LE Ortho LBP

Patients with this spinal condition commonly display the following signs and symptoms - - pain, muscle-guarding - prefer to stand and walk over sitting - flexed postures, lean away from symptomatic side - neurological Sx (in dermatome and possibly myotome affected nerve roots) - increased Sx (peripheralization) with sitting, prolonged flexed postures, transition from sit to stand, coughing, and strain - limited nerve mobility (e.g. limited SLR) - peripheralization of Sx with repeated forward bending (spinal flexion) tests

(posterior) HNP (herniated nucleus pulposus) (in the L spine)

Coupled motion - Some have proposed that the coupling depends on the motion that is introduced *first* in T3-T10 - If *side flexion* is introduced first, what is its coupled motion? - If *rotation* is introduced first, what is its coupled motion?

(side flexion first) contralateral rotation, (rotation first) ipsilateral side flexion

Beighton Scale of Hypermobility / Beighton Ligamentous Laxity Scale (BLLS)

(• Measures systemic hypermobility (not only with foot/ankle) • Check the following o Ability to flex thumb against forearm with wrist flexed. o Ability to extend 5th digit greater than 90 degrees with wrist extended. o Hyperextension > 10 degrees at knee. o Hyperextension > 10 degrees at elbow. o Ability to forward bend with palms to floor o Scoring: > or = to 4 of 9 --> hypermobility)

When determining the appropriate *rehab* approach for a patient, *what treatments* would fit the following *movement control* clinical findings - - Disability = moderate - Symptom status = stable - Pain = moderate to low

(Tx:) sensorimotor (exercises), stabilization, flexibility (movement control)

During Lumbopelvic rhythm trunk *extension* what muscles are active during each phase, - Early phase: - Mid Range: - Standing:

(early:) glutes, hamstrings, (mid:) erector spinae, (standing:) neutral

what are the 5 diagnostic lumbar classifications used with MSI classification

(in order of frequency:) rotation-extension, extension, rotation, rotation-flexion, flexion

this spinal condition is characterized by the breakdown and compression of the fibrous layers of the annulus (of the interbody joint) and displacement of disc material - can cause pain and/or neurologic compromise from either mechanical compression, inflammation or both, as it comes in contact with nearby nerves

HNP (herniated nucleus pulposus)

The Meyerding classification system for grading degrees of vertebral slips is measured by *percentage of slip* - - Grade I: - Grade II: - Grade III: - Grade IV: - Grade V:

< 25 (%), 25-50 (%), 50-75 (%), 75-100 (%), > 100 (%; spondyloptosis)

Rib angle: <___ = stiff EO >___ = stiff IO

<70 >90

Hip Goni Norms - - Flexion: - Extension: - ABD: - ADD: - IR: - ER:

120 (flex), 20 (ext), 45 (ABD), 35 (ADD), 45 (IR), 45 (ER)

Fryette's ____ Law/Rule: lateral flexion and rotation occur in opposite directions (neutral mechanics - facets are not engaged or locked) - only applies to L and T spine. Cervical facets are always engaged

1st

____________ (>12 weeks) LBP, initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)

chronic

interbody joints primary functions:

absorb shock, distribute load (secondary: add stability b/w vertebrae, approximate site for axes of rotation, & serves as deformable intervertebral space)

what 3 components make up global stability

activation (focus: motor control > strength), acquisition (equal focus on motor control & strength), assimilation (focus: motor control < strength)

musculoskeletal is a lifestyle Dr. Sarhmann emphasizes looking at what?

activities!! (how the person moves and does ADLs)

what are possible contributing factors to lumbar rotation syndrome / excessive lumbar rotation

activity related (require repetitive rotational motion; e.g. golf, tennis, curling), sitting habit (sitting with a rotated trunk; sitting crossed legged or leaning to one side), poor control of opposite obliques (e.g. left Internal obliques + right External obliques), asymmetry of IT band, leg length differences

Most patients with _______ (<4weeks) or ___________ (4-12 weeks) LBP improve over time regardless of treatment, nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

acute or subacute

in the typical intervertebral junction, transverse and spinous processes function as outriggers for what purpose

attachment site (for muscles and ligs)

Adolescent back pain ___________: center of the spine and usually exacerbated by extension -spondyloysis describes unilateral/bilateral defect -spondylolisthesis occurs when bilateral pars -scoliosis -scheuermann's disease/juvenile kyphosis

bone-related

________ LBP with inadequate response to nonpharmacologic therapy, consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)

chronic

Erector spinae mm: - (ipsilateral/contralateral) spinal rotators - (ipsilateral/contralateral) side benders/lateral flexors

ipsilateral, ipsilateral

Internal Obliques - - (ipsilateral/contralateral) rotators - (ipsilateral/contralateral) side benders/lateral flexors

ipsilateral, ipsilateral

_____________ approaches for spinal stenosis -drugs (oral diclofenac, corticosteroids and antidepressants) -spinal injections -PT (exercise, flexion, walking, muscle coordination, balance, braces/corsets, pain relieving treatments, manips, posture)

non-surgical

What is the primary diagnosis of LBP (85-95% of cases)

nonspecific LBP (due to the difficulty in localizing the cause)

this is a pulp-like gel located in the mid-to-posterior part of the interbody joint - functions as a modified hydraulic shock absorber - thickened by large proteoglycans; reinforced by type II collagen fibers, elastic fibers, and other non-collagenous proteins - (~toothpaste~/jelly inside donut)

nucleus pulposus

Lumbar *Rotational* syndromes - - Abdominals: (Good/Poor) - Back Extension: (Good/Poor) - Hip flexion/rotation: (Stiff & short/Good & long) - Hip extension: (Stiff & short/Good & long) - Activities:

poor (obliques), good, stiff & short, stiff & short sports/job

Lumbar *Extension* syndromes - - Abdominals: (Good/Poor) - Back Extension: (Good/Poor) - Hip flexion/rotation: (Stiff & short/Good & long) - Hip extension: (Stiff & short/Good & long) - Activities:

poor, good, stiff & short, good & long sits extended/returning from FB

What 6 components are looked at during a general standing examination

posture, forward bend, return from forward bend, back against wall, lateral flexion (side bending), SLS (single leg stance)

The Movement System Impairment (MSI) exam is designed to ID what 3 consistent patterns:

preferred trunk movements, preferred trunk alignments, timing of lumbopelvic movements (and relationships to movements, including extremities, that evoke their symptoms)

what muscles make up the deep group of back mm (transversospinalis mm)

semispinalis, multifidi, rotatores

_____________: the extruded disc material is no longer contained by the outer annulus and has separated and moved away from the IV disc.

sequestration

the geometry, size, and spatial orientation of apophyseal joints in the intervertebral junction greatly influence what

direction of intervertebral motion

Adolescent back pain ___________: disc-related pain is generally exacerbated by flexion and may radiate -approx. 10% of persistent pain in adolescents is disc related

discogenic

Bilaterally, the transversospinalis/deep group of back mm (flex/extend) the spine/axial skeleton

extend

As a group, bilateral contraction of the erector spinae mm (flexes/extends) the trunk, neck, or head

extends

____________: extension of nuclear material beyond the confines of the posterior longitudinal ligament or above and below the disc space, as detected on magnetic resonance imaging (MRI), but may still be in contact with the disc or may be completely sequestrated

extrusion

Red flags that refer pain *to* the low back: ___________: - lumbosacral pain, night pain, symptoms cannot be provoke with mechanical exam __________: -pain occurs after eating in upper lumbar area (L1-2), pain can be relieved by further intake of food, symptoms cannot be provoke with mechanical exam

genital pathologies gastrointestinal pathology

As a general rule: - (Horizontal/Vertical) facet surfaces *favor* axial rotation - (Horizontal/Vertical) facet surfaces (in either sagittal or frontal planes) *block* axial rotation - most apophyseal joint surfaces, are oriented somewhere between the horizontal and vertical planes

horizontal, vertical

During a general supine examination what 6 components/postures are observed

hip flexor length, active hip and knee flexion, hip ABD and ER from hooklying (bent knee falls out), active SLR, passive SLR, shoulder flexion (to 180 deg; looking at lumbar extension)

unilaterally, which erector spinae muscle is the most effective lateral flexor / side bender

iliocostalis

what muscles make up the erector spinae

iliocostalis, longissimus, spinalis

Pain results from muscle _______ as well as improper mechanical _________ and ____________. - the focus of movement system impairment (MSI) is identifying the (tissue generating the pain/mechanical causes of symptoms)

imbalance, posture, movement, the mechanical causes of symptoms

what are possible contributing factors to lumbar flexion syndrome / excessive lumbar flexion

sway back/flat back posture, short glute max &/or hamstrings, short rectus abdominis (may contribute to kyphosis), lengthened paraspinals

the ____________ ______________ approach starts with is the pt irritable and inflamed? (if yes, address with active rest) next, does the pt peripheralize with ext./flex. or have + crossed SLR test? (if yes, prescribe traction) next, does the pt centralize with flex./ext.? (if yes, prescribe specific ex. that centralize symptoms) next, does the pt stop to centralize and have no symptoms distal to knee? (if yes, prescribe manipulation)

symptom modulation

during an active SLR, what structures are responsible for increasing intra-abdominal pressure, which in turn stabilizes the lumbopelvic mechanism

transverse abdominis, thoracolumbar fascia

the typical intervertebral junction has what 3 parts associated with movement and stability

transverse and spinous processes, apophyseal (facet) joints, interbody joints (interbody joints comprised of: IVDs, vertebral endplates, & adjacent vertebral bodies)

Criteria to begin lumbar stabilization (must have 3 or more of these):

younger than 40, hypermobile (greater general flexibility; laxity), instability catch or abnormal movements during lumbar flexion/extension ROM, positive prone instability test (+ for patients who are postpartum, positive pain with: thigh thrust, ASLR, modified Trendelenburg tests, provocation with palpation of the long dorsal SI lig or pubic symphysis)

Fryette's ____ Law/Rule: if motion is reduced in one plane, the motion in the other planes are reduced

3rd

The lumbopelvic rhythm during trunk *flexion* is not a perfect 1:1 ratio, instead lumbar flexion is ~_____deg. and hip flexion is about ~_____deg. - flexion initiates with lumbar flexion and ends primarily with hip flexion

45, 60

A/An (CT scan/MRI) is helpful is pre-op planning (especially in cases of severe dysplasia), whereas a/an (CT scan/MRI) assesses the neural foramen and determines the extent of associated disc disease (can also rule out tumors or infections)

CT scan, MRI

What supplies innervation to the facet joint capsule of the spine - innervation to this area comes from the *level above* and the *same level* (*dual-innervation*) - dual innervation is one of the contributors as to why it is difficult to pinpoint LBP

medial branch of posterior ramus (this branch is also responsible for innervating the multifidi)

When determining the appropriate *management* approach with a patient what are the three possible outcomes: - ______________ management (Findings: red flags, comorbidities precluding rehab, leg pain w/ progressive neuro deficits) (strong evidence) - ____________ management (Findings: medium-to-high psychosocial risk status, low psychosocial risk status w/ predominantly leg pain, and/or minor or controlled comorbidities) (weak evidence) - ___________ management (Findings: low psychosocial risk status, predominantly axial LBP, minor or controlled comorbidities) (moderate evidence)

medical, rehab, self care

List the spinal segments that correlate with the following pain areas - - Lumbar: - Lower lumbar/gluteal: - Posterior thigh: - Lateral thigh: - Anterior thigh: - Groin:

(Lumbar:) L1-L5, (Low lumb/gluteal:) L2-S1, (post thigh:) L3-S1, (lat thigh:) L2-S1, (anterior thigh:) L3-S1, (groin:) L3-S1

When determining the appropriate *rehab* approach for a patient, *what treatments* would fit the following *symptom modulation* clinical findings - - Disability = high - Symptom status = volatile - Pain = high to moderate

(Tx:) directional preference exercises, manips and mobs, traction, active rest (getting back to desired activity but not at level that increases their symptoms and exacerbates their pain) (symptom modulation)

Ely's Test for rectus femoris muscle length:

(The patient lies prone in a relaxed state. The therapist is standing next to the patient, at the side of the leg that will be tested. One hand should be on the lower back, the other holding the leg at the heel. Passively flex the knee in a rapid fashion. The heel should touch the buttocks. Test both sides for comparison. The test is positive when the heel cannot touch the buttocks, the hip of the tested side rises up from the table, the patient feels pain or tingling in the back or legs.)

When determining the appropriate *rehab* approach for a patient, *what treatments* would fit the following *functional optimization* clinical findings - - Disability = low - Symptom status = controlled - Pain = low to absent

(Tx:) S&C (strength and conditioning), work/sport specific tasks, aerobic exercise, general fitness (functional optimization)

Schober's test for spinal mobility

(- tests back flexion - with patient standing, mark L5 level and 10cm above it; have patient try to touch toes and then measure distance between the two lines - positive if increases by less than 5cm - indicates problem with flexion of lower spine) (- two midline marks 10 cm apart starting at the posterior superior iliac spine - remeasure with lumbar spine at maximal flexion - less than 5 cm difference suggests pathology)

Primary motion at the - - C spine: - T spine: - L spine:

(C spine:) rotation (at C1 and C2), (T spine:) side bending, rotation, (L spine:) flexion, extension

criteria that spinal stabilization won't be helpful (must have 3 or more to be positive)

-absent prone instability test -absent aberrant movements during sagittal plane lumbar ROM -absent lumbar hypermobility -score of 9+ on FABQ physical activity subscale (>3 = +LR of 18.8 of seeing less than 5 points of improvement on Oswestry scale)

Fryette's ____ Law/Rule: if the segments are fully engaged in flexion or extension then lateral flexion and rotation occur in the same direction (controversial). - always applies to C spine

2nd

General Recommendations to reduce pain - - _______ minutes of exercise daily - ________ minutes of sunlight daily - Go to bed at (different/the same) time every night - avoid stressful activities, convos, and experiences before bed - relaxation meditation - reduce stress and worry - avoid blue light for ___ hours before bed (tv, tablets, phones, computers)

30-60, 30 (45 on cloudy days), the same, 2

What conservative PT interventions should be performed for patients with Spondylolisthesis (FAST & FITTVP principle)

Flexibility of hip flexors and hamstrings, Activation of core stabilizers, Strength and stability of core stabilizers, Training specific to patient's activity needs/goals Frequency, intensity, time, type, volume, progression

____________ for LBP -previous hx of cancer -failure to improve with a month of conservative therapy -age >50 -unexplained weight loss -no relief with bed rest -insidious onset of symptoms

RED FLAGS (could be cancer...but not guaranteed)

____________ is a spinal condition that affects the lower vertebrae. This disease causes one of the lower vertebrae to slip forward (in the sagittal plane) onto the bone directly beneath it. It's a painful condition but treatable in most cases

Spondylolisthesis

_____________ 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 may also occur in the cervical vertebrae. - most commonly due to repeated and increased stress on the pars interarticularis - estimated to be present in 6-13% of the general population (asymptomatic), but may be the cause of as much as 47% of *LBP in the young athlete* (common cause of adolescent LBP)

Spondylolysis

this condition of the spine is an inflammatory disease that, over time, can cause some of the bones in the spine (vertebrae) to fuse. This fusing makes the spine less flexible and can result in a hunched posture. If ribs are affected, it can be difficult to breathe deeply.

ankylosing spondylitis

Risk factors for disc herniation

age (most susceptible to symptomatic disc injuries b/w 30-45 y/o), degenerative changes (any loss of disc integrity), genetics (strong genetic component), spinal mechanics, pathologies

Red flags that refer pain *to* the low back: ___________: -pain at rest or at night, pulsating abdominal mass is found with inspection/palpation, family hx of CV disease, symptoms cannot be provoke with mechanical exam __________: -older individual, family hx of CV disease, pain in calf with activity/relieved with rest, one foot is colder than the other, symptoms cannot be provoke with mechanical exam __________: -sudden sharp pain of intermittent nature (reaches testicles or labium), same pain w/ fever = renal infection, symptoms cannot be provoke with mechanical exam

aneurysm vascular claudication kidney stone

Red flags that refer pain *from* the low back: ___________: -middle-aged individual, pain on and off (regardless of exertion), progressive loss of ROM, alternating pain in SI joints with walking, later sign: gross bilateral limitation of side bending, pain goes in vertical direction (not laterally or to LE), stiffness in the morning eases w/ movement, no paresthesia ___________: -widespread pain, pain doesn't follow anatomical pattern, high psychological distress, pain disproportionate to provocation and easing tests, hypersensitivity to light touch

ankylosing spondylitis central sensitization disorders

this structure in the Interbody joint is made up of 10-20 concentric layers of collagen fibers with an alternate layering pattern at 65 degrees - collagen rings encase and physically entrap the liquid-based central nucleus - contains material similar to that found in the nucleus pulposus, differing only in proportions - (~hold toothpaste in middle~/outside of donut)

annulus fibrosus

these joints are classified as planar surfaced joints. - typically flat or nearly flat --> cause them to either approximate, separate, and/or slide

apophyseal (joints)

The facet joints of T1-T2 are typically innervated by the medial branches from: a. only T1 b. C8 and T1 c. T1 and T2 d. T2 and T3

b (C8 and T1; innervated by the segment above and same level)

When is intervertebral disc most at risk for rupture? a. in the afternoon seated in a chair with back support b. upon rising in the morning and flexing through their back to pick up their dog c. stretching their hamstrings after a grueling day of instruction to PT/OT students

b (IVD pressure highest in the morning)

while *85%* of patients who present to their PCP have LBP that cannot be attributed to a specific disease or spinal pathology, what *rare* conditions must be ruled out (7)

cancer, compression fx, AS (ankylosing spondylitis), spinal infection, spinal stenosis, herniated disc (symptomatic), cauda equina syndrome

The follow are _________________________: -larger shoulders or chest (increased load on lumbar spine) -no back rest, sitting on the edge of the chair (feet may not reach the ground) (increases hip flexion) -leaning to one side, sitting on one foot (increased lateral flexion) -increased kyphosis (compensate w/ increased lordosis) -tall men with long tibias (increased lumbar flexion) -large abdomen (needs a seat that angles) -other compensations (increases muscular activity of adductors, hamstrings, lumbar ext.)

common impairments with sitting

(consistent/inconsistent) LBP: •intermittent, variable, •L LBP extending to L post. thigh •Paresthesias along the anterolateral aspect of L LE •Pain increased with: L SB, Ext, PSR on L, prolonged walking & sitting •Increased with coughing & sneezing •No Hx of CA or general health concerns

consistent

External obliques - - (ipsilateral/contralateral) rotators - (ipsilateral/contralateral) side benders/lateral flexors

contralateral, ipsilateral

Transversospinalis/deep group of back mm: - (ipsilateral/contralateral) spinal rotators - (ipsilateral/contralateral) side benders/lateral flexors

contralateral, ipsilateral

Lumbar facets start more (curved and sagittal/flat and coronal) superiorly, whereas they are more (curved and sagittal/flat and coronal) inferiorly/caudally

curved and sagittal, flat and coronal

Management of inflammatory back pain involves all of the following EXCEPT: a. stretching exercises b. strengthening exercises c. NSAIDs d. Adding pillows for stability and support e. conditioning exercises (improve CV status) f. Medication (e.g. sulfasalazine, methotrexate)

d (adding pillows for stability and support; when managing inflammatory back pain pillows should be avoided)

(Classification/Diagnosis) refers to the determination of the cause of a patient's signs and symptoms, whereas (classification/diagnosis) is the process of analyzing and arranging clinical data into named categories of clinical entities for the purpose of making clinical decisions regarding therapeutic management

diagnosis, classification (4 primary classification schemes in PT = McKenzie, Sahrmann, O'Sullivan, TBC)

Wiltse classification system for spondylolisthesis causes - - ______________ spondylolisthesis: congenital defect of L5 and S1 vertebrae - ______________ spondylolisthesis: stress Fx involving the pars interarticularis (*most common form of spondylolisthesis*) - ______________ spondylolisthesis: OA of the spinal facet joints - ______________ spondylolisthesis: Fx of the vertebral arch - ______________ spondylolisthesis: bone disease (e.g. Paget's, osteosarcoma) - ______________ spondylolisthesis: occurring after L-spine surgery (e.g. spinal fusion, laminectomy)

dysplastic, isthmic, degenerative, traumatic, pathologic, iatrogenic (Isthmic = most common because pars Fx's can occur for a variety of reasons. 3 ways pars may become fractured: 1) micro Fx leading to complete Fx common in athletes that frequently hyperextend their spines, e.g. gymnasts. 2) pars bone increases in length due to a Fx of the pars that has new bone growth b/w the fractured portions. 3) trauma/sudden forces, e.g. MVA, falls)

A person's disc/IVD is more susceptible to higher forces and thus injury at what point in the day: early morning mid afternoon late evening

early morning

What point of the day are you most flexible: Morning Evening

evening

this source of LBP is reported to cause 5-15% of chronic LBP and is a result of repetitive stress, cumulative trauma, OA, and inflammation - The function of this source is to protect the spine from excessive movement based on its shape and features; bears 3-25% of axial load (increased during standing, decreased while sitting) - Hx & PE: back pain potentially associated w/ groin or thigh pain, paraspinal tenderness, *reproducible Sx with extension & rotation*, coughing does *NOT* exacerbate symptoms - pain from this source should not radiate below the knee - pain should be *mechanical* and *reproducible*

facet joint (facetogenic LBP) (While facet joint OA is decently common that doesn't mean it's the most common cause of LBP)

T/F: LBP alone with no LE symptoms is generally due to lumbar spinal stenosis

false (LBP alone w/o LE symptoms is usually NOT thought to be caused by LSS)

what are possible contributing factors to lumbar rotation with flexion syndrome / excessive lumbar rotation with flexion

fitness activity requiring unilateral movement, leg length differences, occupational (rotation of trunk without rotation of pelvis during work activities), postural habits (sitting cross legged or on one foot), IT band asymmetry (from TFL or glute max), lack of oblique control (on the pelvis)

During a general sitting examination what 4 components/positions are observed: (sitting with lumbar region...)

flat, flexed, extended, knee extension (L spine should remain flat)

Lumbar *Flexion* syndromes - - Abdominals: (Good/Poor) - Back Extension: (Good/Poor) - Hip flexion/rotation: (Stiff & short/Good & long) - Hip extension: (Stiff & short/Good & long) - Activities:

good, poor, good & long, stiff & short sits flexed

Tripod/flipping sign tests for tightness in what muscle group

hamstrings (active knee extension)

__________ messages about LBP -LBP is rarely associated with serious pathology or structural damage -LBP is influenced by many things, such as your activity levels, sleep patterns, mood, worries, response to stress, habitual body postures, and level of conditioning -while there is no ideal posture, varying your posture is helpful -rest, avoidance of activity and taking time off school are usually not helpful -regular physical activity, maintaining a positive mindset, good sleep patterns, maintaining a healthy weight, and learning to handle stress are good -if your back hurts carrying a backpack or playing sports, then get your ack strong and conditioned so it will handle loads better

helpful

__________: displacement of disc material beyond the normal limits of the IV disc space. It may include the nucleus pulposus, cartilage, fragmented apophyseal bone, or annulus fibrosus. Herniated discs are further described as protrusions or extrusions, based on the shape of material outside the disc space.

herniation

(consistent/inconsistent) LBP: •Pain most intense in evening and at night making it sometimes difficult to fall asleep. Sometimes awaken because of pain, but he was able to fall asleep rather quickly after finding a comfortable position. atypical restricted motion pattern •Increased with coughing & sneezing •L hip: passive adduction limited and reproduced L post thigh pain, while passive hip flexion, IR, and ER were equal bilaterally). - noncapsular pattern

inconsistent

Dx Inflammatory back disease - - (Acute/Insidious/Cumulative) onset - Symptoms begin *before* age ______ - (Evening/Morning) stiffness > 1 hour - Activity (worsens/improves) symptoms - Systemic features (skin lesions, eye inflammation, GI and GU sx) - peripheral joint involvement - *infections* - Physical exam: - (hypo/hyper) mobile axial motions in all planes -look for signs of infection or other systemic diseases (AS, psoriasis, IBD, Reiter's)

insidious, 40, morning, improves, hypo

improper movement occurs b/c of ______________ muscle stiffness, stretching a muscle will not correct the faulty movement pattern, but correcting the movement pattern will change the ____________ of the muscle

insufficient stiffness

what mm are the most effective axial rotators of the trunk

internal and external obliques

during axial rotation, the external oblique mm of one side function *synergistically* with what mm?

internal obliques of the other side

what are possible contributing factors to lumbar extension syndrome / excessive lumbar extension

kyphosis, exaggerated lordosis, forward bend (FB), abdominal muscle deficiency (if kyphotic--RA may be short, may need to increase stiffness of thoracic paraspinals), short/stiff hip flexors (and/or paraspinals), obesity, large buttocks

6 most important factors in the Dx of lumbar spinal stenosis (LSS):

leg pain while walking, flexing forward (while walking) relieves Sx, sitting or bending forward relieves pain, normal foot pulses, relief with rest, LE weakness

what is the purpose of quadruped exercises

lengthen thoracic & promote proper hip flexion

what are the important ligaments of the spine

ligamentum flavum, supraspinous and interspinous ligs, ligamentum nuchae, intertransverse ligs, anterior and posterior longitudinal ligs, joint capsule

Name the spinal condition based off the following findings/clinical presentation - - Hx: recurrent episodes of LBP with progressively increasing disability, short-term relief or increased Sx from manipulation/mobs, Hx of trauma, *"catching"* feeling with movement, improvement of Sx with lumbo-sacral orthosis (LSO) - PE: typically *no* ROM limitation, abnormal movement patterns generally present, muscle weakness (pelvic floor, abdominals, multifidus, glute max, iliopsoas, TFL, hammies, rectus femoris) - If correcting improper movement patterns *decreases* pt's Sx --> work on motor control

lumbar instability (PE consists of: "step off", abnormal movements, + Gower's sign, painful arc, reversal lumbopelvic motion, Passive accessory intervertebral movement -PAIVM-, passive physiological intervertebral motion/movements -PPIVM-, radiographic flexion/extension testing, Beighton 9-point scale) (Gowers' sign: that indicates weakness of the proximal muscles, namely those of the lower limb. The sign describes a patient that has to use their hands and arms to "walk" up their own body from a squatting position due to lack of hip and thigh muscle strength)

a degenerative condition in which changes in the discs, ligamentum flavum, and facet joints with aging cause narrowing of the spaces around the neurovascular structures of the spine. These changes lead to pain in the legs and back, as well as impaired ambulation and other disabilities. - A narrowing of the spinal canal in the L spine which can put pressure on the spinal cord and the nerves that travel through the spine. - Age-related changes are the most common cause (aka: *most cases are degenerative*) - Sx: pain or "cramping/burning" in the legs when standing for long periods or when walking, LBP, pain in buttocks, thighs, and legs; reflex changes, balance and sensory loss, decreased gait speed, LE weakness - The discomfort usually eases when bending forward or sitting down. - Tx (non-surgical): drugs (NSAIDs, corticosteroids), spinal injections, physiotherapy

lumbar spinal stenosis (LSS)

the ____________ ______________ approach starts with is there a sensitized neurological structure (if yes, address it) next, is there a joint mobility or muscle flexibility impairment? (if yes, prescribe flexibility ex. or joint mobs) next, is there a motor control impairment? (if yes, prescribe motor control ex.) next, is there a muscle endurance impairment (if yes, prescribe endurance ex.)

movement control

Adolescent back pain ___________: pain tends to be localized to paraspinals of the thoracic/lumbar area rather than over the spine itself

muscular

With patients who have a posterior HNP, what are *contraindications* to the extension approach:

no movement/position decreases pain, saddle anesthesia, bladder weakness, patient in so much pain they're rigid and immobile with any attempted correction

this is the region between the superior and inferior articulating facet of the vertebra - weakest area in the neural arch - susceptible to stress Fx -defects here are known as scotty dog fx's

pars (interarticularis)

key concepts for dx & tx -the body follows the __________ of least resistance for motion -relative stiffness/flexibility -you get what you train -presence of a ________ does not mean that it is being appropriately used -no magic in an exercise unless the desired motion is evident -the way everyday activities are performed is the ________ issue -hypermobility causes __________ & ___________

path muscle critical degeneration & pain

Red flags that refer pain *from* the low back: ___________: -older individual, female, prolonged corticosteroid use, mild trauma or sudden pain w/o reason, hx of osteoporosis, sign of the buttock if sacral insufficiency fx present __________: -athletic female, increased level of vigorous/repetitive activity, pain involves the buttock, pain reproduced with athletic activities, dietary insufficiency, menstrual irregularities, previous stress fxs, non-responsive to previous treatment _________: -young individual, repetitive hyperextension injury, sudden severe bilateral sciatica occurred during athletic activity, pain with extension (passively prone), no urinary bowel incontinence

pathologic fx sacral stress fx acute spondylolisthesis

________: the displaced disc material is continuous with the material within the disc. This is also described as the nuclear material being contained by the outer layers of the annulus and supporting ligamentous structures

protrusion

what are possible contributing factors to lumbar rotation with extension syndrome / excessive lumbar rotation with extension

sports, older age (more common in individuals older than 55), postural habits (standing on one foot or crossing legs, occupational demands of rotating trunk and not entire body), abdominal deficiency, IT band asymmetry

__________ level of evidence for LBP -consider using repeated movements, exercises or procedures to promote centralization in pts with acute LBP and referred lower extremity pain -consider repeated exercises in specific direction determined y treatment response to improve mobility/reduce symptoms -consider utilizing thrust and nonthrust mob procedures -consider utilizing trunk coordination, strengthening and endurance ex. -consider mod to high intensity ex. -incorporate progressive, low-intensity, submaximal fitness ex into pain mgmt/health promotion

strong!!

__________ messages about LBP -LBP means something is seriously wrong, or out of place -when the spine is too mobile, it can lead to chronic LBP -scoliosis causes LBP -poor posture, such as slump sitting, is the cause of LBP -physical activity & carrying school bags should be avoided if painful -with LBP, the spine should be rested and school avoided

unhelpful