Musculoskeletal LQ Week 2 - Lumbopelvic ICF Classification and Interventions 1

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Questions and Answers

What percentage of the population will have experienced low back pain in the past year?

  • 25%
  • 60% (correct)
  • 85%
  • 40%

What is a significant shortcoming of the medical model in managing low back pain?

  • It focuses on identifying the underlying pathology, which is often difficult to determine in LBP. (correct)
  • It ignores the role of psychosocial factors in LBP.
  • It emphasizes symptom relief over functional improvement.
  • All of the above.

What does the ICF stand for?

  • International Classification of Functioning, Disability, and Health (correct)
  • International Classification of Functional Limitations
  • International Classification of Health and Functioning
  • International Classification of Physical Functioning

What is the prevalence of low back pain in the general population?

<p>80% (C)</p> Signup and view all the answers

What is the difference between acute and chronic low back pain?

<p>Acute low back pain lasts less than 6 weeks, while chronic low back pain lasts longer than 6 weeks. (B)</p> Signup and view all the answers

What is the primary reason for using treatment-based classification in managing LBP?

<p>To determine the best course of treatment based on the patient's presentation. (A)</p> Signup and view all the answers

What is the most common type of low back pain?

<p>Non-specific low back pain (A)</p> Signup and view all the answers

Which of the following is an example of a possible subgroup based on the ICF classification?

<p>All of the above. (D)</p> Signup and view all the answers

Which of the following is NOT a predictor variable retained for the Manipulation Clinical Prediction Rule?

<p>Presence of symptoms in the dorsal spine (C)</p> Signup and view all the answers

According to the study findings, what is the chance of a successful outcome at 4 weeks for patients with 4 or more of the 5 Manipulation Clinical Prediction Rule criteria who receive manipulation?

<p>92% (D)</p> Signup and view all the answers

According to the content, which of the following is a key implication for using manual therapy in physical therapy practice?

<p>Manual therapy should be combined with active exercise interventions. (D)</p> Signup and view all the answers

What is the recommended approach for incorporating manual therapy into a physical therapy appointment?

<p>Begin with 40% hands-on treatment and 60% active exercise, gradually decreasing the amount of mobilizations over subsequent appointments. (A)</p> Signup and view all the answers

Which of the following is NOT a self-mobilization technique mentioned in the content?

<p>Cervical traction (C)</p> Signup and view all the answers

What is the primary benefit of the Manipulation Clinical Prediction Rule (CPR)?

<p>To identify patients who are most likely to benefit from spinal manipulation. (A)</p> Signup and view all the answers

What does the research suggest about the effectiveness of spinal manipulative therapy for acute low back pain?

<p>Spinal manipulative therapy is associated with modest improvements in pain and function. (D)</p> Signup and view all the answers

What is the clinical phenomenon referring to a specific repetitive movement or sustained posture that results in pain relief?

<p>Directional preference (A)</p> Signup and view all the answers

What type of evidence is considered to support the effectiveness of spinal manipulation for acute low back pain?

<p>Moderate-quality (B)</p> Signup and view all the answers

What is the primary focus of the Manipulation Clinical Prediction Rule (CPR) validation study?

<p>To identify individuals with low back pain most likely to benefit from manipulation. (A)</p> Signup and view all the answers

What describes the phenomenon where distal pain, originating from the spine, progressively reduces in a distal-to-proximal direction?

<p>Centralization (D)</p> Signup and view all the answers

Which of the following is NOT a finding commonly associated with subacute or chronic low back pain with movement coordination impairments?

<p>Increased lumbar flexion mobility (A)</p> Signup and view all the answers

What is the significance of patient expectations and perceptions in manual therapy?

<p>Meeting patient expectations is essential for enhancing satisfaction with manual therapy care. (D)</p> Signup and view all the answers

What is the expected outcome when a patient experiences centralization of pain?

<p>Increase in low back pain (A)</p> Signup and view all the answers

What is the goal of treatment when a patient exhibits a flexion directional preference?

<p>Promote lumbar flexion exercises (D)</p> Signup and view all the answers

Which of the following statements is TRUE regarding the original theory of directional preference and centralization?

<p>It is based on the sole understanding of disc herniation and nerve root compression (A)</p> Signup and view all the answers

Which of the following factors is NOT a potential contributing factor to low back pain and leg symptoms?

<p>Overuse of muscle strength (D)</p> Signup and view all the answers

What is the most appropriate clinical approach for acute low back pain with related, referred, lower extremity pain?

<p>Utilization of repeated movements and exercises to promote centralization (C)</p> Signup and view all the answers

Which of the following is a potential benefit of centralization?

<p>Improved mobility and reduced symptoms (A)</p> Signup and view all the answers

What is the reason why a patient might experience an increase in low back pain while experiencing centralization?

<p>The pain is moving back to its source, indicating a healing process (D)</p> Signup and view all the answers

What is the goal of treatment for peripheralization of pain?

<p>To move the symptoms back to the center of the spine. (B)</p> Signup and view all the answers

What is the difference between 'extension directional preference' and 'flexion directional preference'?

<p>Extension preference indicates pain relief with extension movements, while flexion preference indicates pain relief with flexion movements. (B)</p> Signup and view all the answers

Which of the following is NOT a component of the physical examination for directional preference in the context of low back pain?

<p>Active range of motion (AROM) in all directions (C)</p> Signup and view all the answers

During physical examination, what does a 'red light' indicate?

<p>Symptoms worsen or peripheralize (A)</p> Signup and view all the answers

Which of the following is a possible intervention for low back pain using a force progression approach?

<p>Active stretching by the patient with self-overpressure (A)</p> Signup and view all the answers

What is a common error in applying the directional preference treatment paradigm?

<p>Not fully exploring repeated movements (C)</p> Signup and view all the answers

What is a 'lateral shift' in relation to low back pain?

<p>A movement of the trunk away from the center of the pelvis (A)</p> Signup and view all the answers

How does a lateral shift impact the treatment plan?

<p>It should be addressed before attempting to restore extension range of motion (C)</p> Signup and view all the answers

Why does the patient often shift away from their painful side?

<p>To achieve a more comfortable postural position (A)</p> Signup and view all the answers

In the context of a lateral shift, what is a possible intervention?

<p>All of the above. (D)</p> Signup and view all the answers

What constitutes a positive neurodynamic test?

<p>Symptoms are reproduced (D)</p> Signup and view all the answers

In which situation would sliders be the preferred intervention?

<p>When the symptoms are highly irritable (D)</p> Signup and view all the answers

Why is it important to perform a limited physical exam rather than a full physical exam?

<p>Based on the patient's condition using SINSS (A)</p> Signup and view all the answers

What is a key aspect of treating conditions based on clinical patterns?

<p>Modify treatment based on patient-specific exam findings (D)</p> Signup and view all the answers

Which mobilization grade is primarily used to address stiffness?

<p>Grade 4 (D)</p> Signup and view all the answers

What is a possible indication for mechanical traction in patients?

<p>Low back pain with radiating pain (D)</p> Signup and view all the answers

Which of the following scenarios presents a contraindication for mechanical traction?

<p>Joint hypermobility (A)</p> Signup and view all the answers

Which traction method involves the patient lying prone with a stabilizing belt around the rib cage?

<p>Prone traction (C)</p> Signup and view all the answers

What does the evidence suggest about the effectiveness of mechanical traction in low back pain treatment?

<p>It is ineffective when added to other standard treatments. (B)</p> Signup and view all the answers

What should physical therapists consider when planning lumbar traction?

<p>Combination of traction mode and dosage (C)</p> Signup and view all the answers

In what situation is mechanical traction likely to be ineffective?

<p>For chronic low back pain with leg pain (A)</p> Signup and view all the answers

What is the main takeaway regarding the use of traction in treating low back pain?

<p>It is less effective compared to standard physical therapy methods. (A)</p> Signup and view all the answers

What is one of the main reasons for the failure to identify patients likely to benefit from mechanical traction?

<p>Evidence showing no modification of effects by patient characteristics (C)</p> Signup and view all the answers

What should physical therapists prioritize as an initial intervention for managing low back pain?

<p>Exercise and standard physical therapy (C)</p> Signup and view all the answers

Which of the following is NOT a variable at a practitioner's discretion when delivering lumbar traction?

<p>Type of exercise regimen prescribed (B)</p> Signup and view all the answers

What is the primary goal of symptom modulation interventions for patients with low back pain?

<p>Reduce pain levels to allow for further treatment. (A)</p> Signup and view all the answers

Which of the following is NOT a key consideration for selecting a lumbar central posterior-to-anterior (CPA) mobilization?

<p>Nature of the pain, whether mechanical or non-mechanical. (D)</p> Signup and view all the answers

A patient presents with acute, moderate-to-severe low back pain with moderate irritability. Their pain is non-mechanical and their stability is not worsening. Based on the SINSS criteria, what is the most appropriate initial treatment approach for this patient?

<p>Prioritize pain management and patient education before addressing mobility. (B)</p> Signup and view all the answers

What is the primary difference between lumbar manipulation and mobilization?

<p>Manipulation uses high-velocity, low-amplitude thrusts, while mobilization involves oscillatory movements. (A)</p> Signup and view all the answers

Which of the following clinical findings is MOST suggestive of acute or chronic low back pain with mobility deficits, indicating potential benefit from mobilization or manipulation?

<p>Limited active range of motion in the lumbar spine (AROM). (A)</p> Signup and view all the answers

Which of the following is NOT a contraindication for lumbar manipulation?

<p>Presence of a disc bulge or herniation. (A)</p> Signup and view all the answers

According to the clinical practice guidelines, what is the evidence grade for using joint mobilization/manipulation to reduce pain and disability in patients with chronic low back pain?

<p>Strong recommendation, based on high-quality evidence. (D)</p> Signup and view all the answers

The text describes two key types of lumbar mobilizations. Which of the following correctly identifies these two types?

<p>Central Posterior-to-Anterior (CPA) and Unilateral Posterior-to-Anterior (UPA). (A)</p> Signup and view all the answers

What is the primary reason for considering a supine lumbopelvic manipulation?

<p>To reduce pain in the sacroiliac (SI) joint region. (D)</p> Signup and view all the answers

Which of the following is NOT a precaution for lumbar manipulation?

<p>Patients with a history of low back pain lasting more than 3 months (chronic pain). (B)</p> Signup and view all the answers

What is the most effective approach to classify and treat patients with low back pain?

<p>Subgrouping patients based on their signs and symptoms, using a treatment-based or ICF classification. (B)</p> Signup and view all the answers

One of the key reasons for using the SINSS criteria in the initial assessment of a patient with low back pain is to:

<p>Guide the selection of appropriate treatment interventions. (C)</p> Signup and view all the answers

In the context of the provided information, what is the most appropriate initial treatment approach for a patient with low back pain who is experiencing significant muscle weakness in their lower extremities?

<p>Focus on pain management and address the underlying cause of the weakness. (C)</p> Signup and view all the answers

When might a manual therapist choose to utilize immobilization rather than manipulation?

<p>When the patient has a strong fear of manipulation and has developed a high level of catastrophizing. (B)</p> Signup and view all the answers

Which of the following is a key limitation of utilizing the SINSS criteria alone to guide treatment decision-making?

<p>The SINSS criteria do not adequately address the patient’s functional limitations. (C)</p> Signup and view all the answers

Which of the following statements accurately reflects the research findings on the effectiveness of lumbar manipulation versus mobilization for low back pain?

<p>Both manipulation and mobilization have shown similar levels of effectiveness in research studies. (C)</p> Signup and view all the answers

What is the primary goal of grouping patients with similar signs and symptoms in low back pain (LBP)?

<p>To match patients to their subgroup classification and improve treatment outcomes (C)</p> Signup and view all the answers

Which subgrouping is most likely to benefit from joint mobilizations or manipulations?

<p>Low back pain with mobility deficits (C)</p> Signup and view all the answers

What is considered a 'red flag' in the context of LBP?

<p>Cauda equina syndrome (A)</p> Signup and view all the answers

Which of the following is NOT a factor considered in the 'SINSS' assessment for determining treatment approach in LBP?

<p>Progression (D)</p> Signup and view all the answers

When centralizing symptoms means the pain moves from the leg back towards the low back it can be a sign of:

<p>Discogenic pain (A)</p> Signup and view all the answers

Which of these is MOST LIKELY to be included in the treatment plan for a patient with low back pain with movement coordination impairments?

<p>Movement control exercises (C)</p> Signup and view all the answers

According to the provided text, which of these would be considered a 'yellow flag' in LBP?

<p>Related cognitive or affective tendencies (C)</p> Signup and view all the answers

What is the main purpose of using the StartBack Screening Tool?

<p>To assess the patient's psychosocial risk status (C)</p> Signup and view all the answers

Which of the following is NOT a characteristic that would typically lead to a patient being categorized as 'Appropriate for Physical Therapy Evaluation and Intervention' in the triaging process?

<p>Hard neurological signs that are worsening or progressing (B)</p> Signup and view all the answers

When would a patient with LBP most likely be referred to a mental health specialist?

<p>If they have a high psychosocial risk status and require additional support (A)</p> Signup and view all the answers

What is the most likely treatment approach for a patient with low back pain with related, referred, lower extremity pain, who prefers flexion and sees improvement with it?

<p>Directional preference exercises (A)</p> Signup and view all the answers

A patient with acute LBP presents with symptoms that worsen with extension and improve with flexion. During the assessment, they report no pain distal to the knee. Which subgrouping is most likely appropriate?

<p>Low back pain with related, referred, lower extremity pain (A)</p> Signup and view all the answers

Which of the following is NOT a common finding in a patient with LBP categorized as 'Low back pain with mobility deficits'?

<p>Pain that is primarily located in the leg (B)</p> Signup and view all the answers

Which symptom is typically relieved by forward flexion in patients with lumbar stenosis?

<p>Leg or buttock pain while walking (C)</p> Signup and view all the answers

What does 'peripheralize' mean in the context of LBP?

<p>Pain that spreads from the low back down the leg (A)</p> Signup and view all the answers

What does an increase in distance walked on an inclined treadmill during the Two-Stage Treadmill Test indicate?

<p>High likelihood of lumbar stenosis (C)</p> Signup and view all the answers

What is the most important consideration for treatment approach in LBP?

<p>The patient's psychosocial factors (A)</p> Signup and view all the answers

Which factor is NOT part of the four-fold approach for managing lumbar stenosis in physical therapy?

<p>Surgery planning (B)</p> Signup and view all the answers

Which subgrouping is the most appropriate for a patient with LBP experiencing significant pain with extension, positive crossed straight leg raise test, and numbness in the leg?

<p>Low back pain with radiating pain (B)</p> Signup and view all the answers

Which test is indicative of neurogenic claudication if improvement in symptoms is noted when leaning forward?

<p>Bicycle Stress Test (D)</p> Signup and view all the answers

What is a common clinical presentation in patients exhibiting lumbar spinal stenosis?

<p>Flexed posture in standing (B)</p> Signup and view all the answers

What is a key factor in determining the effectiveness of extension-based exercises for a patient with extension directional preference?

<p>The presence of a lumbar lateral shift (A)</p> Signup and view all the answers

What condition can result in leg and buttock pain while walking that is relieved by using a shopping cart or bicycle?

<p>Lumbar spinal stenosis (C)</p> Signup and view all the answers

Which of the following is NOT a typical aggravating factor for someone with an extension directional preference?

<p>Standing upright for extended durations (D)</p> Signup and view all the answers

Which exercise is advised to be modified for patients with lumbar stenosis to promote flexion?

<p>Seated quadruped positions (D)</p> Signup and view all the answers

What is the primary goal of the lateral shift correction exercise described in the content?

<p>To reduce pain during standing and walking (C)</p> Signup and view all the answers

What outcome should physical therapists prioritize for patients with lumbar spinal stenosis?

<p>Symptom-free movement before exercises (C)</p> Signup and view all the answers

During the initial stages of treatment for an extension directional preference, what should be a primary focus for patient education?

<p>Minimizing lumbar flexion (D)</p> Signup and view all the answers

Which activity is suggested to be avoided initially for patients with lumbar stenosis?

<p>Prolonged standing (A)</p> Signup and view all the answers

What is the primary objective of the prone extension progression outlined in the content?

<p>Gradually increase tolerance to extension (B)</p> Signup and view all the answers

Which manual therapy technique focuses on improving thoracic spine mobility in patients with lumbar spinal stenosis?

<p>Thoracic extension self mobs (C)</p> Signup and view all the answers

Which of the following is an appropriate recommendation for modifying activities of daily living (ADLs) for a patient with an extension directional preference?

<p>Preparing food at a countertop to avoid forward bending (D)</p> Signup and view all the answers

Which condition may present with lower extremity paresthesia and is aggravated by mobility testing?

<p>Lumbar spinal stenosis (D)</p> Signup and view all the answers

Which of these is NOT a common clinical finding associated with an extension directional preference?

<p>Aggravating factors that include lying prone (A)</p> Signup and view all the answers

What is a key goal of repeated flexion exercises in managing lumbar spinal stenosis?

<p>Centralize symptoms (D)</p> Signup and view all the answers

Which item is NOT part of the seven pragmatic criteria for diagnosing lumbar stenosis?

<p>Upper extremity pain (C)</p> Signup and view all the answers

What is the most prevalent directional preference for low back pain?

<p>Extension directional preference (C)</p> Signup and view all the answers

What is the most common demographic for a flexion directional preference?

<p>Age &lt; 45 years (C)</p> Signup and view all the answers

What kind of evidence suggests that traction might benefit patients with low back pain and nerve root compression?

<p>Preliminary evidence from research (B)</p> Signup and view all the answers

What is the primary goal of the force progression outlined for flexion directional preference?

<p>Improve tolerance to flexion postures (D)</p> Signup and view all the answers

Which of the following is a key characteristic that distinguishes flexion directional preference from lumbar spinal stenosis?

<p>The presence of neurological symptoms (B)</p> Signup and view all the answers

What is the main reason for temporarily avoiding lumbar extension in patients with flexion directional preference?

<p>To allow the lumbar paraspinals to relax (D)</p> Signup and view all the answers

Which of the following is NOT a typical symptom associated with lumbar spinal stenosis?

<p>Pain that improves with lying prone (B)</p> Signup and view all the answers

Which of the following is NOT a typical easing factor for a patient with flexion directional preference?

<p>Lying prone (D)</p> Signup and view all the answers

Which of the following is a characteristic of a patient presenting with lumbar spinal stenosis as opposed to a flexion directional preference?

<p>Pain that worsens with walking or standing (B)</p> Signup and view all the answers

What is the primary goal of neural mobilization techniques?

<p>To decrease pain and improve mobility (B)</p> Signup and view all the answers

Which of the following is an indication for performing a neural mobilization?

<p>Positive straight leg raise test (A)</p> Signup and view all the answers

What is the main difference between sliders and tensioners in neural mobilization?

<p>Sliders aim to increase nerve excursion, tensioners aim to improve tolerance to lengthened positions. (C)</p> Signup and view all the answers

During which position should the slump slider be performed?

<p>Cervical flexed seated position (C)</p> Signup and view all the answers

Which of the following tests indicates a potential nerve root involvement?

<p>Slump test (B)</p> Signup and view all the answers

What could be a physiological response to performing neural mobilizations?

<p>Decreased intraneural edema (C)</p> Signup and view all the answers

When should fewer repetitions or less excursion be used in neural mobilization?

<p>With higher levels of irritability (C)</p> Signup and view all the answers

Which of the following techniques is best for increasing strain on the nerve?

<p>Prone knee bend tensioner (C)</p> Signup and view all the answers

What is the term for the phenomenon where leg pain from the lower back moves proximally during treatment?

<p>Centralization (C)</p> Signup and view all the answers

What should guide the treatment technique and dosage for neural mobilization?

<p>The SINSS framework and irritability level (C)</p> Signup and view all the answers

Which clinical finding may suggest the need for neurodynamic treatment?

<p>Positive nerve provocation test (A)</p> Signup and view all the answers

Which technique focuses on providing nervous system excursion?

<p>Straight leg raise slider (A)</p> Signup and view all the answers

How should treatment progress over the course of care involving neural mobilizations?

<p>From mobilizations to a more active treatment approach with exercise (D)</p> Signup and view all the answers

Which mobilization technique is used for the purpose of reducing mechanosensitivity of the nerve?

<p>Both sliders and tensioners (D)</p> Signup and view all the answers

Flashcards

Treatment-Based Classification

A system to subgroup patients based on their low back pain characteristics for effective management.

Low Back Pain (LBP) Prevalence

80% of adults experience LBP; only 25% seek treatment.

Non-Specific Low Back Pain

85% of LBP cases are non-specific, without a specific pathoanatomical diagnosis.

Pathoanatomical Findings

Anatomical findings on imaging that do not correlate with symptoms in many cases.

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ICF for Low Back Pain

International Classification of Functioning categorizes LBP into several subgroups like mobility deficits and coordination impairments.

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Acute vs Chronic LBP

Acute LBP lasts ≤ 6 weeks; Chronic LBP lasts > 6 weeks.

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Importance of Subgrouping

Subgrouping helps tailor treatment strategies for better patient outcomes in LBP management.

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Recurrent LBP

60% of individuals will experience low back pain again within a year of recovery.

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Lumbar Manipulation Risks

The risk of serious complications from lumbar manipulation is lower than from NSAIDs or lumbar spine surgery.

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Spinal Manipulation for Acute Low Back Pain

Spinal manipulation shows moderate-quality evidence of pain and function improvement for acute low back pain.

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Clinical Prediction Rule (CPR) Variables

Five predictor variables can help identify patients likely to benefit from spinal manipulation.

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Fear Avoidance Beliefs Questionnaire

A score below 19 points indicates lower fear and better outcomes for manipulation of back pain.

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Manipulation Success Rates

Meeting three out of five clinical prediction criteria increases the likelihood of success in therapy.

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Validation Study of CPR

A study confirmed patients with four or five criteria had better outcomes from manipulation compared to fewer criteria.

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Self-Mobilizations Techniques

Self-mobilizations include exercises like lumbar extensions and trunk rotations to alleviate pain.

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Importance of Assessing Expectations

Patients' prior experiences and expectations significantly affect their satisfaction with manual therapy.

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Manual Therapy with Exercise

Manual therapy should be combined with exercise to enhance the effectiveness of treatment for low back pain.

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Functional Re-assessment

Post-treatment assessments help check if mobility improvements lead to less pain in patients.

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Pain Modulation

Process of decreasing pain to progress with treatment.

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Movement Control

Managing movement patterns to reduce pain and improve function.

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Functional Optimization

Improving performance of daily tasks and overall function.

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SINSS Framework

A guide to assess severity, irritability, nature, stage, and stability of symptoms.

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Pain Severity

Level of pain discomfort ranging from mild to maximum.

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Symptom Irritability

How easily symptoms are provoked and how long they last.

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Acute Stage Pain

Pain that is recent, typically lasting less than 6 weeks.

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Chronic Stage Pain

Pain present for longer than 6 weeks, often ongoing.

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Lumbopelvic Mobilization

Therapeutic technique aimed at restoring mobility in the lumbar and pelvic regions.

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Manipulation vs Mobilization

Manipulation is a high-velocity thrust; mobilization is oscillatory movements.

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Contraindications for Manipulation

Conditions or factors that make manipulation unsafe, like fractures or infections.

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Precautions for Manipulation

Conditions that require caution, such as osteoporosis or high fear levels.

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Patient Education

Informing patients about their condition and treatments to empower decision-making.

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Joint Mobilization Techniques

Specific movements to enhance joint mobility and reduce pain.

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Subgrouping Patients

Describing patient sub-groups based on signs and symptoms to guide treatment.

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Evolving Treatment-Based Classification

A method to classify patients and dictate tailored treatment approaches.

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Manipulation Criteria

Indications include <16 days of symptoms, no distal knee pain, and low fear avoidance.

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Stabilization Criteria

Indicated for patients with more mobility, aged <40, and positive instability tests.

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Specific Exercise for Centralization

Exercises that centralize symptoms to the back rather than the legs.

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Traction Indications

For signs of nerve root compression and distal numbness or pain.

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First Level Triage

Initial assessment to determine treatment appropriateness for low back pain.

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Medium Psychosocial Risk

Identifies patients who may benefit from tailored psychological support.

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Low Psychological Risk

Patients without significant concerns; usually can manage with minimal care.

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ICF Classifications

Framework to classify patients based on their symptoms and physical examination findings.

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Low Back Pain with Mobility Deficits

Characterized by limitations in movement; often treated with joint mobilizations.

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Low Back Pain with Radiating Pain

Involves pain that travels down the leg, commonly treated with traction.

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SINSS

A framework assessing Severity, Irritability, Nature, Stage, and Stability of symptoms.

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Yellow Flags

Psychosocial factors that may hinder recovery from low back pain.

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Patient Education in Treatment

Providing information to patients about their condition and self-care as a critical part of recovery.

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Directional Preference

A clinical phenomenon where certain movements improve symptoms.

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Centralization

The phenomenon where distal pain reduces to the spine.

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Extension Directional Preference

Improvement of pain when moving the back into extension.

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Flexion Directional Preference

Improvement of pain when moving the back into flexion.

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Acute Low Back Pain

Low back pain lasting ≤ 6 weeks, often with certain symptoms.

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Chronic Low Back Pain

Low back pain lasting > 6 weeks, potentially recurring.

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Referred Pain

Pain felt in an area not directly injured, like leg pain from back issues.

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Symptoms Reproduction

Symptoms are aggravated during certain movements or tests.

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Nerve Root Involvement

Signs of nerve root damage, including sensory and strength deficits.

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Clinical Examination Findings

Indicators from an exam that show patterns of low back pain.

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Peripheralization of Pain

Movement of pain symptoms from the spine to the extremities.

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Centralization of Symptoms

The goal of treatment to move symptoms back towards the spine.

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McKenzie Classification

A system that categorizes back pain into four syndromes for evaluation.

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Derangement Syndrome

A category where movement direction significantly affects patient symptoms.

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Lateral Shift

Trunk offset over the pelvis in the frontal plane, named by shift direction.

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Key Components in Physical Exam

Includes posture, ROM assessments, and symptom evaluation during movement.

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Assessment Lights

Symbols indicating symptom changes: Red (worsening), Yellow (no change), Green (improvement).

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Force Progressions

Techniques to advance patient movements from mid-range to end-range.

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Lateral Shift Correction

Correcting trunk position before addressing extension range of motion.

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Neurodynamic Testing

Tests performed to identify radiating pain symptoms.

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Positive Neurodynamic Test

A test that reproduces or reduces symptoms during evaluation.

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Intervention Options

Techniques include glides, sliders, flossing, and tensioners for neurodynamic issues.

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Radiculopathy vs. Referred Pain

Radiculopathy involves neurological signs; referred pain does not pinpoint injury area.

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Limited Physical Exam

A focused exam based on severity and irritability (SINSS) instead of a full one.

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Aggravating Factors

Activities that worsen symptoms, like sitting or bending.

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Easing Factors

Activities that relieve symptoms, such as lying prone.

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Force Progression in Extension

Gradually increasing extension exercises from lying to standing.

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Home Exercise Program

Patients practice exercises at home to maintain alignment.

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Prone Position

Lying face down to facilitate extension without flexion.

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Symptoms of Lumbar Stenosis

Pain in the calves and feet that occurs with standing or walking.

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Demographics for Flexion Preference

Patients are typically younger than 45 years with specific symptoms.

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Clinical Presentation of Flexion Preference

Patients may show a fixed lordosis during forward bending.

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Extension Exercise Frequency

Exercises should be done every 2 hours for effective results.

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Patient Education in Therapy

Instructing patients on avoiding flexion to prevent symptom flare-ups.

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Reintroduction of Flexion

Gradual incorporation of flexion exercises post-symptom relief.

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Symptom Modulation

Reducing the symptoms to facilitate treatment.

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Neurogenic Claudication

Pain or numbness in legs due to nerve compression, worsens with standing/walking.

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Vascular Claudication

Pain in the legs due to inadequate blood flow, worsens with exertion.

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Two-Stage Treadmill Test

Diagnosis test for lumbar stenosis: Level walking then incline walking.

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Bicycle Stress Test

Pedaling test to reproduce lower limb pain indicating claudication type.

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Clinical Diagnosis Criteria

7 symptoms for diagnosing lumbar stenosis, like leg pain while walking.

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Mobility Exercises

Flexibility and strengthening exercises focused on lumbar flexion.

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Fear Avoidant Beliefs

Patients' fears about pain affecting their ability to function normally.

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Manual Therapy Techniques

Therapeutic approaches aimed at restoring movement and relieving pain.

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Treatment Goals for Stenosis

Centralize symptoms, improve posture, and enhance mobility.

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ELM Approach for Lumbar Stenosis

Education, manual therapy, exercises, and aerobic conditioning.

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Mechanical Traction

Traction performed by a machine as opposed to manual traction by a therapist.

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Supine 90-90 Traction

Patient lies in a hook-lying position with calves supported at 90° while traction pulls through the pelvis.

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Prone Traction

Traction applied while the patient is lying face down, using a stabilizing belt around the rib cage and pelvis.

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Indications for Traction

Used for symptom modulation in patients with low back pain and high irritability not responding to exercises.

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Contraindications for Mechanical Traction

Conditions like acute trauma, osteoporosis, and pregnancy where traction should not be applied.

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Dosage Variables in Traction

Includes factors like the angle of application, dosage, and duration of traction session.

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Traction Effectiveness

Limited benefit of traction compared to standard physical therapy treatments for back pain.

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Neurodynamics

Focuses on neural mobilization techniques for patients with radiating low back pain.

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Multimodal Plan of Care

Incorporates various treatment modalities, including traction, rather than using traction in isolation.

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Neural Mobilization

A therapy technique used to improve nerve mobility and reduce pain.

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Symptoms of Low Back Pain with Radiating Pain

Includes lower extremity paresthesia, numbness, and weakness related to back pain.

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Neural Provocation Tests

Tests like straight leg raise and slump that reproduce or aggravate symptoms.

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Signs of Nerve Root Involvement

Sensory deficits, strength issues, or reflex problems indicating nerve root damage.

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Slump Test

A diagnostic maneuver to assess neural mobility and nerve pain.

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Straight Leg Raise Test

A physical test to check nerve and muscle pain in the lower limbs.

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Tensioning Technique

Nerve mobilization method applying tension to the nerve while moving two joints.

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Sliding Technique

Nerve mobilization technique using simultaneous joint movements to reduce tension.

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Neurodynamic Treatment Dosage

Guidelines for frequency and intensity of nerve mobilization based on symptom irritability.

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Sliders vs Tensioners

Sliders increase nerve movement; tensioners improve tolerance to lengthened positions.

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Physiological Responses to Mobilization

Mobilization can decrease pain, improve nerve fluid flow, and reduce sensitivity.

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Neurodynamic Examination Findings

Results from assessing nerve movement can direct treatment strategies.

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Centralization Phenomenon

The process where distal pain shifts back towards the spine during treatment.

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Multi-modal Approach to Treatment

Combining different therapies such as mobilizations and exercises for better outcomes.

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Symptoms Onset Timing

Timing and development patterns of symptoms give insight into treatment needs.

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Study Notes

Lumbopelvic ICF Classification and Interventions

  • Low back pain affects ~80% of adults. Only 25% seek care. It's a significant cause of outpatient physical therapy visits (~50%). Recurrence rates are high, with ~85% experiencing recurrent LBP and 40-60% still reporting pain a year later.

Treatment-Based Classification Overview

  • Subgrouping patients with low back pain is critical for effective management.
  • Treatment-Based Classification (TBC) is more effective in early-onset (acute) LBP.
  • Matching treatment to the patient's subgroup improves outcomes.

Medical Model Shortcomings

  • Only ~15% of low back pain has a specific pathoanatomical cause.
  • The remaining 85% is categorized as non-specific low back pain, a symptom rather than a cause.
  • Pathoanatomical findings are common in asymptomatic individuals.
  • MRI findings do not predict LBP, success in rehab, or future disability.

International Classification of Functioning, Disability, and Health (ICF) Categories

  • Low back pain with mobility deficits
  • Movement coordination impairments
  • Related/referred lower extremity pain
  • Radiating pain
  • Cognitive/affective tendencies
  • Generalized pain
  • Acute (≤6 weeks)
  • Chronic (>6 weeks)

Treatment-Based Classification Subgroups

  • Manipulation: Patients with:

    • Symptoms duration < 16 days
    • No symptoms distal to the knee
    • Low fear avoidance (Fear Avoidance Beliefs Questionnaire < 19)
    • At least 1 hypomobile lumbar segment.
  • Stabilization: Patients with:

    • Straight leg raise > 91°
    • Positive prone instability test
    • Aberrant movements
    • Age < 40
    • High recurrence rate
  • Specific Exercise: Patients with:

    • Centralization with 2+ movements in the same direction (e.g., flexion or extension)
    • Directional preference (flexion or extension)
    • Centralization with one direction and peripheralization with the opposite.
  • Traction:

    • Signs/symptoms of nerve root compression
    • Pain/numbness distal to the buttock in the prior 24 hours
    • Peripheralization of pain with extension (+ crossed straight leg raise).

First Level Triage

  • Medical Management: Referrals for cancer, fracture, acute spondylolisthesis, infection, or cauda equina syndrome. Also refer for conditions like aneurysm, vascular claudication, kidney stones, genital/GI pathologies.
  • Appropriate for Physical Therapy: Medium psychosocial risk, pain neuroscience education, leg pain, minor comorbidities, stable neurologic condition.
  • Psychosocial Screening:
    • Low risk: Education + reassurance.
    • Moderate risk: Early PT intervention.
    • High risk: PT with psychosocial training; possible referral to mental health.
  • Self-Care: Low risk psychosocial status, lack of comorbidities and absent leg symptoms, minimal care is needed.

Second Level Triage

  • Analyze patient history and physical exam.
  • Determine the best-fitting ICF subgroups.
  • Identify the most likely appropriate subcategory.

Initial Matching of Interventions to ICF Classifications

  • Mobility deficits (facet pain, spondylosis): Joint mobilizations/manipulations
  • Movement coordination impairments (spondylolisthesis): Movement control exercises
  • Referred lower extremity pain (discogenic): Directional preference exercises
  • Radiating pain (lumbar radiculopathy): Traction, nerve mobilizations
  • Cognitive/affective tendencies (yellow flags): Patient education
  • Generalized pain (central sensitization): Patient education on pain mechanisms and graded exercise.

Considerations to Determine Treatment Approach

  • SINSS: Severity, Irritability, Nature, Stage, Stability
  • Prioritize addressing the most impactful impairments.

Progression Throughout the Plan of Care

  • Symptom modulation: Decrease pain to progress to other interventions.
  • Movement control: Essential when symptom modulation isn't needed.
  • Functional optimization: Improve daily and functional tasks.

Mobilization and Manipulation

  • Indications/Contraindications: Understand which conditions are suitable and unsuitable for joint mobilizations/manipulations.

  • Acute/Chronic LBP with Mobility Deficits: Joint restrictions in ROM. Reproducible low back and/or referred lower extremity pain with segmental mobilization.

  • Clinical Practice Guidelines Recommendations: Joint mobilization/manipulation for pain and disability reduction (acute/chronic). Soft tissue mobilization for short-term pain relief.

Manipulation Clinical Prediction Rule (Derivation/Validation)

  • Derivation: 5 predictor variables for success:
    • No symptoms distal to knee
    • Duration < 16 days
    • Hypomobility in at least one segment
    • Hip IR > 35 degrees
    • Low fear avoidance (FABQ < 19)
  • Validation: Patients with 4/5 criteria had better short- and long-term outcomes compared to those with ⩽3.

Patient Expectations and Perceptions

  • Past experience and understanding of pain influence treatment expectations.
  • Meeting patient expectations enhances satisfaction.
  • Include patients in treatment decisions.

Self-Mobilizations/Soft Tissue Mobilizations

  • Examples of self-mobilizations: lumbar extensions, sidelying trunk rotation, lumbar rotation in hooklying.
  • Include soft tissue mobilization.

Directional Preference/Centralization

  • Directional preference: Specific movement/position improves symptoms.
  • Centralization: Distal pain moves to midline, toward spine.
  • Peripheralization: Symptoms move outward toward the extremities.
  • Extension/Flexion Directional Preference: Identify aggravating/easing factors and examination findings (ROM, posture).
  • McKenzie Classification System: Derangement syndrom, Lateral shift, extension/flexion directional preference.
  • Key Components in Physical Exam (Assessing Centralization/Peripheralization): Posture, ROM (flex/extend/lateral glide, repeat motions).

Intervention (Force Progression)

  • Positions from midrange to end-range, with and without clinician/patient overpressure.

Lateral Shift

  • Patient's trunk offset from pelvis.
  • Correction before restoring extension ROM.
  • Often a shift away from the painful side.

Extension Directional Preference

  • History: Aggravating factors are sitting/forward bending, easing factors are standing/walking/prone lying.
  • Presentation: Lateral shift possible, neutral posture, pain with flexion, decreased pain/centralization with extension.
  • Force Progression: Prone lying, prone on elbows, repeated extension (with/without overpressure).

Flexion Directional Preference/Lumbar Spinal Stenosis

  • Flexion Preference: Less common than extension, hyperactive paraspinals limiting flexion, lordosis maintained with flexion, pain with extension. (Age <45).
  • Lumbar Stenosis: Typical age >65, pain with walking/standing, leg pain in calves/feet, relief with flexion (symptoms worsen with extension).

Bicycle/Treadmill Stress Tests

  • Used to assess neurogenic vs vascular claudication.
  • Significant improvement (less pain) from flexion during these tests suggests lumbar stenosis.

Traction

  • Indications: Moderate-high irritability, not responding to exercise or manual therapy, pain radiating, intolerance to weight bearing.
  • Contraindications: Acute cervical trauma, osteoporosis, steroid use, rheumatologic conditions, hypermobility/instability, pregnancy, etc
  • Effectiveness: Limited evidence regarding efficacy for general LBP. May be helpful for specific subsets.

Neurodynamic Techniques

  • Indications: Radiating leg pain. Use tensioners/sliders, starting with less aggressive options for higher irritability.
  • Examination Findings: Positive nerve provocation tests (Slump, straight leg raise, prone knee bend).
  • Techniques: Sliding/Tensioning techniques.

Summary

  • Accurate diagnosis of LBP is challenging.
  • Subgrouping using ICF and treatment-based classifications is crucial.
  • Match interventions to identified impairments.
  • Guide treatment with SINSS analysis.
  • Recognize the role of patient expectations and perceptions.
  • Use a multimodal treatment approach for optimal outcomes.

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