Spine Eval & Treat Flashcards
LBP Subjective Hx
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
Anterior Column
-vertebral bodies and discs
-Weight bearing and shock absorption
Posterior Column
-articular processes
-Zygapopphhyseal (facet) joints
-Gliding mechanism for movements
Lumbar Spinal Segments
-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
Amount of Motion Determinants
-Disc height ratio
-fibrocartilage compliance
-shape of end plates
-age
-disease
-gender
Type of Motion Determinants
-shape and orientation of articulations
-ligaments and muscles
-size and location of segment (lumbar biggest)
Intervertebral Discs
-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
Spinal Juntions
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
Mechanical Stability
state of equilibrium when body is still
Dynamic or Controlled Stability
Passive: resist forces at end ranges
Active: muscles coodinated to control body
CNS: feedforward and feedback control to augment stiffness
Lumbar Spine Open Packed Position
midway between flexed and extended
Lumbar Spine Closed Packed Position
full extention
Lumbar Spine Capular Pattern
SB= rotation, then extension
L5
-transitional vertebra
-smaller disc
-larger TP, smaller SP
-tends to slide anterior and inferior
Lumbarization: S1 becomes mobile
Sacralization: L5 fuses to sacrum
Zygapophyseal Joint
-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
Annulus Fibrosis
60-70% of water
-layered
-attaches to endplate
-transmit compression forces
Outer zone: sharpey’s fibers (fibrocarttilage)
Intermediate: fibrocartilage
Inner zone: most fibrocartilage
Nucleus Pulposus
70-90% water
-no nerve oor blood supply
-absorb compression
Interspinous Ligament
-bwtn spinouos processes
-resistt hyperflexion
Supraspinous Ligament
-from spinous processes from sacrum to C7
-end of nuchal lig
-resists hyperflexion
Intertransverse Ligament
-bwtn TPs
-well developed in lumbar
-limits LSB
Iliolumbar Ligament
-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
Thoracolumbar Fascia
-T12 SP to PSIS and iliac crest
-muscle attachment
-resisted flx
-assists in extension during lifting
-activation of TA increases tension
Errector Spinae action
- Unilaterally laterally flex vertebral column ipsilaterally.
- Bilaterally extend vertebral column.
- Anterior pelvic tilt
Multifidus action
Stabilize facets by compression.
Quadratus lumborum action
- Unilaterally laterally, hike, pelvis and LSB
- Bilaterally extends vertebral column.
- Bilaterally fix last rib during forced inspiration.
Iliopsoas major action
- Iliacus: Flex the hip
- Psoas: lumbar side bending, vertical stabilizer
- Externally rotate the hip.
- Flex the trunk toward the thigh
- Tilted pelvis anteriorly
- Stabilize the hip joint.
Piriformis
- Hip ER
- Hip ABD
- When >90 flx: Hip IR
External oblique action
- Unilaterally laterally flex vertebral column to the same side.
- Unilaterally rotate the vertebral column to the CONTRA side.
- Bilaterally flex the vertebral column.
- Bilaterally compress, abdominal contents.
- Posterior pelvic tilt
Internal oblique action
- Unilaterally laterally flex vertebral column to the same side.
- Unilaterally rotate the vertebral column to the IPSI side.
- Bilaterally flex the vertebral column.
- Bilaterally compress, abdominal contents.
Transverse abdominous action
Bilat: Compress and support abdominal viscera
-primary stabilizer
-synergist to Miltifidi
-Antagonist to diaphragm with expiration
Axial Compression
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
Intradiscal Pressure
-Laying down to standing to bending
Bending forward 150%»_space; Lifting weight with back beinding and knees straight 169% of load
Lumbar AROM Values
Flexion: 70-90
Extension: 39-50
Rotation: 20-40
LSB: 25-35
Flexion of Lumbar Spine
-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
Extension of Lumbar Spine
-30-50 degrees
-posterior rock and translation
Reistance:
-SPs
-ligs
Rotation of Lumbar Spine
-20-40 degrees
-torsion of disc
-gapping of ipsi and compression of contra facet
Lateral Side Bending of Lumbar Spine
-25-35 degrees
-compression ipsi, contra gapping
-ipsi face glides inf, contra sup
-coupled motion: ipsi LSB, contra rotation
Global Issue of LBP
Acute, Recurrent (MC), Chronic ($$ and harder to diagnose)
-no strong RK to predict outcomes
LBP and Age
Spondylolisthesis: 10-20y
-moving more
Disc Herniation: 15-40y
-loosing water over time
OA/ Spondylosis: >45y
Cancer/compression fx, stenosis: >65
Evaluation Steps of LBP
- Subjective Hx
- Scan/Not (neuro, no MOI, not MSK)
- Observation
- ROM
- Strength
- Special Tests
- Repeated Measures (if needed)
Piriformis Syndrome
-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
Spondylolysis
-fx to pars
-often asymptomatic
-usually L5
-Pt perfer flx
Spondylolisthesis
-Fx and slippage
Grading: I (1-25%) - V (>100%)
Disc Herniation Process
- Endplate compression and degrades
- Exposes NP to blood and irritates it
- NP looses water and height
- Decrease Resistance of loads
- Osteophyte formation
- More load on facet
- Fissure of Annulus Fibrosis
- Disc disruption
Disc Pathology Stages
Protrusion: disc bulge w/o rupture
Prolapse: outlayers of AP contain NP
Extrusion: AP perforated into epidural
Sequestration: disc fragments disconnect
End Plate Fx S/s
-trauma or MOI
-Acute pain
-(-) SLR
-(+) compression test
Internal Disc Disruption S/s
-separation of inner layers
-LBP or referred hip pain
-(-) SLR
Disc Protrusion/Prolapse S/s
-contained
-some AF and PLL intact
-LBP or referred hip
-pain with cough or sneeze
-(-) SLR
Disc Extrusion of Sequestration S/s
-uncontained
-LBP
-Pain with cough/sneeze
-True Sciatica (radicular pain)
-(+) SLR
Nerve Compression Stages
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
Nerve Root Entrapment Causes/Tx
-structural
Causes:
-subluxed facet
-facet osteophytes (MC)
-laminar compression
-disc
-stenosis
-edema
-tumor
-surgical scar
Tx:
-LBP with radic not as great of outcomes
Spinal Stenosis S/s
-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
Facet Dysfunction S/s
-hypomobility at a facet joint
S/s:
-localized pain
-specific AROM deficits
-hyper mobility at another level
Tx:
-manual therapy > mobility > strengthening
Lumbar Instability S/s/Tx
-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
Ankylosing Spondylitis S/s
-chronic inflammatory disease that can restrict motion
-usually SI joint first
-Male, <30
-bamboo spine
Tx:
-meds and conservative management to slow progression
Fibromyalgia S/s
-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
IFC Category: (non-chronic) LBP w/ Mobility Deficits
-hypomobility
-pain in back, butt, thigh
-impaired movement
-(-) neuro
-<3m s/s onset
IFC Category: (Maybe chronic) LBP w/ Movement Coordination Impairments
-instability
-Pain in back, butt, groin or thigh (worse at end range)
-Dec NM control, activity tolerance
-(+) Prone instability test
IFC Category: Acute LBP Referred LE Pain
-referred (not nerve)
-pain in back, butt, thigh, leg
-(+) Repearerd mmts test
-Onset <3 days
IFC Category: (maybe Chronic) LBP w/ Radiating pain
-radiating, nerve
-radiating pain in dermatomal pattern
-nerve weakness
-(+) Neuro exam
-(+) Neurodynamic Tests
-(+) repeated movement tests
IFC Category: LBP w/ Related Cognitive or Affective Tendencies
-sensitivity to noxious stimuli
-range of emotions
-tendencies to elaborate s/s (catastrophizing)
-Inconsistent results
-Onsett <3 Months
-(+) Waddell’s Test
IFC Category: Chronic LBP w/ Generalized Pain
-whold body chronic pain
-inconsistent MSK dysfunction
-appropriate emotion
-changes in brain
-catastrophizing
-Onset >3 months
Manual Therapy Classification
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
Stabilization Classification
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
Extension Direction-Specific Classification
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
Flexion Direction-Specific Classification
CPR
- >50yrs
-Directtional preference for flexion
-Lumbar Spinal stenosis
Tx:
-mobilize or manip spine
-strength and flexibility exercises
-body weight supported treadmill
Lateral Shift Direction-Specific Classification
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
Traction Classification
CPR
-Sx decrease w/manual or auto traction
don’t respond to anything else
*(+) Crossed SLR *
Peripheralization of multipple directions
> 1 Classification
-25%
Prioritize by:
-Level of risk
-Psychosocial factors (lessen outcomes)
-Co-morbidities (lessen outcomes)
Tx:
-Symptoms
-Movement control
-Functional movements
Acute LBP Phase
3-4w
-decrease pain, inflammation
-increase pain-free ROM
-increase NM control
-low level exercise (walking, modalities, manual therapy)
-Pt education
Subacute LBP Phase
<12w
-sig decrease in pain
-Restore full ROM
-restore NM control
-PREVENT CHRONICITY
-Progression of activity
-functional training
-Pt education
Chronic LBP Phase
> 12w (pain without tissue damage)
-maximize function and encourage education
-decrease pain in chronic stage
-Multimodal approach
-address accominations
-de-threaten biggest fears
Pain Science: Stages
Primary Hyperalgesia:
-protective mechanism from damage
Secondary Hyperalgesia:
-decreased pain threshold
Central Sensitization:
-hallmark of chronic pain
-changes in CNS for pain response
Direction-Specific (McKenzie) Terms
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
Conservative Tx for LBP
Active more useful:
-Mobilization/Manip
-Exercise
-Traction
Passive:
-less evidence supported
Progression:
-Manual therapy
-Mobility
-NM Re-ed
-Strength training
-Activity tolerance
Pt Education for LBP
-Remain active
-Decreased focus on anatomy
-decrease stress
Joint Manipulation Contraindications
-Serious pathology
-fracture*
-lack of skill
-Ligament rupture*
-No working hypothesis
-Worsening neuro function*
-Unremmitting night pain*
-Severe multi directional spasms
-UMN Lesions*
