Eating disorders are more common than the average person might think. Unfortunately, the vast majority of people are seriously misinformed about these illnesses and have a tendency to do more harm than good when faced with someone who is struggling with an eating disorder. The best way to end the stigma against eating disorders is to educate more sufficiently on the topics. In light of this, here are some of the biggest misconceptions people have about eating disorders.

1. They are Self-Inflicted

This idea comes from the fact that in order to have an eating disorder, a person must take action to decrease or increase how much they eat. However, eating disorders are about as much of a choice as suicide is; the underlying and unseen mental health issues are the cause, not a conscious decision on the part of the individual.

Eating disorders are also often the result of escalation. What started out as calorie counting becomes an obsession with eating a few calories as possible. What began as regret after an evening of eating unhealthy food became a way to enjoy food yet continue to lose weight. It was not a conscious choice. One thing led to another and suddenly the person can’t stop binging and purging, another can’t eat more than a handful of food a day, and yet another always feels hungry no matter how much they eat.

2. A Person with an Eating Disorder Can Just Change Their Behavior

Eating disorders are not something a person just does. Eating disorders are classified as a mental illness and cannot just be halted on a whim any more than someone can just stop being depressed. Eating disorders require support and treatment, not shame and anger.

The stigma against mental illness is perpetuated when people suffering from eating disorders are told that their mental illness is their fault and that they are hurting themselves and everyone around them. This does not stop the illness but instead makes the person feel worse and more likely to hide their suffering instead of seeking help.

3. Eating Disorders Only Encompass Anorexia and Bulimia

When one thinks of eating disorders, they tend to imagine people who aren’t getting enough calories, whether by purging or not eating. However, compulsive overeating is also an eating disorder, and it experiences far more shame than the more commonly known disorders.

Western society has a very unfavorable view of fat people. They garner less sympathy than someone who has become skin and bone as a result of their disorder. However, being overweight has health ramifications as well and can be very difficult to overcome, particularly when you experience nothing but shaming and less than sympathetic advice.

Overcoming this stigma is just as critical. When someone cannot seem to stop overeating, it is less a matter of their physical health and more telling of their mental state. Treatment for any eating disorder is important, as is the support of friends and family.

Eating disorders are a very complex matter in a society obsessed with thinness and weight loss. Not only must people face shame from their loved ones but some may actually be praised for their weight loss. Both can easily encourage eating disorder.

It is also important to remember that an eating disorder can happen to overweight people just as easily as it can to thin people. If you think someone you know may be developing an eating disorder, get them help. Do not treat them as though it is their fault and do not act as though they could simply stop the behavior. They need help and as a loved one, it is your job to help them get it.

-Michelle Peterson

Bio:

Michelle Peterson is a recovering addict who wishes to eliminate the stigma surrounding people who struggle with addiction. Ms. Peterson’s mission is aligned with that of RecoveryPride, which is to celebrate sobriety and those who achieve it.

The debate about good health and fitness always revolves around diet and exercise. You hear from doctors, nutritionists, fitness experts and friends that all you need to do to stay in shape is eat well and hit the gym often. So you eventually follow the “eat less, move often” mantra too, but what if, despite your best efforts, you see no real results. The reason might be that you’re overlooking the third and vital piece of the puzzle; sleep. This doesn’t, by any means, undermine the importance of exercise and diet towards fitness, yet without proper sleep they remain less efficient.

Why Sleep is Integral for Health and Fitness?

Sleep gives you the energy you need to work out on a regular basis, regulates your metabolism, rejuvenates your body, repairs your muscles and boosts your immune system. This not only helps you keep fit but also generally healthy. On the other hand, not having enough sleep can make you cranky, fatigued and fat. What's more alarming is that it can also put you at the risk for serious issues like hypertension, diabetes and cardiovascular diseases. According to research, even a few hours of a sleep shortfall can shorten life span.

To understand how sleep helps us get in shape, we need to take a look at what happens within our body when we sleep. There are a lot of hormones that are released and work best only when we are sleeping. Foremost is the growth hormone. When we sleep, the body is technically at rest so there's not much energy consumption. This allows the growth hormone to use up all the spare energy and work efficiently. The growth hormone is responsible for rejuvenating the body, building and repairing muscles, promoting fat loss and reducing fat storage. That's essentially what you need to stay fit. According to research, the amount of fat you can reduce, by exercises and diets, is lessened by 55% if you don’t sleep well. That's a huge number and the feeling that your hard work at the gym is not being rewarded enough can be quite depressing. So while you count your calories and reps don’t forget to count your hours of sleep.

Become a Sleeping Beauty!

Sleep also helps to make you look younger. The growth hormone released during sleep rebuilds and repairs body cells making your skin look younger and fresh. No wonder, big brands advertise and stress the importance of applying night cream before going to bed claiming that it will make you look 20 years younger. They work because cellular regeneration and absorption of nutrients to the skin is at its peak when you sleep. However, keep in mind that even the best and most expensive night creams won't work if you are not getting enough quality sleep. Lack of sleep affects the flow of nutrients to the skin making the skin look dull and unhealthy. So instead of spending hundreds of dollars on beauty creams, just keep up with your sleep schedule and you will look and feel fabulous.

Sleep Healthy, Eat Healthy.

Other hormones that come into play while you are sleeping are Leptin and Ghrelin. Leptin is the satisfying hormone which is produced when you sleep. Ghrelin, on the other hand is the hormone that promotes hunger and is stimulated from lack of sleep. Simply put, when you don't sleep enough your stomach will feel empty. Even after having your normal meals you will feel hungry and less satiated. As a result you are likely to select bigger portions and end up eating more than you should be. Now that's not a good thing if you are looking to get fit.

What’s worse is that lack of sleep will make you crave for unhealthy foods. Studies show that the chemical imbalance caused by lack of sleep affects your brain’s ability to make complex decisions and to control your urge especially related to food.

Contrary to the popular belief that you only need sleep when you are tired, sleep has tremendous effects on other bodily functions too. Health, fitness and appearance are all tied to sleep. So start prioritizing sleep and the next time you plan on pulling an all-nighter, remember messing with sleep means messing with your health.

Randy Thompson

I had a professors at the University at Buffalo named Dr. Dennis Lesniak. He taught a 300 level course about common sports injuries and did a great job integrating anatomy, physiology, movement, and dysfunction. After finding out he also owned a CrossFit gym, I said to myself, “I’m going to make him my new best friend.” At my very first visit to his gym and practice, I was in awe of how quickly and effectively he recommended stretches or exercises for every single complaint his members brought to him. Within minutes I watched a 70 year old woman drop below parallel in her squat. I saw a high school wrestler make a 15 pound snatch PR. I convinced myself this was witchcraft and I had to walk across a bed of hot coals and train with the Many-Faced God to get these powers. After a 4 month internship, I didn’t care what it cost or how long it took, I wanted to be able to help CrossFit athletes and weekend warriors the way Dr. Lesniak did. That’s when I decided I was going to be a Chiropractor.

Don’t let this cute origin story fool you, I did my research. I had originally wanted to be a physical therapist after obsessively watching KStarr’s MWOD for months, but after looking into the curriculum, I felt that New York Chiropractic College had what I was looking for. Fast forward a few years, I’m a 10th trimester student about to graduate with my D.C. degree. The grind of clinic hasn’t given me much time to work with too many physical therapists and I’m guessing you haven’t worked with many chiropractors. Let me tell you a little about what we learned in our school and you can tell me in the comment section what you learned in yours!

The Chiro School Experience –

New York Chiropractic College states, “The Doctor of Chiropractic (D.C.) degree requires a minimum of ten 15-week semesters of full-time resident study, including a clinical internship. This is the equivalent of five academic years.” One of the reasons I chose NYCC is because we schedule our semesters as trimesters meaning we have classes through the summer and can finish our education in three years and four months. The academic schedule is rigorous with between 22 and 28 credit hours a semester.

The first year focuses on core sciences such as gross anatomy with human cadaver dissection, biochemistry, neurology, microbiology, and physiopathology. We learn clinical pearl along the way and have collective “Ohhhhh” moments, like how your gallbladder can cause right shoulder pain, at least once a week. We learned mnemonics for the cranial nerves and filled notebooks with doodles of the brachial plexus. Our physiology professor had us remember when oxytocin was released by the phrase, “Wine, dine, 69, and go cry about it.” It was like drinking from a firehose but the fundamentals were drilled in.

The second year focuses on assessment and diagnosis. Classes include full body orthopedic assessment, visceral assessment, laboratory diagnostics, advanced imaging, and public health concerns. This year also heavily focuses on various chiropractic techniques such as chiropractic manipulative therapy, rehabilitative exercises, and passive modalities like heat, cold, interferential current, and cold laser therapy. We started putting together the pieces and practiced case management for typical complaints that might walk in our door. We learned new patient exams and started to feel pretty confident that we could recognize who we could treat and who needed to be referred out.

The third year is our clinical internship. These internships are done in various outpatient facilities across the country. Under close, one-on-one doctor supervision, we perfect our skills, practice case management, and learn to integrate our services within an array of diverse healthcare environments. I’ve had some crazy cases and made some mistakes but the only dumb mistake is one you don’t learn from, right?

Throughout our time at school, there are a variety of electives offered including pediatrics, pregnancy, geriatrics, rehab, nutrition, radiology, and more. Many of these fields have a post-doctoral residency or diplomate program that chiropractors can specialize in too but it not mandatory.
That brings us to a grand total of:

• Anatomy 585 hours
• Biochemistry 75 hours
• Physiopathology 330 hours
• Microbiology and Public Health 135 hours
• Diagnosis 540 hours
• Diagnostic Imaging 270 hours
• Clinical Laboratory 75 hours
• Associated Studies 150 hours
• Chiropractic Philosophy 195 hours
• Chiropractic Technique 615 hours
• Ancillary Therapeutic Procedures 90 hours
• Clinical Practice Issues 195 hours
• Clinical Experience and Outpatient Services 1,305 hours
• Total Core hours 4,560 hours
• Elective Courses 135 hours

That’s a grand total of 4,695 hours that have pushed me, challenged me, made me feel like quitting, made me feel like a king, and might help me save a life one day. I wouldn’t trade it for anything in the world and if I could go back, I’d make the same decision to go to New York Chiropractic College again and again.

Now I’m about to graduate, but I need your help. No man is an island. The best doctors in the world are not all in one profession. Go out and ask other providers how they would treat your patients. What questions would they ask? What exams would they do? How does your treatment vary from mine? I know you can help me learn more about upper extremity complaints to treat musicians (my other passion project). I fully intend to work with physical therapists often because I know you learned way more straps and braces for upper extremity complaints than I did. Now it’s your turn. Go find the neurologist who found a rare entrapment site. Go find the EENT who is experimenting with vertigo treatments. Keep an open mind and always go to the source.

“Absorb what is useful. Discard what is not. Add what is uniquely your own.” ~ Bruce Lee

Bio: Randy Thompson will be graduating from New York Chiropractic College in July of 2016. He is engaged to the beautiful Abigale Marchese, has a cat named Paul, and is looking forward to you reading more about chiropractic at www.RandyThompsonDC.com.

Hello everyone!

Thank you for taking the time to check out my guest post with TSPT. I am a physical therapy student in the Class of 2017 at Northern Arizona University. I attend the Phoenix Biomedical Campus (PBC) in downtown Phoenix, Arizona. The PBC is an integrated health professions campus with MD, PA, PT, OT, AT, social work and nursing programs. I find great value in taking classes and attending seminars with other health professionals and learning about their role in the health care field. This is one of the primary reasons why I chose this campus. I am a Certified Strength and Conditioning Specialist and plan on pursuing an orthopedic residency after graduation. I am interested in PT advocacy, public health and education, private practice, technology in PT, orthopedics and sports. When I am not nerding out over physical therapy, I enjoy spending time with my girlfriend and my two dogs. I also love drinking beer with friends and trying new, different exercises.

Contact Information:
I am easily reached on Facebook (Cruz Romero), and Twitter (@cruzromero602), but you can also email me at cr374@nau.edu. Feel free to reach out and connect anytime.
​
Huge shout out to James Heafner for allowing me to guest post on TSPT. I use TSPT all the time so it is an amazing opportunity to contribute.

Cruz, thank you again for the awesome content! It is evident a great amount of time and effort went into creating the powerpoint and handout. We are fortunate to have you part of the PT profession.

If other people have great content they want to share, please let us know!
-Jim Heafner

A patient I saw recently served as a powerful reminder of how important considering spinal mobility is for managing lower extremity conditions. Patient is an 18yo male dancer, who has been dancing “for as long as he could remember” and until recently had been dancing for several hours a day most days of the week. A few days prior to seeing me, he said that he had been dancing, performed a move with some twisting, and afterwards started having sharp pain in his left knee.

Given the way his pain started, meniscus and other passive structures of the knee seemed like reasonable culprits. Lachman’s, Anterior/Posterior Drawer, Lever Sign and Valgus/Varus stress testing were all negative. Jumping over some of the other objective data, what was most striking to me about the patient was that he was positive for all five of the cluster of meniscal tests1:  (1) history of joint locking, (2) joint line tenderness, (3) positive McMurray’s, (4) pain with flexion overpressure and (5) pain with extension overpressure. According to the study, being positive for 5/5 tests leaves specificity at .99, which the ol’ SpIN-SnOUT tells us means that my patient likely has a meniscal tear of some kind.   

He had limited knee extension and tibial internal rotation on the left, so I first worked to restore those with mobilization and then repeated movements. Repeated knee extensions provided some mild relief, as did IASTM, which I performed on the anterior and posterior knee. If I moved his left tibia in to internal rotation, he reported an immediate increase in symptoms, so I didn’t even try further mobilization. He tested slightly weak for hip and knee strength on the left, so I gave some fairly standard hip strengthening exercises (clamshells, side-lying abduction, etc.).  For homework, I gave him repeated long arc quads, 15 every hour that he was awake, in an effort to re-establish symmetrical knee extension.

When he returned for his second visit, his pain was about the same. This is where it gets interesting. Having recently been thinking about the connection between issues of the spine and issues in the lower extremities, I looked at his global extension – limited. Not a huge limitation, and he was already pretty mobile as a dancer, but it was enough of a limitation to be noticeable. So, I trialed repeated press-ups in prone. After 20 reps, his pain went from a 7/10 to a 4/10. After another 20, 1/10. Because the pain was unilateral and his side-glide to the L was limited, and because I wanted to try to eliminate the pain if possible (gettin’ greedy, I know), I also trialed repeated side-glides to the left (i.e. loading the left), but this didn’t produce any noticeable change. So, I gave him hourly repeated press-ups to do when he was at home, and standing extensions when he was at school or didn’t have a place he could easily lay down prone.

Now, you’d think he would be compliant after we essentially eliminated his pain with the press-ups, but alas, he was not. He didn’t do the press-ups almost at all and his pain was back to where it was before. So, I manipulated his lumbar spine and had him perform repeated press-ups, and this time his pain was gone. I gave him a stern talking-to about doing his homework, and showed him how to make a lumbar roll so we could add to the amount of time he was spending in lumbar extension, and sent him on his way.

Since that appointment, he has been almost pain-free. I say “almost” because – and this is, in my mind, confirmation of the contribution of the lumbar spine to his problem – he said he had a little flare up after he took a road trip and forgot his lumbar roll. From looking at his normally sitting posture, I knew that meant many hours of significant lumbar flexion. However, he knew well enough at this this stage in his therapy to know that he could manage that with repeated lumbar extensions.

So, what do I think there is to be gleaned from this patient experience? For meniscal issues, at least consider the spine. While it is not the only, or even the first, thing to consider – the limitations that are closer to the presenting complaint (like lack of terminal knee extension, then tibial IR limitation) still take priority in my mind – considering the lumbar spine may be of great benefit to your patient. Some it might help, some it might not. Since seeing the patient I’ve described above, I’ve had two other patients who were also positive for all five tests of the meniscal cluster: one was also significantly helped by mobilization and repeated motion of the lumbar spine but the other’s pain was eliminated instead by repeated knee extensions and repeated tibial IR. Helpful for some, maybe not for others, but definitely worth considering, even if your symptoms are somewhere else.

-Harrison

Reference:
1 Lowery DJ, Farley TD, Wing DW, Sterett WI, Steadman JR. "A clinical composite score accurately detects meniscal pathology." Arthroscopy. Nov 2006; 22(11):1174-1179.

Bio: Harrison is a third year Doctor of Physical Therapy student at the Downtown Phoenix Biomedical Campus of Northern Arizona University. His professional interests eclectic but largely center around the intersection of neuroscience and orthopedics and how they can inform each other to produce more effective care for patients.  He is also currently enrolled in the OPTIM program for Orthopedic Manual Therapy (COMT).

What should we do when we encounter an unusual musculoskeletal differential diagnosis in clinic? While in fellowship practice, we do a CAT (critically appraised topics). CATs are an in depth analysis of a research article that answers your carefully thought-out clinical question. I completed this CAT after evaluating a patient with a Morel-Lavallée lesion. This lesion can occur after a shearing injury most commonly from a MVA or fall of over 10 feet. This lesion is rare and commonly missed however the patient’s prognosis depends on early detection of this lesion. Please see attached CAT and power point to learn more about this rare diagnosis and what we should be aware of as we are doing our patient subjective and objective exam.

The Mayo Clinic sought to retrospectively collect data on patients with the diagnosis of Morel-Lavallée Lesion and aggregate data regarding the patient presentation, diagnosis, and treatment. This study provides initial evidence to support diagnosis of Morel-Lavallée Lesions through mechanism of injury, patient symptoms, and confirmation with MRI or CT scan.1 Level 4 evidence: retrospective case series.

Citation: Nickerson TP, Zielinski MD, Jenkins DH, Schiller HJ. The Mayo Clinic experience with Morel-Lavallee lesions: establishment of a practice management guideline. J Trauma Acute Care Surg 2014;76:493-7.

Article co-author’s name and email: Henry Schiller; schiller.henry@mayo.edu.

Three part clinical question: In a 21 year old female with post-traumatic hip pain from a 20 foot fall, what is the best way to rule in a Morel-Lavallée lesion as a source of the patient’s pain?

Search Strategy:

Databases included PubMed, PEDro, Cochrane Database of Systematic Reviews, and National Guideline Clearing House. Through PubMed an initial search under Clinical Queries of “Morel-Lavallée lesion AND diagnosis” with category: diagnosis and scope: broad produced 39 hits and 2 systematic reviews. Search of PEDro, Cochrane Database, and National Guideline Clearing House included the same search terms without results. A subsequent search was performed using “Morel-Lavallée lesion”, “closed degloving injury”, and “posttraumatic seroma” without results. Triage of articles was limited to the PubMed results and due to the limited results, all abstracts were reviewed for applicability. Several abstracts were eliminated as they were a single case report or did not address diagnosis of the lesion. Ten articles were reviewed in their entirety, all were either level 4 or 5 evidence.

Background:

Morel-Lavallée Lesions are closed degloving injuries representing a severe traumatic separation of the skin and the subcutaneous tissue from the underlying fascia. The mechanism of injury is usually trauma that occurs tangential to fascial planes, resulting in a shearing type of injury which has been reported in motor vehicle collisions, falls from 10 or more feet, and contact sports.2 This creates a cavity that is filled with lymph or blood, resulting from the disruption of arteries perforating through the fascia and a mixture of viable and necrotic fat.3,4 After the cavity fills with fluid, a formation of a hematoma or seroma may occur. The inflammatory reaction that follows this injury if not treated in the acute phase can organize the granulation tissue into a fibrous capsule. The capsule prevents the absorption of the fluid and is thought to be the cause of recurrent fluid collection.5

Documented diagnosis and treatment has varied greatly in the literature. Patient presentation typically includes a traumatic mechanism of injury6, swelling, diminished sensation, and pain hours or days after the traumatic event.7 Imaging techniques to confirm a diagnosis include MRI, ultrasound, and CT.7,8 Depending on when the lesion is identified, treatment can include needle aspiration, incision drainage with compression, surgical debridement, and percutaneous drainage with irrigation, suction drainage, and debridement.3,9 Accurate and early diagnosis of this lesion plays a significant role in treatment options and prognosis of patients with a Morel-Lavallée Lesion.

The Study:

While Morel-Lavallée lesions are associated with considerable morbidity in trauma patients, there is a lack of consensus in how to identify and treat these patients.3,5 The Mayo clinic sought to define the factors associated with failure of percutaneous aspiration in order to better identify patients requiring immediate operative management. This study sought to establish a practice management guideline in this rare diagnosis.

Methods: The authors retrospectively searched the Mayo Clinic’s American College of Surgeons Level 1 trauma center database for patient records containing the terms “Morel-Lavallée, closed degloving injury, or posttraumatic seroma” from February 2, 2004 through December 23, 2011. They identified 79 patients with 87 Morel-Lavallée lesions. Patients with masses that were not filled with seroma fluid or with open degloving injuries were excluded. For all included patients, demographic information was collected. The authors also collected information regarding the lesion location, size, associated injuries, primary treatment, and wound course. The patients were divided into a non-operative management (NONOP), percutaneous aspiration (ASP), or operative drainage or debridement (OR) group. Univariate analysis was performed; factors associated with the type of the lesion management and recurrence were compared amongst the groups. Multivariable analysis was also done for features that were clinically relevant and nearing statistical significance.

Subjects: 79 patients were identified with 87 Morel-Lavallée lesions. There were 41 patients in the OR group, 21 in the NONOP group, and 25 in the ASP group. The mean age was 48 (OR), 44 (NONOP), and 41 (ASP). Total age range for all three groups was 14-88 years old. The percentage of males in each group was 54% (OR), 48% (NONOP), and 56% (ASP). A high-energy injury occurred in 54% (OR), 52% (NONOP), and 64% (ASP) of these patients. Recurrence of the lesion occurred in 15% (OR), 19% (NONOP), and 56% (ASP) of the patients with risk of recurrence at 1 year 16% (OR), 11% (NONOP), and 44% (ASP).

Are the results of this diagnostic study valid?

This study is at risk for selection bias which is a threat to is validity. The authors collected information from a single group of patients, in a single geographical area, and these patients sought treatment at a single trauma center. The patients included in this study comprise a limited group of people which might not be applicable to the greater population. For example, each of these patients were treated at a level 1 trauma center which may account for why many of the lesions were associated with high-energy mechanisms of injury (56%) or motor vehicle accidents (25%). Perhaps another hospital without a trauma center would find a lower association between the prevalence of the lesion in association with trauma.

The authors did a retrospective review of electronic medical records and noted occasional incomplete records and reasons for intervention not always documented. They used the Kaplan-Meier analysis to determine the risk of recurrence while censoring patient lost to follow-up. This leaves the study at risk for inaccurate or incomplete data regarding the diagnosis and recurrence of the lesion.

The Evidence:

This study is a descriptive study of the patient presentation, diagnosis, and treatment of patients with a Morel-Lavallée lesion, rather than a purely diagnostic study. Therefore, conclusions drawn regarding the patient presentation and the diagnostic study utilized to confirm the presence of the lesion is a low level of evidence. Identifying common patient presentation and the best utilized imaging tool can assist the provider in correctly identifying a patient that should have a differential diagnosis of a Morel-Lavallée lesion. Patient presentation that providers should consider are patients with a high-energy mechanism of injury as 56% of the lesions found had a high-energy mechanism, 25% of which were motor vehicle collisions. There were no differences found in sex, BMI, DM, smoking history, or alcohol use. The most common locations were thigh (32%), flank (17%), and hip (16%). Diagnosis was made via CT, MRI, US, and US with MRI. CT was used most frequently as the providers were also looking for fractures.

Are the valid results of this diagnostic study important?

Due to the lack of diagnostic evidence presented in this study, it is not possible to determine the statistical importance of clustering the patient presentation and correct image in the diagnosis of a Morel-Lavallée lesion. This study could provide initial evidence for future studies comparing the diagnostic utility of CT, MRI, US, or MRI and US. Other studies have described the characteristics of these imaging tools for Morel-Lavallée lesion3-8,10 but no study exists comparing the sensitivity or specificity of each image. This study could also provide initial evidence for future studies investigating the patient characteristics that lead to earlier diagnosis versus delayed diagnosis. This would be important as delayed diagnosis and treatment of a Morel-Lavallée lesion can lead to a poorer prognosis for the patient.5,6

Can you apply this valid, important evidence in caring for your patient?

This study presents evidence of a lesion that can occur after a shearing, high-mechanism of injury to the thigh, flank, or hip. This would be an important differential diagnosis to consider in a deployment scenario where military members are at high risk for falls or trauma associated with blast injuries. The mechanism of injury presented in this study is applicable to the patients a deployed physical therapist may see in a direct access setting. Unfortunately the availability for advanced imaging may be limited in a deployment setting. The age of the patients presented in this study range from 14-88 with a mean age of 44 which is consistent with the population of patients at Brooke Army Medical Center (BAMC). At BAMC, however, physical therapists do not frequently have the opportunity to practice in a direct access setting and patients most at risk will likely be referred by their primary care manager and may already have imaging ordered. This differential diagnosis should be considered in patients who present to physical therapy with a history of trauma, that have persistent pain lasting past the expected time frame of healing.

Bio: Rachel Condon is an active duty physical therapist in the United States Navy. She earned her DPT from Saint Louis University in 2010 and then went on to Great Lakes Naval Base. While at Great Lakes she eventually became the Physical Therapy Department Head and lead the way by expanding services to include Pelvic Physical Therapy and Telerehab. She pursued continuing education by earning her CSCS and Trigger Point Dry Needling credentials. These skills served her well on her second assignment on the USS Theodore Roosevelt where she served as the primary care provider for all musculoskeletal injuries. She is currently earning her DSc and FAAOMPT through the Army-Baylor University Fellowship in Orthopedic Manual Physical Therapy at Brooke Army Medical Center in San Antonio, TX.

References:

1. Nickerson TP, Zielinski MD, Jenkins DH, Schiller HJ. The Mayo Clinic experience with Morel-Lavallee lesions: establishment of a practice management guideline. J Trauma Acute Care Surg 2014;76:493-7.

2. Bonilla-Yoon I, Masih S, Patel DB, et al. The Morel-Lavallee lesion: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol 2014;21:35-43.

3. Hak DJ, Olson SA, Matta JM. Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallee lesion. J Trauma 1997;42:1046-51.

4. Mellado JM, Bencardino JT. Morel-Lavallee lesion: review with emphasis on MR imaging. Magn Reson Imaging Clin N Am 2005;13:775-82.

5. Weiss NA, Johnson JJ, Anderson SB. Morel-lavallee lesion initially diagnosed as quadriceps contusion: ultrasound, MRI, and importance of early intervention. West J Emerg Med 2015;16:438-41.

6. Parra JA, Fernandez MA, Encinas B, Rico M. Morel-Lavallee effusions in the thigh. Skeletal Radiol 1997;26:239-41.

7. Goodman BS, Smith MT, Mallempati S, Nuthakki P. A comparison of ultrasound and magnetic resonance imaging findings of a Morel-Lavallee lesion of the knee. PM R 2013;5:70-3.

8. Puig J, Pelaez I, Banos J, et al. Long-standing Morel-Lavallee lesion in the proximal thigh: ultrasound and MR findings with surgical and histopathological correlation. Australas Radiol 2006;50:594-7.

9. Powers ML, Hatem SF, Sundaram M. Morel-Lavallee lesion. Orthopedics 2007;30:250, 322-3.

10. Mukherjee K, Perrin SM, Hughes PM. Morel-Lavallee lesion in an adolescent with ultrasound and MRI correlation. Skeletal Radiol 2007;36 Suppl 1:S43-5.

I recently took on my first student, Darrin Staloch, at the Harris Health System. One of his requirements was to conduct a student inservice. He did an exceptional job reviewing neurodynamics of the lower extremity. 

A few questions you should ask yourself as you are looking through this presentation:
1) How do you determine progress when performing a neurodynamic intervention?
2) How are you currently dosing your neurodynamic treatments?
3) Are you incorporating mobilizations and manipulations into your treatment for individuals with LE nerve symptoms?

Biography:
Darrin Staloch is currently a student physical therapist seeking his DPT from Texas Woman’s University in Houston, Texas. He plans to apply for an orthopedic residency upon graduation.  His future plans include pursuing his OCS, becoming a fellow through the AAOMPT, and returning to TWU for his PhD in Physical Therapy.

Childbearing Years:
    Pregnancy and Post Partum
Urinary Dysfunction:
    Incontinence- Stress, urge, or overactive bladder
    Voiding Difficulties (slow or intermittent stream, straining, feeling of incomplete emptying)
    Cystocele
Bowel Dysfunction:
    Fecal or gas incontinence
    Obstructed Defecation
    Functional Constipation
    Rectocele or rectal/anal prolapse
Vaginal Symptoms:
    Pelvic organ prolapse
    Vaginismus
Sexual Function:
    Orgasmic dysfunction
    Dyspareunia in women
    Erectile and Ejaculatory dysfunction in men
Pelvic Pain Conditions:
    Pelvic Floor Tension Myalgia
    Levator Ani Syndrome
    Dyspareunia
    Vulvodynia
    Vulvar Vestibulitis
    Interstitial Cystitis/Painful Bladder Syndrome
    Pudendal Neuropathy and Neuralgia
    Male Chronic Pelvic Pain or Prostatitis
    Male pre & post prostatectomy
Musculoskeletal:
    SI Joint Dysfunction
    Coccyx or Tailbone Pain
    Pubic Pain
    Lumbosacral Strain
    Fibromylagia
    Improvement of Musculoskeletal Function/Abdominal Wall Tone
    Symphysis Pubis Dysfunction
    Low Back, Hip, Pelvis problems that have not responded to previous P.T.

The focus of my practice is musculoskeletal evaluation and treatment for orthopedic, lumbopelvic, obstetric, gynecologic, urologic, and colorectal conditions. I utilize manual therapy, therapeutic exercises, movement re-education/motor planning drills, connective tissue massage, and myofascial release treatments. Observation of function and movement as it relates to the patient’s condition is an essential component of my treatment as well. Today, I would like to share with the readers the intimate relationship the pelvic floor (PF) and orthopedics have in restoring function. First, allow me to begin with a brief overview of the anatomy and role of the PF.

The PF consists of three layers of superficial and deep muscles that encompass and support the pelvis and it’s adjacent structures. Layer 1 includes superficial transverse perineal, bulbocavernosus, and ischiocavernosis. Layer 2, also known as the Urogenital Diaphragm is made up of sphincter urethra, sphincter urethrovaginalis, compressor urethra, and deep transverse perineal. This layer has a fascial connection with the transverse abdominis. Layer 3, the Pelvic Diaphragm, lifts the pelvic floor and consists of the levator ani, pubococcygeus, puborectalis, and the illiococcygeus. Layer 3 connects to a thickened band of fascia formed by the obturator internus (OI) called the arcus tendinous levator ani (ATLA), which attaches at the ischial spine and the posterior pubic symphysis. When external rotation occurs, the OI pulls on the ATLA. Layer 3 uses type I tonic muscle fibers for support (70%) and type 2 phasic muscle fibers for forceful contractions and closure (30%). The PF muscles and their surrounding tissues are innervated by the following nerves: Pudendal Nerve, Levator Ani Nerve, Ilioinguinal Nerve, Genitofemoral Nerve, Perineal Nerve, Inferior Rectal Nerve, Posterior Femoral Cutaneous Nerve, Coccygeal Nerve, and Sacral Nerves. (1)

There are five roles of the PF muscles, which can be remembered by the “5 S’s”. Sphincter control: closes the openings of the urethra, vagina, and rectum and maintains urinary and fecal continence. Stability: assists in stability of sacroiliac joint (SIJ), pubic symphysis, sacrococcygeal, lumbopelvic and hip joint and is critical in enabling effective load transfer from the lower extremities to the pelvis and spine. Sexual function: orgasm, blood flow, and mobility. Support: for the pelvic organs against gravity and intra-abdominal pressure; tone for the vaginal and rectal walls. Sump Pump: a venous and lymphatic pump for the pelvis to prevent congestion.(1)

After being refreshed on the anatomy and function of the PF muscles one might ask how this potentially relates to an Outpatient Orthopedic Therapist. Below are statistics in conjunction with educational information pertaining to the relationship of the PF and the surrounding structures, as well as, when to screen for a potential referral to a Pelvic Health Therapist. My goal is for Pelvic Health Therapists and Orthopedic Therapists to work hand-in-hand to continually provide the utmost in care for our patients.

During my experience treating the PF I have come to realize the subjective complaints of pain vary drastically. Patient’s have reported pain that lingers in the right flank, pain that wraps from ASIS to the top of the iliac crest and even into the SIJ region, pain that radiates down the anterior thigh that can present unilaterally or bilaterally, pain that simulates “sciatica”, coccyx pain, sacral pain, hip and groin pain. Working manually on the PF has reproduced each of these complaints at some point in my experience. The take home message is if you have been treating your patient and they hit a plateau, don’t forget the “floor” in your treatment.

Hypertonicity of the PF affects SIJ stability.(2) The PF contributes to lowering of the vertical SIJ shear forces, increasing SIJ compression and hence increasing SIJ stability.(3) Counternutation of the sacrum occurs when PF tension is high which stiffens the SIJ, whereas multifidi contribute to nutation of the sacrum and segmental spinal control.(11b) Thus, these two work together as part of “core” stability.  In 2007 Bedova supported the theory that PF muscles alter pelvic and hip alignment with 14 female subjects who had MRI- functional stimulation to unilateral PF. The muscle stimulation resulted in femoral head, innominate and coccyx displacement.(5) Force closure of the SIJ occurs when the muscles acting across the SIJ and pubic symphysis such as back extensors, latisimus dorsi, and hip external rotators, PF muscles, abdominal muscles and hip adductors provide stabilizing force. (11a)

It is reported that 64-72% of patient’s with hip dysfunction also experience pelvic floor dysfunction (PFD).(1) Evaluation of the PF and hip components is key to improving PFD. Hip lateral rotators attach to the bony pelvis and ligamentous structures of the pelvis. Increased hip adduction and internal rotation (IR) results in OI lengthening and PF pain ultimately displaying symptoms such as posterior lateral hip pain, sciatica due to piriformis shortening, lateral thigh pain, pain in weight bearing, activities in standing or with prolonged sitting, dyspareunia, pudendal neuralgia, and urgency/frequency. Shirley Sahrmann’s hip diagnosis reports that too much femoral adduction or adduction with IR during function can cause a physical stress on the pudendal nerves. It also tightens fascially the pelvic diaphragm and can lead to PF hypertonus. Addressing tone in the hip can alleviate PF pain and even incontinence.(6)

On the contrary, if the lateral hip rotators are shortened, they may apply compressive forces on the multiple branches of the pudendal nerve. Shortening of the OI and piriformis can also cause “the sciatic nerve sandwich”. An OI trigger point mimics piriformis syndrome. This trigger point refers to the anococcygeal region with spillover pattern to the posterior thigh.  The patient will report symptoms such as fullness in the rectum, pain referred to the ipsilateral thigh, or coccyx pain.(7)  If piriformis syndrome treatment has hit a plateau, releasing the OI can alleviate sciatic nerve symptoms.  According to Prather 2009 hip disorders result in movement impairments that create a muscle imbalance leading to nerve irritation and finally pelvic pain.(8) Overuse of the deep hip rotators and ischiococcygeus result in anterior displacement of the femoral head resulting in anterior impingement, groin pain, and SIJ pain.(9) Chicken or the egg…has your patient’s hip dysfunction created PFD or does your patient have PFD that has lead to hip dysfunction?  Impaired movement patterns of the lumbar spine and hip regions cause physical stress across the pelvic girdle structures resulting in pain and mobility impairments.(10,11) Sacral nutation occurs with lumbar extension and sacral counter nutation occurs with lumbar flexion. PFM tension increases counter nutation of the sacrum.(11a)

The adductor muscles play a large role in pelvic function as well. Aside from having attachment points at the abdominal fascia that can be limited with any type of abdominal scar adhesions the adductor muscle trigger points refer pain in to the urogenital region (layer2) and increases urgency and frequency.(7) Shortened adductors cause anterior rotation of pelvis, counternutation of sacrum, compression/shearing of the symphysis pubis, and decompression of the SIJ.(1)

Stress urinary (SUI) and urge incontinence (UUI) are complications that most believe “come with old age” or occur “because I have had babies”. Although SUI and UUI are common in both of these populations please note one does not have to live with incontinence. A Pelvic Health Therapist can help these situations. Second, these are not the only populations that deal with SUI and UUI. Statistics show that both types of incontinence rate high among competitive female athletes ages 18-25, enough to alter activities around voiding habits.(14a) It is reported that 52% of female athletes experience urine loss during sport or activities.(14b) If you are treating young female athletes in your clinic screening for any incontinence issues is necessary prior to implementing abdominal exercise. If the athlete has incontinence their PF is weak, abdominal exercises and increasing intra-abdominal pressure will jam their pelvic organs down with each contraction. This repetitive jamming will lengthen their PF ultimately making them weaker and exacerbating their problem. Screening even your young athletic population is vital for success in overall health while in rehab. Increased intra-abdominal pressure that occurs with incorrect abdominal work is not the only factor that can increase the risk of incontinence. A BMI >30, chronic cough, asthma, smoking, repetitive lifting, chronic constipation, straining, and high impact exercise are all possible contributing factors to incontinence.(14)    

Numerous postural changes occur with a growing fetus. Greater than 50% of pregnant women with low back pain also had PFD, with increased activity in PF muscles. In all cases, low back pain was present prior to complaints of PFD.(14) It is stated that 41-83% of post-partum women 2-3 months are identified to have sexual dysfunction and 92% of post-partum women who are incontinent at 12 wks will still be at 5 years unless treated.(12) Please educate your pregnant patients on the potential issues of PFD and incontinence. As a healthcare provider often times initiating the conversation will open the door for the patient to feel comfortable discussing otherwise embarrassing issues. If you are uncomfortable asking the questions you can always add them to your initial intake form. If you need to refer out to a Pelvic Health Therapist, please do so. We will work as an extension of you.

Kegels, Kegels, Kegels…..First, if a patient has any kind of pelvic pain they should NOT be doing kegels. Shortening an already hypertonic muscle will only exacerbate issues. Secondly, 50% of women are unable to accurately identify PF muscles with one-time verbal and written instructions. Compensatory patterns are accessory muscle activation of gluteus maximus, hip adductors, and abdominals; breath holding; bearing down.(4) Just as there is a protocol for Achilles tendinopathy rehab there is a protocol that must be followed for PF muscle strengthening (aka: Kegels). Kegels are only assigned to appropriate patients. Screening for any kind of pelvic pain is imperative prior to assigning Kegels.

Statistics show that structural changes in the spine can affect the pelvic floor region as well. It is stated that those with kyphosis have a 1.3 increased risk of incontinence and pelvic organ prolapse for each degree of kyphosis.(1, 4)

I hope that after reading this blog you are more aware about what a Pelvic Health Therapist truly does and how we can be an extension to your practice. I am honored to write a blog on TheStudentPhysicalTherapist.com and have the chance to share my passion with others. Thank you James, Chris, and Brian, for having me.

~Breann Suddock, PT, DPT

I am an Arizona Native who pursued my undergraduate degree from Creighton University and Northern Arizona University while playing D1 soccer at both schools. In 2002 I received my Bachelor’s of Science in Community Health Education from Northern Arizona University. I obtained my certification as a Certified Strength and Conditioning Specialist in 2005 and worked closely with club soccer teams and high school soccer teams throughout the valley. I worked in an outpatient physical therapy clinic for four years followed by three years in sales and marketing for a local radiology company before I decided to seek out PT school. I received my DPT from A.T. Still University in 2013 and currently work for Rehab Plus Sports Rehabilitation in Scottsdale where I am blessed to treat the orthopedic population as well as pelvic health patients.

References:
1. Pelvic Floor Function, Dysfunction and Treatment- Advanced PF3. Herman & Wallace Inc. Pelvic
Rehabilitation Institute. 2010-2013.

2. Kathe Wallace, PT, BCB-PMD. Women’s Health Summit. 2014. 1-32.

3. Pel. 2008.

4. Vickers D, Davila GW. Kegel exercises and biofeedback. In: Davila GW, Ghoniem GM, Wexner SD, eds.
Pelvic Floor Dysfunction: A Multidisciplinary Approach. London: Springer-Verlag; 2006.

5. Bedova. 2007.

6. Sahrmann, Shirley PT, PhD. Hip Diagnosis. Communication with T. Spitznagle.

7. Travel and Simons. Myofascial Pain and Dysfunction. 1992.

8. Prather. 2009.

9. Women’s Health Summit 2014.
    a. Diane Lee lecture: (Gilleard and Brown 1996)
    b. Diane Lee lecture: (Spitznagle et al. 2007)

10. Spitznagle, T. Pelvic Girdle Pain (PGP): Movement Systems Theory. 2006.

11. Spitznagle, Theresa “Tracy” M. PT, DPT,MHS, WCS. 2013. Movement Systems Approach to Musculoskeletal Pelvic Pain. a. The Pelvic Girdle. Diane Lee 2000, pg 53.
    a. Pool-Goudzwaard. 2004

12. Vicierup et al. 2000.

13. Australian Journal of Physiotherapy 52: 11-16

14. PF1: Pelvic Floor Muscle Disorders. Section on Women’s Health 2011.
    a. Dockter M. Kolstad AM, Martin KA, Schiwal LJ. Prevalence of Urinary Incontinence: A
     comparitive study of collegiate female athletes and non-athletic controls. JWHPT. 2007; 31:12-17.
    b. Nygaard IE, et al. Urinary Incontinence in elite, nulliparous athletes. Obstet Gynecol. 1994; 84:183-187.

Are my patients seeing results from what I am doing? One of the biggest questions we, as doctors of physical therapy, face is whether or not we are the reason our patients are seeing improvement or whether it's just the passage of time. It is known that physical therapists can increase mobility and strength, but are we really making functionally important differences in the patient's life? The key to this answer is “test, treat, re-test”.  As a DPT student I've realized the necessity of always performing this and that there is also a great deal of art involved in the process as well. This post is an introduction to the topic, and if it generates enough interest, I can expound more on the current topics and further discuss the art of this subject as well. Definition: Test, treat, re-test is executed by the PT performing a simple, reproducible, reliable test with a patient. The PT will then perform one or more treatments. The PT will then perform the same test.

The following are three examples of this. These example will be integrated later on in this post. 

Example 1
Patient: 64 y.o. Male 3 weeks s/p L TKA.

Test: Measure knee flexion PROM with a goniometer.

Treatment: Grade III, anterior-posterior mobilizations in hooklying for 3 minutes.

Re-test: Measure knee flexion PROM with a goniometer. (Ensure the patient is in the exact same position. A measurement in hooklying often will produce a different measurement than in prone.)

Evaluation: If the knee flexion PROM is greater or if the patient reports less pain then this is a successful treatment.

Example 2
Patient: 13 y.o. Female with 4 months complaint of R anterior knee pain.

Test: 3 second step-down from a 6” box with the R leg on the box. Ask the patient how much pain they are experiencing on the NPRS.

Treatment: Clamshell exercise with a red band; 4 sets of 6 repetitions.

Re-test: 3 second step-down from a 6” box with the R leg on the box. Ask the patient how much pain they are experiencing on the NPRS.

Evaluation: If pain is decreased then this is a successful treatment. 

Example 3
Patient: 45 y.o. Female with 3 weeks complaint of R shoulder pain that has been determined to be impingement.

Test: R shoulder flexion AROM with thumb up. Measure the ROM with a goniometer. Ask the patient how much pain they are experiencing on the NPRS.

Treatment: Seated thoracic manipulation.

Re-test:  R shoulder flexion AROM with thumb up. Measure the ROM with a goniometer. Ask the patient how much pain they are experiencing on the NPRS.

Evaluation: If the more AROM is found or the patient reports less pain then this is a successful treatment.

When to stop in a given session:

It takes experience and skill to know when to stop testing, treating, and re-testing in a treatment session. I develop more experience and skill each day. Currently, I realize that there are 3 main reasons to stop testing, treating, and re-testing in a treatment session.

Reason 1: You stop seeing a re-test benefit.

Application of Reason 1 to Example 1: If upon re-test the patient has greater PROM or less pain with the same PROM then this was effecitve. Thus, you should perform the same treatment of Grade III anterior-posterior mobilizations in hooklying again. Then re-test. You continue this until you stop seeing improvement in your re-test.

Reason 2:  The patient performs the test with full function and no pain. This is an easy decision

 Application  of Reason 2 to Example 2: If upon re-test the patient's pain on the NPRS drops from a 6/10 to a 4/10 then the clamshells were effective.  Thus, you should perform more clamshells. Continue doing this until she performs this test with no pain or her progress stops as happens in the first reason to stop a treatment.

Reason 3: The patient has made significant improvement. This is the art of physical therapy- a much more difficult decision than the first. There is no standard. The clinician's judgment, experience, expertise, and intuition all factor into the decision.  We will investigate two examples for this one due to the higher level of thought processes and areas for variance.

Application of Reason 3 to Example 2: Upon re-test her pain on the NPRS drops from a 6/10 to a 2/10. You know that she is very pleased with this result. Now you, the clinician, have to weigh the benefits of attempting to go to 0/10 pain. She's been complaining of knee pain for 4 months. There's a reasonable chance that she will not go to a 0/10 pain. There's also a chance that with continued re-testing that her pain will increase. In this case it may be best to give her a “high 5” and end the treatment session.

 The following is 2 different scenarios with Example 3 that would require using Reason 1 or Reason 3.

Application of Reason 1 to Example 3: If upon the re-test the patient reports a small improvement from 7/10 pain to 6/10 pain and there is a 5 degree improvement then you can be confident that it helped. You saw the ROM difference and while they may not feel the ROM difference they feel their pain is a little less with the movement. Thus, the thoracic manipulation should be applied again and then re-test afterwards. You will stop this cycle once the gains are stopped,  when the gains are so minimal that they aren't worth performing the intervention again, or when another Reason applies.

Application of Reason 3 to Example 3: You perform the thoracic manipulation and upon re-test the patient has now has 20 degrees improved motion and drops from a 7/10 pain to a 3/10 pain. The drastic improvements are very obvious and the patient wonders how you are so magical. At this point you have patient “buy-in”. They now believe that you are an expert and that whatever you do will be effective.  The chances that performing another thoracic manipulation will be as “magical” as the first are almost non-existent. Tell her you are very pleased with the changes as well and then describe the next intervention. Here you can choose to do an exercise that won't irritate her, but that will also likely help. You won't want to re-test because you've already gotten the buy-in. In future visits you'll want to re-test after these exercises, but let's just be happy with the results we've already obtained.

 Conclusion:
“Test, treat, re-test” is vital in an outpatient, orthopaedic setting. It is vital that we know if we're truly making a difference. Plus, it improves our patient's perception of us. They'll know we're not just throwing random interventions at them in hopes that after 18 visits they're a little better.

Please ask questions and propose scenarios in the comments. I'll respond to many comments and hopefully others do as well. There are a lot of things to consider when testing, treating, and re-testing. What type of problems do you see using this? What benefits do you see using this? Can this be applied to neurological rehabilitation? Can it be applied to a strength and conditioning setting? 

About the Author:
Nick Rainey, SPT, CSCS is an SPT at Rocky Mountain University of Health Professions located in Provo, UT. He is near Atlanta, GA doing a 45 week clinical rotation that is associated with the continuing education company Evidence in Motion. He originally decided to enter the physical therapy profession after talking to a strength and conditioning coach at BYU who felt that it would give him an edge in the strength and conditioning field. He is author of the book The 6 Week Workout Program and its associated blog. Additionally, he is co-owner of Body4Change, a personal training and boot camp company. Nick hopes that the emphases in his career will include reducing people's pain, improving athletic performance, and helping people to be involved in their health care decisions. 

Reaction:
As Nick alludes to at the end of the post, lets not forget that a re-test can also evaluate whether a patient is ready for an advance in the treatment plan.  We agree that you could continue a tx until you stop seeing improvement following an improvement in the re-test, but it is also important to consider advancing the patient's tx plan. Another point we'd like to make is that not every intervention has immediately measurable effects. In those cases, it may not be necessary to perform a re-test after each treatment session. Interventions like manual therapy are likely to have immediate effects and are easy to re-examine quickly. Additionally, remember that if we add interventions we may have to decrease one as well.  Volume can be the culprit in rehabilitation (as well as S&C) and makes it less clear as to what is working (or not working).  Excellent topic choice, thanks Nick! 

One of the most important and interesting, but also very challenging, parts of the job of a Physical Therapist is the treatment of people with spinal cord injuries. A deep understanding of the nervous system, its structure and its function, is a prerequisite before he/she starts applying any kind of physiotherapeutic intervention. In this article and the presentation that goes with it, I briefly present the structure of the nervous system, its major tracts/pathways, as well as a very nice and simple mind map on how to assess and what symptoms to expect after a complete or incomplete spinal cord injury. My notes include my own work and are a based on the lectures I attended and the study notes I received during in the Anatomy and Neurology courses in the European School of Physiotherapy in the Hogeschool van Amsterdam by Dr. Jaap Bakker (MD) and Bert Loozen (PT, MSc). In order to follow and understand this article, you should have also this powerpoint presentation I have created.

A. The Neuron
Having in mind the functional unit of the nervous system, the neuron (slide 2, 3), we can create two conceptual models of a neuron based on the structure and function they have in the human body (slide 4). The first model is a neuron with a long axon and short dendrites. I will use this model for the neurons that transfer action potentials from the Central Nervous System (CNS) to the peripheral organs. The second model is a neuron with two long axons - the peripheral and the central branch. I will use this model for the neurons that transfer action potentials from the peripheral organs to the CNS.

B. An Overview of the Nervous System
A conceptual model we can use in order to organize the structure of the nervous system is presented in slide 5. First of all, we can divide the nervous system into a central part (the brain and the spinal cord) and a peripheral part (the nerves). The CNS can be further divided in a voluntary part (all the actions and reactions we voluntarily do) and an involuntary part or autonomic nervous system (all the actions and reactions our body makes without our "control"). The neurons of the CNS follow specific pathways in the spinal cord, which will be analyzed further. The peripheral nervous system (PNS) can be further divided into an afferent division (all the neurons that transfer action potentials from the peripheral organs to the CNS) and an efferent division (all the neurons that transfer action potentials from the CNS to the peripheral organs). The afferent division of the PNS transfers signals from the musculoskeletal system, the skin and the vitals. The efferent division of the PNS transfers signals to the musculoskeletal system, the glands, the smooth muscle, cardiac muscle and the vitals. So, they can be further divided as seen in slide 5. What is important for someone to realize is that these divisions connect with the pathways of the CNS mentioned before and follow specific routes  which have been identified. Each route serves specific functions and it is these routes one is interested in when he/she tries to assess in a spinal cord injury.

C. The Major Pathways/Tracts of the CNS

C.1. The major tracts of the somatosensory system are the following

• the spinocerebellar tract
  
• the dorsal column
  
• the spinothalamic tract
  
  

You can see the structure and function of each tract in slides 6-8

    C.2. The major tracts of the motor system are the following

• the corticospinal tract
  
• the corticobulbar tract
  
• the extrapyramidal tracts
  
  

You can see the structure and function of each tract in slides 13-15

D. The Motor System and Reflexes
The motor system of our body is divided in two major anatomical parts: the upper motor neuron (UMN) and the lower motor neuron (LMN) (slide 9). The UMN consists of the tracts that “travel” from the brain in the spinal cord. The major tracts just described in C.2. are the tracts of the UMN. The LMN consists of the efferent neurons outside the UMNs. It is important to make this conceptual anatomical framework, because it will help us in the assessment part of a spinal cord injury. Another reason for making this demarcation is for introducing the reflex phenomenon that occurs in our body. The reflex is an involuntary, instantaneous reaction of our body as a response to a stimuli. So, it is a separate “tract” that does not follow any of the above mentioned tracts. In other words, it is a tract - called the reflex arc - that does not "have" to travel all the way up to the brain through the somatosensory tracts and then down to the organ through the motor system tracts. This phenomenon, as well as the LMN structure and function, is presented in slide 10-12.

E. Visualizing the Spinal Cord and the Tracts
Now that we have covered some of the tracts of the CNS and the divisions of the PNS, we can easily visualize them in the spinal cord. It is true that each of these tracts has a certain position in the spinal cord. A very nice step-by-step journey in the spinal cord is presented from slide 16-39.

F. Spinal Cord Injuries
For someone that has absorbed the above mentioned knowledge and is able to visualize the spinal cord, the tracts and the divisions, it should now be easy to understand and predict what is the effect of each spinal cord injury (SCI). A first grouping of SCIs is done based on the level of assessment. This means that , depending on which segment of the spinal cord in injured, a Physical Therapists wants to examine to symptoms of the injury at 3 different levels of the human body: 1. above the level of the injury, 2. at the level of the injury, 3. below the level of the injury.

> General principle
        > above
            > intact
            > motor and sensory functions are completely normal
        > at
            > if afferent fibers destroyed at the point of entry
                > anesthesia > dermatomes
       
            > if reflex arcs and LMN destroyed
                > flaccid paresis > myotomes
                > if more than one segment > paralysis
          
            > varying degrees of sympathetic dysfunctions
        > below
            > anatomically intact, but lost communication with supraspinal centers
          
            > if sensory information cannot reach the brain
                > anesthesia
         
            > if motor commands from the brain cannot reach the isolated segments
                > spastic paralysis
                > reflex abnormalities
            > dysfunction of pelvic organs and varying degrees of sympathetic dysfunctions

Another grouping of SCIs is based on whether the injury was complete or incomplete. In complete lesions, the entire segment of the spinal cord is damaged. In incomplete lesions, a part of the spinal cord segment is damaged. Below, you can find some general rules followed in each case.

> Complete lesions
    > C4 >> diaphragm paralysis >> death
    > C >> tetraplegia
    > T, L >> paraplegia
    > S > conus syndrome
    > example C7
        > reflexes
            > biceps > normal (above)
            > triceps > decreased (at level, myotatic reflex)
            > abdominal > decreased (below, cutaneous reflex)
            > patellar > increased (below, myotatic reflex)
            > plantar > appeared (below, pathological sign)

    > spinal shock
        > directly after spinal cord injury > temporary cessation of all reflex activity below the level of an acute    
           spinal cord lesion
        > only reflex arcs affected
        > areflexia #> hyperreflexia (clonus and pathological signs)
        > atonia > flaccid paralysis #> spastic paralysis
        > autonomic disturbances
        > paralysis and anesthesia remains
        > slowly developing spinal cord transections do not cause a spinal sock

> for Incomplete lesions check slides 40-41. There you can see the effects of an SCI depending of which tract is affected

> also, check slides 42-50, where I guide you in a path of the effects of an SCI at C8-T1 in a step-by-step process

If you liked that and you are interested in going more in details check out this article on my blog. Or you can find more interesting articles and studying tips I have posted here.