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Which of the following is not a differential diagnosis for thoracic spine pain and dysfunction? The improvement in automobile restraint systems has increased survival rates from major spinal column injuries. Overall, 10% to 25% of spinal column injuries are associated with at least some neurologic changes. These changes are more common with injuries at the cervical level (40%) than at the lumbar level (20%). In children falls account for only 9% of significant spine injuries, whereas in older patients, they account for 60%. This statistic has decreased from 110 and 34, respectively, in 1976 (before the spear tackling rules were enacted). The presence of one obvious spinal injury increases the chance of missing another, subtler injury. Significant injury is also more likely in patients with osteopenia or neuromuscular disease. For children older than 8 to 10 years, the spine behaves biomechanically like an adult?s. Younger children have more elastic soft tissues that make multiple, contiguous fractures much more common than in adults. Younger children are therefore far more likely to have upper cervical spine injuries (occiput to C3). The marked elasticity of the pediatric spinal column is greater than the elastic limit of the cord. More than half of these children will have delayed onset of neurologic symptoms, and therefore close and repeated examinations are needed. In trauma patients, the spine is assumed to be unstable until a secondary survey and radiographs have been performed. Directly examine the back by log-rolling the patient while maintaining in-line traction on the neck. Deformity, localized tenderness, step-off, or interspinous widening warrants further evaluation. Maintain a hard cervical collar until the cervical spine has been formally cleared. Until definitive stabilization can be undertaken, patients with significant thoracolumbar injury should be transferred to a rotating frame or other protective bed. High-dose steroid protocols are no longer considered the standard of care in the acute management of spinal cord injury.

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There is no absolute agreement on criteria for return to sport or other activity with diagnosis of spondylolisthesis. Various authors have suggested functional or time-based criteria (see Hopkins and White). Presence of increasing or peripheralizing pain with activity and persistent or increasing weakness are indications to limit or reduce activity. Most literature suggests that bracing in the presence of an acute injury (metabolically active scan) is indicated, generally allowing activity within the brace. A Boston or other brace is felt to be unnecessary in absence of positive findings on bone scan but may be used if helpful in controlling symptoms associated with activity. Postoperatively, these patients are managed as other postlumbar fusion patients are, following the same physiologic guidelines as any patient status post instrumented lumbar spine fusion. Delayed vertebral slip and adjacent disc degeneration with an isthmic defect of the fifth lumbar vertebra. Back pain in young athletes: Significant differences from adults in causes and patterns. Treatment ofsymptomatic spondylolysis andspondylolisthesis with the modified Boston brace. Nonoperative treatmentofactivespondylolysis inelite athletes with normal X-ray findings: Literature review and results of conservative treatment. Functional scoliosis resolves with healing of the lumbar or thoracic injuries or correction of the leg length discrepancy. Curves >20 degrees are 7 times more common in females than in males, and curves >30 degrees have a 10:1 female-to-male ratio. Idiopathic scoliosis usually occurs in adolescents between 11 and 14 years of age. Some form of multifactorial or autosomal dominant inheritance seems to be involved, although most recent research suggests a polygenic inheritance pattern. The proprioceptive system and equilibrium imbalances, possibly related to asymmetry in the brainstem, also may be implicated. What types of initial screening processes appear as most effective in determining whether aggressive active treatment, such as bracing or surgery, is needed? Moire photography is moderately effective in screening for scoliosis but is much less cost-effective. Two-tier screening programs, which include both an initial screener and a secondary screener, tend to be the most effective in reducing false-positive diagnoses.

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Associated symptoms that do not occur with musculoskeletal disorders can be identified via a careful review of systems. A specific strategy such as rest may initially relieve symptoms (ie, pain), but there is typically a recurring progression of increasing frequency, intensity, and/or duration of symptoms. For example, patients may self-diagnose, select unwise self-treatments, or perceive certain symptoms, such as coughing, sweating, or diarrhea as normal and not symptoms of illness. The origin of somatic pain is mechanical and/or chemical stimulation of nerve endings. Somatic pain may be either localized to a body region and/or referred to other body regions. Somatic pain and somatic referred pain are typically static, aching in quality, and difficult to point-localize. Symptoms may present as chronologically observed, characterized by asymptomatic periods with exacerbations or progressively exacerbated symptoms attributed to causal factors or progression of the underlying disorder. The origin of signs and symptoms is mechanical and/or chemical and is attributable to a block in conduction rather than stimulation of nerve endings. Radicular disorders produce lower motor neuron lesion signs and symptoms, which include muscle weakness, atrophy, hyporeflexia, and sensory changes such as paresthesia and/or numbness. Radicular pain is described as shooting or lacerating and is typically felt in a relatively narrow band about 4 cm wide; it is often combined with other radicular symptoms such as tingling, numbness, and burning sensations. Radicular symptoms result from a block in conduction rather than nociceptive stimulation of pain sensitive structures (ie, the spinal nerve or nerve root). Radicular pain from a given nerve root does not always follow a consistent distribution. Somatic referred pain is generated by either mechanical or chemical irritation of somatic structures, such as the dural lining on the nerve root or the epineurium of the spinal nerve. Like radicular referred pain, somatic referred pain is felt in body regions separate from the irritated structures (eg, lumbar facet arthrosis can refer pain to the leg). Physical therapists need to screen for systemic or non?physical therapy involvement because many visceral (organ or organ system) diseases mimic orthopedic symptoms. List common body systems and aggregates of signs/symptoms that may indicate systemic involvement. What are examples of common red flags that typically require physician referral and further investigation? Women may experience pain referred into the right shoulder in addition to shortness of breath (sometimes occurring in the middle of the night) and chronic, unexpected fatigue. Silent attacks (painless infarction without acute symptoms) are more common among nonwhites, older adults (>75 years), smokers, and adults with diabetes (men and women), presumably because of reduced sensitivity to pain. For myocardial infarctions associated with a blood clot, what time frame for the administration of medications that dissolve clots, promote vasodilation, and reduce infarct size is considered the most crucial? Administration of medication within the first 70 minutes after the onset of symptoms is associated with improved outcomes. However, angina pectoralis is less severe, does not last for hours (rarely more than 5 minutes), and is relieved by cessation of all activity and administration of nitrates.

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