L34: Exam Info Lecture Flashcards
(39 cards)
What happens when you can’t tolerate prone?
Do PAIVMs in sidelye or PPIVMs in sidelye (this is better)
What is the difference between repeated movements and directional preference?
- With acute LBP –> Into a position helps with your pain
- What we are looking for
- Repeat movements and reassess
- Pain management
- Exercises to directional preference
What are the 2 purposes of PAVIMs?
- The ‘reactivity’ or pain associated with movement of the vertebral segment
- The mobility of the segment
What grade for PAIVM assessment is used?
- The ‘reactivity’ or pain associated with movement of the vertebral segment
- The mobility of the segment
- Compared to above and below
So… if the patient’s pain is severe and irritable, we might only need information from #1. This only requires ENOUGH stimulus to ascertain if this is the patient’s symptoms – so could range from grade 2 through to 4.
If we want to ascertain information on #2, we need to put enough pressure through to compare it to other movement segments.
How do I differentiate nerve pain from muscle pain?
This is the sensitising manouver – it helps to differentiate between hamstring or calf and neural tissue.
To differentiate hamstring and nerve – we add dorsiflexion.
To differentiate calf and nerve – we can bring the leg back down to neutral (out of hip flexion) and add dorsiflexion and the calf would bring on symptoms with leg down and leg up. Nerve would only give symptoms with leg up in hip flexion (demonstration)
What are 2 situations to use combined/quadrant tests in AROM exam?
- Only if AROM is pain free (With overpressure)
- If AROM is relatively mild, and you want to see if adding another component of the movement makes it worse to determine that that movement (ie extension rotation) is the problematic movement
We wouldn’t use it if the patient is irritable or has a significant loss of ROM
Flexion quadrant: picking up things from the ground
Extension quadrant: gymnastics
Why am I measuring AROM?
As a baseline and re-assessment
What are 4 reasons why we measure AROM?
- So that we can objectively see if the patient is getting better or worse with treatment and/or time.
- To see if there are side to side differences
- So that we can communicate with other health professionals (even insurers etc) and to help with documentation about the patient
- To demonstrate to the patient that they are getting better
- Track improvements –> Can sometimes have slow improvements in persistent pain –> can give patient some encouragement
Why is the Thomas test used in assessment of LBP?
Biomechanically…..a lack of hip extension ROM means the patient is required to have more lumbar extension to compensate on functional tasks.
So…walking, standing, running etc is an issue – especially in spinal stenosis or spondylolysis, we can see if a lack of hip extension is a contributing factor
When is Thomas Test done in assessment?
Not a priority day 1
When are sliders used in neurodynamics?
In most cases. (eg. Radiculopathy)
To reduce sensitivity of nerve, to reduce threat/fear associated with nerve symptoms. To improve physiological movement of nerve
Start with a slider because nerve tissue can be irritable and flare up
When are tensioners used in neurodynamics?
Where Mechanosensitivity may be contributing to a pain presentation
Not a natural progression from slider. Most people will be managed just with slider.
- Nerve pain can go way quite quickly –> if nerve pain resolves –> do not need to progress
Very low irritability and severity present to use.
How to explain neurodynamic exercises?
These are to reduce pain and sensitivity of the nerve.
Explain to the patient that you found there was sensitivity with moving the nerve (from your tests) and the exercise is to help reduce the sensitivity of the nerve and to allow it to move more easily.
Link explanations back to subjective –> how technique/management is relevant to their problem
Few times a day –> at home (depending on how they can fit it in their day)
What are 2 progressions of directional preference exercise for flexion and extension?
Pain management strategy for acute LBP and radiculopathy
- Often don’t require many ‘progressions’ as they are used in the short term or to relieve symptoms during exacerbations
- As they are not ‘strengthening’ exercises, progressing is not a huge priority
However, as the patients range and symptoms improve…
Extension:
- Starting prone, progressing to standing (and progress repetitions as they improve)
- If they can go on prone –> standing is quite hard –> progression –> standing
Flexion:
- Starting in supine – knees to chest, progressing to 4 point kneel (Sit onto heel), progressing to standing (some patients may tolerate all of these)
- Some people will not tolerate = repeated flexion in standing
What are 2 situations where patients brace and breath-hold?
- Acute low back pain where there is high levels of pain (not habitual or maladaptive)
- Those with maladaptive habits with fear avoidance and/or protective responses- Persistent pain
With those with acute low back pain, we can make them aware of it but will likely get better as they improve
- Give some adjustments to help with comfort for acute phase –> should settle
With the latter, addressing this should be a priority – address these behaviours cognitively (through education and advice and making them aware) and through exercise.
- Making them worse –> cognitive re-structuring and specific exercises wo/breath holding and bracing
What motor control exercises do I prescribe?
Your exercise choice should come straight from your assessment
PLUS
What is most functionally relevant that the patient can do
- Functionally relevant (what task they fund difficult and their issues)
- Based on physical exam –> what they struggled with? (eg. squat corrected by using giving some feedback/verbal cues)
- Can use some taping if neccesary
What are 6 questions to focus on the priniciples of motor control?
- Is it functionally relevant as much as possible?
- Does it challenge what they have difficulty with?
- Eg. spondylolysis –> 6 weeks of motor control –> what should you do now for return to sport
- Can you progress it or regress it if needed?
- Forward lean in sitting –> what is progression and regression?
- Will they be compliant?
- Explain why this exercise is important
- Can the patient do it? – through a whole set?
- Can we incorporate it with other exercise principles?
- Eg. spondylolysis or flexion control impairment
- 4 point kneel into sitting
- What other exercises outside of motor control exercises?
- Swimming?
- Eg. spondylolysis or flexion control impairment
How can you explain motor control exercises?
It is important to recognise which patient’s we need to be careful with language and avoidance behaviours
People who have recurrent LBP, some exercises have been shown to be more beneficial
- Built tolerance to take load
- Know where your back is (position) –> awareness
- Language and explanation will likely differ….
- Some exercises have been shown to be more helpful than others – and they are exercises aimed to improve your awareness of the position of your back and aimed to improve the function of the muscles that support your back.
- HOWEVER… we would still be giving clear helpful messages – all exercise is effective and should be continued and still normalise movements of the back.
- Still keep moving your back if you can tolerate it= good to keep back moving
What are 4 patients to use motor control exercises?
- Does end range extension OR flexion as habit AND
- Symptoms are related to these habits
- We can be very clear that the “exercises and strategies are aimed at improving their awareness of their position of their back” and “to get them better at keeping their back in positions where they are not over-loading it”.
- ONLY – if their symptoms are related to end range loading and they are not hyper-vigilant with their back positioning.
What matters with motor control? What are 3 characteristics?
Selecting an appropriate exercise is just one part
- An explanation to the patient about the exercise – why they are doing it
- That you are teaching effectively (demonstration, good verbal cues, using appropriate feedback)
- When finding neutral spine –> check they are relaxed
- Check that they are not bracing (tactile, visual…etc)
- When finding neutral spine –> check they are relaxed
- That the patient knows what to do, when to do it, how many etc and what to look out for, and
What are 4 things you shouldn’t say when explaining manual therapy when mobilising?
- Put these bones back into place
- Realign something
- Help with healing
- Fix your back, break down scar tissue….
What are 5 things you should say when explaining manual therapy when mobilising?
- Reduce pain
- Get your back more comfortable with movements you are having difficulty with
- Relax this area of your back to allow you to move easier
- Do some movements of your back to…get your back moving a bit more
- Help reduce the sensitivity of the nervous system
How do you explain manipulation?
- Similar concept as mobilisation – aimed to reduce pain with movement and/or aimed to improve movement
- When you progress from a mobilisation – explain that you are taking their back a bit further to further help with movement/pain. They may feel a click in their back. Is perfectly safe.
- Take your back a little further
What are the clicks/cracks/popping of the back made by?
Cavitations
- Negative pressure
- Release of nitrogen bubble
- When pull apart of 2 surfaces
