Lumbar Intro Symptom Modulation Flashcards
How to organize your LBP exam
- Symptom modulation: directional preference, manual, peripheralize
- Movement control: stability (SIJ), local mobility, global stability
- Pain neuroscience education: nociceptive, neuropathic, nociplastic
What are some serious pathologies of LBP
- Cauda Equina Syndrome
- AAA
- Femoral Head & Neck Fractures
- Cervical Myelopathy
- Central Sensitization
What are some possible pathologies of LBP
- Back strain (muscular)
- Lumbar spinal stenosis
- Lumbar radiculopathy
- Hip OA
- SIJ
- Spondylolisthesis
- Ankylosing spondylitis
How to determine prognosis using the STart Back Tool Scooring System
- Overall score: ≥3 = medium/high risk to develop chronic LBP
- Psychological score: ≤2 = medium risk; ≥3 = high risk; Refer to PT if medium/high risk
Guidelines from the American College of Physicians (ACP) for LBP
- Recommendation 1 (Acute LBP): non-pharmacological treatment oof heat, STM, TDN, & spinal manipulation
- Recommendation 2 (Chronic LBP): non-pharmacological treatment
- Recommendation 3 (Chronic LBP): If above all fails consider pharmacology but opioids as last resort
Acute LBP non-pharmacologic treatment effect sizes
- Heat: moderate effect
- Massage: small to moderate effect
- Acupuncture: small effect
- Spinal manipulation: small effect
Chronic LBP non-pharmacologic treatment effect sizes
- Exercise: small effect
- Motor control exercise: moderate effect
- Tai Chi/Mindfulness/Yoga: small to moderate effect
- Progressive relaxation: moderate effect
- Acupuncture: moderate effect
- Cognitive behavioral therapy: moderate effect
- Spinal manipulation: small effect
What are the 4 types oof screens
- Serious: based on red flag signs & symptoms
- Yellow flags: conditions that will delay recovery (Biopsychosocial model)
- Neuro screen
- Movement screen
What pathologies make up non-mechanical LBP (1% of patients)
- Neoplasia: spine tenderness & weight loss
- Inflammatory arthritis: morning stiffness & improves with exercise
- Infection: spine tenderness & constitutional symptoms
What pathologies make up non-spinal/visceral disease LBP (2% of patients)
- Pelvic organs (prostatitis, pelvic inflammatory disease, endometriosis): lower abdominal symptoms common
- Renal organs (nephrolithiasis, pyelonephritis): usually involves abdominal sx & abnormal urinalysis
- Aortic aneurysm: epigastric pain & pulsatile abdominal mass
- Gastrointestinal system (pancreatitis, cholecystitis, peptic ulcer): epigastric pain and nausea & vomiting
- Shingles: unilateral, dermatomal pain, & distinctive rash
What pathologies make up mechanical LBP (97% of patients)
- Lumbar strain/sprain: diffuse pain in lumbar muscles, some radiation to buttocks
- Degenerative disk or facet process: localized lumbar pain, similar findings to lumbar strain
- Herniated disk: leg pain often worse than back pain & pain radiating below knee
- Osteoporotic compression fracture: spine tenderness & often Hx of trauma
- Spinal stenosis: pain better when spine is flexed or when seated, aggravated by walking downhill more than uphill, & Sx often bilateral
- Spondylolisthesis: pain with activity, usually better with rest, usually detected with imaging, & controversial as cause of significant pain
What are your normal expectations for a LQ lumbar movement screen
- Touches toes
- Reversal of lumbar lordosis
- Hip to spine flexion ratios about 50% each
- Posterior hip sway
What are your pathologic motion expectations for a LQ lumbar movement screen
- Non-reversal of lumbar lordosis
- Hinge points
- Judder (a little hitch to one side) & deviations
- Gower’s sign: walking hands up thighs to stand from bent over position
What does SINSS stand for
- Severity
- Irritability
- Nature
- Stage
- Stability
What are your goals for your initial subjective
-1) Get a 24 hr picture of the pt’s pain presentation & what makes is better/worse
- 2) Is the LBP mechanical or non-mechanical
- 3) Does the pain appear to be mechanical/does it respond to load/unloading
- 4) Is there a directional preference
- 5) Is there a psychological component
What outcome measures can be used for LBP
- Oswestry Disability Index (ODI)
- Ronald Morris Disability Questionnaire (RMDQ)
What are the 4 treatment based classifications for LBP
- Manipulation
- Stabilization
- Specific exercise AKA direction preference
- Traction
What factors favor and are against manipulation
- Favor: hypo mobility with spring testing, low FABQ scores (FABQ-W <19), & hip medial (IR) rotation ROM >35º
- Against: Sx below the knee, increasing episode frequency, peripheralization with motion testing, & no pain with spring testing
What factors favor and are against stabilization
- Favor: hyper mobility with spring testing, increasing episode frequency, & ≥3 prior episodes
- Against: discrepancy in SLR ROM (>10º) and low FABQ score (FABQ-PA <9)
What factors favor and are against specific exercise AKA directional preference
- Favor: directional preference for extension or flexion, centralization with motion testing, & peripheralization in direction opposite to centralization
- Against: LBP only (no distal Sx) and status quo with all movements
What factors favor and are against traction
- Favor: peripheralization of Sx with no ability to centralize with movement
- Against: LBP only (no distal Sx) and no sign of nerve root compression
What are the 5 lumbar manipulation criteria
- Duration of Sx <16 days
- At least one hip >35º IR ROM
- Lumbar hypo-mobility
- No symptoms distal to knee
- FABQ-W <19
What direction is the STM for superficial and deep
- Superficial: contact is parallel
- Deep: contact is perpendicular
What are the variations of STM techniques
- Sustained pressure with/without 3D lock
- Pressure with short/lengthen
- Pressure with oscillations
- Functional mobilization
Pre-testing for lumbar manipulation CPR
- PA spring testing at each lumbar level
- Prone hip IR/ER
- SI tests: provocation, motion, symmetry
Manipulation process for the lumbar manipulation CPR
- Worse pain side first (coin flip if both equal)
- No cavitation after 2 tries then attempt contralateral side
- Exercise: supine pelvic tilts, continue usual activities, repeated above x2 visits or only 1 if >50% reduction of ODI score
Which lumbar manipulation techniques work well verses not as well
- Works well: Regional Lumbopelvic in Supine and Sidelying Neutral Gapping
- Not as well: PA mobilization technique
McKenzie Centralization Definition
- The phenomenon by which distal limb pain emanating from although not necessarily felt in the spine is immediately or eventually abolished in response to the deliberate application of loading strategies. Such loading causes an abolition of peripheral pain that appears to progressively retreat in a proximal direction. As this occurs there may be a simultaneous development or increase in proximal pain.
Describe a derangement diagnosis
- Obstruction within spinal motion segment
- Instant
- Variable pain within the motion segment
Describe a dysfunction diagnosis
- Structural scar & shortened tissue
- Time to develop 6-8 wks after injury
- Consistent, ERP always on/off
Describe a posture diagnosis
- Abnormal stress on normal tissue, pain from static loading
- Time till Sx produced
- Intermittent pain from THE position
Non-mechanical types of LBP
- Spinal stenosis
- Hip disorders
- Sacroiliac disorders
- Low back pain in pregnancy
- Zygapophyseal disorders
- Spondylolysis and spondylolisthesis
- Spinal infection
- Post-surgical problems
What is the criteria for lumbar spinal stenosis CPR
- Bilateral symptoms
- Leg pain > back pain
- Pay during walking or standing
- Pain relief upon sitting
- Age >48 yrs
- Shopping cart sign (typical of spinal stenosis but not a part of the CPR)
