Low back assessment and treatment Flashcards
Management to LBP to prevent disability
- Promote healthy lifestyles
- Stay active
- Remain at work, or supported early return to work
- Early identification and appropriate education of patients at risk of persistent pain and disability
- Address comorbidities in people with persistent LBP
Awareness of biopsychosocial model of LBP
Advanced understanding of significance of psychosocial factors in predicting disability
A behavioural approach does not prevent investigating mechanisms in non-specific low back pain.
Change systems for LBP
Develop- Develop clear care pathways so people with LBP see the right person for the right treatment at the right time
Stop- Stop the use of alternative inappropriate pathways
Have - Have consistent evidence-based standards for clinical care
Provide- Provide access to effective care
Promote concept of living well with LBP
Person centred care
Focused on:
Restoring and maintaining function
Self-management
Healthy lifestyles
Ways to promote positive health
- Behavioural and cognitive strategies
- People with persistent low back pain need to learn
How to cope through self-management activities
To consult with health care only when needed - Passive strategies like medication and rest are linked with increasing disability
- Active strategies (exercise, continue activities, stay at work)
Reduce disability and
Reliance on formal health care
Unhelpful beliefs
These can lead to unhelpful behaviours such as AVOIDING:
- Normal movement e.g. bending the spine
- Spinal loading
- Physical activity
- Postures such as slumped sitting
- Normal everyday activities including work
Unhelpful beliefs may lead to unhelpful protective behaviours
1) Muscle guarding e.g. analogy of the wrist
2) Bracing of “core muscles”
3) Slow cautious movements
- Sit to stand
- Walking
- Bending
Unhelpful beliefs may lead to wanting an inappropriate treatment
1) Medication e.g. opioids
2) Passive therapies
- We as physiotherapists have to be aware of this
- Use these as part of a multi-modal approach
- Use to encourage relaxation and normal movement
3) Exercises to fix proposed poor posture
4) Injections
5) Surgery
Unhelpful beliefs may lead to psychological responses
Pain vigilance
Fear of active participation in rewarding activites.
Worry about future
Impair mental health
Exacerbated by lack of self-efficacy
Self efficiacy
A patient’s confidence in their ability to perform a specific behaviour and to overcome any barriers to that behaviour
It is:
Behaviour specific and can vary
Can be influenced by pain intensity
psychological wellbeing
any adaptation to illness
10 facts about back pain
LBP is not a serious life-threatening medical condition
Most episodes improve & LBP does not get worse as we age
A negative mindset, fear-avoidance behaviour, negative recovery expectations, and poor pain coping behaviours are more strongly associated with persistent pain
Scans do not determine prognosis of the current episode of LBP, the likelihood of future LBP disability, and do not improve LBP clinical outcomes
Graduated exercise and movement in all directions is safe and healthy for the spine
Spine posture during sitting, standing and lifting does not predict LBP or its persistence
A weak core does not cause LBP, and some people with LBP tend to overtense their “core” muscles. While it is good to keep the trunk muscles strong, it is also helpful to relax them when they aren’t needed
Spine movement and loading is safe and builds structural resilience when it is graded
Pain flare-ups are more related to changes in activity, stress and mood rather than structural damage
Effective care for LBP is relatively cheap and safe. This includes education that is patient-centred and fosters a positive mindset, and coaching people to optimise their physical and mental health (such as engaging in physical activity and exercise, social activities, healthy sleep habits and body weight, and remaining in employment)
Effects of inactivity
Weak muscles
Stiff joints and muscles
Less fit - feel tired
Feel tense- muscle knot up
Feel fed up
Put on weight
Explain what the over/under activity cycle is…
Explain what pacing is regarding LBP…
Problem solving with LBP…
Aim to jointly arrive at solutions, for example
- Goal setting
- Returning to activities
- Pacing etc.
Where possible encourage patient’s to problem solve for themselves, or from within the rest of the BeST group
This is a key skill in the development of self-efficacy
Typical thinking errors in the context of back pain
Black and white thinking
Catastrophising
Should/must statements
Jumping to conclusions
Mental filter
Critical self
Compliance
Compliance is the extent to which the patient’s behaviour matches the physiotherapist’s recommendations
A process where the clinician decides on a suitable treatment, which the patient is expected to comply with unquestioningly
Adherence
Adherence is the extent to which a person’s behaviour e.g. exercising more, corresponds with agreed recommendations from the physiotherapist
A process, in which the appropriate treatment is decided after a discussion with the patient
Concordance
Concordance emphasises an agreement between the physiotherapist and the patient, that respects the patient’s beliefs and wishes on e.g. exercising more.
It acknowledges that patients’ views must be respected even if they make choices, which appear to conflict with the clinician’s views
Palpation objectives
- Detect abnormal tissue texture
- Evaluate symmetry of structures
- Detect variations in range & quality of movement
- Detect variations in quality of end feel
- Proprioceptive awareness of patient
- Detect & evaluate changes over time
*
Tools available when palpating
Skin surface
- Pads of fingers (+/- palm) can be used
Temperature & moisture
- Some find the dorsum of the hand is more sensitive for temp & moisture variability
General tissue feel & movement
- Use 1st, 2nd finger or thumb
- Also get whole hand perspective
Grades of passive movement
Grade I - small amplitude movement performed at the beginning of range. Out of resistance
Grade II - large amplitude movement in a resistance free part of the range
Grade III - large amplitude movement performed into resistance
Grade IV - small amplitude movement performed into resistance
Common Lx Rx MCC Oct24 – in brief
Diaphragmatic breathing
Hourly x 5;
Crook lying 5mins daily - Focus on breathing in for 2 to 3 seconds and relaxed breath out for 3 to 4 seconds, so approx. 10 breaths per minute.
Lateral expansion – lower and upper trunk
5 normal, 2 deep; x 2 per day
No holding breathe
Sensitivity of tissue
Analogy of wrist
Spine likes movement. Vary posture.
Avoid extended periods of end range loading (finger)
Help decrease fear of low back bending
Care if Nv tissue sensitivity
Relaxed, front on awareness when sit, stand, TV etc
Tx versus Lx rotation
Use model of the spine
Avoid any fear of trunk rotation
Whole body rotation exercise in standing
5 to 10 secs x 2 per day
Relaxed neutral knees when standing
Not locked knees
Not flexed knees
Common Lx Rx MCC Oct24 – principles
Person-centred care
Focus on restoring and maintaining function, self-management and healthy lifestyles
Help patients to have a better understanding of their problem
Pain control
Relaxation
Decrease fear of movement
Encourage normal movement
Encourage normal speed of movement
Try to modify painful movements so they are immediately less painful or pain free
General health and wellbeing (MECC)
Give people control
To self-manage
Control any future exacerbations
Write it down or video exercises (video them or you)
Sit to stand
Feet, thigh, bottom not back
Equal weight bearing
Patella alignment
Breathe in
Knee control
Stand to sit
Gravity lowers you
Bend whole trunk from Tx down
Initially relaxed neutral low back if fear++
Equal weight bearing
Patella alignment
Breathe out
1/4 squat e.g. picking up / put down
As for sit to stand & stand to sit
1 x 5 reps then 2 x 5; x 1 per day then x 2 per day
Lunging as further progression, if indicated
Feet, thigh, bottom, neutral trunk, breathe
Walking
Neutral pelvis & shoulders, so gluteals
Knee control / heel control
Thoracic rotation; hands shake; arm swing
Sorbothane insoles
Stairs of steps?
- Up
Power through gluteals
Patella alignment
Feet, thigh, bottom
Neutral pelvis & shoulders, so gluteals
Knee control - Down
Heel lift
Patella alignment
Palpation treatment trunk muscles
QL; ES; Lats to help Tx rotation
QL to help lateral expansion
ES to decrease compressive loading from extension+
Gentle picking-up; 3 to 4 mins
Self-treatment
Lateral expansion to relax QL
Feet, thigh, bottom not back e.g. sit to stand
Palpation treatment lower limb muscles
Quads to help hip extension, to off-load Lx
Gentle picking-up; 3 to 4 mins
Self-massage 20 to 30 secs x 2 to 3 per day
-Before / after e.g. walking if walking problem
Palpation - mobilisation techniques
Transverse pressures (same side) in side lying to aid Lx side flexion
In Tx/lx helps off-load low Lx
Anterior & posterior ilium in side-lying
Anterior innominate in prone lying
Unilateral rib to help lateral expansion – side ly, sit, prone
In Tx and Tx / Lx
Transverse pressures in Tx (prone lying) to help rotation
Central PAs in Tx (prone lying) to help general Tx movts
Mobilising Tx e.g. to help off-load low Lx
Grades III or III- 3 x 30 reps
Other specific exercises
General aerobic exercise e.g. brisk walking
General muscle strength and balance (MECC)
Other specific exercises e.g.
Hip abduction in side-lying (no QL)
Bridging for gluteal muslces
Posterior pelvic tilt to encourage low back flexion
1 x 5 reps then 2 x 5; x 1 per day then x 2 per day
