Lumbar And SIJ Flashcards
Low back pain with movement coordination deficits
Acute versus seven acute versus chronic
Symptoms impairments and interventions
Symptoms:
– Acute/subacute/chronic – referred extremity pain, numerous episodes in recent years
Impairments:pain reproduced with provocation of involved segments, movement coordination impairments
– Acute: pain with rest and initial to midrange movements
– Subacute: pain with mid range and in range movements
–Chronic: pain worsens with sustained and range movements in positions
–Subacute/chronic: mobility deficits and thorax and lumbopelvic region, diminished trunk pelvic muscle strength and endurance
Interventions: neuromuscular reeducation, self-care/management training/work reintegration training.
– Acute: considered temporary external device
– subacute/chronic: manual therapy, therapeutic exercise
low back pain with mobility deficits
Acute vs subacute
Symptoms impairments interventions
Symptoms:
–acute-pain duration less than one month, unilateral, onset link to recent awkward movement or position
– Subacute- unilateral lower back pain, sensation of back stiffness
Impairments:
–Acute-range of motion limitations, restricted segmental mobility, symptoms provoked with spinal movement
– Subacute – symptoms reproduce with end range spinal motions, restricted the thoracic, lumbar, lumbopelvic, or hip range of motion and mobility testing
Interventions:
– Acute/subacute –manual therapy, therapeutic exercise for spinal mobility, patient education for return to active lifestyle
Acute low back pain with related lower extremity pain
Symptoms impairments interventions
Symptoms: symptoms worsen with flexion activities, no paresthesias
Impairments: there extremity pain can be centralized with specific postures, reduced lumbar lordosis, limited lumbar extension mobility, lateral shift
Interventions: therapeutic exercise/manual therapy/traction to promote centralization and improve lumbar extension mobility, patient education, progress to intervention strategies consistent with seven cute or chronic low back pain with movement coronation impairments
Indications for low back pain with related cognitive or affective tendencies
One or more of the following:
– two positive responses to primary care evaluation of mental disorder screen.
1: during the past month have you often been bothered by feeling down depressed or hopeless?
2: during the past month have you often been bothered by little interest or pleasure in doing things?
– High FABQ
– High pain catastrophizing scale
Lumbar spine differential diagnosis recommendation level and three conditions for referral
Recommendation level: a
Conditions for referral:
1: patient clinical findings are suggestive serious medical or pathologic pathology
2: reported activity limitations or impairment of body function and structure are not consistent with those presented in the diagnostic section section of these guidelines
3: patient symptoms are not resolving with interventions aimed at normalizing the patients impairments of body function
Lumbar spine outcome measures and MDC
ODI – 10
Role in Morris disability questionnaire – five
Low back pain interventions and recommendation level
Manual therapy – A
Trunk coordination strengthening and endurance exercises – A
Centralization and directional preference exercises – A
flexion exercises – C
or quarter nerve mobilization exercises – C
Traction – D
Patient education counseling – B
Progressive endurance exercise and fitness activities – A
Subgroup of patients with lumbar spine radicular symptoms they respond well to mechanical traction
Signs of nerve root compression along with Peripheralization of symptoms or positive cross straight leg raise
Low back pain with radiating pain
Acute versus subacute versus chronic
Symptoms impairments and interventions
Symptoms: radiating pain in the lower extremity, or extremity paresthesias numbness and weakness
Impairments: LE radicular symptoms, positive intention test, nerve root involvement
-Acute – initial to mid range, subacute – midrange the end range, chronic – sustained and range
Interventions patient education to reduce compression and manage pain, manual therapy, traction, nerve root mobility
Clinical prediction rule for manual therapy and low back pain
Two most predictive factors of clinical prediction rule
Symptoms ration less than 16 days No symptoms distichs knee Lumbar hypomobility At least one hip greater than 35° internal rotation FABQ score less than 19
Four more increased success with thrust manipulation from 45 to 95%
Most important factors: symptom duration less than 16 days and not having symptoms distal to knee
Clinical prediction rule for stabilization exercises
Age less than 40
Positive prone instability test (+LR= 1.7, -LR= .48)
Presence of aberrant movement with motion testing
Straight leg raise greater than 91°
Three out of four = positive LR 4.0
Fewer than two = negative LR .20
Factors that do not negatively affect recovery from low back pain
Work-related spinal loading, prolonged sitting, participation in sports activities
Clinical prediction rule to determine likely recovery time
Lower than average initial pain
Shorter duration of symptoms
Fewer previous episodes
Yellow flags for low back pain (7)
Emotional distress, hypervigilance, pain catastrophizing, elevated FABQ, low self efficacy, miss understanding of the nature of their pain, misunderstanding about best interventions for long-term success
Lumbar spine fracture rules
Prolonged use of corticosteroids Mild trauma age greater than 50 years Age greater than 70 years Known history of osteoporosis Recent major trauma at any age
Serious medic conditions that may present as low back pain
Metastatic cancer, infection, vertebral fracture, abdominal aortic aneurysm and
Two MRI findings most consistent with physical examination findings
High intensity zone – bright signal in the annular region of the intervertebral disc. Lead to be associated with annular tear that might be a component of discogenic pain
Modic sign – high T2 signal in and near the vertebral and plate. Contributes to impaired diffusion of nutrients and waste products between the subchondral bone of the vertebral body in the IVD. may contribute to discogenic pain
Physical exam in nation finding that is most correlated with discogenic pain
Centralization of symptoms – positive LR equals 2.8
During hip flexion patient with SIJ pain have delayed activation of the following, with early activation of what?
Internal oblique, gluteus maximus, and multifidus on symptomatic side
Early= biceps femoris
Arthrology of sacraloiliac joint
Sacrum primarily concave
Ilium primarily convex
Long posterior sacroiliac ligament function and diagnostic
Restricts anterior rotation of innominate
Tenderness and palpation diagnostic with sensitivity ranging from .76 to .86
Sacrotuberous ligament function
Restricts motion of the sacrum and flexion and restricts posterior rotation of innominate
Essentially opposes long posterior ligament
Iliolumbar ligament function
Restricts L5 transverse, sagittal, and frontal plane’s
Restricts SI joint sagittal plane motion
Thoracolumbar fascia: layers and function with SIJ stability
Posterior middle and the anterior
Connection to quadratus lumborum, transverse of abdominal, internal oblique, external oblique, and erector spinae
Sacral movement with trunk extension/flexion
In mid range movements sacrum flexes with trunk extension and extends with trunk flexion
One standing the movement of the sacrum in full trunk extension is dorsal and in full trunk flexion is ventral
SI joint cluster
Provocation (5)
Palpation (4)
Pain location (1)
Provocation – thigh thrust, sacral thrust/faber, gapping, compression, Gaenslen. Sn=.91, sp=.87
Palpation – standing flexion, supine and sitting, prone knee flexion, PSIS position in sitting sn=.82, sp = .88
Pain location- fortins Sn, not sp
Most reliable single test for SIJ dysfunction
Thigh thrust test SN and SP greater than .8
Lumbar stenosis clinical prediction real
Bilateral symptoms, Leg pain more than back pain, pain during walking/standing, pain relief upon sitting, age greater than 48 years
Greater than four test positive SP = .98-1
Less than three test positive for Sn
SIJ active straight leg raise test
Pain/ weakness with leg raise decreased with compression of pelvis at ASIS
McGill core ratio testing
Ratios and norms
Imbalances indicated if the following occur
1: left side bridge to right side bridge ratio less than .95 or greater than 1.05
2: flexion two extension endurance ratio is greater than one
3: either left or right side bridge extension ratio is greater than .75
Normal values for young fit adults: extension – 130-190 seconds, flexion – 130-160 seconds, right and left side bang 70-110 seconds
Movement test for SI joint
Standing hip flexion test
Lumbopelvic rhythm
SHFT – normally no relative motion should occur on weight-bearing side in this test
Leg Length Discrepancy:
3+cm causes asymmetrical lateral bending with gait
**PT secrets: spine will bend towards longer leg, increasing I/L facet and disc force
Lumbar disc prolapse most often
L4-5>L5-S1> L3-4 > L2-3 >L1-2
Discogenic LBP
typically resolves w/in 3-4 months with 45% patients demonstrating resorption of nucleus over time
- Acute care favors conservative vs surgery
- No significant difference b/t surgery and non-surgical care at 3-5 years f/u
- Sedentary occupation, vibration, smoking, increased BMI, prior full term preggers, and tall stature may predispose to reoperation post discectomy
- increased fitness and strength reduce risk for reoperation
Sacral inclination angle:
angle of sacrum from vertical
-higher degree of listhesis will result in more vertical sacrum
Slip angle:
most sensitive to segmental instability; perpendicular line from S1-S2 bodies compared with line across superior end plate L5
