DOCSLIB.ORG

Lumbar Functional Instability

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Lumbar Functional Instability Adopted: 8/10 Lumbar Functional Instability (AKA, Lumbar: Clinical Instability, Segmental Instability, Joint Instability) Note: In the 4-part diagnosis format used for musculoskeletal cases in the UWS clinic system, functional instability is not usually listed as a primary diagnosis. More commonly it will be accounted for as a significant contributor to a primary diagnosis linked by the phrase “complicated by lumbar functional instability.” Its presence is meant to identify one type of case that may be particularly suited for stabilization exercises. Severe traumatic instability and pathological instability are not included here. Definition Discussion Functional instability of the lumbar spine has The stabilization system of the spine can be been proposed as a distinct subset of patients divided into three subsystems: passive, active with LBP (Dellitto 1995, Demoulin 2007). and neural (Demoulin 2007, Panjabi 2003). The Lumbar functional instability (LFI)* is a clinical passive system consists of the discs, bony and diagnosis based on history and physical ligamentous structures and is primarily examination findings. It is a painful disorder responsible for resistance at the end range of hypothesized to result from a loss of the motion. The active system is composed of spine’s ability to maintain appropriate muscles and their tendinous attachments. This mechanical stiffness** in neutral, midrange, or component plays a major role in maintaining end-range movements. The most widely cited neutral zone stability. Multiple muscles definition is a “significant decrease in the contribute to spinal stability. (Kavcic 2004, capacity of the stabilizing system of the spine McGill 2003) The deep segmental muscles to maintain the intervertebral neutral zones (especially multifidi and transverse abdominis) within the physiological limits so that there is have been proposed as central players by some no neurological dysfunction, no major researchers (Hebert 2010) although whether deformity and no incapacitating pain.” (Panjabi they play a unique role is challenged by others. 1992) (Kavcic 2004, McGill 2002) The neural or motor control subsystem consists of the central and Functional instability is not synonymous with peripheral nervous system and integrates hypermobility or radiographic proprioceptive input from mechanoreceptors instability/hypermobility. Hypermobility and located in soft tissue structures and radiographic instability may be asymptomatic. coordinates activation of stabilizer muscles. LFI These terms denote circumstances where joint is postulated to result from dysfunction of this motion is excessive but may not be associated stabilization system. with qualitative (aberrant) alterations in physiologic motion. (Demoulin 2007) Neutral Zone Instability/Motor Control Insufficiency (MCI) The neutral zone is defined as the component ** LFI is used throughout this document for functional lumbar of physiologic intervertebral motion that can instability, but it is not a generally recognized abbreviation and is not suitable for charting. be induced with minimal internal resistance (Panjabi 2003). It is measured from the joint’s * * In biomechanical terms, spinal stiffness refers to the starting position up to the elastic zone (Panjabi spine’s ability to prevent unwanted movement or buckling. 1992). The elastic zone represents the elastic LUMBAR FUNCTIONAL INSTABILITY Page 1 of 16 capacity of the joint’s soft tissue structures activities potentially hazardous for the and the small amount of additional motion that functionally unstable spine. is available toward the end range of joint motion. Movement into the elastic zone Excessive end range motion/ hypermobility encounters more resistance and is dependent Excessive spinal joint end-range motion has on forced muscular effort on the part of the historically been labeled as either patient or by additional overpressure by an hypermobility or instability. However, examiner. When the forces applied at this point excessive end range motion is not necessarily are removed, the joint springs back from its associated with instability and the terms elastic limits. should not be used interchangeably. For the purposes of this document joint hypermobility Neutral zone instability is postulated to result and radiographic instability will be considered from expansion of the neutral zone or as isolated exam findings. Segmental or deficiencies in motor control with or without regional joint hypermobility is not clinically measurable excessive end range motion. problematic unless it is associated with pain or Expansion of the neutral zone is theorized to perceived as a risk factor for injury. Joint result from degeneration or attenuation in the hypermobility may be body wide or affect passive stabilizers (ligaments and the disc). specific spinal regions or joints. Joint hypermobility does not cross into the realm of Motor control insufficiency (MCI) refers to a instability unless it is inadequately break down in the neuromuscular system that compensated for by the motor system resulting provides the requisite stiffness needed by a in the characteristic signs and symptoms of functioning spine. MCI can result from poorly functional instability. conditioned muscles or from errors in the neurological control and programming of the Excessive end range motion results primarily muscles. It can be seen as a cause of functional from a loss of integrity of segmental spinal instability. This disorder is usually not ligaments, intervertebral disc or bony associated with marked structural deformity, stabilizing structures. This excessive end range excessive end range radiographic hypermobility motion may result from high load traumatic or neurologic deficits. (Panjabi 1992) Therefore events, repetitive microtrauma, a dynamic radiographs will typically not reveal developmental byproduct of activities such as any significant abnormalities of quantitative dance or sports (e.g., gymnastics) or, most movement. commonly, from significant spinal degeneration (degenerative spondylisthesis). Spinal MCI and neutral zone instability are associated degeneration is thought to have a strong with poor coordination of movement, lack of genetic factor (Battié 2009). proper stabilization and episodes of momentary aberrant motion. These events can cause Although there may be clues from a patient’s abnormal tissue loading (e.g., spinal history and physical examination (i.e., “buckling”) and local injury. Immediate palpation) suggesting hypermobility, it can only triggers of painful episodes include sustained be definitively demonstrated on dynamic postures, repetitive low load activities, or a radiographs by excessive listhesis at end range. single repetition of an ordinary activity of A variety of radiographic measures and ranges daily living. Based on biomechanical research, has been proposed (see diagnostic imaging). The National Institute for Occupational Safety There is, however, little agreement on a and Health (NIOSH) suggests that the spine can clinically useful cut point dividing excessive safely accommodate compressive loads at least from normal range of motion (Demoulin 2007). up to 3,400 Newtons during lifting tasks. In the absence of established standards, (Waters 1993) However, in vitro experiments increased end-range segmental motion must be have demonstrated that, in the absence of associated with clinical findings to be muscles and motor control systems, the passive considered significant. Dynamic radiographic elements of the spine alone cannot withstand evaluation is neither routine nor recommended loads of more than 90 Newtons (approximately as a screening tool for the identification of 9.2 kg) (Crisco 1991), making even common possible joint hypermobility. LUMBAR FUNCTIONAL INSTABILITY Page 2 of 16 Excessive end range motion may be also be motion on fluoroscopic video in one study associated with generalized joint laxity. In such (Teyhen 2007). cases it is associated with an increase in gross ROM throughout the body and can be identified Most of the other clinical signs and symptoms by an instrument like the Beighton Ligamentous frequently cited are based on expert opinion Laxity Scale. (See Appendix I.) and extrapolation from biomechanical research. In 2006, using a Delphi methodology, Finally, end range joint motion may be clearly a group of experts identified 15 subjective and excessive and if there is significant disability 14 objective identifiers for instability reflecting and/or significant neurologic deficits, current practice profiles (Cook 2006). The orthopedic consultation and potential surgical clinical clues most cited appear to derive from fusion may be appropriate. 1) the onset and behavior of the symptoms, 2) assessment of the quality of regional and segmental motion, and 3) indicators of poor Diagnosis motor control. The diagnosis of functional instability is made solely on clinical grounds. At this time there is Coding note no clearly established consensus on the criteria Functional instability does not have its own ICD for diagnosing LFI (Cook 2006, Demoulin 2007). code and there does not appear to be a There are, however, certain patterns of commonly used code used in the profession. presentation that suggest that the patient’s However, including functional instability in a spine may have a higher probability of being diagnosis and coding for it may help functionally unstable or would benefit from a communicate that the patient has a more spinal stabilization exercise program (Hicks complex
Load more

Recommended publications
  • Knee Osteoarthritis
    BRIGHAM AND WOMEN’S HOSPITAL Department of Rehabilitation Services Standard of Care: _Osteoarthritis of the Knee Case Type / Diagnosis: Knee Osteoarthritis. ICD-9: 715.16, 719.46 Osteoarthritis/Osteoarthrosis (OA) is the most common joint disease causing disability, affecting more than 7 million people in the United States 1. OA is a disease process of axial and peripheral joints. It is characterized by progressive deterioration and loss of articular cartilage and by reactive bone changes at the margins of the joints and in the subchondral bone. Clinical manifestations are characterized by slowly developing joint pain, stiffness, and joint enlargement with limitations of motion. Knee osteoarthritis (OA) results from mechanical and idiopathic factors that alter the balance between degradation and synthesis of articular cartilage and subchondral bone. The etiology of knee OA is not entirely clear, yet its incidence increases with age and in women. 1 The etiology may have genetic factors affecting collagen, or traumatic factors, such as fracture or previous meniscal damage. Obesity is a risk factor for the development and progression of OA. Early degenerative changes predict progression of the disease. Underlying biomechanical factors, such as varum or valgum of the tibial femoral joint may predispose people to OA. However Hunter et al 2reported knee alignment did not predict OA, but rather was a marker of the disease severity. Loss of quadriceps muscle strength is associated with knee pain and disability in OA. Clinical criteria for the diagnosis of OA of the knee has been established by Altman3 Subjects with examination finding consistent with any of the three categories were considered to have Knee OA.
    [Show full text]
  • Knee Evaluation
    Evaluation of Knee Injuries Dr. Alan A. Zakaria, D.O., M.S. 1080 Kirts Blvd., Suite 400 Troy, Mi., 48084 Team Physician United States Soccer Federation University of Michigan Men’s and Women’s Soccer Objective Identify main anatomic components of the knee Perform basic knee exam along with special tests Identify common knee injury patterns and their physical exam findings. Anatomy ➢ Bony Anatomy ➢ Ligaments ➢ Cartilage ➢ Musculature ➢ Other Soft Tissue Knee Anatomy Two functional joints – Femorotibial – Femoropatellar Femoral condyles – Flex/extend Knee Anatomy Patella – Sesamoid with two concave surfaces and vertical ridge – Increases efficiency of extension Knee Anatomy: Anterior Cruciate Ligament (ACL) Run inferior, anterior, and medially Arises from medial aspect lateral femoral condyle Insert lateral to medial tibial eminence Restrains anterior subluxation of tibia on femur Knee Anatomy: Posterior Cruciate Ligament (PCL) Arises from the posterior intercondylar area of the tibia Inserts at the medial condyle of the femur Restrains posterior subluxation of the tibia on the femur Knee Anatomy: Medial Collateral Ligament (MCL) Postero-superior medial femoral condyle to proximal end of tibia Maximum tension at full extension Restraint to valgus stress Knee Anatomy: Lateral Collateral Ligament (LCL) Posterosuperior lateral femoral condyle to lateral head of fibula Restraint to varus stress Knee Anatomy: Meniscus Load bearing, joint stability, shock absorption Peripheral third vascularized Knee Anatomy: Articular Cartilage Hyaline cartilage
    [Show full text]
  • Nonoperative and Operative Management of Snapping Scapula
    Clinical Sports Medicine Update Nonoperative and Operative Management of Snapping Scapula Robert C. Manske,*†‡ MEd, MPT, SCS, ATC, CSCS, Michael P. Reiman,‡ MEd, PT, ATC, CSCS, and Mark L. Stovak,‡ MD From †Wichita State University, Wichita, Kansas, and ‡Via Christi Regional Medical Center, Wichita, Kansas Snapping scapula is a painful crepitus of the scapulothoracic articulation. This crepitus is a grinding or snapping noise with scapulothoracic motion that may or may not accompany pain. This condition is commonly seen in overhead-throwing athletes. Treatment of patients with this syndrome begins with nonoperative methods; when nonoperative treatment fails, several surgi- cal options exist. This article will discuss both nonoperative and operative management of this common shoulder condition. Keywords: scapulothoracic crepitus; scapulothoracic bursitis; scapular disorders; shoulder rehabilitation Scapular function is crucial to not only the shoulder but ranges from simple annoyance to a truly disabling condi- also the entire upper extremity.As knowledge of the shoul- tion for the symptomatic patient. This crepitus is usually der and its surrounding structures has increased over the described as production of a snapping, grinding, thumping, past decade, so has interest in the scapula. The scapula’s or popping sound with scapulothoracic motion. This sound role is 2-fold: it is required to maintain a stable base of is amplified by the thoracic cavity, which acts as a reso- support for the humerus; it is also required to be mobile, nance chamber as in the body of a stringed instrument.61 allowing dynamic positioning of the glenoid fossa during Historically identified initially by Boinet,5 scapular crepi- glenohumeral elevation.
    [Show full text]
  • Osseous and Soft Tissue Pathology of the Thoracolumbar Spine and Pelvic Region
    AAEP 360° Back Pain and Pelvic Dysfunction / 2018 Osseous and Soft Tissue Pathology of the Thoracolumbar Spine and Pelvic Region Kevin K. Haussler, DVM, DC, PhD, DACVSMR Author’s address—Gail Holmes Equine Orthopaedic Research bar articular processes, lumbar intertransverse joints, and the Center, Department of Clinical Sciences, College of Veterinary sacroiliac region are commonly used in performance horses Medicine and Biomedical Sciences, Colorado State University, with back or pelvic pain.13,14 Nuclear scintigraphy can provide Fort Collins, CO 80523; e-mail: [email protected] useful insights into areas of inflammation or horses with poorly 15,16 Take Home Message—Spinal disorders and sacroiliac joint localized back or pelvic pain. Advanced diagnostic imaging injuries have been identified as significant causes of reduced (CT, MRI) can be applied to the trunk and pelvic region of foals 17 performance in horses. and some small ponies or horses. Unfortunately, small gantry size has prevented full spine imaging in adult horses. I. INTRODUCTION II. CONGENITAL SPINAL MALFORMATIONS Clinical conditions affecting the axial skeleton can be Developmental variations in the morphology of thoracolumbar categorized as: (1) osseous disorders of the vertebral body, vertebral bodies, processes, and joints in horses are known to vertebral arch, or vertebral processes; (2) soft tissue disorders occur.18-23 Knowledge of normal spinal morphology and involving musculotendinous or ligamentous structures; and (3) vertebral anomalies is important for distinction of pathologic neurologic disorders that compromise the spinal cord or spinal change from normal anatomic variations. Congenital alterations nerves. Osseous lesions known to occur in the equine axial in the normal spinal curvature include variable degrees of 1,2 skeleton include spinous process impingement, degenerative scoliosis, lordosis and kyphosis.
    [Show full text]
  • RECURRENT SPONDYLOLISTHESIS, with Trouble. the Most Frequent Anomaly Is Probably in the Long Axis of the Joint Antero-Posterior
    syphilis. I have shown in every case, on making an injection and fell to the floor in a faint. When she awoke there was of tuberculous material into an animal, that the animal never a severe pain in the lower part of her back, but after a time, failed to develop tuberculosis. Among those cases which I with some assistance, she was able to walk home. For a call the hypertrophie, we found cases of inflammatory reac¬ week the pain continued, though less severe, and she was able tion, as well as the development of tubercle; and we believe to go to school, but on the eighth day her legs grew weak that these are cases of mixed infection. Dr. Fassett spoke and began to feel numb. A week later she was unable to concerning the rarity of the occurrence of tuberculosis in the walk at all. The pain radiated down the back of the thighs shaft, as a frequent occurrence in the epiphysis ; and he men¬ and legs, and for a time the family physician thought it tioned the work of Dr. Noyes of Edinburgh, who thinks that might be due to "sciatic rheumatism." As it did not respond it is entirely metaphyseal or epiphyseal. He does not believe to salicylates, a neurologist was called in consultation. that it occurs in the shaft. Yet it certainly does occur in the The knee-jerks were increased, a slight ankle-clonus was shaft. He does not say, however, that it is rare in the present, and the condition was one of spastic paraplegia.
    [Show full text]
  • Affecting Factors and Correction Ratio in Genu Valgum Or Varum Treated with Percutaneous Epiphysiodesis Using Transphyseal Screw
    Journal of Clinical Medicine Article Affecting Factors and Correction Ratio in Genu Valgum or Varum Treated with Percutaneous Epiphysiodesis Using Transphyseal Screws Si-Wook Lee * , Kyung-Jae Lee , Chul-Hyun Cho, Hee-Uk Ye, Chang-Jin Yon , Hyeong-Uk Choi, Young-Hun Kim and Kwang-Soon Song Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1035 Dalgubeol-daero, Dalseo-gu, Daegu 42601, Korea; [email protected] (K.-J.L.); [email protected] (C.-H.C.); [email protected] (H.-U.Y.); [email protected] (C.-J.Y.); [email protected] (H.-U.C.); [email protected] (Y.-H.K.); [email protected] (K.-S.S.) * Correspondence: [email protected]; Tel.: +82-53-258-4771 Received: 30 November 2020; Accepted: 17 December 2020; Published: 18 December 2020 Abstract: This study evaluated the correction rates of idiopathic genu valgum or varum after percutaneous epiphysiodesis using transphyseal screws (PETS) and analyzed the affecting factors. A total of 35 children without underlying diseases were enrolled containing 64 physes (44 distal femoral (DT), 20 proximal tibial (PT)). Anatomic tibiofemoral angle (aTFA) and the mechanical axis deviation (MAD) were taken from teleroentgenograms before PETS surgery and screw removal. The correction rates of the valgus and varus deformities for patients treated with PETS were 1.146◦/month and 0.639◦/month using aTFA while using MAD showed rates of 4.884%/month and 3.094%/month. After aTFA (p < 0.001) and MAD (p < 0.001) analyses, the correction rate of DF was significantly faster than that of PT.
    [Show full text]
  • Lumbar Spinal Conditions
    ANDERc11.qxd 11/16/07 3:53 PM Page 306 CHAPTER 11 Lumbar Spinal Conditions STUDENT OUTCOMES 1. Locate and explain the functional significance of the bony and soft-tissue structures of the lumbar spine. 2. Describe the motion capabilities of the lumbar spine. 3. Identify the factors that contribute to mechanical loading on the spine. 4. Describe specific strategies in activities of daily living to reduce spinal stress in the lumbar region. 5. Identify anatomical variations that can predispose individuals to lumbar spine injuries. 6. Explain the measures used to prevent injury to the lumbar spinal region. 7. Describe the common injuries and conditions of the lumbar spine and low back area in physically active individuals. 8. Describe a thorough assessment of the lumbar spine. 9. Identify rehabilitative exercises for the lumbar region. 306 ANDERc11.qxd 11/16/07 3:53 PM Page 307 CHAPTER 11 Lumbar Spinal Conditions 307 ROLE DELINEATION COMPETENCIES The following Performance Domains and Tasks defined in the National Athletic Trainers’ Associa- tion Board of Certification Role Delineation Study, 5th Edition are addressed in this chapter: BOC COMPETENCIES II. Clinical Evaluation and Diagnosis A. Obtain a history through observation, interview, and/or review of relevant records to assess current or potential injury, illness, or condition. B. Inspect the involved area(s) visually to assess the injury, illness, or health-related condition. C. Palpate the involved area(s) using standard techniques to assess the injury, illness, or health-related condition. D. Perform specific tests in accordance with accepted procedures to assess the injury, illness, or health- related condition.
    [Show full text]
  • Foot Deformity at Time of Delivery in a Premature Infant CANDACE R
    Photo Quiz Foot Deformity at Time of Delivery in a Premature Infant CANDACE R. TALCOTT, DO, and ADAM W. KOWALSKI, MD, Carl R. Darnall Army Medical Center, Fort Hood, Texas The editors of AFP wel- come submissions for Photo Quiz. Guidelines for preparing and sub- mitting a Photo Quiz manuscript can be found in the Authors’ Guide at http://www.aafp.org/ afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@ aafp.org. This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor. A collection of Photo Quiz published in AFP is avail- able at http://www.aafp. org/afp/photoquiz. Previously published Photo Quizzes are now featured Figure 1. in a mobile app. Get more information at http:// www.aafp.org/afp/apps. A female infant was born at 35 weeks’ gesta- when released. Her legs were equal in length. tion by spontaneous vaginal delivery, follow- There were no dysmorphic features, no evi- ing induction of labor for premature rupture dence of sacral dimple, and no signs of of membranes. The pregnancy was otherwise spina bifida. The remainder of the physical uncomplicated. The newborn required three examination, including musculoskeletal and minutes of positive pressure ventilation, but neurologic findings, was normal. transitioned well on room air over the next hour and did not require further treatment Question in the neonatal intensive care unit. Based on the patient’s history and physical At the time of birth, physical examination examination findings, which one of the fol- showed that the newborn’s right foot was lowing is the most likely diagnosis? grossly externally rotated (Figure 1).
    [Show full text]
  • Developmental Anomalies of the Temporomandibular Joint
    Developmental Anomalies of the Temporomandibular Joint R. Bruce Ross, DDS, MSc, FRCD he processes by which the human face develops in the Division of Orthodontics embryo are exceedingly complex, but they work out per- The Hospital for Sick Children fectly—-almost every time. Occasionally, however, the Toronto, Ontario, Canada T development of structures such as those comprising the temporo- mandibular articulation is disturbed, leading to an anomalous Professor Faoulty of Dentistry morphology in later life. It is important to note that an anomaly is University of Toronto not necessarily an undesirable condition requiring treatment. It Toronto, Ontario, Canada may be benign, with no associated problems, and therefore of no consequence; in fact, it may never be identified. Ross and Correspondence to: Johnston' have published a review of the developmental processes Dr R. B. Ross and etiology of undesirable conditions affecting the temporo- Faculty oS Dentistry mandibular joint (TMJ). University of Toronto Craniofacial anomalies may be caused by genetic faults (eg, 124 Edward Street Treacher Collins syndrome) or caused by a teratogenic agent (eg, Toronto, Ontario thahdomide), but most often it appears the cause is multifactorial M5G lG6 0anads Fax:416-813-6375 (eg, cleft hp and palate). When the entire human genome is avail- E-mail: [email protected] able and studied in persons with congenital anomalies, there may well be indicators for, or at least a demonstrable predisposition to, developmental problems. Problems involving the TMJ can be acquired or congenital (developmental). Tbe vast majority seen in a dental office are acquired dysfunctions, traumatic injuries, or pathologic condi- tions.
    [Show full text]
  • JISHANT Assessment of Nasal Trauma
    Journal of the International Society of Head and Neck Trauma (ISHANT) Invited review Assessment of nasal trauma Dr SUMIT SHARMA. MBBS (ENT-Honors) (KGMC-Lko), M.S. (KGMC-Lko), Assistant Professor, Department of E.N.T., Mayo Institute of Medical Sciences, Barabanki, India [email protected] Received July 2016. Accepted following peer review September 2016. Published September 2016 JISHANT 2016:7 Introduction The assessment of nasal injuries accidents, sports injuries and during requires a delicate balance of history physical confrontation. Because of this taking and clinical examination. they are twice as more common in males Management of these injuries must take than in females. The nose is the most into consideration both functional and prominent feature of the face and has cosmetic aspects. Although not an little protection or support. exhaustive review of the literature this Nasal bones are very brittle and can paper discusses key aspects of be broken easily with trivial impacts. assessment with observations from my Low impact forces of 30G can be own experience. sufficient to result in fracture, compared Pathophysiology to the supraorbital rim which requires a force of 200G on impact (2). The ease Nasal bone fractures are the with which the nose is broken may help commonest facial fracture and make up absorb the energy of impact and offer to 39% of all maxillofacial injuries some protection to the brain. Thus it has (1).These types of fractures are mainly been suggested this acts as a protective seen in road traffic mechanism (3). Journal of the International Society of Head and Neck Trauma (ISHANT) From the structural point of view the side of the point of impact.
    [Show full text]
  • Knee Pain with a Focus on Osteoarthritis
    Clinical Integration of Osteopathic Manipulative Medicine Family Medicine: Knee pain with a focus on osteoarthritis Author: Andrea Sarchi, OMS-IV and Sheldon C. Yao, DO Introduction: Knee pain is a common reason for patient visits to primary care clinics and emergency departments. As the largest human joint when considering volume and surface area of articulating cartilage, the knee is highly susceptible to injury, degeneration due to age, inflammation, and infection.1 Therefore, there is a large range of pathology that can occur in the knee and consequently result in pain. These include periarticular bursitis, patellar dysfunctions, referred pain from the hip, femur, or spine, and intra-articular processes such as meniscal injury, ligamentous injury, or fracture, amongst others. One particularly important condition that we must be aware of, especially in the elderly, is osteoarthritis. Osteoarthritis commonly affects the knee, and treatment consists of acetaminophen and other oral NSAIDs, topical NSAIDs and capsaicin, and intra-articular glucocorticoids.2 While these treatments can be very effective, manual therapy has also proven to provide significant relief to patients with osteoarthritis.2-6 Therefore, there are a number of osteopathic manipulative medicine techniques that can be applied to treating osteoarthritis of the knee. Patient presentations and differential diagnosis: As there are numerous causes of knee pain, the presentation can vary widely. One way to classify the different diagnoses and presentations is by anatomic location:7
    [Show full text]
  • Orthognathic Surgery
    ESSENTIALS of Maxillofacial Surgery 2nd edition The American Society of Maxillofacial Surgeons is the oldest American organization representing maxillofacial surgeons who are devoted to improving and promoting the highest level of patient care. Maxillofacial and Craniofacial surgeons specialize in bone and soft tissue repair and reconstruction for enhancement of the face. The Society’s mission is to advance the science and practice of surgery of the facial region and craniofacial skeleton. Continually updated information about the various procedures in maxillofacial surgery, members of the Society, and current issues and news about the specialty can be found at the ASMS website. WWW.MAXFACE.ORG ESSENTIALS OF MAXILLOFACIAL SURGERY 2nd Edition Fan Liang, MD Assistant Professor of Surgery Division of Plastic, Reconstructive and Maxillofacial Surgery R Adams Cowley Shock Trauma Center University of Maryland Sanjay Naran, MD Pediatric Plastic and Craniofacial Surgeon Division of Pediatric Plastic Surgery Advocate Children’s Hospital, Chicago, IL Clinical Instructor, Department of Plastic Surgery University of Pittsburgh School of Medicine Editors Fan Liang, MD Sanjay Naran, MD Contributors Angelo Leto Barone, MD Katelyn Bennett, MD Jessica Ching, MD Russell Ettinger, MD Daniel Gould, MD Thomas Imahiyerobo Jr., MD Graham Ives, MD Breanna Jedrzejewski, MPH, MD Keli Kolegraff, MD Cassie Ligh, MD Meghan McCullough, MD Naikhoba Munabi, MD J. Thomas Paliga, MD Sameer Shakir, MD Todd Thurston, MD, MS Leo Urbinelli, MD, MA Christian Vercler, MD Howard Wang, MD Jason Wink, MD, MSc Jason W Yu, DMD, MD Copyright © 2019 by the American Society of Maxillofacial Surgeons 444 East Algonquin Road Arlington Heights, IL 60005 1st Edition, 2005 Ed.
    [Show full text]