RAT 3: Mobility Deficits and Mvt/Coord Deficits (no contraindications - see other deck)

Question 1

What are the two most serious adverse events related to spinal manipulation?

Answer 1

1. Cauda Equina Syndrome is the most serious complication associated with lumbar spine manipulation. (pg 219)
2. The most serious adverse event related to cervical spinal manipulation is cervical artery dysfunction (CAD) related to vertebral basilar or internal carotid artery insufficiency rarely resulting in stroke or death. pg 220

Question 2

Spinal Manipulation: how does the risk of CES or Cervical ARtery Dysfunction (CAD) compare to the risk associated with medication use?

Answer 2

• The incidence of major adverse events is small. The relative risk of minor or moderate adverse events is similar for MT (manual therapy). exercise treatments, and sham or passive control interventions. The meta-analysis revealed that the relative risk of having a minor or moderate adverse event with MT, meaning high velocity thrust, is significantly less than the risk of taking medications.
  
  • Estimated risk of death from using NSAIDs for OA is 100 to 400 times the risk of death from cervical manipulation.
  • Lumbar manipulation is 3700 to 148000 times safer than NSAIDs and 55,000 to 444,000 times safer than surgery for lumbar disc herniation, and CES is 7,400 to 37,000 times more likely to occur from surgery than manipulation.
• All healthcare interventions have inherent risk that should be weighted against patient-perceived outcomes and available alternatives.

Question 3

Do the effects of spinal manipulation rely on careful detection of a segmental movement deficit?

Answer 3

The current evidence to support a manipulation classification suggests that a successful outcome is linked to correctly identifying individuals who are responders to manipulation rather than a clinician’s ability to accurately localize a dysfunctional segment, localize a technique to a specific level, or use a specific manipulation technique. (pg 220)

However, I thought Dr. Mincer said in class that they are even more effective if they are at the correct level. Maybe we should ask again (or pelase edit this so it is correct if you know the answer already). - Sara

Question 4

How large is the placebo effect of spinal manipulation?

Answer 4

Placebo is estimated to account for 10% to 25% of the benefits of spinal manipulation (pg 221)

Question 5

How does the addition of exercise affect outcomes in patients being treated using spinal manipulation?

Answer 5

I finally asked Dr. Mincer about this. The book doesn’t actually present any studies that compared exercise with no exercise. However they almost always include exercise in all treatment groups

Dr. Mincer said that we should trust her (and our instinct and knowledge of physiology) that the addition of exercise has a positive effect on outcomes in pts being treated using spinal manipulation!!

Question 6

What are the six key exam findings that help a therapist recognize when a patient might benefit from spinal manipulation?

Answer 6

Key Findings Dr. Mincer was looking for

1. No symptoms distal to the knee
2. Recent onset ( less than 16 days)
3. Low FABQWS- less than 19
4. Hypomobility of the L-spine: AROM limited, endrange pain increased but no worse with movement, PAIVM or PPIVM segmental hypomobility low T-spine - lumbar - sacroiliac
5. At least one Hip IR ROM greater than 35° (prone)
6. Regional Deficits: mobility, muscles performance/length, activity limitations

Question 7

What is the CPR for spinal manipulation?

Answer 7

CPR for spinal manipulation

1. duration of symptoms less than 16 days (ie. acute LBP)
2. FABQW subscale 18 or less (same as less than 19)
3. no symptoms distal to the knee
4. at least one hip IR PROM greater than 35° measured in prone
5. hypomobility at one or more lumbar levels assessed with CPA PAIVM or spring test

***note: this is the same as the Key Findings Dr. Mincer was looking for in the table except that it is missing the point about regional deficits.

Question 8

List the specific treatment options for a patient in the Manipulation & Mobilization Subgroup. (Start with listing only four major items)

Or go with 6 things from the chart

Answer 8

In persons with LBP and mobility deficits, a wide variety of manual interventions such as:

1. Mobilization
   
   1. Supine lumbopelvic thrust manip
   2. Side-lying lumbar thrust manip
   3. Nonthrust manip of CPA mobilization
   4. UPA PAIVM
   5. PPIVM
2. MET (Muscle Energy Technique)
3. Soft tissue mobilization
4. Other manipulation techniques plus exercise

****PLUS EXERCISE! (Don’t forget to add exercise to all of these. Mobility exercises (anterior./posterior pelvic tilt in supine or quadriped) and stabilization exercises (TrA activation, ADIM, etc.)

Also, book text references chart on pg 115, that lists the following interventions for this group

1. Lumbopelvic mobilization or manipulation
2. Muscle energy technique (MET)
3. AROM: anterior/posterior pelvic tilt (supine or quad-ruped, 10 reps, 3-4 times daily)
4. AROM and stabilization exercises
5. Active/passive ROM to augment mobilization/manipulation
6. Address regional and functional deficits

Question 9

What are 5 mobilizations we learned about to treat pts in the Manip and Mob Subgroup?

Answer 9

Mobilization

1. Supine lumbopelvic thrust manip
2. Side-lying lumbar thrust manip
3. Nonthrust manip of CPA mobilization
4. UPA PAIVM (I think this is considered a non-thrust manip too)
5. PPIVM (isn’t this more of an exam technique)

Question 10

Movement Coordination Impairments - What 9 key factors aid recognition of non-pregnant patients who may benefit from stabilization?

Answer 10

1. younger (>40)
2. 3 or more prior episodes
3. ↑frequency of episodes
4. generally > flexibility
5. aberrant movement: instability catch or thigh climbing, painful arc mid-range during F/E
6. SLR ROM >91°
7. central (PA) passive accessory intervertebral movement hypermobility
8. no centralization or peripheralization
9. • prone instability test

Question 11

Mvt/Coord Deficits: What are 4 subjective things that could show up with a pt who may benefit from stabilization?

Answer 11

1. giving away and giving out
2. frequent episodes of LBP
3. condition that is progressively getting worse
4. frequent need to manipulate the spine

Question 12

Mvt/Coord Deficits: What are 5 common complaints during posture or movement in a pt who may benefit from stabilization?

Answer 12

1. painful locking or catching during twisting or bending
2. pain during transitional activities
3. pain on returning from a flexed position
4. pain during a trivial or sudden activity
5. difficulty with unsupported sitting; pain that worsens with sustained posture

Question 13

Mvt/Coord Deficits: What are 6 common objective findings in a pt who may benefit from stabilization?

Answer 13

1. poor lumbopelvic control (such as segmental hinging or pivoting with movement)
2. poor coordination or neuromuscular control
3. decreased strength and endurance of local muscles at the level of segmental instability
4. aberrant movements
5. pain with sustained posture and positions
6. poor posture and postural deviations such as a lateral shift

Question 14

What are the two main approaches to spinal stabilization?

Answer 14

Specific Stabilization (motor control approach)

General stabilization

Question 15

Breifly describe the Specific Stabilization approach to spinal stabilization

Answer 15

Also called motor control approach)-

activation of the deep trunk muscles (TrA and MF) is consistently observed as delayed or reduced in LB, while the superficial muscles are often overactive. In these individuals, stabilization exercise involving an early motor control intervention targeting the deep muscles of the TrA MF may be needed, but this is unlikely to be the only target of trunk muscle performance in the exercise program. One misconception about this approach is that the only focus is preferential activation of the TrA and MF. Posture, muscle activation and functional movement patterns are also addressed

Question 16

Breifly describe the General Stabilization approach to spinal stabilization

Answer 16

General stabilization- places greater emphasis on exercises designed to improve the endurance and stabilizing function of the superficial trunk muscles (ie, ES< oblique abs, quadratus lumborum) without preferential activation of the deep trunk muscles.

Question 17

What is the goal of any stabilization program?

Answer 17

“The goal of any stabilization program is optimum control of the spine to meet the patient’s functional demands.” (pg 231 under heading)

Also found this one:

The goals of stabilization exercise are to

train muscular motor patterns to

1. increase spinal stability,
2. reduce pain,
3. control aberrant segmental mobility, and
4. improve daily functional ability.

pg 228

Question 18

which stabilization approach focuses on using principles of moter learning for skill aquisition?

Answer 18

Specific Stabilizing Exercise (SSE)

There are 3 phases

Question 19

. What are the three phases of skill acquisition in learning spinal stabilization?

Answer 19

• Phase 1. Cognitive (learning what to do):
  
  • Example: phase 1 begins with specific low-level activation of the TrA and MF with miniumal superficial activation. Feedback about movement sequence and quality of performance is important as the patient learns what to do.
• Phase 2. Associative (refining the movement pattern):
  
  • Example: Encourages the pain-free, co-contraction strategy in a variety of positions–sitting, standing, walking, or transitions. Consistency in movement develops with less cognitive demand as the movement pattern is refined and previously painful activities are practiced.
• Phase 3. Automatic Phases (developing skill)
  
  • Example: The low-level co-contraction becomes automatic while performing functional daily activities or performing under altered environments of speed, accuracy, or loads.

Question 20

SSE phase 1:

name and example/description

Answer 20

Phase 1. Cognitive (learning what to do):

Example: phase 1 begins with specific low-level activation of the TrA and MF with miniumal superficial activation. Feedback about movement sequence and quality of performance is important as the patient learns what to do.

Question 21

SSE phase 2:

name and example/description

Answer 21

Phase 2. Associative (refining the movement pattern):

Example: Encourages the pain-free, co-contraction strategy in a variety of positions–sitting, standing, walking, or transitions. Consistency in movement develops with less cognitive demand as the movement pattern is refined and previously painful activities are practiced.

.

Question 22

SSE phase 3:

name and example/description

Answer 22

Phase 3. Automatic Phases (developing skill)

Example: The low-level co-contraction becomes automatic while performing functional daily activities or performing under altered environments of speed, accuracy, or loads

Question 23

What is RUSI?

Answer 23

A biofeedback tool tha can be used for facilitating teh TrA and MF in specific approach to SSE.

RUSI = Rehabilitative UltraSound Imaging

Question 24

SSE approach: when can the pt progress from phase 1 with only deep muscle activation to start coordination training between the deep and superficial muscles?

Answer 24

When coactivation can be performed without feedback for 10 repetitions, 10-second holds, and normal breathing, coordination training between the deep and uperficial systems begins for static control and then dynamic control.

Question 25

SSE approach: How do you work on coordination training between the deep and superficial systems with static control?

Answer 25

• Static control involves activation using ADIM or whatever strategy works for the pt, first holding the deep muscles and then imposing resistance in a variety of ways to superimpose superficial muscle activity
• When load is added, the superficial systm is need to maintain neutral, umbopelvic alignment.
• Training in and out of daily postures, sitting, standing, and transitional postures such as sit to stand is also needed.

Question 26

SSE approach: Some examples of static control activities

Answer 26

1. Single leg heel slie, opposite leg supported
2. Single leg heel slide, opposite leg unsupported
3. Single leg slide, opposite leg supported (sliding heel is off mat)
4. Singgle leg slide, opposite leg unsupported (sliding heel is off mat)
5. Bent leg fall out (hooklying - let knee fall to the side and bring back)
6. side-lying hip ABD or clam shell while palpating glute med
7. quadruped arm and leg lift sequences.

Looks like anything where back stays in static position while limbs are moving. See pg 232 and 234 for pictures.

Question 27

SSE approach: How do you work on coordination training between the deep and superficial systems with dynamic control?

Answer 27

• Dynamic control involves activating the deep muscles first, holding the contraction while movement is performed, and breathing normally.
• Some activities include balancing on an unstable surface or wobble board or sitting on a ball while incorporating arm or leg movement. (seems less predictable than static training)
• Balancing on unstable surfaces requires movement and dynamic control of the spine.

Question 28

SSE approach: How do you progress pts who are working on coordination training between the deep and superficial systems with dynamic control?

What might help with mastering the activities?

What activities are important to relearn?

What does this progression of dynamic control lead to?

Answer 28

• Progression of activities involves analysis of the pt’s daily functional requirments related to position, load, and movement such as standing, reaching overhead, lifting, pushing, or pulling.
• Activities are often broken into parts before practicing the entire movements (helps with mastery)
• Activities important to the pt and previously painful to the pt should be relearned.
• This progression leads to the final phase of training centering on performance of functional tasks at home, at work, or in community environmens.

Question 29

SSE approach: what does the final phase of training include and what is the goal of this phase?

Answer 29

• The final phase centers on performance of functional tasks at home, at work, or in community environments
• The goal of the final phase is automatic activation of the deep muscles first, holding the contraction while movement is performed, and breathing normally.

pg 233

Question 30

What is an abdominal brace?

plus 4 points about it (including a comparison to ADIM)

Answer 30

Review (pg. 198): AB is a low-level (5%-10% max voluntary isometric contraction) stiffening or isometric contraction of the muscles around the trunk (ie, abs, paraspinals, and TrA) with no attempt to preferentially activate the TrA.

• The AB stabilizes the spine in bending and twisting perturbations whereas the ADIM does not.
• AB is an optimal method for activating spinal musculature.
• From a mechanical perspective, bracing appears to provide patterns of greater stability, while the ADIM does not appear to enhance stability.
• AB appears to function by providing dynamic spinal stability through all muscles of the trunk, both deep and superficial.

Question 31

How does AB fit into spinal stabilization training?

Answer 31

• The abdominal brace (AB) is based on biomechanical models involving EMG and stiffness analyses. In this view, sufficient spine stability depends on the task and requires involvement of all trunk muscles. For most daily activities, a 10% abdominal wall cocontraction or AB along with the extensors and quadratus lumborum is sufficient to maintain stability
  
  • All muscles are important, especially their endurance component, and clinical focus on one muscle does not ensure stability.
  • AB is considered primary in the general approach/
• Research comparing SSE and a more general exercise approach has shown no differences favoring one appreach over another.
  
  • We have discussed in class how AB may increase IDP (intradiscal pressure) but may not be as difficult to learn, so it depends on yoru pt which approach to use.

Question 32

What is the recommended maximum duration for holding an AB?

Answer 32

7-8 seconds

ABdominal bracing with teh big 3 (exercises) is held no longer than 7-8 seconds with endurance building through repetitions rather than duration. pg 235

Question 33

General Approach: what are the big 3?

what is each for?

Answer 33

The curl-up for the rectus abdominus

The side bridge for the obliques, TrA and Quadratus Lumborum

The bird dog in quadruped for the back extensors

Question 34

General approach: Why are the big 3 recommended?

Answer 34

Reccomended to:

1. challenge trunk muscles,
2. spare the spine of excessive compression
3. ensure sufficient stability

Question 35

How many stages are in the general approach?

Answer 35

5

Question 36

General approach: what are the first 3 stages generally used for? (3)

Answer 36

The first 3 stages are used in rehab to

1. identify and correct abnormal motion and motor patterns,
2. build whole body and joint stability related and transfered to daily activities, and
3. increase endurance.

Question 37

General approach: what are stages 4 and 5 generally used for? (4)

for what?

Answer 37

Stages 4 and 5 involve the developent of:

1. strength,
2. speed,
3. power, and
4. agility

necessary for athletic performance.

Question 38

When are the big 3 used?

Answer 38

Used with AB in the early stages (1-3) of the general approach to spinal stabilization exercises

Question 39

How do you progress performance of the big 3?

Answer 39

by adding repetitions

(AB during big three is held no longer than 7-8 seconds)

Question 40

What is an example of some potential exercises (and progression) for stages 1, 2, 3 of the general approach?

Answer 40

• Might include a warm-up activity such as a 5 min walk or cycle
• basic AROM exercises such as cat and camel
• teaching AB with neutral spine
• assessing and training gluteal activation using (also still using AB)
  
  1. clam shell,
  2. back bridge,
  3. double -legged squat,
  4. single legged squat,
  5. transitions,
  6. rising from sit to stand,
  7. pushing,
  8. pulling, and
  9. lifting exercises.

Question 41

Describe how to teach the AB

Answer 41

The pt is asked to contract the muscles to make them stiff. Teh abdominal wall is not draqwn in or pushed out. Bracing isused to encourage cocontraction of the abdominal wall and paraspinals at low levels (10%-15% maximum voluntary isometric contraction) in supine and then used in functional activities such as getting into and out of car and geting on adn off the toilet.

Question 42

What is the role of the gluteals in spinal stabilization?

Answer 42

• Accurate gluteal activation is necessary for a healthy spine, especially during squatting activities such as getting into and out of a chair or car.
• Substitution by the hamstrings and ES produce excessive load on the spine in the presence of weak glutals

(I believe we previously learned that the glutes are often under-activated in pts with LBP - at least those with lower crossed syndrome)

Question 43

what are the ways to activate and strengthen the glutes? (6)

Answer 43

1. Clam shells (especially glute med)
2. Hip abduction in side-lying or standing (esp glute med)
3. Back bridge (glute max)
4. Double-legged squat
5. single legged squat or lunge (6)

Question 44

Back Bridge Exercise; Describe how to do it and emphasize important things not to forget

Answer 44

• In supine, hooklying with a neutral, braced L-spine, the pt uses imagery for gluteal activation (ie gluteal squeeze).
• Keeping the spine in neutral, the pt initiates a gluteal squeeze, which raises the trunk to form a bridge, and maintains the gluteal squeeze throughout trunk elevation and lowering to the rest postion.
• Hamstrings are minimized by beginning with a gluteal squeeze or blocking the feet and asking for slight knee extension.

Question 45

Describe how to do clamshells. Emphasize important things not to forget

Answer 45

• Start in side-lying with knees and hips flexed.
• Pt palpates the gluteus medius with the fingers posteriorly and thmb on ASIS.
• Keeping heels together, the knees are seperated
• Assess for neutral spine, good trunk stabilization, and motion through the range.

**training may start here or progress to more advanced gluteal activation patterns such as hip ABD in side-lying or standing.

Question 46

Describe how to teach a Double-Legged Squat. Emphasize important cues, etc.

Answer 46

This exercise is a daily activity that many pts with LBP perform incorrectly.

• Begin in standing or sitting and the spine braced in neutral
• The motion requires the hips to move along a 45-degree anlge form the vertical, moving the buttocks back and not down in order to sit down
• The legs are shoulder width apart with the hips externally rotating to engate the glute max
• Initial practice may be done to surfaces higher than normal chair height, but progression to rising to and from a chair follows
• The spine remains in neutral. The arms may be placed in front of the body for balance.