L4: Outcome measures and repeated movement exam Flashcards
What are 3 scenarios when repeated movements are done?
- Has pain
- Acute or subacute pain
- Very rarely done with overpressure and combined movements
When is overpressure movements done?
No pain
What are 2 questions that need to asked?
- Do symptoms change with repeated movements?
- Do symptoms change if task or movement is modified?
What is the purpose of repeated movements?
A patient’s symptom response to repeated movements can tell us their ‘directional preference’ to movement
What is the directional preference?
a position or movement that needs to either be repeatedly loaded or the position sustained to significantly improve one or more of the following:
- Range of movement
- Pain
- Intensity AND/OR location
- centralization: when symptoms move proximally (Out of distal area into the central area (eg. out of leg into back))
- research shows finding the directional preference and centralizing symptoms is an excellent prognostic indicator of successful outcomes in LBP
To understand the patient’s directional preference to movement, what are 2 things we are looking for?
centralisation of symptoms or an improvement in symptoms (from interview and physical exam)
The most common directional preference in acute and sub-acute LBP is _______ (flexion/extension)
extension
______ is a positive prognostic sign in acute and sub-acute LBP
Centralisation
What are 2 questions to ask about easing factors in regards to back pain?
- Are there any movements or positions that reduce the pain? If not….
- What happens when you get up from sitting and walk around?
What are 2 things to find from the physical assessment?
- AROM assessment
- Repeated movement assessment
Why is a directional preference relevant?
Approximately 70-89% of LBP patients have a directional preference
A directional preference to _____ (flexion/extension) is most common.
extension
Exercises to directional preference have _____ (better/worse) outcomes for those with acute LBP in the short and medium term
better
Why is it important to know a patient’s directional preference?
This can influence the exercises we give, strategies to ease symptoms and giving patients strategies for when future occurrences of LBP may occur
Not all patients will exhibit a ________. For others it will be clearly obvious (from the aggravating and easing factors and repeated movement assessment)
directional preference
What happens if the patient is pain-free on ROM (back pain)?
This is unlikely in those with acute pain, however… We can still do repeated movements (extension usually) and then re-assess a functional task that they have pain with.
Those with acute LBP are painful with ALL ______positions. So if someone hurts with prolonged sitting AND standing, this is normal!
prolonged
I hurt for everything –> what is their directional preference? What do you ask?
This is normal so cannot often use prolonged positions
Rather, ask what positions make it get better
How many times do you do repeated movements?
5-10 times
Get better, worse or stays the same
Tell the patient how this helps with management of treatment
What are 4 reasons why we do manual examination?
- Patient’s expect and appreciate it –> feel like they are getting full services
- Observe sensitivity and pain
- Hyperalgesia
- Allodynia
- Palpate important soft tissue, muscle bulk
- Manually observe the spinal
What are 5 structures to palpate in the manual examination?
- Bony landmarks
- Long & segmental muscles
- QL
- Pelvic crest
- Buttock muscles (where appropriate)
What are 4 things we assess in the manual examination?
- Hyperalgesia
- Allodynia
- Hypertrophy or Atrophy
- Replication of patient symptoms
What are 3 characteristics of PAIVMs?
- Passive accessory intervertebral movements
- Higher reliability
- Used to assess intervertebral motion and pain at segment
What are 3 characteristics of PPIVMs?
- Passive physiological intervertebral movements
- Low reliability
- Used to assess intervertebral motion
Both PAIVMs and PPIVMs can be provocative test to determine ______ origin of symptoms - particularly PAIVMs
segmental
Basic test of the properties of the _____ tissue of the segment. Qualitative estimate of motion & tissue resistance to motion
visco-elastic
What are 3 purposes to use PAIVMs?
- Used to determine or confirm painful/reactive level To assess intervertebral motion (hypomobility) – moderate reliability
- Used to ‘clear’ the lumbar spine in cases of buttock, hip, groin, leg pain
- Not getting referred pain
What are 4 purpose to use PPVIMs?
- To assess intervertebral motion (flexion or rotation) – low reliability
- Used to find segment (flexion PPIVM) to then perform manual therapy
- If patient has full/normal ROM – unlikely to provide information
- Only if the patient can’t tolerate prone position
What are 3 main outcomes and diagnosis?
- Postural assessment
- Active assessment
- Manual assessment
Example Case: Patient who is office worker has acute unilateral LBP (acute sprain), difficulty with all movements, pain with sitting at work, prolonged positions and relieved with standing and walking, changing positions.
What are 3 observations?
- Observe standing (particularly for lateral shift)
- Observe functional task (sit to stand or anything else that is difficult)
- Observe sitting (to see posture, anterior/posterior pelvic tilt and if adjusting posture changes symptoms)
Example Case: Patient who is office worker has acute unilateral LBP (acute sprain), difficulty with all movements, pain with sitting at work, prolonged positions and relieved with standing and walking, changing positions.
What are 3 movement exam tests?
- AROM (with overpressure if painfree)
- Repeated movements (extension as indicated from interview)
- Reassess a functional task if unable to see improvement with extension in standing
Example Case: Patient who is office worker has acute unilateral LBP (acute sprain), difficulty with all movements, pain with sitting at work, prolonged positions and relieved with standing and walking, changing positions.
What are 3 manual exam tests?
- Palpation
- Central and unilateral PAIVM (if patient can tolerate prone)
- Flexion PPVIM (if flexion on ROM is limited and/or painful)
Example Case: Patient plays recreational tennis, 8 week history of mild unilateral back pain with increasing training. Pain only with tennis serving > 10 mins and sometimes when running after about 2km. No pain on other activities.
What are 3 observations?
- Observe standing
- Observe functional tasks where possible (running, tennis)
- Motor control tests in standing if relevant for this patient
Example Case: Patient plays recreational tennis, 8 week history of mild unilateral back pain with increasing training. Pain only with tennis serving > 10 mins and sometimes when running after about 2km. No pain on other activities.
What are 2 movement exam tests?
- AROM (with overpressure if painfree)
- Combined movements into lumbar extension quadrant – compare sides – add overpressure if painfree
Example Case: Patient plays recreational tennis, 8 week history of mild unilateral back pain with increasing training. Pain only with tennis serving > 10 mins and sometimes when running after about 2km. No pain on other activities.
What are 3 manual exam tests?
- Palpation
- Central and unilateral PAIVM
- PPIVM (only if there is significant restriction and/or pain on movement tests)
- Quite unlikely because he has full ROM
What are 3 uses of screening tools?
- Tools have been developed based on epidemiological research that report risk factors
- Often considered as ‘diagnostic triage’ to identify those at risk of poor recovery.
- Early identification of at-risk patients allows clinicians to make informed decisions based on prognostic profile
What is the use of outcome measures?
Worksafe, workcover and insurance providers expect that all healthcare providers who provide services for longer than 4-6 weeks will use standardised or customised outcome measures to assist in the clinical justification of their services.
What are 2 functional measure (pelvic and lumbar)?
- Roland-Morris Functional Questionnaire
- Oswestry Disability Index/Questionnaire
To establish functional level, to determine change over time
What is the purpose of functional measures?
To establish functional level, to determine change over time How disable they are due to their back pain (based on scores)
What are 3 risk identification tools?
- Keele STarT Back Screening Tool Acute LBP
- Orebro Musculoskeletal Pain Questionnaire (OMPQ)
- Fear-Avoidance Beliefs Questionnaire (FABQ) Any MSK pain
What are 2 purposes of risk identification tools?
- To determine modifiable risk factors for developing persistent pain (in those with acute LBP)
- To determine psychosocial and behavioural contributions in those with pain
What is the Roland-Morris Functional Questionnaire?
HOW DISABLE THE PATIENT IS (BASED ON ACUTE BACK PAIN)
- 24 items
- YES or NO
- Gives us a 0-24 measure
- Quick and easy measure
What is the Oswestry Disability Index/Questionnaire?
Rate from 0-5 with difficulty of tasks
10 times on list
Total: / 50
What is the Orebro Musculoskeletal Pain Questionnaire?
- Psychosocial risk factors
- General to MSK issues
- Esp. for persistent pain
What is the START Back Screening Tool?
Recommended with every person with LBP
Stratified care = better outcomes
Low (3 or less) , medium or high score ○ /9
What is the aim of the START Back Screening Tool?
Aimed to determine the effect of risk-stratified care for 1,647 patients with LBP.
How does the START Back Screening Tool work?
Classified patients into groups at low, medium, or high risk for persistent disability and provision of risk-matched treatment.
What is a low risk patient in the START Back Screening Tool?
basic patient education and self management - 3 or less on all the questions
What is a medium risk patient in the START Back Screening Tool?
physiotherapy management (approx 6 sessions) utilised to decrease levels of pain and disability. Exercise with or without manual therapy.
Physio and some GP
What is a high risk patient in the START Back Screening Tool?
managed using stratified care, received more health care overall (physician consultations, physiotherapy, mild opioids)
Care from multidisciplinary care (as well as psychologist)
The biggest improvement when using the START Back Screening Tool is with the ______ (low/medium/high) risk patients.
high
Must have different management care for ______risk levels
different
Other outcomes in the ________ included physician change in risk-appropriate referral to physiotherapy, medication prescriptions, and sickness certificates.
START Back Screening Tool
Stratified care for back pain lead to significant _______ (improvements/deteriorations) in patient disability outcomes and a halving in time off work, without increasing health care costs.
improvements
The STarT Back Tool demonstrated good ______performance for non-specific low back pain in ____ (primary/secondary)care.
predictive; primary
What is the Fear-Avoidance Beliefs Questionnaire?
- Suspect if they have poor beliefs…etc
- Used from behaviour or interview
- Seem fearful or avoidant or hesitant
- Work out what they are fearful about –> can target in the management (advice and education) –> increase physical activity in ways the believe are safe
_____ care can improve patient disability outcomes and time off work
Stratified
____ and ____ objective tools are needed (in addition to PSFS) to show patient change over time
Valid; reliable
_____ tools can help us identify risks to address with the patient and/or modify our management approach
Objective
