L20: Other Management Strategies Flashcards
What are 2 ways to target the treatment choice?
- Use information directly from subjective
- Work, aggravating factors, concerns, sports or other activities, history.
- Identifying potential underlying causes
- Use information from physical from both
- What we observe or consider could be underlying reasons they have pain
- Impairments we find in the physical – including whether we can modify symptoms
What is the treatment (based on impairments) for over-bracing on movements from observation of the physical exam?
- Teach unguarded movements and postures, practicing relaxed movements.
- Advice and education
- Reframe their fears and then show them
What is the treatment (based on impairments) for improvement with correcting the lateral shift from observation of the physical exam?
Correct lateral shift – exercise to correct lateral shift
What is the treatment (based on impairments) for improvement with changing pelvic tilt in sitting or standing from observation of the physical exam?
Consider postural correction
What is the treatment (based on impairments) for observing problematic postures on static or dynamic activities associated with symptoms from observation of the physical exam?
Provide correction or modification – consider other relevant personnel to assist (eg coach, cycle fit, workplace ergonomic assessment)
What is the treatment (based on impairments) for avoidance of movement due to fear of symptoms (Hypervigilant) from functional tests and ROM of the physical exam?
Education, reassurance and exercises to improve confidence
- Break movement down to something easier, but still challenges their fears and beahviours
What is the treatment (based on impairments) for bracing and breath holding from functional tests and ROM of the physical exam?
Teach movements that they can do which encourage ROM giving feedback to relax muscles and continue breathing
What is the treatment (based on impairments) for restriction in ROM from functional tests and ROM of the physical exam?
Consider manual examination –> manual therapy, exercise
What is the treatment (based on impairments) for pain on ROM from functional tests and ROM of the physical exam?
Consider manual examination –> manual therapy, exercise
What is the treatment (based on impairments) for centralisation or improved pain and ROM on repeated movement from functional tests and ROM of the physical exam?
Consider repeated movement exercises, advice, manual therapy
What is the treatment (based on impairments) for stiffness, pain on manual examination from manual examination, motor control assessment and strength tests of the physical exam?
Manual therapy
What is the treatment (based on impairments) for difficulty with motor control tests from manual examination, motor control assessment and strength tests of the physical exam?
Start training at a level the patient can tolerate – functionally relevant where possible
What is the treatment (based on impairments) for muscle length tests from manual examination, motor control assessment and strength tests of the physical exam?
- Often this is secondary to a strength/motor control deficit or secondary to adaptive/maladaptive behaviours
- Consider strengthening, stretches, foam roller, massage – or if compensation for something else – consider other management strategies
- Don’t have to lengthen before loading- when loaded, will become more flexible as well
What is the treatment (based on impairments) for muscle strength test from manual examination, motor control assessment and strength tests of the physical exam?
Exercise – strengthening to fatigue at load tolerated by patient
What is the manipulation clinical prediction rule?
Predicted improved results (pain and function) with spinal manipulation vs exercise response
4 out of 5 criteria: 92%
3 out of 5 criteria: 68%
2 out of 5 criteria: 49%
1 out of 5 criteria: 46%
Success considered a 50% reduction in disability measure
Should we measure all the things in the manipulation clinical prediction rule for all patients?
- It provides us with some insight into who may be best suited for manipulation approaches.
- Other research suggests; no symptoms distal to knee and onset of pain less than 16 days are easily measurable and likely effective.
- Exact reasons are not fully understood Effect is thought to occur through:
- Cavitation that releases local pain mediators (gapping facet joint)
- A BIG sensory input – neurophysiological effect
- Increases ROM
- Facilitates muscle relaxation
What are 5 co-existing conditions which are contraindications for manipulation?
- Any pathology that leads to significant bone weakening (osteoporosis)
- Significant structural deformity (significant scoliosis)
- Structural instability (symptomatic spondylolisthesis)
- Inflammatory conditions (ie Ankylosis Spondylitis)
- Vascular deficits: aortic aneurism, bleeding disorders
- Do you have any conditions that wall cause weakening of your bones?
- Any circulatory conditions
What are 3 neurological considerations which are contraindications for manipulation?
- Neurological signs or symptoms
- Not an absolute contraindication but should be used not on patient with significant neurological symptoms
- Potential cord compression
- Should not be used with manual therapy
- Cauda Equina symptoms (or any other red flag)- Should not be used with manual therapy
What are 2 other contraindications for manipulation not including co-existing conditions and neurological considerations?
- Non-mechanical symptoms
- Patient positioning can not be achieved because of pain or resistance.
What is the advice and education for treatment for mechanosensitivity?
- Aimed at reducing threat value
- Messages; the nervous system is well designed to move, appreciating the mechanical continuity of the nervous system
- Understanding the behaviour of peripheral neuropathic pain can reduce the threat value and alter any unhelpful beliefs
- Discuss the nervous system with the patient
- That is it sensitive
- Nerve is sensitive to stretch and compression
- Mechanosensitivity is a contributing factor for tehir pain –> Let them know that
What is the self-management treatment for mechanosensitivity?
Modification to aggravating tasks for example
What is addressing other impairments (exercise and manual therapy) as treatment for mechanosensitivity?
- Impairments found in muscle and articular systems and movement behaviours
- What other findings that are found with mechanosensitivity?
- Increased sensitivity in the pathway of the nerves (eg. neural foramen)
What is neural tissue mobilisation techniques as treatment for mechanosensitivity?
Focus on restoring the ability of the nervous system to tolerate normal forces.
To patient: “ To try and reduce sensitivity as it its quite sensitive at the moment and get it moving a bit more”
What is the treatment of mechanosensitivity in the nervous system?
Neurodynamics
What are neurodynamics?
Neurodynamics refers to the mechanical and physiological components of the nervous system and the interconnections between them
How does neurodynamics work?
The nervous system needs to adapt to mechanical loads such as elongation, sliding, cross-sectional change, angulation, and compression.
What are 4 potential physical signs for neurodynamics?
- Posture: adopts an out of tension posture (e.g. standing with knee bent/ ankle PF to take tension off NR and sciatic nerve)
- Active movements: impairment to movement, (those that compromise space / add movement or load) reinforced with additional manoeuvres
- Passive movement impairment: Comparable and relevant to active movements including e.g. Straight leg raise (SLR), Prone knee bend (PKB), Passive neck flexion (PNF)
- Nerve trunk hyperalgesia/allodynia: nerves tender to palpation
What is the aim of neurodynamic treatments?
Treatment is aimed at neural structures and their mechanical interface
Move nerve, change its tolerance to moving and reduce sensitivity
- Can often be the connective tissue –> not always the nerve
- Can target interface or nerve or both (neurodynamic techqniue)
What are the 3 mechanical parts in neurodynamic treatment?
- neural structures
- innervated tissues
- a mechanical interface. The mechanical interface is defined as the structure(s) that surround the nervous system
What are the 2 ways that altered neurodynamics can be managed?
- treating the nerve (gentle direct neural mobilisation)
- treating the interface (the neighbouring joint or muscle) mobilisation, massage, stretches
What is the difference between massage manual therapy and neurodynamics?
- Massage manual therapy can be used to reduce sensitivity of interface
- Neurodynamic can be used to reduce sensitivity of interface and nerve
What are 6 mechanical, pain related or neural conduction related effects of neurodynamics?
- facilitation of nerve gliding
- reduction of nerve adherence
- increased neural vascularity
- improvement of axoplasmic flow
- reduced sensitivity related to neural movement and loading
- stimulation of large afferent inhibitory fibres
It has been suggested that neural mobilization is an effective treatment modality, although largely anecdotal
What are the 4 different groups that are suitable for neurodynamics?
- Neuropathic sensitization (neuropathic pain with allodynia, hyperalgesia)
- Denervation (significant axonal compromise with sensory/motor loss)
- Peripheral nerve sensitization (positive neurodynamic)
- Musculoskeletal pain (somatic referral)
Treatment included lateral flexion technique and neurodynamic exercises
The peripheral nerve sensitization group showed the greatest response to treatment when compared to the other groups on RMQ, Pain VAS and a global perceived change scale.
There were significant improvements in a 3 week program, consisting of what 3 things?
- slump stretching (30 seconds/session)
- lumbar manual therapy
- exercise
In participants with non-radicular low back pain compared to a group of participants receiving only manual therapy and exercise. They found statistically significant improvements for pain and function > than the control group The results suggest that slump stretching is beneficial for improving shortterm disability, pain, and centralization of symptoms.
It is more effective is you use ____ and ____ combined with neurodynamics.
manual therapy; exercise
What are 2 general guidelines for irritable symptoms when doing neurodynamics?
- Always use gentle, non provocative treatment approaches
- Direct movement of the nerve via specific limb movement
What are 5 guidelines in the initial technique for irritable symptoms when doing neurodynamics?
- Use of technique well removed from area
- No provocation of symptoms
- Consider potential latency
- Use gentle, slow, large amplitude movements, it is often better to direct the patient to perform these techniques as active movements application about 10 – 20 secs
- Reassess often, warn patient of symptoms worsening and advise to discontinue
What is a slider neurodynamic technique?
elongating the nerve at one joint, while simultaneously shortening it at another
What are the 2 techniques of neurodynamics?
- Slider
- Tensioner
What is the IE for sliders?
IE = SLR position flexing knee while dorsiflexing ankle
IE = Slump position moving head into extension while dorsiflexing ankle.
What are the 3 characteristics of slider techniques in neurodynamics?
- Less irritable, less symptom provocation, helps decrease perceived threat.
- Less aggressive – more appropriate for acute conditions
- Can be more complicated to teach and demonstrate
- Can be more time consuming and can hard to do
What is the IE for tensioner?
IE = slump position and flexing neck OR dorsiflexing ankle
IE = SLR position and moving foot on/off dorsiflexion
What is a tensioner neurodynamic technique?
using sensitizing components to “tension” – thought of as “pulling” on both ends
What are the 2 characteristics of tensioner techniques in neurodynamics?
- Mild symptoms, less irritable symptoms
- May reduce intraneural pressure and improve circulation
- Nerve sensitivity under tension
What does the sciatic nerve slider with patient with irritability and high severity look like?
Increasing stretch at foot
Decreasing stretch at head
What are 4 progressions of sciatic nerve slider with patient with irritability and high severity?
- Increase number and amplitude (More effective)
- Technique repeated with nerve under more load (e.g. perform ankle DF in 10 degrees of SLR)
- Use a movement component closer to the symptomatic area
- Patient can be taught self mobilising procedures, this will ensure that treatment is non provocative
What does a sciatic nerve slider look like (moderate)?
This is where you start for most patients who have some symptoms
Back and forth –> in and out of positions
What is a progression of the sciatic nerve slider?
by adding tension
What does a sciatic nerve slider (very mild symptoms) look like?
Very mild symptoms –> pretty comfortable in posterior pelvic tilt
What does a sciatic nerve tensioner look like?
What does a progressive sciatic nerve tensioner look like?
What does a femoral nerve slider look like?
What is the treatment of the interface in segmental mobilisation?
Lumbar segmental mobilisation techniques will move the interface in relation to the nerve roots and spinal nerves
What position should the patient be put in if they have more irritable or severe symptoms?
More irritability/severity = neural tissue in a relaxed, non stressed position (with the hip and knee flexed, hip abducted).
What are the 2 progressions for neural tissue in the treatment of interface?
- Moving / gliding the nerve while joint mobilisation is being performed
- Putting the nerve in a lengthened positioned when performing mobilisation
What are the 3 massage/stretches which is treatment aimed at interface?
- Along path of nerve – interfaces
- Trigger points/ along the path of the nerve
- Sciatic nerve: Piriformis, Hamstring, Calf
- Femoral – Quadricep
What are 2 other modalities in LBP management?
- Massage
- Taping
What is massage?
When moderate and light pressure massage was compared, only moderate pressure contributed to improve pain and anxiety
What are the 3 effects of moderate pressure massage?
- modifying neurophysiological parameters such as heart rate & vagal activity
- decreased cortisol levels with enhanced serotonin and dopamine levels
- influences cortical and spinal excitability and inhibits nociceptive responses at a subcortical and cortical level
There is high efficacy of massage when combined with ____ and _____.
education; exercise
What are the 2 types of tape?
- Rigid
- Kinesiotape
What are the 5 theories with rigid taping of LBP?
- Providing support
- Providing support
- ‘Unloading’
- Muscle inhibition
- Reminder re positions to avoid
- Proprioceptive effect
Why can rigid tape sometimes be confusing?
confusing messages
- This is temporarily (while pain settles)
- Reminder to aggravate positions
- But it is important to go back to bending it as soon as possible once that tape is taken off
What are the 3 theories with kinesiotape of LBP?
- Proprioceptive effect- Sensory input
- Muscle inhibition or facilitation
- Psychological benefit
Used more frequently than rigid in acute
- It doesn’t mechanically stop movement
- Give strong sensory and proprioception input and gives patient awareness
Which tape is more commonly used?
Kinesiosiotape > Rigid
What are the 4 benefits (shown improvements) with kinesiotape?
- disability
- pain
- isometric endurance of the trunk muscles
- trunk flexion range of motion
However, the effects were generally small and not maintained
Is there any benefit to adding stretch for kinesiotape?
adding stretch does not significantly change outcomes
When do you tape the SIJ? Why?
Try this before use the SIJ belt
- Can be more tolerable, easier for athletes
Is there any benefit for using taping in radiculopathy?
- Lift up buttock and side of leg to give support
- Can also give taping on lower back
Moderate-quality evidence that _____ combined with _____ reduces the risk of an episode of LBP.
exercise; education
Engaging in long term consistent formal exercise –> best way to prevent LBP
Low- to very low–quality evidence suggested that _____ alone may reduce the risk of both an LBP episode and use of sick leave.
exercise
_____ and ____ reduce the risk of an episode of low back pain in the next year by 45%, whereas exercise alone reduced the risk by 35%.
Exercise; education
What is the best way to prevent LBP?
Engaging in long term consistent formal exercise –> best way to prevent LBP
History of BP = risk for recurrent BP
What are 4 situations to discontinue treatment of a patient?
- When the patient is relatively pain-free?? (only if this is a realistic, mutually-agreed goal)
- SMART goal (eg. 90% better, engage in more exercise, until reach a certain event)
- When the patient is able to self-manage their symptoms-
- They know what to do
- They know whst the long term plan is
- If the patient is not improving with appropriate treatment- No responding after 4-6 weeks –> seen by another, referred on
- If the patient is consistently worsening
