treatment based classification Flashcards
criteria for manipulation
no symptoms below the knee
recent onset of sym (<16 days)
low FABQW score
hypomobilty of the lumbar spine
hip internal rotation ROM (>35)
criteria for stablization
younger (<40)
greater flexibility
instability catch or aberrant movements during lumbar flexion and extension
positive prone instability test
postpatrum things
aberrant movements
deviate
from the typical or expected movement
pattern, are associated with low back dysfunction
criteria extension
symptoms distal to the buttock
sym centralize with lumbar extension
sym peri with lumbar flexion.
directional perference of extension
criteria flexion
older then 50
directional preference for flexion
imaging for lumbar spinal stenosis
stiff achy back
criteria lateral shift
visible frontal plane deviation of the shoulders relative to the pelvis
directional preference for lateral translation movements of the pelvis
traction criteria
signs and symptoms of nerve root compression
Symptoms of Radiculopathy
Tingling or numbness in the fingers or hand.
Weakness in arm, shoulder or hand.
Decreased motor skills.
Loss of sensation.
Pain associated with neck movement or straining.
Instability catch
any sudden acceleration or deceleration of trunk movement or movement occurring outside the primary plane of motion
Transversus Abdominis action
“Support & compress abdominal viscera; assist in forced expiration, decreases infrasternal angle
“
Rectus Abdominis action
Flexes vertebral column; can posteriorly rotate pelvis when thorax is fixed
Quadratus Lumborum
Fixes last rib so diaphragm acts more efficiently during inspiration;
hikes hip;
ipsilateral side bending when pelvis is fixed
Acting bilaterally forms guy wire support to stabilize lumbar spine in frontal plane”
Blocked Extension Principle
- Flexion worsens status
- Not able to test “Extension Hypothesis”
- Typically, not a “Mobilization Principle” candidate
- Pt: flex brought on their initial problem; we need to restore their ext to get them to centralize
- You cannot go into extension – this motion is blocked
Unstable Status (“Volatile”)
- Rapid worsening with any flexion movement or position
– Flexion – peripheralization - May or may not achieve a rapid improvement with extension
Pt: have inflammation that is interplaying with mech issues
Stable Status (“Mechanical”)
- Gradual improvement with sustained or repeated extension postures
– Clear extension bias - Status will worsen with sustained or repeated flexion
- Pt: have acute LBP and fall in line with textbook def
multifudus
Extension
Iliocostalis Lumborum, pars Lumborum
and
Longissimus Thoracis, pars Lumborum
Back extension, creates posterior shear forces to counteract anterior shear forces
External Abdominal Oblique action
“Support & compress abdominal viscera;
assist in forceful expiration
Acting bilaterally:
flexes spine
Lateral fibers: acting bilaterally, posteriorly rotates pelvis; acting unilaterally, laterally flexes spine
Anterior fibers: acting unilaterally, flex & contralaterally rotate spine”
malaise
geneally feeling unwell often accompanied by fatigue and diffused pain
what are myotomes testing for
you are looking for muscle weakness of a particular group of muscles.
Results may indicate lesion to the spinal cord nerve root, or intervertebral disc herniation pressing on the spinal nerve roots.
emergent medial red flags
extensive neurological involvement
non MSK conditions - red flags
fracture or something that need imaging work up
symptom modulation
preventing worsening status - moderating factors
signs of active inflammation
treatment:
- directional preference
- manipulation
- traction
- active rest
movement control - stage 2
impairment driven - improve dynamic movement control
improve basic functional movement patterns, break faulty compensatory patterns
the symptoms are now under control
treatment:
- flexibility exercises
- stabilization exercises
- sensorimotor exercises
functional optimization - stage 3
return to work or sport - increase functional capacity and tolerance
symptoms are low
treatment:
- strength and conditioning exercises
- work or sport specific tasks
- aerobic exercises
- general fitness exercises
radiculopathy from an acute disc herniation - history and age
30 - 55
acute or reccurrent episodes
radiculopathy from an acute disc herniation - pain pattern
pain and or numbness radiating towards LE below the knee
normally increases with lumbar flexion
radiculopathy from an acute disc herniation - neuro exam
sensory and/or motor changes
diminished/absent deep tendon reflexes unilat
radiculopathy from an acute disc herniation - ROM
guarded and limited
spinal stenosis
- age and history
> 60
insidous onset of chronic progressive LBP
more recent onset of LE pain
spinal stenosis
- pain patterns
LE symptoms increase with ext and are relieved by flexion
spinal stenosis
- neuro exam
sensory and motor changes
spinal stenosis
- ROM
pain and limited ext
what is the start back for
screening for yellow flags
ospro is for what
screening red flags
what is the oswestry
standard screening for low back pain
ospro-YF
looking at specific yellow flags
fear avoidance, depression, anxiety
what is the most significant neurological sign
babinski
what does peri mean in term of low back pain
pain or paresthesia moves distally away from the spine
para is produced previously where it was not seen
sym increase and sustain for at least 30 secs
what is centralization
pain or para moves centrally - towards the spine
paresthesia that was present is abolished
sym is diminished or abolished
any movement that causes ccentralization should be included in treatment
what is paresthesia
an abnormal sensation, typically tingling or pricking (“pins and needles”), caused chiefly by pressure on or damage to peripheral nerves.
status quo
neither centralization or peri is produced
there is a tranisent increase of decrease in pain pbserved with movement
if this is seen - think of doing moblization, traction, or immoblization
what is active rest
when the pt inflammation is so bad that most movement leads to pain
only ADLs for 48 -72 hours
this is a acute issue
may be using modalities to get pain under control
what is a right lateral shift
the shoulder are shifted right and the pelvis is going left
what is directional perferance
situation in which movement in one direction improves pain and limitation of ROM
when do you have the most intradiscal pressure
standing with flexion more when you add a weight
supine<standing<sitting
internal disc distruption
with the internal arch of the internal disc is disrupted even though its external apperence remains noraml
why do people get injured in the fully flexed position
support responsibilities shift from the muscle to the disc
leads to creation of shearing force
disc herniation and fully flexed spine
posterior protustion due to annular failure associated with a fully flexed spine
pathomechanics of a lateral shift
disc herniation
protective muscle spasm
segmental instablity
lumbar radiculopathy history
presence of sciatica
LE pain greater then back pain
dermatome distribution of pain
weakness seen with lumbar radiculopathy
PF, DF, great toe extension, quads
L4, L5, S1, S2
what is Ischemia
when blood flow is restricted to a part of the body
do people with spinal stenosis have pain when seated
normal no
are in pain when they are up on their feet
lumbar spinal stenosis population
greater then 65
do people with spinal stenosis have pain with flexion or extension
extension
traction in extension criteria
younger
worsen with flexion
ISQ with extension
prefer to stand and walk compared to sitting
alternative: auto-traction to extend
traction in flexion criteria
older
worsen with extension
ISQ with flexion
prefer sitting vs standing and walking
alternative: de weighted ambulation
the flexion principle - what kind of spine
stenotic, degenerative,
flex prin - type of spine
flat back, sway back, hyperlordoic
the load is going to the posterior segments
flex prin - special cases
spondylothesis
adherent nerve roots syndromes
what is the mechanism of onset for flex principle
no specific mech
often has a gradual onset
flex prin - demographic
stiff achy back - often with radiating features
variable but late 50s and older
exhibit claudicant behavior - sense of weakness when standing, they do not want to get on their feet
what is the common path of degeneration in the back
the disc degenerates and then the facets joints
what is lumbar spinal stenosis
any narrowing of the lumbar spinal canal, nerve root canal, or intervertbral foramen that produces compression on the neural elements
primary lumbar stenosis
the bone did not form consistent with expectations
secondary spinal stenosis
degenerative chnages
post op changes
fracture
tumor
systematicc disease
what makes up degenerative stenosis
facet joint arthrosis
ligamentum flavum thickening
intervertebral disc bulging
spondylolethesis
structural component of spinal stenosis
degenerative changes
degenerative spondylolethesis
what does flexion do to CSA
it increases CSA -loading
what does extension do to CSA
decrease CSA - unloading
narrowing and spinal extension
greater structure narrowing of the spinal canals –> greater narrowing during ext
Myelopathy
an injury to the spinal cord caused by severe compression that may be a result of spinal stenosis, disc degeneration, disc herniation, autoimmune disorders or other trauma.
shopping cart sign and graded treamill
both of these are putting in pt in flexion their preferred position
the shopping cart is also supporting their trunk wieght
are we treating spinal stenosis with flexion pt
no more treating the impairments caused by the stenosis
surgery and spinal stenosis
complication rates are high
what is the treatment program for flex prin pt’s
flex oriented exercise
de-weighted treadmill
ex for individual impairments
