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Lumbar Spine Red Flags
constant unrelenting LBP: infection or tumor
significant and unexplained weightloss: tumor
blood in urine or stool: urinary pathology
major trauma: fracture
sudden onset of bowel and bladder dysfunction: cauda equina syndrome
pain that does not change with position: infection or tumor
nocturnal pain
saddle anesthesia: cauda equina syndrome
fevers and chills: infection or tumor
progressive bilateral LE paresthesia that are nondermatomal: cauda equina syndrome
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Cauda Equina Syndrome
"central herniation": large central disc herniation
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Myofascial Epidemiology
- Involuntary muscle holding
increased muscle tone (caused by underlying dysfunction)
disappears when supported
hypertonic to touch
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Myofascial Epidemiology
- chemical muscle holding
remains even when supported
doughy to touch
limited ROM (extensibility)
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Myofascial Epidemiology
- voluntary muscle holding
increased tone from pain or fear of pain
disappears when supported
voluntary movements restrained
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Myofascial Epidemiology
- adaptive shortening
normal tone
limited ROM from short muscle
caused by postural adaptation or sustained muscle holding
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Myofascial Epidemiology
- muscle spasm
sudden involuntary contraction or twitch
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Lumbar Spine Syndromes
Myofascial
Facet Joint Dysfunction
Disc Pathology
Stenosis
Hypermobility and Instability
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Instability
Where the osseous-ligamentous and neuromuscular components of the spinal segment are unable to maintain the segment against slippage and other aberrant motions during activity and when at rest.
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Hypermobility
- Excessive joint movement as compared to a normal joint at that level or neighboring joints.
- (4-5 on 0-6 scale; 3 = normal)
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Neutral Zone
Region of intervertebral laxity around the neutral resting position of a spinal segment
Spinal motion is produced with minimal internal resistance
Zone of high flexibility
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Neutral Position
Used clinically.
Posture of the spine in which internal stresses in spinal column and the muscular effort to hold posture are minimal.
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Spondylolysis
vertebrae dissolution/disintegration
unilateral or bilateral defect in the pars interarticularis ("Scotty Dog Sign")
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Spondylolisthesis
vertebrae slippage
forward displacement of the superior vertebrae upon the inferior stationary vertebrae
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5 Types of Spondylolisthesis
Dysplastic: congenital; rapidly progressing neurological defect
Isthmic: most common; pars interarticularis defect from repetitive hyperextension; most commonly seen at L5/S1; majority are asymptomatic
Degenerative: 2nd most common; slippage due to facet arthritis
Traumatic: acute fx of the facet or pars interarticularis
Pathological: caused by damage to posterior elements from tumor, metastases, or metabolic bone disease
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4 Grades of Spondylolisthesis
Grade I = 25% slippage
Grade II = 50% slippage
Grade III = 75% slippage
Grade IV = 100% slippage
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Risks of Manipulation
Absolute Contraindications
Malignancy: progressive worsening of tumors
Tuberculosis
Osteomyelitis: infection of the bone or bone marrow
Osteoporosis
Fracture
Ligamentous rupture
Disc prolapse with nerve root compression
Influenza with fever
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Risk of Manipulation
Relative Contraindications
Lumbar disc herniation
Osteoarthritis
Hypermobility
Severe scoliosis
Depleted general health
Patient unable to relax
Pregnancy: hormonal levels lead to ligamentous laxity
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Risk of Manipulation
Regional Contraindications
Vertebral artery syndrome
Traumatized transverse ligament of C1
Cauda equina syndrome
Suspected spinal aneurism
Post surgery
Rheumatoid arthritis (cervical)
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Risk of Manipulation
Precautions for Manipulation
- Inflammatory Arthritis:
- - DISH (Diffuse Idiopathic Skeletal Hyperostosis): ossification of ligaments
- Lyme Disease
- Psoariatic arthritis
- Scleroderma
- Sjogren's syndrome: autoimmune disease that attacks glands responsible for producing tears and saliva leading to dryness of the mouth, eyes, nose, throat, and skin
- Gout
- Reiter's syndrome or reactive arthritis
- Ankylosing spondylitis
- Lupus
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RED FLAGS
significant trauma
unexplained weight loss
history of cancer
fever
intravenous drug use
steroid use
patient over 50 years old
severe, unremitting night-time pain
pain that gets worse when laying down
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Hoover's Test
- - Test for consistency of effort
- 1. Pt supine
- 2. PT places hands under each calcaneus while pt's legs remain relaxed
- 3. Ask pt to lift 1 leg off of the table keeping the knees straight
- 4. If pt doesn't feel pressure under the opposite heel, the pt may not be giving full effort
- 5. If a pt's leg is weak, the increased pressure in comparison should be noted under the opposite heel
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Waddell's Sign
Assess the possibility of psychological distress or malingering or both by testing the consistency of pt responses to nonorganic physical signs
(+) response for 3 out of 5 test = high probability of nonorganic pathology -> resulting in a need for individual further psychological assessment
- 1. tenderness (pain with gentle palpation and skin rolling)
- 2. Simulation (axial loading simulated with about 5 lbs of pressure through head; axial rotation simulated but rotate pt's pelvis with shoulders to prevent axial rotation)
- 3. Distraction -> (+) SLR, but not (+) when testing pt in Slump Test postion/sitting and perform straight leg raise while talking to pt to see if they have a (+) response
- 4. Regionalization (sxs not matching normal dermatomal or myotomal distribution)
- 5. Overreaction: subjective signs regarding the pt's demeanor and rxn to testing
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CAGE
- Screening checklist for alcoholism
- 1 or more (+) response = (+) result
- C: Have you ever attempted to CUT down on your drinking?
- A: Have you ever been ANNOYED by other people criticizing your drinking?
- G: Have you ever felt GUILTY about your drinking?
- E: Have you ever taken a morning EYE opener?
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Nonmusculoskeletal Causes of LBP: Constitutional Sxs
- Fever
- Sweats
- Nausea
- Malaise
- Fatigue
- SOA
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Musculoskeletal Causes of LBP
- 1. Mechanical
- - intermittent joint
- - joint
- 2. Chemical
- - inflammatory or infective process
- - constant
- - worse @ night due to pooling of irritants from circulatory stasis
- 3. Neurogenic
- - CNS sensitization
- - Source of pain is coming from the CNS, usually chronic pain
- - decreased pain tolerance
- - ANS disruption
- - sleep disturbance
- - depression
- Combination of the 3
- - Acute pain: mechanical & chemical (inflammatory)
- - Chronic pain: mechanical & neurogenic
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PIVM Grades
0 -> Ankylosis/No detectable mvt -> No Rx
1 -> Considerable limitation in mvt -> Gentle Stretching
2 -> slight limitation in mvt -> stretching, thrust
3 -> normal for the individual -> no Rx
4 -> slight increase in mvt -> no Rx, education
5 -> considerable increase in mvt -> stabilization exercises, rx neighboring hypomobility
6 -> unstable -> brace, fusion
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Red Flags for LBP
- Back Related Tumor
- 1. age > 50 y.o.
- 2. hx of cancer
- 3. unexplained weight loss
- 4. failure of conservative therapy
- Back Related Infection (Spinal Osteomyelitis)
- - Osteomyelitis: an acute or chronic inflammatory process of the bone & structures (periosteum, cortex, marrow, cancellous tissue) secondary to infections with pyogenic (bacterial infections producing pus) organisms
- 1. recent infection (UTI or skin)
- 2. intravenous drug user/abuser
- 3. concurrent immunosuppresive disorder
- Cauda Equina Syndrome
- 1. urine retention or incontinence
- 2. fecal incontinence
- 3. saddle anesthesia
- 4. global or progressive weakness in LE
- 5. sensory deficits in feet (L4, L5, S1 areas)
- 6. ankle DF, toe Ext & ankle PF weakness
- Spinal Fx
- 1. hx of trauma (including minor falls or heavy lifts for individuals who have osteoporosis or are elderly)
- 2. prolonged use of steroids
- 3. age > 70 y.o.
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