Lumbar Interventions

Question 1

T/F: Early PT for LBP is associated w/ reduced work time lost, reduced chronic LBP, reduce need for lumbosacral injections, & reduced physician visits.

Answer 1

True

Question 2

Initial management of spondylolysis is (conservative/surgical). PT for spondylolysis or spondylolisthesis should include __ __ to address repetitive activities. __ __ should be also addressed with AROM, STM, progression, and __ intensity/ __ frequency & duration exercises. PT also includes stretching of shortened hip muscle and strengthening for lumbar (stabilization/mobility). What motion should you avoid having your patient perform and what grades of joint mobs should be avoided?

Answer 2

1) conservative
2) activity modification
3) muscle guarding
4) low intensity/high frequency
5) stabilization
6) Avoid ext past neutral & avoid doing Gr 3-5 (ESP. manips and thrust)

Question 3

Tx for radiculopathy/ radicular pain include lumbar stabilization w/ emphasis on functional training and AROM/mobility exercises. What are 2 more interventions for this dx?

Answer 3

1) N glides, tensioners
2) Opening/gapping glides to address hypomobility
if hypermobile, avoid stretching and focus on strength/stability

Question 4

Name 4 Tx for Discogenic pain (disc derangement). What tx could you do for adjacent levels around disc?
Hint: very similar to tx for spondyyy

Answer 4

1) AROM/mobility exercises
2) STM to address guarding
3) Low-intensity/High freq & duration exercises
4) lumbar stabilization exercises (core/back), w/ emphasis on functional training

5) Potential joint mobs to adjacent levels

Question 5

Tx for radiculopathy/ radicular pain with an HNP origin includes stabilization exercises, manipulations/mobs, STM, and mechanical __. ibuprofen is associated with a ___ response.
T/F: Conservative tx is very effective short and long term.

Answer 5

1) traction
2) adverse
3) False, not as effective short-term, but may be equally as effective as other methods (i.e. surgery) long-term

Question 6

Lumbar Spine Stenosis tx include joint mobility mobs gr. ___ with sustained holds for ___ __ and oscillations for __ __ and __. Muscle performance should include coordination training, strengthening, & endurance. Research shows evidence for focusing on what 3 interventions?
What activities require modification for this population?

Answer 6

1) 1-5
2) hypomobile segments
3&4) muscle guarding and pain
5) BWSTT, manual therapy, & exercises (WBing focus)
6) activities that place higher sustained loads on involved structures
consider implications for central vs lateral

Question 7

Z Joint Arthropathy tx includes low intensity/high freq & duration exercises w/ progressively increased ____ __ on the Z joint.
also includes coordination & manual similar to stenosis

Answer 7

compression loading

Question 8

According to research, is the treatment-based classification (TBC) or mechanical dx & therapy (MDT) better for reducing pain & disability in pts with acute LBP? What about chronic LBP?

Answer 8

1) Acute = TBC
2) Chronic = MDT

Question 9

What are 4 Red flags that may indicate a back related tumor?
CAN U? pneumonic think cancer red flags

Answer 9

1) Constant pain NOT alleviated by position or activity, worse at NIGHT
2) Age >50, cancer Hx, conservative tx failed
3) No relief with bed-rest
4) Unexplained wt loss

Question 10

Back Tumor cont..
2 red flags that would increase suspicion for a back tumor are…
1) constant pain not alleviated by ___ & worse with ___
2) failure of conservative therapy within __ days.

Flags that would reduce suspicion are…
1) Findings are consistent w/ 1 or more of the ICF LBP subgroups.
2) S&S resolved w/ subgroup matched interventions.

Answer 10

1&2) movement, & worse with WBing
3) 30 days

Question 11

What are some Red flags that may indicate Cauda Equina Syndrome?
WUFS pneumonic

Answer 11

W-eakness (global or progressive) in LEs
U-rine retention or incontinence
F-ecal incontinence
S-addle anesthesia

Question 12

Cauda Equina Syndrome cont..
2 red flags that would increase suspicion for a Cauda Equina Syndrome are…
1) ___ anesthesia
2) sensory or motor deficit in ___ (& what spinal levels is this body part in?)

Flags that would reduce suspicion are…
LE sensation and motor is ___.

Answer 12

1) saddle
2) feet (L4-S1)
3) normal or improving

Question 13

Red flags for Back-related Infection include recent infection, and reports of fever, malaise, & swelling. What are 2 more red flags?

Answer 13

1) IV drug user/abuser & concurrent immunosuppressive disorder
2) Spine rigidity; accessory mobility may be limited AND
Elevated temp: tuberculosis osteomyelitis, pyogenic osteomyelitis, & spinal epidural abscess

Question 14

Back-related Infection cont…
Other than fever, malaise, & swelling 2 more red flags that increase your suspicion are…
1) Spine ___; which potentially makes accessory mobility limited
2) __ Body Temperature; this can incr. suspicion specifically for ____ osteomyelitis, __ osteomyelitis, & spinal ___ abscess.

2 Flags that would decrease suspicion for this condition is __ body temp & findings consistent w/ LBP subgroups.

Answer 14

1) rigidity
2) elevated
3-5) tuberculosis osteomyelitis, pyogenic osteomyelitis, & spinal epidural abscess
6) normal

Question 15

Red flags for Spinal Compression Fx are (4)___
Hint: 2 of them involve trauma

Answer 15

1) History of major trauma, such as vehicular accident, fall from a height, or direct blow to the spine
2) History of minor trauma for osteoporotic or elderly individuals, such as falls or heavy lifts
3) Age over 75
4) Prolonged use of corticosteroids

Question 16

Spinal Compression Fx cont…
Increased pain with __ __ and TTP over fracture site would increase suspicion for compression fx.

Flags that would reduce suspicion is age =/< ___, symptoms not aggravated w/ ___ or TL ___ movements, and findings consistent w/ LBP subgroups.

Answer 16

1) Weight bearing
2) =/<50 y/o
3&4) WBing or TL FLEXION movements

Question 17

Red flags for AAA include pain in the __, __, or __ areas, and the presence of ___ or ___ and associated RFs (>50, smoker, HTN, DM).

Suspicion for AAA increases when the pt has symptoms not related to stresses associated with somatic LBP and an abdominal girth <___ cm.

Answer 17

1-3) back, abdominal, or groin pain
4&5) PVD or Coronary A Disease
6) <100 cm

Question 18

For ACUTE LBP general recommendations for tx include exercise (trunk muscle activation), joint mobs, & STM. Which of these interventions have weak evidence? Which has strong evidence for pain & disability?
Which has moderate evidence for short-term pain relief?

Answer 18

1) Exercise
2) joint mobs
3) STM
Active pt edu in clinic vs passive pt edu (handouts) is recommended too

Question 19

For CHRONIC LBP general recommendations for tx include exercise training interventions (strengthening, endurance, multimodal, aerobics, aquatics), movement ctrl exercises (trunk motility focused), joint mobs, STM, & dry needling.
1) Which of these interventions have weak evidence for short-term pain & disability reduction?
2) Which has strong evidence for pain relief & disability?
3) Which has strong evidence, but not for one specific target (targets like pain)?
4) Which has moderate evidence, but not for one specific target (targets like pain)?
5) Which has moderate evidence for short-term pain relief & disability reduction?

Answer 19

1) dry needling
2) Joint mobs
3) exercise training interventions
4) movement ctrl exercise
5) STM
Active Pt edu in clinic (esp. on pain), and active tx (yoga, pilates, etc) are recommended to*

Question 20

T/F: Pt edu should focus on pain being related to anatomic issues more than positive beliefs resilience with LBP.

Answer 20

False, Lesser disability in subjects with positive beliefs. Education should focus on positive beliefs and resilience with LBP.

Question 21

T/F: The best tx for chronic LBP in OLDER adults and for pts w/ POST-OP LBP should include general exercise training to reduce pain and disability.

Answer 21

True

Question 22

T/F: Pt edu recommendations on precaution, exercise, & resuming physical activity in research for post-op LBP applies to pts undergoing discectomy, decompression, or fusion surgery.

Answer 22

False; everything true except recommendations don’t apply to pts after a fusion d/t lack of evidence.

Question 23

What are the LBP subgroups of the Impairment/Functional-Based Classification System? (6)

Answer 23

1) LBP with Mobility Deficits
2) LBP with Movement Coordination Impairments
3) LBP with Related (Referred) Radiating LE Pain
4) LBP with Radiating Pain
5) LBP with Related Cognitive or Affective Tendencies
6) Chronic LBP with Related Generalized Pain

Question 24

1) Which chronic LBP subgroup is this most aligned w/?
-LBP or LBP-related LE pain for a >3 month duration
-High scores on the psychosocial subscale of the STarT Back Screening tool
-High scores on the Fear-Avoidance Beliefs Questionnaire
-High scores on the Pain Catastrophizing Scale
-High scores on Patient Health Questionnaire-2 or PHQ-9 or Beck Depression Inventory
Rule out if STarT Back Screening tool total to be 0

2) What acute LBP subgroup would this mostly align w/ if LBP or LBP-related LE pain was <3 months in duration?

Answer 24

1) Chronic LBP with related generalized pain
2) Acute LBP w/ Related Cognitive or Affective Tendencies

Question 25

Tx for Acute LBP w/ Related Cognitive or Affective Tendencies & Chronic LBP with related Generalized Pain include interventions to address ____ contributors to pain, pt edu on ___ neuroscience, and exercise/aerobics/active edu/advice to reduce depressive symptoms associated w/ LBP disability.

Answer 25

1) biopsychosocial
2) pain

Question 26

Acute LBP with Movement Coordination Impairments:
Rule in if:
-__ exacerbation of recurring LBP that may be associated with referred lower extremity pain; often includes ___ episode(s) of LBP/LBP-related LE pain in recent years
-S&S provoked w/ __ROM that worsens w/ __ROM motion or positions, AND provocation of the involved lumbar segment(s)
-Coordination impairments of the ___ region w/ flex & ext or while performing ADLs
-Trunk or pelvic muscle __ and __ deficits
-Mobility deficits of the thorax & hips regions may be present
-Signs of lumbar segmental or sacroiliac __mobility may be present
Rule Out if bilat SLR & rotation at least 80 degr. or normal trunk flex(leg-lowering test)/ext(Sorensen test), lat abdominals, hip abd, & hip/thigh muscle performance tests (star excursion)

9) What would make this chronic LBP of the same subgroup?

Answer 26

1) Acute
2) numerous
3&4) midROM that worsens w/ endROM
5) lumbopelvic
6&7) strength and endurance
8) HYPERmobility
9) S&S provoked at endROM only and LBP is chronic (>3 mo.)
Look for aberrant patterns during AROM screening, check T spine and hips

Question 27

Tx for Acute & Chronic LBP w/ Movement Coordination Impairments include interventions to address trunk activation and movement __ training for less symptomatic motions, trunk muscle __ & __, joint mobs/STM for ___, reduced disability and to improve T-spine & hip mobility, and active edu to pursue an __ lifestyle. Unlike tx for chronic phase/acuity, tx for the acute phase includes edu on the favorable natural hx of acute LBP and __-___ techniques to prevent recurring LBP episodes.

Answer 27

1) control
2&3) strength and endurance
4) pain
5) active
6) self-management techniques

Question 28

TrA coordination tx can work on ___ which is bracing for an action or __ which is volitional ctrl of activation. Potential biofeedback mechanisms include __, __ imaging, & stabilizing ___. Monitor pt for substitution like ___ __, active lumbar motion in the form of __ ___, quick contraction & ___ activation.

Answer 28

1) anticipatory
2) static
3-5) palpation, US imaging & stabilizing cuff
6) Valsalva Maneuver
7) pelvic tilting
8) internal oblique (IO)

Question 29

Multifidi coordination tx can work on static ctrl in __, __, or ___ positioning or on dynamic ctrl by performing ___ or lifting the extremities. Potential biofeedback mechanisms include US imaging and ___.

Answer 29

1-3) prone, SL, or quadruped
4) rotation
5) palpation

Question 30

For pressure biofeedback training, pt will be in supine w/ hips flex at 45 degr & knees at 90 degr. The stabilizer cuff will be posterior to L-spine (L3) and inflated to __ mmHg. Pt activates and maintains activation w/ or w/out LE motion while __ pressure variation of >/=2-3 mmHg. What are 3 LE exercises that can be done w/ pressure biofeedback training?

Answer 30

1) 40 mmHg
2) avoiding
3) Marching, Heel slides, SLR

Question 31

Prone drawing in biofeedback training has the pt in prone w/ cuff anterior to lower abdomen (in line with the ASISs) & inflated to __ mmHg. Pt performs drawing maneuver in attempt to decr. pressure by >/= 10 mmHg. Pt can do isometric holds for __ seconds up to 10x & they can do __/__ lifting exercises.

Answer 31

1) 70
2) 10
3) UE/LE

Question 32

Lumbar stabilization exercises can work on TrA, multifidi/erector spinae, quadratus lumborum, or oblique abdominals. Quadratus lumborum and Obliques can be improved with side support with knees flexed or ext (like a side plank). What is the common dosage for lumbar stabilization exercises (reps)?

Answer 32

20-30 reps, 4-8 sec holds

Question 33

1) Which acute LBP subgroup is this?
-LBP commonly associated w/ referred LE pain that worsens w/ flex and sitting; usually numerous episodes reported
-Rule IN if…
-LBP & LE pain can be CENTRALIZED and DIMINISHED w/ positioning, manual, and/or repeated movements
-Lat trunk shifts, decr. lordosis, limited lumbar ext, & findings associated w/ movement coordination are common
-Rule OUT if… pain is not altered by prolonged positioning, manual, and/or repeated movement (i.e. prone press-ups)

Answer 33

Acute LBP with Related (Referred) LE Pain
think UMN like disc pathology

Question 34

1) Which acute LBP subgroup is this?
-LBP associated w/ radiation (narrow band of lancinating (stabbing)) pain in the INVOLVED LE
-LE paresthesia, numbness, & weakness may be reported
-Rule IN if…
-S&S provoked w/ midROM & worsen w/ endROM spinal mobility, LLTTs (SLRs, slump tests)
-Signs of N root involvement
-Rule OUT if…S&S not provoked by LLTTs

2) The chronic phase of this LBP subgroup is more consistent w/ LBP OR __-back pain w/ associated radiating LE pain that is chronic (>_ mo.) w/ potential __, strength, or __ deficits. Also if S&S are only provoked/aggr. w/ __ROM LLTTs.

Answer 34

1) Acute LBP with Radiating Pain
think LMN like Z-joint pathology
common for these impairments to also be presents in pts w/ Acute LBP w/ Related (Referred) LE pain

2) MID-back pain; chronic (>3 mo.); potential SENSORY, strength, or REFLEX deficits; with sustained END-ROM LLTTs

Question 35

To tx acute LBP with related (referred) LE pain, inventions like manual, postures/positioning, repeated movements, or traction that promote __ and improve lumbar ___ are recommended. Also progression to acute LBP with __ __ __ intervention strategies are suggested.

Answer 35

1) centralization
2) ext
3) movement coordination impairments

Question 36

Tx for acute and chronic LBP with radiating pain include general exercise training & N tissue mobilization exercise to reduce pain and improve mobility of __ (dural) and ___ neural elements. Tx also includes joint mobs & STM to reduce pain, disability, & mobilize structures adjacent to __ __ or nerves w/ mobility deficits. Active edu should focus on performing activities that promote __-__ N mobility.
For Acute, active edu also focuses on favorable natural hx of acute LBP & __-__ techniques like __ that reduce strain/compression on Ns. For Chronic, active edu also focuses on pursuing an __ lifestyle.

Answer 36

1&2) central & peripheral
3) N roots
4) pain-free
5) self-management
6) positioning
7) active

Question 37

T/F: Mechanic traction is an excellent exercise to use for pts w/ chronic LBP with leg pain.

Answer 37

FALSE, based on lack of benefit when added to other interventions

Question 38

T/F: N mobs are excellent tx for long-term improvements in pain & disability in pts w/ chronic LBP with leg pain.

Answer 38

FALSE, everything is true except N mobs only provide SHORT-term improvements

Question 39

Sciatic N mob is commonly done is sitting and can be passive by clinician or active by patient. Gliders/sliders include ankle __ during neck flex, f/b ankle __ during return to neck neutral position.
Tensioners include ankle DF during neck __, f/b ankle __ during return to neck neutral position.

Answer 39

1) PF
2) DF
3) neck flexion
4) PF

Question 40

Acute LBP with mobility deficits involves LB, butt, or thigh pain ____ (weeks/months). S&S onset is often linked to a recent ___/awkward movement or position.
Rule this IN if pt has lower ___ or lumbar ROM deficits and if LBP is reproduced w/ __ROM spinal motion and ___ of involved segments.
Rule this OUT if pt is able to perform ___ endROM spinal motion w/ overpressure pain-free or clinician is unable to reproduce pain w/ ___ (endROM CPA/UPAs) of involved segments.

Answer 40

1) 6 weeks or less !!!
2) unguarded
3) thoracic
4) endROM
5) provocation
6) COMBINED endROM motions (think ext/SBing)
7) provocation

Question 41

Tx for acute mobility deficits include joint mobs to reduce pain/disability, & improve ___ mobility, General exercise training to improve/maintain __, LB, & __ mobility, & active pt edu to pursue an active lifestyle & favorable natural hx of LBP & self-management techniques to prevent ___ LBP episodes, such as activities that enhance ___.

Answer 41

1) thoracolumbar
2&3) thorax, LB, & hip mobility
4) recurring
5) flexibility

Question 42

Lumbar rotation in hook-lying, quadruped TL flex/ext, hook-lying/sitting/standing lumbar flex/ext, & supine knees to chest all are exercises that work on what?

Answer 42

AROM

Question 43

CPRs for LBP pt who likely benefit from spinal manips are:
1) Duration of symptoms ___ days.
2) No symptoms ___ to the ___
3) ____ work subscale score of ___
4) one hip w/ ___ of __ ROM
5) Lumbar spine ___mobility

Answer 43

1) Duration of symptoms <16 days
2) No symptoms distal to the knee
3) Fear Avoidance Behavioral Questionnaire (FABQ) work subscale score <19
4) One hip w/ <35 degr. IR ROM
5) Lumbar spine HYPOmobility

Question 44

T/F: Pts who met Flynn’s CPR & received a manipulation showed the greatest improvement in disability compared to pts who met CPR but only received exercise for stabilization.

Answer 44

True

Question 45

Pragmatic Criteria for lumbar manipulation include consist of what 2 criterion from Flynn’s CPRs?
Both criteria present have been found to be PREDICTIVE

Answer 45

1) Duration of symptoms <16 days
2) No symptoms distal to the knee