Lumbar 1

Question 1

Sympt worsening since onset

Answer 1

• Gentle approach/unstable condition
• Carefully monitor symptom response
• Educational approach, espec. 1:st 24-48h
• Sustained pos. may be of more use than repeated movements.
• May indicate serious pathology.

(2:14 p.383)

Question 2

Onset - what to have in mind when asking about.

Answer 2

• Mostly no apparent reason, says patient
• Usually flexed activities around onset
• Red flags
• Obvious incident: osteoporosis (older female) and spondylolisthesis (adolecents at sports injury)

Question 3

Sympt at onset - if changed location

Answer 3

Always indicate derangement

Question 4

Constant or intermittent

Answer 4

• Constant means 100% of their waking day!
• Constant: inflammatory disease, recent trauma (infl responce) or MECHANICAL DEFORMATION (derangement)
• Never in Postural Syndr. or Dysfunction

Question 5

Constant pain is more difficult to treat than intermittent. Why?

Answer 5

Patient is usually unable to identify a directional or postural preference.

Question 6

Pain that may spread, not change location…?

Answer 6

Inflammatory, as it worsens

Question 7

What makes the pain worse/better?

Question 8

Sitting, driving and bending causes

Answer 8

Flexion. Posterior derangement

Question 9

Standing and walking usually causes

Answer 9

Extension.

Question 10

Theory of pain in rising from sitting position

Answer 10

Usually posterior derangement. Deformity of prolonged sittning prevents immediate CURV REVERSAL or else the act of LEANING FORWARD in order to stand may cause momentary increase in pain. (2:14, p387)

Question 11

Myelopati

Answer 11

Ryggmärgspåverkan. Disk, osteofyter. Gång, smärta, fumlighet i armar.

Question 12

Nociceptor activates by three mechanisms

Answer 12

Thermal, Mechanical, Chemical

Question 13

Management of acute phase of Trauma, subgroup OTHERS: Injury & Inflammation
Hours to days

Answer 13

Protect from further damage.
Prevent excessive inflammatory exudate.
Reduce swelling.
Mid-range movements. Isometric contractions.

Question 14

Management of trauma: Sub acute phase: Repair & Healing

Days to weeks

Answer 14

Gentle tension & loading without lasting pain.
(Prod. NW.)
Progressive return to normal loads & tension.

Question 15

Management of Trauma: Remodelling

Weeks to months

Answer 15

Prevent contractures. Full range movements.
Normal loading & tension to increase strength
& flexibility.

Question 16

Indications for MDT

Answer 16

 Nerve root problems
 Mechanical back pain
- Mostly aged 20-55 years at onset
- Lumbosacral region, buttocks and thighs
- “Mechanical” in nature, that is the pain varies with physical activity and over
time
- Patient is generally well

Question 17

Contraindications for MDT

Answer 17

 Serious spinal pathology
 Cauda equina, cancer, cord signs, infections, fractures, widespread neurological deficit
 The literature suggests the incidence of these is < 2%

Question 18

Describe the clinical characteristics of the Derangement Syndrome

Answer 18

Derangement Syndrome is a clinical presentation associated with a mechanical
OBSTRUCTION of an affected joint. DIRECTIONAL PREFERENCE is an essential feature and
CENTRALISATION is an important phenomenon observed in the spine.

Question 19

Features of Derangement

Answer 19

Inconsistency and change is a characteristic of Derangement. Its clinical presentation is variable;

Question 20

DERANGEMENT; Pattern in the history: 
Location?
Symptom: behavior? when?
Onset?
SPT and Mech-Presentation are influenced by...?
Movements and postures...?
Sustained postures and activities can...?
Back pain history?

Answer 20

 Location of pain may be local, referred or radicular or a combination
 Symptoms may move from side to side, proximally and distally
 Symptoms may be constant or intermittent
 Therefore they are variable during the day and over time
 Pain may arise gradually or suddenly, often with an insidious onset
 Onset may be accompanied by sudden disability
 Symptomatic and mechanical presentations are influenced by postural loading
strategies during activities of daily living
 Movements and postures cause symptoms to increase/decrease, centralise/
peripheralise, produce/abolish
 Sustained postures and activities can rapidly and progressively worsen or
improve the severity and spread of pain
 May have history of previous episodes

Question 21

DERANGEMENT: Pattern in the examination:

• Mechanical presentaiton:
• May include:
• May desplay:
• Can cause lasting changes…?
• Cause symptom so produce/abolish?
• Cause increased/decrease in?

Answer 21

 Mechanical presentation always includes diminished range or obstruction of
movement
 May include temporary deformity, e.g. kyphosis, lordosis, lateral shift
 May display deviation of normal movement pathways.
 Loading strategies can cause lasting changes
 Repeated movements cause symptoms to produce/abolish,
increase/decrease, and pain to centralise/peripheralise
 Repeated movements cause increase/decrease in range of movement

Question 22

Characteristics of Centralisation

Answer 22

 Only occurs in Derangement Syndrome
 Occurs in response to loading strategies (repeated movements or postures)
 Is usually a rapid and always a lasting change in pain location
 Can be reliably assessed

Question 23

Characteristics of Peripheralisation

Answer 23

 The lasting production of distal symptoms

 Occurs in response to loading strategies (repeated movements or postures)

Question 24

Directional Preference describe…?

Answer 24

 Directional Preference describes the clinical phenomenon where a specific
direction of repeated movement and / or sustained position results in a clinically
relevant improvement in either symptoms and / or mechanics though not
always the Centralisation of the symptoms. It is an essential feature of the
Derangement Syndrome.

Question 25

When to restore funktion?

Answer 25

After 2:nd visit usually. In more difficult cases after 10-12 days.

Question 26

What to do if create a new derangement in opposite direction?

Answer 26

?

Question 27

Criteria to establish the clinical relevance of a lateral shift

Answer 27

 Upper body is visibly and unmistakably shifted to one side  Onset of shift occurred with back pain  Patient is unable to correct shift voluntarily  OR, if patient is able to correct shift they cannot maintain correction  Correction affects intensity of symptoms  Correction causes either centralisation or worsening of peripheral symptoms

Question 28

THE DYSFUNCTION SYNDROME | Pain is caused by?

Answer 28

Pain is caused by mechanical deformation of structurally impaired soft tissues. This abnormal tissue may be the product of previous trauma, or inflammatory or degenerative processes. These events cause contraction, scarring, adherence, adaptive shortening, or imperfect repair.

Question 29

THE DYSFUNCTION SYNDROME | Felt when?

Answer 29

Pain is felt when the abnormal tissue is loaded. Articular or contractile structures can be affected – the former is most common in the spine. When affecting articular structures, it is characterised by a painful restriction of end range movement.

Question 30

THE DYSFUNCTION SYNDROME | Pattern in the history (5):

Answer 30

 History of trauma, derangement, or years of poor posture or degenerative changes  Present for at least 8-12 weeks  Pain is Always local except in the case of an Adherent Nerve Root (ANR)  Pain is ALWAYS Intermittent and produced only when loading structurally impaired tissue  Symptoms cease when loading is ended, and the pain never lasts

Question 31

THE DYSFUNCTION SYNDROME | Pattern in the examination (3):

Answer 31

 Consistent direction and amount of movement produces pain  Restricted movement(s) in one or more planes  Appropriate repeated movement will produce symptoms, which do not remain worse

Question 32

THE POSTURAL SYNDROME | Pain cause?

Answer 32

Caused by mechanical deformation of soft tissues or vascular insufficiency arising from prolonged positional or postural stresses affecting the articular structures or the contractile muscles, their tendons or the periosteal insertions. No pathological changes occur in this syndrome.

Question 33

THE POSTURAL SYNDROME | Pattern in the history?

Answer 33

 Usually young  Sedentary lifestyle  Time is an essential causative factor  Symptoms always local and intermittent  But may have simultaneous cervical, thoracic, and lumbar pain  Brought on only by prolonged static loading of normal tissues  No pain with movement or activity  Most common provocative posture is slumped sitting

Question 34

THE POSTURAL SYNDROME | In examination?

Answer 34

 Poor posture – forward head posture, increased thoracic kyphosis, reduced lumbar lordosis  Posture correction abolishes  No loss of movement  Repeated movements have no effect  Pain produced / abolished on static tests

Question 35

OTHER

Answer 35

``` Chronic Pain Syndrome Inflammatory Mechanically Inconclusive Mechanically Unresponsive Radiculopathy Post Surgery SIJ Spinal stenosis Structurally Compromised Traum ```

Question 36

McKenzie Classification – Spinal OTHER Serious pathology (list is not exhaustive) Category Clinical findings (Red Flags) Clinical Examples

Answer 36

Cancer Age >55, history of cancer, unexplained weight loss, progressive, not relieved by rest =May be primary site or metastases Cauda equina syndrome/cord compression Bladder / bowel dysfunction, saddle anaesthesia, global or motorweakness in legs. Clumsiness in legs Spinal fracture History of severe trauma, older age, prolonged steroid use OR young, active with sport related back pain. =Compression fracture, stress fracture of the pars Spinal related infection Fever, malaise, constant pain, all movements worsen =Epidural abscess, discitis, transverse myelitis Vascular Vascular disease, smoking history, family history, age over 65, male>female. History of trauma, dizziness, diplopia, dysarthria and multiple other nonmechanical symptoms =Abdominal aortic aneurism, cervical artery dysfunction