Lumbar eval Flashcards
what is the rhomberg test used for?
Used to test balance. Have patient hold position of feet together without socks or shoes with arms crossed on chest. If patient can hold position for 30’ w/o falling or swaying repeat with eyes closed.
Sharpened Rhomburg position: tandem stance
Grading
normal = hold for 30’
what is the purpose of the Nucleus pulposus
- shock absorber
- Dehydrated discs can increase load to facet joints
- Diurnal variation: lose ~25% fluid during day, rehydrate at night
- fluid loss is also a normal rxn to aging and trauma
- when depressurized ( 2/2 age or trauma)
what kind of joint is the ZPJ? What kind of motion occurs here?
synovial plane joint
- flexion is allowed
excess anterior translation is blocked
What role does a meniscoid play in the ZPJ?
aka fat pads or fat plugs
- may be innervated and be a source of symptoms
What is a motion segment?
IVD + facet joints
how many degrees of flexion and extension are available?
flexion: 45-55
ext: 15-25
what are intrinsic muscles of the back?
Semispinalis, multifidus, rotatores, interspinalis intertransverasasrius - needed to provide precise control - a part of the active system
what are Extrinsic back muscles?
4 abdominals, erector spinae, QL, psoas major, hip muscles -- a part of the active system
what is the role of the diaphragm and pelvic floor
maintain intrabdominal pressure for stability
- therefor breathing mechanics are important
- a part of the active system
Where does the neural system receive its input from and what does it do
Receives input from passive and active subsystems to determine requirement for maintaining stability
- Effectiveness may be impaired with injury -.Failure to regain control may lead to further injury/ reinjury
- Received afferent input
Are you able to retrain the system by synthesizing active, passive and neural systems?
yes.
localized and general stabilization may be achieved by first demonstrating sufficient mobility for movement at each level, accomplished by the passive system AND Stability/ balance/ proprioception at each level accomplished by neural system.
what is the insertion and the origin of the semispinalis muscles ? action? innervation?
semispinalis capitus origin: TP of C3-6 > insertion: base of occiput
extension and lateral flexion
semispinalis cervicis TP of T1-T6> SP C2-5
extension and head rotation to the contra-lateral side
semispinalis thoracis TP T6-12 > SP C6-T4
contralateral rotation of the trunk, bilateral lateral flexion and extension
all innervated by dorsal primary rami
essentially all SS will go from the TP> SP with the exception of capitus which inserts at base of skull. Cervisis and thoracis split the t-spine into 2; one originates at the top 1/2 and the other at the bottom half, respectfully. Cervis goes on to insert at all but the top c-spine SP and Thoracis inserts at all SP of the t-spine but the top 2.
What are conditions you may be screening for in a lumb pelvic screen?
cancer, AAA, Compression fracture, cauda equina syndrome, back related spinal infection, Ankylosing spondylitis .
A patient presents with LBP as their main complaint. They have pain on their flank, TTP on SP they use to be on antibiotics. At this point, what should you do? What could this be?
Take a temperature, esp if symptoms are not lining up to MSK origin. refer out 2/2 possible spinal infection
A patient is about to turn 51 and has been in PT since his 50th birthday, what could you suspect with no PT improvement?
- Cancer/back related tumor
- age >50
- unexplained weight loss
- previous history of cancer
- failure to improve over one month a 100% sensitivity
- Skeleton is most common site of metastases of cancer
- 40% metastases in lumbosacral
- Common metastatic cancer that causes spinal pain is from prostate
a patient has Sensory or motor deficits in feet (L4, L5, S1) and cant remeber the last time he voided. What should be your next question and why?
PT may have cauda equina syndrome. You should ask if they have saddle anesthesia. refer our for Neurologic emergency
Who is at an increased risk for compression fractures?
women over 50 yrs
- presents after major trauma
Where can a Abdominal aortic aneurysm be palpated?
Common on left side of abdomen
what are Clinical manifestations of AAA
- Midline lower thoracic / lumbar pain 2.Palpable pulsating abdominal mass
- Pain descriptors: throbbing, pulsating - (throbbing is a sign for vascular concern)
- Patient unable to find comfortable position
- History of smoking
- Positive family history
Who is at an increased risk for Ankylosing spondylitis ?
amles with hx of Inflammatory arthropathy, systematic rheumatic disorder, chrons or IBS.
If you suspect that someone has Ankylosing spondylitis, what could you see in their presentation?
- Morning stiffness > 30 min duration 2.Improvement in LBP with exercise but not with rest
- Night pain during second half of night only
- Alternating buttock pain
- 2of 4 present: Sn 37%, Sp 84%, +LR 2.3
- 3 of 4 present: Sn 37%, Sp 97%, +LR 12.4
You are trying to figure out of pain is msk related or not, what cluster of Qs do you ask?
i. Does coughing, sneezing, or taking a deep breath make your pain worse? (yes, indicates MSK)
ii. Do activities such as bending, sitting, lifting, twisting, or turning over in bed make your pain feel worse? (yes MSK related))
iii. Has there beenany change in your bowel habit since the start of your symptoms? (no, MSK realted)
then ask
- Does eating certain foods make your pain worse?
- Has your weight changed since your symptoms started?
both should be no for msk related disorder
What information are you looking for regarding renal, urinary disorders?
Do you have any trouble with urination?
Ask about changes in urine color, initiation of stream, incontinence, flow changes (frequency, urgency, output volume, retention, pain with urination)?
For sex specific questions, what info may be valuable?
discharge, pnful sex, period cycle, menopause, pregnancies,
overall, what signs should you look for, for visceral origin pain?
- BMI in low range
- severe pelvic pain
- urinanry freq/ urgency
- sudden and insideous onset of symps with unknown origin
- constant pn worse with walking, bending, - sleep disturbance
- severe disability in young/ healthy pt
- lower ab TTP
- neg med tests
- fam hx of rheumatic and endocrien disorders
what is the modified oswestry
10 items scored as a percent
- increased score = increased disability
what is the FABQ?
-Assess patient belief about work and physical activity
- can ID those who are at risk for prolonged disability
-
what is considered a small but meaningful change on the NPRS for LBP?
1.5-2 points
what should you remember to do when implementing an intervention ?
- test- retest
- asterisk signs
decribe the flow of teh lower quarter screenign exam
- start in standing
- observation and posture
- functional observation and clearing
- fxn myotomal assessment
- clearing movement tests with over pressure
- seated clearing tests
- seated neuro exam
- specific tests - SLR
- prone clearing with central PAs or unilateral
what myotomes are tested with a step up ?
L3 and L4
hip flexion and knee extension
what myotomes are tested with heel walking?
L4 and L5
knee ext and DF
what myotomes are tested with a calf raise ?
S1 plantar flexion and S2 toe flexion
List myotomes
L2-3: hip flexor L3-4: knee extensors L4: ankle dorsiflexor L5: hallux extension S1:ankle plantar flexors
list dermatomes
L1. inguinal area L2: anterior mid-thigh L3: medial knee L4: medial malleolus L5:distal medial dorsum of foot S1: lateral border of foot S2: medial/ posterior calcaneus
what reflexes are in the lower extremity ?
L2-4: patellar reflex
S1-2: achilles reflex
when perfoming the SLR, your patient has familiar synptoms below 40-45 degrees, is associated with what ?
- lumbar radiculopathy
- Above 45 degrees may be adverse neurodynamic
(nerves are sensitive but typically not due to disc herniation/ bulge)
what are indication for higher level of care?
a. Serious or progressive neurological findings
b. Non-responsive to care c.Sinister conditions (Red flags)
d. Yellow flags (depending on magnitude.. refer but still treat)
What are 6 fxns of the vertebrae ?
a. Protect the spinal cord b.Upright posture
c. Transmit bodyweight to lower extremities
d. Shock absorber
e. Allow motion of the head and trunk
f. Muscle attachments for stability and mobility
where is the annulus fibrosis thicker?
anteriorly, allows for lordotic curve
Does teh water content decrease or increase with age?
the NP is made up of 70-90% of water and decreases with age
- when hydrated, allows for
shock absorption and force transfer
lumbar flexion, explain the mechanics
flexion increases foramen opening, which can decompress the nerve root
- restraints for flexion are the posterior anulus, facet capsule, supraspinous ligament, interspinous ligs, PLL, posterior musculature
- during flexion the VB will glide anteriorly slightly and rotate anteriorly.
lumbar extension, explain the mechanics
- the VB will rotate and glide on posteriorly
- restraints for extension are the ALL, anterior annulus and musculature
- facets close with extension
What is hinging ?
- no true lumbar extension occurring
- as the pt tries to extend, the lower lumbar VB stay vertical and there is excess movement in the upper lumbar region
- the patient will be hypermobile at VB and hypomobile at lower segments which may be due to facet or muscular tightness
What occurs when we bend forward?
lumbar and hip flexion occur, about 40* of L flexion and 70* of hip flexion.
- Initially LF> HF
- Middle of bend LF=HF
- Final HF> LF
what occurs when we stand up from a bent postion
initial: hip extension
final: lumbar extension
- watch for reversal; pt initiate with in lumbar extension with LBP
Which side of the lumbar spine compresses during lumbar rotation.
contralateral side closes
what muscles form a force clousure for the pelvis?
Force closure is generated by contraction of the stabilizing muscles and their attachments to the bones and ligaments of the SI joint
-Erector spinae, lats, piriformis, transverse abdominis, internal oblique, gluteus maximus
what is most likelytight on a patient with an anterior pelvic tilt?
Tight illiopsoas
-ASIS is lower than PSIS, ↑lumbar lordosis, weaker abs, sacrum is counternutated
what is lower crossed syndrome
-weak abs
- weak glute max
tight hip flexors; which places strain on lower back during terminal stance of gait
- tight thoracolumbar extensors; loads facet joints
what are complaints that a patient may say that would lead you to believe the issue is of MSK origin?
i. Cyclic (symptomsfluctuate)
ii. Buttocks/thigh
iii. Pain with movement - pain starts with movement
iv. Usually worse through day v.Relieved with change in position
vi. Relieved with lying down / fetal position
vii. May wake at night but east to return to sleep
what are complaints that a patient may say that would lead you to believe the issue is of non MSK origin?
i. Severe,unremitting (don’tease up)
ii. Deep;gnawing; bone pain iii.Often unaffected by position or movement
iv. Severe night pain
v. Severe spasm
If a patient complains of an constant ache, how would you explain the reason?
inflammation, venous hypertension
If a patient complains of pain with movement, how would you explain the reason?
painful stimulus to receptors due to stretch, pressure or crush
- noxious mechanical stimulus
If a patient complains of pain accumulation with movement, how would you explain the reason?
repeated mechanical stress
inflammatory process
degenerative disc; less protection from repetitive loading
If a patient complains of pain increased with sustained postures , how would you explain the reason?
muscle fatigue - fatigue of supporting muscles
- gradual creep of tissues
-
If a patient complains of latent nerve root pain, how would you explain the reason?
movement has produced an acute and temporary nueropraxia
what are predictors of chronicity within the first 6- weeks (yellow flags)
- nerve root pn or specific spinal pathology
- reported severity of pain at acute stage
- beliefs about pn being work related
- psychological aspects of work
- compensation
- time off work 2/2 injury
- the longer someone is off from work w. LBP the lower the prob they return
what age is ankylosing spondylitis most likly found in?
18-45
- a.Chronic, progressive inflammation
b. Involves entheses –bony insertions of ligaments, tendons and capsules c.Primary joints - .SI
- Spine
- Large peripheral -However,it is systemic and may present initially as hip or shoulder pain
OA affects which AGE GROUP primarily ?
45+
Which age group is suspectible for herniation of nucleus pulposus)/ radiculopathy?
30-55
Acute,recurrent iii.Pain,numbness below the knee
iv.LMN signs v.Unilateral vi.SLR (Sn 0.91, Sp 0.26)
vii.Crossed SLR (Sn 0.29, Sp 0.88)
what age group does cauda equina primarily effect?
40-60 -Saddle anesthesia -Urinary retention(Sn 0.9, Sp 0.95) -.LMN and/or UMN signs -Unilateral or bilateral Causes: 1.Trauma 2.HNP 3.Tumor 4.Stenosis
what age group does stenosis primarily effect?
60+
ii. Generally increase with Lx extension, ease with flexion iii.Limited walking, better with flexion
iv. LMN, possible UMNv.Stages TM or bike test
what are risks for spinal infection?
i. Recent infection
ii. Recent surgery or injections
iii. Immunocompromised –prolonged oral steroid use
iv. Druguse
v. Sexualcontact
vi. Diabetes
Diagnostic rule for vertebral fracture ?
i. Female
ii. Age >70
iii. Trauma
iv. Long term corticosteroids
what are serious signs of pathology to look out for?
i. Temp > 100 degrees F
ii. BP > 160/95
iii. Resting pulse > 100bpm iv. Resting respiration > 25/min
What CPR is available to predict who will benefit from lumbar manipulations?
i. Current symptom duration < 16 days
ii. Fear avoidance beliefs questionnaire (FABQ) < 19 iii. Hypomobility of L spine with PA pressure
iv. IR of at least 1 hip < 35 degrees
v. No symptoms below the knee
- When 2 factors were present: Recent onset of symptoms <16 days No symptoms below the knee 91% post test probability of success
what are Factors that favor against manips ?
Factors that favor against manips Symptoms below the knee Increasing episode of frequency Peripheralization with motion testing No pain with spring PA (PA mobility) testing
what else shoudl you consider while treating a patient who falls into the manip sub category
a. You are treating a patient, not just a low back
b. Lear about and address all aspects of the patient
i. Functional requirements of that individual; Work, life, sport
ii. Psychosocial factors
iii. Physical impairments
c. Consider other treatment-based classification subgroups d. Must respect severity and irritability of the patient
what is the prone instability test (PIT)
- perform PAs on the patient to see if pain is reproduced
- if pain is reproduced, have the patient lift legs off from floor while holdign on to the table
- if PAs are less painful, the test is POSITIVE and the patietn may benefit from stability exercises
