(with random Paige Mnemonic) SPINE--PTP IV
Red flags - spinal fracture
-history of trauma -Prolonged use of steroids -Age >70y Paige Mnemonic: TSO T = trauma S = steroids O = Old (70)
How do you ddx neurogenic and vascular claudication?
2 stage tredmill test. - neurogenic claudication is greater tolerance for walking in the inclined position (which flexes the trunk)
Most lumbar spine structures are innervated by how many segmental nerves?
2-3
Facet joints are innervated by what nerves?
Articular branches of the medial branches of the dorsal rami Paige Mnemonic: Horns in the back
What is Olson's progression of Lumbopelvic Mobility exercises?
Cat/cow, child's pose, lower trunk rotation, supine single knee to chest, physioball bilateral knees to chest.
What is a potential red-flag consequence of central stenosis?
Cauda equina syndrome
What treatment is indicated in moderate scoliosis between 25 and 40 degrees?
Combination of bracing and physical therapy (postural education and spinal stabilization)
Where is the most common place for a compression fracture to occur? a. At L5/S1 b. At L4/L5 c. At L2/L3 d. At the thoracolumbar junction
d. At the thoracolumbar junction Paige Mnemonic: Lots of compression specifically on this junction
How is neuropathic pain distinct from nociceptive pain? a. It is central whereas nociceptive is peripheral b. Nociceptive pain involves nonneuronal tissue damage c. Central is caused by nerve hypersensitivity or dysfunction d. B and C
d. B and C
Which cluster of tests is used for SIJ dysfunction? a. Gaenslen's Cluster b. Wainner's Cluster c. McKenzie's Cluster d. Laslett's Cluster
d. Laslett's Cluster
Which spinal pathway deals with pain sensation? a. Fasciculus Gracilis of the PCML b. Rubrospinal c. Reticulospinal d. Lateral Spinothalamic
d. Lateral Spinothalamic
What is the key structure involved in central neuropathic pain? a. Cerebellum b. Pre-frontal gyrus c. Spinal cord d. Thalamus
d. Thalamus
In regard to pain, what does the thalamus do?
lateral: localize sharp pain medial: process nociception information of deep structures
In postural pain syndrome, what injury occurs before muscular injury (guarding and strain)?
ligamentous injury (creep)
What part of the reticular formation allows pain inhibition prior to sending signals down the spinal cord?
locus coeruleus
What is the function of the periaqueductal gray?
main function = pain modulation, Other Functions = Regulation of heart rate and blood pressure, Autonomic processes (bladder control)
Why might the hamstrings be indicated in Lower Cross?
may be a compensatory mechanism to rectify the anterior tilted pelvis, or a result of the weak gluteus maximus
Define good posture:
minimizes joint strain and biomechanical loading - minimal muscular loading
What are the three stages of DDD?
Dysfunction: radial tears in annulus Instability: internal disruption of disk, subluxation, capsular laxity in facet joints Stabilization: osteophytes and/or stenosis
Flat back involves a _______ rotated pelvis, sway back involves a _______ rotated pelvis
Posterior, anterior
What are the three main dysfunctions for Mckenzie classification?
Posture syndrome Dysfunction syndrome Derangement syndrome
What are McKenzie classifications?
Posture syndrome, Dysfunction syndrome, Derangement Syndrome Paige Mnemonic: Penniwise Drugged Danny Penniwise = posture Drugged = dysfunction Danny = Derangement
What are the four Mckenzie diagnoses?
Posture, dysfunction, derangement, and "other"
Lasegue sign
SLR Paige Mnemonic: the L kinda looks like a SLR
Alexa is a 28 year old female who recently had a baby. This happy new mom now has complaints of pain when walking, standing (holding baby), and climbing the stairs. Upon exam you notice she has excessive lordosis from her pregnancy. What is her possible diagnosis? What tests could be performed?
Sacroiliac Joint Dysfunction Exam: Height of pelvis, Muscle Guarding, Alignment of ASIS/PSIS, muscle guarding. Tests: Laslett's Cluster (Sacral Thrust, Thigh Thrust, ASIS Compression, ASIS Distraction, Gaenslen's) MORE COMMON IN WOMEN!
Effective treatment ideas for piriformis syndrome?
Sciatic nerve glides Piriformis muscle massage / manual therapy Ice / heat to piriformis Strengthening of other hip musculature Stretching of piriformis
Transversospinalis are made up of which three muscles?
Semispinalis, rotatores, multifidus
What is the first relay site for delivery of nociceptive data to the brain?
Spinal cord
What is the main pathway for pain through the spinal cord?
Spinothalamic Tract
Anterolateral tract is divided in to what 3 tracts?
Spinothalamic, Spinoreticular, Spinomesencephalic
Beatty maneuver
Splayed foot in supine (NOT A HIP FRACTURE lol but the photo kinda explains it) Paige Mnemonic: BUTTT, Betty might have fractured her hip
Your patient develops pain in both legs after walking for ten minutes that does not relieve immediately upon sitting and resting. Without further information, do you suspect neurogenic or vascular claudication?
Vascular. Sitting and flexed postures offer at least some degree of immediate relief for those with neurogenic claudication.
Which proteoglycan makes up over half of the nucleus pulposus? a. Aggrecan b. Brevican c. Neurocan d. Biglycan
a. Aggrecan
"Bamboo Spine" is a hallmark of what progressive, inflammatory disease? a. Ankylosing Spondylitis b. Osteoporosis c. Spinal Stenosis d.Scoliosis
a. Ankylosing Spondylitis Onset of AS usually occurs insidiously between the ages of 15-40, primarily in males
Compression of the ______ nerve roots would cause a diminished or absent Achilles reflex a. L5-S1 b. L3-L5 c. L1-L4 d. S3-S5
a. L5-S1
11. Which neurotransmitter/neuromodulator does not inhibit nociception? a. Norepinephrine b. L-dopa c. Serotonin d. Endogenous opioids
a. Norepinephrine
__________ nerve fibers sense and carry nociceptive input a. Small b. Large c. Hefty hefty hefty d. None of the above
a. Small
10. Which neurotransmitter/neuromodulator facilitates the transmission of chronic pain signals? a. Substance P b. L-dope c. Brain serotonin d. Endogenous opioids
a. Substance P
If the subjective aspect of pain perception is not addressed during treatment, tissue damage may be cured without lessening the patients perception of pain. a. True b. False
a. True
The descending pain modulation system can increase OR decrease pain perception due to its bidirectional control over nociception. a. True b. False
a. True
Which part of the spinal cord does NOT control Micturition? a. Spinal micturition center b. Cortical micturition center c. Peripheral micturition center d. Pontine micturition center
c. Peripheral micturition center
The synapses of which tract works with the reticular formation of the medulla and pons, relaying information to the thalamus and hypothalamus and therefore is key in the emotional response to pain? a. Spino thalamic b. Spinomesencephalic c. Spinoreticular
c. Spinoreticular
Typically, with a herniated disc, the nerve root that is compressed is: a. The nerve root above the herniated disc b. Two nerve roots inferior the herniated disc c. The nerve root inferior to the herniated disc d. The spinal cord is what is being compressed
c. The nerve root inferior to the herniated disc
Definition of piriformis syndrome?
compression of the sciatic nerve by the piriformis muscle, generally secondary to piriformis muscle overuse
What is the sensitivity of the quadrant test for facet joint dysfunction? a. 37% b. 64% c. 84% d. 100%
d. 100%
At what age does bone density dramatically begin to decrease? a. 18 b. 25 c. 30 d. 40
d. 40
What is an important result of correcting a lateral shift to be aware of?
Vagal syncope
Where is nociceptive input processed in the brain/what area(s) of the brain are affected? a. Occipital lobe b. Broca's area c. A variety of areas (primary and secondary somatosensory cortex, insula, cingulate cortex, prefrontal cortex, amygdala, primary motor cortex, hippocampus, mesolimbic reward circuit, thalamus, cerebellum) d. The soul
c. A variety of areas (primary and secondary somatosensory cortex, insula, cingulate cortex, prefrontal cortex, amygdala, primary motor cortex, hippocampus, mesolimbic reward circuit, thalamus, cerebellum)
What 2 levels are a lumbar IV disc protrusion most likely to occur at? a. T12-L1 & L1-L2 b. L2-L3 & L3-L4 c. L4-L5 & L5-S1 d. T12-L1 & L5-S1
c. L4-L5 & L5-S1 95% of lumbar IV disc protrusions occur at these 2 levels
What midbrain structure is the site of somatic and autonomic response integration, contains descending autonomic tracts as well as endorphin-producing cells that suppress pain, and is where integrated autonomic, behavioral, and antinociceptive stress responses occur? a. Fornix b. Caudal Raphe Nuclei c. PAG (periaqueductal gray matter) d. Serotonergic Tracts
c. PAG (periaqueductal gray matter
What is the composition of the annulus fibrosis?
(Composition in ranking order) -60-70% water -Collagen fibers (mainly type 1--good tensile strength) -Proteoglycans -Elastin fibers Paige Mnemonic: W 1 P E with the annulus (looks like toilet paper) W: water 1: type 1 collagen P: proteoglycans E: elastin fibers
What is the composition of the nucleus pulposus?
(composition in ranking order) -70-90% water -Proteoglycans -Collagen fibers (contains mainly type 2 collagen--good for compressive forces) Paige Mnemonic: Women Possess 2 (boobs--looks like the nucleus pulposus)
A clinical prediction rule in Cook for ruling in/out lumbar stenosis has 5 criteria. What are they?
+ bilateral symptoms Leg pain more than back pain Pain during walking/standing Pain relief upon sitting Age > 48 Paige Mnemonic: Balloon *pop pop* when windy *face palm* (refer to other card for explanation)
Commonly used test for diagnosis of stenosis
-2 stage treadmill test (for neurogenic claudication) Tests endurance of the LEs based on spinal position (flexed is easier for stenotic individuals) If walking inclined is easier = stenosis This test is evaluated on a treadmill. When the patient walks on the flat (0°) treadmill their back is in an extended position. The walking distance in a certain amount of time is recorded. The patient walks on the treadmill a second time with an uphill slope, which means they walk in a flexed position. The walking distance in the same amount of time is recorded again. If the patient walks further on an uphill slope than on the flat treadmill, lumbar spinal stenosis is indicated
According to Olson what is the normal Lumbar spine ROM
-60 flexion, 25 extension -25 lateral flexion, 30 rotation Paige Mnemonic: "r" is half of "f" Lateral flexion and extension is 3/4 moves in that "plane", so each is worth 25
What causes derangement syndrome and how is it treated?
-A change in normal resting positions of joint surfaces -Directional preference
What are the five tests in Laslett's cluster?
-ASIS distraction -ASIS compression -Thigh thrust -Gaenslen's test -Sacral thrust Paige Mnemonic: D, C, T, S, G STILL NEED
What is the general treatment for SIJ dysfunction?
-Address surrounding impairments like tight musculature and general hypomobility -Exercises should avoid pain provoking positions -Promote control of important musculature such as glutes, hamstrings, multifidus
Red Flags - Back related tumor
-Age >50 y -Hx of cancer -Unexplained weight loss -Failure of conservative therapy Paige Mnemonic: I CAN lose 50 lbs without surgery Can = cancer 50 = age lbs = weight loss Without surgery = conservatively
Yellow flags - attitudes and beliefs
-Belief pain is harmful or disabling and must be gone before return to activity -Catastrophizing -Feeling of no control -Passive attitude Paige Mnemonic: Feelings (symptoms)
4+ of the following variables shows a specificity of 98% for CENTRAL stenosis
-Bilateral LE symptoms -Leg pain worse than back pain -Pain during walking/standing -Pain relief with sitting -Age 48+ Paige Mnemonic: Balloons *Pop-Pop* When Windy *face palm* Balloons = bilateral LE symptoms *Pop-Pop* = peripheral pain When Windy = worse walking *face palm* = 48 (the 4 is the shoulder and arm and the 8 is the person)
Repeated motions exercise should do what to the pain?
-Centralize -If the pain peripheralizes, then this direction should be discontinued
Alice is a 62 year old female that was recently helping a neighbor move and lifting boxes when she fell backward and felt pain in her back, she explains it is worse with standing, walking, or sitting and better with lying down. What is her possible diagnosis? What level is most common? What treatment is best for pressure relief?
-Compression fracture -Most common T10-L2 -Extension progression to relieve pressure
John is a 58 year old male who came in for PT d/t pain in back that is worse with any activity or when he sits at his desk for too long and is better with rest and when he "bends forward". What are possible Ddx for his patient and how would you differentiate between them?
-Degenerative disc disease -Spondylolysis: typically also has radiating pain to butt and proximal LE. Can be reproduced with patient standing on 1 leg and leaning back.
Miles is a 19 year old male who was lifting weights when he began to experience pain in his low back. What is the possible diagnosis and at what level is it most common? What is the gold standard for diagnosis?
-Disc Herniation -Most common at L4-L5 or L5-S1 d/t most weight bearing -Gold standard = SLR bilaterally
Differential diagnoses for lumbar radiculopathy
-Disc herniation -Most common in patients under 50 -Spondylosis (stenosis), Spondylolisthesis, or Spondylolysis -Ligamentum flavum hypertrophy -Traumas (burst fractures) -Tumors -Infections (Osteomyelitis, discitis) -An associated inflammatory response to any of these conditions can increase severity of radicular symptoms through chemical effects of inflammatory agents on nerve roots
What are the symptoms of SIJ hypermobility?
-Dull ache in a fixed posture -Can radiate down into posterior thigh -Episodic sharp pain or acute pain associated with displacement -Hypermobility when joint's passive motion is assessed
What are the 5 criteria for the CPR for improvement with Lumbopelvic manipulation for LBP?
-Duration of symptoms <16 days -At least 1 hip with >35 degrees internal rotation -Hypomobility w/ lumbar P/A PIVM testing -FABQ work subscale score <19 -No symptoms distal to the knee Paige Mnemonic: Help friends dispel AIR (A-IR) ("breath in and out slowly") Help: Hypomobile Friends: FABQ <19 Dispel: No distal knee A: acute IR: > 35 internal rotation
Yellow flags - behaviors
-Extended rest -Reduced activity -Avoidance of normal activity -Excessive reliance on ADs -Extreme pain intensity -Less sleep -Increased intake of drugs or alcohol -Smoking Paige Mnemonic: signs--observable
What are the most prevalent poor postures?
-Forward head / text neck -Flat back -Sway back
Where do ribs articulate with vertebrae?
-Head of rib articulates with 2 vertebral bodies -Tubercle of rib articulates with facet on transverse process of vertebral body
What increases risk for piriformis syndrome?
-History of previous direct trauma to the buttock region -A hip/lower back torsional injury -Overuse
What are the symptoms of SIJ displacement?
-Lowered iliac crest in a seated position and standing -Restricted PROM
What causes dysfunction syndrome and how is it treated?
-Mechanically deformed scar tissue -Exercise in the direction of the problem (limitation) to remodel the tissue
What is LATERAL stenosis, what is being compressed and what are the symptoms?
-Narrowing of the IV foramen -This compresses the spinal nerve -Leads to unilateral or bilateral lower extremity radicular pain and sensory, motor, and reflex changes in a dermatomal and myotomal pattern
What are the 4 criteria for the CPR (clinical prediction rule) for lumbar stabilization/motor control exercise program failure?
-Negative prone instability test -Hypomobility with PAIVM testing -Aberrant motion absent -FABQ score <9 Need 2/4 sn: 0.85 sp: 0.87
What are the symptoms of an SIJ sprain?
-Pain and inflammation well localized over the SIJ -Ipsilateral muscle guarding of the thoracolumbar erector spinae
What are the 4 criteria for the CPR (clinical prediction rule) for lumbar stabilization/ motor control exercise program success?
-Positive prone instability test -Aberrant motion present -Age <41 y/o -SLR>91 Need 2/4 for sn: 0.83 sp: 0.56 Paige Mnemonic: PAYS to stabilize P: prone instability A: aberrant Y: young (<41) S: SLR (>91)
Red Flags - Back-related infection
-Recent infection -Intravenous drug user/abuser -Concurrent imunosuppressive disorder Paige Mnemonic: Aids from my heroine Aids: imunosuppressive Heroine: IV drugs
What is the lumbosacral angle?
-S1 is inclined ~30 decrees anterior inferior from horizontal
Ethel is a 78 year old female who played tennis "back in the day" and often practiced her serve. She complains of gradual onset of pain that is intermittent and increases with weight bearing. What is her possible ddx and how would you differentiate?
-Spondylosis (Often gradually onset overtime and with a history of repetitive motions (tennis serving). -Compression fracture (No history of trauma or weight bearing, typically sudden onset.) -Disc Herniation (SLR bilaterally is positive.)
Treatment of radiculopathy
-The main emphasis of treatment for radiculopathy is to eliminate lower extremity symptoms through centralization (McKenzie, extension for disc herniation and flexion for degenerative stenosis) -Lumbar mobilization techniques -If patient has radicular pain (positive slump test) perform nerve glides (if there is no directional preference)
How does an abdominal aortic aneurysm happen?
-Trauma, congenital vascular disease, infection, atherosclerosis, HTN -Family members of someone with one are at a fourfold risk for also developing one
Red flags - cauda equina syndrome
-Urine retention or incontinence -Fecal incontinence -Saddle anesthesia -Global or progressive weakness in lower extremities -Sensory deficits in feet -Weakness with ankle DF/FL and toe extension Paige Mnemonic: SWIS S: saddle W: weakness I: incontinence S: sensory
What organs may refer to the back (lumbar, thoracic, and cervical)?
-Uterus (lumbosacral junction, sacral, thoracolumbar) -Ovaries/ testes (Lower abdominal, sacral) -Kidneys (lumbar spine [ipsilateral], lower abdominal, upper abdominal) -Ureter (thoracolumbar, groin, upper abdominal, suprapubic, medial-proximal thigh) -Urinary bladder (thoracolumbar, suprapubic, sacral apex) -Prostate gland (thoracolumbar, sacral, testes) -Stomach (middle-lower thoracic spine, upper abdominal) -Small intestine (middle thoracic spine) -Pancreas (lower thoracic spine, upper lumbar spine, upper abdominal) -Gallbladder (Right-middle-lower thoracic spine, right upper abdominal) -Liver (right, middle, and lower thoracic spine) -Common bile duct (middle lumbar spine, lower abdominal) -large intestine (middle lumbar spine, lower abdominal) -Sigmoid colon (upper sacral, suprapubic, left lower quadrant of abdomen) -Heart (upper back—between scapula)
Lower cross, whats tight and weak?
-erector spinae and iliopsoas become tight, and the abdominals and gluteus maximus are weak -adaptively shortened including the gastrocnemius, soleus, hip adductors and hip flexors
What is CENTRAL stenosis, what is being compressed and what are the symptoms?
-narrowing of the vertebral foramen -compresses the spinal cord or cauda equina
How do you diagnose muscle strain?
-perform a neurological examination - absence of these symptoms is more likely to direct one towards damage to the active stabilizing structures (muscles and tendons). -Damage to the passive stabilizing structures in the lumbar spine are more likely to create neurological symptoms through the impingement or direct damage to lumbosacral nerves or the spinal cord/cauda equina itself
What are the 6 key features of piriformis syndrome?
1. History of trauma or direct fall to the buttock region 2. Pain originating in the gluteal region that radiates down the leg and often limits the patient's ability to ambulate 3. Gluteal atrophy 4. Palpable "sausage-shape mass" in the gluteal/piriformis region 5. Positive Lasègue sign (passive SLR for neuro pain) 6. Increased complaint of symptoms with forward bending and/or lifting Paige Mnemonic: the fall would inflame the muscle which would limit the nerve. Radiating pain because it travels down the nerve. The other signs are putting the nerve on tension
How many articulations/joints are present in one cervical vertebra?
10 articulations/joints 2 IV, 4 facets, 4 uncovertebral Paige Mnemonic: 3 + 0 + 1 (add each to the number of vertebrae) (101 Dalmatians and [lots of moving parts] and 3 regions) Cervical 7 boned + 3 = 10 articulations Thoracic 12 + 0 = 12 Lumbar 5 + 1 = 6
How many articulations/joints are present in one thoracic vertebra?
12 articulations/joints 2 interbody, 4 facets, 4 costovertebral, 2 costotransverse
One facet joint receives how many nerve innervations?
3
What's special about the thoracolumbar fascia that makes it susceptible to injury?
3 times more nociceptive fibers than in the spinal muscles
The thoracolumbar fascia is made up of how many layers, and what are they called?
3, anterior, middle and posterior Paige Mnemonic: Thora---co---lumbar (3 sections)
In Celsius, greater than _______ degrees is excessive heat temperature sensed by thermal nociceptors.
45 Paige Mnemonic: 4 and 5, I've got hives (from being hot)
In Celsius, less than _______ degrees is excessive cold temperature sensed by thermal nociceptors.
5 Paige Mnemonic: COL5 or cold has 4 letters and that's close to 5
How many articulations/joints are present in one lumbar vertebra?
6 articulations/joints
What is the most common cause of scoliosis?
80-85% of cases are of idiopathic origin, named after when it was developed (infantile, juvenile, or adolescent)
What is the orientation of the facet joints in the lumbar spine?
90 degrees to the transverse plane and 45 degrees to the frontal plane Paige Mnemonic: Transverse plane angle is the incline (plane Taking off [t for transverse and taking]) Frontal/coROnal (ROtation)
What palpation finding is most indicative of a spondylolisthesis?
A step at the affected level due to the forward translation of the vertebrae
Which is responsible for detecting the sensory input in a fast pain response?
A-delta
What innervates the synovial capsule of the facet joint?
Articular Branches of Medial Branch of Posterior Rami
At what spinal levels are uncovertebral joints found?
About C3-C7 Paige Mnemonic: Three is not free (connected by the uncovertebral joints)
What ICF classifications most often coincides with muscle imbalance problems?
Acute, subacute, chronic LBP with movement coordination impairments
In what population is spondylosis most common?
Adults over 60 years of age with a history of repeated trauma with extension/repetitive motions Paige Mnemonic: old and overuse of probably lifting wrong and extension is closing down the holes
What aspect of pain does the frontal lobe produce?
Affective and cognitive aspects
What movements do the facet joints allow for and what do they limit?
All for flexion and extension, but limit rotation.
Alvin is a 36 year old male with complaint of feeling like he can't move his low back, as well as increased pain with some symptoms radiating down the leg. He explains that Advil seems to help him move better. What is his possible diagnosis and what is appropriate treatment?
Ankylosing Spondylitis Inflammation at SIJ leads to bone deposition and calcification = immobility Males at double risk, better w/ NSAIDs, 1/2 AS patients have peripheral symptoms. Tx: Extension exercises, mobility to maintain ROM, Aquatic therapy to reduce intensity/weight at SIJ.
Which layer of the thoracolumbar fascia is the thinnest?
Anterior
Which ligament is commonly thought to be a part of the SI joint capsule?
Anterior Sacroiliac ligament
The ventral rami of spinal nerves innervate what?
Anterior and lateral trunk regions, upper and lower limbs & skin in a segemental pattern
How many and what are the layers of the thoracolumbar fascia?
Anterior layer: Covers anterior surface of QL, mammillary processes of lumbar vertebrae, iliac crest, iliolumbar ligaments and 12 th rib; is continuous laterally with TrA aponeurosis. Middle layer: between the posterior abdominal wall (QL) and deep intrinsic back musculature Posterior layer: covers deep back musculature, erector spinae, latissimus, and extends from 12 th rib to iliac crest and laterally to TrA and internal obliques
What does the ligamentum flavum do?
Applies a continuous compressive force on the discs
Causes of stenosis
Arthritic changes of facet joints (osteophytes) and IV discs, spondylolisthesis, degenerative changes of ligamentum flavum (thickening), or tumor Paige Mnemonic: Steno = narrow, stenosis is a narrowing of the holes where nerves run
What medications can be used to treat spondylosis?
NSAIDs Corticosteroids Muscle Relaxants Paige Mnemonic: no treatment, pain/ inflammation CONTROL
How is spondylolisthesis graded?
By the degree of forward translation Grade 1- 25% Grade 2- 50% Grade 3- 75% Grade 4- Up to 99%
Which is responsible for detecting the sensory input in a slow pain response?
C Fibers
Pace Sign
Pain with resisted ABD and ER Paige Mnemonic: PACE P: piriformis A: action C: causes E: exhaustion
Where is the posterior longitudinal ligament the thickest and why is it important?
Cervical, and allows for more disc herniations posteriorly in the lumbar
Which nociceptor type is associated with peripheral sensitization?
Chemical Paige Mnemonic: Jelly fish sting was sensitive
Which nociceptors are the peripheral terminals of C fibers?
Chemical, Polymodal Paige Mnemonic: think that the C fibers and CP C fibers carry chemical
What is the difference between radicular pain and radiculopathy?
Compression through the dura and into the deeper structures of the nerve will result in paresthesia rather than pain, which is the main difference between radicular pain and radiculopathy (Compression on motor fibers will result in muscle weakness while compression on sensory fibers will result in paresthesia) Radiculopathy slows conduction velocity along nerve fibers while radicular pain does not
What motion does the intertransverse ligament resist?
Contralateral flexion
Which side of the body loses pain and temperature sensation if the spinal cord is lesioned on one side?
Contralateral side of the lesion
Which tract is also known as the "slow pain" tract?
Paleospinothalamic Paige Mnemonic: the paleo diet is a SLOW way to lose weight
What motion does the posterior sacroiliac ligament resist?
Counternutation of the sacrum
Describe the general pathway of the spinothalamic pathway
DRG > ascends levels of cord > synapse in dorsal horn neuron > ventral white commissure > crosses midline > spinothalamic tract > synapse in thalamus > internal capsule > sensory cortex
How does immobility cause pain in the thoracolumbar fascia?
Decreases the amount of movement available between the layers due to chemical changes
Which posterior lumbar muscle group is more likely to need training?
Deep musculature (i.e. transversospinalis) often need more exercise and training for control, recruitment and coordination as the erectors are generally compensating and overactive.
What is spondylosis characterized by?
Degeneration of the intervertebral discs as well as facet joints with initially hypermobility and overtime osteophyte formation. Focused on degeneration of the vertebrae.
How does the iliolumbar ligament relate to IV disc degeneration and LBP?
Degeneration of the lower lumbar IV discs applies excess stress on the ligament because this ligament is working to resist the unchecked forces created.
Alex is a 29 year old male who works as a maintenance main and has pain when standing reaching back on his ladder to change the lightbulbs. He explains the pain increases the more he works and he can't move as much as he used to. What are his possible ddx? What tests could be performed? What are possible treatments?
Degenerative Disc Disease: He's younger, no indication of getting better with rest/flexion. Spondylosis: No complaint of radiating pain, could reproduce with single leg stance and leaning back. Spondylolisthesis: -Worse with activity, hyperextension, decreased ROM. -Tests: prone instability, lumbar posterior shear, prone lumbar extension, step-off palpation. -Tx: Flexion Protocol, stabilization, stretching.
What are the five main etiologies for spondylolisthesis?
Degenerative, isthmic (micro trauma), traumatic, pathologic, dysplastic
Where do signals from the paleospinothalmic tract travel after being relayed through the thalamus?
Diffusely to the frontal lobe and signulate gyrus
Spinal thrust manipulation indication cluster (name all 5). And what percent confidence interval is a score of 4/5 items from the cluster?
Duration of symptoms of less than 16 days No symptoms distal to the knee Lumbar hypomobility At least 1 hip with greater than 35o of internal rotation FABQ-W score less than 19 4/5 is 95% CI Paige Mnemonic: Help friends dispel AIR (A-IR) ("breath in and out slowly") Help: Hypomobile Friends: FABQ <19 Dispel: No distal knee A: acute IR: < 35 internal rotation
Which Mckenzie diagnosis is indicated by pain in the same direction of a loss in ROM?
Dysfunction syndrome
The IV disk receives its blood supply from what?
Endplate capillaries (no direct blood supply)
What motion aggravates pain in patients with spondylolisthesis?
Extension Paige Mnemonic: because the segment is slipped and the SP is going in the wrong place and INCREASING the already increased pressure on the lateral spinal nerves
What are examples of special tests that aid in the diagnosis of piriformis syndrome?
FAIR (Sn, Sp) Lasegue sign (passive SLR) Freidberg sign (pain with passive IR in supine) Pace sign (pain with resisted ABD and ER) Beatty maneuver (S/L ABD. If it causes butt pain = PS. If it causes back and leg pain = IV disc issue) Piriformis sign (splayed foot in supine)
What tests are commonly used to diagnose piriformis syndrome?
FAIR test The combination of a positive active piriformis and seated piriformis stretch tests has been reported to show the highest sensitivity and specificity regarding the diagnosis of SN entrapment (Sn 0.91, Sp 0.80)
True or false: The height of our intervertebral discs decreases overtime as a normal aging process.
FALSE, disc height actually increases with age, the vertebral bodies become more shallow and concave
What is the zygapophysial joint?
Facet joint between the vertebral arch, plane synovial joint between the superior and inferior articular processes.
True or False: Pain perception can be pinpointed to a single area of the brain
False, the system involved in processing nociceptive stimuli involves many different structures throughout the cortex.
True or False: Pain and nociception are interchangeable terms.
False. Pain is a conscious experience, nociception is the neural process that encodes noxious stimuli.
True or false: Central stenosis at L4-L5 will cause upper motor neuron signs.
False. The spinal cord terminates at (or near) L1-L2 and becomes the cauda equina, which produces LMN signs.
What information does the posterior-column medial lemniscal pathway transmit?
Fine touch Vibration Conscious proprioception
What are the 7 types of derangement and their corresponding movement preferences?
First three do not relate to directional preference; they are central/symmetrical, asymmetrical with pain above the knee, and asymmetrical with pain below the knee. Last four are: posterior: extension preference posterolateral: require frontal or transverse component to reduce symptoms anterior: flexion preference lateral shift: require correction prior to directional preference testing
Freidberg sign
Forced IR causes pain Paige Mnemonic: Freidberg was forced
What is the orientation of the facet joints in the cervical spine?
From C2-T1 angled upward and forward with a 45-degree angle to transverse plane, and parallel to frontal plane. Paige Mnemonic: Transverse plane angle is the incline (plane Taking off [t for transverse and taking]) Frontal/coROnal (ROtation)
What is the pain pathway down to the spine?
From thalamus or amygdala synapsing in the periaqueductal gray traveling down to the Raphe nuclei & Locus coeruleus where it synapses again before traveling down the Posterolateral funiculus, decussates then has last synapse and exits the spinal cord.
What is one of the proposed (and most likely) mechanism of referred pain
GVA and GSA cell bodies are found in the same region (dorsal root ganglia). Since the brain is receiving most of its signals from the GSA neurons within the cutaneous tissue, it interprets the pain from the viscera (or structures with less nociceptors) as coming from the somatic sensory nerves. A diffuse pain is felt in the surface area that developed from the same embryonic segment as the structure that is sending the pain signals.
What nerve types are present in the parietal layer (pleura, peritoneum, pericardium)?
General somatic afferent (GSA)
What nerve types are present in the visceral layer (pleura, peritoneum, pericardium)?
General visceral afferent (GVA)
What can PT do to treat spondylosis?
Gentle ROM to maintain mobility Flexibility and stability exercises to decrease stress to facets Education in joint protection Postural training Patient education on warm shower to increase mobility Aquatic therapy in a warm pool
What muscles are most likely to be tight in patients with spondylolisthesis?
Hip flexors, lumbar extensors, hamstrings Paige Mnemonic: potentially because the body is trying to reduce the ROM (distally because it doesn't have it proximally)
What is most likely to be found in a spondylosis exam?
History of repetitive motions or hyperextensions of spine. Back and neck pain Lack or ROM in neck/back Painful spinal movements Increased symptoms with weight bearing Impaired functional rotation and bending Paige Mnemonic: Pain or dysfunction with actions closing down the space
Where does the periaqueductal gray receive afferent input from?
Hypothalamus, Prefrontal cortex, Amygdaloid bodies, Spinal cord
Definition of a red flag
Identify potential serious conditions; physical risk factors
Erector spinae are made up of which three muscles?
Iliocostalis, longissimus, spinalis
Peripheral sensitization: general process
Inflammatory mediators & immune cells around damaged tissue cause membrane changes, and reduce membrane potential and action potential threshold (aka less intense stimulus can now cause noxious input)
How does damage to these ligaments lead to LBP?
Injured mechanoreceptors send corrupted signals to the spinal muscles which result in abnormal muscular responses (e.g. spasms, prolonged contractions) which then puts more strain on the ligaments creating a cyclical pain pattern.
A patient with radiating pain that cannot be centralized falls into which category of Mckenzie diagnosis?
Irreducible derangement
How does the spinoreticular tract differ from the spinothalamic tract?
It travels through the reticular formation and involves emotional aspects of pain
At what level is the cauda equina typically found?
L1-L2
Sciatic nerve roots?
L4-S3
What spinal level is spondylolisthesis most commonly found at?
L5-S1 Paige Mnemonic: this is the wedge shaped IV so its already tipping the segment forward
What is the gold standard for medical diagnosis of spondylolisthesis?
Lateral radiograph w/ patient in standing
Nerves arising from the transverse, ascending and descending branches supply what?
Ligamentum flava, anterior anuli fibrosi of IV discs (posterolateral), posterior longitudinal ligaments, spinal dura mater, blood vessels within the vertebral canal Paige Mnemonic: Transverse grabs posterior structures (except for anterior annulus)
Which ligaments are damaged first in excessive flexion?
Ligamentum flavum, and Supraspinous ligament
The primary somatosensory area is responsible for sensing what aspects of pain?
Location and intensity
What are the 3 main sources for blood supply to the spinal cord?
Longitudinal arteries, anterior/posterior segmental medullary arteries and anterior/posterior radicular arteries
If the lesion to the spinal cord is below the cauda equine, what signs are seen?
Lower motor neuron signs
Where is the anterior longitudinal ligament the thickest?
Lumbar
Brittany is an 18 year old female with presents with general low back pain. She complains that her back is tender and sometimes has pain in her butt. Upon exam you note she has aberrant motion with active movement. What is her possible diagnosis and what factors are indicators for success? What are possible phases of treatment (general)?
Lumbar Spine Instability: -Cardinal Signs: Presence of aberrant motion, General tenderness in lumbar spine, Referred pain to butt and/or thigh, Paraspinal Muscle Guarding, Pain with Sustained postures -CPR for Stabilization Success Age <40, Presence of aberrant motion with active movement, Positive Prone Instability Test, SLR > 90 degrees -Treatment: Phase 1: TrA Isolation Phase 2: Challenge Neutral Pelvis while isolating TrA Phase 3: Dynamic Spinal Motion while maintaining neutral pelvis.
How is radiculopathy diagnosed?
MRI (GOLD STANDARD) (but consider than inflammation doesn't show up on MRI) Combination of neurological examination, electro-diagnosis, and radiology
What causes posture syndrome?
Mechanical deformation of soft tissue due to loading at end ranges of motion (it is treated through postural corrections)
Which nociceptors are the peripheral terminals of A-delta fibers?
Mechanical, Thermal Paige Mnemonic: Delta mountain (MT)
What are the four commonly recognized nociceptor types?
Mechanical, Thermal, Chemical, Polymodal Paige Mnemonic: MMT for CP MM: mechanical T: temperature C: chemical P: polymodal
How does the Supraspinous ligament relate to the spinal stabilizing muscles like multifidus?
Mechanoreceptors within the ligament help recruit these muscles
When I touched the hot stove, I immediately pulled my hand away because of the burning sensation. Which pain path reacted?
Neospinothalamic
Which tract is also known as the "fast pain" tract?
Neospinothalamic Paige Mnemonic: Ne-yo (neo) is a FAST rapper
What treatment is indicated in mild scoliosis of less than 25 degrees?
No treatment, curve should be watched to ensure it doesn't progress
Can spondylosis be cured? If not, what can be done?
No, but inflammation can be reduced, and pain managed with goal for patient to maintain normal level of function.
What is the name of the free nerve endings that detect the sensory input we interpret as pain?
Nociceptors
Define neurogenic claudication:
Pain, paresthesia and cramping of the LE brought on by walking and relieved in sitting Paige Mnemonic: Think claudication being a term from wound care
What motion does the anterior sacroiliac ligament resist?
Nutation of the sacrum
What are characteristics of the neospinothalamic pathway?
Occurs immediately after injury Sharp and stabbing Localized Immediate GSE response
When I touched the hot stove, I pulled my hand away quickly. Afterwards, the spot where I burned myself throbbed for a couple hours. Which type of pain pathway is the throbbing?
Paleospinothalamic
Since the pathways for pain and temperature cross the midline to ascend on the other side of the spinal cord, will you have symptoms on the same or opposite side of where the spinal cord lesion occurred?
Opposite
What is the orientation of the facet joints in the thoracic spine?
Oriented 60 degrees to the transverse plane, and typically 0-30 degrees to the frontal plane. Paige Mnemonic: Transverse plane angle is the incline (plane Taking off [t for transverse and taking]) Frontal/coROnal (ROtation)
What information does the Spinothalamic tract transmit?
Pain Temperature Crude touch Paige Mnemonic: Spike is a bully; he's hot headed (temp), and punched me (crude touch) which hurt (pain)
Define Postural Pain syndrome:
Pain which occurs due to a mechanical deformation of normal soft tissue from prolonged end range loading of periarticular structures
What is AAA a contraindication for?
Performing traction
Where does the spinomesencephalic tract (aka: Spinotectal tract) transmits signal?
Periaqueductal gray, Cuneiform nucleus, Anterior pretectal nucleus
What does the sinuvertebral nerve innervate?
Periosteum, Ligamentum flava, PLL, posterior aspect of annulus fibrosus, meninges, vertberal venous plexux.
What distinguishing piriformis syndrome from other diagnoses (definition of PS)?
Peripheral neuritis (inflammation) resulting from piriformis muscle abnormality or compression of the sciatic nerve in the area where it travels either through or under the muscle
Generally, what are the exercises in phase 1, 2, and 3 spinal stabilization
Phase 1: Drawing in, hook lying marching, bent knee fall outs, hook lying SLR, prone SLR (extension), Clam, biofeedback bent knee fall out Phase 2: Quadruped on physioball leg lifts, (physioball removed) quadruped leg lifts, side lying leg abduction, standing TheraBand shoulder extension, standing TheraBand shoulder abduction, wall sit, physioball marching, physioball diagonal shoulder flex, TheraBand side stepping, supine marching on foam roller, shoulder flexion supine on foam roller, supine marching on physioball. Phase 3: Lung forward with weighted ball to knee, lateral lung w/ weighted ball, wall sit with physioball behind back, TheraBand around knees squat with weighted ball, functional weight (crate) lifting, plank, side plank, bridge on physioball.
Jaclyn presents to the office with pain after she fell while ice skating with her boyfriend and landed on her butt. She complains that when she sits for too long or leans forward it gets worse, and when she has to lift anything heavy it gets worse. What is her possible diagnosis? What test could be performed to confirm? What is appropriate treatment?
Piriformis Syndrome Test: Positive FAIR Test Tx: Stretching, manual therapy, strengthen hip ABD and ADD.
What is the clinical significance of segmental innervation of the vertebral column?
Poor localization of low back pain and variations of referred pain patterns/pain perception among patients with lumbopelvic disorders
After being relayed through the thalamus, pain signals from the neospinothalamic tract travel to the:
Post central gyrus (primary somatosensory area), a second portion of the neospinothalamic system is relayed to the insular cortex
What motions does the ligamentum flavum resist?
Primarily forward flexion, resisting separation of lamina
Generally, what is the Mackenzie Prone extension exercise sequence?
Prone on 2 pillows, prone on 1 pillow, prone, prone on elbows, prone press up, standing backward bending
When the nucleus pulposus has migrated away from the center of the disk and is pushing against an in tact annulus fibrosus, this is called?
Protrusion
What are uncovertebral joints? At what age do uncovertebral joints form?
Pseudojoints that have a synovial membrane with synovial fluid but no joint capsule 10 years of age Paige Mnemonic: also the total amount of cervical articulations to form
Definition of a yellow flag
Psychosocial barriers increase risk of developing or perpetuating long-term disability and work loss Yellow-bellied (means you're scared), your fear is keeping you from participating/ getting better
Signs / symptoms of piriformis syndrome?
Radiating LBP Buttock pain-may radiate into posterior thigh/ proximal lower leg Numbness Paresthesia Externally rotated leg with a limp (splay foot) Difficulty walking/performing functional activities Bowel/Urinary function deficits Tenderness over the greater sciatic notch Neurological deficits should not be present- i.e deep tendon reflexes intact, no myotomal weakness, no dermatomal pattern etc.
Cause of radicular pain? Most common
Radicular pain is thought to be caused by compression or inflammation of the outer-most perineurium of the nerve, which the brain perceives as pain in the periphery. MOST COMMON: Inflammation, rather than mechanical compression, is the most common cause of radicular pain Also, a 2011 study found that a herniated nucleus pulposus can decrease nerve conduction velocity as well as Schwann cell damage and axonal injury
Matt is a 54 year old plumber who has complaints of pain and weakness in this LE with some additional tingling. What is his possible Ddx and how would you differentiate/treat?
Radiculopathy caused by: -Disc Herniation: extension preference & repeated motions -Degenerative Stenosis: Flexion preference and repeated motion Goal: To eliminate symptoms through centralization.
Definition of radiculopathy
Radiculopathy is characterized by pain, numbness, weakness, tingling sensation, or altered reflexes in an extremity due to nerve root compression in the vertebrae
How is spondylosis diagnosed?
Radiograph MRI
The vertebral column is innervated by what?
Recurrent meningeal branches of the spinal nerves (sinuvertebral nerves) Paige Mnemonic: Meningeal does all the bony stuff (men have bones)
What happens to blood supply to the IV disk as a normal part of aging and why?
Reduced blood supply due to gradual hardening of vertebral end plates.
Where does the spinoreticular tract transmits signal to?
Reticular formation, Thalamus, Hypothalamus, & Limbic system
Typical coupled motion in the lumbar spine (although there are differences among individuals)
Rotation and side-bending are opposite, except L5-S1 (this joint is same direction like cervical spine) Paige Mnemonic: LumbaR (L in lumbar is LEFT, R in lumbar is R)
Define a guarded movement:
certain muscles may not contract or relax at appropriate times to facilitate functional movement or activities
What are characteristics of paleospinothalamic pathway?
Sensed slowly, longer lasting Aching, throbbing Defensive, emotional response
What is the main purpose of thoracolumbar fascia?
Serves as an anchor for muscle attachments Allows for distribution of forces between upper and lower extremities
What innervates the IV Disk?
Sinuvertebral nerve, dorsal rami, and branches of the ramus communicant
What is the most common secondary cause of spinal stenosis?
Spondylosis
Your patient presents with a positive prone instability test and a positive posterior shear test (pushing on the back and the abdomen to shear the spine AP). What treatment is most appropriate?
Stabilization exercises
What are the stages of osteoarthritis?
Stage 1: Localized cell death of chondrocytes Stage 2: Articular surface is no longer smooth, leading to greater damage to the surface. Stage 3: Onset of inflammation causing cartilage to be worn away and subchondral bone exposed. Stage 4: Fibrocartilage plug forms in an effort to repair damage to the joint. Stage 5: Deformation occurs, osteophyte formation, failure of joint. Paige Mnemonic: Don't SIP Drinks Don't: death S: Smooth (no longer) I: Inflammation P: Plug (fibrocartilage) Drinks (deformation)
Sharkeisha is a 42 year old female with complaints of pain with standing, walking, and leaning back to the backseat in the car when she has to reprimand her children. She says it's better when she can just lean forward, sit, and not have to do anything. She complains of pain down her R leg that feels like it's tingling. What is her possible diagnosis? How can you differentiate? What treatment may be appropriate?
Stenosis -Lateral: unilateral symptoms typically, narrowing of IV foramen, spinal nerve, LMN signs. -Central: typically bilateral symptoms, narrowing of vertebral foramen, UMN signs (or LMN if at level of cauda equina) Tx: Manual therapy, William's Flexion Exercises
What are the keys for treatment for piriformis syndrome?
Stretching, Manual therapy techniques (passive stretching and myofascial release), strengthening (hip musculature ABD/ADD), activity modification, modalities
What are two categories for the classification of scoliosis?
Structural - inflexible curve of the spine that is irreversible; Nonstructural - curve retains flexibility and will straighten or reverse direction with sidebending
Define Aberrant motions:
Sudden accelerations or decelerations of movement or motion that occur outside the intended plane and are signs of poor muscular control
Which posture creates the least pressure on the IV disk, what about the most?
Supine lease; sitting leaning forward most
What treatment is indicated in severe scoliosis 50 degrees or more?
Surgical spinal fusion
What is expected in regard to progression of spondylosis?
Symptoms will likely develop overtime due to spinal degeneration from repetitive motion. If patient goes without treatment, likely increase in limitation and possible compression of nerves.
The dorsal rami of spinal nerves innervate what?
Synovial joints of the vertebral column, deep muscles of the back & overlying skin in a segmental pattern
Typical coupled motion in the thoracic spine (although there are differences among individuals)
T1-T5 behave like cervical and rotate and side bend same side; lower thoracic behave like lumbar Paige Mnemonic: Thoracic is Torn (middle child doesn't know who he wants to act like)
According to Mckenzie an irreducible derangement most likely means what?
The annulus is not intact.
What happens if the anterior blood supply is affected?
The anterior 2/3 of the spinal cord is impacted and motor deficits will be observed
What happens if the posterior blood supply is affected
The dorsal horn and dorsal columns will be affected and sensory deficits will be observed
How can the ligamentum flavum cause central stenosis?
The ligamentum flavum is continuously under tension, if something where to happen in the spine to relieve that tension, the ligament will bulge, decreasing the foraminal space and impinging on the spinal cord.
What ligament is often implicated in DDD?
The ligamentum flavum. As the disk loses height, the ligamentum flavum can buckle, creating stenosis.
What is important regarding Segmental Medullary and Radicular Arteries?
The longitudinal arteries run from the medulla to conus medullaris with a single anterior vessel and two posterior vessels. The segmental medullary and radicular arteries are primary sources for the majority of the spinal cord as the longitudinal arteries only mainly supply the superior portion.
Where is the ligamentum flavum the strongest, and weakest?
The lower thoracic; mid-cervical
What are the variations of the sciatic nerve that may predispose an individual to piriformis syndrome?
The sciatic nerve dividing and the fibular division passing through the piriformis muscle (~12% of cases); the sciatic nerve dividing and the fibular division passing over the piriformis muscle (~0.5% of cases)
The type spondylolysthesis that can occur due to disk degeneration is called a degenerative spondulolysthesis. What makes it different from the other types we know of?
There is no fracture generally.
Why are the veins within the spinal column important?
They all anastomose! If infection gets here, it can easily travel throughout the body, including the brain due to communication with the dural sinuses
Why are anterior spinal arteries that lie within the vertebral canal important?
They anastomose with adjacent levels and posterior spinal arteries AND they are nutrient arteries. They supply the vertebral bodies for production of red marrow in the center of the vertebral bodies.
The facet joints are innervated by articular branches of the posterior rami, how many nerves supply a single facet joint?
Three nerves supply one facet joint Paige Mnemonic: Facets are the horns in the back (3 horns like a triceratops: 3 nerves) Above, center, below and that's why the pain is diffuse (think the game, left-right-center)
Sciatic nerve parts and what they innervate?
Tibial : hamstring muscles, adductor magnus, and posterior portion of lower leg (gastroc, soleus) Fibular : short head of biceps femoris, anterior (deep) and lateral (superficial) portions of the lower leg
Your patient is a 15 year old girl who is an active gymnast. Two weeks ago she fell onto the springboard during practice. She reports that she has been experiencing tingling and numbness down her legs in addition to low back pain that is worse with activity. She is unable to do backbends due to pain. What diagnosis would you expect?
Traumatic spondylolisthesis
True or False: it is possible for pt to have directional preference with out centralization
True
True or false: Conditions such as dwarfism or myelomeningocele are considered primary causes of stenosis.
True
True or false: Patients with neurogenic claudication should be less likely to experience symptoms when walking at an incline?
True
True/False: Most AAA are asymptomatic?
True Most common symptom is mild-to-severe mid-abdominal to LBP characterized as "persistent but vague"
True or False: Neuropathic pain does not arise from nociceptive input.
True. Neuropathic pain arises from ectopic discharge of a nerve after it has been injured.
What are the main purposes of the lumbar musculature?
Trunk control and stabilization Protection of spine and spinal cord Allow for proprioception and pain feedback
Will lateral stenosis and foraminal stenosis typically produce bilateral or unilateral symptoms?
Unilateral
If the lesion is above the cauda equina and directly on the spinal cord, what signs are seen?
Upper motor neuron signs
What are the 5 major sources for blood supply to the vertebrae and which areas do they mainly cover?
Vertebral and ascending cervical arteries of the neck, segmental arteries of the trunk, posterior intercostal arteries in the thoracic spine, subcostal and lumbar arteries in the abdomen, iliolumbar, lateral and medial sacral arteries in the pelvis
The recurrent meningeal branches (sinovertbral artery) supply what specifically?
Vertebral bodies and IV discs (anterolaterally), periosteum, posterior annuli fibrosi, anterior longitudinal ligament Paige Mnemonic: meningeal does all of the bony stuff (men have bones) (anterior IV). Also, ALL and Posterior annulus fibrosis (the annulus fibrosis is opposite from other structures)
What activities are painful with SIJ dysfunction?
Weight bearing, walking, stair climbing
What population is generally more susceptible to SIJ dysfunction?
Women because hip and line of gravity are separated by a greater distance placing more torque on SIJ
Action of piriformis?
Works to externally rotate the hip in neutral, and abducts the hip in flexion
Which of these structures is NOT a part of the Midbrain? a. hypothalamus b. red nucleus c. substantia nigra d. caudate nucleus
a. hypothalamus
Define muscle strain:
are the stretching or tearing of musculotendinous unit which may be partial or full
Which protein is responsible for the excessive yellow color of the Ligamentum Flavum? a. Type II collagen b. Elastin c. Dystrophin d. Myosin
b. Elastin
Dysfunction of the descending pain modulation system does not have a strong correlation of the transition from acute to chronic pain. a. True b. False
b. False
Which test is NOT included within Laslett's Cluster? a. Compression b. Hip Scour c. Thigh Thrust d. Distraction
b. Hip Scour
Tissues contain ________ receptors a. Pain b. Nociceptive c. Dumb d. Threat
b. Nociceptive
Compression of the L2-L4 nerve roots would cause diminished reflexes in the ___ reflex.' a. Achilles b. Patellar c. Medial Arch d. Popliteal
b. Patellar
In pain inhibition, endorphins released by hypothalamus and midbrain activate descending neurons from the _____ and later bind to descending neurons via opiate receptors. a. Thalamus b. Pons c. Cerebellum d. Medulla
b. Pons
Which of the following is not a diagnostic criteria for a lumbar disc herniation? a. Pain in a dermatomal pattern b. Positive active straight leg raise c. Positive straight leg raise test d. Sensation loss in a dermatomal pattern
b. Positive active straight leg raise
What is a congenital defect of the pars articularis? a. Spondyloptosis b. Spondylolysis c. Spondylosis d. Spondylolithesis
b. Spondylolysis
What degree angle are the thoracic facet joints angled at?' a. ~45 degrees b. ~60 degrees c. ~75 degrees d. ~90 degrees
b. ~60 degrees
What are aspects of the subjective component of pain perception? a. Perception (location, quality, intensity, duration of pain) b. Affective (personality and emotional state) c. Cognitive (beliefs about pain) d. Behavioral (expression of pain) e. All of the above f. Both a & c
e. All of the above
According to the gate control theory, which nerve fibers carry non-nociceptive input and inhibit nociceptive input from reaching the brain and perceiving pain? a. A-alpha b. A-beta c. A-delta d. C fibers e. Both a&b f. Both c&d
e. Both a&b
What factors are NOT involved in the biopsychosocial model? a. Biological b. Psychological c. Social d. Spiritual e. None of the above
e. None of the above
What are the 6 ICF classifications?
i. ICF: Acute/Subacute LBP w/ mobility deficits ii. ICF: Acute/Subacute/Chronic LBP w/ movement coordination impairments iii. ICF: Acute LBP w/ referred LE pain iv. ICF: Acute/Subacute/Chronic LBP w/ radiating pain v. ICF: Acute/Subacute LBP w/ related cognitive or affective tendencies vi. ICF: Chronic LBP w/ generalized Paige Mnemonic: M, C, Re, Ra, emotions, Chronic Monica can reach Rachel's Emotions Constantly M: mobility C: coordination Re: referred Ra: radiculopathy Emotions: Affective/ cognitive Constantly: chronic
Upper Cross (tight/week)? What are the side effects? What is the treatment?
shortening of the levator scapulae, upper trapezius muscles, pectoralis major and minor, sternocleidomastoid and weakness in the deep neck flexors and stabilizers of the lower scapulae Side-effects: cervicogenic headache, more poor lung performance Treatment: middle and lower trapezius strength exercises and levator scapulae and upper trapezius stretching exercises found most effective
Define creep:
stretch of viscoelastic tissue over time that is not fully restored immediately after load is removed
Define Spinal instability:
when the neutral zone (passive subsystem control - ligaments) increases and the surrounding elastic zone (active system - musculature) cannot adequately compensate
