LBP with Referred Pain Flashcards
What is the proposed underlying cause of this condition?
Lumbar Discogenic Pain
-Degenerative Changes to the disk
What is the Differential Diagnosis for this presentation?
- LBP with Radiating pain
- LBP with mobility deficits
- LBP with movement coordination impairments
- LBP with cognitive and affective tendencies
- LBP with generalized pain
What system, structure, pain mechanism, and phases of healing are unique to patients with LBP with Referred Pain?
System
- Musculoskeletal
Structure
- Disk
Pain Mechanism
- Nociceptive
Phase of healing
- Disk/Annulus tear 10-12 weeks
What are common subjective reports for these patients?
- May be gradual or immediate onset of local and somatic referred LBP and LE pain
- Dull ache in the low back that extends down the thigh and below the knee
- Frequently presents with a hx and sx consistent with LBP with movement coordination impairments
What are the Agg and Easing Factors for these patients?
Agg (Peripheralization of referred sx)
- Lumbosacral Flexion
–Sitting
–Bending forward
Ease (Centralization of referred sx)
- Lumbosacral Extension
–Standing and walking
–Prone lying
If a patient reports a perihpherzation of Sx while sitting and a centralization of Sx when they stand and walk, they are said to have a directional preference towards extension
What is the 24hr pain behavior with these patients?
Morning
- If sleeping in flexion, they may wake up with leg pain
- May have difficulty coming up into full lumbar extension initially
Noon to Evening
- Sx may vary throughout the day depending on the patients activites
Night
- Sleeping in flexion may wake them up with leg pain
- May have disrupted sleep
As indicated from the subjective exam, What takes part of the Systems Review?
Cardiopulmonary
- Vitals: BP, HR, Auscultate, Distal pulses
Urogenital/GI
- Assess for mechanical reproduction of Sx and/or adverse response to movement (AROM, PIVM, Compression/Distraction, Neurodynamics tests)
Neuromusculoskeletal
- Reflexes/pathological reflexes
- Dermatomes/myotomes
What should take place in the Neurological Examination?
DTR’s
- Quads, and Achilles
Dermatomes
- L3-S1
- Sharp/Dull
Myotomes
- L3-S1
During the Movement and Provocation examination, what would you see with Active ROM?
ROM limitations and Sx provocation will depend on individual patient presentation
- Extension loss
- Centralization
- Aberrant Motions
During the Movement and Provocation examination, what would you see with PIVM?
- Hypomobility and Sx reproduction at the involved segments
- Possible hyper- or hypomobility at adjacent segments
What test are part of the Neurodynamic Testing?
- Straight Leg Raise (SLR)
- Slump Test
- Femoral Nerve Tension Test (Ely’s Test)
What is the Clinical Course and Prognosis for this condition?
- Lifetime incidence of at least one episode of low back in adults is 75% and 70-80% for adolescents
- Acute LBP is self-limiting with 90% of patients recovering within 6 weeks
- Recurrence ratess for 40-80% have been reported
- Chronic LBP has more viable clinical course with a less favorable prognosis
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 Referred Pain 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 Referred Pain 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 Referred Pain 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 shouldn’t the therapist 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?
Classification, Education, Exercise, Manual Therapy
Classification
- Mechanical Dx and Therapy or Treatment-based classification
Education
- Advice to remain active, pursue an active lifestyle, and self-management
- Favorable natural Hx of acute LBP
Exercise
- Trunk strengthening, endurance, and specific trunk activation training
Manual Therapy
- Thrust and non-trust manipulation and soft tissue mobilization to reduce pain and disability
What are Interventions recommended by the clinical practice guidelines for patients in the Subcute stage?
Classification, Education, Exercise, Manual Therapy
Classification
- Mechanical Dx and Therapy or Treatment-based classification
Education
- Advice to remain active, pursue an active lifestyle, and self-management
- Favorable natural Hx of subacute LBP
Exercise
- Trunk strengthening, endurance, and specific trunk activating training
Manual Therapy
- Thrust and non-trust manipulation and soft tissue mobilization to reduce pain and disability
What are Interventions recommended by the clinical practice guidelines for patients in the Chronic stage?
Education, Exercise, Manual Therapy
Classification
- Mechanical Dx and Therapy or Treatment-based classification
Education
- Advice to remain active, pursure an active lifestyle, and self-management
- pain neuroscience education
Exercise
- Trunk strengthening, endurance, specific trunk activation and movement control training
Manual Therapy
- Thrust and non-trust manipulation and soft tissue mobilization to reduce pain and disability
With Interventions, what is the Mechanical Dx and Therapy (MDT) for patients with LBP with Referred Pain?
- Assessment and treatment utilizing the patients directional preference for sx centralization
- LBP with referred pain calssified as “Derangement” syndrome
- Repeated motions or sustained positions to promote centralization
–Disk related conditions often respond to an extension-oriented program (sagittal plane) {aka McKenzie exercises}
–May have to address the frontal plane (shift correction) prior to sagittal plane
