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Flashcards in Clinical Syndromes Deck (34):
1

3 categories of Lumbar Spine issues

1. Serious spinal pathologies - tumor, infection, fracture, CE syndrome

2. Sciatica - back-related LE symptoms - stenosis, arthritis, inflammation, diabetes, etc

3. Nonspecific LBP - dysfunctions of musculoskeletal tissues

2

Spinal Stenosis
- DEFN
- MOI
- SYMPTOMS

narrowing of central canal or lateral/iV foramina
- more commonly seen in men & >60yrs old

MOI - congenital, age related degeneration or anterior slippage
--> other causes = facet joint arthrosis, LF thickening, buldging of IVD

Symptoms - long history of LBP, leg pain, neurogenic claudication
AGG w/ extension, walking downhill, lying flat
EASING w/ flexion, sitting, walking uphill

OBJECTIVE findings - flat back
due to tight/short hip flexors & lengthened/weak hip extensors

3

Neurogenic Claudication
- what is it
- when should you see it

compression of nerve w/n canal that causes limitation of arterial supply OR claudication due to obstruction of venous return

Brought on by walking & relieved by rest

Peripheral pulses will be present & no localized leg symptoms (like vascular claudication)

4

Spinal Stenosis
- TREATMENT

GOALS - redue pain, improve mobility & muscle balance, improve aerobic fitness

- Educate - ADL's w/ neutral spine,positioning through a posterior pelvic tilt
- Mechanical traction or rotation mobilizatino
- Ther ex - stretch hip flexors & strengthen hip extensors & abdominals

WATCH for ANT tilt compensations

5

Acute Facet Joint
- DEFN
- MOI
- SYMPTOMS

DEFN - mechanical block from meniscoid

MOI - return from flexion

SYMPTOMS - unilateral pain that is sharp over the facet, increased pain w/ stretch/compression of joint, limitations in side bending & extension, local tenderness, history of sudden unguarded movement

6

Meniscoid

synovial fold located at superior/inferior aspects of facet joints that provide & prevent excessive motion

can be dislodged and cause acute facet joint

AKA "locked back"

Usually occurs during return from flexion

7

Acute Facet Joint
-TREATMENT

Manual therapy - unilateral PA, traction, manipulation

Modalities

Ther ex - mobility

Excellent prognosis

8

Chronic Facet Joint
- DEFN
- MOI
- SYMPTOMS

an acute facet joint problem that did not resolve

MOI - DJD, facet hypertrophy, osteophyte formation (arthritis), inflammation, micro-fracture

SYMPTOMS - unilateral pain (may refer to buttock area), stiffness & pain in AM, hypomobility
AGG - prolonged INACTIVITY// activity and tehn worsened again w/ activity
EASING - flexed posture

9

Chronic Facet Joint
-TREATMENT

MT - rotation, uniltaeral PA's, traction, manipulation

Ther ex - stretching & muscle re-education

Address faulty movements

Facet joint injections or nerve block

10

Acute Nerve Root
-DEFN
-MOI
-SYMPTOMS

irritation/inflammation, compression, or tension to the nerve root

MOI - disc pathologies, DDD/DJD

SYMPTOMS - DISTAL > PROXIMAL
pain severly limits activity, very limited ROM, level specific neuro symptoms, positive SLR & slump test

11

Acute Nerve Root
-TREATMENT

MT - manual traction in supine or sidelying

Ther ex - lumbar rotation

Epidural steroid injection

12

Chronic Nerve Root
- DEFN
- MOI
- SYMPTOMS

chronic irritation to the nerve root/adhesion

MOI - history of disc pathology, NR injury, degenerative changes, spinal surgery/scarring

SYMPTOMS - PROXIMAL > DISTAL
- minimal limitation of activity, localized thickness in tissues, stiff at segment, pain w/ OP in ROM, movement impairments

13

Chronic Nerve Root
- TREATMENT

MT - unilateral PA's, rotation, traction, soft tissue work

Mobility exercises

Segmental re-education

Treatment of neurodynamic & movement impairment findings

14

Spondylolysis
- DEFN
-MOI
- SYMPTOMS

Structural Instability

increased IV segment motion due to defect in pars interarticularis

MOI - extreme hyperextension, sports injuries, occupation

SYMPTOMS - increased IV segment motion & pain

15

Spondylolisthesis
-DEFN & classifications
-MOI

Structural Instability

slippage of vertebra (anterior) due to complete fracture

Grades:
I - up to 25%
II - 25-50%
III - 50-75%
IV - >75%

MOI - extreme hyperextension or fracture

16

Functional Instability
- due to
- DEFN

Due to DDD, ligament injury, muscle injury or poor motor control

DEFN -abnormal movement of one vertebrae over another, inability to maintain neutral zone or segmental hypomobility

Radiograph will appear normal

17

Functional instability
- SUBJECTIVE
- SYMPTOMS

Subjective info
- most common at L5/S1 (wt bearing joint)
- pain w/ extreme ext or rotation
- constantly changing their position, which will decrease pain
- history of catching or locking, giving way or feeling of instability **
- AGG by vigorous activity, static posture or returning from flexion **

History - chronic **

18

Functional Instability
- Objective info

Increased LL
End ROM provoke symptoms
Hesitation w/ flexion at 30-40 (global muscles shut down & local muscles kick in)

** + Gower's sign
** Extension reveals hinge
** Cetnral PA painful and altered end fel

Poor pelvic and abdominal control

19

Functional Instability
-TREATMENT (ther ex)

1. Train local muscles FIRST
--> tonic, low threshold exercises (10% contraction needed to stabilize the spine)

2. Pelvic control exercises
3. train endurance!
4. Muscles targeted: TA, multifidus, glutes, external obliques
--> No global muscles (rectus abdominus)

20

DDD
- what is it
- due to...

Normal aging process, becomes pathologic when pain is involved
- disc integrity decreases
- decreased ability to retain water
- decreased ability to distribute load

DUE TO:
1. Biochemical changes: dec rate of proteoglycan synthesis, type II collagen increases
2. Nutrition deprivation due to lack of movement
3. Mechanics: shear forces
4. Genetics: bad collagen

21

DDD
- SUBJ
-SYMPTOMS

Commonly @ lumbosacral joint, males, 40-50's

MOI - insidious, gradual onset due to aging

Symptoms:
1. low grade ache, morning stiffness/pain
2. rarely leg symptoms
3. AGG: extending, bending, sitting, sustained posture, sudden motions
4. ROM limited if acute
5. pain w/ ext & rotation
5. altered tissue texture
6. sustained movements
7. NEG SLR

History of repeated microtrauma, bone spurs, or significant trauma

22

DDD
- TREATMENT

GOALS: decrease compression, promote nutrition, improve mobility/flexibility, strengthen core muscles, promote function

1. Education on body mechanics & unloading
2. Ther ex: hip flexibility, disc rehydration in unloaded position
- 90/90 position, 15-20 minutes

23

Disc Herniation
-DEFN
- Clinical Presentation

displacement of nucleus pulposus
--> Most common @ L4/L5 (L5 nerve root) or L5/S1 (S1 nerve root)

Clinical Presentation:
- usually younger
- symptoms: poorly localized dull ache w/ referral, pain w/ COUGHING & SNEEZING, neurological signs
- lateral shift away from the pain
- sudden onset

24

Intraspongy Disc Herniation

fracture in endplate due to too much loading/compression
- nucleus migrates into vertebral body
- more common in TS
- erosion of trabecular bone = Schmorl's nodes

25

Protrusion

nucleus migrates outward through tear in annulus but does NOT escape from intact outer AF or the PLL

- contained herniation
- more extent protrustion may have neurological symptoms

26

Prolapse/extrustion

nucleus material escapes the AF and the PLL but remains attached to the disc

- intense pain due to chemical reactions

27

Sequestration

free fragment of the NP that is free to migrate

28

Posterolateral vs. Posteromedial disc herniations

Posterolateral - most common
- bulge/protrusion LATERAL to the nerve root
- protective scoliosis: shift to OPPOSITE side

Posteromedial
- protrusion MEDIAL to nerve root
- protective scoliosis: shift to the SAME side

29

Disc Herniation
- TREATMENT

McKenzie Protocal - repeated extension

MT - intermittent traction (best during SUBACUTE stage)

Educate on body mechanics, sit in slightly extended posture to unload

Ther Ex - abdominal bracing, walking, focus on hip motion & limit spine motion

Epidurals, steroids or surgery

30

Sacroiliac Dysfunctions

Torsions or Rotations

Torsions are named after the direction of rotation & direction of axis
- i.e. Right rotation on a Left axis (R on L) = R sacral base is posterior and there is backward (counternutation) torsion

31

Iliosacral Dysfunctions
- rotations

anterior & posterior rotated ilium
- ANT = ASIS anterior and inferior, functionally LONG leg, decreased posterior rotation and decreased hip flexion

32

Iliosacral Dysfunctions
- Upslip/downslip

Upslip = ASIS & PSIS superior
- decreased strength in hip abductors

Downslip = inferior

33

Iliosacral Dysfunctions
- inflare/outflare

Inflare - ASIS medial and PSIS more lateral

vice versa for outflare

34

Symptoms of a Hypermobile SI joint

pain w/ change in position
deep shift or clunk
difficulty with WB activities
positive stability tests
positive SLR

NO centralization w/ repeated motions