
o Percussion – pressure put on spinous process to see if pain is reproduce (to
see if pain is at the spinal level
o Milgrams – positive in all lesions of the lumbar spine
NMS Test 3 Notes 9 of 9
Dr. Christy
TOS
Four Types
o Cervical reibs
o Scalenous anticus syndrome – in and out of popularity
o Hyper abduction syndrome – common, raising arm
o Costoclavicular syndrome – common, pulls clavical onto the bundle (lowering
arm)
These syndromes are neurovascular
Must have pulse disappear and have numbness and tingling
o Pain is a minimal complaint of TOS, compared to disc problems, sprain, or strain
Hip
Flexion and internal rotation, avoid weight bearing
Swing phase – non supportive phase, toe off to heel strike
Supportive phase – heel strike to toe off
Posture-
If hip lesion pain is present
Trendelenburg Gait
Throwing there upper body weight over the supportive hip