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Unit 10 > Examination > Flashcards

Examination Flashcards

1
Q

What is the McKenzie method?

A

Comprehensive approach to conservative management of most activity related spinal disorders

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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

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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

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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

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5
Q

What is MDT an appropriate treatment for?

A

Mechanical LBP and nerve root pathology

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6
Q

What are some contraindications for MDT?

A

Serious spinal pathology, cauda equina, cord signs, infections, fxs, multilevel neuro deficits, non mechanical pain

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7
Q

How might you recognize non-mechanical pain?

A

Pain that doesn’t vary with activity and time

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8
Q

What is centralization?

A

Distal symptoms moving more proximally due to reduced pressure on sciatic nerve

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9
Q

What are the possible classifications in the McKenzie system?

A

Postural syndrome, dysfunction syndrome, derangement syndrome, other

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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.

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11
Q

What is a dysfunction syndrome?

A

Fixed local (except adherent nerve root) symptoms produced with stretch

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12
Q

What is a derangement?

A

Variable intensity and location symptoms and motion loss that can rapidly change

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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!)

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14
Q

What is a spinal/ motion segment?

A

2 vertebrae, disc, and everything else in between

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15
Q

What are some biological reasons you might see dysfunction in a patient?

A

Adaptive shortening, scarring, adhered tissue

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16
Q

What might a patient with adhered tissue surrounding a spinal segment experience?

A

Produces pain before normal end range

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17
Q

What causes dysfunction?

A

Poor posture and freq of flexion, secondary complication of surgery trauma sciatica or poor derangement, restricted mobility, pathology

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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)

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19
Q

How is dysfunction named?

A

For the direction of motion restriction

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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

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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

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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

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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

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24
Q

What are the types of acute spinal deformities that can develop as a result of derangement?

A

Lateral shift, reduced lordosis

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25
Q

How does the nucleus pulposis move with flexion and extension?

A

Flexion - posterior

Extension - anterior

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26
Q

In what direction do most disc herniations occur?

A

Posterolateral

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27
Q

Define disc herniation

A

Intradiscal displacement beyond the limits of the disc space

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28
Q

Compare and contrast the clinical presentation of a reducible and an irreducible derangement

A

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

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29
Q

If you think you’re getting centralization of your patient’s symptoms, what is the most important thing to educate them on?

A

Proximal symptoms may increase

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30
Q

What are some common exam findings for a patient with derangement?

A

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

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31
Q

How is direction preference determined?

A

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

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32
Q

How do you name derangement?

A

Reducible or irreducible and then central/symmetrical, unilateral/asymmetric above the knee, unilateral/asymmetric below the knee

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33
Q

What are some possible directional preferences for patients to have?

A

Flexion, extension, lateral

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34
Q

What activities should we tell someone with an extension directional preference to avoid?

A

Anything involving flexion

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35
Q

By which visit have you likely seen all the improvement in pain/function your patient will be getting via the McKenzie method?

A

7

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36
Q

What is the likely prognosis for a patient who has a centralization response on their first visit?

A

Good to excellent

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37
Q

What are some diagnoses that are classified as “other” using the McKenzie method?

A

Cauda equina, malignancy, bone weakening disorders, infection, fracture, inflammatory disorders, spinal stenosis, hip/SI joint pathology, spondylolisthesis/instability

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38
Q

What are signs of instability or spondy?

A

High beighton score, passive lumbar extension, prone instability, aberrant movement

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39
Q

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?

A

Stenosis

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40
Q

What are some signs of cauda equina?

A

Saddle anesthesia, loss of bowel/bladder control, sexual dysfunction, bilateral LE weakness/pain

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41
Q

What is the conus medularis and where is it located?

A

Terminal end of spinal cord, L1, L2

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42
Q

What are some signs of malignancy?

A

> 50yo, history of cancer, night pain, sudden weight loss

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43
Q

What is the most common functional disability score for the low back?

A

Oswestry

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44
Q

What might a drop attack in gait indicate?

A

Cervical myelopathy or compression of cervical cord (immediate referral!)

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45
Q

What might a foot drag during gait indicate in a low back patient?

A

Radiculopathy

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46
Q

What medications do you want to take special note of when using the McKenzie method?

A

Steroids and anticoagulants (bone weakening)

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47
Q

Categorize the following patient using the McKenzie method: pain in LB after cleaning which progressed into back of right thigh

A

Derangement, unilateral/asymmetrical above the knee

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48
Q

Categorize the following patient using the McKenzie method: bike rider with onset recurrent LBP 20 miles into ride

A

Postural syndrome

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49
Q

Categorize the following patient using the McKenzie method: pain in calf when bends over in exercise class but not when squatting

A

Adherent nerve root

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50
Q

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

A

Extension dysfunction

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51
Q

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

A

Ankylosing spondylitis

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52
Q

Categorize the following patient using the McKenzie method: 25yo female with 3 mo old baby she is nursing. Has pain in PSIS area

A

Instability

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53
Q

Categorize the following patient using the McKenzie method: elderly female with complains of sharp pain with all movements when she changed her sheets.

A

Fracture

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54
Q

When is a lateral shift relevant?

A

Clearly visible deformity, onset concurrent with LBP, shift can’t be voluntarily corrected, flexion and extension painful in WB

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55
Q

What are some nonstructural causes of lateral shift?

A

Pressure on nerve root by derangement or space occupying lesion (tumor), spasm of quadratus

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56
Q

Where will you see weakness if the L4 root is involved?

A

extensor hallicus longus

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57
Q

How might you test your hypothesis that a patient has S1 nerve root damage?

A

Calf raises (eversion if non-ambulatory)

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58
Q

How do you deviate with an adherent nerve root?

A

Towards side of lesion

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59
Q

How do you deviate with a derangement?

A

90% of people deviate away

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60
Q

What are the repeated test movements for the McKenzie method?

A

flexion in standing, extension in standing, flexion in lying, extension in lying, side glide in standing

61
Q

How is a side glide named directionally?

A

For the direction the shoulder is going

62
Q

How might you intervene for a patient with postural syndrome?

A

Education, postural correction, lumbar roll

63
Q

What interventions might you use for a patient with dysfunction?

A

Reproduce symptoms to stretch shortened tissue every 2 hours

64
Q

How long does it take to remodel tissue generally for a patient with dysfunction?

A

4-6 weeks

65
Q

what interventions might you use for a patient with derangement?

A

Centralize symptoms by reducing derangement, maintain reduction (posture, regular exercise, proper body mechanics), recover function in opposite direction, prevent recurrence (continue exercises)

66
Q

What is the extension principle?

A

Pain worse with flexion and better with extension

67
Q

What is the flexion principle?

A

Pain worse with walking/standing, obstruction to bending, better with sitting

68
Q

How do you stretch a unilateral asymmetrical derangement?

A

Opposite leg up

69
Q

What are some ways we can educate to correct posture?

A

Sitting: slouch, overcorrect, relax 10%
Standing: lift chest, milt ant pelvic tilt, abdominal draw in
Lying: modify mattress, posture, support role

70
Q

When do you use the extension principle?

A

Use for (posterior/extension) derangement to centralize or abolish symptoms and for extension dysfunction to reproduce local pain to stretch tissue

71
Q

What is the McKenzie extension progression?

A

Lying prone, lying prone in extension, EIL, extension in lying with self-overpressure, extension in standing, extension mobilization

72
Q

When do you use the lateral compartment?

A

Unilateral/asymmetrical pain not responding or worse with flexion or extension, relevant lateral shift

73
Q

What are the McKenzie lateral procedures?

A

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
Q

When do you use the flexion principle?

A

Use for (anterior/flexion) derangement to centralize/abolish symptoms, flexion dysfunction to stretch shortened tissue, recovery of function after posterior derangement

75
Q

What is the McKenzie flexion principal progression?

A

Flexion in lying, flexion in sitting, flexion in standing, flexion in step standing, flexion in lying with PT over-pressure

76
Q

What are some general exercise guidelines for dysfunction?

A

10 reps every 2-3 hours, discomfort felt locally at end range during exercise and abolished with return to neutral, 4-6 weeks

77
Q

What are some general exercise guidelines for derangement

A

10x ever 2-3 hours or if symptoms increase, centralize/decrease/abolish pain, may temporarily cause new pain

78
Q

What McKenzie classifications will benefit from yoga?

A

Dysfunction, postural syndrome

79
Q

What are the passive stabilizers of the spine?

A

Bone, ligaments, discs

80
Q

What is generally the weak link in the spine in terms of stability?

A

IV discs

81
Q

What is the neutral zone of the spine?

A

Area where the joint is freely movable and not constrained by passive stabilizers

82
Q

What is the key stabilizer of the spine in the neutral zone?

A

Muscles

83
Q

What happens to the neutral zone if the passive stabilizers are weakened (attenuated)

A

Becomes larger (greater motion) and leads to instability

84
Q

If the neutral zone becomes larger, how does this affect the overall ROM?

A

Doesn’t necessarily change it due to bony elements

85
Q

How much force does it take to break an osteoligamentous prep of the spine?

A

20lbs

86
Q

What are the key lumbar muscles are what are their functions?

A

Erector spinae and multifidus, control lumbar flexion and produce lumbar extension

87
Q

What muscles make up longissimus thoracis and what are their functions?

A

Pars thoracis - large extensor moment (superficial)

Pars lumborum - extends and applies posterior shear (deep)

88
Q

What position generates the peak erector spinae activity?

A

Slight to midrange flexion

89
Q

Why is peak erector qpinae activity generated at midrange flexion and not endrange?

A

Passive elements kick in at end range

90
Q

How are the facets in the L-spine oriented?

A

Obliquely

91
Q

What is an example of a test of neural mobility?

A

SLR, slump test

92
Q

What is an example of a joint mobility test?

A

Spring test

93
Q

How do you test the length of the femoral nerve?

A

Hip extension and knee flexion

94
Q

What are the 3 stages of movement control?

A

Activation (learn motor control), acquisition (motor control + strength), assimilation (strength and endurance)

95
Q

In flexion with back erect, what forces work to counteract gravity? Explain briefly.

A

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
Q

What is the function of the multifidi?

A

Mostly compression, small extension moment arm

97
Q

Which generates more anterior shear force: L-spine flexion or hip flexion with L-spine extension?

A

L-spine flexion

98
Q

What is the function of rectus abdominus?

A

Abdominal flexion

99
Q

What is the function of transverse abdominus and internal oblique?

A

Generate intrabdominal pressure

100
Q

What is the problem with producing a strong flexor torque (ex. rectus)?

A

Creates a substantial anterior shear force that the disc needs to resist

101
Q

What are some ways to stiffen the spine?

A

Co-contraction of internal oblique, transverse abdominus,and multifidus

102
Q

What is the function of each of the following muscles?

Rectus abdominis, ex oblique, int oblique, tr abdom, er spinae, multifidus

A

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
Q

In addition to int obliques and tra abdominus, what other structures are essential for generating intraabdominal pressure?

A

Diaphragm and pelvic floor musculature

104
Q

Briefly describe the difference between hollowing and bracing

A

Hollowing - lightly drawing in to activate transverse abdominus and int obliques without creating flexion torque (rectus)
Bracing - activating everything

105
Q

What are some ways to test trunk muscle endurance?

A

Flexion (v -sit), sorenson (glute ham iso), side bridge, unilateral hip bridge

106
Q

What is the sorenson test?

A

Prone hips at table edge, legs strapped to table, maintain trunk horiz with arms across chest

107
Q

What are some clincial indicators of instability that you might come across in your history taking?

A

Freq episodes with minimal perturbation, alternating sides lat shift, frequent manip with short term relief, overt trauma, pregnancy, improved with bracing

108
Q

What is the beighton scale?

A

Scale for generalized laxity

109
Q

What are the components of the beighton scale?

A

Elbow hyperextension, knee hyperextension, thumb hyperextension, MP joint, be able to touch floor with palms

110
Q

What are some clinical indicators for lumbar instability you might find in your exam?

A

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
Q

What are some good clinical tests for instability?

A

Prone instability, passive lumbar extension test

112
Q

You are watching a patient go through lumbar flexion in standing. What signs are you looking for that might indicate instability?

A

Painful arc, gower’s sign, instability catch, reversal of lumbo-pelvic rhythm

113
Q

What is the difference between instability and laxity?

A

Laxity - lots of motion but no symptoms

Instability - excessive motion + symptoms

114
Q

In one study they used wire electrodes in abdominals and multifidi during self-initiated leg and arm movements. What did they find?

A

Healthy subjects contracted transverse abdominus prior to initiating extremity movements but subjects with LBP failed to properly activate abdominals.

115
Q

What is spondylosis?

A

Degenerative disease of the spine

116
Q

What is spondylolysis?

A

Fracture in the pars interarticularis of the spine

117
Q

What is spondylolosthesis?

A

Anterior slippage of the superior vertebral body

118
Q

While only weak evidence, what are the clinical prediction rule for predicting success with stabilization treatment?

A

Positive prone instability test, aberrant movement present, SLR >91 degrees, age <40yo

119
Q

What are the stages of motor learning?

A

Cognitive, associative, autonomous

120
Q

Briefly describe the basic progression of stabilization training

A

Finding neutral –> isometric co-contraction –> progressive loading challenges while maintaining spine stiffness

121
Q

The nexus study came out with several negative criteria that if present, indicates a C-spine xray is not indicated. What are those criteria?

A

No midline tenderness, no focal neurologic deficit, normal alertness, no intoxification, no painful injury distracting attention from a C-spine injury

122
Q

What are some high risk factors that would warrent an xray?

A

> 65yo, dangerous mechanism, paresthesia in extremities

123
Q

What are some low risk factors that allow safe assessment of ROM of C-spine?

A

Simple rear end collision, sitting position in ED, ambulatory at any time, delayed onset, no C-spine tenderness

124
Q

What is a sign in an older adult that indicates a possible stenosis?

A

Back/leg pain relief by sitting

125
Q

How long does it take most patients with sciatica/neurologic symptoms to improve?

A

6 weeks

126
Q

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?

A

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
Q

What is the most common imaging modality to view the disc?

A

MRIs

128
Q

Briefly describe the difference between a T1 and T2 weighted MRI

A

T1 - highlights fat, bone will be brighter, CSF darker

T2 - bone is darker, CSF appears bright white

129
Q

What type of MRI would you use to see the contrast between the nucleus pulposis and annulus?

A

T2

130
Q

What does a darker and more homogenous disc indicate?

A

Desiccation (early degeneration)

131
Q

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?

A

Large extrusion, major neural compromise

132
Q

What is the continuum of disc pathology?

A

Annular tears –> disc bulge –> disc herniation

133
Q

What are some ways that you would describe a herniation

A

Protrusion, extrusion, sequestration, focal/diffuse, location

134
Q

How would an annular tear show up on a T2 weighted MRI?

A

Hyperintense signal (often in posterior anulus)

135
Q

What is a disc protrusion?

A

Disc has gone posterior boarder of vertebrae but is contained within superior/inferior boarders

136
Q

How is a focal protrusion defined?

A

When area is <25% the total width

137
Q

How can you pick out an extrusion in an MRI?

A

There will be a neck

138
Q

What is a sequestration?

A

A herniation where a fragment has separated from the disc

139
Q

What is a Schmorl’s node?

A

Herniation into the spongy bone of the vertebrae through the vertebral end plate

140
Q

What type of herniation shows the best non-operative results based on Matsumoto’s study?

A

Median/diffuse

141
Q

What direction do hernias generally go?

A

Posterolateral

142
Q

What is the early generator of degenerative change in the spine?

A

Disc

143
Q

What are some common degenerative conditions that occur in the spine?

A

Spondylosis, spondylolysis, spondylolisthesis, spinal stenosis

144
Q

Describe the difference between radiculopathy and myelopathy

A

Radiculopathy - comrpession of spinal nerve (LMN)

Myelopathy - compression of the cord (UMN)

145
Q

Describe the classification associated with degenerative changes of the vertebral end plate

A

Modic 1 - edema and inflammatory activity
Modic 2 - red marrow replaced by yellow marrow
Modic 3 - sclerosis of end plates

146
Q

How will each modic classification appear on an MRI?

A

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
Q

What structure is fractured if you see a positive scotty dog sign?

A

Pars articularis (spondylolysis)

148
Q

What position makes myelopathy symptoms worse?

A

Extension

Unit 10 (7 decks)

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