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MSK > Spine Eval & Treat > Flashcards

Spine Eval & Treat Flashcards

1
Q

LBP Subjective Hx

A

Pain: location/movement, MOI/onset, time, description, behavior, intensity, better/worse, 24h bahavior

Pt Demopgraphics: age, race, hobbies, work, participation, impact of s/s, psychosocial considerations

General Health: Prior Hx, Co-morbidites, surgeries, Pregnancies, Medications

Red Flag Qs: Neural involvement, fracture, infection, cancer (Constant pain, intense pain, weight loss), AAA

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2
Q

Anterior Column

A

-vertebral bodies and discs
-Weight bearing and shock absorption

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3
Q

Posterior Column

A

-articular processes
-Zygapopphhyseal (facet) joints
-Gliding mechanism for movements

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4
Q

Lumbar Spinal Segments

A

-3 joints: 2 vertebral bodies and 1 disc, facet joint of sup and inf
-horizontal surfaces favor rotation
-vertical surfaces favor block rotation

-facets in earmuff to limit rotation

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5
Q

Amount of Motion Determinants

A

-Disc height ratio
-fibrocartilage compliance
-shape of end plates
-age
-disease
-gender

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6
Q

Type of Motion Determinants

A

-shape and orientation of articulations
-ligaments and muscles
-size and location of segment (lumbar biggest)

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7
Q

Intervertebral Discs

A

-largest avascular structure in body
-Nucleus Pulposus, Annulus Fibrosis, End plate (bone)
-Thoracic & Lumbar: thicker anteriorly
-nutrition diffuses from endplate

Resists:
-compression
-shearing
-bending
-twisting
-combined motions

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8
Q

Spinal Juntions

A

CV: atlas, axis, head
CT: mobile c spine to stiffer upper t spine
TL: t-spine rotations meet limited L-spine
LS: mobile l spine to stiff SI joints

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9
Q

Mechanical Stability

A

state of equilibrium when body is still

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10
Q

Dynamic or Controlled Stability

A

Passive: resist forces at end ranges

Active: muscles coodinated to control body

CNS: feedforward and feedback control to augment stiffness

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11
Q

Lumbar Spine Open Packed Position

A

midway between flexed and extended

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12
Q

Lumbar Spine Closed Packed Position

A

full extention

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13
Q

Lumbar Spine Capular Pattern

A

SB= rotation, then extension

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14
Q

L5

A

-transitional vertebra
-smaller disc
-larger TP, smaller SP
-tends to slide anterior and inferior

Lumbarization: S1 becomes mobile
Sacralization: L5 fuses to sacrum

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15
Q

Zygapophyseal Joint

A

-synovial joints: articular cartilage, fibroadipose meniscoid
-supported by multifidi and ligamentum flavum
-innervated by medial branch of doral root
-move 5-8mm

Normal disc: 20-25% axial load on facet
Degenerated disc: 70% axial load on facet

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16
Q

Annulus Fibrosis

A

60-70% of water
-layered
-attaches to endplate
-transmit compression forces

Outer zone: sharpey’s fibers (fibrocarttilage)
Intermediate: fibrocartilage
Inner zone: most fibrocartilage

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17
Q

Nucleus Pulposus

A

70-90% water
-no nerve oor blood supply
-absorb compression

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18
Q

Interspinous Ligament

A

-bwtn spinouos processes
-resistt hyperflexion

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19
Q

Supraspinous Ligament

A

-from spinous processes from sacrum to C7
-end of nuchal lig
-resists hyperflexion

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20
Q

Intertransverse Ligament

A

-bwtn TPs
-well developed in lumbar
-limits LSB

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21
Q

Iliolumbar Ligament

A

-lumbar to pelvis
-stabilize L5 from ant displacement and ressits LSB at L4

Anterior band: anterior TP of L5 to ant iliac crest
-resist ipsi side bending and ant translation

Postterior Band: sup TP to ilium
-prevents flx

Superior Band: post TP of L5 to post iliac crest
-prevents flx

Inferior Band: inf TP of L5 to ant iliac crest
-taut in extention

Vertical Band: ant-inf tp of L5 to ilio-pectineal line

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22
Q

Thoracolumbar Fascia

A

-T12 SP to PSIS and iliac crest

-muscle attachment
-resisted flx
-assists in extension during lifting

-activation of TA increases tension

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23
Q

Errector Spinae action

A
  1. Unilaterally laterally flex vertebral column ipsilaterally.
  2. Bilaterally extend vertebral column.
  3. Anterior pelvic tilt
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24
Q

Multifidus action

A

Stabilize facets by compression.

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25
Q

Quadratus lumborum action

A
  1. Unilaterally laterally, hike, pelvis and LSB
  2. Bilaterally extends vertebral column.
  3. Bilaterally fix last rib during forced inspiration.
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26
Q

Iliopsoas major action

A
  1. Iliacus: Flex the hip
  2. Psoas: lumbar side bending, vertical stabilizer
  3. Externally rotate the hip.
  4. Flex the trunk toward the thigh
  5. Tilted pelvis anteriorly
  6. Stabilize the hip joint.
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27
Q

Piriformis

A
  1. Hip ER
  2. Hip ABD
  3. When >90 flx: Hip IR
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28
Q

External oblique action

A
  1. Unilaterally laterally flex vertebral column to the same side.
  2. Unilaterally rotate the vertebral column to the CONTRA side.
  3. Bilaterally flex the vertebral column.
  4. Bilaterally compress, abdominal contents.
  5. Posterior pelvic tilt
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29
Q

Internal oblique action

A
  1. Unilaterally laterally flex vertebral column to the same side.
  2. Unilaterally rotate the vertebral column to the IPSI side.
  3. Bilaterally flex the vertebral column.
  4. Bilaterally compress, abdominal contents.
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30
Q

Transverse abdominous action

A

Bilat: Compress and support abdominal viscera
-primary stabilizer
-synergist to Miltifidi
-Antagonist to diaphragm with expiration

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31
Q

Axial Compression

A

Slow Loading:
-bodies aproximate
-Schmorl’s Node: end plate bows towards vertebra

Disc:
-squeeze out 5-11% of water
-height loss plateaus at 90min

Facet Joint:
-<30% of load unlikely to fail
-37-80% of load will fail after 1000 cycles

32
Q

Intradiscal Pressure

A

-Laying down to standing to bending
Bending forward 150%&raquo_space; Lifting weight with back beinding and knees straight 169% of load

33
Q

Lumbar AROM Values

A

Flexion: 70-90
Extension: 39-50
Rotation: 20-40
LSB: 25-35

34
Q

Flexion of Lumbar Spine

A

-70-90deg
-1st in lumbar spine (not L5-S1)
-anterior rock and translation
-glides backwards 5-7mm

Resistance:
-39% of joint capsule
-19% supra and interspinous ligs

35
Q

Extension of Lumbar Spine

A

-30-50 degrees
-posterior rock and translation

Reistance:
-SPs
-ligs

36
Q

Rotation of Lumbar Spine

A

-20-40 degrees
-torsion of disc
-gapping of ipsi and compression of contra facet

37
Q

Lateral Side Bending of Lumbar Spine

A

-25-35 degrees
-compression ipsi, contra gapping
-ipsi face glides inf, contra sup
-coupled motion: ipsi LSB, contra rotation

38
Q

Global Issue of LBP

A

Acute, Recurrent (MC), Chronic ($$ and harder to diagnose)
-no strong RK to predict outcomes

39
Q

LBP and Age

A

Spondylolisthesis: 10-20y
-moving more

Disc Herniation: 15-40y
-loosing water over time

OA/ Spondylosis: >45y

Cancer/compression fx, stenosis: >65

40
Q

Evaluation Steps of LBP

A
  1. Subjective Hx
  2. Scan/Not (neuro, no MOI, not MSK)
  3. Observation
  4. ROM
  5. Strength
  6. Special Tests
  7. Repeated Measures (if needed)
41
Q

Piriformis Syndrome

A

-Dx of exclusion

S/s:
-hx of trauma so SIJ or glute
-pain around SIJ or piriformis
-worse with lifting, sitting
-palpable tension
-+ SLR
-(+) provocation pain
-(+) LE paresthesias
-Glute atrophy

42
Q

Spondylolysis

A

-fx to pars
-often asymptomatic
-usually L5
-Pt perfer flx

43
Q

Spondylolisthesis

A

-Fx and slippage
Grading: I (1-25%) - V (>100%)

44
Q

Disc Herniation Process

A
  1. Endplate compression and degrades
  2. Exposes NP to blood and irritates it
  3. NP looses water and height
  4. Decrease Resistance of loads
  5. Osteophyte formation
  6. More load on facet
  7. Fissure of Annulus Fibrosis
  8. Disc disruption
45
Q

Disc Pathology Stages

A

Protrusion: disc bulge w/o rupture

Prolapse: outlayers of AP contain NP

Extrusion: AP perforated into epidural

Sequestration: disc fragments disconnect

46
Q

End Plate Fx S/s

A

-trauma or MOI
-Acute pain
-(-) SLR
-(+) compression test

47
Q

Internal Disc Disruption S/s

A

-separation of inner layers
-LBP or referred hip pain
-(-) SLR

48
Q

Disc Protrusion/Prolapse S/s

A

-contained
-some AF and PLL intact
-LBP or referred hip
-pain with cough or sneeze
-(-) SLR

49
Q

Disc Extrusion of Sequestration S/s

A

-uncontained
-LBP
-Pain with cough/sneeze
-True Sciatica (radicular pain)
-(+) SLR

50
Q

Nerve Compression Stages

A

Herdiation of Disc of L4-L5
-compresses root
-1 nerve

Large Herniation of L5-S1:
-compresses nerve root and nerve coming out of same foramen
-multiple nerves

Massive Central Sequestration L4-L5:
-all nerve roots in cauda equina

51
Q

Nerve Root Entrapment Causes/Tx

A

-structural

Causes:
-subluxed facet
-facet osteophytes (MC)
-laminar compression
-disc
-stenosis
-edema
-tumor
-surgical scar

Tx:
-LBP with radic not as great of outcomes

52
Q

Spinal Stenosis S/s

A

-narrowing spinal canal (vascular or neurogenic)
-congenital development or acquired
S/s: butt pain, limping, lack of sensation, dec walking ability

Central:
-spinal canal dec
-claudication, butt pain

Lateral:
-narrowing of facets
-can impinge nerve roott

53
Q

Facet Dysfunction S/s

A

-hypomobility at a facet joint

S/s:
-localized pain
-specific AROM deficits
-hyper mobility at another level

Tx:
-manual therapy > mobility > strengthening

54
Q

Lumbar Instability S/s/Tx

A

-loss of passive restraints to movement
-lack of NM control

S/s:
-catching in back
-inconsistent symptoms
-(+) Prone instability

Tx:
-strengthening/stabilization
-recurrence is common

55
Q

Ankylosing Spondylitis S/s

A

-chronic inflammatory disease that can restrict motion
-usually SI joint first
-Male, <30
-bamboo spine

Tx:
-meds and conservative management to slow progression

56
Q

Fibromyalgia S/s

A

-chronic condition
-causes pain, stiffness and tenderness of muscles, tendons and joints
-physcosocial component

Dx: 11/18 tender points w/o other reason

S/s:
-Pain (100%)
-Fatigue (90%)
Emotional Disturbances (50%)
-Restless sleep
-Disturbances in bowel function

57
Q

IFC Category: (non-chronic) LBP w/ Mobility Deficits

A

-hypomobility
-pain in back, butt, thigh
-impaired movement
-(-) neuro
-<3m s/s onset

58
Q

IFC Category: (Maybe chronic) LBP w/ Movement Coordination Impairments

A

-instability
-Pain in back, butt, groin or thigh (worse at end range)
-Dec NM control, activity tolerance
-(+) Prone instability test

59
Q

IFC Category: Acute LBP Referred LE Pain

A

-referred (not nerve)
-pain in back, butt, thigh, leg
-(+) Repearerd mmts test
-Onset <3 days

60
Q

IFC Category: (maybe Chronic) LBP w/ Radiating pain

A

-radiating, nerve
-radiating pain in dermatomal pattern
-nerve weakness
-(+) Neuro exam
-(+) Neurodynamic Tests
-(+) repeated movement tests

61
Q

IFC Category: LBP w/ Related Cognitive or Affective Tendencies

A

-sensitivity to noxious stimuli
-range of emotions
-tendencies to elaborate s/s (catastrophizing)
-Inconsistent results
-Onsett <3 Months
-(+) Waddell’s Test

62
Q

IFC Category: Chronic LBP w/ Generalized Pain

A

-whold body chronic pain
-inconsistent MSK dysfunction
-appropriate emotion
-changes in brain
-catastrophizing
-Onset >3 months

63
Q

Manual Therapy Classification

A

CPR:
-No sx distal to knee
- <16 days (acute/subacute)
-FABQ score <19 (fear avoidance beliefs)
-1 hypomobile segment
-1 hip >35deg internal rotation (loss of ER)

Tx:
-HVLAT
-ROM

64
Q

Stabilization Classification

A

CPR:
- <40 yrs old
- Post parum/SLR >91 deg (flexible)
- Instability catch or aberrant movements during flx/ext
-(+) Prone instsbility test
-Postpartum:
(+) posterior pelvic pain provocation, ASLR, mod Trendelenburg
OR
Pain w/ palpation of long dorsal SI ligament or pubic symphysis

Tx:
-isolated contraction of deep stabilizers (TA, Multifidi)
-Strengthen large spinal stabilizers (ES, Obliques)
-Hooklying to Side Plank

65
Q

Extension Direction-Specific Classification

A

CPR:
-Sx distant to Butt
-Sx centralize with extension
-sx peripheralize with flexion
-directional preference for extension (standing/walking)

Tx:
-End range exetnsion
-mobilize to promote extension
-Avoid flexion

66
Q

Flexion Direction-Specific Classification

A

CPR
- >50yrs
-Directtional preference for flexion
-Lumbar Spinal stenosis

Tx:
-mobilize or manip spine
-strength and flexibility exercises
-body weight supported treadmill

67
Q

Lateral Shift Direction-Specific Classification

A

CPR
-visible frontal plane shift
-directional preference for lateral translation movements

Tx:
-exercises to correct shift (manual glide from PT or leaning on walls)
-traction

68
Q

Traction Classification

A

CPR
-Sx decrease w/manual or auto traction

don’t respond to anything else
*(+) Crossed SLR *
Peripheralization of multipple directions

69
Q

> 1 Classification

A

-25%

Prioritize by:
-Level of risk
-Psychosocial factors (lessen outcomes)
-Co-morbidities (lessen outcomes)

Tx:
-Symptoms
-Movement control
-Functional movements

70
Q

Acute LBP Phase

A

3-4w
-decrease pain, inflammation
-increase pain-free ROM
-increase NM control
-low level exercise (walking, modalities, manual therapy)
-Pt education

71
Q

Subacute LBP Phase

A

<12w
-sig decrease in pain
-Restore full ROM
-restore NM control
-PREVENT CHRONICITY
-Progression of activity
-functional training
-Pt education

72
Q

Chronic LBP Phase

A

> 12w (pain without tissue damage)
-maximize function and encourage education
-decrease pain in chronic stage
-Multimodal approach
-address accominations
-de-threaten biggest fears

73
Q

Pain Science: Stages

A

Primary Hyperalgesia:
-protective mechanism from damage

Secondary Hyperalgesia:
-decreased pain threshold

Central Sensitization:
-hallmark of chronic pain
-changes in CNS for pain response

74
Q

Direction-Specific (McKenzie) Terms

A

Postural:
-pain not reproduced with repeated testing
-pain when stationary

Dysfunction:
-pain only produced at the end range
-conditioning unchanged after testing

Derangement:
-sx produced with mid range movements
-painful arc
-variable pain patterns
-changes after testing

75
Q

Conservative Tx for LBP

A

Active more useful:
-Mobilization/Manip
-Exercise
-Traction

Passive:
-less evidence supported

Progression:
-Manual therapy
-Mobility
-NM Re-ed
-Strength training
-Activity tolerance

76
Q

Pt Education for LBP

A

-Remain active
-Decreased focus on anatomy
-decrease stress

77
Q

Joint Manipulation Contraindications

A

-Serious pathology
-fracture*
-lack of skill
-Ligament rupture*
-No working hypothesis
-Worsening neuro function*
-Unremmitting night pain*
-Severe multi directional spasms
-UMN Lesions*

MSK (34 decks)

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