Lumbar

Question 1

MRI findings associated with clinical symptoms

Answer 1

High intensity zone = associated with annular tear and discogenic pain
Modic sign = disruption of endplate with bone marrow edema

NOTE: centralization of symptoms is the only clinical test that increase the likelihood of discogenic pain

BOTTOM LINE: HIZ, endplate changes, and/or centralization of symptoms indicates disc problem

Question 2

Metastatic cancer clinical cluster

Answer 2

Screening cluster Sn = 100% (5/5):
History of cancer
Unexplained weight loss
Age greater > 50 or < 17
Failure to improve over predicted time interval

Also:
Night pain or pain at rest

Question 3

Disc or vertebra infection clinical cluster

Answer 3

Immunosuppression
Prolonged fever with temperature> 100.4
History of IV drug use
History of recent UTI, cellulitis, or pneumonia

Other:
Acute pain and tenderness of spinous processes

Question 4

Vertebral fracture clinical cluster

Answer 4

Clinical prediction rule:
Age> 70
Female
Significant trauma
Prolonged use of corticosteroids

Other risk factors:
Mild trauma in age >50
Known history of osteoporosis

Question 5

Abdominal aortic aneurysm clinical cluster

Answer 5

Pulsating mass in abdomen
Throbbing, pulsing back pain at rest or with recumbency (not relieved by change in position)
History of atherosclerotic vascular disease
Age >60

Other:
Male
Recently started weightlifting

Question 6

Structures in degenerative disc disease that can produce pain

Answer 6

Outermost annulus
Subchondral bone adjacent to injured disc
Adjacent tissues

Question 7

Factors influencing/not influencing the development of lumbar DDD

Answer 7

Genetics = strongly linked

No link:
Smoking
Physical loading

Question 8

Age related degenerative changes

Answer 8

Loss of hydration in nucleus
Vertebral end plate disruption
Annulus disruption
- Peripheral rim lesions due to trauma
- Circumferential tears due to repetitive stress
- Radial fissures (primary structural anomaly associated with DD)

Question 9

Treatment for lumbar DDD related to stage of disease (early, later, severe, diurnal changes)

Answer 9

Mild early stage = no additional treatment precautions

Later stage = avoid vigorous or sustained loading at endrage of trunk motion; stabilization through contraction of abdominal and multifidus muscles may improve tolerance

Moderate or severe = avoid long exposure to compression (prolonged sitting or lumbar flexion)

NOTE: increased disc volume in the morning may influence response of discs to load, especially flexion (avoid early morning lumbar flexion)

Question 10

Cancers that metastasize to bone

Answer 10

PB KTLL

Prostate
Breast
Kidney
Thyroid
Lung
Lymphoma

Question 11

Contraindications to manipulation

Answer 11

Any pathology that leads to significant bone weakening
- Bone malignancies
- Bone infection/osteomyelitis
- Osteomalacia
Fracture
Ligamentous instability
Inflammatory arthritis
Neurological compromise:
- Cord compression
- Cauda equina
- Nerve root compression with increasing neurological deficit
Vascular compromise:
- Aortic aneurysm
- Bleeding into joints
Unclear diagnosis/reason for pain
Patient does not want
Patient positioning cannot be achieved

Question 12

Precautions to manipulation

Answer 12

Spondylolisthesis
Hypermobility
Post-surgical joints
Osteoporosis 
Benign bone tumors
Signs of nerve root compression
Pregnancy
Long-term use of steroids
Blood thinners

Question 13

Potential complications of manipulation

Answer 13

Cauda equina

Disc herniation

Question 14

3 step process for validating clinical prediction rules

Answer 14

Derive
Validate
Analyze

Question 15

Levels of CPR validation

Answer 15

Level 1 = perspective study with multiple locations plus an impact study
Level 2 = one large or several smaller perspective studies
Level 3 = similar sample size and type of clinicians as derivation study
Level 4 = retrospective data, narrow population
Derivation study = identifying components of model

Question 16

Types of clinical prediction rules

Answer 16

Diagnostic
Interventional
Prognostic

Question 17

Visceral referral patterns

Answer 17

Pancreas = pain T3 to 10, upper abdominal pain and symptoms in R shoulder
Breast = anterior pain radiates posteriorly to thoracic region and posterior shoulder; skin changes, palpable nodes or lumps
Esophagus = anterior neck pain, difficulty swallowing
Heart = thoracic, neck, jaw, L arm pain; activity increases symptoms

Question 18

Characteristics of pulmonary symptoms

Answer 18

Difficulty breathing

Semi reclined position improves symptoms

Question 19

Characteristics of cardiac symptoms

Answer 19

Acute
Unrelieved with position
Aggravated by activity

Question 20

Kehrs sign

Answer 20

= acute tip of L shoulder due to presence of blood or other areas in the paratomial cavity when lying down and legs are elevated

• Ruptured spleen
• GI bloating/gas
• Ectopic pregnancy

Question 21

Gallbladder (cholecystitis) signs

Answer 21

= inflammation of gallbladder

Right upper quadrant pain and tenderness
Right upper abdominal pain
Right scapular pain
Mid to lower thoracic pain

Question 22

Renal/kidney system referral

Answer 22

Pelvic and low back
Proximal thigh
Left shoulder pain

Changes/problems with urination

Question 23

Gastrointestinal referral patterns

Answer 23

Lower abdominal and centralized LBP

Heartburn, indigestion, and difficulty swallowing (upper GI)
Bloody diarrhea, fecal incontinence (lower GI)

Question 24

Stomach referral pattern

Answer 24

Upper abdominal, middle and lower thoracic (T6-10)

Question 25

Large intestine referral pattern

Answer 25

Buttocks, middle lumber spine or lower abdomen

Question 26

Ankylosing spondylitis (clinical signs, CPR's, diagnosis)

Answer 26

Clinical presentation: Mobility limitations throughout the spine Pain worse in second half of night or in AM Pain increased on days without exercise ``` Most common joints affected (in order): Spine Shoulder Hip Knee ``` ``` CPR: Alternating buttocks pain Morning stiffness > 30 min Improvement with exercise Awakening due to pain during second half of the night only ``` ``` CPR: Age of onset < 40 Insidious onset Improvement with exercise No improvement with rest Pain a night with improvement on getting up ``` Diagnosis: HLAB27 Radiographs

Question 27

Rheumatoid arthritis (signs and symptoms, associated syndromes)

Answer 27

``` More distal symptoms (hands, feet, ankles) BUT not distal IP, only proximal IP joints Knee joint swelling Rapid onset Females Onset 40-50 ``` Associated syndromes: Feltys = causes recurrent infections Sjogrens = dryness of eyes and mouth

Question 28

Contraindications for spinal traction

Answer 28

Spinal infection RA or other acute inflammatory joint disorder Osteoporosis Spinal cancer Central spinal cord pressure (tumor, central HNP)

Question 29

Precautions for spinal traction

Answer 29

Joint hypermobility Acute inflammation Claustrophobia or anxiety associated with traction Cardiac or respiratory insufficiency Pregnancy Symptoms increase with traction / history of aggravation with traction TMJ dysfunction for cervical using chin strap