acute/persistent Internal Disc Derangement - exam 1 Flashcards
Acute IDD due to __________
_________ and _________tear
___________ LEAST common
trauma
annulus and end plate
acute herniations (nuclear migration)
Chronic or persistent IDD due to:
disc changes due to numerous variables allow herniations (nuclear migration) to GRADUALLY develop over time
What is the most prevalent IDD?
chronic/persistent > acute
What spinal region is IDD most common?
-age group?
lumbar region (L4-S1)
30-50 yrs old
What is the resting range of lordosis?
What is the degree of motion for lumbar flexion?
What is the degree of motion for ant. pelvic rotation?
20-45º
45º
60º
There are greater consequences in ______ spinal region due to the narrowest canal
thoracic
________ portion of the disc is the MOST common
posterolateral
Why is the posterolateral portion of the disc most commonly injured?
weaker, thinner with MORE vertical and LESS oblique annular fibers
What functional limitations a pt. with acute IDD will most likely have?
forward bending (FB) w/o twisting/lifting
-FB at the waist
Lumbar spine DOES NOT flex as you think b/c of concurrent
anterior pelvic tilt
Explain the process of acute IDD:
FB creates less disc compression and unevenly distributed annular tension (causes less stability) –> LESS fixated end plate –>
more anterior segmental shearing –>
increased and asymmetrical stress on posterolateral annular and end plate fibers
- water balloon example
What are the MORE common structures involved with acute IDD
LEAST common:
outer annular tearing and end plate avulsion (resists tension)
inner annular tearing and NP herniation (resist compression)
Acute IDD: disk structures are _____________ when damaged
immunoreactive
Acute IDD process of LARGE Immune inflammatory response:
- Excessive ___________ or increased static fluid in/around the disc and spinal n.
- Static fluid has increased ____________ chemicals that sensitize spinal n. and structure to pressure/tension
3.______________ S&S are present
4.NO ________ in PNS or CNS —-> extended ________ phase
- osmotic pressure
- inflammatory
- radiculopathy/radicular
- lymphatic vv. ; inflammatory phase
Acute IDD - L5 Annular tear - NO Nuclear migration what does this indicate?
avulsion; jelly not out of donut tear of attaching structures
Typical postlat IDD:
-symptoms
-annulus
-more
dull/achy spinal P!
annulus high innervated so very P!
significant MORE swelling than cervical disc due to a higher # of GAGs
Typical postlat IDD symptoms: worse situation
radiculopathy: segmental parathesis within 24hrs. into distal extremities
-presence of coldness bc vv. have rich anastomoses and high degree to ischemia
Typical postlat IDD can cause referred P! ________
glutes and groin
What are the functional inhibiting symptoms of typical postlat IDD:
-decreased P! when
-increased P! when
-24hr. behavior
decreased P!- unloaded or lying supported/standing/walking
–> puts tear in slack
increased P!- FB/sitting/coughing/lifting
–> pulls tear, more tension
increased P! in the AM due to pooling of swelling from a static sleeping position
As a PT what will you see in your observation for a pt. with typical postlat acute IDD? (3)
*view pptx. slide 109
lateral shift of the shoulder on the pelvis
SB away from the P!
Counter contralateral SB to level the eyes
-rarely see smaller calf girth
typical postlat acute IDD scan findings:
ROM
-all may movements maybe P!ful
-flx and possible SB away from the injured area of disc likely MOST limited and increased extremity P!
Why is P! provoked with FLX and SB in typical postlat acute IDD pts.
due to pressure being pushed towards the spinal n. and tension on the annulus and end plate tear and dura
Typical postlat acute IDD:
What movements relieve P! and LESS limited
EXT and possibly SB toward the injured area of disc LESS limited
With repetition of _____________, centralization of extremity P! will often occur for pts. with typical postlat acute IDD
EXT and SB; (jelly back into donut)
abolition of distal and/or spinal P! in a _________ to _________ direction in response to repetitive motions or sustained positions is known as centralization
for typical postlat acute IDD what motion will produce centralization?
distal to proximal
ext or hyperext.
Typical postlat IDD sign; Scan
- resistant & MMT:
- stress test:
- neuro test:
- stability test:
1.variable
2. (+) with compression/distraction/PA pressures/torsion *annulus
3. (+) depending on the severity and timing
—-myotomal fatigue
—-DTR hyporeflexia
—-diminished dermatomes
—-(+) dural mobility test
- (+)
Central IDD is MORE common than postlat IDD? T or F
False
What are classical cord S&S of rare Central Acute IDD:
a. DTRs:
b. UMN test:
c. Superficial reflexes:
d. Multi or non-segmental:
e. MD referral:
a. hyperactive
b. (+)
c. hypoactive
d. multi-segmental
e. immobilize w/ emergency referral
based on the belief that MOST spinal P! comes from injuries to the disc which the research says is NOT the case
Mckenzie Method
What is the classification system of the McKenzie Method?
location of symptoms
positions and motions that decrease symptoms
The Mckenzie Method determines ____________ ____________ which may be associated with _________ with the addition of decreasing the severity and improving function.
directional preference
centralization
____________is the MOST common directional preference (>70%)
Extension
Mckenzie Method 3 classification syndromes for Acute IDD:
postural: correct poor posture
dysfunction: stretched the improve end-range motion
derangement: using end range motion to improve the THEORETICAL nucleus migration in the disc
____________ Method: strong evidence of benefit with ________symptoms and when _________ occurs with Acute IDD
McKenzie
LE
Centralization
McKenzie Method:
1. dynamic theory w/herniation is unproven but states that _________ repositions centrally
nucleus
McKenzie Method:
2. What is the process of fluid dynamic or w/o disc herniations:
_____________pressure with a large ___________ swelling response
___________ __________ ________through repetitive motions, MOST often _________
Spine P! initially __________ from the resistance of high osmotic pressure being overcome by increased hydrostatic pressure
Swelling squeezed—— away or towards —- spinal n. into the nucleus and the end plates for draining?
What is PRIORITY?
high osmotic; auto-immune
increasing hydrostatic pressure; extension
increases
away
centralize P!; decrease LE symptoms
PT Rx: acute IDD (5)
-sets and reps?
-POLICED
-directional preference OFTEN extension 10-20 reps every 1-2 hrs prn
-intermittent traction may be helpful w/radiculopthy if no centralization
-postural/ergonomic edu/taping or bracing for ext. preference
What should you tell pt. to limit or not do if possible? (2)
Possible ________ for 1-2 weeks to avoid counter-productive sitting w/driving
limited to no sitting
limited to no driving/FB
HEP
What are the ultimate MET goals for Acute IDD:
–examples:
tissue proliferation and stabilization, particularly of local mm.
unweighted walking
unloader
aquatic
anti-gravity systems (ALTERED-G)
How should we squat and pick up items to minimize excessive stresses and maximize stability and prevent an acute IDD?
MORE circumferential disc compression and evenly distributed annular tension w/ lumbar flexion and posterior pelvic tilt
MORE fixated end plate
LESS ant. segmental shearing and possible rotation with the additional influence of gravity
Persistent IDD aka:
degenerative disc disease or age related disc changed though NOT always due to age
Etiology of Persistent IDD: (7)
Acute IDD
Age (mixed findings)
Lower strength
Sedentary lifestyle
Heavy occupational lifting
Smoking
Genetics
Though it has been shown that 68-85% of persistent IDD can be inherited, it is modified by __________ and ____________
diet and lifestyle
Persistent IDD is NOT from routine ____________ and _____________
loading/physical activities and prolonged driving
- Pathogenesis of Persistent IDD?
- In the growth of ________________ from acute IDD healing can lead to ____________ P!
- Brings excessive and destructive _________(amyloidosis) and low-grade__________enters discs
- gradual; persistent inflammation
- nociceptive fibers; nociplastic P!
- proteins; infection
Persistent IDD:
LESS GAGS so MORE _______ and dehydrated _________
MORE acidic ______ that kill disc cells and limits __________
Annular __________
Thinning and loss of _________ at end plates
Increased inflammation in deposits in a vertebra (modic).
NOW persistent ________ and nuclear ________ GRADUULY developed
fibrotic; muscles
disc; proliferation
disorganization
cartilage
herniations; migration
The nucleus migrates but remains contained in the annulus, the MOST common herniation.
Protrusion (buldge)
The nucleus migrates through the outer annulus
extrusion
The nucleus migrates and breaks away from the annulus
free sequestration
Schmorls Nodes likely develop when
the nucleus migrates into the vertebral body
Persistent IDD does not show bright white on imagining because
it is low grade inflammation not acute
Presentist IDD: Narrowing
initial changes are related to the loss of _________ and __________
_________may develop
joint hypermobility noted during sagittal and frontal plane motions BUT not in ____________ plane
disc height and integrity
instability
transverse plane
Due to joint space narrowing of persistent IDD, it leads to great load bearing on ________ which ultimately may develop ________
facets; stenosis
Persistent IDD S&S:
slow change allows tissue to adapt without symptoms
gradual onset may be like acute S&S if inflamed
“mixed bag”
McKenzie Exercises are more effective with Persistent IDD than Acute. T or F
False; more effective with acute IDD
Persistent IDD: PT Rx
Need to consisder the __________ _________of symptoms from the development of other conditions even if imaging shows disc changes
example of primary drivers:
primary driver
instability
stenosis
age-related joint changes
combinations of above
Prognosis for acute and persistent IDD: 90% improve by _______ wks and resolve symptoms by _____ wks.
6 wks; 12 wks.
MOST acute/persistent IDD pts. will require sx. T or F
False; most will NOT require Sx
What is a negative outcome predictor of acute and persistent IDD?
Persistent IDD has a significant association with (4)
peripheralization
mental distress/depression
P! behaviors
Somoatation - conversion of anxiety into bodily symptoms
fear of work
Acute and Persistent IDD:
-MD Rx: Meds
-purpose of sx and types of sx’s performed?
-indications of sx:
NSAIDs, muscle relaxants, acetaminophen
spinal decompression; laminectomy, partial discectomy
persistent and/or worsening radiculopathy
Is lumbar fusion better than PT for persistent IDD?
no - may lead to adjacent joint hypermobility
