1. 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
  2. Cauda Equina Syndrome
    "central herniation": large central disc herniation
  3. Myofascial Epidemiology
    - Involuntary muscle holding
    increased muscle tone (caused by underlying dysfunction)

    disappears when supported

    hypertonic to touch
  4. Myofascial Epidemiology
    - chemical muscle holding
    remains even when supported

    doughy to touch

    limited ROM (extensibility)
  5. Myofascial Epidemiology
    - voluntary muscle holding
    increased tone from pain or fear of pain

    disappears when supported

    voluntary movements restrained
  6. Myofascial Epidemiology
    - adaptive shortening
    normal tone

    limited ROM from short muscle

    caused by postural adaptation or sustained muscle holding
  7. Myofascial Epidemiology
    - muscle spasm
    sudden involuntary contraction or twitch
  8. Lumbar Spine Syndromes

    Facet Joint Dysfunction

    Disc Pathology


    Hypermobility and Instability
  9. 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.
  10. Hypermobility
    • Excessive joint movement as compared to a normal joint at that level or neighboring joints.
    • (4-5 on 0-6 scale; 3 = normal)
  11. 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
  12. Neutral Position
    Used clinically.

    Posture of the spine in which internal stresses in spinal column and the muscular effort to hold posture are minimal.
  13. Spondylolysis
    vertebrae dissolution/disintegration

    unilateral or bilateral defect in the pars interarticularis ("Scotty Dog Sign")
  14. Spondylolisthesis
    vertebrae slippage

    forward displacement of the superior vertebrae upon the inferior stationary vertebrae
  15. 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
  16. 4 Grades of Spondylolisthesis
    Grade I = 25% slippage

    Grade II = 50% slippage

    Grade III = 75% slippage

    Grade IV = 100% slippage
  17. Risks of Manipulation

    Absolute Contraindications
    Malignancy: progressive worsening of tumors


    Osteomyelitis: infection of the bone or bone marrow



    Ligamentous rupture

    Disc prolapse with nerve root compression

    Influenza with fever
  18. Risk of Manipulation

    Relative Contraindications
    Lumbar disc herniation



    Severe scoliosis

    Depleted general health

    Patient unable to relax

    Pregnancy: hormonal levels lead to ligamentous laxity
  19. Risk of Manipulation

    Regional Contraindications
    Vertebral artery syndrome

    Traumatized transverse ligament of C1

    Cauda equina syndrome

    Suspected spinal aneurism

    Post surgery

    Rheumatoid arthritis (cervical)
  20. 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
    significant trauma

    unexplained weight loss

    history of cancer


    intravenous drug use

    steroid use

    patient over 50 years old

    severe, unremitting night-time pain

    pain that gets worse when laying down
  22. 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
  23. 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
  24. 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?
  25. Nonmusculoskeletal Causes of LBP: Constitutional Sxs
    • Fever
    • Sweats
    • Nausea
    • Malaise
    • Fatigue
    • SOA
  26. 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
  27. 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
  28. 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.
Card Set
Lumbar Spine Syndromes