Lecture 3: Lumbar Spine Interventions Flashcards
manual therapy: classification criteria
Anatomic location
Duration of current episode of pain
Score on FABQ
Results of segmental mobility testing in
PA direction
Hip internal rotation ROM
No sx distal to knee
Less than 16 days
Score of less than 19
At least 1 hypomobile segment in L-
spine
At least 1 hip w/ >35° of internal rotation
treatment “buckets”
Manip/manual therapy
stabilization exercises
direction-specific exercises
traction
stabilization: classification criteria
age?
general flexibility?
aberrant movements in lumbar spine?
lumbar instability?
patient hx?
- younger (<40)
- greater general flexibility (postpartum, average SLR 91)
- visible “instability catch” or aberrant mvmt during lumbar flexion / extension ROM
- prone instability test
- pt hx: post partum, (+) posterirl pelvic pain provocation, ASLR, modified trendeleburg test
OR
pan with palpation of long dorsal SI Ligament or pubic symphysis **
Direction-Specific Exercise Classification
extension?
flexion?
lateral shift?
extension: centralized pain w/ extension, periperalized with flexion
flexion: centralized wtih flexion, peripheralized with extension
lateral shift: visible frontal plane deviation of shoulders relative to pelvis, asymmetrical SB AROM and restricted/painfu; ext AROM
Direction-Specific (Extension):
Classification Criteria
- anatomic location?
- sx response to lumbar ROM?
- subjective response to movement
- distal to buttock
- sx centralize with ext, peripheralize with flx
- directional preference to extensino
Direction-Specific (Flexion):
Classification Criteria
age?
subjective response to movement?
imaging evidence?
- older (>50)
- prefer flexion
- stenosis
Direction-Specific (Lateral Shift):
Classification Criteria
- observation?
- response to movement?
- visible frontal plane shift of shoulders relative to pelvis
- directional preference for lateral traslation movement of pelvis
Traction: Classification Criteria
sx decrease w/ manual or autotraction
Acute Phase Intervention Goals
↓ pain, inflammation and mm spasm
* Promote tissue healing
* ↑ pain-free ROM (i.e. segmental
motion)
* Regain soft tissue extensibility
* Regain NM control
* Allow progression to sub-acute/
functional phase
what is a great inital choice of tx for the acute phase? what is not?
walking (good)
bed rest (bad)
early motion despite sx is encouraged
manual therapy is MOST beneficial for these patients
patient WITHOUT radiating pain
Sub-acute/Functional Phase Intervention Goals
significant ↓ or complete
resolution of pt’s pain
* Restoration of full and pain-free vertebral ROM
* Full integration of entire upper and lower kinetic chains
* Complete restoration of respiratory function
* Restoration of t-spine and UQ/LQ strength and NM control
Research suggests THIS phase =CRITICAL in preventing chronicity and
disability
* # of PT sessions required to achieve goals in THIS phase varies widely
* Correctly categorizing and then re-categorizing pts as tx progresses is VITAL
for successful outcomes in this phase
* Graded activity improved absenteeism (ie.
miss less work) in this phase
sub acute phase
continue encouraging aerobic exercise to increase activity tolerance / functional training and mobility/stretching for increased ROM
Chronic Phase Intervention Goals
-
- Maximize function and
encourage exercise! - Can ↓ pain in chronic stage
- Educate pt regarding using pain
science techniques - Use multi-modal approach
tailored to pt’s needs - Aerobic exercise
- Meds
- Etc
1º Hyperalgesia (1º Sensitization)
Normal hyperalgesia that is a protective
mechanism
2º Hyperalgesia
Adaptations in CNS
* ↑ responsiveness to stimuli from
periphery
Central Sensitization
Hallmark of chronic pain
* Functional changes in CNS
* Altered sensory processing in brain
* Malfunctioning of descending anti-nociceptive mechanisms
* ↑ activity of pain faciliatory
pathways
* Explain Pain Videos online can help educate pts
T/F direction specific exercises makes an attempt at being tissue specifict
FALSE (no attempt)
stabilization exercises
- Hooklying
- Hooklying w/ LE movements
- Quadruped
- Quadruped w/ LE vs UE
- Prone on elbows
- Side plank
- Prone on elbows w/ LE vs UE movements
- Side plank w/ LE vs UE movements
* AROM
* Lumbar extensor strength
* NM re-ed: core musculature
* GLUTE STRENGTH!!!
Functional activity tolerance
* ↑ muscular endurance
* Low intensity for prolonged period vs high
intensity for short period
* Goal: mimic daily life
* ADLs, occupation, leisure
Direction-Specific Exercises: postural
- Pain not reproduced w/ repeated testing
- Pain present when stationary
Direction-Specific Exercises: dysfunction
- Pain only produced at end range
- Fixed pain pattern (always same)
- Will radiate slightly
- Condition unchanged after testing
Direction-Specific Exercises: derangement
- Symptoms produced/altered w/ mid-range movements
- Painful arc may exist
- Variable pain patterns
- Progressive ↑ or ↓ during testing
- Rapid and lasting Δ’s after testing
tx prescription for extension specifict exercises
20 times/hr while awake
tx perscription with flexion specific exercises
6-10 times/hr while awake (more careful w/flexion than ext)
self tx 24 hrs after tx to confirm dx
lateral shift exercise tx
10-20 times/hr while awake
PT perfom glises and follow up w self tx and re-assess
a tracton tx is clincially useful with
- peripheralization of sx with extension
- (+) Crossed SLR
BWST is effective for?
pts with spinal stenosis or radicular sx
(more effective w/ manual therapy)
never glides also a helpful additioin
nerve glides prescription
1-2 sets of 10-15 reps initailly to avoid irritating nervous tissue or sx
progressing as tolerated
T/F majority of evidence supports use of passive modalities for LBP
F
(unless it’s for short term sx mgmt or if pt has difficulty performing the exercises or if it makes pt feel comfy)
Proposed Progression for Tx Session
- Manual techniques (if indicated)
* To ↓ pain and ↑ mobility - Mobility ex’s
* Use new ROM to help maintain it - Neuromuscular re-education
* Learn to control new ROM - Strength training ex’s
* ↑ strength to maintain mobility - Functional/Therapeutic activity tolerance
* Return to PLOF or better
* Prevent injury recurrence
Patient Education
REMAIN ACTIVE
- don’t focus on pain
- postures that dec pain
- counsel if indicated fear avoidance and pain catastrophizing
- focus activity level, NOT pain level**
indications for manips
- Presence of dysfunction
- Neurophysiological effects
contras for manips
- Presence of serious pathology
- Relative to skill and experience
- Fracture
- Ligament rupture
- No working hypothesis
- Worsening neurological function
- Unremitting night pain
- Severe multi-directional spasm
- UMN lesions
what could you do after a joint mob/manip?
further decrease mm tone and imporve L/T relationship and pain
soft tissue technique
exerciss for endurance:
chronicl LBP with and w/o generalized pain
- Chronic LBP w/o generalized pain: Moderate to high intensity exercise
- Chronic LBP w/ generalized pain: Low intensity exercise
dry needling
no clear evidence for LPB
may be for sub-acute LBP
NOT for actue LBP
may help dec pain for chronic pt but only short term changes
- basic training
- Avoid becoming chronic
- ↑ mobility/stability
- Resolve structural faults
- Promote early return to activity
- Educate pt – DAY 1!
- Self – management
- Lifestyle modifications
- ↓ fear avoidance
beliefs/behaviors - Regular exercise
- HEP independence
- occasional 1st aide
- Check-in visits to manage
significant flare-ups - Update HEP as pt progresses
early surgical interventio warranted when: RED FLAGS or failed conservative care
- Cauda equina syndrome
- B&B disturbances
- Onset/progression of significant motor deficits
- Significant instability (spondy grades 4 and 5)
- Severe intractable pain (fx, infection, cancer)
- Progression of spinal deformity (curve >45-50°)
- Sx do not improve in XX amount of time
post op care
- pain control (ice, med, position)
- early mobility and educateto limit stress on healing structres
- mobility/stability ex’s
- functional activity tolerance training
- maintinance and D/C planning
more info slide 64
