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Neuromusculoskeletal > PT4 - Lumbar Spine > Flashcards

PT4 - Lumbar Spine Flashcards

1
Q

What are red flags?

A
  • signs of serious pathology e.g. CES, fracture, tumour, unremitting night pain, sudden weight gain/loss, bladder/bowel incontinence, saddle anaesthesia
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2
Q

What are yellow flags?

A
  • beliefs + appraisals + judgements
  • e.g. unhelpful beliefs about pain => indication of injury as uncontrollable or likely to worsen, expectations of poor TTT outcome, delayed return to work
  • e.g. emotional responses => worry, fears, anxiety
  • e.g. avoidance of activity due to expectations of pain + over reliance on passive TTT
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3
Q

What are Orange flags?

A
  • psychiatric symptoms e.g. clinical depression, personality disorder
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4
Q

What are blue flags?

A
  • relationship between work and health
  • belief that work is too onerous and likely to cause further injury
  • workspace supervisor + workmates are unsupportive
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5
Q

What are black flags?

A
  • system/contextual obstacles
  • legislation restricting options for return to work
    Conflict with insurance staff over injury claim
  • overly solicitous family/health care providers
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6
Q

What is included in the clinical temporal profile?

A
  • speed of onset e.g. acute, subacute, chronic
  • duration e.g. acute, subacute, chronic
  • symptom picture e.g. focal, multi focal, diffuse
  • progression e.g. stable, recovering, fluctuation, unmasking
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7
Q

What is the structure + function of the LSP?

A
  • support/protection for neural + visceral structures
  • allows forward movement of centre of gravity
  • transmission of body weight forces
  • transmission redirection + absorption of forces
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8
Q

In the LSP what works together to control movement and force transmission?

A
  • disc + facet joints
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9
Q

What is the classics presentation of NSLBP?

A
  • unilateral
  • no red flags
  • may or may not have radiations
  • may be relieved by meds
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10
Q

What % of PTs will present with LBP?

A
  • 90% will present with LBP
  • 5% will have leg pain (probably not objective symptoms => neuro reveals no loss of reflexes or power)
  • 1% will be more interesting
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11
Q

What LBP diagnosis are we likely to see in clinic?

A
  • spondylolysis => pars fracture
  • spondylolythesis => slipped pars fracture (lytic => fracture / non-lytic => no fracture, but slippage more likely in older generation due to degenerative spondylolythesis)
  • kidney infection => any changes to smell of urine, blood, temperature change, malaise, overweight/unfit women can result in incontinence
  • neoplasm (space occupying lesion) => less frequent => see every 3/4 years => has LBP => pain gradually getting worse => imaging required as change management of the TTT
  • ankylosing spondylitis/Reiters disease (reactive arthritis => can clear up)
  • PMR => affects either shoulder or hip girdle, never fully symmetrical
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12
Q

What LSP diagnosis are we less likely to see?

A
  • CES => a symptom => disc involvement => unlikely to get central compression => osteoporotic collapse is first sign => starting to go to the toilet more often, not always sure when they need to go (if diagnosed early outcomes are very good) => ask do you know when you need to release bowels/urine?
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13
Q

Why does LBP occur?

A
  • lots of forces go through LSP
  • has the most anomalous (different) vertebrae
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14
Q

What directions do the lumbar facet joints face?

A
  • top => middle = parafacet (face more vertically upwards to integrate with TSP) for flexion/extension
  • lower => facets face frontal direction => allows for more rotation
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15
Q

What’s special about the iliolumbar ligament?

A
  • in a child it’s a MM
  • ## special ligament that runs from L5, sometimes L4 (in PT with attachments at L4+L5 => reduced risk of LBP)
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16
Q

What does the iliofemoral ligament control?

A
  • hip extension => don’t want MM to stabilise legs while walking as not efficient => iliofemoral ligament creates tension on iliolumbar ligament => drives counter rotation of spine
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17
Q

What drives movement?

A
  • fascia + ligamentous material
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18
Q

Which 2 ligaments in the LSP/Legs are a pair?

A
  • iliofemoral + iliolumbar ligaments => work together to be efficient in locomotion
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19
Q

What happens when iliofemoral ligament + iliolumbar ligament are less efficient?

A
  • can happen in arthritis
  • standing becomes less efficient
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20
Q

What’s special about the shape of the LSP vertebrae?

A
  • wedge shaped for weight bearing
21
Q

What happens to multifidus in a healthy back?

A
  • MM development of multifidus can result in a healthy back
  • multifidus blends with the capsule
  • has a proprioceptive capacity especially for rotation
22
Q

What is spinabifida occulta?

A
  • don’t get full union of an SP @ L5
23
Q

What can happen in spinabifida occulta if there isn’t an L5 SP?

A
  • not enough attachment site for multifidus
  • 25% more likely to get LBP
  • the nerve at L5/S1 doesn’t form as well => travels down leg to support perineals
  • perineals control eversion of foot => deep perineal nerve not as well formed can lead to inversion => pres cavus foot
  • as the PT ages, this can result in the arch becoming more pronounced as L5 nerve decays => loss of perineal MM function => painful feet
24
Q

What gives our limbs our shape?

A
  • neuronal tissue out growing
  • determined by healthy maturation of neurological tissue
25
Q

What happens when a PT loses hip ROM?

A
  • normal hip range = 110 flexion + 15-20 degrees extension
  • if lose 20 degrees flexion => lose extension => results in fixed flexed deformity => transfer of forces to LSP => L5 very vulnerable
  • hip joint may not be very painful => fewer nociceptors in hips (less easy to injure) => won’t get early signs of pain in hip OA => will see loss of movement
26
Q

What are common signs of hip OA?

A
  • knee and LBP
27
Q

What might older people present with first before having a diagnosis of hip OA?

A
  • knee OA
  • LBP
28
Q

What should you look for in a PT with LBP?

A
  • observation: hip externally rotated + abducted + flexed (combo of all)
  • passive: no internal rotation => no articular cartilage => no hip pain
29
Q

What is the function of the lumbar spine?

A
  • lordotic spine bears 16% axial load
  • L1-L3 => 11% each
  • L3-S1 => 19th each
  • allows large amount of movement to aid locomotion
  • engages with PLS + TL (thoraco lumbar fascia) to allow force transference
  • anterior component + fluid component + posterior component
30
Q

What happens in Spina Bifida Occulta?

A
  • L5 doesn’t have an SP (benign space lesion)
31
Q

What happens in spinal bifada?

A
  • L5 creation has completely failed
  • nerves haven’t separated and adhere to spine
  • bone + nerves are still attached => as PT grows nerves break away from bone => paralysis e.g. Tanny Grey-Thomson
  • as PT grows nerves stay attached => lose function of lower body
  • most PTs are born without any issues in movement, but lose function
  • during pregnancy take folic acid
  • now PTs are operated on in utero (26-28 weeks)
32
Q

What happens during lumbarisation or sacralisation?

A
  • extra vertebrae
  • increased risk of LBP
33
Q

In the lumbar spine which part of the vertebrae should not be weight bearing?

A
  • facets
  • should smoothly guide
  • articulation with fluid
34
Q

What happens during lordosis in LSP?

A
  • more pressure on facets
  • bone remodels (tries to get away from pressure)
  • more contact
  • no bony restriction
  • more movement in spine forwards
  • results in degenerative spondylylothesis
35
Q

What might you give an older patient with suspected degenerative spondylolythesis?

A
  • more reinforced flexion + core movement
  • look at hip + knee + ankle movements
  • look at thorax for kyphosis
36
Q

What is degenerative spondylylothesis more common in women?

A
  • looser tissues
  • less resistance against pressures
  • child bearing can result in less control around the trunk/pelvis
37
Q

What structure + function of the support systems are in the lumbar spine?

A
  • myofascial support systems => control + propropeption
  • thoraco-lumbar fascia (TLF)
  • anterior longitudinal ligaments
  • posterior longitudinal ligaments
  • posterior ligamentous system
  • facet joint capsule ligaments
  • posterior ligaments - inter spinous, supraspinous, ligamentum flavum
  • posterior layers of TLF
  • lost of proprioceptors around facet joints + pre-stressing tissues => loss of integrity of tissues => potentially maladaption
38
Q

What are the specialisations of the lumbar spine?

A
  • facet shape
  • upper lumbar area => Transitional area + all movements possible (rotation, too) + mainly T12/L1
  • middle lumbar area => centre of gravity + facilitating locomotion (SB)
  • lower lumbar area => force dissipation + transmission + LS (rotation)
39
Q

Which area in the LSP is most vulnerable?

A
  • L3-L4
40
Q

What happens to ligaments in the spine?

A
  • too much stretch
  • not same movement through disc
  • capsule becomes over mobile
  • disc narrowing
41
Q

Describe the life history of the lumbar spine

A
  • happy childhood => normal L5 up to 20 yo
  • goes to work place, less exx + more sitting => more stress + stretch into ligaments in facet area => reduced proprioceptive feedback after 20 mins sitting => go to bar for drink => too much stretch on standing
  • then, one day => reach around for seatbelt => capsule over stretched => disc height loss -> fires into multifidus @ L4/L5/S1 area
  • next day pretty sore => goes to osteopath
  • inflamed + very sensitive => stretched ligaments => MM damage
  • potentially not using lungs + ribs properly => reduced somatic function (dysfunction)
  • mobilise TSP => LSP HVT => alpha motor neuron inhibition => PT feels better => change work station + get back into sport
  • 6 months later PT back @ osteopaths…then 5 months after that (continues) => doesn’t implement the required changes regularly
  • because PT is not changing anything => outer lamellia are not healthy + nucleus pushing posteriorly through lamina fiscia
  • next day no LBP, now pain down leg => nerve root compromise in 30s => lying on back reflexes are really poor
  • lying on side PT does have reflexes => now lying on side can conduct, if can find position of ease => we can probably help with this => Txx + ST to reduce tension out of the nerve roots
  • profound loss of sensation => refer for MRI => after 12 weeks less recovery from nerve root compression
  • PT now plays golf
  • as time goes on less blood flow to disc + LSP disc reduce in height + more TSP kyphosis
  • 50s important for investing in life => invest + encourage better choices
  • ends with spondylitis => results in flexion through LSP
  • Hip OA then affects LSP => if already had spondylitis => more likely to get LSP pain, can we assit with shoes?
42
Q

Give a break down of what you would expect in each decade from 20-50 yo in terms of structural changes in LSP

A
  • 20s ligaments + MM
  • 30s radicular pain down leg
  • 40s disc prolapse
  • 50s spondyloarthritis (facets) + spondylitis (disc)
43
Q

What are the specialisations of the upper lumbar area?

A
  • transitional area
  • all movement possible, rotation
  • mainly T12/L1
44
Q

What are the specialisations of the middle lumbar area?

A
  • centre of gravity
  • facilitating locomotion, SB
45
Q

What are the specialisations of the lower lumbar area?

A
  • force dissipation + transmission
  • LS - rotation
46
Q

What are the lumbosacral specialisations?

A
  • transitional area - mobility/stability
  • structure/function - disc/facet + iliolumbar ligament
47
Q

What is the nerve supply to the spinal segment for the lumbar plexus?

A
  • derived from anterior decision of T12-L4
48
Q

What is the nerve supply to the spinal segment for the lumbosacral plexus?

A
  • derived from anterior decision of L4-S1

Neuromusculoskeletal (23 decks)

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