L17/18: Exercise Management Flashcards
What are the 3 aims of exercise for acute/severe non-specific, specific LBP and pelvic pain?
- Reduce pain
- Improve confidence to move
- Reduce secondary factors (fear avoidance, bracing, loss of mobility)
What are the 6 factors that influence exercise prescription for acute pain?
- The patient’s behaviours- Hypervigilance (for moving) OR no issues (already moving)
- The positions of ease/relieving factors (directional preference)- Esp. acute spinal pain –> based on what aggravates and relieves symptoms
- Exercise towards directional preference if there is one (in acute LBP)
- How irritable symptoms are- If patient gets aggravated symptoms after 5 mins for 30 mins –> make sure exercise is less than 5 mins
- The goals of the patient &the functional tasks they need to return to doing
- What they enjoy doing, have access to and can fit into their day.
What are 4 questions to ask to start to build up tolerance for functional and daily activities (get info from subjective interview)?
- Do you normally get back pain?
- Is it interfering with your ADLs?
- What would you like getting back to?
- Eg, is walking you can easily do? What about gym? Pool?
What are 10 principles for prescribing exercise for acute pain?
- The EXACT choice doesn’t really matter
- Strategies that are self-generated = higher self-efficacy and better control of pain/intensity
- The challenging the task = more confidence they are going to gain
- 4 point kneel/sitting = better than lying in supine as it builds more confidence as they are moving around (unless they are really acute/aggravated easily)
- Start in positions of ease (supine, side lying, 4 point kneeling)
- If tolerable —> exercising in sitting and standing
- Exercises towards directional preference
- Focus on restoring AROM, slow controlled movements (They feel in control)
- Use exercise in and around where symptoms are manageable (ie earlier in the day, around medication use)
- If its better in the morning –> do exercises during that time
- Walking, Swimming/pool based exercises
- No weight-bearing forces
- Frequent position changes - high frequency of exercise use
- Don’t need to give numbers, reps –> educate that if they get pain every 10 mins –> need to stand or walk around to relieve the pain before sit back down
- Encourage gradual increase in activity each day- Do a little bit more each day
Why is it important to do exercises and why does the exact exercise choice not matter?
Will still give same effect (different exercise plan) while some things can be better than others (not a big difference)
- As long as we get the patient moving
- Give the message that moving is helpful
- Don’t aggravate symptoms
What are 5 specific exercise examples?
- Movements in supine (pelvic tilt, knees to chest, knees side to side)
- Movements in 4 point kneeling (flexion and extension and sitting to heels)
- More flexion
- Prone repeated extension onto elbows or hands (where there is directional preference to extension)
- Pelvic tilting in sitting or supine
- If the patient’s main issue is sitting –> they want to return to work where they sit (eg. even if they go for a little bit –> give the message that they go a bit more each day
- Wall exercise (flatten back against wall)
- Pain relief and good for pelvic tilt –> especially if problem is in standing
What are the example exercises in supine or 4 point kneeling?
If a patient has a directional preference of extension, what does it mean for exercise?
- Does not mean avoid flexion based exercises
- Might mean that they stay clear of aggravating factors just until back settles down
- Will still give flexion based exercises
What are 5 specific exercises for a directional preference to extension?
- Walking (short and frequent where symptoms are acute)
- Might be basic –> but it helps relieve pain = good
- Keep moving (eg. 5-10 mins every few hours instead of 1 X 45min walk)
- Standing (frequently getting up into standing)
- Eg. every 15 mins –> get out of sitting, stand and walk around
- Lying prone – repeated pushing up on to hands (passive cobra pose) repeated movement
- 10-20 reps
- Make sure bottom and back are relaxed as it is passive
- Hands on hips in standing – repeated extending
- This can be a bit aggravating so make sure to do passive cobra pose first)
- Other forms of exercise which is upright or neutral – swimming, running (where tolerated) etc
- Just minimise flexion based activities
With a extension directional preference, what are relieving factors?
- Eg. extension directional preference (symptoms) = most common
- Better when get out of sitting and walk around (relieving factors)
- With repeated movements into extension –> pain relief
- They can still have pain with ROM into extension but its repeated movement that helps
What are 5 specific exercise for directional preference to flexion?
- Pelvic tilting (supine or sitting or against wall)
- Flattening back
- Repeated knees to chest in supine
- Done as passively as possible
- Repeated kneeling to sit to heels (childs pose)
- Regular breaks from standing or walking to sit down
- Cycling? Rowing? Arm erg? Where tolerated
How common is a directional preference to flexion?
Less common
Eg. patients with spondylosis
How common is a direction preference to extension?
Most common
Having a directional preference does not mean we have to ‘______’ movements into the opposite direction.
avoid
If a patient has a extension directional preference, what are 3 things it means in terms of exercise?
- Don’t exercises where they do prolonged sitting or bending
- Give some exercises to work ROM in an unloaded position into flexion
- Important to maintain ROM ○ Keep up confidence
- Give only give extension exercises –> can give patient the opinion that bending/flexion is bad = long term negative beliefs
EXAM QUESTION
Jeff has acute LBP (3 day history), no major mechanism of injury. Currently off work due to symptoms. Low score on Start Back Screening Tool. No symptoms below buttock. Aggravated with sitting, eased with standing up and walking for short periods.
Physical assessment: Pain on flexion and extension in standing Reduced pain with repeated extension in standing (directional preference) Pain localised to L5/S1 on manual examination.
What are 4 other things you want to know?
- What does he have access to? – pool and gym and walking
- What he can fit into a day?
- How much sitting AND walking before aggravated? – 20 mins (walk), 10 mins (sit)
- Can he get on and off the floor relatively easy? – yes
- Sometimes they struggle with this in acute period
- If he goes back to work soon – is there somewhere to move his back? – yes
- What has he gotten better with? When you get back to work –> can you do exercises in the workplace?
How do you get a directional preference?
Usually painful in all movements but repeated movements = directional preference
EXAM QUESTION
Jeff has acute LBP (3 day history), no major mechanism of injury. Currently off work due to symptoms. Low score on Start Back Screening Tool. No symptoms below buttock. Aggravated with sitting, eased with standing up and walking for short periods.
Physical assessment: Pain on flexion and extension in standing Reduced pain with repeated extension in standing (directional preference) Pain localised to L5/S1 on manual examination.
What are 3 goals?
- Reduce pain
- Improve ROM
- Reduce threat associated with movement/get more confident with moving back
EXAM QUESTION
Jeff has acute LBP (3 day history), no major mechanism of injury. Currently off work due to symptoms. Low score on Start Back Screening Tool. No symptoms below buttock. Aggravated with sitting, eased with standing up and walking for short periods.
Physical assessment: Pain on flexion and extension in standing Reduced pain with repeated extension in standing (directional preference) Pain localised to L5/S1 on manual examination.
What does his short term exercise plan going to look like?
- Maintaining functional activity (at home and work)
- Walking 10-15 mins, 2-3 times a day
- Frequent position changes – getting up out of sitting or changing sitting position every 10 mins
- Swimming or other ways to keep active
- Directional preference exercises (at home and work)
- Prone extension – 10-20x, 3-4 x day (Passive cobra pose)
- Standing extension – 10x, 3-4 x day
- ROM (at home and work)
- Cat/camel – 10x, 2 x day
- Knees to chest – 10x, 2 x day
- Knee rocking side to side – 10x, 2 x day
- Sitting to heels – 10x, 2 x day If they are off work –> they have all day
Quite committed to do exercise to get back
Why do you not need to be super specific with numbers for motor control or pain exercises?
- Need to say that would have looked at what was suitable for patient based on assessment
- Use clinical reasoning
- Often do not need to do sets
What are the numbers for strength and endurance exercise?
Can go with guidelines
EXAM QUESTION
Tracey has acute LBP (10 day history), after bending to pick up her dog, sudden onset of pain Has stayed at work She read online to avoid bending her back for 2 weeks to not do further damage so has not returned to any flexion High score on FABQ No symptoms below buttock. Aggravated with all prolonged positions
Physical assessment: Very apprehensive to move lumbar spine on functional tests and ROM Pain and reduced ROM on flexion and extension in standing Apprehensive to posterior pelvic tilt in sitting No change with repeated movement tests (No directional preference) Pain localised to L3-5 on manual examination and pain on muscle palpation. (Muscle guarding and sensitisation).
What are 5 other things that needs to be asked to help inform exercise decisions?
- What does she have access to? – walking
- How much sitting AND walking before aggravated? – 10 mins (walk), 30 mins (sit)
- Can she get on and off the floor relatively easy? – no
- Is there somewhere to do exercises at work? – not really
- What might be driving fears (of movement)? (need to show/address belief in clinic before prescribing exercises
EXAM QUESTION
Tracey has acute LBP (10 day history), after bending to pick up her dog, sudden onset of pain Has stayed at work She read online to avoid bending her back for 2 weeks to not do further damage so has not returned to any flexion High score on FABQ No symptoms below buttock. Aggravated with all prolonged positions
Physical assessment: Very apprehensive to move lumbar spine on functional tests and ROM Pain and reduced ROM on flexion and extension in standing Apprehensive to posterior pelvic tilt in sitting No change with repeated movement tests (No directional preference) Pain localised to L3-5 on manual examination and pain on muscle palpation. (Muscle guarding and sensitisation).
What are 5 goals for exercise? What is top priority?
- Reduce threat associated with movement/get more confident with moving back
- Build up confidence
- Reduce pain
- Increase ROM
- Top priority (more important due to belief stopping movement rather than pain stopping movement)
EXAM QUESTION
Tracey has acute LBP (10 day history), after bending to pick up her dog, sudden onset of pain Has stayed at work She read online to avoid bending her back for 2 weeks to not do further damage so has not returned to any flexion High score on FABQ No symptoms below buttock. Aggravated with all prolonged positions
Physical assessment: Very apprehensive to move lumbar spine on functional tests and ROM Pain and reduced ROM on flexion and extension in standing Apprehensive to posterior pelvic tilt in sitting No change with repeated movement tests (No directional preference) Pain localised to L3-5 on manual examination and pain on muscle palpation. (Muscle guarding and sensitisation).
What does her short term exercise plan going to look like?
- Getting moving and building confidence and increasing ROM At home:
- Cat/camel – 10x, 2 x day (at home on bed or sofa)
- Knees to chest – 10x, 2 x day (at home on bed or sofa)
- Sitting to heels – 10x, 2 x day (at home on bed or sofa)
- Getting moving and building confidence and increasing ROM At work:
- Pelvic tilt in sitting at desk (as far as comfortable) – 10x every hour
- Standing against wall – flatten back against wall – 10x every hour
- One foot onto chair and lean forward (every hour)- Lumbar flexion in standing
- Changing positions every 20-25 mins
- Short walks during work hours
- Want to challenge what she was avoiding as long as it does cause pain (only due to beliefs and fears)
What are 3 characteristics of exercise prescription for fear avoidant people?
- Make sure that movement is done it clinical –> can see its not aggravated
- More likely to do at home
- Do not do manual therapy for whole session and get them to do movement for exercise at home = not likely to do it
When do you do sustained VS repeated movements?
- Only do sustained extension –> if seen in interview that it relieves symptoms (or sustained prone on elbows)
- More likely that repeated movements –> helpful
General exercise (strengthening) and ______ based exercise and ______ exercises are demonstrated to be effective for LBP pain and function. _______ differences between exercise approaches
motor control; directional preference; no significant
Exercise is effective especially where: patient’s are introduced to exercise at their level of ______, and the exercises are _____ where required
function; progressive
What are the 4 factors influencing exercise prescription?
- How irritable symptoms are
- Their goals and functional tasks they need to return to doing- What are they likely to do long term?
- What they enjoy doing and can fit into their day
- Findings/impairments from the physical examination (motor control/loss of ROM/fear of movement)
What are 3 situations when exercise is effective?
- Patient’s are introduced to exercise at their level of function (Not to easy or hard)
- the exercises are progressed
- the patient’s preferences are considered (Type of exercise, setting)
What are motor control exercises?
Neuromuscular control of the body (trunk and limbs) in functional tasks, based on the assumption that impairments in motor control may contribute to the individual’s symptoms Static or functional tasks that are contributing to patient’s symptoms
What are 3 principles as exercise prescription for strength and motor control?
- the highest level the patient can achieve effectively with appropriate levels of feedback
- That has the most functional relevance- Make sure that start in functional position
- That does not aggravate symptoms
For some patients this will be directly doing the task that they have difficulty with, others will be very low level.
What are 3 characteristics of understanding flexion and extension pattern?
- Patients aggravating factors (might indicate repetitive loading into one direction)
- Observation of patient’s posture, functional movements and ability to reposition
- The occupation or sport of the patient (might indicate repetitive loading into one direction)
Extension based (eg. Throwing, jumping, landing) OR flexion based (weight training, rowing, cycling)
What are 5 characteristics of flexion control impairment?
- Most common pattern
- Loss of lordosis is accentuated in postures and tasks (ie sitting, cycling, squatting)
- Difficulty repositioning into a neutral position and a tendency to ‘over-shoot’ into flexion
- Movement tests of squatting, sit to stand, sitting (etc) reveal an inability to maintain a neutral spine, OR a tendency to flex and posterior pelvic tilt instead
- May brace abdominal muscle with loss of breathing control and excessive co-activation
What are 4 characteristics of extension control impairment?
- Provocative activities include trying to maintain erect postures or into hyperextension
- Difficulty with repositioning – tendency to hyperextend
- Tendency to maintain lumbar lordosis and difficulty in posterior pelvic tilting
- Tasks associated with hip extension may reveal increased lumbar extension
What are 5 early stages and progression examples of flexion control impairment?
- Practice finding neutral spine in sitting (or 4 point kneel if too difficult)
- Improving awareness by using tape
- Maintain neutral while adding movement (forward lean in sitting/sit to heels in 4 point kneeling) – practice repetitions
- Progress to standing (if standing is relevant)
- Progress load through squat and/or deadlift
- Progression: load, range and complexity of movement
- Progress relevance of task (if relevant) to introduce rotation, load and/or speed
What are 6 early stages and progression examples of extension control impairment?
- Practice finding neutral spine in sitting or 4 point kneel- If sitting is too hard
- Maintain neutral while adding movement (forward lean in sitting if sitting is relevant or arm or leg elevation in 4 point kneeling) – practice repetitions
- Progress to standing (if standing is relevant)
- maintain neutral spine in standing
- Progress load through squat and/or deadlift or add arm and leg movements in 4 point kneel
- Progress load through hip extension in prone (if end range hip extension is relevant)
- Consider overhead activities if relevant (overhead load, throwing)
- Maintain neutral spine in standing while doing overhead activity
Progression can include load, reducing base of support, adding rotation and speed – choice of progression depends on _____ of strength, endurance, power or proprioception AND the motor control impairment
goal
What is the higher progression of flexion control examples?
Consider increasing load and challenging support system where the patient has to actively limit and control lumbar flexion/posterior pelvic tilt (or be aware of their posterior pelvic tilt)
What is the higher progression of extension control examples?
Consider increasing load and challenging support system where the patient has to actively limit hyperextension (or be aware of their hyperextension)
What is progression of training?
These progressions can be used for the motor control patient who doesn’t have one specific activity or movement that is a problem, or where the presence of a flexion or extension impairment is not clear
What are 2 progressions when reducing the base of suppport?
- Supine hip twist on ball (adding rotation control)
- Lie on floor with hips and knees bent to 90 degrees on ball; slowly and with control, rotate knees to one side keeping hips in contact with the floor.
- Seated on ball, Marching
- Sitting on ball with neutral spine, knees at 90 degrees and hands on hips. Feet shoulder width apart. Slowly raise one knee into hip flexion and hold for a 3 -5 second count; keeping hips level than bring knee down to starting position; repeat on opposite side.
What is the supine hip twist on ball (adding rotation control) for reducing BOS?
Lie on floor with hips and knees bent to 90 degrees on ball; slowly and with control, rotate knees to one side keeping hips in contact with the floor.
What is the seated on ball, marching) for reducing BOS?
Sitting on ball with neutral spine, knees at 90 degrees and hands on hips. Feet shoulder width apart. Slowly raise one knee into hip flexion and hold for a 3 -5 second count; keeping hips level than bring knee down to starting position; repeat on opposite side.
What are 2 progressions for endurance?
- Prone Bridging on Elbows
- Lie on table or mat with forearms/elbows on the table/mat; rise up so that you are resting on your forearms and toes; back should be in neutral; hold this position for 15 sec – 1 min. Progress in increments of 15 seconds. Repeat 3-5 times. Use mirror or glass door as feedback. Use knees first if symptoms occur or unable to keep neutral spine.
- Side Bridging on Elbow
- Lie on side with your elbow underneath; rise up and hold this position for 15sec – 1min. Progress in increments of 15 seconds. Repeat 3-5 times. Complete exercise on both sides. Use knees first if symptoms occur or unable to keep neutral spine. Can add endurance component –> only if the patient can tolerate it (wont aggravate) • Use visual feedback (eg. mirror)
What is prone bridging on elbows for endurance?
Lie on table or mat with forearms/elbows on the table/mat; rise up so that you are resting on your forearms and toes; back should be in neutral; hold this position for 15 sec – 1 min. Progress in increments of 15 seconds. Repeat 3-5 times. Use mirror or glass door as feedback. Use knees first if symptoms occur or unable to keep neutral spine.
What is the seated ball, marching?
Lie on side with your elbow underneath; rise up and hold this position for 15sec – 1min. Progress in increments of 15 seconds. Repeat 3-5 times. Complete exercise on both sides. Use knees first if symptoms occur or unable to keep neutral spine.
What is an activity to move ASAP to standing?
Hip Hinge (start of deadlift) Maintaining lumbar neutral hinging at hip, allowing slight bend in knee. A stick/pole can help give feedback to remind of neutral spine
What is an activity when adding load?
Deadlift and single leg deadlift Slow and controlled maintaining neutral spine, progress to add weight (depending on patient goals)
What are 3 activity when adding load and complexity?
- Squat, single leg squat
- Slow and controlled maintaining neutral spine, progress to add weight (depending on patient goals)
- Cable Machine or Theraband – twist
- Can be introduced early at lower loads, progress to add weight (depending on patient goals)
- Cable Machine or Theraband or weighted Reverse Woodchop/Woodchop
- Increase speed, load and complexity of training as required
- Focus on what the patient can do long term (access, preferences)
- functional training ++
- coordination, speed, proprioception, limb loading, functional training, weight training and cardiovascular exercise as indicated and required
- End training goal
EXAM QUESTION
17 year old high school student experiencing a 6 month history of recurrent episodes of acute low back pain and recurrent muscle spasms which are increasing in both frequency and severity.- Where is has to lye down –> worse with prolonged sitting He has a constant mild ache with his back that is present most of the time, especially on sitting and after working out at the gym (weight training – especially after squats and deadlifts). Anything that loads back into flexion –> aggravating Symptoms are worse with flexion based activities and these tend to cause the spasms. Symptoms are eased with lying down. He would like to continue going to the gym and is open to changing his exercise regime to help with his back. On physical assessment: Difficulty finding neutral – sitting in posterior pelvic tilt On squat and deadlift goes into lumbar flexion early on movement, especially at the end. Able to correct with instructions Difficulty maintaining neutral in forward lean test in sitting and standing (goes into lumbar flexion). Able to correct with instructions.
What are 4 example exercise plan?
Sitting might be the main problem (loading in ERO posterior tilt) and then squats (adds more load)
- Gym program – modify squat and deadlift to a LOAD AND RANGE that he has appropriate technique. Consider using increased feedback – access to mirror at gym to check position. Could use taping.
- Correcting sitting posture during the day – practicing finding neutral (to build awareness and reduce end range loading during the day).
- Forward lean exercise in sitting and/or standing – maintaining neutral. Number of repetitions based on assessment
- Too difficult to do independently? Use 4 point kneel maintaining neutral sitting to heels exercise Still go to gym. Modifications
- Reduce load
- Taping of back (tactile) or use visual feedback –> Don’t go into too much posterior tilt
- Show him in the clinic (session), how far he should go in the squat/deadlift
- Might be able to maintain load –> Just change range
- Adjustments to exercise that help build awareness of range (eg. box under bottom)
EXAM QUESTION
17 year old high school student experiencing a 6 month history of recurrent episodes of acute low back pain and recurrent muscle spasms which are increasing in both frequency and severity.- Where is has to lye down –> worse with prolonged sitting He has a constant mild ache with his back that is present most of the time, especially on sitting and after working out at the gym (weight training – especially after squats and deadlifts). Anything that loads back into flexion –> aggravating Symptoms are worse with flexion based activities and these tend to cause the spasms. Symptoms are eased with lying down. He would like to continue going to the gym and is open to changing his exercise regime to help with his back. On physical assessment: Difficulty finding neutral – sitting in posterior pelvic tilt On squat and deadlift goes into lumbar flexion early on movement, especially at the end. Able to correct with instructions Difficulty maintaining neutral in forward lean test in sitting and standing (goes into lumbar flexion). Able to correct with instructions.
What are 3 example exercise plan in terms of education?
- Education would have focused on reassurance
- but letting patient know that they should refrain from end range loading under load/long periods
- this is contributing to his back pain.
- Exercise starts at the HIGHEST level the patient can achieve through a whole set independently
- Make sure other impairments are addressed in exercise plan (flexibility and sitting posture if this is contributing)
