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Ortho > LBP/ SI managment > Flashcards

LBP/ SI managment Flashcards

1
Q

Why is manual therapy treatment beneficial?

A
  1. Psychological changes- Placebo
  2. Biomechanical changes:
    - Improved movement - gains in ROM, normalized movement patterns
    - Improved position – realign the spine (coming out of favor)
  3. Neurophysiological changes
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2
Q

What are the neurophysiological changes in manual therapy?

A
  1. Hypoalgesia – diminished sensitivity to pain
  2. Muscle reflexogenic – decrease in hypertonicity of muscles
  3. Central Mediated- Alterations in pain “experience” in the brain; Lessening in temporal sensation (an experience where brain demonstrates an increased perception of painful stimuli)
  4. Peripheral Inflammatory - Alteration of blood levels of inflammatory mediators
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3
Q

What are the 4 primary lesions that respond to manip?

A
  1. Entrapped synovial folds/plica
  2. Hypertonic muscle
  3. Articular or periarticular adhesions
  4. Segmental displacement
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4
Q

What are the absolute contraindications to manipulation?

A
  1. Cancer of targeted region
  2. Cauda Equina syndrome
  3. Vertebral Basilar insufficiency
  4. Gross Spondylolithesis
  5. Fracture
  6. Psychogenic disorders
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5
Q

What are the precautions to manipulations?

A
  1. Hypermobility- Quick stretch ”reset” the muscle surrounding the joint; Core and muscles around the core are activated better
  2. Severe pain
  3. Muscle guarding
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6
Q

What are the relative contraindications to manipulation?

A
  1. Osteoporosis (depending on intent and direction of movement, and where the osteoporotic bones are)
  2. Systemic disease
  3. Active, acute inflammatory conditions
  4. Neurologic deterioration
  5. Significant segmental stiffness
  6. Long term corticosteroid use (if cervical spine)
  7. Blood clotting disorder
  8. Genetic Disorders with laxity i.e. Down Syndrome
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7
Q

What are the short term and long term benefits of a mob vs a manip?

A
  • For short term relief, manip is better; helps pt perform ROM and strengthening exercises
  • for long term relief, there is NO difference in restoring mechanical ROM
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8
Q

In the lower cervical spine (C3-C7), side flexion results in [contralateral/ ipsilateral] rotation.

A

ipsilateral

  • Should not be used for dx or to steadfastly diagnose patient malalignments or to perform a dedicated treatment technique
  • varies in upper segments of occiput-C2
  • no consistent coupling pattern in thoracic or lumbar spine
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9
Q

True or false:
You don’t need to get caught up on a specific nerve or joint in nerve biasing and joint specific techniques because you are most likely mobilizing multiple nerves, and/or multiple vertebrae

A

True

  • NOT specific to a single nerve (Kleinrensink et al. 2000)
  • Joint specific technique forces are dissipated throughout a large area and are NOT specific to a given segment
  • when mobilizing, you’re mobilizing 3 segments above and below
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10
Q

What are the risk factors for LBP?

A
  1. Occupations That Require Repetitive Lifting: > with Forward Bent/Twisted; Prolonged Sitting
  2. Exposure to Vibration
  3. Cigarette Smoking
  4. Certain Sport Activities: Gymnastics , Cross-country Skiing
  5. Age
  6. Female
  7. BMI
  8. Activity level
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11
Q

What are the risk factors for chronic LBP?

A
  1. Fitness Level/health Status
  2. Duration of Symptoms
  3. Localization of Symptoms (radiating = acute, localized on back = chronic)
  4. Number of Previous Episodes
  5. Job Satisfaction
  6. Attitude Toward Conservative Care
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12
Q

Why is imaging for acute LBP not usually justified or warranted?

A

Pts show signs of recovery shortly after onset

  • MRIs are expensive
  • up to 90% ppl over 60 that are HEALTHY have findings of bulging discs on MRIs
  • incr in MRIs related to incr in surgical procedures that have not consistently shown to reduce painful symptoms
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13
Q

When is it appropriate for an MRI to be used?

A
  1. used when a serious underlying condition is suspected
  2. if symptoms of numbness, weakness in the leg are progressing
  3. If results of the imaging scan are likely to change your immediate treatment options
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14
Q

Are MRIs useful for diagnosing LBP?

A

No, considerable mis-classification in all groups of providers; support for clinical guidelines against routine use of MRI in LBP pts

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15
Q

What causes caudal equine syndrome? what are the symptoms?

A

Causes:
- Large Central Herniated Disk at L4-5 or L5-S1
- Space Occupying Masses (Tumors or Hematomas)
Symptoms:
- Loss of Bowel or Bladder Control
- Saddle Anesthesia Around the Perineum
- Lower Extremity Weakness or Paralysis

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16
Q

What are the clustered results that indicate stenosis?

A
  1. B symptoms
  2. Leg pain > back pain
  3. Pain during walking/standing
  4. Pain relief upon sitting
  5. Age > 48 yrs
    - stenosis falls into hypomobile category
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17
Q

Can you do PT with someone who has lumbar spinal stenosis?

A

Yes, PT regimen yields similar effects to surgical decompression

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18
Q

When should spinal fusions be used, as supported by evidence?

A
  1. Trauma
  2. spondylolisthesis
  3. rarely, disc herniation
  4. rarely, spinal stenosis without spondylolisthesis
    - DDD is NOT an indication
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19
Q

What are the benefits for receiving PT in the 1st episode of LBP?

A

Significantly reduces healthcare costs compared to delayed PT or non-adherent pt tx. Decreased likelihood of:

  1. injections
  2. surgery
  3. advanced imaging
  4. opioids
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20
Q

What are treatment options for pain-dominant problems for acute pain or recent exacerbation of chronic pain?

A
  1. Modalities
  2. Mobilization
  3. Positioning
  4. Exercise
  5. Relative Rest
  6. Aquatic Therapy
  7. Postural Correction
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21
Q

What are treatment options for pain-dominant problems for chronic pain without recent exacerbation?

A
  1. exercise
  2. postural correction
  3. patient education
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22
Q

Where can back pain originate from?

A
  1. Muscle
  2. Apophyseal Joints
  3. Sacroiliac Joints
  4. Spinal Dura
  5. Intervertebral Disc
  6. Ligaments
  7. Dorsal Root Ganglion
  8. Nerve Root
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23
Q

Where are the nociceptors for SI joint? what are the signs that indicate SI joint involvement?

A

Nociceptors from L2-S4

  1. Related to three or more positive pain provocation tests
  2. Pain when rising from sitting
  3. Unilateral pain
  4. Absence of lumbar pain
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24
Q

What is the pain sign that indicates facet joint involvement?

A

Associated with absence of pain when rising from the seated position
-pain comes from capsule that contains free nerve endings

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25
Q

How is the spinal dura implicated in back pain?

A
  • Few nerve fibers innervating the dura mater itself
  • Attaches to the nerve root near the intervertebral foramen
  • Adhesion of the dura mater may limit mobility of the nerve root and stimulate a compressed or irritated nerve root
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26
Q

Where is the intervertebral disc innervated?

A

outer ½ - ⅓ of the annulus innervated by free nerve endings

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27
Q

What are the common characteristics of a pt with a herniated nucleus pulposus?

A
  1. Age: 30-50
  2. Pain Pattern: Location - Back, Leg (Unilateral), Onset: Acute (Prior Episodes), Standing: Decrease, Sitting: Increase, Bending: Increase
  3. SLR: +
  4. Plain X-ray: -
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28
Q

What is an effective (non-PT) treatment that has been proposed for herniated nucleus pulposus?

A

antibiotics

  • nearly ½ of ppl with dx develop bacterial infection
  • antibiotics treat inflammation caused by bacterial infection
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29
Q

What ligament appears to have the greatest concentration of free nerve endings?

A

Posterior longitudinal ligament

- free n endings in ligaments, in general, are stimulated by mechanical stress and chemical mediators

30
Q

Where are the DRGs situated?

A

under the pedicle, adjacent to the superior facet

- sensitive to mechanical deformation in the absence of inflammation

31
Q

What causes nerve root pain?

A
  1. Mechanical compression + inflammation around the n root induces more n. root injury than each factor alone; chem stimulation from inflammation generates pain; compression alone normally does not cause pain
  2. tension/ bending: leads to edema and ischemia
  3. Extruded disc material biochemically irritates the n root
32
Q

What are treatment options for hypo mobile problems?

A
  1. Soft Tissue Mobilization
  2. Segmental Vertebral Mobilization
  3. Exercise
  4. Posture and Body Mechanics Training
33
Q

What are treatment options for hyper mobile problems?

A
  1. Modalities
  2. Soft Tissue Mobilization
  3. Segmental Vertebral Mobilization, Manipulation?
  4. Exercise - stabilization
34
Q

What are treatment options for postural problems?

A
  1. Patient Education
  2. Exercise – core and axial mm
  3. Soft Tissue Mobilization
  4. Joint Mobilization
35
Q

What should you evaluate for treatment of LBP in adolescents?

A
  1. Decreased length of hamstrings and quadriceps
  2. Decreased lumbar extensor strength
  3. Decreased hip joint mobility
    - ^^most likely culprits, but evaluate all m’s above and below spine
    - stabilization category is most likely
    - this group usually doesn’t have “back problems” but rather muscle length issues
36
Q

What questions should you ask when assessing body awareness and sensitivity to determine if pt has a central pain issue?

A
  1. Does thinking about the body part hurt?
  2. Can that part be touched?
  3. Can it be used normally
  4. Is it perceived to be healthy or unhealthy?
  5. Do they have other Central Pain state conditions? (Fibromyalgia, migraines, TMJ, IBS, etc.)
37
Q

What signs and symptoms point to pain caused by tissue damage?

A
  1. connective tissues stiff
  2. swelling
  3. neural tension
  4. sore and stiff muscles
  5. trigge points
  6. weak and deconditioned
  7. predictable patterns of healing
38
Q

What signs and symptoms point to pain caused by central pain state?

A
  1. parasthesia
  2. diffuse pain, unpredictable pattern
  3. flares up with little provocation
  4. allodynia
  5. chronic pain greater 3-6 months
  6. stress and anxiety increase pain response
39
Q

What are the evidence based strategies to treat CLBP?

A
  1. Focus on maintenance of Function: Graded Activity – ignore pain behaviors, focus on goals, improvements, function
  2. Education: Cognitive Behavioral Therapy (CBT), Therapeutic Neuroscience Education (TNE)
  3. Core stability exercise: Pts have rapid atrophy of multifidus, TA has delay in contraction when stabilizing spine while extremities move (tend to activate erectors before TA), Stabilizing mm – QL, Obliques, TA, Erector/ multifidi
  4. Glut max strenghtening
  5. Hamstring length should be evaluated
  6. Aerobic exercise
    * *psychosocial factors are strongest predictors of persistent pain and disability in LBP pts
40
Q

What are key components in cognitive behavioral management of patients with CLBP?

A
  1. be aware of your language
  2. pain does not = harm, injury does not = harm (approx 40% non-symptomatic people have bulging disc on MRI)
  3. You should move despite pain
  4. pain is unavoidable but suffering is optional
41
Q

How can you empower your patient?

A
  1. Highlight goals and positive outcome measures each visit
  2. Stay away from discussions on “pain” and the MRI which found “disc bulges”
  3. Educate our patient that disc pathology does not = symptoms/pain
  4. Highlight the benefits of function
42
Q

How can you tell if a pt is having SI or LBP?

A
  • can occur simultaneously
    1. SI usually can be pinpointed at PSIS or along SI joint
    2. SI more often unilateral, occasionally bilateral
    3. SI pain at end of full active trunk forward and backward bending or SB toward side of pain
    4. PSIS pain after prolonged standing or walking
43
Q

What are the signs for an SI dx?

A
  1. SLR positive on side of pain around 70-90 deg
  2. Positive cluster of SI provocative special tests (3/4)
  3. SI positional tests that indicate asymmetry in pelvis, hip ROM (ER > IR by 15 deg), leg length
  4. Decreased active trunk ROM
    • result from SI manipulation
44
Q

What needs to get fixed first before moving onto the SI joint unless working with pregnant women?

A

More mobile joints: Trunk and hip mobility!

  • symphysis pubis moves very little, 1-2 mm maximally
  • separation of 1 cm occurs in some pregnant women
45
Q

What role does musculature/ ligamenture play in SI pain?

A
  1. Hip ER, IR, flexor, extensor musculature all effect SI motion
  2. Hypermobility and strain on ligaments can cause pain
46
Q

What outcome measures help classify LBP patients into subgroups for treatment?

A
  1. Fear Avoidance Beliefs Questionnaire(FABQ)
  2. Modified Oswestry Low Back Pain Disability Questionnaire
  3. The Roland-Morris Low Back Pain and Disability Questionnaire
  4. The Patient Specific Functional Scale (PSFS)
47
Q

What constitutes a significant change on the outcome measures of pain scale, Oswestry, and FABQ?

A
  • 2 points on pain scale
  • 6 points on oswestry
  • FABQ - 2 sub scales (physical activity and work): >34 on physical activity sub scale = prolonged disability; >18 on work subscale decreases manip success
48
Q

What are the classification criteria for manipulation treatment group?

A
  1. No symptoms distal to the knee
  2. recent onset (< 16d)
  3. Low FABQ score (<19)
  4. Hypomobility of L spine
  5. Hip IR ROM >35 for at least 1 hip
    Factors against: sx below knee, incr episode frequency, peripheralization with motion testing, no pain with spring testing
49
Q

What are the classification criteria for stabilization treatment group?

A
  1. younger age (<40yrs)
  2. Greater general flexibility (postpartum, avg SLR ROM >91)
  3. Instability catch or aberrant movement during lumbar flex/ext ROM
  4. Positive findings for prone instability test
  5. for postpartum pts:
    - positive thigh thrust, ASLR, and modified trendeleburg tests
    - pain provocation with palpation of long dorsal SI big or pubic symphysis
    Factors against: discrepancy in SLR ROM <10, low FABQ (<9)
50
Q

What are the classification criteria for specific exercise treatment group with extension?

A
  1. symptoms distal to buttock
  2. symptoms centralize with extension
  3. symptoms peripheralize with flexion
  4. directional preference for extension
    - possible disc herniation
51
Q

What are the classification criteria for specific exercise treatment group with flexion?

A
  1. older age (>50 yrs)
  2. directional preference for flexion
  3. imaging reveals spinal stenosis
    - possible DJD, stenosis, usually older
52
Q

What are the classification criteria for specific exercise treatment group with lateral shift?

A
  1. visible frontal plane deviation of shoulders relative to the pelvis
  2. directional preference for lateral translation movements of pelvis
    - possible IV disc pathology
53
Q

What are the classification criteria for traction treatment group?

A
  1. S and S of n root compression

2. no movements centralize symptoms

54
Q

What are the interventions proposed for manipulation classification treatment group?

A
  1. Manipulation of the lumbopelvic region

2. Active ROM exercises

55
Q

What are the interventions proposed for stabilization classification treatment group?

A
  1. Promoting isolated contraction and cocontraction of the deep stabilizing muscles (multifidus, transversus abdominus)
  2. Strengthening of large spinal stabilizing muscles (erector spinae, oblique abdominals
56
Q

What are the interventions proposed for specific exercise for extension classification treatment group?

A
  1. End-range extension exercises
  2. Mobilization to promote extension
  3. Avoidance of flexion activities
57
Q

What are the interventions proposed for specific exercise for lateral shift classification treatment group?

A
  1. Exercises to correct lateral shift:
    - After correction of lateral shift these pts may move into extension exercise category and follow treatment ideas for that group
    - If can’t correct lateral shift in standing, can put pt in prone position (non weight bearing)
  2. Mechanical or autotraction
58
Q

What are the interventions proposed for specific exercise for flexion classification treatment group?

A
  1. Mobilization or manipulation of the spine and/or lower extremities
  2. Exercise to address impairments of strength or flexibility
  3. Body weight-supported treadmill ambulation
  4. Hip joint mobilizations: Pts lack hip extension –> greater demand for lumbar extension (which pts in this subgroup can’t tolerate well)
59
Q

What are the interventions proposed for traction classification treatment group?

A
  1. Static force best for younger pts
  2. Intermittent force for older pts
    – subset of patients who benefit from traction are those that have nerve root compression symptoms and don’t experience centralization with repeated movements
60
Q

What are features of nerve root irritation?

A
  1. Extremity pain> spine pain
  2. Quality of paint differs form referred pain
  3. Clear demarcation of pain pattern in extremity
  4. Proximal pain and distal paresthesias
  5. Neural tension testing reproduces extremity pain
  6. Gentle spinal motion results in excessive irritation
61
Q

What are features of nerve root compression?

A
  1. Muscle wasting
  2. Muscle weakness
  3. Sensory impairment
  4. Quality of reflexes altered
62
Q

What are the special tests that implicate nerve root involvement?

A
  1. Slump

2. SLR

63
Q

What are the structures implicated in radiating symptoms?

A

Nerve roots!

- irritation, compression, or combination

64
Q

What are treatments for radiating symptoms?

A
  1. Specific exercise decreased symptoms
  2. Spinal Mobs
  3. Traction
  4. Stability program
  5. Dural adhesion, nerve root impingements =Neural flossing techniques (on/off method or neural gliding)
65
Q

does neural tensioning or sliding result in the greatest excursion in nerve flossing technique?

A

Sliding

  • 5 times larger than tensioning!
  • neurodynamic exercises for the lower limb results in different scientific nerve excursions
66
Q

What special tests are useful for identifying patients in the stabilization classification?

A
  1. Prone instability test
  2. Posterior pelvic pain provocation test (Pt in supine, PT passively flexes patient’s hip to 90° applies posteriorly directed force through femur. + if patient reports deep pain in gluteal area)
  3. Active straight-leg raise test
  4. Provocation of the long dorsal sacroiliac ligament- positive test occurs if at least 1 side is painful, and the pain persists at least 5s after the removal of the therapist’s hand
  5. Provocation of the pubic symphysis with palpation- pain persists at least 5s
  6. Modified Trendelenburg test
67
Q

What are some of the proposed effects for spinal manipulation?

A
  1. Mechanical- breaking up intra-articular lesions
    
2. Neurological- stimulates mechanoreceptors & “resets” nocioceptive pathways

  2. Hydraulic- change the viscosity of synovial fluid
    
4. Relaxation- decrease in muscle tone & restore normal blood flow
    
5. Psychological- both laying hands on the patient & hearing a “pop” are strong influencesReleasing entrapped facet capsule or meniscoid
68
Q

Why does manipulation feel so good?

A
  • Fires type III mechanic receptors, inhibiting m tone

- releases endogenous hormones

69
Q

what are the negative effects of hearing cavitation during manipulation?

A
  1. Hypermobile joints become unstable
  2. Especially with repeated self manipulation
  3. Excessive stress to intervertebral disc
  4. Dependency on release of endogenous opiate-like substances
70
Q

What are the transient side effects of manipulation?

A

muscle and joint soreness, but rarely lead to ST impairment in functional status

  • severe complications (caudal equina) are rare in L spine
  • much less dangerous that NSAIDs (GI bleeds)
71
Q

True or false:

Exercise is really the only thing that will prevent pts from experience disability.

A

False

  • pts receiving only exercise were more likely to experience a worsening in disability
  • adding manipulation will improve outcomes
72
Q

Should we manipulate in the presence of image proven lumbar disc herniation?

A

yes, we can if it is an appropriate treatment for that patient

Ortho (10 decks)

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