Common MSK Conditions Of The Spine Flashcards
1
Q
Describe the bio psycho social model
A
- evidence based
- patient centered
- psychological factors = yellow flags (predictor of poor outcomes, correlation of symptoms persistance)
- social factors (influence outcome, influence disability)
2
Q
Briefly describe the ICF model
A
Health conditions are influenced by body functions and structure, activity and participation, all of these being influenced by the environment factors and personal factors
3
Q
What is the difference between recent and persistent stages ?
A
Recent : <3 months
Persistent: >3 months
4
Q
What are the different outcome durations ?
A
- immediate : closest to immediately following intervention
-short term : 1-3 months - intermediate terme : shortest to 6 months
- long term : closest to 12 months
5
Q
What are the 3 pain mechanisms ?
A
- nociceptive
- neuroplastic
- neuropathic
6
Q
Define the nociceptive pain mechanism
A
Pain that arises from actual or threatened damage to non neural tissues and is due to the activation of nociceptors. Pain is associated with acute actual tissue damage and inflammatory conditions.
7
Q
Define the neuropathic pain mechanism
A
Pain caused by a lesion or a disease of the somatosensory nervous system
8
Q
Define the neuroplastic pain mechanism
A
Central sensitization
Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.
9
Q
Define neck pain
A
Pain in the location Outlined by the superior nuchal line, the spines of the scapulas, the superior border of the clavicles and the suprasternal notch. This pain is with out without radiation to the head trunk and upper limb.
10
Q
List the risk factors for neck pain
A
- gender : female
- prior history of neck pain
- old age
- high job demand
- smoking
- low social/work support
- prior history of MSK condition in the spine
11
Q
What are the patho anatomical characteristics of neck pain and their relation to imaging
A
- specific features or pain generator are rarely identifiable by imaging
- imaging is important to exclude red flags
- imaging allows to recognize specific conditions
- if radiating pain with serious neurological signs is present : RMI
12
Q
In neck pain, Which factors can affect the prognosis ?
A
- high pain intensity : on scale from 0 to 10 (if superior or equal to 6)
- high self-reported disability : use neck disability index (higher Thant 30%)
- high pain catastrophizing : use pain catastrophizing scale (score of 20 or greater)
- high acute posttraumatic stress symptoms : use impact of event scale revised (score of 33 or greater)
- cold hyperalgesia : use the TSA-II neuro sensory analyzer
13
Q
In neck pain, which variables can affect the prognosis ?
A
- lower social support
- preference for passive coping strategies
14
Q
In neck pain, how to measure the outcome ?
A
- neck disability index
- patient specific functional scale
15
Q
In neck pain, how to measure the physical impairement ?
A
- active ROM
- passive ROM
- cervical flexion rotation test
- spurring test
- neck distraction test
- neurodynamics
- cranial cervical flexion and neck flexors endurance test
- pressure pain threshold
16
Q
What are the grade of neck pain
A
Grade 4: signs of major structural pathology
Grade 3: no signs of major structural pathology but presence of neurological signs
Grade 2: no signs of major structural pathology but major interference with activities of the daily living
Grade 1: no signs of major structural pathology and no/minor interference with daily living
17
Q
How to conduct a proper clinical evaluation of patient with neck pain ?
A
1) exclude serious neck problems => or refer to a physician
2) recognize specific neck problems => specific pathway
3) if the neck pain is non specific => prognosis profile by evaluating the impairments (ICF)
4) recommend treatments
18
Q
What is the classification of neck pain without signs of serious medical/psychological condition ?
A
ICF impairement based category :
-NP with mobility deficit
-NP with headache
-NP with movement coordination impairements (whiplash)
-NP with radiating pain (radiculopathy)
19
Q
Define special tests
A
Special tests are used during a physical examination by clinicians in physical therapy and orthopedics. The tests can be used to rule in or rule out whether a patient has a certain musculoskeletal problem. They are helpful in diagnosing orthopedic conditions and injuries. These physical examinations may be useful to classify a patient in the ICF impairement-based category.
20
Q
What are the risks factors of cervical spine anatomical instability ?
A
TRAUMATIC EVENT
- fall
- trauma
- MVA
NON TRAUMATIC EVENT
- rheumatoid arthritis
- Down syndrome
- ankylosing spondylitis
- prolonged oral contraceptive
- prolonged corticosteroid use
21
Q
What are the risk factors of spinal fracture
A
Usually caused by trauma or injury
- age
- prolonged use of corticosteroids
- trauma : compressive axial force, fall > 3m, motor vehicle collision > 100km/h
- osteoporosis
22
Q
How to test cervical spine instability ?
A
Clinical tests lack validity
They will consist in provocating ligamentous structures to reproduce symptoms :
- tectorial membrane
- transverse ligament
- alar ligament
23
Q
What are the self reported symptoms in cervical spine instability ?
A
- recent onset of headaches described as unusual
- impaired ROM with sharp sharp pain at permitted end range or sudden movement
- transient neurological symptoms = upper motor neuron signs; cranial nerve palsy; partial Horner’s syndrome
24
Q
What are the risk factors for cervical artherial pathology ?
A
Rare (vascular dissection)
-Mild to moderate recent trauma
-vascular anomaly
- current or past smoker
- migraine
- high cholesterol
- recent infection
- hypertension
- oral contraception
- family history of stroke
25
What are the signs of cervical artherial pathology ?
PREISCHEMIC SYMPTOMS (may be present for weeks)
- Ipsilateral posterior neck pain
- occipital headache
ISCHEMIC SYMPTOMS (depending and the brain area and tissue damages)
- unsteadiness
- ataxia
- imbalance
- weakness UL/LL
- dysphasia
- dysarthria
- aphasia
- facial palsy
- ptosis
- nausea/vomiting
- dysphagia
- drowsiness
- confusion
- loss of consciousness
26
Define myelopathy
Space occupying lesion within the cervical spine with the potential to compress the spinal cord (CNS involved).
27
What is the subjective examination of myelopathy ?
Symptoms may appear in the LL first with gait related changes :
- upper motor neuron changes
- dysfunctional cortico spinal and spinocerebellar tracts
Later on, lower motor neuron findings in UL:
- loss of strength
- atrophy
- fine finger movements difficulties
28
What are the special tests for myelopathy ?
1. Peripheral neurological examination
- dermatoses
- myotomes
- deep tendon reflexes
2. Upper motor neuron
- Lhermitte sign
- Hoffman’s test
- Babinski’s sign
- clonus
- Romberg
29
What is the subjective examination of cervical radiculopathy ?
Presence of neck pain with radiating pain
Signs of nerve root involvement may be present
Neck pain with radiating pain in the involved extremity (lancinating, burning, electric pain or paresthesia)
30
What are the specific tests for cervical radiculopathy ?
- wainner’s cluster
ULNT1
Painful ipsilateral cervical rotation < 60°
Distraction test
Spurling test
- peripheral neurological examination
Dermatomes
Myotomes
Deep tendon reflexes
31
What is the subjective examination of neck pain with mobility deficit?
- central and/or unilateral pain
- limitation in ROM (with reproduction of symptoms at end range of passive and active motions)
- associated/referred shoulder girdle pain
32
What are the special tests for neck pain with mobility deficit ?
-limited/painful end range in active/passive ROM
-spring test
-trigger points
33
How to manage recent neck pain with mobility deficit ?
-education (stay active)+home training
- manual therapy (cervical + thoracic)
- stretching
- ROM
- general fitness training
34
How to manage subacute neck pain with mobility deficit ?
- manual therapy
- cervicoscapulothoracic endurance exercise
35
How to manage persistent neck pain with mobility deficit ?
Education
Manual therapy
Cervicoscapulothoracic neuromuscular exercises
Dry needling
…etc
36
Define whiplash
Categorized as neck pain with movement coordination impairement.
Bony or soft tissue injury resulting from rear-end or side impact, predominantly in motor vehicles accident, and from other mishaps as a result of an acceleration-deceleration mechanism of energy transfer to the neck. Up to 50% of patients will report an ongoing pain after 12 months.
37
What is the subjective examination of whiplash
- NP that may be associated with referred pain to UL
- mechanism of onset linked to trauma or whiplash
- associated non specific signs and symptoms such as dizziness, nausea, headache, memory difficulties, hypersensitivity to thermal, acoustic, odor or light stimuli
- central sensitization
38
What are the special tests for whiplash
Cranial cervical flexion test
Neck flexor muscles endurance test
Neck extensor muscles endurance test
Sensorimotor impairement (altered muscles activation pattern, proprioceptive deficit, postural balance)
39
In whiplash what are the factors of poor prognosis ?
Initial pain level > 5,5/10
Initial disability level : use neck disability index = > 29%
Symptoms of post traumatic stress
Negative expectations of recovery
High pain catastrophizing
Cold hyperalgesia
40
Which factors are not prognosis related in whiplash ?
Accident related features
Findings on Imaging
Motor dysfunction
41
How to manage recent whiplash ?
Education (stay active as usual)
Pain free cervical gradual ROM exercises
42
What is the management of subacute whiplash ?
Education : pain science, activation and counseling
Active cervical ROM
Exercises :
-isometric strengthening exercises
- stretching
-neuromuscular exercises (posture, coordination, stabilization)
Manual therapy
EPA (tens)
43
What is the management of permanent whiplash ?
Collar is not recommended
Education : pain science, reassurance
Manual therapy
Progressive exercises
- eye head neck coordination
EPA (tens)
44
What are the types of headaches ?
- primary : idiopathic (migraine, tension type headaches)
- secondary : underlying condition (TMJ, cervicogenic headache, trauma)
- cranial neuralgia
45
What describes the cervicogenic headache ?
Secondary type of headache
- mild to intense pain
- non pulsative pain
- usually starts at neck level then headache
- same side
- cervical ROM is reduced
- symptoms made significantly worse by provocative manœuvres
- may present other symptoms (nausea, photo/phonophobia, blurred vision)
46
What are the red flags (differential diagnosis) in case of cervicogenic headache ?
Cervical artery dissection
Upper cervical anatomical instability
47
What is the subjective examination of cervicogenic headache ?
-non continuous, non pulsatile, mild to intense pain
- usually starts at neck level then headache
- same side
- cervical ROM is reduced
- symptoms made significantly worse by provocative manœuvres, neck movements or sustained positions/postures
- may present others symptoms (nausea, photo/phonophobia, blurred vision)
48
What are the special test for cervicogenic headache ?
-limited ROM in rotation
- cervical flexion rotation test
- Upper Cx spring test ++
49
What is the management of acute cervicogenic headache ?
Self SNAG C1-C2
50
What is the management of subacute cervicogenic headache ?
Self SNAG C1-C2
Manual therapy
51
What is the management of chronic cervicogenic headache ?
Manual therapy (cervical and thoracic)
Exercises (cervicoscapulothoracic) :
- strengthening and endurance
- neuromuscular
- motor control (biofeedback)
52
What is the screening for referral in case of thoracic pain ?
In case of anterior chest wall pain :
Triage for cardiac and visceral disorders
Tx spine can mimic pseudo anginal or pseudo visceral pain
In case of abnormal vital signs :
High blood pressure and heart rate
Shortness of breath
General fatigue
Asymmetric pulse
53
In what structures consist the thoracic spine cage ?
-ribs
-costovertebral joints
-facet joints
54
What can be the cause of pain in the thoracic cage ?
Ribs:
Trauma
-fracture
- sprain
Non trauma
Stress fracture (coughing)
Metastasis
Arthroses
55
What is the subjective examination for thoracic pain caused by ribs ?
Localized Pain while coughing or even breathing
56
What is the objective examination in case of thoracic pain caused by ribs
Palpation
Mobilization of rib away from site of pain
57
What can be the causes of thoracic pain
Vertebral body:
Fracture
Scheuermann’s disease
Disc:
Herniated disc (very rare)
Discarthrosis
58
What happens anatomically in case of the thoracic outlet syndrome ?
Compression/tension of NAV (nerve, artery, vein) :
- interscalene space triangle
- costoclavicular space
- sub pectoralis minor space
59
What are the causes of thoracic syndrome outlet ?
CONGENITAL CAUSES
Bony structure
Fibromuscular anomalies
ACQUIRED ABNORMALITIES
Post surgery fibrous scarring
Post traumatic :
- direct trauma
- work or activity related repetitive micro trauma
FUNCTIONAL CAUSE
« Poor posture » : forward head and shoulder
Abnormal function : breathing pattern
60
What are the different manifestations of thoracic outlet syndrome ?
-arterial (1%) ATOS
-veinous (3-5%) VTOS
-neurogenic (90%) NTOS
61
Define ATOS and its subjective examination
Arterial thoracic outlet syndrome
Affecting subclavian artery
Often seen in young adults with a history of vigorous arm activity or sports
Subjective examination
- pain in the hand but seldom in the shoulder or neck
- pallor
- claudication
- coldness and cold intolerance
- paresthesis
- symptoms usually stem spontaneously from arterial emboli
62
What are the specificities and subjective examination of VTOS ?
Venous thoracic outlet syndrome
Affects subclavian and axillary veins
Pain often in younger men and often preceded by excessive activity in the arms or spontaneous oedema in the arm
Subjective examination
- swelling
- oedema
- cyanosis
- feeling of heaviness
- paresthesia in fingers and hand secondary to oedema
- distended superficial veins
63
What are the specificities and subjective assessment of NTOS
Neurogenic thoracic outlet syndrome
Affects the brachial plexus
Common history of neck trauma preceding the symptoms, most commonly from car accidents and repetitive stress on UL at work
Pain is localized in upper plexus : neck ear face
And in the lower plexus : shoulder region, ulnar side of forearm and in ring and small fingers
Subjective assessment :
Paresthesia in the UL
Neck pain
Trapezius pain
Shoulder and or arm pain
Supraclavicular pain
Chest pain
Occipital headache
Paresthesia in all 5 fingers
Loss of dexterity and impaired motor skills
Raynaud phenomenon
64
What are the special tests for OTS ?
- elevated arm stress
- supraclavicular pressure
- costoclavicular manœuvre
- Adon’s test
- Wright’s test
- cervical rotation lateral flexion
65
Define low back pain
It is defined by the location of pain, typically between the lower ribs margins and the buttock creases. It is commonly accompanied by pain in one or both legs.
66
What are the risk factors of low back pain ?
Individual
-Genetic
-degenerativ changes (++) is not strongly related to muscle strength
-psychosocial factors :
Physical distress
Kinesiphobia
Dpression
Work related
-operating heavy equipment
-smoking
-prior history of MSK
-job satisfaction
67
How to assess lower back pain ?
Assessment of psychometric factors
-StarT back tool
- FABq
Assessment of function
-patient specific functional scale
- modified oswestry disability index
- Roland Morris disability index
68
Describe the diagnostic triage for an adult consulting with low back pain
FOCUSED HISTORY AND PHYSICAL EXAMINATION
- duration of symptoms
- alerting features for specific pathologies
- symptoms and signs of radicular syndromes
- psychosocial risk factors
EXCLUDE NON SPINAL CAUSES OF LBP
- hip pathology
- referred visceral pain (eg: pancreatis, pancreatic cancer, prostatitis, pyelonephritis)
-viral syndrome and vascular causes (eg: femoral artery occlusion, aortic aneurysm)
DIAGNOSTIC TRIAGE - 3 broad categories
1)specific spinal pathologies
Vertebral fracture
Malignancy
Spinal infection
Axial spondyloarthritis
Cauda equina syndrome
2) radicular syndromes
Radicular pain
Radiculopathy
Spinal stenosis
3) non specific
Pesumbed MSK origin of LBP (but no tests available in primary care)
69
What are the factors affecting prognosis in recurrent low back pain ?
- history of previous episodes
- excessive spine mobility
- excessive mobility in other joints
70
What are the factors affecting prognosis in persistant low back pain ?
- presence of symptoms below the knee
- psychological distress or depression
- fear of pain
- kinesiphobia
- low expectation
- high pain intensity
- passive coping
71
Classify low back pain with the impairment-based ICF category
- LBP with mobility deficit
- LBP with movement coordination impairment
- LBP with chronic generalized pain
- LBP with radiating pain (radiculopathy)
72
List the serious pathologic causes of low back pain
- vertebral fracture
- malignancy
- spinal infection
- axial spondyloarthritis
- cauda equina syndrome
73
Define lumbar spine stenosis
Caused by narrowing of the spinal canal or foramina due to a combination of degenerative changes such as facets ostheoartritis, ligamentum flavum hypertrophy and bulging disc. The diagnosis requires both the presence of characteristic symptoms and signs as well as imaging confirmation of narrowing of the lumbar spinal canal or foramina. Symptoms result from veinous congestion or ischemia of the nerve roots in the cauda equina due to compression.
74
What is the subjective examination in lumbar stenosis ?
- neurogenic claudication limiting walking tolerance
- in older patient : bilateral leg pain or cramping with or without LBP
- bilateral leg pain exacerbated by extended posture (eg: standing)
- relieved by flexion (eg: sitting)
75
What are the special tests for lumbar stenosis ?
- normal neurological assessment during rest (sometimes mild motor weakness or sensory changes in the lower limb)
- antalgic postures
- straightened posture can amplify leg pain or numbness
- wide based gait
76
What is the subjective examination in lumbar radiculopathy ?
- sign of nerve root involvement (loss of function) may be present
- lumbar pain with radiating pain in the involved extremity (lancinating, burning, electrical pain or paresthesia)
77
What are the special tests for lumbar radiculopathy / sciatica ?
-kemp’s test
-neurodynamic tests
- peripheral neurological examination
Dermatomes
Myotomes
Deep tendon reflexes
- mechanical diagnosis (symptoms change in response to repeated direction-specific movements)
78
What is the subjective examination for low back pain with mobility deficit
See in segmental/somatic disfunction
- acute low back, buttock pain
- onset of symptoms is often linked to a recent unguarded/awkward movement or position
- lumbar ROM limitation
- restricted thoracic, lumbar segmental mobility
79
What are the special tests for low back pain with mobility deficit
For segmental/somatic disfunction
-limited painful end range active and passive ROM
-finger tip to floor
-shrober’s test
-spring test
- mechanical diagnosis ++ (symptoms changes in response to repeated direction-specific movement)
80
What is the subjective examination of low back pain with coordination impairment
See in instability
-chronic recurring low back pain and associated, referred, lower extremity pain
- pain at rest or reproduced with initial to mid-range movements
- pain worsens with sustained end range movements or position
81
What are the special tests in low back pain with coordination impairements
Seen in instability
- prone instability test
-aberrant movements:
Painful arc with flexion or return from flexion
Instability catch sign (active flexion test)
Gower’s sign
Inverted limbo pelvic rhythm
-endurance testing (supine and prone bridges)
82
What is the subjective examination in chronic low back pain ?
Seen in persistant somatoform pain disorder
- low back and/or low back related extremity pain with symptom duration of more than three months
- generalized pain not consistent with other impairment based classification criteria
-influence of behavioral, cognitive and effective factors such as depression, fear avoidance beliefs and/or pain catastrophizing
83
What is the objective examination of chronic low back pain
See in somatoform pain disorder
Catastrophizing scale
Fear avoidance beliefs questionnaire
84
Define central sensitization
Altered mechanism of pain processing within the CNS (eg: enhanced synaptic excitability, lower threshold of activation and expansion of the receptive fields of nociceptive input). Pain distribution is widespread and doesn’t follow an anatomical patter. The pain can also be provoked with low intensity stimula that would not normally generate pain.
85
What is the key feature of central sensitization ?
The disproportionate mechanical provocation patterns in response to clinical examination
86
What type of approach is required by a patient with central sensitization ?
Multidisciplinary approach
87
Describe the management of low back pain
1) detailed history and physical examination
—> to exclude non spinal causes of LBP
2) diagnostic triangle
-serious spinal pathology
Vertebral fracture
Malignancy
Spinal infection
Axial spondyloarthritis
Spinal cord pathology (myelopathy, cauda equina compression )
—> specific therapy according to cause
-radicular syndromes
Radicular pain (sciatica)
Radiculopathy
Symptomatic lumbar spinal stenosis
—> non pharmacological options
Stay active and maintain usual activities or resume ASAP
Physical therapies
Exercise
—> pharmacological options
3) non specific LBP
Acute
Persistent
—> with acute see 2) treatment
—> with persistent :
—> non pharmacological
Exercise program
Psychological approaches
Physical therapy
Interdisciplinary rehab
—> pharmacological
88
What is the subjective examination for sacroiliac joint pain ?
Pain localized at the fortin area
Non responders to mechanical diagnosis
89
What are the special tests for sacro illiac joint pain ?
Laslett’s cluster (3/6):
-distraction
-compression
-thigh thrust
-sacral thrust
-Gaenslen’s ipsilateral
-Gaenslen’s contralateral
90
What are the symptoms of radiculopathy ?
Neuropathic pain:
-sharp, electric shock, burning
-well localized
-radiation below knee
Neurological deficits:
-motor weakness (myotomes)
-sensory deficits (dermatomes)
-diminished deep tendon reflexes
91
What is the subjective examination in radiculopathy ?
Quality of pain
92
What is the objective examination in neuropathy ?
Neurological examination ++
Provocative manœuvres :
Spurling test Cx
Kemp test Lx
Distraction
Neural tension test
