Intro Flashcards
1
Q
Radicular, referred and radiculopathy presentation
A
- Referred = deep, dull, achy and diffuse
- Radicular pain = intense, radiating, sharp, darting,, dermatomal pattern
- Radiculopathy encompasses radicular pain with other neural symptoms (weakness, numbness ect)
2
Q
Directional preference
A
The easing position or movement that needs to be either repeated or sustained to improve pain or ROM (ext most common)
3
Q
Cauda Equina symptoms
A
- Difficulty going to the bathroom, if so is there difficulty starting urination
- Numbness or change of sensation between legs
4
Q
When should standing and sitting posture be considered in a physical exam
A
Therefore, both standing and sitting posture can be incorporated into the physical exam if there is a relationship between posture and the symptoms. Do the symptoms relate to starting or changing postures (new job, extra hours ect) During this exam the aim is to determining if changing the posture will change the pain.
5
Q
Why does poor posture not cause pain
A
- Tissue adapt to stress over time, posture is long term meaning that the tissues have enough time to adapt
- Tissue damage or stress does not always equal pain!
- There is variety in the anatomical makeup of all people and certain asymmetries and irregularities can cause different posture that is still normal for that person.
6
Q
Postural risk factors
A
- Working with trunk in a bent or twisted position for more than two hours a day
- Not being able to change position regularly, sitting posture may not be the issue jus that it is not changed regularly
- Excessive standing (the exam amount of time is unknown)
- High forces involved
7
Q
Effects of movements within the lumbar spine
A
- Extension - loading through posterior structures of lumbar spine, increased pressure eon Z joints, reduced inter-formal space, increased lamina pressure, movement and loading of neural tissue
- Flexion - Increased intervertebral pressure, tensile loading in surrounding structures including ligaments posterior muscle and Z joints, movement and loading of neural tissue
- Side flexion - tensile load on contralateral disc, ligaments and muscles. Reduced ipsilateral interforaminal space
- Rotation - increased lamina pressure
8
Q
Coupled movements
A
Differs between upper and lower segments.
- Upper (l2-L3, L3-L4) - contralateral bending towards the opposite direction of axial rotation. (rotation to the right will cause bending to the left of contralateral side)
- Lower (L4-L5, L5-S1) - ipsilateral bending towards towards same direction of rotation.
9
Q
Lumbo-pelvic rhythm
A
- Bending forward - lumbar flexion followed by anterior pelvic tile
- Bending backwards - posterior pelvic tilt followed by extension
10
Q
Normal lumbar ROM
A
- Flexion, 40-60
- Extension, 15-35
- Lateral flexion, 15-20
- Rotation, 5-15
11
Q
What movements build Combined movements
A
- Ext combined - extension, ipsi rotation, side flexion. LOAD/COMPRESS posterior structures of lower two segments on same side
- Flex combined - flexion, contr rotation and side flexion. TENSION the posterior structures of lower two segments on the opposite side
12
Q
What is a directional preference
A
Position of movement that either needs to either be repeatedly loaded or teh position sustained to significantly improve either pain (intensity and/or location = central) and/or ROM
13
Q
Centralisation and peripheralization
A
Central = when symptoms move proximally Peripheral = When symptoms move peripherally
14
Q
Directional preferences example
A
- Normally directional preference is in extension, this can be noted in the patient interview if they state that standing and going for a walk will improve their symptoms.
- Flexion can also be a directional preference by lying supine and pulling knees to chest
15
Q
How to determine DP and why is this important
A
- Easing factors or positions stated by the patient in the interview. Some may not specifically say this so it is appropriate to ask “what happens when you stand and walk around”
- Repeated movement assessment in physical exam
- It is important to determine DP as it will influence the exercise and strategies provided to the patient around management
16
Q
Setting up for repeated movement exam
A
The likely direction should already be determined from interview.
Make sure the patient understand what is going to happen and why it is important:
- Going to determine what exercises and management, 5-10 times as far as you can comfortably go and aiming to go a bit further each time
- If it is pain provoking then stop
17
Q
Aim of repeated movement exam and how to reasses
A
The aim is to get improvement in one area:
- Slowly increasing extension
- Centralisation or reduce pain
- Improved AROM
Pain is the most likely factor but if the patient was already pain from on AROM then can re assess using a functional task that is given the patient pain
18
Q
What are you looking for with Palpation
A
- Allodynia or hyperalgesia (this may point to centralisation occurring)
- Atrophy or wasting
- Allowing the patient to become comfortable with touch
- Symptom reproduction
- Multifidous → erector spinae → quadratus lumborum
19
Q
PAIVM
A
- Determine segmental origin of symptoms
- Unilateral paivms on contralateral side
20
Q
PPIVM
A
Assess levels of flexion at each segment
21
Q
Lateral shift info
A
- Normally associated with sever LBP
- Patient adopts position in which they lean away from the pain (contralateral shift) i.e lean to left will often mean pain on the right hip
- The patient knows they are in an abnormal position
- Patient will appear normal in supine and the shift is only visible in WB
22
Q
Self correcting a lateral shift
A
This can be done during observation or after AROM
- Patient stands with side that the shift is occurring against the wall with either shoulder or elbow on the wall
- Lean hips towards the wall, holding for a few seconds and then bring them back to the midline if possible
- 5-10 reps and centralisation or ROM/reduction of shift is occurring
- Can apply overpressure with opposite hand
23
Q
Why is manual correction of a lateral shift not ideal
A
Correction can be done manually but because this is likely to cause pain it is much better to get the patient to do this.
24
Q
Aims from correcting a lateral shift
A
- Improvement in pain at rest
- Improvement in pain on AROM
- Reduction of shift in observation
- Centralisation
25
Functional outcome measures
Establish functional level and determine change over time
- Roland Morris functional Questionnaire
- Oswestry Disability Index
- Not just about function
26
Risk identification tools
Determine modifiable risk factors for developing persistent pain in those with acute LBP.
Also determines psychosocial and behavioural contributors in those with pain
Referred to as diagnostic triage to identify those at risk of poor recovery and needing extensive management
- Keele STarT Back screening tool
- Orebro Musculoskeletal Pain Questionnaire (OMPQ)
- Not just for LBP
- Fear avoidance Beliefs Questionaire (FABQ)
27
When (in the PE) is a neuro exam performed
The neuro exam is only performed in patients where it is required (from PI) and will take place after the active assessment (before manual)
28
Uses of a neurological exam
The purpose of the neuro exam is to confirm if the neurological system is effected. It can inform diagnosis as well as management but will also determine if URGET action needs to be taken. Can be used as an outcome measure over time.
29
UML location and effects
Lesion occurring in spinal cored, brain stem or motor cortex. Anywhere above the anterior horn cell.
Stroke, TBI and SCI are all examples of this.
Cause
- Increased reflexivity
- Weakness or paralysis either ipsilaterally or bilaterally that can spread greater than a single myotome.
- Disuse atrophy causes decreased muscle bulk that is widespread
30
LML location and effects
Lesion occurring in or distal to the anterior horn cell.
Cranial nerve nuclei, spinal roots and peripheral nerves.
Cause
- Decreased or absent reflexes
- Ipsilateral weakness or paralysis that is normally more localised to a segment or focal pattern.
- Neurogenic atrophy causing rapid wasting in a focal distribution
31
3 main red flags during neuro assessment
UML/ cord signs not previously diagnosed
Cauda Equina
Significant progression
32
Cauda Equina causes
Example of a lower motor neuron lesion that requires immediate medical referral (have 48 hours)
Main cause is disc herination therefore most common at L4/5 and L5/S1.
Patients with narrow spinal canal may be predisposed to this
33
Cauda Equina Diagnosis
- Parethesia in the saddle region
- Bladder retention or bowel dysfunction (inability or loss of control)
- Sexual dysfunction
34
2 types of cauda equina onset
- Acute
- Rapid development of symptoms that will include sever LBP, sensory and motor deficts in the lower body
- Gradual
- Progressively and symptoms may occur on/off over several weeks or months
- Recurring or persistent LBP with muscle weakness and numbness with baldder and/or bowel dysfunction.
- May occur with bilateral or ipsilateral radicular pain
35
UML diagnostic factors
Cervical - bilateral sensory symptoms in hands and feet, clumsiness when using hands
Thoracic - Bilateral sensory symptoms in feet
Reports of unsteadiness when walking
Weakness in groups of muscle
Increased reflexes - below the level
Requires immediate medical referral
However, if the patient say they have bilateral numbness and/or pins and needle and it is not related to onset of symptoms and usual to the patient this is ok.
If related to symptoms and not usual then refer.
36
What level does the spinal cord stop
L1
37
LML effects
Other than Cauda Equina there is no need for immediate referral
- Decreased sensation or sensory changes in a dermatome or peripheral nerve area
- Weakness or atrophy in muscle supplied by that nerve
- Decreased or absent reflexes in the muscle supplied by that nerve (myotome)
- Note that not all of these symptoms will occur together
38
Why should a neuro exam be performed
- When patient reports symptoms of abnormal conduction i.e p/n, numbeness, weakness that relate to LBP
- UML features (decreased control of active movement, difficulty walking)
- Neuropathic symptoms (burning, shooting)
- Any symptoms that extend below to the buttock crest (ischial tub)
39
Mechanosensitivity definition
Abnormal electrical activity related to mechanical force, loading or changes that lead to or contribute to symptoms. Output of nerves change in response to loading
40
What is a neurodynamic exam
assessment of the response of nerve and their surrounding structures to movement and tension or load
A neurodynamic exam determines if the patient symptoms are associated with mechanosensitvity, can also monitor mechano over time.
41
Why is neurodynamics important with respect to movement
Primary function of the nervous system is impulse conduction therefore need to facilitate this an any position or posture. This means the nervous system needs to be able to move, shorten, lengthen to continue impulse condition.
2 things happen with movement:
- Tension or pressure develops within the nervous system
- Movement of the whole neurosystem relative to its mechanical interface OR within the nerosystem neural elements move in relation to connective tissue
42
Presentation of someone with altered neurodynamics
- Postural variations (protective, deloading)
- Impaired active movements
- Nerve trunk hyperalgesia (areas of superficial tenderness)
- Specific areas of local pain or symptoms
- History of recurrent pain states such as recurrent hamstring or calf sprain
- Positive finding s on neurodynamics test
43
Vulnerable sites of neurodynamic compromise
These occur when a nerve is close to the surface or passing through a mechanical interface.
Lesions affecting the elasticity and movement of the NS normally occur at these sites:
- Soft tissue or osseous tunnel (Carpal tunnel)
- Nerve branching (head of fibula)
- Where nerves are relatively fixed
- Site of trauma
44
When should a neurodynamic exam not be performed
**Contraindications**
- Severe or worsening neurological signs
- Cauda equina symptoms
Spinal cord symptoms
- Sever pain include headache
- Significant dizziness or nausea
- Serious pathology (cancer)
**Cautions**
- Altered pathological status of other structures along nerve path (trauma)
- Systemic disorders
- Altered vascular conditions
- Neurological signs
- Latent response (pain long time after performing movement)
45
Positive finding in a neurodynamic exam
**Positive finding**
Reproduction of all or part of the patients symptoms (must be the same as reported). But then should also be able to reduce these symptoms with movements that reduce tension i.e. ext cervical
Other:
- Decreased ROM when compared to the test performed on the opposite side (SLR)
- Altered resistance through range
- Altered end feel
- Altered physiological response (different order of onset and radiation of areas of response)
46
Test in a neurodynamic exam
1. Passive neck flexion
2. SLR - L4-S2 and sciatic nerve
3. PKB - L2-L4 and femoral neve
4. Slump
47
What is the purpose of sensitising manoeuvres in a neurodynamic exam
Aim to differentiate between nerve and muscle
48
Referred pain definition
Pain perceived as occurring in a region of the body topographically distinct from where the actual source of pain is located
49
Neuropathic pain
A lesion or disease of the NS is identifiable and the pain is limited to a neuro area, nerve or NS structure
50
Radicular pain vs radiculopathy
Radiculopathy can occur in the absence of pain and is when nerve conduction is being affected due to nerve root compromise. While radicular pain is the pain that arise from one or more spinal nerve roots.
Radicular pain is not that same as radiculopathy, they can however often occur together.
51
Causes and appearance of radicular pain
Caused by:
- Mechanical deformation of DRG
- Mechanical stimulation of nerve roots
- Inflammation at or near DRG
- Ischemia to DRG
Differs from nociceptive pain due to the structure effected (DRG)
Sharp, shooting and close to the surface due to a high proportion of cutaneous afferent fibers being affected.
52
Most common site of lumbar radiculopathy
90% occur at L4-5 or L5-S1 due to traversing nerve being impinged by disc
Therefore, L5 or S1 radiculopathy are most common diagnoses
53
Type of nerve roots at each level
- Exiting nerve root
- Nerve root exits spine at a particular level
- Traversing nerve root
- Nerve root goes across the disc and exits the spina at the level below
The traversing nerve root is effected in lumbar radiculopathy
54
Disc herniation with respect to lumbar radiculopathy
High sensitivity but lower specific for a herniated intervertebral disc however the symptoms are most often a chemical response rather than the mechanical force or pressure being exerted by the disc onto the nerve root.
Many people have disc herniation without symptoms therefore radiculopathy is sometimes referred to as symptomatic disc herniation
- Positive SLR can be used to predict disc herniation
55
4 main causes of lumbar radiculopathy
- Chemical irritation (most common)
- Compression/traction
- Repetitive mechanical irritation (friction)
- Anoxia (lack of oxygen)
56
Other, less common causes of lumbar radiculopathy
- Z JT
- (cervical > lumbar) thickening effusion of Z jt capsule causing traumatic synovitis
- Developmental
- Congenitally narrow canal, especially lumbar
57
Symptoms of lumbar radiculopathy
- Dermatomal radiation, more pain on coughing, sneezing or straining
- Sensory dysfunction should be neuro anatomically logical (dermatome or myotome)
- Can have symptoms of central sensation at sites unrelated to the primary source of pain
LBP patient can have both neuropathic and central sensitisation pain
58
Radiculopathy vs central sensitisation
Strongest predictors of central sensitization are
- Disproportionate pain
- Non mechanical pain (random)
- Unpredictable patter of pair provocation (activity evokes pain sometimes)
- Small task = high pain
59
3 main LL nerve plexuses
Lumbosacral plexus = L1-S4
Lumbar = L1-L4
Sacral = L4-S4
60
Sciatic nerve origin and branches
Lower Lumbar and upper sacral plexus = sciatic nerve
Sciatic divides into the posterior tibial and common peroneal nerves at the popliteal fossa
61
Femoral, saphenous, obturator and LFCN basic path
The femoral nerve descends beneath the inguinal ligament.
The saphenous nerve continues down the medial leg into the foot
Obturator nerve exits pelvis through the obturator foramen where it innervates the thigh adductors and a small cutaneous area in the medial thigh.
The lateral femoral cutaneous nerve also has its origin directly from the plexus travels lateral to the femoral nerve underneath the inguinal ligament to innervate the skin of the lateral thigh.
62
Femoral nerve compromise
- Hip or pelvic fracture of masses within the iliacus muscle such as hematoma
- Weakness of quads with sparing of adduction (due to obturator)
- Sensory loss of anterior and medial thigh as well as medial shin to arch of the foot
- Quads reflex loss
63
Saphenous nerve compromise
- Due to trauma or compromise within adductor canal
- Occasionally the infrapatellar branch of saphenous nerve is damage due to mild trauma or knee surgery
- Loss of sensation below the knee, medial shin tom arch of foot and/or paraesthesia (p/n)
64
Lateral femoral cutaneous nerve compromise
- Compromise of trauma of the LFCT nerve as it traverse below the inguinal ligament
- Paraesthesia, pain and or number down lateral aspect of thigh
- No motor or lateral
- Risk factors include obesity, pregnancy, trauma
65
Pelvic and hip coupled movements
Ant pelvic tilt with flexion at hip
Post pelvic tilt with hip extension
Lateral pelvic rotation with abduction
Medial pelvic rotation with adduction
External and internal rotation coupled with transverse pelvic rotation
66
What is sacral nutation
Nutation is referred to as Sacral locking, this is with the SIJ ligaments are on stretch.
This occurs with the upper segment of the pelvic moves anterior while the lower moves posteriorly
Sacrum moves on the ilium
Bilateral movements that cause this are early trunk extension and end range flexion
Unilateral movements that cause are hip flexion
67
What is sacral counter nutation
Counternutation occurs when the lower portion of the sacrum moves into the pelvic and the upper move away
Referred to as sacral unlocking as it is not as stable, normal position of injury.
Bilateral - early trunk flexion and end of trunk extension
Unilateral - hip extension
68
Two main ways in which SIJ achieves stability
Form and Force closure
69
Form closure
Stable position due to bony surface and cartilage.
AP wedge shape of the sacrum.
Integrity of ligament
High coefficient of friction due to cores cartilage and groves through the SIJ
Form closure is the main reason why the ROM at the SIJ is so small, less than 4 degrees rotation and 1.6 mm of translation
70
Force closure
Extra forces provide stability, the myofascial system:
- Muscles
- Fascia
No muscle are directly attached to SIJ but instead overlay the area.
There are multiple different system of myofascial that do this:
- Ant - int/ext obliques, abdominal fascia, adductors
- Post - lats, glut max, thoracolumbar fascia
- Deep longitudinal - erector spinae, deep lamina of thoracolumbar, sacrotuberous ligament and biceps femoris
- Ant oblique - pblique abdominal, contralateral thigh adductor
- Lateral - glut medius and min, contralateral adductor (particularly relevant in WB)
71
Although there is many causes of SIJ pain they can be grouped into 2 (sometimes 4) categories
- Mechanical or inflammatory
| - Intra articular or extra articular
72
What symptoms would likely point towards an inflammatory condition causing SIJ pain
```
Joint stiffness (morning or after rest), swelling, multiple joints, other conditions present (fatigue, fever ect) More systemic symptoms
Some examples are:
```
- Rheumatoid arthritis
- Inflammatory bowel disease
- Ankylosing spondylitis
73
Mechanisms for mechanical SIJ pain
- Nociception from ligaments or gluteal origins
- Irritation due to over load (tendons, ligaments, joint)
- Excessive articular compression
- Fusion (ankylosing spondylitis
- Capsular fibrosis
- Dysfunction or excessive bracing of myofascial
- Insufficient articular compression (decreased form/force), disputed!
- Ligament laxity, lack of ability in myofascial system
74
Factors that may suggest a loss of form or force closure
- Habitual passive postures
- Excessive lateral pelvic and lower trunk rotation (pelvic drop with single leg)
- Poor glute function
- Abdominal bracing strategies
75
How to rule out the lumbar spine during SIJ tests
- Symptoms below L5
- No pain in lumbar with AROM (with OP)
- PAIVS do not replicate symptoms
76
What is spinal motor control
Spinal motor control is the control of spinal orientation to maintain overall spinal position.
77
3 key components to consider for motor control
Strength
Awareness
Overactivity
One of the most important aspects of motor control is the patient having awareness of their movements, its not just about strength and stability but being aware of what they’re doing and performing movements in a relaxed and unguarded way.
78
2 main muscles specific to local force closure on the spine
Maintain continuous low levels of activity, **anticipatory**, not direction specific. Especially relevant around neutral.
- Multifidus - atrophy and delay, particularly at painful segment
- Transverse abdominus - often a timing delay in LBP
79
Changes in muscle with persistent LBP and why is this relevant
Changes in muscle function are associated with injury and pain, particularly in persistent LBP. Specific changes to muscles include:
- Delayed, reduced or altered activation
- Enhanced activity
- Altered movement patterns
- Altered muscle morphology
80
Changes to specific muscles in patients with persistent LBP
These are particularly relevant in chronic LBP
- Abdominals - deeper have reduced strength endurance and activity while the superficial have increased activity
- Multifidus - reduced activity and delay. Wasting in chronic
- G max and Med - reduced endurance and delayed
- G max - Increased activity on lumbar flexion
- Illiacus - Reduced strength and/or endurance
81
Will changes to muscles seen in LBP persist after pain has resided
Yes
82
Main cause for muscular changes in people with LBP
After the initial inflammatory response that will cause muscular changes, the dramatic structural changes in chronic LBP occur due to disuse secondary to changed movement patters, fear avoidance and deconditioning.
83
Training in patients with chronic LBP
Training patients in chronic LBP will need initial consideration of activation patterns due to the individuals adaption but then resistance training for strength and endurance requiring progressive overload.
84
Evidence around motor control training
- Motor control training is better than manual therapy for chronic LBP and disability
- No difference between motor control exercises and other exercise approaches
- Therefore exercise should depend on patient preferences
85
Who may benefit from motor control exercise
Not everyone will benefit, only certain subgroups
The lumbar spine instability questionnaire can be used to determine this, it is mainly looking at perceived instability and persistence as the key factors.
86
Who to assess for motor control issues based on subjective and physical
Subjective:
- History of symptoms relating to repetitive loading
- Persistent LBP
- Feeling like giving way
- Pain when not getting up the right way
Physical:
- Aberrant movements (bracing, breath holding, fear of moving) observed on AROM
- Improvement in pain when task is modified
87
Is changing a techniques considered a motor control assessment
Assessing symptom response in change posture or a techniques is considered a motor control assessment as they assess awareness, strength and endurance
88
Duration of motor control training
- Motor control training will not change pain, function or behaviour in the immediate or short term
- If the patient is likely to be adherent and progress monitoring is not available it is not worth it, consider patient preferences.
89
What are the key features of the 2 main motor control impairments
**Flexion**
Have difficulty maintain neutral spine without going into flexion.
History of pain on flexion based activities especially with end range loading
Observation in sitting or standing as well as AROM may show early flexion and difficulty going into anterior pelvic tilt.
**Extension**
Have difficulty maintain neutral spine without going into extension.
History of pain on extension based activities especially with EOR loading. Prolonged standing.
Observation in sitting or standing as well as AROM may show early extension (lordosis) and difficulty going into posterior pelvic tilt.
90
What if you cant determine motor control impairment
If you cant tell from AROM and PI then move into motor control tests
91
2 types of motor control tests and when would you do them
Functional:
- To confirm motor control impairment
- Assess level of awareness
- Gives guide on where to start motor control exercise
Muscle groups:
- Where there is an improvement in symptoms with isolating a specific muscle group
- Where someone cannot perform the functional tests
92
Which functional motor control test should be chosen and what are the 3 key things being observed
Test determined by motor control impairment (from interview) OR can look at a task that the patient finds challenging.
Looking for three main things:
- Can they control movement
- Are they aware of their movements
- Do they have excessive bracing
93
When should isolate muscles tests for motor control
- When the patient cannot do functional tests or does with excessive bracing
- When there is an improvement in functional by using Ta contraction, particularly with SLR
94
Does poor motor control cause LBP
No
There is also no correlation with poor lifting techniques and LBP
It is just one of the MANY contributing factors (posture, loading ect)
95
What is the point of assessing motor control if it doesn't impact pain
Determining if they will benefit from motor control exercises
