Exam 1 Prep Flashcards
What are the 4 types of herniated nucleus pulposus (HNP)?
-Intra-spongy nuclear herniation
-Protrusion/prolapse w/ and w/ out spinal nerve root involvement
-Extrusion
-Sequestration
What are the 4 grades of intra-spongy nuclear herniation?
-Grade I: subchondral fx in vertebral body
-Grade II: small cracks in ednplates
-Grade III: a crack in which a piece of bone has shifted
-Grade IV: a crack in which pieces of bone has shifted and disc material is forced through the crack
What is a protrusion without spinal nerve root involvement?
-Displacement of nuclear material beyond normal confines of the inner annulus, producing a discreet bulge in the outer annulus
-No nuclear material escapes the outer annulus fibrosis or posterior longitudinal ligament
-Most common in L4-L5 and L5-S1
What is extrusion?
-Displaced nuclear material extrudes into the spinal canal through disrupted fibers of the annulus fibrosis and PLL but is still in contact with the disk
-Nuclear material escapes into the spinal canal as free fragments
What is facet impingement?
-Usually occurs due to a sudden, unguarded movement involving extension, SB, and/or rotation with little to no trauma
-“Nipping” of intervertebral menisci
What is facet sprain?
-More severe injury than impingement or a progression of a repetitive facet impingement
-Moderate to severe trauma
What can facet movement dysfunction be a result of?
-Hypomobility secondary to ligament tear, muscle tear, contusion, meniscoid entrapment, facet subluxation
-Hypermobility secondary to extra-articular or periarticular cause of distinction made by end feel during PPIVM and PAIVM
What is the clinical prediction rules for spinal manipulation?
-Low fear avoidance behavior questionnaire (FABQ) < 19
-Duration of symptoms 15 days or less
-No symptoms distal to knee
-Lumbar spine hypomobility at any level
-Either hip with greater than 35 degrees of internal rotation
What is the clinical prediction rule for lumbar stabilization for LBP?
-SLR > 91 degrees
-+ prone instability test
-Aberrant movements
-Age < 40 years old
What is the diagnostic criteria for ankylosing spondylitis?
-Morning stiffness > 30 minutes
-Improvement in back pain with exercise but not with rest
-Awakening because of back pain during the second half of the night only
-Alternating buttock pain
-Diagnosed if three or more are present
What is the diagnostic criteria for lumbar spinal stenosis?
-Age 60-70= 2 points
-Age > 70= 3 points
-Symptoms present > 6 months= 1 point
-Symptoms improve when bending forward+ 2
-Symptoms improve when bending backward= -2
-Symptoms exacerbated when standing up= 2
-+ intermittent claudication= 1
-Urinary incontinence= 1
How are spinal ligaments innervated?
-Innervated with nocicepetive afferent fibers
-pain generators with chronic or acute tissue strain
What treatments are indicated for facet impingement?
-Joint mobilizations
-Mobilizations with movement
-STM and contract relax
-Muscle energy techniques
-Therapeutic exercise
What treatments are indicated for facet sprain?
-Mild to moderate mobilizations and ROM during acute and subacute stages
-If patient remains immobile during subacute stage, joints may become hypomobile when healed
-Guard against development of postural changes
What treatments are indicated for DDD in the mild to moderate stages?
-With hypomobility: mobilizations, manual or mechanical traction, flexibility exercises, postural training
-With hypermobility: back supports, core stabilization, postural training
-Modalities for pain relief
-Initially, exercise in the direction opposite that of the aggravation
What treatments are indicated for DDD in the severe stage?
-Active mobility therapeutic exercise in positions that eliminate or minimize vertical loading
-If this causes increased symptoms, try bracing or supporting to reduce movement and vertical loading
What treatments are indicated for intra-spongy nuclear herniation?
-Rest and avoiding compressive forces on the disc
-Control the muscle guarding as it increases intradiscal pressure
-Hyperextension and mild traction may help
-Corset or brace
What treatments are indicated for HNP protrusion w/ out spinal nerve root involvement?
-Correct lateral shift then passive extension
-Teach patient to maintain lordosis at all times until symptoms are stable and predictable
What treatments are indicated for HNP protrusion w/ spinal nerve root involvement?
-Exercises, mobilizations, or activities that involve rotation are contraindicated initially
-Active rest
-Once protrusion is stable, restore full ROM in flexion and extension
-Address predisposing impairments of trunk, pelvis, and LE
-Modalities
-Initially SLR, active extension, and sit ups are contraindicated
-Back strengthening exercises as soon as the patient can perform without peripheralization
-Bring patient into normal lordosis and out of flexed position
How long does it take to return to strenuous activity after a disc protrusion with spinal nerve root involvement?
6-10 weeks
What treatments are indicated for radiculopathy?
-Manual or mechanical traction
-Patient education
-Reduce foraminal entrapment
-Therapeutic exercise to address the pt’s key impairments
-Make appropriate referral
What treatments are indicated for spinal stenosis?
-Educate pt’s to avoid aggravating or irritating postures
-Measures to increase mobility and flexibility
-Traction
What treatments are indicated for neurogenic claudication from spinal stenosis?
-Directional preference exercises, typically flexion based
-Manual therapy to increase hamstring and erector spinae length
-Therapeutic exercise and NMRE to facilitate improved control into flattened L/S posture
-Improve fitness level
What treatments are indicated for nerve root adhesions and dural tension/adhesion?
-Mobilizing nerve root adhesion by lower limb tissue tension techniques
-May cause increase in symptoms during technique only, but should subside quickly after stretch is discontinued
-Home nerve mobilization
What treatments are indicated in spondylolysis/spondylolisthesis?
-Unstable segments makes patient vulnerable to joint sprains and muscular strains
-Postural improvement
-Abdominal muscle strengthening
-Flexion exercises
-Support brace for vigorous activity
-Surgical fusion in severe cases
What treatments are indicated for ankylosing spondylitis?
-Patient education: spine will eventually stiffen but it does not have to interfere with everyday life
-Exercises and positioning to resist the gradual development of flexed spine
-Sleep firm mattress and avoid curling on 1 side
-Passive and active extension exercises
-Manual mobilizations for spinal extension during periods of remission
What is Gower’s sign?
Thigh climbing when coming up from flexion
What is instability catch?
Any trunk movement outside of the plan of specified motion during that particular motion with sudden acceleration or deceleration
What is reversal of lumbopelvic rhythm?
The trunk being extended first, followed by extension of the hips and pelvis to bring the body back to upright position
What is painful arc?
Pain only occurring during return from flexion into erect posture
What is painful arc into flexion?
Pain occurring typically during the mid range of motion from erect into flexion
What is BACPAP consortium’s criteria for nociplastic pain?
-Daily > 3 months OR 50% of days > 6 months
-Regional, multifocal, widespread distribution
-Nociceptive pain NOT more likely explanation
-Neuropathic pain NOT more likely explanation
-Evoked pain hypersensitivity, any of following: static mechanical allodynia, dynamic mechanical allodynia, heat or cold allodynia, painful after sensations following above sensation
-History of hypersensitivity in low back region
-At least 1 symptoms: increased sensitivity to light, sound, odors, sleep disturbances, fatigue, or cognitive problems
What is the difference between radiculopathy and radicular pain?
-Radiculopathy: the nerve is being compressed and nerve signals are not being sent properly which can result in pain and WEAKNESS
-Radicular pain: pain from irritation or inflammation of a nerve but will have negative neuro exam
What are red flags for LBP?
-Age > 50
-Bladder dysfunction
-History of cancer
-Immunosuppression
-Night pain (may be indicative of autoimmune disease)
-History of trauma
-Saddle anesthesia
-LE neurological deficit
-Weight loss
-Recent infection: screen for osteomyelitis
-Fever/chills: screen for osteomyelitis
What are yellow flags for LBP?
-Depression: can screen using the patient health questionnaire 2 (PHQ-2)
-Fear avoidance questionnaire
-Other chronic pain inventories
What are special questions for the lumbar spine?
-Any changes in gait?
-Any new weakness?
-Changes in bowel or bladder?
-Unremitting night pain?
-Recent unexplained weight loss?
What are the treatment based classifications?
-Manipulation
-Specific exercise (flexion or extension)
-Stabilization
-Traction
What special tests are used for HNP?
-SLR
-Crossed SLR (ipsilateral symptoms when performing contralateral SLR)
-Millgram’s
-Long axis traction (hold for 60 seconds)
What special tests are for lumbar instability?
-Prone instability test
-Anterior shear test
-Stork standing test
-Prone passive lumbar extension
What strength and endurance tests are there for the L/S?
-Biering Sorenson
-Lateral musculature test (side plank)
What is the Sahrmann core stability test?
-Level 1: hook lying, bring one hip to 100 flexion, then the other
-Level 2: from hip flexed position, slowly lower one foot until heel reaches table and extend
-Level 3: same as 2, but heel is not supported by table
-Level 4: from hip flexed, lower both legs until heels touch table, then extend
-Level 5: same as 4, but heels not supported by table
What special tests are used for neural tension?
-SLR
-Slump test
What is the Stork Standing test?
Pt stands in SLS with knee in front and performs slight lumbar extension and test is repeated bilaterally
What is Biering Sorenson?
Pt lays prone with trunk off table and extends to neutral and holds as long as possible with arms folded against chest
What tests are used for spinal stenosis?
-Bicycle stress test (measure distance pedaled in upright and then in flexed positions)
-Stoop test (walking upright, then slouch)
-Two stage treadmill test (walking w/ out incline, then walking with incline)
What is Milgram’s test?
-Patient performs bilateral SLR to the height of 2-6 inches off the table and holds for at least 10 seconds
-+ for pain or unable to maintain position
What is the anterior shear test?
-Pt in side lying w/ spine in neutral and legs flexed to 70 degrees
-PT stabilizes upper segment and shears through the femurs with hips
-+ for pain or increased mobility
