L/S Interventions Flashcards
Management of Spondylolysis/Spondylolythesis
- Initial → commonly conservative
- activity modifications → address rep activities
- address muscle guarding
- AROM exercises
- STM
- progression
- low-intensity, high frequency and duration exercises
- stretching of shortened hip muscles
- progress lumbar stabilization exercises
Discogenic Pain (disc derrangement) management
- AROM exercises
- address muscle guarding
- STM
- joint mobs → consider adjacent levels
- low-intensity/high-frequency and duration exercises
- progress lumbar stabilization exercises
- emphasis on functional training
Radiculopathy/Radicular pain management
- AROM exercises
- neural mobilizations
- progress lumbar stabilization exercisese
Lumbar Spine Stenosis management
- consider central vs lateral
- activity modifications → activities that place higher sustained loads on involved structures
- joint mobility
- thurst and non-thrust
- sustained holds → hypomobile segments
- oscillations → muscle guarding, pain
- muscle performance
- coordination training
- strengthening
- endurance
Z-Joint arthropathy management
- consider degenerative vs acute
- address muscle guarding
- paraspinal coordination training as indicated
- low-intensity/high frequency and duration as indicated
- consider progression based on degree of increasing compression loading w/z-joint
- manaul therapy interventions
- sustained hold → hypomobile segments
- manipulations and oscillations → muscle guarding, pain
List the impairment/functional-based classification system for the Lumbar Spine
- Mobility deficits (A or SA)
- Movement Coordination deficits (A, SA, or C)
- Related (referred) radiating LE pain (A)
- Radiating pain (A, SA, C)
- Related Cognitive or Affective tendencies (A, SA)
- Chronic LBP with related generalized pain
what do clinical practice guidelines suggest about pt education?
- pt should avoid:
- extended bed rest
- detailed pathoanatomic causative analysis
- should include:
- structural strength of spine
- neuroscience of pain perception
- generally favorable prognosis associated w/LBP
- pain coping strategies that address fear/avoidance
- early return to “normal” activities
- improved activity levels
Describe the body impairments observed in the acute/subacute LBP with related cognitive or affective tendancies
One or more of the following:
- two (+) responses to Primary Care Evaluation of Mental Disorders screen and affect consistent w/depressed pt
- High FABQ and behavioral processes
- High PCS and cognitive processes consistent with rumination, pessimism, or helplessness
what are the primary intervention strategies for acute/subacute LBP w/related cognitive of affective tendencies?
- pt edu and counseling to address specific classification exhibited by pt
- depression
- fear avoidance
- pain catastrophizing
how would you describe the category of:
chronic LBP with related generalized pain
- LBP or low back related LE pain w/symptom duration of >3 months
- generalized pain not consistent w/other impairment-based classification criteria
- presence of depression, fear-avoidance beliefs, and/or pain catastrophizing
primary intervention strategies for:
chronic LBP w/related generalized pain
- pt edu and counseling
- low-intensity, prolonged (aerobic) exercise
- strong evidence for progressive endurance exercise and fitness
- moderate to high intensity
describe the body impairments present in the category of:
acute LBP with movement coordination impairments
this is an acute exacerbation of recurring LBP commonly associated w/referrred LE pain
- LBP an/or low-back related LE pain at rest or produced with inital to mid-range spinal movements
- symptoms reproduced w/provocation of involved lumbar segments
- movement coordination impairments of lumbopelvic region w/low back flexion/extension movements
primary intervention strategies for:
acute LBP w/movement coordination impairments
- Neuro re-edu → promote stabilize in less symptomatic, mid-range position
- consider use of temporary external device
- self-care/home management training pertaining to:
- posture and motion that maintain neutral or symptom alleviating positions
- recommendations to pursue/maintain active lifestyle
impairments to body function with:
subacute LBP w/MCI
- pain with mid-range motions that worsen with end-range movements or positions
- LBP and LB related LE pain reproduced with provocation of involved lumbar segments
- lumbar hypermobility
- mobility deficits of thorax and/or lumbopelvic/hip regions
- diminished trunk or pelvic muscle strength and endurance
- movement coordination impairment during self-care/home management activities
primary intervention strategies:
subacute LBP w/MCI
- neuro re-edu
- manual therapy to address mobility deficits
- Ther-Ex to addresss strength and endurance deficits
- self-care/home management training in maintaining involved structures in mid-range, less symptom-producing positions
- initiate community/work reintegration training w/pain management strategies
impairments to body function with:
chronic LBP w/MCI
Presence of 1 or more of the following:
- LBP or LB related LE pain that worsens with sustained end-range movements or positions
- lumbar hypermobility w/segmental motion assessment
- mobility deficits of thorax, lumbopelvic/hip region
- diminished strength and endurance
- movement coordination impairments while performing community/work related activities
primary intervention strategies for:
chronic LBP w/MCI
- Neuro re-edu
- manual therapy to address mobility deficits
- Ther-Ex to address strength and endurance deficits
- community/work reintegration training
Lumbar stability training Clinical Practice Rule
- Age <40
- +Prone instability test
- Aberrant motions with movement testing present
- present SLR > 91º
- generalized increased mobility
potential biofeedback mechanisms for TrA coordination training
- palpation
- ultrasound imaging
- stabilizer cuff
*be sure to include anticipatory and static
Static vs Dynamic Multifidi coordination training
- Static
- prone
- SL
- Quadruped
- Dynamic
- rotation (concentration on eccentric function)
- SL w/rotation (potentially add resistance)
- extremity lift
- rotation (concentration on eccentric function)
describe acute LBP with related radiating LE pain
- LBP, commonly associated with referred buttock, thigh, or leg pain, that worsens with flexion activities and sitting
- LBP and extremity pain that can be centralized and diminished with:
- positioning
- manual procedures
- repeated motions
- Limited mobility along with chronic LBP w/MCI commonly present
- Lateral trunk shift
- reduced lumbar lordosis
- limited lumbar ext mobility
primary intervention strategies for acute LBP with referred radiating LE pain
- Ther-Ex, manual therapy, or traction that promote centralization and improve lumbar extension mobility
- pt edu in positions that promote centralization
- progress to interventions consistent with:
- Subacute or chronic LBP w/MCI
describe acute LBP with radiating pain
- acute LBP with assocaited radiating pain in the involved LE
- LE paresthesia, numbness, and weakness reported
- Symtpoms are reproduced or aggravated with:
- inital to mid-range spinal mobility
- lower limb tension/SLR
- slump tests
- signs of nerve root involvement may be present
primary intervention strategies for acute LBP with radiating pain
- pt edu on positions that reduce strain or compression to involved nerve roots
- manual/mechanical traction
- manual therapy to mobilize articulations and soft tissue adjacent to involved nerve root that exhibit mobility deficits
- nerve mobility exercises in pain-free, non-symptom-producing ranges
impairments of body function for subacute LBP w/radiating pain
- mid/low and back-related radiating pain or paresthesia that is reproduced at mid-range and worsens at end-range
- lower limb tension/SLR
- slump tests
- may have LE sensory, strength, or DTR deficits associated
primary intervention strategies for subacute LBP w/radiating pain
- manual therapy to mobilize articulations and soft tissues adjacent to nerve roots
- manual/mechanical traction
- nerve mobility and slump exercises in mid-to end ranges
describe chronic LBP w/radiating pain
symptoms are reproduced or aggravated with sustained end-range lower limb nerve tension/SLR/Slump tests
primary intervention strategies for chronic LBP w/radiating pain
- manual therapy
- ther-Ex to address TL and LQ nerve mobility deficits
- pt edu pain management strategies
what does research say about centralization/directional-specific exercises?
strong evidence
consider for pts w/LBP and LE symptoms to improve mobility and reduce symptoms (A, SA or C)
what does research say about traction for L/S patients?
conflicting evidence
Rated as D
consider for pts with LBP, lumbar nerve root compression, +Well Leg Raise Test
DO NOT consider for pts with acute, subactue, chronic LBP
what do the clinical practice guidelines say about nerve mobilizations as an intervention?
weak evidence for
grade C
describe acute LBP w/mobility deficits and list the impairments of body function for this classification
acute low back, buttock or thich pain (duration of 1 month or less)
- L/S ROM limitations
- restricted lower T/S and L/S segmental mobility
- Low back and low-back related LE symptoms reproduced w/provocations of involved segments
Primary intervention strategies for acute LBP w/mobility deficits
- Manual therapy procedure to diminish pain and improve segmental spinal or lumbopelvic motion
- Ther-Ex to improve or maintain spinal mobility
- Pt Edu to encourage active lifestyle
list impairments associated with:
subacute LBP w/mobility deficits
- symptoms reproduced with:
- end-range spinal motion
- provocation of lower T/S, L/S or SI segments
- Presence of 1 or more of the following:
- restricted T/S ROM and associated segmental mobility
- restricted L/S ROM and associated segmental mobility
- restricted lumbopelvic or hip ROM and associated segmental mobility
primary intervention strategies for subacute LBP w/mobility deficits
- manual therapy
- ther-ex
- focus on preventing recurring LBP episodes through use of:
- ther-ex that addresses coexisting:
- coordination impairments
- strength deficits
- endurance deficits
- edu about active lifestyle
- ther-ex that addresses coexisting:
give some examples of AROM exercises that may be used in the treatment of LBP
- Lumbar rotation in hook-lying
- Quadruped thoracolumbar flexion/extension
- Hook-lying lumbar flexion/extension → pelvic tilts
- supine knees to chest (uni or bi)
- sitting/standing lumbar flexion/extension
clinical practice guidelines: manual therapy
strong evidence for
- manipulation considered to address pain and disabiilty
- thrust and non-thrust procedures to address spine mobility impairments, pain and disability
Clinical practice rule via Flynn et all pertaining to benefits of spinal manipulation
Pts with LBP likely to benefit from spinal manipulation:
- Duration of symptoms <16 days
- No symptoms distal to knee
- FABQ score <19
- At least one hip >35º of IR ROM
- Hypomobility in L/S
stabilization exercise vs manipulation
validation study of Flynn’s CPR
- individuals meeting CPR who recieved manip demonstrated greatest improvement in disability
- exercise only group 8x more likely to experience worsening of disability (ODI) at 6 months f/u
what 2 criteria of Flynn’s CPR are the most predictive?
- Duration of current episode of LBP
- <16 days
- Extent of distal symptoms
- none distal to knee
Joint mobilizations for L-Spine
- Oscillations
- PA
- UPA
- Facet Gapping
- Sustained hold
- Extension
- Flexion
- Facet Gapping
- Thurst manipulations
- long leg distraction
- rotation
- supine lumbopelvic
target of force for the lumbar/flexion extension mobilization
- stabilizing → pincer grip on cranial segement
- mobilizing → inferior segment
relative structure movement during lumbar extension/flexion mobilization
caudal segment on cranial segment
target of force for the facet gapping mobilization
- stabilizing
- anterio-lateral ribs with anterior forearm
- lateral aspect of spinous process with 2nd digit of cranial hand
- mobilizing
- posterio-lateral pelvis with anterior distal forearm
- articular pillar (on side away from table) with pad of 2nd digit on the caudal hand
relative structure movement during facet gapping mobilization
gapping of the Z-joint further from table
pt position for long leg distraction manipulation
supine, hip passively flexed (~30 degree), slight abduction
relative structure movement during long leg distraction manipulation
traction force at knee/hip, lateral flexion of lumbar spine
target of force during lumbar rotation manipulation
- Stabilizing
- anterio-lateral ribs w/anterior forearm
- lateral aspect of spinous process with 2nd digit of cranial hand
- Mobilizing
- posterio-lateral pelvis through anterior distal forearm
- manipulation force with trunk/LEs
target of force during the lumbopelvic manipulation
- Mobilizing → ASIS (contact w/palm of hand)
- Stabilizing → posteriolateral trunk/ribcage
relative structure movement during lumbopelvic manipulation
lumbar zygopophysial gapping on trageted side
