Exam 3: Lumbar (5-8) Flashcards
1
Q
What type of pain will disc lesions have
A
somatic referred pain
2
Q
What changes can a disc lesion have on an endplate
A
it predisposes the intervertebral disk
3
Q
What should a patient do if their disc lesion is causing a lack of blood supply
A
get up and move around
4
Q
True or False:
Increasing in intracranial pressure as with breathing, coughing, or sneezing can increase disc lesion pain
A
true
5
Q
What are the two general types of disc lesions
A
tissue and directional lesions
6
Q
What are the two subtypes of tissue disc lesions
A
hard and soft tissue disc lesions
7
Q
In a hard lesion, the (annulus/nucleus) is more involved
A
annulus
8
Q
Does a hard disc lesion respond well to treatment and can it be a candidate for spinal manipulation
A
yes
9
Q
In a soft lesion, the (annulus/nucleus) is more involved
A
nucleus
10
Q
Does a soft lesion respond well to treatment and can it be a candidate for spinal manipulation
A
no
11
Q
Is a hard or soft tissue disc lesion more severe?
A
soft lesions since the nucleus in involved
12
Q
Describe the onset and characteristics of a hard tissue disc lesion
A
annulus affected rim lesion audible pop immediate pain local pain no distal pain
13
Q
Describe the onset and characteristics of a soft tissue disc lesion
A
progressive small tears to the annulus until it reaches the nucleus activity two days ago pain increases AM pain severe distal symptoms
14
Q
(hard/soft) tissue disc lesions will have ridicular type pain
A
soft
15
Q
What are the three subtypes of directional disc lesions
A
posterior-medial
posterior-lateral
alternating
16
Q
Which of the directional disc lesions is the most common
A
posterior lateral
17
Q
What percentage of the population with a directional disc lesion will have a posterior lateral lesion
A
80-90%
18
Q
What is another name for a posterior lateral disc lesion
A
shoulder lesion
19
Q
With a posterior lateral disc lesion, the pain will (increase/decrease) when you lean away and (increase/decrease) when you lean towards it
A
decrease when away
increase when towards
20
Q
(opening/closing) techniques are better for posterior lateral lesions
A
opening
21
Q
What is another name for a posterior medial disc lesion
A
armpit or trunk?
22
Q
With a posterior medial disc lesion, the pain will (increase/decrease) when you lean away and (increase/decrease) when you lean towards it
A
increase when away
decrease when towards
23
Q
(opening/closing) techniques are better for posterior medial lesions
A
closing
24
Q
How do you treat an alternating disc lesion
A
its very challenging, treat it based on the direction that has pain that day
25
Describe the characteristics of a direct posterior disc lesion
The patients are often stuck in flexion and having severe guarding. Hard to treat but responds well to distraction
26
What should we think when we see radicular pain
a nerve root problem
27
What should we think of when we see referred pain
a somatic issue
28
Describe the general site and characteristics of directional disc lesion pain
```
somatic
dull, constant, non specific
Can spread into thighs, groin, hip, and hamstrings
No pain below the knees
blobs or patches of pain
```
29
Where would a patient with a directional disc lesion at the L4 disc have pain at
the hips, often think they have "hip bursitis"
30
Where would a patient with a directional L5 disc lesion have pain at
the coccyx
31
What are clowards points
referred points of pain from the cervical spine
32
Where would a patient with a lesion at the T/L junction have pain
L5 spinous process and to either side
33
What are two predisposing factors of developing disc lesions
bending and driving
34
What are the typical subjective clues of a disc lesion (aggs)
```
increasing intraabdominal pressure
Pain that changes throughout the day
flexed positions
sustained positions
vibrating/driving
```
35
What are the typical subjective clues of a disc lesion (eases)
Movement
supine
avoiding sustained positions
lumbosacral support
36
A disc lesion will often lead to a loss of (kyphosis/lordosis)
lordosis
37
A disc lesion will often have an increase in pain with (flexion/extension)
flexion
38
True or False:
Extension is often limited in patients with a disc lesion
true
39
what does aberrant mean
not normal
40
What are the four general ways to approach treating a disc lesion
education, environmental, unloading, and movement
41
True or False:
Discs heal better if the patient protects the back by not moving as much as normal
false, discs will heal by getting blood flow to the them by moving
42
(flexion/extension) helps diffuse nutrients/blood flow into the discs
extension
43
True or False:
Avoid lifting heavy in the AM and PM when dealing with a disc lesion
true
44
True or false:
LBP is not normal
false, it is normal bc it is the common cold of the MS system
45
True or false:
There is limited evidence for preventing LBP
true
46
What are the three ways to unload the spine while treating a disc lesion as discussed in the powerpoints
traction, aquatic therapy, and lumbosacral support (maybe)
47
True or False:
There is sufficient evidence stating that lumbosacral support will aid in unloading a disc lesion
false, there is very limited evidence
48
Posterior lateral disc lesions are best treated with opening techniques. List the opening techniques that are used to treat PL dis lesions
traction
rotation with painful side up
central PA in SB away
lateral glides
49
Posterior medial disc lesions are best treated with closing techniques. List the closing techniques that are used to treat PM dis lesions
Central PA
Central PA in SB towards
Unilateral on the painful side
Techniques into extension
50
Manipulation is okay to do in patients with disc lesions if the pain is (above/below) the knee
above
51
if a disc lesion is in the anterior portion of the vertebrae, will the patient have a flexion or extension bias
flexion
52
if a disc lesion is in the posterior portion of the vertebrae, will the patient have a flexion or extension bias
extension
53
Typically, in lumbar radiculopathy, will one or multiple nerve roots be affected
one
54
True or False:
Mechanical pressure to a nerve will cause pain
False, it doesn't cause true pain until it becomes ischemic.
55
in lumbar radiculopathy, pro-inflammatory mediators and immune compounds are known to remove myelin from adjacent axons. What is the clinical significance of this
If there's no myelin, the nerve becomes more sensitive because there's more ion channels that are added to the nerve
56
What is the result of mechanical pressure on an exposed/unmyelinated axon
severe pain
57
What is the main role of neuroanatomy
electrochemical communication
58
When does the spinal cord end and the cauda equina begin
L1/2
59
What are the three layers of the meninges
dura mater
arachnoid
pia
60
Where does the sacral plexus provide motor and sensory innervation to
the posterior thigh, most of the lower leg, and the entire foot, and part of the pelvis
61
Which vertebrae are included in the lumbar plexus
L1-1/2 of L4
62
The (femoral/sciatic) nerve is in the lumbar plexus
femoral
63
what are the special tests that test the lumbar plexus
Think femoral nerve so
| prone knee hands and side lying slump
64
Which vertebrae are included in the LS plexus
1/2 of L4-S2`
65
The (femoral/sciatic) nerve is in the lumbar plexus
sciatic
66
what are the special tests that test the LS plexus
straight leg raise
| slump
67
Describe the pain characteristics of radicular/nerve root pain
Deep, burning, throbbing "toothache"
Dermatomal patterns
Distal pain is greater than proximal pain
68
True or False:
A patient experiencing radicular pain is greater than proximal pain
true
69
True or False:
A patient with radiculopathy means they will have pain
False, they will have sensory issues, dermatome/myotome and reflex changes.
Patients with this can experience nerve root pain, but it isn't guaranteed
70
What are the 4 signs of threatening nerve root pain
1. Area of pain: distal more than proximal
2. Nature of pain: severe or latency
3. Irritability to movement
4. Protective deformities: PM towards, PM away
71
What are the initial symptoms of nerve root compression
Numbness in dermatome
Heavy feeling in extremities
Hypersensitivity like pins and needles
Cramping
72
What are the potential effects of nerve root compression
loss of sensation
motor weakness/atrophy
decreased reflexes
73
What are eases of radiculopathy/nerve compression
protective deformity
movement
unloading like traction
upright postures
74
What are some aggs of radiculopathy/nerve compression
```
Neurodynamic tests to stimulate function like driving and slump tests
Loaded walking or WB
Sustain postures
Valsalva
Static stretches
```
75
What is the behavior of symptoms of nerve compression
Latent pain, may need to limit objective exam
| Latency that may come off as severe, sudden unprovoked pain
76
When we think of latency, think of the ____
DRG
77
What are some general signs/tests for nerve compression
shifting
positive neurodynamic tests like SLR, slump, side lying femoral slump test
compression/distraction
screenings
78
Treating lumbar radiculopathy involves space, movement, and blood. What are the three movements that will provoke space
single knee to chest
double knee to chest
trunk rotation
79
A study by Fritz suggests that a subgroup of lumbar radiculopathy patients may benefit from mechanical traction. What must the subgroup be characterized by to work?
Presence of leg symptoms
Signs of nerve root compression
Either peripheralization with extension or a crossed straight leg raise
80
Treating lumbar radiculopathy involves space, movement, and blood. List ways to provoke movement
Active and passive Neuro mobs
| Exercise
81
True or False:
Results of studies have shown that slump mobilization is beneficial for improving long term disability, pain, and centralization of symptoms
False, only short term
82
Blood flow (increases/decreases) nerve sensitivity
decreases
83
Lumbar facet joints guides _____ and ____ plane movement
sagittal and coronal
84
Lumbar facet joints restrain axial ____ and excessive _____.
rotation; translation
85
True or False:
There is more flexion/extension available in the thoracic spine compared to the lumbar spine due to the facet joint position
False, due to the lumbar facets being parallel with the sagittal plane, we have more Flex/Ex in the lumbar than thoracic
86
What type of joint are the lumbar facets joints
synovial
87
Where does the medial branch of the dorsal ramus innervate to
multifidus
| facet joints
88
What is the clinical significance of a facet joint menisci
It is there for protection and cushioning, but can become a protrusion into the joint space and cause pain/stiffness.
89
True or false:
Articular cartilage is vascular
false: it is avascular
90
Explain the importance of movement for articular cartilage
Because articular cartilage is avascular, movement is essential to prove nutrients to the cartilage. Movement causes synovial fluid filled with nutrients to diffuse into the articular cartilage
91
Muscles are (sprained/strained) and ligaments are (sprained/strained)
strain muscles
| sprain ligaments
92
Facet joints dysfunction can be caused by trauma. List ways that sprained ligaments could cause dysfunction
Extension damage via volleyball, basketball, or gymnastics
Flexion damage via weight lifitng
Falls
MVA
93
Facet joints dysfunction can be caused by trauma. List ways that strained muscles could cause dysfunction
Sustained postures
| Excessive lordosis caused by pregnancy/backpacks
94
Facet joint dysfunction can be caused by aging. What are the two general conditions that will progress facet joint dysfunction
Facet joint OA
| Stenosis
95
Changes in lumbar facet joints can occur with age. What condition in found in young adults in response to compressive loading
chondromalacia
96
Changes in lumbar facet joints can occur with age. What condition can be described as thickening and sclerosis in the subchondral bone leading to hypertrophy of facets with osteophytes
Bony hypertrophy of facets
97
Changes in lumbar facet joints can occur with age. What condition occurs with natural cartilage loss
OA
98
What condition of facet joint dysfunction will show chondrocyte swelling and splits in articular cartilage
Chondromalacia
99
Why would there be pain with a loss of articular cartilage
Because the cartilage no longer protects the innervated subchondral bone
100
True or False:
Facet joint positioning can change over time and with age
true
101
True or False:
Stenosis is becoming a real problem in the aging population
true
102
What are the characteristics of pain for facet joints
sharp, stabbing, localized pain with vague spreading around the area
Unilateral
Spasms
proximal pain greater than distal pain
103
What are the aggs for facet joint pain
```
Prolonged standing
Walking a long time/distance
Prone/extension
Extension with rotation
Coughing
Progressive loading during the day
OA: morning stiffness
```
104
What are the eases for facet joint pain
rest/sitting
supine
flexion
movement
105
What are the physical characteristics of facet joint dysfunction
A loss of extension more than side bending
| Sustained/repeated movements
106
Describe the involvement of arthritic and neurological pain along with palpation of facet joint dysfunction
Neurological pain typically not involved
Arthritic pain felt through the range.
Palpation causes localized and side specific pain
107
In general, describe the parameters of performing mobs for painful facet joints
PAIVM
| Large amplitudes with a smooth, slow rhythm
108
What types of joint mob are best for painful facet joints
PA
Unilateral PA
Transverse
109
In general, describe the parameters of performing mobs for stiff facet joints
Passive PAIVM
| End ROM position
110
True or False:
Pain is normal in aging
False it is not normal
111
Why do older people think it is normal to have pain as you age
because as people age they tend to become more sedentary. Changes due to inactivity can lead to painful movements
112
Describe the correlation between age and activity
we become really active in mid years and it gradually declines
113
True or False:
Age is poorly correlated to LBP
true
114
What age group seeks the most care for LBP
40's seeks greater care and a good decrease in seeking care around age 55+
(Slide 7 on Session 8)
115
True or False:
Disc problems become less of an issue as we age
True
116
True or False:
Facet pain tends to increase as we age
true
117
What percentage of the population seeking care for LBP is due to lumbar spinal stenosis
10-15%
118
What are the two things we need to understand in order to understand spinal stenosis
facet joints
| lumbar ligaments
119
What are the two spinal ligaments that can become a problem as we age related to spinal stenosis
Ligamentum flavum and posterior longitudinal ligament. They can harden and buckle
120
What are the degenerative changes of a vertebral body
loses trabeculae
| osteophytes
121
What are the degenerative changes of intervertebral discs
Fluid content
| Fissuring
122
What are the degenerative changes of facet joints
Sclerosis leading to ankylosis
| Spinal stenosis
123
True or False:
Disc bulges can be significant in stenosis
true
124
What are the three types of stenosis discussed in the power point
degenerative, vascular, and postural/positional stenosis
125
Vascular _____, which is a symptom of peripheral artery disease, can cause vascular stenosis
claudication
126
True or False:
Vascular stenosis can be related to postural and/or degenerative stenosis
true
127
What are the symptoms of vascular stenosis
Bilateral, distal typically feet
Temp changes
"My feet are cold all the time"
"My legs and calves hurt so much I have to stop"
128
True or False:
People with vascular stenosis have difficulty walking
True
129
True or False:
People with vascular stenosis will be the most comfortable in sitting
False, they have the most discomfort, standing is better
130
What are the comorbidities that vascular stenosis is associated with
diabetes, peripheral neuropathies, PVD, and smoking
131
True or False:
Vascular stenosis causes pain
False
132
Wearing high heels can attribute to postural stenosis. Heels will (increase/decrease) lumbar (kyphosis/lordosis)
increase lordosis
133
What are four postural changes that will increase lumbar extension/stenosis
obesity
pregnancy
high heels
ligamentous laxity
134
Describe the characteristics of the symptoms of postural stenosis
In younger patients
Increased symptoms with time/loading
Static posture increases pain
Walking eases pain
135
Degenerative stenosis will cause a (increase/decrease) or lumbar (kyphosis/lordosis)
decreased lordosis
136
What is referred to as the "blue collar disease"
Degenerative spinal stenosis
137
Describe the characteristics of symptoms of degenerative stenosis
```
AM stiffness
Progressive throughout the day
Bilateral symptoms unless its foraminal then unilateral
Leg pain greater than back pain
Numbness, pins and needles, weakness
```
138
If the central canal is effected during degenerative stenosis, will there be bilateral or unilateral symptoms
bilateral
139
If the lateral canal is effected during degenerative stenosis, will there be bilateral or unilateral symptoms
unilateral
140
Symptoms will be felt through the (feet/legs/gluteal) regions during the early stage of degenerative spinal stenosis
feet
141
Symptoms will be felt through the (feet/legs/gluteal) regions during the middle stage of degenerative spinal stenosis
legs
142
Symptoms will be felt through the (feet/legs/gluteal) regions during the late stage of degenerative spinal stenosis
gluteal
143
What are the aggs of degenerative stenosis
```
extension
standing
progressive throughout day
prolonged walking
increased body weight
```
144
What are the eases of degenerative stenosis
Flexion/walking in flexion
sitting
supine/hook-lying
145
What is the physical presentation of degenerative stenosis
```
Loss of extension
hypomobility
Progressive stages:
Cord compression
Babinski/clonus
Hyperreflexia
```
146
When performing a treadmill test for LSS, what should the walking speed start at
1.2 mph
147
True or False:
Exercise treadmill testing has poor test-retest reproducibility
false, it has good reliability
148
Explain the procedure of a treadmill test for LSS
Patient walks at 1.2mph or at a comfortable pace until symptoms start.
Let patient rest until symptoms go away
Increase the incline and have the patient walk again until their symptoms come back
If the symptoms take longer to come back, the spinal stenosis is a positive
149
What is the best treatment for LSS and why
PA hip mobs because it aids them in standing up more erect which naturally induces more extension
