1
Q
What is patho-anatomic diagnosis?
A
The anatomical pathology
2
Q
What is an example of a patho-anatomic diagnosis?
A
- Herniated disc L4-5
- Polymyosis
3
Q
What is a prognostic/treatment based?
A
- Manipulation classification
- Specific exercise classification
- Elevated fall risk
4
Q
What are the different ways a diagnostic process can be done?
A
- Pattern recognition
- Hypothetic deductive reasoning
- Algorithms
- Exhaustive
- Logical reasoning
5
Q
What is hypothetic deductive reasoning?
A
When we have an hypothesis/belief that the problem might be some specific disorder, and then we go about ruling in or ruling out
6
Q
What is the algorithm diagnostic process?
A
It helps get us into the space a little better
7
Q
Which of the diagnostic process is inefficient and used by novices?
A
- Exhaustive
8
Q
____ is what makes us good diagnosticians
A
Logical reasoning is what makes us good diagnosticians
9
Q
What are the basic steps in the diagnostic process?
A
- Generate possibilites and their relative likelihood or probabilities
- Gather new info to clarify your initial diagnostic possibilities
- Revise pretest and posttest probabilities
10
Q
What is pre-test probability?
A
For any given patient, there is a baseline probability of a certain condition pretesting
11
Q
What is a post test probability?
A
Application of a clinical diagnostic test alters the baseline probabilty
12
Q
What does the medical model of disease say?
A
- Pain is a reflex response to a physical stimulus
13
Q
According to the medical model of disease, every symptom has an ____
A
According to the medical model of disease, every symptom has an underlying stimulus
14
Q
According to the medical model of disease, alleviating the symptoms requires ___ and ___ the underlying stimulus
A
According to the medical model of disease, alleviating the symptoms requires identifying and alleviating the underlying stimulus
15
Q
In the medical model of disease, we move from pain to ___ and from ___ to cure
A
In the medical model of disease, we move from pain to cause and from cause to cure
16
Q
What is the summary of the medical model of disease?
A
- Signs/symptoms analyzed
- Pathology is determined
- Treatment corrects pathology
- Signs/symptoms disappear
17
Q
There is ___ relationship between physical pathology & associated pain and disability
A
There is little relationship between physical pathology & associated pain and disability
18
Q
According to the biopsychosocial model, what are the things that shape the pain experience?
A
- Pain
- Attitudes & beliefs
- Psychological distress
- Illness behavior
- Social environment
19
Q
What are the 2 major factors that widely shape how a patient’s pain?
A
- Psychological factors
- Cultural factors
20
Q
What are the biopsychosocial model application in clinical practice?
A
- Psychologically informed practice
- Understand your patient
- Screening tools
- Clinical decision making aides
- CPR/CPGs
- Treatment based classification
21
Q
What are the diagnostic processes of choice?
A
- Pattern recognition
- Hypothetico-deductive
22
Q
____ is probabilistic in nature
A
Diagnosis is probabilistic in nature
23
Q
What is the 1st step in the 1st level triage?
A
Medical management
24
Q
What are the possible clinical findings in the medical management level of the 1st level triage?
A
- Red flags
- Medical comorbidities precluding rehabilitation
- Leg pain with progressive neurologic deficits
25
What is the 2nd step in the 1st level triage?
Self-care management
26
What are the possible clinical findings in the self-care management level of the 1st level triage?
- Low psychosocial risk status
- Predominantly axial low back pain
- Minor or controlled medical comorbities
27
What is the 3rd step in the 1st level triage?
Rehabilitation management
28
What are the possible clinical findings in the rehabilitation management level of the 1st level triage?
- Medium to high psychosocial risk status
- Low psychosocial risk status with predominantly leg pain
- Minor or controlled medical comorbidities
29
Individuals identified in the _____ step will be referred out to a different medical provider
Individuals identified in the *medical management* step will be referred out to a different medical provider
30
What are some of the signs of a serious spinal pathology?
- Signs of infection
- Temp > 100 F
- BP> 160/95 mmHg
- Resting pulse > 100/ min
- Resting respiration > 25/min
31
What are the 3 different strategies for management in the TMC model?
- Symptom modulation
- Movement control
- Functional optimization
32
How do individuals that fall in the symptom modulation strategy for management present?
- High disability
- High to moderate pain/irritability & severity
- Volatile symptom status
33
How do individuals that fall in the movement control strategy for management present?
- Moderate disability
- Moderate to low pain/irritability & severity
- Stable symptom status
34
How do individuals that fall in the functional optimization strategy for management present?
- Low disability
- Low to absent pain/irritability & severity
- Controlled symptom status
35
If a patient centralizes with 2 or more movements in the same direction or centralize with a movement in 1 direction and peripheralize with an opposite movement, what is their proposed intervention classification according to fritz?
Specific exercise classification
36
If a patient has a recent onset of symptoms and no symptoms distal to the knee, what is their proposed intervention classification according to fritz?
Manipulation classification
37
If a patient has at least 3 of the following,
- Average SLR ROM >91 deg
- Positive prone instability test
- Positive aberrant movements
- Age < 40
what is their proposed intervention classification according to fritz?
Stabilization classification
38
The treatment from the TBC is an ___ approach to care
The treatment from the TBC is an *initial* approach to care
39
Which of the 3 1st level triage involves direct physical therapy interventions?
Rehabilitation management
40
What were the 5 most predictive variables in determining the success of spinal manipulation intervention?
1. Current symptom duration < 16 days
2. Fear-Avoidance Beliefs Questionnaire < 19
3. Hypomobility of the lumbar spine with PA Pressure
4. IR of at least 1 hip > 35 deg
5. No symptoms below the knee
41
What are the factors favoring spinal manipulation to decrease LBP?
- More recent onset of symptoms
- Hypomobility with spring testing
- Low back pain only(no symptoms below the knee)
- Low FABQ scores (FABQw< 19)
42
What are the factors against spinal manipulation to decrease LBP?
- Symptoms below the knee
- Increasing episode frequency
- Peripheralization with motion testing
- No pain with spring (PA mobility) testing
43
What are some treatments that may accompany a spinal manipulation intervention?
- Manual therapy
- Soft tissue mobilization
- Oscillations
- Gentle manual resisted exercises
44
What are the major muscles that provide core stability and are targeted during motor control/stabilization exercises?
- Transversus abdominis
- Multifidus
- Diaphragm
- Pelvic floor
- Internal and external oblique
- Rectus abdominus
45
What are the treatments for people with a symptom modulation?
- Directional preference exercises
- Manipulation/mobilization
- Traction
- Active rest
46
What are the treatments for people with a movement control?
- Sensorimotor exercise
- Stabilization exercises
- Flexibility exercise
47
What are the treatments for people with a functional optimization?
- Strength and conditioning exercises
- Work - or sport- specific tasks
- Aerobic exercises
- General fitness exercises
48
What is the ultimate goal of exercise progressions?
To mimic each patient's functional needs or goals so that the patient develops the strength, endurance and motor control necessary to maximize recovery
49
What are the variables predicting success for a stabilization exercise intervention?
- (+) prone instability test
- (+) aberrant motions present
- Average straight leg raise >91 deg
- Age of below 40
50
What are the variables predicting failure for a stabilization exercise intervention?
* (-) Prone Instability Test
* Aberrant Movement Absent
* FABQPA < 9
* No Hypermobility with Lumbar Spring Testing
51
The common theme of lumbar instability is _____
The common theme of lumbar instability is *muscle inhibition*
52
What is the first thing in the McKenzie classification system?
History and physical examination
53
In the the McKenzie classification system, what follows the history and physical examination?
Exclude serious pathology
54
In the the McKenzie classification system, what follows the exclude serious pathology?
Provisional MDT classification
55
What are the 3 McKenzie syndromes?
- Derangement
- Dysfunction
- Postural
56
What is derangement in the Mckenzie syndrome?
Loading strategies centralize or make symptoms better
57
What is dysfuction in the Mckenzie syndrome?
Pain only product at limited end range
58
What is postural in the Mckenzie syndrome?
Pain only on static loading, no effect of repeated movements
59
The annulus is weakest in the ___ aspect
The annulus is weakest in the *posterolateral* aspect
60
____ pain activate nociceptors by damage causing high concentrations of chemicals
*chemical* pain activate nociceptors by damage causing high concentrations of chemicals
61
Chemical pain can be reduced by movement by ____, but does not remain reduced
Chemical pain can be reduced by movement by *mechanoreceptor modulation*, but does not remain reduced
62
Chemical pain can not be abolished by ___ or ____
Chemical pain can not be abolished by *repeated motion or sustained positioning*
63
How does mechanical pain activate nociceptors?
By force, stress, deformity and damage
64
Mechanical pain can be reduced and /or abolished by ___
Mechanical pain can be reduced and /or abolished by *repeated motion or sustained positioning in the correct direction*
65
Mechanical pain can become constant with ____ causing constant ___
Mechanical pain can become constant with *internal derangement* causing constant *mechanical deformation*
66
____ describes the phenomenom by which distal pain originating from the spine is progressively abolished in a distal to proximal direction
*Centralization* describes the phenomenom by which distal pain originating from the spine is progressively abolished in a distal to proximal direction
67
Centralization is in response to ___
Centralization is in response to *a specific repeated movement and/or sustained position and this change in location is maintained over time until all pain is abolished*
68
As the pain centralizes, there is often a significant increase in the ___
As the pain centralizes, there is often a significant increase in the *central pain*
69
If spinal pain only is present, this moves from a ____ to a ____ then it is abolished
If spinal pain only is present, this moves from a *widespread to a more central location* then it is abolished
70
What does centralizing mean?
During the application of loading strategies distal pain is being abolished
71
Centralizing is in the process of becoming ___, but this will only be confirmed once ___
Centralizing is in the process of becoming *centralized*, but this will only be confirmed once *the distal pain remains abolished*
72
What does centralized mean?
As a result of the application of the appropriate loading strategies the patient reports that all distal pain has abolished and now the patient only has back pain. The central back pain will then continue to decrease and abolish
73
____ is a positive prognostic indicator
*Centralization* is a positive prognostic indicator
74
____ describes the phenomenon by which
| proximal symptoms originating from the spine are progressively produced in a proximal to distal direction.
*Peripheralization* describes the phenomenon by which
| proximal symptoms originating from the spine are progressively produced in a proximal to distal direction.
75
Peripheralization happens in response to ___
Peripheralization happens in response to * a specific repeated movement and/or sustained position and this change in location of symptoms is maintained over time*
76
Peripheralization may also be associated with ___
Peripheralization may also be associated with *a worsening of neurological status*
77
What does peripheralizing mean?
During the application of
| loading strategies distal symptoms are being produced.
78
In peripheralizing, symptoms are in the process of becoming ___, but this will only be confirmed once the ____
In peripheralizing, symptoms are in the process of becoming *peripheralized*, but this will only be confirmed once the *distal symptoms remain*
79
____ means that as a result of the application of the inappropriate loading strategies the patient reports that the distal symptoms that have been
produced remain.
*Peripheralized* means that as a result of the application of the inappropriate loading strategies the patient reports that the distal symptoms that have been produced remain.
80
Peripheralization is generally is ____ indicator
Peripheralization is generally is *negative prognostic* indicator
81
What are the characteristics of postural syndrome?
- End range stress on normal tissue
- Positional pain. No loss of motion
- No pain during management
82
What are the characteristics of dysfunction syndrome?
- End range stress on shortened tissue
- Pain at end range or upon stretching on "contracted" tissues. Loss of motion
- No pain in midrange movements
83
What are the directions of movement found in a dysfunction syndrome?
- Flexion
- Extension
- Lateral movement
84
When the nerve root is adhered in a dysfunction syndrome, there may be some ___
When the nerve root is adhered in a dysfunction syndrome, there may be some *referred pain*
85
How might a dysfunction be addressed?
Through repeated movement progression
86
What is derangement syndrome?
A clinical presentation associated with a mechanical obstruction of an affected joint
87
When does a patient with derangement syndrome experience pain?
During movement and loss of motion
88
Patients with a derangement syndrome may have a ____
Patients with a derangement syndrome may have a *directional preference*
89
Directional preference describes the clinical phenomenon where ___
Directional preference describes the clinical phenomenon where *a specific direction of repeated movement and/or sustained position results in a clinically relevant improvement in either symptoms and/or mechanics though not always the centralization of the symptoms*
90
___ is an essential feature of the derangement syndrome
*Directional preference* is an essential feature of the derangement syndrome
91
____ encompasses a broader range of responses than centralization
*Directional preference* encompasses a broader range of responses than centralization
92
Centralization refers to the ____
Centralization refers to the *lasting change in the location of symptoms as a result of loading strategies*
93
Directional preference results in ___
Directional preference results in *a lasting improvement in symptoms and/or mechanics though not always a change in location of pain*
94
All centralizers have a ___
All centralizers have a *directional preference*
95
If a patient presents with a lateral shift, does that mean that they won't respond to a manual type intervention?
No it doesn't, the presence of a lateral shift should not deter the PT from doing a manual intervention. It should only be done if patient complains of pain peripheralization rather than centralization
96
In the MDT physical examination, what are the things to do when testing each direction of movement?
- Establish symptoms prior to start of new motion
- Effect on patient's symptoms
- Repeated movements (10x)
97
___ determines treatment progression
*Symptoms* determines treatment progression
98
What do you do if a patient notes that pain is getting worse, increasing and peripheralizing during treatment progressions?
STOP treatment
99
What do you do if a patient reports no changes in pain with treatment progressions?
Proceed with caution
100
What do you do if a patient reports a decrease in pain, and centralization with treatment progression?
CONTINUE with treatment
101
Repeated movement progression is initially ___ that may need ___
Repeated movement progression is initially *patient induced* that may need *therapist augmented*
102
What is the general flow of repeated movement progression in extension?
- Prone lying (static)
- Prone lying in extension (static)
- Extension in lying
- Extension in lying with clinician overpressure
- Extension mobilization
- Extension in standing
103
What is the general flow of repeated movement progression in flexion?
- Flexion in lying
- Flexion in sitting
- Flexion in standing
- Flexion in lying with clinician overpressure
104
What are some therapist augmented techniques?
- Extension with therapist overpressure (belts)
- Extension mobilization/ manipulation
- Mobilization for lateral component
105
What are some things involved in the mobilization for the lateral component of therapist augmented techniques?
- Hips shifted away
- Side lying flexion rotation
- Rotation mobilization in extension
- Rotation manipulation in extension
- Rotation mobilization in flexion
- Rotation manipulation in flexion
106
What is nerve root pain?
Unilateral leg pain below the knee, usually into the ankle or foot
107
In nerve root pain, ___ pain is usually worse than __ pain
In nerve root pain, *leg* pain is usually worse than *back* pain
108
What do people with nerve root pain present with?
- Pain radiating to the foot or toes
- Numbness or paresthesia in same dermatome distribution
- Nerve irritation signs
- Nerve axon loss (motor, sensory, or reflex changes) typically limmited to one nerve root (may be less than one)
109
What are the synonyms of a nerve root pain called?
- Radiculopathy
- Radiculitis
- Sciatica
110
What are the patterns of a radiculopathy ?
* Strength loss in a myotomal pattern
* Sensation loss in a dermatomal pattern
* Decrease or absence of associated DTR(deep tendon/muscle flex reflex)
111
The proportion of LBP patients with concomitant LE symptoms is ___ ,while the ones that has a true sciatica or nerve root involvement is ___
The proportion of LBP patients with concomitant LE symptoms is *70%* ,while the ones that has a true sciatica or nerve root involvement is *5%*
112
What is a referred pain pattern?
Pain down the limb that is not due to the nerve root
113
Referred pain through a muscle or facet joint is often describes as ___
Referred pain through a muscle or facet joint is often describes as *deep, achy, diffuse, dull, cramp-like and poorly localized*
114
What are the key things/things to test in a patient with a radiculopathy?
- Positive straight leg raise
- Positive cross leg test
- Femoral nerve stretch test
115
What is a positive straight leg raise test?
A test that has a score of 40 deg or less
116
The ____ is highly sensitive which means it can produce a false positive, while a ___ is highly specific
The *straight leg raise* is highly sensitive which means it can produce a false positive, while a *cross straight leg raise* is highly specific
117
What is a positive femoral nerve stretch test?
A burning or vague painful sensation down anterior thigh
118
What are the potential causes of leg pain?
- Denervation
- Central sensitization
- Peripheral nerve sensitization
- Adverse neural dynamics
- Myofascial trigger points
119
What is adverse neurodynamics?
When the nerves aren't gilding freely through out the system, hereby creating a degree of irritability
120
Do we tell a patient with sciatica to stay active or go on bed rest?
Trick question
Neither reall y makes a difference in their lives
121
What are the things to do for patients with a radiculopathy?
- Unloading: crutches, less standing, laying flat for periods of time, then going back to the crutches
122
Do injections have a long term or short term benefit for radiculopathy?
Short term. Provides a therapeutic window to get the patient actively involved in a progressive rehab program
MSK 1
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