Lumbar spine Flashcards
Biopsychosocial model
Biological
- Structures involved
- Possible pathology
- Impairment approach (articular, neural, muscular)
- Pain mechanisms
- Stage of disorder
Psychological
- Psychological drivers or moderators
- Depression
- Anxiety
- High stress
- Distress
- Fear avoidance
- Catastrophising
- Injustice beliefs
Social
- Social drivers of moderators
- Work environment/tasks: poor worker support, low job satisfaction, low skill level
- Home/family/social features
- Participation levels
Radiculopathy
- Specific nerve is compressed sufficiently to compromise axonal conduction
- Neurological signs and symptoms (numbness, P&N’s, weakness, reflexes)
- Typically presents with acute LBP and radiating pain down leg
- Maladaptive posture
Physical examination:
- Full neurological exam
- Neurodynamic tests
- CT
- AROM
Treatment:
- If pain is very acute: NSAIDs, rest from aggravating activity, minimising sitting and gentle walking
- If decrease peripheral symptoms, flexion and rotation mobility exercises
- Progress to restore pain-free ROM with gentle positioning and mobility exercises
- TA and multifidus training
Spinal stenosis
Patient interview and physical exam
- Pressure on spinal cord
- Bilateral S&S’s, bladder and bowel
- Narrowing of spinal canal causes compression of the spinal cord within the spinal canal
- Caused by degenerative changes
- Can get claudication leading to leg pain due to impaired venous drainage
- Decreased extension AROM
- Can present with LL neurological signs
- Stooped posture
- Can presents with diminished reflexes (+ve SLR)
Treatment and management:
- Conservative treatment first (reducing lumbar lordosis, back extensor and hip extensor mobility)
- Can have steroid injections and take NSAIDS
- Posture correction is makes positive difference
- Core stretches and strengthening (extension)
Degenerative disc disease
-This is a condition of the discs between vertebrae with loss of cushioning, fragmentation and herniation related to ageing.
Clinical presentation/diagnosis
- Low back pain
- Stiffness
- Restricted and/or painful AROMs
- Pain in glutes are often reported
- MRI
Treatment:
- Resuming regular activities
- Treat impairments
- Can take NSAIDS
- heat
- Manual and mechanical traction
Acute non-specific low back pain
Acute: 1-6 weeks, sub-acute 6-12 weeks
Theories:
- Acute tissue sprain, disc injury
- Entrapment of disc fragment or tissue in Z-joint
- Locked z-joint
Patient interview:
- High levels of pain
- Can be present with lateral shift away from site of pain
- Stressed
- Apprehensive or inability to move
- If symptoms radiate past buttock need a neurological assessment
- Pain PAIVMS and AROM
Treatment:
- Side-lying for treatment if comfortable
- Sustained positions to increase central pain intensity but decrease peripheral pain
- PPIVMS in side lying in the direction that gives positive symptom response (centralisation)
- Gentle PAIVMS
- Correction of lateral shift by therapist or self-correction using wall
- Recover full ROM especially extension
- No aggravating activities – education and avoiding flexion
- Heat and NSAIDS
- Tape to maintain shift correction and prevent flexion
- Home exercises to correct shift and passive extension in lying x 10 reps
Diagnosis NSLBP
Patient interview
- Symptoms influenced by posture/loading and/or movement
- Worse with sustained sit/standing, stiff in AM (underlying hypomobility)
- Pain with sustained flexion and/or getting out of sustained flexion
- Pain turning in bed (torsional load on disc/joint structures)
- Pain eased with movement
- Ache worse end of day
- Weight gain, low activity levels
Physical examination
- Static and dynamic posture
- Functional tests
- AROM +/- OP
- May show a flexion or extension restriction pattern (stretch/opening)
- Repeated, sustained, combined movements
- Screening tests (hip, SIJ, neck)
- Hip quadrant test
- SIJ: compression and distraction
- Physiological motion palpation (PPIVMS)
- Palpation
- Accessory motion palpation (PAIVMS)
- Pain
- Could be due to changes in muscle tone
- Lack of control of segment can result in pain
- Motor control examination: Postural tests such as pelvic tilt, US for multifidus and TA, Muscle length tests
Functional screening tools for NSLBP
o Dallas pain questionnaire
o Roland Morris Disability questionnaire
o Quebec back pain disability scale
o Oswestry low back pain disability questionnaire
Treatment of chronic NSLBP
- Treat impairments found in the objective
- Resolve normal posture and movement
- Restore local and global muscle function
- Assist return to work, workplace task design
- Assurance, advice, education and self-management exercise procedures to prevent recurrent pain
- Manual therapy
- Decrease pain, restore spinal movement
- Soft tissue massage, trigger point releases, myofascial release techniques
- PAIVMS and PPIVMS
- SNAGS
- Taping
- Start in position of ease with milder grades and shorter time durations and progress
- Nerve root: increasing size of IV canal therefore segmental rotation (painful side up), transverse glides towards side of pain, segmental lateral flexion
- Z joint: unilateral PA’s, segmental LF and rotation, transverse glides
- Therapeutic exercise
- Start isometric the move through range and then activity dependent
- Persistent, combined movements, general exercise and fitness, posture advice
- Look at work set-up
- Heat and cold
- Modify/adapt mechanical overload
- Motor control
Nerve trunk pain
-Inflammation causing nociceptive pain
Diagnosis:
-Testing neural tissue interfaces (musculoskeletal environment)
-Looking at conductivity: dermatomes, myotomes, reflexes
-Sensitive NTPT
o Sensitising manoeuvres (neck flexion, LF)
o Positive test: symptoms reproduced, limitation of range, resistance is different to unaffected side
-Often see antalgic posture
-Protective response of muscles to reduce mechanical loads on sensitive NT
-Shortening anatomical distance nerve trunk travels
-Active movement dysfunction and passive movement dysfunction
o Restricted ROM of Cx, shoulder, Lx, and hip
-Mechanical allodynia or nerve trunk palpation
o Sensitive along whole nerve trunk
Categories of LBP
- Serious spinal pathology (malignancy, infection)
- Specific patho-anatomical diagnosis (vertebral #, spondylolisthesis, spinal stenosis)
- Non specific low back pain (lumbar strains, sprains etc.)
Radiculopathy treatment
Treatment:
- Treat extra-neural environment
- Aim to ‘open up’ around nerve to limit compression (physiological LF away Rx treatment)
- Sliders and and progress to tensions
- NSAIDs
- Education
- If severe place in position of ease and treat from there (treat away from pain)
- TENS if acute
- Heat/ice
- Anti-inflammatories
- Can have rest in bed if very acute
- If persistent working on correcting deformities, AROM, more manual therapy such as rotation to open IV canal, address muscular deficits
- Transverse glides into pain
Spondylolysis
Stress fracture or defect at pars from repetitive bone loading.
PI:
- typically gradual onset of pain
- Diagnosed with Xray or MRI
- TOP
- Pain with AROMS
Treatment: 0-8 weeks
- Aim is protect stress fracture (can brace)
- Cease aggravating activities (running, jumping)
- Lumbopelvic control
- Postural control
- Keeping active with walking, cycling exercises
9-16 weeks
- Pain free exercise
- Resumption of low impact activities
- Squats, lunges
- Trunk AROM
- Progress to running and plyometrics from 12 weeks
17 onwards:
-return to sport
Spondylolisthesis
Stress fracture or defect at pars that has resulted in anterior slip of one vertebra on another
PI:
- Diagnosis with Xray or MRI
- Pain
- Decreased ROM
- Postural adaptions
- Can present with radicular pain or a radiculopathy
Treatment: CONSERVATIVE FIRST -TA activation lying on floor or on a ball -Extension and flexion stretches -Functional movements (squats, lunges, calf raises) -Anti-inflammatory medications -Extensor strengthening -If severe may need surgery
Neuropathic pain
- Pain originating from the somatosensory system
- Chronic pain resulting from injury/irritation to the nervous system (CNS or PNS)
- The nerve fibres themselves can be damaged, irritated, dysfunctional or injured
Screening tools:
- LANSS
- NPQ
- DN4
Diagnosis:
- History
- Antalgic posture
- Active movement dysfunction
- Passive movement dysfunction
- Sensitive NDT’s
- Mechanical allodynia on trunk palpation
- Evidence of local musculoskeletal cause
Treatment
- Treat extra-neural component
- Transverse glides (push into pain)
- Education
- NSAIDs
- Address biopsychosocial model
- Taping
- Progress to sliders and tensions
