E2 Flashcards
(134 cards)
1
Q
Axis is located anteriorly at the level of S2, near the junction of the long and short arms of the SI joint
A
Middle transverse
2
Q
Axis on which the sacrum flexes and extends in response to truncal motion
A
Middle transverse
3
Q
What is the normal motion of the middle transverse axis?
A
Slight truncal F/E –> sacrum flexes and extends with the spine
Further flexion (lumbar lordosis begins to reverse) –> sacrum extends
Further extension –> sacrum flexes
4
Q
Who demonstrated the mobility of the sacrum on the middle transverse axis radiographically?
A
Kottke in 1962
5
Q
Who demonstrated the mobility of the sacrum on the superior transverse axis radiographically?
A
Pruzzo in 1971
6
Q
This axis is located in the posterior superior sacroiliac ligaments, about the level of S2
A
Superior transverse
7
Q
Axis the sacrum moves upon with ventilation
A
Superior transverse
8
Q
What is the normal movement of the superior transverse axis?
A
Inhalation –> extension
Exhalation –> flexion
Cranial base flexion –> extension
Cranial base extension –> flexion
9
Q
Axis upon which motion of the sacrum occurs, synchronous with cranial movement during the cranial rhythmic impulse cycle
A
Superior transverse
10
Q
Axis at the level of the ILAs
A
Inferior transverse
11
Q
Axis on which the inominates rotate during the gait cycle
A
Inferior transverse
12
Q
What are the oblique axes named for?
A
Their superior pole
13
Q
This is actually an axis of pelvic rotation during the gait cycle, but it appears to be located posteriorly in the vicinity of the sacrum
A
Vertical
14
Q
Sphinx test –> sacral sulci become more symmetric
A
Anterior dysfunction
15
Q
What is a torsion?
A
Two parts of an object rotating in opposite directions about a single axis
16
Q
What is the normal torsional mechanism of L5?
A
L5 is tightly anchored to the iliac crests by iliolumbar ligaments, so L5 moves with the ilia. When you compare L5 to the position of the sacral base, it appears that the two have rotated in opposite directions about a vertical axis.
17
Q
What is a compensated L5?
A
Normal torsional mechanism of L5
18
Q
What is a non-compensated L5?
A
When L5 rotates with the sacrum rather than the ilia
19
Q
What determines the direction of sacral rotation?
A
Motion of the anterior most point on the sacral promontory
20
Q
What causes an anterior sacral torsion?
A
- Truncal sidebending and rotational forces in extension coming down from the lumbar spine
- Exaggeration of the gait cycle
21
Q
What are the symptoms of anterior sacral torsion?
A
Backache, buttock ache
22
Q
What causes a posterior sacral torsion?
A
Truncal sidebending and rotational forces in flexion coming down from the lumbar spine
(NOT caused by gait cycle)
23
Q
What are the symptoms of a posterior sacral torsion?
A
Intense low back and hip pain, piriformis pain, patient often walks with a limp
24
Q
Extra deep sacral sulci
Increased lumbar lordosis
A
Bilaterally flexed sacrum
25
Really shallow sacral sulci
ILAs very far anterior
Flattening of the lumbar lordosis
Bilaterally extended sacrum
26
What can cause sacral dysfunctions?
HIPLSIT dysfunctions
```
Hip muscles
Inominate
Pubic symphysis
Lumbar dysfunction
Sacroiliac
Thoracic
```
27
What is spondylolysis/listhesis?
A forward slippage of one vertebra on the segment below it
28
Where does spondylolysis most commonly occur?
L5/S1
29
What are the congenital predispositions for spondylolysis?
Spina bifida occulta
Genetically weak/thin parts interarticularis
African American heritage
Sacralization of L5
30
What condition disproportionately affects African Americans?
Degenerative spondylolisthesis (usually at L4)
31
A lytic defect in the pars interarticularis predisposes a person to what condition?
Spondylolysis
32
What has been implicated as a postural fault responsible for spondylolysis/listhesis?
Hyperlordosis
33
Spondylolysis requires...
Upright posture and lumbar lordosis
34
When does spondylolysis develop?
Ages 6 to 8, but presents around age 30
35
What is the main symptom of spondylolysis?
Persistent low back pain for more than four weeks
36
What condition may also be present with spondylolysis?
Sciatica
37
Increased turbulence in spondylolisthesis indicates increased risk for developing...
Abdominal aortic aneurysm
38
What are the physical findings of spondylolysis?
```
Laterally flared ilia
Back and abdomen thrust forward
Short waist with transverse abdominal crease at the level of the umbilicus
Flattened, heart-shaped buttocks
Gait changes
```
39
What indicates spondylolisthesis greater than Grade II?
Stiff-legged, short stride / waddling gait in which the pelvis rotates with each step
40
Palpation findings for spondylolisthesis
Segmental hypermobility
Anteriorly located spinous process (step off)
Rocking of the sacrum into flexion INCREASES symptoms
Paraspinal mucles are boggy/slow to relax
41
Cauda equina involvement in spondylolisthesis warrants what action?
EMG/NCV evaluation
42
What imaging is essential in diagnosis spondylolysis/listhesis?
Standing lateral x-rays of the lumbar spine
43
Isthmic pars interarticularis defect occurs at what spinal levels?
Almost exclusively at L5
44
Congenital defect in neural arch of L5 or upper sacrum --> insufficiency of lumbosacral facets --> plane of facet joints approaches horizontal
Dysplastic spondylolysis
45
Lytic fatigue fracture of the pars
Most common form under age 50
Rapid progression from ages 9-15
Stress fracture which does not heal
Dysplastic spondylolysis, subtype A
46
Elongated but intact pars
| Probably due to repetitive microfracturing with elongation occurring during healing
Dysplastic spondyloylsis, subtype B
47
Acutely fractured pars
History of severe trauma
May heal with immobilization
Dysplastic spondylolysis, subtype C
48
Degenerative spondylolysis accounts for what percentage of all cases?
25%
49
Osteoarthritic changes at apophyseal joints due to long standing segmental instability
Degenerative spondylolysis
50
At what spinal level does degenerative spondylolysis most commonly occur?
L4 due to sacralization of L5
51
Possible causes of pathologic spondylolysis
```
Arthrogryposis
Kuskokwim disease
Osteogenesis imperfecta
Osteitis deformans
Tuberculous osteomyelitis
```
52
Congenital curved joints --> potential for lumbosacral agenesis
Multiple joint contractures
UEs adducted and internally rotated
Diamond-shaped LEs
Skin is very smooth with no skin creases at joints
Arthrogryposis
53
Only occurs in native Eskimos living in a certain region of Alaska
Genetic autosomal recessive disorder
Similar to arthrogryposis
Kuskokwim disease
54
What are the Meyerding grades of spondylolisthesis?
Grade I: 0-25% slip
Grade II: 26-50% slip
Grade III: 51-75% slip
Grade IV: 76-100% slip
55
What is the Napoleon Hat Sign?
Seen in the AP lumbar x-ray in the presence of severe (Grades III-IV) spondylolisthesis
56
What is the effectiveness of treatment in spondylolisthesis?
Works in Grades I and II
Iffy in Grade III
Usually Grades III and IV require surgical fusion
57
What shoes can spondylolisthesis patients not wear?
High heels
58
What activities should people with spondylolisthesis avoid?
Heavy lifting
Contact sports
Gymnastics
Diving
59
How long before exercise affects spondylolisthesis?
8-12 weeks
60
What type of exercises should be performed for spondylolisthesis?
Williams Flexion Exercises
61
What are the goals in manipulation of spondylolisthesis patients?
1. Normalize lumbar lordosis
2. Restore near normal motion to all areas related to the spondylolisthetic segment
3. Stretch tight hamstrings
4. Improve respiratory motion of diaphragm and pelvic floor
62
OMT for spondylolisthesis
Any technique which does not increase lumbar lordosis or extend lumbosacral junctions
63
What does a levitor do?
1. Exerts pressure between the pubic symphysis and sacral apex
2. Transfers weight bearing off the posterior elements forward onto the vertebral bodies
3. By reducing the chronic strain on these tissues, symptomatic relief is obtained
64
No evidence that this treatment is effective in managing chronic spondylolisthesis
Bracing
65
Which medications are not helpful in treating spondylolisthesis?
Muscle relaxants
66
What treatment is helpful in cases of spondylolisthesis with concomitant ligamentous laxity?
Prolotherapy: Injection of proliferant agents into the fibro-osseous junction of the iliolumbar ligaments
67
When is fusion surgery indicated in spondylolisthesis?
1. Neurologic deficits
2. Grade III+ displacement
3. Progression of spondylolisthesis as an adult
4. Significant postural deformity
5. Symptomatic Grades 1-2 unrelieved by good conservative care
68
A 69-year-old male exhibiting flexed posture with head tilted forward, loss of muscle strength, and increasing episodes of tripping and falling would also be expected to show which of the following signs?
a. decreased muscle tightness
b. extension deformities
c. flaccid muscles
d. increased kyphosis of the lumbar spine
e. slow shuffling gait
E
69
A 42-year-old female presents to your office complaining of increasing inability to maintain balance. Your physical exam reveals tremors during movement, postural abnormalities, and ataxia. She most likely has a disorder in which of the following?
a. Basal Ganglia
b. Brainstem
c. Cerebellum
d. Cerebral Cortex
e. Spinal Cord
C
70
You diagnose a 61-year-old female with stress incontinence. She most likely has somatic dysfunction of which of the following?
a. L3
b. L4
c. S1
d. S3
e. S5
D
71
A 30-year-old right-handed female presents to your office with a 7-month history of fatigue and weight loss. For the past 10 weeks, she had noted progressive difficulty walking, slurring of speech, and weakness in both upper extremities. She reported difficulty combing her hair, writing, and climbing the stairs. Magnetic resonance imaging reveals diffuse plaques without evidence of hemorrhage or neoplasm. Which of the following BEST describes the most likely prognosis of this patient’s condition?
a. Anticholinesterase agents control progression of the disease
b. Levodopa will alleviate symptoms of bradykinesia and rigidity
c. The disease is progressive
d. The disease is remitting with periods of relapse
e. The disease is terminal due to metastatic process
C
72
You enter the exam room in your office to evaluate a 45-year-old male and observe that he has tremors while sitting in the chair. Your physical exam reveals that his right arm moves forward when he steps forward on his right foot, his hand and arm muscles are rigid, and he cannot stand up straight. He most likely has a disorder in which of the following?
a. Basal Ganglia
b. Brainstem
c. Cerebellum
d. Cerebral Cortex
e. Spinal Cord
A
73
A 19-year-old male presents to your office complaining pain, numbness, and tingling in his legs, radiating from his hips down to his toes, bilaterally, since “horseplay” at a fraternity party last night. He states that he is having incontinence of bowel and bladder and admits to impotence last night. Which of the following Osteopathic Manipulative Treatment (OMT) techniques would be indicated for this patient?
a. OMT is contraindicated until further evaluation by neurosurgery has ruled-out Cauda Equina Syndrome
b. Using gentle techniques
c. Using High-Velocity/Low Amplitude (HVLA)
d. Using Muscle Energy techniques
e. Using techniques that will decrease venous flow, but increase lymphatic return
A
74
Spondylo = ____
Vertebral
75
Which muscles/ligaments typically contain trigger points in spondylolisthesis patients?
```
QL
Glutes
Piriformis
Iliolumbar ligaments
Posterior sacroiliac ligaments
```
76
What position must be maintained during Williams Flexion Exercises?
Flattened lumbar lordosis
77
What are some examples of Williams Flexion Exercises?
```
Pelvic tilt
Knee to chest
Bent knee sit ups
Seated forward bending
Straight leg raises
```
78
Which OMT should not be used for spondylolisthesis?
Any prone techniques
79
Conservative treatment is successful in what percentage of adolescents with spondylolisthesis?
50%
80
The presence of Napoleon's Hat Sign indicates which grade of spondylolisthesis?
Grade III
81
A 68% spondylolisthesis by Taillard method is equivalent to which of the following Meyerding grades?
Grade III
82
A 39-year-old woman with an L-5 spondylolisthesis due to a pars interarticularis defect presents to your office with increasing low back pain. This pain is most likely being generated by which ligament?
Iliolumbar
83
Of the seven axes of sacral motion, on which does anterior sacral torsion occur during the gait cycle?
Oblique
84
What is not considered a cause of traumatic spondylolisthesis?
Pars interarticularis fracture
85
Which muscle is the most likely source of back pain in spondylolisthesis patients?
QL
86
Dysmenorrhea is associated with which dysfunctions?
Bilaterally flexed sacrum
| Anteriorly translated sacrum
87
A posterior torsion on a left oblique axis is also called....
Right on left sacral torsion
88
A grade II spondylolisthesis patient would most likely develop trigger points in which ligament?
Iliolumbar
89
Which conditions might cause pathologic spondylolisthesis?
Dysplasia of the posterior elements of L5 or S1
| Osteogenesis imperfecta
90
What kind of force is used during muscle energy for torsions?
Maximal sustainable force
91
A 19-year-old is discovered to have a Grade II spondylolisthesis. Which type does he most likely have?
Isthmic
92
Spondylolisthesis patients have increased/decreased PIs for their age.
Increased
93
The sacral sulcus on the side of dysfunction is shallow. Which dysfunction is likely present?
Unilateral extended sacrum
94
Which side of the table do you stand on to treat unilateral dysfunctions?
Opposite the side of dysfunction
95
Anterior sacral torsion treatment
Modified Sims; lie on side of axis
96
Posterior sacral torsion treatment
Lateral recumbent; lie on side of axis
97
Bilateral flexed sacrum treatment
Halloween cat maneuver
98
Bilateral extended sacrum treatment
Hyperextension maneuver
99
Anterior sacral torsions indicate what type of dysfunction at L5?
Type I (opposite)
100
Posterior sacral torsions indicate what type of dysfunction at L5?
Type II (same)
101
Vertical axis motion
Rotation
102
A/P axis motion
Sidebending
103
Oblique axes motion
Torsion (right and left)
104
Transverse axes motion
Flexion/extension
105
What is the motion of the sacrum during the gait cycle?
Normal motion about oblique axes occurs during the cycle. As leg comes forward, sacral sulcus on that side swings forward and the contralateral ILA moves posteriorly and inferiorly.
106
Dysfunction involving the AP axis is always _____.
traumatic
107
At age 20, the prevalence of spondylolisthesis in the population is about ___%.
5
108
PI for spondylolisthesis
0.8-1.15
109
What PE finding indicates spondylolisthesis greater than grade II?
Gait changes: stiff-legged, short stride, waddling gait
110
When would you do a SSEP/DEP?
Only if there are sensory deficits and the EMG/NCV is normal
111
What is the etiology of traumatic spondylolisthesis?
Fractures in other parts of the vertebrae other than pars interarticularis
112
Treatment for traumatic spondylolisthesis
Heals with immobilization
113
What is the success rate of conservative treatment in adult spondylolisthesis patients?
85-90%
114
Positive spring test indicates
Posterior torsion or unilateral extension
115
Where is the hand placed for unilateral flexed muscle energy?
On the dysfunctional ILA
116
Where is the hand placed for unilateral extended muscle energy?
On the dysfunctional sacral sulcus
117
Tenderpoint on superior surface of iliopectineal (iliopubic) eminence
Low ilium/psoas minor
118
Tenderpoint on lateral aspect of the pubic tubercle
Inguinal/pectineus
119
Tenderpoint on superior medial aspect of PSIS between L5 spinous process and PSIS
Upper pole L5
120
Tenderpoint on lateral aspect of ILA
High ilium/coccygeus
121
Tenderpoint medial to PSIS at level of S1
PS1 bilateral
122
Tenderpoint midline on sacrum
PS2-PS4
123
Tenderpoint just medial and superior to ILA
PS5 bilateral
124
Counterstrain: low ilium/psoas minor
Supine
Stand on side of point
Flex hip
125
Counterstrain: inguinal/pectineus
```
Supine
Stand on side of point
Flex hips and knees and rest on thigh
Place good leg over bad leg
Pull patient's ipsilateral lower leg internally to induce adduction and internal rotation of hip
```
126
Counterstrain: upper pole L5
Prone
Stand on opposite side of point
Extend and adduct hip
Rotation if needed
127
Counterstrain: high ilium/coccygeus
Prone
Stand on opposite side of point
Extend and adduct hip to cross over contralateral leg
128
Counterstrain: PS1
Prone
Stand on side of point
Press down on ILA opposite of tenderpoint
129
Counterstrain: PS2
Prone
Stand on side of point
Press down on apex of sacrum --> extension
130
Counterstrain: PS3
Prone
Stand on side of point
May require flexion or extension
131
Counterstrain: PS4
Prone
Stand on side of point
Press down on base of sacrum --> flexion
132
Counterstrain: PS5
Prone
Stand on side of point
Press down on sacral base opposite the point
133
Counterstrain: lower pole L5
Prone
Sit on side of point
Hip flexed 90 degrees
Slight internal rotation and adduction
134
Tenderpoint on the ilium just inferior to PSIS pressing superiorly
Lower pole L5
