MSK 2 - LBP w/ Extension Preference

when can we rule in acute LBP w/ radiating pain

1. symptoms reproduced/aggravated with mid range and worsen w/ end spinal ROM, lower limb tension/SLR, and/or slump test

2. signs of nerve root involvement

when can we rule out acute LBP with radiating symptoms?

lower limb tension (SLR) and slump test don't reproduce LBP or leg pain

when can we rule in acute LBP with referred/related LE pain?

1. low back and LE pain can be centralized and diminished w/ positioning, manual procedures, and/or repeated movement

common signs of acute LBP with referred/related LE pain

lateral trunk shift, decreased lumbar lordosis, limited lumbar extension ROM, movement coordination impairments

when can we rule out acute LBP with referred LE pain

baseline assessment of pain location and level is not changed with prolonged position change, manual therapy, or repeated movement

when can we rule in chronic LBP with referred LE pain

symptoms reproduced/aggravated with sustained end range tension/SLR/slump test

when can we rule out chronic LBP with referred LE pain

lower limb tension/slump test do not reproduce LBP or leg pain

extension classification typical MOI

bending, lifting, twisting

extension typical pt presentation

age late 20s-early 50s

acute LBP, often with radiating features

shift behavior, antalgic posture, muscular spasm, trouble staying in upright postures

why does full flexion tend to cause injury

support must shift from muscles to disks/ligaments when flexed

shear force>tissue tolerance

disc failure is characterized by ___ failure and ___ protrusion of the disc

annular; posterior

what may exacerbate mal-effects of fully flexed spine

vibration

put these in order of lowest to highest intra-discal pressure: sitting, supine, standing

supine

what happens when we bend forward to disc pressure? what about when we bend forward with a weight?

increase; further increase

what are some reasons why patients might centralize with extension

extension causes nucleus to migrate anteriorly

extension moves compression from disc to facet joints

extension allows discs to rehydrate --> dec compression

blocked extension principle characteristics

flexion worsens symptoms, cannot test extension hypothesis, not usually a candidate for mobiilzation

unstable/volatile status characteristics

symptoms worsen rapidly with flexion movement/position, may achieve rapid improvement with extension

stable/mechanical status characteristics

gradual improvement with sustained/repeated extension, worsen with sustained/repeated flexion

what aspect of clinical status, if answered by the patient, requires further explanation

remain the same (improve and worsen are self explanatory)

what constitutes a status quo designation?

neither centralization, nor peripheralization occur

transient increase/decrease in pain occurs during movement

what might we consider with status quo patients

mobility deficits, active rest

examples of worsened symptoms

inc neuro signs, parasthesia inc/peripheralizes, pain inc/peripheralize, deformity inc, AROM dec

examples of improved symptoms

dec neuro signs, parasthesia dec/centralizes, pain dec/centralizes, deformity dec, AROM inc

what constitutes peripheralization

pain/parasthesia moves distally, new parasthesia produced, symptoms present/produced increase in intensity and remain increased for 30+ seconds after movement stops

what constitutes centralization

pain/parasthesia moves centrally towards spine, parasthesia goes away, symptom diminishes/abolished during movement and stays that way for 30+ seconds after movement stops

acute extension classification

unstable pattern, peripheralization w/ flexion, centralization w/ extension

chronic extension classification

stable pattern, pain increases but status quo w/ flexion, pain decreases but status quo w/ extension, history suggesting extension preference is present

co-existing factors in pt history

diagnosed disc or degenerative pathology, LE symptoms, positive neurological symptoms

co-existing factors in pt exam

status improvement during movement testing (flexion, extension, pelvic translocation, repeated/sustained movement)

further movement testing procedures for extension classificaton

repeated/sustained extension in standing/quadruped/prone to confirm that extension movement and/or posture improves status

extension classification pt education

limit sitting, maintain lordosis when sitting (discuss lumbar supports, sitting surfaces), how to get out of bed while maintaining extension (prone on elbows)

80% of lateral shifts are ___

away from herniation

other terms for lateral shift

lumbar list, trunk list, sciatic scoliosis

pathomechanics associated with lateral shift

disc herniation, muscle spasm (protective), segmental instability

typical history elements associated with lateral shift

flexion MOI, acute onset, visual deformity that worsens w/ WB, sitting and walking worsen symptoms, radicular signs/symptoms

typical exam findings with lateral shift

visible deformity

+ side bend test

signs of nerve root compression

asymmetrical side bending

asymmetrical pelvic translocation

if status improves with pelvic translocation in lateral shift pt, what should be attempted next

extension in pelvic translocation

T/F: NWB positions usually increase lateral shift

F, reduce

prone progression for lateral shift

prone lying with shift correction

prone lying with shift over-correction

prone extension exercises

if prone progression does not improve status, what should be considered next?

traction (especially if pt has radicular sx)

after correction of lateral shift, patient must avoid ___

all flexion

progression of treatment for lateral shift patients

NWB correction, WB correction, extension progression, motor control

manual therapy techniques to enable extension

prone P-A, pelvic leg lift, pelvic prone/SB/ext, lumbar extension (closing), side lying pelvic correction (lazy man's roll), long axis distraction