Examination Flashcards
1
Q
What is the McKenzie method?
A
Comprehensive approach to conservative management of most activity related spinal disorders
2
Q
What is force progression as described by the McKenzie method?
A
Self-generated –> self-generated with overpressure –> PT generated –> PT generated to end range with overpressure
3
Q
What differentiates MDT from other methods?
A
Use of repeated movements for assessment and treatment, focus on pt independence and PT intervention as needed
4
Q
What are the central features of MDT?
A
Classification of pts into syndromes based on symptom and mechanical response, centralization, self-treatment via education, force progression
5
Q
What is MDT an appropriate treatment for?
A
Mechanical LBP and nerve root pathology
6
Q
What are some contraindications for MDT?
A
Serious spinal pathology, cauda equina, cord signs, infections, fxs, multilevel neuro deficits, non mechanical pain
7
Q
How might you recognize non-mechanical pain?
A
Pain that doesn’t vary with activity and time
8
Q
What is centralization?
A
Distal symptoms moving more proximally due to reduced pressure on sciatic nerve
9
Q
What are the possible classifications in the McKenzie system?
A
Postural syndrome, dysfunction syndrome, derangement syndrome, other
10
Q
What is the typical patient presentation for postural syndrome
A
Fixed local symptoms with sustained loading. Normal periarticular structures become painful after prolonged static end range loading.
11
Q
What is a dysfunction syndrome?
A
Fixed local (except adherent nerve root) symptoms produced with stretch
12
Q
What is a derangement?
A
Variable intensity and location symptoms and motion loss that can rapidly change
13
Q
What are some common exam findings for someone with postural syndrome?
A
<30 yo, intermittent pain, no motion loss, no pain with repeated movements, local pain produced with static loading at end range (time dependent!)
14
Q
What is a spinal/ motion segment?
A
2 vertebrae, disc, and everything else in between
15
Q
What are some biological reasons you might see dysfunction in a patient?
A
Adaptive shortening, scarring, adhered tissue
16
Q
What might a patient with adhered tissue surrounding a spinal segment experience?
A
Produces pain before normal end range
17
Q
What causes dysfunction?
A
Poor posture and freq of flexion, secondary complication of surgery trauma sciatica or poor derangement, restricted mobility, pathology
18
Q
What are some common exam findings for a patient with dysfunction?
A
Motion loss, pain at end range, no change in pain location/intensity with reps, gradual onset of local symptoms (except ANR)
19
Q
How is dysfunction named?
A
For the direction of motion restriction
20
Q
What are some common exam findings of ANR?
A
Pain in leg with flexion in standing, no pain with flexion in supine, positive SLR, positive slump test
21
Q
With adherent nerve root you have pain in the leg with flexion in standing but not when you bring your knees to your chest in supine. Why?
A
In supine with knees bent the sciatic nerve is on slack (runs posterior to knee joint), but its on tension with lumbar flexion in standing
22
Q
Briefly describe a slump test
A
Sit upright, bring chin to chest, slump over, pull toes to nose, PT passively extends leg. Look up and see if pain goes away
23
Q
What are some clinical signs of derangement?
A
Rapidly reversible obstruction to normal movement, rapid increase of decreased motion, acute spinal deformities, quick changes of symptom location
24
Q
What are the types of acute spinal deformities that can develop as a result of derangement?
A
Lateral shift, reduced lordosis
25
How does the nucleus pulposis move with flexion and extension?
Flexion - posterior
| Extension - anterior
26
In what direction do most disc herniations occur?
Posterolateral
27
Define disc herniation
Intradiscal displacement beyond the limits of the disc space
28
Compare and contrast the clinical presentation of a reducible and an irreducible derangement
With irreducible derangement no strategy shows a permanent change in symptoms while with reducible derangement movement in one direction reduces/centralizes/abolishes symptoms while movement in the other increases/peripheralizes symptoms
29
If you think you're getting centralization of your patient's symptoms, what is the most important thing to educate them on?
Proximal symptoms may increase
30
What are some common exam findings for a patient with derangement?
22-55 yo, pain constant or intermittant, pain local or referred into leg, pain during motion or at end range, sudden or gradual onset, directional preference, centralization/peripheralization
31
How is direction preference determined?
Whether pain located in distal areas decreases in intensity, abolishes, or centralizes and/or whether subjects have improved ROM in response to repeated movement or positional loading strategies
32
How do you name derangement?
Reducible or irreducible and then central/symmetrical, unilateral/asymmetric above the knee, unilateral/asymmetric below the knee
33
What are some possible directional preferences for patients to have?
Flexion, extension, lateral
34
What activities should we tell someone with an extension directional preference to avoid?
Anything involving flexion
35
By which visit have you likely seen all the improvement in pain/function your patient will be getting via the McKenzie method?
7
36
What is the likely prognosis for a patient who has a centralization response on their first visit?
Good to excellent
37
What are some diagnoses that are classified as "other" using the McKenzie method?
Cauda equina, malignancy, bone weakening disorders, infection, fracture, inflammatory disorders, spinal stenosis, hip/SI joint pathology, spondylolisthesis/instability
38
What are signs of instability or spondy?
High beighton score, passive lumbar extension, prone instability, aberrant movement
39
What is the likely diagnosis for a patient who says that they get pain when they walk a block or more, but as soon as they stop or bend over the pain goes away?
Stenosis
40
What are some signs of cauda equina?
Saddle anesthesia, loss of bowel/bladder control, sexual dysfunction, bilateral LE weakness/pain
41
What is the conus medularis and where is it located?
Terminal end of spinal cord, L1, L2
42
What are some signs of malignancy?
>50yo, history of cancer, night pain, sudden weight loss
43
What is the most common functional disability score for the low back?
Oswestry
44
What might a drop attack in gait indicate?
Cervical myelopathy or compression of cervical cord (immediate referral!)
45
What might a foot drag during gait indicate in a low back patient?
Radiculopathy
46
What medications do you want to take special note of when using the McKenzie method?
Steroids and anticoagulants (bone weakening)
47
Categorize the following patient using the McKenzie method: pain in LB after cleaning which progressed into back of right thigh
Derangement, unilateral/asymmetrical above the knee
48
Categorize the following patient using the McKenzie method: bike rider with onset recurrent LBP 20 miles into ride
Postural syndrome
49
Categorize the following patient using the McKenzie method: pain in calf when bends over in exercise class but not when squatting
Adherent nerve root
50
Categorize the following patient using the McKenzie method: 13 yo cellist who practices 10hrs/week complains of LBP which resolves with return to neutral position
Extension dysfunction
51
Categorize the following patient using the McKenzie method: Teenage male with morning stiffness and pain after inactivity in LB and SI area. Better with movement, general fatigue stiffness in hips
Ankylosing spondylitis
52
Categorize the following patient using the McKenzie method: 25yo female with 3 mo old baby she is nursing. Has pain in PSIS area
Instability
53
Categorize the following patient using the McKenzie method: elderly female with complains of sharp pain with all movements when she changed her sheets.
Fracture
54
When is a lateral shift relevant?
Clearly visible deformity, onset concurrent with LBP, shift can't be voluntarily corrected, flexion and extension painful in WB
55
What are some nonstructural causes of lateral shift?
Pressure on nerve root by derangement or space occupying lesion (tumor), spasm of quadratus
56
Where will you see weakness if the L4 root is involved?
extensor hallicus longus
57
How might you test your hypothesis that a patient has S1 nerve root damage?
Calf raises (eversion if non-ambulatory)
58
How do you deviate with an adherent nerve root?
Towards side of lesion
59
How do you deviate with a derangement?
90% of people deviate away
60
What are the repeated test movements for the McKenzie method?
flexion in standing, extension in standing, flexion in lying, extension in lying, side glide in standing
61
How is a side glide named directionally?
For the direction the shoulder is going
62
How might you intervene for a patient with postural syndrome?
Education, postural correction, lumbar roll
63
What interventions might you use for a patient with dysfunction?
Reproduce symptoms to stretch shortened tissue every 2 hours
64
How long does it take to remodel tissue generally for a patient with dysfunction?
4-6 weeks
65
what interventions might you use for a patient with derangement?
Centralize symptoms by reducing derangement, maintain reduction (posture, regular exercise, proper body mechanics), recover function in opposite direction, prevent recurrence (continue exercises)
66
What is the extension principle?
Pain worse with flexion and better with extension
67
What is the flexion principle?
Pain worse with walking/standing, obstruction to bending, better with sitting
68
How do you stretch a unilateral asymmetrical derangement?
Opposite leg up
69
What are some ways we can educate to correct posture?
Sitting: slouch, overcorrect, relax 10%
Standing: lift chest, milt ant pelvic tilt, abdominal draw in
Lying: modify mattress, posture, support role
70
When do you use the extension principle?
Use for (posterior/extension) derangement to centralize or abolish symptoms and for extension dysfunction to reproduce local pain to stretch tissue
71
What is the McKenzie extension progression?
Lying prone, lying prone in extension, EIL, extension in lying with self-overpressure, extension in standing, extension mobilization
72
When do you use the lateral compartment?
Unilateral/asymmetrical pain not responding or worse with flexion or extension, relevant lateral shift
73
What are the McKenzie lateral procedures?
EIL with hips off center, EIL with hips off center and PT over-pressure, extension mobilization with hips off center, rotation mob in extension, rotation mob in flexion, lateral shift correction
74
When do you use the flexion principle?
Use for (anterior/flexion) derangement to centralize/abolish symptoms, flexion dysfunction to stretch shortened tissue, recovery of function after posterior derangement
75
What is the McKenzie flexion principal progression?
Flexion in lying, flexion in sitting, flexion in standing, flexion in step standing, flexion in lying with PT over-pressure
76
What are some general exercise guidelines for dysfunction?
10 reps every 2-3 hours, discomfort felt locally at end range during exercise and abolished with return to neutral, 4-6 weeks
77
What are some general exercise guidelines for derangement
10x ever 2-3 hours or if symptoms increase, centralize/decrease/abolish pain, may temporarily cause new pain
78
What McKenzie classifications will benefit from yoga?
Dysfunction, postural syndrome
79
What are the passive stabilizers of the spine?
Bone, ligaments, discs
80
What is generally the weak link in the spine in terms of stability?
IV discs
81
What is the neutral zone of the spine?
Area where the joint is freely movable and not constrained by passive stabilizers
82
What is the key stabilizer of the spine in the neutral zone?
Muscles
83
What happens to the neutral zone if the passive stabilizers are weakened (attenuated)
Becomes larger (greater motion) and leads to instability
84
If the neutral zone becomes larger, how does this affect the overall ROM?
Doesn't necessarily change it due to bony elements
85
How much force does it take to break an osteoligamentous prep of the spine?
20lbs
86
What are the key lumbar muscles are what are their functions?
Erector spinae and multifidus, control lumbar flexion and produce lumbar extension
87
What muscles make up longissimus thoracis and what are their functions?
Pars thoracis - large extensor moment (superficial)
| Pars lumborum - extends and applies posterior shear (deep)
88
What position generates the peak erector spinae activity?
Slight to midrange flexion
89
Why is peak erector qpinae activity generated at midrange flexion and not endrange?
Passive elements kick in at end range
90
How are the facets in the L-spine oriented?
Obliquely
91
What is an example of a test of neural mobility?
SLR, slump test
92
What is an example of a joint mobility test?
Spring test
93
How do you test the length of the femoral nerve?
Hip extension and knee flexion
94
What are the 3 stages of movement control?
Activation (learn motor control), acquisition (motor control + strength), assimilation (strength and endurance)
95
In flexion with back erect, what forces work to counteract gravity? Explain briefly.
Compression force and erector spinae. Pars lumborum (deep erector spinae) creates posterior shear to offset to offset reaction shear of gravity + extension moment. This minimizes shear forces in disc
96
What is the function of the multifidi?
Mostly compression, small extension moment arm
97
Which generates more anterior shear force: L-spine flexion or hip flexion with L-spine extension?
L-spine flexion
98
What is the function of rectus abdominus?
Abdominal flexion
99
What is the function of transverse abdominus and internal oblique?
Generate intrabdominal pressure
100
What is the problem with producing a strong flexor torque (ex. rectus)?
Creates a substantial anterior shear force that the disc needs to resist
101
What are some ways to stiffen the spine?
Co-contraction of internal oblique, transverse abdominus,and multifidus
102
What is the function of each of the following muscles?
Rectus abdominis, ex oblique, int oblique, tr abdom, er spinae, multifidus
Rectus and ex obl - flexor torque, anterior shear
Int obl and tr abdom - IAP and stiffen spinal cylindar
ER spinae - extensor torque and posterior shear
Multifidus - compression and precision control
103
In addition to int obliques and tra abdominus, what other structures are essential for generating intraabdominal pressure?
Diaphragm and pelvic floor musculature
104
Briefly describe the difference between hollowing and bracing
Hollowing - lightly drawing in to activate transverse abdominus and int obliques without creating flexion torque (rectus)
Bracing - activating everything
105
What are some ways to test trunk muscle endurance?
Flexion (v -sit), sorenson (glute ham iso), side bridge, unilateral hip bridge
106
What is the sorenson test?
Prone hips at table edge, legs strapped to table, maintain trunk horiz with arms across chest
107
What are some clincial indicators of instability that you might come across in your history taking?
Freq episodes with minimal perturbation, alternating sides lat shift, frequent manip with short term relief, overt trauma, pregnancy, improved with bracing
108
What is the beighton scale?
Scale for generalized laxity
109
What are the components of the beighton scale?
Elbow hyperextension, knee hyperextension, thumb hyperextension, MP joint, be able to touch floor with palms
110
What are some clinical indicators for lumbar instability you might find in your exam?
Generalized laxity, painful arc or instability catch, palpable step deformity, hypermobile with spring test, excessive tenderness at 1 segment, increased pain with sustained end range
111
What are some good clinical tests for instability?
Prone instability, passive lumbar extension test
112
You are watching a patient go through lumbar flexion in standing. What signs are you looking for that might indicate instability?
Painful arc, gower's sign, instability catch, reversal of lumbo-pelvic rhythm
113
What is the difference between instability and laxity?
Laxity - lots of motion but no symptoms
| Instability - excessive motion + symptoms
114
In one study they used wire electrodes in abdominals and multifidi during self-initiated leg and arm movements. What did they find?
Healthy subjects contracted transverse abdominus prior to initiating extremity movements but subjects with LBP failed to properly activate abdominals.
115
What is spondylosis?
Degenerative disease of the spine
116
What is spondylolysis?
Fracture in the pars interarticularis of the spine
117
What is spondylolosthesis?
Anterior slippage of the superior vertebral body
118
While only weak evidence, what are the clinical prediction rule for predicting success with stabilization treatment?
Positive prone instability test, aberrant movement present, SLR >91 degrees, age <40yo
119
What are the stages of motor learning?
Cognitive, associative, autonomous
120
Briefly describe the basic progression of stabilization training
Finding neutral --> isometric co-contraction --> progressive loading challenges while maintaining spine stiffness
121
The nexus study came out with several negative criteria that if present, indicates a C-spine xray is not indicated. What are those criteria?
No midline tenderness, no focal neurologic deficit, normal alertness, no intoxification, no painful injury distracting attention from a C-spine injury
122
What are some high risk factors that would warrent an xray?
>65yo, dangerous mechanism, paresthesia in extremities
123
What are some low risk factors that allow safe assessment of ROM of C-spine?
Simple rear end collision, sitting position in ED, ambulatory at any time, delayed onset, no C-spine tenderness
124
What is a sign in an older adult that indicates a possible stenosis?
Back/leg pain relief by sitting
125
How long does it take most patients with sciatica/neurologic symptoms to improve?
6 weeks
126
The american college of radiology put out a set of red flags that if present, suggest the need for imaging. What are thsoe red flags?
Recent significant trauma (or milder trauma age >50), unexplained weight loss, unexplained fever, immunosuppression, history of cancer, IV drug use, osteoporosis, age >70, progressive neurologic symptoms, duration >6 weeks
127
What is the most common imaging modality to view the disc?
MRIs
128
Briefly describe the difference between a T1 and T2 weighted MRI
T1 - highlights fat, bone will be brighter, CSF darker
| T2 - bone is darker, CSF appears bright white
129
What type of MRI would you use to see the contrast between the nucleus pulposis and annulus?
T2
130
What does a darker and more homogenous disc indicate?
Desiccation (early degeneration)
131
Generally there's poor correlation between imaging changes and symptoms. However, there are a few conditions that have a much better correlation. What are they?
Large extrusion, major neural compromise
132
What is the continuum of disc pathology?
Annular tears --> disc bulge --> disc herniation
133
What are some ways that you would describe a herniation
Protrusion, extrusion, sequestration, focal/diffuse, location
134
How would an annular tear show up on a T2 weighted MRI?
Hyperintense signal (often in posterior anulus)
135
What is a disc protrusion?
Disc has gone posterior boarder of vertebrae but is contained within superior/inferior boarders
136
How is a focal protrusion defined?
When area is <25% the total width
137
How can you pick out an extrusion in an MRI?
There will be a neck
138
What is a sequestration?
A herniation where a fragment has separated from the disc
139
What is a Schmorl's node?
Herniation into the spongy bone of the vertebrae through the vertebral end plate
140
What type of herniation shows the best non-operative results based on Matsumoto's study?
Median/diffuse
141
What direction do hernias generally go?
Posterolateral
142
What is the early generator of degenerative change in the spine?
Disc
143
What are some common degenerative conditions that occur in the spine?
Spondylosis, spondylolysis, spondylolisthesis, spinal stenosis
144
Describe the difference between radiculopathy and myelopathy
Radiculopathy - comrpession of spinal nerve (LMN)
| Myelopathy - compression of the cord (UMN)
145
Describe the classification associated with degenerative changes of the vertebral end plate
Modic 1 - edema and inflammatory activity
Modic 2 - red marrow replaced by yellow marrow
Modic 3 - sclerosis of end plates
146
How will each modic classification appear on an MRI?
Modic 1 - dark on T1, more intense on T2
Modic 2 - more intense on T1, darker on T2
Modic 3 - Intensity on both T1 and T2
147
What structure is fractured if you see a positive scotty dog sign?
Pars articularis (spondylolysis)
148
What position makes myelopathy symptoms worse?
Extension
