lumbar back - 3 injuries Flashcards
manipulation - class criteria
no symptoms below the knee
recent onset of symptoms (<16)
low FABQW score (<19)
hypomobility of the lumbar spine
hip IR (>35)
what does FABQW score mean
Fear Avoidance Belief Questionnaire
patients’ fear of pain and consequent avoidance of physical activity because of their fear[2][3].
stabilization - class criteria
younger age (<40)
general flexibility - greater SLR flex
instability catch or abberret movement during lumbar flex or ext
+ prone instability
extension - class criteria
symptoms distal to the buttock
sym centralize with lumbar extension
sym peri with lumbar flexion
directional preference for extension
flexion - class criteria
older age (<50)
directional preference for flexion
imaging evidence of lumbar spinal stenosis
lateral shift - class criteria
visible frontal plane deviation of the shoulder relative to the pelvis
directional perference for lateral translation movement of the pelvis
traction - class criteria
signs and symptoms of nerve root compression
no movement centralize sym
what does peri mean
paresthesia moves distally, away from the spine
a sym presents with increased intensity and remains increased for 30 secs after the completion of the movement
what is centralization
pain or paresthsia moves centrally, towards the spine
paresthesia that was present is abolished
what is status quo
neither centralization of peri is produced
trasient (not perminent) increase or decrease in pain is produced
extension bias - mech of onset
bending lifting twisting
extension bias - demographic
20-50
extension bias - presentation
Antalgic, muscular spasm, difficulty attaining erect upright postures
Extension will cause pain the centralize in these pt
Earlier in the day – have a hard time
Acute LBP – often seen with radiating features
flexion worsen the symptoms
what is the treatment for an extension bias
awakening ritual
extension exercises
what are some examples of extension exercises
prone lying flat
prone on elb
prone position propped on hands
Standing lumbar extension puts hands on the lower back while extending the spine)
End range loading
what is an example of a awakening principle
- Lying prone
- Prone on elbows
- Prone press-ups
- Get out of bed while maintaining extension
- Restrict flexion
other things we can do for ext principle
maintain lordosis while sitting
limiting time in sitting
lateral shift - MOI
– Flexion mechanism
– Acute onset
– Visual deformity, worsens with weight bearing
* Both sitting and walking exacerbate symptoms
– Radicular signs/symptoms
lateral shift - Presentation
Frontal plane deviation of the shoulder in relation to the pelvis, accompanied by some degree of flexion.
– Possible signs of nerve root compression
– Positive side-bending test
– Restricted painful extension
lateral shift - pathomechanical
– Disc Herniation
– Protective muscle spasm
– Segmental instability
how to correct a lateral shift
NWB correction
WB correction
ext syndrome (avoid all flexion)
what are indication for traction
Pt with radicular signs and symptoms who are unable to centralize during ROM testing
Back and leg symptoms, resembling a flex/ext syndrome but who is unable to improve with any active movement
Patients with an acute deformity who are unable to self-correct
what are contraindication to traction
infection or spinal malignancy
Osteoporosis
Hiatal or abdominal hernia
Pregnancy
Acute Lumbago (Low Back Pain Only)
flexion principle - MOI
- No specific mechanism, often gradual onset
flexion principle - demographic
50s older individual - variable
flexion principle - presentation
- Stiff, Achy Back
- May exhibit “Claudicant Behavior”
– Flatback –Swayback
– Hyperlordotic
what is Claudicant Behavior
P/N and sense of weakness when standing, walking (mechanical), they want to sit
flexion principle - movement control
look at pt’s balance, movement control, and where we can make changes to take stress off of their spine
Flexion-oriented exercises
De-weighted treadmill ambulation
Exercises for individual impairments
what does stiff achy back mean
– Stenotic, Degenerative Spine
– Often accompanied by radiating features
lumbar spinal stenosis is associated with what principle
flexion pattern
what is degenerative stenosis
facet joint arthrosis
ligamentum flavum thickening
intervert disc bulging
spondylolesthesis
spinal stenosis presentation
pain with walking that is improved with sitting
improved walking holding a shopping cart
preferred position is sitting
pelvic component - pain pattern
rarely have symptoms below the knee, butt, lateral thigh
status quo pain
pain later in the day
pelvic component - neuro
no neuro component
pelvic component - pop
younger
what is included in cilbulkas criteria
standing flexion test
seated landmark asymmetry
long sit test
prone knee flexion test
** frontin sign
what is included in pelvic component palpation examination
ASIS
PSIS
iliac crest
interpretation of pelvic component - all landmarks are level
normal
interpretation of pelvic component - all landmarks are high on one side
leg length difference
(compared in sitting and standing )
interpretation of pelvic component - asymmetrical height difference
pelvic component
(compared in sitting and standing)
cibulka criteria - what means positive
3/4 test = pelvic component
what is the long sitting test (LST)
patient in the supine lying position, feet off the table
places the thumbs beneath the patient’s medial malleoli
Patient assumes a seated position with the hips flexed as much as possible and the knees fully extended.
Have to do 3 times
what is a positive long sitting test
change in length noticed
Evaluation of the pelvic joint – short to long
what is the prone knee flexion test - procedure
positioned prone with shoes on, the relative leg lengths are assessed visually by looking at the heels of the shoes
patient’s knees are then flexed passively to approximately 90 degrees and the lower extremity lengths are again observed
what is a positive knee flexion test
change in relative lengths between the two positions
- Short to long = pelvic
- Short to shorter = sacral
what is the Seated/standing Flexion Test - procedure
- Places the tips of PT index fingers directly beneath the inferior shelves of PSIS – upward pressure
- Examiner at eye level
- pt bends forward as far as possible while the examiner observes for symmetry of cranial movement of these bony landmarks
what is a positive standing flexion test
one PSIS rises more in the superior direction while the patient is flexed
which flexion test is included in clibukas criteria
standing flexion test
what is Gillet test
- PSIS and S2 palpated in standing
- S2 between the PSIS’s
- Patient is asked to flex one hip towards the chest
what is a negative gillet test
PSIS moves inferiorly (below S2)
what is a positive gillet test
PSIS does not move or moves cranially
what are the treatment options for a pelvic component
Supine lumbo-pelvic roll
Prone Position innominate anterior rotation thrust
Long axis distraction
Prone leg lift technique
what is the procedure for - Prone Position innominate anterior rotation thrust
- Side bend the patient’s trunk and legs away from you
- Have pt rise on elbow opposite form you
- Place two hand on below the furthest PSIS
- Take up the slack and then drive the innominate posture to anterior
o Push cranial and into the table
what is the procedure - Prone leg lift technique
- Bend pt’s leg that is closest to PT and tuck leg under arm (make sure foot is behind arm)
- Lift pt’s leg while applying pressure at PSIS
- Rock up and down
what do you after pelvic component manipulation
have the patient walk so that they are weight bearing on the pelvis
heel rockers
what is the presentation of the sacral component
fortins sign
~vague, non-segmental radiating features
decreased unilateral stance time
Difficulty with transitional movements
Difficulty actively extending the spine
what is fortin sign
patient twice identifies their most painful region within one centimeter of PSIS
sacral component - MOI
Slip and fall onto the buttock
Asymmetrical loading mechanisms
* Not on the last step on the stair
Failure of “ilial” interventions
Hypermobility of the Pelvis
what are some causes of – Hypermobility of the Pelvis
- Trauma – rear end motor vehicle accidents
- Recent Pregnancy
- Birth Control Medication
what is included in Laslett’s Criteria
Distraction
thigh thrust
Gaenslen’s test
Slide lying compression
Sacral thrust
which two test in Laslett’s Criteria means that they have an SI pain
Thigh thrust
Distraction
what are the sacral component correction
Active Mobilization Technique (SIJ)
Prone sacral correction
when do we start to think about the thoraco-lumbar component
If it is not pelvic of sacral then it is thoracolumbar
thoraco-lumbar component is what level and higher
L4 and higher
what are the special test for the thoraco-lumbar component
This is more of a movement model does not have special tests
what is the treatment for the thoraco-lumbar component
Side lying lumbar roll
what testing can we do to discern a thoraco-lumbar component
- AROM standing
- Combo AROM testing
- Seated thoracic rotation
- PA spring testing
what is Combo AROM testing
a. SB + Ext
b. Ext + SB
for spring testing what section are we looking at
L5 to L2
what is the procedure for Prone sacral correction
- Side bend the patient’s trunk and legs away from you
- Have pt raise up on elbow Opposite from you
- Place hand medially from the PSIS – apply pressure obliquely in the angle of the SI joint
- Take up the slack and then drive thrust
what is the active mobilization of the pelvis - procedure
- Pt’s trunk brought towards PT and legs away
- PT palpate pt’s segment and take uppermost leg
o Move leg into flexion and ext, feeling the PSIS move
o Hook uppermost leg on other leg (closing of segment)
o Keep hand on segment of interest - Rotate pt’s trunk
o Grab lowermost arm above elbow and rotate - After deep breath take up any slack and then apply a thrust
Classification of Lumbopelvic stabilization - demographic
<40
(+) Aberrant Motions
(+) Prone Instability Test
FABQ: > 8
(+) Spring test for hypermobility
what is included in the basic screening for stability
Unilateral Bridge with Leg Extended
Bird dog - Quadruped with Alt. UE and LE Extended
Side plank - Unilateral Side Support with Legs Extended
Unilateral Bridge with Leg Extended- bent leg
activation of the Hamstring
Unilateral Bridge with Leg Extended - straight leg
activation of the abdominal obliques, multifidus, other trunk extensors
Unilateral Bridge with Leg Extended - fall onto unsupported side
inadequate abdominal support
what is the function of the multifudus
stabilizes the vertebrae as the spine moves.
Extension and contralateral rotation
what is the function of the abdominal obliques
contributes to a variety of trunk movements
bird dog - extended leg
hamstring, gluteus maximus, and multifidus
bird dog - Activation
external oblique
bird dog - Activation extended arm
upper trunk extensors
for the bird dog what do we want the patients to look like
curve of back (neutral)
side plank - down side
Unilateral involvement of the Gluteus Medius, Multifidus, External Oblique on the activated side
Rectus Abdominis
what tests do we do for the posterior chain
Prone Instability Test
bird dog
Prone Unilateral Leg Lift
what movement are we looking at with the posterior chain
extension of the back
what is the procedure for the Prone Instability Test
pt lying prone at the end of the table , with the pt leg off of the table
pos 1: Push on the lumber spine muscles with pt’s feet on the ground
pos 2: Pt’s feet 2 inches off the ground Push on the lumbar spine muscles
what is a positive prone instability test
less pain when legs are off the ground
what is the prone instability test showing us
this is a test of muscle performance
This showing how activating your muscles can ease the pain
what is the procedure for the Prone Unilateral Leg Lift
pt prone on mat table
have the patient lift leg straight off the table, looking for activation of the contralateral multifudus
what is the function of the erector spinae
Back extension, side bending
what test do we look at for the anterior chain
Unilateral Bridge with Leg Extended
Active Straight Leg Raising (An SLR)
Abdominal Hollowing
Unilateral Bridge with Leg Extended - what muscle are being activated
activation of the abdominal obliques, multifidus, other trunk extensors
hamstrings
also looking at abdominal support
what is the procedure for the Active Straight Leg Raising (An SLR)
“keep your knee straight and pick your leg off the ground – do bilaterally”
repeat procedure while placing force into the ASIS while pt is performing task
what does it mean if position 2 is easier in the active straight leg raise
they are not activating their abs
what does it mean if position 1 is painful in the active straight leg raise
pain - pain is worse when raising the leg that mean pt does not have great activation of the abdominals
o No pain – activating the abdominals
what is the procedure for abdominal hollowing
- have the pt prone and knees bent
- ask them to take a deep breath
what muscle is abdominal hollowing looking at
the transverse abdominus
what is the function of the transverse abdominus
assist in forced expiration,
can abd hollowing be used as a intervention
yes, If the patient is having a hard time activating the TA then you can teach the patient
what are we looking for with abd hollowing
belly breathing
activating the TA
with diaphramgic bretahing what do we want to move
the belly
what movements are we looking for in the lateral chain
Side plank
Rose wall slide
Trendelenburg test
what muscles are being activated with a side plank
downside: Unilateral involvement of the Gluteus Medius, Multifidus, External Oblique on the activated side
what is the procedure for the rose wall slide
pt side lying, bottom knee bent, and top leg straight
- PT sees how high the pt can lift their top leg – this is the limit for their leg raises
- Have the pt lift their leg to this height for multiple reps – sliding on a foam roller
- Look for the change in pt strategies during exercise
what is the procedure for the trandelenburg test
- Pt standing
- PT at eye level of the pelvis
- PT place hands on pt’s iliac crest
- Have pt do single leg stance
- Positive: Look for drop on opposite side to the stance leg
look at my notes for the
stablization exercises
what does it mean when the patient says my LE has a influence on my back pain
think of the pelvic dysfunction
what is nutation
movement into the pelvis
anterior and inf
occurs in response to lumbar extension
to pt with sacral pain complain of pain with walking
yes
what is counter nutation
movement to return to neutral position
prone knee flexion - sacral component positive test
shorter to shorter
