Clinical Presentation Flashcards
1st episode of LBP
80-90% asymptomatic in 6 weeks
98% asymptomatic 24 weeks
99% asymptomatic 52 weeks
Those who become disabled with chronic LNP account for 75-90% of cost associated with LBP
Genetics Age Education and Socioeconomic Class Workload Sciatic Pain
Disc degeneration has degree of inheritance
Age >40/50 low correlation of radiologic findings and clinical sings/sx
Low level formal education and socioeconomic class = inverse (as education goes up,, chronic goes down)
Workload = not a good prognosis with heavy workload
People with sciatica or any leg pain in addition to the back pain have a worse prognosis than someone with just back pain
Smoking
Blood supply vertebra and disc - accelerated degeneration; coughing
Obesity
Increases mechanical demands
Longer prognosis
Psychological Factors
Biomechanical changes (posture) - muscle tension; pain perception; coping; not a cause but effects duration (yellow flag) - can contribute to back pain
Comorbidity
Any other issues going on with their back - prognosis will not be as good
Predictors of recovery in patients with LBP
If baseline pain
Vertebrae Anatomy
Body Disc - annulus fibrosis and nucleus pulposus Vertebral end plates Nerve root canal Zygopophyseal joint (facet)
Annulus Fibrosis
Review anatomy
Crossed fiber orientation - Fibers resist tension with rotation
Nucleus Pulposus
Review anatomy
Vertebral End Plate
Review anatomy
Facet joints
Synovial; plane Closed packed position = extension With flexion - they open up With extension - close down Side bending to same side - closed Side bending opp side - opened
Facet joint orientation
prevents forward slip of the upper vertebral on the lower vertebra
Vertical orientation prevents shear of sup vertebrae on the inferior vertebrae
Ligaments and pain
Lengthening a ligament will lead to pain
ALL - extension would inc pain
Anterior Longitudinal Ligament
Extends from ant sacrum to ant tubercle of C1
Connects anterolateral vertebral bodies and disks
Maintains stability and prevents excessive extension of spinal column
Posterior Longitudinal Ligament
Extends from sacrum to C2, runs with vertebral canal attaching the posterior vertebral bodies
Prevents excessive flexion of spinal column and posterior disc protrusion
Ligamentum Flavum
Binds lamina above each vertebrae to the lamina below
Prevents separation of laminae
Hypertrophies (gets bigger) with age
Supaspinous
Connects spinous processes C7-S1
Limits separation of spinous processes
Interspinous
Connects spinous proceeses C1-S1
Limits separation of spinous processe
Intertransverse
Connects adjacent transverse processes of vertebrae
Limits separation of transverse processes
Iliolumbar
Binds transverse processes of L5 to posterior aspect of iliac crest
Stabilizaed L5 and prevents ant shear
Quadratus Lumborum
palpation
Multifidus
Palpation
Erector Spinae
Palpaton
Muscles!!!
Make diff BS?
Thoracolumbar Fascia
3 layers - separate into Anterior, middle, and post compartments
Provides attachment for transversus abdominis (transverse abdominis attaches to lumbar fascia so can tense when contracted and help with stability)
Spinal stability against shear
Resists segmental flexion
Passive resistance to flexion (fascia has big role in passive support in a flexed position)
Nerve Supply and Vascularization!
Review it!
Flexion/Extension
Consider muscle imbalances
Structures compressed and lengthened
Inflamed facet joint capsule –> pain with flexion
Ant part of Annulus Fibrosis –> Extension would be painful
Nerve —> Extension more painful
Erector Spinae –> Passive lengthening, active shortening
Tight Hamstrings may
post rotate pelvis –> flattens out lumbar spine (need to check hamstrings with pt with back pain)
Tight Psoas
can result in hyper-extension of lumbar spine
Roation/Lateral flexion
IVD and Z joints
Facet joint is also loaded and compressed with weight bearing, discs and facets are compressed
Axial Loading
IVD mechanics
Z joints
Red Flags - Back related tumor
Back related tumor = over 50 yo, Hx of cancer, unexplained weight loss
Red Flags - Back related infection (spinal osteomyelitis)
recent infection (UTI ot skin infection)
Intravenous drug used/abuser
Concurrent immunosuppressive deisroder
Red Flags - Cauda Equina Syndrome
Urine retention or incontinence Fecal incontinence Saddle anesthesia Gloabal or progressive weakness in LE Sensory deficits in L4 S1 dermatomes Weakness in L4 S1 myotomes
Red Flags - spinal fracture
Hx of trauma
Pronlonged use of steroids
Age over 70 yo
What are things that are associated with localized inflammation
Ligament tears
Muscle contustions, strains, and tears
Diastasis Recti Abdominis
Ligament Tear
Mechanism
Typically associated with a trauma
How to determine the ligament involved in a ligament tear
Know your anatomy
Mechaism of how it happened
Aggracating/Releaiving factors
Iliolumbar Ligament Sprain
Most common
Stabilizes L5 on S1
Will complain of pain at mideal iliac crest area
Daignosis through deep palpation
Intervention for Iliolumbar Ligament Sprain
Acute = ice, ultrasound, rest
Need to move along with process of healing –> AROM once pain calmed down
Chronic = need to stretch and work the muscles in the area that may tighten the joint
LBP with ligament tear is exacerbated by…
lengthening of ligaments
Ligament injury can also be associated with
instability of the spine
Delitto article
Muscle Contusions, Strains, Tears
Mechanism
Trauma
Muscle guarding following the injury
LBP with muscle contusion, strain, tear is exacerbated by
stretch of muscle
Contraction of muscular tissues
Intervention for Muscle contusion, strain, tear
Gradual/controlled return to movement and function
Acute = ice, ultrasound, treat inflammation
Eventually AROM
Further contract muscles more and do strengthening
Common site for muscle contusion, strain, tears
Erector Spinae is most common
For erector spiane muscle contusion, strain, tear which examination findings would you expect to reproduce the comparable sign?
are we lengthening or shortening the muscle?
Diastasis Recti abdominis
Musculoskeletal changes during pregnancy
Ligament Laxity
Pelvic floor dysfunction
Separation of the linea alba
Spondylolysis
fracture (lysis) in pars inticularis
Degenerative change in the spine
Spondylolisthesis
shear or slip where one vertebrae slips forward on another
Can have spondylolisthesis without spondylolysis
Both lysis and listethesis are more common in females and younger people
Spondylolysis
Mechanism
Most common
Mechanism = congenital or repeated microtrauma
Most common is L5/S1
People who go into extension a lot
Spondylolysis
Examination
Pain with extension
Positive test for instability
Plain film radiography: lateral or oblique views
Step deformity - separation where spinous process is sticking out and not conencted to vertebrae
Spondylolysis Intervention
Correct muscle imbalances
Deep abdominal/trunk muscle strengthening
Education to avoid excess mpact/lumbar hyperextension
Bracing (only in acute if needed)
Surgical intervention
Sponsylolisthesis Mechanism
Mostly commonly degenerative or traumatic
Shear forces
Lumbosacral angle (L5/S1)
Ligamentous laxity
Spondylolisthesis Examination
Graded - percentage of slip Spinal instability Pain with extension activity Pain at LS junction Lumbar and hamstring muscle tone (compensatory)
Spondylolisthesis Intervention
Correction of muscle imbalances Rectus femoris and iliopsoas stretching Lumbar stabilization program Pelvic position for symptom relief -- you want them post tilt and avoid ant tilting (exten) Surgical if failed conservative
Postural syndrome mechanism
acute pain or myofascial and articular shortening from a fixed postural impairment
Postural syndrome examination
Postural
Limited muscle function - shortened or lengthened
May be hyper- or hypo mobility with joint examination
Lower Crossed Syndrome - Examination - Short
Erector spinae and iliopsoas; gastrocnemius, soleus, hip adductors
Lower Crossed Syndrom Examination Weak
abdominal and glut max
Lower Crossed Syndrome Examination Posture
Anterior pelvic tilt, excessive lumbar lordosis, hips flexed, may lead to hamstring strain, knee pain, LBP
Disc Herniation Types
Protrusion
Prolapse
Sequestration
Disc Herniation Protrusion
Does not escape AF or PLL
Disc Herniation Prolapse
Nuclear material remains attached to disc, but bulges posterolaterally into IV canal
Nuclear material escapes AF or PLL
Disc Herniation Sequestration
Nuclear material becomes a free fragment in the IV canal
Disc Herniation Examination
Lumbar flexion is most painful
Feels better with standing and laying down
LBP and or LE pain/numbness/weakness
ROM - often repeated flexion with peripheralize and extension will centralize
Also aggravating - vasalva/cough/sneeze
Usually unilateral
Disc Herniation Examination - Neuro Eval
may have nerve root involvement
Dermatomal sensory, myotomal, reflex changes
Dural signs/neurodynamic tests (SLR/Slump)
Bowel/bladder changes
Posture –> possible lateral shift
“LBP with radiating pain intervention”
disc herniation, DDD, radiculopathy
pt education in positions that will reduce strain
Manual traction
Manual therapy to mobilize articulations and soft tissues in the area
Nerve mobility exercises in pain free ranges
Degenerative Disc Disease
Degenerative changes by 2nd decade # of annular layers dec NP hydrophilic mucoid tissue gradually replaced by fibrocartilage Disc becomes less resilient Imaging can be misleading These pt will like flexion
Radiculopathy
irritation of the sensory nerve root causing pain and/or paresthesia in the distal part of a dermatome
Radiculopathy - sciatic pain
low back pain radiating to leg
Radiculopathy - mechanism
postural
direct trauma
extremes of motion
compression
Radiculopathy - chronic nerve root adhesion (type of radicul)
Post surgery
Prolonged radiculopathy
Positive dural signs/neurodynamic tests
Radiculopathy Examination
ROM - symp inc with distance nerve travels (straight leg raise) OR movements that compress the nerve
Dermatomes, myotomes, reflexes
Neurodynamics
Degenerative Spinal Stenosis/Spondylosis
Narrowing of spinal canal or itnervertebral foramen
Degenerative Spinal Stenosis/Spondylosis Mechanism
Central = facet hypertrophy; ligamentum flavum thicken; bulging IVD; aging Lateral = facet hypertrophy; loss of IVD height; IVD bulge
Degenerative Spinal Stenosis/Spondylosis Examination
Nerve root ischemia/cauda equina symptoms Aggravated by walking, extension loading Uni or bilateral leg pain Relieved by flexion, sitting Flattened lumbar lordosis Limited hip flexibility Diff from claudication with bicycle test
Degenerative Spinal Stenosis/Spondylosis Intervention
Flexion exercises; manual therapy; treadmill
Pateitn education
surgical decompression
Zygapophyseal Joint Dysfunction
Facet joint syndrome
Due to hypo- or hyper-mobilitty
Intra-articular meniscoid entrapment; capsular tightness
Lesion to join and pain sensitive structures
Zygapophyseal Joint Dysfunction - Examination
Usually unilateral symptoms
Paint at end range (usually extension)
AROM PPIVM (passive physiological intervertebral motion) and PAIVM
Ext and ipsilateral side bending = painful
Usually a small area of pain - very localized
Zygapophyseal Joint Dysfunction Classification
LBP with mobility deficit
Classified Intability of lumbar spine
Altered strucutral integrity of lumbopelvic complex
Imparied recrutment of global and local muscles
CHanges in enural control system
Classified Intability of lumbar spine Patient Reports
recurrent locking, catching, or giving way of the back during active motion
trouble finding a comfortable position
Classified Intability of lumbar spine Examination
Recurrent/catch/locking/click/clunk
Inconsistent symptoms
ROM - Excessive, aberrant, MID RANGE pain, spinal angulation of ROM, skin creases, diff recovering from end range
Segmental mobility testing -> hypermobility
Strength –> impaired trunk strength./endurance
Instability intervention - predictors of success with stabilization exercises
if have at least 3 of these, stabilization ex should work!
SLR > 91 deg
Age
Instability intervention - predictors of non success with stabilization exercises
If 3 of these stabilization ex wont work!
fear avoidance beliefs quest.
LBP classification for instability
LBP with movement coordination impairment
Intervention for instability
muscle re-education temporary external devices for passive restraint education self care manual therapy Therapeutic exercise work re-integration
Radiculopathy cleland Hypothesis
If pt is complaining most of the leg pain (but also have the back stiffness and stuff) but leg is main complaint - may be good indicator of a radiculoahthy
