LUMBAR SPINE Flashcards
(131 cards)
1
Q
Lumbar Spine
L3 dermatome
A
distal anterior medial thigh
2
Q
Local muscles of the trunk control what?
A
Inter-segmental motion
(Multifidus, intertransversari, interspinalis, transversus abdominus, internal
oblique, deep Erector spinae)
3
Q
50-75% slippage=
A
Grade 3
4
Q
name of muscle
A
quadratus lumburum
5
Q
in the lumbar spine, passive range of motion examination is done by
A
two parts:
- Osteokinematic PROM: good reliability
-
Arthrokinematic (segmental) motion tests: poor reliability:
- PAIVM (Passive accessory intervertebral motion: joint glides to determine end-feel (hyper, hypo, normal) and pain/no-pain
- PIVM (Passive intervertebral motion): move the spine osteokinematically and
palpate motion of a single segment
6
Q
what is the main function of the interspinales and intertransversarii muscles
A
- Primary function may be as motion indicators
- Small muscles with small moment arms and loaded with proprioceptors
7
Q
The multifidus attaches to the spinous processes and, therefore, has an excellent moment arm for _________ . It also has a compressive element and contributes to sacral nutation.
A
spinal extension
8
Q
Right Rotation of the lumbar spine is associated with posterior rotation of the right ilium. The right ASIS will move ________ as L5 rotates right relative to the sacrum.
In this position the right SI joint is _______ .
A
- superiorly
- “gapping.”
9
Q
what it is for?
name of test?
A
Gaenslens test
- SI pain provocation test
10
Q
>95% of lumbar disc herniations occur at
A
L4-5 or L5-S1
11
Q
Right Rotation of the lumbar spine is associated with posterior rotation of the right ilium. The right ASIS will move superiorly as L5 rotates right relative to the sacrum. In this position the right SI joint is “gapping.” Given the ___________ ligaments this makes sense. As the ilium moves posterior it “drags” the ipsilateral transverse process with it. Or conversely, as L5 rotates right it provides “slack” in the iliolumbar ligament “allowing” posterior rotation of the ilium.
A
iliolumbar
12
Q
A
SPONDYLOLYSIS
Fx of pars inter-articularis
13
Q
what are the 5 predictors that has been validated to thrust the spine?
A
- No symptoms distal to the knee
- Recent onset < 16 days
- FABQW < 19
- Hypomobility of at least 1 segment
- At least 35 degrees one hip IR
14
Q
💡during AROM
Reproduction of symptoms when the pelvis was stabilized implicates a dysfunction originating primarily from the _____ .
A
spine
15
Q
The psoas and DES provide opposite tensions to the spine, thereby ________ it, similar to “guy wires” for a tent pole.
A
stabilizing
16
Q
zygapophyseal joints.
A
facet joint
17
Q
“main goal of the examination of the lumbar spine is….
A
reproduction of pain.”
(Dr. )
18
Q
👉🏻what is the cut off time for pt with LBP?
name of test
A
Sorensen Test (Sn: 92%, -LR 0.08; Sp: 94%, +LR 15.4)
- Patient presentation: younger age < 40 years, hypermobility in SLR, aberrant movements during, lumbar flexion and extension, Positive prone instability test.
- normal 2-3 minutes
- Cut off for patients with LBP is > 28-29 sec (Arab et al, 2009)
19
Q
“a predictor for who may develop LBP” (Dr. M)
A
Sorensen test
20
Q
A
Slump Test (Sn: 84%, -LR 0.19; Sp: 83%
- lumbar radiculapathy
- Patient slumps as far as possible producing full trunk flexion; examiner adds firm overpressure
- +ve test is reproduction of patient’s symptoms
21
Q
Nutation (meaning to nod) is defined as the relative _______ of the base (top) of the sacrum relative to the ilium.
A
anterior tilt
22
Q
name of manipulation
A
LUMBOPELVIC THRUST MANIPULATION
23
Q
______% of patients with LBP will have non-specific mechanical LBP
A
85%
24
Q
💡can develop into which pathology?
Clinical significance of the ligamentum flavum
A
- It is located inside the spinal canal
- With age, the ligament flavum will degenerate and may hypertrophied (becoming fibrotic) → spinal stenosis
25
when you directly impart forces to a single segment creating joint glides and determine the end-feel and amount of motion of a single segment (hypo, hyper, normal). You will also determine the
presence or absence of pain at each segment you push on.
**Passive accessory intervertebral motion**
**PAIVM**
26
Contraction of the erector spinae muscles will cause sacral \_\_\_\_\_\_\_
nutation
27
L2-L4 reflex
patellar
28
Patients with acute symptoms should be informed that...
recovery is likely in a short-period of time, but recurrence is likely and this does not mean a failure of treatment
29
contraindicated exercises in a patients with **spondylosis**
extension ex in the early phase
30
* age \> 50
* with Degenerative narrowing of the spinal canal or intervertebral foramen
* with Neurogenic claudication **(bilateral leg pain)** with walking
**Spinal Stenosis**
31
S2 dermatome
heel
32
Anterior displacement of spine above pars inter-articularis fracture
SPONDYLOLISTHESIS
33
* **Urinary retention (Sn: 0.90, Sp: 0.95)**
* Motor deficits at multiple levels
* Fecal incontinence
* Saddle anesthesia
* Sensory deficits in the buttocks, posterior superior thigh, and perianal region
**CAUDA EQUINA**
medical emergency
History question: Do you feel numbness between your legs when you wipe after using the toilet?
34
name each disc pathology in the picture
35
L2/L3 myotome
**hip flexion**
36
# Specificity and Sensitivity
lumbar radiculopathy special tests
* Crossed Straight Leg Raise (Sn: 25%, -LR 0.79; **Sp: 95%**): rule in
* Straight Leg Raise **(Sn: 97%**, -LR 0.05; Sp: 57%): rule out
* Slump Test (Sn: 84%, -LR 0.19; Sp: 83%)
* Femoral Nerve Tension Test (Sn 84%)
37
# what it is for?
name of test?
**Thigh Thrust Test**
* SI pain provocation test
38
Provocations in ____ or more tests plus tenderness in Fortin’s area is fairly conclusive of SI joint origin to the pain.
**three**
39
Neurogenic claudication, also known as pseudoclaudication, is
* **bilateral leg pain**
* claudication, from the Latin for limp, because the patient feels a painful cramping or weakness in the legs.
* NC should therefore be distinguished from vascular claudication, which is when the claudication stems from a circulatory problem, not a neural problem.
40
TBC: mobilization group treatment
* Mobilization and manipulation of the lumbopelvic region
* Active ROM exercises
41
L2 dermatome
anterior mid thigh
42
THORACOLUMBAR FASCIA is located directly under the skin, and is very important for
**lumbar stability**
43
* DF weakness
* Great toe extension weakness
* Ankle reflex S1 (Sn 0.83)
* Sensory deficit
* Clinical tests:
* SLR (Sn0.91)
* X-SLR (Sp 0.88)
**Sciatica**
44
# grade?
\<25% slippage =
Grade 1
45
primary stabilizers ligaments of the SI joint
* Anterior SI ligaments
* Posterior SI ligaments
46
L4 dermatome
medial melleolus
47
# 📖 Donald Neuman textbook
The downward force of gravity resulting from body weight passes through the lumbar vertebrae, usually just anterior to an imaginary line connecting the midpoints of the two sacroiliac joints. At the same time, the femoral heads produce an upward directed compression force (GRFV) through the acetabula. Each of these two forces acts with a separate moment arm to create a _______ torque about the sacroiliac joints
**nutation**
48
# 💡During AROM examination
Reproduction of symptoms when the lumbo-pelvic region rotates as a unit implicates a ______ dysfunction.
**hip**
49
intermittent low back pain with increasing frequency, excessive ROM, catching, weakness, increased joint mobility, “fidgeter”, returns from FB by holding onto thighs:
all suggest hypermobility and necessity of Stabilization exercises
50
# TBC
* Symptoms distal to the buttock
* Symptoms peripheralize with lumbar flexion
* Symptoms centralize with extension
**Specific Exercise Extension** group
51
TBC: stabilization group treatment
* Strengthening of the large global muscles
* Motor control training of the deep local muscles
52
# Movement Analysis II
Clinically ______ exercises temporarily reduce pressure on a lumbar nerve root impinged by obstructed foramen
**flexion**
But flexion also increases compresses forces anterior disc which push nucleus posterior
53
what is the main difference between **facet joint syndrome** and **spinal stenosis**?
* In both the pain is worse with extension and improves with flexion
* **However, in** **facet** **joint syndrome pain is very localized, whereas in spinal stenosis the pain radiates down the** **the leg**
54
* **Morning stiffness** and repeated episodes of waking night pain
* **Onset of pain before 40**
* **Pain persisted over 3 mo**
* Slow gradual onset
* Improvement with exercise
**Ankylosing Spondylitis**
55
treatment of spinal stenosis
* Flexion exercises
* Mobilization of the hips
* Body weight support treadmill
* Manual therapy
56
# cut off time for pt with LBP?
name of test
Supine Isometric Chest Raise Test (Sn: 96%, - LR 0.24; Sp: 72%. +LR 4.0)
* Cut off for patients with LBP is \> 34 sec for males and \> 24 seconds for females (Arab et al, 2009)
57
90% of patients with herniations function normally in
6 months
58
Note facet orientation, orientation return back to frontal plane from sagittal plane facets of lumbar spine. This prevents _______ slippage of the lumbar segment
**anterior**
59
# TBC
* Signs and symptoms of nerve root compression
* No movements centralize symptoms
Traction group
60
What are the **predictors** for the development or prognosis of LBP?
Not identified yet
Patients with lower than average initial pain, shorter duration of symptoms, and fewer previous episodes recovered quicker (not validated)
61
Seronegative arthritis characterized by inflammation and, eventually, ankylosis
**Ankylosing Spondylitis**
62
pain location in spondylolysis
Lumbosacral pain
63
Nutation at the sacroiliac joints increases the compression and shear forces between joint surfaces, thereby increasing articular \_\_\_\_\_\_\_
stability
| (close-packed position of SIJ)
64
spinal stenosis responds best to?
disc herniation responds best to?
1. flexion
2. extension
65
* 50% of patients with LBP return to work in 2 weeks, while 83% returned in 3 months
* **28% of patients with LBP still had symptoms at \_\_\_\_\_\_\_\_**
**12 months**
66
Lumbar spine predominantly favors flexion and extension and some constant degree of lateral flexion, especially at the L5-S1 facet joint. This is important for lower segmental lumbar side bending, which is necessary for \_\_\_\_\_\_\_.
**gait**
67
# MA II
The facet surfaces of the L5-S1 apophyseal joints are usually oriented in a more _____ plane than those of other lumbar regions
**frontal**
68
# TBC
* No symptoms distal to the knee
* Recent onset \< 16 days
* FABQW \< 19
* Hypomobility of at least 1 segment
* At least 35 degrees in one hip
**Mobilization** group
(only clinical prediction rule that has been validated)
69
Right Rotation of the lumbar spine is associated with _______ \_\_\_\_\_\_\_\_\_ of the right ilium.
**posterior rotation**
70
which muscles insert in the thoracolumbar fascia?
* **Latissimus** and **glut** **maximus**
* Diagonal relationships between gluteus maximus and latissimus dorsi
* Can be used for excercise prescription
* Has attachments across entire lumbar spine and SI joints.
* Increased muscle activity = increased stabilization
71
Reduced AROM, either symmetric or asymmetry, with limitation of pain in one direction, short history of complaints, absence of neuro signs, perhaps related to overuse or mild trauma, with decreased motion in one segment seen in AROM and in PAIVMs all suggest:
**Mobilization**
72
* Younger age \< 40 years
* SLR \> 90 degrees (hypermobility)
* Aberrant movements during lumbar flexion and extension
* Positive prone instability test
**Stabilization** group
73
# cut off time for pt with LBP?
name of test
**Prone Isometric Chest Raise Test** (Sn: 80%, -LR 0.08; Sp: 80%, +LR 15.3)
* Patient presentation: younger age \< 40 years, hypermobility in SLR, aberrant movements during, lumbar flexion and extension, positive prone instability test
* Cut off for patients with LBP is \> 31-33 seconds (Arab et al, 2009)
74
"**Extensor Hallucis Longus weakness** is pretty specific for ____ nerve root radiculopathy." (Dr. M)
**L5**
75
S1 myotome
ankle plantar flexion
76
in left lumbar rotation, which SI joint is "gapping"?
left SIJ
77
During the **neutral gapping thrust manipulation**, the therapist’s superior hand is on the ____________ pushing toward the table. The therapist’s inferior hand is on the _____________ pulling upwards to the ceiling.
1. **superior segment’s spinous process**
2. **inferior segment’s spinous process**
78
Global muscles of the trunk
* Rectus abdominus
* Psoas (Dr. M)
* external oblique
* superficial erector spinae
79
Intervention for reduced force closure:
* SI belt
* Postural alignment
* Local muscle co-contraction—stabilization exercises (as per lumbar)
80
Intervention for excessive force closure:
* Education regarding need for **relaxation**
* Relaxation exercises
* Stop excessive exercising/stabilizing exercises
* Easy aerobic exercise, yoga…
81
L5 myotome
**great toe extension**
(specific for L5 nerve root radiculopathy)
82
Degenerative narrowing of the spinal canal or intervertebral foramen
Spinal Stenosis
83
to determine motion at a joint segment, you move the spine osteokinematically and
palpate motion of a single segment (hypo, hyper, normal). That is, as you move the spine with one hand, you are feeling the joint motion with the other.
**Passive intervertebral motion**
**PIVM**
84
# TBC
* Visible frontal plane deviation of the shoulders relative to the pelvis
* Directional preference for lateral translational movements
Specific Exercise group, lateral shift
85
L1 dermatome
inguinal region
86
is there lateral flexion in the lumbar spine?
yes, especially at the L5-S1 facet joint becasue they oriented in a more frontal plane
87
WHICH MUSCLES **LOCAL** VERSUS **GLOBAL** FOR STABILITY?
combination of both (Dr. M)
88
**Stabilization Special Tests:**
(Younger age \< 40 years, hypermobility in SLR, Aberrant movements during, lumbar flexion and extension, Positive prone instability test)
| (Endurance and stabilizations exercises)
* **Sorensen Test** (Sn: 92%, -LR 0.08; Sp: 94%, +LR 15.4)
* **Prone Isometric Chest Raise Test** (Sn: 80%, -LR 0.08; Sp: 80%, +LR 15.3)
* **Supine Isometric Chest Raise Test** (Sn: 96%, - LR 0.24; Sp: 72%. +LR 4.0)
89
# 💡 muscles
To correct **anterior innominate**, use activation of
**hamstrings/glutes** to pull innominate posterior
90
L3/L4 myotome
knee extension
91
We categorize the “pelvic disorder” and start treatment. Using the model suggested by O’Sullivan there are specific and non-specific categories. Specific means _________ pain disorders such as fractures and infections. These require medical management rather than PT. Remaining are those with dominant psycho-social factors and those with mechanical factors.
**inflammatory**
92
# Mark Dutton
Because the multifidus is segmental in origin and **innervation**, any impairment of this muscle can produce palpable changes in the muscle, thus directing the clinician to
the segment that is dysfunctional
93
# TBC
* Older age \> 50
* Directional preference for flexion
**Specific Exercise** flexion group
94
name of tests
**Femoral Nerve Tension Test** (Sn 84% Porcher et al, 1994)
Disc problems L2 to L4
lumbar radiculopathy
1. One hand on PSIS
2. Bend knee until the onset of symptoms
3. Back the leg out of the position
4. The examiner can use PF, DF, or head symptoms to sensitize the findings
5. Further sensitization can be elicited by hip extension
95
Radiculopathy signs which respond to motion by improving or centralizing suggests:
Specific Exercise
96
L5 dermatome
**lateral leg**
97
# What it is for?
name of test
**Gillet Test** (poor reliability)
**SI dysfunction**
In those with pelvic pain in which SI joint dysfunction is suspected, the PSIS may move superiorly instead, or not move at all.
98
S1 dermatome
lateral foot
99
At left toe off and right heel strike, the left ilium is anteriorly rotating while the right
ilium is posteriorly rotating. The lumbar spine is rotated _____ slightly
right
100
S1 reflex
achilles
101
The function of the ligament flavum is to resist separation of the lamina during
**flexion**, but there is also appreciable strain in the ligament with **side bending.**
102
High levels of pain, which cannot be diminished by position or motion, allowing little assessment, suggests:
Traction (although this category should rarely be used and there is less evidence that traction works)
103
*Counternutation* occurs by _______ sacral-on-iliac rotation,\_\_\_\_\_\_\_ iliac-on-sacral rotation, or both motions performed simultaneously.
1. posterior
2. anterior
104
* Inhibition of local muscles
* Sway back
* Often hormonal—related to pregnancy
* +ASLR test
* Compression RELIEVES PAIN
Diagnosis of r**educed force closure**
105
spondylolysis population
* Gymnast
* Dancers
* Weightlifters
106
# Donald Neuman text-book
The sacroiliac joints perform two functions:
1. **a stress relief mechanism within the pelvic ring:** this stress relief is especially important during walking and running and, in women, during childbirth
2. **a stable means for load transfer between the axial skeleton and lower limbs**
107
which muscle is located closest to the spinous process in the lumbar spine?
multifidus
108
L4 myotome
dorsiflexion
109
Spondylolysis can progress to
**spondylolisthesis**
110
# what makes it positive?
name of tests
**Prone Instability Test** (Sn: 61%, -LR 0.69; Sp: 57%, +LR 1.41 Fritz et al, 2005)
1. A PA spring test is given over the back and symptoms are assessed
2. Pt lift their legs
3. +ve test is reduction of symptoms
111
close- packed or more stable position of the sacrum.
nutation
112
Global muscle of the trunk control what?
**Move entire spine**
113
S3-S4 dermatome
genitals
114
**Examination order:**
1. Review of patient reported materials
2. Initial observation
3. History
4. Review of systems → refer out/continue exam/focus on specific structures
5. Structural Inspection
6. Screening exam
7. Movement analysis: demonstration of what hurts
8. AROM
9. PROM
10. MMT (endurance test in the spine)
11. Special tests
12. Palpation for tenderness
115
# 💡two things
the primary function of the **deep erector** **spinae** is...
to prevent anterior shear of each segment and to provide vertical compressive force.
116
very important ligament in prevention of anterior displacement of L5 on Sacrum
**Iliolumbar ligament**
117
Full extension reduces diameter intervertebral
foramina by \_\_\_\_% and vertebral canal \_\_\_%
1. **11%**
2. **15%**
* Individuals with nerve root impingement limit extension activities
* Extension migrates nucleus anterior therefore individuals with posterior or posterior-lateral disc herniations may show relief with extension
118
# SIJ Joint
Are either centralisation or peripheralisation phenomena observed?
if yes →
if no →
* If yes → diagnosis of symptomatic **disc** lesion
* if no → Are three or more SIJ provocation tests positive?
119
intervertebral discs get nutrition from \_\_\_\_\_\_\_\_
**movement**
"Discs are meant to accept load." Dr. M
120
# name of ligament
resists **nutation** or **posterior innominate motion**
**Sacrotuberus** and **Sacrospinous** ligaments
121
types of spondylolisthesis
* **Isthmic (usually L5-S1)**
* children
* High incidence in gymnasts, weight lifters
* Tx: PT, regular X-rays, fusion, pars repair with screw, reduction of deformity
* **Degenerative (usually L4-L5)**
* Less severe than isthmic
* Lumbar stabilization ex.
122
SUPERFICIAL ERECTOR SPINAE VERSUS DEEP ERECTOR SPINAE: underneath the thoracolumbar fascia is the\_\_\_\_\_\_\_\_\_\_\_\_, which is the attachment for the superficial ES
**superficial erector** **spinae** **aponeurosis**
123
Nutation occurs by ______ sacral-on-iliac rotation, ________ iliac-on-sacral rotation, or both motions performed simultaneously.
1. **anterior**
2. **posterior**
124
# name of test
1. One hand palpates left PSIS
2. the other hand palpates S2
3. Patient flexes the hip to 90 deg
**Gillet Test**
In those with pelvic pain in which SI joint dysfunction is suspected, the PSIS may move superiorly instead, or not move at all.
(Poor reliability)
125
50% of patients with Low Back Pain (LBP) return to work in \_\_\_\_\_\_\_, while 83% returned in 3 months (Henschke et al, 2008)
**2 weeks**
126
* Compression INCREASES Pain in the SI area
* Negative ASLR
* Posture is OVERLY conscious and held—rigid
* Anxious, fearful, stressed
Diagnosis of excessive **force closure**
127
local muscles of the spine
* Multifidus
* intertransversari
* interspinalis
* transversus abdominus
* internal oblique
* deep Erector spinae
(they control inter-segmental motion)
128
# Movement Analysis II
Full lumbar extension increases amount of load and area of contact at
facet joints
129
The Deep Erector Spinae attach to the\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ and, therefore, have little moment arm for spinal extension.
**transverse processes**
130
# 6 evidence articles
Evidence supporting theory of dysfunctional “local” muscles
1. Multifidus, at the level of the LB injury, is shown to be smaller than at other levels
2. Transversus abdominus shown to be slower to “turn on” in those with LBP in quick response tasks
3. Transversus abdominus fires first before trunk extensors in lifting tasks
4. Transversus abdominus fires for BOTH trunk extension and trunk flexion
5. Specific training of the local system has been shown to be effective in the treatment of subsets of patients with LBP.
However, more recent evidence has NOT shown that specific exercise is superior to more general exercise for low back pain patients who are not in specific subgroups
131
**LUMBAR LIGAMENTS**
* Anterior longitudinal ligament
* Posterior longitudinal ligament
* Ligamentum flavum (yellow ligament)
* Inside the spinal canal
* Supraspinous ligaments
