Term
| Explain the 3 aspects of pain according to Paris |
|
Definition
emotional - the patient comes in with high emotional aspect of pain due to anxiety about the situation;
not being able to function is scary, not knowing why you cannot is even worse
• physical - tissue damage, chemical irritants, nocioceptors firing
• rational - patient doesn’t know what is going on
• following our examination with explanation of the findings the circles equalize
• physical - tissue damage, chemical irritants, nocioceptors firing
• rational - patient doesn’t know what is going on
• following our examination with explanation of the findings the circles equalize |
|
|
Term
| Differentiate the ideas of McKenzie versus Paris and how backward bending relieves pain |
|
Definition
McKenzie
• backward bending reduces/centralizes the disc thus taking pressure of the nerve root and
reducing the patients symptoms
• Paris
• gate control theory - firing of large fiber proprioceptors blocks onward transmission of nociception
(pain) and that will reduce and therefore centralize pain
• elevates the water content of the disc - repetitive motion has been shown to increase the water
content and lessen the irritability of the disc to its peripheral and perhaps invading nociceptors
• mobilizes the facet joint - backward bending stretches the facets more than forward bending
• promotes circulation generally relieving irritability
• helps relieve the fear of movement thus promotes functional recovery
• neural tension is reduced due to slackening of the cauda equina when a lordosis is achieved and
maintained
• over time the disc protrusion loses its proteoglycans and thus its ability to attract water and so
begins to shrink |
|
|
Term
| thoracic positional faults FB |
|
Definition
normally the facets upslide bilaterally, spinous processes open up
• patient should have a history of forward bending injury
• patient limited in backward bending secondary to being stuck in forward bending
• T9 stuck in upslide on T10, T9/T10 space stays wide
• T8/T9 space is smaller |
|
|
Term
| thoracic positional faults BB |
|
Definition
normally facets downslide bilaterally, spinous processes approximate
• patient should have a history of backward bending injury
• patient limited in forward bending due to being stuck in backward bending
• T9 hung up in downslide on T10, spinous processes remain approximated, T9/T10 space
small
• T8/T9 space wider over the positional fault |
|
|
Term
| thoracic positional faults Rotation |
|
Definition
have to be able to differentiate if vertebrae are hung up in rotation versus anomaly of spinous
processes
• look at patient’s AROM, symptoms and palpate for mobility |
|
|
Term
| Explain how you treat common positional faults |
|
Definition
forward bending
• fingers on TPs of approximated vertebrae
• backward bending
• fingers on TPs of approximated vertebrae
• rotation
• with right rotation fault, SP off to left
• top finger
• lower finger |
|
|
Term
| four primary effects of manipulation |
|
Definition
1. psychological
• there is a significant placebo effect with hands on treatment
• cavitation has significant psychological effect
2. neurophysiological
• gate control
• primarily from types I and II mechanoreceptors
• works with all grades of manipulation
• centralization of pain
• primarily from types I and II mechanoreceptors
• works with all grades of manipulation
• muscle inhibition
• reflex look that relaxes the surrounding musculature, with sustained pressure the muscles
continue to relax
• movement and subsequent nutrition (physiological effect)
3. biomechanical
• stretch restrictions within the capsule
• restore fiber glide
• restore ability to elongate (crimp)
• stretch or snap adhesions between the capsule and bone ends
• joint capsule is lubricated and with injury amount of GAGs decreases
• capsule loses lubrication secondary to decrease in hydrophilic effect
• leads to inflammatory response and micro-adhesions between collagen fibers, fibers can no
longer glide on each other
• manipulation snaps these micro-adhesions
4. chemical
• probable release of endorphins |
|
|
Term
| four types of mechanoreceptors |
|
Definition
Type I
• postural
• located in capsule (high concentration in subcranial region)
• fired by oscillations, graded or progressive
• Type II
• dynamic - change in direction and velocity
• located in capsule
• fired by oscillations, graded or progressive
• Type III
• inhibitive
• located in capsular ligaments
• fired by stretch or sustained pressure, thrust
• have to stretch capsule to stimulate type III mechanoreceptors - at lease grade III manipulation
• Type IV
• nociceptive
• located in most tissues (not in forehead skin, cartilage, brain tissue or nerve tissue)
• fired by injury and inflammation
• want to make sure to ask the patient if it’s a good hurt or bad hurt |
|
|
Term
| Define grades I thru V manipulations |
|
Definition
grade I (non-thrust, neurophysiological)
• small amplitude, beginning range
• grade II (non-thrust, neurophysiological)
• large amplitude, beginning to middle range
• grade III (non-thrust, mechanical)
• large amplitude, middle to end range
• grade IV (non-thrust, mechanical)
• small amplitude, end range
• grade V (thrust, mechanical)
• high velocity, small amplitude |
|
|
Term
| Describe the stress/strain curve |
|
Definition
stress = amount of force
• strain = amount of deformation
• toe region - uncrimping/tautening of tissues, taking up slack
• elastic region - strain will not induce permanent deformation in tissues
• plastic region - strain will induce permanent deformation in tissues
• want to stretch into plastic range to see true lengthening
• necking - point where the tissue starts to weaken
• failure - tissue failure |
|
|
Term
| What is the ‘pop’ you hear with cavitation |
|
Definition
• gas is released, primarily nitrogens, from the synovial fluid and remains intracapsular
• gas distends the joint and stretches it
• distended capsule fires type III mechanoreceptors which relaxes the muscles and relieves tension
• benefits:
• continuing stretch on capsule
• firing of type III & GTOs of attaching musculature (multifidus)
• reflex inhibition of muscle tone in neighboring muscles
• negative effects:
• if already hypermobile, can become more hypermobile
• increased stress on disc
• dependency brought on by feeling of immediate relief |
|
|
Term
| Name 4 reasons why females are more likely to have SI problems than males |
|
Definition
1. smaller & smoother joint surfaces = more movement
2. axis of support anterior to joint and center of gravity
• male gravity line through the axis of rotation, females is behind axis of rotation (posteriorly
rotated)
• potential ligamentous strain, hypermobility, displacement
3. hormonal changes = lax ligaments
4. strains = childbirth, intercourse, functional activity, one legged standing |
|
|
Term
| What exam findings do you expect with SI hypermobility and how do you treat it |
|
Definition
• history:
• strain from childbirth, 1 legged standing, intercourse, golf
• structure:
• pelvis asymmetry
• findings:
• positive provocation tests (pain over sacral sulcus)
• treatment:
• SI belt
• stabilization |
|
|
Term
| What differentiates instability from hypermobility |
|
Definition
| with instability the patient cannot maintain neutral |
|
|
Term
| Name 4 abnormal muscle states as described by Paris |
|
Definition
1. Involuntary guarding
2. Chemical muscle holding
3. Voluntary muscle guarding
4. Adaptive shortening |
|
|
Term
|
Definition
cause:
• injury
• dysfunction
• signs and symptoms:
• hypertonicity
• protective muscle guarding
• elevated resting tone
• abnormal elastic response to touch
• treatment:
• treat the cause of the impairment
• ex: facet capsular entrapment |
|
|
Term
|
Definition
cause:
• sustained involuntary guarding
• muscles have been in heightened state of contraction for a few days with limited blood
flow, full of muscle waste product
• may possibly lead to a compartmental syndrome
• signs and symptoms:
• doughy to touch
• limited ROM
• treatment:
• heat and massage
• want to flush chemicals out of muscle |
|
|
Term
| voluntary muscle guarding |
|
Definition
• cause:
• pain or fear of pain
• often follows involuntary and chemical states
• signs and symptoms:
• slow and guarded motions - patient voluntarily trying to protect region
• trunk moves as a whole
• treatment:
• once sure nothing serious (fracture)
• ignore, give reassurance
• gentle oscillatory movements, repetitive motion |
|
|
Term
|
Definition
cause:
• chemical muscle holding
• slouching posture
• signs and symptoms:
• normal tone
• shortened length, loss of ROM
• altered posture
• treatment:
• myofascia stretching |
|
|
Term
| Name 3 characteristics that tell you a problem is mechanical/musculoskeletal in nature |
|
Definition
movement increases or decreases symptoms
2. mechanism of injury
3. consistency of symptoms - can you reproduce the pain |
|
|
Term
| Name 3 things that can cause a lateral shift and how you differentiate between the 3 |
|
Definition
1. facet capsular entrapment (shifted left = right capsular entrapment)
• sudden onset
• downslide limited (cervical - BB, ROT and SB same side; lumbar - BB, ROT away, SB towards)
• holds head in slight rotation or side bending away from entrapment
• no neurological signs
• local tenderness over facet
2. disc
• repetitive injury with slow onset
• neurological signs
• diffuse pain
• more limited in forward bending with disc than with facet capsular entrapment & mechanical
block
• sitting increases symptoms
• pain referred beyond knee
3. mechanical block
• no pain
• something non-neurological blocking movement |
|
|
Term
| How do corrective treatments differ with 3 causes of lateral shift |
|
Definition
1. capsular entrapment
• multifidus isometric
• lumbar roll
2. disc
• McKenzie
• traction
3. mechanical block
• gapping |
|
|
Term
| Tell me everything you know about the intervertebral disc |
|
Definition
23 IV discs
• 3 parts
1. nucleus pulposus
• type II collagen (resists compression)
• proteoglycan aggregates
• loses integrity with age, less likely to herniate
2. annular fibrosis
• 10-12 layers
• type I collagen (resists tension)
• only 1/2 fibers resist rotary movements due to fiber organization/orientation
• fibers are less organized & more gelatinous as you go deeper
3. intervertebral end plates
• 80% water
• receives nutrition thru reabsorption/imbibing fluid
• GAGs, proteoglycans inside disc that have electric negative charges
• fluid intake from extracellular fluid
• mostly avascular and aneural except outer annulus
• potential for healing
• herniated nucleus pulposus
• must have weakness that comes from stretched annulus
• creep deformation & elongation
• weakness has a damming effect
• nucleus migration, then annulus ruptures, protrusion then extrusion
• once extruded, the body considers it foreign and lysozomes attack and degrade it |
|
|
Term
|
Definition
| segmentally innervated skin |
|
|
Term
|
Definition
| segmentally innervated muscle |
|
|
Term
|
Definition
| pathology of a nerve root with dermatome, myotome and reflex patterns |
|
|
Term
| Compare and contrast disc injury & stenosis & give best 3 exam findings to differentiate |
|
Definition
• age
• young patient - think more disc
• older patient - think more stenosis
• onset
• disc - repetitive injury with MOI
• stenosis - gradual onset with no known MOI
• best exam findings will be history - age, onset, MOI
• both you will see dermatomes, myotomes, neural reflexes |
|
|
Term
| What is the criteria/characteristics of a muscle that acts as a stabilizer |
|
Definition
• depth of muscle/location
• deeper the muscle, better the stabilizing ability
• attachment site
• intersegmental attachments = more control of segments
• segments = functional unit of spine
• tonic - more holding capacity |
|
|
Term
| Tell me everything you know about the transverse abdominus |
|
Definition
• attaches to TPs in lumbar spine and the thoracolumbar fascia
• palpate medial to ASIS
• biomechanical function
• works synergistically with multifidus to function as a lumbar stabilizer
• corset effect
• with weakness you see decreased stability of the lumbar spine
• instructions to patient on how to contract
• pull belly button inwards |
|
|
Term
| Tell me everything you know about the multifidus |
|
Definition
muscle in the body that runs from cervical spine to the sacrum
• attaches segmentally in lumbar spine spanning 2-3 segments
• attaches to thoracolumbar fascia
• 20-40% overlaps the joint capsule
• multifidus isometric to relieve capsular entrapment
• works synergistically with transverse abdominus to function as a lumbar stabilizer
• corset effect
• atrophies with back pain
• don’t know why exactly
• doesn’t spontaneously recover when pain resolves
• ultrasound girth measurements show this
• why exercises are important |
|
|
Term
| What muscles attach to the thoracolumbar fascia |
|
Definition
transverse abdominus
• multifidus
• internal oblique
• quadratus lumborum |
|
|
Term
| What 7 muscles attach to the nuchal line |
|
Definition
1. SCOM
2. trapezius
3. splenius capitis
4. semispinalis capitis
5. rectus capitis posterior minor
6. rectus capitis posterior major
7. superior oblique |
|
|
Term
| Explain the 3 aspects of pain according to Paris |
|
Definition
emotional - the patient comes in with high emotional aspect of pain due to anxiety about the situation;
not being able to function is scary, not knowing why you cannot is even worse
• physical - tissue damage, chemical irritants, nocioceptors firing
• rational - patient doesn’t know what is going on
• following our examination with explanation of the findings the circles equalize
• physical - tissue damage, chemical irritants, nocioceptors firing
• rational - patient doesn’t know what is going on
• following our examination with explanation of the findings the circles equalize |
|
|
Term
| What is thoracic outlet syndrome |
|
Definition
• TOS = neurovascular compromise to the upper extremity
• signs and symptoms
• weakness
• numbess
• cyanosis
• Reynauds
• venous engorgement
• increase symptoms with overhead activity or exertional activity
• causes
• elevated 1st rib, presence of cervical rib, hypertrophies anterior scalene, wide insertion slip and
tight pec minor
• treatment - stretch tight muscles, manipulation, posture, breathing |
|
|
Term
Child comes into your direct access clinic with an extension/side bending injury where he heard
an audible pop with subsequent back pain - what are you thinking and what do you do? |
|
Definition
spondylolisis/spondylolisthesis
• brace patient
• call primary care physician and let them know you suspect patient has spondylo & you want to refer
him to the MD to see their medical opinion and if they think patient requires imaging |
|
|
Term
| Differentiate between musculoskeletal headache and medical headache |
|
Definition
• can relieve or increase symptoms with movement
• starts in upper thoracic spine or cervicothoracic junction and refers up to head
• versus HA that manifests itself in head and cannot be reduced with movement (medical) |
|
|
Term
| Tell me everything you know about ligamentum flavum |
|
Definition
runs lamina to lamina
• elastic properties
• buckles/infolds with BB
• tautens with FB
• helps prevent capsular entrapment
• turns into altanto-occipital membrane at C1/C2 |
|
|
Term
| What is important regarding Jull’s work with deep neck flexors? |
|
Definition
patients with neck pain tend to have weak neck flexors
• CCFD
• restoring strength can help reduce pain |
|
|
Term
| What is important regarding Hides, Richardson and Jull’s work and lumbar stabilization? |
|
Definition
multifidus atrophies with one episode of back pain
• doesn’t spontaneously recover following resolution of pain
• importance of strengthening following injury |
|
|
Term
| Define manipulation according to the guide and Paris |
|
Definition
• guide - skilled passive movement to a joint or soft tissues at varying speeds and amplitudes,
including a high velocity short amplitude thrust
• Paris - skilled passive movement to a joint with therapeutic intent |
|
|
Term
| Define pain and differentiate pain from suffering |
|
Definition
Pain = unpleasant physical or emotional experience
• Suffering = when you don’t know why you are in pain |
|
|
Term
| Differentiate between the patient intake forms regarding pain |
|
Definition
body scale = location of pain
• verbal analog scale (1-10) = intensity of pain
• McGill pain questionnaire = nature of pain
• Functional index scale (Oswestry) = behavior of pain |
|
|
Term
| Tell me everything you know about the atlas |
|
Definition
C1 vertebrae
• Articulates with the occiput and C1/C2
• Has 5 joint surfaces: 2 superior articular facets, 2 inferior articular facets, 1 anterior odontoid
• Moves in the direction of the occiput
• Transverse ligament holds odontoid in place |
|
|
Term
| Tell me everything you know about the axis |
|
Definition
• C2 vertebrae
• Articulates with atlas/C1 and C3 vertebrae
• Has 9 joint surfaces: 2 superior articular facets, 2 inferior articular facets, 1 IV disc, anterior odontoid,
posterior odontoid, 2 joints of von lushka/uncinate processes
• Transverse ligament holds it in place
• most important ligament in the body - keeps is from compressing spinal cord
• only allow 3mm translation
• 50% rotation in cervical spine occurs at C1/C2 |
|
|
Term
| Describe the ligamentous anatomy of the spine |
|
Definition
igamentum nuchae
• occiput - C7/T1
• anchor system for the posterior neck muscles
• ligamentum flavum
• C2/3 - sacrum
• lamina to lamina
• posterolateral wall of canal
• supports the spinal cord
• has an elastic quality that helps to assist regaining of upright posture from FB
• anterior longitudinal ligament
• occiput - sacrum
• wider in lumbar segments than in cervical
• posterior longitudinal ligament
• becomes tectorial membrane at C2
• wider in cervical segments than in lumbar
• increases likelihood of disc herniation in lumbar spine
• supraspinous ligament
• replaced with erector spinae tendons at L3/4
• interspinous ligament
• proceeds upward and backward permitting a greater ROM while still resisting excessive range
(Paris article)
• alar & apical ligament
• off odontoid
• alar stabilizes, restricts rotation and SB to opp side
• apical attaches at apex of odontoid |
|
|
Term
| Differentiate between functional and non-functional movement |
|
Definition
• functional = those motions which we normally perform in the course of a day
• non-functional = those motions which are not normally performed |
|
|
Term
| What is the 0-6 PIVM grading system and how does a PT treat each grade |
|
Definition
0 ankylosis - fused ignore
1 considerable restriction - hypomobile non-thrust
2 slight restriction - hypomobile non-thrust or thrust
3 normal none
4 slight increase - hypermobile stabilize
5 considerable increase - hypermobile stabilize
6 unstable stabilize or potentially none with need for fusion |
|
|
Term
| What is the release phenomenon as described by Cyriax |
|
Definition
painful paresthesia that occurs when pressure is removed from a neurovascular complex
• importance with positional distraction/relieving pressure from nerve root |
|
|
Term
| What are the main shock absorbers of the spine |
|
Definition
curvature
• discs - 80% water, water disperses shock
• muscles - most absorption (glut max & med) |
|
|
Term
| Differentiate between rotation/torsion and nutation biomechanically |
|
Definition
rotation/torsion = a rotary movement of the ilium on the sacrum
• nutation = rotary movement of the sacrum on the ilium (flexion) |
|
|
Term
| Tell me everything you know about the erector spinae |
|
Definition
• second layer of muscles in back under the first layer (extremity muscles)
• iliocostalis, longissimus, & spinalis
• the long extensors or compressors of back
• load the spine but offer little in the way of protection
• unable to resist buckling
• fibers cross the midline below the L3 spinous process
• replace the supraspinous ligament that ends around L3
• fibers link up with middle 1/3 of glut max via lumbodorsal fascia |
|
|
Term
| Tell me everything you know about the quadratus lumborum |
|
Definition
• anatomy:
• deep muscle that attaches to 12th rib and ilium
• function:
• lateral stabilizer of trunk
• lateral flexion of vertebral column, with ipsilateral contraction
• extension of lumbar vertebral column, with bilateral contraction
• fixes the 12th rib during forced expiration
• levates ilium, with ipsilateral contraction
• often needs to be stretched and strengthened |
|
|
Term
| What are the 4 methods of stretching a muscle and describe how each works |
|
Definition
1. sustained stretch
• fatigues the stretch reflex
• must be in excess of 15 minutes
2. PNF
• a technique that employs contract/relax/stretch to stretch the collagen of the muscle when it is
momentarily relaxed
3. inhibitive distraction
• uses pressure over the origin or insertion of a muscle to inhibit the GTOs and thus cause the
muscle to relax prior to the therapeutic stretch
4. overpower the muscle
• this can rarely be achieved with the exception of the hemiparetic patient where muscle tone has
been lost or in child with acute torticollis |
|
|
Term
| What are the 7 characteristics of instability |
|
Definition
1. history of creep of tissue elongation
• inability to sit for long periods of time
• discomfort increases as day goes on, relieved with rest
2. presence of step or rotation on standing
3. presence of hypertonic muscle on standing
4. absence of step, rotation or hypertonic state with lying
5. shaking/juttering with movement
6. grade 5-6 PIVM
7. radiograph that shows excessive translation |
|
|
Term
| Explain McNab’s classification of disc dysfunction |
|
Definition
• type I (disc protrusion - bulging annulus)
• localized annular bulge
• type II (disc protrusion - bulging annulus)
• diffuse annular bulge
• type III (disc herniation - torn annulus)
• prolapsed nucleus
• type IV (disc herniation - torn annulus)
• extruded nucleus
• type V (disc herniation - torn annulus)
• sequestrated nucleus - free body |
|
|
Term
| What are the 3 innervations to the annulus |
|
Definition
recurrent branch off ventral rami
• gray communicans
• sinuvertebral |
|
|
Term
| Define stenosis and the common areas it can occur |
|
Definition
• stenosis = narrowing of an opening, lumen, etc
• commonly occurs in lumbar spine & cervical spine
• central spine stenosis
• lateral forminal stenosis |
|
|
Term
| Tell me everything you know about Baastrups disease |
|
Definition
kissing spinous processes
• artificial joint between spinous processes in lumbar spine that is arthritic
• cause
• inflammatory reaction is source of pain
• poor posture
• pot belly with excessive lordosis
• short stocky males
• treatment
• pelvic tilt
• stretch psoas and myofascia
• weight loss
• healthy back living - pt education
• surgery |
|
|
Term
| Explain the condition of kissing lamina and how a patient would present |
|
Definition
a condition of friction between the lamina at one or more cervical levels
• mostly in elderly women
• cause
• excessive M/C lordosis
• stiff U/T
• M/C hypermobility, instability
• loss of disc height
• collapse of lateral interbody joints
• signs & symptoms
• central neck pain
• treatment
• posture and stabilization
• avoid BB and circumduction
• manipulation U/T |
|
|
Term
| What is Maigne syndrom/thoraco-lumbar syndrome |
|
Definition
pain over the lateral thigh and occasional giving way of the leg
• often confused with hip impairment
• cause
• instability at the T/L junction involving the lateral cutaneous nerve to the thigh
• signs & symptoms
• pain over lateral thigh
• spontaneous giving way of leg
• tenderness over iliac crest laterally
• treatment
• stabilization of T/L junction
• multifidus exercises
• strengthen hips |
|
|
Term
| Tell me everything you know about scoliosis |
|
Definition
• PT role in screening, monitoring and preventing worsening of scoliosis
• named for direction of convexity and location in spine
• causes
• idiopathic
• biomechanical causes
• unlevel sacral base
• leg length discrepancy
• flat foot
• slipped femoral capitus
• abnormal femoral neck angle
• atlas displacement
• treatment
• postural correction
• bracing
• bracing and exercises have been shown to reduce curve up to 50% if caught during growth
spurt
• more than 40 degree curve following bracing, consider surgery with rod placement
• pressure pads
• sustained pressure deforms or reforms
• place pressure on lower half of convexity
• duration starts at 15 min - progress to 2 hours or more |
|
|
