Red Flags, Contrindications & Lumbar Examination Flashcards
Absolute Contraindications (HVLA)
- Bone (Any pathology leading to bone weakening (tumour, infection, trauma, congenital, inflammatory).
- Neurological Dysfunction: (Cervical myelopathy, cauda equina compression, nerve root compression)
- Vascular Insufficiency: ( CAD, aortic aneurysm)
- Lack of diagnosis.
- Lack of patient consent.
- Patient position can’t be achieved due to pain or resistance.
Relative Contraindications (HVLA)
- Adverse reactions to previous manual therapy
- Disc herniation or prolapse
- Vertigo
- Inflammatory arthritis
- Spondylolysis / Spondylolisthesis
- Osteoporosis
- Advanced degenerative joint disease & spondylolysis
- Ligamentous laxity / hypermobility
- Arterial calcification
- Long term corticosteroid therapy
List classes of adverse events to HVLA
- Transient side effects
- Substantive reversible impairment
- Substantive non-reversible impairment
- Serious non-reversible impairment
Transient side effects to HVLA
After manual therapy typically 50% of patients will experience transient side effects and will tend to resolve within 24-72 hours.
- Local pain or discomfort
- Stiffness
- Headache
- Tiredness / Fatigue
- Radiating pain or discomfort
Substantive reversible impairment to HVLA
Lumbar:
- Minor vertebral body compression fracture
- Disc herniation/prolapse
- Nerve root compression
Cervical:
- Disc herniation
- Nerve root compression
- cervical and upper thoracic spine strain
Substantive non-reversible impairment to HVLA
Lumbar:
- Significant vertebral body compression fracture
- Posterior element fracture with disruption of the spinal canal
- Unresolved disc herniation
- Unresolved radiculopathy
Cervical:
- Unresolved disc herniation /prolapse/extrusion
- Unresolved radiculopathy
Serious non-reversible impairment
Lumbar:
- Cauda equina syndrome (surgical emergency)
Cervical:
- Stroke
- Spinal cord compression
Musculoskeletal examination
Clinical Examination:
1. Assess blood pressure (new patient)
2. Clinical examinations (e.g. neurological examination, cardiovascular examination)
Osteopathic Screening:
- Multi region screening, functional movements
Specific to the region:
1. Observation
2. AROM
3. PROM
4. Palpation
5. Joint play / segmental definition
6. Special tests (orthopedic, neurodynamic and musculoskeletal)
Indication for HVLA
- Pain (e.g. low back pain, neck pain)
- Restricted motion
- Segmental TART findings
- Tenderness
- Asymmetry
- Restricted ROM
- Tissue texture change
Therapeutic mechanisms of HVLA
Likely:
- Pain inhibition (dorsal horn ‘gating’ & descending inhibition)
Possible:
- Improvement in proprioception
- Freeing of entrapped synovial folds (in cases of acute LBP)
Discredited:
- Reduction of ‘subluxation’ or reposition of ‘bone out place’
Kinematics of Lumbar Spine
Has three degrees of freedom, with movements in all three planes of motion
Facet glide of lumbar vertebra
Flexion - upwards and forward
Extension - downward & back
What is normal coupled motion of lumbar spine
Type 1 (coupled side bending and rotation to the opposite side in neutral/extension)
What is normal coupled motion for cervical spine
Type 2 (coupled side bending and rotation to same side)
Lumbar HVLA coupled motion
L3-L5 (Neutral/Extension) Position:
Coupled motion: Type 1 (side bending, rotation to opposite side)
Facet Opposition Locking: Type 2 (side bending, rotation to same side)
L3-L5 (Flexion) Position:
Coupled motion: Type 2 (side bending , rotation to same side)
Facet Opposition Locking: Type 1 (side bending, rotation to opposite side)
