RAT 4: ND,Chronic Pain, and PGP Flashcards
(81 cards)
1
Q
When is neurodynamic treatment indicated? (3)
A
- ND mobilization is indicated under the lumbar stenosis category pg 119
- Altered neurodynamics are identified during exam pg 250
- For algorithm of LBRLP, if LANSS scale is below 12 and there are no hard neuro signs
2
Q
What is teh goal of neurodynamic mobilization?
A
reduce neural tissue mechanosensitivity and restore its movement capabilities
3
Q
What other interventions should be addressed prior to initiating neurodynamics? (3)
A
- joint or soft tissue mobilization
- motor control training
- neurobiology education- role of nervous system in movement and pain related to mechanical loading
4
Q
What are the two categories of neurodynamic treatment?
A
- Non-provocative gliding techniques
- Tensile loading techniques
5
Q
Are non-provocative gliding techniques passive OR active movement?
A
Both
6
Q
Who is contraindicated for Tensile loading techniques? (3)
A
Patients with hard neurological signs of impaired conduction like:
- weakness
- impaired sensation
- diminished DTRs
7
Q
Nonprovocative gliding techniques are thought to result in __________
A
a larger longitudinal excursion with minimal increase in strain and to produce sliding movement between neural and adjacent non-neural tissue
8
Q
How are the gliding neurodynamic mobilizations performed?
A
In an on/off manner or oscillatory manner
Not to be performed as a stretching technique
9
Q
What are the 3 primary classifications of chronic low back pain?
A
- Adaptive or Protective Altered Motor Response to an Underlying Disorder
- Altered Motor Response and Centrally Mediated Pain Secondary to Psychosocial Factors
- Maladaptive Motor Control Patterns that Drive the Pain Disorder
10
Q
What characterizes patients in the Adaptive or Protective Altered Motor Response to an Underlying Disorder category?
A
- high pain levels
- disability
- movement and/or control impairments that are secondary and adaptive to an underlying pathological process
11
Q
What, if any, pathological processes are likely to be present in patients with Adaptive or Protective Altered Motor Response to an Underlying Disorder? (9)
A
- red flag conditions
- pathology of the disc
- stenosis
- radiculopathy
- spondylosis
- spondylolisthesis
- inflammatory disorders
- neuropathic
- centrally or sympathetically mediated pain disorders
12
Q
What general approaches to PT intervention are most indicated and what is the likely response for patients with Adaptive or Protective Altered Motor Response to an Underlying Disorder?
A
PT management in conjunction with the primary medical or surgical intervention
13
Q
What additional types of intervention might be warranted for patients with Adaptive or Protective Altered Motor Response to an Underlying Disorder?
A
CLBP management (for a small group of them)
14
Q
What characterizes patients into the Altered Motor Response and Centrally Mediated Pain Secondary to Psychosocial Factors category? (6)
A
- Pain disorder is driven by nonorganic factors
- high level of disability
- altered central pain processing
- enhanced, constant pain
- movement and MCIs
- pathological anxiety, fear, anger, depression, negative beliefs, emotional issues, poor coping strategies , negative social influences
15
Q
What, if any, pathological processes are likely to be present in patients with Altered Motor Response and Centrally Mediated Pain Secondary to Psychosocial Factors?
A
None
16
Q
What general approaches to PT intervention are most indicated and what is the likely response for patients with Altered Motor Response and Centrally Mediated Pain Secondary to Psychosocial Factors? (3)
A
Interdisciplinary care:
- Cognitive Behavioral Therapy (CBT)
- psychological intervention
- graded exposure to functional activities
17
Q
What additional types of intervention might be warranted for patients with Altered Motor Response and Centrally Mediated Pain Secondary to Psychosocial Factors?
A
- clinical psychology or psychiatry
- exercise ALONE is unlikely to cure
18
Q
What characterizes patients in the Maladaptive Motor Control Patterns that Drive the Pain Disorder category? (5)
A
- the largest group
- maladaptive movements and poor coping strategies produce chronic abnormal tissue loading with reduced or excessive spinal stability
- ongoing pain, disability and distress
- MI (movement Impairment) presenting with pain avoidance behaviors or MCI presenting with pain provocation behaviors
- central sensitization
19
Q
What, if any, pathological processes are likely to be present in patients with Maladaptive Motor Control Patterns that Drive the Pain Disorder?
A
may have a specific diagnosis or classified as nonspecific CLBP
20
Q
What general approaches to PT intervention are most indicated and what is the likely response for patients with Maladaptive Motor Control Patterns that Drive the Pain Disorder?
A
PT intervention to address the movement and control deficits (most likely to respond to PT intervention as primary intervention)
21
Q
What additional types of intervention might be warranted in patients with Maladaptive Motor Control Patterns that Drive the Pain Disorder?
A
Cognitive behavioral approach
22
Q
2 subgroups of Maladaptive Motor Control Patterns that Drive the Pain Disorder
A
- Movement Impairment Classification of Pain Avoidance Behavior
- Motor Control Impairment Classification of Pain Provocation Behavior
23
Q
What characterizes patients in the subgroup: Movement Impairment Classification of Pain Avoidance Behavior? (5)
A
- painful loss or impairment of active and passive physiological movement associated with high levels of muscle guarding and co-contraction when moving in the impaired range
- mvmt restriction or rigidity (excessive stability)
- fear moving into the painful direction and perceive pain as damaging
- beliefs of harm, anxiety and hypervigilance
- poor coping strategies
24
Q
What general approaches to PT intervention are most indicated and what is the likely response for patients in subgroup: Movement Impairment Classification of Pain Avoidance Behavior? (5)
A
- education that pain is not harmful or damaging , but avoiding mvmts help to maintain the disorder
- desensitization through graded mvmt strategies (cognitive desensitization and central pathway)
- mobs, manips, STM (soft tissue mobilization) to restore motion, which reduces their fear of those movements.
- relaxation, breathing control, postural training, graded exposure exercises and functional activities
- cardiovascular xercise
*Reduction in fear and MI results in less pain and disability
*Focus on pain and stabilization tend to reinforce avoidance
25
What characterizes patients into subgroup: Motor Control Impairment Classification of Pain Provocation Behavior? (8)
1. demonstrate P through range pain or painful arc
2. end range pain during static or dynamic tasks (in all directions)
3. develop compensatory strategies to stabilize the motion toward the end range
4. adopt postures and mvmt that are provocative without being aware of it
5. poor proprioceptive awareness of the lumbopelvic region
6. gradual onset of pain and absence of withdrawal reflex
7. have mvmt related fear
8. fail to respond to general exercise programs
26
What general approaches to PT intervention are most indicated and what is the likely response for patients in subgroup: Motor Control Impairment Classification of Pain Provocation Behavior? (4)
1. Cognitive behavioral training model
2. desensitization
3. educate pt to control posture and mvmt patterns to avoid repetitive strain to painful tissues
4. motor learning interventions using SSEs
27
What are the typical components of a cognitive behavioral approach to chronic low back pain? (3)
1. Strategies: education, graded exposure, graded exercise, confrontation of negative beliefs, which are likely to be effective at reducing threat and fear-avoidance beliefs (research- most effective at least 100 hours of treatment)
2. may include imagery and motivational self-talk, relaxation or biofeedback, coping strategies such as assertiveness, and reduction of negative cognitions, changing maladaptive beliefs and personal goal setting
3. use quotas or goals for gradual return to activities, family involvement, reframing of affective and cognitive responses, introduction of positive coping and relaxation skills
28
What is graded exposure?
* engagement in hierarchy of feared activities
* confronts/challenges person's beliefs until harmful appraisals reduced or eliminated while progressing through fearful activities
* may benefit people with chronic pain and high levels of fear avoidance behavior
29
What is graded exercise?
* operant conditioning to improve exercise and activity tolerance and reinforce healthy functional behaviors.
* quota driven, pt must reach intensity/rep count/ etc prescribed by the PT
* pain reduction is not the primary goal of graded exercise.
30
What is the main goal of pain education?
Decrease the threat value associated with pain by increasing patient understanding
31
How are patient education and patient satisfaction related?
* “the most consistent determinant of patient satisfaction is the therapist’s attributes:... skill to communicate about the patient’s condition, prognosis, and self-management”. (pg. 287)
* Therapist interaction → patient satisfaction→ timely and efficient treatment→ best clinical outcomes
32
What is the role of modalities in the management of chronic low back pain? (5)
* **Therapeutic Ultrasound** - not sufficient evidence to warrant recommendation for Tx of LBP
* **TENS** use is not supported in the routine care of acute or chronic LBP
* **Cold**- Insufficient evidence and conflicting evidence exists for any differences between heat and cold for LBP.
* **Heat Wrap (HW)**- moderate evidence demonstrates that HW therapy provides small short term reduction in pain and disability in a mixed population. With acute and subacute LBP and that the addition of exercise further reduces the pain and improves function.
* **Current evidence** does not support the routing, broad, first line use of modalities in the management of CLBP
33
What are the potential benefits of aerobic exercise for patients with chronic low back pain?
* In aerobics-only interventions, clinically significant improvements were found sporadically in 6 variables:
* depression
* tender points
* global well-being
* physical function
* self-efficacy
* symptoms.
_Caveat_- While this systematic review is not related to persons with CLBP, it does demonstrate the potential benefits of aerobic exercise for persons with chronic pain.
34
Briefly summarize the effects of surgery, in general, for chronic low back pain. (3)
* Study by Kovacs et al found: Surgery showed better results for pain, disability and quality of life, although not for walking ability.
* Benefits of surgery are noticeable and remains for up to 2-4 years, but differences tend to be smaller at the end of this period
* Implantation of a specific device and decompressive surgery with or without fusion are more effective than continued conservative treatment when the treatment has failed for 3-6 months.
35
Is surgery more likely to be effective for dominant leg pain or dominant low back pain?
Patients with dominant leg pain and degenerative spondylolisthesis and spinal stenosis appear to have better outcomes at 1-2 years compared to pts with dominant LBP
36
General rehab guidelines for Lumbar Discectomy
1. Limit flexion and rotation for 8-12 weeks
2. No joint mobilizations of surgical segments for 3 months
3. Use modalities as needed and be sure to address scar
37
Exercise guidelines per protocol (Lumbar Discectomy) (5)
* Week 1: Begin walking program, ADIM, and flexibility exercises immediately after surgery
* 3-4 Weeks: Begin aerobic conditioning
* 4-6 Weeks: Begin lunges and progress core stabilization exercises
* 6-8 Weeks: Progress to higher level core stabilization and more functional exercises weeks 6-8
* High impact/sports activities must be cleared by surgeon
38
General rehab guidelines used for all types of Lumbar Fusions (4)
* No impact loading for at least 3 months
* Avoid end range rotation, extension, repetitive/prolonged flexion for at least 3 months
* Avoid intensive abdominal strengthening for 3 months
* Equivocal research regarding post-op guidelines
39
Exercise guidelines per protocol (Lumbar Fusion) (3)
* 0-3 months: Begin lumbar stabilization program shortly after surgery. Begin aquatic therapy weeks 2-3 or after wound has healed. Begin low impact aerobic exercise at week 6
* 3-6 months: Progress stabilization and aerobic exercises. Begin resistance training while maintaining neutral spine. Begin spinal flexibility exercises
* 7-12 months: Begin running program if appropriate. Continue lumbar stabilization and resistance exercises.
40
What therapist attributes have the most positive impact on patient satisfaction? (7)
* Professionalism
* competence
* friendliness
* caring
* ability to show empathy and respect
* the skill to communicate about the patient’s condition, prognosis and self management
* timely and efficient treatment with adequate frequency and follow-up
41
True or False: Pelvic girdle pain only occurs in conjunction with LBP
False
PGP occurs separately or in conjunction with LBP but excludes gynecological or urological disorders.
42
When should the diagnosis of PGP take place relative to lumbar spine examination?
Diagnosis occurs after exclusion of a symptomatic lumbar spine
43
PGP is multifactorial and related to \_\_\_\_\_, \_\_\_\_\_\_, \_\_\_\_\_, and \_\_\_\_\_\_\_.
Hint: Think MOI
1. pregnancy
2. trauma
3. arthritis
4. OA
44
What movement does the sacrum move relative to the ilia as a result of load bearing to stabilize the pelvic girdle?
flexion, nutation
45
Clinical tests for SIJ pain (4)
Pain or functional disturbances related to PGP must be reproduced by the following clinical tests:
* P4 test
* Patrick’s or FABER’s test
* palpation of the LDL
* Gaenslen test
LDL = Long dorsal sacroiliac ligament
46
Clinical tests for PS Pain
Pain or functional disturbances related to PGP must be reproduced by the following clinical tests:
* palpation of the symphysis and modified trendelenburg test of the pelvic girdle - while standing on one leg with the contralateral hip and knee flexed to 90 degrees, pain at the PS is a positive sign
47
Functional test for PGP pain
ASLR test
48
Can movement of the SIJ be reliably detected through motion palpation?
No
49
Points about imaging PGP pain (3)
* typically imaging has little vale in non-AS PGP
* MRI is preferable to other forms of imaging- less radiation and better at discriminating changes in and around SIJ
* Imaging techniques generally only needed in AS, presence of red flags, and when surgical interventions are being considered
50
Contraction of what superficial muscles increase SIJ stiffness? (4)
Through doppler imaging, SIJ stiffness was increased by contraction of:
* Erector Spinae
* latissimus Dorsi
* Biceps femoris
* Gluteus maximus.
51
Four groups of superficial muscle slings are theorized to provide pelvic girdle stability
Turn card for links to videos
[https://www.youtube.com/watch?v=GwrxQB3547A](https://www.youtube.com/watch?v=GwrxQB3547A)
[https://www.youtube.com/watch?v=gjxytSr\_qoE](https://www.youtube.com/watch?v=gjxytSr_qoE)
[https://www.youtube.com/watch?v=VtWQQNSZ6KU](https://www.youtube.com/watch?v=VtWQQNSZ6KU)
[https://www.youtube.com/watch?v=VtWQQNSZ6KU](https://www.youtube.com/watch?v=VtWQQNSZ6KU)
52
What are the 4 slings?
* Anterior Oblique Sling
* Posterior Oblique Sling
* Lateral Sling which includes:
* Longitudinal Sling connects:
53
What is form closure?
What happens at SIJ to maximize joint stability
Optimal stability at SIJ by the joint structure or the osteoligamentous system
\_\_\_\_\_\_\_
sacral nutation and relative posterior tilt occurs as a self locoking mechanism for stability
54
Muscles involed in Anterior Oblique Sling (3)
Provides links between the:
* External obliques anterior abdominal fascia
* Contralateral internal oblique. and
* Thigh adductor
55
Muscles involed in Posterior Oblique Sling (2)
Provides links between the:
* Latissimus Dorsi, and,
* Gluteus maximus through the thoracolumbar fascia
56
Muscles involed in Lateral Sling (4)
* Hip joint stabilizers
* Gluteus medius
* Gluteus maximus
* TFL
57
Muscles involved in Longitudinal sling (4)
* Peronei
* Biceps femoris
* Sacrotuberous ligament
* Deep lamina of the thoracolumbar Erector spinae
58
Muscles that showed delayed activation/onset in study regarding SIJ pain (3)
* LM (Lumbar Multifidi)
* Internal obliques
* Gluteus maximus
59
Contraction of what deep muscle increases SIJ stiffness?
What other deep muscle groups may have a role in SIJ stabilization?
Contraction of the TrA is thought to provide some stiffness in the SIJ due to its connection to the thoracolumbar fascia.
\_\_\_\_\_\_
The TrA, deep LM and diaphragm are activated in a feedforward manner prior to initiation of rapid arm movement in anticipation of lumbopelvic stabilization.
60
How is the 4-item test cluster used to rule in SIJ dysfunction?
* Distraction
* Thigh thrust
* sacral thrust
* compression.
With no centralization or peripheralization. Only 2 of these 4 tests need to be positive for a diagnosis of SIJ related pain.
61
6-item cluster used to rule SI dysfunction out?
If all 6 tests do not produce familiar pain, SIJ can be ruled out.
1. distraction
2. thigh thrust
3. Gaenslen
4. compression
5. sacral thrust
6. McKenzie assessment for peripheralization and centralization
62
What are the typical types of disorders that fall into the Specific PGP classification and how are these generally identified?
1. Inflammatory disorders
2. Infectious disorders
3. Disorders of spondylogenic origin
4. Systemic diseases
63
Examples of inflammatory disorders present in specific PGP classification (5)
* AS
* Reiter’s syndrome
* Psoriatic Arthritis
* RA
* may be associated with inflammatory bowel disorder
64
Examples of Infectious Disorders in specific PGP classification
osteomyelitis or tuberculosis.
65
Examples of disorders of spondylogenic origin in specific PGP classification (3)
* fractures
* Paget’s
* osteoporosis,
66
Examples of systemic disorders in specific PGP classification
* endocarditis
* GI/ GU disorders
* primary tumors are rare, but metastasis from prostate cancer, colorectal cancer, multiple myeloma is possible
67
What do you do as a PT if you have a patient in the Specific PGP Classification?
Typically patient is referred out but PT may be indicated to address the effects of certain disorders such as AS or in post-fx management
68
Briefly describe the general characteristics of Nonspecific Inflammatory PGP
* Nonspecific includes: pelvic pain disorders that are centrally or peripherally mediated, with a small group presenting with inflammatory pain.
* Characteristics: constant, unremitting pain, ↑ with WB, compression and pain provocation tests; relieved by NSAIDS or local injection
* Does not have a specific inflammatory disorder or known etiology
69
Briefly describe the general characteristics of Nonspecific Inflammatory and Centrally Mediated PGP
* may have dominant or nondominant psychosocial factors as the drivers of pain.
* Characteristics: widespread, severe and constant nonmechanical pain, allodynia, generalized hyperalgesia, central sensitization associated with fear, anxiety, depression and catastrophizing.
70
What is Peripherally Mediated PGP?
Includes physical factors such as reduced or excessive force closure with or without cognitive psychosocial factors as drivers of the pain experience and guide intervention.
71
What are the basic characteristics of Peripherally Mediated PGP?
* Characteristics include a well defined localized SIJ pain and associated connective tissue or myofascial structures with or without complaints of PS pain.
* usually unilateral, intermittent, aggravated and eased by specific postures and movements, related to WB in vertical; mechanism or time of onset is clear (like repeated activity or direct trauma- fall onto the buttock, landing hard onto one leg to the pelvis or peripartum)
* Pain is not usually provoked or associated with spinal movement.
* Consistent local motor control changes that inhibit the deep system or over activate the superficial system are present,which negatively impacts force closure during various functional tasks.
72
The two basic types of Peripherally Mediated PGP Disorders.
1. Reduced force closure or Insufficient compressive force
2. Excessive force closure or Excessive compressive force
73
Typical patient characteristics of **Reduced force closure or Insufficient compressive force** (7)
* excessive strain to the sensitized SIJs/PS secondary to ligamentous laxity, reduced passive stability
* reduced force closer leads to impaired load transfer through the pelvis = ongoing nociceptive mechanism for pain
* reduced force closer associated with Postpartum and positive ASLR normalized with pelvic compression
* reduced co-contraction of deep muscles (iliopsoas, gluts) and compensation through over activation of superficial muscles (quadratus, thoracic ES, external and internal obliques and RA)
* functional impairments in walking, sitting, standing, or loaded rotational activities like cycling & rowing
* assume sway back in standing, slump in sitting, habitual standing on one leg or thoracic upright sitting
* lumbar spine related pain and centralization /peripheralization are not present
74
Management of **Reduced force closure or Insufficient compressive force** (3)
* pain eased with SIJ belt, training optimal postural alignment, relaxation of the overactivated musculature
* mobilization, MET, soft tissue massage and manipulation of SIJs - short term relief
* focus on retraining optimal loading strategies
75
Typical Patient Characteristics **Excessive force closure or Excessive compressive force** (7)
* nociception is based on excessive, abnormal and sustained loading of sensitized SIJ and PS from excessive muscular ctivation or hypomobility due to stiffness in articular structures
* pain is localized to SIJ
* pain provocation tests (+)
* ASLR is (-), compression or belt are provocative and don’t decrease the effort to lift the leg
* habitual postures associated with high level of superficial muscle activation
* ischiococcygeus, piriformis and superficial LM, when overactivated compress various parts of the SIJ (butt-gripping strategy = large divot posterior to greater trochanter, pelvis in posterior tilt, lower lumbar spine in F, LE are ER; when unilateral, the pelvis may be rotated in the transverse plain)
* motor control strategies may be due to excessive cognitive muscle training or protective guarding and are provocative
76
Managament of **Excessive force closure or Excessive compressive force** (5)
* cardiovascular exercise, relaxation, stretching, soft tissue mobilization, MET, manipulation
* discontinuation of stabilization exercises
* reduce the overactivation of muscles (reduce force closure) through relaxation strategies, diaphragmatic breathing, muscle inhibitory technique
* retraining of optimal loading strategies
* address influences from lumbar spine, hip and LE
77
What are the mechanisms of injury associated with PGP?
Potential MOE for PGP are similar to those for non specific LBP. These include:
* Falls or lifting with torsional stress
* Trauma
* Sudden heavy lifting
* Prolonged lifting and bending
* Rising from a stooped position
* MVA with same side on the break
* Repeated torsional stresses such as golf, bowling, skating
78
How useful is the history for distinguishing between LBP and PGP?
Overall, the Hx appears to provide little or no statistically significant diagnostic value for PGP. However, the pts. story is still valuable from a clinical reasoning perspective to understand the patient’s problem, generate hypothesis, and to assist in planning the objective examination.
79
subjective info assists with differentiation between CLBP & PGP (8)
* Pain area whether localized or widespread
* Levels of disability and impairment
* History related to specific & surrounding events as contributors to the development of symptoms
* Family history of PGP
* Presence of active or passive coping strategies
* The patient’s pain beliefs and the presence of psychosocial and FAB
* Presence of incontinence and/or sexual dysfunction
* MOI and AGG factors are SIMILAR and cannot be used to differentiate the two
80
What are the key objective tests and how should they be interpreted to distinguish PGP from LBP?
Three categories of tests are traditionally used to examine the pelvic girdle:
1. Positional palpation tests - aim to diagnose by detecting asymmetry in pelvic bony landmarks of the ASIS & PSIS, the iliac crests, greater trochanters, sacral sulcus, and the inferolateral angle of the sacrum.
2. Motion palpation tests- designed to diagnose PGP by the detection of motion relative abnormal pelvic landmarks during active or passive motion tests, such as the standing hip flexion test, standing flexion test, sitting flexion test, modified trendelenburg test, PKB, supine to sit test or sacral sparing test
Clinically, positional and motion palpation tests seek to establish pelvic asymmetry followed by interventions to restore symmetry
3. Provocation test- aim to provoke the patient’s specific pain by stretching or compressing the SIJ or PS and associated structures. This cluster of tests includes: distraction, compression, thigh thrust, Gaenslen’s and sacral thrust. Performed to reproduce or increase a pts. familiar symptoms in the SIJ in an attempt to implicate or rule out a symptomatic SIJ
81
What do the terms form closure and force closure mean regarding PGP and what are the typical therapeutic approaches for each?
* Force closure- role of neuromuscular system
* Form closure- describes the role of joint structure or the osteoligamentous system
*Theoretically, optimizing force and form closure is thought to enhance pelvic girdle stability with deficits in either one, potentially leading to poor loading strategies and non-optimal stability.*
