Spinal Disorders Quiz

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Questions and Answers

What symptom is commonly associated with spinal stenosis?

Immediate relief upon standing

Constant severe pain in the back

Intermittent pain in one or both legs (correct)

Increased mobility without discomfort

What characterizes lumbar instability?

Abnormal movement in quality or quantity (correct)

Normal motion under all circumstances

Easily corrected with rest

Consistent and predictable movement patterns

Which of the following conditions is indicated by transient neurologic signs?

Spondylosis without defect

Spondylolisthesis (correct)

Lumbar instability without symptoms

Normal vertebral alignment

What is a defining characteristic of spondylolysis?

Defect in the pars interarticularis Signup and view all the answers

Which of the following is considered a 'red flag' for low back issues?

Age more than 50 years with a history of cancer Signup and view all the answers

Which structure primarily carries 20% to 25% of the axial load in the lumbar spine?

Facet joint Signup and view all the answers

What is the primary role of the intervertebral disc in the lumbar spine?

Act as a shock absorber Signup and view all the answers

Which ligament primarily limits flexion of the lumbar spine?

Interspinous ligament Signup and view all the answers

Which muscles are classified as global muscles in the lumbar stabilizing system?

Rectus abdominis and Erector spinae Signup and view all the answers

Which component of the spinal stabilizing system is responsible for receiving sensory feedback?

Neural control subsystem Signup and view all the answers

What distinguishes the active subsystem from the passive subsystem in spinal stability?

The active subsystem generates forces for stability Signup and view all the answers

Which of the following best describes the annulus fibrosus?

Outer ring of the intervertebral disc Signup and view all the answers

Which ligament stabilizes the connection between L5 and S1?

Iliolumbar ligament Signup and view all the answers

What is neurogenic claudication primarily characterized by?

Pain, paresthesias, and cramping of the lower extremities Signup and view all the answers

In which posture is the spinal canal further narrowed?

Lordotic posture Signup and view all the answers

What is the main focus of the two-stage treadmill test?

To assess endurance in inclined walking Signup and view all the answers

What is indicated by a positive SLR (Straight Leg Raise) test?

Lower leg pain at specific angles Signup and view all the answers

Which symptom is noted in lumbar radiculopathy that does not centralize?

Peripheralization of leg pain with lumbar backward bending Signup and view all the answers

What is the resting position of the lumbar spine?

Midway between flexion and extension Signup and view all the answers

During forward bending, how does the nucleus pulposus behave?

Migrates posteriorly Signup and view all the answers

Which statement accurately describes the coupled movement in the lumbar spine during side bending?

It is contralateral in neutral and ipsilateral in flexed or extended positions. Signup and view all the answers

What happens to the intervertebral foramen during right side bending?

The left intervertebral foramen opens and the right closes. Signup and view all the answers

In which position does the lumbar spine experience full extension?

Close-packed position Signup and view all the answers

What characterizes low back pain syndrome?

Pain in the lumbosacral area with potential referral to the thigh or knee Signup and view all the answers

During backward bending, what occurs to the inferior facet of the superior vertebra?

It glides down and backward. Signup and view all the answers

What is the effect of side bending on the spinal canal?

It lengthens and opens. Signup and view all the answers

Which exercise category is associated with lumbar hypomobility?

Manipulation Signup and view all the answers

What condition is an exception to the treatment-based classification system that correlates well with imaging findings?

Lumbar spinal stenosis Signup and view all the answers

Which of the following factors is NOT part of the clinical prediction rules for lumbar hypomobility?

High fear avoidance beliefs Signup and view all the answers

What benefits may patients experience after achieving symptomatic improvement from lumbar manipulation?

Improved general conditioning and strengthening Signup and view all the answers

What indication suggests a directional preference toward lumbar extension?

Symptoms centralize with backward bending Signup and view all the answers

Which treatment approach showed better outcomes compared to guideline-based treatment over 4 weeks?

Classification-based physical therapy Signup and view all the answers

What might patients with leg pain that peripheralizes require?

Stabilization exercise and spinal traction Signup and view all the answers

What is a key characteristic of lumbar radiculopathy that does not centralize?

Leg pain that persists despite treatment Signup and view all the answers

Which of the following symptoms is NOT typically associated with cauda equina syndrome?

Chronic fatigue Signup and view all the answers

What is one factor that increases the risk of spinal fractures?

Prolonged use of steroids Signup and view all the answers

What is the first step recommended for the diagnosis of acute low back pain?

Identifying red flags through history taking Signup and view all the answers

Which treatment approach is recommended for chronic low back pain?

Exercise therapy Signup and view all the answers

What is a common misconception about the anatomic structures causing low back pain?

Most cases have a clear single anatomic cause Signup and view all the answers

What should be done if no red flags are present in a patient with acute low back pain?

Consider conservative management and activity encouragement Signup and view all the answers

Which medication should be considered first in the treatment of acute low back pain?

Paracetamol (acetaminophen) Signup and view all the answers

What is the role of psychosocial factors in the treatment of acute low back pain?

They should be assessed and integrated into management Signup and view all the answers

Study Notes

Physical Therapy for Lumbar Spine - Part 1

The lumbar spine comprises 5 vertebrae (L1-L5), the sacrum, and the coccyx.
Facet joints make up 20-25% of the axial load, with 70% of this load during disc degeneration.
Superior facets face medially and backward, while inferior facets face laterally and forward.
Intervertebral discs (20-25% of the vertebral column) act as shock absorbers between vertebrae.
The annulus fibrosus and nucleus pulposus are key components of the disc.
Ligaments (anterior longitudinal, posterior longitudinal, ligamentum flavum, supraspinous, interspinous, intertransverse, and iliolumbar) stabilize L5/S1, limiting extension, flexion, and other movements.
Muscles (e.g., rectus abdominis, external and internal obliques, quadratus lumborum, psoas major, multifidus, erector spinae, and longissimus) support the spine.
The spine's stabilizing systems include passive (ligaments, joints, bone) and active (muscles/tendons) components. A neural control subsystem receives sensory feedback.
5 vertebrae: Each has a body anteriorly and an arch posteriorly.
Posterior arches create the spinal canal and intervertebral foramina.
Facet joints and intervertebral discs allow articulation between vertebrae.

Objectives

Memorize the related clinical anatomy.
Memorize the related clinical biomechanics.
Define low back pain syndrome.
Describe the pathology-based classification of low back pain (LBP) and common pathological conditions.
Identify red flags of the lumbar spine.
Recognize evidence-based treatment for acute LBP.
Recognize and understand impairment-based classification of LBP.

Clinical Anatomy

Each vertebra has a body anteriorly and an arch posteriorly.
Posterior arches form spinal canal and intervertebral foramina.
Intervertebral articulation occurs via facet joints and intervertebral discs.

Facet Joints

Synovial joints bear 20-25% of the axial load, increasing to 70% with disc degeneration.
Superior facets face medially and backward (concave).
Inferior facets face laterally and forward (convex).

Intervertebral Disc

Account for 20-25% of the vertebral column's length.
Act as shock absorbers, allowing movement between vertebrae.
Composed of annulus fibrosus and nucleus pulposus.

Ligaments

Limit spinal extension, flexion, and various movements.
Include anterior longitudinal, posterior longitudinal, ligamentum flavum, supraspinous, interspinous, intertransverse, and iliolumbar ligaments.

Muscles

Support the spine.
Include rectus abdominis, external and internal obliques, quadratus lumborum, psoas major, multifidus, erector spinae, and longissimus.

Stabilizing Systems of the Spine

Components of the active and passive system working together with the neural control subsystem.

Clinical Biomechanics

Resting position: Midpoint between flexion and extension.
Close-packed position: Full extension.
Capsular pattern: Limited side flexion and rotation, with extension.
Coupling mechanism: Side bending couples with rotation (contralateral in neutral; ipsilateral in flexed/extended posture) based on Fryette.

Forward Bending

Inferior facet of the superior vertebra glides forward and upward on the superior facet of the inferior vertebra.
Nucleus pulposus migrates posteriorly, annulus fibrosis bulges anteriorly.
Spinal canal and intervertebral foramen lengthen and open.

Backward Bending

Inferior facet of the superior vertebra glides downward and backward on the superior facet of the inferior vertebra.
Nucleus pulposus migrates anteriorly, annulus fibrosis bulges posteriorly.
Spinal canal and intervertebral foramina close..

Side Bending (Right)

Inferior facet of the superior vertebra slides up on left and down on right.
Right intervertebral foramen closes, left one opens.
Movement is contralaterally coupled with rotation in the neutral position, and ipsilaterally in flexed/extended posture.

Rotation (Right)

Superior facets of superior vertebra open on right, close on left.
Right intervertebral foramen opens, left one closes.
Coupled with contralateral side bending in neutral posture, and ipsilateral side bending outside the neutral position.

Effect of Posture on Discal Pressure

Numerical data shows higher loads on the discs with particular postures.

Low Back Pain Syndrome

Characterized by one or more of the following:
- Pain in lumbosacral spine, buttocks, or thigh (to knee) thought to have a spinal origin.
- Pain, paresthesia, or sensation changes in leg/foot area thought to have a spinal origin (radicular symptoms).
- Reflex alterations or loss of motor function in lower extremities of spinal origin (radicular signs).

Pathology Based Classification

Three basic questions during the initial clinic visit:
- Systemic or visceral disease underlying the pain?
- Evidence of neurologic compromise/surgical emergency?
- Findings affecting the choice of conservative therapies
Considerations for determining a pathology-based diagnosis.

Examination

History
Palpation
Mobility tests (active, passive, accessory intervertebral mobility)
Neurological tests
Stability tests
Functional outcomes (e.g., ODI, FABQ)

Longer duration of symptoms
Symptoms in buttock or leg
Absence of lumbar hypomobility(with PAIVM testing)
Less hip total rotation range of motion
Less discrepancy in left-to-right hip medial rotation range of motion.

Evidence (Guidelines)-Based Treatment for Acute LBP

11 countries' guidelines emphasize a diagnostic triage of non-specific LBP, radicular syndrome, or specific pathological conditions.
History taking and physical examination prioritize identifying red flags and screening the neurological system.
Radiographic examinations aren't initially indicated in the absence of red flags.
Psychosocial factors are considered.

Treatment for Acute Low Back Pain

Reassure patient of a favorable prognosis; advise to stay active.
Prescribe medication (e.g., paracetamol, NSAIDs, and muscle relaxants as necessary).
Discourage bed rest
Consider spinal manipulation for pain relief.

Treatment-Based Classification of LBP

Modifies the traditional anatomical model based on clinical research results.
Improves reliance on clinical prediction rules, randomized controlled trials, and reliability studies.
Exercises are based on McKenzie's approach for "derangements."
Avoids common pitfalls of identifying the specific anatomic cause of symptoms.
Lumbar spinal stenosis is an exception, showing strong correlation between the findings and outcomes

Four Categories (Treatments Based)

Lumbar Hypomobility (Manipulation)
Lumbar Spine Instability (Stabilization)
Lumbar and Leg Pain That Centralizes (Specific Exercise)
Lumbar Radiculopathy That Does Not Centralize (Traction)

Lumbar Hypomobility (Manipulation)

Clinical prediction rules (4/5).
- Hypomobility with passive accessory intervertebral joint movement testing
- Low back and leg pain not exceeding the knee
- Low Fear Avoidance Beliefs (FABQ work subscale <19)
- Recent onset (<16 days) of back pain
- Adequate hip rotation (>35° IR)

Lumbar Spine Instability (Stabilization)

Instability occurs when the neutral zone increases relative to the total ROM. Stabilizing systems can't compensate.
Imbalance between global and local muscles.
Global muscles are often strong and overactive in a hold-type activity
Local muscles are often weak, atrophied, and delayed in response

Clinical Findings (Instability)

Aberrant motions (e.g., acceleration/deceleration).
General lumbar tenderness, referred pain in buttocks/thigh.
Paraspinal muscle guarding
Pain with sustained postures
Passive intervertebral mobility/joint play testing indicating hypermobility.
Decreased passive restraints to motion at the end range of motion.
Imaging, vertebral fractures, disc degeneration, vertebral displacements, and ligament damage

Significant Predictors (CPR) of Lumbar Stabilization Exercise Program

Predictors of success (3/4): Positive prone instability test, aberrant motion present, age <41, SLR >91
Predictors of failure: Negative prone instability test, hypomobility with PAIVM testing, absent aberrant motion, FABQ score ≤9

Prone Instability Test

(Procedure of the test itself is omitted)

Spinal Stabilization Exercise Program

Begins with cognitive motor learning phase focusing on proper muscle contraction and movement control.
Starts with local muscle activation.
Progressively integrates global muscle activation.
Leads to functional training

Lumbar and Leg Pain That Centralizes (Specific Exercise)

McKenzie emphasizes the direction that repeated movements should follow.
Movements should control centralization/peripheralization of the symptoms.
Avoid positional movements that cause symptoms to spread to the periphery.

Mechanical Diagnosis

Includes different syndromes: derangement, postural, dysfunction.
Derangement syndrome: disturbances in normal resting positions.
Postural syndrome: mechanical deformation of normal soft tissues due to prolonged end-range.
Dysfunction syndrome: structurally impaired tissue deformation causing pain at limited range

Repeated Movement Test

Patients repeat flexion, extension, and lateral bending 10 times each.
- Derangement: Symptom production, increase, or peripheralization.
- Articular dysfunction: End-range pain
- Posture syndrome: No pain with any test or repetition of a test

Centralization

Pain progressively diminishes from distal to proximal in response to therapeutic loading.

Three Syndromes

Extension, Flexion, Lateral Shift
- Extension: Centralization with backward bending, peripheralization with forward bending
- Flexion: Centralization with forward bending, peripheralization with backward bending (imaging evidence of lumbar spinal stenosis for older patients)
- Lateral shift: Frontal plane shoulder deviation from pelvis leading to centralization with side glide and backward bending

Patients with Directional Preference; Once Improvement Achieved:

Patients with extension preference may have symptomatic intervertebral discs with an intact annulus.
Patients with flexion preference may have underlying spinal stenosis.
Improvement allows for general conditioning, mobility and strengthening (stabilization exercises) to improve and prevent future episodes of back pain.
Leg pain that peripheralizes may indicate a poorer prognosis for conservative management, indicating potential candidacy for modifications to activity level, stabilization exercises, and spinal traction therapy.

Lumbar Spinal Stenosis (Flexion Syndrome)

Neurogenic claudication: Pain, numbness and cramping in lower extremities worsened by walking, alleviated by sitting.
Spinal canal further narrowed in lordosis, widened in flexion.
Spinal extension commonly limited. Sitting or spinal flexion often alleviates leg symptoms.

The Two-Stage Treadmill Test:

Patient walks on a level treadmill for up to 10 minutes.
10-minute rest period.
Walking on a 15-degree incline for up to 10 minutes.
Speed adjusted to a comfortable pace.
Patient reports any symptom increases beyond baseline level.
Ability to stop before 10 minutes if symptoms severe.
Positive test: Increased tolerance for walking on the incline causing increased flexion.

Lumbar Radiculopathy That Does Not Centralize (Traction)

No lumbar movements alleviate symptoms.
No directional preference in history/physical examination for lower leg pain relief with lumbar movement.
Peripheralization with lumbar backward bending.
Positive SLR (<45° hip flexion)
Positive crossed SLR test (<45° hip flexion)
Lower extremity neurological signs (weakness, numbness, reduced reflexes).
Poor tolerance to standing or sitting.
Symptoms relieved with traction

Effect of Spinal Traction

Widens intervertebral foramina.
Temporarily reduces disc herniation/protrusion size.
Creates negative pressure in disc ('sucking back').
Straightens spinal curve.
Mobilizes facet joints (nonspecific).
Stretches spinal muscles.

Contraindications and Precautions of Spinal Traction

Contraindicated movements, acute strains, hypermobility/instability, rheumatoid arthritis, respiratory problems, compromised structural integrity.
Additional contraindications: malignant disease, tumors, osteoporosis, infection, current pregnancy, uncontrolled hypertension.
Other precautions that may apply: aortic aneurysms, severe hemorrhoids, cardiovascular disease, abdominal/hiatal hernia (especially for lumbar mechanical traction).

Positional Distraction

Alternative to lumbar traction, performed at home.
Isolates specific spinal level for neuroforamen opening.
Uses tightly rolled pillow in a sheet under the patient.
Combines lumbar flexion, lateral flexion away from the targeted spinal segment, and rotation toward the affected side.
Typically lasts 10-20 min; three to six repetitions per day for patients at home.

Physical Therapy for Lumbar Spine - Part 2

Recognize factors that compound complex chronic low back pain.
Identify principles of treatment of chronic low back pain.
Determine indication of lumbar discectomy and recognize its steps.
Explain and design program of postoperative physical therapy for lumbar discectomy.

Chronic Low Back Pain

Treatment-based classification is most effective in patients 18-60 years with acute LBP.
Further assessment of movement impairments warranted for patients not fitting within one category.
- Extremity movement impact on spine motion and symptoms.
- Muscle length and strength assessment.
- Spinal impairments both above and below the primary pain area

Factors That Compound Complex Chronic Back Pain

Psychosocial factors (Elevated fear avoidance belief, depression, anxiety disorders)
Underlying pathologic conditions (Rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, fibromyalgia)
Movement impairments and muscle imbalances
Multiple joint impairments
Deconditioning

Movement Impairment (Chronic LBP)

Secondary/adaptive to underlying pathologic process.
A result of psychological/social factors like altered central processing, pain amplification, and movement disorder.
Maladaptive movement and motor patterns causing chronic abnormal tissue loading and ongoing pain/distress.

Muscle Imbalance (Chronic LBP)

Originate from imbalances in phasic and postural muscle function.
Postural: Triceps, rectus femoris, thigh adductors, hamstrings, iliopsoas, TFL, some trunk erectors, quadratus lumborum, upper portion of pectoralis major, upper traps, levator scapula, upper extremity flexors
Phasic muscle function: Hypotonia, inhibition, and weakness; less frequently activated in most movements,
Imbalance between these two groups often causes pain and degeneration across the joints.

Management of Chronic LBP

Focuses on conditioning and strengthening exercises.
Addresses muscle imbalance through mobility/stretching and strengthening exercises.
Employs myofascial techniques for myofascial tightness.
Incorporates manipulation with overall management of spinal disorder to address impairment.
Gradually progresses into lumbar stabilization and conditioning program, focusing on improving thoracic and hip mobility.
Re-evaluation of patient's symptoms, reduced pain, enhancement of mobility, and reduced muscle tone throughout treatment process

Lumbar Microdiscectomy

Surgical procedures for decompressing neural tissues by removing disc materials causing neurologic symptoms.
The goal is to relieve symptoms that aren't alleviated by conservative care.
Success rates are between 60-90% for radiculopathy-related cases.
Outcomes can be varied: 10-40% of patients experience pain, reduced movement, reduced function, and subsequent need for additional PT

Indications for Lumbar Microdiscectomy

Failure of conservative treatment
Unbearable or recurrent episodes of radicular pain
Significant neurologic deficit or worsening neurological deficit.
Cauda Equina Syndrome

Postoperative Physical Therapy Phases

Phase I (Protective Phase): 1-3 weeks, wound healing focus.
- Protect surgical site.
- Maintain nerve root mobility.
- Reduce pain/inflammation.
- Educate patient on minimizing fear & apprehension.
- Establish consistently good body mechanics.
Phase II (Functional Recovery Phase): 4-6 weeks, focus on increasing strength.
- Understand neutral spine
- Improve cardiovascular condition.
- Increase trunk strength to 80%.
- Increase soft tissue mobility/LE flexibility and strength.
- Maintain nerve root mobility.
Phase III (Resistive Training Phase): 7-11 weeks, focus on function.
- Ensure patient is independent in self-care & ADLs.
- Increase tolerance to activities.
- Progress return to previous level of function.

Suggested Home Maintenance - Weekly Goals

Week 1: Protect incision site, gradual increase in walking/mobility, avoid prolonged flexion positions, gentle nerve root gliding, and ice as needed.
Weeks 2-3: Increased walking, progressive exercise program, maintain nerve root mobility, lumbar posture, avoid prolonged flexion.
Weeks 4-6: Understanding neutral spine, increase cardiovascular and strength, partial/full press-ups, prone exercises, stretching, and aerobic condition.
Weeks 7-11: Loaded exercise program, increase in activity, progressive strengthening.

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Description

Test your knowledge on spinal disorders with this quiz that covers symptoms associated with spinal stenosis, characteristics of lumbar instability, and more. Understand key indicators like transient neurologic signs and red flags for low back issues.