Lumbar Flashcards
spondylosis
abnormal or diseased
spondylolysis
defect or fracture of pars interarticularis of vertebral arch
spondylolisthesis
forward displacement
Autoimmune disorders key symptoms
- multiple joint issues
- skin issues
- abnormal lab values (CRP, ESR)
- long term steroids, immunosuppresants
cauda equina syndrome
- bilateral leg symptoms
- saddle anesthesia SN
- bowel/bladder changes SN
- vague or intermittent
- red flag medical emergency
myotomes
L1-2: hip flexion
L3-4: knee extension
L4-5: ankle df
L4: ankle inversion
L5: big toes extension
S1: ankle pf, hip extension
SLR
- (+) if reproduction of normal distal symptoms
- sensitive for herniated disc compressing nerve root
X-SLR
- SLR on uninvolved side provokes pain down involved extremity
- potentially there is a large space occupying lesion
- specific
femoral nerve stretch test (prone knee bend)
- (+) is a burning or vague painful sensation down anterior thigh
- includes hip extension
radiculopathy
- strength loss in myotomal pattern
- sensation loss in dermatomal pattern
- decrease of associated DTR
manual therapy for acute LBP
Level A: thrust or mobilizations to reduce pain and disability
Level B: soft tissue for short term pain relief
manual therapy for chronic LBP
Level A: thrust or mobilizations to reduce pain and disability
Level B: thrust or joint mobilizations to reduce pain and disability with leg pain
Level B: soft tissue massage in conjunction with other treatment for short term relief
Level C: dry needling with other treatment for short term relief
leg pain CPG
level B: exercise training including specific trunk muscle activation and movement control
Level B: neural mobilizations with other treatment for short term relief
Level D: should not use mechanical traction
cancer
- skeleton is most common site of metastases
- 40% lumbosacral metastases
- common metastatic cancer causing lumbar pain is prostate
- prior hx of cancer: +LR 23 SP 98%
- ## age >50, unexplained weight loss, previous hx of cancer, failure to improve over 1 month: 100% SN, .06 -LR
spinal infection
- LBP, flank, pelvic pain
- local tenderness over spinal process with percussion
- concurrent infection or drug use
- fever
spinal compression fracure
- major trauma SP
- pain and tenderness
- age over 50
- femal
AAA
- midline lower thoracic/lumbar pain
- palpable pulsating mass
- patient unable to get comfy
- history of smoking
- positive family history
- history of AAA or vascular athersclerotic disorder
Emergent conditions for surgery
- cauda equina: decompression within first 48 hours or permanent neuro damage is possible
- trauma resulting in instability: fall or MVA
non-emergent conditions for surgery
- stable fracture
- herniated disc
- spinal stenosis
decompression surgery
- removal of structural elements of the spine thought to be impinging upon the neural canal
- referred to PT 2-6 weeks after surgery
- laminectomy, discectomy, fusion
fusion surgery
- form of surgery where the theorized mechanism of pain is the result of instability
- fusion seeks to decrease the accessory motion thus stabilizing th espine
disc arthroplasty
- prosthetic replacement for damaged IVD
nucleoplasty
- minimally invasive decompressive procedure using RF waves to destroy a portion of the nucleus
intradiscal electrothermal therapy
- various devices to deliver heat to the disc to either lower pressure, contract/cauterize tissue and seal the outer elements of the disc to limit loss of nuclear elements
laminectomy
- spinous process and lamina are removed
- facet joints remain
- treated with stabilization
decompression rehab 2-6 weeks
- TLSO
- amb as tolerated; AD as needed
- Bend, sit, and twist as tolerated with laminectomy or fusion
- limit bending and twisting and sit >30 min at a time with discectomy
- ankle pumps, quad, glute, ham sets, SAQ, LAQ
- abdominal bracing- add arms, legs, then both (wks 4-6)
- stab should all be in supine early in rehab
- treadmill as tolerated
- lumbar roll, neutral posture
- TENS, ICE
- STM
decompression rehab 5-12 weeks
- initiate wall slides, leg press, supine/sidelying abduction
- prone stabilization and quad stabilization (arms or legs but not both)
- progression 0-15/20# lifting
- flexibility in hams, gastroc, soleus, quads, hip flexors
decompression surgery 12-24 weeks
- begin work simulation activities
- progress treadmill to running as tolerated
- continue stability with prone planking, prone with arms extended, side planks
return to full PLOF at 6 months
Acute low back pain Level A (should use)
Manual
- thrust or nonthrust joint mobilization
acute low back pain Level B (may use)
Exercise
With leg pain
- muscle strengthening and endurance
- specific trunk activation
Manual
- STM
- Massage
Classification
- TBC
Patient Education
- active education and advise
- biopsychosocial contributors to pain
- self-management techniques
- favorable natural history
acute low back pain level C (can use)
Exercise
- general exercise training
Classification
- Mechanical diagnosis and therapy
acute low back pain level D (knowledge gap)
Exercise
- trunk mobility
- aerobic exercises
- multimodal exercises
Manual
- neural tissue mobilization
- TPDN
- traction
Classification
- Cognitive function therapy
- prognostic risk stratification
- pathoanatomic-based classification
- movement system impairment
Patient education
- pain neuroscience education
Chronic low back pain Level A (should use)
Exercise
- general exercise training
- muscle strengthening and endurance
- specific trunk activation
- aerobic
- aquatic
- multimodal
MOVEMENT CONTROL
- specific trunk activation
- movement control
OLDER ADULTS
- general exercise training
Manual
- thrust and nonthrust joint mobilization
Patient education
- PNE not as a stand alone treatment
- active treatment (yoga, stretching, Pilates, strength training)
chronic low back pain Level B (may use)
Exercise
- movement control
- trunk mobility
LEG PAIN
- specific trunk activation
- movement control
Manual
- STM
- massage
LEG PAIN
- thrust or nonthrust joint mobilization
- neural tissue mobilization
Classification
- mechanical diagnosis and therapy
- prognostic risk stratification
- pathoanatomic-based classification
Patient education
- active education as not stand alone
POST OP
- general education
chronic low back pain level C (can use
Exercise
POST OP
-general exercise training
Manual
- TPDN
Classification
- TBC
- Movement system impairment
- cognitive functional therapy
chronic low back pain level D (knowledge gap)
Exercise
- comparisons of different approaches
- optimal dosing parameters
Manual
- comparisons of manual therapy and active treatments
- value of manual therapy in multimodal approaches
Classification
- direct comparisons of different systems
Is traction supported with chronic low back pain with leg pain?
no
spinal stenosis
- older patients >65
- bilateral leg pain when standing or walking, resolves with leaning over or sitting
- does not improve with resting upright, worsens when walking downhill
neurogenic claudication (spinal stenosis)
- flexion improves, extension worsens
- walking distance varies
- must sit to get relief
- pulses present
- back pain common
- bilateral leg pain
- occasional weakness
- walking uphill is better
- walking downhill is worse
vascular claudication
- posture does not affect symptoms
- consistent walking distance
- stop activity to get relief
- diminished or absent pulses
- back pain uncommon
- leg pain may be unilateral or asymmetric
- weakness uncommon
- walking downhill unchanged or better
- walking uphill unchanged or worse
Dermatomes
- T12/L1 (L1) Iliac crest and groin
- L1-L2 (L2) anterior thigh
- L2/L3 (L3) anterior lower thigh and shin
- L3/L4 (L4) Medial calf and big toe
- L4/L5 (L5) lateral leg and anterior foot
- L5/S1 (S1) lower half of posterior calf, sole of foot and lateral two toes
- L5/S1 (S2) posterior thigh, sole and plantar aspect of heel
myotomes
- T12/L1 (L1) psoas
- L1/2 (L2) psoas
- L2/3 (L3) quad
- L3/4 (L4) tibialis anterior
- L4/5 (L5) extensor hallucis longus
- L5/S1 (S1) flexor hallucis longus, gastroc
- L5/S1 (S2) hamstrings
reflexes
- L2/3 (L3) patellar tendon
- L3/4 (L4) patellar tendon
- L5/S1 (S1) achilles
- L5/S1 (S2) hamstring (lateral)
category 1 red flag
- blood in sputum
- loss of consciousness or altered mental status
- neurological deficit not explained by monoradiculopathy
- numbness/paresthesia in perianal region
- pathological changes in bowel and bladder
- patterns of symptoms not compatible with mechanical pain
- progressive neurological deficit
- pulsatile abdominal masses
category 2 red flag
- age >50
- clonus
- fever
- elevated sedimentation rate
- gait deficits
- history of disorder with predilection for infection or hemorrhage
- history of metabolic bone disorder
- history of cancer
- impairment precipitated by recent trauma
- long term corticosteroid use
- long term work comp
- nonhealing sores
- recent history of unexplained weight loss
- writhing pain
category 3 red flag
- abnormal reflexes
- bilateral or unilateral radiculopathy/paresthesia
- unexplained referred pain
- unexplained significant upper r lower limb weakness
Lhermittes sign
- midline thoracic spine tingling produced with cervical flexion
local muscle characteristic
- deep
- aponeurotic
- slow twitch
- endurance activities
- poor recruitment
- activated at low resistance levels
- lengthen
local muscles
primary
- transversus abdominis
- multifidi
secondary
- internal oblique
- medial fibers of external oblique
- QL
- diaphragm
- pelvic floor muscles
- iliocostalis and longissimus
Laslett cluster SI joint tests
Thigh thrust
distraction
compression
sacral thrust
gaeslens provocation
other SIJ tests
Yoemens (prone hip extension)
stabilization special tests
- prone instability test
- posterior pelvic pain provocation test
- active straight leg raise test
- provocation of the long dorsal sacroiliac ligament
- provocation of pubic symphysis with palpation
- modified trendelenburg
meralgia paresthetica
entrapment of lateral femoral cutaneous nerve (sensory distribution to lateral hip and proximal anterior thigh
- cause most often by compression, use of tool belts, tight paints, belts lines in obese patients
internal oblique
when acting bilaterally, it is trunk flexor, when acting unilaterally, it creates ipsilateral rotation
According to Panjabi, the mechanism by which the spine is stabilized includes
- passive subsystem
- active subsystem
- neural subsystem
risk factors for diastasis rectus abdominis
- obesity
- narrow pelvis
- multipara
- 3rd trimester
- multiple births
- excess uterine fluid
- large babies
- weak abdominal muscles prior to pregnancy
McKenzie classification
- postural syndrome
- derangement syndrome
- dysfunction syndrome
Postural syndrome
young patient’s with intermittent symptoms of insidious onset who often have sedentary jobs
- mechanical deformation of normal soft tissues from prolonged end range loading of peri-articular structures
- treat with posture correction.
Derangement syndrome
- pain occurring as a result of a disturbance in normal resting position of affected joint surfaces
- reducible- loading produces lasting change in symptoms
- irreducible- fits history criteria for derangement but no loading strategy produces lasting changes in symptoms
- treat based on directional preference
- constant pain presentation
dysfunction syndrome
- pain occurring as a result of mechanical deformation of structurally impaired tissues
- tissues are scarred, adhered, or adaptively shortened
- treat in direction of dysfunction
- intermittent pain presentation
appendicitis
common in people younger than 30 years old and is normally associated with vomiting and fever.
A 46 year old female presents to your clinic with right groin and right lower-quadrant abdominal pain. She describes it as deep, dull, and achy with occasional cramping. The pain started 6 weeks ago without any known cause or trauma. The patient is only able to identify that her symptoms are worse during menstruation and that has accompanied increased menstrual bleeding. She also reports that taking nonsteroidal anti-inflammatory medication is the only thing that decreases her symptoms. Patient denies any other significant medical or surgical history including recent episodes of fatigue, fever, nausea, and bowel/bladder issues.
what is your primary hypothesis
uterine fibroids
