Class 6/7: ARJC-Stenosis Flashcards
prevalence of stenosis
most common dx for adults >60/65
if younger due to spondylolisthess=is
30% asymptomatic individuals had canal narrowing
2 methods of compression with stenosis
outside in
-unilateral more than bilateral
-due to ARJC/ARDC, instability, or enfolding of ligamentum flavum
inside out
-sheath around n = fibrotic
-increased blood supply causes enlarged n
-fibrotic wont expand
structures involved with stenosis
ischemic compression
venous congestion
no lymphatic vv in PNS/CNS
symptoms of lateral stenosis
unilateral LE > LBP
segmental paresthesias + gripping pain b/c of ischemia
pain decreased with FB, sitting, in morning (pain moves from LE to LBP)
pain increased in LE with standing/walking
greater symptoms with decline walking
observation for stenosis pt
slouched
possible scoliosis
ROM finding for stenosis pt
flx/cont. SB decrease pain (but may not be able to open foramen completely so possible limited ROM)
Ext/ips SB increase pain (possible limited ROM due to contact with n)
Rot = inconsistent
neuro and stress test findings for stenosis
+ neuro for radiculopathy
possibly + PA/torsion when SUSTAINED
Accessory motion findings for lateral stenosis
hypomobility in adj joints (lower thoraci and LE, especially hip)
hypomobily in flexion and contralateral SB
special test results for lateral stenosis
possible + stability tests for excessive shear
LE discrepancies
balance deficits with wide based gait
cooks CPR
factors for cooks CPR
bilateral symptoms
LE P! > LBP
P! with walking/standing
P! relief with sitting
> 48 yrs old
how to differentiate between neural and vascular causes
Ankle Brachial Test for peripheral artery disease
-ratio of tibial and brachial aa
-Normal = 0.9-3.1
-0.41-0.9 = mild
-less that 4 = severe
bicycle test
-upright cylce then bend to lean on handlebars for 3 min each
-if stenosis = pain decreases with bent position
-if not better = PAD
central stenosis S&S
cord or cauda equina syndrome
no change with SB/RT
PT Rx for stenosis (foraminal opening)
pt edu of foramen/good prognosis
flx directional preference
possibly helpful intermittent tx
neural mobs
manual therapy
what specific manual therapies are best for stenosis
manipulation most effective for sub group of stenosis with LBP
-lower thoracic
-lumbar manipulation most effective when combined with ex
-early evidence fo support for additional hip jt mobilizaiton
MET for stenosis
aerobic
-unweighted walking
-cycling as effective as unweighted walking
-primary influence = circulation improvements
balance training ONLY if able to be upright w/o symptoms
local muscle stabilization
corsets
sx indications for stenosis
presence of constant/worsening symptoms
failure to obtain relief with 3-6 months of non-surgical treatments
sx effectiveness for stenosis
inconclusive best sx with spinal decompression of laminextomy and/or partial discectomy w/ or w/o fusion
benefit with pain/disability
walking distance NOT better
if just stenosis = outcome can be just as good as PT
if stenosis + spondylolisthesis = substantially greater pain relief and improvement in fx vs PT at 4 yrs
what is spondylolysis
bony defect or fx of pars interarticularis unilaterally and bilaterally
etiology of spondylolysis
congenital
repetitive stress (especially ext/RT)
direct trauma
prevalence of spondylolysis
6-12%
most common level for spondylolysis
L5/S1
S&S of spondylolysis
acute = fx S&S plus + B torsion test
persistent = asymptomatic often; like instability if symptoms are present
what is spondylolisthesis
anterior vertebral segment slippage
2 most common types of spondylolisthesis
isthmic or adolescent with spondylolysis
-most common
-age group with most rapid slippage
-due to repetitive trauma or ext
degenerative
-b/c of ARDC
-50+ years old
-No fx
what are the degrees of slippage with spondylolisthesis
Grade I = 0-25%
Grade II = 26-50%
Grade III = 51-75%
Grade IV = 76-100%
S&S of spondylolisthesis
worse case of instability
possible lateral or central stenosis S&S with slippage
no correlation with slippage and degree of symptoms
PT Rx and prognosis for spondylolysis and spondylolisthesis
like worse version of instability
MET = local muscles (better results than traditional therex alone
84% children/YA improved after 1 year with up to 25% slippage
better results with unilateral lesion/early intervention
Sx indications/outcomes for spondylolisthesis
sx indicated if confirmed imaging w/o conservative benefits
sx outcomes = 83% excellent to good outcome with modified scott technique vs others (i.e. fusion)
structures involved with facet joint impingement
meniscoid
-synovial fat/fibrous tissue
-compensate for in-congruency of articular surface
-facilitate spread of synovial fluid
facet joint
pathomechanics of facet impingement
meniscoid becomes wedged due to a prolonged position/quick movement
associated with instability
prevalance of ARJC
l4-S1 most common
progresses with ARDC
what is spondylosis
ARJC at multiple levels
what is spondylolysis
fracture
what is spondylolisthesis
anterior slippage (could be due to fx or other causes)
etiology of degenerative vs acute ARJC
degenerative = more common, older, chondrocytes cant keep up
acute = rare, younger, activem high shear forces
etiology of ARJC (specific causes)
prior trauma
age
genetics
other diseases (i.e. RA)
sedentary life
components of synovial joints and how they contribute to ARJC
articular cartilage = frays/blisters/tears and narrows joint space
subchondral bone overloaded/injured
osteophyte/spur formation b/c of stress
fibrous capsule slackens/thickens/stiffens
synovial membrane produces less fluid
periarticular tissue inflammation
what causes the persistent pain and inflammation with ARJC
stress on tissues like bone
increased nociceptive response
local production of nitrous oxide = more interstitual inflammaiton and excess collagen
blood released from bone marrow
lumbar symptoms for ARJC
gradual onset LBP
pain with prolonged positions (especially standing b/c synovial fluid is squeezed out w/o refill)
morning stiffness or after prolonged position that lasts more than 30 min
pain/limit with standing , walking, or lying on stomach
some movement helps, some makes worse
observation for ARJC
forward bent in standing/walking
ROM ARJC
painful/limited
pain with ext, ips SB, and cont RT
one sided more common
capsular pattern
combined motion ARJC
consistent block often into ext quadrant
OR
opposing quadrants blocked
resisted/MMT for ARJC
depends on acuity
stress test findings with ARJC
pain with compression (especially in ext, ips SB, cont RT)
PA/torsion glides painful
distract can relieve if acute
acessory motion and neuro for ARJC
hypomobility
possibly + neuro if stenosis
which stages of ARJC have capsular pattern
early (if past trauma)
intermediate
NOT late stage b/c bony end feel due to osteophytes
which stages of ARJC have hypermobility
just early stage due to narrowing if there is no past trauma
Rx for each stage of ARJC
early = POLICED, JM for CPP, MET
intermediate = JM for CPP, MET for involved jt and adj jt
late = JM and MET with focus on adj jt
PT Rx for ARJC
focus on improving integrity of cartilage and mobility
POLICED
wt management and avodi provocation
assistive device to unload cartilage
JM for pain, cartilage integrity, and mobility
MET for ARJC
ultimate focus on improving motion, cartilage integrity, and neuromusclular benefits
no evidence for supplements
