PT 521 TBC Lumbar Spine

False

True or False? Most patients with ALBP spontaneously recover in 4-6 weeks.

lumbar strain/sprain, facet impingement, sacroiliac joint dysfunction

Common lumbar pathologies which fit into the manipulation/mobilization category

disc bulge/herniation, stenosis, spondylolysis, spondylolisthesis

Common lumbar pathologies which fit into the direction specific exercise category

lumbar segmental instability, congenital hypermobility

Common lumbar pathologies which fit into the stabilization category

Traction

What TBC classification has been thrown out due to recent research?

acute, subacute, sciatica, spinal stenosis

TBC model evidence is appropriate for what kinds of LBP?

chronic nonspecific LBP

TBC model evidence is not appropriate for what kind of LBP?

manipulation/mobilization, direction specific exercise, stabilization, nociplastic

What are the 4 TBC categories for LBP?

nociplastic

Which TBC category is specifically for chronic low back pain?

facet impingement, spondylosis, lumbar strain/sprain, lumbago

common medical diagnoses for the manipulation/mobilization category

A

level of evidence available for the ability of manipulations to reduce LBP and disability

B

level of evidence available for the ability of massage or soft tissue mobilizations for short term LBP relief

C

level of evidence available for the ability of exercise training intervention and specific trunk muscle activation to reduce LBP

fails to account for progression between different TBC categories

What is one downside to the levels of evidence available regarding the reduction of LBP?

1. Positive Clinical Prediction Rule for Manipulation

3. Closing pattern

2. Sacroiliac Joint Dysfunction

3 ways to rule in or rule out the mobilization/manipulation category

≥50% pain reduction in Oswestry within 48 hours

In the study to identify CPRs for lumbar manipulation, what did they consider "success" from the manipulation?

1. Duration of current episode <16 days

2. No symptoms extending below knee

3. FABQ score <19

4. ≥1 hypomobile lumbar segment on PA glide

5. 1+ hip with >35º of IR PROM

What are the CPRs for those most likely to respond to manipulation? (5)

2.61

LR for 3/5+ CPRs for manipulation

24.38

LR for 4/5+ CPRs for manipulation

Infinite

LR for 5/5+ CPRs for manipulation

general lumbosacral manipulation, side lying neutral gapping manipulation

Between general lumbosacral manipulation, side lying neutral gapping manipulation, and non-thrust PA mobilization, which is better at decreasing Oswestry scores?

True

True or False? Disability reduction is not related to specific type of manipulation, but just requires a thrust.

closing patterns, sacroiliac dysfunction

If an individual is negative on the CPR for manipulation, what else can be assessed to rule in the manipulation/mobilization category

Quadrant test

How can we assess closing patterns in the lumbar spine?

patient actively moves into extension, sidebending, and rotation to the ipsilateral side, holding for 3-5 seconds

describe the quadrant test

Ruling Out (SN = 100 for facet joint impingement)

Is the quadrant test valuable for Ruling In or Ruling Out?

Side Lying Neutral Gapping Manipulation

what manipulation is particularly valuable for patients demonstrating a clear closing pattern?

hands & knees rocking, prone press up, transversus abdominis draw in, breathing

stretches to use post-manipulation

stay active (walking, biking, swimming), AVOID BED REST

education to use post-manipulation

2-4 days (should be 50% better according to studies)

Post-Manipulation, how soon should you follow up with your LBP patient?

repeat manipulation

What do you do if your patient is not at least 50% better at a follow-up appointment after a manipulation?

assess for movement dysfunction/flexibility and motor control, progress to individualized program and fitness integration

When your patient is improved ~50% after manipulation, what are the next steps?

SFMA

what do we use as a guide to choosing our areas to asses or treat in an exam?

false (high)

True or False? Low back pain has a low recurrence rate.

sign of the buttock

what test performed in an SI dysfunction exam could indicate more sinister pathologies, such as sacral fractures or tumors (red flag)

Performing a SLR to the point of limitation then flexing the knee to see if hip flexion improves

what is the sign of the buttock test?

no chang ein hip flexion ROM with knee straight or flexed

positive test criteria for the sign of the buttock

- Unilateral PSIS Fortin's sign

- Groin pain

- Buttocks pain

historical factors for SIJD

PSIS pain, groin pain

pain in these areas is good for ruling in SIJD

movement testing, palpation

what do traditional models use to asses SI joint

pain-provoking special tests (movement testing and palpation have poor reliability)

What is the best way to asses the SI joint?

- distraction

- thigh thrust

- compression

- sacral thrust

- gaenslen

test item cluster for SIJC

3 of 5

how many SIJD test item cluster tests must be positive in order to rule in

vertical force applied to the ASIS directed dorsal and laterally

describe the force applied in the distraction test

No

when performing the distraction test, your patient indicates they have pain along their ASIS? Is this a positive test

- Sacrum fixed to table w/ 1 hand

- posterior force applied through femur toward table

describe thigh thrust test

perform without hand underneath the sacrum first

how can we initially modify the thigh thrust test for our patients?

Vertical force applied to iliac crest toward floor in sidelying

describe the compression test

BOTH SIDES

if patient states they have general pain around their left SIJ region, which side should you perform the compression test on?

Vertical directed force applied through midline of the sacrum

describe the sacral thrust test

Stress SI by posterior rotation of the pelvis on one side and the anterior rotation on the other

describe the gaenslen test

gaenslens

which test of the SIJD test item cluster actually offers little diagnostic accuracy

Distraction test, thigh thrust

in clinical models, what two tests are often performed first to identify SIJD (if both tests are positive)

general lumbosacral manipulation, innominate rotation correction, inner core motor control

main treatment considerations for sacroiliac joint dysfunction

structural palpation, supine long sit test,

tests for innominate rotation assessment

PSIS and ASIS

if we determine there is an SIJD issue with test item clusters, where can we assess what the issue is with palpation ?

Left

if there is a left posterior innominate rotation, what ASIS is high?

left upward pelvic shift

if left PSIS and left ASIS are both high, then what is the issue

supine long sit test

purpose of this test is to determine if an apparent Leg Length Discrepancy is caused by a torsion in the Sacroiliac Joint

reset pelvis (bridges)

what is a necessary step to take before performing and performing tests of the pelvic/sacroiliac region?

leg length discrepancy

If medial malleoli are uneven in supine and long sitting, is there a true leg length discrepancy or is is due to SI joint torsion?

muscle energy technique

technique to improve SI joint torsion

Left Hip Extensors, Right Hip Flexors

what muscles would you want to activate in the muscle energy technique for a Right Posterior Innominate Rotation.

5-6 second hold, 3-5 reps

dosage for pelvic muscle energy technique

pelvic shotgun

what technique is used to follow up the muscle energy technique for pelvic rotation?

guidance (NOT diagnosis/Ruling)

what is the ASLR test used for when considering pelvic rotation?

subject reports 1 leg is heavier

positive criteria for the ASLR test

compression through pelvic floor, TA, Lumbar Multifidus

Facilitation techniques for ASLR test

localized symptoms with negative imaging and joint hypomobility present

indication of facet impingement diagnosis in the manipulation/mobilization category

localized symptoms with negative imaging & muscle guarding/trigger points present

indication of lumbar strain/sprain diagnosis in the manipulation/mobilization category

PSIS pain + groin pain and positive test item cluster

indication of SI dysfunction diagnosis in the manipulation/mobilization category

pain and/or numbness/tingling distal to the knee

The direction specific exercise TBC typically involves patients who report what symptoms?

bulging/herniated disc, lumbar stenosis, spondylolysis/spondylolisthesis

Common diagnoses included in the direction specific exercises TBC

Protrusion: nucleus remains within annulus

stage 1 of disc herniations

Prolapse: Nucleus has reached the edge of the disc but annulus is in tact

stage 2 of disc herniations

Extrusion: Annulus ruptures

stage 3 of disc herniations

Sequestration: Annulus ruptures and fragments become lodged in epidural space

stage 4 of disc herniations

Perform repeated movement testing

How do you Rule In or Rule Out the Direction Specific Exercise category?

set baseline of pain and location

Important step prior to performing repeated movement testing

find specific direction that decreases pain, improves ROM, or centralizes symptoms

Goal of repeated movement testing

10

How many reps of repeated movements should you perform in one set?

3 sets of 10

If repeated movement testing seems to make no difference during the first set, how many sets are we required to perform?

unloaded positions

If you are unable to get any change with a repeated movement direction after performing several sets, what else can you try?

hands on low back

For extension repeated movement specifically, how can the patient drive their back into further extension?

side glides in standing

If we have no change in symptoms with our repeated movement testing in flexion or extension, what else can we examine?

direction of the shoulders

how are side glides in standing named?

asymmetrical symptoms, hip excursion

what are we looking for with side glides in standing?

Extension

Sitting and forward bending increases intensity of pain whereas walking or backward bending decreases. This individual would have a direction preference in what direction?

True

True or False? Centralization may actually increase local low back pain.

centralization: change in symptom location

directional preference: improvement in symptoms, not necessarily location

difference between centralization and directional preference

False (opposite)

True or False? All of those who have a directional preference are centralizers, but NOT all centralizers have a directional preference.

extension responder, flexion responder, relevant lateral component, acute lateral shift

Subclassifications of direction specific responders

false (mostly posterolateral)

true or false? a TRUE posterior disc bulge is pretty rare

flexion

if our patient has aggravated symptoms while sitting, which repeated movement do we start with?

loaded flexion & extension, unloaded flexion & extension, and added force have already been ruled out

when would it be appropriate to perform slide glides in standing

- symptoms distal to buttock

- symptoms centralize with extension

- symptoms peripheralized with flexion

- directional preference for extension

characteristics of an extension responder

- reduce derangement

- maintain reduction

- recover function (reverse direction)

- prevent recurrence

flow of treatment for extension responders

- patient generated force

- patient generated overpressure

- therapist generated overpressure

- mobilization

force progression for directional responders

1. symptoms remain unchanged with repeated motions

2. when you hit a plateau

in what scenarios would it be appropriate to ratchet up the forces applied to direction-specific responders?

prone lying, prone lying in extension, extension in lying

methods to reduce derangement for extension responders