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123 Cards in this Set
- Front
- Back
what are the congenital abnormalities of the LB
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1) lumbarized sacral vertebrae
2) sacralized lumbar vertebrae 3) asymmetry of facet joints |
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describe a lumbarized sacral vertebrae
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6 lumbar vertebrae present but S1 has the characteristics of a lumbar vertebra ... leaving only 4 sacral vertebrae
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describe a sacralized lumbar vetebrae
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4 lumbar vertebrae with L5 being fused to the sacrum
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what is a consequence of the sacralized lumbar vertebrae
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decreased mobility that we cannot regain
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how is a congenital abnormality dx
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radiographs - often found as part of a standard exam for back pain
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what is important to remember about a congenital abnormality
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they are nto always responsible for the problem at hand
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what is the treatment for a congenital abnormality
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- full detailed evaluation needs to be performed
- address problems based on findings keeping in consideration any relevant tx approac specific for the congenital abnormalities |
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what tx approach is used for congeintal abnormalities
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problem oriented approach... so if decreased mobility, find a way to increase it somewhere else (i.e. hamstring stretch)
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what is the general tx for individuals with 6 lumbar vertebrae
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- use lumbar stability exercises due to excessive motion created by the additional moving segment
- use strengthening exercises, corset, postural correction |
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when is a traumatic fracture especially important to r/o
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when we have direct access!
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what are the S and S for a traumatic fx
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- hx of trauma
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what is the most important component of a possible traumatic fx
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radiological exam is absolutely necessary to determine if there is a fx
a series needs to be taken of every patient who complains of spinal pain (post trauma) |
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what is the tx for a traumatic fracture
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- restore strength, mobility, endurance, and function after healing occured
- possible immobilization in a rigid brace such as the BOB - possibly surgery |
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how does osteoporosis cause a fracture (compression)
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Osteoporosis is a metabolic process related to endocrine disorders, nutrition, and activity..... it leads to compression fractures of the vertebral body secondary to weakening of the bone
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where are compression fractures due to osteoporosis most common
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in the thoracic spine, but can be in the lumbar spine
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what part of the vertebra does the fracture usually involve in osteoporosis
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the anterior portion of the vertebral body (hopefully not affecting the nerve roots)
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what are the S and S for a compression fracture due to osteoporosis
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- (+) findings on a radiograph
- sharp, localized pain - increased pain with flexion - spinal abnormalities (prominent spinous process, marked kyphosis) - possible nerve root compression signs |
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what would a single thoracic fracture reslt in
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a FB fault of that vertebra causing a a prominante spinous process and increased interspinous space below that prominent spinous process
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what is another name for a compression fracture of a single v. body
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a wedge fracture, becasue it collapses in the front
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what would multiple thoracic fractures result in
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marked kyphosis of the t-spine
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why is it unlikely to have nerve root compression signs
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it is compressed anteriorly and the nerve root travels through the foramen located posteriorly
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what is the treatment for a compression fracture
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- education on harmful positions (i.e. teach to log roll out of bed)
- active and passive extension exercises - good lumbar support in sitting to promote better sitting posture - heat and electrical stim can help relieve discomfort |
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when should extension exercises begin for a patient with a compression fracture
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as soon as the patients pain has decreased to the point that he/she can tolerate them
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what should be avoided for a patient with a compression fracture
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- all activities and positions involving spinal flexion
- sleeping in flexed positions - using large pillows under head |
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what is the role of a spinal corset
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maintain extension and prevent flexion
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where does the corset get placed
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depends on the fracture.... anywhere between sternal notch and pubis
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when is the corset worn
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worn when up in a chair or walking, not worn at night or when lying down
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what is a spondylolysis
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defect of the pars interarticularis of the nural arch of the vertebra
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what is a spondylolisthesis
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bilateral defect of the pars interarticularis with slippage of the anterior portion of the vertebra causing separation of the anterior and posterior elements
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lysis = ________ whereas listhesis = _________
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lysis = defect.... listhesis = slippage
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what would you expect to see on a radiograph for a spondylolysis
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collar on scotty dog
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what would you expect to see on a radiograph for a spondylolisthesis
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"decapitated dog"
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where do BOTH of the spondys occur
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at the pars interarticularis
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what is the pars interarticularis
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its the boney bridge between the super facets and inferior facets on the same vertebra
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what is the etiology of a spondylolysis and/or spondylolisthesis
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- congenital weakness of pars interarticularis occuring as a stress fracture ..... often related to athletics or vigorous activities during adolescence
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what sports are more likely to cause a spondy
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sports requiring hyperlordosis (gymnastics) and contact sports (football)
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when is an evaluation for a possible spondlolysis indicated
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in any teenager with a hx of back pain for >2-3 weeks
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what is the imaging that should be used for dx a spondylolysis
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bone scan because since its a stress fx, it may not appear on a radiograph until 3-4 weeks post injury
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what would the "hot" spot on a bone scan reveal.... and how should this patient be treated
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possibility of healing..... treat with bracing
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what would a "cold" spot on a bone scan reveal..... and how should this patient be treated
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a non-uniont has resulted..... bracing may be useful to reduce pain and provide stability to the segment but healing is unlikely to occur
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where is a spondy most common and why
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at L5 on S1 where the facets are in the frontal plane
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what direction would the vertebral bodies move in a L5 on S1 spondylolisthesis
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L5 moves anterior on S1
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what is a grade 1 spondy
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0-25% slippage of L5 on S1 (asymptomatic)
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what is a grade 2 spondy
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25-50% slippage, possible cord signs
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what is a grade 3 spondy
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50-75% slippage, most likely cord signs, should be fused
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what is a grad 4 spondy
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75-100% slippage, most likely cord signs should be fused
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what does the grade denote for spondys
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how far the top vertebra (L5) is displaced on the inferior vertebra (S1)
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what grade is the lowest that should be palpable
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grade 3 (grades 1 and 2 are not palpable, grades 3 -4 should be)
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If there was a spondylisthesis of L5 S1 what would a palpation exam reveal
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L4 would feel more anteriorly displaced over L5.... this is because the spinous process and inferior facets of L5 (fall below pars) stay put, while the sup facets and body (sup. to pars) move anterior causing everything in above to follow in chain-like fashion
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what is the direction of a radiograph for a spondy dx
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posterior oblique
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what are the S and S for a spondy
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- (+) radiographs
- step deformity in severe cases (L4 feels anterior to L5) - hyperlordosis - standing aggravates pain - sitting relieves pain (especially slumped) - neurological signs (if anterolisthesis) |
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what position can the step deformity caused by a spondy be felt in
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standing and sidelying, step disappears when prone with pillow under stomach
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when will a spondylolisthesis be the cause of the problem
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only if the segment is unstable, if the segment is stable it may not be the primary cause of the problem for a patient to come in
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what are the cord signs
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- bladder/sexual dysfunction
- numbness in saddle area - weakness >1 myotome - numbness >1 dermatome |
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how could you differentiate between facet jt pain vs. spondy pain
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facet joint is more localized vs. spondy pain which is not very easy to sort out
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what is the treatment for a spondy
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1) avoid stressful physical labor and vigorous sctivities
2) address posture (decrease lordosis) 3) abdominal strengthening 4) stretch hipflexors if tight 5) gentle flexion exercises 6) brace to possibly help reduce vertical forces |
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what can you recommend to a patient while standing to decrease the lordosis
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use a step stool so 1 leg up causes a posterior roll in the pelvis
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what must be considered when stretching the hip flexors for a patient with a spondy
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stabilize the back to avoid the forward translation of the lumbar segment
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what is lumbar central spinal stenosis
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narrowing of the spinal canal which causes compression of the cauda equina
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where does the spinal cord end
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L4.... below L4 cauda equina!
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what causes the symptoms in lumbar central spinal stenosis
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vascular insufficiency of the cauda equina nerve roots
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what is the difference between lateral spinal stenosis and central spinal stenosis
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lateral refers to narrowing of intervertebral foramen compressing spinal nerve roots whereas central refers to narrowing of spinal canal compressing cauda equina nerve roots
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what population is most likely to have lumbar central spinal stenosis
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elerly >50s
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what is the etiology for lumbar central spinal stenosis
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- contenital deformity
- spondylosis/DDD/DJD (due to foloding or bulging of lig. flavum, thickening of lamina and vertebral body, ostephytes that diminish size of sc) - disc protrusion (posterocentral) - cancerous growth |
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what are the S and S for central spinal stenosis
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- pain in low back and one or both legs
- numbess and tingling in feet and legs (not dermatome specific) - motor weakness - decreased DTR - syptoms appear upon walking, relieved by rest and FB - imaging showing reduction in size of sc |
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what is the hallmark of central spinal stenosis
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exercising causes leg pain ... probably related to blood supply to nerve root- especially when more than one nerver root is involved and/or both sides
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why does BB aggravate symptoms of central spinal stenosis
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reduces volume of spinal canal and increases nerve root bulk ... also bulges lig. flavum
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how can you differentiate central spinal stenosis from vascular intermittent claudication
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VIC will not cause back pain and flexion does not relieve the pain
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what tests could be used to differentiate between VIC and central spinal stenosis
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Stoop test and bycycle test of vangelderen
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what is the stoop test
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1) walk until symptoms
2) rest in FB (measure time for relief of sympt) 3) repeat walking until symptoms 4) rest in extension (measure time for relief of sympt) |
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what are the results of a stoop test indicative of
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if no difference in recovery time = vascular problem
recovery faster with FB position = spinal stenosis |
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what is the bicycle test of van gelderen
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1) pedal with back extended until apparition of symptoms
2) continue pedaling with back in flexion 3) if pain alleviated with flexion, return to pedaling with back in extension |
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what are the results of the bicycle test of van gelderen indicative of
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when pedaling with back in flexion...
pain will increase if vascular claudication pain will decrease if spinal stenosis (then confirmed if returning to pedaling with back in extension returns symptoms) |
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what is the treatment for central spinal stenosis
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conservative...
- educate patient to avoid activities aggravating the disorder - lumbar support - treat dysfunction, mobility - avoid BB and teach relief of symptoms with FB - severe cases- surgery |
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why do flexion exercises help with spinal stenosis if we cannot increase the canal size
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because flexion increases the volume of the spinal canal, not the diameter
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what is ankylosing spondylitis
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inflammatory arthritic disorder characterized by progressive joint sclerosis and ligamentous ossification
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where does ankylosing spondylitis first appear
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first in SIJ later spreads into lumbar and t-spine and rib cage can eventually progress to complete ankylosis of the joints
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ankylosing spondylitis may ease the pain but at what cost
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leading to disability dependent on the fixed position of the joint
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what affects the prognosis of ankylosing spondylitis
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age.... younger patient is at onset = worse prognosis
gender.... men do worse than women |
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what is the incidence of ankylosing spondyliits in men vs. women
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men 3x more likely to get it then women
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what do 90% of people with anklyosing spondylitis have compared to only 10% of the general population
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antigen HLA-B27
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what are the S and S for ankylosing spondylitis
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1) onset between 20-35
2) first appears as vague LBP with general stiffness especially in the AM 3) movement relieves stiffness 4) symptoms typically recurring with episodes lasting weeks or months 5) flattening of Lspine and increased rounding of Tspine 6) (+) signs of SIJ and L-spine calcification on radiographs |
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what is the tx for ankylosing spondylitis
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- avoiding work that requires heavy work (as to not flare up the inflammatory process)
- education on posture and exercises to avoid fixed flexion deformity |
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what are the components to avoid a fixed flexion deformity
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- sit and stand with lordosis
- avoid prolonged sitting and FB postures - sleep on firm matress - avoid using more than 1 pillow - avoid lying curled up on your side - ROM exercises for shoulders and hips - gentle exercises and lumbar support to maintain proper mobility and posture - medication and modalities during acute episodes |
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what is a coccyx injury
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injury to sacrococcygeal joint includeing sprain, subluxation, and fractures
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why is a coccyx injury very painful
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because the area is highly innervated
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why is the coccyx joint likely to become hypomobilie while healing
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due to the sclerosing process
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what is the etiology for a coccyx injury
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direct trauma or childbirth
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what are the S and S for a coccyx injury
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- hx of direct trauma or child birth
- painful to palpation and hypomobilie - unable to sit on both buttox at the same time - increased pain in slouched posture |
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what are the treatments for a coccyx injury
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- surgical removal likely if hypermobile or dislocated in flexed position
- if joint hypomobile or in extension use of US, mobilization techniques, and coccyx pillow can give good results |
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what is a true leg length inequality
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actual asymmetry due to a fx, growth abnormalities, coxa vara/valga with a difference >0.5 inche (1cm)
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what is a functional leg length inequality
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asymmetry due to improper alignment of structures (unilateral foot pronation, genu valgus, tightness of adductor muscles, SIJ lesions)
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what are the S and S of a true leg length inequality
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- iliac crests and g. trochanters will be differnt height in standing and tests implicating SIJ will be negative
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what is the consequence of a leg length difference
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lumbar scoliosis with convexity TOWARD SHORT LEG
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what consequences would you expect on the side of the concavity (longer leg)
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adaptive muscle shortening, ligamentous and capsular hypomobility, DJD of facet joints
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what consequences would you expect on the side of the convexity (short leg)
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osteoarthritic spurring of the facet joints and disc protrusion is promoted
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what is the first step to treating a leg length difference
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must determine the cause true or functional
if functional correct the cause or use a lift under short side. if true use a lift under short side |
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before correcting the leg length difference what must have already been treated/restored
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mobility, strength and normal posture
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what does the correction of the leg lenght's effect on the scoliosis tell us
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if correcting leg lenght does not correct the scoliosis then it will likely create new difficulties because structureal changes may have taken place in the back
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if the leg length difference is > 0.5 inche, what should the initial correction be
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half of the measured difference
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when can a correction for leg length be made inside the shoe
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if the lift is 3/8 inch or less
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when can a correction for the leg length be made outside the shoe
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if lift is >3/8 inch
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what are some examples of systemic diseases that can cause back pain
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venereal disease, gout, lupus erythematosus, RA and urological infections, also metastatic lesions and visceral structures
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what are the red flags indicative of systemic disease or referred pain
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- pain increasses with rest
- not associated with specific movements or positions - insidious onset - covers large areas - migrates and/or is not well defined - no hx of trauma - lack of objective findings on investigation - do not respond to physical therapy in a timely manner |
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how do you proceed if you suspect a patient has a visceral or systemic disorder
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still treat with "safe" procedures such as correction of posture, education on lifting, gentle ther ex, and make contact with physician for proper screening
- AVOID modalities and mobs |
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what are the benign tumors that can result in severe back pain
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1) osteoid-osteoma
2) hemangloma 3) meningloma 4) neurinoma |
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what is an osteoid-osteoma
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found in bone, may cause severe back pain, especially at night
- relieved by aspirin and excision of the tumor |
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what is a hemangloma
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extradural tumor, may enlarge and press on the spinal cord leading to pain and dysfunction
- excise tumor |
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what is a meningloma
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benign extramedullary intradural tumor (within dura but not SC)
- enlarges to produce severe symptoms needs surgery |
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what is a neurinoma
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benign intramedullary intradural tumor that can impair spinal cord function
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when can a correction for leg length be made inside the shoe
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if the lift is 3/8 inch or less
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when can a correction for the leg length be made outside the shoe
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if lift is >3/8 inch
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what are some examples of systemic diseases that can cause back pain
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venereal disease, gout, lupus erythematosus, RA and urological infections, also metastatic lesions and visceral structures
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what are the red flags indicative of systemic disease or referred pain
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- pain increasses with rest
- not associated with specific movements or positions - insidious onset - covers large areas - migrates and/or is not well defined - no hx of trauma - lack of objective findings on investigation - do not respond to physical therapy in a timely manner |
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how do you proceed if you suspect a patient has a visceral or systemic disorder
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still treat with "safe" procedures such as correction of posture, education on lifting, gentle ther ex, and make contact with physician for proper screening
- AVOID modalities and mobs |
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what are the benign tumors that can result in severe back pain
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1) osteoid-osteoma
2) hemangloma 3) meningloma 4) neurinoma |
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what is an osteoid-osteoma
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found in bone, may cause severe back pain, especially at night
- relieved by aspirin and excision of the tumor |
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what is a hemangloma
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extradural tumor, may enlarge and press on the spinal cord leading to pain and dysfunction
- excise tumor |
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what is a meningloma
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benign extramedullary intradural tumor (within dura but not SC)
- enlarges to produce severe symptoms needs surgery |
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what is a neurinoma
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benign intramedullary intradural tumor that can impair spinal cord function
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what is the difference between a primay and secondary malignant tumor
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primary: arises locally in a specific bone or neural tissue
secondary: metastatic spread, extremely common due to rich blood supply |
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what is the most common malignant tumor in the back
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multiple myeloma which invades and replaces cancellous bone, causeing low back pain
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what structures may be involved in a benign tumor
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bone, soft tissue, neural structures
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