RBA Flashcards by Rob Flannigan

how common is myotomal deficit in spine Drg?

difference in lumbar vs cervical?

common

more so in cervical

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can stenosis symptoms be radicular and referred? What areas of the spine?

only see radicular in cervical

lumbar both

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can stenosis have an acute onset? how common?

yes, trauma can reveal stenosis

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can NRE have an acute onset? how common?

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what provokes stenosis symptoms? How quickly?

extension activities of course

can be immediate or require sustained to expose in lumbar
typically immediate in C/S

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how to confirm or rule out stenosis diagnosis in lumbar spine

IF patient denies obstruction...
- go RFISit or RFIL to provoke
if no...
- go REIS over fulcrum, look for NE or P, NW
- then test over 48-72 hours to R/O Drg

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how long does a NRE take to develop

12 weeks, longer than other fixed lesions

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Do you see obstruction with nerve root entrapment?

No, maybe minimal. but, will see some temporary “stiffness” after sitting due to creep loading.
Never will fully obstruct after prolonged sitting

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are nerve root entrapment symptoms constant or intermittant

constant.

-sometimes only proximal pain is constant, and limb symptoms are intermittent

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what is the minimum time for onset of ANR or dysfunction?

at least 8 weeks, shorter than NRE

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uni- or multi-directional for dysfunction?

can be multi-directional, but one will dominate

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with dysfunction, does patient have PDM or ERP? Describe

ERP, but at a premature end range

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mechanically inconclusive- radicular, referred, or local pain?

referred and local primarily

radicular is rare

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mechanically inconclusive- chronic, acute, subacute

primarily chronic

-occasionally see acute or subacute

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mechanically inconclusive- intermittent or constant?

both

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mechanically inconclusive- what makes them worse?

usually all movements and positions make them worse over time
- rarely a clear pattern

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mechanically inconclusive- can they be obstructed?

NO, they will not have any functional deficit when their pain is worse

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mechanically inconclusive- typical ROM loss?

none, nonspecific

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mechanically inconclusive- PDM or ERP?

usually multidirectional ERP, less PDM

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mechanically inconclusive- nerve tension?

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mechanically inconclusive- space occupation producing limb symptoms?

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RBA approach for suspected mechanically inconclusive

1 focus on RFISit/RFIL to eliminate Drg

if they can’t tolerate, or yellow flags dominate
–> give SOC for 48 hours

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Must have general baselines in an IMC RBA

- spine and extremity

ERP or PDM with ROM (or space occupation)
functional complaint
nerve tension (esp. L/S)
myotomes (esp. C/S)!!
postural correction!!
extremity baselines b4 spinal screen

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must have baselines for an RBA of the shoulder

- besides the obvious (ROM of course, but what specifically is often missed)

resisted movements

- OP to ROM, esp. flexion, abduction

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must have baselines for an RBA of the elbo- besides the obvious (ROM of course, but what specifically is often missed)

- resisted movements of elbow, wrist, grip | - OP extension, compare sides

must have baselines for an RBA of the wrist | - besides the obvious (ROM of course, but what specifically is often missed)

OP to active ROM

must have baselines for an RBA of the hip | - besides the obvious (ROM of course, but what specifically is often missed)

- resisted, passive, and OP at end range - at least 1 weight bearing functional test - FABERs supine or seated

must have baselines for an RBA of the knee | - besides the obvious (ROM of course, but what specifically is often missed)

- terminal extension, supine, with OP | - 1 weight bearing funct. test (squat, climb stairs, etc)

must have baselines for an RBA of the ankle | - besides the obvious (ROM of course, but what specifically is often missed)

accessory movements of the mid- and hindfoot

General order to the RBA, after funnel Hx

1. set baselines 2. perform necessary test to confirm/rule out Hx based theory 3. test hunch if desired 4. if hunch is wrong, immediately focus exam on Hx-based Ddx

which has more scientific support: symptomatic or mechanical improvement?

symptoms!

does symptomatic improvement confirm Dx of Drg? | If not, what is needed?

No. | mechanical improvement must confirm Dx

If mechanics improve first, is this enough to confirm Dx of Drg? If not, what else is needed?

suggests Drg only | - symptoms must respond within 3 days, or reassess

In what populations/conditions do mechanics often improve initially without symptom change?

geriatrics mechanical C/S headaches thoracic region

Pt case- symptoms improved, but mechanics are worse - what do you do? - what are you thinking?

Stop and reassess, likely will need GR tutor - person may have 2 simultaneous conditions, or weird structural thing - somethings off, fortunately this is uncommon

Pt case- symptoms worsened, but mechanics are better - what do you do? - what are you thinking?

- decrease force first. may have direction right, but need to back off

What is massively important to assess in the spine, but often forgotten! (esp. by me...)

Postural correction! - can confirm Drg Dx just with this! - they've been slouched sitting during history, it's the perfect oppportunity

4 general rules of RBA | think C-, T-, and L-Spine

1. If Drg and Pt knows the Better - go with relieving direction 2. If Drg and Pt doesn't know the Better - goes with worse, provoke 3. No Drg Evidence - C and L-Spine: flexion, provoke - T-Spine: blast extension - repeated with OP, mob, sustained in lying 4. Must have ? to Answer before Movement test`

If a patient has thoracic pain, and there's no evidence suggesting Drg from the funnel Hx, where do you start?

with Extension! repeated with OP mobilization SUSTAINED in lying

How many baselines should you retest during the RBA?

or a few key indicators after the initial baseline setting. retesting everything is inefficient and confusing

The 2 purposes of baselines

1. prove the existence of "Must Haves" for a condition e. g. nerve tension for ANR 2. reference point of course B, S, or W

How important is nerve tension as a baseline in the spine?

L-spine: "gift from the gods" - commonly rapidly reversible, great for patient buy-in C-spine: good, but not as commonly rapidly reversible - only retest once for change, could scare patient T-spine: irrelevant?

3 primary conditions that cause nerve tension

1. Drg 2. ANR (uncommon) 3. Inflammatory (very uncommon)

In a patient with a derangement and ANR, when do you start remodeling?

only after Drg fully reduced, AND maintained

What are the characteristics of nerve tension in a inflammatory mechanism patient?

not classic | - Pt can move through it to some degree

what is starting treatment often for inflammatory patient with positive nerve tension? (besides anti-inflamm chemicals)

SOC - if they respond to this, gentle end range nerve stretches may help, proceed cautiously - only to tolerance, remember 15-20 min

How to test for nerve tension with C-spine

1. modified Elvey's seated - if weakly positive, confirm supine 2. full Elvey's supine - ensure shoulder depression! and pivotal response

how to educate patient around (+) nerve tension?

immediate after confirming it with test! - draw on whiteboard the 3 possibilities 1. Hung Up (rapidly reversible) 2. Tight (longer, but can fix at home) 3. inflamm explain possibilities, and what we'll do to confirm one or the other

PDM in the spine equals...

Derangement! | until proven otherwise

PDM in the lumbar spine can very rarely be this condition, rather than a Drg

lumbar spondylolisthesis | - will fool you for a few visits

What are the 2 most basic, but often the most important, or only present, baselines to have before the movement exam?

PDM | ERP

ERP as a baseline is seen most commonly in what classification?

Drg!

Why is unilateral ERP (like with side glide or rotation) a great Pt education opportunity?

There's proof on the unaffected side that this shouldn't hurt!! Point that out to them.

What simple baseline is often most revealing (for me and patient) in the cervical spine?

rotation! - premature ERP is gold - cue Pt awareness of where in ROM and intensity

What if there's no baselines?! Pt has no symptoms, ROM is fine, functional test negative

Try OP or mobilization (accessory movements) to ROM

accessory movement (OP or Mob) baselines for the L/S

1. shift over-correct B/L with EIS 2. exten. mob, prone or sphinx 3. EIS over fulcrum

accessory movement baselines (OP or Mob) for the C/S

retraction, rotation, and side flexion with OP | - if I need to save time, do it myself

accessory movement baselines (OP or Mob) for the T/S

perform seated | - ext. and rotation OP/mob

accessory movement baselines (OP or Mob) for the hip

flexion, extension, FABERs with OP

accessory movement baselines (OP or Mob) for the knee

terminal ext of course, flex

accessory movement baselines (OP or Mob) for the ankle/foot

calcaneal and midfoot/forefoot | - inversion and eversion

accessory movement baselines (OP or Mob) for the elbow

terminal extension | - Specifically, bounce and clunk the joint

How does Mark Miller test terminal extension of the elbow?

- Pin Pt hand between my trunk and arm | - grab elbow and snap up into extension

RBA Flashcards

(63 cards)