Low back assessment and treatment

Question 1

Management to LBP to prevent disability

Answer 1

• 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

Question 2

Awareness of biopsychosocial model of LBP

Answer 2

Advanced understanding of significance of psychosocial factors in predicting disability

A behavioural approach does not prevent investigating mechanisms in non-specific low back pain.

Question 3

Change systems for LBP

Answer 3

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

Question 4

Promote concept of living well with LBP

Answer 4

Person centred care

Focused on:
Restoring and maintaining function
Self-management
Healthy lifestyles

Question 5

Ways to promote positive health

Answer 5

• 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

Question 6

Unhelpful beliefs

Answer 6

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

Question 7

Unhelpful beliefs may lead to unhelpful protective behaviours

Answer 7

1) Muscle guarding e.g. analogy of the wrist
2) Bracing of “core muscles”
3) Slow cautious movements
- Sit to stand
- Walking
- Bending

Question 8

Unhelpful beliefs may lead to wanting an inappropriate treatment

Answer 8

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

Question 9

Unhelpful beliefs may lead to psychological responses

Answer 9

Pain vigilance
Fear of active participation in rewarding activites.
Worry about future
Impair mental health
Exacerbated by lack of self-efficacy

Question 10

Self efficiacy

Answer 10

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

Question 11

10 facts about back pain

Answer 11

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)

Question 12

Effects of inactivity

Answer 12

Weak muscles
Stiff joints and muscles
Less fit - feel tired
Feel tense- muscle knot up
Feel fed up
Put on weight

Question 13

Explain what the over/under activity cycle is…

Question 14

Explain what pacing is regarding LBP…

Question 15

Problem solving with LBP…

Answer 15

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

Question 16

Typical thinking errors in the context of back pain

Answer 16

Black and white thinking
Catastrophising
Should/must statements
Jumping to conclusions
Mental filter
Critical self

Question 17

Compliance

Answer 17

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

Question 18

Adherence

Answer 18

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

Question 19

Concordance

Answer 19

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

Question 20

Palpation objectives

Answer 20

• 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
  *

Question 21

Tools available when palpating

Answer 21

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

Question 22

Grades of passive movement

Answer 22

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

Question 23

Common Lx Rx MCC Oct24 – in brief

Answer 23

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

Question 24

Common Lx Rx MCC Oct24 – principles

Answer 24

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)

Question 25

Sit to stand

Answer 25

Feet, thigh, bottom not back
Equal weight bearing
Patella alignment
Breathe in
Knee control

Question 26

Stand to sit

Answer 26

Gravity lowers you
Bend whole trunk from Tx down
Initially relaxed neutral low back if fear++
Equal weight bearing
Patella alignment
Breathe out

Question 28

1/4 squat e.g. picking up / put down

Answer 28

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

Question 29

Lunging as further progression, if indicated

Answer 29

Feet, thigh, bottom, neutral trunk, breathe

Question 30

Walking

Answer 30

Neutral pelvis & shoulders, so gluteals
Knee control / heel control
Thoracic rotation; hands shake; arm swing
Sorbothane insoles

Question 31

Stairs of steps?

Answer 31

• Up
  Power through gluteals
  Patella alignment
  Feet, thigh, bottom
  Neutral pelvis & shoulders, so gluteals
  Knee control
• Down
  Heel lift
  Patella alignment

Question 32

Palpation treatment trunk muscles

Answer 32

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

Question 33

Palpation treatment lower limb muscles

Answer 33

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

Question 34

Palpation - mobilisation techniques

Answer 34

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

Question 35

Other specific exercises

Answer 35

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