3a - Lumbar Mgmt & Exam Flashcards
what are 2 vascular systems that lumbar pain can arise from
AAA
vascular claudication
what are a consideration of passive structures (ie ligs, joints, disc) in their physiology
all are innervated and can all be a source of pain (except for the nucleus propulsus)
what ligaments are involved at the lumbar level vertebrae
ALL, PLL, lig flavum, supraspinous, interspinous, intertransverse
how many joints do lumbar vertebrae have
6
- 4 facets
- 2 IVD
what are 3 components to a lumbar disc
vertebral endplate
annulus fibrosus
nucleus propulsus
muscles in the local vs global systems
local/deep = stability
- transverse ab
- multifidi
- thoracolumbar fascia
global/superficial = mobility
- psoas
- QL
- HS
what is the structure of the transversus abdominis in the local/deep ms system
forms a ring around abdomen
what is the function of multifidi and how does this fit into the local system
prevent rotation
- stabilizes lumbar spine
psoas attachments and implications of that
attaches to ant lat vertebrae of T12-L5
- can pull on lumbar spine if stiff from prolonged sitting/in bed
shortened psoas -> inc lumbar lordosis
QL attachments and function
attaches to iliac crest, 12th rib, TPs of L1-4
SB, hip hike, hip drop
HS attachment and implication of that
pelvic attachment at ischial tub
less direct connection
- if stiff will limit amt of pelvic motion
what is the purpose of anticipatory feed forward mechanisms in the lumbar spine
multifidi and stabilizers activate prior to motion/activity
what is the function of the neural system in the lumbar spine and what are 4 contributing components
controls function of ms
SC
nerve root
CNS control
brain
CNS control vs brain in their function in the neural system in the lumbar spine
CNS:
- anticipatory feed forward mechanism
- inhibition for local ms
- excitation for global ms
brain:
- central processing (sensitization)
what are the biomechanics of facet glides in the LB
superior glide for flex
inferior for ext
superior facets face sup and med
inferior facets face ant and lat
what motions are most easily achieved in the LB
flex/ext
what is motion resistance in the LB typically d/t
resistance of compression on structures in same direction and tensile forces of structures in opposite direction
extrinsic vs intrinsic risk factors for developing LBP, and what is an important consideration for all of these risk factors
extrinsic
- occupation (ie lifting, flex, rotation)
- operating heavy equip
- low job satisfaction
intrinsic
- age & genetic for spine degen
- HTN and lifestyle, smoking, obesity
- psychosocial prog predictor (fear/depression)
risk factors multifactoral, pop specific, and weakly associated w LBP development
what are 3 prognostic factors for development of recurrent LBP
- hx of previous episodes
- excessive spine mobility
- excessive mobility in other joints
what are 5 prognostic factors for development of chronic LBP
- *presence of sx below knee -> indicates more severe incident**
- psych distress
- fear avoidant, low expectations of recovery
- pain of high intensity
- passive coping style
what are red flags associated w the lumbar spine
cauda equina syndrome
spinal fx
neoplastic conditions (CA)
ankylosing spondylitis
infection
s/sx of UMNL
AAA
gyne - endometriosis, ectopic
what impact do yellow flags often have on LBP
things that keep LBP around for longer
what concerns do we have w a FABQ work sub scale score >34
prolonged disability
what does a FABQ work sub scale score <18 indicate ab PT interventions
more likely to benefit from HVT
what does a FABQ physical activity scale score >13 indicate ab PT interventions
more likely to benefit from behavior modification
what cluster components are a strong predictor of chronic LBP
high FABQ
strenuous job
low ed background
imaging findings DDD
what does the STarT back screening tool tell you (SBST)
overall risk for developing chronic LBP
what is the prognosis for someone w a low risk STarT score
pt very likely to improve
what are the key factors for a PT intervention in someone w a low risk STarT score
address pt concerns and provide info
what PT intervention is indicated for someone w a low risk STarT score
single session
- give advice and encourage self management
- give education and tell them can reconsult if necessary
ex: person coming in for shoulder issue and say that their back hurt a bit when woke up in morning
what are the main aims of PT in a medium risk STarT score
restore function (including work)
minimize disability even if pain is unchanged to support appropriate self-management
what PT interventions are indicated for someone w medium risk STarT score
4-6wks of pt
- tailored to pt and based on specific findings
what is the specific focus of PT in high risk STarT score pts
cog, emotional, and behavioral responses to pain and their impact on function
what PT interventions are indicated for high risk STarT pts
psych informed PT to address physical sx and function & psych obstacles to recovery
enable pts to manage on-going and future LBP
what are the 3 dimensions assessed in the pain catastrophizing scale (PCS)
rumination
magnification
helplessness
biomedical vs biopsychosocial model of healthcare
biomedical:
- focus = dz
- abnormalities of measurable bio changes
- specific tissue damage
- specific dx to treat pt
- doesn’t always work bc not always something to be fixed
biopsych
- focus = illness
- health made up of bio, psych, and social factors impacting condition
- bio equal wt to other factors
- local tissue approach if pain is proportional to physio response to injury
what are 4 validated outcome tools in the LB
- pain body diagram
- oswestry disability index
- capture perceived disability in pts w LBP - roland-morris disability Q
- ask pts to gauge if each item is possible to accomplish - numeric pain rating scale (NPR)
nociceptive pain in the LB: what is it, qualities, alleviators?
(somatic) mechanical/physio processes in injured tissue
-> pain proportional to nature and extent of injury or potential threat
deep, dull, aching pain
- can be sharp in early stages
dec w dec tissue stress
-> better w positional changes
how does peripheral neurogenic pain present in the LB
superficial, burning, shooting, w/i all or part of nerve innervation field
+/- paresthesias or corresponding ms weakness in neuroanatomical field
central/nociplastic pain in the LB: what is it caused by, what is it, qualities, exacerbators?
disturbance in central processing
non anatomical (widespread), sensory dysfunction not neuroanatomically logical with ongoing pain after expected healing time
hyperalgesia in multiple areas
- allodynia present
exacerbated by:
- emotion
- poor response to meds
what are 2 hypotheses for a lateral shift in posture
psoas unilateral activation
-> get SB and lumbar compression as pulls on lumbar spine
injury and SBing that direction may be less painful
what is a sx that is an indication for repeated motions ROM exam
leg pain
- look for centralization or peripheralization of sx
what are aberrant mvmt patterns and what are 2 examples
compensations/deviations in motion
- reverse lumbar lordosis
- gower sign
what are qualities of trunk ms do we want to assess in the exam
power
endurance
length tension
ms imbalance
what is an example of LE functional strength assessments
walking on heels, toes
what specific trunk ms do we want to assess strength and ms activation? what ms may compensate if they are weak/unable to isolate
transverse abdominis
multifidi
rectus abdominis compensation
what are 5 flexibility / ms length tests
thomas test
modified thomas test
obers
elys
SLR or 90/90
what are the dermatomes for L2-S1
L2 - med thigh
L3 - ant med distal thigh
L4 - med 1st toe, ant med calf
L5 - lat calf
S1 - lat foot
what are the myotomes for L2-S1? what is a consideration with testing these myotomes
L2 - hip flex
L3 - knee ext
L4 - ankle DF
L5 - 1st MTP ext
S1 - ankle PF
L2 & 3 difficult to test w acute LBP bc direct ms attachments
- effort based test
L4 and S1 are easier to test
- good bc more commonly injured nerves and associated w radiculopathy
what are 3 neural tension tests
SLR / Cross SLR
femoral n. tension test
slump
SLR neural tension test vs cross SLR for pain on R
SLR - lift up R
- highly sensitive for herniated disc (good to r/o if neg)
cross SLR - lif up L
- highly specific for herniated disc (good to r/i if pos)
what are 4 provocation tests and what does a (+) indicate
quadrant
compression
prone instability
sign of buttocks
indicates would benefit from stabilization exercises
what are 3 non organic signs
waddels
flip test
hoover test
when if referral to imaging indicated
presence of suspected path identified through red flags
- ie progressive neuro s/sx
if imaging is indicated, which are used and which is the most sensitive? what is a consideration of this
radiographs, MRI, CT
MRI highly sensitive
- may reveal findings that aren’t clinically relevant as a result
what is a challenge w someone coming to PT after getting abnormal MRI findings back
come in saying things tha tPT can’t fix
- biopsychosocial model clashes
what PT intervention has the highest level of evidence in acute LBP
thrust / nonthrust joint mobs
what PT interventions have the highest level of evidence in chronic LBP
exercise:
- general
- ms strength/endurance
- specific trunk activation
- aerobic
- multimodal
thrust/nonthrust joint mobs
pt ed: active treatment
- incorporate pain neuroscience
what are 3 reasons to classify LBP
improve clinical outcomes by matching subgroups of pts to optimal intervention strategies
dec inefficient variability in treatment
standardize treatment approaches
what are 3 types of classification systems for LBP and which is the most applicable to PT
evaluation
prognosis
treatment**
what are 3 evaluation classification systems for LBP and what are each’s main differential
patho-anatomical
- identify red flags
ICD
- billing
ICF
- function based dx
acute vs sub acute vs chronic LBP time line
acute = sx<1mo
sub acute = sx 1-3mo
chronic = sx >3mo
what are 2 prognosis classification systems for LBP and what are each’s main differential
STarT Back
- low, med, high risk
OMPSQ
- more wc related
what are 4 treatment classification models and what are their differentials
TBC
- treatment based
MDT
- mechanical dx
MSI
- mvmt system impairment
CB-CFT
- cog functional therapy
what are 4 treatment classification models based on
mvmt/loading patterns related to pain reduction and treatment response
what model is pathanatomic classification very similar to
biomedical model
what is a main limitation of patho-anatomic classification
difficult to identify specific structures as clear pain generators in lumbar spine
- particularly for LBP
what is the mvmt system impairment classification (MSI)
pt w LBP categorized into 1 of 5 syndromes based on sx elicited during specific positions and mvmts
- lumbar ext
- flex
- rotation
- rot-ext
- rot-flex
uses impairment as classification
what is cognitive functional therapy and what does it utilize
multidimensional clinical reasoning framework
- designed to identify and target modifiable factors that drive pain, pain-related distress, and disability
utilizes graded exposure to mvmt
what did the 4 TBC (treatment based classification) groups use to be up until 2015 and why has this been changed since
manip
specific exercise (flex, ext, lat shift)
traction
stabilization
changed bc some people meet portion of criteria, some don’t meet any, some met multiple
- no recommendation for high psychosocial distress
how are new TBC guidelines that have been updated since 2015 different from before
“first contact” triage
- 3 management tracks
rehab professional triage
- 3 approaches
risk of co-morbidities and psych assessed at both levels
what rehab approach did stabilization exercises from the old TBC guidelines move to in the updated guidelines since 2015
mvmt control group
what rehab approach did active rest from the old TBC guidelines move to in the updated guidelines since 2015
sx modulation
in the updated TBC guidelines what are the 3 management tracks at first contact triage and who is appropriate for each
medical management
- red flag
- screen co-morbidities
self-care management
- unlikely to develop disabling LBP during current episode
- provide advice/guidance
rehab management
- majority of pts w LBP
in the updated TBC guidelines what are the 3 rehab approaches that a rehab professionals triages the rehab management pts into
sx modulation
mvmt control
functional optimization
in the updated TBC guidelines what are the clinical findings and treatments appropriate for the sx modulation rehab approach
clinical findings:
- disability high
- sx status volatile
- pain high to mod
treatments
- directional preference exercise
- manip/mob
- traction
- active rest
in the updated TBC guidelines what are the clinical findings and treatments appropriate for the mvmt control rehab approach
clinical findings:
- disability mod
- sx status stable
- pain mod to low
treatments:
- sensorimotor exercises
- stabilization exercises
- flexibility exercises
in the updated TBC guidelines what are the clinical findings and treatments appropriate for the functional optimization rehab approach
clinical findings:
- disability low
- sx status controlled
- pain low to absent
treatments:
- strength and conditioning exercises
- work or sport specific tasks
- aerobic exercises
- general fitness exercises
