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MSK II > Exam 1 - Thoracolumbar spine > Flashcards

Exam 1 - Thoracolumbar spine Flashcards

1
Q

___ of facets determines direction and amount of motion

A

orientation

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2
Q

what plane are thoracic facets oriented and what motion do they favor

A

frontal plane
favors side bending but are limited by ribs

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3
Q

what plane are lumbar facets oriented and what motion do they favor

A

sagittal plane
favors flexion and extension

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4
Q

t/f
lumbar spine has the most degrees of motion with flx/ext and rotation

A

false
lumbar spine has most degrees of motion in flexion and extension
least amount of motion with rotation

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5
Q

what are the 4 variables of stabilization

A

joint integrity
muscle function
neuro input
passive stiffness

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6
Q

give examples of local muscles in the thoracolumbosacral region

A

psoas
pelvic floor
transversus abdominis
quadratus lumborum
transversospinalis

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7
Q

t/f
if one muscle of the thoracolumbar region fires, all local muscles should fire

A

true
bc all of the muscles are around the spine and work to stabilize

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8
Q

pain, swelling, joint laxity, and disuse can cause…

A

decreased and delayed motor performance/control of local muscles

inhibition preferential to type I muscles

local muscle atrophy (multifidus) leading to fat infiltration

increased stress on non-contractile tissues

increased demand of global muscles

fiber transformation from type 1 to type 2

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9
Q

what are examples of non contractile tissues

why is there increased stress on the non contractile tissues when local muscles are inhibited

A

ligaments, cartilage

increased stress is d/t stress being placed on non contractile structures because the local muscles are unable to stabilize

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10
Q

muscle activation of __% is sufficient to keep stability and can improve muscular endurance

A

30%

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11
Q

does muscle activity return spontaneously because the pain is gone

A

no

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12
Q

what is nociceptive pain

A

non-nervous tissue compromise
MSK and viscerogenic

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13
Q

what is neuropathic pain

A

nervous tissue compromise
radicular, radiculopathy, peripheral

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14
Q

what is nociplastic pain

A

altered pain perception without complete evidence of actual/threatened tissue compromise

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15
Q

how would a patient report spondylotic pain

A
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16
Q

what is spindylogenic pain

A

common
local/referred spinal pain from noxious stimulation of spine structures

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17
Q

can spondylogenic pain cause visceral dysfunction

A

no
the spine cannot affect organ function

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18
Q

what are S&S of spondylogenic pain

A

non-segmental pain
rare paresthesia’s
vague, deep, achy, boring pain
neuro - WNL
can’t reproduce symtoms

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19
Q

describe somatic convergence or referred pain

A

sensory afferents converge and share same innervation

greater referral of proximal and deep structure than distal and superficial

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20
Q

what area is the most often area of referred sponylogenic pain in the lumbar region

A

gluteal region and proximal thigh

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21
Q

what is viscerogenic pain

A

referred pain from an organ

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22
Q

what is viscerosomatic convergence

A

viscera and somatic sensory afferents converge on and share the same innervation

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23
Q

can viscerogenic pain be mechanically reproduced

A

no

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24
Q

what is radicular pain

A

extopic or abnormal discharge form highly inflammed spinal nerve

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25
Q

what are radicular pain symptoms

A

lancing, electrical shock like pain in a 2-3 inch band down an extremity

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26
Q

what are the signs of radicular pain

A

dermatomes, DTRs, mytomes - WNL
dural mobilty test - +

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27
Q

what is radiculopathy pain

A

blocked conduction of spinal nerve due to compression and/or inflammation

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28
Q

what are the signs of radiculopathy pain

A

segmental paresthesia’s
slow progression to ill defined area
possible weakness (with 80%) loss of conduction

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29
Q

what are the signs of radiculopathy pain

A

neuro scan - + for spinal nerve hypoactivity

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30
Q

what is peripheral nerve pain

A

decreased condition of nerve brance

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31
Q

what are the symptoms of peripheral nerve pain

A

non-segmental
intermittent and short duration
fast progression to well-defined area
possible weakness

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32
Q

what are the signs of peripheral nerve pain

A

dermatomes, DTR, mytomes - WNL
non segmental peripheral nerve hypoactivity
dural mobility - +

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33
Q

what is the pathogenesis of nociplastic pain

A

thinning of myelin sheath

increased sensitivity and misinterpretation by peripheral nociceptors

persistent excitation of alpha-delta and C fibers

increased sensitivity and misinterpretation by central structures

loss of descending anti-nociceptive mechanisms

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34
Q

why can symptoms of nociplastic pain spread

A

somatic convergence

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35
Q

describe somatic convergence

A

shared areas of innervation share symptoms

brain perceives the pain as coming from even more areas with persistent symptoms

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36
Q

how do c fibers contribute to nociplastic pain

A

c fibers transmit pain
split and travel at least 2 spinal segments superiorly and inferiorly

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37
Q

what are the S&S/criteria for possible nociplastic pain

A

> /= 3 months pain
regional/spreading symptoms
pain that cannot be entirely explained
pain hypersensitivity or allodynia

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38
Q

what are the S&S/criteria for probably nociplastic pain

A

sensitivity to sound, light, odor
sleep disturbances
fatigue
cognitive problems

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39
Q

what are the S&S of autonomic nervous system nociplastic pain

A

pitting edema with lymph compromise
decreased sebaceous gland and hair follicle activity
sweaty hands/feet

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40
Q

what are the indicated S&S of autonomic nervous system nociplastic pain

A

decreased peripheral arterial shunting leading to coldness/clamminess

loss of laterality

increased erector pili muscle activity

+ graphesthesia

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41
Q

what are the indicated interventions for nociplastic pain

A

joint mobilizations/manipulations
patient education
MET

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42
Q

what is the MET prescription for nociplastic pain

A

low-moderate global aerobic and resistance activities
2-3x/week
30-90 minutes per session
at least 7 weeks duration

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43
Q

how does MET improve nociplastic pain

A

endogenous/opiate analgesua
helps pt interpret pain as nonthreating
reorganizes homunculus

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44
Q

what is the prognosis of nociplastic pain

A

varying degrees of improment
longer recovery
likely not full resolution of symptoms

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45
Q

you are assessing the functional motion and A/PROM of the thoracolumosacral region

you find a fulcrum/sharp angle in the lower thoracic region. what should you do next

A

assess in flexion and extension to see if the fulcrum is still present

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46
Q

you are assessing the functional motion and A/PROM of the thoracolumbosacral region

you find a fulcrum in SB and in FLX. what is indicated

A

contralateral z joint

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47
Q

you are assessing the functional motion and A/PROM of the thoracolumosacral region

you find a fulcrum in SB and in EXT. what is indicated

A

ipsilateral Z joint

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48
Q

you are assessing the functional motions and A/PROM of the throacolumbosacral region

what curve of the spine is considered normal for rotation

what curve of the spine is considered abnormal

A

S curve
C curve

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49
Q

what is considered abnormal during thoracolumbosacral extension

what is indicated

A

skin crease
hypermobility or instability

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50
Q

creasing that is asymmetrical during thoracolumbosacral extension indicates…

A

excessive anterior shearing

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51
Q

the lumbar spine is the leading cause of

A

worldwide disability
activity limitation and work absence

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52
Q

what is the prevalence of LBP
(sex, age, education)

A

women > men
older > younger
lower educational status
higher physical work demands

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53
Q

what are the risk factors of developing LBP

A

previous LBP
co-morbidities
poor mental health
smoking, obesity, low activity levels
awkward postures, heavy lifting, fatigue
genetics with ARD changes only

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54
Q

what is the functional ROM of the lumbar spine for sit to stand

A

35 to 42 flexion

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55
Q

what is the functional range of motion to pick up an object from the floor

A

60 flexion

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56
Q

___% of asymptomatic individuals had abnormal findings with MRI

A

33%

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57
Q

___% of symptomatic individuals had an abnormality with MRI

A

50

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58
Q

what characteristics would indicate a pt with LBP should get an MRI

A

> 50 years with hx of cancer
saddle paresthesias
bowel and bladder dysfunction
specific neurological deficits
progressive/disabling symtpms
no improvement after 6 weeks of conservative Rx

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59
Q

t/f
imaging improves outcomes and guidelines consistently recommend routine imaging

A

false
imaging does not improve outcomes and guidelines consistently recommended against routine imaging

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60
Q

nearly all cases have an unidentified ____ source of LBP

A

nociceptive

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61
Q

what can occur with overutilization of unsupported and ineffective Rx for LBP

A

higher costs
contributes to greater opioid addiction
greater imaging and radiation exposure
more likely to have invasive procedures
fear avoidance behaviors promoted with passive interventions

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62
Q

what education and advice would you give a pt with LBP to not do

A

against bed rest and in-depth explanation of the cause

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63
Q

what education and advice would you give a pt with LBP to do

A

spinal anatomical and structural strength
neuroscience explaintion
overall favorable prognosis
staying active with ADLs
emphasis on functional improvements

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64
Q

how does one’s emotions about/towards LBP affect pain/persistence of symptoms

A

greater emotion leads to greater pain and persistence

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65
Q

what is the prognosis of dry needling with LBP

A

very low-moderate evidence of benefit

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66
Q

what is the prognosis of modalities for LBP

A

generally ineffective and not recommended
short term benefits only

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67
Q

what is the prognosis of soft tissue massage for LBP

A

only short term benefit

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68
Q

what are the 4 LBP Rx classification subgroups

A

mechanical traction
directional preference
mobilization/manipulation
stabilization

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69
Q

what is the prognosis of mechanical traction for LBP

A

no benefit with static traction

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70
Q

what pt characteristics show more support when mechanical traction is used

A

18-60 years
paresthesias in last 24 hours distal to knee
owestry questionnaire > 30
(+) n root compression, crossed SLR, centralization

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71
Q

what is centralization

A

abolition of distal and/or spinal pain in a distal to proximal direction in response to repetitive motion or sustained positions

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72
Q

t/f
mechanical traction is not indicated when used alone in pts with acute/subacute/persistent LBP, non-radicular LBP, pts with varying symptom patterns

A

true

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73
Q

pt reports LBP with pain decreasing with repetitive back hyper/extension. the pain now is located into just the glute. what exercises would you include in the pt’s program

A

hyper/extension
lat pulldowns/rows in standing

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74
Q

what is directional preference

A

position, motion, and/or factor that alleviates symptoms

can help to choose positions and motions to avoid symptoms and promote exercise and activity

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75
Q

what pt characteristics indicate manipulation/mobilization

A

> /= 4 of 5
no symptoms distal to knee
symptoms < 16 days
lumbar joint hypomobility
fear avoidance behavior questionnaire at work < 19

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76
Q

are joint manipulations or joint mobilizations more effective for patients with LBP

A

joint manipulations are more effective

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77
Q

what is the purpose of joint mobilizations/manipulations

A

gets the pt back to exercise faster
short course at most

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78
Q

t/f
stabilization is safe and effective to do early with a pt with acute LBP

A

true

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79
Q

what is the order of treatments for functions with patients with sub-acute and persistent LBP

A

motor activation/coordination and stabilization

aquatic therapy, pilates, yoga

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80
Q

t/f
motor control is ineffective for non-specific LBP and functions in isolation or with other exercises

A

false
motor control is effective for non-specific LBP and functions in isolation or with other exercises

improves trunk control and creates earlier muscle activation

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81
Q

what exercises should be included with LBP to improve stabilization

A

trunk balance
progressive endurance exercises

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82
Q

what muscle function is commonly impaired with pts that have LBP

A

diaphragmatic breathing

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83
Q

what is the prognosis of stretching with LBP

A

no difference in pain and function

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84
Q

what is the purpose of cognitive behavioral therapy with patients that have LBP

A

first line rx with persistent LBP

helps patients understand and manage all biopsychosocial elements contributing to their symptoms

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85
Q

__% patients report pain at 3 and 12 months with persistent LBP

A

66%

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86
Q

__% of patients have reoccurrence of LBP within 1 year

A

33%

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87
Q

what pt factors influence the prognosis of LBP

A

mental status, lack of self-efficacy
fear avoidance behaviors
beliefs/behaviors
low education/income
high pain intensity and multiple painful areas

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88
Q

when are medications indicated for LBP

A

recommended only with inadequate response to exercise and cognitive behavioral therapy

mostly insufficient and not recommended

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89
Q

how should medication be used with low back pain

A

any utilization should be limited and very selective with the lowest effective dose

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90
Q

what is the prognosis of epidural and facet joint injections

A

not recommended for non-specific low back pain

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91
Q

when are epidural injections indicated for LBP

A

recommended for radicular pain
don’t reduce risk of surgery
create rare but serious side effects

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92
Q

what are the 2 methods acute IDD occurs
which is the least common

A

annular and end plate tear
acute herniations (nuclear migration) - least common

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93
Q

what is the most prevalent IDD

A

chronic or persistent

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94
Q

describe chronic or persistent IDD

A

disc changed due to numerous variables allowing herniations (nuclear migration) to gradually develop over time

most are not symptomatic

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95
Q

what region of the spine is IDD most common

A

lumbar region

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96
Q

persistent IDD is the cause of LBP in _% of patients

A

5%

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97
Q

what ages are most affected by IDD in the lumbar region

A

30-50 years

98
Q

what spinal segments most commonly have IDD

A

L4-L5, L5-S1

99
Q

t/f
IDD is common in the throacic region

A

false
<1% of all symptomatic disc herniations are in the thoracic region

100
Q

what region of the spine has the greatest consequences of IDD, why

A

throacic region
area of the narrowest canal
more likely to press on the cord
very rare

101
Q

what area of the disc is most commonly affected by IDD, why

A

posterolateral portion - just lateral to posterior longitudinal ligament
weaker, thinner, more vertical/less oblique annular fiber

102
Q

what degrees is considered normal for resting lumbar lordosis

A

20-45

103
Q

what is the etiology for acute IDD

A

forward bending at the waist with or without twisting/lifting

104
Q

describe how the lumbar spine moves to result in a acute IDD

A

anterior pelvic tilt

less circumferential disc compression, uneven annular tension

less fixated end plate

more anterior segmental shearing, possible rotation stresses, gravity influence

increased asymmetrical stress on weaker and thinner posterolateral annular and end plate fibers

105
Q

why would lumbar flexion increase pain with a patient with IDD

A

causes anterior shearing
most likely the method the injury was created

106
Q

with acute IDD, more commonly __ annular tearing and end plate avulsion and less commonly __ annular tearing and NP herniation

A

outer, inner

107
Q

describe the disc

A

shock absorber
long, large inflammatory pahse
resists compression d/t type 2 collagen
hydrophilic = lots of GAGs
no lymphatic drainage
avascular/aneural

108
Q

what occurs when disc structures are injured

A

large and extended autoimmune inflammatory response

increased static fluid around disc and spinal nerve

static fluid has increased inflammatory chemicals that sensitize spinal nerve and structures to pressure/tension

no lymphatic drainage

109
Q

what S&S would you expect with an injured disc

A

radiculopathy/radicular S&S

110
Q

what are typical posterolateral IDD symptoms

A

Dull/achey spinal pain
radiculopathy
referred pain to glutes and groin

111
Q

would you expect more or less swelling in the lumbar region vs the cervical with IDD, why

A

significantly more swelling than cervical discs

higher number of GAGs

112
Q

what symptoms with IDD indicate a worse situation

A

presence of coldness
presence of radiculopathy

113
Q

what would increase pain/symptoms with posterolateral IDD

A

forward bending
sitting
coughing
lifting
more pain in morning d/t pooling of swelling

*anything that increases tension on ligament

114
Q

what would decrease pain/symptoms with posterolateral IDD

A

unloaded or lying supported/standing/walking

standing in lordotic position allow disc to slacken

*moving moves fluid around and away from spinal nerve

115
Q

what would you expect to observe in a patient with postlateral IDD

A

lateral shift of shoulder on pelvis
- side bend away from pain
- counter contralateral side bend to level eyes

116
Q

when would calf wasting occur and what does this indicate

A

4-6 weeks

indicative of severe spinal nerve compression, more of a sign of persistent radiculopathy

117
Q

what ROM is expected with pt with posterolateral IDD signs

A

all motions may increase pain

FLX, possible SB away from injured area limited
EXT, possible SB toward injured area less limited
RT not consistent

118
Q

why would flexion and side bending away from the injured area of IDD increase extremity and spinal pain

A

pressure placed on spinal nerve by pushing the swelling toward the spinal nerve
tension on annulus and end plate

119
Q

why would extension and possible side bending toward injured areas of disc be less limted

A

repetitions cand push the swelling away from the affected area

120
Q

what would you expect to find with repetitions of lumbar extension with IDD

A

centralization of pain with repetition

can increase spinal pain d/t increased hydrostatic pressure on disc with high osmotic pressure

121
Q

what is centralization of symptoms

A

abolition of distal and/or spinal pain in a distal to proximal direction in response to repetitive motions or sustained positions

122
Q

what woud you expect to find in a scan of a pt with acute IDD

A

RST and MMT - variable
ST- possible (+), torsion and PA pressures
neuro - possibly (+)

123
Q

what are unique central S&S of acute IDD

A

cord or cauda equina S&S depending on the level

124
Q

what is the basic belief of the McKenzie method

A

based on the belief that most of the spinal pain comes from injuries to the disc

research does not support the theory

classified based on symptom location and position/motion that decrease symptoms

125
Q

what position is most commonly (~70% of cases) the directional preference

A

extension

126
Q

what are the 3 classification syndromes of the McKenzie method

A

postural
dysfunction
derangement

127
Q

what is the postural classification syndrome of the Mckenzie method

A

essentially correct poor posture

128
Q

what is the dysfunction classification syndrome of the Mckenzie method

A

essentially stretches to improve end range motion

129
Q

what is the derangement classification syndrome of the Mckenzie method

A

essentially using end range motion to improve theoretical nucleus migration in the disc

130
Q

t/f
the Mckenzie method is supported by strong evidence that shows the benefit with LE symptoms and when centralization occurs with acute IDD

A

true

131
Q

what are the mechanisms of action of the Mckenzie method

A

dynamic disc theory with herniations

fluid dynamics with or without herniations

132
Q

what is the dynamic disc theory with herniations of the Mckenzie method

A

nucleus repositions centrally
unproven

133
Q

what is are the fluid dynamics with or without herniations of the Mckenzie method

A

high osmotic pressure with large auto-immune swelling response

increased hydrostatic pressure through repetitive motion, most often extension

134
Q

what symptoms might a patient with IDD report with repetitive extension

A

spine pain initially increases d/t resistance of high osmotic pressure being overcome by increased hydrostatic pressure

135
Q

how does repetitive extension improve symptoms of acute IDD

A

swelling/fluid is squeezed away from spinal nerve into the nucleus and the end plates for drainage

centralizes pain, LE symptoms decrease

136
Q

what is the effectiveness of the Mckenzie method

A

good evidence, but is not superior to other treatments for pain/disability

overall/long-term treatment effect is small to moderate

137
Q

why is treatment needed beyond Mckenzie method

A

annulus and end plate are torn = loss of stability

stabilization still needed

138
Q

what is the PT Rx for acute IDD

A

POLICED

directional preference for centralization - extension

intermittent traction can be helpful with radiculopathy

neural mobilizations

pt education - posture

HEP to avoid counter-productive sitting with driving

139
Q

what would be included with pt education for acute IDD

A

postural/ergonomic education/taping/bracing for ext preference

limited to no sitting
limited to no driving
limited to no forward bending

140
Q

what is the purpose of MET with acute IDD

A

tissue proliferation
stabilization
local muscle activation
unweighted walking

141
Q

how should we properly squat

A

more circumferential disc compression, evenly distributed annular tension with lumbar flexion and posterior pelvic tilt

more fixated end plate

less anterior segmental shearing

142
Q

what is the etiology of persistent IDD

A

acute IDD
mixed findings with age
lower strength
sedentary lifestyle
heavier occupational lifting
smoking
genetics

143
Q

explain how genetics influence one’s likelihood of developing persistent IDD

A

lumbar IDD associated with age-related disc changes in cervical region

65-85% inheritance but can be modified by diet and lifestyle

144
Q

how does routine loading and driving affect persistent IDD

A

not from routine loading and prolonged driving

routine loading was beneficial

145
Q

what is the pathogenesis of the persistent IDD or how are the disc and adjacent structures changing

A

less GAGs = more fibrotic/dehydrated nucleus
more acidic disc = kills disc cells, limits proliferation
annular disorganization
thinning/loss of cartilage @ end plates
increased inflammation/fatty deposits in vertebra

146
Q

how does persistent inflammation influence persistent IDD

A

in-growth of nociceptive fibers from acute IDD healing can lead to nociplastic pain

brings excessive and destructive proteins and low-grade infection to disc

147
Q

what are the 3 categories of hernation per miller

A

protrusion
extrusion
free sequestrian

148
Q

describe the protrusion category of herniation per miller

A

NP migrates but remains contained in annulus

149
Q

what is the most common NP herniation

A

protrusion (buldge)

150
Q

describe the extrusion category of hernation per miller

A

NP migrates thru the outer annulus

151
Q

describe the free sequestrian herniation

A

NP migrates and breaks away from annulus

152
Q

what is likely to develop where the NP migrates into the vertebral body

A

schmorl’s nodes

153
Q

why would a herniated disc no be bright white on a T2 MRI

A

no fluid d/t no GAGs
no acute inflammation because of slow progression

154
Q

what are the initial effects of decreased disc height and integrity

A

instability
joint hypermobility in sagittal and frontal plane motions only
joint space narrows
foramen narrows leading to stenosis

155
Q

what are the later changes that will occur with decreased disc height and integrity

A

greater age-related joint changes
can lessen prior instability d/t stiffening of joint

156
Q

what 3 conditions will affect the disc

A

stenosis
age-related joint changes
hypermobility/instability

157
Q

how do S&S progress with persistent IDD

what would you expect with persistent IDD

A

slow changes allow tissues to adapt w/o symptoms

158
Q

about how many people with persistent IDD have a lack of symptoms with changes in imaging

A

2/3

159
Q

what symptoms would you expect with persistent IDD

A

gradual onset of symptoms
acute IDD S&S if inflamed
“mixed bag”

160
Q

what PT Rx is effective with pt with persistent IDD

A

acute IDD Rx if inflamed
consider primary driver of symptoms

161
Q

why is the Mckenzie method only effective with acute IDD and not as effective with persistent IDD

A

Mckenzie method works to move inflammation away from spinal nerve

with persistent IDD, there is no inflammation/fluid to be moved

Mckenzie method shows short term benefits

162
Q

how does Mckenzie method compare to manual therapy and stabilization exercises with persistent IDD

A

Mckenzie method is not superior to exercise or manual therapy with persistent IDD

163
Q

what is the prognosis for acute and persistent IDD

A

likely prolonged inflammatory phase

90% improve in 4-6 weeks, symptoms resolve in 12 weeks

164
Q

what is the prognosis for surgery with acute and persistent IDD

A

most do not require surgery

PT is slower than surgery but results in the same outcome after 2 years

surgery could offer quicker short term results

waiting ~4 months on surgery did not minimize benefits of surgery

165
Q

what is the negative outcome predictor for acute and persistent IDD

A

peripheralization

166
Q

peripheralization of acute and persistent IDD has a significant association with..

A

mental distress/depression
pain behaviors
somatization - conversion of anxiety into bodily symptoms
fear of work
non-organic signs

167
Q

worse outcomes with __ months prior to any treatment with acute/persistent IDD

A

> 6 months

168
Q

what is the prognosis/muscle relaxants/acetaminophen of NSAIDS for acute/persistent IDD

A

conflicting and unclear
steroid dose pack is prescribed for large inflammatory response

169
Q

what is the prognosis of epidural injection for acute/persistent IDD

A

short term but not long term relief/functional changes

170
Q

what is teh prognosis of antibiotic treatment for acute/persistent IDD

A

benefits potential infection source

171
Q

what is spinal decompression that could be performed by MD

what are the indications for spinal decompression

A

laminectomy, partial discectomy

persistent and/or worsenign radiculopathy

use when symptoms unresponsive to non surgical treatment

172
Q

describe the risks/benefits of lumbar fusion

A

no difference vs PT in long term outcomes

not additive to laminectomy/discectomy

may lead to adjacent joint hypermobility

173
Q

describe the pros/cons of total disc replacement with persistnet IDD

A

better load distribution across segments

safe/effective treatment >5 years post op

no difference vs PT @ 2 years post op

174
Q

what are the 4 variables of stabilization

A

joint integrity
passive stiffness
neural input
muscle function

175
Q

what is functional instability

A

instability that can be stabilized with muscle activity/positioning

176
Q

what is mechanical instability

A

instability that cannot be completely stabilized with muscle activity/positioning

177
Q

what sex is hypermobility more common

A

males

178
Q

what are the etiologies of hypermobility/instability

A

traumatic/recurrent sprians
ARDC
repetitive extension activities
creep
adjacent joint hypomobility
connective tissue disorder

179
Q

what segment is hypermobility most common

A

L4-S1

180
Q

what are the symptoms of functional instability

A

predictable pain

spine and referred pain. possible paresthesia

decreased pain with positional changes/support

increased pain with prolonged positions, repetitive bending and arching, sudden motions, strenuous ADLs

catching

easy self manipulation

181
Q

what are the signs of functional instability in the scan and CM

A

< 40 years of age

limited, aberrant motion if acute
limited, painful extension

PROM > AROM

greater flexibility overall

no acute - often WNL or excessive except for extension that can still be limited

inconsistent block

182
Q

what AROM would you expect with functional instability

A

aberrant/ddeviating
painful arc
uncoordination
Gower’s sign
LE/pelvis compenations

183
Q

what signs would you expect with RST and neuro in functional instability

A

acute = painful
strong, painless bc global muscles are not affected

neuro (-)

184
Q

what would you expect to find during ST for functional instability

A

PA pressures (+)
mixed findings with distx

185
Q

what would you expect to find in accessory motion testing with functional instability

A

possible hypomobility if hypermobility present
(T10-12 rotation, SI joint motion, hip hyperextension)

186
Q

what special tests would you expect to be positive with functional instability

A

prone LE extension test
linear stability (most likely anterior shearing)
possibly active straight leg raise

187
Q

what muscle is excessively recruited with LBP

what does this lead to

A

psoas

excessively recruited psoas can further add to the hyperextension and anterior shearing most often occurring with lumbar hypermobility

188
Q

describe mechanical instability

A

unpredictable pattern of provoking activities
worsening symptoms with more frequent episodes
increased pain with lesser ADLs

189
Q

t/f
(+) stability tests wont stabilize fully with repositioning and/or muscle activity

A

true

190
Q

will mechanical instability show up on imaging

A

yes
shearing is so severe it will show up on imaging

191
Q

what are the MD rx for severe shearing/slippage

A

prolotherapy for stbailization into iliolumbar ligaments along with PT

spinal fusion

192
Q

what is the PT rx for functional and mechanical instability

A

rx - ligamentous laxity
POLICED
postural education to activate local muscles and for chair support
JM to increase adjacent joint hypomobility
bracing/taping
MET

193
Q

what MET is efficient for functional and mechanical instability

A

emphasis on stabilization (local muscles)
hip exercises provided greater pain and disability improvements
hyperextension is contraindicated

194
Q

what are other names for age-related joint changes

A

degenerative joint disease
osteoarthritis
spondylosis (if multiple spinal levels)

195
Q

what are the most common regions for age related joint changes

A

L4-S1

progresses along with age related disc changes

196
Q

are degenerative or acute tears more common with age related joint changes

A

degenerative is most common, older > younger

acute tears are rare, younger > older, involves high shear forces

197
Q

what is the etiology of age related joint changes

A

prior trauma
age
genetics
other diseases (RA)
sedentary lifestyle with underloading

198
Q

what are the 5 components of synovial joint and what happens to them with age related joint changes

A

articular cartilage - frays, blisters, thins
joint space - narrows
fibrous capsule - slackens then thickens/stiffens
synovial membrane - produces less synovial fluid
synovial fluid - decreases

199
Q

persistent pain and inflammatory response with age related joint changes are partly d/t…

A

stress on other tissues like bone

increased local nociceptor sensitivity for greater pain transmission fostering inflammation

local production of nitrous oxide leads to more interstitial inflammation and excess collagen

bone being released from bone marrow

200
Q

what are the lumbar symptoms of age related joint changes

A

gradual onset of LBP

P! with prolonged positions - standing, sleeping

morning stiffness or after prolonged positions >30 mins

possible paresthesias

movement can help but too much movement increases pain

201
Q

why do pts experience pain with prolonged positions with age related joint changes

A

synovial fluid is squeezed out without ability to refill

202
Q

what would you expect to observe and find in the scan with age related joint changes

A

observation - possibly forward head posture

ROM - pain with ext, ipsilateral SB, contralateral RT
- capsular pattern of restriction

CM - consistent block often in ext quadrant or opposing quadrants consistently blocked

RST - depends

ST - (+) compression, particularly in ext, ipsilateral SB, contralateral RT
- (+) PA and unilateral torsion

neuro - (-), could be (+) for radiculopathy

203
Q

what would you expect to find with accessory motion tests with age related joint conditions

A

hypomobility

204
Q

what is the PT rx for age related joint changes

A

greater focus on improving integrity of cartilage and mobility

POLICED

JM for pain, cartilage integrity and mobility

205
Q

what is the focus of MET with age related joint changes

A

ultimate focus on improving motion, cartilage integrity, neuromuscular benefits

206
Q

describe stenosis

A

narrowing around and compression of neurological structures

207
Q

what is the prevalence of stenosis

A

most common dx for spinal sx in adults > 60 yrs

30% asymptomatic individuals had canal narrowing on imaging

208
Q

what are the 2 ways compression of the spinal cord occurs with stenosis

A

inflammation of the sheath around the nerve and becomes fibrotic - nerve can’t expand

spurring/narrowing of spinal canal

209
Q

compression from the outside in with stenosis is due to…

A

age related disck and joint changes - most common

instability - older and younger

enfolding of lig flavum

210
Q

what are the typical symptoms of lateral stenosis

A

unilateral LE > LBP
segmental paresthesias
gripping type pain d/t ischemia

211
Q

what will decrease symptoms with lateral stenosis

A

forward bending
sitting
in morning - disc is more hydrated = more space
incline walking

212
Q

what will increase symptoms with lateral stenosis

A

standing and walking

213
Q

what would you observe with a pt that has lateral stenosis

A

slouched
possible scoliosis

214
Q

what ROM would increase pain with lateral stenosis

A

extension
ipsilateral SB

215
Q

what ROM would decrease pain with lateral stenosis

A

flexion
contralateral SB

216
Q

what would you expect to find with neuro and stress tests for lateral stensosis

A

(+) neuro for radiculopathy
ST (+) PA pressures/torsion when sustained

217
Q

what would you expect to find with accessory motion with lateral stenosis

A

hypomobility in lumbar flexion and contralateral SB

adj joint hypermobility in lower throacic and LE (hip)

218
Q

what would you expect to find with lateral stenosis with special tests

A

stability test - excessive shearing
LE discrepancies (LLD, impaired mechanics)
balance deficits with wide based gait
Cooks CPR

219
Q

what tests would you use to differentiate stenosis vs vascular symptoms

A

ankle-brachial index test for peripheral arterial disease

bicycle test

220
Q

what is the bicycle test used to differentiate stenosis vs vascular symptoms

A

cycle upright then bend to lean on handlebars for 3 min each

is stenosis, pain will decrease with bent position. if it doesn’t, PAD is indicated

221
Q

what are the PT implications for stenosis

A

directed at foraminal opening

pt education of foramen and good prognosis
directional preference into flexion
intermittent traction may be helpful with radiculopathy
manual therapy
neural mobilizations
MET

222
Q

what MET is benefical for stenosis

A

aerobic
balance training (physioball if unable to stand)
local muscle stabilization

223
Q

when is surgery indicated for stenosis

A

presence of constant and/or worsening symptoms

failure to obtain relief within 3-6 months of nonsurgical treatments

224
Q

what are the common surgeries that are utilized for LBP

A

laminectomy, partial discectomy

225
Q

what is spondylolysis

A

bony defect or fracture of pars interarticularis unilaterally or bilaterally

226
Q

what is the etiology of spondylolysis

A

congenital
repetitive stress (extension and rotation)
direct trauma

227
Q

what spinal segments are most commonly involved with spondylolysis

A

L5-S1

228
Q

what are the S&S of spondylolysis

A

acute - fracture S&S and (+) torsion test

persistent - asymptomatic, instability S&S if symptomatic

229
Q

what are the 2 most common types of spondylolisthesis

A

isthmic or adolescent with spondylolysis

degenerative

230
Q

describe isthmic or adolescent with spondylolysis

A

most common
age group with most rapid slipping
repetitive or traumatic extension

231
Q

describe degenerative spondylolisthesis

A

d/t age related disc changes
>50 years old
no fracture

232
Q

what are the S&S of spindylolisthesis

A

worse case of instability
possible lateral or central stenosis S&S with slippage
no correlation with lippage and degree of symptoms

233
Q

what is the prognosis of surgery for spondylolisthesis

A

83% excellent to good outcomes with modified Scott technique

234
Q

what structures are involved with facet joint impingement

A

meniscoid
facet joint

235
Q

what are teh pathomechanics of facet joint impingement

A

meniscoid becomes wedged d/t prolonged position or quick movement

associated with instability

236
Q

what are the S&S of facet joint impingement

A

woke up or made a quick movement and couldn’t move

acuity with age related joint diseases S&S

underlying instability S&S

237
Q

what is the PT rx for facet joint impingement

A

isometrics to use attaching multifidi to pull meniscoid out of the way

gapping manipulation

stabilization to address cause

inflammation, symptoms, and function often improve on its own before PT pursued

238
Q

describe scoliosis

what are the 2 types

A

> /= 10 degree curvature

SB and contralateral rotation

structural, functional/postural

239
Q

describe structural scoliosis vs functional/postural

A

structural = doesnt go away with FB

functional = goes away with FB, able to modify with PT

240
Q

describe sway back posture

A

increased lumbar lordosis
anterior pelvic tilt
flexible body type

241
Q

describe flat back posture

A

straight spine
flattening of normal curves
greater proportion of persistent LBP d/t less dissipation of forces
posterior pelvic tilt
rigid body type

242
Q

describe rounded or crouched body posture

A

increased throacic kyphosis
flattening of lumbar curve
posterior pelvic tilt
often associated with FHP

MSK II (5 decks)

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