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clinical prediction rules - lumbar
clayton's presentation and handouts
97
Anatomy
Graduate
04/23/2012

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Cards

Term
what are the 4 categories of treatment for LBP
Definition
manipulation, stabilization, specific exercise, traction
Term
if the problem is hypomobility or misalignment, what treatment should help
Definition
manipulation: manually move it back into place
Term
what are the 5 clinical prediction rules that indicate successful treatment with manipulation
Definition
1. no symptoms distal to the knee; 2. onset of symptoms < 16 days; 3. low FABQ-W < 19; hypomobility of lumbar spine; hip IR ROM > 35 for at least 1 hip
Term
what does the number of clinical prediction rules present mean
Definition
the more clinical prediction rules present, the greater the possibility of success
Term
what does FABQ-W mean/what is it
Definition
fear avoidance beliefs questionnaire for work; questionnaire asking how work affects back pain
Term
of the 5 clinical prediction rules for manipulation, how many should be present to warrant a manipulation
Definition
just 3
Term
of the 5 clinical prediction rules for manipulation, how many should be present for manipulation to be necessary
Definition
4
Term
if too much movement is the problem, what is the goal/treatment
Definition
stabilization
Term
what is the physiological method of stabilization
Definition
strengthening core muscles of the back; retraining core muscles of the back to control spine movement during activity
Term
for the following questions, list the best treatment for the problem
Definition
ok
Term
asymmetrical lateral flexion ROM
Definition
manipulation or specific exercises
Term
diagnosis of lumbar spinal stenosis
Definition
specific exercise
Term
unilateral LBP without symptoms into lower extremities
Definition
manipulation
Term
LE symptoms
Definition
specific exercise
Term
no movements centralize symptoms
Definition
traction
Term
asymmetrical bony landmarks of the pelvis
Definition
manipulation
Term
positive SI dysfnction tests including supine-long sit test, prone knee bend test, standing flexion test
Definition
manipulation
Term
visible lateral deviation
Definition
specific exercise
Term
frequent recurrent episodes of LBP with minimal perturbation. "Back hurts every 3 months. I just step down off the curve, and I'm out for a few weeks"
Definition
stabilization
Term
hypermobility of the lumbar spine. "When I push their back, it's easy to move them."
Definition
stabilization
Term
asymmetrical sidebending AROM
Definition
specific exercise or manipulation
Term
previous history of a lateral-shift deformity with alternating sides: back's all over the place, side to side
Definition
stabilization
Term
frequent prior use of manipulation with dramatic but short-term effects
Definition
stabilization
Term
symptoms of nerve root compression
Definition
specific exercise or traction
Term
trauma, pregnancy, or use of oral contraceptives
Definition
stabilization
Term
relief with immobilization such as bracing
Definition
stabilization
Term
radiography shows instability
Definition
stabilization
Term
symptoms centralize
Definition
specific exercise
Term
symptoms peripheralize
Definition
specific exercise
Term
what are the core muscles to target for stabilization
Definition
rectus abdominis, transversus abdominis, internal/external obliques, erector spinae, multifidi, quadratus lumborum
Term
what are the 5 clinical prediction rules that indicate successful treatment with stabilization
Definition
< 40 yo, average SLR > 91 deg, aberrant movements present, + Prone Instability Test, tender to palpation long dorsal SI ligament and pubic symphysis
Term
if someone is postpartum, what are the clinical prediction rules for stabilization
Definition
posterior pelvic pain, positive active SLR, positive modified trendelenberg
Term
if someone has 3/4 clinical prediction rules for stability, what is their probability of success with treatment
Definition
67.00000%
Term
how is success defined
Definition
50% improvement
Term
if someone is hypomobile, is treatment by stabilization likely to be successful
Definition
no
Term
if someone has a negative prone instability test, is treatment by stabilization likely to be successful
Definition
no
Term
if someone has a FABQ-PA >9, is stability treatment likely to be successful
Definition
no
Term
what is a FABQ-PA
Definition
fear avoidance beliefs questionnaire for physical activity
Term
if someone has no aberrant movements, are stabilization exercises likely to be helpful?
Definition
no
Term
what are the 4 failure predictors for stabilization treatment
Definition
hypomobility, negative prone instability test, FABQ-PA >9, no aberrant movement
Term
how many negative CPRs for stability need to be present to suggest that the patient is likely to fail with stabilization treatment
Definition
3
Term
what is the goal of specific exercise treatment
Definition
produce lasting centralization of symptoms
Term
how to determine whether something is a good specific exercise
Definition
if it makes the pain go away, do it! If it hurts, don't do it!
Term
define centralization
Definition
pain moves from an area more distal or lateral to a location more central
Term
what is directional preference
Definition
decrease or abolish lumbar midline pain. Includes centralization
Term
is directional preference a part of centralization
Definition
no
Term
is centralization a part of directional preference
Definition
yes
Term
define peripheralization
Definition
pain moves from an area more proximal to an area more distal/lateral
Term
what is a status quo movement
Definition
movements that do not produce centralization or peripheralization
Term
is it ok for an initial increase in central LBP to occur initially with centralization
Definition
yes
Term
what is a possible reason why specific exercises in extension provide relief
Definition
disc is pushed back into place with extension movement
Term
what is a possible reason why specific exercises in flexion provide relief
Definition
open up space in flexion that restores normal function/motion and decreases compression
Term
what are the 4 clinical prediction rules that indicate successful treatment with specific exercise
Definition
> 50 yo, symptoms distal to butt, directional preference, response to lateral translation movement
Term
if someone has lumbar spinal stenosis, what will be their directional preference
Definition
flexion
Term
if someone has disc protrusion, what will be their directional preference
Definition
extension
Term
describe the basics of specific exercise treatments
Definition
repetitive, end-range movements in the direction that centralizes pain. Avoid peripheralization movements. Correct lateral shift deformities. Mobilize to promote centralization movement.
Term
how can traction fix the problem?
Definition
if nerve root compression is the problem, removing pressure and decompressing trapped spaces should relieve stress/pain
Term
what is the goal of traction treatment
Definition
to centralize pain enough to progress to another classification
Term
what are the 2 clinical prediction rules that indicate successful treatment with traction
Definition
signs and symptoms of nerve root compression, no movements centralize symptoms
Term
what are signs and symptoms of nerve root compression
Definition
positive SLR, diminished reflexes, diminished sensation, diminished strength
Term
what position to use for traction
Definition
the one that best centralizes symptoms, progressing toward neutral
Term
what intensity to use for traction
Definition
40-60% of body weight
Term
when to use static traction
Definition
long static hold for young patients with disc pathology
Term
when to use intermittent traction
Definition
short intermittent holds for older patients with stenosis
Term
what is the difference between a mobilization and a manipulation
Definition
a mobilization is a grade 1-4 low velocity oscillation. A manipulation is a grade 5 high velocity low amplitude thrust.
Term
do manipulation techniques in the low back need to be specific
Definition
no. the choice of manipulation technique is not as important as the choice of patient for whom spinal manipulation will be successful
Term
does it matter which level you manipulate in the low back
Definition
no. there is movement at several spinal levels with passive motion
Term
what should be done following spinal manipulatoin
Definition
simple active ROM exercises. For example, pelvic tilts in supine
Term
what is the purpose of strengthening the deep core stabilizers of the low back
Definition
to retrain the muscles to control the motion of the spine during movement.
Term
in stabilization, should the deep muscles of the back be trained specifically, or is compensation from other muscles ok
Definition
the deep muscles of the back should be trained specifically without compensation of surrounding larger muscles
Term
how do deep back muscles contract functionally
Definition
as a low level, prolonged tonic holding contraction
Term
how should deep back muscles be trained/strengthened
Definition
as a low level, prolonged tonic holding contraction
Term
how often should deep back muscles be strengthened in order for them to be retrained as a motor skill
Definition
many times throughout the day
Term
how is it possible to target only the deep core muscles of the back and not have potential for contracting compensatory muscles
Definition
begin training in positions with decreased external loads to avoid large muscle use activation. Begin in position of quadruped or prone with spine in neutral to teach contraction of deep muscles. Avoid end-range movements.
Term
how is it possible to monitor for use of larger, compensatory muscles when trying to activate deep core muscles
Definition
observe for movement of the ribcage, shoulders, and pelvis.
Term
should contraction of the deep core muscles affect breathing
Definition
no
Term
is the transverse abdominis a deep core muscle or a larger surrounding muscle
Definition
deep core muscle
Term
is the lumbar multifidis a deep core muscle or a larger surrounding muscle
Definition
deep core muscle
Term
is the erector spinae a deep core muscle or a larger surrounding muscle
Definition
larger surrounding muscle
Term
is the external oblique a deep core muscle or a larger surrounding muscle
Definition
larger surrounding muscle
Term
is the internal oblique a deep core muscle or a larger surrounding muscle
Definition
larger surrounding muscle
Term
is the rectus abdominis a deep core muscle or a larger surrounding muscle
Definition
larger surrounding muscle
Term
is the quadratus lumborum a deep core muscle or a larger surrounding muscle
Definition
larger surrounding muscle
Term
how to begin core training
Definition
instruct patient to draw in navel towards spine. Palpate transverse abdominis medial to ASIS. Palpate lumbar multifidus in paraspinal area of lower spine
Term
what is the progression of positions for training the transverse abdominis
Definition
quadruped (to make activation of rectus difficult) - hooklying - standing - functionl activities - hooklying with marching - hooklying with SLR
Term
how to progress multifidus/erector spinae strengthening if you start with quadruped single arm or leg lfits
Definition
quadruped opposite arm and leg lifts
Term
how to progress multifidus/erector spinae strengthening if you start with bridgin
Definition
bridging with leg lifts
Term
how to progress multifidus/erector spinae strengthening if you start with prone extension
Definition
superman
Term
what is the progression of positions for training the oblique abdominals if you start with horizontal position with knees as base
Definition
horizontal position with ankles as base
Term
what are some other oblique strengthening exercises
Definition
trunk curl-ups with rotation; hanging leg lifts
Term
what is a good exercise for strengthening the quadratus lumborum
Definition
horizontal support exercises
Term
how to determine intensity and repetition for strengthening/stability exercises
Definition
listen to the patient. Start with 10 contractions of 10s holds. Progress by increasing hold time, increasing repetitions, and progressing position
Term
what are some specific exercises when flexion is the preferred motion
Definition
1. posterior pelvic tilt/flatten back. 2. supine knees to chest: sustained 20-30s and repeated. 3. quadruped rocking to heels
Term
what are additional ways to support improvement with specific exercises
Definition
manual therapy to increase motion; bodyweight supported treadmill training; address strength/flexibility/conditioning
Term
what are some specific exercises when extension is the preferred motion
Definition
quadruped rocking forward; prone 30s - prone on elbows 30s - prone push-up x 10
Term
what are some specific exercises for when latearl shift is the preferred motion
Definition
prone lateral shift correction - add extension; standing shift correction - progress to extension exercises
Term
what are examples of aberrant movements during lumbar flexion that are part of the CPR for stabilization
Definition
reversal of lumbopelvic rhythm, painful arc, instability catch, gower's sign
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