LBP with Movement Coordination Impairments Flashcards
What are the 3 subsystems of functional spinal stability?
- Neural (The neurological structures responsible for coordinating muscle contraction through CNS and PNS)
- Passive (Bone, joint, lig., disc)
- Active (Musculature)
With the proposed underlying causes of movement coordination impairments, what are the 2 zones of the spine? What is Clinical Instability?
- Neutral Zone
–Motion around mid-positon; minimal passive resistance. (similar to loose-packed position) - Elastice Zone
–Motion around end-range; against passive resistance
Clinical Instability:
- Increased size of the neutral zone
- Reduction of passive resistance to motion in elastic zone
- Inability for the active and neutral subsystem to accommodate this lack of passive control
With the proposed underlying causes of movement coordination impairments, what happens if the patients has Recurrent Sprains/Strains?
–What are some ways a patient can get these recurrent sprains/strains?
This results in increased extensibility of the passive structures in the presence of muscle performance deficits are the likely impairments of body structure and function that are contributing to the patients symptoms.
- Recurrent strain to lig., muscle, tendinous, and/or joint tissues including the after effects of disk herniations can be cause by:
–prolonged end-range positioning;
–stress from awkward and dysfunctional movement pattern - Muscle performance deficit can be caused by lack of coordination and endurance; as well as flexibility and strength
What is the proposed underlying cause of the condition?
Spondylolysis (this most often occurs after a hyperextension to the lumbar spine)
- Pars articularis Fracture
Sponylolisthesis
- Bilateral pars articularis fracture
- Facet degeneration
- Muslce performance deficits of lumbar spine and lower quarter musculature
–Coordination and endurance
–Flexibility and strength
With the proposed underlying causes of movement coordination impairments, what are Local Muscle Performance Deficits?
Impairment coordination and Endurance
- Lumbar Multifidus
(Provides control via segmental attachments posteriorly) - Transverse Abdominus
(Provides control anteriorly)
Should be addressed initially
With the proposed underlying causes of movement coordination impairments, are Global Muscle Performance Deficits?
Impaired Flexibility, Coordination, and Resting Tone
- Rectus Abdominis
- Internal Oblique
- Extenal Oblique
- Erector Spinae
What system, structure, pain mechanism, and Phase of healing is unique to this patient presentation?
System:
- MSK
Structure:
- Bones
- Muscles, tendons,, Ligaments and Disc
- Nervous System
Pain Mechanism:
- Nociceptive
Phase of Healing:
- Disk/Annulus tear 10-12 weeks; Bone 6-8 weeks
Subjective Exam
What are General Sx with Pts with Movement Coordination Impairments?
- Recurrent LBP and related referred LE pain
- Possibly a Hx of trauma
- Reports of “giving out”, “catching”, or muscle spasms
- Fatigue, pain, “tightness” maintaining upright static postures
- Sharp pain, possibly with sudden movements
- Difficulty with forward bending
- Need for external support or lying in a supported position
- Frequent need for self-manipulation
Subjective Exam
What are some Agg/Easing Factors for this patient?
Agg
- Prolonged Static weight-bearing positions
–Prolonged sitting or standing - Uncontrolled movments
- Transitional movements
–Sit to/from stand
–Bending forward
Ease
- Changing positions
–Sitting to standing or stanind to sitting
–Anterior Pelvic tilt to/from posterior pelvic tilt - Non-weight bearing positions or neutral positions
- Lumbar AROM and stretching
- Self-manipulations
- Back rest support in sitting or back brace
Whats the 24hr pain behavior for this patient?
Morning
- Often patient wakes up without LBP, may be the BEST time of day
Noon to evening
- Sx may vary throughout the day depending on the patients activities
- May have increased pain with maintaining static positions that worsens through the day
- End of day may be WORST time of day
Night
- Sx may improve with assuming supported non-weightbearing positions in bed
Patients with Movement Coordination Impairments may have Spondylolithesis, what are some test and measures that may be done together during the Structural Exam?
Palpation, may find:
- Lower Lumbar Step
- Horizontal banding, Increased Muscle Tone
Lumbar Posterior Shear Test (this test for the translation of the segment)
During the Movement and Provocation Exam, what may we find with AROM?
- Excessive spinal motion
- Aberrant motions
–Altered lumbopelvic rhythm, Gower’s sign, deviation from the sagittal plane, instability catch, shake, judder, painful arch - Poor recruitment and disassociation of the lumbopelvic region
- Motions that is not smooth regardlass of speed throughout ROM including segmental hinging, pivoring and fulcruming
Aberrant Pattern
With AROM we me find Altered Lumbopelvic rhythm, what does this mean?
In forward bending, hip motion greater than lumbar spine motion during the first third of the movement and/or lumbar spine motion greater than hip motion during the last third of the movement
Aberrent Pattern
With AROM we me find Gowers sign, what does this mean?
In return to upright, lumbar spine motion greater than hip motion during the first third of the movement and or hip motion greater than lumbar spine motion during the last third of the movement
Aberrant pattern
With AROM we me find Deviation from sagittal plane, what does this mean?
Return to upright stance performed by using hands to climb up the thighs, which is considered a type of altered lumbopelvic rhythm
With AROM we me find Instability, catch, shake or judder, what does this mean?
A sudden acceleration, stop, or deceleration; observations of a momentary quiver, vibration, or shake seen in the paravertebral muscles; or brief out of plane movement
With AROM we me find Painful arc of motion, what does this mean?
Pain noted by the patient that increases through a portion of the total arc of movement; a general increase in pain throughout the motion does not constitute arc
During the Movement and Provocation Exam, what may we find with Passive intervertebral Motion (PIVM)?
- Hypermobility at involved segment(s) with loose end-feel
- Low back and related LE pain reproduced with provocation of the involved segments
- Possible hypomobilities at adjacent segments
With patients with LBP with Movement Coordination Impairments, what are some Orthopaedic Exams you can do?
- Prone Instability Test
- Prone Lumbar Extension test
With patients with LBP with Movement Coordination Impairments, what is a Orthopaedic Exam you can do to rule in/out SI Joint?
Laslett Provocation Cluster (4-item or 6-item)
- Thigh Trust (Most Sensitive)
- ASIS Distraction (Most Specific)
- ASIS Compression
- Sacral Trust
- Gaenslen’s Right (6-item only)
- Gaenslen’s Left (6-item only)
The first 4 test are part of a 4-item cluster, once there is 2/4 (+) there is no longer need for further testing and SIJ pain is suspected
When conducting the Muscle Performance Examination, what muscles do you test when testing Muscle Recruitment and Endurance?
- TA
- Lumbar Multifidus
- QL
- Diaphragm
- Glute Med., and Min.
- Glute Max.
When conducting the Muscle Performance Exam, what muscles should we MLT?
- Hamstrings
- Psoas Major
- Rectus Femoris
- Piriformis
- QL
With LBP with Movement Coordination Impairments, what is the Diagnostic Test-Item Cluster?
- =/> 53° of lumbar AROM
–Measured with Dual Inclinometer - Lack of hypomobility with central PA accessory motion testing
What is the Clinical Course and Prognosis of LBP with Movement Coordination Impairments?
- Acute LBP is self-limiting with 90% of patients recovering within 6 weeks
- Recurrence rates from 40-80%have been reported
- Chronic LBP has more variable clinical course with a less favorable prognosis
What are some factors that may impact new or recurrence of LBP with Mobility Deficit?
- Female gender
- Olde age
- Educational status
- Physcially demanding occupation
- HTN
- Lifestyle (smoking, overweight/obesity)
- High activity/sedentary
- Hx of previous episode
- Excessive spine mobility
- Excessive mobility in other joints
What are some factors the may impact Prognosis?
- Sx below the knee
- Psychological distress or depression
- Low expectations of recovery
- Fear of pain, movement, or reinjury
- Higher pain intensity
- Passive coping style
How would a patient present if they have LBP with Movement Coordination Impairments in the Acute stage of healing?
- Severity and irritability are often high
- Pain at rest or with initial to mid-range spinal movements: before tissue resistance
- Pain control is often the intervention goal at this stage
How would a patient present if they have LBP with Movement Coordination Impairments in the Subacute stage of healing?
- Severity and Irritability are often moderate
- Pain experienced with mid-range motions that worsen with end-range spinal movements: at tissue resistance
- Movement control is often the intervention goal at this stage
How would a patient present if they have LBP with Movement Coordination Impairments in the Chronic stage of healing?
- Severity and Irritability are often low
- Pain that worsens with sustained end-range spinal movements or positions: Overpressure into tissue resistance
- Functional Optimization is often the intervention goal at this stage
General Education
During the interventions portion of the rehab, when educating the patient, what should and what should the therapist not do?
Should Not
- Increase the perceived threat or fear
- Promote extended bed rest
- Provide in-depth anatomical explanations
Should
- Promote the inheret strength of the spine
- Neuroscience that explains pain perception
- Favorable prognosis
- Active copoing strategies
- Early resumption of activities
- Importance of improvement in activity levels
What are Interventions recommended by the clinical practice guidelines for patients in the Acute stage?
Education, Exercise, Manual Therapy
Education
- Advice to pursue an active lifestyle
- Favorable natural Hx of acute LBP
- Self-management techniques
–Postures and movements that maintain neutral, symptoms allegiating positions
–Temporary use of external support
–Routine participation in activites that promote the maintenance of improve movement coordination
Exercise
- Specific trunk activation training to promote dynamic (muscular) stability to maintain the involved lumbosacral structure in less symptomatic, mid-range positions
- Trunk muscle strengthening and endurance exercise to address indentified trunk and pelvic-region movement system impairment
Manual Therapy
- Thrust and non-trust manipulation and soft tissue mobilization, and massage to diminish pain, reduce disability, improved thorax and hip mobility, and mobilize hypomobility lumbopelvic segments
What are Interventions recommended by the clinical practice guidelines for patients in the Subcute stage?
Education, Exercise, Manual Therapy
Education
- Advice to pursue an active lifestyle
- Favorable natural Hx of acute LBP
- Self-management techniques
–Postures and movements that maintain neutral, symptoms allegiating positions
–Routine participation in activites that promote the maintenance of improve movement coordination
Exercise
- Specific trunk activation training to promote dynamic (muscular) stability to maintain the involved lumbosacral structures in less symptomatic, mid-range positions while performing self-care and work-related functional activities
Manual Therapy
- Thrust and non-trust manipulation and soft tissue mobilization, and massage to diminish pain, reduce disability, improved thorax and hip mobility, and mobilize hypomobility lumbopelvic segments
What are Interventions recommended by the clinical practice guidelines for patients in the Chronic stage?
Education, Exercise, Manual Therapy
Education
- Advice to pursure an active lifestyle
- Pain neuroscience education
- Self-management techniques
–Postures and movements that maintain neutral, symptoms allegiating positions
–Routine participation in activites that promote the maintenance of improve movement coordination
Exercise
- Specific trunk activation training to promote dynamic (muscular) stability to maintain the involved lumbosacral structures in less symptomatic, mid-range positions while performing household, community, occupational or recreational activities
- Trunk muscle strengthening and endurance exercises to address identified trunkl and pelvic-region movement system impairments
Manual Therapy
- Thrust and non-trust manipulation and soft tissue mobilization, and massage to diminish pain, reduce disability, improved thorax and hip mobility, and mobilize hypomobility lumbopelvic segments
What is the Clinical Prediction Rule for Lumbar Stabilization Exercise Program?
- (+) Prone Instability Test
- Aberrant motions present
- Age < 41 (Most Significant)
- SLR > 91°
What is the Clinical Prediction Rule of Failure for Lumbar Stabilization Exercise Program?
- Negative (+) Prone Instability Test
- Hypomobility with PAIVM testing
- Aberrant motions absent
- FABQpa score </=9
