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MSK 1 > Week 3 > Flashcards

Week 3 Flashcards

1
Q

What is the flow of the patient management model?

A
  • Examination
  • Evaluation
  • Diagnosis
  • Prognosis
  • Intervention
  • Outcomes
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2
Q

What are the two exams involved in the examination step of the patient management model?

A
  • Subjective and objective exam (history and physical exam)
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3
Q

The patient management model is an _____ based model

A

The patient management model is an impairment based model

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4
Q

What does the nagi model of disablement suggest?

A

That there is some sort of active pathology going on in the body

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5
Q

What is the general flow in the nagi model of disablement?

A
  • Active pathology
  • Impairment
  • Functional limitations
  • Disability
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6
Q

What is an active pathology?

A

Interruption or interference with normal processes and efforts of the organism to regain normal state

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7
Q

What is an impairment?

A

Anatomical, physiological, mental, or emotional abnormalities or loss

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8
Q

What is a functional limitation?

A

Limitation in performance at the level of the whole organism or person

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9
Q

What is a disability?

A

Limitations in performance of socially defined roles and tasks within a socio-cultural and physical environment

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10
Q

Examination findings lead to ___

A

Examination findings lead to interventions

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11
Q

We monitor ____ to see if impairments are changing

A

We monitor signs and symptoms to see if impairments are changing

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12
Q

What are the signs/symptoms that we normally think about to determine if impairments are changing?

A

Asterisk/provocative signs

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13
Q

What is an impairment intervention/maxim to provide for a stiff patient?

A
  • Manipulate (thrust/non-thrust)
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14
Q

What is an impairment intervention/maxim to provide for a tight patient?

A

Stretch/ improve flexibility

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15
Q

What is an impairment intervention/maxim to provide for a weak patient?

A

Strength

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16
Q

What is an impairment intervention/maxim to provide for a patient if coordination is lacking?

A

Facilitate/inhibit muscles to improve coordination

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17
Q

What is an impairment intervention/maxim to provide for a patient whose fear of movement is high?

A

Graded exposure

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18
Q

What is an impairment intervention/maxim to provide for a patient when there is a misunderstanding?

A

Educate

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19
Q

What should our treatment approach be?

A
  • Test
  • Treat
  • Retest
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20
Q

____ provides most of the information needed to clarify the cause or establish a hypothesis

A

The patient’s story provides most of the information needed to clarify the cause or establish a hypothesis

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21
Q

When does the interview of a patient stop in the duration of treatment?

A

NEVER, the interview is continuous should be done for as long as the patient is in your care

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22
Q

What are the key components we want to get out a patient’s story?

A
  • Patient profile
  • Chief complaint
  • Body chart
  • Present episode
  • Aggravating and easing factors
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23
Q

What is severity in SINSS?

A

Intensity of patient’s complaint and the extent that they limit pain

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24
Q

What is irritability in SINSS?

A

The amount of activity to aggravate/alleviate symptoms

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25
Q

What is nature in SINSS?

A

The source of patient’s pain.

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26
Q

What is stage in SINSS?

A

Acute, sub-acute, chronic

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27
Q

What is stability in SINSS?

A

Is pain getting better, staying the same, or worsening

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28
Q

____ refers to the type and extent or degree of injury/illness

A

Nature refers to the type and extent or degree of injury/illness

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29
Q

What is an acute on chronic stage of pain?

A

When a person has a chronic pain, but has a flare up

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30
Q

What is the stage of most back pain?

A

Acute on chronic

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31
Q

___ clarifies the historical examination

A

Physical examination clarifies the historical examination

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32
Q

What are the components of the physical exam?

A
  • Observation
  • Clearing test (spine, joints above and below)
  • Active movement
  • Passive movement (physiologic, accessory, neural)
  • Palpation
  • Functional tests
  • Isometric tests
  • Special tests
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33
Q

What are the treatment techniques for an impairment based intervention?

A
  • Address impairments
  • Reduce, centralize, or abolish symptoms
  • May relieve or provoke symptoms
  • Take into account: SINSS (worse, same, better) (vigor of techniques)
  • Test-treat-retest
  • Choose one or two techniques and complement with specific HEP
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34
Q

___ indicates the value of each technique

A

On-going assessment indicates the value of each technique

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35
Q

A ___ response during a session indicates a better prognosis (outcome) over time

A

A positive response during a session indicates a better prognosis (outcome) over time

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36
Q

What does an on-going assessment do at the beginning of a treatment session?

A
  • Determine effect of last treatment session (immediate, evening, next morning)
  • Re-assess History/physical exam
  • Forms the basis for treatment session
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37
Q

What does an on-going assessment do as each technique is performed?

A
  • Be alert t changes on the patient’s symptoms

- Palpate, observe, question

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38
Q

What does an on-going assessment do after each technique is used?

A
  • Determine the immediate effect of a technique (reassess…

- Determine how to proceed (repeat, modify, add, or discontinue the treatment technique)

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39
Q

What does an on-going assessment do at conclusion of a treatment session?

A
  • Determines the effect of the whole treatment session
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40
Q

What are the potential pain generators in the lumbar spine?

A
  • Muscles
  • Ligaments
  • Dura mater
  • Nerve roots
  • Zygapophyseal joints
  • Sacroiliac Joint
  • Annulus fibrosus
  • Thoracolumbar fascia
  • Vertebrae
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41
Q

What is radicular pain?

A

Sharp, shooting, superficial or deep pain into the leg in a defined band < 4cm wide

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42
Q

What is a radiculopathy?

A

Radiating paresthesia, numbness in a dermatome, weakness (myotome), or combo of these, but not pain

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43
Q

What is somatic pain?

A

Poorly localized, aching pain

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44
Q

Compression of nerve root causes

____ but not pain

A

Compression of nerve root causes

radiculopathy but not pain

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45
Q

Radicular pain is elicited only when ____

A

Radicular pain is elicited only when *a

previously damaged nerve root is compressed.*

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46
Q

Patient may not always present with

____ and radicular pain.

A

Patient may not always present with

radiculopathy and radicular pain.

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47
Q

What are the non contractile tissue pain generators?

A
  • Nerve Root
  • Discogenic Pain
  • Zygapophyseal Joints
  • (Facet Joint Syndrome)
  • Sacroiliac Joint
  • Ligament and Fascia
  • Vertebrae
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48
Q

Where is the site of pain of an herniated nucleus pulposes compressed nerve root?

A
  • Butt, leg, foot
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49
Q

Where is the site of pain of a normal nerve root if felt at all?

A
  • Butt

- Leg

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50
Q

Where is the site of pain of the annulus of the disc?

A

Back

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51
Q

Where is the site of pain for the vertebral endplate?

A

Back

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52
Q

Where is the site of pain for the facet capsule?

A

Back

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53
Q

Actively irritated spinal nerve root

reproduced sciatica ___% of time

A

Actively irritated spinal nerve root

reproduced sciatica 99% of time

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54
Q

___ nerve root insensitive to

pain most of the time

A

Normal nerve root insensitive to

pain most of the time

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55
Q

Patients with post-laminectomy scar had perineural fibrosis that sensitized the nerve root. This scar tissue led to nerve pain
by ___

A

Patients with post-laminectomy scar had perineural fibrosis that sensitized the nerve root. This scar tissue led to nerve pain
by limiting the mobility of the nerve root

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56
Q

Exposure to nuclear material of disc causes an ____

A

Exposure to nuclear material of disc causes an inflammatory response

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57
Q

In the absence of disc material, an inflammatory response may result from
____

A

In the absence of disc material, an inflammatory response may result from
traumatic compression

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58
Q

Animal models suggest that compression of the nerve root causes ____ and ____

A

Animal models suggest that compression of the nerve root causes local edema and ischemia

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59
Q

____ is the most common source of compressive radiculopathy

A

IVD herniation is the most common source of compressive radiculopathy

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60
Q

Herniation of the L4/5 disc will affect what nerve root and why?

A

Affect L5 nerve root, because lumbar roots emerge below their vertebrae

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61
Q

On what spinal levels do IVD herniation most commonly occurs?

A
  • L4/5 (50%)

- L5/S1 (46%)

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62
Q

What part of the annulus s innervated?

A

Outer 1/3

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63
Q

How is the annulus most commonly injured?

A
  • Torsion and repetitive flexion
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64
Q

Radial fissures that develop in the

inner 2/3 of annulus reach outer 1/3 may cause __ but not ___

A

Radial fissures that develop in the

inner 2/3 of annulus reach outer 1/3 may cause back pain but not leg pain

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65
Q

___ and ____ are so co-mingled that it is almost impossible to stimulate them individually

A

PLL and central annulus are so co-mingled that it is almost impossible to stimulate them individually

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66
Q

Stimulation of the central annulus and the PLL creates ___ LBP

A

Stimulation of the central annulus and the PLL creates central LBP

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67
Q

Unilateral stimulation of PLL directed pain to

the ____ side being stimulated.

A

Unilateral stimulation of PLL directed pain to

the same side being stimulated.

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68
Q

Stimulating a disc herniation caused buttock pain but no ___

A

Stimulating a disc herniation caused buttock pain but no sciatica

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69
Q

What is sciatica?

A

Pain that is felt in the legs

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70
Q

Prevalence facet joint pain up to ___%

A

Prevalence facet joint pain up to 25%

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71
Q

Why has the fact/ZPJ joints been identified as a source of back and leg pain?

A
  • Generate pain in healthy subjects
  • Reproduce “familiar” LBP pain in patients
  • When injected, can relieve pain in certain patients
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72
Q

____ of the facets may cause pain

A

Degenerative arthritis of the facets may cause pain

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73
Q

What are some theories as to what can cause pain originating from the ZPJ/facet joint?

A
  • Meniscoid entrapment
  • Synovial impingement
  • Mechanical injury to the joint’s capsule
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74
Q

Stimulation of the ZPJ/ facet joint at levels L4-5 produces pain where?

A

Buttock or trochanteric region

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75
Q

Stimulation of the ZPJ/ facet joint at levels L2-5 produces pain where?

A

Groin

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76
Q

What are the factors significantly correlated with pain relief from facet injection?

A 
• Older age
• Previous history of LBP
• Normal gait
• Maximal pain with extension from
fully flexed
• The absence of leg pain
• The absence of muscle spasm
• No pain with Valsalva maneuver
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77
Q

It takes great ____ to elicit pain from the ZPJ joint. The pain produced was ___

A

It takes great * ‘experimenter force’* to elicit pain from the ZPJ joint. The pain produced was localized an didn’t reproduce
patient’s deep LBP

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78
Q

Occasionally facet capsule was painful and it referred pain into the ___, “Very rarely” into the ___, and “Never” the ___

A

Occasionally facet capsule was painful and it *referred pain into the back, “Very rarely” into the butt, and “Never” down the lower limb. *

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79
Q

Facet capsule and articular cartilage was

“never” ____, even when pierced

A

*Facet capsule and articular cartilage was

“never” tender, even when pierced*

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80
Q

Facet can become sensitized to pain in the presence of _____

A

Facet can become sensitized to pain in the presence of inflammation

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81
Q

L1/2, L2/3, and L4/5 facet joints always

referred pain to ____

A

L1/2, L2/3, and L4/5 facet joints always

referred pain to *lumbar spine *

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82
Q

Referral to the gluteal region by the facet joint was from ____(68% of the time)

A

Referral to the gluteal region by the facet joint was from L5/S1 (68% of the time)

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83
Q

L2/3, L3/4, L4/5, and L5/S1 facet joint occasionally referred pain to the ___ (10% to 16% of the time)

A

L2/3, L3/4, L4/5, and L5/S1 occasionally referred pain to the trochanteric region (10% to 16% of the time)

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84
Q

Referral to ___, posterior thigh, and ___ regions were most often from L3/4, L4/5, and L5/S1 facet joints (5% to 30% of the time)

A

Referral to lateral thigh, posterior thigh, and groin regions were most often from L3/4, L4/5, and L5/S1 facet region (5% to 30% of the time)

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85
Q

Can pain maps be used to determine the origins of facet joint pain? And why?

A

No it can not. Because most facet joint pains are overlapping

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86
Q

What is facet joint pain described as?

A 
• Deep and achy
• Localized to a unilateral or bilateral
paravertebral area.
• Common referral areas for facet are
• Flank pain
• Buttock pain (rarely below the knee)
• Pain overlying the iliac crests
• Pain radiating into the groin
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87
Q

During what time of the day is facet pain worse?

A

In the morning

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88
Q

What aggravates facet pain?

A

Extension, twisting, stretching, lateral bending

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89
Q

The SI joint is a _____ synovial joint that is innervated from the dorsal primary rami of ___

A

The SI joint is a diarthrodial synovial joint that is innervated from the dorsal primary rami of S1-S4

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90
Q

Injection of irritant solutions into SIJ provokes pain into ___

A
  • Buttock
  • Lower lumbar region
  • Lower extremity
  • Groin
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91
Q

What is the reported prevalence ranges of patients with LBP origination from the SI joint?

A

2-30%

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92
Q

The people that experienced pain from the Slipman 2001 research with injection to the SI joint felt pain where?

A

In the fortin area

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93
Q

The people that did not experienced pain from the Slipman 2001 research with injection to the SI joint felt pain where?

A

The area inferolateral to the fortin area

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94
Q

How can lumbar ligaments and fascia cause LBP?

A
  • Trauma
  • Overload (postural)
  • Faulty Movement Patterns
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95
Q

Common tendon of ____

and long dorsal SI ligament, along with ____ can cause pain

A

Common tendon of longissimus thoracis

and long dorsal SI ligament, along with thoracolumbar fascia can cause pain

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96
Q

Prevalence of lumbar ligamentous sprain is

___

A

Prevalence of lumbar ligamentous sprain is

low

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97
Q

Spondylosis refers to ___

A

Degenerative changes of the lumbar vertebrae

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98
Q

Bone pain can arise from ____

A
  • Paget’s disease
  • Primary or secondary tumors
  • Fractures
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99
Q

Spondylolysis is a ___

A

Spondylolysis is a defect of the pars related to a fatigue fracture

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100
Q

The incidence of ____ is related to activity

A

The incidence of spondylolysis is related to activity

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101
Q

____ is an anterior displacement of one vertebra over the other

A

Spondylolisthesis is an anterior displacement of one vertebra over the other

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102
Q

Spondylolisthesis is usually a progression from a ___

A

Spondylolisthesis is usually a progression from a spondylolysis

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103
Q

Anterior slippage of spondylolisthesis can compress the ___ and lead to ___

A

Anterior slippage of spondylolisthesis can compress the spinal canal and lead to cauda equina like symptoms

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104
Q

In what population are patients more likely to experience a slippage of spondylolisthesis?

A

In patients with a bilateral defect

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105
Q

What are some vertebral anomalies that may cause LBP?

A
  • Transitional lumbar vertebrae (TLV)

- Spina bifida occulta (SBO)

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106
Q

Specific somatic pain generators are ____

A

Contractile tissue

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107
Q

Muscles in patients with LBP become dysfunctional and demonstrate ___

A
  • Atrophy
  • Reduced activity with movements
  • Decreased muscle strength
  • Increased fatigueability
  • Change in % of fiber types
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108
Q

What stage of pain does atrophy of paraspinal muscles occur with LBP patients?

A

Acute and chronic

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109
Q

Most atrophy occurs in what muscle?

A

Multifidus

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110
Q

____ is the likely cause of atrophy according to Hides et al

A

Reflex inhibition is the likely cause of atrophy according to Hides et al

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111
Q

____ of multifidus after distention of the facet joints by injection with saline solution

A

Rapid inhibition of multifidus after distention of the facet joints by injection with saline solution

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112
Q

Patients with LBP have a significantly higher portion of ____ muscle fibers

A

Patients with LBP have a significantly higher portion of type IIB (fast twitch glycolytic) muscle fibers

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113
Q

The longer the duration of LBP, the ___ the change of muscle fibers to type IIB

A

The longer the duration of LBP, the higher the change of muscle fibers to type IIB

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114
Q

What are the things that the change in muscle fiber type result in with patients with LBP?

A
  • Increased fatiguability
  • Compromised spinal stability
  • Increased stress on non-contractile structures
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115
Q

What are the common disorders in muscles with patients with LBP?

A

• Muscle strain
• Spasm or guarding
• Myofascial complaints, such as trigger
points.

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116
Q

The common disorders in muscles with patients with LBP leads to…?

A

• Altered activity in painful muscle
• Lower blood flow in the painful muscles
• Impaired circulation contributes to muscle
pain by causing metabolites to accumulate

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117
Q

What are trigger points?

A

Tender, firm, 3-6mm nodules that provoke radiating, aching pain into localized reference zones

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118
Q

Mechanical stimulation of a taut band/ trigger point elicits a ____

A

Mechanical stimulation of a taut band/ trigger point elicits a localized muscle twitch.

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119
Q 
Myofascial Pain (MP) syndrome occurs
when muscles are short/contracted with \_\_\_\_
A 
Myofascial Pain (MP) syndrome occurs
when muscles are short/contracted with
*increased tone, stiffness, and trigger points (TrPs)*
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120
Q

Myofascial Pain (MP) and trigger points (TrPs) may occur due to …?

A 
• Direct or indirect trauma
• Exposure to repetitive strain
• Postural dysfunction
• Nerve root dysfunction (neuropathic pain)
- Site of tissue damage
- Result of proximal radicular disorder
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121
Q

Muscles affected by neuropathic pain may be injured due to …?

A

• Prolonged spasm, mechanical overload,

or metabolic/nutritional shortfalls

122
Q

Research suggests that MP with TrPs is a ____ disorder

A

Research suggests that MP with TrPs is a spinal segmental reflex disorder

123
Q

Is trigger point dry needling effective?

A

Yes, but research needs to be done

124
Q

True or false

Nerve root pain may not follow a specific dermatome

A

True.

Yes mufti, believe it. This is actually what the man said

125
Q

True or false

Dermatomal distribution of pain may not be useful in the diagnosis of radicular pain

A

True

Yes mufti, believe it. This is actually what the man said

126
Q

What intervention should a PT be careful of when a patient presents with spondylolisthesis?

127
Q

What intervention should a PT be careful of when a patient presents with disc extrusion?

A

Manipulation

128
Q

What is lumbar spinal stenosis?

A

A number of degenerative conditions of the aging spine

129
Q

What are some of the name of the degenerative conditions found in lumbar stenosis?

A
  • Lumbar spondylosis

- Degenerative disc disease

130
Q

What are some associated pathologies with lumbar spinal stenosis?

A
  • Clinical instability
  • Lumbar spinal stenosis
  • Degenerative spondylolisthesis
131
Q

What is the general term that the cochrane collaboration uses for lumbar spinal stenosis?

A

Degenerative lumbar spondylosis

132
Q

What is stenosis?

A

A focal narrowing in any canal

133
Q

What is vascular stenosis?

A

A narrowing of an artery or vein

134
Q

What is central stenosis?

A

A narrowing of the central/neural canal

135
Q

What is a lateral stenosis?

A

A narrowing of the lateral foramen where the nerve root exits

136
Q

Is there a correlation between canal diameter and pain?

A

No there is not

137
Q

What are the most common causes of lumbar spinal stenosis?

A
  • Arthritic or degenerative changes
138
Q

What are some of the patho-physiology involved with lumbar spinal stenosis?

A

Neural compression and vascular ischemia(stenosis in the muscles)

139
Q

Lumbar spinal stenosis has a ____ component to it

A

Lumbar spinal stenosis has a *dynamic (motion or activity) component to it

140
Q

____or ____ will decrease the cross sectional area of the central spinal canal and the neuro-foramen

A

Extension or increased axial compression will decrease the cross sectional area of the central spinal canal and the neuro-foramen

141
Q

____ or ___ will increase the cross sectional area of the central spinal canal and the neuro-foramen

A

Flexion or decreased axial compression will increase the cross sectional area of the central spinal canal and the neuro-foramen

142
Q

What is prevalance?

A

The percentage of a population that is affected with a particular disease at a given time.

143
Q

What is prognosis?

A

Predicting the course & outcome of a medical condition

144
Q

Lumbar spinal stenosis (LSS) is prevalent and disabling in the ____ population

A

Lumbar spinal stenosis (LSS) is prevalent and disabling in the aging population

145
Q

What percent of primary care and specialist visits present with LSS?

A
  • 4% primary care

- 14% specialist

146
Q

How does LSS change over time?

A

It doesn’t really change for the most part

147
Q

What is the clinical presentation of LSS?

A
  • Low back pain
  • Buttock pain
  • Bilateral calf pain
  • Slow/abnormal gait
  • Forward bent posture
  • CLAUDICATION
148
Q

What is claudication?

A

Limping. Impairment in walking, or pain, discomfort or tiredness in the legs that occurs during walking and is relieved by rest

149
Q

What are the requirements to rule neurogenic claudication condition in?

A

The constellation consists of symptoms that
are triggered with standing, relieved with sitting and located above the knees and that have a positive shopping cart sign. LR+ = 13

150
Q

What are the requirements to rule vascular claudication condition in?

A

The constellation consists of symptoms that are relieved with standing alone and located below the knees. +LR = 20

151
Q

What is the evaluation of neurogenic claudication after walking?

A

Increased weakness

152
Q

What is the evaluation of vascular claudication after walking?

153
Q

What are the palliative/easing factors of neurogenic claudication?

A
  • Bending over

- Sitting

154
Q

What are the palliative/easing factors of vascular claudication?

155
Q

What are the provocative factors of neurogenic claudication?

A
  • Walking downhill

- Increased lordosis

156
Q

What are the provocative factors of vascular claudication?

A
  • Walking uphill

- Increased metabolic demand

157
Q

Are pulses present or absent in neurogenic claudication?

158
Q

Are pulses present or absent in vascular claudication?

159
Q

Is the shopping cart sign present or absent in vascular claudication?

160
Q

Is the shopping cart sign present or absent in neurogenic claudication?

161
Q

What occurs with the van Gelderen bicycle test with neurogenic claudication?

A

No leg pain

162
Q

What occurs with the van Gelderen bicycle test with vascular claudication?

163
Q

What is neurogenic claudication?

A

Some compression or dysfunction of the nerve root or spinal canal

164
Q

What is vascular claudication?

A

A lack of good blood flow to exercising muscle

165
Q

What are the factors to help rule out LSS?

A
  • Younger than 65

- No back and leg pain (pain below buttocks)

166
Q

What are the aggravating/easing factors associated with LSS?

A
  • No pain when seated
  • No pain with flexion
  • Sitting (best)
  • Standing/ walking (worst)
167
Q

What are the symptoms against LSS?

A

Symptoms that are induces with flexion, better with extension, and have a +SLR test

168
Q

What are the symptoms for LSS?

A
  • Symptoms worse with standing & extension, better with flexion
  • Older (>60 yrs), chronic (>6 mo)
    • intermittent claudication but good peripheral circulation
  • No diabetes
169
Q

What are the physical examination findings of LSS?

A
  • Posture – flexed at thoracic, lumbar, and hips
  • Gait: wide-based, flexed, assistive device
  • Lumbar ROM Restrictions - restricted &/or pain with extension; +/- with ipsilateral side bending & ipsilateral quadrant
  • Segmental mobility: hypomobile thoracic, lumbar, and hips
  • Hip Passive Accessory mobility: hypomobile (posterior to anterior: PA > other directions)
  • Muscle Length: Iliopsoas & Rectus Femoris tightness; anterior chest wall tightness; gastric-soleus tightness
170
Q

What is the neurologic physical presentation of LSS?

A

(MSRs, Weakness, Sensation)
• 20-50% of patients; at least 1 spinal level involved
• Ankle plantarflexion weakness

171
Q

What is the muscle performance/motor control of patients with LSS?

A
  • Gluteus Medius/Maximus & hip ER weakness

* Difficulty activating abdominals, poor motor control

172
Q

Where should limitations be looked for in the knee, ankle, and foot with patients that present with LSS?

A

Look for limitations in knee extension & ankle DF

173
Q

What are the test used to rule in LSS?

A
  • Two-stage treadmill test

- Bicycle test

174
Q

What is the two-stage treadmill test?

A

A diagnostic tool that compares walking tolerance on a leveled surface and on a 15% incline at a self selected pace

175
Q

The two-stage treadmill test uses a ___ reference standard

A

The two-stage treadmill test uses a radiological reference standard

176
Q

What is the best classification of LSS using the two-stage treadmill test?

A
  • Earlier onset of symptoms & prolonged recovery with level treadmill walking (Sp = 0.95; + LR = 14.5)
  • Longer total walking time with incline (Sp = 0.92; + LR = 6.5)
177
Q

How is the bicycle test done?

A
  • Patient instructed to pedal a stationary bike with increased lordosis
  • Cycle until reproduction of posterior buttock, thigh pain and paresthesias.
  • Patient instructed to continue pedaling while leaning forward into lumbar flexion.
178
Q

What does improved symptoms in the slump position with a bicycle test indicate?

A

Increased likelihood of neurogenic claudication

179
Q

What does increased symptoms in the slump position with a bicycle test indicate?

A

Increased likelihood of vascular claudication

180
Q

Is there a difference between PT and surgery with LSS over a 2 year period?

181
Q

Which has better long term effects: manual therapy, walking and exercise or flexion, exercise and walking interventions?

A

Manual therapy, walking and exercise had longer effects

182
Q

Is there a real difference between the two stage treadmill test and the bicycle test?

A

No there isn’t

183
Q

What type of study was done to compare the two-stage treadmill test and the bicycle test?

184
Q

What approach is recommended to treat patients with LSS?

A

PT impairment based management approach

185
Q

What does the PT impairment based management approach look like?

A
  • Centralize symptoms if patient has peripheralized symptoms

- Restore upright posture

186
Q

How will symptoms be centralized for LSS?

A
  • Repeated flexion exercises

- Rotational exercises in side-lying

187
Q

How will upright posture be restored in patients with LSS?

A
  • Increase Thoracic/Lumbar Extension
  • (Rotational Mob/Manip, PA, Translatoric Mob/Manip)
  • Increase Hip Extension - Mob/Manip, Stretch hip flexors
188
Q

How do we work on muscle balance for patients with LSS?

A

LE Strengthening - Gluteals, Hip Abd/ERs,

Calf, other as needed

189
Q

How do we work on conditioning for patients with LSS?

A

Intentional Walking, Cycling Programs

190
Q

How do we work on core stabilization for patients with LSS?

A

Abdominal motor control emphasis

191
Q

What is the aerobic exercise protocol for patients with LSS?

A

• Start at inital 20mins with goal of 45mins in clinic exercises
• Daily intentional walk 3x/week
In clinic
• Treadmill speed and incline to maximize comfort/minimize LE symptoms
• Once can’t walk finish on the stationary bike
• Rating of perceived exertion (RPE) >7 on a 10pt scale terminate exercise

192
Q

What are the education topics to use with patients?

A
  • Confront Symptoms & Fear Avoidance Beliefs
  • Discuss life goals
  • Counteract negative messages that aging means deterioration
  • Discuss and address any depression symptoms
  • BE POSITIVE!
193
Q

Should PT be intensive with patients with LSS?

A

YES! BE INTENSIVE! B! E! INTENSIVE

194
Q

Which has a higher chance of resulting in surgery: MRI or X-ray?

195
Q

What term is used frequently to drive spinal fusion?

A

Lumbar spinal instability

196
Q

What is the “goal” of spinal fusion surgery?

A

To stabilize a segment of the spine that has “weakened” and eliminate motion at that segment

197
Q

Ideally, what is the stabilization “achieved” through spinal fusion surgery supposed to do?

A

Reduce pain that is associated with vertebral movement

198
Q

What is spinal fusion originally created for?

A

Significant trauma to the spine in order to prevent neurological damage

199
Q

What is the basis of spinal fusion being a part of pain management?

A

Based entirely on a mechanical “model” that excessive motion is the source of pain…despite hard evidence to the contrary

200
Q

In the early 2000s, spinal fusion rose by ___%

A

In the early 2000s, spinal fusion rose by 77%

201
Q

Which is better at improving pain and disability in chronic LBP: fusion or non-operative care?

A

There is not much of a difference in the two

202
Q

Surgeons in what setting are likely to be more conservative when it comes to fusion?

A

Academic practices. Those in private practices are more likely to pick surgery

203
Q

Which is more likely to be dependent on opiods: fusion surgery patients or artificial discs patients?

A

Fusion surgery

204
Q

The pain neuromatrix suggests that pain is produced in the ___ as a reaction to a ____ to body tissue that requires an action.

A

The pain neuromatrix suggests that pain is produced in the brain as a reaction to a perception of danger to body tissue that requires an action.

205
Q

Pain response involves ____ and ____ components making it a multisystem process.

A

Pain response involves sensory and emotional components making it a multisystem process.

206
Q

Popular belief is that pain is always reflective of tissue damage, however, pain can be the result of ____ or ___ tissue damage

A

Popular belief is that pain is always reflective of tissue damage, however, pain can be the result of actual or perceived tissue damage

207
Q

True/false

Pain cannot be trusted as an adequate reflection of the state of tissues

A

True

Pain CANNOT be trusted as an adequate reflection of the state of the tissues.

208
Q

What are the effects of pain: cortical output?

A
  • Reduces cortical processing capacity
  • Slows decision making
  • Increases cognitive error rate
  • Pain sufferers report forgetfulness and being easily distracted
  • Immune activity is modified
  • Hypothalamus-pituitary-adrenal axes and sympathetic nervous system activity is altered
  • Reproductive system function is reduced
209
Q

What are the effects of pain: motor output?

A
  • Motor output serves to: promote escape, limit provocation of the painful part
  • Motor changes are driven by higher centers
210
Q

What is the pain neuromatrix?

A

The neuromatrix is the combination of cortical mechanisms that when activated produce pain

211
Q

What are the areas of the brain that are involved in the pain experience?

A
  • Anterior cingulate cortex (ACC)
  • Insular cortex
  • Thalamus
  • Sensorimotor cortex
212
Q

True or false

There is no pain center in the brain

213
Q

What is the pain matrix?

A

The many regions of the brain that can be activated during a pain experience

214
Q

___ and ____ which are physiologic reactions in the brain, may also affect the pain matrix, because the same areas of the brain are activated during this

A

Beliefs and attitudes which are physiologic reactions in the brain, may also affect the pain matrix, because the same areas of the brain are activated during this

215
Q

Long term pain may be a result of ____

A

Long term pain may be a result of enhanced brain activity

216
Q

A brain in chronic pain is a ____ brain

A

A brain in chronic pain is a hyperactive/hypersensitive brain

217
Q

What is secondary hyperalgesia?

A

The sensitive/painful area around the point of injury

218
Q

What is primary hyperalgesia?

A

Pain at the point of injury

219
Q

Central sensitization refers to ___

A

Central sensitization refers to when the spinal cord or brain begin to adapt to pain and widespread pain/hyperalgesia begin to occur into the periphery

220
Q

___ and ____ fibers produce a painful stimulus while ___ produces light touch

A

C afferent and A-delta fibers produce a painful stimulus while A-betafibers produces light touch

221
Q

What happens to the A-beta fibers overtime?

A

Overtime during a period of chronic pain, the spinal cord adapts and A-beta fibers sprout branches that connect to the C- afferent fibers, hence making light touch painful

222
Q

What does the brain being hypersensitive mean?

A

Less brain activity is needed to stimulate a pain experience

223
Q

There is an unclear relationship between pain and the ____, ____, and decreased tolerance to normal/traditional therapeutic approaches

A

There is an unclear relationship between pain and the state of the tissues, unpredictable flare-ups, decreased tolerance to normal/traditional therapeutic approaches

224
Q

What are the 3 aspects of managing patients with long-term pain?

A
  • Reduction of threatening input so as to reduce activity of the pain neuromatrix and thereby reduce its efficacy
  • Targeted activation of specific components of the pain neuromatrix without over activating the neuromatrix
  • Upgrading physical and functional tolerance by graded exposure to threatening inputs across sensory and non-sensory domains
225
Q

___ is a mainstay of pain management programs

A

Patient education is a mainstay of pain management programs

226
Q

The goal of education is to ____

A

The goal of education is to reconceptualize the problem

227
Q

___ is prevalent in patients with chronic low back pain

A

Depression is prevalent in patients with chronic low back pain

228
Q

___% of patients seeking care in an outpatient PT setting have listed depression as a comorbidity

A

15% of patients seeking care in an outpatient PT setting have listed depression as a comorbidity

229
Q

Depression is associated with ___ in the LBP population

A

Depression is associated with increasing pain, disability, medication usage, and unemployment in the LBP population

230
Q

Depressive symptoms were ___ in 35-75% of patients seeking treatment from a primary care MD

A

Depressive symptoms were NOT IDENTIFIED in 35-75% of patients seeking treatment from a primary care MD

231
Q

What is a depression screen?

A

2 written screening questions for depression plus the addition of a question inquiring if help is needed

232
Q

What are the 2 depression screening questions and the additional question to screen for depression?

A
  1. During the past month have you often been bothered by feeling down, depressed or hopeless?
  2. During the past month have you often been bothered by little interest or pleasure in doing things?
  3. Is this something with which you would like help (additional question)
233
Q

What are the possible answers to the depression screen questions?

A
  • Yes
  • No
  • Yes, but not today(only for the additional question)
234
Q

What question is the highest likelihood ratio of depression?

A

Help question alone

235
Q

What question is the 2nd highest likelihood ratio of depression?

A

Either screening question AND the help question

236
Q

What question is the lowest likelihood ratio of depression?

A

The 2 screening questions alone

237
Q

The 2 screening questions are good for ___, and why?

A

The 2 screening questions are good for ruling out, because they have good sensitivity, but lack diagnostic specificity

238
Q

A response to the 2 screening questions and the additional help question ___ overall specificity for major depression and is good for ruling ___

A

A response to the 2 screening questions and the additional help question improve overall specificity for major depression and is good for ruling in

239
Q

How often should depression be screened? and Why?

A

Regularly, because it may directly affect POC

240
Q

The goal in patient communication is to use language as a means to ___

A

The goal in patient communication is to use language as a means to collaboratively determine the treatment plan and make the patient an active participant in their care

241
Q

Language is not merely a vehicle which caries ideas, it is a ____

A

Language is not merely a vehicle which caries ideas, it is a shaper of ideas

242
Q

What are ideas?

A

Beliefs which may foster success or spawn failure

243
Q

What are some of the scary word when it comes to LBP?

A
  • Herniated disc
  • Ruptured disc
  • Sliped disc
  • Compressed disc
  • Pinched nerve
  • Degenerative disc disease
  • Arthritic joints
244
Q

What are some general terms or phrases that might scare a patient?

A
  • Bone on bone
  • To a 29 y/o, you have the spine of an 80 y/o
  • You don’t have a curve in your lower back
  • Your SI is out of place
  • This bone in your neck is rotated
  • This rib is out
245
Q

Why would a clinician use harmful words?

A
  • Clinical uncertainty evokes the use of jargon that creates the illusion/ perception of certainty
  • Alarmist language, which may be used to indicate a sense of urgency or attempt to illicit action on the part of the patient
246
Q

PTs need to search for words with ____

A

PTs need to search for words with clear, precise meaning and with connotations that do not evoke dread in the patient

247
Q

What are the 3 essential Rs in patient care?

A
  • Relate
  • Repeat
  • Reframe
248
Q

What is empathetic communication?

A

Language that aides the process of healing by bolstering patient’s strengths, validating their perspective, and teaching them how to grow to be more self reliant

249
Q

How do we treat patients that exhibit hypervigilance, catastrophic beliefs about pain or passive coping strategies?

A
  • Patient pain neurophysiology education has been shown to be effective for reducing pain in chronic LBP and widespread pain
  • Patient education about central sensitization of pain pathways was part of a successful rehab program
250
Q

What was found in the study where a group got really good PT and another group got a cognitive component along with PT?

A

Patients with the added cognitive component had better oswestry results and their pain was greatly reduced

251
Q

ROM provides a starting point for the ____

A

ROM provides a starting point for the facilitation of the recovery of joint motion

252
Q

What is Orthopedic Manual PT (OMPT)?

A

Any hand-on treatment provided by the physical therapist

253
Q

OMPTs can include…?

A
  • Joint Mobilizations
  • Manipulation
  • Stretching
  • Passive Motions
  • Soft Tissue Techniques
  • Manual Resistance
  • And on and on…
254
Q

What is the premise behind OMPT?

A

Assessment

255
Q

When is assessment performed?

A
  • An initial visit: eval
  • Continuously During Each Treatment Session
  • Continuous pragmatic assessment
256
Q

What is being assessed in an OMPT?

A
  • Patient Response
    • Motion
      • Pain, Quantity, Quality
    • Functional Outcomes!
257
Q

The expert PT uses careful assessment to adjust and fine tune ____ intervention to the specific needs of the patient

A

The expert PT uses careful assessment to adjust and fine tune joint mobilization intervention to the specific needs of the patient

258
Q

_____ is the cornerstone of a good assessment

A

Communication is the cornerstone of a good assessment

259
Q

What is joint mobilization?

A

Manual therapy techniques designed to address the altered mechanics of a joint and pain reduction techniques

260
Q

What are the altered mechanics addressed by manual therapy techniques?

A
  • Pain and Muscle Guarding
  • Joint Effusion
  • Contractures or Adhesions in the Joint Capsule
  • Malalignment or subluxation of bony surfaces
261
Q

Joint mobilization are techniques designed specifically to address ___

A

Joint mobilization are techniques designed specifically to *address restricted capsular tightness by restoring normal mechanics within a joint. *

262
Q

PT must use the knowledge of arthrokinematics to minimize the ____ within a joint when performing joint mobilization techniques

A

PT must use the knowledge of arthrokinematics to minimize the compressive forces within a joint when performing joint mobilization techniques

263
Q

Use of joint mobilization when not indicated can lead to ___

A

Use of joint mobilization when not indicated can lead to harm

264
Q

What are the characteristics of angular stretching?

A
  • Lever increases force at the joint
  • Can cause excessive joint compression
  • Roll without a slide does not replicate normal function
265
Q

What are the characteristics of joint mobilization?

A

• Force applied close to joint at an intensity
concurrent with pathology
• Direction of mobilization can mimic slide
• Selective application

266
Q

What are the neurophysiologic effects joint mobilization?

A
  • Stimulate Mechanoreceptors
  • Inhibit nociceptive stimuli, spinal cord, or brain
  • Small amplitude osccilations
267
Q

What are the mechanical effects joint mobilization?

A

• Motion of Synovial Fluide
- Small amplitude and oscilations
• Re-arrange collagenous fibers in joint capsule
- Large amplitude or sustained stretch

268
Q

PTs should stay away from joint mobilization after acute injuries in the presence of ____

A

PTs should stay away from joint mobilization after acute injuries in the presence of bony or joint instability, large joint effusion, vascular disorders like hemophilia, osteoporosis

269
Q

What are some contraindications for joint mobilizations?

A
  • Inflammatory arthritis
  • Herniated disks with nerve with compression
  • Bone disease
  • Neuro
  • Malignancy
  • Tuberculosis
  • Osteoporosis
  • Ligamentous rupture
  • Neurological involvement
  • Bone fracture
  • Congenital bone deformities
  • Vascular disorders
  • Hyper-mobility
270
Q

The barrier concept helps us to understand ____ vs ___ motion

A

The barrier concept helps us to understand normal vs abnormal motion

271
Q

What is perceived by the practitioner just before the restrictive barrier?

A

Resistance to motion

272
Q

Recognition of the restrictive barrier is an important point in being able to ___

A

Recognition of the restrictive barrier is an important point in being able to properly gauge the grade of techniques

273
Q

What are the types of joint mobilizations?

A
  • Physiologic (osteokinematic motion)

- Accessory (arthrokinematic motion)

274
Q

The bending of the knee is an example of what type of motion?

A

Osteokinematic motion

275
Q

The rolling and gliding of joint surfaces as it goes through its normal ROM is an example of ____ motion

A

The rolling and gliding of joint surfaces as it goes through its normal ROM is an example of accessory/arthrokinematic motion

276
Q

Why are joint mobilizations special?

A

They can reproduce arthrokinematic motions that patients cannot do on their own

277
Q

What is the concave-convex rule?

A

Concave joint surfaces slide in the SAME direction as the bone movement (convex is STABLE)

278
Q

What is an example of a concave on convex motion?

279
Q

What is the convex-concave rule?

A

Convex joint surfaces slide in the OPPOSITE direction of the bone movement (concave is STABLE)

280
Q

The glenohumeral joint is an example of what rule?

A

The convex-concave rule

281
Q

What are the grades of joint mobilization?

A 
I. Small Amp, Out of Resistance, PAIN
II. Large Amp, Out of Resistance, PAIN
III. Large Amp, Into Resistance, MOTION
IV. Small Amp, Into Resistance, MOTION
V. (Manipulation), pushes beyond Restrictive Barrier (HVLAT)
282
Q

How are the grading of joint mobilization organized?

A

By both the relationship to the restrictive barrier as well as the size of amplitude in which they are performed

283
Q

Grades 3 and 4 of joint mobilization are into the ___, while grades 1 and 2 are not

A

Grades 3 and 4 of joint mobilization are into the restrictive barrier, while grades 1 and 2 are not

284
Q

The optimal grade of joint mobilization for pain relief is ____ and then ___

A

The optimal grade of joint mobilization for pain relief is grade 1 and then grade 2

285
Q

What are the optimal grades for mechanical effects/motion in the barrier are…?

A

Grades 3 & 4

286
Q

The use of the specific grade of mobilization is determined by…?

A
  • Stage of Healing
  • SINSS (Severity, Irritability, Nature, Stage, Stability)
  • Response to Treatment
287
Q

The grading of joint mobility is ____ between each PT

A

The grading of joint mobility is not reliable between each PT

288
Q

What are the things to look for when assessing joint accessory motion?

A
  • Limited PROM
  • Firm, capsular end feel with over pressure
  • Hypomobility in accessory motion testing
289
Q

What are the treatment specific guidelines to follow when performing joint mobilizations?

A
  • Patient should be relaxed!
  • Explain purpose of treatment & sensations to expect to patient
  • Assess BEFORE, DURING, & AFTER treatment
  • Stop the treatment if it is too painful for the patient
  • Use proper body mechanics
290
Q

The resting position of the joint during joint mobilization should be…?

A
  • Maximum joint play - position in which joint capsule and ligaments are most relaxed
  • Evaluation and treatment position utilized with hypo-mobile joints
291
Q

The loose-packed position of the joint during joint mobilization should be…?

A
  • Articulating surfaces are maximally separated
  • Joint will exhibit greatest amount of joint play
  • Position used for both traction and joint mobilization
292
Q

The close-packed position of the joint during joint mobilization should be…?

A

• Joint surfaces are in maximal contact to each other

293
Q

What is the general rule for the preparation of joint mobilization?

A

Extremes of joint motion are close-packed, & midrange positions are loose packed

294
Q

What evaluations should be done prior to treatment?

A
  • AROM & PROM

* Pain Level Throughout Motion

295
Q

Where does the treatment plane lie?

A

Treatment plane lies on the concave articulating surface, perpendicular to a line from the center of the convex articulating surface

296
Q

Joint traction techniques are applied _____ to the treatment plane

A

Joint traction techniques are applied perpendicular to the treatment plane

297
Q

What are the things to do/remember when performing joint mobilization?

A

• Use Big Hands
- Avoid uncomfortable manual contacts
• Begin with Gentle Oscillatory (Grade I) motions
• Get a sense of available motion
• Decide upon technique
- Direction and Grade
• Perform Mobilization
- General Acceptable Dosage is 3 sets of
30 seconds

298
Q

The concepts of using big hands involves using _____ grip more than any ____ grip or one that uses the tips of the fingers

A

The concepts of using big hands involves using palms and lumbrical grip more than any pinsor grip or one that uses the tips of the fingers

299
Q

What grades of joint mobilization are bast used in the acute stage of healing?

A

Grades 1 and 2

300
Q

PTs should be able to identify appropriate ___ and ___ of mobilization for given condition and stage in healing process.

A

PTs should be able to identify appropriate direction and grade of mobilization for given condition and stage in healing process.

MSK 1 (5 decks)

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