OCS - Lumbar spine, OA, Pelvis, SI Coccyx and Abdomen

Pain while rising from sitting is postiviely associated with both _____ and ______, but negatively associated with zygopophyseal pain.

SI discogenic

Neural Tension X-SLR

SLR on contralateral side provokes pain down involved extremity => potentially large space occupying lesion

Grade A Evidence for examination hip OA -- clinicians should use the following at baseline and 1 follow up

WOMAC physical function sub-scale 6 minutes walk test 30 second chair-stand test TUG Stair measure Hip ROM and Strength ALL directions Numeric PS FABER

True of False: 1 in 2 people will be affected by OA

True

True of False: Psychosocial factors appear to play a larger prognostic role than physical factors in LBP

True

You are rehabilitating a 23yo MALE with LBP. Before you discharge him, you want to test his trunk endurance strength to prevent future injury. What is the ideal ratio for trunk flexion stabilizer endurance relative to trunk extension endurance hold times? a. 1.0 b. 0.8 c. 0.6 d. 0.4

a. 1.0 -- the ideal ratio is approximately 1.0 for a young male. For young female, the ratio is 0.79

Specific Exercise: Centralization Group

exercise that centralizes, reduces sx or addresses the patient's condition specifically

Lumbar Extension-Rotation Test -- used to assess what?

facet joint pain

spondylolisthesis

the forward slipping movement of the body of one of the lower lumbar vertebrae on the vertebra or sacrum below it -congenital -degenerative -traumatic -pathologic

Individuals with esophageal pathologies

the patient would more likely present with difficulty swallowing and anterior neck pain, not thoracic symptoms.

What other tests should be done in evaluation for lumbar disc disease to help rule out vascular claudication?

the posterior tibial and dorsal pedis artery hip and knee also should be screened

What may localized pain suggest?

tumor infection fracture

non-arthritic hip pathology

-osseous abnormalities (ante- or retroversion) -local or global ligamentous laxity -connective tissue disorders -nature of patient's activity and participation

4th sacral nerve root compression

-pain lower sacral region, peroneal, genital -neural tension negative -saddle paresthesia -limitation of any lumbar motion -bladder, bowel, genital dysfunction -diminished anal reflex

CPR hip OA

-pain worse with squatting -positive scour for groin / lateral hip pain -flexion AROM produces lateral pain -extension AROM painful -PROM IR < 25 degrees

Structure: 1. Primary disc 2. Radiographic instability 3. SI Joint dysfunction 4. Secondary disc (degenerative) 5. Spinal stenosis 6. Facet impingement 7. Nerve root adhesion

Finding: 1. Flattened back 2. Excessive lordosis (spondylolisthesis) 3. Flattened back 4. Hypertrophic supraspinous ligament 5. Flattened back 6. Flexed back, usually unilateral, shift 7. Bad posture, avoids forward flexion, avoid extending the knee, even sometimes in standing

Recommended outcomes

Roland Morris LBP Disability Questionnaire MDC: 5-8 points Oswestry: MDC 5-6 Numeric pain rating scale: MDC 2.4 Patient specific scale: MCID: 1.4 FABQ STarT Back Questionnaire

Directional Preference: Extension Bias Criteria

•Sx distal to buttock (beyond gluteal fold) •Sx centralized with lumbar extension •Sx peripheralize with lumbar flexion •Directional preference for extension

sports hernia (athletic pubalgia) treatment

Manual therapy at the hip and SI (mobs) Core strengthening (lower abs)

Risk factors for restricted motion after ACL reconstruction

-open surgery -reconstruction performed 7 days after initial injury

S-LANSS

Online pain scale - iconic pain assessment tool with threshold score > 12

Upper lumbar disc herniation -- Red Flag in someone in their 20's

(+) femoral nerve tension test

Neural Tension Test: SLR

(+) for <50 degrees hip flexion High Sn 92, Low Sp 28

Femoral Nerve Tension Test

(+) if burning or vague painful sensation down anterior thigh - not as reliable

Treatment Based Classification Low Back Pain

* Sx Modulation (Manual, Directional Preference, Traction and / or immobilization) * Movement Control * Functional Optimization

Red flags for back pain

*History of Cancer *Night pain - not improved with positional change *Unexplained weight loss / gain *Fracture: hx of fall, spondylolisthesis issue, wedge fracture in someone with osteoporosis *Infection - post steroid injection, osteomyelitis *Steroid use *IV drug use - tend to be more sick and have issues outside the norm

Sample of evidence for Multifidus

-80% of all LBP demonstrated multifidus atrophy -Multifidus atrophy more pronounced on side of Sx -decreased EMG activity at unstable segment -decreased endurance if LBP -increased atrophy / fatty infiltrates in pts with poor outcome after surgery -increased atrophy associated with poor outcomes after laminectomy -increased recovery of muscle after surgery in those with favorable post-op outcomes

Treatment Based Classification-Sx Modulation: Manual Therapy

-Acute, centralized back pain -CPR: * < 16 days (acute) * no pain below the knee * Segmental hypomobility * one hip IR ROM > 35 degrees * FABQ-W < 19 •Exclusion - Pregnancy, lumbar fusion <18 months

CPR Ottawa Knee Rules

-Age > 55 -tenderness at the head of the fibula -isolated tenderness of the patella during palpation -inability to flex the knee to 90 degrees -inability to WB immediately and upon ED evaluation

OARSI recommendations

-All patients should be given education about change in lifestyle, exercise, pacing of activities, weight reduction, and other measures to unload the involved joints (walking aids) -Some thermal modalities may be helpful -TENS may help with short term pain control

Manual PT CPR (manipulation and exercise)

-Duration of sx < 16 days -No sx distal to the knee -Lumbar hypo-mobility -At least 1 hip with > 35 degrees IR -FABQ-W score <19 > 4 predictors increase the probability of success with thrust manipulation with +LR 7.2!! -make sure to follow up with exercise -in patient's with spinal stenosis, 78% of pt's improved with manual treatment compared to 41% of exercise alone - High level of evidence: spinal mobilization / manipulation is effective for subgroups of pts and as a component of a comprehensive tx plan, rather than in isolation

Do not forget about the hip mm when treating the back; Tendencies:

-Glut med (weak) -Glut Max (inhibited) -Rectus Femoris (tight) -iliopsoas (tight) -hs (tight) Proper functioning of spinal mm yields spinal stiffness. Proper function of hip and pelvis mm yields the stable foundation the stiffened spine rests upon.

CPR (Kellgren and Lawrence system of) classification of OA of knee

-Grade 0: no radiographic features of OA are present -Grade 1: doubtful joint space narrowing and possible osteophytic lipping -Grade 2: definite osteophytes and possible joint space narrowing on AP WB radiograph -Grade 3: multiple osteophytes, definite joint space narrowing, sclerosis, possible bony deformity -Grade 4: large osteophytes, marked joint space narrowing, severe sclerosis and definite bony deformity

Rotational Manipulation

-Have the pt in SL, facing you, bottom knee straight and top knee bent, foot resting in popliteal fossa -Place fingers of distal hand in spinous process space, take the bottom arm and slide patient into rotation until feel movement at the target segment, then place that arm under the pt's head -mobilize the area, have patient take a deep breath in and then thrust downward -- if set up correctly, do not need to apply rotational force with the thrust

Slump Test

-In traditional Slump test assessment, the patient's knee is fully extended. However, current evidence suggests that people may be positive without fully extending the knee. -The mean knee extension angle was found to be 15.1 degrees in a recent study by Davis et al.

Cholecystitis

-Inflammation of the (gallbladder) -will often have right upper quadrant pain and tenderness, but there are no reports of left shoulder pain.

Chicago Roll Manipulation Technique

-Patient supine, position them so that they are in a "V" position, pointing toward you (head and feet away from you) -Here, you are targeting the manipulation on the side opposite you, L5-S1 gapping -Have patient position hands behind the head, lacing their fingers -Place your arm close to the head of the patient and place it in the crease of the elbow so that you can roll the patient toward you -Other hand is in other ASIS -Apply pressure downward at ASIS at the same time rotating the pt -at end range, apply a quick thrust

Tx Spinal stenosis

-Manual therapy -Body weight supported treadmill ambulation has evidence of positive effect despite severity -PT and surgery has shown equivalence -Surgery for non-responders: decompression vs decompression with fusion

CPR - Ankylosing Spondylitis

-Morning stiffness > 30 min -Improvement in back pain with exercise but not with rest •Awakening because of back pain during the second half of the night only -Alternating buttock pain -Age at onset < 40 years old -Insidious onset -Improvement with exercise -No improvement with rest -Pain at night with improvement on getting up

Importance of Multifidus

-Most closely lined to spinal segmental support -Action: Extension, control of anterior translation and rotation during flexion Segmental support and control > extension Main goal of multifidus is to stiffen the spine

spinal cord herniation

-Often causative factor of Brown-Sequard Syndrome - weakness or paralysis on one side of the body and loss of sensation on the opposite side -caused by prolapsed cervical disc, tumor, stenosis

Classification: Specific Exercise Flexion

-Older age, > 65 yo -sx distal to the knee -signs and sx of nerve root compression, neurogenic claudication, or both -sx centralize with lumbar flexion -sx peripheralize with lumbar extension Tx:Flexion exercises -mobilization to promote flexion De-weighted ambulation -avoidance of extension exercises

5th lumbar nerve root compression

-Pain SIJ, buttock, inner 3 toes, medial sole of foot -neural tension -possible lateral deviation during flexion -weakness of peroneal, EH, hip abductors -diminished reflexes, FL, achilles, EH

Treatment Based Classification-Sx Modulation: Traction and / or Immobilization

-Radicular signs / sx -pain does not centralize with extension -positive dural signs: + crossed SLR test -severe unrelenting pain

Classification: Specific Exercise Extension

-Sx distal to the knee -signs and sx of nerve root compression -sx centralize with lumbar extension -sx peripheralize with lumbar flexion Tx: Extension exercises -mobilization to promote extension -avoidance of flexion activities

Back pain prevalence

-The female gender has a higher prevalence of low back pain, but the differences between the female and male gender have been reported differently across the literature. -A lower educational status leads to a higher prevalence of low back pain, and these individuals also have longer episodes in duration and less positive outcomes.

Risk Factors of Spinal Stenosis

-obesity -smoking -lifestyle -genetic factors

Hip OA from CPG risk factors

-age -hx of hip developmental disorders -previous hip joint injury -reduced hip ROM (especially IR) -presence of osteophytes -lower socioeconomic status -higher bone mass -higher BMI

meniscus pathology - from CPG

-clinicians should consider age and greater time from injury as predisposing factors for having a meniscal injury -patients who participate in high-level sports or had increased knee laxity after an ACL injury are more likely to have later meniscal surgery

Meralgia Paresthetica

-compression of the *lateral femoral cutaneous nerve * -pain & tingling sensation but *no motor loss* -cause: obesity, postural changes, tight clothing, pregnancy

Sjogren's syndrome

-destruction of lacrimal (eyes) and minor salivary glands, often with RA -attacks the glands that make tears and saliva. This causes a dry mouth and dry eyes.

Treatment Based Classification-Sx Modulation: Directional Preference

-exhibits centralization phenomenon during one direction of movement -Postural preference

Patellofemoral pain risk factors

-female sex -decreased quadricep flexibility -hypermobile patella -altered VMO response time -decreased knee extension strength -diminished quadriceps explosive strength

Classification: Stabilization AKA "Movement Control"

-frequent prior episodes of LBP -increasing frequency of episodes of LBP -instability catch or painful arcs during lumbar flexion and extension ROM -hypermobility of the lumbar spine -positive prone segmental instability test Tx: Promoting isolated contraction and co-contraction of the deep stabilizing muscles -strengthening of large stabilizing muscles •Transverse Abdominis Contraction •Multifidus Contraction (4 point arm and leg lifts) •Stability progression •Maintain and Challenge TrA and Multifidus •Progressively increase the degrees of freedom to challenge tissue

CPR Hip OA (Altman)

-hip pain -hip IR < 15 degrees -hip flexion < 115 degrees If hip IR is > 15 degrees then: -pain with IR -age > 50 -AM stiffness <60 minutes

CPR Meniscal Pathology

-history of catching or locking reported -joint line tenderness -pain with forced hyperextension or positive bounce home test -pain with maximal passive knee flexion -pain or audible click with McMurray maneuver

Signs and sx of septic arthritis (kids)

-limping -refusal to walk or WB -fever -recent trauma to the joint -fussiness -patient will hold hip in flexion and ER and a knee in flexion -damage to articular cartilage begins 18-24 hours from the start of infection and irreversible damage occurs within a few days

CPR Key findings of hip pain and mobility deficits (from JOSPT CPG)

-moderate anterior or lateral hip pain during WB -AM stiffness <60 minutes -hip IR < 24 degrees -increase hip pain with passive IR -absence of history, activity limitation, and/or impairments inconsistent with hip OA

Spinal Stenosis

-narrowing of the spinal canal with compression of nerve roots and vascular structures -variable combination of static back pain, LE radicular pain, or neurogenic claudication -exacerbated by standing / walking / extension

Classification: Manipulation CPR

-no sx distal to the knee -recent onset of sx, <16 days -FABQ (<19) -hypo-mobility of the lumbar spine -normal hip IR (> 35 degrees) or discrepancy in hip IR ROM Tx: Manipulation or mobilization targeted to the SIJ or the lumbar spine AROM exercises •Mobilization (Low Velocity and Non-thrust Grade I-IV) Does NOT produce the same reduction in Oswestry or pain as Manipulation

CPR ACL classification surgery vs non-surgery (Fitzgerald et. al) -- COPER

-number of "giving way" episodes < 1 -single-limb hop test for involved limb > 80% -KOS-ADLS > 80% -GRS (global rating of perceived function) > 60% Must meet all criteria to be classified as potential coper

Disc Disorders

-posterior elements change (20-25 years) -contained (protrusion) -extrusion (prolapse) -sequestration (nucleus pulposus of a herniated disc extrudes through the annular fibers and a piece of the nucleus breaks free) -vertical prolapse (Schmorl's nodes)

non-contact ACL injuries (from CPG) risk factors

-shoe surface interaction (dry weather conditions and artificial turf surface) -increased BMI narrow femoral notch width increased joint laxity pre-ovulatory phase of the menstrual cycle in females -combined loading pattern, and strong quad activation during eccentric contraction

Classification: Traction

-signs and sx of nerve root compression -no movements centralize sx Tx: Mechanical Traction •This is the smallest group (8-12%) and some research is not including it •Criterion •Neurologic Signs •Leg sx below the knee •Peripheralization with all movement (non-directional) •Positive Crossed SLR •Not much evidence exists due to small population of group

CPR Delay in diagnosis SCFE (slipped Capital Femoral Epiphysis)

-stable slip -medicaid insurance -distal thigh or knee pain

One feature that differentiates ankylosing spondylitis from psoriatic arthritis

-the presence of unilateral involvement of the sacroiliac joint (with AS) -- psoriatic more peripheral •like ankylosing spondylitis and psoriatic arthritis, reactive arthritis does not commonly impact the sacroiliac joints. -SI joint pain is often the first symptom of ankylosing spondylitis.

CPR Patellar Taping for PFPS

-tibial angulation >5 degrees -postive patellar tilt test

CPR MCL Pathology

-trauma by external force to the leg -rotational trauma -pain with valgus stress test at 30 degrees -laxity with valgus stress test at 30 degrees

CPR predictors for favorable response to PT in patients with hip OA (needs validation)

-unilateral hip pain -age < 58 -pain > 6/10 on NPRS -40m self paces walk test time of < 25.9 seconds -duration of sx < 1 year

Classification: Specific Exercise Lateral Shift

-visible frontal plane deviation of the shoulders relative to the pelvis -asymmetrical side bending AROM -painful arc and restricted extension ROM Tx: Pelvic translocation exercise -NWB shift correction exercises

Prognostic factors for development of recurrent pain include:

1 - hx of previous episodes 2 - excessive spine mobility 3 - excessive mobility in other joints 4 - pain of high intensity 5 - a passive coping style

Prognostic factors for development of chronic pain include:

1 - presence of sx below the knee 2 - psychological distress or depression 3 - fear of pain, movement and re-injury or los expectation of recovery

Depression Screen -- 2 questions to ask are?

1- During the past month, have you often been bothered by feeling down, depressed, or hopeless? 2- During the past month, have you often been bothered by little interest or pleasure in doing things? If the pt responds no to both questions, depression is highly unlikely. Answering yes to 1 or both, suspicion is raised for depressive sx

Lumbar Spinal Stenosis Cluster

1. Bilateral sx 2. leg pain > back pain 3. pain during walking / standing 4. pain relief upon sitting 5. age >48 years

Problem with Red Flags

1. Red flag screening is not consistent with best practice in LBP management 2. Variability in definitions for red flag sx limits research and clinical progress in this area -- we don't understand prevalence 3. Guidelines do not help - ie- 24 different red flags for malignancy 4. Clinicians do not actually screen for red flags - they manage LBP conditions they see

3 constructs to consider with back pain evaluation (3)

1. Sensory / Discriminatory - location, quality, intensity 2. Cognitive / Evaluative - thoughts, beliefs, expectations 3. Motivational / Affective - Fear / Anxiety, withdrawal

Stepwise process for stabilization exercise

1. Transverse abdominus - place hands medial to ASIS for feedback, assure no movement (BP cuff -- pressure should not change); may have to try Kegel exercise 2. Multifidi - palpate near base of sacrum in 4 point, may need to lift leg straight up

100% sensitivity that an individual has a malignancy (4/4)

1. Unexplained weight loss 2. Age > 50 years 3, Prior history of cancer 4. Failure to improve over one month

5 Predictors of response to PT in patients with hip OA

1. Unilateral hip pain 2. 40M self-paced walk test < 25.9 seconds 3. Age < 58 years 4. Duration of Sx < 1 year 5. Pain > 6/10 3 or more present: 99%

Scale commonly used to assess severity of OA (x-ray)

1. minute osteophytes with normal joint space 2. Identifiable osteophytes but joint space is still maintained (mild) 3. Moderate reduction in joint space (moderate) 4. Severe reduction in joint space (severe)

_____ women and _____ men over 50 will have osteoporosis related fracture with _____ % mortality rate within _____ months of hip fracture

1/2 1/4 20 12

Per CPG: 4 recommended outcomes

1: SF-36 (short form 36) 2: ODI (Oswestry); MCID 10 points or 30% from baseline score 3: Roland-Morris Disability Questionnaire 4: Numeric PRS; MCID 2

Risk Factors Cancer

Age Prior hx of cancer Failure to improve Unexplained weight loss >50 unexplained weight loos failure to improve All 3 => Sn 100, +LR cancer 2.4

CPR knee OA who would benefit from a hip mobilization

92% chance of a favorable short-term response to a hip mobilization if 1/5 of the following parameters are met, 97% chance if 2/5 are met: -Hip or groin pain or paresthesia -Anterior thigh pain -Passive knee flexion less than 122 degrees -Passive hip internal rotation < 17 degrees Pain with hip distraction

FABQ-W cutoff scores

>29 (scale of 0-42) has been suggested as in indicator of poor RTW status >22 has been suggested in nonworking populations

Sign of the Buttock

A straight leg raise is performed passively by the examiner. If the SLR is positive, the end-feel is usually spasm or capsular, but definitely painful. Return the patient to neutral. Passively flex the patient's hip, but this time with the ipsilateral knee flexed to end-range. Assess for if further hip flexion was achieved. If no change in range of motion, the pathology is within the hip or buttock, and not the hamstrings or sciatic nerve. The second part of the test usually has an empty end-feel and is more painful than the first part. To be positive, the Sign of the Buttock must have all present: restriction of SLR concurrently with limited hip flexion and a non-capsular pattern of restriction of hip joint ROM. Indicative of neoplasm, ischial bursitis, hamstring tendinopathy

Typical weakness found in hip OA

ABD most affected, then hip Ext

Medication Recommended first for OA

Acetaminophen; Zhang et al. and the American College of Rheumatology recommend it to be used first in those who have mild to moderate pain associated with knee osteoarthritis (Zhang 2007, ACR 2012).

Defined Chronicity Acute Sub-acute Chronic

Acute <6 weeks Sub-acute 6-12 weeks Chronic >12 weeks

Staging LBP: Treatment Based Classification Approach Stage I

Acute: Inability to perform basic functions -unable to stand > 15 minutes -unable to sit > 30 minutes -unable to walk > 1/4 mile Oswestry > 40% (40-60%) Goals: Pain modulation Tx: categorized by signs/sx -- primarily utilizing CPRs to guide which treatment is expected to be most effective

ARTS of manual therapy

Asymmetry ROM Tissue Texture Changes Symptomatology

Classic Manual Therapy Diagnostics (4) (ARTS)

Asymmetry Range of Motion Tissue Texture Changes Symptomatology

Articular cartilage

Avascular and is not innervated and therefore is an unlikely source of pain

Osteogenesis Imperfecta (OI)

Common and severe bone impairment of genetic origin, affects the formation of collagen during bone development resulting in frequent fractures during fetal and new-born period

Good to know...

Based on evidence from 2 placebo controlled RCTs, arthroscopic surgery has no effect beyond placebo for treating knee OA

CPR Pittsburgh Knee Rules

Blunt trauma or a fall as MOI AND either of the following: -age > 50 or < 12 inability to walk 4 steps in the ED

Risk Factors for Fracture

Bone density Trauma Age Gender (FEMALE)

Other recommended scales

Brief Illness Perceptions Survey: Injury Pain Catastrophizing Scale

Lab values which detect inflammation

CRP - C-reactive protein ESR - Erythrocyte Sedimentation Rate

Types of Spinal Stenosis

Central: associated mainly with axial back pain and neurogenic claudication; motor or sensory radicular sx possible; L4-L5, followed by L3-L4 and L5-S1 Lateral: sub-articular recess, unilateral or bilateral Foraminal: unilateral radiculopathy with pain and possible weakness of corresponding muscular territory

Centralization

Characterized by spinal pain and referral spinal sx that are progressively abolished in a distal to proximal direction in response to therapeutic movement and positioning strategies

MDT Classification Non-loading sx decrease

Derangement - irreducible

MDT Classification Loading decreases sx

Derangement - reducible

Mckenzie classification: Non-loading sx decrease

Derangement irreducible

Use this chart to determine if patient likely has OA - Atlman clinical criteria

Clinically: Age > 50 Stiffness for > 30 minutes Crepitus Bony Tenderness Bony Enlargement No palpable warmth At least 3 of 6 Sn 95 Sp 69

Morel-Lavallée lesion of the lumbar region.

Closed soft-tissue degloving injury commonly associated with high-energy trauma. The hip, thigh and pelvis are the most commonly affected locations. Timely identification and management of a Morel-Lavallée lesion is crucial because distracting injuries in the polytraumatized patient can result in a missed or delayed diagnosis. Bacterial colonization of these closed soft-tissue injuries has resulted in their association with high rates of perioperative infection. Recently, MRI has been used to characterize and classify these lesions. Definitive management is dictated by the size, location, and age of the injury and ranges from percutaneous drainage to open debridement and irrigation

Mckenzie classification: Loading decreases sx

Derangement reducible

compartment syndrome - and the 5Ps

Common symptoms observed in compartment syndrome include a feeling of tightness and swelling. Pain with certain movements, particularly passive stretching of the muscles, is the earliest clinical indicator of compartment syndrome The "5 P's" are oftentimes associated with compartment syndrome: pain, pallor (pale skin tone), paresthesia (numbness feeling), pulselessness (faint pulse) and paralysis (weakness with movements). Numbness, tingling, or pain may be present in the entire lower leg and foot

Traction CPG

Conflicting evidence for the efficacy of intermittent lumbar traction for pts with LBP Moderate evidence: clinicians should not utilize intermittent or static lumbar traction for reducing sx in pts with acute or sub-acute, non-radicular LBP or in patient with chronic LBP Per MedBridge: A sub-group of patients responsive to traction may exist: -patients with leg pain -signs of nerve root compression -peripheralize with extension movements - (+) crossed SLR test

_______: sacrum rotates posterior as ilium rotates anteriorly _______: sacrum rotates anterior as ilium rotates posteriorly

Counternutation Nutation

Staging LBP: Treatment Based Classification Approach Stage III

Difficulty returning to high demand activity -manual labor -athletics -homemakers Oswestry: <20% Goals: Enable to work (work re-conditioning) Return to sport

Which treatment based classification group? -exhibits centralization phenomenon during one direction of movement

Directional Preference

MDT Classification Pain at end range

Dysfunction - adherent nerve root

Mckenzie classification: Pain at end range

Dysfunction - adherent nerve root

"Improvement" stabilization group

FABQ > 9 points No aberrant movements No lumber hypermobility with PA spring testing Negative prone instability test Psychometrics · >1 variable = +1.1 LR / -0.2 LR · >2 variables = 6.3 LR / -0.18 LR · >3 variables = 18.8 LR / -0.43 LR · 4 variables = 6.0 LR / -0.84 LR

True or False: Just the joint surface is involved with OA

False: Not just surface involved but the entire joint

Centralization and Directional Preference Exercises and Procedures CPG

Good evidence: use of repeated movements, exercises or procedures (actively, actively with overpressure, or passively) to get the response -to promote centralization This is for true lumbar radiculopathy Postural preference - activities to promote centralization

Cluster to rule in sports hernia

Having 3/5 of the following: 1. Pinpoint tenderness over the pubic tubercle at conjoined tendon 2. Palpable tenderness over deep inguinal ring 3. Pain with no obvious hernia evident 4. Pain at origin of adductor longus tendon 5. Dull, diffuse pain in groin

Total Shoulder Guidelines (generally based on expert opinion and no up to date studies) -minimize IR past frontal plane

Hemi shoulder arthroplasty guidelines - similar to that of TSA

ACL injuries lead to knee OA despite reconstruction

High % of patients with ACLR will develop knee OA in 10-15 years Younger patients more likely to require revision surgery and have worse prognosis High incidence of OA with ACL injury may be related to associated chondral or meniscal injury or inflammatory response

Progressive Endurance Exercise and Fitness Activities CPG

High level evidence: 1- moderate to high intensity exercise for pt's with chronic LBP without generalized pain 2-Incorporate progressive, low-intensity, sub-maximal fitness and endurance activity into the pain management and health promotion strategies for pt's with chronic LBP with generalized pain

Capsular pattern for the hip:

Hip IR < hip abduction < hip flexion

Found on articular surface of synovial joints Functions to bear and distribute compressive loads and reduce friction between joint surfaces

Hyaline Cartilage

Classification Scheme Stages I, II, III

I -- very severe, highly sensitive II - tolerate some exercise, activity III - RTW, activity

Capsular Pattern at the hip

IR, abduction, flex >15 degrees IR difference is considered pathological

Directional Preference

Identified by examining the patient's symptomatic and mechanical response to repeated movements or sustained positions Movement in a specific direction causes centralization of symptoms, movement in the opposite direction causes peripheralization

The rate of limitations _____ sharply with age and with having prior injury and the severity of pain in the OA joint correlates with the severity of compartmental OA

Increases

External hip derotation test

Indicative of gluteal tendinopathy

Abnormal loading Obesity Genetics Aging are all contributors to _____.

Inflammation

Individuals with breast pathologies

It is possible for breast pathologies to radiate to the thoracic region, but it typically starts anteriorly and radiates posteriorly to the thoracic region and posterior shoulder. There would also likely be skin changes, palpable nodes or lumps found in those with breast conditions.

Trunk coordination, strengthening & endurance exercises CPR

Level A Evidence in sub-acute and chronic categories and SP lumbar discectomy -age <40 -positive prone instability test -presence of aberrant movements with motion testing -SLR > 91 degrees -hypermobility If 3/4 above: +LR 4 => stabilization exercise

APTA ICF CPG for LBP

Level A evidence: clinicians should use validated self-reports outcome measures Level F evidence: clinicians should routinely assess activity limitations and participation restrictions and use consistent test and measures over time

Flexion exercises for low back CPG

Level C evidence: Utilized for stenosis patients, they don't always fall into direction preference category Exercise alone may not be enough Manual therapy, strengthening, nerve mobilization, progressive walking -- encourage walking Education on management Management for Spinal Stenosis: weight supported treadmill ambulation

Joints affected by OA: _____ most frequent, _____ 2nd, _____ 3rd

Knee shoulder hip Actually -- Though the knee and hip get more attention, it is the hand that is the most frequent site of complaint and has the highest self-report and radiographic evidence of OA at 43.3%.

CPR knee OA (clinical exam)

Knee pain plus 3 of the following: -age >50 -AM stiffness under 30 minutes -crepitus -tenderness -bony enlargement -no palpable warmth Sn 95%, Sp 69%

CPR knee OA (clinical and radiographic)

Knee pain plus one of the following: -age > 50 -AM stiffness < 60 minutes -crepitus and osteophytes Sn 91%, Sp 86%

Which are the most common levels for disc herniation to occur?

L4-L5 and L5-S1 -- of 40,000 operations, 95% of disc herniations were at these 2 levels

What is the most common vertebrae affected by spondylolyisis of a pars interarticularis leading to a spondylolisthesis?

L5

Individuals with pancreas pathologies

Likely to show thoracic region symptoms as well as upper abdominal pain and possible symptoms in the right shoulder.

LBP cost

Low back pain is the leading cause of global disability, but it is not responsible for the highest health expenditure. Cardiovascular disease and cancer are responsible for the highest health expenditure.

Grade A Evidence for hip OA Treatment

Manual PT (thrust, non-thrust, and STM) Flexibility, strength and endurance exercise

Which treatment based classification group? -Acute centralized LBP -pain < 16 days -no pain below the knee -segmental hypomobility -one hip IR ROM >35 degrees -FABQ-W >18

Manual Therapy Group

Risk factors of AAA

Men more than women 5th-6th decades of life Initiation of weight lifting program Obesity Smoking Elevated blood pressure Atherosclerosis Personal or family history of AAA High cholesterol Emphysema Genetic factors Symptoms: rapid HR, cold clammy skin, sensation of throbbing, pulsing, ripping.

Grade A evidence American College of Radiology for HIP OA

Moderate hip pain AM stiffness < 1 hour Hip IR ROM < 24 degrees OR Hip IR and Hip 15 degrees Flexion < non painful side OR Pain with passive hip IR

Juvenile RA Sx

More marked in the AM - just after waking up Sx may include: -onset <16 -swollen, red or warm joint (up to 6 weeks) -limping or problems using a limb -rash (trunk or extremity) that comes and goes with fever -Stiffness, pain, and limited joint movement -Body wide sx (pale, swollen lymph gland, "sick" appearance -- immune system on overdrive

Onycholysis

Onycholysis is when a person's nail or nails detach from the skin underneath. Although not a serious health condition by itself, onycholysis can be a symptom of a potentially serious illness.

Which treatment based classification group? -reversal of lumbopelvic rhythm -gower's sign -hypermobility -painful "catch"

Movement control (stabilization) group

Femoral Nerve Tension Test (Prone knee bending test)

Nerve root impingement L2-4 •The patient is prone symmetrically on the bed, the clinician places one hand on the patient's pelvis to prevent movement and feel for any compensations, while the other hand flexes the involved knee as much as possible and maintain the position for 45 seconds. A positive test will be reproduction of the patient's symptoms. Pain following the femoral nerve or the mid lumbar roots (Lower back area, anterior thigh) can direct the clinician to entrapment of the nerve and L2-L4 roots. A tight rectus femoris can also produce pain in the anterior thigh, thus it is important to perform the test on both sides and compare the symptoms.

Spinal Stenosis Vs Intermittent Vascular Claudication Posture Walking Pain Relief

Neurogenic: Flexion improves, extension worsens Vascular: Flexion / Extension has no effect Neurogenic: Distance Varies Vascular: Consistent Distance Neurogenic: Sitting Vascular: Stop activity to get relief

Spinal Stenosis Vs Intermittent Vascular Claudication Weakness Walking downhill Walking uphill

Neurogenic: Occasionally Vascular: Uncommon Neurogenic: Worse Vascular: Unchanged or better Neurogenic: Better Vascular: Unchanged or worse

Spinal Stenosis Vs Intermittent Vascular Claudication Pulses Back pain Leg pain

Neurogenic: Present Vascular: Diminished or absent Neurogenic: Common Vascular: Uncommon Neurogenic: (Usually Bilateral) Vascular: May be unilateral or asymmetric

Fryette's Laws of Spinal Motion

Neutral Mechanics: SB and Rotation couple OPPOSITE Non-neutral (dysfunctional or end of range) SB and Rotation couple SAME

Juvenile RA

No clear risk factors Autoimmune disease where immune system attacks body Factors that may be associated: -girls more likely than boys -family hx of anterior uveitis with eye pain -inflammatory arthritis (AS) -inflammatory bowel disease -Arthritis and family hx of psoriasis in a first degree relative

Bracing in OA

Not proven to be of any benefit - removed from the CPG

Spinal Stenosis Risk Factors

Obesity Smoking Lifestyle Genetics

What is the best view on radiographs to identify a scotty dog sign in the lumbar spine?

Oblique -- It offers ultimate visualization of the pars interarticularis of a vertebra. When the pars interarticularis is fractured, the scotty dog will appear to have a collar on the oblique radiographic view

CPR ACL Copers vs Non-Copers (Kaplan 2011 JOSPT)

Opposed to copers, the non-copers have: -deficits in quad strength -vastus lateral atrophy -quad activation deficits -altered knee movement patterns -reduced knee flexion moment -greater quad / ham co-contraction

RA

Ottawa Panel recommended the use of ultrasound, thermotherapy, electrical stimulation, TENS and low-level laser for the use of this condition, but cryotherapy was not included as being recommended.

Postural Syndrome - McKenzie

Pain arising as a result of mechanical deformation of normal soft tissues from prolonged end range loading or peri-articular structures Treatment principle = posture correction

Allodynia definition

Pain from a stimulus that doesn't normally cause pain

Derangement Syndrome - McKenzie

Pain occurring as a result of a disturbance in the normal resting position of the affected joint surfaces -Reducible derangement: Loading strategy produces lasting change in sx -Irreducible derangement: fits hx criteria for derangement but no loading strategy produces lasting change in sx Treatment principle = dependent upon "directional preference"

Dysfunction Syndrome - McKenzie

Pain occurring as a result of mechanical deformation of structurally impaired tissues -tissues that are scarred, adhered or adaptively shortened Treatment principle = exercise in the direction of the dysfunction; Aim - remodel the implied affected tissue

CPR for hip OA

Painful squatting Painful flexion Scour test that produced groin pain Painful extension IR <25 degrees

Tietze syndrome

Painful swelling of one or more costochondral articulations Usually <40yo Pain, sudden or gradual, may radiate to arms/shoulders Aggravated by sneeze, cough, deep inspiration, twisting motion Mimics cardiac pain Treatment: NSAIDs

Gaenslen's Test

Patient supine with the painful leg resting on the edge of the treatment table. The examiner flexes the non symptomatic hip, while the knee also flexed. The therapist stabilizes the pelvis and applies passive pressure to the leg being tested (symptomatic) to hold it in a hyperextended position. A downward force is applied to the lower leg (symptomatic side) putting it into hyperextension at the hip, while a flexion based counterforce is applied to the flexed leg pushing it in the cephalic direction causing torque to the pelvis. (+) TEST: pain in SIJ

Lhermitte's sign

Patient will have shock-like sensation radiating into the person's arms or legs with extreme flexion or extension, causing stretch and compression of the spinal cord (classic for MS but is not specific)

Treatment Based Classification: Function

Patient's who exhibit non-severe, mild LBP and require programs based in more functional activities than in pain modulation or neuromuscular re-education

Treatment Based Classification: Movement Control (Stabilization)

Patients who exhibit LBP of moderate severity, hx of multiple episodes of LBP, movement aberrations commonly seen with LBP -reversal of lumbopelvic rhythm -Gower's sign -Hypermobility -Painful catch -Think "core" strengthening -Neuromuscular re-education

CPR - Lumbopelvic manipulation for patients with (PFPS)

Patients with PFPS will have a positive immediate response if: Side to side difference in hip IR > 14 degrees -Ankle dorsiflexion with knee flexed > 16 degrees -Navicular drop > 3mm -No self-reported stiffness with sitting >20 min -Squatting reported as most painful activity If present, chance of a successful outcome improves from 45% to 80%

Pre-op predictor of ambulatory status at 6 months after THA

Patients with a preoperative TUG score of < 10 seconds are likely to walk without an assistive device at 6 months after THA

FRS left

Positionally: the superior vertebrae is flexed, rotated left and SB left From a movement perspective: a "closing restriction" or decreased ability to extend, right rotate and right SB at that level Restriction of Motion During Backward-Bending -- If something interferes with the capacity of either facet to close normally, restriction of backward-bending will occur. For example, if a left facet does not close normally, but the right does close normally, right sidebending will be possible but left sidebending will be restricted. Since rotation is coupled to sidebending in the lumbar spine, rotation will also be restricted by facet joint dysfunction. The segment is said to be restricted in extension, rotation left, and sidebending left. The positional diagnosis is FRS-Right, and the motion restriction is ERS-Left.

McKenzie Tribe - name 3 syndomes

Postural Dysfunction Derangement (and other syndromes)

Mckenzie classification: Pain only on static loading

Postural Syndrome

MDT Classification Pain only on static loading

Postural syndrome

Cauda Equina

Rapid sx within 24 hours 89% Sn History of back pain 94% Sn Urinary retention 90% Sn Loss of sphincter tone 80% Sn Sacral sensation loss 85% Sn LE weakness or gait loss 84% Sn

Kehr's sign

Referred pain down the left shoulder; indicative of a ruptured spleen. -often is felt when the person is lying down -female who has an unknown or known ectopic pregnancy will often report abdominal pain, and the left shoulder pain that causes a Kehr's sign

Altered auto-immunity is not a stress induced pathway. Altered auto-immune function is typically associated with _____, not Osteoarthritis.

Rheumatoid Arthritis

How would you assess the neurodynamics of the saphenous nerve?

passive hip flexion, knee extension, DF, eversion

Yeoman's Test

See Image

Compression Test SI

See image

Distraction test SI

See image

Treatment Based Classification (4)

Specific Exercise: Centralization Mobilization Immobilization / motion control / stability Traction (radiculopathy - decompression)

-Complaints of deep groin pain -Pain exacerbated with sport specific activities -Palpable tenderness over pubic ramus at insertion or rectus abdominis and / or conjoined tendon -Pain with resisted hip ADD at 0, 45, and/or 90 degrees of hip flex -Pain with resisted abdominal curl-up

Signs and Sx of Sports Hernia Diagnosis

_____ is a hip condition that occurs in teens and pre-teens who are still growing. For reasons that are not well understood, the ball at the head of the femur (thighbone) slips off the neck of the bone in a backwards direction SCFE usually develops during periods of rapid growth, shortly after the onset of puberty. In boys, this most commonly occurs between the ages of 12 and 16; in girls, between the ages of 10 and 14.

Slipped capital femoral epiphysis (SCFE)

AAA risk factors

Smoking Male Atherosclerosis 5th to 6th decade obesity HTN family hx Initiation of weight lifting program

Sn, Sp, +LR and -LR Over 50 yo unexplained weight loss failure to improve

Sn 100% Sp 0% +LR 2.4 -LR 0.06

Sn, Sp, +LR and -LR History of Cancer

Sn 55% Sp 98% +LR 23.7 -LR 0.25

Centralization definition

Spinal pain and referred spinal sx that are progressively abolished in a distal to proximal direction in response to therapeutic movement and positioning strategies

Spondylolysis

Spondylolysis is defined as a defect or stress fracture in the pars interarticularis of the vertebral arch. The vast majority of cases occur in the lower lumbar vertebrae (L5), but spondylolysis may also occur in the cervical vertebrae.

What is the position the lower extremity should be placed to assess the sural nerve?

Straight leg raise with ankle dorsiflexion and inversion

Staging LBP: Treatment Based Classification Approach Stage II

Sub-acute: can sit, stand and walk -pain prevents ADL's -Oswestry 20-40% Goals: Pain modulation continues Address Impairments (flexibility, aerobic conditioning, spinal stabilization, etc.)

Type of injection shown to have greater response with OA

The effectiveness of a hyaluronate injection is greater than a corticosteroid injection according to Zhang et al. (Zhang 2007)

Patellar-pubi-percussion test

The patient is positioned in supine and the bell of the stethoscope is placed on the pubic symphysis, held in place by the patient. The patient's legs are positioned symmetrically and extended while the clinician percusses each patella. The clinician stabilizes the patella, ensuring that the leg being tested remains in the neutral position. The clinician compares the sounds from each leg for differences in pitch and loudness. These sounds should be equal in the case of normal bony structure. If there is a bony disruption, the affected side will have a duller, more diminished sound when compared to the unaffected side. Strong clinical value

Posterior cutaneous nerve of thigh

The posterior femoral cutaneous nerve, also known as the posterior cutaneous nerve of the thigh, is a sensory branch of the sacral plexus. It arises from anterior and posterior divisions of anterior rami of S1, S2 and S3 nerves. It supplies the skin of the posterior thigh, buttock and the posteriorscrotum/labia

Posterior pelvis pain provocation test

The posterior pelvic pain provocation test is a pain provocation test used to determine the presence of sacroiliac dysfunction. It is used (often in pregnant women) to distinguish between pelvic girdle pain and low back pain. AKA Thigh Thrust Test: With the patient supine, the hip is flexed to 90° (with bended knee) to stretch the posterior structures. By applying axial pressure along the length of the femur, the femur is used as a lever to push the ilium posteriorly. One hand is placed beneath the sacrum to fixate its position while the other hand is used to apply a downward force to the femur. Broadhurst and Bond suggest to add hip adduction towards the midline while Laslett & Williams advise to avoid excessive adduction due to discomfort for the patient. this test has been described as useful in detecting patient's with spinal instability

What are the physical findings in a patient with unilateral paracentral disc herniation at L4-L5?

The traversing L5 nerve root is commonly compressed with a paracentral disc herniation at L4-L5. Sensory deficit occurs in the anterolateral leg, dorsum of the foot, and great toe. Motor weakness includes the extensor hallucis longus, gluteus medius, and extensor digitorum longus and brevis. Usually, no reflex changes are present

Central Sensitization

These patients may need to be managed differently: signs include: chronic or long-standing pain widespread pain, multiple pain areas hyperalgesia allodynia high fear avoidance kinesiophobia

Mobilization Group

Thrust or Non-thrust manipulation mobilization with movement muscle energy techniques

Sign of the Buttock Test

To screen for sacral tumor or fracture: 1. Flex hip with knee extended 2. Flex same hip with knee flexed If pain at same hip angle with both maneuvers, (+)

Which treatment based classification group? -radicular signs / sx -pain does not centralize with extension -positive dural signs (XSLR+) -Severe, unrelenting pain

Traction / Immobilization Group

Grading OA -- list the following in order Grade _____: Total loss of hyaline cartilage, subchondral bone formation = bone on bone contact Grade _____> Fibrillation, fissuring erosion = discontinuity in cartilage, now affecting mid zone of cartilage Grade _____: Increased H20, decreased proteoglycans = cracks develop in superficial area and no longer smooth Grade _____: Deformation = cyst and bone formation, bone attempts to remodel itself, palpable nodes of bone formation = subchondral bone formation leads to joint deformity, osteochondrosis Grade _____: Chondrocyte proliferation, hypertrophy, apoptosis = cartilage erosion and cavity formation Grade _____: Calcification / sclerosis = bone spurs develop, cell death occurs, increased cracking in mid zone and unable to withstand forces

V II I VI IV III

Lumbar Stabilization "Success" stabilization group (>50% increase on Oswestry)

Variables · Age < 40 · SLR > 91° · Aberrant motions present · Positive prone instability test Psychometrics · >1 variable = +1.3 likelihood ratio · >2 variables = +1.9 likelihood ratio · >3 variables = +4.0 likelihood ratio

CPR orthotics for PFPS

Vincenzino, et al: -age > 25 -height <165 cm (5.4 feet) -worst pain < 53.25 mm on VAS -Mid foot width difference > 10.96 cm Barton, et al: -Motion control properties (weighted mean) >5.0 -Usual pain . 22.0 -ankle DF (knee flexed) > 41.4 degrees -reduced pain during a single leg squat with the foot orthosis

Type of E.Stim considered most effective for OA

Zhang et al discussed transcutaneous electrical nerve stimulation as a short term pain control modality in those with knee osteoarthritis. (Zhang 2007)

Sacral Thrust Test

___Pt is prone ___Examiner puts base of their hand on the center of sacrum and applies a P-A force ___Positive finding: pain over the SIJ ___Indication: SIJ syndrome

Thigh Thrust Test

___Pt is supine & examiner passively flexes hip to 90 degrees ___One hand palpates the SI joint while the other hand thrusts (pushes) down through the knee and hip (long axis compression) ___Bilaterally performed ___Positive finding: SIJ pain on the same side ___Indication: SIJ syndrome

In a patient with absolute lumbar stenosis due to degenerative changes, what would you expect the anterior posterior diameter of the spinal cord on myelography to be? a. 8mm b. 10mm c. 12mm d. 15mm

a. 8mm -- Myelography has historically been used to diagnose lumbar stenosis. An anterior posterior diameter of < 10mm is considered absolute lumbar stenosis

A 64-year-old female self refers to physical therapy for low back pain. She describes her pain as "tearing" and "ripping", and the physical therapist knows this is not a musculoskeletal issue. In those who have which of the following diagnoses, is pain described this way? a. Abdominal aortic aneurysm b. Cauda equina c. Spinal infection d. Spinal tumor

a. Abdominal aortic aneurysm -- Reason: This description of symptoms often coincides with a rupture of an abdominal aortic aneurysm, and thus necessitates immediate medical attention. (Goodman and Snyder 2000) --Although a medical emergency, it is uncommon to hear pain in the low back described as tearing and ripping in those with cauda equina syndrome. --People with a spinal infection more often have local tenderness over spinous processes, and they have significant pain and difficulty with weight bearing and ambulation. --spinal tumor can cause a multitude of symptoms, but tearing and ripping pain is not one of those symptoms.

What is the most sensitive SIJ dysfunction test? a. Thigh thrust test b. Gaenslen's test c. Compression test d. Distraction test

a. Thigh thrust test is the most sensitive, Sn 88 Gaenslen's Sn 50-53 Compression test Sn 69 Distraction test Sn 60 Sacral thrust test Sn 63

Per question 1 and 2: You are able to reproduce saphenous nerve testing sx. Further questioning reveals that she only experiences the sharp pain and radicular sx with sitting. Your repeated motions testing of the lumbar spine has no effect on the sx. Examination of the hip reveals a positive FADIR test, passive ROM of the left hip to 105 degrees of flexion, 5 degrees of extension and 12 degrees of IR. The right hip was WNL. What is the most likely dx? a. acetabular labral cyst b. L3-L4 disc herniation c. adhesion of the gracilis d. hip OA

a. acetabular labral cyst -- given the patient's positive hip findings, limited hip ROM, and inconclusive lumbar spine examination, you should suspect answer choice A as the primary pathology. Hip OA could be a factor, however, she is under 50 and less likely to have significant arthritis

Which nerve innervates the adductor longus and gracilis, and provides sensation to the medial thigh? a. anterior branch of the obturator nerve b. posterior branch of the obturator nerve c. femoral nerve d. sciatic nerve

a. anterior branch of the obturator nerve -- the posterior branch of the obturator nerve innervates the obturator externus and adductor magnus and has no sensory innervation. In general, the femoral nerve innervates muscles along the anterior thigh and the sciatic nerve innervates muscles along the posterior thigh

According to the CPR for manipulation developed by Tim Flynn and colleagues in 2002, what item from the CPR is the best univariate predictor of a successful outcome with manipulation? a. duration of sx < 16 days b. FABQ < 19 c. at least one hip with > 35 degrees of IR d. no sx distal to the knee

a. duration of sx < 16 days -- of all the items for the CPR for lumbar manipulation, duration of sx was the best univariate predictor of a successful outcome

A patient is referred to you after a radio-frequency ablation failed to relieve her lumbar facet arthropathy. What nerve innervates the facet joint? a. medial branch of the dorsal rami b. lateral branch of the dorsal rami c. dorsal root ganglion d. primary ventral ramus

a. medial branch of the dorsal rami -- medial branch innervates the facet joints

A 26 yo male presents to you with a new onset of LBP and radicular sx to the posterior aspect of his right thigh after he was performing deadlifts at the gym. During your examination you notice his sx centralize to his lower buttock with repeated active extension in prone position. The patient has low amounts of fear and passive hip IR > 35 degrees. What is the best intervention for this pt today? a. repeated active lumbar extension in prone position b. SL lumbar manipulation c. isometric trunk stabilizer strengthening d. nerve tensioners with sciatic nerve bias

a. repeated active lumbar extension in prone position -- In a revision and update of the treatment based classification system for LBP, it has been suggested that interventions should be performed in a hierarchical progression. For example, before considering lumbar manipulation, centralization exercises should be exhausted until the pt no longer centralizes with movement. Then, a manipulation can be performed. This case is difficult bc the pt fits the CPR for lumbar manipulation, but also centralizes with repeated lumbar extension.

What is the most specific dx test for ruling in cauda equina syndrome? a. urinary retention b. unilateral or bilateral sciatica c. unilateral or bilatera motor / sensory deficits d. sensory deficit or perianal region

a. urinary retention -- urinary retention has a high degrees of both Sn (0.9) and Sp (0.95) with a +LR of 18. All the other choices are sensitive tests, but would be difficulty for the clinician to differentiate b/t other lumbar pathologies

A 70 yo female patient referred to PT for LOB reports that her primary complaint is bilateral cramping sensation after walking 200 feet and when riding a bike for 15 minutes. What is causing her cramping? a. vascular claudication b. chronic exertional compartment syndrome c. lumbar stenosis d. neurogenic claudication

a. vascular claudication -- answers c and d are similar and can be eliminated since lumbar stenosis commonly causes neurogenic claudication and those are similar answer choices. This patient's sx are not suggestive of chronic exertional compartment syndrome. The pt has sx with both walking and riding a bike, which would indicate vascular claudication. A pt with sx of neurogenic claudication due to lumbar stenosis would likely have sx with walking but not with riding the bike

spondylosis

abnormal condition of the vertebrae, diseased

Level III evidence

acetabular retroversion may be related to development of hip OA

Clinical exam for sacral fracture - 2 causes (insufficiency fracture due to osteoporosis, or young undernourished over exercising female)

age (may vary older to much younger) hip pain with IR tenderness with palpation over sacrum tenderness with palpation over the hip diffuse pain throughout the pelvis complex

Spine Cancer risk factors

age > 50 previous history of cancer failure to improve 1 month of PT no relief bed rest duration > 1 mo unexplained wt loss insidious onset

What may night pain suggest?

ankylosing spondylitis tumor

When a lumbar disc herniation is lateral, patients feel they must move _____ the side of the irritated nerve

away from

An industrial worker is referred to you for LBP that has not resolved in 6 months. Since the episode of LBP, she has been unable to RTW due to debilitating pain. What are the chances that the pt will RTW? a. 20% b. 40% c. 60% d. 80%

b. 40% if she has not yet already RTW after 6 months -- If she is out a full year from work, her chances decreased to 20%. If she has been out of work for 2 years, there is essentially a 0% chance she will RTW

Which of the following organs is associated with a high alkaline phosphatase enzyme rate? a. Appendix b. Liver c. Prostate d. Spleen

b. Liver -- Reason: Alkaline phosphatase is an enzyme that is found in bone, the intestines, the gall bladder and liver. Elevated levels of this enzyme often implicate either bony tissue or the liver. (Goodman and Snyder 2013)

According to Panjabi, the mechanism in which the spine is stabilized does not include the: a. Passive subsystem b. Motor subsystem c. Neural subsystem d. Active subsystem

b. Motor subsystem -- he proposed the passive subsystem, made up of bones and ligaments, and the dynamic system, made up of muscle stabilization and neural subsystem all combine to stabilize the spine

A 26-year-old patient has posterior heel pain, and has also recently been diagnosed by their podiatrist with having plantar fasciitis. A physical therapist is performing an examination/evaluation on this patient, and believes the patient's symptoms are coming from a neurological issue instead of plantar fasciitis and heel pain. Which of the following nerves may be causing these symptoms? a. Common peroneal nerve b. Posterior tibial nerve c. Sciatic nerve d. Sural nerve

b. Posterior tibial nerve -- Reason: Shacklock refers to dysfunction in the posterior tibial nerve as the carpal tunnel syndrome of the lower extremity, and indicates that it is often overlooked. Hence, if an individual appears to have posterior heel pain and plantar fasciitis, the posterior tibial nerve should be assessed. (Shacklock 2012) --The common peroneal nerve would not cause posterior heel pain and plantar fasciitis like symptoms. Instead, symptoms would be in the region of the lateral foot. --The sciatic nerve would likely cause more proximal symptoms, along with posterior leg symptoms, but not necessarily plantar fasciitis like symptoms. --The sural nerve is assessed by performing a straight leg raise with ankle dorsiflexion and inversion, and it is possible that medial symptoms would appear. However, the correlation to plantar fasciitis and posterior heel pain has not been made with this nerve.

A middle aged patient presents to you with LBP and a Later sign. He denies radicular sx, and reports increased stiffness in the morning, but it improves with movement. What is the most likely diagnosis? a. lumbar stenosis b. ankylosing spondylitis c. chronic LBP d. L3 spondylolisthesis

b. ankylosing spondylitis -- patients with this condition usually do not have radicular sx and reports stiffness in the morning that decreases with movement

Risk Factors Fractures

bone density prolonged use of corticosteroid drugs age female trauma Probability of spinal fracture higher when multiple red flags present

A 70 yo white male is referred to you for LBP. His past PMH is significant for smoking, but the pt quit 5 years ago. He has a 15 year hx of chronic LBP. His LBP is unchanged by active lumbar movements and has no reproducible hip or SI pain upon assessment. He reports a decrease in activity level and increase in LBP within the last 4 weeks. He is unable to describe a position that eliminates his sx. He has been to PT in the past and has had success in managing his back pain. He denies a previous hx of cancer, changes in bowel or bladder function, or paresthesia into the legs. Neural tension testing was negative. There is no disturbance in gait. Pain is gettin worse and wakes him up at night. He reports his pain being different than previous episodes of back pain. What should the PT do next during the exam? a. ask more about the bowel and bladder b. palpate the abdomen and back and auscultate the stomach c. screen the pt for morning stiffness and presence of psoriasis or onycholysis d. recommend a 6-minutes walk test

b. palpate the abdomen and back and auscultate the stomach -- given the location of the pt's pain, his age, and hx of smoking the PT should palpate the abdomen and back and auscultate the stomach to screen for and abdominal aortic aneurysm

Which of the following has the best utility to diagnose lumbar spinal stenosis? a. sx decreased with sitting b. sx are abolished with sitting c. sx improved walking with shopping cart d. pain below buttocks

b. sx are abolished with sitting -- all of the answer choices are suggestive of lumbar spinal stenosis, however, answer choice b has the highest specificity

What is the maximum time the pt can wait before undergoing surgery for Cauda Equina Syndrome? a. <12 hours b. < 48 hours c. < 72 hours d. < 96 hours

c. < 72 hours -- surgical intervention for cauda equina syndrome needs to be performed within 72 hours to decrease risk of permanent neurological compromise. Surgical intervention < 48 hours from onset of sx has been associated with better outcomes.

An individual with low back pain is also reporting bladder dysfunction. When the physical therapist asks further questions, they find that the patient has noted changes in the frequency of urination, has had episodes of retention altering with incontinence, and recently noticed hematuria. Which of the following may be present? a. Gallbladder stones b. Gastrointestinal pathology c. Infection d. Spinal tumor

c. Infection -- Reason: Patients with an infection will often report symptoms of bladder dysfunction and also may have weight loss, fever, chills, night sweats, or some recent infection like pneumonia or a urinary tract infection. (Goodman and Snyder 2013) --Individuals with gallbladder stones are more likely to have symptoms in the upper abdominal region and thoracic spine spreading to the right scapula. They are unlikely to report bladder dysfunction. --Although low back pain is a potential cause of a gastrointestinal pathology, bladder dysfunction is far less common and individuals will report symptoms in their abdominal region that are often affected by eating. --Those with a spinal tumor may have low back pain, but they are more likely to have constitutional symptoms such as fevers, night sweats, chills, weight loss, pain that is not altered by a change in position, and significant night pain.

What type of lumbar spine fracture of the pars interarticularis is characterized by fatigue failure resulting in stress fracture according to the Wiltse-Neman classification? a. dysplastic b. pathologic c. Isthmic IIA d. Isthmic IIB

c. Isthmic IIA - fatigue failure resulting in stress fracture Isthmic IIB -- is indicative of an elongated pars interarticularis dysplastic -- is due to a congenital defect pathologic -- caused by structure weakness or pathology like a tumor Isthmus means "narrow passage"

Which of the following are risk factors for Diastasis Rectus Abdominus? a. Wide pelvic rim b. 1st child c. Multiple births d. 2nd trimester

c. Multiple births -- risk factors include obesity, a narrow pelvis, multipara, 3rd trimester, multiple births, excessive uterine fluid, large babies and weak abs prior to pregnancy; prevention or gentle abdominal exercises are preferred intervention

A 16 yo track athlete is referred to you with a hx of LBP and new onset of right hip pain. The hip pain has gradually worsened. She reports no MOI and started training for the track season last month. She has a BMI of 18 and reports amenorrhea. Which special test needs to be performed to screen out pathology? a. Fulcrum test b. Thigh thrust test c. Patellar-pubi-percussion test d. Repeated motion testing of lumbar spine

c. Patellar-pubi-percussion test -- the pt has many characteristics that should make you be suspicious of a femoral neck fx (amenorrhea, young female athlete, insidious onset). The patellar pubic percussion test should be performed early in the examination as a screening test for femoral neck fx. It has better Sn than the fulcrum test. The thigh thrust test is used to r.o. pelvic girdle related pain. Repeated motion testing should be performed later in you examination, after the screening phase, to r.o. contribution of the L-spine

In patients with suspected L4 radiculopathy, which of the following muscles would most likely show atrophy? a. Adductor magnus b. Gastrocnemius c. Quadriceps d. Semimembranosus

c. Quadriceps -- Reason: An L4 radiculopathy would most often lead to atrophy of the quadriceps muscle than any other muscle in the lower extremity (Cleland and Koppenhaver 2011). -- Although the adductors may be impacted in an L4 radiculopathy due to their innervation by the obturator nerve that includes the L4 nerve root, adductor magnus is unlikely to exhibit atrophy in an L4 radiculopathy. -- The gastrocnemius is more apt to have atrophy in lower level lumbar radiculopathies. -- The semimembranosus is not innervated by the L4 nerve root, so there would be no atrophy if this muscle if an L4 radiculopathy were present.

Which is the best surgery for a patient with degenerative spondylolisthesis resulting in stenosis? a. decompression surgery and fusion b. microdiscectomy c. decompression surgery alone d. disc replacement

c. decompression surgery alone -- There was no significant difference between subjects who received decompression surgery alone and a combination of decompression and fusion surgery at 2 and 5 year follow ups. Spinal fusions are known to have higher operating times and higher costs when compared to decompression surgery alone

Which of the following is true concerning inter-rater reliability of the McKenzie classification system? a. generally good for all clinicians b. generally improves with practitioner clinical experience c. generally improves with specifically trained practitioners d. generally poor for all clinicians

c. generally improves with specifically trained practitioners

A 58 yo runner presents to you with c/o decreased speed and weakness that started insidiously. He reports having a left hip replacement last year. Observation revealed a more muscular right buttock compared to the left. MMT demonstrated 3+/5 strength for left hip extension and 5/5 right hip extension. Hip abduction was 5/5 bilaterally. Injury to which nerve is likely causing this impairment? a. iliohypogastric nerve b. superior gluteal nerve c. inferior gluteal nerve d. obturator nerve

c. inferior gluteal nerve -- this nerve supplies the gluteus maximus. Injury to this nerve is rare, but can occur after hip replacement surgery

A 55 yo male presents to you with reports of sudden sharp LBP that comes and goes. He reports it radiates to his right testicle. He does not have a fever. Your low back examination is inconclusive. What is the most likely dx and best management for this pt? a. central sensitization - multidisciplinary management recommended b. renal infection - refer to ED c. kidney stone - refer to ED d. transverse myelitis - refer to ED

c. kidney stone - refer to ED -- The patient's sx are suggestive of a kidney stone. A fever would likely accompany a renal infection such as urosepsis. Weakness would likely accompany transverse myelitis

Increased tension in the latissimus dorsi and / or gluteus maximus can cause slackening in which ligament? a. interosseous SI ligament b. short posterior SI ligament c. long posterior SI ligament d. iliofemoral ligament

c. long posterior SI ligament

You have been treating a 33yo pt for left knee pain that started 5 weeks ago after starting to train for a half marathon. She is new to running and wears tight fitting compression pants. Although her knee pain is improving she reports a sensation of numbness in her anterolateral thigh. What is the most likely pathology? a. femoral neuropathy b. L2-L3 disc extrusion c. meralgia paresthetica d. iliotibial band syndrome

c. meralgia paresthetica -- these sx are classic for maralgia paresthietica which is characterized by entrapment of the lateral femoral cutaneous nerve, a sensory nerve only

SI dysfunction can be difficult to diagnose, especially since pathology at the lumbar spine and hip can mimic SI dysfunction. Laslett and colleagues developed a cluster of tests to identify SI dysfunction including the: -distraction test -thigh thrust test -Gaenslen's test -compression test -sacral thrust test What additional testing would increase the diagnostic utility of identifying SI dysfunction? a. Negative FADIR b. peripheralization of sx with repeated lumbar flexion c. no effect with repeated motions examination d. elevated right ASIS and right PSIS

c. no effect with repeated motions examination -- if the pt does not centralize or peripheralize with repeated motion testing of the lumbar spine, the diagnostic utility of the SI cluster improves

A 30yo patient if referred to you for subacute lumbar radiculopathy down the right leg. Both repeated lumbar flexion and repeated lumbar extension increase his sx and cause peripheralization from the mid thigh to the mid calf. What should you consider next for both examination and treatment of this pt? a. lumbar traction b. lumbar manipulation c. repeated side glides d. neurodynamics of the Sciatic nerve

c. repeated side glides -- if a patient peripheralizes and sx increase with repeated flexion and extension, this may indicate a lateral component to their radiculopathy. The clinician should assess if the sx centralize with repeated side glides in the frontal plane

A 30 year old female accountant is referred to PT with c/o sharp pain originating in the left groin and radiating to the medial aspect of upper thigh, lower leg and foot. What nerve is affected? a. sciatic nerve b. femoral nerve c. saphenous nerve d. tibial nerve

c. saphenous nerve

A physical therapist is assessing a patient with Ehlers-Danlos syndrome and using the Beighton scale to confirm the patient's diagnosis. The patient has passive hyperextension of only the left knee and elbow beyond ten degrees, can touch both thumbs to the flexor aspect of the forearm and also has passive dorsiflexion and hyperextension of the fifth metacarpal phalangeal joint beyond 90 degrees bilaterally. The patient is unable to, however, touch the palms of their hands flat on the floor with active forward flexion of the lumbar spine. What is the patient's Beighton scale score? a. 4 b.5 c.6 d.7

c.6 -- Reason: This patient scored a six out of nine on the Beighton scale. She missed three points; one for only having one knee that passively hyperextended beyond ten degrees, one for only have one elbow that passively hyperextended beyond ten degrees, and lastly, the patient was unable to touch the palms of their hands flat on the floor with active lumbar flexion. (Boyle 2003)

Based on the scientific literature, which of the following patients would benefit the most from a lumbar manipulation? a. 63 yo male with acute onset of LBP and radicular sx into the left posterior thigh above the knee b. 70 yo male with acute LBP and radicular sx to anterior thigh above the knee and previous hx of L4-L5 fusion c. 20 yo female with acute onset of LBP and + SLR test of < 45 degrees d. 18 yo male with acute LBP and radicular sx to posterior thigh above the knee

d. 18 yo male with acute LBP and radicular sx to posterior thigh above the knee -- most studies assessing the effectiveness of the CPR for lumbar manipulation exclude subjects under the age of 18 and older than 60; also, subjects with previous hx of surgery to the lumbar spine or buttock are excluded; subjects with signs suggestive of nerve root compression are excluded from these studies too (choice C)

The centralization phenomenon observed during repeated motion testing occurs frequently. Which direction is the least common for a pt to centralize their referred pain into the LE? a. lumbar extension in standing b. lumbar extension in lying c. side glide with overpressure d. lumbar flexion

d. lumbar flexion -- Pt's can centralize with repeated lumbar flexion, however, pt's more commonly centralize with repeated lumbar extension or side glides

A physical therapist is treating a patient with low back pain that radiates into the posterolateral hip region, but also into the anterolateral leg region and crossing down all the way to the big toe. Which reflex should the physical therapist anticipate may show changes? a.Achilles reflex b. Lateral hamstring reflex c. Medial hamstring reflex d. Patellar tendon reflex

d. Patellar tendon reflex -- Reason: The description of symptoms for this patient match possible involvement of the nerve root that is also tested by the Patellar tendon reflex (Cleland and Koppenhaver 2011). --If the Achilles reflex were affected, it would be more likely to see posterolateral thigh symptoms, but also radiation down the posterior leg to the heel. --If the lateral hamstring reflex were involved, the patient would be more apt to have symptoms in the sacroiliac region, hip and lateral thigh/leg region. --If the medial hamstring reflex were involved, the patient would be more apt to have symptoms in the sacroiliac region, hip and lateral thigh/leg region.

A PT examining a pt with LBP performs a special test and decides to initiate a series of exercises designed to stabilize the lumbo-pelvic spine. A positive result of which test likely precipitated this decision? a. Standing leg length test b. Yeoman's test c. Gaenslen's test d. Posterior pelvis pain provocation test

d. Posterior pelvis pain provocation test -- this test has been described as useful in detecting patient's with spinal instability

All of the following are predictors that a subject would fail core stabilization treatment for LBP, except which answer choice below? a. negative prone instability test b. absence of aberrant movement c. a score of 9 or higher of FABQ d. Postpartum pt with pelvic girdle pain

d. Postpartum pt with pelvic girdle pain -- Answer choices a, b, and c would indicate that a pt would not benefit from core stability exercise for LBP. In fact, if patients have all 3 answer choices present, their probability of failing core stability exercises for their LBP increases to 86%. d is correct bc out of all the answer choices, this would indicated the pt would benefit the most from core stability exercise

A physical therapist is performing a lower extremity dermatome screen on a patient with low back pain. The patient has diminished sensation in the lateral region of the heel and foot. Which of the following nerve roots is most likely implicated? a. L3 b. L4 c. L5 d. S1

d. S1 -- Reason: The description of sensory deficits matches what is seen with the S1 nerve root. (Cleland and Koppenhaver 2011)

A 7yo male reports to you with left hip pain radiating into the groin, a limp with ambulation, and a fever. The pt denies any MOI. Sx have been going on for 15 days now. You decide to refer the pt to urgent care. Blood work revealed an ESR of 45mm/hr and WBC count of 12,100 mm3. What is the most likely dx? a. Legg-Calvé-Perthes disease b. Slipped capital femoral epiphysis c. Transient synovitis d. Septic arthritis

d. Septic arthritis - Transient synovitis is a self-limiting hip pathology common in children that usually resolves within a week. Septic arthritis can have a similar presentation as transient synovitis, but can have more significant consequences if not caught early. If this pt's sx did not resolve after a week, and he had elevated lab values, it would be indicative of septic arthritis

A physical therapy intervention plan for ankylosing spondylitis includes manual therapy for the spine, shoulder and hips, as well as strengthening for the rotator cuff, lower extremities and spine. The physical therapist also prescribes a home exercise program for self-mobilization to the spine. Based on the current evidence, is this intervention plan appropriate for a patient with ankylosing spondylitis? a. No, this patient should not be treated with any manual therapy because no literature has shown manual therapy to be helpful in those with ankylosing spondylitis. b. No, this patient should only be treated with a home exercise program for therapeutic exercises because evidence has shown that home exercise programs are better than supervised care for patients with ankylosing spondylitis. c. Yes, but modalities should also be included in this patient. d. Yes, current evidence indicates that both manual therapy and supervised physical therapy is the most appropriate for an individual with ankylosing spondylitis.

d. Yes, current evidence indicates that both manual therapy and supervised physical therapy is the most appropriate for an individual with ankylosing spondylitis. -- Reason: Manual therapy and supervised therapeutic exercises have evidence for positive outcomes in those with ankylosing spondylitis. Also, self mobilization of the spine has been proven to assist in improving patient symptoms, so this overall intervention plan is appropriate. (Jordan 2012)

A patient is referred to you post-partum for localized LBP. Which factor would make her least likely to have successful bout of PT focusing on stabilization? a. age < 30 b. age < 35 c. age < 40 d. age < 45

d. age < 45 -- individuals that are younger than 40 years are more likely to succeed from a stabilization program than individuals aged b/t 40 and 45

You've decided a pt referred to you for LBP will benefit from strengthening exercises. What would be the best intervention? a. transverse and multifidus strengthening b. rectus abdominis strengthening c. external and oblique abdominal strengthening d. all of the above

d. all of the above -- there is no strong evidence to support that specific deep core muscle training is superior to strengthening of larger spinal muscles or vice versa

What ROM findings would you suspect in a young boy with a SCFE? a. increased hip flexion b. increased hip abduction c. increased hip IR d. increased hip ER

d. increased hip ER -- typically present with limited hip IR, abduction and flexion. ER of the hip will likely be increased due to the slippage

A patient is referred to you for a new onset of LBP and burning pain in the right upper lateral thigh. She was previously seen for LBP and sciatica of the right leg 5 years ago. Since then she has given birth to 3 kids and is 50 pounds heavier. Examination reveals no myotomal or dermatomal deficits. The burning pain increases during periods of prolonged sitting. What is the likely cause of her concordant pain? a. anterior labral cyst compressing the saphenous nerve b. L3-L4 lumbar radiculopathy c. femoral nerve entrapment d. lateral femoral cutaneous nerve entrapment

d. lateral femoral cutaneous nerve entrapment -- The saphenous nerve does not provide sensory innervation to the proximal lateral thigh; L3-L4 radiculopathy has a different dermatome than the proximal anterior lateral thigh; It would likely be confused with a L2-L3 radiculopathy rather than a L3-L4 radiculopathy; In addition, if the pathology is a the lumbar roots, this would likely affect the respective dermatomes and myotomes. The femoral nerve is both a motor and sensory nerve. The lateral femoral cutaneous nerve is a branch of the lumbar plexus and is sensory only. It is mostly affected in individuals with a high BMI

In a direct access setting you are evaluating a 9 year old pt for LBP and radicular sx along the anterior and anterior medial aspect of leg. You perform femoral nerve tension test, and it is positive. What should your next course of action be? a. perform repeated motion testing to assess if sx centralize b. since sx do not go below the knee, perform lumbar manipulation c. more info is needed to direct care d. refer pt to a physician or specialist for imaging

d. refer pt to a physician or specialist for imaging -- the pt's sx suggest radiculopathy in the upper lumbar spine. In a young individual, these sx are rare and warrant a referral to rule out more sinister pathology

You are mentoring a student PT on the treatment of a pt with a suspected disc herniation. As her CI, you want her to perform a lumbar manipulation, but she is worried she will make the disc herniation worse. How should the CI respond? a. manipulation will worsen the disc herniation b. try lumbar mobilization first, and attempt manipulation if tolerated well c. the pt meets the CPR for lumbar manipulation d. the risk of worsening a lumbar disc herniation is only 1 in 3.7 million

d. the risk of worsening a lumbar disc herniation is only 1 in 3.7 million -- it still wouldn't be indicated to manipulate someone who is fearful or guarding during the manipulation set up. You do not have enough information to know that the pt meets the CPR for lumbar manipulation

Traction Group

decompression oriented procedures that are designed to reduce radicular sx

Later sign

defined as a gross limitation of side bending

Articular cartilage receives its nutrients thru _____ thru mechanical pressure. Total relief of pressure _____ nutrition. Prolonged immobilization produces a build up of ____ and ____ develop

diffusion impedes fibro fatty tissue adhesions

transverse myelitis

disorder caused by inflammation of the spinal cord. It is characterized by symptoms and signs of neurologic dysfunction in motor and sensory tracts on both sides of the spinal cord.

Grade B Evidence for hip OA Treatment

education US short term use

Risk Factors of Knee OA

females greater than males increased BMI knee injury early degenerative changes occupation requiring frequent kneeling or squatting high impact sports altered joint mechanics

What are the physical findings in a patient with unilateral paracentral disc herniation at L3-L4?

generally involves compression of the traversing L4 nerve root, with possible sensory deficits in the posterolateral thigh, anterior knee and medial leg. Motor weakness is variable in the quad and hip adductors. Changes are also apparent in the patellar reflex

Schmorl's nodes

herniation of the nucleus pulposus through the vertebral endplate

PCS (Pain Catastrophizing Scale)

higher scores = higher level of pain catastroophizing

What may systemic sx (fever, weight loss) suggest?

infection or tumor

Cluneal nerves

innervate the skin of the gluteal region

(manual) Side lying traction

more vigorous than supine traction technique

iliohypogastric nerve

originates from the lumbar plexus that supplies sensation to skin over the lateral gluteal region and motor to the internal oblique and transverse abdominal muscles innervates the anterior surface of the scrotum or labia majora, and a small portion of the upper antero-medial thigh is a branch of the first lumbar nerve (L1).

obturator nerve

passes through obturator foramen to innervate adductor muscles, L2-L4

(manual) Supine traction technique

pull downward on the knees

Risk Factors of Infection

recent orthopedic surgery skin infections poorly controlled DM impaired immune system circulation disorders illicit drug use => post-surgical infection => osteomyelitis => sepsis

Lateral cutaneous nerve of thigh

skin over lateral, anterior, and posterior aspects of thigh, L2, L3

Immobilization - Stabilization Group

strengthening (stabilization) local and non-specific strengthening exercise general activation exercises

Non-specific LBP definition

sx of unknown cause -- Most patients (>85%) who are seen in primary care have "non-specific LBP"

Hoffman's sign

tapping/downward flicking distal phalanx of long or ringer finger elicits flexion of the distal thumb and index finger; associated with upper motor neuron lesions

•Legg-Calve-Perthes disease is a childhood condition that occurs when blood supply to the ball part (femoral head) of the hip joint is _____ _____ and the bone begins to die. •This weakened bone gradually breaks apart and can lose its round shape. The body eventually restores blood supply to the ball, and the ball heals. But if the ball is no longer round after it heals, it can cause pain and stiffness. The complete process of bone death, fracture and renewal can take several years. Age 4-10

temporarily interrupted

Individuals with heart pathologies

there may be pain along the thoracic spine, however, that will also likely present with neck, jaw and/or arm pain

When the herniation is medial to the nerve root, the patient lists _______ the side of the nerve root in an attempt to decompress the nerve root

toward

Grade C Evidence for hip OA Treatment

weight loss impairment based function and gait and balance training individual Rx of ther ex

Rheumatoid arthritis vs Osteoarthritis

• In those who have rheumatoid arthritis, it is common to see arthritis in the proximal interphalangeal joint, but not the distal. Individuals with osteoarthritis will see symptoms in both the proximal and distal interphalangeal joints. •Individuals with osteoarthritis and rheumatoid arthritis can both see symptoms in their foot and ankle. •Knee joint swelling is a common finding in both pathologies. •Osteoarthritis is not a pathology with a rapid onset, but instead patients typically indicate they have a very slow onset over several years. Those with rheumatoid arthritis often notice symptoms onset over a matter of weeks or months.

Depression Screener

•2 question depression screener •"During the past month, have you often been bothered by feeling down, depressed or helpless" •"During the past month, have you often been bothered by little interest or pleasure in doing things?" •If the patient answers "no" to these questions, the Sn is 97%, not considered depressed •For a Yes Sp is 67% •Addition of "help" question: raised Sp to 94% for clinical depression

Directional Preference: Extension - Intervention Procedures

•End-range extension exercises •Mobilization to promote extension (manual treatment) •Avoidance of flexion activities

Stabilization (AKA Motor / Movement Control) CPR -Likelihood of patients responding with a >50% reduction in disability following a program of lumbar spinal stabilization exercises

•Age < 40 years old •Average SLR > 91 degrees •Positive PIT test (prone instability test) •Aberrant movements present •Pain arc in flexion or return from flexion •Gower's sign - walking the hands up the legs to help getting to upright position •Instability Catch •Reversal of the lumbopelvic rhythm -- patient extends the spine prior to extend the hips (don't have to have all 4 present, can be any one of them)

CPR - Stabilization for Low Back Pain

•Age < 40 years old •Straight leg raise > 91° •Aberrant movement present •Positive prone instability test (don't have to have all 4 present, can be any one of them)

CPR - Vertebral Compression Fracture

•Age > 52 years •No presence of leg pain •Body mass index < 22 •Does not exercise regularly •Female gender

Specific causes of lower back pain

•Fractures •Cancer •AAA - abdominal aortic aneurysm •Kidney disease •Cauda Equina •Infections Be sure to ask about systemic fever, weight loss / gain, bowel / bladder trouble, GI bleed (self medicating with NSAIDS), saddle anesthesia's, psychosocial impact

CPR - Lumbar Spinal Stenosis

•Bilateral symptoms •Leg pain > back pain •Pain during walking/standing •Pain relief upon sitting • > 48 years old

Psychosocial Impact of LBP

•Catastrophizing •Kinesiophobia Pay attention to fear based things - good predictors in outcomes

Risks of spinal manipulation

•Cauda equina is the most serious potential consequence of a lumbopelvic manipulation. However, the risk is 0.001 for every 10,000 individuals. This is less than sudden death from exercise, GI bleeds from use of NSAIDs, and death from a fusion surgery. •A disc herniation could be a possible unlikely consequence of a thrust manipulation to the lumbopelvic region. However, it is not as serious as cauda equina. •A spinal fracture is highly unlikely to occur from a lumbopelvic manipulation, if performed correctly. • It is possible that unremitting pain may occur due to a lumbopelvic manipulation; however, pain is manageable and is not the most serious potential consequence from thrust manipulation.

CPR - Sacroiliac Joint Pain

•SI distraction •Thigh thrust test •Gaenslen's test •SI compression •Sacral thrust • (FABER if using van der Wurff )

FABQ - Fear Avoidance Beliefs Questionnaire

•Designed to identify patients' beliefs about how physical activity and work affect their current LBP •16 item questionnaire - each item scored from 0-6, higher numbers indicate greater fear and avoidance beliefs •Work Subscale •Physical Activity Subscale •Increased score linked to delayed recovery and increased likelihood of disability •FOTO - alternate scale

Directional Preference: Flexion - Intervention Procedures

•End range flexion •Mob or manipulation of the spine and / or LE's (hips) •Impairment based exercise •Body weight-supported treadmill

CPG for patient's with OA

•Exercise •Manual treatment - if when done at other joints besides the involved joint were proven to be helpful •Has not yet been shown increased benefit in doing both manual treatment and exercise •Booster sessions can help patient's knee pain Both alone have been shown to be beneficial

CPR - Mechanical Traction for Low Back Pain

•FABQ-W score < 21 •No neurological deficit involvement •Age older than 30 •Non-manual work job status

Specific Causes of LBP relieved by change in position

•Individuals who have cauda equina are more likely to have saddle anesthesia due to loss of sensation in the second through fifth sacral nerve roots and perianal region. However, they can have pain relieved by rest or position change. • It is very common for individuals with an abdominal aortic aneurysm to have night pain, pain not relieved with rest, and pain not related to position change or movement •There are several characteristics associated with individuals who have cancer, and pain unrelieved by position change or rest are possible signs of a non-musculoskeletal condition such as cancer •Individuals with an infection will have symptoms such as a fever, chills and/or night sweats. During an examination and evaluation, these individuals will be unable to change their pain levels with position change or rest.

Reverse total shoulder arthroplasty guidelines / considerations

•Joint protection (avoid IR up to 12 weeks), limit IR/add in conjunction with extension -Typically will not dislocate in ER and ABD -Limits will be IR / ADD with Ext -ER dependent upon condition of teres minor

Directional Preference: Lateral Shift - Intervention Procedures

•Lateral shift correction is done prior to flexion or extension directional preference •Exercises to correct lateral shift •Mechanical or auto-traction

Directional Preference: Flexion Bias Criteria

•Older age (>50 years) •Directional preference for flexion •Imaging evidence of lumbar spinal stenosis

Manipulation and Osteoporosis

•Osteoporosis is a precaution for thrust manipulation, not a contraindication. Along with that, if an individual has been assessed thoroughly for osteoporosis throughout the body, and there are no other locations of osteoporosis beyond, for example, the hips, a thoracic manipulation is appropriate. •Thoracic manipulation has proven to be an effective, safe intervention approach for individuals with neck pain. Although this patient may benefit from cervical mobilization also, there is no reason that this individual cannot have a thoracic manipulation

There are several metastatic cancers that cause low back pain PB KTLL

•Prostate, breast, kidney, thyroid, lung and lymphoma cancer are all metastatic cancers that increase the risk of cancer related low back pain. A mnemonic to remember these are PB KTLL or lead kettle. •patients with colon and ovarian cancer are less likely to exhibit low back pain and pain will often refer to the pelvic, abdominal and thigh region. •leukemia has not been implicated as cancer • ovarian cancer is more likely to cause lower abdominal and sacral pain

Yellow Flag

•Psychological risk factors that can result in increased disability •Depression screener •FABQ - Fear Avoidance Beliefs / Behavioral Questionnaire •Oswestry: ODI - 60-75% range may have sx magnification •Target these yellow flags as part of treatment

risk factors of osteomyelitis

•Recent orthopaedic surgery •Skin infections •Poorly controlled diabetes •Impaired immune system •Circulation disorders •Illicit drug use

Sources of pain in those with OA

•Synovium •Bone •Nerves in the area innervating the knee •Debris in the joint from the disease process •Subchondral bone now WB surface •periostitis from osteophyte formation (bone inflamed) •Bone marrow lesions •Changes in nerve structure in tissues and bc hypersensitive

Ankylosing Spondylitis

•The shoulder is the most commonly involved joint in ankylosing spondylitis besides the spine. •Peripheral joints adjacent to the spine are often involved, so although the knee is not directly adjacent to the spine, it has the potential to be affected in ankylosing spondylitis. However, the knee is not the most commonly involved joint. •The hip is commonly involved in those who have ankylosing spondylitis, but it is most often seen when individuals have significant shoulder joint involvement. •Joints peripheral to the spine are commonly involved in ankylosing spondylitis, and the elbow is not directly adjacent to the spine nor has it been found to be commonly involved in ankylosing spondylitis.

ODI - Oswestry Disability Index

•Used to determine percentage of disability •Modified version replaces sex life question with social life question due to lack of patient response (MODI) •10 questions with 6 possible answers •Based on current (today) condition • Calculate points for overall % of disability (score of >75% likely non-movement component if not hospitalized; score <12% can safely RTW and normal activities)

General Information LBP

•Yellow flags and psychosocial factors have one of the largest roles in determining an outcome in a patient with low back pain. Specific screening tools, including fear avoidance, depression and physical distress, should be used during initial evaluations with patients with low back pain. •Diagnostic imaging often shows false positive and false negative results, which does not help determine the prognosis in a patient who has low back pain. Over-utilization of imaging is a current problem for musculoskeletal issues due to the limited reliability of these images. •Higher disability scores may assist in a physical therapist's prognosis for a patient with low back pain, but it has not been shown in the current literature to be the most relevant in helping determine a patient's outcomes in treatment for low back pain.

Felty's syndrome (presence of 3 conditions):

•is a rare, potentially serious disorder that is defined by the presence of 3 conditions: 1. rheumatoid arthritis (RA) 2. enlarged spleen (splenomegaly) 3. decreased white blood cell count (neutropenia), which causes repeated infections.

CPR - Prognosis of pelvic girdle pain (PGP).

•prior history of pregnancy •orthopedic dysfunctions (i.e. gluteus medius and pelvic floor muscle dysfunction) •increased body mass index (BMI) •Smoking •work dissatisfaction •lack of belief of improvement