SPINE

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

"central herniation": large central disc herniation

increased muscle tone (caused by underlying dysfunction)

disappears when supported

hypertonic to touch

remains even when supported

doughy to touch

limited ROM (extensibility)

increased tone from pain or fear of pain

disappears when supported

voluntary movements restrained

normal tone

limited ROM from short muscle

caused by postural adaptation or sustained muscle holding

sudden involuntary contraction or twitch

Myofascial

Facet Joint Dysfunction

Disc Pathology

Stenosis

Hypermobility and 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.

• Excessive joint movement as compared to a normal joint at that level or neighboring joints.
• (4-5 on 0-6 scale; 3 = normal)

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

Used clinically.

Posture of the spine in which internal stresses in spinal column and the muscular effort to hold posture are minimal.

vertebrae dissolution/disintegration

unilateral or bilateral defect in the pars interarticularis ("Scotty Dog Sign")

vertebrae slippage

forward displacement of the superior vertebrae upon the inferior stationary vertebrae

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

Grade I = 25% slippage

Grade II = 50% slippage

Grade III = 75% slippage

Grade IV = 100% slippage

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

Lumbar disc herniation

Osteoarthritis

Hypermobility

Severe scoliosis

Depleted general health

Patient unable to relax

Pregnancy: hormonal levels lead to ligamentous laxity

Vertebral artery syndrome

Traumatized transverse ligament of C1

Cauda equina syndrome

Suspected spinal aneurism

Post surgery

Rheumatoid arthritis (cervical)

• 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

fever

intravenous drug use

steroid use

patient over 50 years old

severe, unremitting night-time pain

pain that gets worse when laying down

• - 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

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

• 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?

• Fever
• Sweats
• Nausea
• Malaise
• Fatigue
• SOA

• 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

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

• 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.