Week 2 Flashcards
What is patho-anatomic diagnosis?
The anatomical pathology
What is an example of a patho-anatomic diagnosis?
- Herniated disc L4-5
- Polymyosis
What is a prognostic/treatment based?
- Manipulation classification
- Specific exercise classification
- Elevated fall risk
What are the different ways a diagnostic process can be done?
- Pattern recognition
- Hypothetic deductive reasoning
- Algorithms
- Exhaustive
- Logical reasoning
What is hypothetic deductive reasoning?
When we have an hypothesis/belief that the problem might be some specific disorder, and then we go about ruling in or ruling out
What is the algorithm diagnostic process?
It helps get us into the space a little better
Which of the diagnostic process is inefficient and used by novices?
- Exhaustive
____ is what makes us good diagnosticians
Logical reasoning is what makes us good diagnosticians
What are the basic steps in the diagnostic process?
- Generate possibilites and their relative likelihood or probabilities
- Gather new info to clarify your initial diagnostic possibilities
- Revise pretest and posttest probabilities
What is pre-test probability?
For any given patient, there is a baseline probability of a certain condition pretesting
What is a post test probability?
Application of a clinical diagnostic test alters the baseline probabilty
What does the medical model of disease say?
- Pain is a reflex response to a physical stimulus
According to the medical model of disease, every symptom has an ____
According to the medical model of disease, every symptom has an underlying stimulus
According to the medical model of disease, alleviating the symptoms requires ___ and ___ the underlying stimulus
According to the medical model of disease, alleviating the symptoms requires identifying and alleviating the underlying stimulus
In the medical model of disease, we move from pain to ___ and from ___ to cure
In the medical model of disease, we move from pain to cause and from cause to cure
What is the summary of the medical model of disease?
- Signs/symptoms analyzed
- Pathology is determined
- Treatment corrects pathology
- Signs/symptoms disappear
There is ___ relationship between physical pathology & associated pain and disability
There is little relationship between physical pathology & associated pain and disability
According to the biopsychosocial model, what are the things that shape the pain experience?
- Pain
- Attitudes & beliefs
- Psychological distress
- Illness behavior
- Social environment
What are the 2 major factors that widely shape how a patient’s pain?
- Psychological factors
- Cultural factors
What are the biopsychosocial model application in clinical practice?
- Psychologically informed practice
- Understand your patient
- Screening tools
- Clinical decision making aides
- CPR/CPGs
- Treatment based classification
What are the diagnostic processes of choice?
- Pattern recognition
- Hypothetico-deductive
____ is probabilistic in nature
Diagnosis is probabilistic in nature
What is the 1st step in the 1st level triage?
Medical management
What are the possible clinical findings in the medical management level of the 1st level triage?
- Red flags
- Medical comorbidities precluding rehabilitation
- Leg pain with progressive neurologic deficits
What is the 2nd step in the 1st level triage?
Self-care management
What are the possible clinical findings in the self-care management level of the 1st level triage?
- Low psychosocial risk status
- Predominantly axial low back pain
- Minor or controlled medical comorbities
What is the 3rd step in the 1st level triage?
Rehabilitation management
What are the possible clinical findings in the rehabilitation management level of the 1st level triage?
- Medium to high psychosocial risk status
- Low psychosocial risk status with predominantly leg pain
- Minor or controlled medical comorbidities
Individuals identified in the _____ step will be referred out to a different medical provider
Individuals identified in the medical management step will be referred out to a different medical provider
What are some of the signs of a serious spinal pathology?
- Signs of infection
- Temp > 100 F
- BP> 160/95 mmHg
- Resting pulse > 100/ min
- Resting respiration > 25/min
What are the 3 different strategies for management in the TMC model?
- Symptom modulation
- Movement control
- Functional optimization
How do individuals that fall in the symptom modulation strategy for management present?
- High disability
- High to moderate pain/irritability & severity
- Volatile symptom status
How do individuals that fall in the movement control strategy for management present?
- Moderate disability
- Moderate to low pain/irritability & severity
- Stable symptom status
How do individuals that fall in the functional optimization strategy for management present?
- Low disability
- Low to absent pain/irritability & severity
- Controlled symptom status
If a patient centralizes with 2 or more movements in the same direction or centralize with a movement in 1 direction and peripheralize with an opposite movement, what is their proposed intervention classification according to fritz?
Specific exercise classification
If a patient has a recent onset of symptoms and no symptoms distal to the knee, what is their proposed intervention classification according to fritz?
Manipulation classification
If a patient has at least 3 of the following,
- Average SLR ROM >91 deg
- Positive prone instability test
- Positive aberrant movements
- Age < 40
what is their proposed intervention classification according to fritz?
Stabilization classification
The treatment from the TBC is an ___ approach to care
The treatment from the TBC is an initial approach to care
Which of the 3 1st level triage involves direct physical therapy interventions?
Rehabilitation management
What were the 5 most predictive variables in determining the success of spinal manipulation intervention?
- Current symptom duration < 16 days
- Fear-Avoidance Beliefs Questionnaire < 19
- Hypomobility of the lumbar spine with PA Pressure
- IR of at least 1 hip > 35 deg
- No symptoms below the knee
What are the factors favoring spinal manipulation to decrease LBP?
- More recent onset of symptoms
- Hypomobility with spring testing
- Low back pain only(no symptoms below the knee)
- Low FABQ scores (FABQw< 19)
What are the factors against spinal manipulation to decrease LBP?
- Symptoms below the knee
- Increasing episode frequency
- Peripheralization with motion testing
- No pain with spring (PA mobility) testing
What are some treatments that may accompany a spinal manipulation intervention?
- Manual therapy
- Soft tissue mobilization
- Oscillations
- Gentle manual resisted exercises
What are the major muscles that provide core stability and are targeted during motor control/stabilization exercises?
- Transversus abdominis
- Multifidus
- Diaphragm
- Pelvic floor
- Internal and external oblique
- Rectus abdominus
What are the treatments for people with a symptom modulation?
- Directional preference exercises
- Manipulation/mobilization
- Traction
- Active rest
What are the treatments for people with a movement control?
- Sensorimotor exercise
- Stabilization exercises
- Flexibility exercise
What are the treatments for people with a functional optimization?
- Strength and conditioning exercises
- Work - or sport- specific tasks
- Aerobic exercises
- General fitness exercises
What is the ultimate goal of exercise progressions?
To mimic each patient’s functional needs or goals so that the patient develops the strength, endurance and motor control necessary to maximize recovery
What are the variables predicting success for a stabilization exercise intervention?
- (+) prone instability test
- (+) aberrant motions present
- Average straight leg raise >91 deg
- Age of below 40
What are the variables predicting failure for a stabilization exercise intervention?
- (-) Prone Instability Test
- Aberrant Movement Absent
- FABQPA < 9
- No Hypermobility with Lumbar Spring Testing
The common theme of lumbar instability is _____
The common theme of lumbar instability is muscle inhibition
What is the first thing in the McKenzie classification system?
History and physical examination
In the the McKenzie classification system, what follows the history and physical examination?
Exclude serious pathology
In the the McKenzie classification system, what follows the exclude serious pathology?
Provisional MDT classification
What are the 3 McKenzie syndromes?
- Derangement
- Dysfunction
- Postural
What is derangement in the Mckenzie syndrome?
Loading strategies centralize or make symptoms better
What is dysfuction in the Mckenzie syndrome?
Pain only product at limited end range
What is postural in the Mckenzie syndrome?
Pain only on static loading, no effect of repeated movements
The annulus is weakest in the ___ aspect
The annulus is weakest in the posterolateral aspect
____ pain activate nociceptors by damage causing high concentrations of chemicals
chemical pain activate nociceptors by damage causing high concentrations of chemicals
Chemical pain can be reduced by movement by ____, but does not remain reduced
Chemical pain can be reduced by movement by mechanoreceptor modulation, but does not remain reduced
Chemical pain can not be abolished by ___ or ____
Chemical pain can not be abolished by repeated motion or sustained positioning
How does mechanical pain activate nociceptors?
By force, stress, deformity and damage
Mechanical pain can be reduced and /or abolished by ___
Mechanical pain can be reduced and /or abolished by repeated motion or sustained positioning in the correct direction
Mechanical pain can become constant with ____ causing constant ___
Mechanical pain can become constant with internal derangement causing constant mechanical deformation
____ describes the phenomenom by which distal pain originating from the spine is progressively abolished in a distal to proximal direction
Centralization describes the phenomenom by which distal pain originating from the spine is progressively abolished in a distal to proximal direction
Centralization is in response to ___
Centralization is in response to a specific repeated movement and/or sustained position and this change in location is maintained over time until all pain is abolished
As the pain centralizes, there is often a significant increase in the ___
As the pain centralizes, there is often a significant increase in the central pain
If spinal pain only is present, this moves from a ____ to a ____ then it is abolished
If spinal pain only is present, this moves from a widespread to a more central location then it is abolished
What does centralizing mean?
During the application of loading strategies distal pain is being abolished
Centralizing is in the process of becoming ___, but this will only be confirmed once ___
Centralizing is in the process of becoming centralized, but this will only be confirmed once the distal pain remains abolished
What does centralized mean?
As a result of the application of the appropriate loading strategies the patient reports that all distal pain has abolished and now the patient only has back pain. The central back pain will then continue to decrease and abolish
____ is a positive prognostic indicator
Centralization is a positive prognostic indicator
____ describes the phenomenon by which
proximal symptoms originating from the spine are progressively produced in a proximal to distal direction.
Peripheralization describes the phenomenon by which
proximal symptoms originating from the spine are progressively produced in a proximal to distal direction.
Peripheralization happens in response to ___
Peripheralization happens in response to * a specific repeated movement and/or sustained position and this change in location of symptoms is maintained over time*
Peripheralization may also be associated with ___
Peripheralization may also be associated with a worsening of neurological status
What does peripheralizing mean?
During the application of
loading strategies distal symptoms are being produced.
In peripheralizing, symptoms are in the process of becoming ___, but this will only be confirmed once the ____
In peripheralizing, symptoms are in the process of becoming peripheralized, but this will only be confirmed once the distal symptoms remain
____ means that as a result of the application of the inappropriate loading strategies the patient reports that the distal symptoms that have been
produced remain.
Peripheralized means that as a result of the application of the inappropriate loading strategies the patient reports that the distal symptoms that have been produced remain.
Peripheralization is generally is ____ indicator
Peripheralization is generally is negative prognostic indicator
What are the characteristics of postural syndrome?
- End range stress on normal tissue
- Positional pain. No loss of motion
- No pain during management
What are the characteristics of dysfunction syndrome?
- End range stress on shortened tissue
- Pain at end range or upon stretching on “contracted” tissues. Loss of motion
- No pain in midrange movements
What are the directions of movement found in a dysfunction syndrome?
- Flexion
- Extension
- Lateral movement
When the nerve root is adhered in a dysfunction syndrome, there may be some ___
When the nerve root is adhered in a dysfunction syndrome, there may be some referred pain
How might a dysfunction be addressed?
Through repeated movement progression
What is derangement syndrome?
A clinical presentation associated with a mechanical obstruction of an affected joint
When does a patient with derangement syndrome experience pain?
During movement and loss of motion
Patients with a derangement syndrome may have a ____
Patients with a derangement syndrome may have a directional preference
Directional preference describes the clinical phenomenon where ___
Directional preference describes the clinical phenomenon where a specific direction of repeated movement and/or sustained position results in a clinically relevant improvement in either symptoms and/or mechanics though not always the centralization of the symptoms
___ is an essential feature of the derangement syndrome
Directional preference is an essential feature of the derangement syndrome
____ encompasses a broader range of responses than centralization
Directional preference encompasses a broader range of responses than centralization
Centralization refers to the ____
Centralization refers to the lasting change in the location of symptoms as a result of loading strategies
Directional preference results in ___
Directional preference results in a lasting improvement in symptoms and/or mechanics though not always a change in location of pain
All centralizers have a ___
All centralizers have a directional preference
If a patient presents with a lateral shift, does that mean that they won’t respond to a manual type intervention?
No it doesn’t, the presence of a lateral shift should not deter the PT from doing a manual intervention. It should only be done if patient complains of pain peripheralization rather than centralization
In the MDT physical examination, what are the things to do when testing each direction of movement?
- Establish symptoms prior to start of new motion
- Effect on patient’s symptoms
- Repeated movements (10x)
___ determines treatment progression
Symptoms determines treatment progression
What do you do if a patient notes that pain is getting worse, increasing and peripheralizing during treatment progressions?
STOP treatment
What do you do if a patient reports no changes in pain with treatment progressions?
Proceed with caution
What do you do if a patient reports a decrease in pain, and centralization with treatment progression?
CONTINUE with treatment
Repeated movement progression is initially ___ that may need ___
Repeated movement progression is initially patient induced that may need therapist augmented
What is the general flow of repeated movement progression in extension?
- Prone lying (static)
- Prone lying in extension (static)
- Extension in lying
- Extension in lying with clinician overpressure
- Extension mobilization
- Extension in standing
What is the general flow of repeated movement progression in flexion?
- Flexion in lying
- Flexion in sitting
- Flexion in standing
- Flexion in lying with clinician overpressure
What are some therapist augmented techniques?
- Extension with therapist overpressure (belts)
- Extension mobilization/ manipulation
- Mobilization for lateral component
What are some things involved in the mobilization for the lateral component of therapist augmented techniques?
- Hips shifted away
- Side lying flexion rotation
- Rotation mobilization in extension
- Rotation manipulation in extension
- Rotation mobilization in flexion
- Rotation manipulation in flexion
What is nerve root pain?
Unilateral leg pain below the knee, usually into the ankle or foot
In nerve root pain, ___ pain is usually worse than __ pain
In nerve root pain, leg pain is usually worse than back pain
What do people with nerve root pain present with?
- Pain radiating to the foot or toes
- Numbness or paresthesia in same dermatome distribution
- Nerve irritation signs
- Nerve axon loss (motor, sensory, or reflex changes) typically limmited to one nerve root (may be less than one)
What are the synonyms of a nerve root pain called?
- Radiculopathy
- Radiculitis
- Sciatica
What are the patterns of a radiculopathy ?
- Strength loss in a myotomal pattern
- Sensation loss in a dermatomal pattern
- Decrease or absence of associated DTR(deep tendon/muscle flex reflex)
The proportion of LBP patients with concomitant LE symptoms is ___ ,while the ones that has a true sciatica or nerve root involvement is ___
The proportion of LBP patients with concomitant LE symptoms is 70% ,while the ones that has a true sciatica or nerve root involvement is 5%
What is a referred pain pattern?
Pain down the limb that is not due to the nerve root
Referred pain through a muscle or facet joint is often describes as ___
Referred pain through a muscle or facet joint is often describes as deep, achy, diffuse, dull, cramp-like and poorly localized
What are the key things/things to test in a patient with a radiculopathy?
- Positive straight leg raise
- Positive cross leg test
- Femoral nerve stretch test
What is a positive straight leg raise test?
A test that has a score of 40 deg or less
The ____ is highly sensitive which means it can produce a false positive, while a ___ is highly specific
The straight leg raise is highly sensitive which means it can produce a false positive, while a cross straight leg raise is highly specific
What is a positive femoral nerve stretch test?
A burning or vague painful sensation down anterior thigh
What are the potential causes of leg pain?
- Denervation
- Central sensitization
- Peripheral nerve sensitization
- Adverse neural dynamics
- Myofascial trigger points
What is adverse neurodynamics?
When the nerves aren’t gilding freely through out the system, hereby creating a degree of irritability
Do we tell a patient with sciatica to stay active or go on bed rest?
Trick question
Neither reall y makes a difference in their lives
What are the things to do for patients with a radiculopathy?
- Unloading: crutches, less standing, laying flat for periods of time, then going back to the crutches
Do injections have a long term or short term benefit for radiculopathy?
Short term. Provides a therapeutic window to get the patient actively involved in a progressive rehab program
