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Semester 2 PM Exam 3 > Clinical Presentation > Flashcards

Clinical Presentation Flashcards

1
Q

1st episode of LBP

A

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

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2
Q 
Genetics
Age
Education and Socioeconomic Class
Workload
Sciatic Pain
A

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

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3
Q

Smoking

A

Blood supply vertebra and disc - accelerated degeneration; coughing

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4
Q

Obesity

A

Increases mechanical demands

Longer prognosis

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5
Q

Psychological Factors

A

Biomechanical changes (posture) - muscle tension; pain perception; coping; not a cause but effects duration (yellow flag) - can contribute to back pain

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6
Q

Comorbidity

A

Any other issues going on with their back - prognosis will not be as good

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7
Q

Predictors of recovery in patients with LBP

A

If baseline pain

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8
Q

Vertebrae Anatomy

A 
Body
Disc - annulus fibrosis and nucleus pulposus 
Vertebral end plates
Nerve root canal
Zygopophyseal joint (facet)
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9
Q

Annulus Fibrosis

A

Review anatomy

Crossed fiber orientation - Fibers resist tension with rotation

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10
Q

Nucleus Pulposus

A

Review anatomy

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11
Q

Vertebral End Plate

A

Review anatomy

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12
Q

Facet joints

A 
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
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13
Q

Facet joint orientation

A

prevents forward slip of the upper vertebral on the lower vertebra
Vertical orientation prevents shear of sup vertebrae on the inferior vertebrae

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14
Q

Ligaments and pain

A

Lengthening a ligament will lead to pain

ALL - extension would inc pain

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15
Q

Anterior Longitudinal Ligament

A

Extends from ant sacrum to ant tubercle of C1
Connects anterolateral vertebral bodies and disks
Maintains stability and prevents excessive extension of spinal column

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16
Q

Posterior Longitudinal Ligament

A

Extends from sacrum to C2, runs with vertebral canal attaching the posterior vertebral bodies
Prevents excessive flexion of spinal column and posterior disc protrusion

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17
Q

Ligamentum Flavum

A

Binds lamina above each vertebrae to the lamina below
Prevents separation of laminae
Hypertrophies (gets bigger) with age

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18
Q

Supaspinous

A

Connects spinous processes C7-S1

Limits separation of spinous processes

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19
Q

Interspinous

A

Connects spinous proceeses C1-S1

Limits separation of spinous processe

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20
Q

Intertransverse

A

Connects adjacent transverse processes of vertebrae

Limits separation of transverse processes

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21
Q

Iliolumbar

A

Binds transverse processes of L5 to posterior aspect of iliac crest
Stabilizaed L5 and prevents ant shear

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22
Q

Quadratus Lumborum

A

palpation

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23
Q

Multifidus

A

Palpation

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24
Q

Erector Spinae

A

Palpaton

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25
Q

Muscles!!!

A

Make diff BS?

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26
Q

Thoracolumbar Fascia

A

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)

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27
Q

Nerve Supply and Vascularization!

A

Review it!

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28
Q

Flexion/Extension

A

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

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29
Q

Tight Hamstrings may

A

post rotate pelvis –> flattens out lumbar spine (need to check hamstrings with pt with back pain)

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30
Q

Tight Psoas

A

can result in hyper-extension of lumbar spine

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31
Q

Roation/Lateral flexion

A

IVD and Z joints

Facet joint is also loaded and compressed with weight bearing, discs and facets are compressed

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32
Q

Axial Loading

A

IVD mechanics

Z joints

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33
Q

Red Flags - Back related tumor

A

Back related tumor = over 50 yo, Hx of cancer, unexplained weight loss

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34
Q

Red Flags - Back related infection (spinal osteomyelitis)

A

recent infection (UTI ot skin infection)
Intravenous drug used/abuser
Concurrent immunosuppressive deisroder

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35
Q

Red Flags - Cauda Equina Syndrome

A 
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
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36
Q

Red Flags - spinal fracture

A

Hx of trauma
Pronlonged use of steroids
Age over 70 yo

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37
Q

What are things that are associated with localized inflammation

A

Ligament tears
Muscle contustions, strains, and tears
Diastasis Recti Abdominis

38
Q

Ligament Tear

Mechanism

A

Typically associated with a trauma

39
Q

How to determine the ligament involved in a ligament tear

A

Know your anatomy
Mechaism of how it happened
Aggracating/Releaiving factors

40
Q

Iliolumbar Ligament Sprain

A

Most common
Stabilizes L5 on S1
Will complain of pain at mideal iliac crest area
Daignosis through deep palpation

41
Q

Intervention for Iliolumbar Ligament Sprain

A

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

42
Q

LBP with ligament tear is exacerbated by…

A

lengthening of ligaments

43
Q

Ligament injury can also be associated with

A

instability of the spine

Delitto article

44
Q

Muscle Contusions, Strains, Tears

Mechanism

A

Trauma

Muscle guarding following the injury

45
Q

LBP with muscle contusion, strain, tear is exacerbated by

A

stretch of muscle

Contraction of muscular tissues

46
Q

Intervention for Muscle contusion, strain, tear

A

Gradual/controlled return to movement and function
Acute = ice, ultrasound, treat inflammation
Eventually AROM
Further contract muscles more and do strengthening

47
Q

Common site for muscle contusion, strain, tears

A

Erector Spinae is most common

48
Q

For erector spiane muscle contusion, strain, tear which examination findings would you expect to reproduce the comparable sign?

A

are we lengthening or shortening the muscle?

49
Q

Diastasis Recti abdominis

A

Musculoskeletal changes during pregnancy
Ligament Laxity
Pelvic floor dysfunction
Separation of the linea alba

50
Q

Spondylolysis

A

fracture (lysis) in pars inticularis

Degenerative change in the spine

51
Q

Spondylolisthesis

A

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

52
Q

Spondylolysis
Mechanism
Most common

A

Mechanism = congenital or repeated microtrauma
Most common is L5/S1
People who go into extension a lot

53
Q

Spondylolysis

Examination

A

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

54
Q

Spondylolysis Intervention

A

Correct muscle imbalances
Deep abdominal/trunk muscle strengthening
Education to avoid excess mpact/lumbar hyperextension
Bracing (only in acute if needed)
Surgical intervention

55
Q

Sponsylolisthesis Mechanism

A

Mostly commonly degenerative or traumatic
Shear forces
Lumbosacral angle (L5/S1)
Ligamentous laxity

56
Q

Spondylolisthesis Examination

A 
Graded - percentage of slip
Spinal instability 
Pain with extension activity 
Pain at LS junction
Lumbar and hamstring muscle tone (compensatory)
57
Q

Spondylolisthesis Intervention

A 
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
58
Q

Postural syndrome mechanism

A

acute pain or myofascial and articular shortening from a fixed postural impairment

59
Q

Postural syndrome examination

A

Postural
Limited muscle function - shortened or lengthened
May be hyper- or hypo mobility with joint examination

60
Q

Lower Crossed Syndrome - Examination - Short

A

Erector spinae and iliopsoas; gastrocnemius, soleus, hip adductors

61
Q

Lower Crossed Syndrom Examination Weak

A

abdominal and glut max

62
Q

Lower Crossed Syndrome Examination Posture

A

Anterior pelvic tilt, excessive lumbar lordosis, hips flexed, may lead to hamstring strain, knee pain, LBP

63
Q

Disc Herniation Types

A

Protrusion
Prolapse
Sequestration

64
Q

Disc Herniation Protrusion

A

Does not escape AF or PLL

65
Q

Disc Herniation Prolapse

A

Nuclear material remains attached to disc, but bulges posterolaterally into IV canal
Nuclear material escapes AF or PLL

66
Q

Disc Herniation Sequestration

A

Nuclear material becomes a free fragment in the IV canal

67
Q

Disc Herniation Examination

A

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

68
Q

Disc Herniation Examination - Neuro Eval

A

may have nerve root involvement
Dermatomal sensory, myotomal, reflex changes
Dural signs/neurodynamic tests (SLR/Slump)
Bowel/bladder changes
Posture –> possible lateral shift

69
Q

“LBP with radiating pain intervention”

A

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

70
Q

Degenerative Disc Disease

A 
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
71
Q

Radiculopathy

A

irritation of the sensory nerve root causing pain and/or paresthesia in the distal part of a dermatome

72
Q

Radiculopathy - sciatic pain

A

low back pain radiating to leg

73
Q

Radiculopathy - mechanism

A

postural
direct trauma
extremes of motion
compression

74
Q

Radiculopathy - chronic nerve root adhesion (type of radicul)

A

Post surgery
Prolonged radiculopathy
Positive dural signs/neurodynamic tests

75
Q

Radiculopathy Examination

A

ROM - symp inc with distance nerve travels (straight leg raise) OR movements that compress the nerve
Dermatomes, myotomes, reflexes
Neurodynamics

76
Q

Degenerative Spinal Stenosis/Spondylosis

A

Narrowing of spinal canal or itnervertebral foramen

77
Q

Degenerative Spinal Stenosis/Spondylosis Mechanism

A 
Central = facet hypertrophy; ligamentum flavum thicken; bulging IVD; aging 
Lateral = facet hypertrophy; loss of IVD height; IVD bulge
78
Q

Degenerative Spinal Stenosis/Spondylosis Examination

A 
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
79
Q

Degenerative Spinal Stenosis/Spondylosis Intervention

A

Flexion exercises; manual therapy; treadmill
Pateitn education
surgical decompression

80
Q

Zygapophyseal Joint Dysfunction

A

Facet joint syndrome
Due to hypo- or hyper-mobilitty
Intra-articular meniscoid entrapment; capsular tightness
Lesion to join and pain sensitive structures

81
Q

Zygapophyseal Joint Dysfunction - Examination

A

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

82
Q

Zygapophyseal Joint Dysfunction Classification

A

LBP with mobility deficit

83
Q

Classified Intability of lumbar spine

A

Altered strucutral integrity of lumbopelvic complex
Imparied recrutment of global and local muscles
CHanges in enural control system

84
Q

Classified Intability of lumbar spine Patient Reports

A

recurrent locking, catching, or giving way of the back during active motion
trouble finding a comfortable position

85
Q

Classified Intability of lumbar spine Examination

A

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

86
Q

Instability intervention - predictors of success with stabilization exercises

A

if have at least 3 of these, stabilization ex should work!
SLR > 91 deg
Age

87
Q

Instability intervention - predictors of non success with stabilization exercises

A

If 3 of these stabilization ex wont work!

fear avoidance beliefs quest.

88
Q

LBP classification for instability

A

LBP with movement coordination impairment

89
Q

Intervention for instability

A 
muscle re-education
temporary external devices for passive restraint
education self care
manual therapy 
Therapeutic exercise
work re-integration
90
Q

Radiculopathy cleland Hypothesis

A

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

Semester 2 PM Exam 3 (4 decks)

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