PTA103Neuromuscular ConditionsW2021
PTA 103 Intro to Clinical Practice 2

Instructional Use Statement

The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution or commercial purposes. It is not intended to serve as medical advice or treatment. Marc Duyck PTA, MEd. CSCS

 Image is of a brain and spinal cord

Lesson Objectives

Image is of a neuron that is sending signals to other neurons

Here is a screen-cast introduction to this lesson builder

1. Review the structures and function of the neurological and neuromuscular systems
2. Describe the role of CNS components in producing and coordinating movement.
3. Discriminate between clinical symptoms that present in localized and diffuse neuromuscular pathological conditions encountered in the physical therapy service
1. Upper motor neuron disorders
2. Lower motor neuron disorders
3. Disorders of the basil ganglia
4. Cerebellar disorders
5. Peripheral nerve injury
4. Describe mechanisms of central and peripheral nervous system injury that results in a decline in function
5. Select interventions to reduce effects of neuromuscular conditions on function in case simulations
6. Select standardized tests and measures used to assess response to treatment in simulated neuromuscular cases
7. Identify roles of interdisciplinary team members that support optimizing activity in patients with neuromuscular dysfunctions
8. Plan and prioritize interventions that includes family education and training, and discharge planning in a simulated case.

Readings:

See Moodle Week 6 Neuromuscular Resources for assigned readings this week

Neurological System Functions

Fun

 In order to understand what can go wrong, we need to know what normal function looks like. It is easier to understand signs and symptoms of disease when you can reference the involved structures and processes. PT interventions, tests, and measures become more meaningful when you have a general understanding of deficits and potential for rehabilitation.

Functional Overview

1. Sensory: Monitor internal and external stimuli

2. Integration: Brain and spinal cord process sensory input and initiate responses

3. Control: Muscles and glands

4. Homeostasis: Regulate and coordinate physiology

5. Mental activity: Consciousness, thinking, memory, emotion

Organization of the Nervous System

Concepts and Terminology to Learn

• Peripheral Nervous System  
• Central Nervous System     
• Autonomic Nervous System
• Motor Neurons    
• Sensory Neurons

Components on the Nervous System

–Brain, spinal cord, nerves, sensory receptors

Subdivisions

–Central nervous system (CNS): brain and spinal cord

–Peripheral nervous system (PNS): sensory receptors and nerves

Brain

Brain

•Part of CNS contained in cranial cavity

•Control center for many of body's functions

Parts of the brain

•Cerebrum/cerebral cortex: conscious thought, control

•Brainstem: connects spinal cord to brain; integration of reflexes necessary for survival

•Cerebellum: involved in control of locomotion, balance, posture

•Diencephalon: thalamus, subthalamus, epithalamus, hypothalamus

Cerebrum

•Largest portion of brain

•Composed of right and left hemispheres each of which has the following lobes: frontal, parietal, occipital, temporal, limbic, insular

Cerebral Lobes

•Frontal: executor of function: voluntary motor function, motivation, aggression, sense of smell, mood

•Parietal: sensory integrator for pain, temperature, detection of taste, and touch; coordinates reading

•Temporal:  Reception and evaluation for smell and hearing; memory, abstract thought, judgment; Insula is within temporal lobe.

•Occipital: reception and integration of visual input

•Central sulcus: between the pre central gyrus/primary motor cortex and post central gyrus/primary somatic sensory cortex

Limbic System

•Part of cerebrum and diencephalon

•Basic survival functions such as memory, reproduction, nutrition

•Emotions

•Various nuclei of the thalamus

•Part of the basal nuclei, hypothalamus, olfactory cortex, fornix

Diencephalon

• Connects the brain to the brainstem: image above
• Components: thalamus, subthalamus, epithalamus, hypothalamus

Thalamus

•Sensory information from spinal cord synapses here before projecting to cerebrum

•Relay information to motor, mood, emotion, and sensory integration areas in the cerebral cortex

Subthalamus

•Involved in controlling motor function

•Contains subthalamic nuclei, parts of red nuclei and substantia nigra.

•Several ascending and descending nerve tracts

Epithalamus

•Pineal gland

• –may influence sleepiness, helps regulate biological clock, may play a role in onset of puberty
• –Role in emotional and visceral responses to odors

Hypothalamus

•Most inferior portion of diencephalon

•olfactory reflexes and emotional responses to odors

•Controls endocrine system.

•Receives input from viscera, taste receptors, limbic system, nipples, external genitalia, prefrontal cortex

•Efferent fibers to brainstem, spinal cord (autonomic system), to posterior pituitary, and to cranial nerves controlling swallowing and shivering

•Important in regulation of mood, emotion, sexual pleasure, satiation, rage, and fear

Brainstem

•Comprised of midbrain, pons, and medulla oblongata.

•Considered Peripheral Nervous System (PNS)

•These peripheral nerves originate from brain.

•Two pairs arise from cerebrum; ten pairs arise from brainstem

A pontine CVA is a stroke involving the brainstem.

•Continuous with spinal cord; has both ascending and descending nerve tracts

•Regulates: sleep, heart rate, blood vessel diameter, respiration, swallowing, vomiting, hiccupping, coughing, and sneezing

Crainial Nerves

• Considered Peripheral Nervous System (PNS)
• These peripheral nerves originate from brain.
• Two pairs arise from cerebrum; ten pairs arise from brainstem

•Indicated by

• –Roman numerals I-XII from anterior to posterior
• –Names

•May have one or more of three functions

• –Sensory (special or general)
• –Somatic motor (control of skeletal muscles)
• –Parasympathetic (regulation of glands, smooth muscles, cardiac muscle)

Cranial Nerve Reflexes

• X (Vagus): reflexes having to do with heart rate, blood pressure, and respiration
• Reflexes involving both cranial nerves and brainstem:

• Turning the eyes toward sudden noise, touch on skin, flash of light
• Eyes tracking a moving object.
• Reflex using VIII, V, and VII to contract muscles associated with middle ear that protect ear ossicles
• Chewing reactions to textures of food, movement of tongue pushing food under tooth-row and out of harm's way

Trigeminal Nerve

Cerebellum

• •Key Point:  COORDINATION; Ataxia = lack of coordination
• •Makes comparisons between the motor plan from the cortex and the position sense from the muscles/joints and facilitates movement precision/correction
• •Influences timing and force of voluntary muscular contraction

•Finger-to-nose test: what this is testing is coordination ruling out ataxia. If a pt had an impaired finger to nose test, the PTA would not interpret meaning, but give/chart this information as impaired or not impaired and share results with the supervising PT.

Cerebrum versus Brainstem

• •Brainstem and diencephalon maintain homeostasis of basic/primitive functions
• •Cerebrum and cerebellum coordinate, plan, and memorize higher level sensori-motor function

The two systems interact in automatic and conscious ways throughout the life cycle

Blood Supply to the Brain

•Anterior Cerebral Artery (ACA)

• Frontal, parietal, and basal ganglia

•Middle Cerebral Artery (MCA)

• Lateral surfaces of the frontal, parietal, temporal and occipital lobes

•Posterior Cerebral Artery (PCA)

• Midbrain, thalamus, occipital lobe, medial and inferior temporal lobe

 Image is of the various arteries that supply blood to the brain

Basilar Artery

–Includes anterior inferior cerebellar artery (AICA), superior cerebellar artery

–Supplies pons and cerebellum

–Primary blood supply to midbrain

–Complete occlusion can be fatal

Circle of Willis

•Ring of 9 arteries

•Provides multiple sources of circulation/blood supply to the cerebrum

Vertebral Arteries

–Carry one-third of blood supply to the brain

–Originate from the subclavian artery

–Branches into three parts

• •Anterior Spinal
• •Posterior Spinal
• •Posterior Inferior Cerebellar Artery (PICA)

–All three branches supply blood to medulla

–PICA supplies inferior cerebellum

Internal Carotid Arteries

–Originate from the common carotid

–Becomes the posterior communicating arteries (PCA)

–Divides into anterior and middle cerebral arteries

Ventricles

Ventricles are interconnected by aqueducts and wall openings

Blockage in the central canal or fourth ventricle can lead to hydrocephalus (enlarging ventricles) and may require an external shunt for treatment

Cerebrospinal Fluid (CSF)

CSF

Similar to serum, but most protein removed

• •Bathes brain and spinal cord
• •Protective cushion around CNS
• •Choroid plexuses produce CSF which fills ventricles and other parts of brain and spinal cord

Composed of ependymal cells, their support tissue, and associated blood vessels

Blood-cerebrospinal fluid barrier

• •Endothelial cells of capillaries attached by tight junctions
• •Substances do not pass between cells
• •Substances must pass through cells
• •Makes the barrier very selective

Types of Neurons

Peripheral nervous system image is of a sensory and afferent: action potentials toward CNS 

•Functional classification

• Sensory or afferent: action potentials toward CNS sensory receptor see above
• Motor or efferent: action potentials away from CNS - spinal cord to muscle for example
• Interneurons or association neurons: within CNS from one neuron to another

•Structural classification

• Multipolar: most neurons in CNS; motor neurons
• Unipolar: single process that divides into two branches. Part that extends to the periphery has dendrite-like sensory receptors

PNS/Peripheral Nervous System Goodman Reading Summary

PNS/Peripheral Nervous System Goodman Reading Summary Guided Learning 12 min

Divisions of PNS/Peripheral Nervous System

Most nerves contain a mixture of neurons

• Includes motor, sensory, neurons of the somatic nervous systems and autonomic nervous system (ANS) which includes sympathetic and parasympathetic neurons

Afferent pathways: sensory responses from the periphery (touch, position, pain)

Efferent pathways: motor responses from the center/spinal cord to the periphery

• Includes somatic motor nerves that innervate skeletal muscles

Autonomic nervous system (ANS):

Organs receive dual innervations from both sympathetic and parasympathetic branches to maintain homeostasis

Divisions of ANS

• Sympathetic. Prepares body for physical activity such as fight or flight response.

• Sympathetic (thoracolumbar)

• Parasympathetic. Rest, relax, digest, eliminate
• Regulates resting or vegetative functions such as digesting food/esophagus, stomach, intestines or emptying of the urinary bladder.

• Enteric. plexuses within the wall of the digestive tract. Can control the digestive tract independently of the CNS, but still considered part of ANS because of the parasympathetic and sympathetic neurons that contribute to the plexi.

 Connection between the PNS and ANS broken down.

Take home message:Example: If while chewing/digesting an orange (ANS/parasympathetic branch), I receive a stimulus such as noxious heat from a stove to my finger/part of the peripheral nervous system, a response occurs involving sensory receptors (heat to my fingers) and a motor response (motor axon to motor endplate) when I pull my finger off of the stove. In the meantime my ANS is stimulated specifically the parasympathetic branch, and my digestion stops because my ANS and PNS communicate and right now the focus is getting my finger away from the noxious heat/stove!

Neuronal Communication

Image is of a neuron that is excited and communicating with other neurons!

• Cells produce electrical signals called action potentials.

• Action potential provide the transfer of information from one part of the body to another part of the body.

• Electrical properties result from ionic concentration differences across the plasma membrane and the permeability of the membrane.

 Peripheral Nervous System and Age-Related Changes

 Image is of an older adult

Decreased sensory receptors on skin

• Increased skin injury

• Slowing of action potential propagation

• Decreased neurons, decreased neurotransmitter receptors, decreased speed of transmission

• Decreased autonomic sensory function

ANS Parasympathetic Responses: Changes in Bowel/bladder, BP regulation, H20 regulation

.

Neuromuscular Pathology

Implications for Clinical Decision-Making

• Communication of dysfunction and observations depends on a mutually understood vocabulary between health care providers

• PTAs are more effective in planning and patient communication when terms used in a PT evaluation report are understood

• Understanding disease presentation and progression increases relevance of tests, measures, and interventions, area of concern in discharge planning, equipment management, communication, and home safety

Sources of Neuromuscular Pathology

• Impaired circulation (embolic ("clot") or hemorrhagic ("bleed")

• Disease of brain cells (degenerative)

• Disease at the neuromuscular junction

• Trauma (traumatic brain injury, spinal cord injury, peripheral nerve injury)

• Idiopathic (unknown origin)

Common Pathology Classes

Ischemic Versus Hemorrhagic Injury

R CVA impairments versus L CVA impairments

Most CVAs occur due to a blockage or bleeding in the middle cerebral artery. The vessel in red illustrates the distribution of the middle cerebral artery and its respective branches.

Common characteristics of cerebral CVA are:

Arteriovenous Malformation (AVM)

• Disorganized collection of abnormally thin dilated blood vessels in the brain

• Directly shunts arterial blood into the venous system

• Result in increased pressure within the AVM and risk for hemorrhagic stroke

• Signs and symptoms include seizures, HA,dizziness, syncope, aphasia, motor and/or sensory deficits

 Guided Learning Goodman Ch 20 (Do not read chapter) and Goodman assigned Reading on Traumatic Brain Injury. 15 minutes

Traumatic Brain Injury

• Primary cause of death and disability in children and young adults (Goodman, 2020)

• Greater incidence in males (2:1)

• Child abuse accounts for the majority of TBI cases in children

• Primary causes of TBI in general population

• MVA (motor vehicle accidents)
• Falls
• Violence
• Sports-related injuries
• Coup-Contracoup describes the mechanical forces on the brain as it strikes the inside of the skull as a result of high velocity impact

• Service-related TBI doubled between 2005 and 2011, largely from blast exposures and active and reserve-related duty (CDC, 2013)
• Glasgow Coma Scales and Rancho Los Amigos Scales and provide global assessment of cognitive functioning upon injury and during recovery respectively

Secondary Effects of Traumatic Brain Injury

• Swelling
• Bleeding
• Hypotension
• Respiratory complications
• Hypoxia
• Neuronal damage and death (diffuse axonal injury)
• Increased intracranial pressure

 Guided Learning Goodman Ch 23 SCI pp 709-715. Just over 8 minutes

Guide to Physical Therapy Practice Patterns

Neuromuscular Practice Patterns in Physical Therapy

The Guide to Physical Therapy Practice frames seven, impairment-based patterns that are consistent with patients and clients encountered in the physical therapy service. The language in practice patterns reflects the commitment to documenting and tracking how a person functions within their disease versus focusing on the disease.

Physical Therapy practice patterns connect affected body structures and functions with outcomes in the examination process. The result is a clear application of the International Classification of Functioning, Disability, and Health (ICF) which aids in evidence-based treatment planning. Within practice patterns, the physical therapist evaluates how body systems and conditions and the associated impairments impact function and disability within the patient's individual circumstance.

The table below outlines how physical therapy approaches establishing a PT diagnosis. A PT prognosis will factor in specific patient situations and circumstances (such as co morbidities, support systems, etc., work/home activities) in order to set treatment goals, frequency and duration.

Coordinating Care

Many providers are involved in coordinating care for patients and clients with neuromuscular dysfunction. All health care providers share a commitment to patient and family education and patient-centered practice. Examples of providers and some of their focused scope of practice include:

• Physiatry - physical medicine and rehabilitation doctors
• Neurologists - physicians that specialize in the brain and nervous system
• Neurosurgeons - surgical procedures to protect optimize function of the nervous system
• Neuropsychologists - provide therapeutic intervention and assessments of cognitive functioning
• Speech language pathologists - provide therapeutic interventions for improving swallowing, speech production (quality, fluency), and communication/problem solving
• Occupational therapists - provide therapeutic interventions for improving activities of daily living and self-care activities, community reintegration, and fine motor skills
• Respiratory Care- provide therapeutic interventions to support respiratory function and ventilation
• Nutritionists - provide dietary guidelines and monitoring of nutritional status and weight based on condition
• Nursing - provide round-the-clock care and monitoring of physiological status and provide interventions, medications to stabilize and improve health condition per physician orders
• Therapeutic recreation therapists - provide interventions that foster enjoyment and positive interactions and self-efficacy
• Chaplains - provide spiritual support to patients and families on areas of personal need and in adjustment to disability
• Radiology - provide imaging studies that inform the team of anatomical, physiological, and pathophysiological status in multiple body systems

PT Examination

Image is of a PT evaluating a pt with a

neurological condition

Key elements of a physical therapy examination includes

• Cognitive or Mental status screening
• consciousness, attention, orientation, and general cognition (e.g., memory, information processing)
• Communication
• includes speech and language disorders
• Motor control
• volitional versus involuntary movements, isolated or synergistic
• Motor learning
• ability sustain motor performance over time, interpret motor feedback, transfer skills to different environments
• Postural control, balance and coordination
• Coordination
• muscle activity during voluntary movement
• muscle groups working together to perform a task (timing, accuracy, sequence) = synergy
• level of skill and efficiency
• start, control and stop according to activity/environment demand
• Gait and Locomotion
• Neuromuscular tone
• Range of Motion and Flexibility
• Integument integrity
• skin observations, pressure areas
• Pain
• Sensation and Sensory Integration
• deep tendon reflexes (DTRs)
• pathological reflex testing
• proprioception
• kinesthesia
• sensory discrimination (sharp & dull, hot & cold, vibration, light touch & pressure, right & left discrimination)
• Cranial nerve integrity
• Peripheral nerve conduction / electromyography (EMG)
• Manual Muscle Testing
• Functional Task and Mobility Analysis
• Protective and Support Equipment
• Standardized Outcome Measures
• Functional Independence Measure (FIM)
• Performance Oriented Assessment of Mobility (Tinetti)
• Functional Reach Test
• Timed Get Up and Go Test
• Timed Walking Test
• Berg Balance Scale
• Barthel Index
• Aerobic Capacity and Endurance

Summary of Patient-Client Management for Patients and Clients with Neuromuscular Conditions

• PT examination
• Review of history, reason for referral, review of systems, tests and measures, special tests, review of diagnostic studies (outcomes of imaging, lab results)
• PT Evaluation
• Interpret examination findings and apply clinical reasoning
• Considers personal and contextual factors
• Differentially diagnose and make appropriate referrals as needed for coordinating care
• PT Diagnosis
• Select practice pattern(s) that reflect a neuromuscular pattern within the scope of practice
• PT Prognosis
• Generate goals and expected outcomes; includes a plan of care (interventions, frequency, duration) to achieve goals

Role of the PTA

• Prepare for safe and effective interventions by thoroughly reviewing the PT Examination findings, associated progress reports, and the plan of care
• Recognize declines in function or abnormal responses to interventions and report findings to the supervising PT
• Perform interventions within the POC to achieve stated goals
• Monitor and report physiologic responses to interventions
• Assess motor control and motor learning: report to PT if steep or gradual decline in this area is observed.
• Assess cognitive status: orientation to place, person, time of day, year: communicate to PT and or care team significant changes in this area.
• Communicate barriers, questions, and concerns to the supervising physical therapist
• Complete and repeat tests and measures as indicated to monitor patient response and progress
• Educate patients and family members in use of positioning, equipment, assistive devices, energy conservation, home and community safety (including fall prevention)
• Include age-appropriate and instructional strategies consistent with the patient's developmental and cognitive status
• Coordinate with the interprofesional health care team to optimize safety and recovery

Interventions

• Skilled services selected to progress patient toward goals
• Performed by the PT or the PTA as directed by the supervising PT
• Examples include
• therapeutic exercise (ROM, strengthening, stabilization, postural exercises, endurance training)
• biophysical agents (modalities)
• therapeutic activities (functional training, family training, transfer training)
• gait and locomotion
• training in the use of orthotics, prosthetics, and equipment / assistive technology
• static and dynamic balance and coordination training
• gross motor control and learning
• sensory training
• positioning for pain relief and pain management
• skin care and protection

Tests and measures

Tests and measures provide data that informs the physical therapy plan of care. Outcomes of tests and measures may prompt communication with the supervising PT and other health care personnel, particularly when there are marked changes over time that suggest a need for care plan review or emergency action. Examples of common tests and measures in this population include:

• ROM, strength, functional performance, observation (e.g. posture, skin)
• Pain scales, tone, reflexes, sensation
• Coordination
• Time, distance, quality, assistive devices, cuing, patient support equipment during gait and locomotion
• Physiological responses to movement (vital signs) and endurance
• Orientation (A&O)
• Motor planning and performance - simple to complex movements and associated problem-solving during movement
• Pain management effectiveness
• Standardized functional assessments
• Functional Independence Measure (FIM)
• Modified Ashworth Scale - assesses level of hypertonicity
• Barthel Index - grossly assess activities of daily living functional status
• Specific tests for neurologically-involved patients are covered in PTA 204/204L

Image is of an adult with a spinal cord injury 

Functional Independence Measure (FIM): Review from Fall term

Terminology for Neuromuscular Conditions

Image is of a physical therapist assistant working with a RN

in the care of a person with a neurological health condition

Key terms for understanding descriptions of neuromuscular conditions are listed below.  They are used throughout your text resources and in medical records.  Refer to this list during lecture presentations and course reading in order to differentiate between signs and symptoms of neurological and neuromuscular conditions

Terms associated with impairments and dysfunction of the neuromuscular system

1. Agnosia = inability to interpret sensory input
2. Akinesia = inability to voluntarily initiate movement
3. Allodynia = pain from non-noxious stimulus (e.g., touch)
4. Analgesia = loss of pain/sensitivity
5. Areflexia = loss of spinal reflexes
6. Arousal = readiness of the human system for activity
7. Aphasia = inability to produce functional (expressive) or integrate (receptive) speech
8. Apraxia = inability to perform skilled purposeful movements
9. Ataxia = lack of coordination
10. Attention = selective awareness of the environment or responsiveness to a stimulus or task without being distracted by other stimuli
11. Athetosis = slow, involuntary, writhing, twisting movement
12. Balance = all forces acting on a body so that the center of mass is within the base of support
13. Bradykinesia = decreased amplitude and velocity of movement; slowed movements
14. Causalgia = painful burning sensation
15. Chorea = involuntary, continuous, rapid, irregular and jerky movements
16. Clonus = series of involuntary muscle contraction in response to a stretch
17. Cognition = process of knowing, includes awareness and judgment
18. Dementia = broad based memory impairment
19. Dermatome = skin area of sensation supplied by one dorsal root
20. Diplopía = double vision
21. Dysarthria = impairment of speech articulation (speech errors in volume, pitch, quality)
22. Dysdiadochokinesia: A patient's inability to perform rapidly alternating movements: example inability to alternate between heel and toe rocking in a seated position,
23. Dysesthesia = impairment of sensation where touch is perceived as pain
24. Dyskinesia = over activity of muscles
25. Dysmetria = impairment judging distance or range of a movement
26. Dysphagia = impairment of strength and coordination of chewing and swallowing
27. Dystonia = involuntary adoption of abnormal postures
28. Fasciculation = small, local, involuntary twitch contraction
29. Festinating = shuffling pattern
30. Flaccidity = absence of strength, muscular activation
31. Hemianopsia = loss of half of the visual field
32. Hemiparesis = weakness on one side of the body/limb
33. Hyperalgesia = increased sensitivity to sensory stimuli
34. Hyperreflexia = exaggerated responses of spinal reflexes
35. Hypertonia = increase in muscle tone
36. Hypokinesia = reduction of movement
37. Hypotonia = decrease in muscle tone
38. Incomplete = partial innervations remains distal to spinal cord lesion
39. Limits of stability (LOS) = maximum distance an individual is willing to lean in any direction without LOB or changing the BOS
40. Neglect = inattention to or lack of awareness of one side
41. Neuralgia = pain associated with nerve inflammation
42. Neuropathic = result of nervous system/tissue pathology
43. Nystagmus = rhythmic, quick alternating movements of the eyes
44. Quadriplegia = weakness in all four extremities
45. Reflex = involuntary, predictable, specific response to a stimulus
46. Rigidity = resistance to passive movement of the limb
47. Spasticity = hypertonic resistance to passive stretch
48. Somatosensory = sensation received from the skin and neuromuscular system
49. Orientation = awareness of time, person, place
50. Paraplegia = weakness in the lower part of the trunk or legs
51. Parasthesia = abnormal sensation (numbness, prickling, etc) without apparent cause
52. Paresis = weakness
53. Posture = the control of relative position of parts by skeletal muscles with respect to each other and gravity
54. Proprioception= joint position sense
55. Thermanalgesia = inability to perceive heat
56. Thermanesthesia = inability to perceive hot/cold
57. Tremor = involuntary oscillating contraction from opposing muscle groups
58. Vegetative = No conscious interaction; reflexive; sleep-wake cycles
59. Vertigo = sensation of dizziness

Definition of Coordination

1.      Muscle groups working together to perform a task during a voluntary movement (timing, accuracy, sequence) = synergy.

2.      Level of skill and efficiency of movement with the nervous system as a key variable.

3.      Start, control and stop muscle activity according to activity/environment demand with the nervous system as a key variable to accomplish the task.

 End of Lesson

References:

Cameron. M. 2011. Physical Rehabilitation for the PTA. Elsevier. MO

Goodman. C. 2018 Pathology for the PTA. 2nd Edition. Elsevier. MO.

Linder, A. et al. 1997. Postpartum obturator nerve syndrome: case report and review of the nerve compression syndrome during pregnancy.

1997;119(3):93-9