Week 8: Qs, In Class Notes, RAT Flashcards
What is a working definition of functional instability?
It’s a Dx based on history and PE findings.
It’s a P disorder hypothesized to result from loss of spine’s ability to maintain appropriate mechanical stiffness in neutral, midrange, or end range movements.
What are key differences between structural and functional instability?
Structural: excessive endrange motion beyond anatomical barrier. Tissue damage of things that are supposed to prevent endrange motion e.g. disc, ligament, fracture, etc. Radiographic evidence.
Functional: joint unstable in midrange, control by co-contraction of muscles through neutral zone. No tissue damage. No radiographic evidence. No excessive end range motion.
What is the neutral zone?
From the joints starting position up until the elastic zone. It is the mid range of the joint.
5 clues from Hx suggesting lumbar instability?
1–Episodic and triggered by trivial events
2–Reports of catching, locking, giving away
3–Immediate P with sitting (but dissipates over time to DDX from disc herniation)
4–Temporary response to manipulation
5–Decreased response to manipulation over time
Specific examples of aberrant lumbar motion?
Painful arc
Instability catch
Reverse lumbopelvic rhythm
Clinical prediction rule for predicting who might respond to lumbar stabilization program?
<40 yo
SLR mobility >91˚ (ave both legs)
Aberrant movement with lumbar flexion
Positive prone instability test
What is a clinical prediction rule?
They look at a whole series of factors for something you want to know and they find the shortest list to give you criterion on what to do
Describe the painful arc in the low back
During flexion and extension pt may displace a ROM which reproduces CC and may be accompanied by painful catch. Pain is in the middle, not at the beginning or the end.
Describe the instability catch
Painful catches are associated with temporary loss of motor control and buckling at particular segment(s) during ROM or activity.
Version 2: In flexion or extension, they get to the unstable part so they have to wiggle their back around to keep doing the flexing/extending.
What are 3 segmental findings that would suggest possible instability?
Prone instability test
Decreased resistance with prone joint play
Increased motion with motion palpation
Describe the prone instability test
Pt prone with LE off the end of a table, feet on the floor.
Doc applies P-A pressure to lumbar SP to test for P. If there is pain, pt lifts feet.
(+) sign is absence of P which suggests functional instability and potentially good response to a stabilization program
What are 6 motor control tests?
1–Segmental abnormal movement
2–Painful arc abolished with abdominal bracing
3–Poor motor control during trunk forward lean
4–Poor motor control of pelvic clocking and abdominal hollowing
5–Poor motor control during hip extension test
6–Poor motion control during single leg stand
Describe segmental abnormal movement
What is (+) finding?
(+) Segmental hinging or pivoting with AROM
(+) “wiggling” or non-smooth spinal motions in any plane
(+) spinal “hinging” or sharp angular ion of spine may be present in lat flex
Describe painful arc abolished
What is (+) finding
Pt maintains abdominal brace or deep abdominal activation e.g. abdominal hollowing
(+) improvement or abolishment of painful arcs and movements
Describe trunk forward lean
What is (+) finding?
Pt sitting. Pt leans forward from hips, doc observes spinal curves.
(+) Inability to bend forward >15˚ w/o flexing lumbar or overcompensating with hyperlordosis
Describe pelvic clocking and abdominal hollowing
What is (+) finding?
Difficulty in learning how to control pelvic motion (e.g. inability to find and hold neutral pelvis)
OR
Inability to perform controlled abdominal hollowing
Describe hip extension test
(+) finding?
Prone pt. Lift 1 leg off table, then the other.
(+) TEST FAILURE = lateral shift toward side of hip extension, excessive lordosis, rotation of SPs toward hip extension
Describe single leg stand
(+) findings
20 second single leg stand or sitting on exercise ball with open eyes. Doc’s eyes at level of pelvis and behind
(+) spine deviates from vertical
(+) shift in pelvic crest height
(+) compensatory movements of arms or opposite leg
(+) 2+ brief corrective movements from the starting position
(+) 1 prolonged corrective movement
Spondylolysis: who gets it?
47% young athletes / 5% adult athletes (adults M>F)
What is the MC finding on PE in spondylolysis pts?
P with hyperextension is MC Hx and PE finding
What is the initial ancillary study in order to make Dx of spondylolysis?
Radiographs are initial. More advanced imaging may be req in a variety of circumstances
What are the 2 MC types of spondylolisthesis?
Isthmic/lytic
Degenerative
W>M
Pathoanatomical isthmic/lytic spondylolisthesis?
Defect in pars from stress fractures or bone remodeling after traumatic Fx
Pathoanatomical degenerative spondylolisthesis?
D/t facet arthritis and remodeling
What is the MC location for isthmic spondylolisthesis?
L5
What is the MC location for degenerative spondylolisthesis?
L4
Describe Phalen Dixon sign
Increased flexion at hips and knees
What would be the most diagnostic finding based on observation or palpation for spondylolisthesis?
Step defect L4-L5
In 1 study of 30 patients what was the +LR for the step defect finding at L4-L5?
+LR 4.6
Describe how to do the passive leg extension test
what is (+) finding
In what type of spondylolisthesis pts will this be most likely positive?
Both patient’s legs lifted to 30 cm and gently tractioned so the lumbar spine settles into extension.
(+) pain or feeling of heaviness in low back that disappears when legs are lowered
Most likely positive in degenerative spondylolisthesis pt because elderly patient
In 2017 review of literature, what combination of findings (2) was most diagnostic for spondylolisthesis?
Step defect (intervertebral slip) Segmental hypermobility
What radiographic view is diagnostic for spondylolisthesis?
Lymbosacral spot view
How do you measure severity of listhesis?
Meyerding Grading System
Grade 0 — 0% slip forward Grade 1 — 0-25% Grade 2 — 26-50% Grade 3 — 51-75% Grade 4 — 76-100% Grade 5 — complete
What would be imaging tests, findings and measurements that suggest structural instab of spondylolisthesis?
Flexion-extension radiographic study with >4mm sagittal translation between the views
Measure the posterior body line
What are some clues from Hx that suggest pt has degenerative form of spondylolisthesis?
> 50yo
F>M
Chronic P onset with P occurring over months or longer
What are (3) absolute indications for surgery for spondylolisthesis?
Serious or progressive neuro deficits
CES
Neurogenic claudication 2˚ to instab causing dynamic stenosis associated with high grade slippage
What are (3) relative indications for surgery for spondylolisthesis?
Persistent radiculopathy despite conservative Tx
If Sx continue >6-9 months despite activity restriction and bracing
Loss of QOL because of neurogenic claudication
What is done during surgical procedure for spondylolisthesis?
Decompression with or without fusion
Think about it: the absolute indications for surgery include serious/progressive neuro deficits so you want to decompress the spinal cord. And then if that causes more instability in the spine, you want to fuse the spine to increase stability.
On average, how long before pt can return to sport of choice?
Stop sports >3 months = better improvement
Spondylolysis • 5.4-5.5 months return to sport
High level athletes can return once Sx become tolerable
What indicators can you use to know its safe to return to sport?
If plain films do NOT detect a frank fracture and a defect shows only on SPECT scan and Sx are resolving
Using the 4 tool kit recommended by LeF, outline key ingredients for Tx plan for spondylolysis and spondylolisthesis. What are the major differences?
Divide into initial phase of care — subacute — rehab
[insert]
What are the details regarding prescribing a rigid braces?
23 hours/day for 3-6 months
What are weaning suggestions for a rigid brace?
Slowly weaned off as Sx resolve after 3 months.
Day 1: 30 minutes of brace free time 3x
Day 2: +30 minutes
…2 weeks.
Should you do neuro exam on a pt with spondylolysis or spondylolisthesis? Which one? What might you expect to find?
Yes — spondylolisthesis. It’s very rare but in a very extreme listhesis, there can be L5 or L4 involvement.
Might find a weak tib anterior
If radiographs are normal but you still suspect spondylolysis, what are your next choices on imaging?
MRI or CT or SPECT
What are the pros/cons for MRI or CT or SPECT?
SPECT: better at detecting pars Fox
MRI: better for neuro signs. Less radiation than CT. $$$
CT: lots of radiation, $$$
What radiographs are ordered for spondy?
AP, lateral radiograph
AP axial L/S spot and/or obliques
What strategy will you use when radiographing a potential spondy pt?
Peds: AP and lateral views. If no visible Fx, then AP axial L/S spot and/or oblique
The initial 2 view strategy exposes pt to 7-9x less radiation dose than SPECT and 1/2 radiation dose than 4-view plain film + CT
What muscle most consistently goes into spasm with spondylolysis and -listhesis?
Hamstring
Your pt has leg pain with spondylolisthesis or -lysis. How likely is it that they have (+) SLR?
Rarely positive (12% sensitivity compared to 80-100% in disc hern)
How likely is it that a spondylolysis or -listhesis pt will have neuro deficits?
No neuro deficits with -lysis
Not common neuro deficits with -listhesis. In SIGNIFICANT spondylolisthesis… MC L5 NR followed by L4 NR
Tell me about Dejerine’s Traid. What is (+) finding?
Coughing, sneezing, bowel movement
(+) only if it hurts the leg
Is Dejerine’s (+) if it creates LBP?
NO. It means nothing about nerve damage. (+) only if it creates P to leg.
Are contributing and complicating factors (the 4th part of the 4 part dx) pain generators?
What are examples of complicating factors?
No
Short leg, upper cross syndrome, functional instability
When might you order xray in low back and cervicals?
Trauma/Fx concern
Significant neuro deficits
Red flag for disease
The difference is that in the low back you have higher level of concern for NR damage because of the cord.
Which of the following would be the single strongest clue supporting deranged disc?
A) positive XSLR
B) repetitive lumbar rotation reduces territory of the foot numbness
C) patellar hyperreflexia
D) positive valsalva maneuver creates leg pain
B) repetitive lumbar rotation reduces territory of the foot numbness
Which of the following ancillary tests is generally considered the gold standard for confirming facet diagnosis?
A) MRI
B) plain film radiograph
C) CT
D) intra-articular anesthetic injections
D) intra-articular anesthetic injections
Which of the following would generally be considered the most useful measure of the degree of severity of a patient’s acute low back condition?
A) palpatory segmental hypermobility
B) their PSFS rating
C) measuring AROM
D) severity of pain measured on face scale
E) muscle testing their core stab muscles
B) their PSFS rating
Which is a more helpful exam finding regarding kemp’s test?
A) a positive test for LBP helps to rule in a facet syndrome
B) negative test for LBP helps to rule out facet syndrome
C) both positive and negative tests are equally helpful
D) positive test only supports facet syndrome if it causes leg pain
B) negative test for LBP helps to rule out facet syndrome
Local pain with Kemp’s test supports facet syndrome BUT Kemp’s can be positive in deranged disc and sprains as well so a positive test doesn’t rule in. Rather, a negative Kemp’s test is better as evidence against/helps to rule out facet syndrome (“pertinent negative”).
Your patient has traumatic hyperflexion injury, posterior neck pain and no arm symptoms. Both active and passive cervical flexion are painful at end range. Muscle tests in the arm are strong, but cervical extension muscle testing is painful and weak. Cervical distraction and compression, valsalva, and extremity sensory and reflex tests are all normal. Palpation reveals tender cervical thoracic junction locked into extension. What is your dx (use the 4 part format).
Cervical strain with CT joint dysfunction
Indicate whether the exam finding would support
A) sprain/join injury
B) strain
C) could be either one
Pain with active range of motion
C) could be either one
Strain because muscles contract with AROM.
Sprains because if the joint is also swollen it can hurt anywhere in the range of motion.
Indicate whether the exam finding would support
A) sprain/join injury
B) strain
C) could be either one
Pain only at end range during passive range of motion
C) could be either one
Strains generally have no pain with PROM except when the muscle is passively stretched.
Sprains hurt at end range because the ligament is being pulled at.
Indicate whether the exam finding would support
A) sprain/join injury
B) strain
C) could be either one
Pain with a resisted full range of motion
C) could be either one
Strain because resisted means the muscle is contracting.
Sprain, if the joint capsule is involved, would hurt with resistance as well.
Indicate whether the exam finding would support
A) sprain/join injury
B) strain
C) could be either one
Pain starting at midrange passive range of motion
A) sprain/join injury
Strain — you are not tugging the muscle belly at midrange, so the muscle shouldn’t be involved. So you r/o the muscle and are left with:
Sprain — more likely the pain that is felt at midrange is ligamentous.
What would be an exam finding that would satisfy the T of the PART checklist to help support a joint dysfunction diagnosis?
tissue tenderness (that is asymmetrical from the other side)
What are the 3 key indications from the PE that would denote that a sprain of a collateral ligament in the knee was moderate to severe?
1 — mod swelling and ecchymosis (visualized)
2 — moderate laxity of ligament
3 — pain at end range during passive ROM
