L19: Management of specific conditions

Question 1

What is hypervigiliance?

Answer 1

• Do a task that is challenge the patient’s fear but in a pain free way
• Eg. pelvic tilt in 4 point kneel (but within ranges)

Question 2

What is important for bracing, hypervigilant or breath holding?

Answer 2

Makes it easier but still challenge the patient

Question 3

Cognitive retrain the fears and beliefs: back is safe to move –> show _____

Answer 3

movements

Question 4

Patients who have difficulty with finding _____ spine –> do this as an exercise for them

Answer 4

neutral

Question 5

What is radiculopathy?

Answer 5

• Can present with no pain at all (eg. foot drop, numbness on outside of foot or weak calf strength
• It is not neuropathic pain –> rather a condition presenting with nociceptive and neuropathic pain

Question 6

How to explain motor control exercises to a patient without giving the impression that they should always keep their back straight?

Answer 6

Question 7

We should carefully consider using _____/_____ exercises in someone with fear avoidant behaviours or bracing or those who we think may get the wrong idea

Answer 7

motor control; neutral spine

Might keep saying “keep your back straight while you do this”

• Can encourage more fear avoidant behaviour –> must be wary

Question 8

Motor control/neutral spine exercises are MOST APPROPRIATE for those who have adopted a ____ or _____ habit where there is a loss of detecting and keeping a neutral spine. They maybe continuing to load sensitive structures at end range.

Answer 8

flexion; extension

Question 9

What is lumbar spinal stenosis?

Answer 9

Degenerative condition with diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes.

Question 10

What are 4 symptoms of lumbar spinal stenosis?

Answer 10

1. Gluteal and/or lower extremity pain and/or fatigue
2. Symptoms on upright exercise such as walking
3. Relief with forward flexion, sitting and/or recumbency
4. Patient often has stiffness due to associated degenerative changes

Question 11

Patients whose pain is not made worse with walking have a low likelihood of _____.

Answer 11

stenosis

Question 12

What is the best imaging for spinal stenosis?

Answer 12

MRI is suggested as the most appropriate to confirm

Question 13

Do medical/interventional treatments improve outcomes compared to natural history in spinal stenosis?

Answer 13

• A systematic review of the literature yielded no studies to answer this question.
• In the absence of reliable evidence, a limited course of active physiotherapy is an option for patients with lumbar spinal stenosis.
• Self- management advice and education
  
  • Improving tolerance during exercise

Question 14

What are 5 education, advice and exercise (conservative approach) in lumbar stenosis?

Answer 14

1. Explain condition
2. Work with patient to consider modifications to tasks, positions of ease, self management – including activity pacing
3. Manage comorbidities and secondary impairments – balance, strength, ROM
   
   • Do they have a significant ROM impairment ?
4. Lumbar strengthening/ muscle function – including lumbo-pelvic global WB muscles – bias to flexion position to relieve symptoms
5. Find regular exercise that the patient can do/enjoys that does not aggravate symptoms (stationary bike, swimming, exercise classes, pool classes, tai chi)

Question 15

What are 6 manual therapy and exercise for focussed impairments (conservative approach) in lumbar stenosis?

Answer 15

Specific interventions

1. Various for Lumbar spine – Flexion, Rotation or Lateral flexion in flexion, PA’s with spine in Flexion
2. Avoid extension positions and extension exercises
   
   • Might not be able to tolerate prone –> do PA with a pillow under body
3. Can use neural mobilisations – SLR to reduce neural sensitivity if present
4. Increase knee and hip extension where appropriate
   
   • Increase ROM in other joints –> take the load off the painful/stiff area
5. Mobilise adjacent areas – higher lumbar levels, thoracic spine as indicated
6. Adjacent regions – self mobilization and flexibility/ muscle stretches – aimed at reducing lumbar extension moment in standing and walking (Hip Flexors, Quadricep)

Question 16

What are the 3 non-conservative treatment for lumbar stenosis?

Answer 16

1. Decompressive Laminectomy with or without spinal fusion
2. Epidural Nerve Block
3. Facet Cortisone

Question 17

In most cases, spondylolysis symptoms resolve within 6 to 12 weeks with _____ management

Answer 17

conservative

• Conservative management approx 85% of cases
• Potential for recurrence is high

Question 18

What are 7 management for spondylolysis?

Answer 18

1. Symptomatic management (rest, NSAIDs ONLY where required)- Interferes with bone healing (anti-inflammatories)
2. Activity/sport modification with graduated return
   
   • Depends on severity and symptoms –> activity modification
3. Time off may be required
   
   • Only used if it unstable or if the patient symptoms are so severe (eg. Loss of muscle strength, coordination, proprioception, QoL)
4. Bracing may be required to limit extension
   
   • Not often used (eg. thoracolumbar brace)
5. Restoring normal muscle strength and motor control, gradually increasing to functional movements
6. Restoring or improving thoracic and lumbar mobility
   
   • Depending on symptoms (must be pain free) –> can start loading rather early on
7. Restoring normal muscle length – especially hip extension

Question 19

What are 4 management for symptomatic spondylolithesis?

Answer 19

Similar to spondylolysis –> only difference: more evident for motor control training/ graduated strength training

1. Activity modification
2. Medications where required (NSAIDs)
3. Exercise – local motor control has been advocated – graduated in complexity.
4. Number of treatments or specific protocols have not yet been established specified the intervention period (10 weeks) of motor control training, finding positive treatment effects maintained over 30 months compared to controls.

• Ferrari et al (2016) found 5-8 sessions of supervised graded motor control exercise effective for function and pain (retrospectively).

Question 20

How to basically manage inflammatory spondyloarthropathies?

Answer 20

Physiotherapy is usually the starting point rather than medical

Question 21

______ affects up to 2% of Australians and more common in men than women. Approximately 5% of chronic lower back pain cases

Answer 21

Ankylosing spondylitis

Question 22

What are 8 Ankylosing spondylitis symptoms?

Answer 22

1. Gradual onset lower back pain and stiffness a major symptom (around the SIJ)
2. Early morning pain / stiffness which persists up to or >45 mins
3. Pain/stiffness improves after exercise and is worse after rest. Good response to NSAIDS
4. ROM may be normal
5. Persistence of symptoms for >3 months.
6. Sleep disturbance
7. Eye inflammation, pain in the eye or brow region, pain associated with exposure to light, blurred vision or eye redness
8. Symptoms of inflammatory bowel disease

Question 23

There is a strong genetic link; genes (IL23R and ARTS1) and the gene HLA-B27. Approximately one in eight carriers of the HLA-B27 gene develop the condition. It commonly presents in the late teenage years or 20s, although can start as late as 45. Long term inflammation results in bony growth

Answer 23

A

Question 24

What is the diagnosis of Ankylosing spondylitis?

Answer 24

There is no specific test for diagnosis, but imaging by Xray and MRI may show evidence of inflammation of the SIJ.

Blood tests: C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), plasma viscosity (PV) and genetic tests.

The delay between onset of symptoms and diagnosis is 5–7 years on average.

Chronic back pain is common and recognition of early disease requires a high index of suspicion.

Question 25

The delay between onset of symptoms and diagnosis is 5–7 years on average for _______.

Answer 25

Ankylosing spondylitis

Question 26

______ pain is common and recognition of early disease requires a high index of suspicion for Ankylosing spondylitis

Answer 26

Chronic back

Question 27

What are the 4 radiographic grading of sacroiliac joint in xray?

Answer 27

Question 28

What are 3 lumbar spine changes in AS?

Answer 28

Question 29

What are the 2 AS assessment?

Answer 29

1. True lumbar flexion (with bubble inclinometer)
2. Modified Schober Test
   
   • Targets lower lumbar flexion range PSIS to 10 cm above
   • Record increase in ROM with flexion Usually monitoring (physio purpose)

Patients often know that have AS

Question 30

What are 5 key features of inflammatory low back pain (inflammatory spondyloarthropathies)

Answer 30

1. Pain onset younger that 40 years of age
2. Insidious onset.
3. Symptom improvement with exercise.
4. Pain worsening with rest.
5. Pain at night (without improvement on getting up).

Diagnosis of inflammatory LBP is 77% sensitive and 91.7% specific if at least 4 or the 5 features are present

Question 31

What are 3 medication treatment for inflammatory spondyloarthropathies?

Answer 31

1. NSAIDs and Corticosteroids
2. disease-modifying anti-rheumatic drugs (DMARDs)
3. biological disease-modifying anti-rheumatic drugs (bDMARDs) –work by targeting certain overproduced proteins that cause inflammation and damage to bones, cartilage and tissue. Includes anti-TNF (anti tumour necrosis factor alpha)*
   
   • Try to minimise the inflammatory response which reduces the impact on back symptoms

*Anti-TNF a drug manufactured through biological process acts to interfere with cytokine function, block co-stimulation of T cells and deplete B cells = immunosuppressant effect.

Question 32

Physiotherapy and rehabilitation should start as soon as _____ is diagnosed

Answer 32

AS

Question 33

Physiotherapy should be planned according to the patients’ _____, _____ and ____ with close monitoring.

Answer 33

needs; expectations; presentations

Question 34

Lifelong _____ exercise is the mainstay of treatment for AS.

Answer 34

regular

Question 35

_____ physiotherapy is recommended for the highest benefit, and group exercise is also favoured to home exercises (Level 5) in AS.

Answer 35

Group

Question 36

_____, _____ and _____ exercises, as well as pool and land-based exercises are helpful in AS.

Answer 36

Stretching, flexibility and breathing

Question 37

What are 11 principles of managemen of SIJ Pain?

Answer 37

1. Patient education
   
   • Know why they are continuing to get symptoms; what is aggravating it
2. Relative rest and avoidance of aggravating activities when acute
3. Postural or activity modification
   
   • Know why they are continuing to get symptoms; what is aggravating it
4. NSAIDS
5. Joint mobilization (neurophysiological effect).
6. Not higher grades in pregnancy
   
   • Do not do gr 4 or 5
7. Use of SIJ belt if required and helpful (and demonstrated efficacy when used with exercise)
   
   • Good sign –> Better with compression (eg. applied tape; manual therapy)
     
     • Only temporary
8. Restore normal ROM
   
   • Initiate therapeutic exercise/loading to address strength and motor control deficits (transverse abdominus in functional positions, Gluteals).
   • Day 1 should be able to start –> need to improve tolerance to standing
     
     • Do this as soon as possible
9. Muscle stretching (where appropriate – not excessive in pregnancy)
   
   1. Iliopsoas and Piriformis
10. IMPROVE TOLERANCE TO LOAD
11. Strengthening – based on physical assessment findings – enhancing weight bearing capacity, including posterior chain, possibly aimed also at enhancing motor control.

Question 38

What are 5 other management of SIJ pain?

Answer 38

1. Anti-tumour necrosis factor (TNF) medication medications (if inflammatory condition such as AS)
2. Cortisone injections may provide both diagnostic and therapeutic utility
3. Prolotherapy
4. Radiofrequency denervation
   
   • Reduce or stop nerve signalling (activity)
5. Surgical interventions (usually fusion) for significant structural instabilities, fracture or infection

Question 39

In PS management, there is a _____ (large/small) variations between diagnosis and return to sport for rehabilitation program – average of about 80 days – less with basketball, longer with soccer

Answer 39

Large

Question 40

What are 6 conservative management in the early stage of pubic symphysis pain?

Answer 40

1. Early accurate diagnosis with immediate removal from activities
2. Rest potentially for 6-8 weeks to settle bony irritation.
3. Regaining effective flexibility without stressing joint.
   
   • Lack of hip ROM = risk factor for PS –> needs to restore this
4. Start lumbo-pelvic control training (motor control)
5. Maintain adequate fitness (swim, bike, and rower) by cross-training.
6. If the athlete has pain with ADL’s (e.g. coughing, sitting, getting in or out of a car) then should limit cross training and remove aggravating activities.

Question 41

What is the problem with PS pain and what can it cause?

Answer 41

Hernias can occur due to attachment of adductors so close to PS

Question 42

What are 4 conservative management in the late stage of pubic symphysis pain?

Answer 42

1. When pain free with ADL’s add in straight line running
2. Add local strengthening – adductors, rectus
3. Add in progressive agility work
4. Minimising pain during exercise and respect pain post exercise

Question 43

What are 7 conservative management in the “return to sport” stage of pubic symphysis pain?

Answer 43

1. Negative squeeze test
   
   • How much PS is able to tolerate shearing load?
2. Pain free contraction Rectus/Adductors
3. Pain free palpation
4. Pain free stretching
5. Pre-injury times and intensities (i.e. beep test)
6. Complete full training sessions (2 weeks)
7. Completed full game (friendly, lower grades) without symptoms

Question 44

What is different with PS management in terms of rest?

Answer 44

The earlier they are able to rest –> the earlier it gets better

• Usually people don’t stop –> Can get really bad and takes a long time to get better

Question 45

What are 7 non-conservative management of pubic symphysis pain?

Answer 45

1. Prolotherapy
2. Surgery

Question 46

What is prolotherapy?

Answer 46

Based on the presumed “proliferative” effects on chronically injured tissue.

Hypothesized to cause local irritation, with subsequent inflammation and tissue healing

Several injections every 2 to 6 weeks over several months.

Inject into injured tissue

• Starts inflammatory response
• Aid in tissue healing
• Usually not close to tendons but in joints

Question 47

What is surgery for PS pain?

Answer 47

Surgical procedures include debridement of the symphyseal cleft, bilateral partial adductor tenotomy, bilateral tenotomy of the conjoint tendons and wedge resection of the symphysis pubis or fusion.

Surgery is used a last resort (eg. older athletes –> Last seasons)