Lumbar Spine Treatment Flashcards
What are the treatment options for the spine?
- Education
- Passive treatments
- Active treatments
- Lifestyle modifications
What should treatment selection be based on?
- Diagnosis: Triage, specific vs non-specific
- Stage: Actue, subacute, chronic
- Irritability
- Client problems & priorities/contributing factors
What is the back pain triage?
- Simple musculoskeletal back pain (95% of LBP)
- Spinal nerve root compression (4% of LBP)
- Serous spinal pathology (1.5% of LBP)
What red flag conditions require urgent referral?
- CE
- Unstable, severe or progressive neuro signs
- Fractures
- VBI
- Non-mechcanical symptoms with additional red flag findings
What red flag conditions require referral “very soon”?
- Ankylosing spondylitis
- Non-mechanical symptoms without other signs, not responding within a couple of sessions
- Significant yellow flags
- Neurogenic claudication
What are the patterns of back pain?
- Facet joint
- Disc
- Leg pain dominant vs back pain dominant
- Centralisation & peripheralisation
What should patient education include?
- About the injury
- About contributing factors
- Expected recovery time frame
- About treatment options
- Reduce threat value of LBP
What are the common themes of pain-related fear?
- Predictability, controllability & intensity of pain
- Negative past personal experiences of pain
- Influence of societal back beliefs
- Process of seeking diagnostic certainty
What is the general prognosis for a patient with acute LBP?
90% of people recover in 6 weeks
What does research show regarding bed rest for the spine?
- Avoid completely or limit to < 2 day
- > 2 days detrimental to recovery
What are some of the passive interventions for LBP?
- Taping (early-on in acute LBP)
- Traction
- Manual therapy
- Mobilisation
- Manipulation
What is the physiological reasoning behind traction?
- Providing the nerve root with more room
- Relieving pressure
What does the evidence show regarding traction?
- Lots of evidence to show it doesn’t work in short, medium or long term
- But may help some patients
What does manual therapy involve?
- Treat a pattern (e.g. open a facet joint) or
- Treat what you see
What is mobilisation?
Passive movement that can be controlled by the patient (PPIVM, PAIVM)
What is manipulation?
- Passive movement consisting of a high velocity, small amplitude thrust within the joint’s limit
- Cannot be controlled by the patient
How are PAIVMs graded?
Maitland Joint Mobilisation Grading Scale
1: Small amplitude, early range
2: Large amplitude, early-mid range (back & forth)
3: Large amplitude, mid-end of range
4: Small amplitude, end of range
5: (Manipulation) Small amplitude, quick thrust at end of range
When should grade 1/2 and grade 3/4 mobilisations be used?
- If pain is primary complaint, grade 1-2
- If stiffness is primary complaint, grade 3-4
What are the indications for mobilisations?
Joint pain & dysfunction e.g. restricted AROM & PPVIM and/or painful restriction with PAIVM
What are the CIs for mobilisations?
- Acute inflammatory disease
- Infection
- Tumours/cancer
- Atherosclerosis
- Aneurysms
- DVT
- Spinal cord compromise
- Cauda equina syndrome
What are the precautions for mobilisations?
- Neurological changes
- Rheumatoid arthritis
- Osteoporosis
- Ligament laxity
- Pregnancy
- Prolonged use of anticoagulants & corticosteroid
What are the active interventions for LBP?
- Exercise (general/specific)
- Posture
- Behavioural therapy
- Back schools
- Lumbar supports
- Muscle energy techniques
What factors related to LBP does general exercise positively influence?
- Poor sleep
- Deconditioning
- Depression
- Anxiety/stress
- Provides analgesic effects
What are the two types of specific exercise for LBP?
- McKenzie
- Core
What does McKenzie exercise involve?
Uses directional preference to determine the movement that reduces pain (flexion, extension, lateral flexion etc) - treatment then focuses on this movement
What does evidence show regarding core exercise for LBP?
- Core muscles (multifidus, TA) work differently after an episode of LBP (turn on later)
- Patients with LBP don’t turn on these muscle in preparation for movement
- May be beneficial to train these muscles
What are the ways of re-training the core muscles?
- Palpation with cues/ECG
- Real-time ultrasound
What does research show regarding posture in people with LBP?
- They tend to hold their spine more rigid, don’t adjust their posture
- Can result in great muscle fatigue, loading of the facet joints
What is the optimal sitting posture for people with LBP?
- Neutral spine position with slight lumbar lordosis & relaxed thorax
- Avoid painful end-range positions
- Activate key trunk muscles
What is the general rule for treating acute LBP?
- Choose passive intervention to reduce pain & restore movement
- Education & early return to activity is essential
What is the general rule for treating subacute/chronic LBP?
Greater focus on active interventions & lifestyle modifications
What are the reasons for using outcome measures?
- Objectively record changes
- Compliance for third party payers (Work cover etc)
- Identify treatments that work & are cost-effective
- Early identification of people with high-risk of ongoing pain
What should be measured for outcome measures?
- Symptoms
- Function
- QOL
- Fear of movement (kinesiophobia)
- Fear-avoidance beliefs
What are the types of outcome measures?
- VAS/numerical rating scale
- Questionnaires
- Physical tests (ROM, pain-free ROM, muscle endurance tests)
- SMART evaluation
What are two outcome measures for lumbar flexion?
- Modified Schober
- Fingertips to floor
- Biering sorensen test (back endurance)
