OCS - Lumbar 2

Intermittent claudication vs. Neurological claudication

Peripheral vascular disease, cardiovascular disease, ABI < 1

Cramping and tightness in the calves and leg

Intermittent claudication

Intermittent claudication vs. Neurological claudication

Spinal stenosis

Low back pain, cramping in the buttock, thigh, calves, and leg

Neurological claudication

Intermittent claudication vs. Neurological claudication

Pain increases with exercising/walking

Pain relieved with rest, standing to rest, bicycle test negative

Intermittent claudication

Intermittent claudication vs. Neurological claudication

Pain increases with extension, standing, walking/exercising

Pain relieved with flexed/stooped posture, walking up hill, bicycle test positive, positive shopping cart sign

Neurological claudication

Intermittent claudication vs. Neurological claudication

Mangament: internmttent walking program: walking to the point of moderate or near maximal pain followed by resting and repeating again

Intermittent claudication

Intermittent claudication vs. Neurological claudication

Managament: Manual therapy, flexion exercises and body weight supported treadmill training

Neurological claudication

What ABI values are indicative of artieral disease?

<0.95

CPR Manipulation Rules

Symptoms <16 days, no symptoms distal to knee, FABQW <19, hypomobility of one or more lumbar segments, hip internal rotation ROM 35 degrees at least one hip,

Intervention for CPG Manipulation Group

Supine SIJ thrust, sidelying lumbar thrust, emphaize active exercises like pelvic tilt

CPG Stabilization Group

<40, general flexibility (post partum, average SLR >91 degrees), instability/aberrant movements, + PIT

Exercises for CPG Stabilization group

Deep stabilizing muscles like multifidus, large stabilizing muscles erector spinae, obilque

dead bugs, planks, bird dogs

CPG for Specific Exercise/Directional Preference

Flexion

>50, symptoms distal to buttock, directional prefrence for flexion (stenosis)

Exercises for Flexion Directional Prefrence

Flexion exercises, manual therapy, and body weight supported treadmill ambulation

CPG for Specific Exercise/Directional Preference

Extension

Symptoms distal to buttock, directional prefrence for extension (centralizes), and symptoms peripheralize with lumbar flexion

Exercises for Extension directional preference

Mckenzie, mobilization to promote extension

CPG for Specific Exercise/Directional Preference

Lateral Shift

Visible frontal plane deviation of shoulders to pelvis, directional prefrence for lateral translation

Exercises for Lateral shift directional preference

Lateral shift mckenzie

CPG for Traction

Sxs of nerve root compression, affected dermatomes/myotomes, decreased reflexes, postive nerve tension, (+) SLR, peripheralization with flexion and extension

What is the least evidence based Lumbar CPG?

Traction

Treatment for CPG Traction

12 minutes w/ 40-60% of patients body weight. Progress to intermittent traction 30 sec on, 10 sec off

When using the 2007 CPG and a patient fits between 2 categories, which should you try to give prefrence towards?

Specific Exercise

2012 TBC

Clinical Findings

*Red Flags

*Medical comorbiditeis precluding rehab

*Leg pain with progressive neurologic deficits

Medical Management

2012 TBC

Clinical Findings

*Medium to high psychosocial risk status

*Low psychosocial risk status with predominatly leg pain

*Minor or controlled medical comorbitiies 

Rehabilitation Managment 

2012 TBC

Clinical Findings

*Low psychosocial risk status

*Predominately axial low back pain

*Minor or controlled medical comorbitiies 

Self Care managment

2012 TBC - Rehabilitation Management

Clinical Findings

Disability: high (>40 on oswestry, 7+ on Numerical Pain)

Symptom Status: volatile

Pain: high to modeate

Symptom Modulation

2012 TBC - Rehabilitation Management Symptom Modulation

Treatment

Directional prefrence exercise, manipulation/mobilization, traction, active rest

2012 TBC - Rehabilitation Management

Clinical Findings

Disability: moderatre (21-40 on oswestry, 3-6 on Numerical Pain)

Symptom Status: stable 

Pain: moderate to low

Movement Control 

2012 TBC - Rehabilitation Management Movement Control 

Treatment

Sensorimotor exericse (nerve glides), stabilization exercises, flexibility exercise 

2012 TBC - Rehabilitation Management

Clinical Findings

Disability: low (0-20 on oswestry, 0-3 on Numerical Pain)

Symptom Status: controlled

Pain: low to absent

Functional Optimization

2012 TBC - Rehabilitation Management Functional Optimization

Treatment

Strength and conditioning exercises, work-or sport specific tasks, aerobic exercises, general fitness

Best Recommended Level A evidence outcome measures for Lumbar pain

Oswestry and Roland-Morris

A Level recommendations for Lumbar Manual therapy

Acute and Chronic Low back pain

Acute: Thrust manipulation

Chronic: thrust and non thrust manipulation

A Level Recommendations for Acute Low Back Pain exercise

Direction preference

A Level Recommendations for subacute and chronic Low Back Pain exercise

Trunk coordination, strengthening, and endurance exercise (post-lumbar microdiscectomy)

A Level Recommendations for chronic Low Back Pain exercise

without generalized pain (only in one spot)

With generalized pain (pain all over , peripheral sensitionation)

GP: mod to high intensity exercise

WGP: low intensity fitness and endurance

Treatment for Spinal Stenosis (C Level)

flexion exercise + MT + strength + progressive walking (body weight support treadmill) 

What level of evidence is good lumbar patient education?

Level B

What level of evidence is lumbar traction?

Level D

Should you do traction when there is not radicular pain? When should you use it?

No. Nerve root compression sxs or periphalization with both flexion and extension

What is the A level recommendation for ACUTE Lumbar treamtnet in 2021 CPG

Thrust/non thrust mobilization + active techniques (make sure they move at home and exercise)

What is the B level recommendation for ACUTE Lumbar treamtnet in 2021 CPG

Pt education, exercise, and TBC

What is A level recommendation for CHRONIC low back pain in 2021 CPG

All exercsies (including aquatic, specific trunk activation, strength and endurace) and Patient education combined with active treatments (MT + exercise, yoga pilates)

ABI Values:

Some disease

0.9-0.8

ABI Values:

moderate disease

0.8 - 0.5

ABI Values:

severe disease

<0.5

Pathoanatomical Low Back Pain: (warning don’t think about this way of back pain too much)

Facet Pain.

Where is the pain? What type of motions aggravate it? Radicular pain?

What relieves it?

Unilateral, unilateral muscle spasm, lack of radicular features, pain in extension, sidebending, or rotation to ipsilateral side

Relief from facet joint injection

Pathoanatomical Low Back Pain: (warning don’t think about this way of back pain too much)

Discogenic Pain.

Where is the pain? What type of motions aggravate it? Radicular pain?

Axial, midline back pain, aggravated with flexion, sitting intolerance (30 min), aggravated with bilateral hip flexion, no radicular signs

Pathoanatomical Low Back Pain: (warning don’t think about this way of back pain too much)

Radiculopathy Pain.

Where is the pain? What type of motions aggravate it? Radicular pain?

Radiating pain, motor/sensory/reflex changes matching nerve root, + neural tension,

What is the special test for Kidneys?

Murphy’s Test (Percussion)

Active Adolescents with extreme kyphosis

Scheuermann’s Disease

What are the 5 principles of the Schroth Method?

auto-elongation, deflection, derotation, rotational breathing, and stabilization

Schroth Method:

When working on standing side shifts, which direction should the shift go?

In the direction of the concavity (to encourage spine to shift towards midline).

Cobb Angle:

Normal Spine

0-10 degrees

Cobb Angle:

Mild

10-25 degrees

Cobb Angle:

Moderate Scoliosis

25-45 degrees

Cobb Angle:

Severe Scoliosis

>45 degrees.

In idiopathic adolescent scoliosis, when is a brace recommended?

Mild-Moderate Cobb angle