Class 1: Spine/Thoracolumbar Flashcards
describe what you may see with stiff areas
may not be painful
could cause other hypermobile areas
why are hypermobile areas generally more painful and how should you treat
because the axis of motion is less controlled
treat by stabilizing with smaller/deeper muscles
describe the orientation of the thoracic facets
more vertical
generally set up for frontal plane
however ribs limit the amount of side bend even with the frontal plane orientation
describe the orientation of the lumbar facets
slightly curved
more in sagittal plane (i.e. like praying hands that move anterior/posterior
favor flexion/ext
with trunk rotation how much is occuring at the lumbar spine
not much; maybe 2 degrees per segment
most is from lower thoracic where there are not true ribs
4 variables for stabilization
- joint integrity
2.passive stiffness - neural input
- muscle function
characteristics of local muscles
postural
aerobic
type 1
deeper
stabilization > rotary forces
aerobic > anaerobic
closer to axis
global muscle characteristics
further from axis
superficial
rotary more than stabilization
spurt mm
anaerobic
type II
action of psoas
frontal plane stabilizer
pelvic floor/transversus abdominus important function
increase contraction of multifidus
smaller transversospinalis is associated with what (i.e. multifidus/rotatores)
smaller = higher injury rate and LBP
pain swelling laxity and disuse can cause what
atrophy of local muscles
inhibition (preferable to type I)
decreased performance of local muscles
increased stress on non-contractile structures
if there is a decrease in local muscle activation what happens to global muscles
inefficient and increased activity to compensate
muscle fiber transformation with pain, swelling, and joint laxity
type I changes to type II
muscles have less endurance than original
does normal muscle activity return when pain is gone
no
muscle activation of 30% is enough tto keep stability and improve endurance
what is pain phenotyping
set of observable pain characteristics of an individual resulting from the interaction between the body and the environment
3 types of pain phenotyping
nociceptive
nociplastic
neuropathic
what is nociceptive pain
non nervous tissue
MSK - including spondylogenic
viscerogenic
what is neuropathic pain
nervous tissue compromise
radicular. radiculopathy, and peripheral
what is nociplastic pain
altered pain perception
w/o complete evidence of actual tissue compromise
what is spondylogenic pain
from the spine
common
local/refferred from spinal structures
cannot cause visceral dysfunction
explain somatic convergence
senseory afferents converge on and share the same innervation
greater referral from proximal/deep structures than distal/superficial
symptoms of spondylogenic pain
rarely paraesthesias
non segmental pain
vague/deep/achy/boring
reffered to vague area due to somatic convergence that settles to consistent location
signs of spondylogenic pain
neuro = WNL
cant reproduce entire symptom pattern with motion
how might spondylogenic pain present in the thoracic region
along the respective vertebral levels with overlap in the trunk
what is the common presentation of spondylogenic pain in the lumbar spine
most often in gluteal region and proximal thigh
may go as far as the foot
inconsistent pattern between individuals
what is viscerogenic pain
from an organ
due to viscerosomatic convergence
i.e. kidneys can refer into T10-L1 dermatomes
S&S of viscerogenic pain
usually cant be mechanically reproduced
neuro = WNL
what is viscerosomatic convergence
viscera and somatic sensory afferents converge on and share the same innervation
what is radicular pain
ectopic or abnormal discharge fron highly inflammed spinal nerve (dorsal root)
symptoms of radicular pain
lancing, electrical shock like pain along an extremity in a narrow band
signs of radicular pain
dermatomes, DTRs, and myotomes likely WNL
possibly difficult to localize segment if acute/mild (takes time for hypoactivity to show)
+ dural mobility tests b/c high inflammation
not common
imaging is helpful for involved level
what is radiculopathy
blocked conduction of a spinal nerve due to compression and or inflammation
symptoms of radiculopathy
segmental paraesthesias: constant/long duration; slow progression to vague area due to derm overlap
possible weakness (80% conduction loss required)
signs of radiculopathy
neuro + for spinal n hypoactivity
imaging is helpful for involved n
symptoms of a peripheral n issue
non-segmental paraesthesias
intermittent/short duration
fast progression to well defined area of numbness; minimal overlap
possible weakness
signs of peripheral n issue
derms, DTRs, and myotomes WNL
non segmental peripheral n hypoactivity (decreased sensation/possible weakness)
+ dural mobility
what is nociplastic pain
sensitization to pain (original term)
sensatization = underlying mechnaism
altered pain perception without complete evidence of actual or threatened tissue compromise
pathogenesis of nociplastic pain x5
thinning of myelin sheath
increased sensitivity and misinterpretation by PERIPHERAL nociceptors
Increased sensitivoty and misinterpretation by central structures (sensations occur easier and are harder to block)
somatic convergence (c-fibers split and travel 2 segments sup and inf)
persistent excitation of A-delta and C fibers (this inhibits larger myselinated A-beta fibers presynaptically which makes it harder to override pain)
functional questionaires for nociplastic pain
central sensitization inventory
neurophysiology of pain test (fear avoidance, catastrophizing, and understanding)
regional specific ones
prevalence of nociplastic pain/associated conditions
growing prevalence
migraines
neck pain
shoulder pain
lateral elbow pain
LBP
ARJC
persistent fatigue syndrome
fibromyalgia
S&S/criteria for “possible” nociplastic pain
more than 3 months of pain
regional or spreading symptoms
pain that can’t be explained
hypersensitivity to non-painful stimuli
S&S/criteria for probable nociplastic pain
addition of any of the following to “possible” criteria:
sensitivity to light, sound, or odor
sleep disturbances
fatigue
cognitive problems
S&S that indicate the autonomic nervous system x7
pitting edema with lymph compromise
decreased sebaceous gland activity (fragile skin, decreased mobility of skin, excessive reddening with scratch test)
sweaty hands/feet
cold/clammy from artery shunting
loss of laterality
increased erector pili activity
+ graphesthesia
possible JM Rx for nociplastic pain (theoretical benefits) x5
has theoretical benefits :
stimulates inhibitory pain mechanisms (more endorphins)
induces presynaptic inhibition (limits pain transmission and overrides pain better)
reduced dorsal horn excitability
decreases inflammatory mediators
MET for nociplastic pain
low to moderate global aerobic and resistive activities
2-3x/wk
30-90 min sessions
at least 7 wk duration
benefits of met for nociplastic pain
endogenous/opiate analgesia
interpret pain and motion as non-threatening
reorganizes homunculus
benefits of neuroscience edu/behavioral therapy for nociplastic pain
not just mind over matter
explain the sensitivity and miinterpretation to reduce stress/anxiety
challenges fears and ensures exercise safety
transitions pt to adaptive coping
prognosis for nociplastic pain
vary levels of improvement
longer recovery
likely not a full resolution of symptoms
