Spine exam 1
One of your patients, a 55 year old female who suffers from low back pain, is scheduling her PT appt for next week. In your previous appts you chose to perform a posteroanterior central vertebral pressure (PACVP) to help increase her extension. Unfortunately in the following week, you are only able to work two days. Since your schedule is filling up you should
Fit her into your schedule. + Interrater reliability is low for joint play, so the best option would be for you to perform these tests each time.
Upon examination of a 14 year old with low back pain, you have the following findings: your patient experiences pain at night, but states it is relieved when the patient moves positions, the patient has an overprotective family and excessive pronation of the L foot. Which of the following is a red flag from this examination?
Patient's age: + According to Magee in Orthopedic Physical Assessment 6th edition (Table 9-6), a presentation age < 20 years old is a red flag and an indication of serious spinal pathology
A PT performs the slump test on a pt with a dx of lumbar disc herniation whose complaint is pain in the posterior thigh. Which of the following findings would indicate a positive test result?
Pain in the posterior thigh that is relieved with cervical extension + Is correct because according to Magee, a (+) slump test is indicated by a reproduction of the patient's symptoms in the test position that is relieved by reducing tension on the nervous systems through movement of a body segment not directly affecting the joints or muscles in the location of the symptoms. Since the Sciatic nerve is the one being tested, cervical, thoracic and lumbar flexion along with knee extension and DF will put the nerve on the most tension. Furthermore, the sciatic nerve supplies sensory stimulation to the posterior thigh. Therefore, the pt will experience pain on the posterior thigh, and if the cervical spine is extended, that will allow there to be slack on the Sciatic nerve.
Mechanical Diagnosis & Therapy (McKenzie system) - Use of repeated ______ motion to assess for peripheralization or centralization of symptoms and or directional preference for motion - Diagnostic classification: -- Postural -- Derangement -- Dysfunctions -- Other: chronic pain syndrome, hip joint pain, spinal stenosis, suspected fracture + What is the cause of pain? Repeated, prolonged tissues stress. + PTs will identify that they follow this method
active
What symptoms are most likely to accompany compression of the S1 nerve root? + Decreased strength of ankle ________, ankle _________, and hip _________; diminished sensation along the ________ aspects of the foot and lower leg and the heel; diminished ________ reflex.
plantarflexion, eversion, extension, lateral, achilles
+ Biggest factor leading to back pain is ________ _________ of back pain other factors: obesity, sedentary, age + Why is the anatomy important? Might get a patient that had a laminectomy to create ______ space in the canal + facet joint orientation approaches sagittal plane moving _______ allowing for flexion/extension of the lumbar spine + L5/S1 Facet Orientation -- as you move inferiorly it moves more _________ -- always ________ vertebrae moving on inferior (when we talk about lumbar spine) -- L5 sits on the sacrum
previous history, more, inferiorly, obliquely, superior
Psychosocial _______ Flag Barriers to Recovery - belief that pain and activity are harmful - "sickness behaviors" (such as extended rest) - low or negative moods, social withdrawal - treatment that does not fit best practice - problems with claim and compensation - history of back pain, time-off, other claims - problems at work, poor job satisfaction - heavy work, unsociable hours - overprotective family or lack of support
yellow
Red Flags - presentation age < _____ years or onset > _______ years - _________ trauma, such as a fall from a height, car accident - constant, progressive, nonmechanical pain - _________ pain - previous history of carcinoma, systemic steroids, drug abuse, HIV - ________ loss (unexpected) - systematically unwell - persisting severe restriction of _________ flexion - widespread neurology - structural deformity - investigations when required sedimentation rate (ESR) > 25 plain x-ray: vertebral collapse or bone destruction - _______ in urine or stools
20, 55, violent, thoracic, weight, lumbar, blood
A 20 y/o female gymnast presents to your PT clinic after receiving an X-ray that indicated a Grade 2 spondylolisthesis of L4-L5. Her PCP recommended imaging after she had complained of back stiffness, pain that increased with flexion, and difficulty remaining in one posture for extended periods of time. With this information, what treatment approach would be best for this patient's diagnosis and symptoms?
A flexion treatment approach, stabilization exercises that target the intrinsic core musculature and stretching of the hip flexors. + This is the correct course of action for this patient because with spondylolisthesis we need to prevent movements that create over extension of the spine to avoid exacerbating the current symptoms the patient is having. Spondylolisthesis often coincides with a weak intrinsic core as well as tight hip flexors due to an increased anterior pelvic tilt. Adding stabilization exercises and hip flexor stretching would be indicated in the treatment process for spondylolisthesis.
A 45 y/o female presents to outpatient PT with c/o LBP on her R side. She reports an acute injury where she was bending over to pick up a basket of laundry and felt her R side seize up. She immediately felt symptoms in her back and had trouble standing back up. Pt reports that she feels relief when lying down and when laterally flexing to the R side in sitting or standing. Pt reports increases in pain when she flexes forward, and PT observed slight R rotation at lumbar spine to reach full flexion. Pt presented with observable slight lateral flexion to R side and increased lumbar lordosis. During neurological testing the pt presented with no deficiencies in her dermatomes or myotomes. Patient demonstrated pain with TA activation and was TTP at R lumbar paraspinal muscles. What dx would be consistent with the signs and sx this pt presents with?
Acute R-sided muscle strain of paraspinals + lateral flexion and rotation to the R side would relieve pain by putting R paraspinals on slack. It is likely that pt was not properly stabilizing the spine upon lifting laundry basket, and the load on the flexed paraspinals caused a strain followed by seizing and guarding of the R lumbar musculature, making her TTP
Pt is a 74 y/o male who presents with "dull achy" pain that started 3 weeks ago after he reports throwing his grandson in the pool. He states that the pain increases with forward flexion and extension. Pt does not complain of any radiating or referred pain in the lower extremities and MMT of the lower extremity is within normal limits. Pt reports no prior back injuries. According to the IFC classification systems, classification would this pt be best diagnosed as?
Acute low Back pain with mobility deficits. + This classification would be the correct answer for this patient's symptoms out of these options because it is characterized as acute pain that can be associated with a recent unguarded/awkward movement. In this case the aggravating factor was throwing his grandson in the pool and his mobility is now limited due to pain. He has no radiating pain and it is not more than an acute injury since the symptoms have only been around for 3 weeks.
A 35 yo Olympic weightlifter comes in for his initial evaluation with ℅ frequent episodes of LBP that has been present ever since an accident while lifting about 5 years ago. Lifter continues to mention he has decreased bouts of strength ever since the injury with radiating pain going down into his R leg. Pt mentions that to cope with this, he takes some active recovery days and religiously stretches everyday to help mitigate any long term effects. He is frustrated that his lifts are not as strong and heavy as they once were, and has come to PT to improve mobility and stability in B LE. According to the case presented, which PT-ICF Based Category does this pt fit into?
Chronic LBP with Radiating Pain: + This answer IS CORRECT for many reasons. It holds down the injury timeline well, as being over 6 months of pain. Also emcompasses recurring pain that also is associated with radiating pain and strength loss. As this pt also reports that he has decreased strength and weakness while exercising, this category of the PT-ICF is the best fit for this pt.
Pt is a 40 year old female who reports to physical therapy with complaints of LBP for the past 5 months. The pt states that they have been experiencing numbness and tingling down their right LE that goes to their calf. Pt symptoms are reproduced during the slump test and SLR. Pt also demonstrates a slight decrease in overall strength of their R LE compared to their left. Based on the following clinical findings, what would be the best PT ICF diagnosis for this patient?
Chronic LBP with radiating pain + Since the pt has been experiencing symptoms for more than 3 months it is chronic LBP. This is also considered a proper diagnosis for this patient because they are experiencing radiating pain down their LE to their calf and have deficits in strength on the same side. Lower extremity paresthesias and numbness are also noted with this patient which is another clinical finding that matches this diagnosis.
What is the main source of nutrition for the nucleus of the intervertebral disc?
Diffusion through the cartilaginous end plates. + This is the correct answer because the disc has no direct blood supply and the end plate provides a medium for nutrition to be transmitted from bone to the disc
Mike is a 24 y/o weightlifter with ℅ intermittent chronic low back pain that is exacerbated with long sitting times and heavy squats at the gym. Pt. reports only being able to squat heavy when wearing a weightlifting belt. Pt. has been symptomatic for 5 years, stating that it "comes and goes". Pt. was unsure of MOI but thinks it started after taking a strong swing at a pitch during a baseball game. Pt denies any radicular sxs with SLR and Slump tests and has normal sensation and reflexes. Pt. was positive for aberrant motion & marching test. Based on the hx and subjective complaints, what is the LEAST logical dx for this pt?
Disc Herniation + In pts with a herniated disc, symptoms will often radiate down the leg. Pain will typically increase with extension. Myotomes, reflexes, and dermatomes would be affected. Neuro tests (slump & SLR) would be positive. None of the above pertains to Mike's case, making this the best answer.
While driving a ball during a golf match, a 56 y/o male pt felt an immediate sharp pain in the right lower back. The following morning the pt reported stiffness, but pain relief when sitting or bending forward. Based on this information, the source of the pain is MOST likely?
Facet Joint Compression + Facet joint is typically aggravated with trunk rotation and extension, such as with a golf swing. Closed pack position of the facet joints for the lumbar spine is in trunk extension and the capsular pattern is side flexion, rotation, and extension. Therefore it makes sense that this pt may illicit facet joint pain since a golf swing combines all of these motions. Facet joint pain is usually relieved with trunk flexion. Due to the flexed position of the trunk while sitting, these pts usually feel the most relief in a seated position. Furthermore, facet joint symptoms are usually exhibited due to a mechanical cause
What is the primary structure in the lumbar spine responsible for the limited rotation that is available?
Facet joints + This is the correct answer because according to the Orthopedic Physical Assessment textbook the facet joints direct the movement within the lumbar spine and their shape makes it so there is minimal rotation available in the lumbar spine as they have moved more into the sagittal plane the more inferior they are.
A 52 year old female patient arrives at your PT with chronic back pain. Patient indicates that 2 months ago she began to experience a "shooting and burning" pain traveling down the anterior portion of her right thigh. This pain seems to worsen whenever the patient extends her lumbar spine. What neurological special test would be MOST appropriate and likely to recreate the patients radicular symptoms?
Femoral Nerve Traction Test + Rationale: The femoral nerve is created by the joining of nerve roots L2-L4. Disk herniation or degenerative changes leading to narrower foramen in this area may cause entrapment of the femoral nerve roots. Impingement of the femoral nerve or its roots will likely cause a radiating, burning pain along its sensory distribution, most commonly the anterior thigh. The femoral nerve traction test is utilized specifically to test for femoral nerve entrapment by placing the femoral nerve in a stretched position. Since the patient indicated the pain is radiating into the ANTERIOR portion of her thigh (the distribution of the femoral nerve), the femoral nerve traction test would be the most appropriate choice and the one most likely to recreate her symptoms.
A 22 yo male presents to the clinic with low back pain and pain radiating down their left leg and to the great toe. Upon observation you notice the patient is standing and sitting in right lateral flexion. Patient reports the symptoms first came on while performing a heavy deadlift in the gym for the first time in months. When asking the patient if anything alleviates their symptoms, the response you get is right lateral flexion and forward flexion both help to improve their pain and radicular symptoms. Patient also states the pain is worst when they extend their back and flex to the left. Which of the following diagnoses is most likely the cause of the patient's pain?
Herniated disc on the L side of the spine putting pressure on the L L4 spinal nerve root + This is most likely cause of the pt's pain. A herniated disc is most likely to occur while the spine is in flexion. The patient also reports that lateral flexion to the right and forward flexion help to alleviate pain. Both of these positions will help to decrease the pressure on the L L4 spinal nerve root by opening up the L transverse canal in the spine.
Pt is a 58 y/o woman presenting with LBP and dx of L5-S1 disc herniation on referral from MD. Her pain began last week after doing a front flip on the diving board. Pt went to urgent care where they gave her an x-ray. Imaging showed a small disc herniation at L5-S1 region. Upon examination pt reported pain throughout lumbar flexion and rotation that was relieved with extension. Pt reported sharp non-traveling pain on the posterior thigh while performing the SLR. Reflexes were intact. MMT of bilateral ankles and knees were 4/5. Hip MMT was unable to be tested d/t pt pain. Pt denied numbness or tingling. What is the probable cause of pain for this pt?
It is likely the pts pain is from a lumbar strain d/t lack of neurological symptoms, intact reflexes, and no observed weakness. + This is the correct answer because there are no neurological symptoms, reflexes are intact, and there is no weakness. The pain throughout SLR is d/t hamstring tightness.
A 56 yr old male patient arrives at your clinic following a major snowstorm two months ago where he reports shoveling his driveway and hurting his back. The patient reports his pain remains at a 4/10 on the NRS throughout the day but jumps to a 7/10 anytime he bends forward such as picking an object up off the floor. The patient works from home and has found that reclining his desk chair is the most alleviating position. The patient describes his pain as a numbness and tingling sensation that travels down his left leg. Examination leads to a (+) L SLR. Patellar tendon reflex 0 on L and 2+ on R. Knee extension MMT 2+/5 on L and 4/5 on R. Pt demonstrates diminished sensation on the L anteromedial distal thigh and leg when compared to the R. Based on your findings, you believe the patient has a herniated disc at which spinal level?
L3 + The nerve roots at L3 contribute to the innervation of the quadriceps muscles via the femoral nerve performing knee extension. To test this myotome, a knee extension MMT can be performed and compared bilaterally to elicit any asymmetrical weakness which would result in a positive test. Similarly, the L3 nerve roots also contribute to the patellar tendon reflex which should be tested bilaterally looking for abnormal responses such as hypo-reflexive response as seen in this case presentation. Lastly, the L3 nerve roots contribute to the peripheral nerve distribution located at the anteromedial distal thigh and leg. This dermatome distribution can be tested with the patient's eyes closed and the examiner using a light finger touch or qtip to elicit the touch receptors. With a disc herniation at the L3 spinal level, myotome weakness, hypo-reflexive reflexes, and diminished sensation ipsilaterally would all be common findings at the above described locations.
Your patient is a 35 y/o female complaining of low back and right sided leg pain. Pt reports onset of pain when lifting 5 y/o son up and out of car seat. Pt is experiencing numbness on the medial aspect of the thigh/knee and anterior lower leg and is unable to hold resistance against knee extension. During the PKB (prone knee bend) test, patient experiences pain on the unilateral lumbar area, buttock, and posterior thigh. Which of the following injuries do you suspect?
L3 radiculopathy: + This is the correct answer because the L3 dermatome is most notably responsible for sensation of the medial aspect of the thigh/knee and anterior lower leg, which is where the pt. is experiencing paresthesias. The L3 myotome is responsible for knee extension, which the patient cannot hold with resistance. The PKB test is with L3 root syndromes causing pain on the unilateral lumbar area, buttock, and posterior thigh
A pt exhibits pain and sensory loss in the posterior thigh, lateral calf, and dorsal foot. Extension of the Hallux is poor, however the Achilles reflex is normal. What spinal level would you expect to be involved?
L5 + For this question, the L5 nerve root is the best answer. That is because the L5 dermatome supplies the buttocks, back and side of thigh, lateral aspect of leg, dorsum of foot, inner half of sole and toes 1-3. There will be muscle weakness in the extensor hallucis, peroneals, glute med, ankle DF, hamstrings, and there will be calf wasting. A pt will experience paresthesias along the lateral aspect of the leg and first three toes. Therefore, according to Magee, with sensory loss to the posterior thigh, lateral calf, and dorsal of the foot, as well as poor extension of the big toe, L5 would be the cause
Are the lumbar discs smaller or larger in size compared to the discs of the thoracic and cervical vertebrae and what is its significance?
Larger disc size and better shock absorber, but limited motion + Rationale: The discs of the lumbar vertebrae are larger in size compared to the disc heights of the thoracic and cervical vertebrae. The lumbar discs are better shock absorbers than the thoracic and cervical discs; however, lumbar discs have limited motion.
Jim is a 36 y.o. male former professional soccer player who presents to PT with low back pain of insidious onset. Pt reports increased pain with motions that involve reaching overhead and extending the lumbar spine such as "fixing a ceiling fan." Pt denies any radicular sxs. Based on the hx and subjective complaints, pts has dysfunction of a lumbar facet jt (most pressure during extension). What clinical test should be used to confirm this dx?
Lumbar Quadrant Test + The motion of the lumbar quadrant test places the lumbar facet joint to its maximally stressed position to the side in which rotation occurs. It also causes maximum narrowing of the intervertebral foramen and therefore the most provocative position. If positive (reproduction of sxs) it is typically indicative of a lumbar facet dysfunction.
When evaluating a 40-year-old male plumber for low back pain, you have the patient perform a forward flexion test. The patient is able to reach down to 2 inches from the floor with their fingertips. The patient demonstrates excessive hip flexion during the test and reports pain at a 4/10 in the lower back during the movement. Where is the restriction during forward flexion most likely coming from?
Lumbar vertebrae + This is the most likely choice given the information available. Lumbopelvic rhythm involves the lumbar vertebrae, pelvis, and hamstrings working together to allow forward flexion to the floor. If there is excessive mobility in the hips, it most likely means there will be a restriction somewhere in the lumbar vertebrae
Which direction is an intervertebral disc most likely to herniate in the lumbar spine with an MOI of forward flexion and what ligament is this direction likely attributed to?
Posterolateral direction, Posterior Longitudinal Ligament + Rationale: With forward flexion, the nucleus is shifted posteriorly as the anterior aspects of the vertebrae are compressed and the posterior aspects of the vertebrae are distracted. However, the disc will not herniate directly posteriorly because the PLL is strong and prevents herniation in that spot. The PLL also slightly fans laterally. This insertion of the fanned part of the PLL is particularly weak which would be more susceptible for herniation.
A 57 yo female presents to your outpatient clinic with a referral from her PCP for evaluation and treatment of an acute L sided lumbar strain. Pt reports slipping on ice in her driveway and twisting as she fell. She immediately felt a stabbing pain in her low back that has continued to bother her since and is now having frequent muscle spasms. Upon your initial evaluation, which findings would you expect to see that are consistent with a lumbar strain diagnosis?
Pt demonstrates empty end feel and muscle guarding when asked to perform active ROM movements like forward trunk flexion, R lateral flexion and R trunk rotation. + With a muscle strain someone's pain can be exacerbated through extension by contracting the muscle or by stretching in into flexion. The pain can often be a limiting factor to a pt's ROM in multiple planes. Mvmt tests can target and provoke pain for a differential diagnosis.
What muscles contribute to forward flexion of the trunk?
Rectus Abdominis, bilateral external obliques, bilateral internal obliques, psoas major. + All these muscles together perform forward flexion of the spine. Both the internal obliques need to fire at the same time to provide flexion otherwise trunk rotation will occur. Same thing goes for the external obliques. Psoas major does not contribute as much force to the motion as the other muscles.
A 55 year-old M presents with low back pain that started 2 weeks ago while he was helping his son move into his new apartment. He reports the pain has progressively gotten worse and is now radiating down the back of his right leg. He reports new weakness that has caused him to fall. Pain is worse throughout the day and is relieved by changing positions. Upon examination you find that the symptoms are reproduced in extension and lateral flexion to the right side. Great toe extension is 3-/5 on the R foot. Pt has decreased sensation to light touch along the L5 dermatome. You suspect a lumbar disc herniation based on your findings at the L5-S1 level. What would be the BEST test to perform?
SLR + According to the Orthopedic Physical Assessment textbook, this is an essential test to perform with suspected neurological dysfunction associated with spinal disc injuries. It has a high interrater and test-retest reliability score. * slump is more provocative and painful
A 52-year-old male presents to PT due to recent falls at work and reports uncontrollable stumbling and leg weakness leading up to the falls. When taking medical history you find out pt has LBP and was previously diagnosed with osteoarthritis and more recently lumbar spinal stenosis. Pt works in a restaurant kitchen where he stands for long periods of time and for the past week has been having leg cramps starting progressively earlier into his 8-hour work shifts; he reports feeling anxious at the beginning of his shifts now, as they seem to aggravate his symptoms. Today, pt is experiencing pins and needles down both legs. Upon questioning you find out that pt has been having trouble voiding urine for a couple of days. What should your next step be in treating this pt?
Send to emergency to assess for cauda equina syndrome. + Pt symptoms of falling due to stumbling, leg weakness, paresthesia (pins and needles) and recent bladder changes are consistent with cauda equina syndrome, which is a possibility due to spinal stenosis. This is an emergency condition potentially requiring surgery.
A 55-year-old female comes in for PT with low back pain with radiating symptoms going down the L leg to the L knee. The patient has medical records sent over from her primary care. Included in those records are results for a lumbar MRI that show L4-L5 disc herniation with free nuclear material visible in the spinal canal. What type of herniation is this?
Sequestration + This best describes what the herniation would be categorized as the annulus fibrosis would be completely ruptured and material from the nucleus pulposus would be free in the spinal canal.
When a patient is in a position of Lumbar Spine Flexion, what do you expect to occur at the Spinous processes and in what direction will the nucleus migrate?
Spinous Processes will move farther apart creating a gap, nucleus will migrate posteriorly with rationale. This answer is correct because, in lumbar spinal flexion, the anterior body of the vertebrae are compressed while the posterior body is distracted, causing the spinous processes to move apart from each other. Anterior compression of the vertebral body will cause the nucleus to migrate posteriorly to the space of lesser compression.
Patient is a 55 y/o M presenting with LBP. He reports stiffness upon waking and pain in the lower back that sometimes radiates to the R buttocks area. Patient reports pain is worse at the end of the day after working at his desk job and only gets relief when lying in bed. Upon examination, pt is hypomobile in all spinal AROM. Myotomes, dermatomes, and reflexes are all intact. The patient is displaying signs and symptoms MOST consistent with which medical diagnosis?
Spondylosis + Spondylosis, osteoarthritis (OA), or degenerative joint disease (DJD) refers to progressive bony changes in the facet and vertebral body margins (Kisner&Colby, 444). McGee refers to spondylosis as degeneration of the intervertebral disc (McGee, 550). Because spondylosis is a degenerative condition, these changes begin to occur only after the second decade of life (Magee, 552) and are usually more evident in people over 45 y/o (Magee, 555). Common signs and symptoms associated with spondylosis are back pain, with no myotome/dermatome dysfunction, sx aggravated with flexion and relieved with extension (Magee Table 9.2, 556). Since the patient is demonstrating pain in the back that does not radiate all the way down the leg, myotomes/dermatomes are intact, and symptoms are worse when working at a desk job (flexion), while relieved with lying down (extension), this all leads to the diagnosis of spondylosis.
A 53-year-old female patient arrives at your PT clinic with complaints of low back pain that she has had for 2 years. She works full time as an accountant and spends 8+ hours per day sitting. She reports local pain in the low back that does not radiate down either LE. You note a positive Gower's sign as well as a painful arc and a catch when returning to neutral from a flexed position. Results of PIVMs, prone instability test, and resisted isometric movements indicate possible lumbar instability/hypermobility and decreased activation of trunk muscles. Which of the following should occur first in your treatment plan?
Teach the pt to perform a drawing-in maneuver in supine + Rationale: The drawing-in maneuver increases activation of the deep trunk muscles. It can also help to reduce anterior translation of the lower lumbar vertebrae and lead to overall improved stability of the lumbar spine and a decrease in pain due to instability. This is a low-level exercise that can be incorporated in future higher level exercises and movements.
In a patient with a pendulous stomach, they may have weak abdominal muscles and tight hip flexors contributing to an increased lordotic curvature of the lumbar spine. You also notice that the patient tends to walk with their hips externally rotated. Why is the patient presenting with this posture?
To reduce anterior shear force and compression of the lumbar spine + This is the correct answer because according to the Mechanical Low Back Pain textbook the lever arm increases between the spine and the abdomen with more of the weight lying anteriorly when the individual has a pendulous stomach, which causes an increase in the anterior shear force and compression on the lumbar spine.
A 50 year old male presents with low back pain that has gotten progressively worse over the past month. Patient reports no significant mechanism of injury, but states that his pain has gotten worse since starting a new job that requires lifting heavy boxes. Patient also reports pain and that sometimes he feels "pins and needles" go down his R leg. PT's examination is as follows: - Pain increases with sitting and R side-bending - Pain decreases with standing and L side-bending - Dermatomes: decreased sensation L5-S2 on R, sensation intact on L - Myotomes: weakness present with toe extension and ankle eversion on R compared to L - Reflexes: Patellar 2+ bilaterally, achilles 1+ on R, 2+ on L SLR on R: pt reports pain, PT immediately records a positive test. SLR on L negative - PT states that the patient's signs and symptoms are consistent with an L5 R lateral disc herniation. Why might this be incorrect?
When performing the SLR test, PT did not ask the patient where they felt pain on their R side If the patient only felt pain along their posterior leg, this could just be hamstring tightness. If the patient also felt back pain, this is more indicative of a disc herniation
+ ________ LBP with _______ _______: Acute low back, buttock or thigh pain (< 6 weeks) Onset of symptoms is often linked to a recent unguarded/ awkward mvmt or position Mobility deficits associated with the pain + ________ LBP with _________ ________ __________ Acute exacerbation of recurring LBP that is commonly associated with referred lower extremity pain Symptoms often include numerous episode of low back and/or low back- related lower extremity pain in recent years EX: pt goes to reach for something & feels pain + __________ LBP with ____/____ ____ pain LBP commonly associated with referred buttock, thigh or LE pain that worsens with flexion activities and sitting Reports numerous low back related lower extremity pain episodes
acute, mobility deficits, acute, movement coordination impairments, acute, related, referred, LE
+ _____ LBP with __________ pain Acute LBP with associated radiating (narrow band of lancinating) pain in the involved LE LE paresthesias, numbness & weakness may be reported pain shooting down the leg will occur on one side that lateral canal is smaller for some reason (osteophyte) pain down the leg → the farther it goes down the leg, the worse the dx Ask the patient: where does the tingling go? + ________ LBP with related _________ or affective tendencies Acute or subacute low back or low back related LE pain Pt afraid of pain which is why they have this problem Avoidant
acute, radiating, acute, cognitive
+ __________ Longitudinal Ligament -- Very innervated; can cause a lot of pain if injured -- limits _________ -- very developed in lumbar spine -- reinforces discs anteriorly + __________ Longitudinal Ligament: -- fans out & attaches to the disc on the posterior side -- Herniated Disc: likely to herniate in the Posterior Lateral direction (where you lose the attachment of PLL) -- limits flexion -- reinforces discs posteriorly + ____________ Ligament: --palpate between spinous processes -- limits flexion + ____________ Ligament: -- can't necessarily palpate directly bc it's deep to the Supraspinous Ligament -- limits flexion
anterior, extension, posterior, supraspinous, interspinous
Forces + Forward Flexion = _________ Compression = _______ Tension + Lateral flexion = _________ compression = ________ tension + Torsion = Annular fibers orientation dictates resistance = Facet joints resist torsion + Shear = Anterior or posterior (or medial/ lateral) mvmt of superior on inferior = Facet joints: Annulus
anterior, posterior, ipsilateral, contralateral
+ Iliolumbar: strong ligaments -- Prevents _________ shear of L4 & L5 on sacrum -- Anchoring the vertebrae to the sacrum + SIJ ligaments: Anterior & Posterior SIJ ligament -- Sacrotuberous & Sacrospinous are indirect _________ -- Some say none-very little mvmt & some say lots of mvmt of the SI joint
anterior, stabilizers
Philosophies of classification systems/ PT management of LBP + _____________ - pathological models -- biomechanics / arthrokinematics -- Assessment of abnormal positions, mvmts & treatments -- Kaltenborn, paris, osteopathic approaches (Maitland?) -- PRO: Special tests telling you what is wrong, know where the pain SHOULD be (ACL tear) + ________ response models -- Symptom response of the patient to tests and measures is the important factor -- Treatment aimed at reducing pain or restoring mvmt Maitland, MDT/McKenzie -- CON: mainly subjective; perceived as negative * he prefers this + ________ models -- Biomechanical & patient response approach -- Mulligan, (MDT/McKenzie) -- Taking approaches from both models
biomechanical, patient, mixed
+ _________ LBP with ______ __________ __________ Chronic, recurring LBP that is commonly associated with referred LE pain 3 months is considered chronic + __________ LBP w/ ________ pain Chronic, recurring, mid back and or LBP with associated radiating pain & potential sensory, strength, or reflex deficits in the involved LE LE paresthesias, numbness, and weakness may be reported Irritability - what irritates it? How quickly or how difficult is it to aggravate that symptom? + __________ LBP w/ ____________ Pain Low back &/or Low back related LE pain with symptom duration for longer than 3 months Generalized pain not consistent with other impairments- based classification criteria Cognitive processes or affective behaviors exhibited that suggest the presence of fear avoidance beliefs, pain, catastrophizing, depression
chronic, movement coordination impairments, chronic, radiating, chronic, generalized
+ Thoracolumbar Fascia -- Thick, fibrous -- SP & supraspinous ligament, laterally over erector spinae muscles to lateral raphe (Internal Oblique, TA) -- Medially & anterior over erector spinae to Transverse Process + Erector spinae (function) -- Concentric: _______ -- Eccentric: work to decelerate quick ________ -- Isometric: sitting or standing erectly -- Lateral flexion to the _____ side +Sagittal vs Frontal vs Horizontal -- The farther the muscle is from the Anterior-Posterior axis, the better it will be for __________ __________
extension, flexion, same, lateral flexion
+ Multifidus -- Sacrum, comdon, sacrotuberous, lumbar mamillary processes, PSIS, facet joint capsule -- SP (2-4 levels) -- Sacrotuberous ligament to SI -- Dynamic Stability of SI; important for _______ and lumbar _______ -- Bigger in the lumbar spine than it is more superiorly + Intersegmental muscles → interspinales, intertransversarii Smaller muscles -- Contribute to motion and proprioception + Quadratus Lumborum -- Moving & stabilizing pelvis/ lumbar spine in frontal horizontal planes -- Can provide extension when activated _________ + Psoas Major/Iliopsoas -- ________ both the spine and hip -- Lumbar vertebrae (transverse process) → lesser trochanter of femur -- Test with the Thomas test in supine
extension, stabilization, bilaterally, flexes
Why might you not feel an injury to the nucleus of your disc? Is there a good prognosis for healing of more than ½ of your disc after injury? + The nucleus of your disc is not ___________. The prognosis is poor because only the outer _______ of your annulus has blood supply.
innervated, 1/3 + The nucleus of your disc is not innervated. The prognosis is poor because only the outer ⅓ of your annulus has blood supply. Rationale: The intervertebral disc itself has no nerve supply though the peripheral ⅓ of the annulus fibrosis may have some innervation from the sinuvertebral nerve (Magee p.553). The discs are also avascular for the most part with only ⅓ of the periphery of the disc receiving some blood supply (Magee p.553). Blood supply is necessary for tissue healing and nutrients to be delivered to the healing tissue. The disc can get some nutrients through diffusion by the disc's end plate. The injury to the disc could disrupt the delivery of any nutrients especially if the patient does not want to move as movement is what causes diffusion.
W/ Right Rotation -- Compression of ______ facet joint -- Separation of ______ facet joint -- facet joint on _______ - distraction -- facet joint on _______ - compression Disc pressure - Disc pressure is ______ in sitting and reclined 10-20° --- Also be aware of cervical spine and the effects reclining may have on it - Disc pressure is _______ in sitting as opposed to standing
left, right, right, left, lowest, higher
_________ Model -- Diagnostic classification: physical exam & imaging and other tests to determine lesions -- What is the cause of the pain? = Lesion to anatomical structures or disruptions to physiological actions = OA, herniated disc, spondylolisthesis -- osteophytes, traction spurs, ARTHRITIC changes -- what causes the pain? we don't know (90% of the time) -- What are their limitations? we don't know
medical
Treatment based classification of LBP + Diagnostic classification -- Uses history and physical exam to place patients into 1 of 4 separate treatment subgroups for intervention 1. ________/manipulation 2. S____________ 3. Specific _______ 4. T________ -- What is the cause of pain? Not clearly identified -- some PTs use a mix of the different classification systems -- for this class- strongly emphasize subjective, exam, diagnose, treatment -- don't really care in this system what causes the pain
mobilization, stabilization, exercises, traction
Central canal stenosis refers to a ____________ of the spinal canal, which may cause compression of the spinal cord. Individuals with spinal stenosis often have _________ symptoms with pain occurring in the back, buttocks, thighs, calves, and feet. Pain is typically increased with _________ and relieved with ________, and peak incidence is in individuals in their 70's. Myotomes are commonly affected and there is often pain in dermatomes.
narrowing, bilateral, extension, flexion
Progression of a herniated disc + _________ - nuclear material does not become free in the spinal canal; the disc just bulges posteriorly with the annulus fibrosis still intact. + __________ - here only the outermost fibers of the annulus fibrosis still contain the nuclear material. The nucleus pulposus is still contained in the disc itself. + ____________ - with this, the nucleus pulposus has broken through the annulus fibrosis and into the epidural space. Nuclear material has not yet escaped fully and moved into the spinal canal. + ______________ -annulus fibrosis would be completely ruptured and material from the nucleus pulposus would be free in the spinal canal
protrusion, prolapse, extrusion, sequestration
Mechanical LBP - pain is usually cyclic - low back pain is often ________ to the buttocks and thighs - ___________ stiffness or pain is common - start pain (i.e. when starting movement is common) - there is pain on forward _________ and often also on returning to the erect position - pain is often produced or aggravated by _________, side flexion, rotation, standing, walking, sitting, and exercise in general - pain usually becomes worse over the course of the day - pain is relieved by a change of position - pain is relieved by lying down, especially in the ______ position
referred, morning, flexion, extension, fetal
Facet joint is typically aggravated with trunk ______ and ________, such as with a golf swing. Closed pack position of the facet joints for the lumbar spine is in trunk ________ and the capsular pattern is side ________, _________, and __________. Therefore it makes sense that this pt may illicit facet joint pain since a golf swing combines all of these motions. Facet joint pain is usually relieved with trunk _______. Due to the flexed position of the trunk while sitting, these pts usually feel the most relief in a seated position. Furthermore, facet joint symptoms are usually exhibited due to a mechanical cause
rotation, extension, extension, flexion, rotation, extension, flexion
___________ refers to a forward displacement of one vertebra over another (Magee, 550). It is also often seen in individuals that are hypermobile and/or have ligamentous laxity (Kisner&Colby, 464). It is often thought to be a progression of spondylolysis so the signs and symptoms are similar to spondylolysis. There is a grading system to this condition, and if the vertebra has slipped far enough forward that it is compressing the spinal cord, patients can have cauda equina symptoms.
spondylolisthesis
___________ refers to a defect in the pars interarticularis or the arch of the vertebra (Magee, 550). It is often seen in individuals that are hypermobile and/or have ligamentous laxity (Kisner&Colby, 464). It is typically seen in adolescent athletes (age 10-15) and although most individuals don't have symptoms, but if they do, pain is usually exacerbated with extension and relieved with flexion
spondylolysis
Common signs and symptoms associated with ________ are back pain, with no myotome/dermatome dysfunction, sx aggravated with flexion and relieved with extension
spondylosis
Intervertebral discs - increase in size: ________ to _______ - ______cartilage - Functions to dissipate shock - in the actual disc you won't be able to tell the difference between the nucleus & annulus Intervertebral Disc: Nucleus -- 70-90% water -- PG: glycosaminoglycans & protein -- Primarily Type II _______ -- Designed to resist compression -- Proteoglycans attract water → younger individuals have greater amounts of proteoglycans Intervertebral Disc: Annulus -- Lamellae -- Increase in type 1 collagen: resist tensile forces -- Lamellae go in opposite directions to help with ability to resist tension & makes disc stronger -- Attached to vertebrae via cartilaginous end plates: hyaline cartilage & fibrocartilage -- ______ Plate: transition between bone & cartilage -- Direct connection to bone (annulus) -- Nutrition: ______ blood supply the further you move inwards. End plate allows blood supply. -- Compression & Distraction allows change in blood flow direction -- As you get older proteoglycans decrease, ability to dissipate forces decreases
superior, inferior, fibrocartilage, collagen, end, poor
with an anterior pelvic tilt: -- __________ & __________ ligaments are on slack (tension decreased), ALL would demonstrate tension, space of disc increases anteriorly & decreases posteriorly -- intervertebral foramen- (nerve roots travel) w/ extension space ________; decreases contact of disc on nerve root (may help pain decrease if radicular symptoms), but decreasing space which might cause radiculopathy symptoms (w/ flexion space increases) + with flexion/ extension facet joints slide past each other -- slide/ glide occurs _______ & _______ with flexion - slide/glide occurs _________ with extension
supraspinous, interspinous, decreases, superior, anterior, inferior
Rotational motion at the functional unit of the spine is in the _________ plane. Left rotation of the superior vertebrae results in the relative movement of the anterior body to the ______ and the spinous process to the _______.
transverse, left, right