2- LBP ASSESSMENT & MANAGEMENT Flashcards
(19 cards)
LBP GENERALITIES:
- anatomical region
- clinical definition
- key points
Table
LBP GENERALITIES: classification overview
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LBP GENERALITIES: socioeconomic impact
- Global economic burden: annul global cost estimated at 900 billion dollars, including direct healthcare
& indirect productivity losses - Direct costs: medical consultations, imaging, interventions…
- Indirect costs: work absenteeism, presenteeism, early retirement, accounts for 90% of total LBPrelated costs globally
- Workforce impact: LBP leading cause of lost workdays, average 5-7 days off per episode
- Projections: burden expected to rise by 20% by 2050 due to aging population & sedentary lifestyles
- Progressing pathology: due to stress & poor food
LBP GENERALITIES: relevance of psychosocial factors:
- social determinants
- psychosocial yellow flags
- stratified care model
Effect of education: understanding of condition influence management of it (from not knowing to false sources)
Social determinants
Low socioeconomic status, educational attainment & occupational factors increase risk & prolonged recovery
Psychosocial “Yellow Flags”
- Fear-avoidance beliefs, catastrophizing, low self-efficacy, depression / anxiety
- Use validated screens: StarT Back Tool & Orebro MSK pain questionnaire
Stratified care model
- Risk stratification: administer StarT Back to categorize low, medium or high risk of chronicity
- Matched treatment:
o Low risk: brief advice, education & encouragement to stay active
o Medium risk: standard PT with emphasis on movement, manual therapy as needed
o High risk: enhanced psychosocially informed PT incorporating cognitive behavioral
techniques, goal setting & graded exposure
Mature organism model: IPO classification
Table
Mature organism model: relevance of classifications + key benefits
Table
Key benefits
- Tailored care: ensures targeted, efficient interventions (Pt centered approach)
- Resource optimization: reduces unnecessary imaging, referrals & treatments (easiest way possible for
us, not stuck on unworking treatment)
- Patient engagement: empowers self-management with clear rationale
- Outcome prediction: improves prognostic accuracy & follow-up planning
MDT principles:
- generalities
- key concepts
- goals
Founded by Robin McKenzie (1981), emphasis on patient self-treatment & repeated movements
Key concepts
- Mechanical loading: specific end-range motions alter intradiscal pressure & joint mechanics
- Centralization phenomenon: redistribution of pain from distal => proximal indicates positive response
Goals
- Identify mechanical syndrome via standardized assessment
- Prescribe directional exercises to achieve centralization
- Educate posture / ergonomics to maintain effect
MDT principles:
- mechanical syndrome overview
- derangement subgroups
Tables
MDT principles:
- Standardized assessment protocols
Standardized assessment protocols
1. Baseline palpation & observation: assess posture, alignment, lateral shift, muscle spasm,
compensation from body, breaking down position & try to unload sensitize tissue
2. Active movement screen: AROM flexion, extension, side-glide; note pain location / intensity. Not only
ROM: repeat movement at end of range to see how pain modulate & see progression
3. Repeated movement testing:
a. Extension in lying (EIL): 10 reps, monitor changes
b. Extension in standing (EIS): as above, if EIL negative
c. Flexion in lying (FIL): 10 reps, choose if EIL/EIS peripheralize
d. Lateral translations: correct shift via side-glide standing (mirror-image)
4. Symptom response charting: record centralization, peripheralization, loading response, range change
5. Syndrome classification: assign postural, dysfunction or derangement subgroup
MDT principles:
- treatment decision algorithms
Table
MDT treatment:
- home exercise & patient education
- prognostic indicators & outcomes
Home exercise & patient education
- Exercise prescription: high frequency (hourly), moderate volume (10-15 reps), low intensity (painfree). No peripheralization.
- Education components:
o Pain neuroscience; normalize pain experience
o Activity modification: safe lifting, ergonomics
o Self-monitoring: symptom diary & progression logs
- Self-efficacy: teach patient to adjust dose based on symptoms, goal setting for return to work &
activities
Prognostic indicators & outcomes
- Positive predictors: rapid centralization (if centralize in 1st session, very good, if not came in 2w), early
directional preference identification, short symptom duration (< 16 days)
- Negative predictors: chronicity (> 3 months), fear-avoidance, lateral shift uncorrected
Mulligan therapy:
- historical background & theoretical rationale
Historical background & theoretical rationale
- Brian Mulligan: PT who observed pain-free accessory mobilizations combined with active movement
improved function
- Theoretical rationale:
o Accessory motion normalization corrects positional faults in facet joints or SIJ during active movement
o Neuromodulation: sustained glide provides afferent input reducing pain via mechanoreceptor stimulation
- Contrast to passive mobilizations: MWM emphasizes patient-active engagement to reinforce
neuromuscular control
Mulligan therapy: pill & crocks
PILL response (desired outcome of MWM technique)
- Pain-free: technique must be executed without eliciting pain (not always depending on case)
- Instant: immediate improvement in pain or movement range
- Long-lasting; sustained benefit beyond initial application
- Logical: consistent with patient’s presentation & mechanical theory
CROCKS principles (treatment considerations)
- Contraindications: screen for red flags
- Repetitions: determine optimal number of repetitions for effect
- Overpressure: gradual addition of overpressure at end-range if tolerated
- Cooperation: active patient engagement & feedback
- Knowledge: therapist & patient understanding of technique rationale
- Sustain & sense: maintain glide while sensing symptomatic change
Mulligan therapy: Common lumbar MWM techniques
Table
Mulligan therapy: treatment algorithms & dosing for MWM
Table
Subjective examination:
- history domains
- flag screening
- outcome measures
- classification keywords
History domains
=> Onset, duration, location, intensity, radiation, aggravating / easing factors
Flag screening
- Red flags: trauma, unexplained weight loss, night pain, neurological deficits
- Yellow flags: psychosocial risks via FABQ, StarT Back Tool (fear-avoidance & catastrophizing)
Outcome measures (PROMs)
- NRPS
- ODI
- RMDQ
- PSFS
Classification keywords (patient-reported signs / symptoms)
- Centralization / peripheralization: patient describes shift of pain toward / away from spine
- Directional preference: reports relief / aggravation with specific movement (extension, flexion, sideglide)
- Neurogenic symptoms: numbness, tingling, shooting leg pain suggest radiculopathy
- Mechanical instability signs: sensation of giving way or catching
- Inflammatory indicators: morning stiffness > 30 min, improvement with exercise
Objective examination:
- observation & functional tasks
- active ROM & MDT application
- accessory mob & MWM appli
- neurodynamic & neurologic tests
- muscle control & special tests
Observation & functional tasks
- Posture (standing/sitting), gait analysis, sit-to-stand, bend test
- Symptom modification variants (active corrections to posture)
Active ROM & MDT application
- Perform flexion, extension, lateral flexion, rotation: note pain, location, intensity & directional symptom changes
- Identify centralization / peripheralization & directional preference => classify via MDT & prescribe directional exercises
Accessory mobility (PPIVMs/PAIVMs) & MWM application
- Segmental passive glides to assess end-feel, resistance, pain reproduction
- Trial Mulligan MWM: apply sustained accessory glide during active movement, look for positive PILL response => immediate integration as treatment if positive
Neurodynamic & neurological tests
- SLR, slump test (dural mechanosensitive)
- Myotomes, dermatomes, reflexes (L1-S2)
Muscle control & special tests
- LUOMAJOKI (motor control impairment testing
Management overview:
- core principles
- active approach
Core principles
1. Biopsychosocial approach across all phases
2. Early active management: avoid bed rest
3. Stratified care based on risk & patient preference
Active approach
First-line interventions:
- Patient education:
o Reassure generally favorable prognosis, encourage self-efficacy
o Explain pain biology & importance of movement
- Activity advice:
o Continue or resume normal activities & work as tolerated
o Gradual return to exercise, avoiding fear-based avoidance
Management overview:
- structured exercise, self-management & manual therapies
Structured exercise, self-management & manual therapies
Comprehensive exercise framework: integrates motor control, strength / endurance, flexibility, aerobic exercise
& targeted manual therapies for optimal LBP recovery
- Motor control training:
- Objective: restore coordinated activation & timing of trunk muscles to support dynamic tasks, forward & feedback control
- Exercises: Luomajoki, abdominal drawing-in, quadruped limb lifts, bridging with biofeedback
- Integration: follow MWM to enhance facilitation of muscle activation after mobility gains - Strength & endurance training:
- Exercises: deadlifts, hip thrusts, bird-dog for 8-12 reps, 2-3 sets, 2-3x/week
- Progression: ad load or volume as tolerated, monitor symptom response - Flexibility & mobility work:
- Exercises: hamstring neural mobilization, hip flexor & thoracolumbar fascia stretching
- Technique adjunct: use Mulligan SNAGs to address accessory joint restrictions before stretching - Aerobic & general physical activity
- Brisk walking, cycling, swimming: 20-30 min moderate intensity, 3-5 x/week
- Enhancement: incorporate directional preference movements from MDT into aerobic warm-ups
Self-management & education:
- MDT self-exercises: directional preference exercises (10-15 reps, 1-2h)
- Mulligan self-SNAGs: belt-assisted glides every 2-3h
- Pacing & goal setting: SMART goals, symptom diaries, graded exposure
Evidence basis:
Multimodal programs including exercise, MDT & MWM show greater reductions in pain / disability than
exercise alone
