Exam 2: Lumbar Spine, SI Joint, & Special Topics Flashcards
1
Q
What is the goal of industrial PT?
A
to prevent and reduce work injuries and rehabilitation for safe, timely return to work
2
Q
Complications of Work Injuries
A
Affect the employee, employer, medical professionals, rehab nurse/consultant, and attorneys
3
Q
What percentage of their paycheck does an employee receive when being off work because of a work-related injury?
A
66%
4
Q
What is the effect of a work-related injury on employers?
A
- must replace employee (retraining cost or possible increases workload for others)
- worker’s comp cost (affects the company’s bottom line; 25% related to healthcare)
5
Q
Lost Time
A
the cost associated with an employee suffering a work-related injury; including the employee’s salary and HC costs
6
Q
OSHA Recordable
A
increasing # of OSHA recordable causes concern that there are significant areas of the factory that are putting employees at risk; anything BEYOND first-aid care
7
Q
T/F: Injuries associated with known pre-existing conditions are payable under WC if aggravated?
A
True
8
Q
Independent Medical Examiner
A
A medical professional that is not involved with injured individual’s care, but who is responsible for administering FCE to determine disability qualification
9
Q
Examples of In-Clinic Industrial PT
A
- Functional capacity evaluations
- Work hardening/conditioning
- Prework screen or Post-Offer Employment Testing
- Education
10
Q
Functional Capacity Evaluation
A
establishes the employee’s capacity to perform essential job functions described in an employer’s job description
11
Q
FCE Components
A
- 1-2 day test approximately 4-6 hours/day
- work history and job description
- musculoskeletal evaluation (ROM; strength)
- material handling
- validity criteria
- summary letter or case reference
12
Q
What are two options to detect legitimacy of effort?
A
Heart rate and grip strength
13
Q
The results of the FCE are used to determine if the patient:
A
- can return to work
- can return to work with modifications
- should continue PT
- needs work conditioning/hardening
- is eligible for disability
14
Q
Work Conditioning
A
addresses physical and functional needs which may be provided by one discipline; utilizes physical conditioning and functional activities related to work
- 4 hours/day
- 5 days/week
- 8 weeks
15
Q
Work Hardening
A
- addresses physical, functional, behavioral, vocational needs within a multidisciplinary or unidisciplinary model
- requires an FCE
- utilizes real or simulated work activities
- provided in multi-hour sessions
- 8 hours/day or more
- 5 days/week
- up to 8 weeks
16
Q
Prework Screening/Post-Offer Employment Testing
A
- physical performance test
- allows company to decide whether or not applicant is able to perform the job
- Americans with Disabilities Act (ADA)
17
Q
Out of Clinic
A
- education
- onsite PT
- job site analysis
18
Q
What are problems in which PTs run into when trying to make ergonomic suggestions?
A
- lack of ergonomics education
- making recommendations without having objective data to justify making a change
- lack of experience or exposure to industrial operations
19
Q
What are the only self-report questionnaires to be validated in older patients?
A
- modified Oswestry Disability Index
- Quebec Back Pain Disability Questionnaire
20
Q
What are the four general themes associated with aging?
A
- decreased mobility
- decreased postural awareness
- decreased balance
- changes w/in the CNS
21
Q
Older adults with LBP demonstrate:
A
- asymmetrical gait pattern
- increased double limb support time
- increased step width d/t possible pain avoidance strategy
- decreased stair ascent and descent performance
22
Q
What are frequent comorbidities of older adults w/ LBP?
A
- insomnia
- depression and anxiety
- maladaptive behaviors
- hip and knee pathology
- fibromyalgia
23
Q
Predictors of LBP-Related Disability for Older Adults
A
- leg pain
- depression
- anxiety
- hip OA
- knee OA
- neck pain
- falls
24
Q
What changes occur in the disc around the 2nd decade?
A
- annular disorganization
- alteration of endplates
- nuclear fibrous transformation
25
Baastrup Disease
- term for approximating spinous processes
- clinical significance unclear
- part of a cascade of other degenerative changes
26
Age-Related CHanges in Muscle
- musculoskeletal reaction time
- muscle endurance
- tendon and cartilage structure
- flexibility
- balance
27
Z Joint Syndrome
- low back, buttock, hip, thigh pain
- extension > flexion
- dural tests negative
- PIVM reveals motion loss
- compression/distraction negative
28
Causes of Central and Lateral Stenosis
- central: disc bulging, enlarged Z joints, and ligamentum flavum
- lateral: hypertrophied Z joints
29
Stenosis S/Sx
- age ≥ 65 YOA
- LE pain
- No S/Sx improve pain when seated
- Sx worse with walking
- Numbness
- Wide-based gait
- Abnormal Romberg test
- Weakness
- vibration deficit
- absent Achilles tendon reflex
30
Progression of Lumbar Spinal Stenosis
- disc degeneration and bulging
- loss of disc height > intrusion into canal
- increased load on the facets > hypertrophy narrows canal
- decreased tension in ligamentum flavum, buckling in canal
31
General Conservative Approach for Patients with LBP
- flexion/distraction types of manual techniques
- flexion self-mobilization exercise
- body-weight supported treadmill
- recumbent/semi-recumbent bike
- hip exam and treatment
32
Intervention for Spinal Instability
- spinal mechanical treatment (mobilization/manipulation; traction)
- re-education of motor system
- stabilization/neuromuscular re-education
- patient education
33
Treatment for Z Joint Syndrome
- flexion directional preference
- bias toward flexion self-mobilization
- passive flexion/distraction mobilization
- positional distraction
- abdominal musculature reconditioning
- avoidance of extension
34
S/Sx of AAA in Patients with LBP
Review in PT830 notes
35
S/Sx of Metastatic CA in Patients with LBP
Review in PT830 notes
36
Neck Pain with Mobility Deficits
- loss of motion
- pain at ends of active/passive motion
- no overt neurological deficit
- movement or position dependent
- typically reduced PIVM
- pain w/ provocation of involved PIVM
37
Neck Pain with Radiating Pain
- neck pain w/ radiating pain reproduced w/ Spurling's test/ULTT
- neck pain w/ radiating pain relieved w/ cervical distraction
- may have UE sensory, strength, or reflex deficits associated w/ involved nerve
38
Myelopathy Features
- objective UE and/or LE weakness
- atrophy of hand intrinsic musculature
- sensory disturbances
39
Polymyalgia Rheumatica
- avg onset apx 70; rare <50 YOA
- females > males; 3:1
- neck, bilateral hip/shoulder pain and stiffness
- difficulty w/ AM mobility (>1 hr)
- systemic symptoms including fatigue, loss of appetite, wt loss, low-grade fever, night sweats
- elevated ESR and CRP
- rapid response to glucocorticoids
- often w/ concurrent giant-cell arteritis
40
Neck Pain with Radiculating Pain Treatment
- upper quarter and nerve mobilization
- traction
- thoracic mobilization/manipulation
41
Risk Factors for Compression Fracture
- weight <125 lbs
- previous fx after age 45
- parental hip fracture
- current smoker
- current use of cortisone/prednisone
- secondary osteoporosis
- aromatase inhibitor
- celiac disease/colitis
- DM type 1
- menopause < 45 YOA
- ETOH >20 drinks/week
42
What is meant by the phrase "muscle engine"?
- a theory for the origin of LBP; poor abdominal muscle function drives back pain
43
What is the incidence of LBP in the general population?
70-90%
44
What is the natural progression of LBP?
- 40% remit in one week
- 60-85% remit in three weeks
- 90% remit in two months
45
What percentage of patients who consulted about LBP had fully recovered at a 12-month follow-up?
Only 25%
46
What are the proposed categories for back pain?
- persistent mild
- recovering
- severe chronic
- fluctuating
47
What are the causes for LBP?
- no particular incident (58%)
- lifting (17%)
- turning (11%)
- accident (3%)
- sports (2%)
- bending position (4%)
- chilling (4%)
- uncomfortable sitting (1%)
48
What three factors increase the load on the spine?
- fatigue
- decreased strength
- increased dynamic load
49
Transient Back Pain
- present on no more than 90 consecutive days
| - does not recur over a 12-month observation period
50
Recurrent Back Pain
- pain present on less than half the days in a 12-month period
- multiple episodes over the year
- number of episodes tends to increase over time
- recurrence rate is 90% for those who have sought medical treatment for LBP
51
Chronic Back Pain
- pain present on at least half the days in a 12-month period
52
Acute Back Pain
- pain is not recurrent or chronic
| - onset is recent and sudden
53
The SI joint is generally considered a ________ _____, which consists of:
synovial joint
- joint cavity w/ synovial fluid
- adjacent bones united by ligaments
- fibrous capsule surrounding joint
- surfaces allow motion
54
The anteroinferior portion of the SI joint is described as a ________, while the posterosuperior portion is described as a ___________
synovial; syndesmosis
55
What is the anatomy of the lateral articular surface?
- concave
- auricular shaped
- long arm A-P = S2-3
- short arm S-I = S1
- hyaline cartilage on the surface, but is contoured depending on the age of the individual
56
The innominate contains _____________ on its surface
fibrocartilage
57
What is the difference in the SI joint between males and females?
- males have thicker bone and more prominent bony landmarks for heavier build and stronger muscles
- females have wider, shallower, larger superior and inferior apertures for childbearing; the distance between the iliac crests and ischial tuberosities is increased and the sacrum is less curved
58
Changes in the SI occurring in the third decade:
- change in joint surface well developed and limits motion only about the horizontal axis (i.e. sagittal plane)
- degenerative changes consist of joint irregularity, fibrillation, and crevice formation
59
T/F: The SI joint is capable of providing proprioceptive and nociceptive input to the CNS
True
60
The posterior aspect of the SI joint receives innervation from:
lateral branches of posterior primary rami of L4 - S3; esp S1 and S2
61
The anterior aspect of the SI joint receives innervation from:
lateral branches of posterior primary rami of L2 - S2; esp L4 and L5
62
Sacrospinous Ligament
- inferolateral sacrum and coccyx to ischial spine
63
Anterior SI Ligament
- thickening of the SI joint capsule
| - weakest of all the ligaments
64
Long Dorsal SI Ligament
- resists counternutation
- palpable directly caudal to PSIS
- very firm to palpation
- women w/ PRPGP frequently experience pain in this ligament
- sacrum to PSIS and iliac crest
- blends w/ T-L fascia, erector spinae and multifidus
65
Sacrotuberous Ligament
- 3 bands
- ischial tuberosity to sacrum and coccyx
- some fibers blend into piriformis, glut max, multifidus, and hamstrings (biceps femoris)
- primary structure compressing SIJ surfaces
66
Short Dorsal Ligament
sacrum to the iliac crest
67
Interosseus Ligament
- lateral sacral crest to iliac tuberosity
| - strongest of SI ligaments
68
Iliolumbar Ligament
- L5 to ilium
- assists in lumbopelvic stability in the coronal and sagittal planes
- 4 bands
- the sacroiliac portion has a direct restraining effect of SI movement
69
The SI motion increases the most when which ligament is cut?
interosseus
70
What are the key muscles surrounding the SI joint?
- biceps femoris
- transversus abdominis
- gluteus maximus
- latissimus dorsi
- sacral multifidi
- erector spinae
- pelvic floor
71
Which three muscles are the most important for SI joint stability?
- gluteus maximus
- biceps femoris
- erector spinae
72
Nutation
resisted by interosseus and sacrotuberous ligaments
73
Counternutation
sacrum moves backward on ilia; anterosuperior glide of sacrum on innominates
74
Pubic Symphysis
- amphiarthrodial joint
- fibrous joint moves little or none at all
- normal amount of movement ranges from 0.5 to 2.5 mm
- fibrocartilaginous disc between articular surfaces of 2 pubic bones
- resists tensile, shearing, and compressive forces
- only in pregnancy does the pubic symphysis move more
75
What is the historical perspective of back pain?
- SI joint
- disc
- facet joint
- spinal engine
- Si joint manipulation
76
Clinical Findings of Idiopathic Acute LBP
- palpable paraspinal muscle rigidity
- forward list (flexion); sciatic shift
- lordotic flattening; never increased lordosis
- classical explanations include muscle spasm, muscle guarding, and muscle splinting
77
Why is muscle spasm classified as such?
- pain
- paraspinal muscle rigidity
- response to medication
- ecclesiastical succession
78
Bourdon Tube Effect
injecting fluid into one end of the tube changes another
79
What is the effect of lumbar compartment syndrome on paraspinal muscule activity?
the paraspinals are completely shut off in response to the fluid; pt's must rely on ligaments, capsule, glutes, etc.
80
Rx for Lumbar Compartment Syndrome
- ice; rest
- medications
- high voltage pulsed current
- high amplitude NMES
- massage
- exercise
81
What are the three serious causes of LBP?
- tumor
- infection
- progressive deformity
82
What are the five sites for nerve entrapment?
1. anterior to the dura and nerve sleeves (sinuvertebral and spinal n. from disc)
2. medial part of nerve canal (spinal n.)
3. posterolateral part of main canal (cauda equina from enlarged posterior joints)
4. lateral part of nerve canal (spinal and sinuvertebral n. from enlarged superior articular process)
5. posterior joints (medial branches of PPR)
83
Panjabi and White Back Injury Classification
```
I = non-displaced (i.e. fissuring)
II = fluid ingestion into disc
III = annuus disruption; no neuromuscular deficit
IV = no disc narrowing; positive SLR and sciatica
V = wandering disc and remissions, exacerbations (leg-to-leg)
VI = nuclear material sequestered
VII = DJD, DDD
```
84
McKenzie Classification Scheme - Postural Syndrome
- mechanical deformation of soft tissue 2˚ to postural stresses
- intermittent pain brought on by particular postures
- development over time
- cessation of pain with a change in position or postural correction
- NO TRUE LOSS OF MOTION
85
Dysfunction Syndrome
- mechanical deformation of soft tissue 2˚ to adaptive shortening (loss of movement in certain directions, pain before normal full ROM is achieved)
- intermittent pain that is increased with stretching and decreased pain when the stretch is released
- partial loss of movement
86
Derangment Syndrome
- mechanical deformation of soft tissue 2˚ to internal derangement
- change in position of the nucleus pulposus (?)
- change in annulus position
- usually constant pain (but may be intermittent)
- partial loss of movement (extension > flexion)
- loss of lumbar lordosis
87
Multifidi muscle wasting in LBP is __________ and occurs on the ___________ side
unilateral; symptomatic
88
CT scan of pts with LBP will reveal:
Type I fibers hypertrophy, while type II fibers atrophy
89
CT scan of pts with LBP will reveal:
Type I fibers hypertrophy, while type II fibers atrophy
90
What findings are associated with lumbar disc herniation?
- selected atrophy of type II fibers
- angulated (disorganized) fibers
- increased type IIb:IIa ratio (decreased endurance)
- findings increased with age and symptom duration
91
Waddell's testing
- Tenderness
- Simulations tests
- Distraction tests
- Regional disturbances
- Severe over-reaction
92
Behavioral Features of Malingering Patients
- secondary gain; conscious deception
- very slow or no recovery
- poor response to treatment with "worsening"
- hostile; little cooperation with treatment or testing
- nervous; late for visits
- spreads visits as far apart as possible; numerous cancellations
- abandons S/Sx when believed to be unobserved
- rapid recovery after a financial settlement
93
When should malingering patients be transferred to a specific cardiovascular conditioning/core stabilization program?
- do not centralize their symptoms within two treatments
| - have high Waddell scores ≥3/5
94
S/Sx of Tumor
- males > 50 YOA
- metastatic prostate CA
- primary bone tumors are rare
- women - breast CA metastasis to the spine
- X-ray may show marked increase or decrease in bone density
- Radiographic changes occur after 30% of vertebrae involved
- primary bone tumors
95
S/Sx of Infection
- recent bacterial infection
- IV drug abuse
- immune suppression from steroids, transplant, HIV
- urological instrumentation
96
CPR for Spinal Fracture
- Prevalence = 4%
- significant trauma
- prolonged corticosteroid use
- age >70 YOA
- female sex
≥3 = 87% post-test probability
97
S/Sx of Ankylosing Spondylitis
- morning stiffness > 30 minutes
- improvement in back pain with exercise
- alternating buttock pain
- awakening due to back pain during the second half of the night only
2/4 = +LR = 3.7
98
S/Sx of Cauda Equina Syndrome
Presence of 1 or more:
- bowel/bladder dysfunction (urinary retention and/or loss of anal sphincter tone)
- saddle/genital anesthesia
- sexual dysfunction
99
S/Sx of Claudication
- pain worse with an additional peripheral problem (e.g. peripheral neuropathy)
- diminished distal pulses
- differs from spinal stenosis
- complain of legs collapsing
- stong distal pulses
100
Clinical Presentation of Spondylolysis/Spondylolisthesis
- extension or hyperextension will recreate Sx
| - palpation of "step sign" with spondylolisthesis
101
Rx for Spondylolysis/Spondylolisthesis
- avoid aggravating positions
- abdominal strengthening
- pelvic tilt
- stabilization exercises
- corset
102
S/Sx of Spinal Stenosis
- pain usually > 50 YOA
- morning pain/stiffness
- sitting relieves pain
- leaning forward relieves pain
- extension aggravates pain
- bilateral leg pain symptoms (leg pain)
103
Examination Findings with Spinal Stenosis
- flat back
- LE muscle atrophy, especially foot intrinsics
- possible trophic changes in the distal 1/3 of leg, foot
- decreased extension
- evolving nerve root signs
- sensory may be confused with peripheral neuropathy
- motor/DTRs/neurotension
104
Is surgery recommended in patients with spinal stenosis?
No; short-term results are usually good, but they deteriorate over time
105
Extrusion Points of Disc
- 25% posterior
- 50% posterolateral
- 10% lateral
106
Paramedian Prolapse
lean toward to alleviate sx; worse w/ traction
107
Lateral Prolapse
lean away to alleviate sx; better w/ traction
108
Nociceptive Pain
- localized to an area of injury/dysfunction
- clear, proportionate, mechanical/anatomical nature to AGG, EASE
- usually sharp w/ movement/mechanical provocation; may be more dull ache or throb at rest
109
Neuropathic Pain
- pain referred in a dermatomal or cutaneous distribution
- Hx of nerve injury, pathology, or mechanical compromise
- pain/symptom provocation with mechanical/movement tests (i.e. SLR) that move/load/or compress tissues
110
Central Pain
- pain disproportionate to injury
- disproportionate AGG/EASE
- psychosocial sx
- diffuse palpation
111
What is the CPR for Spinal Manipulation?
- symptoms < 16 days
- symptoms not distal to the knee
- FABQ-W ≤ 19
- hypomobile spine
- hip IR > 35˚ in at least one hip
112
When does a patient fit in the "specific exercise" category of the treatment-based classification system for LBP?
- patient centralizes with 2 or more movements in the same direction OR centralizes with movement in one direction and peripheralizes with movement in the opposite direction
113
What are the contraindications for flexion exercises?
- acute disc prolapse (acute nerve root signs)
- presence of lateral or forward list
- immediately after prolonged rest - disc is hyperhydrated and more susceptible to injury
- postural LBP - decreased LBP present
114
What is the rationale for flexion exercises?
- open IV foramen
- open facet joints
- stretch back extensors
- strengthen abdominals and gluteals
- reduce muscle imbalance
- reduce the lumbosacral angle
- improve nutrition to disc
115
What is the rationale for extension exercises?
- spine is able to tolerate greater axial compression with normal lordosis
- unloads disc and allows fluid influx - enhances normal nutrition
- pts with LBP have decreased back extensor strength
- prolonged flexion posture often associated with the onset of LBP
- individuals free of LBP - extensor strength > flexor strength
116
Contraindications for extension exercises
- acute disc prolapse in which extension peripheralizes radicular sx
- multi-operated back
- decreased mobility in forward bending (scarring)
- spinal stenosis
- spondylolisthesis
- elderly patients
117
When does a patient fit into the "stabilization" category of the treatment-based classification system for LBP?
3 or more:
- average SLR ROM > 91˚
- positive prone instability test
- positive aberrant movements
- age < 40 YOA
118
When does a patient fit into the "traction" category of the treatment-based classification system for LBP?
- patient peripheralizes with extension movement
| - has a positive crossed SLR test
119
Which patients are unlikely to return to work? What should the therapist do in these situations?
- do not centralize their symptoms within two treatments AND
- have high Waddell scores (e.g. ≥3/5)
- the therapist may consider cardiovascular conditioning, core stabilization, etc.
120
What occurs in the cortex in patients with LBP?
- the somatosensory representation of the low back becomes larger
- areas for motor activation become larger
- brain activation accounted for 80% variance for pain duration and intensity
121
What happens to interneurons in patients with LBP?
- interneurons are removed, resulting in less filtering of messages that are eventually perceived as painful
122
What are the 4 pillars of neuroscience for pts with LBP?
1. education
2. movement (increased blood flow, aerobic exercise, re-conditions tissues)
3. coping (diaphragmatic breathing)
4. sleep hygiene
123
What are the 4 pillars of neuroscience for pts with LBP?
1. education
2. movement (increased blood flow, aerobic exercise, re-conditions tissues)
3. coping (diaphragmatic breathing)
4. sleep hygiene
124
What is a technique to improve diaphragmatic breathing?
4-2-4
- Rise in with diaphragm for 4-count
- Release for 2-count
- Rest for 4-count
- Repeat for 3-7 breaths/min
125
Intrapelvic Motion
- rotation up to 4˚
- translations up to 1.5 mm
- flexion/extension range from 0.5 - 3.5 degrees
- vertical displacement range from 0.2 - 1.6 mm
126
What happens in the SIJ during forward bending?
- the sacrum nutates and stays
| - with return to upright, nutates position continues until almost erect, then counternutation
127
What are the risk factors for PGP and pregnancy?
- increased body mass
- number of prior pregnancies
- younger age
- low education level
- pre-existing LBP
- hx of hypermobility
128
Common findings of PGP in post-partum women?
- pain during standing and walking
- pain w/ passive hip flexion
- sacral thrust
- tenderness over long dorsal ligament
- decreased maximal isometric trunk strength
- difficulty w/ ASLR
129
Clinical Presentation of SIJ pain
- SI joint pain provocation tests
- pain when rising from sitting
- unilateral pain
- lack of midline lumbar pain
130
What variables are associated with a positive response to injection?
- shorter duration of sx
- nonsmokers
- no sx increase w. standing, walking, stairs
131
What are the movement patterns commonly observed in patients with PGP?
- patients tend to initiate trunk flexion from a position of posterior pelvic tilt w/ more lumbar motion (less hip) vs lumbar pain origin
132
Fixated Instability Concept
- underlying instability
- fixation in non-neutral
- joint architecture surfaces
- may be an apparent hypomobility
133
Pain characteristics of ankylosing spondylitis
- usually dull in character
- poorly localized and often deep gluteal area
- sometimes intermittent and alternating sides
- often becomes bilateral
134
Diagnostic Criteria for LBP
- buttock pain
- no LBP
- painless spine palpation
- negative SLR
- provoked by sitting
- sciatic distribution
- buttock pain from active/passive tests
- sciatic pain from stretching/resisted contraction
- no perineal irradiation
135
When is centralization more likely?
- Good outcome: shorter duration of sx and younger pts
| * Failure to centralize is a predictor of poor outcome and is associated w/ psychological issues
136
Posterior Sling System
- posterior oblique sling
| - gluteus maximus and contralateral latissimus dorsi
137
Local muscle system
- diaphragm
- transversus abdominis
- pelvic floor
- multifidus (deep)
138
Sacral multifidus
- 3 layers
- has an effect of approximating vertebra, sacrum, ilia
- results in increased stiffness
139
Osteoporosis Risk Factors
- low Ca intake
- vegetarian diet
- high protein diet
- anorexia
- smoking
- alcohol
- meds associated w/ thyroid dz
- steroids
- anticoagulants
- anticonvulsants
- hepatobiliary dz
140
Pain Referral Patterns of the Thoracic Spine
T5 - Chest - Cardiac Dz
T9 - Rib margin - visceral (i.e. perf ulcer)
T11 - umbilicus or lower abdomen - acute abdomen
L1 - inguinal region - renal
L3 - anterior thigh - ureteric, hernia
141
Radiographic changes occur only after what % of the bone is lost?
30%
142
What is the evidence for compartment syndrome in the spine?
- well-defined fascial/osseous boundaries for epaxial muscles
- intra-compartment injections remain in the compartment
- saline injections > palpable rigidity > flattened lordosis; relieved by fasciotomy
- no activity in lumbar multifidi on EMG
143
Diagnostic injection is used to determine:
- posterior facet syndrome
| - piriformis syndrome
144
Manipulation is often used for:
- posterior facet syndrome
| - sacrolilac syndrome
