L2 Manual Skills Flashcards
Causes of LBP
70-80% unknown medical cause
10-27% mechanical with known cause that PTs can treat
3% known medical cause that is non-MSK
Systemic S/S
disturbs sleep
deep aching/throbbing
reduced by pressure
constant or waves of pain
skin changes
weight loss
fevers
not aggravated by mechanical stress
Mechanical S/S
generally lessens at night
sharp or superficial ache
usually decreases with stopping of activity
aggravated by mechanical stress
Contributing conditions to insufficiency insufficiency Spinal Fractures
osteoporosis, hyperthyroidism, renal failure, chronic GI disorders
Fx of thoracolumbar spine
age >75
trauma
presence of osteoporosis
LBP >7/10
thoracic back pain
if greater than 3/5 S?S are present, high likelihood of fracture
High Risk for Cervical Spine Fracture
> 65, dangerous MOI, paresthesias in extremities
If the patient can ____, they most likely don’t have a cervical fracture
actively rotate neck 45°
Low Risk factors for Cervical Spine Fractures
simple rear end
sitting in the ED
ambulatory at any time
delayed onset of pain
absence of midline tenderness on C Spine
Red flags for cancer
history of cancer
age over 50
unexplained weight loss
failure of conservative therapy
Kidney–Visceral Back Pain
pain location: in back or side part of the body
pain types: severe, sharp, sudden
pain with urination. Nausea, vomiting, blood in urine, sweating
need to refer
Nephrolithiasis
most common cause of kidney visceral pain
males > females
high bmi is a rf
Cholecystitis
inflammation of gall bladder
middle aged women
upper RQ abd pain
radiation between scapulae
nausea, vomiting
Triple A
most common type of aneurysm
increasing incidence as people get older
more common in men and with people with hypertension and atherosclerosis
patient may report feeling an abdominal heart when laying down
Definite signs of triple a
definite pulsatile mass
abdominal bruit
Herpes Zoster Rash
-unilateral lesions that don’t cross midline
-painful, itchy, blisters
-fever
-headache, chills, upset stomach
-2-4 of S/S
-thoracic trunk location, in a dermatomal pattern
Spinal Infection
advanced age
open wound in spinal region
intravenous drug use
HIV
long term steroid use
diabetes
organ transplant
malnutrition
cancer
Cauda Equina
most commonly due to massive disc herniation
can also be from infections, tumors, stenosis, birth abnormalities, post-operative complications, spinal anesthesia
S/S of cauda equina syndrome
urinary retention
urinating more frequently
fecal incontinence
sexual dysfunction
saddle paresthesia
unexplained LE weakness
What is the most common serious spine pathology?
fracture
Lumbar Spinal Stenosis S/S
-worse with extension, better with flexion
-stooped posture, leaning on grocery cart
-decreased walking tolerance
-neurogenic claudication (central)
-radiculopathy (lateral)
-LE weakness
-General onset
Primary vs Secondary LSS
Primary: congenital
Secondary: Acquired
Secondary is more common
LSS Test Cluster
- Bilateral LE symptoms
- LE pain > back pain
- Pain during walking or standing
- Pain relief upon sitting
- Age > 48 years
high snout (0 S/S) and high spin (over 4 S/S)
Other tests to determine LSS
2 stage treadmill test (walking on incline would be less painful)
romberg test: impacted balance
30s prone hip extension test (S/S would come on w/legs raised)
Pain Management for LSS
NSAIDs
TENS
low grade CPA and STM
Decreased spinal ROM and jt mobility of LSS
central and unilateral PAs
flexion/rotation ROM
Decreased walking tolerance of LSS
modified WB program
inclined treadmill
increase cadence
decrease stride length
Decreased hip muscle performance of LSS
hip jt mob
increasing ext and rotation
hip flexor/quad lengthening
Decreased trunk muscle performance of LSS
trunk stabilization with LE ex
bridging
quadruped
planks
Decreased hip muscle performance LSS
hip strengthening
emphasize on extension and abduction
LSS prognosis
expect at least 6 to 12 weeks for improvement
might need steroid injection, elective surgery, or radiofrequency ablation
Spondylolisthesis
slip forward of the spine
can be degenerative, microtraumatic changes, traumatic, congenital, systemic
Degenerative spondylolisthesis
common in older female obese adults
Isthmic and Traumatic Spondylolisthesis
more common in pediatric population
usually hyperextension with impact like gymnasts, football, butterfly stroke
most happen at l5/S1 and are managed conservatively
Degenerative Disc Disease
more than 50% of the population >30 /yo, and increases to 90% of pop >65
S/S of DDD
loss of height
loss of motion in flex and ext
marked hypomobility
possible radicular S/S
Manual Therapy
specialized, skilled hands-on techniques to produce a force on the body to restore function, increase ROm, decrease pain
joint directed
use of muscles to move jt
improve muscle extensibility
reduce muscle tone
Mobilizations
passive therapeutic movement within a range of motion at variable amplitudes and speed
not always at the end of available range
Manipulation
passive therapeutic movement of small amplitude and high velocity at the end of available ROM
Passive physiologic intervertebral movements
flex, ext, SB, rotation
Passive accessory intervertebral movements
slide, glide, roll, spin, translate
Closed packed and manual therapy
typically don’t do manual therapy in closed packed position because jt surfaces are the most congruent
Barrier Concept
Joint movement is limited by anatomic barrier
passive motion occurs within the physiologic to anatomic barrier
active ROM occurs between the physiologic barrier
in a dysfunctional system, the motion loss decreases how much active motion is present
Type 1 Spinal Motion
neutral mechanics
SB and rotation occur to opposite sides
Type 2 mechanics
when supine is flexed or extended, SB and rotation occur to the same side. Uncoupled motions
easier to feel and manipulate the cervical spine
Type 3 Mechanics
motion in one plane reduces motion in remaining two planes
Why do we need mobilize joints?
synovial fluid movement
extensibility of soft tissues
maintain proprioception
muscles can’t move locked jts
muscles can’t heal w/locked jts
jt that lack normal mob increase wear
Theoretical Benefits of Manipulative Therapy
stretching of soft tissue
pain inhibition
positive patient expectation
provider expectation
neural plastic changes
alteration in motor neuron excite
increase in cortical drive
Manipulative therapy does NOT
release joint adhesion
nitrogen gas bubbles cavitating
correcting a subluxed segment
fixing alignment
Biomechanical benefits of manual therapy
vertebral segment movement
gapping of facets
increase tissue extensibility
not site specific
short term changes
doesn’t change alignment
Neurophysiological benefits of manual therapy
patient expectations
stimulation of spinal afferents
enhanced motor neuron excitability
reflex post synaptic inhibition
inhibition of nociceptive transmission
when to NOT manipulate with HVLA thrust
active infection
suspected or known fracture
osteoporosis
acute whiplash associated disorder
cauda equina syndrome
worsening neurologic condition
RA
cancer
cervical instability
vertebro artery insufficiency
adverse reaction
patient declines
CPR for manipulation success for patients with LBP
- Duration of S/S less than 16 days
- S/S not distal to knee
- FABQ work subscale <19
- At least one hip IR PROM >35°
- Hypomobility at one or more lumbar levels with spring testing
What two symptoms of childs/lynn study are the most important for manipulation and success with LBP
recent onset
no symptoms distal to knee
Biggest mistakes with manual therapies
- not practicing enough
- not screening patients
- Saying all patients need manual therapy or manupulation
- Not adjusting your treatment plan as you go
Transient Side Effects of Manipulation
local discomfort, headache, tiredness, radiating discomfort
usually resolves within 24 hours and rarely lead to impairment
Causes of complication arising from manual therapy
incorrect patient selection
lack of diagnosis and complications
indadequate assessment
wrong forces
lack of consent
poor technique
excessive force, magnitude, leverage
poor positioning
lack of feedback
Contraindications to manipulation
bony issues
nerve issues
vascular
lack of diagnosis
lack of patient consent
Bony issues for manip
tumor
infection
metabolic
congenital
iatrogenic
inflammatory
traumatic
Nerve Issues for manip
cervical myelopathy
cord compression
cauda equina syndrome
nerve root compression
Vascular contraindications for manip
diagnosed vertebrobasilar insufficiency
aortic aneurysm
bleeding diastheses
severe hemophilia
Precautions for spinal manip
adverse reaction to previous manual therapy
disc herniation or prolapse
pregnancy
spndylolisthesis
ligamentous laxity
psychological dependence
Grade 1 mob
small amp
out of resistance
Grade 2 Mob
large amplitude
out of resistance
Grade 3 Mob
large amplitude
into resistance
for pain
Grade 4 Mob
small amplitude
into resistance
for pain
Grade 5 Mob
small amplitude
quick thrust at end range
