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• Across sessions focuses on pain reduction, achieving mobility, control, strength, and function.
• Within sessions involves soft tissue mobility, joint manipulation/mobility, stretching, and neuromuscular training.
• SINSS stands for severity, nature, irritability, stage, and stability.
• Acute lower back pain (LBP) is naturally recurring with flare-ups; recovery is likely in a short time, but recurrence is common.
• Patients with lower initial pain, shorter symptom duration, and fewer previous episodes recover faster.
• The anterior longitudinal ligament limits extension.
• The annulus fibrosus is located outside.
• The nucleus' purpose is inside.
• Nutrition happens with movement.
• Thoracolumbar fascia is key for lumbar stability.
• Psoas and QL provide opposite tensions to stabilize the spine.
• The QL attaches to the transverse processes and has minimal leverage on the spine; it prevents anterior shear of each segment and provides vertical compressive force.
• Multifidus extends the spine, has a good moment arm, is compressive and contributes to sacral nutation.

Yellow, Blue, and Black Flags

• Yellow flags relate to thoughts, behaviors, and emotions.
• Blue flags relate to work concerns.
• Black flags relate to insurance limits, finance issues, and isolation during recovery.

Zygapophyseal (Facet) Joint Arthropathy

• Degeneration from repetitive loading leads to osteoarthritis.
• Upper lumbar (L1-L3) refers pain to the flank, hip, and upper lateral thigh.
• Lower lumbar (L4-L5) refers pain to the posterior and lateral aspect of thigh, and possibly the calf.
• Treatment includes hip and spine mobilization and light resistance work.

Spinal Stenosis

• Narrowing of the spinal canal or intervertebral foramen.
• Common in people over 50; high sensitivity (90%) and specificity (70%).
• Treatment involves flexion exercises, hip mobilization, treadmill use, manual therapy, injections, laminectomy/fusion.
• Ankylosing spondylitis is a seronegative arthritis with inflammation and eventual ankylosis.
• Pain starts in the SIJ and moves up the spine, with morning stiffness and night pain episodes.
• Sciatica is general pain radiating from the buttock to the posterior lower extremity.
• Herniated nucleus pulposus is caused by smoking, disc protrusion, diabetes mellitus, trauma, torsion, and lifting.
• 90% occur at L4-S1 levels.
• Sitting worsens symptoms, standing improves them.
• Responds well to extension exercises.
• 90% resolve within 6 months; correct the shift first because inflammation causes radicular symptoms.
• Spondylolysis is fracture of pars inter-articularis and is the most common reason for LBP in adults; treat with bracing, rest, and physical therapy for acute progressive chronic cases (Scotty dog).
• Spondylolisthesis is anterior displacement of spine above the fracture and requires stability; avoid extension exercises.
• Cauda equina involves urinary retention, inability to fully empty the bladder, motor deficits, and medical emergency.
• Requires decompression within 3-4 hours.
• Severe LBP in both legs.

Symptom Modulation

• High disability, volatile symptom status, and high-moderate pain.
• Treatments include directional preference exercises, manipulation/mobilization, traction, and active rest.

Movement Control

• High disability, stable symptom status, and moderate-low pain.
• Treatments include sensorimotor, stabilization, and flexibility exercises.

Functional Optimization

• Low disability, controlled symptom status, and low-absent pain.
• Treatments include strength/conditioning, work/sport-specific, aerobic, and general fitness exercises.
• Structural inspection involves gluteal folds, PSIS, iliac crests, ASIS, and greater trochanters.

Screening Exam

• Dermatomes:
  • L1: Inguinal region
  • L2: Anterior mid-thigh
  • L3: Distal anteromedial thigh
  • L4: Medial malleolus
  • L5: Lateral leg/thong, space/great toe
  • S1: Lateral foot
  • S2: Medial heel
  • S3/S4: Genitals

Myotomes

• L2/L3: Hip flexion
• L3/L4: Knee extension
• L4: Dorsiflexion
• L5: Great toe extension
• S1: Ankle plantarflexion
• S2: Hamstring contraction

Reflexes

• Patellar reflex tests L2-L4.
• Achilles reflex tests S1.
• Movement analysis includes step up/down, squat, gait, bend/lift, sit to stand, gait, on/off socks, cross legs and work-required activity.
• Assess the quality, ROM, pain, and symptom location.
• Hip Drop tests L5-S1.
• PROM: PAIVM and PIVM
• The post to anterior non-thrust of spinous process technique involves the patient being prone; contact the spinous process with one hand, place the other hand on top, take up the slack, and perform a glide, repeat on transverse process.
• Lumbopelvic thrust manipulation involves the patient being supine, translate the pelvis towards you and max side, rotate the trunk so the patient is on the shoulder, contact the patient's ASIS and grasp the shoulder/scapula; once ASIS elevates perform a smooth thrust.
• Neutral gapping thrust manipulation involves flexing the top leg while palpating motion at L4-L5, grasp the patient's arm to side bend and rotate, place the thumb on the L4 spinous process, position the patient's arm around yours, and log roll the patient towards you to perform HVLA thrust.
• Sorenson test involves hanging off the edge of the table prone with the torso off the plinth; normal data suggests holding the position for 2-3 minutes.
  • Cut off for LBP is less than 28-29 seconds.
• Prone iso chest raise test involves laying prone on the plinth and lifting the chest and head off.
  • Cut off for LBP is 31-33 seconds. Supine iso chest raise test= supine, hands over chest, hips and knees bent to 90, basically do a sit up and hold.
  • Cut off for LBP is 34 seconds for males and 24 seconds for females.

Special Tests

• Crossed SLR: In the prone position, the physical therapist lifts the uninvolved leg straight up to rule in disc herniation.
• SLR: In the supine position, the physical therapist lifts the involved leg straight up to RO disc herniation.
• Slump Test: The patient sits with legs off the table, head goes down into flexion, knee extension with dorsiflexion, spinal flexion, neck flexion, knee extension, ankle dorsiflexion, and release neck flexion (knee flexion and dorsiflexion or knee extension and plantarflexion to floss the sciatic nerve).
• Femoral Nerve Tension Test: In the prone position, perform knee flexion and lift into hip extension.
• Facet Joint Test (X rotation): The patient sits on a table with arms crossed across the chest, the physical therapist passively places the patient in lumbar rotation which is positive if pain occurs at end-range rotation.
• Prone Instability Test: The patient's torso is flat on the table, feet on the floor to start, the patient holds onto the table and lifts legs; a PA spring test is repeated.

Sacroiliac Joint

• L5 relative to the sacrum, ilia, and sacrum.
• Iliolumbar ligaments are important in preventing anterior displacement of L5 on the sacrum (prevents shearing).
• Can be sprained, but there is no swelling present.
• Sacrotuberous ligaments resist nutation (rocking/sway) or posterior innominate motion.
• Nutation is sacral flexion, while counternutation is sacral extension.
• Motion at the SI joint is now recognized to exist however it is small, about 3 degrees with lines of reaction of force from the floor up through the hip joint that tend to rotate the ilia posterior, lines of force from body weight tend to rotate the sacrum into nutation (flexion).
• The closed pack position is sacrum nutation.
• Right rotation: posterior rotation: The right ASIS is more superior with gapping on the right side forms compression on the left side.
• PSIS is at the level of S2.
• Gillet test: hip hike palpate middle of sacrum at S2
• Active SLR test: measure the ability for the patient to lift the leg in supine and transfer load to the pelvis.
• Lumbopelvic dissociation involves the patient being prone with one knee flexed to 90 degrees on one and opposite PSIS, with posterior iliac crest passively internally rotating the hip.
• A positive pain provocation test requires 3/5 positive findings for SIJ dysfunction.
• Distraction (Gapping): The patient is supine with crossed arm pressure over both ASIS to distract the aspect of the SIJ and compress the posterior part of the joint.
• Compression: The patient is sidelying with the affected side up, the examiner assesses resting symptoms, hope flexion 45-90 degrees, knees flexed 90 degrees, compresses the anterior SIJ with distraction to the posterior aspect of the SI.
• Thigh Thrust: The patient is supine with the affected hip flexed to 90 degrees with the opposite leg straight on the table, examiner places hand under sacrum just medial to PSIS to stabilize it, PT applies downward pressure through the long axis of the femur.
• Gaenslen’s Test (Pelvic Torsion): The patient is supine, guides symptomatic knee to the chest with a force pushing into hip flexion, the other leg is forced into hip extension, creates posterior rotation.
• Sacral Thrust: The patient is prone, vertical downforce through the sacrum (S3) causes anterior shear.
• FABER: The patient is supine, the physical therapist brings the affected side into hip flexion and rests the lateral side of the ankle above the knee, the physical therapist stabilizes the opposite ASIS and ensures the lower back stays neutral, the physical therapist lowers the involved side to the table.
• Fortin’s Finger Test: The patient points to pain region should be 1 cm of the PSIS, palpate to confirm.
• Sacroiliitis: inflammatory process of SIJ
• Correction of anterior innominate: ASIS lower, PSIS higher...
• Correction of upslip/superior shear, ASIS higher, PSIS higher...