Case 6: L4/5 Persistent LBP with Central Sensitization

Question 1

Precautions to consider through PE

Answer 1

• Thorough exam but not to focus on minute details
• Be aware of Language
• Aggravating pain excessively will discourage the patient

Question 2

Ax Priorities

Answer 2

1. Observation + Functional (Sitting)
2. AROM
3. Neurological
4. Neurodynamic
5. Palpation + PAIVMS
6. Motor control tests (not prioritised)

Question 3

Ax Observation + Functional tests/results

Answer 3

Standing with slight anterior tilt
Sitting very upright
Unable to Post tilt without manual guidance. When in EOR post-tilt, feels pulling in lower back - uneasy feeling
No pain increase on ant tilt

Question 4

Ax AROM tests/results

Answer 4

Flexion:
- Doesn’t reverse lumbar curve and remains lordotic until EOR
Extension
- Feels tight EOR pain
Side Flexion
- Feels tight EOR pain

Question 5

Ax Neurological tests/results

Answer 5

All neg

Question 6

Ax Naurodynamic tests/results

Answer 6

SLR with DF - L and R strong pulling into thighs and buttocks and slightly in back. Replicates pain

Question 7

Ax Palpation + PAIVMS tests/results

Answer 7

Palpation:
- Very tender through QL + Buttocks + Iliac crest

PAIVMS:
- ↓ L3 – 1/10 back pain
- ↓ L4 – 2/10 back pain
- ↓ L5 – 3/10 back pain

L4/5 + L5/S1 UL PA - reactive

Question 8

Ax Motor control tests/results

Answer 8

Not prioritised but can do
4 pnt kneel
forward lean in sit or stand
prone hip ext

Question 9

Tx Priorities

Answer 9

1. Advice + Education
2. Enhance self-efficacy for non-threatening tasks ie confidence building
3. Discuss longer-term management regarding regular exercise
4. Manual therapy for symptoms

Question 10

Tx Advice + Education

Answer 10

• Reconcepualise problematic pain beliefs, reassurance, the importance of self-management
• Provide an analogy about problem with being upright and bracing all the time - this can make pain worse
• Normative info regarding MRI findings (healing time frames - as it has been 6 months)
• Workplace strategies, ie regular breaks, using back of chair for support
• Ensure understand role of exercise management - especially exercise and strategies around relaxing the back and moving it more
• Links/handouts to provide knowledge and concerns of pain
• Give hope about recovery

Question 11

Tx Enhance self efficacy for non-threatening task ie confidence building

Answer 11

Exercise options that pat can achieve
- Larger ROM in sitting, supine, and 4 point kneeling
- walking, cycling, swimming
- working up to some gym-based exercises asap
Upright first as the patient will be most comfortable

Break down difficult tasks
ie sitting relaxed in a chair
forward bend down the wall
post pelvic tilt

Question 12

Tx Discuss longer term management regarding regular exercise

Answer 12

Discuss RTW and Return to Gym with a gradual build up.
Exercises at gym now?
Where would you start?
How would wee progress?

Question 13

Tx Manual Therapy