Lecture Reading Material Flashcards
(127 cards)
1
Q
LOCQSMAT (L)
A
Point to it? Write location as clearly as possible (R, L, b/l)
Does it radiate to an extremity? How far? What side? What surface?
2
Q
LOCQSMAT (O)
A
What caused it? When did it happen? Gradual or sudden onset?
3
Q
LOCQSMAT (C)
A
First ask: are the symptoms constant or intermittent
Constant - Truly 24 hours a day, prevent sleep, percent of day
Intermittent - Associated with certain circumstances, frequency and duration, morning/night pattern, is there night pain, getting worse/better, prior history
4
Q
LOCQSMAT (S)
A
(0-10)
ADLs - miss any work, affect performance/ self-home care. Record specific activites
Know MCID
5
Q
LOCQSMAT (Q)
A
Describe the pain or symptoms. Use patient’s words
6
Q
LOCQSMAT (M)
A
Prescribed medication, OTC medications, vitamins, long time medication
7
Q
LOCQSMAT (A)
A
Associated
Allergies
8
Q
LOCQSMAT (T)
A
Chiropractic care and last physical
F: last gyn
+40 m: A rectal exam to evaluate prostate
9
Q
Family health history
A
Start with mother, father, GD, GM
Deceased: how old, cause, any other problems
If notable ask other relatives
10
Q
Personal: general categories
A
Occupation Exercise Interests Diet Sleep pattern Bowel habits Urinary habits Habits - alcohol, smoking, drugs Living situation Domestic violence Stress
11
Q
Red Flags for Cancer
A
- Age > 50
- History of cancer
- Unexplained weight loss
No relief with bed rest
One month of no treatment
Pain duration over one month
12
Q
Constitutional signs and symptoms as Red Flags for disease
A
Fever Malaise Loss of apetite Significant, unexplained fatigue Bilateral sciatica in patients over 50 Sciatica with bizarre, non-dermatomal sensory symptoms Sciatica non-responsive to treatment or negative low back findings Urinary changes Multiple Joint Involvement Sexual dysfunction Abnormal menstrual bleeding/pain GI symptoms GU symptoms
13
Q
Red Flags for Serious Diseases from Physical Exam
A
Neurological deficits in older patients (20% of spinal malignancy have neurological defects)
Alarm sign - Patient points to specific area in leg/pelvis during SLR. MB local mass.
Pain with spinal percussion - local over 1-2 SP, painful and lingers
Hip pain with contracture
Pronounced loss of hip flexor strength - Can be suggestive of COL affecting cord
Palpable mass
Significant bony tenderness - bony diseases
Vascular deficits - PAD and DVT
Deformity
AAA
14
Q
Red Flags from Ancillary Studies
A
Back pain with elevated ESR
Back pain with increased serum calcium, protein and/or alkaline phosphatase - Bone cancer
Back pain with anemia
Back pain with pathological imaging
15
Q
MCID
A
General musculoskeletal: 2-3 points
LBP Score of 5 or more: 2 points
LBP below 5: 1 point
Child: 1 point
16
Q
UWS 4-Part Diagnosis
A
Pathoanatomical
Neurological
Biomechanical
Complicators
17
Q
Pathoanatomical
A
Anatomical or othropedic
Location, HA - tension/cervicogenic/vascular, nerve entrapment
18
Q
Neurological
A
Include neurological signs, include the nature of radiation, as well as location
19
Q
Biomechanical
A
“chiropractic portion”
Diagnosis based on joint dysfunction or muscle dysfunction that generates pain
include location and type of ailment (MFTP, myofibrosis, etc.)
20
Q
Biomechanical (joint dysfunction diagnosis)
A
Includes:
Location - general region
An acceptable term for joint dysfunction: segmental dysfunction, joint dysfunction, or subluxation syndrome
Do not use the term restriction
21
Q
Complicators
A
Factors that are not pain generators
Include if they may affect condition
Central canal, functional instability, DDD, Bone anomalies and structural changes, Upper/lower cross syndrome
22
Q
Fracture Activity Modifications
A
Keep the fracture stable, try not to bump it (compress/distract/bend)
Use opposite extremity
23
Q
Acute Low Back Pain Modifications
A
Hold neutral pelvis, hip hinge and perform abdominal bracing during transition movements, long drives, sleep position
Avoid sustained bending, sitting, immobility
24
Q
LBP with Extension Modifications
A
Avoid standing for more than 20 minutes without position change
Alleviate extension during standing periods by leaning or putting foot up on a step
Avoid working with hands above head, lifting heavy objects alone
25
LBP with Flexion Modifications
Limit sitting or change sitting to reduce flexion
Hip hinge during transition movement
Rise form chair by perching on edge, keeping back straight and push off with arms
26
LBP with Rotation Modifications
Avoid asymmetrical loads, use two hands to push or pull
| Change hands to avoid painful motion
27
Neck Injury Extension Modifications
Avoid sustained extension, take breaks from position
| Avoid sustained or repetitive chin poking
28
Neck Injury Flexion Modifications
Avoid sustained flexion
| reading in bed, long periods of looking down reading
29
Overuse Syndrome Modifications
Requires temporarily stopping the activity then a graded return
Use braces to protect area during activities and sleep may require orthopedic support/devices
30
Working up Musculoskeletal Problems Pneumonic
No Men Love PiGs Stealing SuCculent Pork
(disease), Neuro, MOI, Load, Pain generators (biomech), Severity, Structural Complicators, Prognosis
Order is first to last
31
What is the difference between radiculitis and radiculopathy
- itis: An inflamed nerve root but does not present with neuro deficits
- opathy: A damaged nerve root that has neuro deficits
32
What is the difference between radicul- and neur- issues
Radicul-: Damage to a nerve root
| Neur-: Damage to a peripheral nerve
33
Causes of Radicular Pain Syndrome
| A: _____, ______, _____
A: Herniated Disc (lumbar), Spinal stenosis (lumbar), Osteophyte in the IVF (cervical)
34
Causes of Radicular Pain Syndrome
| B: _____, ______, _____, _____, _____, _____, _____
B: SOL, NR adhesion, Istability (str. not fun.), fracture, infection, Traction injury or compression injury (Cx only), spondylolisthesis (Lx if unstable)
35
5 Point Screen for Cervical Nerve Roots neuropathic lesion
```
Pain
Paresthesia
SMR neurological changes
"Big 5" orthopedic tests
Other Spinal Load Tests (reproduces Sx immediately)
```
36
Hints for neuropathic pain
Pain distribution is dermatomal or follows a nerve
Quality is sharp, stabbing or electrical
MORE SEVERE THAN neck/back pain
Certain positions aggravate the extremity Sx
Aggravated by hot, cold, or light pressure
37
Big 5 orthopedic tests
```
Cervical lateral and maximal compression
Cervical distraction (reduces pain)
ULTT - median nerve
Shoulder abduction tests
Valsalva
```
38
5 Point Screen for Lumbar Nerve Roots neuropathic lesion
```
Pain
Paresthesia
SMR neurological changes
Positive Nerve Tension Tests
Other Spinal Loading procedures (AROM, Valsalva, Kemp's)
```
39
Nerve Tension Tests for Lx Nerve Roots
SLR, Bowstring, femoral nerve stretch test
40
Ancillary for assessing radicular pain
x-rays, CT, MRI, and electrophysiological studies
| Nerve Conduction Studies and needle electromyelography
41
Deep somatic referred pain syndrome causes
```
Facet syndrome
Disc derangement
Subluxation syndrome
Mayo fasciae pain syndrome
Generalized sprain/strain
Maigne’s syndrome
```
42
Clinical indicators of deep referred pain syndrome
Diffuse pain
Diffuse parenthesis
Absence of nerve compression signs
Absence of nerve stretch signs
Ortho tests may be positive but will not create pain in referral pattern
Ancillary tests are not needed and usually negative for nerve involvement
43
Broad categories of Injury mechanisms
| _____, _____, _____, _____, _____
Traumatic, repetitive stress, (end range)postural, sudden uncoordinated movement, normal activity in an unstable spine
44
Causes of repetitive stress
Job or sports related. Often a combination of ergonomic and biomechanical
45
Causes of a sustained postural overload
Slowly irritated by long sustained loads especially at end range
Prolonged standing - extension
Prolonged sitting - flexion
Pain from joints and ligaments but not muscles
46
The two steps of analysis of the mechanism of injury
Decide the broad category of injury
| Decide what were the magnitude and direction of the forces involved
47
What are the two main types of Injurious loads to the low back
Torsional injuries
Compression injuries
(or a combination)
48
Structures most at risk for traumatic compression in neutral
First rule out: end plate or compression fracture
Second suspicion: ligamentous sprain due to shear loads
Third suspicion: nonspecific tissue (posterior disc herniation is unlikely)
49
Compression fracture clues from history in neutral compression
(age and load)
Moderate to severe loads in adults
Mild to moderate loads in patients over 50
Spontaneous in patients over 70
50
Compression with the spine in flexion at end range
First rule out: Disc injury (internal derangement/mb herniation), compression fracture (moderate to heavy load or in an osteoporotic patients), traumatic, sprain of posterior ligaments
Second suspicion: Joint injury (facet/SI), joint dysfunction, MFTPs, etc.
51
Compression with spine in extension at end range
First rule out: Stenosis, facet syndromes, joint dysfunction
52
An older patient with leg symptoms that suffered a compression load in extension
Stenosis
53
Treatment considerations for compression in flexion at end range
Avoid hyperflexion behaviors and postures
Treatments that promote extension and avoid flexion exercises
Find weak link that might promote flexion (bilateral iliopsoas tightness)
54
Treatment considerations for compression in extension at end range
Avoid hyperflexion (heels, standing, lifting weight above waist, prone on a soft mattress)
Flexion therapies
Weak link in kinesthetic chain that promotes extension loads (weak abs and tight extensors)
55
Structures most at risk with torsional injuries
First rule out facet injury if more in neutral; A disc injury if combined with flexion
Second suspicion is a sprain, strain, or joint dysfunction
56
Treatment considerations for torsional injuries
Avoid torsional side-posture adjustments that reproduce the injury
Correlate with dominant hand (avoid twisting in the direction of the injury
Avoid lateral bending that reproduces the torsion
57
Clues from the history indicating for the load sensitivities
_____, _____, _____
Aggravating and relieving factors - find out specifically what aggravates and relieves symptoms and analyze the likely mechanical loads on the spine
Effects on ADLs - by finding activity intolerances it is possible to find out what loads to avoid and what is damaged
Description of the patient's work or recreation activities
58
Clues from physical indicating load sensitivities
| _____, _____, _____
AROM
Basic orthopedic tests that load the joints
Repetitive or sustained loading
59
DDx list for Flexion load sensitivity
| _____, _____, _____
```
Disc derangement/herniation
Posterior ligament sprain
Compression fracture (high load or osteoporosis)
```
60
Treatment strategies for flexion load sensitivities
| _____, _____, _____, _____, _____
Teach hip hinging strategies (neutral pelvis and abdominal bracing)
Avoid sustained or repetitive flexion (bending, lifting, squatting, sitting)
Have patient do Brugger or lumbar roll when sitting
Teach how to sit on ischial tuberoisities
Consider exercises that promote extension
61
DDx list for extension load sensitivities
| _____, _____, _____, _____, _____
```
Facet syndromes
Anterior disc derangement (uncommon)
Stenosis
Osteophytes in the IVF (older pts with leg symptoms)
Sponylolisthesis (unstable)
```
62
Treatment strategies for rotational load sensitivities
Avoid or modify asymmetrical rotational activities
| Avoid twisting to that side
63
DDX list for compression (axial) load sensitivity
Fractures
Disc herniation
Disc derangement
(though more often compression loads create bone injury once a disc is injured and swollen compressive loads can very often aggravate symptoms
64
Treatment strategies for compression (axial) load sensitivities
_____, _____, _____, _____, _____
```
Unload the spine using traction
Distraction
Avoid prolonged sitting and standing
Limited bed rest (if severe)
Avoid exercises with high load penalties
```
65
A loading directon that either ____, ____, ____
Centralizes symptoms, Improves symptoms, results in an increase in global range of spinal motion
66
History of acute tears in derangement
Patient feels pop and pain comes on 30 min - 24 hr
| Severe, sharp and stabbing with sudden movements aggravated by any movement of lumbar spine
67
Referred pain with disc derangement
Unilateral or sometime bilateral to the butt or LE
68
History for posterior disc derangement
Sitting aggravates patient relatively rapidly and may be relieved by standing
Flexion load sensitivity but also aggravated by rotation and/or side bending
Dejerine's triad
69
PEx for posterior disc derangement
| _____, _____, _____, _____, _____, _____, _____
Pain centralization (key predictor fo rdiscogenic pain)
Normal or flexion antalgia (sweet spot where disc is unloaded)
Lateral pelvic shift (correction is an early treatment goal)
AROM is painful and reduced (usually more in flexion)
Valsalva maneuver may induce pain
May be sensitive to axial compression
Pain with static palpation of adjacent SP
70
Dejerine's triad
Pain with:
Straining with a bowel movement
Counging
Sneezing
71
Muscle tests that produce axial compression
Active double straight leg raise
4 Quadrants test
Muscle testing hip flexors
72
Working diagnosis for Disc Derangement
| _____, _____, _____
Low back pain with referred butt, thigh, or leg pain that worsens with flexion activities and sitting
Low back and LE pain that can be centralized and diminished with positioning, manual procedures and/or repeated movements
Lateral trunk shift, reduced lumbar lordosis, limited lumbar extension mobility and movement and coordination impairments are common
73
Disc Derangement pertinent negatives
| _____, _____
Nerve tension tests and SMRs are all unremarkable
| SI provocation does not provoke the patient's familiar pain
74
Radiographs and CT for Disc Derangement imaging indication
Usually not indicated unless there is consideration for a more aggressive treatment (surgical fusion)
X-ray, flex-extension, and CT are usually normal. There is usually no disc thinning
75
MRI for Disc Derangement
Far more useful for ruling out. Absence of degeneration on an MRI was the only test to reduce likelihood
High intensity zone may help rule in
76
Discography for Disc Derangement
Considered a gold standard
| A positive MUST reproduce the patient's characteristic pain and the dye demonstrate internal derangement
77
What percent of lumbar pain is discogenic in origin?
40%
78
What percent of lumbar pain is from the facet?
5-40%
| 60% if part of osteoarthritis
79
Clues from history that indicate lumbar facet syndrome
| _____, _____, _____, _____, _____, _____, _____
Deep achy back pain localized to the paravertebral area
If acute there is transient pain with sudden movements
There may also be back stiffness that is more evident in the morning
Worse with hyperextension/rotation/lateral bending
Worse when trying to get out of bed, trying to stand after prolonged sitting, inactivity
Pain is relieved by moving around
Walking and sitting are least painful
80
PEx for facet syndrome
| _____, _____, _____, _____
Aggravated with extending up from flexion
Active hyperextension
Passive extension (prone extension test)
Extension combined with rotation produces local pain
Static palpation over the facets is tender
Motion palpation reveals a painful restricted joint
81
A _____ Kemp's test is good for _____ because _____
Negative, ruling out facet syndrome, it is commonly positive but it can also be positive for deranged disc and sprains
82
Describe true positive Kemp's test
Kemps test that creates leg pain. Indicates a possible nerve lesion.
Should think about conditions other than facet syndrome
83
What are a few conditions indicated by true positive Kemp's test
_____, _____
IVF stenosis, Spur in IVF
84
Evidence against facet syndrome from PEx
Pain is unlikely to centralize from repetitive or sustained end range loading
No relief with recumbency (pert)
Negative Kemp's test (pert)
85
Pragmatic working diagnosis for facet syndrome
| _____, _____, _____
Patient with paraspinal pain (unilateral or bilateral) who has
one of the following:
Extension > flexion increased pain, pain with rotation, combined extension and side flexion or Kemp's, pain with palpation over facet and possible joint restriction
No evidence of:
Nerve involvement, pain centralization, positive painful SI joint challenging
86
Ancillary studies for facet syndrome
Imaging is not needed
| Degeneration has little correlation with the syndrome
87
Facet Block Protocol
>80% with a double facet block process
| Corticosteroids and a local anesthetic and typically also with contrast medium
88
Three Roads to a Sprain or Strain Diagnosis
| _____, _____, _____
High load trauma:
If muscle tests are strongest positive then think strain
Passive joint loading tests are the strongest positives think sprain
Mechanism of injury unclear:
Evidence of tissue damage during PEx but dx unclear
can use sprain, strain or sprain-strain but unclear derangement or facet syndrome
Postural syndrome
Symptoms appear to result from holding sustained postures, physical is usually negative except spine is held in a sustained posture
89
Strain Diagnosis
| _____, _____, _____, _____
Trauma - repetitive microtrauma?
Contract: Isometric muscle tests are most provocative tests in rotation or extension
Palpate: Palpation is painful over the muscle or its attachments
Passive loading: End range stretching may also be painful
90
Sprain Diagnosis
| _____, _____, _____, _____
Trauma such as lifting or slip and fall (repetitive micro or sustained)
Passive orthopedic tests: provocative even before end range and more painful than muscle tests
Palpate: Palpation is pain over ligament if it is superficial; muscles may be in spasm
Contract: Isometric muscle tests are painless or least provocative
91
Iliolumbar ligament syndrome referral pattern
PSIS
Greater trochanter
Inguinal crease
QL attachment
92
Iliolumbar ligament syndrome diagnosis
L/S pain and some referrals
tenderness to deep palpation between L4 TP and crest (recreates chief pain)
Tender along medial iliac crest
Possible FABERs test
93
What combination of three findings has a + LR 4.95 for cervical facet lesions?
_____, _____, _____
An extension rotation test that reproduces familiar pain >3/10
Pain with static palpation over the facet
Restriction to P-A glide
94
What are pertinent negative findings for cervical facet lesions
_____, _____
No palpatory tenderness over facet
| No palpatory restriction with P-A glide
95
Degrees of sprain by %
```
0-20% = first degree
20-75% = second degree
>75% = third degree
```
96
Degrees of strain by %
< 10% = Grade 1
10-50% = Grade 2
>50% = Grade 3
97
Findings from history of a patient with Joint Dysfunction Syndrome
Commonly complains of pain located in the midline to paraspinal region with or without pain referral to LE
Pain may refer to the knee but less likely to the foot
98
Primary findings from PEx for Joint Dysfunction Syndrome
Palpatory segmental bony or soft tissue tenderness/dyesthesia [reliable]
Painful and/or altered segmental mobility testing (JP, SROM, EP)
Palpable alterations in paraspinal tissue texture or tone
99
Secondary findings from PEx for Joint Dysfunction Syndrome
```
Palpable malposition (mb normal for that person)
Repetitive loading in the direction of EP restriction ma improve symptoms
Alterations in sectional or global range of motion
Observational alteration in paraspinal tissue symmetry
```
100
When diagnosing Joint Dysfunction Syndrome it is recommended that ____ or more of ___ and ___ are present
Two, primary, secondary
101
Pertinent negatives for Joint Dysfunction Syndrome
There must be no signs of nerve root involvement.
If there is NR involvement there must be a search for other causes, especially if there is severe signs of compression (eg. muscle weakness)
102
What are the two approaches for assessing severity of Musculoskeletal conditions?
_____, _____
Amount of tissue damage
| Effect on patient
103
Grade 1 strain
| _____, _____, _____, _____, _____
```
Pain with resistance
Little or no weakness
No defect
Minimal swelling and bruising
No pain with PROM except for when muscle is stretched
```
104
Grade 2 strain
| _____, _____, _____, _____, _____
```
Pain with resistance
Mild to moderate weakness
Possible small defect
Moderate swelling and bruising
Pain with passive stretching
```
105
Grade 3 strain
| _____, _____, _____, _____
Moderate to severe weakness
Larger defect
Rapid and extensive bruising and/or swelling
Muscle balls up, retracts, loses contour
106
1st degree sprain
| _____, _____, _____, _____, _____, _____, _____
```
Pain on stress of tissue only at end range
No pain with isometric muscle testing
Local tenderness
Mild local swelling
No gross instability
Minimal pain with weight bearing
```
107
2nd degree sprain
Pain on stress of tissue before end range
No pain with isometric muscle testing
Generalized and marked tenderness and swelling
Mild laxity - no gross instability
Localized bruising
Moderate to marked ROM loss
Moderate to severe pain with weight
108
3rd degree sprain
Gross instability
Generalized swelling
Disruption of tissue
Pain ranges from minimal to severe
Possible hemarthrosis and extensive bruising
Marked ROM loss
Abnormal motion and/or pain with muscle contraction
109
_____ and symptoms are considered extremely significant and require urgent referral
Cauda Equina signs
110
Mild loss with radiculopathy
Sensory with or without loss of one motor grade
111
Moderate loss with radiculopathy
Absence of deep tendon reflex with more than one grade of motor loss
112
Severe loss with radiculopathy
Motor loss to a grade 3 or below
113
Disability classification of myelopathy
G0: Root signs and symptoms; no cord involvement
G1: Signs of cord involvement; normal gait
G2: Mild gait involvement, able to work
G3: Gait abnormality; able to work
G4: Only able to move with help
G5: Chair or bed-ridden
114
Whiplash (Quebec classification)
G0: No complaint of neck problems. No physical signs
G1: Complaint of neck pain, stiffness, or tenderness only. no physical signs
G2: Neck complaint and musculoskeletal signs
G3: Neck complaint and neurological signs
G4: Neck complaint and fracture or dislocation
115
2 Situations of when to suspect Lumbar Spinal Stenosis
| _____, _____
Any patient over 60 with dominant leg pain made worse by walking or standing and relieved by flexion or sitting
Also any patient > 50 with a radicular syndrome or CES
116
_____ of _____ with pain and numbness in LE may have _____
47%, older adults (65+), lumbar spinal stenosis
117
64% in patients with leg symptoms > ___
70 years old
118
What is spinal stenosis?
Clinical syndrome of neurogenic claudication and/or radicular pain due to narrowing of the spinal canal and NR impingement
The loss of area impairs blood flow to venules and results in venule engorgement and compression of NR
119
Three main contributing factors of LSS
| _____, _____, _____
Bulging disc
Facet joint enlargement
Lig. flavum thickening
(degenerative spondylolisthesis and unstable spondylolisthesis are also possible)
120
The two different neurological presentations of clinical stenosis
_____, _____
Neurogenic claudication (more common) - leg pain with walking, leg pain sensitive to spinal position. "lumbar spinal stenosis with neurogenic claudication"
Radicular/sciatica - leg pain unrelated to activity or extension, unilateral or bilateral leg pain in > 1 dermatome, May occur alone or concurrent with neurogenic claudication. "lumbar spinal stenosis with sciatica"
121
Basic signs and symptoms of Lumbar Spinal Stenosis
Mechanical: _____, _____, _____
Neurological: _____, _____, _____, _____
Mechanical clues: Leg symptoms made worse by walking, Extension increases leg symptoms, flexion often improves symptoms
Neurological clues: Balance and leg proprioception can be affected, CES (rare), Basic neurology: deficits present about 50% of cases; SLR is rarely possible
122
Best clues for Lumbar Spinal Stenosis
| _____, _____, _____, _____
Wide gait
No pain when sitting
Burning sensation or intermittent priapism when walking
Urinary disturbance
123
Ancillary studies for Lumbar Spinal Stenosis
Start with radiograph, confirm with MRI, electromyographic paraspinal mapping
124
Final diagnosis of spinal stenosis requires 3 factors:
| _____, _____, _____
Characteristic signs and symptoms
Radiographic (MRI or CT) evidence of lumbar spin al stenosis
Exclusion of other causes of back pain
125
Ancillary studies for PAD
| _____, _____, _____
Duplex/Doppler US
Ankle-brachial index
Magnetic resonance angiography
126
Treadmill test as a DDX for PAD and Spinal Stenosis
Stenosis patient can walk farther uphill than flat
| PAD patient will not improve with uphill
127
PAD management
Walking near pain threshold at least 3x/week
Toe raises 3x/day. Do reps until there is pain and the 5 more
Lifestyle changes to support cardiovascular health
