case 6 - LBP with central sensitization Flashcards
assessment priorities
- Neurological
- Functional tasks
AROM lumbar
assessment priorities
2. Functional tasks
a. Standing
b. Sitting/transfers
i. Functionally relevant
ii. Giving her the most trouble
iii. Looking for hypervigilance, bracing, maladaptive behaviours, movement behaviours, fear avoidance
Can get VAS/PSFS for these
assessment priorities
1. Neurological
a. Symptoms below buttock
b. More of a screening for her but still priority to ensure no neurological signs
Neurological Assessment
Neurological Assessment
An evaluation of a patient’s nervous system to assess sensory
(sensation) and motor (strength) responses and reflexes.
• Single leg calf raise - perform six repetitions on each leg
and look for fatigue to test S1 and S2 dermatomes
• Sensation Testing -lying supine with legs exposed, use a
tissue to check ‘normal’ sensations on arm (eyes closed)
then work through each dermatome (L1 to S2) with two
light strokes in each. Compare sensation levels on each side.
Rate differences out of 10 and perform sharp/blunt test in
those areas.
a. L1– groin/upper/inner thigh
b. L2 - mid/lower/inner thigh
c. L3 - medial knee
d. L4– lower medial shin and inside dorsum of foot
e. L5 - big toe and across toes
f. S1 - lateral border of foot
g. S2 – medial heel
• Manual Muscle Tests - Test strength of muscles in each
myotome using isometric contractions for 4-5 seconds and
compare sides.
1. L2 – iliopsoas, resist hip flexion
2. L3 – quads, resist leg extension
3. L4 – tibialis anterior, resist dorsiflexion/inversion
4. L5 – EHL, resist big toe extension
5. L5/S1 – EDL, resist tow extension
6. L5/S1 – peroneus longus/brevis, resist eversion
7. S2 – toe flexors, resist toe flexion
8. L5/S1/S2 – hamstrings, resist knee flexion
(prone)
• Reflexes -Knee jerk (L3/4) hit patellar tendon with
hammer six times with knee in slight flexion using pillow,
your knee or arm. Achilles (S1/2) hit achilles tendon six
times with pillow under knee, external rotation and
abduction of knee and pull toes into DF to put tendon on
stretch *clench teeth for better reflex response
assessment priorities
AROM lumbar
a. Baseline measure for rehab
b. See side to side differences
c. So that we can communicate with other health professionals (even insurers etc) and to help with documentation about the patient
Also looking for movement behaviours/bracing/breath holding etc
other assesment
LP dissociating in sitting or 4 point kneel
a. Observing for behaviours of movement (anything abnormal)
With all these movements looking to see if it is mechanical
management priorities
1.A & E
2. Retraining normal movement
manual therapy
management priorities
1.A & E
1.A & E
- Diagnosis: Based on my physical assessment I believe you have persistent low back pain coming from some of the segments in your back L4/L5:
• You also might be experiencing something called central sensitization. You can think of it like an alarm system, so with your original injury the alarm system was set off and now the alarm system has become more sensitive and even with a safe task or movement, the alarm is sounding.
- Prognosis: Aim is to improve function rather than symptoms
- Reassurance: The spine is strong, resilient and adaptable.. Pain is poorly related to tissue damage. Protection can persist when there is no longer the need to protect. Pain that persists is more about sensitivity to it rather than the damage. The nervous system is a very complex system that consists of over 400 individual nerves. Importance of self management
- Providing normative information regarding MRI findings Reassure patient about condition and that pain/findings are poor correlation. Help understand her condition better and that she is not as injured as she may believe
- Ensure the patient understands the role and efficacy of exercise management – especially the exercises and strategies around relaxing the back and moving it more. Self-management is one of the best evidence based forms of treatment for lumbar (as well as exercise)
- Specifically discuss workplace strategies - regular breaks, using back of chair for support. Importance of being at work. Better prognosis and long term outcome
management priorities
Retraining normal movements
- motor control - Break down difficult tasks Examples: sitting relaxed in chair, forward bend down wall, posterior pelvic tilt etc – many options here
- Address abnormal movement behaviours
- Get patient more confident with moving again without agg symptoms
- Self-efficacy
management priorities
Manual therapy
- Address mechanosensitivity (perhaps with no. 2). sliders ??
- To reduce symptoms - example of what to say above
other management
Discuss longer term management re regular exercise – come up with plan (graded re-exposure)
- Discuss the plan to return to the gym and gradually build up.
- Are there exercises a the gym that she could do now?
- Graded exposure
- Begin to become for functional again
- Reach goals
