Lumbopelvic Article Review - USE

What are the four clinical physical therapy approaches discuss in the article?

a. Movement system impairments

b. Mechanical diagnosis and therapy

c. Motor Control Training

d. Integrated Systems Model

In the MSI model, what are the three major determinants causing a joint to move "too readily?"

a. Joint relative flexibility (intra and inter joint)

b. Relative stiffness (passive tension of muscle and connective tissue)

c. Motor performance and learning

An important component in the examination and treatment of a patient with LBP using the MSI model involves correct performance of basic activities including

a. Any activities that elicit symptoms, correct to reduce, or eliminate the symptom.

b. Daily activities that elicit symptoms like cooking, raking, fitness, or sports activities

Which approach is typically NOT considered a motor control approach?

a. Mechanical Diagnosis and Therapy

__________ and _____________ are two clinical findings in the MDT model that have been shown to be elicited in 70- 91% of patients with acute LBP.

Direction preference,

pain centralization

Describe the basic premise of the Motor Control Training model:

Looks for sensory and motor aspects of the spine and tailors the program toward the aspects that appear to be suboptimal. Muscle, alignment, and movement are taken into consideration and attempts to optimize those components with regards to function. Basically, want all your muscles firing correctly.

Increased or augmented activation of muscles is referred to as_____________, whereas decreased or compromised activation of muscle is referred to as______________

up regulation,

down regulation

Name the four biomechanical principles of the MCT model:

a. A controlled lumbo-pelvic unit is important for function.

b. Maintenance of a "neutral" lumbar spine position

c. For many functions, movement should be initiated from the periphery.

d. Adequate mobility/flexibility of adjacent joints and muscles

The Integrated Systems Model (ISM) is compatible with the Regional Interdependence model. Describe this model

That pain in one area of the body may be a result of disfunction in another area of the body. This can hold true for the mind as well. Fear, anxiety, etc. can also exacerbate pain as well.

Assessment using the ISM approach involves what four elements?

a. Choosing relevant assessment task according to patient's movement goals

b. Analyzing how the patient performs the task using observation and manual examination.

c. Correcting alignment, biomechanics and/or control with manual examination and or words/cues to assess the impact of changing performance and the impact changes on other body regions.

d. Choosing to first treat the area of the body that has the greatest impact on performance of the task regardless of the location of pain

Treatment using the ISM approach may include what three elements?

a. Education to address negative thoughts/beliefs about pain and manual therapy to mobilize any joints thought to be fibrotic or where mobility is reduced secondary to over-active muscles or fascia.

b. (ii) Motor control training teach better recruitment strategies for neuromuscular support of joints for both static loading and movement; to restore optimal recruitment of transversus abdominis, deep multifidus and the pelvic floor muscles

c. Movement training - to build strength, endurance and capacity for the individual's movement goals.

What are the seven areas of convergence between the four models:

a. All approaches incorporate detailed assessment (including patientinterview and physical examination) to guide individualized treatment, but the elements addressed differ.

b. All approaches include clinical reasoning. Although some individual elements of the approaches may help some patients when used in isolation, effect sizes appear to be larger when treatment involves integrated use of multiple components in a clinical reasoning framework with matching to individual patients.

c. All approaches assume tissue loading contributes to symptommaintenance.

d. Some aspects of treatment aim to optimize tissue loading.

e. Correction of posture/alignment is considered in all approaches,particularly with reference to maintenance of a specific alignment during sustained postures.

f. Careful and progressive instruction regarding how to appropriately limit lumbar motions and move appropriately at the hips during function is a common theme in most.

g. Attention is placed on the patient-therapist alliance; importance of identifying subgroups, understanding the patient's goals and expectations, use of appropriate communication skills, patient education, safety, self-care and patient independence, working together with the patient/medical/multidisciplinary team, setting realistic goals, re-assurance to minimize fear avoidance, understanding pain processes and their relevance, the importance of pain free movement and a need to promote LBP prevention

Describe the structure and biophysical function of the vertebral end plate and its role in low back pain

a. The vertebral endplate is there to help disperse the force that is caused by gravity and increased with bending/lifting. It spreads these compressive forces to adjacent vertebrae and if it becomes too thin more force is placed onto the discs. When there is too much force placed onto the discs it can result in inflammation or degenerative changes (bulges/protrusions) at the disc.

Describe the non-invasive treatments for low back pain and sciatica:

a. Provide information and education of the source of the LBP. Helps for self-management

b. Group exercise programs

c. Mobilization/manipulation

d. Psychogenic therapies or behavior modification in tandem with above

e. NO Acupuncturef. NSAIDSg. Maybe weak opioids?

h. NO OPIODS/paracetamol

Describe the four possible reasons why consideration of biomechanics may not lead to improved outcomes:

a. Need the consideration of other factors that guide treatment

b. Biomechanical interventions may not be perfected yet for greatest benefit

c. May only be effective in narrow subset of patients and identifying them not possible yet

d. May not be the cause of the patient's pain

Name and describe the three biomechanical models discussed in the article:

a. Intervertebral mechanical dysfunction in non-specific low back pain

i. Generally looking at the motion of the different segments of the Lumbar spine and seeing what type of movement is available.

b. The Kinesiopathologic model - conceptual for processes contributing to LBP

i. This model looks more at the movement of the person as a whole and specifically their muscles. Lots of emphasis on flexibility and how well they are able to perform different motions due to muscle flexibility.

c. Anatomy, biomechanics, and pathology of SI joint

i. Pretty much exactly in the name

What joint is postulated to act as an important stress reliever in the 'force-motion' relationship between the trunk and legs?

SI joint

What clinical tests are recommended for Pelvic Girdle Pain (PGP):

a. Posterior pelvic pain provocation test (P4/thigh thrust test)

b. Patrick (FABER) test.

c. Gaenslen test pain with palpation of the long dorsal SIJ ligament

d. Symphysis palpation test

e. Modified Trendelenburg test.

f. Functional test: active straight leg raise test.

Describe the influence of lumbar lordotic curvature (LLC) on the center of mass (COM) and the resultant functional significance:

a. Places the center of mass of the torso above the hip and enables the soft tissue around the spine to neutralize shear loads, enhances ability to bear gravitational force, maintain erect posture and conserve energy

What five factors were considered significant determinants of LLC?

a. Age

b. Gender

c. LBP chronicity

d. Severity

e. Spinal disease entity

The results of the study demonstrated that subjects with LBP had LLC compared to HCs.

subjects with LBP had DECREASED LLC compared to HCs.

Describe the four components of the Clinical Prediction Rule (CPR) for lumbar stabilization:

a. (1) age less than 40 years

b. (2) average straight leg raise (SLR) of 91° or greater

c. (3) the presence of aberrant lumbar movement, and

d. (4) a positive prone instability test.33

Describe the components of the lumbar stabilization exercise (LSE) program and the criteria for progression from each stage:

a. Education of muscles

b. isolated contraction of the trans-versus abdominis and lumbar multifidus through an abdominal drawing-in maneuver (ADIM) in the quadruped, standing, and supine positions.

c. Additional loads were placed on the spine through various upper extremity, lower extremity, and trunk movement patterns. Exercises were performed in the quadruped, side lying, supine, and standing positions, with the goal of recruiting a variety of trunk muscles.

Functional exercises were last.

Describe the components of the manual therapy (MT) program:

a. Thrust and non-thrust manipulation techniques

b. Manual stretching of hip and thigh.

c. They performed a combination of a and b.

The MCID for the MODI is:

2

The MCID for the NPRS is:

1.5

Although the study failed to validate the CPR, a modified CPR demonstrated better predictive validity in identify patients likely to benefit from LSE. What two components of the original CPR were included in the mCPR:

1. : (presence of aberrant movement and a positive prone instability test)

Describe the timeframes for acute, subacute and chronic LBP:

a. Acute less than 1 month

b. Subacute 2-3 months

c. Chronic >3 months

Describe the different classifications of LBP using the CPG:

Describe the three indications suggestive of serious medical conditions or psychosocial factors requiring referral to an appropriate medical practitioner

a. The patient's clinical findings are suggestive of serious medical or psychological pathology.

b. The reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/classification section of these guidelines.

c. The patient's symptoms are not resolved with interventions aimed at normalization.

Describe the interventions recommended for treating specific classifications of LBP:

Describe the categories of factors associated with disabling low back pain:

a. Cognitive

b. Emotional

c. Social

d. Physical

e. Lifestyle

f. Coping Responses

g. Genetics

Cognitive Functional Therapy is defined as:

a. A flexible integrated behavioral approach for individualizing the management of disabling LBP. This approach has evolved from the integration of foundational behavioral psychology and neuroscience within physical therapist practice. It is underpinned by a multidimensional clinical reasoning framework in order to identify the modifiable and nonmodifiable factors associated with an individual's disabling LBP.

. Therapeutic alliance is defined as:

a. Motivational approach that tries to be reflective, empathetic, and uses validating communication to combat LBP

Describe the primary aims of CFT:

a. Help make sense of pain

b. Develop effective pain coping strategies and negate bad emotions

c. Adopt a healthy lifestyle

Prather H, et al.

Review the Key Points related to Findings and Implications:

a. The movement of the hip and pain related to a hip disorder may impact LBP or coexist in people with LBP.

Rabin A, et al

Review the Key Points related to Findings and Implications:

...

Clarke Davidson KL, et al. Trunk Muscle Responses to Demands of an Exercise Progression to Improve Dynamic Spinal Stability 2017.

Summarize the results of the study:

a. 5 levels and they were all able to recruit the abdominal muscles, but it was not in a linear progression (ex. going up one level made does not make it 10% harder could be 50%). Can be used for treatment especially endurance of trunk.

Describe the five levels of the exercise protocol:

...

Describe the amount of motion at the SIJ and pubic symphysis discussed in the author's response:

...

Review the relevant anatomical considerations of the lumbar zygapophyseal joint:

a. Three types of structures were found: adipose tissue pad, fibro-adipose meniscoid, and connective tissue rim.