RBA Flashcards
how common is myotomal deficit in spine Drg?
difference in lumbar vs cervical?
common
more so in cervical
can stenosis symptoms be radicular and referred? What areas of the spine?
only see radicular in cervical
lumbar both
can stenosis have an acute onset? how common?
yes, trauma can reveal stenosis
can NRE have an acute onset? how common?
No
what provokes stenosis symptoms? How quickly?
extension activities of course
- can be immediate or require sustained to expose in lumbar
- typically immediate in C/S
how to confirm or rule out stenosis diagnosis in lumbar spine
IF patient denies obstruction... - go RFISit or RFIL to provoke if no... - go REIS over fulcrum, look for NE or P, NW - then test over 48-72 hours to R/O Drg
how long does a NRE take to develop
12 weeks, longer than other fixed lesions
Do you see obstruction with nerve root entrapment?
No, maybe minimal. but, will see some temporary “stiffness” after sitting due to creep loading.
Never will fully obstruct after prolonged sitting
are nerve root entrapment symptoms constant or intermittant
constant.
-sometimes only proximal pain is constant, and limb symptoms are intermittent
what is the minimum time for onset of ANR or dysfunction?
at least 8 weeks, shorter than NRE
uni- or multi-directional for dysfunction?
can be multi-directional, but one will dominate
with dysfunction, does patient have PDM or ERP? Describe
ERP, but at a premature end range
mechanically inconclusive- radicular, referred, or local pain?
referred and local primarily
radicular is rare
mechanically inconclusive- chronic, acute, subacute
primarily chronic
-occasionally see acute or subacute
mechanically inconclusive- intermittent or constant?
both
mechanically inconclusive- what makes them worse?
usually all movements and positions make them worse over time
- rarely a clear pattern
mechanically inconclusive- can they be obstructed?
NO, they will not have any functional deficit when their pain is worse
mechanically inconclusive- typical ROM loss?
none, nonspecific
mechanically inconclusive- PDM or ERP?
usually multidirectional ERP, less PDM
mechanically inconclusive- nerve tension?
No
mechanically inconclusive- space occupation producing limb symptoms?
no
RBA approach for suspected mechanically inconclusive
1 focus on RFISit/RFIL to eliminate Drg
- if they can’t tolerate, or yellow flags dominate
- –> give SOC for 48 hours
Must have general baselines in an IMC RBA
- spine and extremity
ERP or PDM with ROM (or space occupation) functional complaint nerve tension (esp. L/S) myotomes (esp. C/S)!! postural correction!! extremity baselines b4 spinal screen
must have baselines for an RBA of the shoulder
- besides the obvious (ROM of course, but what specifically is often missed)
resisted movements
- OP to ROM, esp. flexion, abduction
must have baselines for an RBA of the elbo- besides the obvious (ROM of course, but what specifically is often missed)
- resisted movements of elbow, wrist, grip
- OP extension, compare sides
must have baselines for an RBA of the wrist
- besides the obvious (ROM of course, but what specifically is often missed)
OP to active ROM
must have baselines for an RBA of the hip
- besides the obvious (ROM of course, but what specifically is often missed)
- resisted, passive, and OP at end range
- at least 1 weight bearing functional test
- FABERs supine or seated
must have baselines for an RBA of the knee
- besides the obvious (ROM of course, but what specifically is often missed)
- terminal extension, supine, with OP
- 1 weight bearing funct. test (squat, climb stairs, etc)
must have baselines for an RBA of the ankle
- besides the obvious (ROM of course, but what specifically is often missed)
accessory movements of the mid- and hindfoot
General order to the RBA, after funnel Hx
- set baselines
- perform necessary test to confirm/rule out Hx based theory
- test hunch if desired
- if hunch is wrong, immediately focus exam on Hx-based Ddx
which has more scientific support: symptomatic or mechanical improvement?
symptoms!
does symptomatic improvement confirm Dx of Drg?
If not, what is needed?
No.
mechanical improvement must confirm Dx
If mechanics improve first, is this enough to confirm Dx of Drg?
If not, what else is needed?
suggests Drg only
- symptoms must respond within 3 days, or reassess
In what populations/conditions do mechanics often improve initially without symptom change?
geriatrics
mechanical C/S headaches
thoracic region
Pt case- symptoms improved, but mechanics are worse
- what do you do?
- what are you thinking?
Stop and reassess, likely will need GR tutor
- person may have 2 simultaneous conditions, or weird structural thing
- somethings off, fortunately this is uncommon
Pt case- symptoms worsened, but mechanics are better
- what do you do?
- what are you thinking?
- decrease force first. may have direction right, but need to back off
What is massively important to assess in the spine, but often forgotten! (esp. by me…)
Postural correction!
- can confirm Drg Dx just with this!
- they’ve been slouched sitting during history, it’s the perfect oppportunity
4 general rules of RBA
think C-, T-, and L-Spine
- If Drg and Pt knows the Better
- go with relieving direction - If Drg and Pt doesn’t know the Better
- goes with worse, provoke - No Drg Evidence
- C and L-Spine: flexion, provoke
- T-Spine: blast extension- repeated with OP, mob, sustained in lying
- Must have ? to Answer before Movement test`
If a patient has thoracic pain, and there’s no evidence suggesting Drg from the funnel Hx, where do you start?
with Extension!
repeated with OP
mobilization
SUSTAINED in lying
How many baselines should you retest during the RBA?
or a few key indicators after the initial baseline setting.
retesting everything is inefficient and confusing
The 2 purposes of baselines
- prove the existence of “Must Haves” for a condition
e. g. nerve tension for ANR - reference point of course
B, S, or W
How important is nerve tension as a baseline in the spine?
L-spine: “gift from the gods”
- commonly rapidly reversible, great for patient buy-in
C-spine: good, but not as commonly rapidly reversible
- only retest once for change, could scare patient
T-spine: irrelevant?
3 primary conditions that cause nerve tension
- Drg
- ANR (uncommon)
- Inflammatory (very uncommon)
In a patient with a derangement and ANR, when do you start remodeling?
only after Drg fully reduced, AND maintained
What are the characteristics of nerve tension in a inflammatory mechanism patient?
not classic
- Pt can move through it to some degree
what is starting treatment often for inflammatory patient with positive nerve tension? (besides anti-inflamm chemicals)
SOC
- if they respond to this, gentle end range nerve stretches may help, proceed cautiously
- only to tolerance, remember 15-20 min
How to test for nerve tension with C-spine
- modified Elvey’s seated
- if weakly positive, confirm supine - full Elvey’s supine - ensure shoulder depression! and pivotal response
how to educate patient around (+) nerve tension?
immediate after confirming it with test!
- draw on whiteboard the 3 possibilities
1. Hung Up (rapidly reversible)
2. Tight (longer, but can fix at home)
3. inflamm
explain possibilities, and what we’ll do to confirm one or the other
PDM in the spine equals…
Derangement!
until proven otherwise
PDM in the lumbar spine can very rarely be this condition, rather than a Drg
lumbar spondylolisthesis
- will fool you for a few visits
What are the 2 most basic, but often the most important, or only present, baselines to have before the movement exam?
PDM
ERP
ERP as a baseline is seen most commonly in what classification?
Drg!
Why is unilateral ERP (like with side glide or rotation) a great Pt education opportunity?
There’s proof on the unaffected side that this shouldn’t hurt!!
Point that out to them.
What simple baseline is often most revealing (for me and patient) in the cervical spine?
rotation!
- premature ERP is gold
- cue Pt awareness of where in ROM and intensity
What if there’s no baselines?! Pt has no symptoms, ROM is fine, functional test negative
Try OP or mobilization (accessory movements) to ROM
accessory movement (OP or Mob) baselines for the L/S
- shift over-correct B/L with EIS
- exten. mob, prone or sphinx
- EIS over fulcrum
accessory movement baselines (OP or Mob) for the C/S
retraction, rotation, and side flexion with OP
- if I need to save time, do it myself
accessory movement baselines (OP or Mob) for the T/S
perform seated
- ext. and rotation OP/mob
accessory movement baselines (OP or Mob) for the hip
flexion, extension, FABERs with OP
accessory movement baselines (OP or Mob) for the knee
terminal ext of course, flex
accessory movement baselines (OP or Mob) for the ankle/foot
calcaneal and midfoot/forefoot
- inversion and eversion
accessory movement baselines (OP or Mob) for the elbow
terminal extension
- Specifically, bounce and clunk the joint
How does Mark Miller test terminal extension of the elbow?
- Pin Pt hand between my trunk and arm
- grab elbow and snap up into extension