L7 Radicular Conditions Flashcards
Key Exam Findings: Manip/Mob
- No symptoms distal to knee
- Recent onset <16 days
- Low FABQ
- Lumbar hypomobility
- Hip IR PROM >35°
Key Exam Findings: Stabilization
- younger age, <40
- 3+ prior episodes
- Increasing frequency of episodes
- Aberrant movement patterns
- SLR >91°
- pos PIT
- General Hypermobility
Key Exam Findings: Specific Direction/Centralization
- Symptoms distal to knee
- Symptoms centralize w/repetitive EXT or FLEX
- May have + nerve root signs
- pos SLR
- Presence of lateral shift
- Older Age
Key Exam Findings: Traction
- pos leg symptoms
- pos nerve root signs
- peripheralization with EXT
- inability to centralize
- peripheralization with crossed SLR
Interventions for Manip/Mobilization pts
- mob, manip, MET
- AROM
- stabilization
- address regional deficits
Interventions for Stabilization pts
- local activation of deep core
- general strengthening
- postural awareness
Interventions for Specific Direction/Centralization patients
- Directional specific exercises initially unloaded and progress to loaded
- temporary avoidance of aggravating direction
- Neurodynamics
Interventions for Traction patients
- mechanical or manual traction
- Modified WB temporarily
- Progress to repeated EXT
Radicular Pain
pain caused by a problem at the nerve root
ex: sciatica
Radiculopathy
weakness, numbness, loss of function caused by a problem at the nerve root
can be due to disc herniation, bone spur, trauma, stretching
Referred Pain
pain from a problem in a muscle, joint, etc that is felt in a place different to where the problem is
Directional Preference/Specific Exercise
pt reports flexion consistently makes LE pain appear and worsen, standing up and walking makes it feel better
specific exercise for this pt would be extension based until flexion isn’t aggravating
Loading Strategies
passive or active forces applied by patient or PT with the goal of effecting positive change, progressing towards end of range without flaring pt symptoms
Centralization at the ____
1st appt is a positive predictor of success with PT
What do nerves need to be healthy?
blood flow
movement
space
Progression of Disc Lesions
- Bulging
- Protrusion
- Extrusion
- Sequestration
Why can disc herniations get better?
the autoimmune system recognizes disc herniations into the spinal column as foreigners, so disc herniations cause an inflammatory response of neovascularization, matrix protease activation, increased inflammatory cells, phagocytosis, and enzymatic degradation.
most do not require surgery
What are signs that a disc herniation might need surgery?
cauda equina syndrome
progressive loss of nerve function
lack of response to conservative function
Progression of Sciatica
- Compression
- Ischemia
- Impaired axonal transport, demyelination, axon degeneration
- Loss of nerve function
- Chemical irritation
- Inflammation
- Gain of nerve function (pain, hyperreflexia, hyperesthetic)
Radiculopathy Prevalence
-most common in male 30-50
-3-5% of US population
-majority of cases spntaneously resolve over time
RF for Radiculopathy
driving occupations
lifting and twisting
previous history of LBP
obesity
smoking
multiple pregnancies
Patient Exam for Radicular Conditions
- Observation
- Functional Testing
- Movement Testing; AROM with OP and Repeated Motions
- Neural Exam
Femoral Nerve Tension
neurodynamic test for LE
passively flex the knee and maintain for >20s looking for reproduction of neurologic symptoms
indicative of L2-L4 lesion
Differenetial diagnosis for radiculopathy
gluteal tendinopathy
focal neuropathies
hip joint issues
AVN
SIJ
piriformis irritation
Radicular Pain…
leg pain > back pain
neuro descriptors
+ SLR
below knee
loss of function
well localized
shooting
dermatomal
Referred pain…
back pain > leg pain
poorly localized
dull, aching pain
- SLR
Surgery for radiculopathy
clear myotomal deficits
unresponsive to PT
increases speed of recovery but has same outcomes as conservative care
Mechanical Diagnosis and Therapy (MDT)
classifying patients into a particular category based on a thorough patient history and careful analysis of patient response to repeated, end range movements and postures
emphasizes patient empowerment and self-treatment
high reliable, not just extension of spine
Primary Syndrome Classifications
Derangement
Dysfunction
Posture
Other
Derangement
-most common syndrome
-mechanical obstruction to movement within the joint
-inconsistent and changes
-symptoms can be local, referred, radicular, combo
-Onset is sudden, with no known cause, or gradual
-S/S can be influenced by postures or normal daily activities and may change throughout the day
What is a hallmark of derangement syndrome?
directional preference
Treatments for derangement involve
specific movements that cause the pain to decrease, centralize, and/or abolish
Dysfunction Syndrome
-refers to pain which is result of mechanical deformation of structurally impaired tissues
-S/S are present for 6-8 weeks
-pain is ALWAYS intermittent and arises at end range
-includes adhered nerve roots
Treatment for Dysfunction Syndrome
repeated movements in direction of dysfunction or direction that causes pain
aim is to remodel the tissue that is limiting movement through exercises that become pain free over time
Posture Syndrome
-refers to pain which occurs due to a mechanical deformation of normal soft tissue from prolonged end range loading of periarticular structures
-pain arises during static positioning
-pain disappears when pt moves out of static position
-no pain with active movement
Treatment for Posture Syndrome
patient education
correction of posture
avoiding provocative postures
avoid prolonged tensile stress on normal
Other Syndrome (MDT)
spinal stenosis
hip disorders
SI disorders
LBP in pregnancy
chronic pain syndrome
inconclusive or unresponsive
structurally compromised
post surgical problems
trauma
Extension Direction Specific Exam Findings
s/s distal to knee
s/s centralize w/ext
s/s peripheralize with flex
+ nerve root compression
+ SLR
Flexion Direction Specific Exam Findings
S/S peripheralize w/ext
nerve mobility deficits
older age >65
possible LSS
s/s distal to knee
+ nerve root compression
+ SLR
Lateral Direction Specific Exam Findings
s/s peripheralize w/ext
s/s centralize w/flex
frontal plane deviation of shoulders
asymmetric side bending ROM
+ nerve root and SLR
limited SB ROM opposite of lateral shift
Extension Direction Specific Interventions
-extension exercises
-mob to promote ext
-avoid flexion
-address neurodynamics
Flexion Direction Specific Interventions
-flex exercises
-mobs to promote flex
-modified ambulation
-avoid ext
-address neurodynamics
Lateral Direction Specific Interventions
-lateral shift correction in standing
-NWB shift correction
-address neurodynamics
Derangement w/ Lateral Shift
-shift is named for direction shoulders are going, typically away from painful side
-perform slide glide/shift with patient
Patient should stop action if
worsening ROM
pain
peripheralization
Patient should continue action if
centralizing
increased ROM
reduction in pain
Patient should exercise caution when
produced symptoms, not worse afterwards
What to do once pt has centralized
reclassify them
stabilize
mobilize
educate
Are manips or mobs better for lumbar dic herniation with radiculopathy?
MOBs with neurodynamic mb
Overview of patients: referred pain from spine
-back pain with POS spine exam
-treat w/mob or stabilization, reassess LE s/s
Overview of patients: radicular pain from spine
derangement classification
-centralize with one direction and peripheralize with another
-MDT repeated or sustained exercises and postures that centralize pain
Overview of patients: adhered nerve root dysfunction
-scar tissue around nerve
-chronic s/s
-end range directionally specific movements produce s/s but no worse after movement
-neural mobs and spinal mob
Overview of patients: traction
no specific movement that central
+ crossed LSR
responds well to manual/mech/self tract
Traction for Lumbar Disc
purpose: increase lateral foraminal space for neurovascular flow
dosage: 30-40lbs or 25% BW for 5-10 min. 60s on and 20s off
prone or supine
Traction for Lumbar Joint
purpose: increase space for facet jt, intervertebral jt
dosage: 50 lbs or 50% BW for 10-30 min, 15s on and 15s off
supine with pt in hook lying
Sidelying nerve and joint mobs
for sciatic and femoral
30s of oscillating grade 2-3 sidebend mobs for 2-3 sets
reassess neural tension and other impairments afterwards
