3.2. Thoracolumbar subjective Flashcards
T OR F: Diagnosing pain due to a disc is primarily diagnosis of inclusion.
FALSE
diagnosis of EXCLUSION
Most of the examination commonly revolves around differentiating symptoms of _____ (2), which refers radicular symptoms into the leg from other conditions more likely to cause localized pain
herniated disc or space-occupying lesion
If there are no radicular symptoms below the (1) ____, it often becomes difficult for the examiner to determine where in the spine the problem is, or whether the problem is truly in the lumbar spine or coming from problems in the pelvic joints, primarily the (2)_____.
BELOW the KNEE
pelvic joints: SI Joints or Hips
Only about ____% of cases can a definitive diagnosis as to the pathology of back pain be made.
15%
What are the 2 main categories of LBP?
Back pain dominant/ Mechanical cause
Leg pain dominant/ Nonmechanical cause
pattern of LBP that suggests disc involvement, sprain, strain
pattern 1 of back pain dominant
pattern of LBP that suggests facet joint involvements, strain
pattern 2 of back pain dominant
pattern of LBP that suggests nerve root irritation, primarily by a disc or some other space-occupying lesion or an injury accompanied by inflammatory swelling
pattern 3 of leg pain dominant
pattern of LBP that suggests neurogenic intermittent claudication/pressure on the cauda equina
pattern 4 of leg pain dominant
Age predisposition for Scheuermann’s disease
13-16 y/o
Age predisposition for Idiopathic scoliosis
adolescent females
Age predisposition for lumbar disc problems
15-40 y/o
Age predisposition for ankylosing spondylitis
18-45 y/o
Age predisposition for spine osteoarthritis and spondylosis
> 45 y/o
Sex predisposition for ankylosing spondylitis
MALES
Age predisposition for spine malignancy
> 50 y/o
MOI for rib injuries
trauma
MOI for thoracic spine problems
disease processes (e.g., scoliosis) and may have an insidious onset
Sex predisposition for scoliosis & LBP
FEMALES
Female patients should be asked about any changes that occur with menstruation, such as altered pain patterns, irregular menses, and swelling of the abdomen or breasts
T OR F: Pain from true thoracic trauma tends to be diffused to the area of injury.
FALSE
Pain from true thoracic trauma tends to be LOCALIZED to the area of injury.
MOI for facet syndromes
present as stiffness and local pain, which can be referred
T OR F: Lifting commonly can cause LBP
TRUE
forces are exerted on lumbar spine & disc
T OR F: The force exerted on the disc can be calculated as roughly five times the weight being lifted.
FALSE
roughly as TEN TIMES the weight being lifted
Pressure on the disc can be decreased by increasing the _____ of the backrest
supported inclination
Using the ____ for support can also decrease the pressure on the disc
arms
When one is standing, the disc pressure is approximately ____ of the pressure that occurs in the relaxed sitting position.
35%
Lower back stress tends to be ______ (%) higher in ____ (men or women)
15% to 20%; men>women
because men are taller and their weight is distributed higher in the body
T OR F: Back pain tends to be more prevalent in people with strenuous occupations
TRUE
T OR F: Familial influences have an effect on back pain
TRUE
Patients who have chronic low back pain develop what syndrome?
deconditioning syndrome
Compounds chronic low back pain problems as it leads to decreased muscle strength, impaired motor control, and decreased coordination and postural control.
deconditioning syndrome
With thoracic disc lesions, (1) ____
movements do not often show the characteristic pain pattern, and (2)_____ deficits are difficult if not impossible to detect.
(1) ACTIVE movements
because of the rigidity of the thoracic spine
(2) SENSORY and STRENGTH deficits are difficult to detect
The examiner should remember that _____ structures may refer pain to the thoracic region
Abdominal structures:
stomach,
liver,
pancreas
What diseases usually cause pain that follows the path of the ribs or a deep, “through-the-chest” pain? (2)
Thoracic root involvement or spondylosis
Acute back pain lasts for?
3-4 weeks
Subacute back pain lasts for?
12 weeks
Chronic back pain lasts for?
> 3 months
Unilateral pain with no referral below the knee caused by injury to muscles (strain) or ligaments (sprain), the facet joint, or, in some cases, the sacroiliac joints
mechanical LBP
pain is moving toward or is centered in the lumbar spine
Centralization
implies the pain is being referred or is moving into the limb
Peripheralization
T OR F: Injuries in the lumbar spine ted to be peripheralized in the limbs.
FALSE
There is seldom if ever
peripheralization of the symptoms.
The symptoms tend to stay CENTRALIZED in the back.
T OR F: If the muscles and ligaments are affected, movement will decrease and pain will increase with repeated movements.
TRUE
Pain on standing that improves with ____ and pain on forward flexion with no substantial muscle tenderness suggests ____.
walking
disc involvement
T OR F: A minor disc injury (protrusion) will show pain when pain-provoking (stress) tests are used. The sacroiliac joints may show the same symptoms, but the pain is more likely to be bilateral if it is a central protrusion.
FALSE
The SI JOINTS will show pain when pain-provoking (stress) tests are used.
A MINOR DISC INJURY (PROTRUSION) may show the same symptoms, but the pain is more likely to be bilateral if it is a central protrusion.
Disc problems account for only about ___% of low back pain cases.
5%
The examiner must be careful when looking at the lumbar spine that he or she does not consider every back problem a disc problem
Anterolateral leg pain is suggestive of?
L4 disc problems
Definitive diagnosis of a disc problem often requires _____
neurological pain extending below the knee
This means that although there may be pain in the back and in the leg, the leg pain is dominant
Pain radiating to the posterior aspect of the foot suggests?
L5 disc problems
Pain radiating into the leg below the knee is highly suggestive of?
disc lesion
Pain below the knee strongly suggests a disc lesion but ISOLATED BACK & BUTTOCK does not exclude disc involvement.
Lumbar and sacroiliac pain referral sites
buttock and posterior leg,
lateral aspect of the leg
Minor injuries like disc protrusions may only cause _____ pain.
BACK OR BUTTOCK pain
Minor injuries can complicate diagnosis, as they may also stem from muscle, ligament, or facet joint injuries or degeneration.
Hip pain usual sites & referral sites
typical site of pain: groin, anterior thigh
referral site: medial side of the knee
Pain referred around the chest wall tends to be ____ in origin.
costovertebral
T OR F: The hip can be ruled out by assessing for the presence of a hip capsular pattern and a positive sign of the buttock.
FALSE
The hip can be ruled out by assessing for the ABSENCE of a hip capsular pattern and a NEGATIVE sign of the buttock.
Pain related to breathing may signal _____ problems or may be related to movement of the ____.
PULMONARY problems
movement of RIBS
_____ nerve root pain is typically severe and referred in a sloping band along an intercostal space.
THORACIC nerve root pain
Pain between the scapulae may indicate a _____ lesion
CERVICAL lesion
T OR F: Dural pain would not be accentuated by coughing, sneezing, or straining.
FALSE
Dural pain is often accentuated by these maneuvers
T OR F: Symptoms above a line connecting the inferior angles of the scapulae should be considered of thoracic origin until proven otherwise, especially if there is no hx of trauma.
FALSE
should be considered CERVICAL origin until proven otherwise
T OR F: Increase in intrathecal pressure would indicate the problem is in the lumbar spine and affecting the neurological tissue.
TRUE
actions such as coughing & sneezing increase the _____ (the pressure inside the covering of the spinal cord)
intrathecal pressure
T OR F: Pulling and pushing activities are particularly bothersome for patients with lumbar issues.
FALSE
Pulling and pushing activities are particularly bothersome for patients with THORACIC issues.
T OR F: Passive use of the arms can irritate a thoracic lesion
FALSE
ACTIVE use of the arms can irritate a thoracic lesion
Costal pain may be triggered by ____ 2)
breathing and/or overhand arm motions
often makes breathing easier because this facilitates the action of the accessory muscles of respiration
bracing the arms
T OR F: Pain may be referred to the thoracic spine or ribs from thorax or abdominal conditions
TRUE
What kind of pain is often vague, dull, and indiscrete, potentially accompanied by nausea and sweating.
Visceral pain
Where is cardiac pain referred?
shoulder (C4) and posteriorly to T2
Where is stomach pain referred?
T6–T8 posteriorly
most common space-occupying lesion in the lumbar spine and most common cause of radiating pain below the knee
disc pathology
Where is ulcer pain referred?
T4–T6 posteriorly
Sitting may increase pain, suggesting ____ is causing mechanical deformation or increased intradiscal. pressure.
sustained flexion
commonly results in increased pain during sitting, lifting, twisting, and bending
disc pathology
If standing, walking, and lying increases pain, ____ may be causing the issues.
EXTENSION is the mechanical deformation
especially in relaxed standing or in prone lying
T OR F: Persistent or worsening pain in the supine position may suggest neurogenic or space-occupying lesions
TRUE
space-occupying lesions such as infection, swelling, or tumor
T OR F: Pancreatic tumors may radiate pain to the thoracic spine
FALSE
radiates pain to LUMBAR spine
Stiffness or pain after rest may indicate conditions like ____ (2)
Ankylosing spondylitis or Scheuermann disease
T OR F: Pain from mechanical breakdown generally increases with activity and decreases with rest.
TRUE
_____ pain often worsens with prolonged maintenance of a single posture (especially flexion).
Discogenic pain
T OR F: Pain from spinal issues is almost always influenced by posture and movement.
TRUE
What is the key to proper back posture?
pelvis
Pelvis in neutral position
ASIS 1-2 finger widths below PSIS
What are the muscles balancing the pelvis?
abdominals,
hip flexors (iliopsoas, rectus fem, sartorius),
hip extensors (glutes max, hamstrings),
back extensors (erector spinae)
morning stiffness relieved by activity
OA of facet joints
respond to pathology with tightness, spasm, or adaptive shortening
Postural (static) muscles (e.g., iliopsoas)
tend to response to pathology with atrophy
Dynamic (phasic) muscles (e.g., abdominals)
Can occur when pathology affects both postural and dynamic muscles
Pelvic Crossed Syndrome
Painful arc of movement
Pain on _____ (2) may indicate a disc protrusion or instability in part of the range of motion (ROM)
forward or side flexion
Difficulty moving to the seated position
Lumbar Instability/Muscle Spasm
Pain in flexion (e.g., sitting), which may increase the longer the patient is seated
Discogenic Pain
Occurs if pressure is relieved from a nerve trunk
paresthesia
Occurs if the pressure is on the nerve trunk
numb sensation
T OR F: The nerve root is always compressed by the disc at the same level, except when the protrusion is more lateral.
FALSE
SELDOM is the nerve root compressed by the disc at the same
level
nerve roots extend in such a way that it is rare for the disc to pinch on the nerve root of the same level
Abnormal sensations in the perineal area often have associated _____ problems
micturition (urination) problems
notes: may indicate a MYELOPATHY - warrant immediate surgical intervention d/t potential long term bowel or bladder problems if pressure on SC is not relieved ASAP
How many degrees are the difference in straight leg raise in lying and sitting
10-20 degrees
because of the change in lordosis and position of the pelvis
What level of IV disc would compress the L5 nerve root?
L4 IV Disc
T OR F: If the patient lies supine, the lumbar spine often falls into extension increasing the stress on the posterior elements of the vertebrae
FALSE
if the patient lies in PRONE
What is the best sleeping position?
side-lying with the legs bent in a semifetal position
T OR F: In prone lying, the spine tends to flatten out, decreasing the stress on the posterior elements.
FALSE
in SUPINE lying
T OR F: having problems with micturition (urinating) may involve conditions more than the lumbar spine
TRUE
2 common fear-avoidance questionnaire used in lumbar examination
Fear- Avoidance Beliefs Questionnaire (FABQ),
Linton and Hallden’s Acute Low Back Pain Screening Questionnaire
Disc derangement can cause? (4)
Total urinary retention (can’t empty bladder),
Chronic, long-standing partial retention,
Vesicular irritability,
Loss of desire or awareness of the necessity to void
Long-term use of steroids can lead to?
osteoporosis
T OR F: Psychosocial issues often play a role in low back pain, especially if it is chronic
TRUE
outlines yellow flags indicating psychosocial barriers for recovery with questions related to attitudes and beliefs about back pain, behavior, compensation issues, diagnosis and treatment, emotions, family and work
New Zealand Acute Low
Back Pain Guide
T OR F: The yellow flags in New Zealand Acute Low Back Pain Guide should be seen as factors that can be influenced negatively to facilitate diagnosis and increase work loss and long-term disability
FALSE
The yellow flags in New Zealand Acute Low Back Pain Guide should be seen as factors that can be influenced POSITIVELY to facilitate RECOVERY and DECREASE work loss and long-term disability
