Lumbar Exam - Pattern Recognition and Irritability Flashcards
4 groups for pattern recognition
- Pain with mobility deficits
- Pain with movement coordination impairments
– Often with referred pain to the buttock, thigh, leg - LBP with radiating pain (i.e. neurodynamic deficits)
- Pain with cognitive deficits
– Cognitive/affective tendencies
– Generalized pain
Common Medical Dx - Joint Mobility
- Facet joint syndrome
- Degenerative disc disease
- OA of the facet joint
LBP with Joint Mobility Deficits - Subjective
- Central or unilateral; specific spot
- Limitation in back motion that consistently reproduces Sx
- Referred pain associated with facet irritation
- Commonly aggravated with SB and/or extension movements - “pinching sensation”
LBP with Joint Mobility Deficits - Objective
AROM Assessment:
* Pain usually when moving TOWARD side of symptoms and/or extension
* Restricted motion and/or pain esp. with overpressure (loading of spine)
Joint Mobility:
* Manual traction alleviates (unloading of spine)
* Hypomobility and or pain mid to end range with PA assessment
* Hypomobility of thoracic and/or pelvis and hip over time
Soft Tissue Mobility/Flexibility
* May have associated soft tissue tenderness of muscle in vicinity of pain
Neuro: Negative neuro screen
Irritability Levels
High Irritability: Sx’s easily provoked
* Muscle GUARDING before end ranges, AROM limited
* Light PA pressure reproduces symptoms over articulation
* Takes a long time for symptoms to resolve once irritated
Moderate Irritability: Sx’s not as easy to provoke
* Pain at end ranges of AROM
* Moderate PA pressure reproduces symptoms over articulation
* Able to alleviate symptoms when get out of provocative positions
Low Irritability: Sx’s minimal
* Pain with overpressure into end ranges of AROM
* Full PA pressure reproduces symptoms over articulation
* Able to alleviate with change in position
LBP Joint Mobility Interventions
Education
* Advise to stay active, downplay imaging, natural course of back pain
Manual therapy
* Thrust and non-thrust mobilizations to the lumbar spine, also thoracic/pelvis/hip as needed
* Manual stretching
* Soft tissue mobilizations as needed
Self ROM - Therapeutic Exercise
* Self-mobilizations, SNAGS
* General stretching and self ROM
Motor coordination and movement re-education as needed (especially if more chronic symptoms)
Manual Therapy helps to facilitate motion but in order to MAINTAIN it we must…
teach patients specific exercises
Common Medical Dx for LBP with Soft Tissue Irritability (mobility deficits or movement coordination impairments)
- Muscle strain
- Myofascial pain syndrome
- Active Trigger points
- Lumbar instability
- Lumbar disc disorders (when leg pain present)
LBP with SOFT TISSUE Irritability - Subjective
- Mobility impairment acute or chronic
- Pain distribution more vague, muscle referral patterns
- Sx caused by overuse and/or longer periods of loading of tissue (Ex: static posture)
- Pain affected with stretching (either better or worse)
- Sx increase throughout the day
- Often recurrent in nature (Motor coordination impairments)
- Common LE referred pain (commonly involved Motor Coordination impairment
LBP with SOFT TISSUE Irritability - Objective
Posture:
* Poor posture and unable to maintain “ideal”
AROM Assessment:
* May be restricted motion and/or pain/stretch esp. with motion away of symptoms (stretching)
* Predominant aggravating motion is flexion and side bending
* Aberrant motions
* Possible relief/centralization with repeated motions/directional preference
Joint mobility:
* Normal mobility, mm guarding at end range, possible segmental hypermobility, hypomobility above and below (thoracic and hips), possible +prone instability
Palpation/Flexibility:
* Pain, symptom reproduction and increased tone of relevant muscles. Presence of trigger points
Motor assessment:
* Poor motor coordination and/or endurance
Neuro:
* Negative neuro screen for true radicular symptoms
LBP with SOFT TISSUE Irritability Intervention
Education
Manual therapy
* Soft tissue mobilization
* Manual stretching
* Thoracic, lumbopelvic and hip non-thrust and thrust mobilization techniques (as needed)
Therapeutic Exercise
* General stretching and self ROM, repeated motions esp. with leg pain
Motor coordination and movement re-education as needed (especially if more chronic symptoms)
Common Medical Dx for Low Back Pain with Neurodynamic Mobility Deficits
- Herniated, bulging, slipped, prolapsed, “torn”disc (and others)
- Spondylosis
- Lumbar radiculopathy
- Sciatica (easily confused with referred pain)
- Spinal stenosis (more chronic, older)
Often space occupying lesion for younger; spinal stenosis for older
LBP with Radiating Pain - Subjective
- Acute to chronic symptoms
- Associated with radiating pain usually along the dermatome (most common is posterior leg, L5 and S1)
- Deep ache or shooting pain in the leg
- Symptoms affected by back or leg position
- Lying down relieves symptoms, back and leg position may matter
- May have pins and needles
- May describe weakness
LBP with Radiating Pain - Objective
AROM Assessment:
* Restricted motion and/or pain is variable. Acute/younger usually worse with flexion, Chronic/older often worse with extension and walking
* May show a direction of motion that alleviates symptoms (directional preference) with repeated motions (centralization)
Joint Mobility:
* Manual traction alleviates
* May have hypomobility above and below symptomatic segment (spine and hips)
Neuro:
* Potential positive neuro findings (sensation, strength, DTR), Slump, SLR, Well-leg raise
LBP with Radiating Pain Intervention
- Education
- Manual therapy
– Manual traction (acute/irritable)
– lumbar mobilizations (may be with neurodynamic mobilization)
– Thoracic and hip mobilizations as needed - Neurodynamic mobilizations
- Mechanical traction (acute/irritable) - no evidence of benefit from chronic symptoms
- Neuromuscular re-ed and endurance exercises as needed
Altered Cognition/Beliefs/Emotions - Subjective
- Chronic/persistent pain but may be acutely flared
- Told multiple diagnoses – “I Don’t know what is going on”
- Multiple failed interventions
- Multiple diagnostic tests. Focus is on findings
- Often bilateral symptoms (“migrating”)
- Other areas of Muskuloskeletal pain(“migrating”)
- Describes being afraid to do activities
- Hypervigilance about activities & display catastrophization characteristics
- Altered emotions/beliefs
Questions to explore cognition, beliefs and experiences
- Why do you think you still hurt?
- What do you think should be done for your (injured area)
Altered Cognition/Beliefs/Emotions - Objective
- Questionnaires
– FAB or Tampa Scale of Kinesiophobia
– Central Sensitization Inventory
– Depression screen
– Pain catastrophizing scale - Self limits motion assessment (empty end feels)
- Sensitization to light touch during palpation (pain pressure thresholds?) at many locations
- Positive neurodynamic mobility
- Feels joint is swollen during motion (Cortical “smudging”)
- POOR coordination/motor control
- Diminished right/left discrimination (recognize app)
Altered Cognition/Beliefs/Emotions INTERVENTIONS
- Address what you identify
– Tell patients what it is NOT - Cognition - Educate to diminish fear and catastrophic beliefs
– PNE: sensitivity of tissues vs tissue damage
– Words that heal
– Left and Right Discrimination and motor imagery - Behavioral - modify beliefs and address functional goals
– Graded exposure to acitivity; Goal is to not decrease pain but to increase tolerance to activity – Less specifics on “Strengthening” “stabilization” and focus on ACTIVITY
– Patient centered goals and problem solving - Other
– Educate about imaging results
– Sleep education
– Diaphragmatic Breathing
– Motion is important! Find position they tolerate moving
– Focus on dosage of activity, less focus on quality
Prior to intervention…determine an ____
ASTERISK SIGN (aka: Comparable sign)
Specific MOTIONS which provoke symptoms?
Specific EXAM FINDINGS which provoke symptoms?
Specific FUNCTIONS which provoke symptoms?
REASSESS Asterisk sign to determine effectiveness of treatment and refine your clinical reasoning
(WITHIN or BETWEEN session changes)
