Week 7: questions, in class notes, RAT Flashcards by Beck Forsland

Which lumbar ortho exams suggest lumbar disc?

Bilateral active SLR
Bragard or Bowstring confirms disc herniation if SLR was hard positive
Kernig
knees to chest (position bias disc vs facet)
Farfan torsion (Lx facet/disc)
Bechterew’s
Deyerlie (confirms)

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What lumbar ortho exams suggest facet?

knees to chest (position bias disc vs facet)
farfan torsion (Lx facet/disc)
kemp’s

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What lumbar ortho exam suggests SI?

Active SLR, resistance ASLR
Patrick FABERE - SI/hip
modified LaGuerre (hip)
Thigh thrust
Thomas Gaenslen’s
SI distraction
SI compression
Sacral thrust

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What are 4 indications for cervical xrays?

1 - moderate to high trauma load if it fulfills Canadian annexus rules
2 - red flags for disease
3 - cord or radicular signs/Sx
4 - nonresponsive to conservative care

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When would you MRI? What are the schools of thought?

1 - If there are signs of CES
2 - Progressive mm weakness with conservative care
3 - Profound mm weakness
4 - If patient wants surgical consult
5 - If patient doesn’t respond as expected
6 - If there is suspected upper lumbar disc herniation

Schools of thought:

1: whenever there are nerve problems, MRI
2: only MRI if disc herniation has deficits
3: nope, only MRI if there is cord damage e.g. severe motor loss

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If Kemps creates LBP only, what might it be?

Think Facet. Could be anything else including deranged disc

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If kemps creates leg pain think:

Encroachment of IVF e.g. spur, stenosis, disc herniation

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What is classic stenosis signs?

P with walking

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Define: Neuropathic pain

Umbrella term that includes lesion of the brain, spinal cord, NR, plexus, or peripheral nerves

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Define radicular pain syndrome

A type of neuropathic syndrome specifically due to a nerve root lesion.

2 types:

Radiculitis (an inflamed nerve root but no neurological deficits) or
Radiculopathy (a nerve root damaged to the point it has neurological deficits).

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Define brachial plexitis

a type of neuropathic pain caused by inflammation of the brachial plexus.

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Define Brachial plexopathy

a type of neuropathic pain caused by damage to the plexus severe enough to cause neurological deficits.

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Define neuritis

type of neuropathic pain caused by inflammation of a peripheral nerve (as opposed to a nerve root or plexus)

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Define neuropathy

type of neuropathic pain caused by damage to a peripheral nerve (as opposed to a nerve root or plexus) severe enough to cause neurological deficits. The result of a disease or an entrapment.

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At what age would you want to x-ray a patient with sudden onset of spontaneous LBP?

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MC location for compression fix?

TL junction

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4 scenarios when you should order MRI in suspected lumbar disc herniation

Signs of CES
Profound or progressive mm weakness
If patient wants surgical consult
If there is suspected upper lumbar disc herniation

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What are 3 PE items from 5 point check list to detect neural damage in a patient with LB and leg pain?

SMR testing (aka nerve compression tests)
Nerve tension tests
Spinal loading procedures (e.g. AROM, kemp’s, knees to chest)

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List 5 positive PE findings that would particularly support a cervical disc derangement dx

Deep referred arm pain may be improved by repetitive end range movements into chin retraction, extension or some other direction
Palpatory tenderness midline
Positive valsalva
Relieved by cervical distraction
Aggravated by cervical compression

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What 2 traumatic mechanisms (besides hyperextension) could directly injure a cervical nerve root?

Lateral flexion injury: falling on the head and shoulder

Compression: landing on the head

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Patient has neck pain and sharp pain along back of triceps and a “numb” feeling in 4th and 5th fingers. Neck AROM is severely limited in flexion due to neck pain. Cervical compression and valsalva create neck pain and the shoulder abduction test decrease finger numbness. SMRs are normal. Write a complete diagnosis.

Cervical disc herniation with C8 radiculitis to the medial hand

What are clues that support radicular syndrome? Patient has neck pain and sharp pain along back of triceps and a “numb” feeling in 4th and 5th fingers. Neck AROM is severely limited in flexion due to neck pain. Cervical compression and valsalva create neck pain and the shoulder abduction test decrease finger numbness. SMRs are normal.

Pain: arm pain and quality is sharp and distribution is along the back of triceps
Paresthesia: numb feeling in 4th and 5th fingers
Ortho: shoulder abduction reduces arm pain
SMRs: normal
Spinal loading: no postive tests for radicular syndrome

List all the clues that this is probably a herniated disc (as opposed to stenosis, spur, tumor) Patient has neck pain and sharp pain along back of triceps and a “numb” feeling in 4th and 5th fingers. Neck AROM is severely limited in flexion due to neck pain. Cervical compression and valsalva create neck pain and the shoulder abduction test decrease finger numbness. SMRs are normal.

Neck flexion aggravates the patient (r/o stenosis)
Cervical compression and valsalva created neck pain which suggests disc involvement
Shoulder abduction reduces arm pain which suggests nerve involvement (r/o disc derangement)

What are pathoanatomical lesions? memorize

Sprain
Strain
Facet syndrome
Deranged disc
Fracture

What are biomechanical lesions? **memorize**

Joint dysfunction or segmental dysfunction Myofascial trigger point Myospasm

What are key findings used to determine severity of a muscle tear in the extremities? Explain how they can be used to cite the grade of the tear.

Weakness: no/mild vs mod vs seve P w/ passive ROM: none vs pain, vs P/no P Defect: none vs small vs large

What would tests/Sx look like for grade 1 sTRAIN?

P with resistance No defect Minimal swelling, bruising No P with PROM (except when passively stretched) NO gross instab NO P with isometric mm testing No weakness (or little) NO defect

What would tests/Sx look like for grade 2 sTRAIN?

``` P w/ resistance Mild-mod weakness Small defect Mod swelling, bruising P with passive stretching (otherwise PROM is P-free) ```

What would tests/Sx look like for grade 3 sTRAIN?

``` P/no P with resistance Mod-sev weakness Larger defect Rapid, extensive swelling and/or bruising MM balls up, retracts, loses contour ```

What are 2 major parameters to consider when assigning a degree of severity to a MSK case?

Amount of tissue damage | Affect on patient (ADL, PSFS, OPS)

When measuring the effect on a patient, what are 2 main methods that are used?

ADL PSFS OPS

What are some key exam procedures and their findings to assess the amount of tissue damage in the extremities?

ROM End play Observation (bruising, swelling, erythema, hemearthrosis) Isometric mm testing

Why don’t these same methods listed in the Qs above work well in the spine (except, sometimes, the cervical spine)?

The spine is difficult to find end play Tissue damage is often too deep to show signs on the skin It’s difficult to isolate muscles in the spine

What are the key findings used to determine the severity of a ligament injury in the extremities?

PROM Observation (swelling, ecchymosis) Instability Weight bearing pain

What would tests/Sx look like for 1st degree/mild sPrain?

P on stress at endrange Local tenderness Mild local swelling Minimal P w/ weight bearing NO P w/ isometric mm testing NO gross instab

What would tests/Sx look like for 2nd degree/moderate sPrain?

``` P on stress of tissue before end range Generalized, marked tenderness, swelling Mild laxity Local bruising Mod ROM loss Mod-sev P w/ weight bearing ``` NO P w/ isometric mm testing (or mild P set phase)

What would tests/Sx look like for 3rd degree/severe sPrain?

``` Gross instab Variable response to isometric mm testing: NO P, P “set phase,” or sig weakness Generalized swelling Tissue disruption Min-sev P Hemearthrosis and extensive bruising Marked ROM loss Abnormal motion and/or P with mm contraction ```

What type of SMR neuro deficit is considered to be the worst?

Muscle weakness NR damage is more severe if there is motor weakness present.

What is the key distinguishing feature between grade 2 and grade 3 whiplash?

Grade 2 - MSK signs | Grade 3 - neuro deficits

Describe the grades of whiplash using the Quebec system

``` Grade 0: no complaint, no findings Grade 1: neck complaint, no findings Grade 2: neck complaint, MSK signs Grade 3: neck complaint, neuro deficits Grade 4: neck complaint, fracture or dislocation ```

What are 1˚ findings to support lumbar joint dysfxn?

Pain with palpation in open packed position ROM: segmental Tissue, texture, tone alterations in paraspinals (loss of symmetry)

What are 2˚ findings to support lumbar joint dysfxn?

Palpable malposition Repetitive loading Alterations in sectional or global ROM Observational alterations in paraspinal tissue symmetry

What are MEDICARE requirements for lumbar joint dysfxn?

At least 2 examination findings must be present: 1-must be either A or R of PART mnemonic 2-second could include any of the PART mnemonic

Does palpation for altered motion have acceptable inter- and intra-examiner reliability?

Inter-examiner (2+ examiners, 1 exam) is poor 0.17 Intra- (1 examiner, 2+ exams) is slightly better 0.35 Exclude Gillette’s test (SIJ) and intra- goes to 0.44

Does motion palp for pain/tenderness have acceptable reliability for inter- and intra-examiner reliability?

Inter- 0.53 | Intra- 0.91

What kappa value has been suggested as minimally acceptable?

0-0.25 is poor 0. 26-0.50 is fair 0. 51-0.75 is mod-good 0. 76-1.00 is good-excellent For physical medicine a 0.40 is generally acceptable though this number is arbitrary.

How would you explain what that number is actually telling you?

Agreement between 2 diff examiners doing the same exam (inter) or multiple exams with the same examiner (intra) is 40% better than pure chance

What are some key pertinent negatives for lumbar joint dysfxn?

Signs of NR involvement signals a search for additional pathoanatomical Dx especially when serious NR compression signs are present Red flags for serious disease

Where does lumbar joint dysfxn diagnosis fit into the 4-part diagnosis?

Biomechanical

How is nerve damage different from disc damage?

Nerve damage: - P in extremity sharp, stabbing, dermatomal - Paresthesia: numbness, tingling, etc in extremity - SMR deficits - (+) Orthos - (+) Spinal loading Disc derangement: - P in back: deep, achy, poorly localized midline/bilateral, constant/intermittent - SMRs (nerve compression tests) normal - 1˚ complaint: sitting intolerance, may aggravate LBP rapidly - Pain centralization of Sx! ONLY exam finding supported by clinical evidence based on 3 studies - Dejerine’s triad / Valsalva (spinal loading?) - usually flexion load sensitivity, but can be aggravated by rotation, side bending - minor’s sign

What degree of sprain is unstable?

3rd degree

What would you do to judge the severity of a sprain?

``` Check to see if they have: P at endrange weight bearing tenderness instability P with isometric mm testing ```