Valerie Phelps

Differential Diagnosis and Management of Spinal Nerve Root-related Pain

Abstract: Pain originating from spinal nerve roots demonstrates multiple pathogeneses. Distinctions in the patho‐anatomy, biomechanics, and pathophysiology of spinal nerve roots contribute to pathology, diagnosis, and management of root‐related pain. Root‐related pain can emerge from the tension events in the dura mater and nerve tissue associated with primary disc related disorders. Conversely, secondary disc‐related degeneration can produce compression on the nerve roots. This compression can result in chemical and mechanical consequences imposed on the nervous tissue within the spinal canal, lateral recess, intervertebral foramina, and extraforminal regions. Differences in root‐related pathology can be observed between lumbar, thoracic, and cervical spinal levels, meriting the implementation of different diagnostic tools and management strategies.

Pain Generators of the Lumbar Spine

Abstract Different anatomical structures and pathophysiological functions can be responsible for lumbar pain, each producing a distinctive clinical profile. Pain can arise from the intervertebral disc, either acutely as a primary disc related disorder, or as result of the degradation associated with chronic internal disc disruption. In either case, greatest pain provocation will be associated with movements and functions in the sagittal plane. Lumbar pain can also arise from afflictions within the zygapophyseal joint mechanism, as result of synovitis or chondropathy. Either of these conditions will produce the greatest pain provocation during three‐dimensional movements, due to maximal stress to either the synovium or joint cartilage. Finally, patients can experience different symptoms associated with irritation to the dural sleeve, dorsal root ganglion, or chemically irritated lumbar nerve root. Differential diagnosis of these conditions requires a thorough examination and provides information that can assist the clinician in selecting appropriate management strategies.

Disorders of the sacroiliac joint.

Abstract: Controversies have surrounded the sacroiliac joint. The sacroiliac joint (SIJ) is a considerably complex and strong joint with limited mobility, mechanically serving as a force transducer and a shock absorber. Anatomical changes are seen in the SIJ throughout an individuals lifetime. The ligamentous system associated with the SIJ serves to enhance stability and offer proprioceptive feedback in context with the rich plexus of articular receptors. Stability in the SIJ is related to form and force closure. Movement in the SIJ is 3‐D about an axis outside of the joint. The functional examination of the SIJ is related to a clinical triad.

Whiplash Associated Disorders: Pathomechanics, Diagnosis, and Management

Abstract:  Whiplash has been defined as an injury mechanism, an injury, a medico‐legal or social dilemma, and a complex chronic pain syndrome. Whiplash associated disorders are frequent in the cervical spine, especially as a result of a motor vehicle accident. The mechanisms responsible for whiplash‐related tissue trauma are complex and a clinicians understanding of these complexities lends to a more complete appreciation for the anatomical structures and pathological processes that are involved, as well as a comprehensive diagnosis and appropriate management. While several classification scales have been developed for whiplash associated disorders, a thorough and tissue‐specific examination is merited. Management should be directed toward pain reduction and normalization of mechanics. While conservative measures can address many of clinical sequelae of whiplash, both invasive pain management procedures and surgical interventions may be paramount to a patients complete recovery.

Ergonomic pain--part 1: etiology, epidemiology, and prevention.

Abstract: Work‐related musculoskeletal disorders (MSDs) have reached a costly epidemic proportion in recent years, producing ergonomic pain as their most frequent clinical consequence. While work‐related MSDs have declined in incidence, their prevalence continues. Individuals develop symptoms as a consequence of numerous factors that include force, sustained posture, repetitive motion, and vibration. Different combinations of these factors lend to different pathomechanical and pathophysiological consequences that appear to be unique to different regions of the body and related to distinctive work environmental and task characteristics. Federal and state agencies have made considerable attempts to regulate the work environment in a preventative fashion in order to reduce the incidence of ergonomic pain and other sequelae of work‐related MSDs.

Diagnosis and management of the painful shoulder. Part 2: examination, interpretation, and management.

Abstract: Diagnosis, interpretation and subsequent management of shoulder pathology can be challenging to clinicians. Because of its proximal location in the schlerotome and the extensive convergence of afferent signals from this region to the dorsal horn of the spinal cord, pain reference patterns can be broadly distributed to the deltoid, trapezius, and or the posterior scapular regions. This pain behavior can make diagnosis difficult in the shoulder region, as the location of symptoms may or may not correspond to the proximity of the pain generator. Therefore, a thorough history and reliable physical examination should rest at the center of the diagnostic process. Effective management of the painful shoulder is closely linked to a tissue‐specific clinical examination. Painful shoulder conditions can present with or without limitations in passive and or active motion. Limits in passive motion can be classified as either capsular or noncapsular patterns. Conversely, patients can present with shoulder pain that demonstrates no limitation of motion. Bursitis, tendopathy and rotator cuff tears can produce shoulder pain that is challenging to diagnose, especially when they are the consequence of impingement and or instability. Numerous nonsurgical measures can be implemented in treating the painful shoulder, reserving surgical interventions for those patients who are resistant to conservative care.

Diagnosis and Management of Cervicogenic Headache and Local Cervical Syndrome with Multiple Pain Generators

Abstract Numerous pain generators can be responsible for cervicogenic headache and pain in both the cervical and thoracic regions. A 45-year-old female presented in the clinic with a 20-year history of cervicogenic and migraine headaches, accompanied by a prolonged history of local cervical and interscapular pain. The cervicogenic symptoms were attributed to secondary discrelated changes in the cervical spine, as evidenced by specific provocation behaviors and segmental limitation patterns. The patient was educated regarding the presenting problems, and ergonomic changes were initiated. The limitations were addressed with joint-specific mobilization techniques, accompanied by specific home exercises. The patient demonstrated initial rapid improvements that were characterized by reduced symptoms and increased motion, followed by gradual full motion recovery and resolution of cervicogenic symptoms. This recovery pattern suggests the efficacy of manual techniques in the management of cervicogenic headaches and local cervical syndrome, even in the context of rather prolonged symptoms.

Disc Related and Non‐Disc Related Disorders of the Thoracic Spine

Abstract: Different anatomical structures and pathophysiological functions can be responsible for lumbar pain, each producing a distinctive clinical profile. Pain can arise from the intervertebral disc, either acutely as a primary disc related disorder, or as result of the degradation associated with chronic internal disc disruption. In either case, greatest pain provocation will be associated with movements and functions in the sagittal plane. Lumbar pain can also arise from afflictions within the zygapophyseal joint mechanism, as a result of synovitis or chondropathy. Either of these conditions will produce the greatest pain provocation during three‐dimensional movements, due to maximal stress to either the synovium or joint cartilage. Finally, patients can experience different symptoms associated with irritation to the dural sleeve, dorsal root ganglion, or chemically irritated lumbar nerve root. Differential diagnosis of these conditions requires a thorough examination and provides information that can assist the clinician in selecting appropriate management strategies.

Diagnosis and Management of the Painful Shoulder. Part 1: Clinical Anatomy and Pathomechanics

Abstract: Distinctive anatomical features can be witnessed in the shoulder complex, affording specific pathological conditions. Disorders of the shoulder complex are multifactoral and features in both the clinical anatomy and biomechanics contribute to the development of shoulder pain. The sternocalvicular, acromioclavicular, glenohumeral, and scapulothoracic joints must all participate in function of the shoulder complex, as each biomechanically contributes to functional movements and clinical disorders witnessed in the shoulder region. A clinicians ability to effectively evaluate, diagnose, and treat the shoulder is largely reliant upon a foundational understanding of the clinical anatomy and biomechanics of the shoulder complex. Thus, clinicians are encouraged to consider these distinctions when examining and diagnosing disorders of the shoulder.

Diagnosis and management of cervicogenic headache.

Abstract:  Upper cervical pain and/or headaches originating from the C0 to C3 segments are pain‐states that are commonly encountered in the clinic. The upper cervical spine anatomically and biomechanically differs from the lower cervical spine. Patients with upper cervical disorders fall into two clinical groups: (1) local cervical syndrome; and (2) cervicocephalic syndrome. Symptoms associated with various forms of both disorders often overlap, making diagnosis a great challenge. The recognition and categorization of specific provocation and limitation patterns lend to effective and accurate diagnosis of local cervical and cervicocephalic conditions.