L21: Flexion related pain Flashcards
What are the 3 types of flexion pain?
- acute pain with flexion
- fear of flexion
- flexion as habit
What are 9 symptoms of acute pain with flexion?
- Common presentation for acute LBP with or without referred pain or radiculopathy
- Usually a peripheral nociceptive driver
- Flexion consistently aggravates pain- Injured structure being loaded in both positions
- Extension often painful as well- Injured structure being loaded in both positions
- Likely has a directional preference
- May have a lateral shift
- May be a good idea to temporarily limit flexion activities- This is okay temporarily (couple days) if the patient is not tolerating it (eg. struggling to move around)
- Allow to settle in the short term- Give message that limit to flexion is only SHORT TERM
- Needs to go back to going movements as soon as they can tolerate it `
What are 10 education points to explain what acute pain with flexion is?
- Care with implying an ‘injury’ (unless there has been a clear mechanism)
- Pain is more due to chemical sensitivity of tissues, especially to movement
- Reassurance of good outcomes
- Spine is resilient, robust and strong
- Pain and damage are poorly linked
- Use of metaphors (paper cut, bee sting, sunburn)
- Find out what matters to the patient – what do they need to know?
- Role of ‘neutral’ spine may be important here:
- Not ‘rigid’, not ‘avoiding’ movements
- Still loading the spine, just not into highly aggravating symptoms
In acute pain with flexion, We are treating the ‘_____’ to the pain, not an injury or tissue damage.
response
What are the 3 exercise options for acute LBP pain with flexion?
- ROM (managing pain, increasing ROM)- Into most challenging positions
- Exercises to Directional Preference
- Improving tolerance to load – consider neutral positions
What does the amount of exercise depend on?
Amount for exercise depends on patients available time, commitment and goals
What are 4 characteristics of exercise in directional preference with a patient with acute LBP with flexion?
- Temporary
- To manage symptoms
- Allows patient to actively manage their symptoms
- Still maintaining ROM into other directions
What are 4 characteristics of exercise within tolerated ROM with a patient with acute LBP with flexion?
- Adding load
- “Stressing” the spine in a tolerated way
- Desensitising
- Allows patient to recognize their pain is controllable and load is ok
What are 4 other modalities with a patient with acute LBP with flexion?
- Temporary modifications to work activities, driving, postures etc (Eg. change them even for a short while)
- Manual therapy (High velocity thrusts), massage, neurodynamic exercises
- Taping
- Continue other exercise (neutral/upright spine if possible)
When and how do we reintroduce flexion in a patient with acute LBP with flexion?
- Ensure it is only ‘avoided’ in the short term – ensure this is very clear for the patient
- Introduce as soon as possible- Don’t need to have full range of movement to do this
- Introduce in lower loaded, controlled positions:
- Seated
- Supine
- 4 point kneeling
- Progress to more challenging positions
- Let patient know that if symptoms are temporarily aggravated – that is normal and ok
How common is fear of flexion?
Not as common as first and last
- Often seen if they have had an acute episode of LBP
- Negative and false beliefs
What are 6 presentations of a patient with fear of flexion?
- Actively avoiding bending/flexion activities
- May have longer history, history of imaging, given messages of being over vigilant with back (Or breath holding)
- Example: Believes core must be strong and cant bend back too many times
- May demonstrate hypervigilant behaviours and beliefs Pain rising from chair. Going sitting to supine
- Pain transitioning between movements
- Rigid, guarded, inability to relax spine from anticipation or habit rather than pain
- Pain out of flexion (prolonged loading)
- Need to ask if its mechanical or fear (can you not do these movements because pain is stopping you or you are hypervigliant the pain
What are 5 things to consider in a patient with fear of flexion?
- What is the role of fear and expectation?
- What do we need to find out from the patient?
- What is driving the sensitivity to movement?
- Why are they holding themselves in this position?
- Possibly a temporary helper (not flexing) became a bad habit
- Can become sensitive to bending if it is avoided
What are 6 interventions to consider in a patient with fear of flexion?
- Addressing beliefs about their condition and movement
- You spine is designed to go and withstand these movements
- Reduce cognitive threat by re-educating
- Setting goals and being gradual with approach
- Slowly introduce flexion while changing beliefs
- Need to feel safe –> can that they can move their back
- If not wrong –> will reinforce negative beliefs- If done wrong –> will reinforce negative beliefs
- Perform flexion exercises regularly to desensitize
- Do it to get less sensitive 6.Manual therapy and other modalities
What are 6 education pointers for a patient with fear of flexion?
- Reassurance about no serious condition
- Address misconceptions about previous investigations or what has previously been told
- Reduce ‘threat value’ of pain
- Pain they are getting isn’t entirely related to the amount of “injury”
- Pain is more about sensitivity than about tissues or damage
- Why relaxation of the back is important from a physical perspective – consider metaphors.
- Eg. if you keep your wrist straight the whole day. What would happen to you back? Do you think it would be comfortable?
- Importance of normal movement – all movements
What are 6 characteristics of exercise for a patient with fear of flexion?
- Used hand in hand with education
- Starting with what is tolerated – side flexion, supine, 4 point kneeling
- showing the patient they can flex the spine
- Progress to standing and sitting exercises to allow flexion
- Adding side bending, twisting
- Introduce functional activities
- Use feedback
- watching in mirror
- Give some confidence and make sure they are relaxed and unguarded
What are 4 other interventions for a patient with fear of flexion?
- Breathing
- Hands on feedback
- Discourage ‘safety’ behaviours
- Showing the patient they CAN tolerate movements
What are 2 characteristics of manual therapy for a patient with fear of flexion?
- Manual therapy can still play a role
- Appropriate explanation about the role of manual therapy
What are 3 characteristics of motor control for a patient with fear of flexion?
- Yes – but reframed in a different way – rather than ‘strengthening’ and ‘protecting’
- Motor control type exercises can encourage cognitive awareness of movement
- Squats? 4 point kneel to heels?
What is a flexion as a habit for a patient?
- Flexion control impairment
- Habitual end range loading
What are 9 characteristics of a patient with a flexion habit?
- Gradual onset LBP regular flexion based activities
- Symptoms worsening with prolonged flexion based activities (ie rowing, cycling, work activities, sitting).
- Might be challenging to work out from interview that pain is due to repeated end range activity
- History taking - increasing flexion activities? Increasing stress on spine?
- MALADAPTIVE – consistent loading in end range postures
- Flexion behaviours on functional tasks, squats, sitting
- Consider other contributing factors – hamstring flexibility limiting anterior pelvic tilt
- Poor awareness of movement? – difficulty dissociating lumbo-pelvic movements (Keep their back in a certain position) on motor control tests?
- Consider symptom modification tests
What are 6 education pointers for a patient with flexion as a habit?
- Need to unload sensitive structures from end range positions.
- NOT injury or damage
- Why have they maintained this habit? Lack of awareness? Loss of control to movement?
- Key is CHANGING habit
- Posture/technique does not have to be perfect
- Care needed to ensure we don’t contribute to unhelpful beliefs
What are 6 characteristics of exercise with flexion as a habit?
- Managing impairments
- Restoring anterior pelvic tilt & lumbo-pelvic dissociation
- Motor control exercises to manage flexion moment
