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136 Cards in this Set
- Front
- Back
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"Triage" of low back and lower extremity pain presentations
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mechanical vs. non-mechanical
Radicular (nerve root) vs. non-radicular (referred pain) Influences to perception of pain (didn't really get into this aspect) |
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What tends to be the difference between AM and PM pain?
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AM is often inflammation
PM - mechanical loading, fatigue, can be more aggressive with exercise |
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Triage I - mechanical or non-mechanical
approach to exam |
pathomechanical vs. pathoanatomical approach
- pattern established in history --time course -- AM vs PM presentation -Mechanical stresses produce familiar symptoms - "matches" of mechanical stresses become apparent in the physical exam |
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INfo gained from assessment
A diagnostic "cluster" consisting of... |
underlying disorder (medical diagnosis)
Estimate of balance between loads applied to system and load tolerance Psychosocial context of problem Related impairments, limitation of activities, restrictions in participation Estimation of the mechanisms of adaptation |
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Triage 2
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Referred pain into lower extremity from tissues non nerve root in lumbopelvic region?
or Pain in lower extremity from nerve root tissue? |
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How do articulating processes relate to each other
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inferior articulating process lies medial to superior articulating process
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What are the borders of the intervertebral foramen?
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posterior - facet jts.
Anterior - disk Pedicles are roof and floor |
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What is the liability of the annulus fibrosus?
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tension
Sagittal plane motion + rotation = increased disc vulnerability |
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Clinical correlates to discogenic disorders
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XS tension to annulus - pain - things that increase tension reproduce the pain
Tensile failure of annulus resulting in inability to contain nuclear material - pain Discogenic - annulus is pain source - tension Leads to nerve root irritation Once you injure something it's never the same repair, not regeneration |
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non-mechanical (chemical) effect: "neurotoxicity" - nerve root irritation
How does it happen? |
1. Nucleus pulposus material itself is provocative
2. Healing process - leakage form cells releases inflammatory chemicals. Cytokines related to nucleus pulposus or associated granulation tissue -tumor necrosis factor - alpha - interleukin-IB - Interferon-y That stuff is in the "pea soup" Drugs can be more targeted if you know what cytokines are active |
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Features of nerve root irritation
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extremity pain > spine pain
quality of pain differs from referred pain clear demarcation of pain pattern in extremity proximal pain and distal paresthesias neural tension testing reproduces extremity pain gentle spinal motions result in excessive irradiation |
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What is the hallmark of nerve root irritation
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proximal pain and distal paresthesias
paresthesias include - vibration, ants, tingling, numbness, cold, etc. 90% of diagnosis is in history these are symptoms, so they can't be objectively measured |
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Features of nerve root compression
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muscle wasting
muscle weakness (ventral root) sensory impairment (dorsal) quality of reflexes altered (either/both) These are signs that can be objectively measured |
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Three influences to perception of pain that must be weighed to target treatment
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chemoreceptors
mechanoreceptors biopsychosocial Figure out which "wheel" is spinning fastest weigh them and target treatment |
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Elements of "clinical" study of musculature
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analysis of movement
palpation manipulation of soft tissues exercise |
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Lumbopelvic region: Muscle fascial dynamics
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Facial networks
-thoracolumbar - fascia lata - abdominal mechanism when you prescribe exercise for patients with back pain, it's often based on these networks Better clinical utility than just origins and insertions |
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Thoracolumbar fascia: muscle relationships
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Latissimus Dorsi
Gluteus Maximus Internal abdominal oblique Transversus abdominus (those all attach to thoracolumbar fascia) Superficial erector spinae Deep erector spinae Multifidus (those are encased in fascia) Quadratus lumborum Psoas major (those lie anterior to fascia) |
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Muscles attached to thoracolumbar fascia
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lats
glute max internal oblique transversus abdominus see x-section of lumbar spine - key picture for visualizing relationships |
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Focusing for training effect - latts
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easy to apply load to latts
figure out least compromising position for spine and find a way to overload (picture of guy rotated to different angles - upright, supine, prone) "pulls" with attention to muscle orientation |
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How does glute max interact with fascia?
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hooks into fascial systems and links thoracolumbar fascia and fascia lata
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What is the importance of body position during a squat
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look at where center of gravity lies in relation to hip, knee, and ankle
more in front of hip = flexion moment and demand on hip extensors more behind knee = knee flexion moment and demand on quadriceps Balance COG depending on what they want Power lifters - huge butts Olympic lifters - giant thighs |
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Lunge body mechanics
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step out with one leg
lunge foot strikes ground with heel immediate move to foot flat at footflat, hips drop straight down (*) Note how hip descent minimizes tibia moving forward of foot good exercise for flexibility, hip control |
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Attachment of transversus abdominus and internal oblique to thoracolumbar fascia
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attaches right at the corner of the fascia
pulling laterally Strong attachment provides stability we'll detail the heck outta this later |
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Muscles encased in thoracolumbar fascia
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superficial erector spinae
deep ES - medial longissimus group - lateral iliocostalis group Multifidus |
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Concept of muscles being "encased" in fascia, and importance
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picture of thoracolumbar fascia cut and reflected back
When a muscle contracts, it broadens -pull AND push on fascia - contributions to stability of spine - have been cases of compartment syndrome in back -relative hypertrophy Lifters: peak for competition, detrained. As they hypertrophied, less pain. During detraining, back pain increased again. Problem is instability |
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Superficial erector spinae
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first muscles you see after reflecting TL fascia
Enormous tendon Superficial -Erector spinae aponeurosis -Up to thoracic area in back of ribcage Nerves on dissection picture Posterior ramus coming through All back muscles have branches of ventral roots |
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Deep erector spinae
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Compartments are pretty easy to see
spread fascia to get down to spine PA force = pushing through skin, fascia, and muscle tissue Muscles go up and forward to attach to transverse processes of lumbar vertebrae |
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Forces created by deep erector spinae
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lever arm isn't that great but does have compression and posterior shear
triangle showing DES pull has compression component pointing down, and posterior shear component muscle has to contract a lot to prevent shear mistake to just treat symptom (tender muscle) - usually protective mechanism |
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What factors make a "match" (about deep erector spinae involvement? not sure about the context)
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can't tolerate mechanical shear
+ tenderness there = match on bottom slide on page 11 of musculature Slide notes: DES go up and twist |
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What's the only muscle belly on the dorsal surface of the sacrum?
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Multifidus
has big cross sectional area |
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Difference between multifidus and deep erector spinae
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multifidus goes to spinous processes
so, it has a pretty good lever arm for extension |
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Multifidus muscle changes in low back pain
potential causes |
structure and morphology
-selective type II atrophy -internal structural changes in type I fibers --core-targetoid fibers & moth eaten fibers (don't worry) -increased adipose tissue within muscle Potential causes -disuse atrophy - inactivity - axonal injury - neuropraxia --nerve root injury -- supplied by posterior ramus at each level -- probably both things contribute mid '90s, surgeons took biopsies of M -saw histological changes -cause or effect? -lots of studies -changes easy to see |
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Multifidus Muscle Contraction
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->
bulk of fascial envelope Lumbar joint compression Extensor of lumbar spine Lumbar joint capsule tension -> lumbar spine mobility and stability part of attachment blends w/ joint capsule of facets |
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Use of MRI to evaluate lumbar muscle activity during trunk extension exercise at varying intensities
Roman chair exercise used with different intensities |
Multifidus demonstrate largest T2 increase at all 3 intensities, followed by erector spinae and quadratus lumborum
T2 refers to skeletal muscle proton transfer times - a measure of the muscle exercising At lower intensity medial ES (longissiumus) displays higher T2 increase than lateral ES (iliocostalis) At higher intensity, lateral ES shows higher than medial Lats and glutes stabilize back (pull arms up/in to get lats) Stabilize pelvis and move back |
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Spinal muscles that "pull" and "push"
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muscle "pull"
latissiumus dorsi gluteus maximus internal oblique transversus abdominus Muscle "push" superficial erector spinae deep erector spinae multifidus |
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Iliolumbar ligament
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between ilium and lumbar vertebrae (duh)
a replacement of muscle tissue (essentially) Infant upright has shear (why did I write that note?) Most disc breakdown and dessication at L4/L5 Ligament protects L5/S1 |
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Iliopsoas attachments
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attaches to anterior transverse processes and vertebral bodies
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psoas major acting over lumbar spine and pelvis
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anterior shear
compression pelvic anterior rotation innominate anterior torsion goes down and forward, over pubic ramus and back to lesser trochanters Pregnant women - more shear from COG - tend to walk with hips in ER to take stress off psoas |
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Roles of trunk muscles
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generation of movement
balance and external moments while sustaining given postures move leg or arm - must contract trunk lying prone and can't hyperextend thigh - may be from back not balancing movement by keeping hip stable |
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Layers (over PSIS and somewhere else) from superficial to deep
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skin
thoracolumbar fascia erector spinae aponeurosis deep erector spinae quadratus lumborum transveres processes psoas major skin fat thoracolumbar fascia E.S. aponeurosis Multifidus muscle |
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Muscles associated with abdominal fascia system
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Muscles attached:
- External oblique -> serratus anterior - Internal oblique - Transversus abd - Pectoralis major Muscles Encased: -Rectus abdominus |
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How should you overload the abdominal mechanism (fascia)
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do it through shoulder girdle
back problems aggravated by sit-ups |
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What do you call a split in the abdominal fascia? How can it happen?
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split is called diastasis
can happen with pregnancy with large baby or from strong contraction or valsalva |
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External Oblique
attachments and actions |
attached to all ribs, has serrated appearance (serratus anterior joins with it)
to lateral aspect of abdominal fascia and ilium (iliac crest) Actions: 1. increase tension to fascia (which pushes abdominal contents into spine, helping check shear forces) 2. flex upper trunk 3. flex (post tilt) pelvis 4. rotary moment - contralateral trunk rotation |
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Muscle linkages to external obliques
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pectoralis major (pecs tie in to fascia, not directly to obliques)
serratus anterior |
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Internal oblique attachments and actions
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Thoracolumbar fascia and iliac crest
to last rib(s?) and abdominal fascia (deep to external oblique) Biggest/thickest abdominal muscle Actions: 1. increases tension to abdominal fascia 2. Rotation - ipsilateral |
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Resistive gait
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use trunk (obliques) to bring legs forward
with PNF High level athletes - train by running against resistance, etc. |
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Transversus abdominus attachments and actions
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Thoracolumbar fascia, ribs, iliac crest
To Lateral abdominal fascia Actions: 1. cinch up TL fascia 2. Cinch up abdominal fascia - pulls abdomen in |
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Rectus abdominus actions
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1. thorax toward pelvis
2. pelvis toward thorax 3. adds tension to fascia by filling it obliques anchor rectus tendons |
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Why is Rectus Abdominus structured the way it is
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long distance
-needs fast rate of shortening -So, series of small muscles between tendons Tendons must be "tied down" by obliques for efficiency curl-up exercise doesn't just work rectus -obliques must be active to anchor tendon points |
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An overload challenge creates what types of changes?
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anatomical, biochemical, and neural changes
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Why should you protract your shoulders in a plank?
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lots of posterior shear at glenoid-humeral interface
protracting decreases by unloading the shoulder joint brings in key muscles - serratus and pec |
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The Serape Effect
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The Big Picture of the Trunk
linking the musculature of the shoulder complex, abdominal mechanism, hip complex Line of force criss-crosses (not directly connected) Rhomboids, serratus, obliques (I think those are the involved muscles) |
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What motions/muscles are involved in the turkish get-up?
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strong protraction (1 ->2)
Obliques and hips (3 -> 4) Lunge in place, maintaining scapula (4 -> 5 -> 6 -> 7) Eccentric on the way back down |
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What did a study find was the best predictor of throwing speed?
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(strength of?) abdominal mechanism
nothing to do with strength of shoulder girdle linkage between them |
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Functions of the abdominal wall - works in concert with pelvic floor, diaphragm, and spinal extensors to...
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works in concert with pelvic floor, diaphragm, and spinal extensors to form trunk cylinder (like a football)
Most important anti-gravity muscle group - for stabilization Increased intraabdominal pressure creates cylinder Can't keep pressure up for long - compresses vessels (inferior vena cava) Ability to create pressure is dependent on healthy pelvic floor and spinal extensors support braces are supposed to help pressurize the cylinder |
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Functions of the abdominal wall
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works in concert with pelvic floor, diaphragm, and spinal extensors to form trunk cylinder
Increases tension to thoracolumbar and abdominal fascia Checks anterior shear of lumbar spine by controlling sagittal plane position of pelvis Controls rate and amplitude of lumbar spine torsion Controls frontal plane of pelvis during gait Controls the relationship between abdominal wall and thorax Increases compression at sacroiliac and symphysis interphases |
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Functions of the abdominal wall - Increases ____ to ___ and _____ fascia
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Increases tension to thoracolumbar and abdominal fascia
work with other muscles to create connective tissue cylinder of support |
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Functions of the abdominal wall - Checks ____ ____ of lumbar spine by controlling _____ plane position of pelvis
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Checks anterior shear of lumbar spine by controlling sagittal plane position of pelvis
Breakdown of lumbar spine -> increased translation -alters intervertebral foramina and spinal canal -surgical candidates Hip flexors and spine extensors create extension force Force couple for spinal flexion: hip extensors, abs People (gymnasts, etc) decrease back pain by having tight hamstrings |
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Functions of the abdominal wall - Controls ___ and ______ of lumbar spine torsion
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Controls rate and amplitude of lumbar spine torsion
Control loads that get to structures that could be damaged - e.g. annulus fibrosus Have great lever arm - far from spine |
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Functions of the abdominal wall - Controls ______ plane of pelvis during ____
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Controls frontal plane of pelvis during gait
Watching someone walk may be the best way to evaluate abdominal muscles -when the pelvis is "all over the place" = weakness |
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Functions of the abdominal wall - Controls the relationship between ______ ____ and ______
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Controls the relationship between abdominal wall and thorax
Forward head posture is not DUE to weakness of scapular retractors Need strong abdominal wall or thoracic cage collapses and abs follow with head and neck after that Neck muscles attached to front of thorax -aerobic exercise is good for abdominal wall strength/health |
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Functions of the abdominal wall -
Increases compression at sacroiliac and symphysis interphases |
Increases compression at sacroiliac and symphysis interphases
Compression increases friction an enhances stability -stability also provided by posterior SI lig and interosseous lig |
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Why is thoracic pain not common?
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the ribs are great stabilizers, doesn't wear out like lumbar spine
If you meet a 50-yr-old male with T-spine pain - think cancer - metastatic |
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Features of thoracic spine
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long spinous processes that point down
kyphosis 2 unique articulation points for ribs - costovertebral and costotransverse joints |
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What type of fracture is common in the thoracic spine?
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crush fractures are common because of thinning of trabeculae coupled with forced flexion
Potential for compromise of neural structures Inject "cement" inside vertebral body or hollow tube -> ballon, take balloon out and inject "cement" (fix the shape first) |
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Facets and rib articulations in thoracic spine
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Facets oriented in frontal plane
Costotransverse joint Costovertebral joint - on vertebral body Synovial joints, easy to determine if they have issues - breathe deeply, rib pivots at joints Head of rib spans 2 vertebrae - bottom of 1 body and top of another |
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What are the concepts of mobilization based on?
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orientation (of facets, etc)
Distraction between joint surfaces spinous process isn't a good lever in T-spine Transverse process better oriented |
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What is required for the motion of pushing arms overhead?
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Thoracic spine extension
and Trunk stabilization |
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2 types of scoliosis
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Structural - fixed lateral curve with vertebral rotation (bony abberation - problem with having fixed rotation is that you start to change the thoracic cage and mechanically compromise heart and lungs)
Non-structural - corrects with sidebending, traction, etc. -HNP, leg length discrepancy |
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Scoliosis classifications
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Ideopathic - no know cause (applies to all?)
Infantile (0-3 yrs) - <1% Juvenile (3-10 yrs) - 20% Adolescent (older than 10 years) - 80% 1:1 ratio female to male with curves less than 10 degrees 10:1 female to male ratio with curves greater than 30! Typically 3:1 female:male overall |
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How are curves named in scoliosis?
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Named according to side of convexity
Primary curve named first Secondary curve (if present) named second Dorsal = thoracic International standard for naming, so it's clear Picture of woman with right thoracic (though she's sidebent to left) and left lumbar scoliosis Thoracic also called dorsal |
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How is spinal rotation seen in x-ray?
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Seen in AP view because pedicles are off-center
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How do you measure degree of spinal curvature?
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Cobb angle
Find top and bottom vertebrae - vertebrae at the "ends" of curve 1st line is parralel to the superior plateau of the top vertebra 2nd line is parallel to inferior plateau of bottom vertebra 3rd and 4th lines are at right angles to those and angle is measured where those intersect (not the angle directly between them on the inside but between one and the "tail" of the other after they cross) |
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What is involved in a scoliosis evaluation?
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Postural evaluation:
-scapula height and position - vertebral spinous processes - waist angle - iliac crest height and position - analysis of rib contour - bend forward Advanced cases - respiratory function |
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Scoliosis treatment
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Treatment determined by chronological age and skeletal age analysis through radiographic analysis
Exercises: -strengthening of trunk -Stretching - concavity, rib derotation Bracing - fairly supported Surgery - none but surgery have strong evidence |
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How does scoliosis treatment vary with age?
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10 yr old with 58 degree curve is different than 17 year old
Growth plates will close quickly after 17, while there's more time for 10 yr old to get worse So, more aggressive treatment for 10 yr old |
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What was the first brace for scoliosis?
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The Milwaukee brace - developed by Blount
Anterior force on posterior rib-hump and vice versa - derotating force and distraction force A NAIL in chin piece to keep head from falling forward |
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Describe the Boston brace
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for scoliosis
Same principles as early Milwaukee brace -de-rotation -distraction Made out of continuous contoured plastic Kids are still active and able, but supposed to keep brace on 23 hrs/day |
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What are Harrington Rods?
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When scoliosis is advancing rapidly and/or there is respiratory compromise - treated with surgery and insertion of Harrington rods
Ends of rod hook onto pedicles Crank it up/apart until slight cracking of bones is heard Stops curve from developing - no evidence that it reverses it May need upgrade with growth, or may not have to trade it out at all ROM = 0 |
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What are the 3 levels of scoliosis treatment
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1. watch it - compare chronological and skeletal age
2. non-invasive management - exercise and bracing 3. Surgery - Harrington Rods |
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Fascia Lata system - compartments
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compartmentalizes muscles of the thigh
Quads in anterior compartment Hamstrings in posterior compartment Adductors (magnus, sartorius, gracilis) in medial IT band is thickening of lateral wall |
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Fascia Lata - Gluteus maximus
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Thoracolumbar compartment
Gluteus Maximus is the muscle linkage between the thoracolumbar and fascia lata systems About 2/3 of glute attaches to fascia system (1/3 on femur) |
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Hamstrings act over sacroiliac joint via...
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sacrotuberous ligament
Muscles blend Dynamic tension of ligamentous complex Hip extensors are very important for back pain |
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Anterior compartment of fascia lata
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Quads
Hypertrophy important for stability - contraction creates broadening of muscle and increases tension on facia lata Concept for lateral release: ppl with patellofemoral problems "loosen" up fascia lata on lateral side Thought was that patella would move slightly medially |
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Fascia lata - muscles "pulling" and muscles "pushing"
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Glute - pulling
Quads - pushing |
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upward (posterior) tilting of the pelvis
a. results in anterior torsion of the sacroiliac joint b. results in an extension moment at the lumbosacral joint c. can be accomplished by concentric contraction of the gluteus maximus muscles d. decreases anterior shear stress of the L5 vertebrae on the sacrum |
c. can be accomplished by concentric contraction of the gluteus maximus muscles
d. decreases anterior shear stress of the L5 vertebrae on the sacrum |
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Extension of the Lumbar spine
a. increases the height of the intervertebral foramen b. has a greater ROM than rotation of the lumbar spine c. decreases the lumbar lordosis d. increases the compressive load more at the bone-disk interface than the apophyseal joints |
b. has a greater ROM than rotation of the lumbar spine
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Structures located within the spinal canal would include the
a. posterior longitudinal ligament b. ALL c. Ligamentum flavum d. dura mater |
a. posterior longitudinal ligament - PLL
c. Ligamentum flavum d. dura mater |
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When a patient forward bends their lumbar spine from the standing position
a. the lumbar lordosis would normally decrease b. an eccentric muscle contraction of the spinal extensors helps control this motion c. disc pressure would increase as compared to standing upright d. tension in the PLL would increase as compared to standing upright |
a. the lumbar lordosis would normally decrease
b. an eccentric muscle contraction of the spinal extensors helps control this motion c. disc pressure would increase as compared to standing upright d. tension in the PLL would increase as compared to standing upright |
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Based upon the reason that irritation of the nerve root is painful, an epidural anesthetic and steroid medication that is injected into the spinal canal is designed to
a. shrink the annulus fibrosus b. decrease intradiscal pressure c. decrease inflammation in the spinal canal d. free adhesions between the adjacent vertebrae |
c. decrease inflammation in the spinal canal
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Symptoms or signs of nerve root involvement in the low back would
a. demonstrate lower extremity reflex changes in muscles of the lower extremity b. feature pain that is more diffuse in the LE rather than a clearly demarcated zone of pain in the LE c. leg pain would typically be more of a complaint than back pain d. feature pain in the proximal aspect of the dermatome and paresthesias in the distal aspect of the dermatome |
a. demonstrate lower extremity reflex changes in muscles of the lower extremity
c. leg pain would typically be more of a complaint than back pain d. feature pain in the proximal aspect of the dermatome and paresthesias in the distal aspect of the dermatome |
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The reason/s that laminectomies are performed is/are to
a. remove pressure from the psoas b. decompress the spinal canal c. stabilize adjacent vertebral bodies d. reinforce the lumbar facets |
b. decompress the spinal canal
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In addition to mechanical compromise of the neural tissue as a result of disc pathology, disc surgeries are performed to
a. minimize the inflammatory effect of nucleus pulposus material in the spinal canal b. decrease tension to the ligamentum flavum c. remove tension from the facet joint capsule d. create more compression between the inferior and superior articular facets |
a. minimize the inflammatory effect of nucleus pulposus material in the spinal canal
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Contraction of the hamstrings from the standing position, feet fixed to ground
a. when performed bilaterally, anteriorly tilts the pelvis b. " " ", creates an extension moment at the lumbosacral junction c. " " ", results in increased facet joint compression d. On the right side, creates a posterior torsional moment of the right ilium on the sacrum |
d. On the right side, creates a posterior torsional moment of the right ilium on the sacrum
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The lateral recess refers to
a. lateral aspect of annulus fibrosus b. region that the lamina merges with the spinous process c. lateral extent of the spinal canal adjacent to the IVF d. Junction of the vertebral body w/ the lateral aspect of the annulus |
c. lateral extent of the spinal canal adjacent to the IVF
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The components of the intervertebral disc include
a. water b. muscle tissue c. proteoglycans d. collagen |
a. water
c. proteoglycans d. collagen |
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structures which lie anterior in relationship to the ligamentum flavum include
a. intervertebral disc b. dura mater c. interspinous ligament d. PLL |
a. intervertebral disc
b. dura mater d. PLL |
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Rotation of the lumbar spine
a. is approx equal to rotation available at hip joints b. at the bone-intervertebral disk interface is limited because of the orientation of the annulus fibrosus c. results in increased compression between facet surfaces on the right when the trunk is rotated to the left d. is approximately 20 degrees at the L4-L5 articulation |
b. at the bone-intervertebral disk interface is limited because of the orientation of the annulus fibrosus
c. results in increased compression between facet surfaces on the right when the trunk is rotated to the left |
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The ______ contribute/s to the boundaries of the IVF
a. interspinous ligament b. apophyseal joint c. intervertebral disk d. lamina |
b. apophyseal joint
c. intervertebral disk |
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The motion that has the greatest potential to simultaneously injure a lumbar apophyseal joint in compression and the annulus fibrosus in tension during sports/work is
a. flexion b. rotation c. compression d. extension |
b. rotation
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The reason/s that the nucueus pulposus has a large proportion of water is
a. the collagen fibers absorb water b. proteoglycan molecules chemically bind the water c. there's a large number of small blood vessels distributed throughout the nucleus pulposus d. there's a high proportion of cartilage in nucleus |
b. proteoglycan molecules chemically bind the water
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The posterior longitudinal ligament
a. is located anterior in relationship to the cauda equina b. is wider in the lumbar region than the cervical region c. would have increased tension imparted to it with an extension motion of the lumbar spine d. is anterior to the intervertebral disc |
a. is located anterior in relationship to the cauda equina
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The nucleus pulposus
a. has the greatest proportion of pain fibers in the spine b. has a greater supply of blood than the cancellous bone of the vertebrae c. is covered on its superior and inferior surfaces by the cartilaginous endplates d. has less collagen fibers than the annulus fibrosus |
c. is covered on its superior and inferior surfaces by the cartilaginous endplates
d. has less collagen fibers than the annulus fibrosus |
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Spondylolisthesis of the fifth lumbar vertebrae
a. would change the shape of the spinal canal b. would change the shape of the intervertebral foramen c. can result from fractures of the pars interarticularis d. would benefit from treatment approaches designed to decrease the lumbosacral angle rather than increase it |
a. would change the shape of the spinal canal
b. would change the shape of the intervertebral foramen c. can result from fractures of the pars interarticularis d. would benefit from treatment approaches designed to decrease the lumbosacral angle rather than increase it - less shear |
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anatomical factors that would result in, or contribute to, spinal stenosis would include
a. anterior longitudinal ligament that is wider than normal b. an interspinous ligament that is thicker than normal c. a ligamentum flavum that is thicker than normal d. psoas major muscle hypertrophy |
c. a ligamentum flavum that is thicker than normal
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In order of highest disk pressure to lowest, the correct order of body positions would be
a. sitting, sitting and leaned forward, lying supine b. sitting, standing, lying supine c. standing upright holding a 20lb weight while leaning forward, standing and leaning forward w/o weight, standing upright d. sitting leaned forward and rotated in the lumbar spine, seated, standing |
b. sitting, standing, lying supine
c. standing upright holding a 20lb weight while leaning forward, standing and leaning forward w/o weight, standing upright d. sitting leaned forward and rotated in the lumbar spine, seated, standing |
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Pain sensitive structures in spine include
a. nuclues pulposus b. cortical bone c. PLL d. facet joint capsule |
d. facet joint capsule (innervated, pain source)
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From superficial to deep (or posterior to anterior) the correct sequence of anatomical structures would be
a. interosseous ligament, sacroiliac cavity, anterior aspect of SI joint capsule b. Sacroiliac joint cavity, anterior aspect of SI jt capsule, psoas major c. posterior SI ligament, anterior aspect of SI joint capsule, interosseous ligament d. sacrum, pelvic viscera, pubic symphysis |
a. interosseous ligament, sacroiliac cavity, anterior aspect of SI joint capsule
b. Sacroiliac joint cavity, anterior aspect of SI jt capsule, psoas major d. sacrum, pelvic viscera, pubic symphysis |
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With a standing frontal plane posture assessment in which the left side of the pelvis is lower than the right
a. there is more shear force at the right SI than left SI joint b. there is increased compression of the hip joint on the right as compared to the left c. there is increased opening of the lumbar IVF on left as compared to right d. the lower lumbar apophyseal joints on the right side are in a more compressed position than those on the left side |
a. there is more shear force at the right SI than left SI joint
b. there is increased compression of the hip joint on the right as compared to the left c. there is increased opening of the lumbar IVF on left as compared to right d. the lower lumbar apophyseal joints on the right side are in a more compressed position than those on the left side |
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Nutation of the sacrum on the ilium
a. decreases tension to the sacrotuberous ligaments b. increases tension to the interosseous ligaments c. is approximately in the range of 15-20 degrees of motion d. would most likely be greater (more available range) in a male who is 65 years old than in a male who is 20 years old |
b. increases tension to the interosseous ligaments
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Disc material that extrudes in to the spinal canal has the potential to compromise the
a. ventral roots b. PLL c. interosseous ligament d. dorsal rami |
a. ventral roots
b. PLL |
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Radicular pain is characterized by
a. greater pain in the spine than extremities b. pain from abdominal or pelvic viscera c. a sharply demarcated, clearly outlined area of pain in the extremity d. an increase in leg pain with straight leg raising |
c. a sharply demarcated, clearly outlined area of pain in the extremity
d. an increase in leg pain with straight leg raising |
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True-false
pain in the posterior thigh from facet joint irritation is an example of facet joint referred pain |
True
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T/F
The lumbar apophyseal joint lie anterior to the IVF |
false
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T/F
The L1-L2 region is located at approximately the level of the iliac crests |
false
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T/F
The cortical bone of the vertebral body is a primary storage area for blood |
F
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T/F
Lumbar extension creates more facet joint compression than lumbar flexion |
T
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T/F
The inferior articular process of the 4th lumbar vertebrae is medial to the superior articular process of the 5th |
T
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T/F
The straight leg raise test is designed to determine nerve root compression, not nerve root irritation |
F
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T/F
The L5-S1 articulation fuses as we age |
F
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T/F
More pain and stiffness in the morning upon awakening as compared to pain at the end of the day would lead one to consider inflammation as a source of pain with this patient |
T
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T/F
The outer aspect of the annulus fibrosus is avascular and aneural |
F
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T/F
The ALL reinforces the anterior aspect of the facet joint capsule |
F
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T/F
With facet joint problems, leg pain is typically worse than back pain |
F
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T/F
As the disc space narrows, there is increased contact (increased facet joint pressure) between the facets |
T
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Pain in the lower extremity from low back involvement is always nerve root involvement
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False
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T/F
Dorsal and ventral roots are located in the spinal canal |
T
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T/F
Hypomobility of the lumbar spine, as assessed by P-A spring tests is one of the criteria for the manipulation clinical prediction rule for low back pain |
T
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T/F
The lateral recess is positioned just lateral to the intervertebral foramen |
F
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T/F
There is typically more ROM at the SI joint than the lumbosacral joint |
F
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T/F
No cerebrospinal fluid is found in the spinal canal; it is limited to the brain region |
F
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T/F
During pushoff on the R lower extremity, there would be greater apophyseal joint compression on the right than the left in the lumbar spine |
T
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T/F
The forward slipping of L5 on the sacrum is referred to as spondylosis |
F
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T/F
The cartilaginous endplate refers to the cartilage positioned between the superior and inferior articular processes |
F
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Posterior torsion of the ilium on the sacrum increases tension to the sacrotuberous ligament
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T
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