Class 5/6: Persistent IDD-Hypermobility Flashcards
etiology of persistent IDD
acute IDD
age = mixed findings
lower strength
sedentary life
heavier lifting
smoking
genetics (lumbar IDD associated with ARDC)
how much of persistent IDD can be inherited
65-85% but can be modified by diet and lifestyle
what are things that are NOT a cause of persistent IDD that some may think are
routine load/PA
prolonged driving
pathogenesis of persistent IDD
in growth of nociceptive fibers from acute IDD
excessive/destructive proteins cause low grade infection
less gags = dehydrated nucleus
annular disorganization
thinning of cartilage/end plates
fatty deposits in vertebrae
THEN persistent herniations develop once disc changes occur
what is protrusion
nucleus migrates but remains in annulus
most common
what is extrusion
nucleus migrates thru outer annulus
what is free sequestrian
nucleus migrates and breaks away from annulus
where do schmorls nodes develop
where the nucleus migrates into the vertebral body
why is a herniated disc not white on an MRI
because it lacks the same water content as a normal disc
how does narrowing play a role in the case of persistent IDD
changes in disc height/integrity lead to instability and hypermobility (sagittal and frontal plane only)
then the space in the joint narrows which leads to instability and greater loads on the facets
stenosis can develop from there
what are later changes that can occur with persistent IDD after the initial narrowing
greater ARJC
less of the prior instability due to stiffening of the joint
symptoms presentation for persistent IDD
slow change allows tissues to adapt without symptoms for some time
i.e. 2/3 of people who have disc issues on imaging have no symptoms q
PT Rx for persistent IDD
acute IDD Rx if inflamed
Mckenzie exercises less effective compared to acute IDD
effect of mckenzie exercises with persistent IDD
NOt better than stabilization
NOT better than manual therapy + non-stabilization exercises
short term benefit
no difference in pain/function vs no intervention at all
important thing to consider for PT in relation to Rx for persistent IDD
need to consider the primary driver of symptoms from the development of other conditions even if the imaging shows disc changes
i.e., ARJC, stenosis, instability, etc
prognosis for acute AND persistent IDD
like ligament/cartilage healing with longer timelines due to prolonged inflammatory phase
90% see improvements by 6 weeks
most dont need surgery
slower healing but the same overall outcomes without surgery after 2 years
Worse outcomes are present for IDD when symptoms are present for more than how long prior to treatment
more than 6 months prior to any treatment including sx
meds that may be used for IDD
NSAIDS, muscle relaxants and acetaminophen
conflicting benefits
possibly Rx for steroid pack for large inflammatory response
epidural = short term relief
antibiotic for benefits related to infection
effectiveness of sx for IDD
waiting an average of 4.5 months on sx did not minimize benefits of sx
some studies how earlier and improved benefit of sx vs PT with severe acute IDD
what are the indications for a spinal decompression sx such as a laminectomy or a partial discectomy
persistent/worsening radiculopathy
use when symptoms are unresponsive to non-surgical treatments
effectiveness of lumbar fusion for IDD
no difference vs PT long term
not additive to a laminectomy or discectomy
can cause adj joint hypermobility/instability
total disc replacement (TDR) effectiveness for IDD
better at load distribution across segments
safe/effective treatment more than 5 years post op
at 2 year follow up no differences compared to PT alone without radiculopathy for in return to work, life satisfaction, fear avoidance behavior, drug use, and back performance
4 variables of stabilization
joint integrity
passive stiffness
neural input
muscle function
what are the 2 types of instability
functional = CAN be stabilized with m activity/positioning
mechanical = CANNOT be completely stabilized with m activity/position
etiology of instability
traumatic/recurrent sprain
ARDC
repetitive ext activities
creep
connective tissue disorder
which segment is hypermobility most common
L4-S1
lower lumbar
what can you get points for when testing for benign joint hypermobility syndrome
palms touch floor
each knee that hyperextends
each elbow that hyperextends
each thumb that touches forearm
each little finger that has 90 degree MCP hyperext
minor criteria for hypermobility
> 4/9 beighton scale
arthralgia > 3 months > 4 jts
what are the minor criteria for instability
beighton scale <3/9
arthralgia > 3 months in 1-3
soft tissue injury in > 3 locations
tall slim body
abnormal skin
varicose veins
what are the requirements to be diagnosed with benign joint hypermobility syndrome
2 major criteria
1 major and 2 minor
4 minor
symptoms of functional instability
predictable pain
spine and referred pain
possible paresthesias
decreased pain with posiiton/support
increased pain with prolonged position, repetitive bending, sudden motions, and strenuous ADLs
catching
self manipulation
ROM signs for functional instability
acute = aberrant
P! with ext due to anterior shear
Flx = Gowers sign = use hands to get up
PROM > AROM
not acute = often WNL except ext crease
greater flexibility
inconsistent block
signs that indicate aberrant AROM
painful arc
uncoordinated
Gower’s sign
LE/pelvis compensation
positive if one or more are present
resisted/MMT for functional instability
if acute = painful
most often strong and painless bc global muscles arent affected
neuro for functional instability
- except possible hyperparesthesia with pinwheel
stress tests for functional instability
+ PA stress tests
mixed findings with distraction; depends on severity
acessory motion for functional instability
possibly hypomobility if hypermobility is stuck like a drawer
possible adj hypomobility (T10-12 RT, SI jt motion, and hip ext common)
special tests that may be positive with functional instability
possible + prone LE ext test
likely + linear stability
possible + active SLR
inhibited local muscles
describe what you may find in relation to linear stability tests with functional instability
most often anterior shear
LBP can lead to excessively recruited psoas (maintains lordosis when standing; excessive recruitment can cause hyper ext and anterior shearing with L/S hypermobility)
what is ASLR and how is it scored
active SLR
score 1 pt for each:
-tremor
-pain
-ips pelvic RT to raised LE
-slow motion
-unable to raise LE
symptoms of mechanical instability
same as functional but worse AND
pain is unpredictable
worse/more frequent symptoms
increased pain with lesser ADLs
+ stability tests dont fully stabilize
what might radiographs show for instability
stress radiographs = compare vertebreal position in various positions for mechanical instability
may also be a spindylolisthesis
functional instability can exist without radiological evidence
MD Rx for shearing/slipping with mechanical instability
prolotherapy for stabilization into iliolumbar ligaments + PT
spinal fusion if:
-mechanical instability
-similar long term results to multi discipline PT
-higher cost/greater risk
PT Rx for instability
like ligament laxity
POLICED
postural edu to activate local muscles/chair support
JM to increase adj hypomobility
bracing/taping
MET emphasizing stabilization of local muscles, hip exercises, and contraindicated hyperext
