Lecture 2B: Lumbar Exam and Eval Flashcards
factors that influence complexity of LBP presentation
- genetics
- age
- lack of formal ed
- lower SES
- race
- physcial workload
- presencce of radiating pains
- smoking
- obesity
- psych
- comorbidities
potential causes of sciatica
- nerve root
- tumor
- abscess
- arthritis
- vertebral collapse
- inflammatory nerve disease
- toxins
- DM
- syphilis
need a thorough lumbar exam for neuro and vascular (hip, pelvis, LE exam)
low back pain algorithm chart
SUPER IMPORTNAT MEMORIZE AND UNDERSTAND
Pain discriptor and origin
- “deep, ache, boring”
- “dull, achy, sore, burning, cramping”
- “sharp knife like pain, tingling, shooting, numbness, weakness”
- “burning, stabbing, throbbing, tingling, cold”
- “deep pain, cramping, stabbing”
- bony tissue
- muscle/fascia
- nerve
- vascular
- visceral
more info slide 7,8,9
ALWAYS do this with a patient even though LPB and a serious pathology is LOW.
systems review
note: examine findings for consistent patterns to indicate serious pathology (back cancer)
intervention based solely on response to tissue loading and sx response
McKenzie and Maitland (treatment-based)
intervention based on treating pathological structure (CT healing model)
I.D. pathologic structure and stage it
Cyriax (structure based)
ULTIMATE GOAL for LBP patient
self-mgmt
Pt presents with:
Hx of trauma to SIJ and gluteal regions
* Pain around SIJ/piriformis mm
* Symptoms worsened w/ stooping or
lifting
* Palpable tension (i.e. rope-like) in
piriformis mm belly
* (+) SLR test
* Gluteal atrophy (depending on length
of symptoms)
piriformis syndrome
Defect in pars interarticularis, often asymptomatic
* Can be unilateral or bilateral
* Can be stress or trauma related
* Exact causes are unknown
* Typically occurs at L5, but can occur anywhere
Tx: surgical intervention only indicated when
conservative management has failed
Spondylolysis
patient with spondylolysis prefers (flex/ext)
flexion
- walking may be painful
spondylolsthesis
will lead to spinal instabilit. surgery indicated if PT didn’t work or neuro s&s occur
grades:
* Grade I: 1-25%
* Grade II: 26-50%
* Grade III: 51-75%
* Grade IV: 76-100%
* Grade V: >100%
order of susceptible structures to compression
- END PLATE
- vertebral body
- disc
disc herniation process
- End-plate fx d/t excessive compression
- Lesion heals OR disc DEGRADATION
- Exposes NP to blood supply
- Inflammatory response
- NP progressively loses H2O and disc
height - ↓ ability to resist loads
- ↑ load to AF (load on outer AF may be
painful) - Osteophyte formation on VB
- ↑ load on facet joints and more
osteophyte formation - Radial fissure in AF
- Internal disc disruption
stages of disc pathology
-
Protrusion: disc bulge w/o AF
rupture -
Prolapse: only outer layers of AF
contain NP - **Extrusion: **AF perforated and
disc material moves into
epidural space -
Sequestration: disc fragments
from AF and NP disconnect
end plate fx
- Trauma or specific MOI
- Acute pain/spasm
- (-) SLR
- (+) compression test
internal disc disruption
- Separation of inner layers
- LBP and/or referred hip/upper leg
pain - (-) SLR
- Dx made: discogram
Disc protrusion and prolapse
(contained)
- Some AF and PLL are intact
- LBP and/or referred hip/upper leg
pain - Pain w/ cough and sneeze
- (-) SLR
Disc extrusion and sequestration
(uncontained)
- LBP
- Pain w/ cough and sneeze
- True sciatica (radicular pain)
- (+) SLR
L4-5 disc pathology typically affects
L5 nerve roots
IMPORTANT TABLE SLIDE 20
Large herniation of L5–S1 disc
Compromises not only nerve root
crossing it (1st sacral nerve root)
but
also nerve root emerging through
same foramen (5th lumbar nerve
root)
Massive central sequestration of
disc at L4–L5 level
Involves all of nerve roots in cauda
equina and may result in B&B
paralysis
T/F LBP w/ radiculopathy outcomes not as favorable as mechanical LBP, but
conservative management often possible
true
foraminal encroachment
- Subluxed facet
- Facet osteophytes
- Vertebral osteophytes
- Laminar compression
- Disc protrusion/HNP
- Lateral stenosis
- Post-surgical scar
- Edema
- Tumor
all of the following could be Sx of ?
persistent buttocks pain,
limping, lack of sensation in LEs
(claudication) & ↓
walking/standing ability
vascular or neurogenic
vascular= think about the calf and walking
spinal stenosis
- Mid-line sagittal spinal canal
diameter ↓ - May elicit neuro claudication or
pain in buttocks, thigh or leg
centra stenosis
- Narrowing b/t sup facet & post
vertebral margin - May impinge nerve root &
subsequently elicit radicular pain
lateral stenosis
more stenosis classification slide 24
Hypomobility at 1 or both facet joints at a
lumbar segment
* AKA: segmental dysfunction
Pain and potential restriction w/ specific
lumbar AROM directions - Patterns may indicate area of dysfunction and is reprodocible
localized pain
TX: manual therapy, mobility, strengthening ex
z joint (facet) dysfunction
- Loss of normal passive restraints to motion
- Loss of active NM control
- Reports of recurrent back pain that ‘catches’
or ‘locks’ - Inconsistent symptomology
- Structural instability: (+) prone instability test
- Tx: responds well w/ conservative
management, recurrence is common if
program not maintained/activities △
clinical lumbar instability
- Chronic inflammatory disease of
unknown origin - 1st affects spine & progresses to
fusion of involved joints - Males, <30 y/o
- Typically follows a 20-yr course
- 90-95% of pts w/ AS have human
leukocyte antigen B27 - “Bamboo-spine” in radiography
- Tx: meds + conservative
management to slow progression
AS
- Lateral curvature of spine
- Can be congenital or acquired … many causes
- Can be structural or functional
- Pt lacks normal flexibility and SB becomes
asymmetrical - Idiopathic scoliosis accounts for 75-85% of all
cases of structural scoliosis - Tx: may require surgery if angle of curves are
severe enough
scoliosis
- Chronic condition
- Causes pain, stiffness & tenderness of muscles, tendons
& joints - Characterized by:
- Pain (100%)
- Restless sleep
- Wake up feeling tired
- Fatigue (90%)
- Emotional disturbances (>50%)
- Disturbances in bowel function
fibromyalgia
diagnosis of fibromyalgia
11/18 tender points w/o other reason for tenderness (unexplainable)
- AKA “shingles”
- Skin rash caused by same virus as chickenpox
- Exacerbation/recurrence w/ emotional
stress, immune deficiency, or w/ cancer - Contagious w/ person who has not had
chickenpox OR when sores are open & oozing - Several weeks of pain, burning (typically in
low back) prior to development of rash - Tx: medical management indicated, halt PT
until rash is no longer contagious
herpes zoster
table on slide 31
Acute or Sub-acute LBP w/ Mobility Deficits
Impairments:
* Segmental or global hypomobility
* Pain in ____, ____, ____ or
thigh
* Impaired functional movements
(i.e. squatting, lifting)
* (-) neuro tests
* Onset of symptoms <3 months
back, buttock, groin, thigh
Acute, Sub-acute or Chronic LBP w/ Movement
Coordination Impairments
Impairments:
* Segmental or global instabilities
* Pain in back, buttock, groin or thigh
* Worsens w/ ____ ____movements
* ↓ ____ control of voluntary
movements
Muscle weakness
* Fatigueable
* Non-fatigueable
* ↓ activity tolerance (i.e. sitting,
standing, running)
* Impaired functional movements (i.e.
squatting, lifting)
* (+) ____ segmental instability test
end range
NM
prone
Acute LBP w/ Related (Referred) LE Pain
Impairments:
* Segmental or global hypomobility
or instabilities
* Significant pain in back, buttock,
groin or thigh
* Postural deficits
* ↓ activity tolerance (i.e. sitting,
standing, running)
* Impaired functional movements
(i.e. squatting, lifting)
* Onset of symptoms <3 days
* (+) ____ testing
repeated movements
Acute, Sub-acute or Chronic LBP w/ Radiating Pain
Impairments:
* Segmental or global hypomobility or
instabilities
* Radiating pain (often times below the
knee) in a dermatomal pattern
* Muscle weakness
* Fatigueable
* Non-fatigueable
* ↓ activity tolerance (i.e. sitting,
standing, driving, running)
* Impaired functional movements (i.e.
squatting, lifting)
* (+) ____ exam
* (+) ________ tests
* (+) ____ ____ movements tests
neuro exam
neurodynamic exam
repeated movements tests
Acute or Sub-acute LBP w/ Related Cognitive or
Affective Tendencies
Impairments:
* Sensitivity to ____ stimuli
* Displays range of emotions
* Pain in back, buttock, groin or thigh, lower leg
* Tendency to ____ physical symptoms
for emotional/affective reasons
* High scores on ____ and Pain
Catastrophizing Scale
* Impaired ____
* ↓ activity tolerance (i.e. sitting, standing,
running)
* Impaired functional movements (i.e.
squatting, lifting)
* Inconsistent MSK exam results
* Onset of symptoms <3 months
* (+) ____’s test
- noxious
- elaborate
- FABQ
- ADL
-waddell’s test
Chronic LBP w/ Related Generalized Pain
Impairments:
* ____ pain (present in back, other body structures or globally)
* ____ w/ MSK dysfunction
* Appropriateness of emotion
* △’s in brain and sensory structures
* High scores on ____ and Pain
Catastrophizing Scale
* Impaired ____
* ↓ activity tolerance (i.e. sitting,
standing, running)
* Impaired functional movements (i.e.
squatting, lifting)
* Inconsistent MSK exam results
* Onset of symptoms >3 months
- generalized
- inconsistent
- FABQ
- ADL
