3b - TBC DP traction and manip Flashcards
what is centralization
spinal pain and referred sx are progressively abolished in a distal-to-prox direction in response to therapeutic loading or mvmt strategies
what is peripheralization and what is this associated with
spinal pain and referred sx spread distally or further into limb as a result of loading strategies
associated w poorer prognosis
what is a directional preference
direction in which centralization (or sx alleviation) occurs
what does evidence say about the prevalence in centralization and what this indicates
low prevalence but was a pos prognostic indicator even if pain worsened
what predicts higher disability in radiating pain
baseline elevation in fear-avoidance beliefs about work and lack of centralization phenomenon
- lack of centralization also predicts higher pain intensity
what are the strongest predictive variables of chronicity in LBP
pain patter classification (noncentralization) and leg pain
what are the possible classifications under sx modulation
directional preference
- flex
- ext
- lateral shift
traction/active rest
manip/mobilization
ext preference: demographics
25-40yo
ext preference: MOI
*trauma (high load/lift and twist)
excessive repetitive motion
insidious
ext preference: aggravating factors
*flexion sensitivity *
prolonged flex activities
- sitting, driving, biking
ext preference: relieving factors
dec sleep in fowler position
walking short distances
standing
backwards/ext stretching
ext preference: functional ranking of pain in walking, standing, sitting
worst
1. sitting
2. standing
3. ext
best
if ext preference sx alleviated in fully supine position what can this indicate
mechanical stress
ext preference: ROM/quality of motion findings
limited & painful flex
end range ext may have pain
(+) repeated ext motions alleviates sx and may centralize sx
ext preference: joint play findings
hypomobile PA glide in lumbar spine
ext preference: ms function findings
strength, control, and endurance
- weak glut max/med
- poor pelvic control
- poor TrA, multifidi activation
ext preference: neuro exam findings
may have myotomal weakness
may have sensory deficits
ext preference: helpful special tests that may be positive and what could they indicate
possible signs of NRCS
(+) neuro exam
(+) SLR - herniated disc, neural tension
(+) slump - herniated disc (esp if crossed)
ext preference: interventions
start w preference
- end range ext exercises
mobilization to inc ext
functional training w short term task modifications
- ant pelvic tilt -> pelvic control
- esp in sitting w post tilt, ant tilt will provide relief
browder ext protocol
treat impairments!
what is a good strategy for interventions in ext preference pt who is highly volatile
browder ext protocol
- prone -> POE -> prone press up -> standing ext
flex preference: demographics
typically >50yo
younger (16-25) if after trauma
flex preference: MOI
insidious in older (>50yo)
- d/t degen changes over time
- spinal stenosis -> narrowing leads to more space in a flex position
trauma in younger, athletes
- spondylosis - articularis fx
- high load
- lift and twist
- excessive repetitive motion
flex preference: aggravating factors
ext based activity
- walking
- standing
- standing from a chair**
flex preference: relieving factors
sitting
- not always better, more in oldies
leaning forward on cane
leaning on grocery cart
flex preference: ROM/quality of motion findings
limited/painful ext
flex preference: joint play findings
hypomobile LS/tspine in older
hypermobile LS in younger
hypomobile hip capsule
flex preference: ms function findings
strength, control, and endurance
- weak glut max/med
- poor pelvic control
- poor TrA, multifidi activation
flexibility, ms length
- stiff psoas or rectus fem
what role do muscle function findings play in sx modulation w a flex preference and why is this important
if stiff psoas and hip capsule (common in sitting a lot), motion happens thru path of least resistance
- if pt has stiff hip and thoracic, the lumbar spine has to take a majority of ext
important bc we can’t change bone structure but we can change mobility of hip and spine
flex preference: neuro exam findings
may have myotomal weakness
may have sensory deficits
flex preference: special tests that may be important and what do they tell us
(+) 2 stage treadmill test
possible signs of neurogenic claudication
possible signs of NRCS
when does reclassification happen for those initially classified as sx modulation w a directional preference and what is a consideration of this
reclassify when no longer in sx modulation
- may continue to have directional preference in movement control classification
flex preference: interventions and examples
flex biased exercise
- post pelvic tilt
- single/double knee to chest
- dead bugs
- child’s pose
mobilization
- early stages: to LS to inc flex
- mob hips and thoracic spine into ext
functional training
- post pelvic tilt -> pelvic control
- teach them ant tilt after to connect to function and why feels worse when doing activities
treat other impairments!
what will be your main directional preferences
flex and ext
- lateral is less common
lateral shift: MOI
trauma
- high load
- lift and twist
- excessive repetitive motion
lateral shift: aggravating factors
pain w most motions
- worst SB in opposite direction of shift
pain worst sitting > standing > walking
- may be different, less consistent
lateral shift: relieving factors
laying flat (often w legs up)
lateral shift: posture findings
shoulders deviated from pelvis in frontal plane
- shift named direction shoulders are moved in relation to lumbar spine
lateral shift: ROM and quality of motion findings
directional preference for pelvic translational mvmts
asymmetrical SB
lateral shift: neuro exam findings
may have myotomal weakness
may have sensory deficits
lateral shift: special tests that may be positive
possible signs of NRCS
(+) neuro exam
(+) SLR
(+) slump test
lateral shift: 3 interventions
manual therapy to correct shift
functional training w short term activity modifications
graded loading exercises
what are types of graded loading exercises to do with a lateral shift
TrA
-> pelvic tilting (mid range)
—–> progressions of “core” activation
what is an important positioning consideration of traction in lateral shift and why
supine traction
- when they stand up, will feel way worse
what does evidence say about the efficacy of direction preference specific interventions (ie flex, ext, lat)
people have tendency to get better in general
but people will get better faster and more often w good treatment that is specific to directional preference
- matching care matters in LBP
what pt pop in general fits in traction/active rest group for sx modulation
someone having difficulty w centralizing and peripheralizing
- not clear what feels better and what is worse
traction/active rest: demographics
any age
traction/active rest: MOI
often an event such as bending, twisting, lifting
traction/active rest: aggravating factors
higher compressive activities
traction/active rest: relieving factors
mvmt (but not too much mvmt)
traction/active rest: ranking of walking, sitting, standing
best
walking
standing
sitting
worst
*follows pattern of compressive activities
traction/active rest: key exam findings
s/sx of NRCS
- (+) CSLR
pain and numbness extending distal to buttock in previous 24hrs w/o ability to centralize thru repeated mvmts
what are 7 types of lumbar traction
mechanical
sustained (static)
intermittent
manual
autotraction
positional
inversion
what are 2 benefits to using harness traction
- allows for manual adjustments based on directional preference
- line of pull is from pelvis
- if you apply traction via legs, creates slight ant pelvic tilt bc acetabulum is slightly ant to pelvis
what is Steve’s issue w traction in PT
if can give someone self-traction techniques to do at home
- you have improved person’s self-efficacy –> sx are better –> improve px
what are 7 contraindications to manips in the LS
- signs of NRCS, myelopathy, or cauda equina
- OP or other bone dz
- fx
- acute inflammation
- unstable med condition
- progressing CNS disorder
- demyelinating disorders (ie MS, ALS)
what is the evidence for lumbar manip in the LS
really good lol
what is the lumbar spine clinical prediction rule
classifying pts w LBP who, will respond favorably to HVT (4 of 5 signs)
1. duration of sx <16days
2. no sx distal to knee (aka no NRCS)
3. LB hypomobility
4. 1 hip >35deg IR
5. FABQ work subscale score <19
(aka low fear avoidance)
TBC manip category: MOI
typically inciting incident
- bending, twisting, lifting
- may be after repetitive motion
TBC manip category: aggravating factors
pain w most motions
TBC manip category: pain levels
high
TBC manip category: posture
guarded/stiff
- walking carefully
TBC manip category: ROM and quality of motion
limited and painful
stiff, guarding motions that are limited
TBC manip category: joint play
hypomobile
TBC manip category: neuro exam and special tests
no sx distal to knee (pain, sensation, weakness)
(-) CSLR, aka neg for NCRS
- if (+) must have neg reflexes, strength, sensation testing
what interventions should follow manips
mid range ROM
- pelvic tilts
- lower trunk rotation
- cat camel
what are the 3 buckets we triage pts w LBP into based on appropriateness for therapy
med management
rehab management
self-care management
those who classify into sx modulation will be treated with one of what 4 subgroups
active rest
traction
directional preference
manip
