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MSK II - Exam 1 > Spine- Thoracolumbar VI- Hypermobility and Instability and DJD > Flashcards

Spine- Thoracolumbar VI- Hypermobility and Instability and DJD Flashcards

1
Q

What are the 4 variables of stabilization?

A
  • joint integrity
  • passive stiffness
  • neural input
  • muscle function
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2
Q

What is hypermobility/instability defined as?

A
  • abnormal movement of spinal segment under loaded conditions, resulting in pain/disability that changes instantaneous axis of motion
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3
Q

What are the two types of instability?

A
  1. functional
  2. mechanical
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4
Q

What is functional instability?

A

Instability that CAN be stabilized with muscle activity and/or positioning

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5
Q

What is mechanical instability?

A

Instability that CANNOT be completely stabilized with muscle activity and/or positioning

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6
Q

Which gender has hypermobility more often?

A

Females more than males

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7
Q

What are the potential etiologies of hypermobility/instability?

A
  • trauma or recurrent sprains (such as IDD)
  • age related disc changes
  • repetitive extension activities (dancing, gymnastics, power lifting)
  • creep due to persistent poor posturing
  • Adjacent joint hypomobility, even more so with fusions
  • connective tissue disorder - generalized hypermobility
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8
Q

What are some connective tissue disorders that can cause hypermobility/instability?

A
  • benign joint hypermobility syndrome
  • Ehler’s Danloss syndrome
  • marfan’s syndrome
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9
Q

What segment in the lower spine is hypermobility most common?

A

L4-S1

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10
Q

Which planes in the lumbar spine is hypermobility more common in?

A

Sagittal and frontal planes

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11
Q

What are symptoms of functional instability?

A
  • predictable pain (every time I do …)
  • spine and referred pain, possibly paresthesias from nociplastic pain due to sensitization
  • no clear directional preference
  • catching (high spec)
  • easy self manipulation
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12
Q

What positions will help/cause pain with functional instability?

A
  • decreased pain with positional changes and support
  • increased pain with prolonged positions, prolonged and repetitive forward bending or arching, strenuous activities, and possibly sudden motions

** pain in groin due to shared innervation

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13
Q

Why can strenuous activities cause pain with functional instability?

A

increased demand for stabilizaiton

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14
Q

What is a sign in the patients history that can indicate functional instability is possible?

A

often less than 40 years old

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15
Q

What will we find with our ROM with acute functional instabilty?

A
  • limited and painful with extension because of increased anterior vertebral shearing, followed by SB
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16
Q

What will we find with general ROM if the functional instability is presenting as an acute condition?

A

Limited and painful with aberrant motion

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17
Q

What can we find with flexion with functional instability?

A
  • may be limited with Gower’s sign
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18
Q

What is Gower’s sign?

A

UE assistance returning from forward bending

(using hands as assistance)

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19
Q

What will be different between PROM and AROM with functional instability?

A

PROM greater than AROM, particularly in non weight bearing vs weight bearing

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20
Q

What can we find with ROM if functional instability is not presenting as an acute condition?

A

Often WNL or excessive except for extension that still may be limited with creasing

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21
Q

What will we find with combined motions with functional instability?

A

Possible inconsistent block

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22
Q

What are signs of aberrant AROM with functional instability?

A
  • painful arc of motion, primarily in sagittal plane
  • uncoordinated motion, primarily in sagittal plane
  • Gower’s sign
  • LE/Pelvis compensations
  • positive if ≥ 1 present
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23
Q

What will we find with resisted testing/MMT with functional instability?

A
  • if acute, may be painful
  • MOST often strong and painless bc global muscles not effected
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24
Q

What will we find with neuro tests with functional instability?

A

Negative neuro tests except possibly a hypersthesia with pinwheel during sensation testing and bring DTRs

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25
Q

What will we find with stress tests with functional instability?

A
  • positive PA stress tests
  • Mixed findings with distraction depending on severity
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26
Q

What will we find with accessory motion testing with functional instability?

A
  • possible hypomobility if hypermobile joint is stuck like drawer example
  • possible adjacent hypomobility
    > T 10 rotation
    > SI joint motion
    > Hip hyperextension
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27
Q

What special tests will be positive with functional instability?

A
  • possible positive prone LE extension test
  • likely positive segmental stability
  • possible positive straight leg reaise
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28
Q

What will segmental stability be most likely positive for with functional instability?

A

excessive anterior shearing

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29
Q

What muscle can be excessively recruited with LBP?

A

The psoas

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30
Q

What does the psoas maintain in standing?

A

lordosis

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31
Q

What can an excessively recruited psoas do to functional instability?

A
  • excessively recruited psoas can further add to the hyperextension and anterior shearing MOST often occuring with lumbar hypermobility/instability
32
Q

What will happen to local muscles with functional instability?

A

Can be inhibited

33
Q

What are the symptoms for mechanical instability?

A

Same as functional instability, plus worse with
- unpredictable pattern of provoking activities
- worsening symptoms with MORE frequent episodes
- increased pain with even trivial and LESSER ADLs.

34
Q

What are the signs of mechanical instability?

A

same as functional instability except worse and with
- positive stability tests that wont fully stabilize with repositioning and / or muscle activity

35
Q

What are tests and measures for functional and mechanical instability?

A
  • radiographs
36
Q

Can functional instability exist without radiological evidence?

A

YES

37
Q

What is a stress radiograph?

A

Comparing vertebral position in various positions for mechanical instability - may be a spondylolisthesis

38
Q

What can exist at rest, which is shearing all the time?

A

Step deformity

39
Q

What is PT rx for functional and mechanical instability?

A
  • rx like ligamentous laxity
  • POLICED
  • postural ed to activate local lmuscles and for chair support
  • JM- increase adjacent joint hypomobility
  • Bracing/Taping prn
40
Q

What is MET for functional and mechanical instability focusing on?

A
  • emphasis on stabilization, particularly of local muscles
  • addition of hip exercises provided greater pain and disability improvements
41
Q

What is contraindicated for MET with instability?

A

hyperextension

42
Q

What is the MD rx in cases of severe slippage and shearing?

A
  • prolotherapy for stabiilzation into iliolumbar ligaments along with PT
  • Spinal fusion
43
Q

What is prolotherapy?

A
  • injection of a fluid that creates inflammation into a ligament to get it to scar, creating intentional fibrosis to increase the stabilization of the ligement
44
Q

What is an indication for a spinal fusion?

A

Mechanical instability

45
Q

What are the results/downsides of a spinal fusion?

A
  • similar long-term results to multi-disciplinary PT
  • higher costs are greater risks
46
Q

What are other names for age-related joint changes?

A
  • Degenerative Joint Disease (DJD)
  • Osteoarthrisis (OA)
  • Spondylosis if multiple spinal levels
47
Q

What segment is the age-related joint changes MOST common?

A

L4-S1

48
Q

What progresses with age-related joint changes?

A

age-related disc changes

49
Q

What is the etiology of age related joint changes??

A

** Degenerative MORE common
-Rarely acute tears
- Prior trauma
- age
- genetics due to age related disc change contributions
- other disease such as RA
- sedentary lifestyle with underloading

50
Q

What age population is degenerative age related joint changes more common in? Why?

A

-older individuals
– chrondrocytes cant keep up

51
Q

What population are acute tears from age-related joint changes most common in? How?

A
  • younger active individuals
  • involving high shear forces
52
Q

What are the 5 components of a synovial joint?

A
  • joint space
  • articular cartilage
  • synovial fluid
  • capsule
  • synovial membrane
53
Q

What happens to the synovial joint articular cartilage with age related joint changes?

A

frays, blisters, tears and thins so JOINT SPACE narrows

54
Q

What happens to subchondral bone with age-related joint changes?

A

overloaded and injured including marrow with greater load

55
Q

What happens due to excessive bony stress?

A

Osteophyte or spur formation

56
Q

What happens to the fibrous capsule due to age related joint changes?

A

slackens (very little, maybe ~1mm) then thickens and stiffens

57
Q

What happens to the synovial membrane with age related joint changes?

A

Produces less synovial fluid and nutrients

58
Q

What happens to periarticular tissue with age related joint changes?

A

Inflammation in the ligaments, capsule, muscles, etc

59
Q

Why is there persistent pain and inflammatory response with age related joint changes?

A
  • stress on other tissues like bone
  • increased local nociceptor sensitivity for greater pain transmission fostering inflammation
  • local production of nitrous oxide leads to MORE interstitial inflammation and excess collagen (joint fibrosis)
  • blood released from bone marrow
60
Q

What is the onset of lumbar symptoms with age related joint change?

A

Gradual

61
Q

What will cause pain in the lumbar region with age related joint changes?

A
  • prolonged extended positions, particularly standing and possibly sleeping depending on position
62
Q

What will cause stiffness in the lumbar region with age related joint changes?

A
  • morning or after prolonged positions
63
Q

What will be painful and limited in the lumbar region with age related joint changes?

A
  • while standing and walking or lying on stomach
64
Q

Why is sleeping position important with age related joint changes regarding lumbar symptoms?

A
  • sleeping on stomach is a hyperextended position, back without pillows is also a lordotic position which will squeeze synovial fluid out and not allow refilling
65
Q

What will we see with observation of the lumbar region with age realted joint changes?

A

possibly forward bent in standing/walking

66
Q

What will we find with ROM with lumbar age related joint changes?

A
  • Pain with extension, ipsilateral side bend and contralateral rotation
  • typically one side more than the other but may be bilateral
  • capsular pattern of restiction
67
Q

What will we find with combined motion with lumbar age related joint changes?

A

consistent block often into an extension quadrant OR opposing quadrants consistently blocked

68
Q

What will we find with resisted tests / MMT with lumbar age related joint changes?

A

depends on acuity

69
Q

What will we find with stress tests for age-related joint changes?

A
  • pain with compression, particularly if added while in extension, ipsilateral side bend and/or contralateral rotation
  • PA glides and unilateral torsion likely painful
  • distraction relieving if acute
70
Q

What will we find with neuro testing with lumbar age related joint changes?

A

Often negative but could be positive for radiculopathy if spurring creates stenosis on spinal nerve

71
Q

What will we find with accessory motion with lumbar age related joint changes?

A

Hypomobility

72
Q

What is the PT rx for age related joint changes?

A
  • greater focus on improving integrity of cartilage and mobility
  • POLICED
  • JM for pain, cartilage integrity and mobility
73
Q

What POLICED can we do for age related joint changes?

A
  • Pt. education of weight management and avoiding provocation
  • assistive device/orthotics to unload involved cartilage (cane, waist wrap)
74
Q

What is the MET for age related joint changes focusing on?

A
  • improving motion, cartilage integrity and neuromuscular benefits
75
Q

What supplements are for age related joint changes? What should we know about them?

A
  • Glucosamine and Chondroitin sulfate
  • NO evidence of minimum clinically important outcomes compared to placebo in the knee

MSK II - Exam 1 (7 decks)

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