Full Mckenzie Lumbar Flashcards
1
Q
What percentage of adults experience back pain in their lifetime
A
- 50-80%
2
Q
Back can be episodic, recurrent, and persistent (True/False)
A
- True
3
Q
What are the risk factors for back pain
A
- PMH of prior back pain
- Heavy lifting or frequent lifting
- Whole body vibration (driving/machinery)
- Prolonged/frequent twisting
- Prolonged/frequent bending
- Awkward postural stresses
- Psychosocial factors
4
Q
The average person flexes how many times per day
A
- 3000-5000 times per day
5
Q
What posture causes increased and decreased disc pressure
A
- Kyphosis & flexion = increased disc pressure
- Lordosis & extension = decreased disc pressure
6
Q
Innervated structures of lumbar spine that can produce pain
A
- Facet joint capsule
- Out layer of annulus fibrosis of intervertebral disc
- Vertebral bodies, dura mater
- Nerve root sleeve & connective tissue of nerves
- Spinal musculature
7
Q
Describe chemical pain
A
- constant
- acute onset
- Signs of inflammation: swelling, rubor, calor, tenderness
- all movements are painful
- no movement reduces symptoms
8
Q
Describe mechanical pain
A
- intermittent but can also be constant
- certain repeated movements reduce or abolish/centralize symptoms
- movements in one direction may lessen symptoms whereas symptoms in another direction may increase symptoms
9
Q
Describe chronic pain
A
- may not be influenced by mechanics alone
- need to account for psychosocial factors
- length of time present does not mean mechanical assessment and treatment are not beneficial
- may take longer than patient’s that are not chronic
- chronic pain may not respond to treatment.
10
Q
What are the 3 tissue repair phases
A
- Inflammatory: 0-5 days
- Repair: 5-21 days
- Remodeling: 21+ days
11
Q
Describe the components of the intervertebral disc
A
- Concentric layers of annulus fibrosis surround nucleus pulposus
- Nucleus distributes forces evenly
- Outer annulus is innervated
- Posterolateral annulus is weakest
12
Q
Define the intervertebral disc terminology
A
- Displacement: intradiscal mass displacement within annulus
- Protrusion: intact annular wall (disc bulge); reducible condition
- Extrusion: annular wall breached by intradiscal mass that protrudes through but remains in contact with the disc
- Sequestration: annular wall breached by intradiscal mass that has separated from disc (irreducible)
13
Q
What are the cardinal features of MDT
A
- Classification of subgroups
- Focus on centralization
- Self treatment & patient education
- Progression of forces
14
Q
Describe lumbar dysfunction pain
A
- Pain caused by mechanical deformation of structurally impaired soft tissue
- Contracture, scarring, adherence, adaptive shortening of tissue
- Pain is intermittent
- Pain only occurs at end range of restricted movement
- Present at least 6-8 weeks
- Pain is localized (except in case of adherent nerve root)
- Symptoms do not persist after repeated movement testing
15
Q
Describe a lumbar extension dysfunction
A
- End range pain in extension that does not remain worse upon repeated movement
- Ext ROM will not progress with repeated movement
16
Q
Describe a lumbar flexion dysfunction
A
- End range pain in flexion that does not remain worse after repeated movement
- Flexion ROM will not progress with repeated movement
17
Q
Describe postural syndrome
A
- Intermittent pain brought on only by prolonged static position.
- Rarely seen in clinic
- Pain is localized
- No pain with movement
- No ROM deficits
- Posture correction decreases symptoms
18
Q
Define derangement
A
- Clinical presentation which demonstrates directional preference in response to loading strategies & is typically associated with the movement loss
19
Q
Describe a lumbar derangement
A
- Most common classification
- symptoms are variable, inconsistent and can change
- movements can increase/decrease symptoms
- sustained postures can increase/decrease symptoms
- temporary deformity may be present: lateral shift, lordosis or kyphosis
20
Q
Patterns in patient history for derangement
A
- Symptoms local, referred or radicular
onset can be gradual or sudden - Symptoms can change sides
- Symptoms can move proximal/distal
21
Q
Patterns in examination for derangement
A
- ROM Loss in one or more directions
- May have obstructed movement (movement loss that is temporary and changes rapidly with repeated movements
- Can have temporary deformity: Lordosis, kyphosis, lateral shift
- May have deviation with movement
- Repeated movements and sustained loading strategies
- Cause symptoms DURING and AFTER
- Can increase or decrease baseline ROM
- Range of motion can increase or decrease
22
Q
What is a hallmark of derangement
A
- Rapid change
23
Q
Define directional preference
A
- Clinical phenomenon where a specific direction of movement results in a clinically relevant improvement in symptoms
- There is not always a change in the location of the pain
24
Q
Define centralization
A
- Phenomenon by which distal pain originating from the spine is progressively abolished in a distal to proximal direction
- This is in response to a specific repeated movement and/or sustained position & this change in location is maintained over time
25
Q
Describe Directional Preference and Centralization
A
- Only Present in Derangement Syndrome
- Occurs with repeated movement/sustained positions
- Most common with Extension
- Less common with lateral or flexion
- Will see improvement in symptoms
- May see improved function and/or mechanics
- If present this indicates a good prognosis
- Failure to find this indicated poor prognosis
26
Q
Red flags/contraindications for MDT of the lumbar spine
A
- Serious spinal pathology
- Cancer
- Infections
- Fractures & osteoporosis
- Cauda Equina Syndrome
- Spinal cord signs
- Ankylosing spondylitis
- Recent surgery: fusion 3 mo to 1 year for good stabilization; discectomy no concerns
27
Q
Red flag clues
A
- Age >55
- Hx of cancer
- Unexplained weight loss
- Constant, progressive, non-mechanical pain, worse at rest
- Systemically unwell
- Persisting severe restriction of lumbar flexion
- Widespread neurological deficit
- Prolonged steroid use
- Hx of intravenous drug use
- Hx of significant trauma enough to cause Fx or dislocation
- Hx of trivial trauma & severe pain in potential osteoporotic individual
- No movement or position centralizes, decreases, or abolishes pain
28
Q
Describe a R versus L lateral shift
A
- R lateral shift: vertebra above has laterally flex to the right in relation to vertebra below. Shoulders to the right
- L lateral shift: vertebra above has laterally flexed in relation to the vertebra below. Shoulders to the left.
29
Q
If during motion testing the pain abolishes or centralizes further testing of movements is not necessary (True/False)
A
- True
30
Q
When is static testing indicated
A
- Severe pain or very acute pain
- When repeated movements do not effect symptoms
- If patient only reports symptoms with prolonged position
31
Q
Lists the lumbar static tests
A
- Slouch sitting
- Long sitting
- Sitting erect
- Standing slouched
- Standing erect
- Lying Prone in extension
32
Q
Terminology during movement
A
- Increase (↑): Symptoms already present increase in intensity
- Decrease (↓): Symptoms already present decrease in intensity
- Produce (P): symptoms produced that were not present
- Abolish (A): Symptoms disappear during testing
- Centralising: Movement of pain from distal to proximal
- Peripheralising: Movement of pain from proximal to distal
- No Effect (NE): movement has no effect during testing
33
Q
Terminology after testing
A
- Worse (W): Symptoms produced or increased with movement and remain aggravated after testing
- Not Worse (NW): Symptoms produced or increased with movement return to baseline after testing
- Better (B): Symptoms decreased or abolished during movement remain better after testing
- No Better (NB): Symptoms decreased or abolished during with movement or loading return to baseline after testing
- Centralised: Distal pain abolished by movement that remains abolished after testing
- Peripheralized: Distal pain produced during movement testing remains after testing
- No effect: Movement or loading has no effect on symptoms after testing
34
Q
Describe a red light situation
A
- Produce worse
- Increase worse
- Peripheralize worse
35
Q
Describe a yellow light situation
A
- Produce not worse
- Increase not worse
- Decrease not better
- Abolish not better
36
Q
Describe a green light situation
A
- Decrease better
- Abolish better
- Centralizing better
37
Q
Slide 61
A
38
Q
What are the 4 stages of management of derangement
A
- Reduction
- Maintenance
- Recovery of function
- Prevention of recurrence
39
Q
Clues for extension/posterior derangement for central symmetrical symptoms
A
- Hx: flexion injury/activity at onset
- Aggravating factors: sitting, b ending, rise from sitting
- Alleviating factors: lying with legs straight, standing, walking, sitting upright
- Exam: reduced lordosis
- Repeated motions: repeated flexion may increase or worsen
40
Q
Clues for flexion/anterior derangement for central symmetrical symptoms
A
- Worse with walking and standing
- Have obstructed flexion ROM
- Improve with sitting
- May have excessive or fixed lordosis no reversal of curve in flexion
- Good response to flexion in lying
- Usually have a dramatic improvement in flexion ROM when rechecked in standing
- Test end range sustained extension prone lying on elevated plinth 2-3 mins: Pt will have obstructed flexion ROM
41
Q
Clues for lateral component
A
- Unilateral or asymmetrical symptoms
- Activities of flexion and extension are aggravating factors
- Asymmetric ROM loss with side glides
- Centralizing or reduces symptoms with lateral movements
- Peripheralization or worsening with prone lying or extension in lying
- Symptoms unchanged after several days of extension exercises
- Is there a shift that needs to be corrected?
42
Q
Extension with lateral component
A
- Position hips off center away from the painful leg
- Prone lying in extension with hips off center
- Extension in lying with hips off center
- Extension in lying with hips off center and clinician overpressure
- Side glides in standing
- Extension mobilization with hips off center
- Rotation mobilization in extension
- Consider return to sagittal plane extension once centralized.
43
Q
Exercise prescription
A
- 10-15 repetitions, multiple sets if needed of appropriate principle.
- Exercise should be least force that decreases, abolish or centralize symptoms
- Have patient perform every 2 hours.
- Consideration for ability level (may need less frequency)
- Consideration for severity of symptoms (may need increased frequency)
- Avoid movements that exacerbate symptoms
44
Q
Is derangement stable
A
- End range symptoms produce no worse
- No pain during movement
- Symptoms that produce do not remain worse
- Symptoms do not peripheralize
- Symptoms should not increase with repetitions
45
Q
Describe recovery of function “5x5x5”
A
- Reintroduce flexion
- Begin with least force: flexion in lying
- Progression flexion force as tolerated~ every 5 days
- 5-6 repetitions, 5-6 times per day
- Follow with5 reps extension
- Avoid flexion in early AM
- Recovery of function not required with anterior derangements
- Don’t need to recover extension with anterior derangement
46
Q
Prevention of recurrence
A
- Continue recovery of function program for 6 wks
- HEP: 2x/day, 10 reps flexion & 10 reps extension for life
- Continue use of lumbar support roll for life
