Week 3 Flashcards
(300 cards)
1
Q
What is the flow of the patient management model?
A
- Examination
- Evaluation
- Diagnosis
- Prognosis
- Intervention
- Outcomes
2
Q
What are the two exams involved in the examination step of the patient management model?
A
- Subjective and objective exam (history and physical exam)
3
Q
The patient management model is an _____ based model
A
The patient management model is an impairment based model
4
Q
What does the nagi model of disablement suggest?
A
That there is some sort of active pathology going on in the body
5
Q
What is the general flow in the nagi model of disablement?
A
- Active pathology
- Impairment
- Functional limitations
- Disability
6
Q
What is an active pathology?
A
Interruption or interference with normal processes and efforts of the organism to regain normal state
7
Q
What is an impairment?
A
Anatomical, physiological, mental, or emotional abnormalities or loss
8
Q
What is a functional limitation?
A
Limitation in performance at the level of the whole organism or person
9
Q
What is a disability?
A
Limitations in performance of socially defined roles and tasks within a socio-cultural and physical environment
10
Q
Examination findings lead to ___
A
Examination findings lead to interventions
11
Q
We monitor ____ to see if impairments are changing
A
We monitor signs and symptoms to see if impairments are changing
12
Q
What are the signs/symptoms that we normally think about to determine if impairments are changing?
A
Asterisk/provocative signs
13
Q
What is an impairment intervention/maxim to provide for a stiff patient?
A
- Manipulate (thrust/non-thrust)
14
Q
What is an impairment intervention/maxim to provide for a tight patient?
A
Stretch/ improve flexibility
15
Q
What is an impairment intervention/maxim to provide for a weak patient?
A
Strength
16
Q
What is an impairment intervention/maxim to provide for a patient if coordination is lacking?
A
Facilitate/inhibit muscles to improve coordination
17
Q
What is an impairment intervention/maxim to provide for a patient whose fear of movement is high?
A
Graded exposure
18
Q
What is an impairment intervention/maxim to provide for a patient when there is a misunderstanding?
A
Educate
19
Q
What should our treatment approach be?
A
- Test
- Treat
- Retest
20
Q
____ provides most of the information needed to clarify the cause or establish a hypothesis
A
The patient’s story provides most of the information needed to clarify the cause or establish a hypothesis
21
Q
When does the interview of a patient stop in the duration of treatment?
A
NEVER, the interview is continuous should be done for as long as the patient is in your care
22
Q
What are the key components we want to get out a patient’s story?
A
- Patient profile
- Chief complaint
- Body chart
- Present episode
- Aggravating and easing factors
23
Q
What is severity in SINSS?
A
Intensity of patient’s complaint and the extent that they limit pain
24
Q
What is irritability in SINSS?
A
The amount of activity to aggravate/alleviate symptoms
25
What is nature in SINSS?
The source of patient's pain.
26
What is stage in SINSS?
Acute, sub-acute, chronic
27
What is stability in SINSS?
Is pain getting better, staying the same, or worsening
28
____ refers to the type and extent or degree of injury/illness
*Nature* refers to the type and extent or degree of injury/illness
29
What is an acute on chronic stage of pain?
When a person has a chronic pain, but has a flare up
30
What is the stage of most back pain?
Acute on chronic
31
___ clarifies the historical examination
*Physical examination* clarifies the historical examination
32
What are the components of the physical exam?
- Observation
- Clearing test (spine, joints above and below)
- Active movement
- Passive movement (physiologic, accessory, neural)
- Palpation
- Functional tests
- Isometric tests
- Special tests
33
What are the treatment techniques for an impairment based intervention?
- Address impairments
- Reduce, centralize, or abolish symptoms
- May relieve or provoke symptoms
- Take into account: SINSS (worse, same, better) (vigor of techniques)
- Test-treat-retest
- Choose one or two techniques and complement with specific HEP
34
___ indicates the value of each technique
*On-going assessment* indicates the value of each technique
35
A ___ response during a session indicates a better prognosis (outcome) over time
A *positive* response during a session indicates a better prognosis (outcome) over time
36
What does an on-going assessment do at the beginning of a treatment session?
- Determine effect of last treatment session (immediate, evening, next morning)
- Re-assess History/physical exam
- Forms the basis for treatment session
37
What does an on-going assessment do as each technique is performed?
- Be alert t changes on the patient's symptoms
| - Palpate, observe, question
38
What does an on-going assessment do after each technique is used?
- Determine the immediate effect of a technique (reassess...
| - Determine how to proceed (repeat, modify, add, or discontinue the treatment technique)
39
What does an on-going assessment do at conclusion of a treatment session?
- Determines the effect of the whole treatment session
40
What are the potential pain generators in the lumbar spine?
* Muscles
* Ligaments
* Dura mater
* Nerve roots
* Zygapophyseal joints
* Sacroiliac Joint
* Annulus fibrosus
* Thoracolumbar fascia
* Vertebrae
41
What is radicular pain?
Sharp, shooting, superficial or deep pain into the leg in a defined band < 4cm wide
42
What is a radiculopathy?
Radiating paresthesia, numbness in a dermatome, weakness (myotome), or combo of these, but not pain
43
What is somatic pain?
Poorly localized, aching pain
44
Compression of nerve root causes
| ____ but not pain
Compression of nerve root causes
| *radiculopathy* but not pain
45
Radicular pain is elicited only when ____
Radicular pain is elicited only when *a
| previously damaged nerve root is compressed.*
46
Patient may not always present with
| ____ and radicular pain.
Patient may not always present with
| *radiculopathy* and radicular pain.
47
What are the non contractile tissue pain generators?
* Nerve Root
* Discogenic Pain
* Zygapophyseal Joints
* (Facet Joint Syndrome)
* Sacroiliac Joint
* Ligament and Fascia
* Vertebrae
48
Where is the site of pain of an herniated nucleus pulposes compressed nerve root?
- Butt, leg, foot
49
Where is the site of pain of a normal nerve root if felt at all?
- Butt
| - Leg
50
Where is the site of pain of the annulus of the disc?
Back
51
Where is the site of pain for the vertebral endplate?
Back
52
Where is the site of pain for the facet capsule?
Back
53
Actively irritated spinal nerve root
| reproduced sciatica ___% of time
Actively irritated spinal nerve root
| reproduced sciatica *99%* of time
54
___ nerve root insensitive to
| pain most of the time
*Normal* nerve root insensitive to
| pain most of the time
55
Patients with post-laminectomy scar had perineural fibrosis that sensitized the nerve root. This scar tissue led to nerve pain
by ___
Patients with post-laminectomy scar had perineural fibrosis that sensitized the nerve root. This scar tissue led to nerve pain
by *limiting the mobility of the nerve root*
56
Exposure to nuclear material of disc causes an ____
Exposure to nuclear material of disc causes an *inflammatory response*
57
In the absence of disc material, an inflammatory response may result from
____
In the absence of disc material, an inflammatory response may result from
*traumatic compression*
58
Animal models suggest that compression of the nerve root causes ____ and ____
Animal models suggest that compression of the nerve root causes *local edema and ischemia*
59
____ is the most common source of compressive radiculopathy
*IVD herniation* is the most common source of compressive radiculopathy
60
Herniation of the L4/5 disc will affect what nerve root and why?
Affect L5 nerve root, because lumbar roots emerge below their vertebrae
61
On what spinal levels do IVD herniation most commonly occurs?
- L4/5 (50%)
| - L5/S1 (46%)
62
What part of the annulus s innervated?
Outer 1/3
63
How is the annulus most commonly injured?
- Torsion and repetitive flexion
64
Radial fissures that develop in the
| inner 2/3 of annulus reach outer 1/3 may cause __ but not ___
Radial fissures that develop in the
| inner 2/3 of annulus reach outer 1/3 may cause *back pain but not leg pain*
65
___ and ____ are so co-mingled that it is almost impossible to stimulate them individually
*PLL and central annulus* are so co-mingled that it is almost impossible to stimulate them individually
66
Stimulation of the central annulus and the PLL creates ___ LBP
Stimulation of the central annulus and the PLL creates *central* LBP
67
Unilateral stimulation of PLL directed pain to
| the ____ side being stimulated.
Unilateral stimulation of PLL directed pain to
| the *same* side being stimulated.
68
Stimulating a disc herniation caused buttock pain but no ___
Stimulating a disc herniation caused buttock pain but no *sciatica*
69
What is sciatica?
Pain that is felt in the legs
70
Prevalence facet joint pain up to ___%
Prevalence facet joint pain up to 25%
71
Why has the fact/ZPJ joints been identified as a source of back and leg pain?
* Generate pain in healthy subjects
* Reproduce “familiar” LBP pain in patients
* When injected, can relieve pain in certain patients
72
____ of the facets may cause pain
*Degenerative arthritis* of the facets may cause pain
73
What are some theories as to what can cause pain originating from the ZPJ/facet joint?
* Meniscoid entrapment
* Synovial impingement
* Mechanical injury to the joint's capsule
74
Stimulation of the ZPJ/ facet joint at levels L4-5 produces pain where?
Buttock or trochanteric region
75
Stimulation of the ZPJ/ facet joint at levels L2-5 produces pain where?
Groin
76
What are the factors significantly correlated with pain relief from facet injection?
```
• Older age
• Previous history of LBP
• Normal gait
• Maximal pain with extension from
fully flexed
• The absence of leg pain
• The absence of muscle spasm
• No pain with Valsalva maneuver
```
77
It takes great ____ to elicit pain from the ZPJ joint. The pain produced was ___
It takes great * 'experimenter force'* to elicit pain from the ZPJ joint. The pain produced was *localized an didn’t reproduce
patient’s deep LBP*
78
Occasionally facet capsule was painful and it referred pain into the ___, “Very rarely" into the ___, and “Never" the ___
Occasionally facet capsule was painful and it *referred pain into the back, “Very rarely" into the butt, and “Never" down the lower limb. *
79
Facet capsule and articular cartilage was
| "never" ____, even when pierced
*Facet capsule and articular cartilage was
| "never" tender, even when pierced*
80
Facet can become sensitized to pain in the presence of _____
Facet can become sensitized to pain in the presence of *inflammation*
81
L1/2, L2/3, and L4/5 facet joints always
| referred pain to ____
L1/2, L2/3, and L4/5 facet joints always
| referred pain to *lumbar spine *
82
Referral to the gluteal region by the facet joint was from ____(68% of the time)
Referral to the gluteal region by the facet joint was from *L5/S1* (68% of the time)
83
L2/3, L3/4, L4/5, and L5/S1 facet joint occasionally referred pain to the ___ (10% to 16% of the time)
L2/3, L3/4, L4/5, and L5/S1 occasionally referred pain to the *trochanteric region* (10% to 16% of the time)
84
Referral to ___, posterior thigh, and ___ regions were most often from L3/4, L4/5, and L5/S1 facet joints (5% to 30% of the time)
Referral to *lateral thigh, posterior thigh, and groin regions* were most often from L3/4, L4/5, and L5/S1 facet region (5% to 30% of the time)
85
Can pain maps be used to determine the origins of facet joint pain? And why?
No it can not. Because most facet joint pains are overlapping
86
What is facet joint pain described as?
```
• Deep and achy
• Localized to a unilateral or bilateral
paravertebral area.
• Common referral areas for facet are
• Flank pain
• Buttock pain (rarely below the knee)
• Pain overlying the iliac crests
• Pain radiating into the groin
```
87
During what time of the day is facet pain worse?
In the morning
88
What aggravates facet pain?
Extension, twisting, stretching, lateral bending
89
The SI joint is a _____ synovial joint that is innervated from the dorsal primary rami of ___
The SI joint is a *diarthrodial* synovial joint that is innervated from the dorsal primary rami of *S1-S4*
90
Injection of irritant solutions into SIJ provokes pain into ___
* Buttock
* Lower lumbar region
* Lower extremity
* Groin
91
What is the reported prevalence ranges of patients with LBP origination from the SI joint?
2-30%
92
The people that experienced pain from the Slipman 2001 research with injection to the SI joint felt pain where?
In the fortin area
93
The people that did not experienced pain from the Slipman 2001 research with injection to the SI joint felt pain where?
The area inferolateral to the fortin area
94
How can lumbar ligaments and fascia cause LBP?
* Trauma
* Overload (postural)
* Faulty Movement Patterns
95
Common tendon of ____
| and long dorsal SI ligament, along with ____ can cause pain
Common tendon of *longissimus thoracis*
| and long dorsal SI ligament, along with *thoracolumbar fascia* can cause pain
96
Prevalence of lumbar ligamentous sprain is
| ___
Prevalence of lumbar ligamentous sprain is
| low
97
Spondylosis refers to ___
Degenerative changes of the lumbar vertebrae
98
Bone pain can arise from ____
* Paget's disease
* Primary or secondary tumors
* Fractures
99
Spondylolysis is a ___
Spondylolysis is a *defect of the pars related to a fatigue fracture*
100
The incidence of ____ is related to activity
The incidence of *spondylolysis* is related to activity
101
____ is an anterior displacement of one vertebra over the other
*Spondylolisthesis* is an anterior displacement of one vertebra over the other
102
Spondylolisthesis is usually a progression from a ___
Spondylolisthesis is usually a progression from a *spondylolysis*
103
Anterior slippage of spondylolisthesis can compress the ___ and lead to ___
Anterior slippage of spondylolisthesis can compress the *spinal canal and lead to cauda equina like symptoms*
104
In what population are patients more likely to experience a slippage of spondylolisthesis?
In patients with a bilateral defect
105
What are some vertebral anomalies that may cause LBP?
- Transitional lumbar vertebrae (TLV)
| - Spina bifida occulta (SBO)
106
Specific somatic pain generators are ____
Contractile tissue
107
Muscles in patients with LBP become dysfunctional and demonstrate ___
* Atrophy
* Reduced activity with movements
* Decreased muscle strength
* Increased fatigueability
* Change in % of fiber types
108
What stage of pain does atrophy of paraspinal muscles occur with LBP patients?
Acute and chronic
109
Most atrophy occurs in what muscle?
Multifidus
110
____ is the likely cause of atrophy according to Hides et al
*Reflex inhibition* is the likely cause of atrophy according to Hides et al
111
____ of multifidus after distention of the facet joints by injection with saline solution
*Rapid inhibition* of multifidus after distention of the facet joints by injection with saline solution
112
Patients with LBP have a significantly higher portion of ____ muscle fibers
Patients with LBP have a significantly higher portion of *type IIB (fast twitch glycolytic)* muscle fibers
113
The longer the duration of LBP, the ___ the change of muscle fibers to type IIB
The longer the duration of LBP, the *higher* the change of muscle fibers to type IIB
114
What are the things that the change in muscle fiber type result in with patients with LBP?
- Increased fatiguability
- Compromised spinal stability
- Increased stress on non-contractile structures
115
What are the common disorders in muscles with patients with LBP?
• Muscle strain
• Spasm or guarding
• Myofascial complaints, such as trigger
points.
116
The common disorders in muscles with patients with LBP leads to...?
• Altered activity in painful muscle
• Lower blood flow in the painful muscles
• Impaired circulation contributes to muscle
pain by causing metabolites to accumulate
117
What are trigger points?
Tender, firm, 3-6mm nodules that provoke radiating, aching pain into localized reference zones
118
Mechanical stimulation of a taut band/ trigger point elicits a ____
Mechanical stimulation of a taut band/ trigger point elicits a *localized muscle twitch.*
119
```
Myofascial Pain (MP) syndrome occurs
when muscles are short/contracted with ____
```
```
Myofascial Pain (MP) syndrome occurs
when muscles are short/contracted with
*increased tone, stiffness, and trigger points (TrPs)*
```
120
Myofascial Pain (MP) and trigger points (TrPs) may occur due to ...?
```
• Direct or indirect trauma
• Exposure to repetitive strain
• Postural dysfunction
• Nerve root dysfunction (neuropathic pain)
- Site of tissue damage
- Result of proximal radicular disorder
```
121
Muscles affected by neuropathic pain may be injured due to ...?
• Prolonged spasm, mechanical overload,
| or metabolic/nutritional shortfalls
122
Research suggests that MP with TrPs is a ____ disorder
Research suggests that MP with TrPs is a spinal segmental reflex disorder
123
Is trigger point dry needling effective?
Yes, but research needs to be done
124
True or false
Nerve root pain may not follow a specific dermatome
True.
Yes mufti, believe it. This is actually what the man said
125
True or false
Dermatomal distribution of pain may not be useful in the diagnosis of radicular pain
True
Yes mufti, believe it. This is actually what the man said
126
What intervention should a PT be careful of when a patient presents with spondylolisthesis?
Extension
127
What intervention should a PT be careful of when a patient presents with disc extrusion?
Manipulation
128
What is lumbar spinal stenosis?
A number of degenerative conditions of the aging spine
129
What are some of the name of the degenerative conditions found in lumbar stenosis?
- Lumbar spondylosis
| - Degenerative disc disease
130
What are some associated pathologies with lumbar spinal stenosis?
- Clinical instability
- Lumbar spinal stenosis
- Degenerative spondylolisthesis
131
What is the general term that the cochrane collaboration uses for lumbar spinal stenosis?
Degenerative lumbar spondylosis
132
What is stenosis?
A focal narrowing in any canal
133
What is vascular stenosis?
A narrowing of an artery or vein
134
What is central stenosis?
A narrowing of the central/neural canal
135
What is a lateral stenosis?
A narrowing of the lateral foramen where the nerve root exits
136
Is there a correlation between canal diameter and pain?
No there is not
137
What are the most common causes of lumbar spinal stenosis?
- Arthritic or degenerative changes
138
What are some of the patho-physiology involved with lumbar spinal stenosis?
Neural compression and vascular ischemia(stenosis in the muscles)
139
Lumbar spinal stenosis has a ____ component to it
Lumbar spinal stenosis has a *dynamic (motion or activity) component to it
140
____or ____ will decrease the cross sectional area of the central spinal canal and the neuro-foramen
*Extension or increased axial compression* will decrease the cross sectional area of the central spinal canal and the neuro-foramen
141
____ or ___ will increase the cross sectional area of the central spinal canal and the neuro-foramen
*Flexion or decreased axial compression* will increase the cross sectional area of the central spinal canal and the neuro-foramen
142
What is prevalance?
The percentage of a population that is affected with a particular disease at a given time.
143
What is prognosis?
Predicting the course & outcome of a medical condition
144
Lumbar spinal stenosis (LSS) is prevalent and disabling in the ____ population
Lumbar spinal stenosis (LSS) is prevalent and disabling in the *aging* population
145
What percent of primary care and specialist visits present with LSS?
- 4% primary care
| - 14% specialist
146
How does LSS change over time?
It doesn't really change for the most part
147
What is the clinical presentation of LSS?
- Low back pain
- Buttock pain
- Bilateral calf pain
- Slow/abnormal gait
- Forward bent posture
- CLAUDICATION
148
What is claudication?
Limping. Impairment in walking, or pain, discomfort or tiredness in the legs that occurs during walking and is relieved by rest
149
What are the requirements to rule neurogenic claudication condition in?
The constellation consists of symptoms that
are triggered with standing, relieved with sitting and located above the knees and that have a positive shopping cart sign. LR+ = 13
150
What are the requirements to rule vascular claudication condition in?
The constellation consists of symptoms that are relieved with standing alone and located below the knees. +LR = 20
151
What is the evaluation of neurogenic claudication after walking?
Increased weakness
152
What is the evaluation of vascular claudication after walking?
Unchanged
153
What are the palliative/easing factors of neurogenic claudication?
- Bending over
| - Sitting
154
What are the palliative/easing factors of vascular claudication?
Stopping
155
What are the provocative factors of neurogenic claudication?
- Walking downhill
| - Increased lordosis
156
What are the provocative factors of vascular claudication?
- Walking uphill
| - Increased metabolic demand
157
Are pulses present or absent in neurogenic claudication?
Present
158
Are pulses present or absent in vascular claudication?
Absent
159
Is the shopping cart sign present or absent in vascular claudication?
Absent
160
Is the shopping cart sign present or absent in neurogenic claudication?
Present
161
What occurs with the van Gelderen bicycle test with neurogenic claudication?
No leg pain
162
What occurs with the van Gelderen bicycle test with vascular claudication?
Leg pain
163
What is neurogenic claudication?
Some compression or dysfunction of the nerve root or spinal canal
164
What is vascular claudication?
A lack of good blood flow to exercising muscle
165
What are the factors to help rule out LSS?
- Younger than 65
| - No back and leg pain (pain below buttocks)
166
What are the aggravating/easing factors associated with LSS?
- No pain when seated
- No pain with flexion
- Sitting (best)
- Standing/ walking (worst)
167
What are the symptoms against LSS?
Symptoms that are induces with flexion, better with extension, and have a +SLR test
168
What are the symptoms for LSS?
- Symptoms worse with standing & extension, better with flexion
- Older (>60 yrs), chronic (>6 mo)
- + intermittent claudication but good peripheral circulation
- No diabetes
169
What are the physical examination findings of LSS?
* Posture – flexed at thoracic, lumbar, and hips
* Gait: wide-based, flexed, assistive device
* Lumbar ROM Restrictions - restricted &/or pain with extension; +/- with ipsilateral side bending & ipsilateral quadrant
* Segmental mobility: hypomobile thoracic, lumbar, and hips
* Hip Passive Accessory mobility: hypomobile (posterior to anterior: PA > other directions)
* Muscle Length: Iliopsoas & Rectus Femoris tightness; anterior chest wall tightness; gastric-soleus tightness
170
What is the neurologic physical presentation of LSS?
(MSRs, Weakness, Sensation)
• 20-50% of patients; at least 1 spinal level involved
• Ankle plantarflexion weakness
171
What is the muscle performance/motor control of patients with LSS?
* Gluteus Medius/Maximus & hip ER weakness
| * Difficulty activating abdominals, poor motor control
172
Where should limitations be looked for in the knee, ankle, and foot with patients that present with LSS?
Look for limitations in knee extension & ankle DF
173
What are the test used to rule in LSS?
- Two-stage treadmill test
| - Bicycle test
174
What is the two-stage treadmill test?
A diagnostic tool that compares walking tolerance on a leveled surface and on a 15% incline at a self selected pace
175
The two-stage treadmill test uses a ___ reference standard
The two-stage treadmill test uses a *radiological* reference standard
176
What is the best classification of LSS using the two-stage treadmill test?
* Earlier onset of symptoms & prolonged recovery with level treadmill walking (Sp = 0.95; + LR = 14.5)
* Longer total walking time with incline (Sp = 0.92; + LR = 6.5)
177
How is the bicycle test done?
* Patient instructed to pedal a stationary bike with increased lordosis
* Cycle until reproduction of posterior buttock, thigh pain and paresthesias.
* Patient instructed to continue pedaling while leaning forward into lumbar flexion.
178
What does improved symptoms in the slump position with a bicycle test indicate?
Increased likelihood of neurogenic claudication
179
What does increased symptoms in the slump position with a bicycle test indicate?
Increased likelihood of vascular claudication
180
Is there a difference between PT and surgery with LSS over a 2 year period?
No
181
Which has better long term effects: manual therapy, walking and exercise or flexion, exercise and walking interventions?
Manual therapy, walking and exercise had longer effects
182
Is there a real difference between the two stage treadmill test and the bicycle test?
No there isn't
183
What type of study was done to compare the two-stage treadmill test and the bicycle test?
An RCT
184
What approach is recommended to treat patients with LSS?
PT impairment based management approach
185
What does the PT impairment based management approach look like?
- Centralize symptoms if patient has peripheralized symptoms
| - Restore upright posture
186
How will symptoms be centralized for LSS?
- Repeated flexion exercises
| - Rotational exercises in side-lying
187
How will upright posture be restored in patients with LSS?
- Increase Thoracic/Lumbar Extension
- (Rotational Mob/Manip, PA, Translatoric Mob/Manip)
- Increase Hip Extension - Mob/Manip, Stretch hip flexors
188
How do we work on muscle balance for patients with LSS?
LE Strengthening - Gluteals, Hip Abd/ERs,
| Calf, other as needed
189
How do we work on conditioning for patients with LSS?
Intentional Walking, Cycling Programs
190
How do we work on core stabilization for patients with LSS?
Abdominal motor control emphasis
191
What is the aerobic exercise protocol for patients with LSS?
• Start at inital 20mins with goal of 45mins in clinic exercises
• Daily intentional walk 3x/week
In clinic
• Treadmill speed and incline to maximize comfort/minimize LE symptoms
• Once can’t walk finish on the stationary bike
• Rating of perceived exertion (RPE) >7 on a 10pt scale terminate exercise
192
What are the education topics to use with patients?
* Confront Symptoms & Fear Avoidance Beliefs
* Discuss life goals
* Counteract negative messages that aging means deterioration
* Discuss and address any depression symptoms
* BE POSITIVE!
193
Should PT be intensive with patients with LSS?
YES! BE INTENSIVE! B! E! INTENSIVE
194
Which has a higher chance of resulting in surgery: MRI or X-ray?
MRI
195
What term is used frequently to drive spinal fusion?
Lumbar spinal instability
196
What is the "goal" of spinal fusion surgery?
To stabilize a segment of the spine that has "weakened" and eliminate motion at that segment
197
Ideally, what is the stabilization "achieved" through spinal fusion surgery supposed to do?
Reduce pain that is associated with vertebral movement
198
What is spinal fusion originally created for?
Significant trauma to the spine in order to prevent neurological damage
199
What is the basis of spinal fusion being a part of pain management?
Based entirely on a mechanical “model” that excessive motion is the source of pain…despite hard evidence to the contrary
200
In the early 2000s, spinal fusion rose by ___%
In the early 2000s, spinal fusion rose by *77*%
201
Which is better at improving pain and disability in chronic LBP: fusion or non-operative care?
There is not much of a difference in the two
202
Surgeons in what setting are likely to be more conservative when it comes to fusion?
Academic practices. Those in private practices are more likely to pick surgery
203
Which is more likely to be dependent on opiods: fusion surgery patients or artificial discs patients?
Fusion surgery
204
The pain neuromatrix suggests that pain is produced in the ___ as a reaction to a ____ to body tissue that requires an action.
The pain neuromatrix suggests that pain is produced in the *brain* as a reaction to a *perception of danger* to body tissue that requires an action.
205
Pain response involves ____ and ____ components making it a multisystem process.
Pain response involves *sensory and emotional* components making it a multisystem process.
206
Popular belief is that pain is always reflective of tissue damage, however, pain can be the result of ____ or ___ tissue damage
Popular belief is that pain is always reflective of tissue damage, however, pain can be the result of *actual or perceived* tissue damage
207
True/false
Pain cannot be trusted as an adequate reflection of the state of tissues
True
| Pain CANNOT be trusted as an adequate reflection of the state of the tissues.
208
What are the effects of pain: cortical output?
- Reduces cortical processing capacity
- Slows decision making
- Increases cognitive error rate
- Pain sufferers report forgetfulness and being easily distracted
- Immune activity is modified
- Hypothalamus-pituitary-adrenal axes and sympathetic nervous system activity is altered
- Reproductive system function is reduced
209
What are the effects of pain: motor output?
- Motor output serves to: promote escape, limit provocation of the painful part
- Motor changes are driven by higher centers
210
What is the pain neuromatrix?
The neuromatrix is the combination of cortical mechanisms that when activated produce pain
211
What are the areas of the brain that are involved in the pain experience?
- Anterior cingulate cortex (ACC)
- Insular cortex
- Thalamus
- Sensorimotor cortex
212
True or false
There is no pain center in the brain
True
213
What is the pain matrix?
The many regions of the brain that can be activated during a pain experience
214
___ and ____ which are physiologic reactions in the brain, may also affect the pain matrix, because the same areas of the brain are activated during this
*Beliefs and attitudes* which are physiologic reactions in the brain, may also affect the pain matrix, because the same areas of the brain are activated during this
215
Long term pain may be a result of ____
Long term pain may be a result of *enhanced brain activity*
216
A brain in chronic pain is a ____ brain
A brain in chronic pain is a *hyperactive/hypersensitive* brain
217
What is secondary hyperalgesia?
The sensitive/painful area around the point of injury
218
What is primary hyperalgesia?
Pain at the point of injury
219
Central sensitization refers to ___
Central sensitization refers to *when the spinal cord or brain begin to adapt to pain and widespread pain/hyperalgesia begin to occur into the periphery*
220
___ and ____ fibers produce a painful stimulus while ___ produces light touch
*C afferent and A-delta* fibers produce a painful stimulus while *A-beta*fibers produces light touch
221
What happens to the A-beta fibers overtime?
Overtime during a period of chronic pain, the spinal cord adapts and A-beta fibers sprout branches that connect to the C- afferent fibers, hence making light touch painful
222
What does the brain being hypersensitive mean?
Less brain activity is needed to stimulate a pain experience
223
There is an unclear relationship between pain and the ____, ____, and decreased tolerance to normal/traditional therapeutic approaches
There is an unclear relationship between pain and the *state of the tissues, unpredictable flare-ups,* decreased tolerance to normal/traditional therapeutic approaches
224
What are the 3 aspects of managing patients with long-term pain?
- Reduction of threatening input so as to reduce activity of the pain neuromatrix and thereby reduce its efficacy
- Targeted activation of specific components of the pain neuromatrix without over activating the neuromatrix
- Upgrading physical and functional tolerance by graded exposure to threatening inputs across sensory and non-sensory domains
225
___ is a mainstay of pain management programs
*Patient education* is a mainstay of pain management programs
226
The goal of education is to ____
The goal of education is to *reconceptualize the problem*
227
___ is prevalent in patients with chronic low back pain
*Depression* is prevalent in patients with chronic low back pain
228
___% of patients seeking care in an outpatient PT setting have listed depression as a comorbidity
*15%* of patients seeking care in an outpatient PT setting have listed depression as a comorbidity
229
Depression is associated with ___ in the LBP population
Depression is associated with *increasing pain, disability, medication usage, and unemployment* in the LBP population
230
Depressive symptoms were ___ in 35-75% of patients seeking treatment from a primary care MD
Depressive symptoms were *NOT IDENTIFIED* in 35-75% of patients seeking treatment from a primary care MD
231
What is a depression screen?
2 written screening questions for depression plus the addition of a question inquiring if help is needed
232
What are the 2 depression screening questions and the additional question to screen for depression?
1. During the past month have you often been bothered by feeling down, depressed or hopeless?
2. During the past month have you often been bothered by little interest or pleasure in doing things?
3. Is this something with which you would like help (additional question)
233
What are the possible answers to the depression screen questions?
- Yes
- No
- Yes, but not today(only for the additional question)
234
What question is the highest likelihood ratio of depression?
Help question alone
235
What question is the 2nd highest likelihood ratio of depression?
Either screening question AND the help question
236
What question is the lowest likelihood ratio of depression?
The 2 screening questions alone
237
The 2 screening questions are good for ___, and why?
The 2 screening questions are good for *ruling out*, because they have good sensitivity, but lack diagnostic specificity
238
A response to the 2 screening questions and the additional help question ___ overall specificity for major depression and is good for ruling ___
A response to the 2 screening questions and the additional help question *improve* overall specificity for major depression and is good for ruling *in*
239
How often should depression be screened? and Why?
Regularly, because it may directly affect POC
240
The goal in patient communication is to use language as a means to ___
The goal in patient communication is to use language as a means to *collaboratively determine the treatment plan and make the patient an active participant in their care*
241
Language is not merely a vehicle which caries ideas, it is a ____
Language is not merely a vehicle which caries ideas, it is a *shaper of ideas*
242
What are ideas?
Beliefs which may foster success or spawn failure
243
What are some of the scary word when it comes to LBP?
- Herniated disc
- Ruptured disc
- Sliped disc
- Compressed disc
- Pinched nerve
- Degenerative disc disease
- Arthritic joints
244
What are some general terms or phrases that might scare a patient?
- Bone on bone
- To a 29 y/o, you have the spine of an 80 y/o
- You don't have a curve in your lower back
- Your SI is out of place
- This bone in your neck is rotated
- This rib is out
245
Why would a clinician use harmful words?
- Clinical uncertainty evokes the use of jargon that creates the illusion/ perception of certainty
- Alarmist language, which may be used to indicate a sense of urgency or attempt to illicit action on the part of the patient
246
PTs need to search for words with ____
PTs need to search for words with *clear, precise meaning and with connotations that do not evoke dread in the patient*
247
What are the 3 essential Rs in patient care?
- Relate
- Repeat
- Reframe
248
What is empathetic communication?
Language that aides the process of healing by bolstering patient's strengths, validating their perspective, and teaching them how to grow to be more self reliant
249
How do we treat patients that exhibit hypervigilance, catastrophic beliefs about pain or passive coping strategies?
- Patient pain neurophysiology education has been shown to be effective for reducing pain in chronic LBP and widespread pain
- Patient education about central sensitization of pain pathways was part of a successful rehab program
250
What was found in the study where a group got really good PT and another group got a cognitive component along with PT?
Patients with the added cognitive component had better oswestry results and their pain was greatly reduced
251
ROM provides a starting point for the ____
ROM provides a starting point for the *facilitation of the recovery of joint motion*
252
What is Orthopedic Manual PT (OMPT)?
Any hand-on treatment provided by the physical therapist
253
OMPTs can include...?
* Joint Mobilizations
* Manipulation
* Stretching
* Passive Motions
* Soft Tissue Techniques
* Manual Resistance
* And on and on…
254
What is the premise behind OMPT?
Assessment
255
When is assessment performed?
- An initial visit: eval
- Continuously During Each Treatment Session
- Continuous pragmatic assessment
256
What is being assessed in an OMPT?
* Patient Response
* Motion
* Pain, Quantity, Quality
* Functional Outcomes!
257
The expert PT uses careful assessment to adjust and fine tune ____ intervention to the specific needs of the patient
The expert PT uses careful assessment to adjust and fine tune *joint mobilization* intervention to the specific needs of the patient
258
_____ is the cornerstone of a good assessment
*Communication* is the cornerstone of a good assessment
259
What is joint mobilization?
Manual therapy techniques designed to address the altered mechanics of a joint and pain reduction techniques
260
What are the altered mechanics addressed by manual therapy techniques?
* Pain and Muscle Guarding
* Joint Effusion
* Contractures or Adhesions in the Joint Capsule
* Malalignment or subluxation of bony surfaces
261
Joint mobilization are techniques designed specifically to address ___
Joint mobilization are techniques designed specifically to *address restricted capsular tightness by restoring normal mechanics within a joint. *
262
PT must use the knowledge of arthrokinematics to minimize the ____ within a joint when performing joint mobilization techniques
PT must use the knowledge of arthrokinematics to minimize the *compressive forces* within a joint when performing joint mobilization techniques
263
Use of joint mobilization when not indicated can lead to ___
Use of joint mobilization when not indicated can lead to *harm*
264
What are the characteristics of angular stretching?
* Lever increases force at the joint
* Can cause excessive joint compression
* Roll without a slide does not replicate normal function
265
What are the characteristics of joint mobilization?
• Force applied close to joint at an intensity
concurrent with pathology
• Direction of mobilization can mimic slide
• Selective application
266
What are the neurophysiologic effects joint mobilization?
* Stimulate Mechanoreceptors
* Inhibit nociceptive stimuli, spinal cord, or brain
* Small amplitude osccilations
267
What are the mechanical effects joint mobilization?
• Motion of Synovial Fluide
- Small amplitude and oscilations
• Re-arrange collagenous fibers in joint capsule
- Large amplitude or sustained stretch
268
PTs should stay away from joint mobilization after acute injuries in the presence of ____
PTs should stay away from joint mobilization after acute injuries in the presence of *bony or joint instability, large joint effusion, vascular disorders like hemophilia, osteoporosis*
269
What are some contraindications for joint mobilizations?
- Inflammatory arthritis
- Herniated disks with nerve with compression
- Bone disease
- Neuro
- Malignancy
- Tuberculosis
- Osteoporosis
- Ligamentous rupture
- Neurological involvement
- Bone fracture
- Congenital bone deformities
- Vascular disorders
- Hyper-mobility
270
The barrier concept helps us to understand ____ vs ___ motion
The barrier concept helps us to understand *normal vs abnormal* motion
271
What is perceived by the practitioner just before the restrictive barrier?
Resistance to motion
272
Recognition of the restrictive barrier is an important point in being able to ___
Recognition of the restrictive barrier is an important point in being able to *properly gauge the grade of techniques*
273
What are the types of joint mobilizations?
- Physiologic (osteokinematic motion)
| - Accessory (arthrokinematic motion)
274
The bending of the knee is an example of what type of motion?
Osteokinematic motion
275
The rolling and gliding of joint surfaces as it goes through its normal ROM is an example of ____ motion
The rolling and gliding of joint surfaces as it goes through its normal ROM is an example of *accessory/arthrokinematic* motion
276
Why are joint mobilizations special?
They can reproduce arthrokinematic motions that patients cannot do on their own
277
What is the concave-convex rule?
Concave joint surfaces slide in the SAME direction as the bone movement (convex is STABLE)
278
What is an example of a concave on convex motion?
The knee
279
What is the convex-concave rule?
Convex joint surfaces slide in the OPPOSITE direction of the bone movement (concave is STABLE)
280
The glenohumeral joint is an example of what rule?
The convex-concave rule
281
What are the grades of joint mobilization?
```
I. Small Amp, Out of Resistance, PAIN
II. Large Amp, Out of Resistance, PAIN
III. Large Amp, Into Resistance, MOTION
IV. Small Amp, Into Resistance, MOTION
V. (Manipulation), pushes beyond Restrictive Barrier (HVLAT)
```
282
How are the grading of joint mobilization organized?
By both the relationship to the restrictive barrier as well as the size of amplitude in which they are performed
283
Grades 3 and 4 of joint mobilization are into the ___, while grades 1 and 2 are not
Grades 3 and 4 of joint mobilization are into the *restrictive barrier*, while grades 1 and 2 are not
284
The optimal grade of joint mobilization for pain relief is ____ and then ___
The optimal grade of joint mobilization for pain relief is *grade 1 and then grade 2*
285
What are the optimal grades for mechanical effects/motion in the barrier are...?
Grades 3 & 4
286
The use of the specific grade of mobilization is determined by...?
* Stage of Healing
* SINSS (Severity, Irritability, Nature, Stage, Stability)
* Response to Treatment
287
The grading of joint mobility is ____ between each PT
The grading of joint mobility is *not reliable* between each PT
288
What are the things to look for when assessing joint accessory motion?
- Limited PROM
- Firm, capsular end feel with over pressure
- Hypomobility in accessory motion testing
289
What are the treatment specific guidelines to follow when performing joint mobilizations?
* Patient should be relaxed!
* Explain purpose of treatment & sensations to expect to patient
* Assess BEFORE, DURING, & AFTER treatment
* Stop the treatment if it is too painful for the patient
* Use proper body mechanics
290
The resting position of the joint during joint mobilization should be...?
* Maximum joint play - position in which joint capsule and ligaments are most relaxed
* Evaluation and treatment position utilized with hypo-mobile joints
291
The loose-packed position of the joint during joint mobilization should be...?
* Articulating surfaces are maximally separated
* Joint will exhibit greatest amount of joint play
* Position used for both traction and joint mobilization
292
The close-packed position of the joint during joint mobilization should be...?
• Joint surfaces are in maximal contact to each other
293
What is the general rule for the preparation of joint mobilization?
Extremes of joint motion are close-packed, & midrange positions are loose packed
294
What evaluations should be done prior to treatment?
* AROM & PROM
| * Pain Level Throughout Motion
295
Where does the treatment plane lie?
Treatment plane lies on the concave articulating surface, perpendicular to a line from the center of the convex articulating surface
296
Joint traction techniques are applied _____ to the treatment plane
Joint traction techniques are applied *perpendicular* to the treatment plane
297
What are the things to do/remember when performing joint mobilization?
• Use Big Hands
- Avoid uncomfortable manual contacts
• Begin with Gentle Oscillatory (Grade I) motions
• Get a sense of available motion
• Decide upon technique
- Direction and Grade
• Perform Mobilization
- General Acceptable Dosage is 3 sets of
30 seconds
298
The concepts of using big hands involves using _____ grip more than any ____ grip or one that uses the tips of the fingers
The concepts of using big hands involves using *palms and lumbrical grip more than any pinsor* grip or one that uses the tips of the fingers
299
What grades of joint mobilization are bast used in the acute stage of healing?
Grades 1 and 2
300
PTs should be able to identify appropriate ___ and ___ of mobilization for given condition and stage in healing process.
PTs should be able to identify appropriate *direction and grade* of mobilization for given condition and stage in healing process.
