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OS > Lumbar Spine Somatic Dysfunction Lecture > Flashcards

Lumbar Spine Somatic Dysfunction Lecture Flashcards

1
Q

Incidence of Lower Back Pain

A
  • 85% of the General Population will have Lower Back Pain
  • 2 to 5% of the general population reports LBP yearly
  • Back pain occurs in 35% of Adolescent athletes
  • Overuse back injuries are prone to recurrence
  • 26% males/ 33% females
  • 27% of back pain in Adults is due to Musculoskeletal Strains
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2
Q

General Consideration

A
  • LBP is the #2 reason patients of to the doctor
  • Majority of causes DO NOT REAUIRE Surgical Intervention
  • Causes a Massive financial burden
    a) Cost of Treatment
    b) Expense of Lost work
    c) Legal costs (Workmans comp, Disability, Person Injury)
  • Emotion burden as well
    a) Increased Stress
    b) Depression
  • $100 BILLION IN TOTAL COSTS/ YEAR!!!!!11
  • 75% of total cost is attributed to Less than 5% of patients with LBP
  • This means we spend to most money on a very small percentage of patients with LBP ($75 Billion on 5% of LBP patients)
  • Majority of pain is due to MECHANICAL DYSFUNCTION
  • Lumbar spine is Frequent site of:
    a) Strain
    b) Pain
    c) Disability
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3
Q

Anatomy

A
  • Vertebrae are built to support heavy loads in a fairly Neutral Plane
  • Structure allows for fair amount of FLEXION and EXTENSION
  • Less of Sidebending and Rotation due to SAGITTAL ORIENTATION of FACETS
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4
Q

Anatomic Variants

A
  • SACRALIZATION of L5!!!!!!!!!!
  • Lumbarisation of S1!!!!!!!!!!!!!!!!!!
  • Spondylolysis: Fracture in PARS INTERARTICULARIS!!!!
  • Lumbar Herniated Disc!!!!
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5
Q

Etiologies

A

1) MECHANICAL
- Arthritis
- Spondylosis/ Spondylolysis/ Spondylolisthesis
- Degenerative Disc Disease
- Somatic Dysfunction

2) NON-MECHANICAL
a) VISCEROGENIC
- Ex: Renal Colic, Endometriosis

b) VASCULOGENIC
- Ex: Abdominal Aortic Aneurysm

3) INFECTION
- Osteomyelitis
- Diskitis

4) TUMORS
- Primary: MYELOMA
- Metastatic:
a) Breast
b) Prostate
c) Lung
d) Kidney

5) METABOLIC
- Osteoporosis

6) Rheumatologic
- Rheumatoid Arthritis

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6
Q

Red Flags in Low Back Pain

A
  • Major Trauma Mechanism

- Age > 50 or

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7
Q

Example of Mechanical Etiology: Spina Bifida

A
  • Recall that the spinous process is formed from LAMINAE
  • FAILURE of FUSION —> Spina Bifida (“Split Spine’)
  • Neural Tube Defects: DECREASED incidence with FOLATE Supplementation
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8
Q

Spina Bifida 3 types

A

1) Spina Bifida Occulta
- Congenital
- Common L5-S1
- Asymptomatic
- May have patch of coarse her over site
* **NO SPINAL PROTRUSION

2) Meningocele
- Meninges FORCED OUT between Vertebral Spaces

3) Myelomeningocele
- MOST COMMON TYPE
- Unfused portion of the Spinal Column allows Spinal Cord to PROTRUDE through an OPENING!!!

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9
Q

Example of Mechanical Etiology: SPINAL STENOSIS

A
  • The spinal canal contains the CONUS MEDULLARIS, FILUM TERMINALE, and CAUSE EQUINA
  • Cord terminates at the level of L1-2
  • Diameter can become COMPROMISED —> “Stenotic”
  • The diameter also Normally DECREASES with Age

Causes of Compromise:

  • Hypertrophy of Posterior Longitudinal Ligament
  • Thickening of Ligamentum Flavum
  • Osteoarthritis
  • Exostoses
  • Tumors
  • Disc Rupture
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10
Q

Cauda Equina Syndrome

A

Multiple Etiologies:

  • Infection/ Inflammation
  • Herniated Disc
  • Metastasis
  • Spinal Stenosis
  • **These all place pressure on the CAUDA EQUINA

Causes:

  • Pain, numbness, or tingling in low back/ Lower extremity
  • Progressive weakness and Paralysis of Lower Extremity
  • Bladder and Bowel incontinence, Sexual Dysfunction
  • This is often a SURGICAL EMERGENCY!!!!!
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11
Q

So, How do we figure out the Problem?

A

** A THOROUGH H&P!!!!!!!!

Especially the ROS!!!!!

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12
Q

Examination

A
  • Observation
  • Palpation
  • Motion Testing
  • Neuromuscular Exam: Strength and Sensation
  • Vascular Assessment
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13
Q

Lumbar Exam

A

1) Range of Motion
- Patient seated/ Standing

2) Screen with Fingers
- Note skin changes, tenderness, etc
- TART
- Hip Drop Test for Lumbar SB

  • hone in on these areas for further examination
    a) Gross motion testing (Flexion, Extension, Rotation, Sidebend)
    b) Single segment motion
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14
Q

Barrier Concept

A

1) Anatomic Barrier (Passive ROM)
2) Physiologic Barrier (Active ROM)
3) Pathologic Barrier (Loss of Motion)
- This is where the complaint lies
- This is where you will be working with your patients

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15
Q

Mechanics

Lumbar Spine

A
  • Just like Thoracic Spine
  • Follows TYPE I mechanics in NEUTRAL POSITION
  • Follows TYPE II mechanics in NON-NEUTRAL Position
  • This is the rule in Normal Mechanics and Dysfunction
  • Lumbar SP and TPs are at the SAME LEVEL!!!!
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16
Q

Lumbar Exam

A
  • Patient either prone or seated
  • Induced an ANTERIOR FORCE on the Right Transverse Process (LEFT ROTATION)
  • Repeat for the Left (RIGHT ROTATION)
  • Repeat Rotation Test with Flexion, then Extension, and compare to Neutral
17
Q

Type I Mechanics

A

TONGO (Maintained by LONG RESTRICTOR MUSCLES!!!!!!!)

  • Predominantly in the NEUTRAL SPINE
  • Sidebending and Rotation occur in the OPPOSITE Directions

L3-5 N RR SL

**SIDBENDING OCCURS FIRST!!!!!!!

18
Q

Type II Mechanics

A
  • Predominantly in the FLEXED or EXTENDED Spine
  • Rotation and Sidebending occur in the Same Direction

L4 F RR SR

***ROTATION occurs FIRST!!!!!!

  • Maintained by SHORT RESTRICTORS!!!!!!
    a) Intertransversarii
    b) Multifidus
    c) Rotatores
19
Q

Nomenclature

A
  • Named for position of ANTERIOR ASPECT of Superior/ Cephalic Bone in relation to Inferior/ Caudad Bone (Relationship of L4 to L5)

Description:

1) Level of Dysfunction
2) Neutral of Flex/Ext
3) Type:
a) Type I: SIDEBENDING FIRST, then Rotation
b) Type II: ROTATION FIRST, then Sidebending

20
Q

Lumbar Exam

A

1) If motion is roughly the same in both Flexion and Extension:
- Neutral Dysfunction
- Follows Type I Mechanics

2) If motion is more restricted in Flexion or Extension:
- It is a Flexion/ Extension Dysfunction
- Follows Type II Mechanics

3) The Flexion/ Extension component of the POSITION DIAGNOSIS is the plane in which the Restriction move MORE FREELY!!!

21
Q

Lumbosacral Mechanics

A
  • Sacrum and Lumbar spine move in Opposite Directions

***LUMBAR FLEXION —-> SACRAL EXTENSION

***LUMBAR EXTENSION—–> SACRAL FLEXION

22
Q

Viscerosomatic Reflexes

A
  • Also called “Segmental Facilitation”
  • Our visceral organs are innervated by Nerves Originating from different segments of the Spinal Cord
    1) SYMPATHETIC —-> THORACOLUMBAR Region

2) PARASYMPATHETIC —-> CRANIOSACRAL REGION
- Dysfunction in these Organs can cause Palpable Somatic Dysfunctions at these associated Segments
- VIscerosomatic = From VISCERA —> SOMA!!!

23
Q

Viscerosomatic Reflexes

A

1) Pancreas: T6-9 Bilaterally
2) Kidney, Ureters: T10-L1 on Corresponding side
3) Ovaries, TEstes: T10-L1 on Corresponding side
4) Adrenals: T10-L1
5) Appendix: T11- L2 on RIGHT with associated Ribs
6) Uterus: T10-L2
7) Urinary Bladder, Prostate: L1-2
8) Colon: T8-L2, Ascending RIGHT Side, Descending LEFT SIDE
9) Rectum, Anus: L1-2

24
Q

Chapman’s Reflex

A
  • FRANK CHAPMAN D.O
  • Tender point “CLUES” used for Dx of Visceral Dysfunction
  • Anterior and Posterior Points
  • Tender point is PALPABLE as a Small Smooth Firm Nodule (2-3 mm) —> Like a Pea
  • Good inter examiner reliability and correlates with Discharge Diagnoses
25
Q

Chapman’s Reflexes

Anterior Points

A

1) Periumilical: Adrenal, Kidney, Bladder
2) 5th ICS: Stomach (left), Liver (right)
3) 6th ICS: Stomach (left), Liver/ Gallbladder (Right)
4) 7th ICS: Spleen (Left), Pancreas (Right)

26
Q

Chapman’s Reflexes

Poster Points

A

1) Kidney
2) Bladder
3) Urethra
4) Uterus
5) Colon
6) Pelvic Organs

27
Q

Management

A
  • Address the cause
  • Use OMT to adress Mechanical causes and Help in VISCERAL CAUSES

Medical Management:

1) NSAIDS: Caution with Renal Insufficiency or GERD
2) Muscle Relaxants
3) Tricyclic Antidepressants
4) Narcotics JUDICOUSLY!!!!!

  • Surgical Management if indicated
28
Q

Note of Prescribing Narcotics from CDC

A
  • Each day 46 people die from an overdose of Prescription Painkillers in the US
  • Health care wrote 259 million prescriptions for Painkillers in 2012, enough for every American adult to have a bottle of pills
  • 10 of highest prescribing states for Painkillers are in the South

What can we (Healthcare providers) do?
- Use monitoring programs to ID patents who may be misusing their prescription drugs

  • Follow best practices for responsible Painkiller prescribing:
    1) Screen for substance abuse and mental health problems
    2) Avoiding combinations of prescription painkillers and sedatives unless theres is a specific medical indication
    3) Prescribe the LOWEST EFFECTIVE DOSE and only the Quantity needed
  • Talk with out patients
  • Discuss risks and benefits of pain treatment options, including those that don’t include prescription Painkillers (Like OMM)!!!!!!

OS (9 decks)

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