Orthopedics: LBP treatment (Activation, Acquisition, Assimilation)

Prone Instability Test Findings

(+) Findings - Reduction/abolition of symptoms with hip extension (-) Findings - No change or increase in symptoms - No pain with CPA/UPA Suggests movement control, Deep longitudinal system, or Posterior oblique system

Factors for successful LBP treatment

- Younger age (< 40 years old) - Average SLR > 91° - Aberrant motions during flexion or extension o instability "catch" o painful arc o juddering o deviation out of plane of motion o Gower's sign o reversal of lumbopelvic rhythm - Prone Instability Test

Passive Lumbar Extension Test Procedure

1. Patient is in prone with feet hanging over the end of the table 2. Therapist stands at end of table and elevates both legs simultaneously about 30 cm (12 in) 3. Maintain knee extension 4. Introduce gentle pull on the legs

Abdominal Drawing-in Test

1. Patient lies in prone with a pressure biofeedback device (or BP cuff inflated to 70 mmHg) in the small of their back 2. Patient contracts their transverse abdominous for 10 seconds Negative test finding - 6 to 10 mmHg drop in pressure

Modified Trendelenburg Test

1. Patient stand on 1 leg 2. PT looks at angle of hips for hip drop

SLR ROM procedure

1. Patient supine. Inclinometer positioned on tibial crest just below tibial tubercle. 2. Leg raised passively by the examiner, other hand maintains knee extension. 3. Leg is raised slowly to maximum tolerated straight leg raise (not the onset of pain).

Lateral Trunk Endurance Test Procedure

1. Subject places 1 elbow flexed to 90 degrees below the shoulder 2. Legs are extended in line with the torso with 1 foot in front of the other 3. The non-weight bearing UE is placed on the opposite shoulder 4. Timer is started when subject attains this position 5. Test is stopped when subject is no longer able to maintain this position

Extensor Endurance Test Procedure

1. Subject prone on a treatment table with the lower body braced against it using straps or tester's body weight 2. Torso is positioned off the table above the ASIS with the UEs weight bearing on a chair to support the body weight before the test starts 3. Start timer when the subjects attains the test position ○ Torso parallel to the ground and the arms placed across the chest

Flexor Endurance Test Procedure

1. Subject reclines against a bolster (60º from the table top) 2. Arms positioned across the chest with hips and knees in 90-90 alignment 3. Timer starts when the bolster is slid away 10 cm (4 inches) from the subject's back 4. Test is stopped when the subject's back touches the bolster

Spine Rotators and Multifidus Test Scoring

5: Contralateral arm and leg lifts without pelvic deviation 4: Single leg lift while maintaining neutral pelvis 3: Maintenance for neutral pelvis with arm lift 2: Unable to maintain level pelvis during arm lift but still able to lift arm/leg Test Failure: Inability to maintain neutral pelvis during lift

How to treat impaired ability to coordinate low back movements

Acquisition approach Training to acquire the skill of coordinating movements of lumbar spine and adjacent regions Exercises - single plane co-contraction exercises, balance and coordination exercises

How to treat impairments to isolated movements

Activation approach Training to activate hypoactive muscles or isolated movement patters Exercises - abdominal hollowing, scapular retraction, and breathing pattern exercises

How to treat impaired control of multiplayer movements under dynamic loading conditions

Assimilation approach Training to assimilate loaded multiplayer movements into ADLs Exercises - step-ups, STS, Multiplayer movement progressions.

Treating Acquisition Summary

Deep Muscles • Transverse Abdominous: Elbow-toe with arm/leg lift. • Multifidus: Back bridge, Back bridge with leg lift. Superficial Muscles • Rectus abdominis: curl-up. • Obliques: Elbow-toe with arm/leg lift, or Side bridge. • Erector spinae: Back bridge with single-leg lift.

Prone Instability Test Procedure

First identify painful segments with CPA/UPA 1. Patient in prone with torso and pelvis supported on table and legs over edge with feet resting on floor 2. Apply CPA/UPA to provocative segment. 3. Patient actively extends hips to lift legs off floor • patient may hold on to table 4. Repeat CPA/UPA with hips actively extended

Treating Assimilation

Issues with: - Lifting/lowering - Pushing/pulling - Reaching/Handling - Torsional loads - Reciprocating movements

Gait system training

Loads: Posterior oblique - Gluteus maximus - Thoracodorsal fascia Deep longitudinal - Peroneus longus/anterior tibialis - Biceps femoris - Sacrotuberous ligament - TDF - Erector spinae

Lateral System

Muscles - Gluteus Medius - Gluteus Minimus - Adductors • SIJ and pubic symphysis

Deep Longitudinal System

Muscles •Erector spinae •Deep lamina of thoracolumbar fascia •Sacrotuberous ligament •Biceps femoris •Peroneus longus •SIJ (examples in slides)

Passive Lumbar Extension Test Findings

Positive finding - Reproduction of low back pain upon raising Utility - Suggests "clinical instability" • Helps rule in and rule out • May be likely to respond to Movement Control, and Stabilization Exercises

Posterior Oblique System

Structures - Latissimus dorsi - Gluteus maximus - Thoracodorsal fascia - Sacroiliac joint (examples on slides)

McGill's Torso Muscular Endurance Test Battery

Test ratios may indicate muscular imbalance ○ Flexion and lateral scores should be < extension score ○ Flexion/Extension < 1 ○ Lateral/Extension < .75 ○ Lateral tests should be symmetrical < 0.05

Anterior Oblique System

•Muscles - External oblique - Internal oblique - Serratus anterior - Anterior abdominal fascia - Adductors (add. longus*) - Pectoralis major - Pubic symphysis Examples on slides