Trauma or specific MOI Acute pain/spasm (-) SLR (+) compression test

Lecture 2B: Lumbar Exam and Eval Flashcards by Maria Benjamin

factors that influence complexity of LBP presentation

genetics
age
lack of formal ed
lower SES
race
physcial workload
presencce of radiating pains
smoking
obesity
psych
comorbidities

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potential causes of sciatica

nerve root
tumor
abscess
arthritis
vertebral collapse
inflammatory nerve disease
toxins
DM
syphilis

need a thorough lumbar exam for neuro and vascular (hip, pelvis, LE exam)

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low back pain algorithm chart

SUPER IMPORTNAT MEMORIZE AND UNDERSTAND

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Pain discriptor and origin
- “deep, ache, boring”
- “dull, achy, sore, burning, cramping”
- “sharp knife like pain, tingling, shooting, numbness, weakness”
- “burning, stabbing, throbbing, tingling, cold”
- “deep pain, cramping, stabbing”

bony tissue
muscle/fascia
nerve
vascular
visceral

more info slide 7,8,9

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ALWAYS do this with a patient even though LPB and a serious pathology is LOW.

systems review

note: examine findings for consistent patterns to indicate serious pathology (back cancer)

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intervention based solely on response to tissue loading and sx response

McKenzie and Maitland (treatment-based)

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intervention based on treating pathological structure (CT healing model)

I.D. pathologic structure and stage it

Cyriax (structure based)

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ULTIMATE GOAL for LBP patient

self-mgmt

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Pt presents with:

Hx of trauma to SIJ and gluteal regions
* Pain around SIJ/piriformis mm
* Symptoms worsened w/ stooping or
lifting
* Palpable tension (i.e. rope-like) in
piriformis mm belly
* (+) SLR test
* Gluteal atrophy (depending on length
of symptoms)

piriformis syndrome

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Defect in pars interarticularis, often asymptomatic
* Can be unilateral or bilateral
* Can be stress or trauma related
* Exact causes are unknown
* Typically occurs at L5, but can occur anywhere

Tx: surgical intervention only indicated when
conservative management has failed

Spondylolysis

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patient with spondylolysis prefers (flex/ext)

flexion
- walking may be painful

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spondylolsthesis

will lead to spinal instabilit. surgery indicated if PT didn’t work or neuro s&s occur

grades:
* Grade I: 1-25%
* Grade II: 26-50%
* Grade III: 51-75%
* Grade IV: 76-100%
* Grade V: >100%

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order of susceptible structures to compression

END PLATE
vertebral body
disc

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disc herniation process

End-plate fx d/t excessive compression
Lesion heals OR disc DEGRADATION
Exposes NP to blood supply
Inflammatory response
NP progressively loses H2O and disc
height
↓ ability to resist loads
↑ load to AF (load on outer AF may be
painful)
Osteophyte formation on VB
↑ load on facet joints and more
osteophyte formation
Radial fissure in AF
Internal disc disruption

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stages of disc pathology

Protrusion: disc bulge w/o AF
rupture
Prolapse: only outer layers of AF
contain NP
**Extrusion: **AF perforated and
disc material moves into
epidural space
Sequestration: disc fragments
from AF and NP disconnect

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end plate fx

Trauma or specific MOI
Acute pain/spasm
(-) SLR
(+) compression test

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internal disc disruption

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Separation of inner layers
LBP and/or referred hip/upper leg
pain
(-) SLR
Dx made: discogram

Disc protrusion and prolapse
(contained)

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Some AF and PLL are intact
LBP and/or referred hip/upper leg
pain
Pain w/ cough and sneeze
(-) SLR

Disc extrusion and sequestration
(uncontained)

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LBP
Pain w/ cough and sneeze
True sciatica (radicular pain)
(+) SLR

L4-5 disc pathology typically affects

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L5 nerve roots

IMPORTANT TABLE SLIDE 20

Large herniation of L5–S1 disc

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Compromises not only nerve root
crossing it (1st sacral nerve root)
but
also nerve root emerging through
same foramen (5th lumbar nerve
root)

Massive central sequestration of
disc at L4–L5 level

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Involves all of nerve roots in cauda
equina and may result in B&B
paralysis

T/F LBP w/ radiculopathy outcomes not as favorable as mechanical LBP, but
conservative management often possible

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true

foraminal encroachment

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Subluxed facet
Facet osteophytes
Vertebral osteophytes
Laminar compression
Disc protrusion/HNP
Lateral stenosis
Post-surgical scar
Edema
Tumor

all of the following could be Sx of ? persistent buttocks pain, limping, lack of sensation in LEs (claudication) & ↓ walking/standing ability vascular or neurogenic ## Footnote vascular= think about the calf and walking

spinal stenosis

* Mid-line sagittal spinal canal diameter ↓ * May elicit neuro claudication or pain in buttocks, thigh or leg

centra stenosis

* Narrowing b/t sup facet & post vertebral margin * May impinge nerve root & subsequently elicit radicular pain

lateral stenosis ## Footnote more stenosis classification slide 24

Hypomobility at 1 or both facet joints at a lumbar segment * AKA: segmental dysfunction Pain and potential restriction w/ specific lumbar AROM directions - Patterns may indicate area of dysfunction and is reprodocible localized pain TX: manual therapy, mobility, strengthening ex

z joint (facet) dysfunction

* Loss of normal passive restraints to motion * Loss of active NM control * Reports of recurrent back pain that ‘catches’ or ‘locks’ * Inconsistent symptomology * Structural instability: (+) prone instability test * Tx: responds well w/ conservative management, recurrence is common if program not maintained/activities △

clinical lumbar instability

* Chronic inflammatory disease of unknown origin * 1st affects spine & progresses to fusion of involved joints * Males, <30 y/o * Typically follows a 20-yr course * 90-95% of pts w/ AS have human leukocyte antigen B27 * “Bamboo-spine” in radiography * Tx: meds + conservative management to slow progression

* Lateral curvature of spine * Can be congenital or acquired ... many causes * Can be structural or functional * Pt lacks normal flexibility and SB becomes asymmetrical * Idiopathic scoliosis accounts for 75-85% of all cases of structural scoliosis * Tx: may require surgery if angle of curves are severe enough

scoliosis

* Chronic condition * Causes pain, stiffness & tenderness of muscles, tendons & joints * Characterized by: * Pain (100%) * Restless sleep * Wake up feeling tired * Fatigue (90%) * Emotional disturbances (>50%) * Disturbances in bowel function

fibromyalgia

diagnosis of fibromyalgia

11/18 tender points w/o other reason for tenderness (unexplainable)

* AKA “shingles” * Skin rash caused by same virus as chickenpox * Exacerbation/recurrence w/ emotional stress, immune deficiency, or w/ cancer * Contagious w/ person who has not had chickenpox OR when sores are open & oozing * Several weeks of pain, burning (typically in low back) prior to development of rash * Tx: medical management indicated, halt PT until rash is no longer contagious

herpes zoster

table on slide 31

Acute or Sub-acute LBP w/ Mobility Deficits Impairments: * Segmental or global hypomobility * Pain in ____, ____, ____ or thigh * Impaired functional movements (i.e. squatting, lifting) * (-) neuro tests * Onset of symptoms <3 months

back, buttock, groin, thigh

Acute, Sub-acute or Chronic LBP w/ Movement Coordination Impairments Impairments: * Segmental or global instabilities * Pain in back, buttock, groin or thigh * Worsens w/ ____ ____movements * ↓ ____ control of voluntary movements Muscle weakness * Fatigueable * Non-fatigueable * ↓ activity tolerance (i.e. sitting, standing, running) * Impaired functional movements (i.e. squatting, lifting) * (+) ____ segmental instability test

end range NM prone

Acute LBP w/ Related (Referred) LE Pain Impairments: * Segmental or global hypomobility or instabilities * Significant pain in back, buttock, groin or thigh * Postural deficits * ↓ activity tolerance (i.e. sitting, standing, running) * Impaired functional movements (i.e. squatting, lifting) * Onset of symptoms <3 days * (+) ____ testing

repeated movements

Acute, Sub-acute or Chronic LBP w/ Radiating Pain Impairments: * Segmental or global hypomobility or instabilities * Radiating pain (often times below the knee) in a dermatomal pattern * Muscle weakness * Fatigueable * Non-fatigueable * ↓ activity tolerance (i.e. sitting, standing, driving, running) * Impaired functional movements (i.e. squatting, lifting) * (+) ____ exam * (+) ________ tests * (+) ____ ____ movements tests

neuro exam neurodynamic exam repeated movements tests

Acute or Sub-acute LBP w/ Related Cognitive or Affective Tendencies Impairments: * Sensitivity to ____ stimuli * Displays range of emotions * Pain in back, buttock, groin or thigh, lower leg * Tendency to ____ physical symptoms for emotional/affective reasons * High scores on ____ and Pain Catastrophizing Scale * Impaired ____ * ↓ activity tolerance (i.e. sitting, standing, running) * Impaired functional movements (i.e. squatting, lifting) * Inconsistent MSK exam results * Onset of symptoms <3 months * (+) ____’s test

- noxious - elaborate - FABQ - ADL -waddell's test

Chronic LBP w/ Related Generalized Pain Impairments: * ____ pain (present in back, other body structures or globally) * ____ w/ MSK dysfunction * Appropriateness of emotion * △’s in brain and sensory structures * High scores on ____ and Pain Catastrophizing Scale * Impaired ____ * ↓ activity tolerance (i.e. sitting, standing, running) * Impaired functional movements (i.e. squatting, lifting) * Inconsistent MSK exam results * Onset of symptoms >3 months

- generalized - inconsistent - FABQ - ADL

Lecture 2B: Lumbar Exam and Eval Flashcards

(42 cards)