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MSK II FINAL > Lumbar Spine Management > Flashcards

Lumbar Spine Management Flashcards

1
Q

CPG #1
Acute LBP with Mobility Deficits - CHARACTERISTICS

A

Restricted spinal ROM

Possible segmental hypomobility

LBP is reproduced with provocation of involved segments

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2
Q

Acute LBP with Mobility Deficits - INTERVENTION GOALS

A

Reduce Pain

Improve mobility

Address strength and control impairments

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3
Q

Acute LBP with Mobility Deficits - suggested matched interventions

A

thrust or non-thrust joint mobs

soft tissue mobs and massage

generalized exercise training

active education and advice to pursue an active lifestyle

education on favorable natural history of acute LBP and self-management techqniues

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4
Q

3 interventions for Acute LBP with Mobility Deficits:

A

Reduce pain with spinal joint mobilizations or manipulations

Therapeutic exercise to improve spinal mobility, increase strength, increase endurance, and improve coordination

Pt education to stay active

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5
Q

Grade I –

A

small amplitude oscillations within resistance free range

Small amplitude, low velocity oscillations at the beginning of the available range of movement, within resistance free range.

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6
Q

Grade II –

A

large amplitude oscillations within resistance free range

Large amplitude, low velocity oscillations in the middle of the available range of movement.

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7
Q

Grade III –

A

large amplitude oscillations up to the point of resistance

Large amplitude, low velocity oscillations in the middle of the available range of movement.

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8
Q

Grade IV –

A

small amplitude oscillations at point of tissue resistance

Small amplitude, low velocity oscillations at the end of the available range of movement, into tissue resistance

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9
Q

Grade V –

A

small amplitude high velocity thrust beyond tissue resistance but before anatomical limit

High velocity, small amplitude thrust beyond tissue resistance but before anatomical limit.

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10
Q

Mobilization, Manipulation and Manual Therapy

A

Historically used interchangeably as synonyms (which they are not), and therefore grouped together in analysis of methodology and results

Soft tissue mobilization, joint mobilization and manipulation

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11
Q

PROM
Passive Physiologic Intervertebral Movements (PPIVM)

A

flexion
extension
side bending
rotation

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12
Q

mobilization
Passive Accessory Intervertebral Movements (PAIVM)

A

PA
- central
- cranial
- caudal
- unilateral

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13
Q

Flynn T, Fritz J, Whitman J et al. A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who Demonstrate Short-Term Improvement With Spinal Manipulation

A

Predictor variables
- Symptoms < 16 days (strongest)
- At least 1 hip with >35o IR
- Hypomobility with LSP spring test
- FABQW score <19
- No Symptoms distal to knee

Probability of success = 68% when 3/5 variables present = worth a trial of manipulation

Probability of success = 95% when 4/5 variables present = definitely manipulate

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14
Q

Lumbopelvic manipulation

A

Lumbopelvic rotation HVT

If cavitation is heard or felt, proceed to therapeutic exercise

If no cavitation on 1st attempt, reposition and repeat, if no cavitation on 2nd attempt, treat opposite side a maximum of 2 attempts per side

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15
Q

Therapeutic exercise

A

Supine pelvic tilt home exercise program

(10 reps, 3-4 x /day)

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16
Q

Patient education

A

Instruction to maintain usual activity levels within pain limits

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17
Q

Clinical bottom line

A

4 or more predictor variables, 95% probability that a patient with acute LBP will experience at least 50% improvement in function (modified ODI) from lumbopelvic manipulation and exercise within 2 treatment sessions (4-8 days)

Having symptoms for less than 16 days was the most accurate individual variable in the rule

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18
Q

Comparison of the effectiveness of 3 manual PT techniques in a subgroup of pts with LBP who satisfy a CPR

A

3 techniques:
Supine global lumbar rotation thrust as used in CPR development study, maximum of 2 attempts per side
Side lying more specific lumbar rotation thrust sore side up, maximum of 2 attempts
Prone central PA to L4 and L5, 2x60 seconds at each level, 30 seconds between each set

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19
Q

Why do spinal manipulations make our patients feel better?

A

Pain relief (often immediate)

Temporary hypermobility of the joint that restores normal joint play

HVT may result in ‘cavitations’ (sudden release of synovial gas)

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20
Q

Pain relief (often immediate) =

A

Psychological

Freeing trapped mensicoid or disc fragment

Neurophysiological effect: ascending and descending pain inhibition

Reflexogenic effect: muscle relaxation

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21
Q

HVT may result in ‘cavitations’ (sudden release of synovial gas)

A

Takes time (20-30 mins) for the synovial joint to reabsorb the gas … hence the ‘latent period’ when joints can not be ‘re-popped’

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22
Q

Lumbar HVT L3-4 R) rotation

A

patient: L) side lying, L) leg extended, R) hip and knee flexed

therapist: facing patient at level to mobilize

procedure: The most efficient delivery of thrust is with body weight shift, drive force along the long axis of patient’s femur, therapist’s upper extremities should be maintaining the joint position at the end of available range

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23
Q

Lumbar HVT L3-4 R) rotation

Indications:

A

restore lumbar motion in any direction since this is a gapping technique

reduce pain

low back pain that fits CPR

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24
Q

Lumbar HVT L3-4 R) rotation positioning

A

Extend segments above L3

Flex LSp from below up to L4 using top leg as lever [ligamentous tension locks lower segments]

R) Rotate upper segments down to L3 [helps to lock]

Rotate pelvis to L) so L4 rotates L) under fixed L3 [creating R) rotation at L3-4]

Mobilization or HVT delivered through PT’s L) forearm against pt’s iliac crest and lateral hip, good body contact, PT’s weight on L) leg to ‘drop’ to deliver HVT

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25
Q

Therapist positioning - Lumbar HVT L3-4 R) rotation

A

Good body contact is critical

Good PT posture and strong connection between upper and lower body

PT’s upper body should be over pt’s pelvis

PT’s front leg close to plinth

pt’s top knee held between PT’s thighs and plinth

PT’s back leg in line with long axis of pt’s femur

HVT is best delivered by weight shift from front leg to back leg

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26
Q

Which side up for LSP rotation HVT?

A

LBP that fits the CPR
> Sorest side up
> If both sore, flip a coin!
> If no cavitation on first choice side, try the other side

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27
Q

Which side up for LSP rotation HVT?- Radicular symptoms in the buttock and thigh

A

> Sore side down
This closes down the affected side

Radicular symptoms below the knee = NO HVT

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28
Q

Two leg rotation

A

If pt presents with pain or limited straight leg raise (SLR) and no signs or sx below the knee try 2 leg rotation TOWARDS THE SIDE OF LIMITED SLR.

Pt position: supine and holding onto plinth with opposite hand if necessary.

Therapist position: stand on side of symptoms, flex up both hips and knees with feet off table.

Rotate toward painful side, you may need to stabilize opposite shoulder.

Alter the degree of hip flexion and rotation to resolve pain

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29
Q

Self sustained lumbar joint mobilization with motion
Extension or Flexion

A

Pt position: standing using belt or strap under spinous process to be mobilized.

Apply an anterior and cranial glide.

Keep elbows flexed throughout the movement.

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30
Q

Clinical Importance of Stages of Healing

A

Optimal healing zone

Knowing stages allows you to match tissue’s loading capacity to appropriate treatment

Rule of Thumb: DO NO HARM
Overload too early-> injure further
Underload later-> tissue not strong enough, gets re-injured

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31
Q

Therapeutic Exercise Examples

A

P/AA/AROM

Strengthening within newly gained range

Work proximal to distal

Address control= simple to complex, stable to unstable, static to dynamic

Incorporate functional/work-specific/sport-specific exercise

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32
Q

PELVIC TILT - SUPINE

A

Lie on your back with your knees bent.

Next, arch your low back and then flatten it repeatedly.

Your pelvis should tilt forward and back during the movement.

Move through a comfortable range of motion.

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33
Q

rotation ROM

A

positional traction for the lumbar spine

SB over a 6-8inch roll causes longitudinal traction to the segments on the upward side

SB with rotation adds a distraction force to the facet’s on the upward side

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34
Q

Patient Education =

A

Stay active within your pain tolerance

Walk, swim, etc.

The ACSM guidelines for exercise

Proper body mechanics

Frequently change posture

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35
Q

diagonal lift

A

is used when lifting moderately heavy items from floor level

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36
Q

straight leg lift

A

only used when bending of the knees and hips is limited, and you cannot get close to the load

special care must be exercised when using this method to prevent aggravation of your back condition

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37
Q

CPG #2
LBP with Movement Coordination Impairment
CHARACTERISTICS

A

Poor lumbopelvic control, aberrant movement

LBP is reproduced with provocation of involved segments

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38
Q

LBP with Movement Coordination Impairment
INTERVENTION GOALS

A

Improve neuromuscular control
Decrease pain with movement
Decrease fear/apprehension

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39
Q

Acute LBP with Movement Coordination Impairment - suggested matched interventions

A

specific trunk activation training

trunk muscle strengthening and endurance exercises

thrust or non-thrust joint mobs, soft tissue mobs, and massage

active education and advice to pursue and active lifestyle

education on the favorable natural history of acute LBP and self-management techniques

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40
Q

Chronic LBP with Movement Coordination Impairment - suggested matched interventions

A

specific trunk activation and movement control training

trunk muscle strengthening and endurance exercises

thrust or non-thrust joint mobs, soft tissue mobs, and massage

active education and advice to pursue and active lifestyle

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41
Q

3 interventions for Acute and Chronic LBP with Movement Coordination Impairments

A

Reduce pain by improving patient awareness of muscle activity and lumbopelvic control

Therapeutic exercise to improve spinal stability, increase strength, increase endurance, and improve coordination

Pt education to stay active

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42
Q
A
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43
Q

Radiographically Appreciable Instability =

A

Greater than normal ROM between two vertebral segments

Objectifiable or structural

Radiographs focus on end-range segmental motion

Marked disruption in osseoligamentous constraints

Can lead to surgical fusion

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44
Q

Functional/Clinical Instability

A

Increased segmental motion in the neutral zone (mid-range)

Negative radiographs

Loss of neuromotor ability to control segmental motion in the neutral zone

Three subsystems
Passive
Active
Neural control

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45
Q

Functional/Clinical Instability definition

A

An inability to efficiently coordinate the passive, active and neural control subsystems to allow functional movements without neurological dysfunction, major tissue deformity or incapacitating pain

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46
Q

Subjective Signs of Functional/Clinical Instability

A

Catching

Giving way

Feeling of instability

Minor perturbation = major pain

Pain with transitional movements, changing position

Pain with sudden or unexpected movements

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47
Q

Objective Signs of Functional/Clinical Instability

A

Aberrant movement

Poor lumbopelvic control

Painful arc

Hinging

Muscle guarding

Gower’s sign (thigh walking - MSK)

Painful PA spring test

Hypomobile adjacent segments

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48
Q

Intervention Commonly used terms…

A

Spinal stabilization
”stiffening”

Dynamic stabilization

Rhythmic stabilization

Core strengthening

Neuromuscular rehabilitation

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49
Q

Stabilization Basic Principles

A

Develop awareness

Train in neutral or positional bias

Develop control

Spine-> Extremities

Simple-> Complex

  • Increase reps, load, cognitive demand
  • Isometric, rhythmic, perturbations
  • Progress from a stable to an unstable surface
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50
Q

Deep segmental muscle activation strategiesSpine stiffening strategies

A

Abdominal drawing-in maneuver (ADIM)

Abdominal bracing maneuver (ABM)

Posterior pelvic tilt (PPT)

= all contribute to neutral spine

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51
Q

ADIM

A

Targets transversus abdominis

Co-contraction of multifidi

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52
Q

ADIM Cues:

A

“Draw the belly button toward the spine”

“abdominals like a corset”

“Pull your belly away from your pants”

Allow normal breathing

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53
Q

ABM

A

Lateral flare of the abdominal wall

Global muscle activation

Cues: “Widen your waist”

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54
Q

Posterior Pelvic Tilt =

A

Uses lumbar flexion

Targets rectus abdominis

Sometimes used to teach patient awareness of a neutral spine

Can be painful for patients with an acute disc lesion or functional/clinical instability

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55
Q

Multifidi

A

Palpate intersegmentally

Instruct the patient to “make the muscle swell”

Can facilitate with ADIM or pelvic floor activation

Can also use extension-based strengthening ex’s

56
Q

CPG #3
LBP with related (referred) leg pain- suggested matched interventions

A

mechanical diagnosis and therapy interventions

progress to acute LBP with movement coordination impairments and intervention strategies

57
Q

acute LBP with movement coordination impairments - suggested matched interventions

A

specific trunk activation training

trunk muscle strengthening and endurance exercises

thrust or non-thrust joint mobilization, soft tissue mobs, and massage

active education and advice to pursue an active lifestyle

education on the favorable natural history of acute LBP and self-management techniques

58
Q

acute LBP with radiating pain - suggested matched interventions

A

general exercise training and neural tissue mobilization

thrust or non-thrust joint mobs, soft tissue mobs, and massage

education on the favorable natural history of acute LBP and self-management techniques

59
Q

chronic LBP with radiating pain - suggested matched interventions

A

general exercise training and neural tissue mobilization exercises

thrust or non-thrust joint mobilization, soft tissue mobilization, and massage

active education to pursue an active lifestyle

60
Q

Local pain =

A

experienced at the site of origin

61
Q

Referred pain =

A

perceived in different area than that of the site of origin

62
Q

Radicular =

A

follows the nerve root distribution

63
Q

Non-radicular =

A

perceived in an unrelated site, can be generated by structures other than the nerve root (disc, facet, ligament)

64
Q

Nociceptive =

A

inflammatory pain in response to activation of peripheral nociceptors by mechanical, pressure, temperature changes or chemical activation

65
Q

Non-nociceptive =

A

“neurogenic” or “neuropathic,” result of direct stimulation of nervous tissue, PNS or CNS

66
Q

Centralization and Directional Preference

A

Lumbar Flexion vs Extension
> Can also include correction of a lateral shift

Use of repeated movements to assess the effect of motion on the symptoms

Exercises are used for pain relief

Approach is most effective for patients who respond readily to mechanical provocation

Mechanical treatment based on the mechanical diagnosis
> If the patient does not respond with movement or position, it’s not mechanical

Empowers the patient to be responsible for recovery

67
Q

Self lumbar SNAG Extension or Flexion

A

Pt position: standing using belt or strap under spinous process to be mobilized.

Apply an anterior and cranial glide.

Keep elbows flexed throughout the movement.

68
Q

Traction – Manual and PositionalConflicting evidence: purpose

A

Increase the intervertebral foraminal space
> Decrease nerve root compression and intradiscal pressure

Facilitate improved circulation/blood supply to the tissues

Aid in muscle relaxation
> Elongate muscles, decrease sensitivity to stretch, decrease muscle guarding

69
Q

Traction – Indications

A

Spinal nerve root compression d/t disc pathology (protrusion, prolapse, extrusion, sequestration) or stenosis

Generalized hypomobility of the lumbar spine
> Separates the facets, general capsular stretch

Muscle spasm that may be aggravating nerve root, facet or disc signs/symptoms

70
Q

Traction – Contraindications

A

Spinal infections – meningitis, arachnoiditis

Spinal cancer – traction may increase the danger of metastases or promote instability

Cord involvement

RA

Osteoporosis

Recent fracture

71
Q

Traction – Precautions

A

Ligamentous laxity d/t sprain, pregnancy, generalized hypermobility (e.g. Ehlers-Danlos syndrome)

Traction anxiety

Acute disc lesion

72
Q

Manual traction =

A

Controlled by the therapist

Can isolate specific region

73
Q

Positional traction =

A

Can be isolated to a specific intervertebral segment or facet joint

Patient can assume positions at home

74
Q

Manual Traction – Lumbar

A

1) Apply traction leaning body weight away from patient
> hip joint close packed
> grasp above malleoli
> take up soft tissue slack

2) Apply traction through seatbelt around hips

3) Apply traction through seatbelt around hips
> Seatbelt in 1st web space, as near to hip joint as possible
> Seatbelt in popliteal fossae, use foam or towel to protect

75
Q

Mechanical Traction - Fritz, Cleland, Childs. Subgrouping patients with low back pain: Evolution of a Classification Approach to Physical Therapy.

A

Signs and symptoms of nerve root compression

No movements centralize symptoms

Treat with mechanical or auto-traction

76
Q

Lack of evidence supporting use of traction in patients with LBP

A

Problems with use of heterogenous patient groups in these studies

More research needed to identify patients with LBP who might respond to traction

More research needed to determine optimal dosage of traction force, patient position, duration, frequency

77
Q

Clinical Prediction Rule predictor variables: Mechanical Traction

A

Peripherilization of symptoms with repetitive lumbar extension

Positive crossed SLR

SLR with reproduction of symptoms @ 45o or less

78
Q

Presence of 1 or more predictor variables helps identify patients with nerve root compression, who will have a likelihood of experiencing a 50% reduction in disability after 6 weeks of the following protocol:

A

Lumbar traction in the first 1-2 weeks, positioned in prone to maximize centralization, static traction at 40-60% of patient’s body weight, for 12 minutes, patient remains prone for 2 minutes after completing traction

10 prone press up performed after above 2 minutes prone rest prior to standing up

manual therapy (grade III or IV lumbar spine PA’s)

extension exercises (sustained and repeated extensions in prone and standing, exercises progressed as tolerated aiming to achieve max extension ROM without peripherilization, 3 sets x 10 reps, throughout the day every 4-5 hours)

Patient education for functional activities, centralization principles

79
Q

Nerve Mobilization

A

Indicated when neurodynamic provocation tests are (+)
> SLR, slump (sciatic and femoral n.)

Use supported by the Clinical Practice Guideline for Low Back Pain
> Patients with subacute and chronic LBP with radiating pain

80
Q

SLR =

A

In 1st 30o of SLR the slack or crimp in sciatic nerve is taken up

81
Q

Pain provocation in 0-30o of SLR may indicate:

A

Acute spondylolisthesis
Tumor in the buttock
Gluteal abscess
Very large disc protrusion
Acute inflammation of the dura
Sign of the buttock

82
Q

Between ___ of SLR the spinal nerves & dural sleeves and the roots of L4-S2 stretch ___

A

30-70o

2-6mm.

83
Q

After __ there is further tension but no further stretch, also _____ are now involved.

A

70o

hamstrings, gluteus maximus, and the hip sacroiliac and lumbar spine joints

84
Q

Straight Leg Raise Testing:
Test Sequence

A

Passive hip flexion maintaining full knee extension

Hip must pass 35o to take up slack in the sciatic nerve

At 70o hip flexion sciatic nerve is at maximum length, symptoms after 70o flexion should be attributed to the hip jt, SIJ or lumbar spine

85
Q

SLR: Positive Test

A

SLR <70o limited by pain

Pain is neurologic in nature

Pain is “the patient’s pain”

86
Q

SLR: Sensitization

A

Cervical flexion may increase symptoms (pulling dura from above)

Hip adduction+internal rotation (sciatic nerve passes lateral to ischial tuberosity)

Ankle dorsiflexion (pulling dura from below)

Thoracolumbar side bend away may increase symptoms

Pre-positioning in cervical flexion

Pre-positioning in ULTT median nerve one or both arms

87
Q

SLR: addition of ___ and nerve bias

A

Addition of DF+Ev = tibial nerve bias

Addition of DF+Inv = sural nerve bias

Addition of PF+Inv = fibular nerve bias

88
Q

Sciatic NervePathway

A

Largest in body

89
Q

Locations for sciatic nerve entrapment:

A

Low lumbar spine
> IVD
> Spinal canal
> IVF

Piriformis muscle
Hamstring muscles

90
Q

Sciatic nerve sensitization:

A

Hip adduction and internal rotation

91
Q

Tibial Nerve Pathway

A

Largest terminal portion of sciatic nerve

92
Q

Tibial Nerve sensitization position of the foot and ankle:

A

Dorsiflexion and eversion

93
Q

Fibular Nerve sensitization position of the foot and ankle:

A

Plantarflexion and inversion

94
Q

Sural Nerve Sensitization position of the foot and ankle is:

A

Dorsiflexion and inversion

95
Q

Slump Test=

A

general test of neurodynamic mobility

Assesses excursion of neural tissues within the vertebral canal and IVF and detects impairments to neural tissue mobility from a number of sources.

During full spinal flexion the cauda equina becomes taut and the lumbosacral nerve roots and root sleeves are pulled into contact with the pedicle of the superior vertebra

96
Q

Advantages of Slump over SLR

A

Slump increases the compressive forces through the IVD

Slump may reproduce the functional position in which the patient experiences symptoms

Slump may provoke symptoms in a patient with posterior instability of the lumbar spine

97
Q

Slump testing: Test Sequence

A

Slump (“best slouch you can do”), now adjust the upper body until sacrum is perpendicular to plinth

Guide (but do not push) head and neck into flexion (“chin to chest and keep it there”)

Active knee extension

Active ankle dorsiflexion

98
Q

Alternate Sequence for slump:

A

Passive lower extremity movement

99
Q

Slump Sensitization:

A

Cervical extension should reduce symptoms

DF+Ev = tibial nerve bias
DF+Inv = sural nerve bias
PF+Inv = fibular nerve bias

100
Q

Femoral Nerve

A

Branch of lumbar plexus from ventral rami L2-L4

Although femoral nerve terminates in anterior thigh, the saphenous continuation is the reason why knee flexion is a component of the femoral nerve provocation test

101
Q

Femoral Nerve Sensitization:

A

Hip extension & knee flexion

102
Q

Provocation test for saphenous nerve would be:

A

Hip extension, hip abduction, hip lateral rotation, knee extension, ankle dorsiflexion, ankle eversion

Saphenous nerve is a sensory only continuation of femoral nerve supplying medial tibia

103
Q

Prone Knee Bend TestFemoral nerve

A

Used to indicate presence of upper lumbar (L2-4) disc herniations or nerve root impairments

Dura is stretched at 80-100o knee flexion

Acute L4-S1 disc protrusions may yield a positive PKB

104
Q

Femoral Nerve Testing 2 options

A

Prone Knee Bend

“Side lying Slump”

105
Q

Prone Knee Bend

A

Test Sequence
> Passively flex knee
> Passively extend hip

Positive Test
> Unilateral pain in lumbar spine, buttock, anterior thigh at 80-100o of knee flexion

> Sensitize by pre-positioning the trunk in side bending away (contralateral SB)

106
Q

“Side lying Slump”

A

patient = Side lying, neck and trunk fully flexed, bottom hip and knee fully flexed

therapist = Behind patient’s pelvis

Test Sequence
1) Start hip and knee at 90/90
2) Extend hip
3) Flex knee

Cervical extension may reduce symptoms

107
Q

Nerve mobilization – Contraindications

A

Nervous system malignancies

Infection

Spinal cord injuries

Worsening neurological symptoms

Cauda equina symptoms

CNS disorders

Suspected acute or severe disc lesions

Extreme pain

108
Q

Nerve mobilization – Precautions

A

Do not over lengthen a nerve bed

Do not tension the nerve for prolonged periods

Sustained mobilization with quickly lead to ischemia in the nerve
> Within 7 seconds, all the beneficial effects of nerve mobilization have occurred.

> Continued hold can lead to ischemia

109
Q

Irritable nerve tissue =

A

Constant pain
Easily provoked
Long time to dissipate once provoked
Paresthesia
Spasm
Requires gentle treatment

110
Q

Non irritable nerve tissue =

A

Intermittent pain
More difficult to provoke
Resolves quickly once tension released
Tolerates more aggressive treatment

111
Q

Nerve Mobilization: Rationale

A

To improve nerve conduction velocity by restoring dynamic balance between the relative movement of the neural tissues and surrounding mechanical interfaces

To reduce intrinsic pressure on the neural tissues

112
Q

Nerve Mobilization: Proposed benefits

A

Improved mobility of the connective tissue

Facilitation of the nerve glide

Reduction of intraneural edema

Dispersion of noxious fluids

Increased neural vascularity and intraneural circulation

Improved axoplasmic flow

113
Q

Nerve Mobilization = Sliders

A

(movement without tension)

Mobilize nerves in nerve bed with a minimal increase in nerve tension

Simultaneous application of longitudinal force one end of the nerve bed (increasing tension) and release of tension at the other end (unloading/reducing tension)

Larger longitudinal excursion of nerve than tensioners

Large amplitude movement through mid range, minimal increase in nerve strain

114
Q

Nerve Mobilization = Tensioners

A

Like a neural provocation test.

Elongation of the nerve bed by moving one or several joints (creates tension)

Nerve movement occurs near end range of nerve bed elongation

Larger strain increases, and smaller longitudinal excursion of nerve than sliders

115
Q

2 types of tensioners:

A

1 ended: tension applied at one point along the nerve bed while other end is stabilized

2 ended: tension applied in opposing directions at two points along the nerve bed

116
Q

Neurodynamic interventions = early phase

A

(Tissue is IRRITABLE)

Passive, gentle controlled oscillatory motion to interfacing structures

In early range of elongation of nerve bed (taking up the slack)

Smaller range movements required to monitor symptoms and remain in the symptom free range

117
Q

Neurodynamic interventions = mid phase

A

(Tissue is less IRRITABLE)

Progress to sliders that move the nerve through the interfacing structures

In mid range of elongation of nerve bed (maximum sliding occurs)

Larger range movements are possible

118
Q

Neurodynamic interventions = later phase

A

(Tissue is not IRRITABLE)

Progress to tensioners that affect both the nerve and the interfacing structures

At end of range of nerve bed (all available sliding has occurred)

Only small movements will result in large changes in strain/tension in the nerve

119
Q

Nerve Mobilization – Dosing

A

Movement is better and safer than stretch

Gentle, painfree

Hold 7 seconds, repeat 5 times per treatment session
> Please note: Dutton describes a variety of dosages on pages

Other sources – 1 per second, 20 reps or 1-2 minutes (IAOM)

Instructions to the patient – no reproduction of symptoms

120
Q

SI joint Test Clusters

A

Van der Wurff’s

Laslett’s

121
Q

Van der Wurff’s

A

Compression/gapping, Thigh thrust, FABER, Gaenslen’s (passive physiologic nutation/counternutation)

Sn = 85%
Sp = 79%

122
Q

Laslett’s

A

Laslett’s

Sn = 88%
Sp = 78%

123
Q

Sacro Iliac Joint injuries
Mechanism of Injury:

A

SI ligament sprain
Fall onto the buttocks
Mis-step onto a straight leg
Pregnancy related

124
Q

Sacro Iliac Joint injuries
Key findings:

A

Tenderness to palpate the SIJ

Symptom reproduction with provocation testing *

Pain with walking

Pain with changing positions

No sx below the buttocks

125
Q

Sacro Iliac Joint injuries
Incidence rate:

A

15-30% of non-radicular LBP
32%-61% of patients following lumbar fusion

Most common in elderly and younger active people

45% of all pregnant womenreport SIJ pain

126
Q

Side lyingAnterior rotation ilium on sacrum

A

patient = Side lying, bottom hip and knee fully flexed and held by patient if able

therapist = Standing facing patient

> Flex patient’s top hip and knee

> Therapist’s (caudal side) forearm under patient’s lower leg, therapist’s (caudal side) hand on patient’s top ischial tuberosity

> Therapist’s (cranial side) hand on patient’s iliac crest

> Anteriorly rotate the top ilium using both hands

127
Q

Side lyingAnterior rotation ilium on sacrum - Indications

A

SIJ pain provocation/alleviation

This can be used clinically during treatment (if it alleviates pain) of posterior hip and SIJ pain and dysfunction (e.g. SIJ pain during hip movements)

The lower leg is maintained in hip and knee flexion to create posterior rotation (counter rotation) which helps to stabilize the non tested ilium and pelvic ring

128
Q

Side lyingPosterior rotation ilium on sacrum

A

patient = Side lying, bottom hip and knee extended

therapist = Standing facing patient, Caudal leg on plinth to maintain patient’s leg in extension

Flex patient’s top hip and knee

Therapist’s (caudal side) forearm under patient’s shin, (caudal side) hand on patient’s top ischial tuberosity

Therapist’s (cranial side) hand on patient’s ASIS

Posteriorly rotate the top ilium using both hands

129
Q

Side lyingPosterior rotation ilium on sacrum: indications

A

SIJ pain provocation/alleviation

This can be used clinically during treatment (if it alleviates pain) of posterior hip and SIJ pain and dysfunction (e.g. SIJ pain at end range hip flexion)

The lower leg is maintained in extension to create anterior rotation (counter rotation) which helps to stabilize the non tested ilium and pelvic ring

130
Q

Pelvic ring stabilization with SIJ Belt & stabilization exercises wearing SIJ Belt

A

Indicated if ASLR test is positive, or other reciprocal leg activities or pelvic torsion activities provoke pelvic ring pain.

Apply the belt in supine just above greater trochanters

Belt needs to be tight.

If pain provoked with belt, try mobilization/manipulation 1st

Wear it during pain provoking activities (some sources: 23hrs/day, up to six months)

Wear for pelvic ring stabilization exercises during early phases of rehabilitation

131
Q

SIJ/pelvic ring stabilization
Education recommendations:

A

Avoid static posture > 30 minutes

Avoid sitting on affected buttock

Avoid sitting with legs crossed

Avoid unipodal standing

132
Q

SIJ/pelvic ring stabilization - study

A

Thirteen healthy individuals without a history of LBP were selected for this study to ensure that an optimal pattern of muscle contraction could be attained. SIJ laxity was measured through color doppler

Transverse abdominis contraction increased SIJ stiffness to a significantly greater degree than the general abdominal exercise pattern (p = 0.02)

133
Q

SIJ/pelvic ring stabilization - study - onset of IO =

A

In control subjects, onset of IO and multifidus occurred before initiation of weight transfer

In SIJ pain subjects, onset of IO, multifidus and glut max was delayed on symptomatic side
> Onset of biceps femoris was earlier
> Onsets were different between symptomatic and asymptomatic sides

134
Q

SIJ/pelvic ring stabilization - muscles

A

Oblique course between gluteus maximus, TLF and Lat dorsi

Fibers course perpendicular to SIJ orientation

On landing, ipsilateral glut max fires with contralateral lat dorsi
> Resulting in dynamic stabilization

Hydraulic amplification
> Contraction of erector spinae/multifidus dilate posterior layer of TLF

Increased intra-abdominal pressure further stabilizes the spine

135
Q

SIJ/pelvic ring stabilization:
Therapeutic exercise targets

A

Co-contraction of lat dorsi with contralateral glut max

Transverse abdominis, erector spinae, multifidus recruitment

MSK II FINAL (13 decks)

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