4 - LBP Cheat Sheet

SI-Joint Patient Profile

• Age: 25-45 yrs • Gender: female > males; pt pregnant/post-pregnancy/previous pregnancies • MOI: extreme loading of 1 leg; torsion movements of trunk; lifting with trunk torsion • Aggs: transitional movements, running, climbing stairs, walking • Unilateral backpain in SIJ area, may have pain in posterior thigh or groin

Key question to ask pt before maniuplation

Any pain below the knee? This rules out nerve root pain (in which case you wouldn't do manipulation)

What should you do for EVERY low back pain pt?

Every back pt needs: dermatome, myotome, reflex screen to rule out *nerve root compression*

Good manual intervention for Flexion biased pt? Exercise?

Intervention: - Baby cradle lumbar mobilization - hip joint mobilization Exercise: BPcuff (add pelvic tilts)>> Quadruped (mad cat + rock back)>> Unloader/bike/Alter-G Also can add mini squats as active exercise

S/S Specific Exercise: Flexion

Symptoms - Better with sitting (in flexion) - Worse walking and even worse standing, worse with overhead activities (require extension) - Increased pain with prone lying, or supine with the knees straight Signs - Increased lumbar lordosis, may prefer slouched sitting - Limited flexion(not much more to gain) - Painful endrange extension - Repeated flexion decreases pain, repeated extension increases pain - Sustained flexion decreases pain, sustained extension increases pain - Short iliopsoas, latissimus dorsi, pectorals, erector spinae and large glutes - Weak lower abs with increased lordosis

Self Correction of Lateral Shift

The direction of side-gliding is named by the direction that the shoulder moved, rather than the hips

Describe common aberrant movements

(1) instability catch- a sudden acceleration or deceleration of trunk movement, or a movement occurring outside the sagittal plane (eg, lateral flexion or rotation during flexion) 2) Gower sign (thigh climbing): on return from a flexed position, patients are observed to use their hands to push upon their thighs or other surface to assist with the attainment of an erect posture 3) reversal of lumbopelvic rhythm upon return from the flexed position, patients bend their knees and an anterior shift of the pelvis occurs before achieving an erect posture (4) painful arc of motion: an increase in symptoms is experienced during lumbar spine flexion, or return from flexion, which occurs at a particular point (or range) and is not present before or after this point.

Classic Presentation: Stabilization Pt

*'Too loosey goosy and needs to stabilize (as opposed to stiff like manipulation)' Classic presentation: long lean limber female (person has loose ligaments) - *Recurrent episodes or flareups of pain* - *Aberrant movement* (Things aren't stacked like they should be and stabilized) - *Sustained Posture worse than moving* - *Excessive ROM in Extension* - *Difficulty resuming upright position*

Specific Exercise - Extension (S/S)

*- Symptoms distal to buttock* - Symptoms centralize with extension, peripheralize with flexion - Directional preference for extension - Extension group often younger than flexion group *usually have disco-genic issue, less likelihood of facet jt degeneration* *- YOUNGER*

CPR for Specific Exercise

*Directional preference (less pain) or centralization* of symptoms with movement in a certain direction (Flexion/Extension/Lateral) Looking for: 1. where is pain (looking for where it moves- looking for motion that centralizes it) 2. rating on pain (get starting point for pain intensity)

Classic Presentation: Traction pt

*EVERYTHING HURTS!* - Think: nerves are flared up, need to unload and open up foramina - People that cannot handle sitting - Pain shooting down legs - Leg pain > Back Pain - Need to self traction. - *no movements centralize pain*

Joint Mobilization Contraindications (9)

*Fracture* (hairline fx can be difficult to see post trauma) *Ligament rupture* *No working hypothesis* (condition may need referral, do palliative for now) *Multi level nerve root pathology* (never caused by mvmt dys) *Worsening neurological function* (not effective, ex. CE syndrome) *Unremitting, severe non mechanical pain* *Unremitting night pain* (preventing patient from falling asleep) *Empty end feel due to pain* *UMN lesion*

CPR for Stabilization

- Age less than 40 years - Average SLR >91 degrees - *+ PIT* - Positive prone instability test - Aberrant motion present +LR: When at least 3of the 4 criteria were met: +LR = 4.0 When only 1 of the 4 criteria was met: -LR =.20 When only 2 of the 4 criteria were met: -LR = .30

Manual Correction of Lateral Shift

- Has two parts: correct the lateral shift deformity, THEN restore full extension. - Go slowly and listen to patient symptoms

Specific Exercise - Flexion (S/S)

- Older age (>50) - Directional preference for flexion - Imaging evidence for lumbar spinal stenosis

Nerve Root Pain Red Flags

- Rapidly developing and progressive neurologic loss of sensory and motor function - Bowel and/or bladder incontinence *both indicate possible CES*

CDR for Manipulation

- Recent onset of symptoms (<16 days) - Hypomobility at any level (PA testing) - No symptoms distal to the knee - FABQ work subscale score <19 - Hip IR with 1 or both hips *> 35 degrees* Stats: When at least 4 of the 5 criteria were met: +LR =13.2 When only 1 or 2 of the criteria were met: -LR = .10

CPR for Traction

- S/S of nerve root compression (*SLR + at 45°* (reproduce their s/s and you see it is sciatic by adjusting distal), *hard neural signs: reflex/sensory/muscle strength deficit - Pain or numbness extending *distal to the buttock* in the previous 24 hours (more leg pain better fit in category) *- No Centralization w any mvmt*: Peripheralization of pain with extension* - *Positive crossed SLR*

Classic Presentation: Manipulation Patient (?? - need help w this)

- STIFF - not a frequent episode -acute event

Specific Exercise - Lateral (S/S)

-Visual frontal plane -Directional preference for lateral translation movement of the pelvis

Stabilization Intervention

1. Motor Control Progression w/ BP cuff to work TA (work deeper stabilizers first): Supine A/P tilts >> Marching >> Bent Knee Fall Out Prone: retracting, hip extension, knee flexion 2. Quadruped (work multifidus) or standing weight shift

What should you be thinking if pt has symptoms distal to buttock?

Specific Exercise or Traction

Spine Ailments that fall under Specific Exercise: Spondylosis and Spondylolisthesis IV Disc LSS

Spondylosis/Spondylolisthesis: Flexion IV Disc: Generally Extension Lumbar Spinal Stenosis: Flexion

Exercise Follow-Up to Traction

Stabilization! (stabilize area so you can maintain/support distracted position)

Traction Intervention

Static traction in: prone or supine 90-90 or alter-g (do what works) 10-12 minutes 40-60% bodyweight 3-4 times/week *if pain lessens enough, have them try exercises in new range*