RAT 3: DSE (includes handouts), LSS, and Traction Flashcards
What are the 3 subgroups of DSE classification?
- extension
- flexion
- lateral shift
How does spinal stenosis fit into the DSE subgroups?
the clinical presentation of persons with symptomatic LSS (lumbar spinal stenosis) are under the flexion subgroup
Which DSE subgroup is most commonly encountered?
extension subgroup
What are the key exam findings for the extension subgroup? (5)
- symptoms distal to knee
- centralize with E
- peripheralize with F
- s/s of nerve root compression may be present
- +SLR may be present
What are the key exam findings for the flexion subgroup? (7)
- directional preference for F
- nerve mobility deficits possible
- older >65
- imaging evidence of LSS (lateral spinal stenosis)
- s/s distal to knee
- s/s of nerve root compression may be present
- +SLR may (or may not) be present
What are the key exam findings for the lateral shift subgroup?
10 from book
or
10 from pg 241
10 listed in book (pg 117)
- symptoms peripheralize with extension
- symptoms of neurogenic claudication may be present
- nerve mobility deficits possible
- visible frontal plane deviation of the shoulders relative to the pelvis
- asymmetrical side-bending AROM
- Gross limitation of side-bending ROM in the direction opposite the lateral shift
- Painful and restricted extension AROM
- s/s nerve root compression may be present
- SLR may be present
- Nerve mobility deficits possible
10 from pg 241
- unilateral or asymmetrical symptoms
- sudden or recent postural change
- flexion and extension activities aggravate
- sidelying may be an easing position
- S/S of nerve root compression may be present
- visible shift or frontal plane deviation
- decreased lumbar lordosis
- asymmetrical lateral flexion AROM
- PAIVM may be hypomobile and/or provocative
- S/S centralize with shift correction
What are the 3 overall components of treatment for patients in the extension subgroup?
Table 4-3 on on pg 117 under Intervention Guidleines for extension subgroup says the following
- extension exercises
- Mobilization to promote extension
- Temporarily avoid flexion activities
- Address neurodynamics and other deficits as needed
(not sure what Dr. Mincer was going for in this question. There was also some info in the text on pg 240 that I have included below
- The specific exercise prescription is repeated extension
- The home exercise program includes
- maintenance of the lumbar lordosis via temporary avoidance of flexion
- posture correction
- appropriate level of extension exercises repeated 10 times every 2-3 hours
DSE: What is the Extension subgroup specific exercise prescription?
repeated extensions
pg 240
DSE: What is the Extension subgroup home exercise program? (3)
The home exercise program includes
- maintenance of the lumbar lordosis via temporary avoidance of flexion
- posture correction
- appropriate level of extension exercises repeated 10 times every 2-3 hours
DSE flexion subgroup: how often (reps and frequency) should repeated extension be completed at home?
appropriate level of extension exercises repeated 10 times every 2-3 hours
What are the steps in the extension progression? (9)
- Prone on 1 or 2 pillows
- Prone lying without pillows
- Prone lying on elbow
- Prone press-ups or REIL
- Prone press up with exhalation at the end of extension (lock and sag)
- REIL with belt fixation
- REIL with therapist overpressure
- Extension mobilization (via CPA PAIVM)
- REIS
DSE extension progression: how does one determine where to start and how to progress?
- not all start at the lowest level and do not progress through each level
- The starting point is determined by the clinician
-
The progression is determined by pt response
- in the presence of unilateral symptoms that worsen, temporarily centralize, or do not change with sagittal plane motion, a trial of extension in lying with ips off center is recommeded (hips are usually shifted away from the painful side)
***if the response to repeated ext is limited mobility with end-range pain that is increased but no worse with no centralization or peripheralization (no lasting changes)- consider manipulation or mobilization or trying the mobility deficit classification. More examiniation is warranted to assign a diagnostic classification.
What are the steps in progression for the lateral shift subgroup?
- pt self correction of lateral shift in standing or against the wall
- if unsuccessful, PT performs manual shift correction in standing
- if shifts in standing are successful and centralization occurs, pt is instructed in self correction in prone (REIL) as well as in standing
**The exact progression depends on the pt’s response
How should a therapist respond to reports of increased LBP when doing direction specific exercise?
Often, prescribed exercise may cause an increase in LBP as the leg pain improves or goes away (a common response). The exercises should be continued, and discontinued only if peripheralization occurs.
What is “recovery of function”?
I believe it is a McKenzie phase where you introduce flexion and functional activities again after pain has subsided from direction spedific treatments.
“resuming movements that have been avoided” is what Dr. Mincer said.
Book pg 241:
- when pt is asymptomatic for a period of several days, recovery of function begins
Book pg 241:
- when pt is asymptomatic for a period of several days, recovery of function begins
- The pt begins exercise in the direction that has been avoided or that has produced peripheralization
- example: in the extension subgroup category, RFIL exercises at the rate of 5-6 reps 5-6 times per day are intiatiaed, followed by repeated extension over 1-2 days. (sandwich the flexion exercises with extension exercises)
- If no return of symptoms, flexion may progress slowly to sitting and standing, always followed by repeated extension exercises
Dr. Henderson’s Class discussion points:
- can begin recovery of function about 3 days after pt is asymptomatic as a result of the correction exercises.
- Dr. Henderson said she has found the necessary length of asymptomatic time correlated with how long-lasting/severe the pt’s condition was before tx.
- Gradually introduce flexion. If pt does not have any syptoms with flexion, they are probably safe to go back to daily activities.
- Sandwich the bad with the good. “do press-ups (or whatever makes you better) before and after the aggravating activity.”
- Once they are asymptomatic and are doing good, move on to Maintanence phase.
**We have not closed the full loop until we have completed the “recovery of function” phase
DSE: what should you prescribe for the maintenance phase?
Dr. Henderson:
- Once pt has completed recovery of function and are asymptomatic and doing good (I imagine for at least 3 days), the maintenance phase can begin
- Ask the pt to do 10 reps in the morn and 10 reps in the evening as a prophylactic move.
- can get buy-in for this when discussing how mayny things the pt does throughout the day that is in flexion.
- Also teach pts what to do if the problem recurs.
- (the liklihood of recurrence is high for most pts, because the reasons that caused the original problem to start are lifestyle things that are hard to change.)
- Tell pts that those who are able to make small lifelstyle changes to improve overall lifestyle and back care are less likely to have recurrence.
What are 3 advantages of the DSE classification that Dr. Henderson has noted?
Some Advantages of this Classification:
- Typically can get quick buy in from pt
- Typically pts can recover quickly
- Can provide tools to pt to take care of it again on their own
When did Dr. Henderson say was the ideal amount of time to pass between first visit and follow up for pts in the DSE category?
Why?
Ideal to see a responding pt in 24 hours after first visit. They will change quickly if they are responding.
Describe what to do next if a pt peripheralized with extension and flexion did not make them better.
What should we do (and how quickly) if a pt responds to our next tx approach?
Why?
If extension peripheralized and flexion did not make them better, we try lateral progression. If it works and they feel better 24 hours later, try repeated extension again. Can only get them so much better with lateral.
DSE: what is something additional to consider treating in a pt who responds to DSE?
In Dr. Henderson’s experience, most pts that respond to DSE also have an underlying ROM or other deficit. This is especially true of those who have been having problems longer or several episodes. So then they may be moved to another classification for a while. Dr. Henderson believes that addressing the other issues can make a difference in preventing recurrence.
Book says the majority of persons with LBP require multimodal tx (pg 242 at end of DSE discussion)
DSE: Dr. Henderson clinical pearls
Always begin with ____________/_____________ progression unless there is a ___________ ___________.
- Always begin with sagittal/extension progression unless there is a shift present
DSE: Dr. Henderson clinical pearls
Always try (loaded or unloaded) exercise first because of . . .
- Always try loaded first because of increased compliance
DSE: Dr. Henderson clinical pearls
What is the only reason to change to a different progression?
- The only reason to change to a different progression is if you have exhausted the progression you are currently using or the current progression has worsened the s/s
DSE: Dr. Henderson clinical pearls
What should you do if there is no change when doing a progression?
- If there is no change, add more force. Continue down the current progression until you have changed the s/s or you have exhausted the progression
DSE: Dr. Henderson clinical pearls
loaded vs unloaded - does gravity make a difference?
yes, point says
Loaded vs. unloaded- gravity does make a difference
(but I can’t remember what she meant exactly)
DSE: Dr. Henderson
What do I do the next day if
- patient returns to his/her next appt and he/she is better?
change nothing
DSE: Dr. Henderson
What do I do the next day if
- If patient returns to his/her next appt and he/she is the same?
- add more force until you have fully exhausted the progression
DSE: Dr. Henderson
What do I do the next day if
- If patient returns to his/her next appt and he/she is worse?
- consider another progression especially if s/s are unilateral
DSE: Dr. Henderson
What do I do the next day if
- If patient is doing lateral progression at home and he/she returns to the f/u appt and is better?
return to extension/sagittal progression
DSE: Dr. Henderson
More Back and Less Leg Pain, Means What
- If your patient has more back pain and less leg pain?
then he/she is improving
DSE: Dr. Henderson
Centralization
- means what?
- symptoms may get more/less intense?
- relates to progress how?
- Centralization:
- Radicular s/s move distally to proximally.
- Symptoms may increase in intensity as they centralize.
- Centralization is a good sign for progress
DSE: Dr. Henderson
- What are 4 signs of improvement?
- Centralization
- Improved quality of pain (sharp-dull)
- Increased ease of movement
- Increased extension/lateral ROM
DSE: What are the 4 criteria for a relevant lateral shift? (from handout)
- Upper body is visibly shifted
- Shift occurred with onset of s/s
- Patient is unable to correct shift or is able to correct shift, but is unable to maintain correction
- Correction of shift affects intensity of s/s
DSE: Describe how to do a correction of relevant lateral shift? (from handout in 3 points)
- Ensure equal weightbearing through both feet
- Begin with intermittent pressure first. Do not release back to beginning of ROM. Continue to progress further into range of motion. Repeat 10-15 reps or until overcorrection is achieved.
- After correction is achieved, maintain overcorrected position and progress into extension.
Picture: Correction of a right lateral shift
What is the typical presentation of a patient with symptomatic lumbar spinal stenosis? (6 potential impairments)
Table 4-5 on pg 119: Potential Impairments BAsed on Examination Column
- lumbar active ROM deficits
- decreased walking tolerance
- hip ROM deficits– priority to extension
- decreased hip muscle performance- priority to hip ext and abd
- decreased trunk muscle performance- priority to poor abd activation
- altered neurodymanic
What are the 3 main complaints of a patient with symptomatic lumbar spinal stenosis?
pg 242-243
Main pt complaints are
- LBP with
- related LE symptoms and
- diminished walking tolerance
What is the typical progression of a patient with symptomatic lumbar spinal stenosis?
- LSS is a relatively stable disorder in which severe disability and neurological deficits may develop over time, but not usually in a rapid manner.
- Some persons with LSS remain the same or improve over time.
- The long-term picture is not one of expected deterioration, but it is unknown who may improve over time.
- Rather than a wait-and-see approach, surgical or conservative management strategies are recommended for symptomatic LSS
- A trial of conservative care is recommended prior to surgical intervention
What are some appropriate interventions for each of the impairments typically seen in patients with symptomatic spinal stenosis?
- lumbar active ROM deficts (5)
- side-lying rotational mobilization or manipulation in neutral
- CPA or UPA PAIVM
- thoracic spine mob or manip as needed
- single or double knee to chest
- home rotational exercise to augment manual therapy
What are some appropriate interventions for each of the impairments typically seen in patients with symptomatic spinal stenosis?
- decreased walking tolerance (5)
- BW-supported treadmill,
- walking,
- cycling,
- aquatic therapy,
- mall walking
What are the parameters for using BW supported treadmill training (BWSTT) for helping with decreased walking tolerance in LSS?
- bodyweight
- intensity
- duration
- progression
BW supported treadmill
- Bodyweight: use min (20-40% BW) needed to eliminate buttock/thigh/ leg symp,
- if unable to eliminate symptoms, use use 50% BW
- Intensity: self-selected, regular, comfortable pace, not exceeding 7 on 10-point perceived exertion scale
- Duration: to tolerance, max 45 mins;
- progression: to tolerance, each visit increase by 10% BW
What are the parameters for daily walking for helping with decreased walking tolerance in LSS?
- distance and pace that does not agg LE symp
- using similar parameters as for the BW-supported treadmill
What are some appropriate interventions for each of the impairments typically seen in patients with symptomatic spinal stenosis?
- hip ROM deficits (6)
- priority?
priority to extension
- supine inferior glides to hip in flexion
- supine iliacus/ psoas lengthening
- prone PA glide
- prone rectus femoris lengthening (book showed MET to do for this)
- other LE (knee, ankle, foot) as needed
- Home exercise to augment the manual therapy
What are some appropriate interventions for each of the impairments typically seen in patients with symptomatic spinal stenosis?
- decreased hip muscle performance (9)
- priority?
priority to hip ext and abd
- clamshell,
- bridging,
- sidelying abd
- B squat,
- sit to stand,
- step up
- lep press
- HEP
- aquatic therapy
What are some appropriate interventions for each of the impairments typically seen in patients with symptomatic spinal stenosis?
- decreased trunk muscle performance (7)
- priority?
priority to poor abd activation
stabilization ex
- ADIM/abdominal brace
- (sit/stand),
- heel slides,
- wall slides,
- bridging,
- quadruped (single leg lifts),
- side bridge
What are some appropriate interventions for each of the impairments typically seen in patients with symptomatic spinal stenosis?
- altered neurodymanic (1)
neurodynamic mobilization
List the contraindications and precautions for traction? (16)
- any condition for which movement is contraindicated
- acute sprains or strains
- inflammatory processes
- hypermobility or instability
- RA
- respiratory problems
- cancer
- metastases
- osteoporosis
- infection
- current pregnancy
- uncontrolled hypertension
- aortic aneurysm
- severe hemorrhoids
- abdominal hernia
- hiatal hernia
***I think Dr. Mincer mentioned that most of these are for mechanical traction and have to do with the pressure from the belts as well as on the spinal structures.
What are the three types of traction?
- positional
- manual
- mechanical
What are two ways traction can be performed?
sustained
intermittent
What is the optimal doseage, position, and type of traction?
(dr H guidelines for lumbar HNP and DDD)
But optimal parameters are uknown
Dr. mincer wanted us to remember what Dr. Henderson gave us last year. When I asked her she said sort of a mix between HNP and DDD (since they overlap a lot)
Both HNP and DDD
- Weight: 30-40% of body weight (no more than %50)
- Position: Supine Hooklying
Lumbar Spine HNP
- ON:OFF time: 60:20
- Duration: begin with 3-5 min progress to 15 min
Lumbar Spine DDD
- ON:OFF time: 30:10 (intermittent)
- Duration: Begin with 10-12 min progress to 20 min
***PT/PTA nees to remain by pt for one full cycle.
What is the goal of traction?
“ a goal of traction is centralization with progression to another classification and matched or impairment-based intervention” pg 247
What is an advantage of positional traction?
pt can do it at home
What is manual traction typically used for?
as a trial to determine if mechanical traction might help
What are the 5 key factors indicating when to treat using traction?
- leg symp (below the buttock), pain, and/or paresthesia
- S/S of nerve root compression
- periph with extention
- inability to centralize symptoms
- periph with crossed SLR
What are 3 things characteristics of LSS that we discussed in class?
- Repeated motion will not produce lasting change in pain
- they probably have “DP” for flexion
- traction is a likely tx category
What are the specific traction settings we learned from dr. Henderson in fall 2014 for Lumbar herniated disc (HNP) and DDD?
- Weight
- Position
- ON:OFF time
- Duration
Dr. mincer wanted us to remember what Dr. Henderson gave us last year. When I asked her she said sort of a mix between HNP and DDD (since they overlap a lot)
Both HNP and DDD
- Weight: 30-40% of body weight (no more than %50)
- Position: Supine Hooklying
Lumbar Spine HNP
- ON:OFF time: 60:20
- Duration: begin with 3-5 min progress to 15 min
Lumbar Spine DDD
- ON:OFF time: 30:10 (intermittent)
- Duration: Begin with 10-12 min progress to 20 min
***PT/PTA nees to remain by pt for one full cycle.
