RAT 3: DSE (includes handouts), LSS, and Traction Flashcards Preview

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Flashcards in RAT 3: DSE (includes handouts), LSS, and Traction Deck (56)
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1

What are the 3 subgroups of DSE classification?

  1. extension
  2. flexion
  3. lateral shift

2

How does spinal stenosis fit into the DSE subgroups?

the clinical presentation of persons with symptomatic LSS (lumbar spinal stenosis) are under the flexion subgroup

3

Which DSE subgroup is most commonly encountered?

extension subgroup

4

What are the key exam findings for the extension subgroup? (5)

  1. symptoms distal to knee
  2. centralize with E
  3. peripheralize with F
  4. s/s of nerve root compression may be present
  5. +SLR may be present

5

What are the key exam findings for the flexion subgroup? (7)

  1. directional preference for F
  2. nerve mobility deficits possible
  3. older >65
  4. imaging evidence of LSS (lateral spinal stenosis)
  5. s/s distal to knee
  6. s/s of nerve root compression may be present
  7. +SLR may (or may not) be present 

6

What are the key exam findings for the lateral shift subgroup?

10 from book

or

10 from pg 241

10 listed in book (pg 117)

  1. symptoms peripheralize with extension
  2. symptoms of neurogenic claudication may be present
  3. nerve mobility deficits possible
  4. visible frontal plane deviation of the shoulders relative to the pelvis
  5. asymmetrical side-bending AROM
  6. Gross limitation of side-bending ROM in the direction opposite the lateral shift
  7. Painful and restricted extension AROM
  8. s/s nerve root compression may be present
  9. + SLR may be present
  10. Nerve mobility deficits possible

10 from pg 241

  1. unilateral or asymmetrical symptoms
  2. sudden or recent postural change
  3. flexion and extension activities aggravate
  4. sidelying may be an easing position
  5. S/S of nerve root compression may be present
  6. visible shift or frontal plane deviation
  7. decreased lumbar lordosis
  8. asymmetrical lateral flexion AROM
  9. PAIVM may be hypomobile and/or provocative
  10. S/S centralize with shift correction

7

What are the 3 overall components of treatment for patients in the extension subgroup?

Table 4-3 on on pg 117 under Intervention Guidleines for extension subgroup says the following

  1. extension exercises
  2. Mobilization to promote extension
  3. Temporarily avoid flexion activities
  4. Address neurodynamics and other deficits as needed

(not sure what Dr. Mincer was going for in this question. There was also some info in the text on pg 240 that I have included below

  • The specific exercise prescription is repeated extension
  • The home exercise program includes
    1. maintenance of the lumbar lordosis via temporary avoidance of flexion
    2. posture correction
    3. appropriate level of extension exercises repeated 10 times every 2-3 hours

 

 

8

DSE: What is the Extension subgroup specific exercise prescription?

repeated extensions

pg 240

9

DSE: What is the Extension subgroup home exercise program? (3)

The home exercise program includes

  • maintenance of the lumbar lordosis via temporary avoidance of flexion
  • posture correction
  • appropriate level of extension exercises repeated 10 times every 2-3 hours

10

DSE flexion subgroup: how often (reps and frequency) should repeated extension be completed at home?


appropriate level of extension exercises repeated 10 times every 2-3 hours

11

What are the steps in the extension progression? (9)

  1. Prone on 1 or 2 pillows
  2. Prone lying without pillows
  3. Prone lying on elbow
  4. Prone press-ups or REIL
  5. Prone press up with exhalation at the end of extension (lock and sag)
  6. REIL with belt fixation
  7. REIL with therapist overpressure
  8. Extension mobilization (via CPA PAIVM)
  9. REIS

12

DSE extension progression: how does one determine where to start and how to progress?

  • not all start at the lowest level and do not progress through each level
  • The starting point is determined by the clinician
  • The progression is determined by pt response
    • in the presence of unilateral symptoms that worsen, temporarily centralize, or do not change with sagittal plane motion, a trial of extension in lying with ips off center is recommeded (hips are usually shifted away from the painful side)

***if the response to repeated ext is limited mobility with end-range pain that is increased but no worse with no centralization or peripheralization (no lasting changes)- consider manipulation or mobilization or trying the mobility deficit classification. More examiniation is warranted to assign a diagnostic classification.

13

   What are the steps in progression for the lateral shift subgroup?

  • pt self correction of lateral shift in standing or against the wall
  • if unsuccessful, PT performs manual shift correction in standing
  • if shifts in standing are successful and centralization occurs, pt is instructed in self correction in prone  (REIL) as well as in standing

**The exact progression depends on the pt's response

14

How should a therapist respond to reports of increased LBP when doing direction specific exercise?

Often, prescribed exercise may cause an increase in LBP as the leg pain improves or goes away (a common response). The exercises should be continued, and discontinued only if peripheralization occurs.

15

What is "recovery of function"?

 

I believe it is a McKenzie phase where you introduce flexion and functional activities again after pain has subsided from direction spedific treatments.

 

"resuming movements that have been avoided" is what Dr. Mincer said.

16

Book pg 241:

  • when pt is asymptomatic for a period of several days, recovery of function begins

Book pg 241:

  • when pt is asymptomatic for a period of several days, recovery of function begins
  • The pt begins exercise in the direction that has been avoided or that has produced peripheralization
    • example: in the extension subgroup category, RFIL exercises at the rate of 5-6 reps 5-6 times per day are intiatiaed, followed by repeated extension over 1-2 days. (sandwich the flexion exercises with extension exercises)
  • If no return of symptoms, flexion may progress slowly to sitting and standing, always followed by repeated extension exercises

Dr. Henderson's Class discussion points:

  • can begin recovery of function about 3 days after pt is asymptomatic as a result of the correction exercises.
    • Dr. Henderson said she has found the necessary length of asymptomatic time correlated with how long-lasting/severe the pt's condition was before tx.
  • Gradually introduce flexion. If pt does not have any syptoms with flexion, they are probably safe to go back to daily activities.
  • Sandwich the bad with the good. “do press-ups (or whatever makes you better) before and after the aggravating activity.”

  • Once they are asymptomatic and are doing good, move on to Maintanence phase.

**We have not closed the full loop until we have completed the "recovery of function" phase

17

DSE: what should you prescribe for the maintenance phase?

Dr. Henderson:

  • Once pt has completed recovery of function and are asymptomatic and doing good (I imagine for at least 3 days), the maintenance phase can begin
  • Ask the pt to do 10 reps in the morn and 10 reps in the evening as a prophylactic move.
    • can get buy-in for this when discussing how mayny things the pt does throughout the day that is in flexion.
  • Also teach pts what to do if the problem recurs.
    • (the liklihood of recurrence is high for most pts, because the reasons that caused the original problem to start are lifestyle things that are hard to change.)
  • Tell pts that those who are able to make small lifelstyle changes to improve overall lifestyle and back care are less likely to have recurrence.

18

What are 3 advantages of the DSE classification that Dr. Henderson has noted?

Some Advantages of this Classification:

  1. Typically can get quick buy in from pt
  2. Typically pts can recover quickly
  3. Can provide tools to pt to take care of it again on their own

19

When did Dr. Henderson say was the ideal amount of time to pass between first visit and follow up for pts in the DSE category?

Why?

Ideal to see a responding pt in 24 hours after first visit. They will change quickly if they are responding.

 

 

20

Describe what to do next if a pt peripheralized with extension and flexion did not make them better.

What should we do (and how quickly) if a pt responds to our next tx approach?

Why?

If extension peripheralized and flexion did not make them better, we try lateral progression. If it works and they feel better 24 hours later, try repeated extension again. Can only get them so much better with lateral.

21

DSE: what is something additional to consider treating in a pt who responds to DSE?

In Dr. Henderson’s experience, most pts that respond to DSE also have an underlying ROM or other deficit.  This is especially true of those who have been having problems longer or several episodes.  So then they may be moved to another classification for a while. Dr. Henderson believes that addressing the other issues can make a difference in preventing recurrence.

 

Book says the majority of persons with LBP require multimodal tx (pg 242 at end of DSE discussion)

22

DSE: Dr. Henderson clinical pearls

Always begin with ____________/_____________ progression unless there is a ___________  ___________.

  • Always begin with sagittal/extension progression unless there is a shift present

23

DSE: Dr. Henderson clinical pearls

Always try (loaded or unloaded) exercise first because of . . .

  • Always try loaded first because of increased compliance

24

DSE: Dr. Henderson clinical pearls

What is the only reason to change to a different progression?

  • The only reason to change to a different progression is if you have exhausted the progression you are currently using or the current progression has worsened the s/s

25

DSE: Dr. Henderson clinical pearls

What should you do if there is no change when doing a progression?

  • If there is no change, add more force. Continue down the current progression until you have changed the s/s or you have exhausted the progression

26

DSE: Dr. Henderson clinical pearls

loaded vs unloaded - does gravity make a difference?

yes, point says

Loaded vs. unloaded- gravity does make a difference

(but I can't remember what she meant exactly)

27

DSE: Dr. Henderson

What do I do the next day if

  • patient returns to his/her next appt and he/she is better?

change nothing

28

DSE: Dr. Henderson

What do I do the next day if

  • If patient returns to his/her next appt and he/she is the same?

  • add more force until you have fully exhausted the progression

29

DSE: Dr. Henderson

What do I do the next day if

  • If patient returns to his/her next appt and he/she is worse?

  • consider another progression especially if s/s are unilateral

30

DSE: Dr. Henderson

What do I do the next day if

  • If patient is doing lateral progression at home and he/she returns to the f/u appt and is better?

return to extension/sagittal progression