Lumbar TBC

LBP management approaches

repeated movement exercise
manipulation
movement system
motor control training

LBP traditional approach

defined by duration — <6 wks (acute), 6-12 (subacute), >12 (chronic)
rule out red flags, NSAID, continue current activity
Myth —> most acute LBP spontaneously gets better in 4-6 wks

lumbar pathologies & conditions

lumbar sprain/strain
facet impingement
SI jt dysfunction
disc bulge/herniation
stenosis
spondylosis
spondylolisthesis
lumbar segment instability
congenital hypermobility

treatment based classification (TBC)

if Oswestry score 25+
manipulation/mobilization
direction specific exercise
stabilization
nociplastic

traction for acute LBP

conflicting evidence
cannot recommend as treatment

TBC model evidence

moderate evidence for acute & subacute LBP
less confidence for chronic nonspecific LBP
added nociplastic subgroup for chronic

manipulation & mobilization diagnoses

facet impingement
spondylosis
lumbar strain/sprain
lumbago (general mechanical LBP)

manipulation & mobilization CPG

thrust & non-thrust mob for pain & dysfunction (grade A)
massage or soft tissue mob for pain (grade B)
exercises (trunk muscle activation) (grade C)

Rule In vs Rule Out manipulation/mobilization

positive CPR for manipulation
show closing pattern
SI jt dysfunction

CPR for manipulation

for those most likely to have positive outcome
symptoms <16 days (acute onset)
dont go below knee
FABQw score <19
hypomobile lumbar segment(s) on PA glide
one or both hips >35 passive IR

+LR of CPR for manipulation

3/5 + —> +2.61
4/5+ —> +24.38
5/5+ —> infinite

importance of mobilization used for LBP

use thrust manipulation over mobilization
thrust resets tone briefly (neuro effect)

closing pattern

extensin & SB incr pain on IL side
quadrant test

quadrant test

pt actively ext, SB & rotates to IL side
do standing or seated, stabilize CL hip
hold 3-5 seconds
positive = symptoms (if down LE, may mean direction category instead)
high SN (100) for facet impingement

post-manipulation treatment

stretching & motor control
walking, avoid bed rest

post-manipulation stretches & exercises

hands & knees rocking
TrA draw-ins
prone press-ups

post-manipulation progression

follow up in 2-4 days
re-assess disability — expect 50% decr
if not at least 50% better, repeat manipulation
if improved, assess movement & motor control
progress to fitness integration

importance of movement assessment

high reoccurrence of LBP
use SFMA to guide other areas to assess/treat
figure out why pt had back pain

sign of buttock

SLR to point of limitation
flex knee — hip flexion should incr
positive = no hip flexion change (red flag for non-MSK pathology)

SI joint historical factors

Fortin’s sign (high Sn, mod Sp)
groin pain (mod Sp)
buttocks pain (high Sn)
PSIS + groin pain = high Sp
pain incr when stand, walk & sit (high Sp)

Fortin’s sign

point of max discomfort
positive = pt points to PSIS region (one side)

SI joint assessment

palpation alone has low reliability
better Sp & Sn when combine w/ pain provoking tests

SIJ dysfunction test cluster

distraction
thigh thrust
compression
sacral thrust
Gaenslen
at least 3/5 produce symptoms = high Sn

distraction test

pt supine, legs straight
cup hands, push post & lat on ASIS
gradually incr pressure until pain
positive = SI pain

thigh thrust test

pt supine, bend one knee up & leg into hip flexion
drop sternum onto pt knee (post glide) & gradually incr pressure
if no symptoms, place hand under pt sacrum & repeat
test bilaterally
positive = reproduce SI pain

compression test

pt sidelying & facing away
hips 45 flex, knees 90 flex
cup hands just above GT & slowly sink BW toward table
test bilaterally, watch for pain on rebound
positive = reproduce SI pain

sacral thrust test

pt prone
hand on SI (S2) w/ fingers toward pt head
other hand on top (fingers perpendicular)
gradually incr pressure
positive = reproduce SI pain

Gaenslen test

least helpful diagnostically
pt supine, one leg full hip flex, other full hip ext
dont worry about sacrum tilt
drop off to side if pt very mobile
positive = reproduce SI pain

SIJ dysfunction flow chart

distraction & thigh thrust tests —> if both +, rule in SI
if not, continue until get another positive or rule out SI
compression test
sacral thrust
all tests negative —> rule out SI
< 3 positive —> SI unlikely (dont palpate pelvis)

SIJ dysfunction treatment

general lumbosacral manipulation
innominate rotational correction
inner core motor control

innominate rotation assessment

use if rule in SI jt
assess PSIS / ASIS level & symmetry
pt glute bridge up & down (reset pelvis)
palpate under most distal part of ASIS — see if thumbs level
name based on symptomatic side — if side higher, is rotated forward
test on PSIS —> if true rotation issue, will be opposite of ASIS test

supine long sit test

assess innominate rotation
pt bridge up & down, straighten legs
palpate most distal medial malleolus
if uneven, have pt sit up, reassess
if better, confirms pelvis issue
positive test = relative leg symmetry changes

muscle energy technique for innominate rotation

activate muscles to correct asymmetry
activate hip extensors of ant tipped side & flexors of post tipped side
pt supine hips & knees 90 flex — PT in lunge, pt legs on top of PT leg
iso hip ext into PT leg & iso hip flex into PT hand on knee

muscle energy technique dosage

hold submax (~20% effort) 5-6 seconds (3-5 times)
follow with pelvic shotgun

pelvic shotgun

pt hooklying supine
resisted ABD, then resisted ADD
resisted ABD — increase distance between on each rep
resisted ADD — start wide (after ABD), get closer each rep

active SLR test

load transfer test via pelvis, not looking for pain
raise leg 2 inch 2-3 times
guides treatment, does NOT diagnose
positive = 1 leg reported as heavier

active SLR scores

not difficult at all = 0
minimally difficult = 1
somewhat difficult 2
fairly difficult = 3
very difficult = 4
unable to do = 5

ASLR facilitation techniques

pt supine
pelvic floor — compress at GTs
transverse abdominis — compress at ASIS’s
lumbar multifidus — push in toward spine
if makes ASLR easier, need to train that muscle
if none help, check if lumbar nerve issue

mobilization & manipulation summary

facet impingement — local symptoms, negative imaging, hypomobile joint(s)
lumbar strain/sprain — local symptoms, negative imaging, muscle guarding / trigger points
SI dysfunction — PSIS & groin pain, positive test cluster

direction specific exercise category

report pain and/or numbness & tingling below knee
repeated exercise takes strain off discs
refer back to info from neural clearing tests

direction specific common diagnoses

bulging/herniated disc
lumbar stenosis
spondylosis / spondylolisthesis

disc herniation stages

stage 1 = protrusion (nucleus stays in annulus)
stage 2 = prolapse aka bulged disc (nucleus reaches edge, annulus intact, can affect nerve)
stage 3 = extrusion aka herniation (annulus ruptures)
stage 4 = sequestration (annulus rupture, nucleus leaks)

rule in vs rule out direction specific exercise

repeated movement testing
high Sp if centralizes

repeated movement testing

set baseline — ask pt pain out of 10 and symptom location
flexion in standing
extension in standing
side glide in standing
flexion in lying
extension in lying

repeated movement protocol

do sets of 10 — 3 sets minimum before changing posture
start with motion you think will make it worse
then do motion that improves symptoms
do standing until symptoms worse or no more improvement
move to lying postures
no changes with flex or ext —> check side glides

repeated movements in lying

perform after standing
can be prescribed as home exercises
prescribe one set every hour

repeated movement subclassifications

extension responder (bulged disc)
flexion responder (stenosis)
relevant lateral component
acute lateral shift

lumbar flexion disc mechanics

disc compressed anteriorly
nucleus displaced posterior
posterior annulus stretched
increase disc pressure to 80% in full flexion

lumbar extension disc mechanics

disc compressed posterior
nucleus displaced anterior
anterior annulus stretched
decrease IVF size
decrease disc pressure by 35%

side glide in standing

named for direction of shoulders
compare sides for symptoms & hip excursion

peripheralization

proximal symptoms at spine radiate distally

centralization

distal pain decreases proximally
may increase local LBP
widespread pain becomes more localized

directional preference

specific direction and/or sustained position improves ROM and/or symptoms

centralization vs directional preference

centralization = lasting change in symptoms location
preference = lasting improvement, but not always pain location change
all centralizers have direction preference, not all those with preference can centralize

extension responder

symptoms distal to buttock (bulging/herniated disc)
centralize with extension
peripheralize with flexion
extension directional preference

repeated movement progression

reduce derangement — centralize symptoms
maintain reduction — education, force progression, MT to centralize
function recovery — reverse direction & motor training
prevent recurrence — core stability & discharge

force progression

pt generated forces —> pt overpressure —> PT overpressure —> mobilization

lock load & sag

pt generated overpressure — ext unloaded
prone press up + deep breath (let low back drop)
do on last 1-2 reps of set

extension responder education

avoid sitting >20 minutes
use lumbar roll for extended driving/sitting
exercises every hour
avoid fetal position (sleep)

PT generated overpressure

PA glides & MWM
maintain constant pressure as pt moves
start with light force & gradually increase

relevant lateral component

for extension responder
off center prone press-ups — scoop pt hips to one side (maintain position)
wall side glides — named for direction of shoulders

acute lateral shift responder

visible shoulder & hip deviation (not in line)
directional preference for pelvis translation
named for shoulder position
usually shift away from symptoms
correct shift before sagittal plane movements

acute lateral shift mobilization

goal = pull hips opposite of where shoulders need to go
stand on sit on side shoulders shifted to
brace shoulder on pt pelvis
wrap arms around pelvis & pull toward you
slow & easy reps
reinforce with standing or wall side glides

wall side glides

inside foot placed against wall
position feet slightly wider than shoulder width
inside hand/elbow on wall, outside hand on hip
move inside foot next to outside foot
outside hand pushes hip inward (just touch GT to wall)