PHTY301 m5-11

What are the 4 normal sagittal curves of the spine?

Cervical lordosis, thoracic kyphosis, lumbar lordosis, sacral/coccygeal kyphosis.

What movements are "pure" movements in the lumbar spine?

Flexion and extension (other movements are coupled, e.g. rotation with lateral flexion).

What is the major load-bearing structure of the IV disc and what bears most compressive load?

The intervertebral disc; the nucleus pulposus takes on most of the compressive load.

What happens to the disc when endplates are injured?

Interferes with nutrition leading to degradation of the disc matrix (compression/release normally drives nutrient exchange via osmotic pressure).

Differentiate radicular pain from radiculopathy.

Radicular pain = referred pain from nerve root sensitisation (compression/chemical irritation). Radiculopathy = nerve compressed enough to compromise axonal conduction (loss of sensation, muscle weakness, reflex loss).

What does bilateral S&S with bladder/bowel involvement suggest?

Spinal (central) stenosis - pressure on the spinal cord.

Name 3 epidemiological facts about LBP.

Prevalence increasing; more common in females; highest prevalence 40-50yo; childhood LBP predicts adult LBP.

List the 3 categories of contributing factors to LBP.

Physical factors, cognitive factors, social/emotional factors.

What structures can be palpated in the lumbar spine (directly or indirectly)?

Z joints, transverse processes, spinous processes, lamina (indirect), pars interarticularis (indirect), muscles.

What screening tools/questionnaires are used for LBP?

Dallas Pain Questionnaire, Roland Morris Disability Questionnaire, Quebec Back Pain Disability Scale, Oswestry LBP Disability Questionnaire, STarT Back Tool.

What are the time frames for acute, sub-acute, and persistent LBP?

Acute = 1-3 days to 6 weeks; sub-acute = 6-12 weeks; persistent = >3 months.

What % of LBP presentations are due to serious spinal pathology?

<1-2%.

What defines radiculopathy vs radicular pain in clinical terms?

Radiculopathy = altered reflexes, sensation, or muscle power (loss of axonal conduction). Radicular pain = irritation/pain from nerve root without necessarily a conduction deficit.

What causes central spinal stenosis and what is the classic symptom pattern?

Thickening of ligamentum flavum narrowing the spinal canal; tingling/numbness/ache/cramp into legs, aggravated by walking, eased quickly by stopping/flexion (neurogenic claudication).

How do you differentiate neurogenic from vascular claudication?

Have patient ride a bike until leg pain occurs, then lean forward - if spinal flexion eases the pain, it's neurogenic (spinal stenosis).

What test indicates a fracture when assessing LBP?

Resisted hip flexion reproducing symptoms suggests a fracture.

Where is spondylolysis most common and what structure is affected?

Most commonly L4/5 or L5/S1; defect/stress fracture in the pars interarticularis.

What imaging view is used to detect spondylolysis ("Scotty dog")?

Oblique view X-ray.

List the 4 acceptable disc pathology terms in order of severity.

Protrusion/bulge (no tear) -> Localised herniation (annulus tear, nucleus into annulus) -> Extrusion (nucleus into epidural space) -> Sequestration (nucleus fully escaped, can migrate).

What age group is most associated with disc pathology?

Late 20s-40 years old.

What population/features characterise lumbar spinal stenosis?

ages 60+, most common at L4/5, long history of mechanical LBP, bilateral non-dermatomal leg symptoms, stooped posture/loss of lordosis, rarely bowel/bladder involvement.

What is the difference between isthmic and degenerative spondylolisthesis?

Isthmic = lesion in the pars (most common L5/S1), usually younger patients. Degenerative = no pars defect, caused by Z joint/disc changes, F>M, older patients, long history of back ache.

What are common problems in MSK pain management?

Overuse of opioids, failure to provide education/advice, dependency on physio, overuse of imaging, overuse of surgery.

List the physiotherapy aims for LBP management.

Assurance/education/advice/self-management; resolve pain in articular/muscular/neural systems; restore posture and movement; restore muscle function; staged resumption of activities; assist RTW.

What manual therapy technique is indicated for suspected nerve root compromise?

A technique that opens the intervertebral canal - segmental rotation (painful side up), transverse glides towards the side of pain, segmental lateral flexion (painful side up).

What technique is suggested for suspected discal pathology?

Rotation technique with a central effect, patient positioned on the non-painful side.

What techniques are suggested for suspected Z joint involvement?

Techniques with unilateral effect - unilateral PA's, segmental LF, segmental rotation, transverse glides.

List 5 absolute contraindications to high velocity manipulation.

Suspected CNS involvement, lumbosacral anomalies, fixed spinal deformity, hypermobility, advanced diabetes, malignancy, inflammatory/infective arthritis, bone disease, haemophilia/anticoagulants, gross foraminal/canal encroachment, recent major trauma, segmental instability, post-surgical fusion, lack of consent, muscle spasm, acute severe nerve root pain.

What special care populations need consideration for manipulation?

Pregnancy and post-partum period, and cases of unsure presenting pathology.

Compare conservative treatment targets for nociceptive, neuropathic, and nociplastic LBP.

Nociceptive - target the nociceptive driver (1st line: physical therapy, activity modification). Neuropathic - personalised based on type of neuropathy (exercise therapy, neural mobilisation). Nociplastic - address perpetuating factors (psychology, pain education, exercise, multidisciplinary).

Are opioids recommended for nociplastic LBP?

No - strongly discouraged; short term relief only.

What are the three subsystems involved in spinal stability/motor control?

Passive musculoskeletal, active musculoskeletal, and neural/feedback systems.

Differentiate local vs global muscles.

Local muscles directly attach to lumbar vertebrae and act as stabilisers (no torque, e.g. multifidus, TrA). Global muscles produce torque on the spine/trunk without directly attaching to it (e.g. erector spinae, rectus abdominis, obliques).

What is the role of multifidus?

Controls the rocking action of one vertebra on the next, increases segmental stability, adjusts lumbar lordosis.

What changes occur in LBP patients' muscles compared to pain-free individuals?

Atrophy/fatty infiltrates in multifidus; decreased activation of TrA and MF; increased activation of internal/external obliques; augmented trunk stiffness; slower preparatory trunk movements.

What outcome measure tools are recommended for NSLBP?

Orebro and STarT Back.

What is the typical recovery timeframe given in advice/education for LBP?

Most LBP gets better within 12 weeks.

What type of exercise has the strongest evidence and which is most beneficial?

All exercise except flexibility training is beneficial; Pilates shown to be more beneficial.

How many targeted exercises/days per week are generally sufficient?

2-3 targeted exercises performed most days of the week.

What is the typical progression sequence for motor control treatment?

Correction of motor control faults (posture, movement, muscle activation) -> Static control of lumbopelvic orientation -> Dynamic control of lumbopelvic orientation and movement -> Functional re-education specific to patient goals.

Define pelvic girdle pain location.

Pain between the posterior iliac crest and gluteal fold, particularly near the SIJ; may refer diffusely into the thigh.

True or false: pregnancy hormones causing increased pelvic laxity is the cause of PGP.

False (myth) - hormonal changes in pregnancy do not correlate with pain.

Where is Fortin's area and what is its significance?

1cm inferomedial to the PSIS; an area of high mechanoreceptor density that can be a pain source, extending toward the medial ischium and pubic symphysis.

Define nutation and counternutation of the sacrum.

Nutation = anterior tilt of sacrum relative to the ilia (loads sacrotuberous, interosseous ligaments, SIJ capsule). Counternutation = posterior tilt of sacrum relative to ilia (loads long/short dorsal SI ligaments, sacrospinous ligament).

Which ligament is most important to counteract nutation forces?

The sacrotuberous ligament (assisted by interosseous ligament and SIJ capsule).

What positions/postures increase nutation force on the SIJ?

Standing, upright sitting, prone + bilateral hip flexion, hypervigilant postures with excessive lumbar lordosis.

What is the load transfer/active straight leg raise (ASLR) test assessing?

The SIJ's ability to withstand load and transfer load from legs to trunk; assesses diaphragm/respiration, abdominal pattern, pelvic floor, and lumbopelvic motion.

What does a positive ASLR test indicate?

Trunk or pelvic floor weakness/altered motor control due to altered loading patterns of pelvic joints/ligaments/muscles/fascia.

What is form closure vs force closure of the SIJ?

Form closure = inherent joint stability from bony shape (wedge sacrum, convex ilium, cartilage). Force closure = stability from muscle contraction placing tension on lumbopelvic fascia, increasing SIJ stiffness.

What treatment approach has the greater success rate for PGP - manual therapy or exercise alone?

Manual therapy has a greater success rate than exercise alone.

List key management strategies for PGP.

Load management (gradual progression), address motor control (pelvic floor, TrA, multifidus), strengthen glutes, check breathing pattern, avoid abdominal bracing, address psychosocial factors, temporary pelvic support if required.

What is the normal thoracic kyphotic curve range?

20-50 degrees.

Differentiate Gibbus and Dowager's hump.

Gibbus = local, sharp posterior angulation. Dowager's hump = usually due to osteoporotic wedge fractures.

What percentage of thoracic spine pain has a musculoskeletal origin?

Less than 35%.

What is "regional interdependence" and give an example.

Movement dysfunction in one region may underlie symptoms in another - e.g. shoulder pain secondary to restricted thoracic extension (needed for full shoulder elevation).

What visceral structures can refer pain to specific thoracic levels?

Heart (left-sided T4-T8), gallbladder (T9), appendix (right-sided T12-L1), lungs (any thoracic level, pleural origin = acute radiating pain).

List 5 thoracic red flags.

Severe constant pain with sleep disturbance, severe pain post-trauma, past history of tumour, prolonged corticosteroid use, systemically unwell/fever, severe pain after minor incident, unexplained weight loss, SOB/chest pain on exertion, bowel/bladder dysfunction, lower limb weakness/gait disturbance, P&N's in legs.

Describe the presentation of ankylosing spondylitis.

Gradual onset, begins in low back and progresses up the spine, persistent symptoms, significant morning stiffness that slowly subsides with movement.

How do you differentiate structural from non-structural (functional) scoliosis?

Structural scoliosis does NOT correct with forward bend; non-structural/functional scoliosis DOES correct with forward bend.

What are the two main sites of compression in thoracic outlet syndrome?

Scalene triangle (subclavian artery + lower trunk of brachial plexus) and between clavicle/1st rib, or posterior to pec minor (axillary artery/vein + cords of brachial plexus).

What special tests assess thoracic outlet syndrome?

Roo's test, Adson's test, Wright's test, Halstead.

What is T4 syndrome and its likely cause?

Upper extremity paraesthesia/pain plus/minus neck/thoracic S&S in a glove distribution, thought due to ANS dysfunction of the upper thoracic spine.

Why does thoracic disc protrusion typically produce cord rather than nerve root symptoms?

Because of the relatively narrow canal at this level - results in cord compression; ask about bilateral symptoms and bladder/bowel involvement.

Describe the typical presentation of an acute thoracic spine sprain.

Sudden onset, commonly unilateral, directional movement restriction matching injury force, pain with respiration if CV/CT joint involved, shallow breathing, significant local tenderness, strong inflammatory response.

What is the treatment progression for an acute "locked" thoracic joint?

Manipulation preferred if positive response to mobilisation; heat prior to manipulation; followed by rotation/extension mobility and breathing/rib expansion exercises.

List S&S of mid-thoracic instability.

Localised central mid-thoracic pain radiating dermatomally around the chest, possible sympathetic S&S (cold, sweating, burning, nausea), all movements aggravate especially contralateral rotation.

What is the treatment focus for mid-thoracic instability?

Mobilisation/manipulation of hypomobile segments above/below, stabilisation exercises (multifidus isometric/concentric), taping, scapular exercises in neutral, then thoracic extensor strengthening, proprioceptive exercises.

What is the difference between costochondritis and Tietze's syndrome?

Costochondritis = activity-related pain at multiple costochondral junctions (push ups, bench press). Tietze's syndrome = painful inflammation at a single CC joint, treated with NSAIDs/steroid injections.

List key S&S of osteoporosis.

Vertebral compression/anterior wedging/biconcave shape, height loss >4cm over 10 years, Dowager's hump, weaker back extensors, decreased lumbar/thoracic ROM, poor balance and mobility.

Name the absolute contraindication categories for spinal manipulation.

Bony compromise pathology, recent surgery, inflammatory conditions, traumatic injury, clinical issues (consent, skill, diagnosis), neurological issues (cord compression, cauda equina, nerve root compression, sudden vomiting/vertigo), vascular issues (VBI, aortic aneurysm, bleeding disorders, cardiac insufficiency, acute abdomen).

What is the major cause of significant blood loss in pelvic ring fractures, and how much blood can accumulate?

Venous injury (more common than arterial), large fracture surfaces, soft tissue damage; up to 4L can accumulate in the pelvic free space.

List nerves at risk of injury with pelvic fractures.

Lumbar nerve roots, sacral plexus, superior gluteal, obturator, sciatic, pudendal.

What is the emergency management sequence for haemodynamically unstable pelvic fractures?

Identify the source of bleeding (pelvic angiography, laparotomy) -> control bleeding (embolisation, pelvic stabilisation) -> massive transfusion protocol.

Describe Lateral Compression (LC) Type 1-3 in the Young-Burgess classification.

Type 1 = sacral buckle fracture + pubic rami fracture. Type 2 = unilateral rami fracture + ipsilateral posterior iliac fracture (rotationally unstable, vertically stable). Type 3 = internal rotation with contralateral external rotation, bilateral posterior instability.

Describe APC (AP Compression) Type 1-3.

Type 1 = diastasis <2cm or rami fracture, anterior SI ligament stretched, posterior SI ligaments intact. Type 2 = diastasis >2cm + vertical rami fracture, disrupted anterior SI/sacrotuberous/sacrospinous ligaments (rotationally unstable, vertically stable). Type 3 = complete disruption of symphysis + anterior/posterior SI ligaments (vertically and rotationally unstable).

What is a vertical shear injury and its mechanism?

Vertically oriented force to a hemipelvis (fall from height, MVA), disrupting the ipsilateral SI joint posteriorly and its ligaments - similar to APC type 3 in severity.

Describe the Tile classification system.

Type A = rotationally and vertically stable. Type B = rotationally unstable, vertically stable. Type C = rotationally and vertically unstable.

What does the inlet view demonstrate vs outlet view on pelvic X-ray?

Inlet view (45 degree angling) shows AP displacement, IR/ER of hemipelvis, SIJ widening, sacral impaction fractures. Outlet view (45 degree caudad) shows sacral fractures and vertical shift.

What is the role of CT in pelvic ring injury assessment?

Routine part of assessment; better visualisation of posterior ring injuries; used for pre-operative planning.

Match management to fracture type: LC1, LC2, LC3, APC1-3, VS.

LC1 = non-operative, partial weight bearing. LC2 = ORIF of ilium. LC3 = posterior fixation. APC1 = non-operative, partial weight bearing. APC2 = external fixation or anterior plate plus/minus posterior fixation. APC3 = external fixation or anterior plate AND posterior fixation. VS = posterior fixation.

What myotome/dermatome distinguishes the sciatic nerve in pelvic trauma assessment?

Extensor hallucis longus and ankle plantar flexion (myotomes); sensory loss below the knee except medial leg/foot (saphenous nerve/femoral territory).

What does the obturator nerve supply (sensory and motor)?

Medial thigh sensation; medial compartment of thigh muscles (obturator externus, adductor longus/brevis/magnus, gracilis).

What does the pudendal nerve supply?

Dermatomes - penis/clitoris, labia, posterior scrotum, perineum, anus. Myotomes - bulbospongiosus, ischiocavernosus, levator ani, external urethral/anal sphincters.

What are the indications for elective spinal surgery for a prolapsed disc?

No improvement with conservative therapy, increasing neurological deficit, bladder/bowel symptoms suggesting cauda equina, objective findings consistent with reported symptoms.

Differentiate discectomy and microdiscectomy.

Discectomy = often with partial laminectomy, lower rate of return of weakness/reflex loss. Microdiscectomy = disc excised through small incisions under endoscopic control.

What is a laminectomy and when is it indicated?

Removal of a piece of lamina to decrease pressure on the spinal cord/nerve root - indicated for spinal stenosis.

List indications for spinal fusion surgery.

Instability (degenerative disc disease, traumatic unstable fractures, fracture dislocations, spondylolisthesis), congenital/acquired deformity (scoliosis, kyphosis), other conditions (osteomyelitis, TB, neoplasms).

What is artificial disc replacement and its contraindication?

Preserves the motion segment as an alternative to fusion; contraindicated with significant facet joint degeneration.

What are common surgical complications of spinal surgery?

Neurologic injury, dural tear, haematoma formation, wrong site surgery/inadequate decompression, respiratory complications, circulation issues, infection, hardware failure.

How does mechanism of injury relate to spinal fracture stability?

Flexion (crush fracture) - loss of height increases instability risk. Vertical compression (burst fracture) - likely stable. Flexion+rotation (fracture/dislocation) - normally highly unstable. Hyperextension (vertebral arch fracture) - likely unstable.

Why are spinal cord injuries different in younger vs elderly patients?

Younger - usually high energy trauma. Elderly - lower energy trauma with pre-existing degenerative canal narrowing.

What imaging is best for ligamentous disruption vs bony fractures of the spine?

MRI for ligamentous disruption; CT excellent for fractures.

What is the management for unstable cervical spine injuries?

Skeletal traction (skull tongs), halo thoracic vest, or operative fixation.

List complications of spinal fracture.

Neurological injury, circulatory issues, skin/pressure injuries, respiratory complications, infection.

What signs differentiate dural tear, haematoma, DVT, and infection post spinal surgery?

Dural tear = postural headache. Haematoma = worsening neurological symptoms. DVT = painful, warm/tender calf. Infection = excess wound ooze/drainage.

What is the key discharge difference between decompression and fusion/scoliosis surgery?

Decompression surgery generally has a shorter length of stay than fusion or scoliosis correction surgery (which is more painful).

Describe the 3 stages of neural mobility exercises post-surgery.

Stage 1 - large through-range DF/PF, hip abduction/adduction, hip rotation in neutral, progressing to PF/DF with small SLR (leg on pillow). Stage 2 - through-range knee extension in some hip flexion; some tolerate gentle SLR. Stage 3 - combined techniques progressed with increasing hip flexion.

What are key considerations for post-scoliosis surgery patients?

Higher pain due to multi-level fusion; significant changes to posture/biomechanics/body image/balance/gait; extended operative time increases risk of circulation, pressure, respiratory, and visual complications; possible blood loss affecting Hb and mobility; back care education important.

What functional progression alternatives exist for patients with spinal precautions?

Hoist transfer, slide transfer, Sara Stedy, pivot transfer, rollator.