MSK Spine

How do trabecular bone patterns grow?

Up and down and criss crossing

What are the parts of the axial skeleton?

Head, spine, coccyx

What is the one place where appendicular skeleton attaches to axial skeleton?

Clavicle

C7 = what palpation landmark?

Cervicothoracic junction

T3 = what palpation landmark?

Scapular spine

T7 = what palpation landmark?

Inferior scapular angle

T12 = what palpation landmark?

12th rib

L4 = what palpation landmark?

Iliac crest

What are the typical spinal curvatures?

Cervical lordosis

Thoracic kyphosis

Lumbar lordosis

Sacrococcygeal kyphosis

What ligament lies on the anterior of vertebral bodies?

Anterior longitudinal ligament

What ligament lies on the posterior of vertebral bodies?

Posterior longitudinal ligament

How many facet joints does each vertebrae have?

2 superior, 2 inferior

What does PPIVM stand for?

Passive physiologic intervertebral motion

What is PPIVM?

Osteokinematic motion between 2 vertebrae of the spine. The more “obvious” spinal movement

What does PAIVM stand for?

Passive accessory intervertebral motion

What is PAIVM?

The accessory motion that comes from the vertebrae needed extra space to move

What do the vertebrae do during thoracolumbar flexion?

SPs move apart, bodies collapse in

Facet joints separate

What do the vertebrae do during thoracolumbar extension?

SPs move toward each other, bodies separate

What direction do transverse processes move during thoracolumbar lateral flexion?

Together in same direction of the flexion, separate in opposite side of bend

I.e. if pt is bending right, TPs come together on the right side

During thoracolumbar rotation, what direction does the SP move?

Twists in opposite direction of the movement

i.e. if rotating right, SP moves left

What is coupled intervertebral motion?

The previously held belief that to get osteokinematic motion of the spine, 2 motions must occur simultaneously

I.e. to flex forward, there is both flexion and minor rotation

When seated, a pt has posterior pelvic tilt. How does this affect the lumbar spine?

Increased lumbar flexion

When seated, a pt has anterior pelvic tilt. How does this affect the lumbar spine?

increased lumbar extension

What is pes cavus?

The sternum/chest caving in

What are the 3 somotypes and what do they mean?

Endomorph: large body

Mesomorph: strong/medium body

Ectomorph: skinny/lean body

What is an example of a structural abnormality that could be considered a normal variety?

Scoliosis - so many people have it

What muscles are tight in upper crossed syndrome?

Suboccipitals, upper trap, levator scap

Pec major and minor

What muscles are weak in upper crossed syndrome?

Deep neck flexors, middle/lower traps

What muscles are tight in lower crossed syndrome?

thoracolumbar extensors, iliopsoas and rectus femoris

What muscles are weak in lower crossed syndrome?

Deep abdominals and glute max/med

What is step length?

initial contact of 1 foot to initial contact of other foot

What is stride length?

initial contact of 1 foot to initial contact of the same foot

What is moderate velocity for steps?

111-120 steps/min

What is vigorous velocity for steps?

125-135 steps/min

What are the parts of stance phase of gait cycle?

intial contact

loading response

midstance

terminal swing

preswing

What are the parts of swing phase of gait cycle?

initial swing

midswing

terminal swing

What are the 3 GRFs opposing movement?

Vertical

Anteroposterior

Medial-lateral

What does it mean that LBP is not a self-limiting problem?

It does not often go away on it’s own

What is the next step after determining the pt has some red flags?

Screen for non-NMS pathological conditions

What are the 2 most common locations of lumbar disc lesions?

L4-5, L5-S1

What direction do lumbar disc lesions typically occur?

Posterolateral

If the disc between L4 and L5 has a lesion, what nerve root would be affected?

L5 - the nerve root below the lesion

A lumbar disc lesion can have referred symptoms to what other region?

The leg

What is the difference between radiculopathy vs radiculitis?

Radiculitis is intermittent pressure on the nerve root, radiculopathy is constant

What is foraminal stenosis?

Any condition that laterally narrows the foramen of vertebrae, typically causing nerve root compression

What patient positioning typically eases radiculopathy?

Sidelying with painful side up, or supine with knees flexed

What is the typical acute intervention for radiculopathy?

Pain management

Bedrest 24-48 hours

Trial manual traction

Monitor neuro signs

What is the typical acute intervention for radiculopathy?

Add ROM

gentle mobility in NWB

What is the typical chronic intervention for radiculopathy?

Continue AROM

Address regional impairments

Restore LE mobility, stability, motor control

At what level does the spinal cord end?

L1

What is degenerative disc disease (DDD)?

With age/over time, IV discs start to push out into vertebral canal

What is degenerative joint disease (DJD)?

With age/over time, increased joint friction or bone spurs grow in lumbar spine

DJD is the same as?

OA - osteoarthritis

What is lumbar (central) spinal stenosis (LSS)?

Bilateral posterior compression of the cauda equina

What is the difference between vascular claudication and neurogenic claudication?

Vascular: cramping pain in muscles, typically LE

Neurogenic: pain/NT in muscle from nerve compression

What are common s&s of spinal stenosis w/ neurologic claudication?

Chronic LBP

Weakness, burning, N/T

Saddle anesthesia

Bowel/bladder dysfunction

What is an aggravating factor of spinal stenosis w/ neurologic claudication?

Prolonged or repeated extension: walking downhill

How do pts with neurologic claudication compensate for pain?

Flexing forward, like pushing a grocery cart

Where is pain usually felt with vascular claudication?

butt, thighs, calves

When walking at 15% incline, a patient with neurogenic claudication will tolerate it _____ than a patient with vascular claudication?

Better

What factors are used in the lumbar spinal stenosis dx support tool?

Bilateral leg pain

Leg pain worse than back pain

Pain relief upon sitting

Age > 48 yo

How did PT intervention compare to surgery for lumbar spinal stenosis?

Almost the exact same outcome and prognosis over time - PT just as effective

What is the difference between cauda equina syndrome and lumbar/central stenosis?

CES is a traumatic MOI, usually from acute injury. LSS is from age and degeneration

What are s&s of CES (cauda equina syndrome)?

Saddle anesthesia

Bilateral paresthesia of LE

Urinary/fecal incontinence

Sudden onset

What is the definition of spondylosis?

General term for lumbar spine degeneration

Define spondylolysis

defect of pars interarticularis (area between superior and inferior facets); often stress fx

Define spondylolisthesis

separation of anterior and posterior elements of vertebrae - stress fx worsens into real fracture and slides away

In what population is spondylolisthesis most common?

10-15yos, playing sports that cause extension - gymnastics, swim, football

Ankylosing spondylitis is a type of what autoimmune disease?

RA

What is the progression of ankylosing spondylitis?

SI joint up axial skeleton

What type of blood test is used to dx ankylosing spondylitis?

HLA-B27

How do the natural curves of the spine change with ankylosing spondylitis?

Loss of lumbar lordosis, increased thoracic kyphosis, into stooped over position

What are the clinical predictions rules for dxing ankylosing spondylitis?

Morning stiffness > 30 mins

Improvement in back pain w/ exercise but not rest

Nocturnal awakening in 2nd half of the night

Alternating buttock pain

What are the 3 anatomical structures involved in a soft tissue injury?

Ligament, tendon, muscle

What is an active trigger point?

hyperirritable nodule located within taut muscle

What is a latent trigger point?

painful nodule only with excessive stimulation/palpation

What is a secondary trigger point?

located in synergistic and antagonist muscle

What are the goals of the acute healing phase?

Tissue healing, protection, mobility

What are the goals of the subacute healing phase?

AROM, Performance initiation, stabilization, motor control

What are the goals of chronic healing phase?

Performance improvement, advanced skill, agility, coordination

What is nociplastic pain?

Chronic pain/central sensitization

Define impairment

A problem at the tissue/organ level; any loss of normal physical or mental abilities

Define disability

Difficulty carrying out tasks or activities of daily life - pt can’t take care of themselves

What is the treatment for a dx of LBP with mobility deficits?

Mobility training

What is the treatment for a dx of LBP with movement coordination impairments?

Motor control training - strength and stability

What kind of patient will benefit from direction specific exercises for LBP?

Their pain goes away with certain movements - flexion, extension, etc

DSE is good for what kind of symptom relief?

Distal symptoms - will help pain centralize and move away from periphery

Why do you not want “mechanical LBP” to be the main dx?

Because it’s not specific - doesn’t tell you the treatment needed

What is the first type of test to be done after differential dx?

Screening tests

What are the 4 factors to rule out cancer?

Under 50

No previous cancer hx

No unexplained WL

Has not failed 1 month of conservative therapy

What are sx of cauda equina syndrome to screen for?

Hx of back pain

Rapid sx onset over 24 hrs

Saddle anesthesia

Bowel/bladder dysfunction

What are the 2 tests for spinal fracture?

Closed fist percussion test, supine sign test

What additional tests might need to be screened for during emergent/non-MSK triage?

Cognition

Mental status

UMN

Cranial nerve

Vitals

What does the optimal breathing pattern look like?

Belly breathing - inhale = belly poke out

What would cause a right lateral shift posture?

A left side herniated disc

What percent scoliosis curvature is considered a normal variant?

Less than 10%

If a patient has a thoracic upright posture when sitting, what position is the lumbar spine in?

Excessive lumbar lordosis - lumbar extension

What are the competing regions to rule out for lumbar spine (LBP)?

Thoracic, SIJ, Hip

What is the screening/sensitive test for thoracic spine competing region?

Thoracic ROM and overpressure - seated position

What is the screening/sensitive test for SIJ competing region?

Thigh thrust - 30 sec hold or stop when they feel pain