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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
what does a FABQ physical activity scale score >13 indicate ab PT interventions
more likely to benefit from behavior modification
26
what cluster components are a strong predictor of chronic LBP
high FABQ strenuous job low ed background imaging findings DDD
27
what does the STarT back screening tool tell you (SBST)
overall risk for developing chronic LBP
28
what is the prognosis for someone w a low risk STarT score
pt very likely to improve
29
what are the key factors for a PT intervention in someone w a low risk STarT score
address pt concerns and provide info
30
what PT intervention is indicated for someone w a low risk STarT score
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
31
what are the main aims of PT in a medium risk STarT score
restore function (including work) minimize disability even if pain is unchanged to support appropriate self-management
32
what PT interventions are indicated for someone w medium risk STarT score
4-6wks of pt - tailored to pt and based on specific findings
33
what is the specific focus of PT in high risk STarT score pts
cog, emotional, and behavioral responses to pain and their impact on function
34
what PT interventions are indicated for high risk STarT pts
psych informed PT to address physical sx and function & psych obstacles to recovery enable pts to manage on-going and future LBP
35
what are the 3 dimensions assessed in the pain catastrophizing scale (PCS)
rumination magnification helplessness
36
biomedical vs biopsychosocial model of healthcare
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
what are 4 validated outcome tools in the LB
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
nociceptive pain in the LB: what is it, qualities, alleviators?
(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
how does peripheral neurogenic pain present in the LB
superficial, burning, shooting, w/i all or part of nerve innervation field +/- paresthesias or corresponding ms weakness in neuroanatomical field
40
central/nociplastic pain in the LB: what is it caused by, what is it, qualities, exacerbators?
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
what are 2 hypotheses for a lateral shift in posture
psoas unilateral activation -> get SB and lumbar compression as pulls on lumbar spine injury and SBing that direction may be less painful
42
what is a sx that is an indication for repeated motions ROM exam
leg pain - look for centralization or peripheralization of sx
43
what are aberrant mvmt patterns and what are 2 examples
compensations/deviations in motion - reverse lumbar lordosis - gower sign
44
what are qualities of trunk ms do we want to assess in the exam
power endurance length tension ms imbalance
45
what is an example of LE functional strength assessments
walking on heels, toes
46
what specific trunk ms do we want to assess strength and ms activation? what ms may compensate if they are weak/unable to isolate
transverse abdominis multifidi rectus abdominis compensation
47
what are 5 flexibility / ms length tests
thomas test modified thomas test obers elys SLR or 90/90
48
what are the dermatomes for L2-S1
L2 - med thigh L3 - ant med distal thigh L4 - med 1st toe, ant med calf L5 - lat calf S1 - lat foot
49
what are the myotomes for L2-S1? what is a consideration with testing these myotomes
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
what are 3 neural tension tests
SLR / Cross SLR femoral n. tension test slump
51
SLR neural tension test vs cross SLR for pain on R
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
what are 4 provocation tests and what does a (+) indicate
quadrant compression prone instability sign of buttocks indicates would benefit from stabilization exercises
53
what are 3 non organic signs
waddels flip test hoover test
54
when if referral to imaging indicated
presence of suspected path identified through red flags - ie progressive neuro s/sx
55
if imaging is indicated, which are used and which is the most sensitive? what is a consideration of this
radiographs, MRI, CT MRI highly sensitive - may reveal findings that aren't clinically relevant as a result
56
what is a challenge w someone coming to PT after getting abnormal MRI findings back
come in saying things tha tPT can't fix - biopsychosocial model clashes
57
what PT intervention has the highest level of evidence in acute LBP
thrust / nonthrust joint mobs
58
what PT interventions have the highest level of evidence in chronic LBP
exercise: - general - ms strength/endurance - specific trunk activation - aerobic - multimodal thrust/nonthrust joint mobs pt ed: active treatment - incorporate pain neuroscience
59
what are 3 reasons to classify LBP
improve clinical outcomes by matching subgroups of pts to optimal intervention strategies dec inefficient variability in treatment standardize treatment approaches
60
what are 3 types of classification systems for LBP and which is the most applicable to PT
evaluation prognosis treatment**
61
what are 3 evaluation classification systems for LBP and what are each's main differential
patho-anatomical - identify red flags ICD - billing ICF - function based dx
62
acute vs sub acute vs chronic LBP time line
acute = sx<1mo sub acute = sx 1-3mo chronic = sx >3mo
63
what are 2 prognosis classification systems for LBP and what are each's main differential
STarT Back - low, med, high risk OMPSQ - more wc related
64
what are 4 treatment classification models and what are their differentials
TBC - treatment based MDT - mechanical dx MSI - mvmt system impairment CB-CFT - cog functional therapy
65
what are 4 treatment classification models based on
mvmt/loading patterns related to pain reduction and treatment response
66
what model is pathanatomic classification very similar to
biomedical model
67
what is a main limitation of patho-anatomic classification
difficult to identify specific structures as clear pain generators in lumbar spine - particularly for LBP
68
what is the mvmt system impairment classification (MSI)
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
what is cognitive functional therapy and what does it utilize
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
what did the 4 TBC (treatment based classification) groups use to be up until 2015 and why has this been changed since
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
how are new TBC guidelines that have been updated since 2015 different from before
"first contact" triage - 3 management tracks rehab professional triage - 3 approaches risk of co-morbidities and psych assessed at both levels
72
what rehab approach did stabilization exercises from the old TBC guidelines move to in the updated guidelines since 2015
mvmt control group
73
what rehab approach did active rest from the old TBC guidelines move to in the updated guidelines since 2015
sx modulation
74
in the updated TBC guidelines what are the 3 management tracks at first contact triage and who is appropriate for each
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
in the updated TBC guidelines what are the 3 rehab approaches that a rehab professionals triages the rehab management pts into
sx modulation mvmt control functional optimization
76
in the updated TBC guidelines what are the clinical findings and treatments appropriate for the sx modulation rehab approach
clinical findings: - disability high - sx status volatile - pain high to mod treatments - directional preference exercise - manip/mob - traction - active rest
77
in the updated TBC guidelines what are the clinical findings and treatments appropriate for the mvmt control rehab approach
clinical findings: - disability mod - sx status stable - pain mod to low treatments: - sensorimotor exercises - stabilization exercises - flexibility exercises
78
in the updated TBC guidelines what are the clinical findings and treatments appropriate for the functional optimization rehab approach
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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