case 3 - recurrent NSLBP

Question 1

RECURRENT NSLBP ASSESMENT PRIORITIES

Answer 1

Functional TaskS
Lumbar ROM/repeated mvtns
Motor control → lumbo-pelvic dissociation, forward lean

Question 2

RECURRENT NSLBP ASSESMENT

Functional Task

Answer 2

1. Observation → Sitting (looking for muscle imbalance)/ pelvic tilt

Deadlift, Squat

i. Good for TDT
ii. Good baseline to start see how much feedback he needs to correct and can use as treatment from there
iii. Functionally relevant/ reproduces symptoms

Question 3

RECURRENT NSLBP ASSESMENT

Lumbar ROM/repeated mvtns

Answer 3

a. Baseline measure & reassessment (shows patient they getting better)
b. See side to side differences
c. So that we can communicate with other health professionals (even insurers etc) and to help with documentation about the patient
d. Pain
e. See if they have directional preference (TDT) - direct treatment. Says better when stands up

Question 4

RECURRENT NSLBP ASSESMENT

Motor control → lumbo-pelvic dissociation, forward lean

Answer 4

• Assess his ability/awareness to find neutral spine

Can regress to 4pK or TA contraction

Question 5

OTHER ASSESMENT

Answer 5

4. Palpation + PAIVMs

5. Muscle length → Hamstrings

Question 6

MANAGEMENT PRIORITIES

Answer 6

1. Advice and education
2. Motor control – as functional as possible
3. ADDRESS OTHER CONTRIBUTING IMPAIRMENTS
4. REDUCE

Question 7

MANAGEMENT

1. Advice and education

Answer 7

• Diagnosis and prognosis → reasoning for spasms
• : From the physical examination, I have found that you have not sustained any major injuries to your back and are experiencing some symptoms around the L4/5 region of your back (show on model). 80% of patient recover completely between 4-6 weeks.
• Reassurance → spasm does not equal injury
• Acute episodes of pain and spasm don’t indicate that you have any major injuries, but your back is getting aggravated.
• There is a strong link between some of the activities you are performing at the gym and your pain. Particularly, the sensations you feel is a result of continued end range loading of increasingly sensitive structures in the spine so I would like to work together with you to retrain the way you are performing some of these activities.
• Activity modification → load Mx, motor control, progression
• encourage continuing gym, but consider reducing the amount of weight and range at which you are currently lifting in your squat and deadlift while we work to improve the way you are performing the task.
• Particulary important to become aware of maintain a neutral spine and adequate technique to stop reoccurance
• Still going to school is important if he is considering having days off >good prognostic factor and better long term outcomes

Question 8

MANAGEMENT

Motor control – as functional as possible

Answer 8

• Can use feedback(mirror and tape)
• Lumbo-pelvic dissociation
• Neutral spine in sitting → forward lean
• Neutral spine in 4 pt seat to heels
• Neutral spine forward lean in standing – progressing to deadlift movement
• Deadlift, Squat
  key is finding a functional level that the patient can do independently

Question 9

MANAGEMENT

1. Addressing the other contributing impairments

Answer 9

a. Addressing thoracic mobility (foam roller, stretches)
b. Addressing hamstring length/flexibility and flexibility into hip flexion – make sure patient keeps a neutral spine with doing these.
Has reducing hamstring length which may be contributing to excess lumbar flexion. Correction of this may help motor control

Question 10

MANAGEMENT

- reduce pain

Answer 10

• Manual therapy at L4/5 – rotation for example Massage Flexion MWM/SNAG 4pt kneel
• Because want them to be satisfied and be able to do treatment
  Say to patient: I’m doing this technique/movement to: • Reduce pain • Get your back more comfortable with movements you are having difficulty with

Question 11

ADDITIONAL

Answer 11

• Advice about how to manage if it happens again,
• how to manage episodes of muscle spasms/flare ups
• Advice on breathing control on lifting weights and not over bracing
• Progress motor control to gym based exercise – progress complexity of movement from forward lean in standing to deadlift movement or/and squat – add load, increase range, reduce feedback needed. Forward lean in standing could be progression exercise for patient
• Progress endurance in keeping neutral spine in sitting