L19: Management of specific conditions Flashcards
(47 cards)
What is hypervigiliance?
- Do a task that is challenge the patient’s fear but in a pain free way
- Eg. pelvic tilt in 4 point kneel (but within ranges)
What is important for bracing, hypervigilant or breath holding?
Makes it easier but still challenge the patient
Cognitive retrain the fears and beliefs: back is safe to move –> show _____
movements
Patients who have difficulty with finding _____ spine –> do this as an exercise for them
neutral
What is radiculopathy?
- Can present with no pain at all (eg. foot drop, numbness on outside of foot or weak calf strength
- It is not neuropathic pain –> rather a condition presenting with nociceptive and neuropathic pain
How to explain motor control exercises to a patient without giving the impression that they should always keep their back straight?
We should carefully consider using _____/_____ exercises in someone with fear avoidant behaviours or bracing or those who we think may get the wrong idea
motor control; neutral spine
Might keep saying “keep your back straight while you do this”
- Can encourage more fear avoidant behaviour –> must be wary
Motor control/neutral spine exercises are MOST APPROPRIATE for those who have adopted a ____ or _____ habit where there is a loss of detecting and keeping a neutral spine. They maybe continuing to load sensitive structures at end range.
flexion; extension
What is lumbar spinal stenosis?
Degenerative condition with diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes.
What are 4 symptoms of lumbar spinal stenosis?
- Gluteal and/or lower extremity pain and/or fatigue
- Symptoms on upright exercise such as walking
- Relief with forward flexion, sitting and/or recumbency
- Patient often has stiffness due to associated degenerative changes
Patients whose pain is not made worse with walking have a low likelihood of _____.
stenosis
What is the best imaging for spinal stenosis?
MRI is suggested as the most appropriate to confirm
Do medical/interventional treatments improve outcomes compared to natural history in spinal stenosis?
- A systematic review of the literature yielded no studies to answer this question.
- In the absence of reliable evidence, a limited course of active physiotherapy is an option for patients with lumbar spinal stenosis.
- Self- management advice and education
- Improving tolerance during exercise
What are 5 education, advice and exercise (conservative approach) in lumbar stenosis?
- Explain condition
- Work with patient to consider modifications to tasks, positions of ease, self management – including activity pacing
- Manage comorbidities and secondary impairments – balance, strength, ROM
- Do they have a significant ROM impairment ?
- Lumbar strengthening/ muscle function – including lumbo-pelvic global WB muscles – bias to flexion position to relieve symptoms
- Find regular exercise that the patient can do/enjoys that does not aggravate symptoms (stationary bike, swimming, exercise classes, pool classes, tai chi)
What are 6 manual therapy and exercise for focussed impairments (conservative approach) in lumbar stenosis?
Specific interventions
- Various for Lumbar spine – Flexion, Rotation or Lateral flexion in flexion, PA’s with spine in Flexion
- Avoid extension positions and extension exercises
- Might not be able to tolerate prone –> do PA with a pillow under body
- Can use neural mobilisations – SLR to reduce neural sensitivity if present
- Increase knee and hip extension where appropriate
- Increase ROM in other joints –> take the load off the painful/stiff area
- Mobilise adjacent areas – higher lumbar levels, thoracic spine as indicated
- Adjacent regions – self mobilization and flexibility/ muscle stretches – aimed at reducing lumbar extension moment in standing and walking (Hip Flexors, Quadricep)
What are the 3 non-conservative treatment for lumbar stenosis?
- Decompressive Laminectomy with or without spinal fusion
- Epidural Nerve Block
- Facet Cortisone
In most cases, spondylolysis symptoms resolve within 6 to 12 weeks with _____ management
conservative
- Conservative management approx 85% of cases
- Potential for recurrence is high
What are 7 management for spondylolysis?
- Symptomatic management (rest, NSAIDs ONLY where required)- Interferes with bone healing (anti-inflammatories)
- Activity/sport modification with graduated return
- Depends on severity and symptoms –> activity modification
- Time off may be required
- Only used if it unstable or if the patient symptoms are so severe (eg. Loss of muscle strength, coordination, proprioception, QoL)
- Bracing may be required to limit extension
- Not often used (eg. thoracolumbar brace)
- Restoring normal muscle strength and motor control, gradually increasing to functional movements
- Restoring or improving thoracic and lumbar mobility
- Depending on symptoms (must be pain free) –> can start loading rather early on
- Restoring normal muscle length – especially hip extension
What are 4 management for symptomatic spondylolithesis?
Similar to spondylolysis –> only difference: more evident for motor control training/ graduated strength training
- Activity modification
- Medications where required (NSAIDs)
- Exercise – local motor control has been advocated – graduated in complexity.
- Number of treatments or specific protocols have not yet been established specified the intervention period (10 weeks) of motor control training, finding positive treatment effects maintained over 30 months compared to controls.
- Ferrari et al (2016) found 5-8 sessions of supervised graded motor control exercise effective for function and pain (retrospectively).
How to basically manage inflammatory spondyloarthropathies?
Physiotherapy is usually the starting point rather than medical
______ affects up to 2% of Australians and more common in men than women. Approximately 5% of chronic lower back pain cases
Ankylosing spondylitis
What are 8 Ankylosing spondylitis symptoms?
- Gradual onset lower back pain and stiffness a major symptom (around the SIJ)
- Early morning pain / stiffness which persists up to or >45 mins
- Pain/stiffness improves after exercise and is worse after rest. Good response to NSAIDS
- ROM may be normal
- Persistence of symptoms for >3 months.
- Sleep disturbance
- Eye inflammation, pain in the eye or brow region, pain associated with exposure to light, blurred vision or eye redness
- Symptoms of inflammatory bowel disease
There is a strong genetic link; genes (IL23R and ARTS1) and the gene HLA-B27. Approximately one in eight carriers of the HLA-B27 gene develop the condition. It commonly presents in the late teenage years or 20s, although can start as late as 45. Long term inflammation results in bony growth
A
What is the diagnosis of Ankylosing spondylitis?
There is no specific test for diagnosis, but imaging by Xray and MRI may show evidence of inflammation of the SIJ.
Blood tests: C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), plasma viscosity (PV) and genetic tests.
The delay between onset of symptoms and diagnosis is 5–7 years on average.
Chronic back pain is common and recognition of early disease requires a high index of suspicion.
