MSC II Exam 2

If herniation is lateral to the nerve root, will bending towards the affected side or away from the affected side relieve the pain?

leaning away will relieve (contralateral)

If herniation is medial to the nerve root, will leaning away or leaning towards the affected side cause more pain?

leaning away will cause more pain

What kind of herniation syndrome if loading strategies decrease, abolish, or centralize symptoms? (DH)

derangement - reducible

What kind of herniation syndrome if no loading strategies decrease, abolish, or centralize the symptoms? (DH)

derangement - irreducible

What kind of herniation syndrome if pain only at end ranges?

dysfunction (adherent nerve root)

What kind of herniation syndrome if pain only on static loading with physical examination showing normal

postural

What kind of mckenzie herniation classifications are symptomatic? What kind are symptomatic and mechanical? What does this mean?

symptomatic - postural symptomatic and mechanical - derangement and dysfunction symptomatic if pain, mechanical if difference in movement

Which herniation syndrome will patient pursue centralization of symptoms and avoid peripheralization of symptoms?

derangement

What syndrome if LIMITED ROM and pain at end range?

dysfunction (ANR)

Postural syndrome only has pain at when? What is an example?

static loading, example = slouched posture lengthening posterior tissues

What is McKenzie's prone progression for herniation?

prone, prone on elbow, prone on hand

Methods for maintenance of positions for healing annular fibers in treating HNPs?

use lumbar roll to maintain correction and proper posture

What kind of movements to avoid in treating HNPs?

rotation, flexion

What is the process for intervening with herniation?

1) establish diagnosis 2) determine irritability 3) determine outcome to measure to re-assess

What are the three components of movement?

mobility/flexibility, power/endurance, motor control

What kind of things should the patient demonstrate prior to doing LBP stabilization exercises in terms of positive tests, mobility and motions at segments, age, prior episodes, and SLR?

positive prone instability, aberrant motions, hypermobile segments, younger than 40, 3 or more prior episodes with increasing frequency, and over 91 SLR bilaterally

Clinical guideline summary for LBP says what required to do mechanical nerve root tension (flossing)?

difficulty flexing in standing, positive neural tension signs

If neuro signs, leg symptoms, and no centralization during objective exam, what kind of intervention? (AKA nonreducible derangement)

traction (mechanical or manual)

Name this wadells sign: disproportionate pain to light touch, not correlating with anatomic structures

superficial or nonanatomic tenderness to palpation

Name this waddells sign: Axial compression of the head or rotational simulation maneuver elicits "pain" despite no actual provocation

simulation sign

name this waddels sign: when a test that was painful originally when performed is not painful anymore when they are in a distracted state

distraction sign

What score on Wadell's means no organic reason for pain? What are the five signs?

3/5 or higher 1. superficial/non anatomic tenderness to palpation 2. simulation sign 3. distraction sign 4. regional sensory/motor disturbance 5. overreaction

Score on Oswestry index that is normal?

0-20%

In lower crossed syndrome, match hip and trunk muscles? Which are facilitated/inhibited?

hip flexors with back extensors (facilitated) hip extensors with trunk flexors (inhibited)

Pain in the thoracic spine is often ____ related

posture (excessive kyphosis)

Is trunk extensor weakness or trunk extensor endurance a bigger issue in thoracic back pain?

endurance

Subacute low back pain with mobility deficits seen at what part of range in spinal motions?

mid to end range

Spinal instabilities with acute low back pain with movement coordination impairments seen at what part of range?

initial to mid range

Thoracic pain is higher in females or males?

females

Acute, subacute, or chronic: symptoms produced with mid-range motions that worsen with end range movements

subacute

Trunk coordination, strengthening, and endurance exercises used in acute, subacute, or chronic?

subacute and chronic

Most common part of spine affected by metastases from other cancers?

T-spine

What are the facilitated muscles in upper crossed syndrome?

SCM/pectorals + upper trap/levator scapula

What are the inhibited muscles in upper crossed syndrome?

deep cervical flexors + lower trap/serratus anterior

according to clinical guidelines Activities/exercise to promote centralization is recommended as intervention if pt meets what 2 criteria?

Peripheralization/Centralization during objective exam preference for one posture

What kind of interventions for reducing pain and disability in older patients with chronic low back pain with radiating pain? (4)

flexion combined with manual therapy, strengthening, nerve mobs, walking

most common area for abdominal aortic aneurysm?

below renal artery

Symptoms of herpes zoster?

pain and itching in cranial or spinal dermatome before a unilateral maculopapular rash

Most common vertebral dermatome for shingles

T5-6

What are the "typical" ribs

ribs 3-9

What are the "atypical" ribs and where do they attach?

1,2,10,11,12 all attach to their respective vertebrae

What are the true, false, and floating ribs?

true - 1-7 false - 8-10 floating - 11-12

Most flexion allowed in what part of the t-spine?

lower

Dowager's hump associated with

osteoporosis or long term corticosteroid use

What is the Gibbus deformity? What is it associated with as for a cause?

sharp posterior angulation of spine, associated with infection, fracture, or bony anamoly

T/F: there is reduced motion at the thoracic spine compared to the L-spine/C-spine due to the facet orientation

false - less motion but NOT due to the facet orientation

____ disorders such as _____ can refer to the thoracic spine

renal; pyelonephritis (kidney infection), nephrolithiasis (kidney stones)

Typical and atypical thoracic vertebrae?

typical T2-10 atypical T1,T11,12

T/F: during forward flexion, nonstructural scoliosis does not appear whereas structural scoliosis appears

true

Ribs on side of convexity and concavity in scoliosis would do what?

convexity - spread apart concavity - come together

What is T4 syndrome? What does it manifest as?

hypomobility of a segment (normally T4) leading to sympathetic reaction; can manifest as glove like numbness/paresthesias in arms/hands

What techniques can resolve T4 symptoms?

manual therapy

local tenderness of bony points, positive slump test, positive upper limb tension tests, depression or prominence of one or more spinous processes, and local thickening and stiffness of one segment

T4 syndrome

5 criteria for spinal manipulation according to CPR

1. Duration of current LBP under 16 days 2. no symptoms distal to knee 3. FABQ under 19 points 4. at least one hypomobile segment in LS 5. 1 or both hips at least 35 IR

What is Scheuermann's disease?

hyperkyphosis in adolescents (13-16), an osteochondrosis of the spine

In Scheuermann's disease, what happens at the vertebral bodies, end plates, IV space, and ALL?

vertebral bodies wedge anteriorly end plates have Schmorl's nodes, IV space narrowed ALL thickened

Compensatory increase in lumbar lordosis in adolescents associated with what disease?

Scheuermann's

In Scheuermann's, if kyphosis under ____ then exercise intervention only. What kind of interventions?

under 60 degrees intervene with muscle stretching hip flexors, pecs, and hamstrings extension exercise

What degree for bracing + exercise or surgery in Scheuermann's?

bracing + exercise if over 60 degrees surgery only over 80 degrees

Genetic marker for ankylosing spondylitis

carry HLA-B27

Age and sex of ankylosing spondylitis typically? What ethnicity?

adult 20-30 years old, males 2-3 times more likely northern european most common

Back pain worsens with what motions in Scheuermann's? Where is this pain usually located?

extension and rotation - apex of the kyphosis

Radiographic changes in ankylosing spondylitis (2)

intervertebral ossification like bamboo spine, sacroiliitis which leads to SI ankylosis

Symptoms of ankylosing spondylitis (5)

back pain and stiffness, fever, IBD, uveitis, peripheral joint involvement

History questions about ankylosing spondylitis? What would 4 or more positive answers tell you?

morning stiffness, reduction in discomfort with exercise, onset of back pain before 40, gradual onset, pain over 3 months 4 or more tells you high probability of AS

BASDAI, BASFI, and BASMI all for what (bath forms)

ankylosing spondylitis

Tragus to wall measurement used to detect what? What score of 15 or 30 tell you?

change in AS posture under 15 is mild, over 30 severe

Components of the BASMI (5)

cervical rotation, tragus to wall, lumbar side flexion, modified schobers, intermalleolar index

treatment goals for AS (3)

symptom relief, posture correction, delaying the inevitable

Education pieces for AS? (3)

daily exercise crucial, joint protection, posture

Best approach for exercise in AS (3)

multimodal approach with aerobics, strengthening, pulmonary

things to avoid with AS movements

high impact, abrupt movements, FLEXION

sex, ethnicity, body type, nutritional risk factors for osteoporosis?

female, northern european or asian, ectomorph skinnier builds, and lack of calcium and Vit D in diet

Diagnosis of osteoporosis done with

bone densitometry (dexa scan)

What makes up bone strength

bone mineral density and bone quality

Regions of the body with high cancellous bone (most affected by osteoporosis)

spine, hip, distal forearm, proximal humerus, pelvis

T-scores for osteopenia, osteoporosis, and severe osteoporosis

ostopenia: T score between -1.0 and -2.5 SD osteoporosis: over -2.5 T score severe osteoporosis: over -2.5 T score with one or more fraactures

Exercise focused on what components in osteoporosis

increasing bone and muscle strength and balance

What exercises indicated for osteoporosis with no fractures

resistance, aerobics, tai chi

What kind of strengthening exercise may indirectly reduce fall risk and fracture in osteoporosis

spinal extensors strengthening

impact exercise does a better job increasing BMD in pre or post menopausal women

pre

85-90% of adult bone mass acquired by what age in males and females

18 females, 20 males

Vertebroplasty versus kyphoplasty? (thoracic vertebral fracture)

vertebroplasty - cement injection in v-body that doesn't restore shape kyphoplasty - balloon injection to help restore shape/height of fx. bone

Due to the compensatory lumbar lordosis that is present in Schuermann's disease, there is an increased risk of what other pathology?

spondylolisthesis due to increased shear (from increased lordosis/sacrohorizontal angle)

Short muscles requiring lengthening in hyperkyphosis? (4)

upper cervical extensors, levator, pecs, upper trap

Lengthened muscles requiring shortening in hyperkyphosis? (3)

cervical flexors, scap retractors, upper thoracic extensors

Functional versus structural scoliosis

functional can be corrected by posture shift, structural cannot

____ to ___% of scoliosis is idiopathic

80-90

Radiologic criteria for scoliosis

over 10 degrees cobb angle, VB rotation, vertebral deformity

How do we name a scoliosis curvature?

Segment of the spine + side of the convexity

If someone has R thoracic scoliosis, how might they be rotated?

Rotated to right (toward the convexity)

Which side would we see a posterior rib hump in scoliosis? Why? Will anterior ribs be pushed out on the same side

Side of the convexity because the posterior ribs are pushed posteriorly No anterior ribs will be pushed out on contralateral side

Peak height growth velocity occurs before or after Risser sign emerges

before

Four things to monitor for scoliosis curve progression

cobb angle, age of curve onset, current age, risser grade

Definition of progression of scoliosis in terms of degrees and time?

-Greater than 5 degrees of progression in 6 months or less

relative progression is defined as: ↑≥_____° Cobb/______ months (reference value ≥ 20°) ↑≥______° Cobb/______ months (reference value ˂ 20°) •Two consecutive ↑≥_____° in two periods of _____ months

•↑≥5° Cobb/6 months (reference value ≥ 20°) •↑≥10° Cobb/6 months (reference value ˂ 20°) •Two consecutive ↑≥3° in two periods of 3 months

Screening test for scoliosis? What is positive screen?

Adams forward bend test, 5 degrees is positive

What is scoliometer used for? What is a drawback of using it?

measures angle of trunk rotation, only tells you rotation component and not what is happening at vertebra

Scoliometer positive screen in sitting/standing, SRS recommendation?

5 deg, 7 degrees

T/F: A scoliosis pt typically sidebends opposite the side of the convexity and rotates toward the side of the convexity

true

What is the Beighton score test out of? What does it measure? What score indicates that a pt is likely to have hypermobility?

out of 9 points measures HYPERmobility in scoliosis >4 = likely to have hypermobility

Stop progression at puberty, prevent/treat respiratory dysfunction, prevent/treat spinal pain syndromes, improve aesthetics

goals of conservative management of scoliosis

Risser of 0 and over 50 deg most likely needs what?

surgery

When bracing for scoliosis, want to see at least ___% correction in a x-ray

50%

What features of PSSE can we use as PTs to help reduce a mild scoliosis curve?

pelvic corrections auto-elongation (breathing) de-angulation (side shift of torso/move into concavity) derotation/dekyphosing stabilization/muscle activation

What is the risser sign? 0=?, 5=?

radiographic depiction of the iliac apophysis appearance that can designate skeletal maturity, 0 = immaturity, 5 = complete maturity

Pain in what position in facet syndrome? What positions relieve? radicular or no radicular features? How can you differentiate from stenosis?

pain in extension/ I/L side bend + rotation, relieved by flexion, no radicular features. Differentiate with unilateral PA provoking pain, pain localized in back

Characteristics of DDD (4)

NP dehydrated, annular rings weakened, facet joints approximate, IVF narrow

Unilateral or bilateral pain in DDD/DJD? What would you see with central and unilateral PA?

unilateral; central PA provokes pain, unilateral limited motion

Pain in what movements with DDD/DJD?

extension, rotation, I/L sidebending

thoracic herniations more common in what part of T spine

lower T-spine

Mechanism of injury in thoracic fracture? Most common fracture types?

from hyperflexion or loading - most common are anterior wedge fractures or burst fractures

Pain in what positions with stenosis? What positions relieve pain?

pain in standing, prone, extension relieved by sitting, supine, flexion

Stenosis typically unilateral or bilateral

unilateral

What muscles might you want to stretch in stenosis and why?

hip flexors and paraspinals because putting into more APT will cause extension which will cause more pain

Stability exercise targeting what muscles in stenosis?

abs and glutes

What three categories do rib conditions fall under?

structural, rotational, respiratory

Treat rib conditions with what techniques?

manips/mobs

Beevor's sign positive could tell you what if the umbilicus deviates cranially? What about if it moves laterally?

T10 segment involvement laterally, could be contralateral motor deviation

Inspirations restrictions for a depressed or elevated rib?

depressed

Distraction extension technique indicated for what?

hypomobility w extension

What rib pathology has less prominent rib angle and has more prominent thoracic findings?

anterior subluxation

What rib pathology has more prominent rib angle and less prominent thoracic findings?

posterior subluxation

In external rib torsion, prominence/tenderness at the superior or inferior part of the rib angle? What happens at the intercostal space above and below?

prominent and tender on the superior border of the rib angle, at intercostal space above, is WIDENED, below is narrow

In internal rib torsion, prominence/tenderness at the superior or inferior part of the rib angle? What happens at the intercostal space above and below?

prominent and tender on inferior border of rib angle, intercostal space above is NARROW, and wide below

Surgical intervention for scoliosis is indicated when there is over ____ degree curve in T spine and ____ in thoracolumbar spine

50; 40

What is the range of degrees that indicates bracing for scoliosis? How much progression in one year would indicate bracing under 30 deg?

30-45 5 deg

What risser grades allow for bracing?

0-2

What are the contraindications to a brace for scoliosis?

lordotic spine, skeletal maturity, hypokyphosis

T/F: bracing is rare in the older adult

true (non-opeartive tx. is more common - PT, meds, nerve blocks, epidural steroids)

Scoliosis changes occur in what planes?

coronal, sagittal, and axial plane

Scoliosis presents similarly to a ___ patholgoy in PFTs

restrictive

What distinguishes early onset vs late onset for scoliosis?

early: 0-9 y.o late: >10 y.0

What are some pulmonary medical causes of thoracic pain? (3)

PE pleurisy tracheobronchial pain

What are some cardiac medical causes of thoracic pain? (4)

angina, abdominal aortic aneurysm, MI

What are three GI medical causes of thoracic pain?

esophageal disorders *c-spine referral too*, peptic ulcer disease, cholecystitis

Biggest red flag symptoms (5)

insidious onset with no mechanical association, symptoms unchanged by movement/position, bowel and bladder changes, night pain, weight loss

What is thoracic pain persisting after herpes zoster

postherpetic neuralgia

How would you differentiate referred thoracic pain from an ulcer vs cholecystitis?

eating makes ulcer pain better/stool consistency altered, pain for cholecystitis is 1-3 after eating (especially from fatty foods)

Scheurman's disease has an associated increase in risk in what other two conditions?

lumbar spondylolisthesis and scoliosis

What two muscle groups are typically adaptively short in Scheuermanns?'

hamstrings and hip flexors

T/F: neuro symptoms don't normally appear in scheuermann's?

true

Chronic seronegative spondyloarthritis aka Marie Strumpell disease affecting SI, facet joints, C-V joints, and IVD articulations

ankylosing spondylitis

What are the three main joints that 1/3 of AS patients will have involvement at?

shoulders, knees, hips

Why should we tell AS patients to think tall/maintain upright position

Their spine is constantly autofusing

What is a spinal weighted kypho-orthosis? (WKO) What condition is it mainly used for?

Weighted backpack with the majority of the weight in the lower back region to pull upper thorax posteriorly thoracic vertebral fracture

T/F: The lower the risser/cobb angle, the bigger the impact PT will have on the scoliosis pt

true

convexity side is usually associated with (protracted/retracted) shoulders concavity side is usually associated with (protracted/retracted) shoulders

convexity= protracted concavity= retracted

We need to treat the asymmetry that is present in scoliosis with ____ exercise

asymmetrical exercise

What is the recommended hrs/day a scoliosis pt should wear their brace?

16-18 hrs

Flat back can be defined as ____ of kyphosis. What is excessive kyphosis?

less than 20 deg, >45 deg

Lateral shift/sciatic scoliosis is considered a ___ scoliosis and is typically ____

functional, correctable

Describe the owestry index percentages along with each category?

0-20%: minimal disability 21-40%: moderate disability 41-60%: severe disability 61-80%: crippled 81-100%: bed bound/exaggerating

scoliosis is defined as a frontal plane curve of ___ or more deg

10

What are the four etiologies of scoliosis?

congenital, neuromuscular, idiopathic, degenerative

What are the five mechanisms of HNP?

1. spine compression loads -- *endplate failure* 2. repeated full flexion 3. Long periods of sitting 4. repetitive loading (fatigue is a factor) 5. shear + twisting loads

What are the three classifications of disc herniation according to mckenzie philosophy?

derangement, dysfunction, postural

Concept of mckenzie: HNP leads to a disturbance of ____ ___ of articular surfaces of adjacent vertebrae secondary to changes in the ___. This ultimately leads to a disturbance of normal ___ ___.

resting position nucleus movement mechanics

mckenzie classification: frequency of compaints (responses) postural= (intermittent/constant) dysfunction= (intermittent/constant) derangement= (intermittent/constant)

p= intermittent dys= intermittent derange= intermittent OR constant

Which mckenzie classification has pain response during the motion?

derangement

what are perferred loading strategies for each mckenzie classification? postural= dysfunction= derangement=

p= avoid symptoms dys= pursue symptoms derange= pursue centralization, avoid peripheralization

Why should you avoid rotation in exercise or mobilizations when patient has HNP?

rotation narrows disc space and increases intradiscal pressure

3 goals of treating HNP

1) treat pain 2) decrease muscle guarding 3) restore function/mobility

which waddells nonorganic sign is this? A nonanatomic distribution of abnormal sensation is reported rather than an anatomic, dermatomal distribution of pain or numbness

regional sensory or motor disturbance

which waddells nonorganic sign is this? Verbally or physically reacts in an inappropriate, theatrical manner to light touch or gentle examination.

overreaction

Nerve flossing has what two effects

slackening on one end and tensioning on the other end

Two characteristics that were negatively associated with seeking PT for neck pain

age (older pts) and male

osteomyelitis, symptoms?

bone inflammation secondary to infection neck pain, stiffness, fever

Alantoaxial instability (upper cervical) pain location, symptom presentation

pain localized to the suboccipital area, UMN symptoms, headaches, blurred vision, BILATERAL UE/LE paresthesias, nystagmus

Congenital conditions associated with atlantoaxial instability

down's syndrome or bony malformation

Neck Disability index score of 5= __, 0=___? What was the MCID?

5=most disabled, 0=least disabled MCID was 7

Special tests (such as modified sharp purser) typically go where in the tests/measures process

later or at the end

What did specificity and sensitivity for the vertebral artery test find positive and negative tests results meant

positive could indicate, but negative not clinically meaningful

cluster for radiculopathy (4)

spurling's, cervical distraction, rotation under 60, ULNT median passive

If ___ out of 4 cluster tests positive, high confidence of radiculopathy

3

ligament stability tests

sharp-purser alar ligament stress transverse ligament test tectorial membrane shear AO membrane shear

5 D's of vertebrobasilar insufficiency

dizziness, diplopia, dysarthria, dysphagia, drop attacks

Most cervical tests tend to be highly specific or sensitive

specific (bad because neg results are not clinically meaningful)

how can RA cause AA instability?

destruction of dens/transverse ligament or both

what are 4 inflammatory conditions that can cause AA instability? what medication

RA psoriatic arthritis ankylosing spondylitis osteomyelitis chronic corticosteroid use

Summarize diagnostic accuracy, more useful clinically than other statistics

likelihood ratios

The further likelihood ratios are from 1 the (weaker/stronger) the evidence for the presence or absence of disease

stronger

Pancoast's tumor

lung upper lobe tumor that invades the brachial plexus

Cardiovascular conditions referring to the neck (4)

acute MI, coronary insufficiency, abdominal aorta, carotodynia (painful carotid artery)

Likelihood ratios for positive tests above _____ and for negative tests below _____ provide strong evidence to rule in or rule out diagnoses

10, 0.1

What is an activity that increases the risk of cervical neck pain?

cycling

The greatest risk factor for an injury is _____

previous injury to that area

Someone who is in subacute osteomyelitis is at risk for developing _____

discitis

What are the age classifications for infantile, juvenile, and adolescent scoliosis?

infantile: birth - 3 juvenile: 4-10 adolescent: 11-? (depends)

We want clearing tests to be highly ___ to rule out the condition. What is a good example

sensitive, UNLT (median)