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MSK 2 > 3a - Lumbar Mgmt & Exam > Flashcards

3a - Lumbar Mgmt & Exam Flashcards

1
Q

what are 2 vascular systems that lumbar pain can arise from

A

AAA
vascular claudication

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2
Q

what are a consideration of passive structures (ie ligs, joints, disc) in their physiology

A

all are innervated and can all be a source of pain (except for the nucleus propulsus)

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3
Q

what ligaments are involved at the lumbar level vertebrae

A

ALL, PLL, lig flavum, supraspinous, interspinous, intertransverse

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4
Q

how many joints do lumbar vertebrae have

A

6
- 4 facets
- 2 IVD

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5
Q

what are 3 components to a lumbar disc

A

vertebral endplate
annulus fibrosus
nucleus propulsus

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6
Q

muscles in the local vs global systems

A

local/deep = stability
- transverse ab
- multifidi
- thoracolumbar fascia

global/superficial = mobility
- psoas
- QL
- HS

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7
Q

what is the structure of the transversus abdominis in the local/deep ms system

A

forms a ring around abdomen

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8
Q

what is the function of multifidi and how does this fit into the local system

A

prevent rotation
- stabilizes lumbar spine

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9
Q

psoas attachments and implications of that

A

attaches to ant lat vertebrae of T12-L5
- can pull on lumbar spine if stiff from prolonged sitting/in bed

shortened psoas -> inc lumbar lordosis

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10
Q

QL attachments and function

A

attaches to iliac crest, 12th rib, TPs of L1-4

SB, hip hike, hip drop

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11
Q

HS attachment and implication of that

A

pelvic attachment at ischial tub

less direct connection
- if stiff will limit amt of pelvic motion

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12
Q

what is the purpose of anticipatory feed forward mechanisms in the lumbar spine

A

multifidi and stabilizers activate prior to motion/activity

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13
Q

what is the function of the neural system in the lumbar spine and what are 4 contributing components

A

controls function of ms

SC
nerve root
CNS control
brain

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14
Q

CNS control vs brain in their function in the neural system in the lumbar spine

A

CNS:
- anticipatory feed forward mechanism
- inhibition for local ms
- excitation for global ms

brain:
- central processing (sensitization)

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15
Q

what are the biomechanics of facet glides in the LB

A

superior glide for flex
inferior for ext

superior facets face sup and med
inferior facets face ant and lat

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16
Q

what motions are most easily achieved in the LB

A

flex/ext

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17
Q

what is motion resistance in the LB typically d/t

A

resistance of compression on structures in same direction and tensile forces of structures in opposite direction

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18
Q

extrinsic vs intrinsic risk factors for developing LBP, and what is an important consideration for all of these risk factors

A

extrinsic
- occupation (ie lifting, flex, rotation)
- operating heavy equip
- low job satisfaction

intrinsic
- age & genetic for spine degen
- HTN and lifestyle, smoking, obesity
- psychosocial prog predictor (fear/depression)

risk factors multifactoral, pop specific, and weakly associated w LBP development

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19
Q

what are 3 prognostic factors for development of recurrent LBP

A
  1. hx of previous episodes
  2. excessive spine mobility
  3. excessive mobility in other joints
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20
Q

what are 5 prognostic factors for development of chronic LBP

A
  1. *presence of sx below knee -> indicates more severe incident**
  2. psych distress
  3. fear avoidant, low expectations of recovery
  4. pain of high intensity
  5. passive coping style
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21
Q

what are red flags associated w the lumbar spine

A

cauda equina syndrome
spinal fx
neoplastic conditions (CA)
ankylosing spondylitis
infection
s/sx of UMNL
AAA
gyne - endometriosis, ectopic

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22
Q

what impact do yellow flags often have on LBP

A

things that keep LBP around for longer

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23
Q

what concerns do we have w a FABQ work sub scale score >34

A

prolonged disability

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24
Q

what does a FABQ work sub scale score <18 indicate ab PT interventions

A

more likely to benefit from HVT

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25
Q

what does a FABQ physical activity scale score >13 indicate ab PT interventions

A

more likely to benefit from behavior modification

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26
Q

what cluster components are a strong predictor of chronic LBP

A

high FABQ
strenuous job
low ed background
imaging findings DDD

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27
Q

what does the STarT back screening tool tell you (SBST)

A

overall risk for developing chronic LBP

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28
Q

what is the prognosis for someone w a low risk STarT score

A

pt very likely to improve

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29
Q

what are the key factors for a PT intervention in someone w a low risk STarT score

A

address pt concerns and provide info

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30
Q

what PT intervention is indicated for someone w a low risk STarT score

A

single session
- give advice and encourage self management
- give education and tell them can reconsult if necessary

ex: person coming in for shoulder issue and say that their back hurt a bit when woke up in morning

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31
Q

what are the main aims of PT in a medium risk STarT score

A

restore function (including work)
minimize disability even if pain is unchanged to support appropriate self-management

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32
Q

what PT interventions are indicated for someone w medium risk STarT score

A

4-6wks of pt
- tailored to pt and based on specific findings

33
Q

what is the specific focus of PT in high risk STarT score pts

A

cog, emotional, and behavioral responses to pain and their impact on function

34
Q

what PT interventions are indicated for high risk STarT pts

A

psych informed PT to address physical sx and function & psych obstacles to recovery

enable pts to manage on-going and future LBP

35
Q

what are the 3 dimensions assessed in the pain catastrophizing scale (PCS)

A

rumination
magnification
helplessness

36
Q

biomedical vs biopsychosocial model of healthcare

A

biomedical:
- focus = dz
- abnormalities of measurable bio changes
- specific tissue damage
- specific dx to treat pt
- doesn’t always work bc not always something to be fixed

biopsych
- focus = illness
- health made up of bio, psych, and social factors impacting condition
- bio equal wt to other factors
- local tissue approach if pain is proportional to physio response to injury

37
Q

what are 4 validated outcome tools in the LB

A
  1. pain body diagram
  2. oswestry disability index
    - capture perceived disability in pts w LBP
  3. roland-morris disability Q
    - ask pts to gauge if each item is possible to accomplish
  4. numeric pain rating scale (NPR)
38
Q

nociceptive pain in the LB: what is it, qualities, alleviators?

A

(somatic) mechanical/physio processes in injured tissue
-> pain proportional to nature and extent of injury or potential threat

deep, dull, aching pain
- can be sharp in early stages

dec w dec tissue stress
-> better w positional changes

39
Q

how does peripheral neurogenic pain present in the LB

A

superficial, burning, shooting, w/i all or part of nerve innervation field

+/- paresthesias or corresponding ms weakness in neuroanatomical field

40
Q

central/nociplastic pain in the LB: what is it caused by, what is it, qualities, exacerbators?

A

disturbance in central processing

non anatomical (widespread), sensory dysfunction not neuroanatomically logical with ongoing pain after expected healing time

hyperalgesia in multiple areas
- allodynia present

exacerbated by:
- emotion
- poor response to meds

41
Q

what are 2 hypotheses for a lateral shift in posture

A

psoas unilateral activation
-> get SB and lumbar compression as pulls on lumbar spine

injury and SBing that direction may be less painful

42
Q

what is a sx that is an indication for repeated motions ROM exam

A

leg pain
- look for centralization or peripheralization of sx

43
Q

what are aberrant mvmt patterns and what are 2 examples

A

compensations/deviations in motion
- reverse lumbar lordosis
- gower sign

44
Q

what are qualities of trunk ms do we want to assess in the exam

A

power
endurance
length tension
ms imbalance

45
Q

what is an example of LE functional strength assessments

A

walking on heels, toes

46
Q

what specific trunk ms do we want to assess strength and ms activation? what ms may compensate if they are weak/unable to isolate

A

transverse abdominis
multifidi

rectus abdominis compensation

47
Q

what are 5 flexibility / ms length tests

A

thomas test
modified thomas test
obers
elys
SLR or 90/90

48
Q

what are the dermatomes for L2-S1

A

L2 - med thigh
L3 - ant med distal thigh
L4 - med 1st toe, ant med calf
L5 - lat calf
S1 - lat foot

49
Q

what are the myotomes for L2-S1? what is a consideration with testing these myotomes

A

L2 - hip flex
L3 - knee ext
L4 - ankle DF
L5 - 1st MTP ext
S1 - ankle PF

L2 & 3 difficult to test w acute LBP bc direct ms attachments
- effort based test

L4 and S1 are easier to test
- good bc more commonly injured nerves and associated w radiculopathy

50
Q

what are 3 neural tension tests

A

SLR / Cross SLR
femoral n. tension test
slump

51
Q

SLR neural tension test vs cross SLR for pain on R

A

SLR - lift up R
- highly sensitive for herniated disc (good to r/o if neg)

cross SLR - lif up L
- highly specific for herniated disc (good to r/i if pos)

52
Q

what are 4 provocation tests and what does a (+) indicate

A

quadrant
compression
prone instability
sign of buttocks

indicates would benefit from stabilization exercises

53
Q

what are 3 non organic signs

A

waddels
flip test
hoover test

54
Q

when if referral to imaging indicated

A

presence of suspected path identified through red flags
- ie progressive neuro s/sx

55
Q

if imaging is indicated, which are used and which is the most sensitive? what is a consideration of this

A

radiographs, MRI, CT

MRI highly sensitive
- may reveal findings that aren’t clinically relevant as a result

56
Q

what is a challenge w someone coming to PT after getting abnormal MRI findings back

A

come in saying things tha tPT can’t fix
- biopsychosocial model clashes

57
Q

what PT intervention has the highest level of evidence in acute LBP

A

thrust / nonthrust joint mobs

58
Q

what PT interventions have the highest level of evidence in chronic LBP

A

exercise:
- general
- ms strength/endurance
- specific trunk activation
- aerobic
- multimodal

thrust/nonthrust joint mobs

pt ed: active treatment
- incorporate pain neuroscience

59
Q

what are 3 reasons to classify LBP

A

improve clinical outcomes by matching subgroups of pts to optimal intervention strategies

dec inefficient variability in treatment

standardize treatment approaches

60
Q

what are 3 types of classification systems for LBP and which is the most applicable to PT

A

evaluation
prognosis
treatment**

61
Q

what are 3 evaluation classification systems for LBP and what are each’s main differential

A

patho-anatomical
- identify red flags
ICD
- billing
ICF
- function based dx

62
Q

acute vs sub acute vs chronic LBP time line

A

acute = sx<1mo
sub acute = sx 1-3mo
chronic = sx >3mo

63
Q

what are 2 prognosis classification systems for LBP and what are each’s main differential

A

STarT Back
- low, med, high risk
OMPSQ
- more wc related

64
Q

what are 4 treatment classification models and what are their differentials

A

TBC
- treatment based
MDT
- mechanical dx
MSI
- mvmt system impairment
CB-CFT
- cog functional therapy

65
Q

what are 4 treatment classification models based on

A

mvmt/loading patterns related to pain reduction and treatment response

66
Q

what model is pathanatomic classification very similar to

A

biomedical model

67
Q

what is a main limitation of patho-anatomic classification

A

difficult to identify specific structures as clear pain generators in lumbar spine
- particularly for LBP

68
Q

what is the mvmt system impairment classification (MSI)

A

pt w LBP categorized into 1 of 5 syndromes based on sx elicited during specific positions and mvmts
- lumbar ext
- flex
- rotation
- rot-ext
- rot-flex

uses impairment as classification

69
Q

what is cognitive functional therapy and what does it utilize

A

multidimensional clinical reasoning framework
- designed to identify and target modifiable factors that drive pain, pain-related distress, and disability

utilizes graded exposure to mvmt

70
Q

what did the 4 TBC (treatment based classification) groups use to be up until 2015 and why has this been changed since

A

manip
specific exercise (flex, ext, lat shift)
traction
stabilization

changed bc some people meet portion of criteria, some don’t meet any, some met multiple
- no recommendation for high psychosocial distress

71
Q

how are new TBC guidelines that have been updated since 2015 different from before

A

“first contact” triage
- 3 management tracks

rehab professional triage
- 3 approaches

risk of co-morbidities and psych assessed at both levels

72
Q

what rehab approach did stabilization exercises from the old TBC guidelines move to in the updated guidelines since 2015

A

mvmt control group

73
Q

what rehab approach did active rest from the old TBC guidelines move to in the updated guidelines since 2015

A

sx modulation

74
Q

in the updated TBC guidelines what are the 3 management tracks at first contact triage and who is appropriate for each

A

medical management
- red flag
- screen co-morbidities

self-care management
- unlikely to develop disabling LBP during current episode
- provide advice/guidance

rehab management
- majority of pts w LBP

75
Q

in the updated TBC guidelines what are the 3 rehab approaches that a rehab professionals triages the rehab management pts into

A

sx modulation
mvmt control
functional optimization

76
Q

in the updated TBC guidelines what are the clinical findings and treatments appropriate for the sx modulation rehab approach

A

clinical findings:
- disability high
- sx status volatile
- pain high to mod

treatments
- directional preference exercise
- manip/mob
- traction
- active rest

77
Q

in the updated TBC guidelines what are the clinical findings and treatments appropriate for the mvmt control rehab approach

A

clinical findings:
- disability mod
- sx status stable
- pain mod to low

treatments:
- sensorimotor exercises
- stabilization exercises
- flexibility exercises

78
Q

in the updated TBC guidelines what are the clinical findings and treatments appropriate for the functional optimization rehab approach

A

clinical findings:
- disability low
- sx status controlled
- pain low to absent

treatments:
- strength and conditioning exercises
- work or sport specific tasks
- aerobic exercises
- general fitness exercises

MSK 2 (20 decks)

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