Class 5/6: Persistent IDD-Hypermobility Flashcards by Braden Talbert

etiology of persistent IDD

acute IDD

age = mixed findings

lower strength

sedentary life

heavier lifting

smoking

genetics (lumbar IDD associated with ARDC)

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how much of persistent IDD can be inherited

65-85% but can be modified by diet and lifestyle

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what are things that are NOT a cause of persistent IDD that some may think are

routine load/PA
prolonged driving

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pathogenesis of persistent IDD

in growth of nociceptive fibers from acute IDD

excessive/destructive proteins cause low grade infection

less gags = dehydrated nucleus

annular disorganization

thinning of cartilage/end plates

fatty deposits in vertebrae

THEN persistent herniations develop once disc changes occur

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what is protrusion

nucleus migrates but remains in annulus

most common

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what is extrusion

nucleus migrates thru outer annulus

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what is free sequestrian

nucleus migrates and breaks away from annulus

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where do schmorls nodes develop

where the nucleus migrates into the vertebral body

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why is a herniated disc not white on an MRI

because it lacks the same water content as a normal disc

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how does narrowing play a role in the case of persistent IDD

changes in disc height/integrity lead to instability and hypermobility (sagittal and frontal plane only)

then the space in the joint narrows which leads to instability and greater loads on the facets

stenosis can develop from there

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what are later changes that can occur with persistent IDD after the initial narrowing

greater ARJC

less of the prior instability due to stiffening of the joint

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symptoms presentation for persistent IDD

slow change allows tissues to adapt without symptoms for some time

i.e. 2/3 of people who have disc issues on imaging have no symptoms q

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PT Rx for persistent IDD

acute IDD Rx if inflamed

Mckenzie exercises less effective compared to acute IDD

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effect of mckenzie exercises with persistent IDD

NOt better than stabilization

NOT better than manual therapy + non-stabilization exercises

short term benefit

no difference in pain/function vs no intervention at all

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important thing to consider for PT in relation to Rx for persistent IDD

need to consider the primary driver of symptoms from the development of other conditions even if the imaging shows disc changes

i.e., ARJC, stenosis, instability, etc

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prognosis for acute AND persistent IDD

like ligament/cartilage healing with longer timelines due to prolonged inflammatory phase

90% see improvements by 6 weeks

most dont need surgery

slower healing but the same overall outcomes without surgery after 2 years

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Worse outcomes are present for IDD when symptoms are present for more than how long prior to treatment

more than 6 months prior to any treatment including sx

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meds that may be used for IDD

NSAIDS, muscle relaxants and acetaminophen

conflicting benefits

possibly Rx for steroid pack for large inflammatory response

epidural = short term relief

antibiotic for benefits related to infection

effectiveness of sx for IDD

waiting an average of 4.5 months on sx did not minimize benefits of sx

some studies how earlier and improved benefit of sx vs PT with severe acute IDD

what are the indications for a spinal decompression sx such as a laminectomy or a partial discectomy

persistent/worsening radiculopathy

use when symptoms are unresponsive to non-surgical treatments

effectiveness of lumbar fusion for IDD

no difference vs PT long term

not additive to a laminectomy or discectomy

can cause adj joint hypermobility/instability

total disc replacement (TDR) effectiveness for IDD

better at load distribution across segments

safe/effective treatment more than 5 years post op

at 2 year follow up no differences compared to PT alone without radiculopathy for in return to work, life satisfaction, fear avoidance behavior, drug use, and back performance

4 variables of stabilization

joint integrity
passive stiffness
neural input
muscle function

what are the 2 types of instability

functional = CAN be stabilized with m activity/positioning

mechanical = CANNOT be completely stabilized with m activity/position

etiology of instability

traumatic/recurrent sprain ARDC repetitive ext activities creep connective tissue disorder

which segment is hypermobility most common

L4-S1 lower lumbar

what can you get points for when testing for benign joint hypermobility syndrome

palms touch floor each knee that hyperextends each elbow that hyperextends each thumb that touches forearm each little finger that has 90 degree MCP hyperext

minor criteria for hypermobility

>4/9 beighton scale arthralgia > 3 months > 4 jts

what are the minor criteria for instability

beighton scale <3/9 arthralgia > 3 months in 1-3 soft tissue injury in > 3 locations tall slim body abnormal skin varicose veins

what are the requirements to be diagnosed with benign joint hypermobility syndrome

2 major criteria 1 major and 2 minor 4 minor

symptoms of functional instability

predictable pain spine and referred pain possible paresthesias decreased pain with posiiton/support increased pain with prolonged position, repetitive bending, sudden motions, and strenuous ADLs catching self manipulation

ROM signs for functional instability

acute = aberrant P! with ext due to anterior shear Flx = Gowers sign = use hands to get up PROM > AROM not acute = often WNL except ext crease greater flexibility inconsistent block

signs that indicate aberrant AROM

painful arc uncoordinated Gower's sign LE/pelvis compensation positive if one or more are present

resisted/MMT for functional instability

if acute = painful most often strong and painless bc global muscles arent affected

neuro for functional instability

- except possible hyperparesthesia with pinwheel

stress tests for functional instability

+ PA stress tests mixed findings with distraction; depends on severity

acessory motion for functional instability

possibly hypomobility if hypermobility is stuck like a drawer possible adj hypomobility (T10-12 RT, SI jt motion, and hip ext common)

special tests that may be positive with functional instability

possible + prone LE ext test likely + linear stability possible + active SLR inhibited local muscles

describe what you may find in relation to linear stability tests with functional instability

most often anterior shear LBP can lead to excessively recruited psoas (maintains lordosis when standing; excessive recruitment can cause hyper ext and anterior shearing with L/S hypermobility)

what is ASLR and how is it scored

active SLR score 1 pt for each: -tremor -pain -ips pelvic RT to raised LE -slow motion -unable to raise LE

symptoms of mechanical instability

same as functional but worse AND pain is unpredictable worse/more frequent symptoms increased pain with lesser ADLs + stability tests dont fully stabilize

what might radiographs show for instability

stress radiographs = compare vertebreal position in various positions for mechanical instability may also be a spindylolisthesis functional instability can exist without radiological evidence

MD Rx for shearing/slipping with mechanical instability

prolotherapy for stabilization into iliolumbar ligaments + PT spinal fusion if: -mechanical instability -similar long term results to multi discipline PT -higher cost/greater risk

PT Rx for instability

like ligament laxity POLICED postural edu to activate local muscles/chair support JM to increase adj hypomobility bracing/taping MET emphasizing stabilization of local muscles, hip exercises, and contraindicated hyperext