L/S Interventions

Question 1

Management of Spondylolysis/Spondylolythesis

Answer 1

1. Initial → commonly conservative
2. activity modifications → address rep activities
3. address muscle guarding
   
   • AROM exercises
   • STM
   • progression
   • low-intensity, high frequency and duration exercises
4. stretching of shortened hip muscles
5. progress lumbar stabilization exercises

Question 2

Discogenic Pain (disc derrangement) management

Answer 2

1. AROM exercises
2. address muscle guarding
   
   • STM
   • joint mobs → consider adjacent levels
3. low-intensity/high-frequency and duration exercises
4. progress lumbar stabilization exercises
   
   • emphasis on functional training

Question 3

Radiculopathy/Radicular pain management

Answer 3

1. AROM exercises
2. neural mobilizations
3. progress lumbar stabilization exercisese

Question 4

Lumbar Spine Stenosis management

Answer 4

1. consider central vs lateral
2. activity modifications → activities that place higher sustained loads on involved structures
3. joint mobility
   
   • thurst and non-thrust
   • sustained holds → hypomobile segments
   • oscillations → muscle guarding, pain
4. muscle performance
   
   • coordination training
   • strengthening
   • endurance

Question 5

Z-Joint arthropathy management

Answer 5

1. consider degenerative vs acute
2. address muscle guarding
3. paraspinal coordination training as indicated
4. low-intensity/high frequency and duration as indicated
   
   • consider progression based on degree of increasing compression loading w/z-joint
5. manaul therapy interventions
   
   • sustained hold → hypomobile segments
   • manipulations and oscillations → muscle guarding, pain

Question 6

List the impairment/functional-based classification system for the Lumbar Spine

Answer 6

1. Mobility deficits (A or SA)
2. Movement Coordination deficits (A, SA, or C)
3. Related (referred) radiating LE pain (A)
4. Radiating pain (A, SA, C)
5. Related Cognitive or Affective tendencies (A, SA)
6. Chronic LBP with related generalized pain

Question 7

what do clinical practice guidelines suggest about pt education?

Answer 7

1. pt should avoid:
   
   • extended bed rest
   • detailed pathoanatomic causative analysis
2. should include:
   
   • structural strength of spine
   • neuroscience of pain perception
   • generally favorable prognosis associated w/LBP
   • pain coping strategies that address fear/avoidance
   • early return to “normal” activities
   • improved activity levels

Question 8

Describe the body impairments observed in the acute/subacute LBP with related cognitive or affective tendancies

Answer 8

One or more of the following:

1. two (+) responses to Primary Care Evaluation of Mental Disorders screen and affect consistent w/depressed pt
2. High FABQ and behavioral processes
3. High PCS and cognitive processes consistent with rumination, pessimism, or helplessness

Question 9

what are the primary intervention strategies for acute/subacute LBP w/related cognitive of affective tendencies?

Answer 9

1. pt edu and counseling to address specific classification exhibited by pt
   
   • depression
   • fear avoidance
   • pain catastrophizing

Question 10

how would you describe the category of:

chronic LBP with related generalized pain

Answer 10

1. LBP or low back related LE pain w/symptom duration of >3 months
2. generalized pain not consistent w/other impairment-based classification criteria
3. presence of depression, fear-avoidance beliefs, and/or pain catastrophizing

Question 11

primary intervention strategies for:

chronic LBP w/related generalized pain

Answer 11

1. pt edu and counseling
2. low-intensity, prolonged (aerobic) exercise
3. strong evidence for progressive endurance exercise and fitness
   
   • moderate to high intensity

Question 12

describe the body impairments present in the category of:

acute LBP with movement coordination impairments

Answer 12

this is an acute exacerbation of recurring LBP commonly associated w/referrred LE pain

1. LBP an/or low-back related LE pain at rest or produced with inital to mid-range spinal movements
2. symptoms reproduced w/provocation of involved lumbar segments
3. movement coordination impairments of lumbopelvic region w/low back flexion/extension movements

Question 13

primary intervention strategies for:

acute LBP w/movement coordination impairments

Answer 13

1. Neuro re-edu → promote stabilize in less symptomatic, mid-range position
2. consider use of temporary external device
3. self-care/home management training pertaining to:
   
   • posture and motion that maintain neutral or symptom alleviating positions
   • recommendations to pursue/maintain active lifestyle

Question 14

impairments to body function with:

subacute LBP w/MCI

Answer 14

1. pain with mid-range motions that worsen with end-range movements or positions
2. LBP and LB related LE pain reproduced with provocation of involved lumbar segments
3. lumbar hypermobility
4. mobility deficits of thorax and/or lumbopelvic/hip regions
5. diminished trunk or pelvic muscle strength and endurance
6. movement coordination impairment during self-care/home management activities

Question 15

primary intervention strategies:

subacute LBP w/MCI

Answer 15

1. neuro re-edu
2. manual therapy to address mobility deficits
3. Ther-Ex to addresss strength and endurance deficits
4. self-care/home management training in maintaining involved structures in mid-range, less symptom-producing positions
5. initiate community/work reintegration training w/pain management strategies

Question 16

impairments to body function with:

chronic LBP w/MCI

Answer 16

Presence of 1 or more of the following:

1. LBP or LB related LE pain that worsens with sustained end-range movements or positions
2. lumbar hypermobility w/segmental motion assessment
3. mobility deficits of thorax, lumbopelvic/hip region
4. diminished strength and endurance
5. movement coordination impairments while performing community/work related activities

Question 17

primary intervention strategies for:

chronic LBP w/MCI

Answer 17

1. Neuro re-edu
2. manual therapy to address mobility deficits
3. Ther-Ex to address strength and endurance deficits
4. community/work reintegration training

Question 18

Lumbar stability training Clinical Practice Rule

Answer 18

1. Age <40
2. +Prone instability test
3. Aberrant motions with movement testing present
4. present SLR > 91º
   
   • generalized increased mobility

Question 19

potential biofeedback mechanisms for TrA coordination training

Answer 19

1. palpation
2. ultrasound imaging
3. stabilizer cuff

*be sure to include anticipatory and static

Question 20

Static vs Dynamic Multifidi coordination training

Answer 20

1. Static
   
   • prone
   • SL
   • Quadruped
2. Dynamic
   
   • rotation (concentration on eccentric function)
     
     • SL w/rotation (potentially add resistance)
   • extremity lift

Question 21

describe acute LBP with related radiating LE pain

Answer 21

1. LBP, commonly associated with referred buttock, thigh, or leg pain, that worsens with flexion activities and sitting
2. LBP and extremity pain that can be centralized and diminished with:
   
   • positioning
   • manual procedures
   • repeated motions
3. Limited mobility along with chronic LBP w/MCI commonly present
   
   1. Lateral trunk shift
   2. reduced lumbar lordosis
   3. limited lumbar ext mobility

Question 22

primary intervention strategies for acute LBP with referred radiating LE pain

Answer 22

1. Ther-Ex, manual therapy, or traction that promote centralization and improve lumbar extension mobility
2. pt edu in positions that promote centralization
3. progress to interventions consistent with:
   
   • Subacute or chronic LBP w/MCI

Question 23

describe acute LBP with radiating pain

Answer 23

1. acute LBP with assocaited radiating pain in the involved LE
2. LE paresthesia, numbness, and weakness reported
3. Symtpoms are reproduced or aggravated with:
   
   • inital to mid-range spinal mobility
   • lower limb tension/SLR
   • slump tests
4. signs of nerve root involvement may be present

Question 24

primary intervention strategies for acute LBP with radiating pain

Answer 24

1. pt edu on positions that reduce strain or compression to involved nerve roots
2. manual/mechanical traction
3. manual therapy to mobilize articulations and soft tissue adjacent to involved nerve root that exhibit mobility deficits
4. nerve mobility exercises in pain-free, non-symptom-producing ranges

Question 25

impairments of body function for subacute LBP w/radiating pain

Answer 25

1. mid/low and back-related radiating pain or paresthesia that is reproduced at **mid-range** and worsens at end-range * lower limb tension/SLR * slump tests 2. may have LE sensory, strength, or DTR deficits associated

Question 26

primary intervention strategies for subacute LBP w/radiating pain

Answer 26

1. manual therapy to mobilize articulations and soft tissues adjacent to nerve roots 2. manual/mechanical traction 3. nerve mobility and slump exercises in mid-to end ranges

Question 27

describe chronic LBP w/radiating pain

Answer 27

symptoms are reproduced or aggravated with sustained end-range lower limb nerve tension/SLR/Slump tests

Question 28

primary intervention strategies for chronic LBP w/radiating pain

Answer 28

1. manual therapy 2. ther-Ex to address TL and LQ nerve mobility deficits 3. pt edu pain management strategies

Question 29

what does research say about centralization/directional-specific exercises?

Answer 29

strong evidence consider for pts w/LBP and LE symptoms to improve mobility and reduce symptoms (A, SA or C)

Question 30

what does research say about traction for L/S patients?

Answer 30

conflicting evidence Rated as D consider for pts with LBP, lumbar nerve root compression, +Well Leg Raise Test DO NOT consider for pts with acute, subactue, chronic LBP

Question 31

what do the clinical practice guidelines say about nerve mobilizations as an intervention?

Answer 31

weak evidence for grade C

Question 32

describe acute LBP w/mobility deficits and list the impairments of body function for this classification

Answer 32

acute low back, buttock or thich pain (duration of 1 month or less) 1. L/S ROM limitations 2. restricted lower T/S and L/S segmental mobility 3. Low back and low-back related LE symptoms reproduced w/provocations of involved segments

Question 33

Primary intervention strategies for acute LBP w/mobility deficits

Answer 33

1. Manual therapy procedure to diminish pain and improve segmental spinal or lumbopelvic motion 2. Ther-Ex to improve or maintain spinal mobility 3. Pt Edu to encourage active lifestyle

Question 34

list impairments associated with: subacute LBP w/mobility deficits

Answer 34

1. symptoms reproduced with: * end-range spinal motion * provocation of lower T/S, L/S or SI segments 2. Presence of 1 or more of the following: * restricted T/S ROM and associated segmental mobility * restricted L/S ROM and associated segmental mobility * restricted lumbopelvic or hip ROM and associated segmental mobility

Question 35

primary intervention strategies for subacute LBP w/mobility deficits

Answer 35

1. manual therapy 2. ther-ex 3. focus on preventing recurring LBP episodes through use of: * ther-ex that addresses coexisting: * coordination impairments * strength deficits * endurance deficits * edu about active lifestyle

Question 36

give some examples of AROM exercises that may be used in the treatment of LBP

Answer 36

1. Lumbar rotation in hook-lying 2. Quadruped thoracolumbar flexion/extension 3. Hook-lying lumbar flexion/extension → pelvic tilts 4. supine knees to chest (uni or bi) 5. sitting/standing lumbar flexion/extension

Question 37

clinical practice guidelines: manual therapy

Answer 37

strong evidence for 1. manipulation considered to address pain and disabiilty 2. thrust and non-thrust procedures to address spine mobility impairments, pain and disability

Question 38

Clinical practice rule via Flynn et all pertaining to benefits of spinal manipulation

Answer 38

Pts with LBP likely to benefit from spinal manipulation: * **Duration of symptoms \<16 days** * **No symptoms distal to knee** * FABQ score \<19 * At least one hip \>35º of IR ROM * Hypomobility in L/S

Question 39

stabilization exercise vs manipulation

Answer 39

validation study of Flynn's CPR * individuals meeting CPR who recieved manip demonstrated greatest improvement in disability * exercise only group 8x more likely to experience worsening of disability (ODI) at 6 months f/u

Question 40

what 2 criteria of Flynn's CPR are the most predictive?

Answer 40

1. Duration of current episode of LBP * \<16 days 2. Extent of distal symptoms * none distal to knee

Question 41

Joint mobilizations for L-Spine

Answer 41

1. Oscillations * PA * UPA * Facet Gapping 2. Sustained hold * Extension * Flexion * Facet Gapping 3. Thurst manipulations * long leg distraction * rotation * supine lumbopelvic

Question 42

target of force for the lumbar/flexion extension mobilization

Answer 42

1. stabilizing → pincer grip on cranial segement 2. mobilizing → inferior segment

Question 43

relative structure movement during lumbar extension/flexion mobilization

Answer 43

caudal segment on cranial segment

Question 44

target of force for the facet gapping mobilization

Answer 44

1. stabilizing * anterio-lateral ribs with anterior forearm * lateral aspect of spinous process with 2nd digit of cranial hand 2. mobilizing * posterio-lateral pelvis with anterior distal forearm * articular pillar (on side away from table) with pad of 2nd digit on the caudal hand

Question 45

relative structure movement during facet gapping mobilization

Answer 45

gapping of the Z-joint further from table

Question 46

pt position for long leg distraction manipulation

Answer 46

supine, hip passively flexed (~30 degree), slight abduction

Question 47

relative structure movement during long leg distraction manipulation

Answer 47

traction force at knee/hip, lateral flexion of lumbar spine

Question 48

target of force during lumbar rotation manipulation

Answer 48

1. Stabilizing * anterio-lateral ribs w/anterior forearm * lateral aspect of spinous process with 2nd digit of cranial hand 2. Mobilizing * posterio-lateral pelvis through anterior distal forearm * manipulation force with trunk/LEs

Question 49

target of force during the lumbopelvic manipulation

Answer 49

1. Mobilizing → ASIS (contact w/palm of hand) 2. Stabilizing → posteriolateral trunk/ribcage

Question 50

relative structure movement during lumbopelvic manipulation

Answer 50

lumbar zygopophysial gapping on trageted side