MSK 2 Exam 1
when we do a rotation mobilization we stabilize L2 and we are really moving ________ relative to _______?
L3 relative to L2
What nerve root is MOST likely to be compressed by an L3 disc herniation?
L4 nerve root
where do more than 90% of symptomatic lumbar disc herniations occur at?
L4/L5 and L5/S1 levels
If L4 disc is herniated, which nerve root is most likely to be compressed?
L5 nerve root
What is the MOST likely diagnosis if your patient reports acute low back pain with right leg pain and demonstrates weakness with right great toe extension and numbness on the dorsum of the right foot at the third metatarsal phalangeal joint?
L5 radiculopathy
where is spondylolythesis most common site?
L5-S1
_________is the imaging procedure of choice in patients suspected of having cord compression or spinal cord injury
MRI
According to the ACR, _________should be considered for those patients presenting with red flags raising suspicion for a serious underlying condition, such as cauda equine syndrome, malignancy, or infection
MRI of the lumbar spine
"palms facing you" is the orientation of which facet?
superior articular facet
What structure is being identified in this image?
superior articular process
what happens to the posterior elements of the vertebra in an anterioposterior translation?
superior articular process of inferior vertebra restrictors anterior translation of the superior vertebra
what is the orientation description of the superior articular facet
superior-posterior-medial
A patient with low back pain has a positive Modified Thomas Test. What position is going to be the MOST comfortable for the patient?
supine hook lying
what is the patient position for the Gaenslen's SIJ provocation test?
supine with one hip flexed and one hip extended
LBP is a ____________ with many different potential causes
symptom
What BEST describes low back pain? An extremely common:
symptom
What is the BEST description of the sacral thrust test?
symptom provocation test
the lateral shift is typically associated with....
symptoms in contralateral lower extremity
what is the nature of a black flag?
system or contextual obstacles
objective exam = _______+_________
systems review + tests and measures
what is the purpose of the prone knee bend test?
test for femoral nerve pathology or L2-L3 nerve root involvement
A lateral shift is named by what?
the direction the shoulders have shifted relative to the pelvis
the extent to which a given joint can resist forward displacement depends on what?
the extent to which its superior articular facets face backwards
the extent to which the joint can resist rotation is related to what?
the extent to which its superior articular facets face medially
how do we grade spondylolisthesis by?
the percentage of slippage (25%, 50%, 75%, 100%)
When would it be MOST appropriate to ask questions to differentiate a serious cause of low back pain from other causes of low back pain? I would ask them when completing:
the review of systems
Laslett et al. stated that you should consider doing these 2 SIJ provocation tests first?
the thigh thrust and the distraction
In reality, what happens to the spine in a passive accessory intervertebral movement?
the whole spine usually moves
lumbar radicular pain occurs when?
there is nerve-root involvement
why can clinician not predict which spinal stenosis patients will benefit from or do well with surgery ?
there is strengths of MRI and CT imaging BUT prognostic information is lacking
what is the symptom description for vascular claudication?
throbbing
ankle DF with the SLR emphasizes what branch of the sciatic nerve?
tibial branch
what is another purpose for completing repeated movements besides ability to recognize centralization?
to improve motion
what type of force do we want stressed at the pelvis during the Gaenslen's SIJ provocation test?
torsion
what is an acute aortic dissection caused by?
transverse disruption in the intima and media
what are the changes in skin with vascular claudication?
trophic changes (skin color, texture, temperature)
T/F: Approximately two-thirds of patients still report some low back pain at 12 months.
true
T/F: Clinical practice guidelines consistently recommend against the routine use of imaging for people with low back pain.
true
T/F: Low back pain is the number one cause of disability globally.
true
T/F: With R leg pain, the lateral shift of your patient would be typically towards the L
true
T/F: the modified thomas test position can reproduce familiar lumbar spine pain
true
what is structural differentiation?
application of remote movements (ie, remote to the location of symptoms perceived during the standard SLR) to determine whether the ROM and symptom response are suggestive of increased nerve mechanosensitivity.
How should a patient be positioned during the lumbar spine palpation examination?
area in a relatively neutral position or the position of greatest comfort
what is the zygapophyseal joint?
articulation of the superior articular process of one vertebra and the inferior articular processes of the vertebra above it
what should you ask the patient to let you know when performing repeated movements?
ask them to let you know immediately if they experience a change in symptoms
In the systems review, how would we rule in/rule out triage of red flags (serious conditions) or refer patient out?
assess neurological signs (myotomes, dermatomes, DTRs, abnormal reflexes)
what did the article by Kulig et al. look at?
assessment of the lumbar spine kinematics during a manual posterior-to-anterior mobilization
what is vascular claudication?
atheromatous change in the internal iliac a. that results in ischemia to the sciatic n.
_________ and the resulting _________ are the underlying causes of most vascular back pain
atherosclerosis; peripheral arterial disease
how do we have the capacity to control motion in multiple directions in the spine?
because of the orientation of the annulus fibers of the IV disc
In lumbar PPIVM flexion and extension, the interspinous space is palpated and movement where is assessed as the segment is passively taken through its physiologic range?
between the spinous processes
leukemias cancer is in what tissue?
blood-forming cells
what is spondylolysis?
breaking down of a vertebral structure
What type of cancer is MOST likely to metastasize to the spine?
breast
In a T2 Lumbar Spine MRI, are water and fat dark or bright?
bright
what is the symptom description for neurogenic claudication?
burning
In the article by Cook et al. what is the +LR and post-test probability for having 4/5 of of the positive findings?
+LR: 4.6 & post test probability: 76%
Clinician should consider referring the pt for medical management when the pt presents with what? (4)
-"red flags" (medical or psychological) -comorbidities not amenable for rehab -progressive neurological deficits -symptoms that are not resolving with rehab interventions
what are the promising clinical diagnostic rules for disc herniation with nerve root involvement? (3)
-(passive) straight leg raise test positive for referred leg pain -3 positive our of 4 history or physical exam findings: dermatomal pain location in concordance with a nerve root, corresponding sensory deficits, reflex weakness, motor weakness -supplementary physical exam finding: crossed straight leg raise test positive (opposite leg)
what are the promising clinical diagnostic rules for spinal stenosis? (2)
-3 positive out of 5 history findings: age more than 48 years, bilateral symptoms, leg pain more than back pain, pain during walking/standing, pain relief upon sitting -supplementary physical examination finding: improved walking tolerance with the spine in flexion or relief by forward bending
What muscle length tests would be important to perform with a patient with low back pain? (2)
-90-90 Hamstring muscle length test -Modified Thomas test (hip flexors)
What is the test and measures sequence? (8)
-AROM -Passive physiologic motion -Passive accessory motion -Muscle length tests -Resisted isometrics -MMT -Palpation -Special tests
T/F: With nociceptive pain, baseline symptoms need to be assessed at the beginning of treatment and end of treatment only
False
when do we assess baseline symptoms? (5)
-Before any movement or testing begins -With every change of position -Return to baseline following symptom provocation -After several tests to check for latency or gradual increase -Monitor for baseline periodically throughout the objective to assess increase due to summation or to assess for potential peripheralization or centralization
With a vertebral infection, what does the initial diagnostic work-up include? (5)
-CBC -ESR -CRP -MRI -urgent referral for specialist care
What are the 7 early warning signs of cancer?
-Change in bowel or bladder habits -A sore that does not heal -Unusual bleeding or discharge -Thickening or lump in breast or elsewhere -Indigestion or difficulty swallowing -Obvious change in wart or mole -Nagging cough or hoarseness
explain lumbar spine quadrant AROM with overpressure (2)
-Combined movement of extension, sidebending, and rotation -Intent: Increase physical stress on one side of lumbar spine
what are the two special tests used for lumbar spine assessment?
-FABER test -Scour test
what repeated movement do we want to assess in a lumbar spine assessment? (5)
-Flexion in standing -Extension in standing -Right and left side gliding -Flexion in lying (knees to chest) -Extension in lying (prone press up)
what are the initial diagnostic work-up for a high suspicion of cancer? (4)
-Full blood count (FBC) -erythrocyte sedimentation rate (ESR) -C-reactive protein (CRP) -MRI
what are the major factors for an abdominal aortic aneurysm? (8)
-HTN -age > 60 -male -history of smoking -atherosclerosis -CAD -family history of abdominal aortic aneurysm -use of statins
what are the differential diagnoses of spondylolythesis? (4)
-Hip OA -myelopathy -spinal tumors -vertebral infection
what are the promising clinical diagnostic rules for spondylolisthesis? (3)
-IV slip by inspect or palpation -segmental hypermobility by use of manual passive physiological motion test -supplementary physical exam finding in the elderly: passive leg extension test positive
what is the potential neurological involvement of spondylolthesis? (3)
-L5 radiculopathy -Cauda equina -neurogenic claudication
In the article by Cook et al. what is the -LR and post-test probability for being negative on diagnostic rule?
-LR: 0.19 & -post-test probability: 11.4%
what is included in the initial diagnostic work-up for cauda equina syndrome? (3)
-MRI -CT -urgent referral to spine surgeon
what do you want to do when utilizing the slump test for your patient? (2)
-Monitor symptom response at each stage of testing, examine carefully -assess symmetry in ROM, resistance, and symptom response
what is the systems review order? (11)
-Observation -Vitals -Posture -Functional Demonstration Tests -AROM: Lumbar spine Flexion, Extension, Side-Glide Thoracic spine (overpressure) -PROM: Hip -Special tests: FABER test, Scour test -Myotomes -Dermatomes -Deep Tendon Reflexes -Pathological Reflexes
With clinical decision making, A physical therapist's responsibility is to recognize when: (4)
-PT patient management is necessary -consultation with, or referral to, another healthcare provider is necessary -both PT management and referral to another healthcare provider is necessary -self-care management is necessary
Explain lumbar spine flexion AROM with overpressure (3)
-Patient bends forward -PT: stabilize pelvis and apply pressure to "bow" the lumbar spine -Avoid applying pressure that increase hip flexion
what are two special tests for disc herniation with nerve root involvement?
-SLR -Crossed SLR
In the systems review for lumbar AROM, what are we looking for/assessing? (6)
-Single motion in each direction -Assess quality, quantity, and willingness to move -Assess for smooth, uniform curve with flexion and extension -Centralization? -Peripheralization? -Directional Preference?
what is a positive result for the prone knee bend test? (2)
-Unilateral neurological pain in the lumbar area, buttock, or anterior thigh may indicate an L2 or L3 nerve root lesion. -Pain in the anterior thigh may indicate tight quadriceps muscles or femoral nerve symptoms.
what is passive accessory intervertebral motion used to assess and determine?(3)
-accessory glide that a joint possesses -determine if joint is normal, hypo mobile, hypermobile -determine symptom behavior
what are the findings significantly associated with underlying cancer described in deyo & diehl 1988? (6)
-age > or equal to 50 -previous history of cancer -duration of pain >1mo -failure to improve with conservative therapy -elevated ESR -anemia
what are red flags that refer pain TO the lower back? (5)
-aneurysm -vascular claudication -kidney stone -genital pathologies -GI pathology
If I have a fracture of pars interarticularis of L5, what will happen to the vertebral structures?(3)
-anterior translation of vertebral body of L5 relative to S1 -L4 spinous process moves anterior with L5 vertebral body -L5 spinous process remain in posterior position causing bump to be observed with either palpation or observation
what is a grade 1 spondylolisthesis?(2)
-arch defect in L5 with mild forward displacement of L5 on S1 -backache but no gross disability
Questions to determine your level of concern from Finucane et al. article (6)
-are the symptoms staying the same, getting better or worse? -is the pt responding to health care management? -what is the consequence of a delay in referral? -is the pt being seen for a repeat visit? -does the pt have other comorbidities? -what is the overall pt presentation? (SINSS, pain mechanisms, clinical profile)
vascular claudication is the result of these four things:
-ateriosclerosis -arterial embolism -thrombo-angitis obliterans -symptoms in the legs
What are the risk factors of an abdominal aortic aneurysm? (9)
-atherosclerosis -HTN -medial degeneration and aging -aortitis -congenital abnormalities -trauma -smoking -cellular enzyme dysfunction -hyperlipidemia
what are two examples of yellow flags with nature of pain behavior?
-avoidance of activities due to expectations of pain and possible re-injury -over reliance on passive treatments, such as hot packs, cold packs and analgesics
what are two examples of blue flags?
-belief that work is too onerous and likely to cause further injury -belief that workplace supervisor and workmates are unsupportive
What are the three different natures of yellow flags?
-beliefs, appraisals and judgements -emotional responses -pain behavior (including pain coping strategies)
We want to consider the following aspects of a patient during a lumbar spine assessment: (6)
-body type -gait -attitude -posture -markings -step deformity (spondylolysthesis)
what are the most common causes of bony metastases? (3)
-breast cancer -lung cancer -prostate cancer
When a patient presents with pain that is not relieved with rest or awaken patients at night that is unrelated to movement or positioning this increases the risk of what? (3)
-cancer -infection -abdominal aortic aneurysm
what are the risk factors for infections with LBP? (3)
-chronic comorbidities -immunosuppressive disorders -intravenous drug users
what are two examples of orange flags?
-clinical depression -personality disorder
physical stresses that can happen if the facet joint is involved as the symptom generator? (3)
-compression -shear -tension
what are the two types of lumbar spinal stenosis that cook 2011 describes?
-congential -acquired
3 types of bony defect of the pars interarticularis of the spine
-congential -acquired -developmental
what are the secondary changes to changes in the IV disc? (6)
-degeneration of the IVD -loss of loading capability -decreased mobility or mild hyper mobility --> osteophyte formation -bulging into the IVF (flat tire effect) -loss of vertical height of the IVF -increased weight bearing on facets --> degenerative changes consistent with OA
What are the SIJ provocation tests? (5)
-distraction -thigh thrust -Gaenslen's test -compression test -sacral thrust
what are overpressures defined as?
passive oscillatory motions that are applied at the limit of the active range
what are four examples of yellow flags with nature of emotional responses?
-distress not meeting criteria for diagnosis of mental disorder -worry -fears -anxiety
what do you document when performing passive physiologic intervertebral motion? (2)
-document as normal, hypomobile, hypermobile -document symptoms
Why do we assess baseline symptoms? (5)
-establish the baseline symptoms -establish the relationship between patient position and symptoms (ex: flexion bias or extension bias) -determine the length of time for symptoms to settle to baseline (ex: irritability) -determine if repeated stress to tissue provokes symptoms -determine the irritability of the patient's tissues
what would be the provocative position or movement if the facet joint is involved as the symptom generator? (3)
-extension -rotation -sidebending
factors that are negatively associated with abdominal aortic aneurysm are....(3)
-female -black race -diabetes
In the systems review for lumbar AROM, what movements are we looking at? (3)
-flexion -extension -slide-gliding
In the systems review, what are we focusing on in the structural screening purpose?
-focusing on body regions above and below area of symptoms (structural differentiation)
what are examples of lumbar flexion functional demonstration test? (2)
-forward bending -lifting object from the floor
how do we identify red flags during the examinations? (2)
-health questionnaire -structured history and physical examination
what does extensive diagnostic testing tend to lead to? (3)
-higher costs -potential over-treatment -elicitation of unnecessary fear and concern on part of the patient
A diagnosis of lumbar radicular pain should include these 5 factors:
-history of dermatomal leg pain -leg pain worse than back pain -worsening of leg pain during coughing, sneezing, or straining -positive straight leg raise test
what are the risk factors of a vertebral compression fracture? (4)
-history of osteroporosis -use or glucocorticoids (corticosteroids) -older age -significant trauma
Questions to consider in observation: (4)
-how do they move? transfers? gait? -how do they respond to their environment? -what positions do they adopt? -antalgic posture or movement?
what would be the possible dysfunctions if the facet joint is involved as the symptom generator?(2)
-hypermobility -hypomobility
what is the differential diagnosis with patients who have a past or present history of any type of cancer? (2)
-increases risk of cancer causing low back pain -back pain may be caused from metastatic tumors arising from the prostate, breast, kidney, thyroid, lung
urinary retention, changes in frequency of urination, incontinece, dysuria, hematuria may indicate what? (2)
-infection -cauda equina syndrome
what are some other conditions associated with calculus formation? (5)
-infection -urinary stasis -dehydration -excessive ingestion -absorption of calcium
What are the two NICE (National Institute for Health and Care Excellence) guidance advices in regards to cancer?(2)
-investigation for myeloma in people aged 60 years or older with persistent bone pain (particularly back pain) or unexplained fracture -investigation of pancreatic cancer in people aged 60 years or older with back pain and weight loss
systems review questions to ask (6)
-is the pt appropriate for physical therapist patient management? -does this patient have a serious condition that requires referral? -does the pt have msk signs and symptoms? -is the problem coming from the lumbar spine? -what is likely the classification of the patients low back pain? -how are the regions above and below the lumbar spine contribution to the patients problem?
what are four examples of black flags?
-legislation restricting option for return to work -conflict with insurance staff over injury claim -overly solicitous family and health care providers -heavy work with little opportunity to modify duties
Two questions to ask when assessing symptoms (ex: when doing centralization on a pt or a passive straight leg raise)
-let me know immediately if you have a change in symptoms -are your symptoms the same, better, or worse?
acquired lumbar spinal stenosis is secondary to hypertrophy of one or more of the following elements? (4)
-ligamentum flavum -PLL -epidural fat -osteophytic disease of vertebral body
what are the warning signs of cauda equina syndrome?(12)
-loss of feeling/pins and needles between your inner thighs or genitals -numbness in or around your back passage or buttocks -altered feeling when using toilet paper to wipe -increased difficulty when you try to stop or control your flow of urine -increase difficulty when urinating -loss of sensation when passing urine -leaking urine or recent need to use pads -inability to stop a bowel movement or leakage -loss of sensation when you pass a bowel movement -change in ability to achieve and erection or ejaculate -loss of sensation in genitals during sexual intercourse
what are the most common cancers in the U.S? (5)
-lung -breast -colon -prostate -skin
what is grade 3 spondylolisthesis? (2)
-more extensive slipping combined with a wide separation at the arch defect and degenerative change of the disc -grossly symptomatic
what is a grade 2 spondylolisthesis? (2)
-more forward slipping between L4 and L5 with collapse of the IV disc -symptomatic back with restriction of motion, muscle and curtailment of activities
what are the important tests and measures to include in the physical exam for lumbar spinal stenosis? (7)
-movement exam -gait analysis -balance tests -sensory-motor testing -palpation of peripheral pulses -treadmill testing -ankle brachial index (ABI)
3 examples of red flags
-new bladder or bowel dysfunction (possible caudate equina syndrome) -intravenous drug use, fever or recent infection (possible spinal infection) -previous history of cancer (possible vertebral metastases)
What are some other S&S with a vertebral infection? (9)
-new onset of LBP -fever -history of intravenous drug use -recent infection -immunosuppresion -recent spinal procedure -chills -pain with rest or at night -consider spinal TB in endemic areas or in migrants from these areas
For the SI joint, what is the best evidence we have for promising clinical diagnostic rules? (3)
-no centralization of symptoms -dominant pain in SIJ without pain in the ischial tuberosity area -3 positive out of 5 physical exam findings: distraction, compression, thigh thrust, Gaenslen's test, sacral thrust
what do we want to look at in the physical exam when determining vascular versus neurogenic claudication? (4)
-observation of LE skin texture and color -palpation of peripheral nerves -comparison of treadmill versus a cycling exercise test -ABI test (lower ABI suggests increased likelihood of peripheral a. disease)
what are some red flags that refer pain FROM the lower back? (8)
-pathologic fracture -sacral stress fracture -acute spondylolisthesis -cancer -infections -cauda equina -ankylosing spondylitis -central sensitization disorders
what are interventions for spinal stenosis? (4)
-patient education -manual therapy -exercise -aerobic training
What are 4 normal responses to standard SLR?
-posterior thigh symptoms -symptoms in popliteal region -occasional symptoms in posterior calf -ROM variable and a present amount of 'normal' asymmetry in ROM between limbs is unknown
what are two special tests for lumbar spine instability?
-prone instability test -anterior instability test
These type of cancers can metastasize to the spine...(5)
-prostate -breast -kidney -thyroid -lung
what are the 3 functions of the zygapophyseal joint?
-protect the motion segment from anterior shear forces, excessive rotation, and flexion -production of spinal motions including coupling movements -restriction of extension and sidebending
Explain lumbar spine extension AROM with overpressure (3)
-pt performs backward bending -PT stands behind patient to prevent patient from losing balance backwards -Apply pressure into lumbar extension using "small" oscillation
what are two types of bacterial infections that can cause LBP?
-pyrogenic (staphylococcus aureus, S epidermidis) -granulomatous diseases (TB, brucellosis)
In the systems review, when identifying normal and abnormal, what are we facilitating? (3)
-recognition of normal joint appearance and alignment -spectrum of normal joint ROM -basic abnormalities of msk structure and function
what are examples of lumbar transition functional demonstration tests? (3)
-sit to stand -return from flexion -rolling over in bed
Various types of disc herniations and inflammation may result in pressure on the: (3)
-spinal cord itself (upper lumbar spine) leading to myelopathy -cauda equina leading to cauda equina syndrome -nerve roots (most common)
What are some other causes of cauda equina syndrome? (5)
-spinal metastases -spinal hematoma -epidural abscess -vertebral fracture -transverse myelitis
neurogenic claudication is the results of these two things:
-spinal stenosis -symptoms in the back or sciatic nerve distribution
what are some differential diagnoses for lumbar spinal stenosis?(6)
-spinal tumors -peripheral neuropathies -diabetic neuropathies -illiacus arterial involvement -local msk abnormalties -hip OA
what are four signs of spinal fracture?
-spine tenderness -neurological signs -spinal deformity -contusion or abrasion
what are 3 examples of infections causing LBP?
-spondylodiscitis -vertebral osteomyelitis -epidural abscess
what are examples of lumbar extension functional demonstration test? (4)
-standing -walking, short distance -walking, long distance -reaching overhead
what are some general considerations for patient positioning during palpation exam of the lumbar spine? (4)
-support spinal curves -position the patient to support/accommodate deformity, if present -avoid placing strain on adjacent areas of the spine or peripheral joints -patient should be warm and relaxed
what two other regions do we want to asses AROM with when assessing the lumbar spine?
-thoracic spine -hip
what are some red flags that are typically documented by PTs for patients with LBP? (11)
-trauma -age -history of cancer -fever, chills, night sweats -weight loss -recent infection -immunosuprresion -rest/night pain -saddle anesthesia -bladder dysfunction -lower extremity neurological deficit
what are the four main purposes of the systems review?
-triage of red flags -structural screening -identifying normal and abnormal -identifying symptom behavior
what are three examples of yellow flags with nature of beliefs, appraisals and judgements?
-unhelpful beliefs about pain: indication of injury as uncontrollable or likely to worsen -expectations of poor treatment outcome -delayed return to work
what would be the location of symptoms if the facet joint is involved as the symptom generator?(2)
-unilateral, no symptoms below the knee -absence of radicular signs and symptoms and no centralization
what are some interventions for lumbar spinal stenosis?(18)
-unweighted treadmill walking -sidelying rotational lumbar manipulation -sidelying transitional lumbar manipulation -supine hip distraction manipulation -hip anterior glide joint mobilization -supine hip lateral glide joint mobilization -supine hip inferior glide joint mobilization -manual stretch hip flexors in modified thomas test position -prone thoracic manipulation -aerobic exercise -single knee to chest stretch -double knee to chest passive physiologic motion grade III -lumbar rotation stretch -thoracic extension self mobilization -lower abdominal strengthening -clams -prone rectus femoris stretch with strap -standing iliopsoas stretch
suspected injuries when applying the prone knee bend test (2)
-upper lumbar radiculopathy -femoral nerve entrapment
what are two differential diagnoses for spinal stenosis?
-vascular claudication -neurogenic claudication
what is grade 4 spondylolisthesis?
-verterbrae slipped forward more than halfway -severe disability
Questions about evidence to support red flags from Finucane et al. article (4)
-what is the prevalence of this pathology? -are the S&S associated with this pathology based on high-quality evidence? -are the S&S associated with the pathology based on consensus only? -does the pt have multiple red flags?
what are 3 characteristics of spinal stenosis?
-wide-based gait -positive romberg sign -sensory or motor deficits in one or both LE's
what is the nature of blue flags?
perceptions about the relationship between work and health
what are the 8 steps in the method for lumbar spine AROM with overpressure?
1. Ask the patient to move to the onset of pain or to the end of the range based on severity and irritability. Ask them to let you know immediately if they experience symptoms. 2. Assess quantity & quality of movement, willingness to move. 3. Ask patient to return to upright position. 4. Ask the patient to move to the onset of pain or to the end of the range based on severity and irritability. Ask them to let you know immediately if they experience symptoms. 5. Assess quantity & quality of movement, willingness to move. 6. If appropriate, apply overpressure. Begin gently and gradually increase vigor. 7. Assess symptoms. 8. If symptoms are felt, release the overpressure and assess for location of symptoms, quality and comparability.
what are the two functions of the intervertebral discs?
1. allow movement between vertebral bodies 2. transmit loads from one vertebral body to the next
Know the lumbar vertebrae anatomy
1. body 2. pedicle 3. transverse processs 4. accessory process 5. mammillary process 6. spinous process 7. vertebral foramen 8. superior articular facet 9. lamina 10. inferior articular facet
what are the biomechanic requirements of the IV disc? (3)
1. sustain weight 2. deformable 3. injury resistant
what are the 6 steps of the slump test?
1.Establish resting symptoms in sitting with hand behind back 2. trunk flexion, then move sacrum to vertical for standard amount of hip flexion 3. neck flexion 4. ankle df 5. active knee extension (easier to measure ROM as last component of test) 6. Execute appropriate sensitizing maneuver, most commonly will be gradual release of neck flexion component
Specific low back pain is approximately ____% of back pain
10%
With spondylolythesis the most rapid slippage is between the ages of _____-____ years?
10-15
By convention, an infrarenal aorta that is _____cm in diameter or larger is considered aneurysmal
3
What BEST represents the prevalence of osteoporotic compression fractures among adult patients with low back pain in primary care?
4%
what is the pretest probability of lumbar spinal stenosis describe in Cook et al?
40.3%
In article by Deyo & Diehl 1988, they described ~_____ cases of cancer per 1,000 patients with LBP
7
lumbar spinal stenosis is associated typically with low back pain in patients of what age?
>60 years
what is a clinical decision rule?
A clinical tool that quantifies the individual contributions that various components of the history, physical examination, and basic laboratory results make toward the decisions, prognosis, and likely response to treatment in a patient.
What is the BEST interpretation of a negative likelihood ratio below 0.5?
A negative index test will REDUCE the odds of having the disorder at least by half
____________is characterized by the onset of intense pain, described as sharp, tearing, or stabbing.
Abdominal Aortic Aneurysm
What was the theory of the central posterior-to-anterior force on spinous process of L3 in the article by Kulig et al.?
As we move L3 anterior, that would create tension on the ligaments. As we create that tension, then it's going to bring that inferior articular pillar anterior. Because this falls inferior to the axis of rotation, we get a relative extension moment of L2 on L3 with that motion. On the other side, the inferior articular process of L3 is going to bump into the superior articular process. With that compression there, when we move the superior articular process anterior now because that part of the vertebra is superior to the axis of rotation, we get a flexion moment of that vertebra below. Extension of L2 Flexion of L3 Key point: Movement at multiple segments in the spine.
What BEST represents an irrational belief that something is far worse than it really is?
Catastrophizing
Absence of sensation in the second-fifth sacral nerve roots (perianal region) has a differential diagnosis of
Cauda Equina Syndrome
Urinary retention & overflow incontinence are important signs of this diagnosis that causes LBP
Cauda Equina Syndrome
________is a useful screening tool for patients with LBP and suspected cancer
ESR (erythrocyte sedimentation rate)
IN a T1 Lumbar Spine MRI, are water and fat dark or bright?
Dark
What is the MOST common cause of radicular pain and radiculopathy?(2)
Disc herniation and local inflammation
With low back pain we typically want to ask this questions about our patient...
Does my patient with LBP require diagnostic imaging?
Which of the following BEST represents a yellow flag?
Excessive worry about possible reinjury
this test screens for hip, lumbar, or SI symptoms of an iliopsoas spasm
FABER TEST
Van der Wuff et al. stated that this test can substitute for the sacral thrust SIJ provocation test?
FABER test
T/F: Screening for red flags is only required when the patient does not have a specific diagnosis, was referred by a specialist physician or has had diagnostic imaging done
FALSE: Level 1 Triage and medical screening for red flags is still required when the patient has had all of these
T/F: Uncomplicated LBP and/or radiculopathy require imaging
FALSE; The ACR states that they are benign, self-limited conditions that do not warrant any imaging studies
T/F: the vertebral end plate has strong attachments to the vertebral bodies
FALSE; it has weak attachments
T/F: Someone with a disc herniation will MOST LIKELY develop leg symptoms and conditions like drop foot.
FALSE; just because someone has a disc herniation does not mean they will have leg pain and develop conditions like drop foot or cauda equina. It may have happened over time
T/F: few symptoms by themselves is indicative of a serious medical condition
FALSE; pattern or cluster of red flags is more clinically relevant
T/F: Back pain with referred lower extremity pain is the same thing as radiculopathy
FALSE; referred lower extremity pain could be a referral from any structure proximally thats referring down into the leg. Radiculopathy means there is nerve root involvement.
T/F: Together, breast, colon, and skin cancer account for 68% of bony metastases, including spine
FALSE; should be breast, lung, and prostate cancer
T/F: In the case of LBP, symptoms offer guidance in detecting underlying pathology
FALSE; symptoms offer little to no guidance in detecting underlying pathology
T/F: In spondylolythesis there is only unilateral pars defects
FALSE; there is bilateral pars defects
T/F: Neurogenic claudication is associated with diminished, absent lower extremity pulses
FALSE; there is no change in pulses
T/F: The interspinous spaces of the lumbar spine are much smaller than those of the thoracic and cervical spines, meaning they will be a lot closer together.
FALSE; they are broad and much larger than those of the thoracic and cervical spines, meaning they are going to be further apart
T/F: With a kidney stone, symptoms will decrease and a patient will be more comfortable in a position of increased lumbar extension
FALSE; typically with mechanical back pain we can find a position they are comfortable. this is not true for a kidney stone
T/F: To date we are aware of an identified association between patient report of symptoms, functional outcomes (oswestry), visual analog scale, and anatomical impairment in LSS
FALSE; we are UNAWARE
T/F: If we have a patient who presents with an acute IV disc injury, we want to avoid forward bending activities all the time.
FALSE; we are not going to avoid forward bending just because it puts tension on the IV disc. (similar to what we saw in the ACL literature with knee extension)
T/F: With neurogenic and vascular claudication there is no symptoms with standing.
False; In vascular claudication there is no symptoms in standing and with neurogenic claudication there is symptoms with standing
T/F: with the lumbar spine, it isn't as important to expose the area you are working on than with the shoulder
False; it is important to expose the area
T/F: the typical presentation with a L lateral shift would be L lower extremity pain
False; it would be R lower extremity limb pain because it is associated with the contralateral LE
T/F: lumbar spine overpressures are performed as large amplitude oscillations
False; small
what test is this?
Gaenslen's test
this structural differentiation during the SLR is more appropriate when SLR symptoms are perceived distal to the knee
Hip IR
Overpressure into what position may reproduce symptoms in a patient with an abdominal aortic aneurysm?
Hip flexion
the FABER test includes what 3 motions:
Hip flexion, hip abduction, hip external rotation
When does a patient have a poor prognosis with a lateral shift and leg pain?
If the patient is shifted to the same side as the leg pain.
how can you tell the difference between spinal stenosis and vascular claudication when doing the bike test?
If they still have symptoms with flexion, it will likely be vascular claudication
What BEST describes the purpose of repeated movements during the physical examination of a patient with low back pain? The purpose is to:
Improve your ability to recognize centralization
what is the Wennberg hypothesis in regards to uncertainty?
In response to uncertainty concerning diagnosis and appropriate treatment, clinicians develop a specific style of practice that, over time, is influenced by many idiosyncratic factors
What BEST represents false-positive findings on imaging studies?
Individuals without low back pain showing abnormal findings
What happens to the ligament and so on if we start to lose the height of the disc associated with aging?
It will tend to put the ligaments on slack. With the ligaments on slack we are going to have more joint play at that segment. With more joint play at that segment, the facet joints are going to undergo a compression and shearing in loading. Which then you are going to get some bony changes to those facet joints (following wolf's law) and you may get osteophyte formation because of this.
If there are persistent or progressive symptoms during or after 6 weeks of conservative management and the patient is a surgery or intervention candidate or diagnostic uncertainty remains, what is the imaging modality of choice in evaluation of LBP?
MRI of the lumbar spine
When is medical management MOST appropriate?
Patient presents with unresolved symptoms after rehabilitation for 30 days
According to the ACR, what is recommended during the initial evaluation in patients with histories of low-velocity trauma, osteoporosis or chronic steroid use?
Radiography
What BEST represents a positive Crossed-Straight Leg Raise Test?
Reproduction of familiar symptoms in the leg resting on the table
the development of caudal movement and longitudinal tension is biased toward these segments....
S1>L5>L4
________ creates caudad movement and longitudinal tension of the sciatic nerve and the neuraxis and meninges
SLR
T/F: Both spondylosis and spondylolythesis are worse with movements/positions of extension and rotation
TRUE
T/F: Having a recent bacterial infection such as UTI with LBP increases risk of another infection causing LBP
TRUE
T/F: In a patient with lumbar spinal stenosis, the least amount of pain/symptoms would be in a sitting position
TRUE
T/F: Morning stiffness is a common symptom with ankylosing spondylitis
TRUE
T/F: One consequence of physical therapists' uncertainty in patient management is wide variation in treatment for low back pain.
TRUE
T/F: Radiculopathy can coexist with radicular pain
TRUE
T/F: Reflexes are normal with vascular claudication
TRUE
T/F: Spondylolythesis has a mechanical presentation
TRUE
T/F: There is a not a strong correlation between having a disc herniation and also having symptoms
TRUE
T/F: Usually facet joint symptoms are unilateral
TRUE
T/F: We tend to not get any localized symptoms in the lumbar spine muscles (i.e. paraspinals, multifidus etc.)
TRUE
T/F: With a low suspicion of cancer, you should defer work-up until a trial of therapy has been completed
TRUE
T/F: With vascular claudication there is pain present in all spinal positions
TRUE
T/F: Young men are more likely to present with ankylosing spondylitis than young women
TRUE
T/F: a pattern or cluster of red flag findings that raises the clinicians suspicion of serious medical conditions is clinically relevant
TRUE
T/F: cauda equina syndrome is a medical emergency
TRUE
T/F: in the face of suggestive historical findings, and elevated ESR, a negative x-ray of the spine should be interpreted with caution
TRUE
T/F: there is a bony restraint to an anterioposterior translation of the lumbar spine
TRUE
T/F: Large, free disc fragments can often cause NO neurological deficit or pain
TRUE; degree of neural compromise and potential for pain cannot be judged accurately by the size or type of disc material
what are you looking for in a lumbar spine assessment when doing an intrarticular test?
With the compressive and shearing forces, does it reproduce symptoms?
what is an infection?
The state or condition in which the body or a part of it is invaded by a pathogenic agent (microorganism or virus) which, under favorable conditions, multiplies and produces effects which are injurious.
What would someone with lumbar symptoms and short hamstrings look like?
They would probably be in more lumbar flexion and less hip flexion.
what test is this?
Thigh thrust
Triage for medical management asks:
What is the physician going to do? (diagnostic testing, medication, surgery, injection)
lamina
What structure is being identified in this image?
In the systems review structural screening section, what is the "symptom generator" representing?
What structure is the cause of the patients symptoms?
Acute aortic dissection that is caused by transverse disruption in the intima and media results in the formation of what?
a hematoma within the media
the "slide-glide" test is used for what?
a lateral shift correction
cauda equina syndrome is usually due to...
a massive, centrally herniated disc
When doing lumbar spine AROM with overpressure how do we determine if a joint that appears to have full range of active motion, is in fact "normal"?
a normal joint should be able to tolerate a reasonable stretch (overpressure) without pain
In the prone position, the lumbar spine falls toward extension. If the patient has a relative flattened lumbar spine, this may position the area at the end of the available range. how can we place the spine in a more neutral position?
a pillow below the abdomen
What will be present during abdominal palpation in a patient with an abdominal aortic aneurysm?
a very strong, non-tender abdominal pulsation may be detected
Pulse is _________after exercise with vascular claudication
absent
what is the most common type of lumbar spinal stenosis?
acquired
With vascular claudication pain increases with __________ and is promptly relieved by __________
activity; rest
mechanical irritation of the dura, nerve root sleeve or nerve root may result in what?
adverse neural dynamics due to intraneural and extraneural factors
what is the nature of a red flag?
alerting features that when present raise suspicion of serious pathology
palpation examination of the lumbar spine should include what?
all structures under the area of symptoms and which may refer into the area of symptoms
an abnormal dilation in a weak or diseased arterial wall causing a sac-like protrusion is termed?
aneurysm
This structural differentiation is more appropriate when SLR symptoms are perceived in the low back, buttock, and posterior thigh regions
ankle df
What BEST describes the outer part of the intervertebral disc?
annulus fibrosis
Where do we apply our pressure in the compression SIJ test?
anterior iliac crest
what is spondylolisthesis?
anterior slippage and inability to resist shear forces of a vertebral segment in relation to the vertebral segment immediately below it
this test is used to assess for anterior spinal instability of individual segments of the L-spine
anterior stability test
progressive or severe neurological deficit in the LE may indicate what differential diagnosis?
cauda equina syndrome
With lumbar flexion, what happens to the IV disc (annulus fibrosis)?
causes compression and bulging of the anterior annulus fibrosis and stretching of the posterior annulus fibrosis
For an IV disc, what is the best evidence we have for promising clinical diagnostic rules? (1)
centralization of symptoms
In the systems review, when identifying symptom behavior, what are we looking for? (3)
centralization, peripheralization, and/or directional preference
strain=
change in length/change in force
what kind of disease is ankylosing spondylitis?
chronic inflammatory disease
when you are doing a intraarticular test what is the goal?
compress and grind the joint
what test is this?
compression
The ACR states that in the absence of red flags the first line treatment for chronic LBP is what?
conservative therapy with both pharmacologic and nonpharmacologic therapy
what is stenosis?
constriction or narrowing of a passage
Arthrokinematics of Lumbar spine Z-joints in axial rotation
contralateral inferior facet of "upper" vertebra impacts/compresses superior facet of "lower" vertebra, while ipsilateral "gapping" occurs between facets
Patients with recurrent LBP and histories of prior surgical intervention should be evaluated with what type of imaging?
contrast-enhanced MRI
the posterior elements of the vertebrae (from the pedicle back) help to do what?
control motion
___________is a more accurate test for detecting herniated lumbar discs
crossed SLR
If conservative management fails for spondylolisthesis, what would be the next steps?
decompression and fusion surgery
how are reflexes with neurogenic claudication?
decreased but returns quickly
acquired lumbar spinal stenosis occurs in conjunction with ____________ changes of the lumbar disc and facets
degenerative
An important part of PT's clinical decision making for patients presenting with complaints of LBP is to...
determine the appropriate management approach
a systematic process used to identify the proper diagnosis from a competing set of possible diagnoses is termed?
differential diagnosis
What activity limitation is BEST associated with lumbar spinal stenosis?
difficulty walking
what are the lower extremity pulses with vascular claudication?
diminished, absent pulses
what are shmorl nodules cause by?
direct vertical pressure on the disc causes the disc to push fluid into the vertebral body. If the pressure is great enough, the result may be herniation of the nucleus pulpous into the vertebral body.
What is the cause of radicular pain and radiculopathy?
disc herniation in conjunction with local inflammation is the most common cause
what test is this?
distraction
what happens at the zygapophyseal joint when L2 moves into extension?
down glide of the inferior facet of L2 on to the superior facet of L3
what is a positive sign of the FABER test?
either a loss of motion compared to the contralateral side or provocation of symptoms.
carcinoma cancer is in what tissue?
epithelial
what is a positive result for the anterior stability test?
examiner feels the superior vertebra slip forward or an increased muscle spasm occurs
With ankylosing spondylitis there has been improvement seen with ________ but not with _______
exercise; rest
in the prone position, the lumbar spine falls toward _________
extension
the anterior longitudinal ligament is stretched in what position/movement of the vertebral column?
extension
the posterior longitudinal l. is slack in what movement?
extension
what are the aggravating factors of lumbar spinal stenosis?
extension activities (walking, prolonged standing, side bending)
With neurogenic claudication, pain increases with spinal __________ and decreases with spinal ___________
extension; flexion
In spondylolysis there is pain with _________ and/or __________
extension; rotation
the annulus fibrosis is perforated, and distal material (part of the nucleus pulpous) moves into the epidural space in which type of disc herniation?
extrusion
what type of disc herniation is this?
extrusion
T/F: If a patient gets new pain during an SIJ provocation test, we would consider this result to be positive
false; the test would only be positive from "familiar symptoms" that led them to seek diagnosis and treatment
the anterior longitudinal ligament is compressed in what position/movement of the vertebral column?
flexion
the posterior longitudinal l. is stretched during what movement?
flexion
what would be the relieving position or movement if the facet joint is involved as the symptom generator?
flexion
what are the easing factors of lumbar spinal stenosis?
flexion activities (sitting)
What two forces does the PT apply in the Gaenslen's test so that pelvis is stressed with a torsion force?
flexion force and extension force to femurs
what do the sensory changes present like with neurogenic claudication?
follows more specific dermatomes
stress=
force/area
what do clinical decision rules attempt to do?
formally test, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments
what type of activities in the lumbar spine tend to increase the pressure in the IV disc?
forward bending
aortic aneurysms can be describes as either ___________ or __________
fusiform (circumferential dilation) or saccular (balloon-like)
what happens at the zygapophyseal joint when L2 moves into R rotation?
gapping at the R facet and closing at the L facet
glioma cancer is in what tissue?
glial
What BEST represents a procedure that accurately identifies the true disease condition (negative or positive) of the subject?
gold standard
symptomatic back with restriction of motion, muscle and curtailment of activities describes what grade of spondylolisthesis?
grade 2
grossly symptomatic describes what grade of spondylolisthesis?
grade 3
severe disability describes what grade of spondylolisthesis?
grade 4
chronic LBP =
greater than 3 months
If we have an anterior posterior translation of a superior segment onto the inferior segment, what will happen to the IVD?
half of the fibers of the annulus fibrosis will be under tension and the other half will not
what is the normal motion for a prone knee bend test?
heel touches the buttock
As the IV disc changes with time, we tend to lose the ________ of the disc
height
this body region is also important to look at when examining the lumbar spine
hips
During the _________, is when we have a determination of symptom characteristics
history
What are lumbar spine AROM with overpressure used to determine?
if a joint which appears to have full range of active motion is in fact "normal". A normal joint should be able to tolerate a reasonable stretch without pain.
when is a side-glide test considered positive?
if it produces either a centralization or peripheralization of patients symptoms
when is slide-glide test considered positive for a relevant lateral shift?
if the slide-glide produces either a centralization or peripheralization of the patient's symptoms
Where does the pain occur in an abdominal aortic aneurysm?
in the chest and spreads toward the back and into the abdomen and is unaffected by position
slump test is used to look for
increased nerve mechanosensitivity
what is the neurodynamic test used for in a patient with LBP?
increased nerve mechanosensitivity
what is the differential diagnoses with patients 50 years or older with back pain... an increased risk of? (4)
increased risk of: cancer, abdominal aortic aneurysm, fracture, infection
Identify the condition that is BEST associating with this question, 'Have you been diagnosed as having an immunosuppressive disorder?'
infection
Constitutional symptoms (fever, chills, night sweats) with LBP may increase the risk of _________ or __________
infection or cancer
Unexplained weight loss or gain over 10 pounds in 3 months, not directly related to a change in activity of diet may be indicative of differential diagnosis of __________ or ___________
infection or cancer
Arthrokinematics of Lumbar spine Z-joints in extension
inferior facets of "upper" vertebra glide inferiorly on superior facets of "lower" vertebra
Arthrokinematics of Lumbar spine Z-joints in flexion
inferior facets of "upper" vertebra glide superiorly on superior facets of "lower" vertebra
Particularly in the acute phase, spondylolythesis is associated with spinal _________
instability
what is palpated during a PPIVM of lumbar flexion and extension?
interspinous space
If we have centralization of symptoms, where in the lumbar spine would we likely think their symptoms were coming from?
intervertebral disc
what are the three layers of the aorta?
intima, media, adventitia (outermost)
Arthrokinematics of Lumbar spine Z-joints in lateral flexion
ipsilateral inferior facets (in reference to direction of lateral flexion) of "upper" vertebra glide inferiorly while contralateral side glides superiorly
__________may occur in the presence of diseases associated with hypercalcemia
kidney stones
what is the side-glide test used for?
lateral shift correction
what does a radiograph show with a patient who has spondylolythesis?
lateral spot view while the patient stands upright, and during flexion and extension
__________with progressive neurologic deficits is appropriate for physician referral
leg pain
In a patient with ankylosing spondylitis, as their spine begins to stiffen they start to lose their ___________
lordosis
W/ lumbar spinal stenosis, a patient will have a flattened lumbar __________
lordosis
Which factor is the BEST predictor of developing disabling low back pain?
low back pain with accompanying pain in the leg
What does this MRI show?
lumbar canal stenosis
what is the most common indication for spinal surgery among medicare recipients?
lumbar spinal stenosis
The clinician should start palpation exam at _____________region and progress superiorly to __________region
lumbosacral; thoracolumbar
lymphoma cancer is in what tissue?
lymphatic
what is cancer?
malignant neoplasia marked by the uncontrolled growth of cells, often with invasion of healthy tissue locally or throughout the body
What would you see in your functional demonstration test that would make you want to do the modified thomas test?
may see pain with extension or excessive lumbar extension in gait (because don't have adequate hip extension)
Hip IR in SLR test increases ___________ of the lumbosacral nerve roots
mechanical loading
sarcoma cancer is in what tissue?
mesenchymal
Describe the pain presentation of spondylolythesis
midline pain at the lumbosacral junction
Pathology related to aging and degenerative changes in the lumbar spine must affect the ____________ and ___________ of the motor segment
mobility and function
What BEST describes the content of the nucleus pulposus?
mostly water
What is important to include in your assessment when your patient currently has LBP with related LE symptoms, or a history of LBP with related LE symptoms? (3)
myotomes, dermatomes, DTRs
what 3 neurological tests will be positive with nerve root involvement?
myotomes, dermatomes, DTRs
patients with symptoms secondary to spinal stenosis have what when compared to asymptomatic individuals?
narrower spinal canals
what is lumbar spinal stenosis?
narrowing of any part of the lumbar spinal canal
this structural differentiation during the SLR increases tensile loading of the neuraxis, meninges, and sciatic nerve
neck flexion
what is cauda equina syndrome?
nerve compression within the spinal canal that occurs below the L1-L2 interspace after the termination of the spinal cord
The prone knee bend test is an example of what kind of special test?
neurodynamic
With ___________ claudication, pain is related to exercise and sensations spread from area to area
neurogenic
lumbar spinal stenosis would fall under ________ claudication
neurogenic
what are the changes in skin with neurogenic claudication?
no trophic changes; look for subtle strength deficits (e.g., partial foot drop, ip flexor or quadriceps weakness; calf muscle atrophy)
What low back pain classification is MOST common?
non-specific
ankylosing spondylitis is commonly misdiagnosed as what?
non-specific low back pain
What is the BEST classification for people presenting with low back pain for which identifying the specific nociceptive source is not possible?
nonspecific low back pain
the protein content of CSF is __________ with vascular claudication
normal
clinical depression would be an example of what color flag?
orange flag
A 44 year old patient who is a frequent IV drug abuser comes in for an MRI as she has complaints of LBP...what does the MRI likely show?
osteomyelitis and spondylodiscitis of the spine secondary to intravenous drug abuse. (destruction of L5 vertebral body in this particular MRI)
What BEST represents a positive Hip Scour Test?
pain
what is the behavior of symptoms with neurogenic claudication?
pain increases with spinal extension, decreases with spinal flexion
what is the relationship of symptoms to activity with neurogenic claudication?
pain may respond to prolonged rest
what is the behavior of symptoms with vascular claudication?
pain present in all spinal positions
what is a positive test for the prone instability test?
pain provoked with legs relaxed/supported by the floor. is eliminated when legs are raised slightly off the floor
melanomas cancer is in what tissue?
pigmented skin cells
myelomas cancer is in what tissue?
plasma cells
inability to maintain the body balance when the eyes are shut and the feet close together would be associated with this finding?
positive romberg sign
What is the differential diagnosis for LBP trauma?
possible fracture, especially in an older or osteoporotic patient
With an anteroposterior rotation (tilting) what will happen to the IV disc (annulus fibrosis)?
posterior fibers will be under tension and the anterior fibers will be under compression
With lumbar extension what happens to the IV disc (annulus fibrosis)?
posterior tilting and gliding causes compression and bulging of the posterior annulus fibrosis and stretching of the anterior annulus fibrosis
what is the direction of force for the thigh thrust (SIJ provocation tests)?
posterior-medial
pulse is ________ after exercise with neurogenic claudication
present
A positive SIJ pain provocation test has to do with what
produce or increases their "familiar symptoms"
In which type of disc herniation is only the outermost fibers of the annulus fibrosis contain the nucleus?
prolapse
what type of disc herniation is this?
prolapse
This is proposed as a test for segmental instability in the lumbar spine
prone instability test
If you suspect your patient might have a femoral nerve involvement, what test would you apply?
prone knee bend test
In _________ disc herniation, there is no escape from outer annulus fibrosis or the posterior longitudinal ligament
protrusion
What type of disc herniation results in the LEAST disruption to the annulus fibrosus?
protrusion
what type of disc herniation is this?
protrusion
the disc bulges posteriorly without rupture of the annulus fibrosis describes what type of disc herniation?
protrustion
what did backstrom et al 2011 say about providing an explanation of the current concepts of pain?
provide an explanation of the current concepts of pain as an output and not an input to help reframe the patient's relationship with the problem and motivate them to increase their functional status
what is the nature of orange flags?
psychiatric symptoms
If we lose the height of the disc, what happens to the ligaments?
puts them on slack
what should an elevated ESR prompt?
radiography
what is included in the initial work-up for a vertebral compression fracture?
radiography (if negative result and there is continuing clinical suspicion consider MRI)
the protein content of CSF is _________ with neurogenic claudication
raised
What is an important consideration when applying the prone knee bend test?
rectus femoris tightness
What is a step deformity?
related to a spondylolisthesis which causes an anterior translation of a vertebra on another and you get a step deformity
what does the strength of diagnostic accuracy for SLR to detect herniated lumbar discs appear to be?
relatively low
Other tumors, including ________ and ______ cancer, can also metastasize to the spine and spinal metastases can be the first presentation of cancer
renal and gastric cancer
what is a positive result for the crossed SLR test?
reproduction of the patient's familiar pain in the involved leg.
what is a positive result for SLR test?
reproduction of the patient's familiar pain, sensitization, and asymmetry findings.
what would a positive finding of the scour test be?
resistance felt anywhere in the arc (asymmetry, provocation of symptoms). The resistance may be caused by capsular tightness, an adhesion, or myofacial restriction, or loss of hip congruity (labral lesion).
If the facet joint is more in the sagittal plane, what is the consequence?
restrict anterior motion
Typically, because of the orientation of the facet joints in the lumbar spine, we do not get a lot of what motion?
rotation
what test is this?
sacral thrust
Standard SLR is performed in straight __________ plane for best reproducibility
sagittal
This picture represents what type of impairment?
schmorl nodules
what is the intraarticular test called that is utilized when assessing the lumbar spine?
scour test
Formation of distal fragments from the annulus fibrosis and nucleus pulpous outside the disc proper describes what type of disc herniation?
sequestration
what type of disc herniation is this?
sequestration
In a lateral shift correction, we apply pressure to the thorax to produce__________force at lumbar region to "correct" the shift
shearing
what kind of force do we want to produce at the SIJs during a sacral thrust pain provocation test?
shearing
Which movement is used to correct a lateral shift?
side-gliding
The +LR for a diagnostic test is 10. When the diagnostic test is positive, what happens to the probability that the patient has the condition?
significant change in posttest probability
the relevant lateral shift must be corrected using ____________, before the patient attempts the ___________exercises
slide-glides; McKenzie repeated extension exercises
what kind of referral is advised for a patient with ankylosing spondylitis?
specialist rheumatology
What condition, if present, but undiagnosed by the physical therapist, would MOST likely result in harm to the patient during a typical intervention delivered by a physical therapist?
spinal fracture
Your patient is a 70 year old female with acute low back pain. What is the MOST likely diagnosis based on this information?
spinal stenosis
____________ was defined in 1975 as any type of narrowing of the spinal canal, nerve root canals, or IV foramina
spinal stenosis
Where do you contact the lumbar spine when you perform a central posterior-anterior glide?
spinous process
________ is the posterior element of the vertebrae
spinous process
what happens to the spinous process when L2 moves into R rotation?
spinous process would go to the left
___________ is a "hill" as __________ is a "valley"
spinous process; interspinous space
Does this image represent spondylolysis or spondylolisthesis?
spondylolisthesis
This photo represents what
spondylolisthesis
Does this represent spondylolysis or spondylolisthesis?
spondylolysis
bony defect of the pars interarticularis of the spine describes what?
spondylolysis
where do we start when assessing passive physiologic intervertebral motion? (lumbar flexion and extension)
start at L5-S1 interspinous space
spondylolythesis is associated with palpation of a _________
step deformity
what happens at the zygapophyseal joint when L2 moves into flexion?
up glide of the inferior facet of L2 relative to the superior facets of L3
what is the sensory change described as with vascular claudication?
variable
W/__________claudication, pain is related to exercise and occurs at various sites simultaneously
vascular
this is associated with vascular insufficiency during walking
vascular claudication
__________ is the anterior element of the vertebrae
vertebral body
________ helps with fluid diffusion into the disc
vertebral end plate
this is considered part of the IVD because of its strong attachment to the IVD
vertebral end plate
Lumbar radiculopathy is characterized by the presence of what?
weakness, loss of sensation, or loss of reflexes associated with a particular nerve root, or a combination of these, and can coexist with radicular pain
With repeated movements, when should the lumbar assessment be terminated?
when a clear symptomatic response is revealed (centralization or peripheralization)
when does the palpation exam of the lumbar spine begin?
when completing the body chart and confirming locations of symptoms
what is one consequence of professional uncertainty in clinical care?
wide variation in treatment for the same condition
When is low back pain MOST likely to improve substantially?
within 6 weeks
is spondylolythesis more common in women or men?
women
What can you say if all 5 SIJ provocation test are negative?
you can rule out SIJ pain