Common Conditions and Anatomy Lumbopelvic Unit 1 Flashcards
1
Q
Spinal Stenosis
A
- narrowing of : central canal and or intervertebral foramen
Associated with:
- age
spondylosis
- congenital variants- trefoil canal
- trauma or degeneration induced structural changes/listhes
2
Q
Foraminal Stenosis
A
- Secondary stenosis its acquired
advancing age - gradual onset
- neurogenic claudication of one or both legs
- symptoms increased with prolonged walking and standing
- Better sitting and eased with leaning forward
- consistent aggravating factors
3
Q
Foraminal Stenosis Special Tests
A
Bike test
2- stage treadmill (+)
4
Q
Foraminal Stenosis Findings
A
- Global ROM decreased
- Pronounced decrease in Lumbar extension
- Observed decrease lordosis and often increased kyphosis
Segmental mobility is usually hypomobile
REPETITIVE MOTION EXTENSION WORSENS AND FLEXION IMPROVES (usually)
5
Q
What is the Cluster/CPR for Lumbar Stenosis
A
- Bilateral Symptoms
- Leg pain more than back pain
- Pain during walking/standing
- Pain relief upon sitting
- Age >48
1 of 5 Sn= 96 Sp= 20 LR+=1.2 LR-=.19
4 of 5 Sn=6 Sp=98 LR+= 4.6 LR-= .95
6
Q
What are some interventions for Foraminal Stenosis
A
- Posture
- DP: flexion, contralateral lateral flexion
- Anterior/posterior balance and quadriceps
- traction- positional distraction
- Manual: mobilization (opening), soft tissue psoas release
- bodyweight supported treadmill or bike
- education
7
Q
Central Stenosis with cord compression Etiology
A
Congenitally narrowed canal, broad based protrusions, neoplasm osteophytes and listhesis
8
Q
Central Stenosis with Cord Compression Findings
A
- Diffuse sensory loss
- Non- dermatomal stocking pattern
- Hyperreflexia
- babinski
- Hoffman
- ataxia and abnormal romberg
- wide base gait ( Sn = 0.43/ Sp= 0.97)
- Lower extremity buckling
9
Q
Discogenic Pathology/ Nomenclature
A
DDD= desiccation, end plate sclerosis, decreased height, decreased signal on T2MR
Disc Bulge= >50% (180 degrees) may be asymmetrical
Herniation= localized : disc protrusion intact annulus: disc extrusion outer annulus torn
Fissure= deflect
High Intensity Zone= increased signal on T2 image at outer annulus
Internal Disc Disruption= internal fissuring (radial, T, Transverse)
10
Q
Discogenic Pathology History
A
- gradual or sudden onset
- somatic or radicular
- Variable pain pattern
- AM worse
- Symptoms increase with coughing and sneezing
- Worse with slouched sitting, bending, and lifting
- trouble rising from sitting
- improved standing and walking
- Walk off pain
11
Q
Discogenic pathology is most common cause of________
A
Radiculopathy
- age 2-0-55 most common
- Herniations 50% post/lat, 25% central, 10% lateral
- 95% at L4-5 or L5-S1
- Site of pathology reflects pain location
12
Q
What are some things you might find during a discogenic pathology examination?
A
Static Positioning:
- flexion = worsens
- extension= improves
Neurological signs:
- hyporeflexia
- motor loss > sensory
- UMN if cord impingement
- MRI used most often GOLD STANDARD IS DISCOGRAPHY
13
Q
What special tests would you do for discogenic pathology?
A
SLUMP
SLR with nerve root involvement
14
Q
Discogenic Pathology Tests and Measures
A
- Posture may have an acute deformity/kyphosis or shift/list
- AROM limited in all planes with obstruction toward herniation
- repetitive motion - internal bulge/ protrusions
- Repetitive motion extrusion, sequestration or large protrusion
15
Q
Discogenic Pathology Interventions
A
- Posture: Anterior pelvic tilt, lordosis, avoidance of A.M. flexion
- DP- extension and or lateral group most often
- Impairments: flexibility and muscle performance
- Traction if no DP: monitor annular competence
- Mobilization- as required for complete reduction
- neural mobilization PRN
- medical= micro lumbar discectomy, fusion, disc replacement, IDET
16
Q
Facet Joint Dysfunction (zygapophyseal joint) Anatomy
A
- Synovial joint with capsule and fat pad
- Capsule attached to ligamentum flavum anterior and multifidus posterior
17
Q
Facet Joint Dysfunction (zygapophyseal joint) Disorders Inflammatory or Mechanical
A
- Joint Inflammation= synovitis or hemarthrosis (trauma)
- Impingement = articular fat-synovitis capsular folds - fibrillated/detached cartilage
- DJD (if pronounced may lead to stenosis )= with degenerative change; decreased disc height leads to increased weight bearing load on facet
18
Q
Mechanical Facet Joint Disorders: Dysfunction leads to
A
Leads to impaired joint mobility and or theoretical malpositioning
19
Q
Mechanical Facet Joint Disorders: What are the Facet mobility patterns?
A
- Facet joint guide movement of the spine
- In the lumbar spine the facet joints:
-OPEN with FLEXION
-CLOSE with EXTENSION - OPEN on CONTRALATERAL side of LATERAL FLEXION
20
Q
Mechanical Facet Joint Disorders: Facet Coupling when standing in neutral
A
L1-L5
- Right lateral flexion couples with left rotation (EXECEPT AT L5-S1
- Opens on ipsilateral side of rotation (EXCEPT AT L5-S1
21
Q
Facet Joint Dysfunction : History
A
- Sudden/gradual onset
- Reports of “stiffness” or “feeling stuck”
- Unilateral pain in the lumbar, gluteal and thigh region
- No symptoms increase with sit to stand
- Often will meet CPR for thrust manipulation
22
Q
Facet Joint Dysfunction: Tests and Measures
A
- AROM: facet opening or closing pattern - movement obstruction or restriction
- Repetitive Motion: will not see centralization/peripheralization no directional preference
- Hypomobile segmental testing
- Palpation: tenderness and guarding in region of affected joint
- Absence of neurological findings
23
Q
Facet Joint Dysfunction: Intervention
A
- restore mobility/correct dysfunction
- mobilize/manipulation
- supportive intervention for impairments
- medical Interventions: corticosteroid injection/percutaneous radiofrequency neurotomy/ facetectomy or joint replacement
24
Q
Lumbar Segmental Instability (LSI): Radiological Instability
A
- End range Instability
- Based on >3mm translation on stress films (non-invasive gold standard)
- May require surgical stabilization
25
Lumbar Segmental Instability (LSI): Clinical Instability
- thought to be excessive motion in a segments neural zone
- decrease capacity of the stabilizing system to maintain neutral zone within physiological limits
- Clinical dx only can't see on films
- Requires clinical rx
26
Lumbar Segmental Instability (LSI):
- Loss of motion stiffness in segments neutral zone
- Decrease capacity of stabilizing system
- Clinical Instability: loss of system control
- Radiological instability: failure of passive system : trauma/neoplasm/degeneration/hyperlaxity/ iatogenic
27
Lumbar Segmental Instability (LSI): History
- static positioning Increases pain
- symptom improve with bracing/support
- Self manipulates/ often seeks/requests
-radiological: found 10-20% asymptomatic
- prior episodes often with minimal perturbation
28
Lumbar Segmental Instability (LSI): Symptoms
- Consistent clicking or clunking noises
- protracted pain (with full ROM)
- Excessive active ROM
- Inability to recover normally from full ROM/commonly flexion
- Compression symptoms (vertebrobasilar/spinal cord) which are not associated with a history of an IVD herniation or stenosis
- Minor arching for a few days after a sensation of giving way
- repeated episodes of feeling unstable or giving way/ following minor provocation
- Back pain that most commonly described as recurrent, constant, catching, locking
29
Lumbar Segmental Instability (LSI): Tests and Measures
- Observation: self supports spine or s observed to be restless
AROM
- Isolated lumbar flexion >53 degrees (+LR 4.8)
- Spasms at end range of mobility and worsening with repetitive motion
- Aberrant movement : painful arc, catching, Gower sign, reversal of lumbopelvic rhythm
Segmental Mobility Testing PA Glide
- Lack of hypomobility (+LR 9.0) or Hypomobility (+LR 2.4)
Special testing
- generalized ligamentous laxity testing : Beighton score >2 (+LR 2.5)
- prone Instability test (+)/ passive lumbar extension test (+)
30
Lumbar Segmental Instability (LSI): Intervention
- Determine position of comfort and "maintain"
- Stabilization in position of comfort
- orthosis in acute stage due to trauma
- Ok to mobilize neighboring hypomobile levels ( high failure rate to manipulate at unstable levels)
- Educate: avoid prolonged positioning
31
SIJ and Pelvic Girdle Disorder
- Rarely below knee
- Absence of Lumbar pain
- may refer distally to the buttock, groin, and post thigh
32
SIJ and Pelvic Girdle Disorder: Exam Findings
- pain with sit to stand
- no centralization /peripheralization
- 3 or more pain provocation tests
(+) sacral thrust
(+) gaenslen's
(+) distraction/compression
(+) thigh thrust
33
SIJ and Pelvic Girdle Disorder: Interventions
- If hypomobile /mobilize
- if hypermobile stabilize
34
Peripherally Mediated Pelvic Girdle Pain Disorder : general
- Well defined, localized SIJ pain
- May be associated with CT or myofascial structures
- Usually unilateral and intermittent
- MOI= repeated activity or trauma (fall onto butt or landing hard on one leg)
35
Peripherally Mediated Pelvic Girdle Pain Disorder : Specific to reduced Force Closure
- Insufficient compressive force
- Excess strain due to ligament laxity and motor control deficits
- Postpartum PGP
36
Reduced Force Closure Exam Findings
- Reduced TrA, multifidus, iliopsoas, glutes
- Overactive QL, ES, EO, RA,OI
- Swayback posture, slump sitting, asymmetrical standing
- No L spine pain, centralization or peripheralization
(+) ASLR
37
Reduced Force Closure Interventions
- Stabilization
- SIJ belt
- Posture co-contraction strategies
- Relax overactive mm
38
Excessive Force Closure
- Excessive compressive forces or sustained loading at SIJ
- Overactivation of pelvic local motor system
- Hypomobility due to trauma or fusion
- Localized to SIJ
39
Excessive Force Closure Exam Findings
(+) Pain provocation Test
(-) ASLR
- high level of mm co-contraction in local and global
40
Excessive Force Closure Interventions
- Mobilization/Manipulation
(CPR= pain not extending below knee symmetrical PSIS is seated/ (+) seated flexion test/(+) prone knee bend test)
- Alternating submax isometric hip abd/add
- butt gripping strategy: PPT, L-spine in flexion, LE's ER
- Cardiovascular exercise
- Stretching
- STM
- MET
- Diaphragmatic breathing
41
Spondylosis
- Fx at the par interarticularis
- Loaded rotational movements or extension loading can lead to damage
- Common in young males
42
Spondylolysis Exam Findings
- Scotty dog sign - utilize oblique view
43
Spondylolysis Interventions
- Correct mm imbalances
- Increase trunk mm strength
- Surgery if failed conservative management
44
Spondylolisthesis
- 4x more common in woman
- Commonly @L4-L5
- No association with LBP
- Forward slippage of one vertebrae on another
- Can be attributed to degenerative changes or defects at vertebrae
- Chronic mechanical midline pain
- Exacerbated by repetitive extension and torsional activities
45
Spondylolisthesis Exam Findings
- may complain of leg pain manifesting as neurogenic claudication
- Bilateral thigh/leg fatigue
- Normal lumbar flexion
- Increased lumbar and hamstring mm tone due to compensation
- May have palpable/visible step off
- Utilize lateral view
46
Spondylolisthesis Interventions
- Pelvic positioning
- Active lumbar stabilization
- Stretching rectus femoris and iliopsoas to decrease anterior tilt
47
Ankylosing Spondylitis
- Chronic Progressive rheumatoid disorder
- Inflammatory spondyloarthropathy
- Insidious
- Age <40
Male>female
48
Ankylosing Spondylitis Exam Findings
- Ligament ossification with bamboo spine appearance
- Pain > 3 months
- Limited chest expansion
Cluster (3/4)
- pain improved with exercise not relieved with rest
- Awakening due to LBP in the second half of the night
- AM stiffness >30 minutes
- Buttock pain
49
Ankylosing Spondylitis Interventions
Treat body impairments
50
Cauda Equina Syndrome
- Urine retention
- fecal incontinence
- Sensory or motor deficits in feet L4,L5,S1
- Saddle anesthesia
- EMERGENCY
51
What are poor prognostic factors of LBP
- Hx of LBP
- Low education
- Poor status
- Peripheralization
- Can't modify at work
- Depression/fear avoidance
52
Where does LBP frequently originate from?
- Skin
- Postero/lateral annulus
- Compressed nerve root
- PLL
- vertebral end plate
53
What does the Waddell Screen Help Identify?
What comprises the screen ?
- Yellow falgs
- overreaction to exam like wincing, verbalizing, muscle tension, sweating
- Stimulation- movements like axial loading produce pain
- Distraction- (SLR)
- Tenderness
- Regional disturbances
-
54
What muscles Make up the intermediate layer of the posterior trunk?
- Serratus posterior superior and inferior
- Helps with rib elevation/depression
55
What are the 3 groups of muscles making up the deep musculature of the posterior trunk?
Superficial
Intermediate
Deep
1. Superficial= Erector spinae (longissimus, spinalis, iliocostalis)
2. Intermediate= transversospinal (semispinalis, multifidus, rotatores)
3. Deep= Short segmental = Interspinalis/intertransveraris
56
1. the right external oblique rotates you what direction?
2. The left oblique rotates you what direction?
1. Left
2. Right
57
What would you stretch and strengthen to help foraminal lumbar stenosis
Stretch
- ES
- Iliopsoas
- rectus femoris
Strengthen
- ABs
- Hammies
- Glutes
58
T/F Spinal flexion is worse for disc problems but better for opening IV foramen like with stenosis
true
59
What Makes up the pelvic ring?
- SIJ
- Pubic Symphysis
- Coxae Bones
60
When is intradiscal pressure highest?
When sitting and bending over holding a weight
Second highest when standing bending over holding a weight
61
What is the effect of Females having a CoG more posterior than males?
Increases rotational forces in female pelvis
Increases need for stabilization
62
Why is the SIJ like no other joint in the body
No muscles perform active movements of the joint
Its a stress relieving joint
63
What is the most stable position of the sacrum
A little bit of nutation
64
What are the extrinsic ligaments of the SIJ ?
- Superior/Inferior Iliolumbar & sacrotuberous = resist nutation and ER
- Sacrotuberous connects with biceps femoris/resists nutation
65
What is the most Important ligament of the SI ligaments?
Interosseous
- joints lateral sacrum to PSIS
- nutation torque stretches the interosseous and sacrotuberous ligament which compresses and stabilizes the SIJ
66
What is inflare?
IR of ilium
67
Is hip extension or flexion associated with counternutation
- Hip extension
68
Is lumbar extension or flexion associated with nutation
Lumbar extension
69
What tests would be positive with lumbar disc herniation?
-SLR
-SLUMP
-Hyporeflexic
-Repeated flexion increases pain and peripheralization
- Pseudo-Gower Sign (using hands on knees to stand)
70
How is -listhesis different from -lysis ?
- lithesis = slippage
- Lysis= fracture
71
Which x-ray angle is good to view the facets and thus visualize spondylolysis?
Oblique
72
What type of tilt do you want to avoid with spondylolysis?
Anterior
73
What radiograph view allows us to see the intervertebral foramina well?
Lateral
74
What is one of the first things you see on an x-ray with ankylosing spond?
Blurring of the arcuate lines on the sacrum
75
What is the gold standard for abdominal or pelvic pain/trauma for imaging?
CT with contrast
76
What is directional prefernce?
A favorable response to repeated movements (centralized, reduced pain, increased mobility without peripheralization)
77
For Passive SLR list the nerve associated with each ankle movement
1. Tibial Nerve= DF with eversion and great toe extension
2. Sural Nerve= Dorsiflexion with inversion (posterolateral leg sensation)
3. Saphenous Nerve= PF with eversion (posteromedial leg sensation)
4. Common fibular nerve=PF with inversion
78
Which pain provocation test of the SIJ stresses the sacrotuberous ligament?
Thigh trust
79
What is the proper hip extension firing pattern?
1. hammies
2. glute max
3. Contralater QL
- Ipsilateral QL
80
How can you differentiate between SIJ, hip problems and lumbar problems
- (+) provication tests like thigh thrust and gaenslan + posterior pelvic palpation
-SIJ sign of the buttock, hip scour, FADIR, Trendelenburg, hop test, fulcrum test
- Hip- spring test, SLR/Crosses SLR, femoral nerve tension test, bilateral sx, leg pain >back pain, pain with walking and relieved when sitting --> lumbar stenosis
81
What is the diagnostic gold standard used for chronic LBP when MRI doesn't show anything?
Discography
82
What are the 4 lumbar special tests ?
1. Lumbar Quadrant test
2. Prone instability
3. Passive Lumbar Extension
4. Crossed SLR sign
83
Name 5 pain provocation tests for SIJ
1. Distraction and compression
2. Gaenslen's
3. FABER
4. Sacral Thrust
5. Thigh Trust
