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120 Cards in this Set
- Front
- Back
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how many PCP visits are musculoskeletal in nature?
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30%; 2nd most common reason to present to PCP (URI/headaches are 1st)
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how many workers comp cases are due to back injury?
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33%
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main age group of LBP?
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20-50 yrs old
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most important question for LBP patients?
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any bowel or bladder dysfunctions, especially incontinence
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what might be injured if there is pain when you try to extend your back?
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Psoas
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what might be injured if there is pain in buttock/ext. rotation of leg?
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piriformis
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what might hypertonic piriformis cause?
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radicular pain along path of sciatic n.
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what are the main cancers to be concerned about that could be causing LBP?
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mets from breast, prostate cx
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5 red flag alarm symptoms
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1. age > 50
2. prior history of cx 3. unexplained fevers, night sweats, weight loss 4. pain lasting more than 1 month; intractable; unrelieved with rest 5. no improvement following conservative therapy |
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what do you use_____ for?
-xray -CT -MRI -bone scan |
-alarm sxs (cx? infec? fracture?)
-bone -soft tissue imaging -suspicion of multiple myeloma |
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symptoms of discogenic (radicular) pain
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-acute; constant, sharp, shooting
-dermatomal radiation, unilateral -increased by cough, sneeze, sitting -improved with lying down -may have long hx chronic BP |
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what is most common cause of discogenic LBP?
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irritation of a nerve root
-will be in specific sensory distribution, can progress to motor deficit |
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most important motor deficit to be concerned about?
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loss of bowel/bladder control
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what are signs that necessitate ruling out cauda equina syndrome?
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progressive motor deficit; saddle anesthesia
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what is most common direction of HNP?
why? |
posterior lateral direction
because post. longitudinal lig. is narrower |
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how do you dx/treat HNP?
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MRI *major; CT, myelogram
treat: heat/ice; OMT; corticosteriods; NSAIDS; opioids; epidural injec; surgery as last resort -may also use tricyclic antidepress, gabapentin for pain unresponsive to opioids |
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does a bulging disc always cause symptoms?
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NO. 52% of 20-80 yr olds have bulging/protruding and are asymptomatic
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what is the most common type of HNP?
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posterolateral herniation at level of L4/L5
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treatment for cauda equina syndrome?
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EMERGENT surgery
-very rare; 50% secondary to tumor |
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define facet tropism
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asymmetry of facet joint--> predisposition to early degenerative joint disease
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define sacralization
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deformity in which L5 fuses with sacrum; predisposes pt to pain, early disc herniation
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define lumbarization
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deformity in which S1 fuses to lumbar spine. less common
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what is spina bifida?
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defect in closure of vertebral lamina-->herniation of spinal contents
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define spina bifida occulta
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no herniation
-only discernable from tuft of hair over site |
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define spina bifida meningocele
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herniation of meninges through defect
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define spina bifida meningomyelocele
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herniation of meninges AND nerve roots through defect. associated with neurological defects
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What is lumbosacral angle?
significance? |
intersection of horiz. line with sacral base line; normal = 25-35 degreees
increased angle = increased lumbosacral joint shear, LBP (increased instability, lumbar lordsis) |
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how much of LBP is somatic dysfunction?
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70%
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what is aggravated if you can bend over but cant straiten up?
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psoas
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what are major mm. involved with LBP?
(7) |
psoas(trtmt: ME, stretch)
piriformis (sacral sheer trtmt) quadratus lumborum (pt. may present side bent) erector spinae (pt leaning back, dont want to flex forward) gluteal mm. abd. mm hamstrings |
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what does dr. greenman say about postural/tonic mm?
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respond to dysfuction by becoming HYPERTONIC, SHORTENED, sometimes SPASTIC
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what does dr. greenman say about dynamic/phasic mm?
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respond to dsyfunction by INHIBITION, HYPOTONICITY, WEAKNESS
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presentation of iliopsoas mm?
location of pain? |
hunched forward
ant. thigh |
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presentation of piriformis mm?
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pain radiating along path of sciatic n.
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what are 5 segmental/ligametous dysfunctions involved in LBP?
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1. L5
2. SI joint; sacral torsions 3. short leg 4. stretch of iliolumbar lig. 5. myofascial injury (esp. pts in trauma/accidents) |
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what is main motion of lumbar spine?
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flexion/extension
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what somatic dysfunction is psoas spasm associated with?
which side to these vert rotate to? |
L1- and L2
rotated to same side as spasm |
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what is straight leg test testing?
what is a + test? |
testing for disc pathology
+ test if there is pain between 20-60 degree raise |
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motor test for psoas mm tests?
action? |
flex hip
L1-L2 motor n. root |
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motor test for quadriceps action?
tests? |
extend leg at the knee
L3 motor nerve root |
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motor nerve test for tibialis anterior action?
tests? |
dorsiflex foot
L4 motor nerve root |
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motor nerve test for extensor hallucis longus action?
tests? |
extend big toe
L5 motor nerve root |
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motor nerve test for gastrocnemius action?
tests? |
plantarflextion
S1 motor nerve root |
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normal results for motor nerve test?
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muscle strengh LE 5/5 bilaterally
0=flaccid, no tone 1=tone, no mvmt 2=mvmt with grav, not against 3=mvmt against grav, not resis 4=slightly diminished strength agains resistance |
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sensory examination result?
levels tested? |
"sensation intact bilaterally"
L1-S1 |
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what does patellar reflex test?
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L4
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what does achilles reflex test?
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S1
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how are reflexes graded?
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+2/4 = midrange/normal
0=no response 1=minimal 3=slightly hyperactive 4=hyperactive with clonus |
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what does patrick's test test for?
how do you set it up? |
hip pathology, SI joint problem
FABERE: flex, ABduct, ext. rotation, extension |
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what does thomas test test?
what do you look for? |
tight hip flexor or psoas muscle (on extended side)
lood for gap in popliteal fossa or increased lumbar lordosis |
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flexed lumbar segment-still technique--how is pt. positioned?
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pt supine with knee flexed up on side of ease; leg = adducted at hip (will be at about same level as affected segment, midline of body)
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flexed lumbar segment-still technique--how is dr?
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dr. standing on side of ease; sensing (cephalad) hand = under pts lumbar area/on affected transverse process; operating hand on flexed knee
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what is treatment for flexed lumbar segment-still technique?
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1. induce compression on flexed knee with vector towards affected segment
2. abduct knee, slightly rotate pelvis posterior toward table on side of ease 3. finally, push knee inferior towards pts. other foot--segment should release 4. leg extended--returned to neutral. Retest |
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how does flexed lumbar segment still technique differ from extended?
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1. starting pose = tree pose
2. flexed knee is abducted with lateral/ext. rotation. segment should relax. 3. produces extension of inferior segment and SB of the hip toward side of ease 4. pressure on flexed knee; adduct until crossing midline 5. push knee inferior towards pt. other foot--palpable release |
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early thoughts about Stills techniques?
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HVLA and articulatory techniques
--quick, done with rapid motions --dlick not necessary, no repetitious mvmts noted --direct positional technique |
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Who was Charles Hazard?
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student of dr. Still in 1897
teacher on staff at American School of Osteopathy as student; professor after graduation 4 key quotes about how Dr. Still "does it" |
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Dr. Hazard's Description?
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Dr. Still in the case of lateral spinal lesions, stands in front of the patient, who is sitting. He passes both arms around the body and clasps his hands over the point of the lesion. He sinks the spine down upon this point, bends the patient toward the side of the deviation of the vertebrae to force it back to place while he rotates the body toward the opposite side
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What was Dr. Van Buskirk's research?
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1989 found Dr. Hazard's notes, then 2 yrs later experimented with techniques
moderate to low velocity; audible click not necessary; sinking down pressure ~5lbs axial pressure/traction maintained thruout mobilization until release; direct force over the dysfucntional segment not necessary; only increases pt. discomfort |
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Van Buskirk's description of still technique
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"first the affected joint is isolated at its presenting position and its position slightly exaggerated. Second, axial compressive forces are applied through the joint at right angles to the plane(s) of restriction. Finally a gentle, low velocity motion is introduced in the plane(s) of restriction toward and thru the area where the restriction barrier had been
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is still technique similar to FPR?
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in appearance only
--positioning and use of compressive force -Type 1 or type 2 differentiation not necessary for FPR since dysfunct. treated in neutral -position held for brief period; traction or compression applied then segment moved back to neutral--NOT thru barrier as with Still Dr. Schiowitz = didn't see techniques similar to FPR or Still's prior to developing FPR |
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what are 4 requirements of still technique?
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1. start in exaggerated position of rest
2. carry tissue through area of restriction 3. maintain added compressive force/traction throughout entire articulatory phase 4. must have specific dx |
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where does the force vector run?
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from point of compression to and through dysfunctional tissue
NOT parallel to axix of spine nor limb being used as lever |
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what are the dx for still technique?
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1. spinal segments type 1 or 2
2. non-spinal somatic dysfunc. involving sacrum and ilium, named according to position they are in and or direction in which motion is easiest |
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what are the steps of still technique?
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1. find dysfunction
2. move to position of ease 3. exaggerate possition of ease to relax tissue surrounding 4. introduce vector of force (5#) 5. carry affected tissue towards and through restriction 6. palpable release 7. return to neutral, retest |
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contraindications of still technique?
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advanced bone wasting
fractures radiculopathy/nerve entrapment patient objection or inability to tolerate facet syndrome/facet arthritis |
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what is FPR?
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1. developed by dr. Schiowitz
2. developmed for more efficient treatment time 3. modification of indirect myofascial release 4. enhanced by treating in neutral with added compression 5. treatment directed towards normalization of hypertonic mm, superficial and deep |
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what is mechanism of action of FPR?
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resetting the gamma loop; unload spindles; decrease excitation of mm controling extrafusal mm fiber (inverse myotactic reflex)
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what are 2 types of FPR?
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1. normalization of palpable abn. tissue texture
2. influence the deeper mm involved in joint motility |
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what does compressive force do in FPR?
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1. reduces proprioceptive noise
2. allows reduction of gamma gain |
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what type of technique is FPR?
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passive, indirect, positional
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what is important about Still technique treatment sequence?
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treat lumbar/pelvic dysfunction before sacral!
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how do you set up a flexed lumbar spine treatment?
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flex and ADDUCT the leg, move through abduction and extension to treat
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how do you set up an extended lumbar spine treatment?
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flex and ABDUCT the leg to set up, move through adduction and extention to treat
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how to treat anterior innominate?
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doc on dysfunct. side
flex leg to 45-60 degrees ab or ad duct til tissue relaxes compress, flex, adduct release at 30deg of flexsion, continue to full extension |
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how to treat posterior innominate?
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doc on dysfunc side
flex hip to > 90 deg; ADduct across midline compress, abduct; extend |
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how to treat superior shear?
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ext rotate ankle/let; compress into SIJ; internall rotate with traction
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how to treat pubic rami disfunc?
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flex knees; feet touching
compress to pubic rami, ABduct release should be about 60deg. keep at that angle, extend legs out |
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naming sacral dysfunction in still technique
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1. seated flexion test
--name to + side 2. motion test, ID free axis --name to freer axis e.g. diagonal R SI dysfunction = +R seated flex test free motion on R axis R on R or L on R |
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diagonal vs. unilateral sacral dysfunction naming
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diagonal if ILA posterior on OPPOSITE side of + seated flexion test
Unilateral if ILA is posterior on SAME side as + seated flexion test |
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treatment of sacral dysfunction, still technique
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legs/knees flexed to 90 degrees
cephalad hands on pts knees, bend legs to superior pole of restricted axis compress thru knees, direct at sacrum lower feet/legs to R across and away from midline at 30-45 deg off midline = extension |
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what are the key hypertonic structures?
(x7) |
hip capsule (ant/post)
quadratus lumborum LE flexors (iliosoas, rectus femoris, hammies, gastrocnemeus) tensor fascia lata hip adductors piriformis lumbar erector spinae |
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AP view shows:
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unlevel sacral base
functional short leg |
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lateral view shows:
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dejenerative joint disease
DDD facet syndrome |
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L-S juction spot view
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spondylolisthesis
L5-S1 grade III/IV |
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L/R oblique view shows
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spinal stenosis
spondylolysis (L5-S1) (loss of scottie dog neck) |
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how to tell L vs R oblique view?
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look for normal ilium--that is the 'side' view you're looking at
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what are 3 components of fitness
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1. aerobic conditioning
2. strengthening with resistance 3. flexibility |
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What is williams ex?
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flex the lordotic lumbars
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what is mckenzie ex?
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extend the flat lumbars
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what does core strengthening do?
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strengthens transversus abdominus
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what is Janda/Greenman system?
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reprogram motor control
1. proprioceptive retraining 2. stretch the hypertonic mm. 3. retrain the inhibited mm 4. aerobic conditioning |
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principles of motor control
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1. stabilizes the body in space using postural balance and control mvmt through space
2. utilizes neutral processing of information from the periphery at multiple levels 3. the more distal an injury, the more effect it has on PNS 4. spinal cord learns good and bad behavior |
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hierarchy of motor system
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1. spinal cord
2. brain stem 3. motor cortex 4. premotor cortex |
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what is extrafusal mm fiber?
where does its info come from? |
big ones that move
respond to info from alpha motor neuron |
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what is intrafusal mm. fiber?
where does its info come from? |
small
respond to info from gamma motor neuron |
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what is reciprocal inhibition?
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when one side flexes, inhibits ipsilateral extensor
also enhances contralat extensor and inhibits contralat flexor |
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what does reciprocal inhibition have to do with somatic dysfunction?
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mm learns 'bad' behavior which persists, causes maladaption unless it is corrected/retrained
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what are antagonist mm?
what happens with injury? |
postural/static mm
hypertonic when injured; inhibit dynamic mm |
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what are agonist mm?
what happens with injury? |
dynamic/core mm
inhibited with injury |
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how do you disinhibit dynamic mm?
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stretch the hypertonic mm (antagonists)
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what are the long cable mm of body?
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erector spinae
iliopsoas and QL quads/hamstrings TFL/ITB and hip adductors gastroc/soleus and tibialis ant |
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what are the platmorm mm of the body?
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thoraco-abdominal diaphragm
pelvic diaphragm meniscus of knee plantar fascia of foot |
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what are the posterior mm. slings?
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ext abd. oblique/ser ant criss cross
trap and lats to contralateral gluteus |
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what is 5th layer of back mm?
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QL
iliopsoas |
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how are lumbar erector spinae injured?
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uppers get tight
lowers get inhibited |
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how is QL injured?
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QL gets tight
somato-somatic reflex (T11-L2) facilitates psoas and QL |
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how is iliopsoas injured?
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gets tight
AL2 SCS tenderpoint |
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how are abd. mm injured?
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inhibition
loss/delay of function of transversus abdominus |
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how is piriformis injured?
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gets tight--sciatic n. entrapment
anterior sacral torsion |
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how is gluteus injured?
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gets inhibited
G-max = hip extensor G-med = hip abductor |
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which muscle crosses 3 joints?
what 3 joints? what is common problem |
Iliopsoas
LSJ, SI, Hip tight, commonly on R--inhibits gluteus |
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how does quadriceps get injured?
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rectus femoris gets tight
vastus lat/med get inhibited |
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what happens to hamstrings?
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gets tight
substitutes for weak gluteus |
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what happens to hip adductors (medial)
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gets tight, usually on R
short/long adductors; sartorius |
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what happens to lateral leg/TFL/ITB?
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gets tight
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what happens to anterior/lateral leg?
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gets inhibited
(tibialis anterior, fibularis...) decreased dorsiflexion, eversion-->inversion injury e.g. sprained ankle |
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what happens to posterior leg?
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gets tight/restricted
decreased dorsiflexion/eversion |
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what mm. fire for hip extension
what is common problem? |
hams
glut max low lumbar erector spinae high lumbar erector spinae problem: late/poor firing of glut max--substitute QL |
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what mm fire for hip abduction?
what is common problem? |
glut med
TFL QL lumbar erector spinae problem: late firing of glut med |
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what is the dirty half dozen
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1. short leg/pelvic tilt syndrome
2. non-neutral mechanisms of lumbar spine 3. pubic dysfunction 4. innominate shear dysfunction 5. restriction of ant. nutation of sacrum (backwards sacrum) 6. muscle imbalance btw trunk/LE |
