Case 3: L4/5 Mechanical LBP with Flexion MC Impairment Flashcards
Ax Priorities for pat
- Observational + Functional
- AROM + Repeated repetitions if acute
- Motor control assessment
- Manual Exam (Palp + PAIVMS)
- Hamstring length + Hip Mobility
Ax Observational + Functional
- Posterior pelvic tilt in standing
- Post pelvic tilt in sitting, difficulty finding neutral pos
- Functional Tasks:
1. Squat - going into lumbar flexion at 1⁄2 way. Able to correct with verbal cues.
2. Deadlift - CURVATURE in back, huge flexion
3. Sitting pos as related to pain
Ax AROM + Repeated repetitions if acute
AROM
- Flexion: Pain on EOR
- Extension: Pain on EOR
- Lateral flexion: Decreased side flexion through lumbar, same on both sides
Ax Manual Exam (Palp + PAIVMS)
Palpation:
- Tenderness through QL + ES, replicating the spasm
PAIVMS:
- ↓ L4 – 4/10 back pain
- ↓ L5 – 2/10 back pain
Ax Motor Control
Deadlift, squat and sitting tests
- Forward lean test in sitting – difficulty with keeping neutral spine on forward lean without visual cues from mirror. Able to achieve 10 repetitions with mirror.
- Forward lean test in standing - difficulty with keeping neutral spine on forward lean without visual cues from mirror. Able to achieve 10 repetitions with mirror.
Ax Hamstring length + Hip Mobility
- Hamstring length – 60 degrees L and R
- Normal hip flexion ROM
Tx Priorities
- Advice and Education
- Motor control Impairment
- Addressing impairments with Tx mobility + hamstring length
- Pain management - if major issue
Tx Advice and Education
- From your PE, I have found that you have not sustained any major injuries to your back and are experiencing some symptoms around the L4/5 region of your back (show on model)
- 80% of patients recover completely in 4-6 weeks - Acute episodes of pain and spasm don’t indicate that you have any major injuries, but your back is getting aggravated.
- But, I think there is a link between some of the activities you are performing at the gym and your pain, so I would like to work together with you to retrain the way you are performing some of these activities. - Letting the patient know clearly that the main contributing factor is the continued end range
loading of increasingly sensitive structures in the spine (this is apparent from history and
physical and the fact that sensitisation is already apparent) - Advice for Frequent changes of position (especially in more acute stages), especially the prolonged sitting. Make the prescription specific – eg get up and do short walk every hour. Use the back rest of the chair, especially if has a lordotic support.
Tx Motor control - Flexion impairment
Key is flexion control – as functional as possible – ideas included:
* Correcting the deadlift and squat and seeing if the patient could achieve this properly – reduce load and range if required and use feedback including mirror, pole along spine or tape
* Neutral spine in sitting – 10-20 sec hold every time back becomes uncomfortable or even better be very specific with prescription, eg. every 15-30 minutes.
* Neutral spine in 4 point kneeling
* Keeping neutral spine in sitting to forward lean
* Keeping neutral spine in 4 point kneeling to sit to heels (if he cannot do more challenging exercises) * Neutral spine forward lean in standing – progressing to deadlift movement
* NOTE – key is finding a functional level that the patient can do independently – utilise
feedback (ie mirror, pole along spine or tape) and then be ready to progress if too easy or regress if
unable to do complete set.
* Need to be doing frequently to improve MC – more than just at gym sessions
Tx Addressing the other contributing impairments
Addressing thoracic mobility (foam roller, stretches)
Addressing hamstring length/flexibility and flexibility into hip flexion – make sure patient keeps a neutral spine with doing these.
Tx Pain management (if pain is a major issue)
Manual therapy at L4/5 – rotation for example
Flexion MWMs
Exercises to directional preference during acute episode
QL massage/release/stretch
