Musculoskeletal LQ Week 3 - Lumbopelvic ICF Classification and Interventions 2

Musculoskeletal LQ Week 3 - Lumbopelvic ICF Classification and Interventions

• Movement Control Exercises: Beneficial for patients with movement coordination impairments. Includes trunk muscle activation, strengthening, and endurance exercises.
• Acute Low Back Pain (Movement Coordination): Characterized by pain, particularly during initial-mid range spinal motions. Movement coordination impairments in flexion and extension are prominent issues. Referred lower extremity pain may occur.
• Chronic Low Back Pain (Movement Coordination): Recurring back pain, often with referred lower extremity pain. Symptoms worsen with sustained end-range movements or positions. Common finding include hypermobility, mobility deficits (thorax, lumbopelvic/hip), reduced trunk/pelvic strength and endurance. Movement coordination issues in daily activities also occur.

Movement Coordination Impairments Clinical Pattern

• Aberrant movement: May occur during active range of motion assessments.
• Hypermobility: Observed through passive accessory joint examination.
• Muscle activation issues: Difficulty activating individual muscles or isolated movement patterns during muscle performance testing, demonstrated through (+) prone instability tests and (+) active straight leg raise.

Clinical Practice Guidelines Recommendations

• Grade A (Evidence): Physical therapists should use trunk muscle activation and movement control exercises for chronic LBP and movement control impairments. Exercise programs should incorporate trunk muscle strengthening and endurance, multimodal exercises, aerobic exercise, aquatic exercise, and general exercises.

• Grade B (Evidence): Physical therapists may recommend movement control exercises or trunk mobility exercises for chronic LBP.

Stabilization Theory

• Compensation: Injury or tissue overload often leads to compensatory movement patterns.
• Inadequate compensation: Muscles may fail to appropriately compensate, resulting in instability.
• Muscle retraining: Training is needed to better restrain aberrant micromotion and improve spinal stability. This theory, however, may not be completely accurate for all patients. Spine stability is presumed, but any injury changes the way we move and muscle activation patterns. Interventions focus on pain reduction and functional movement.

Movement Control Framework – Intervention

• Isolated muscle activation: Activate specific muscles or muscle groups (e.g., transversus abdominis, abdominal muscles).
• Limb motion activation: Activate and contract muscles while moving limbs (control of spinal motion during arm/leg movement).
• Functional/painful tasks: Contract muscles during functional activities and during movements that provoke pain.
• Deactivation: Muscle deactivation may be necessary to address excessive muscle activation in certain patients (e.g., multifidus).

Lumbar Activation Exercise Progression

• Assessment: Assess abdominal bracing and multifidus activation/deactivation.
• Treatment: Activate hypoactive muscles, use isolated movement patterns.
• Progression: Start with single-plane activation, progress to isometrics, and gradually advance to non-weightbearing or gravity-assisted positions, progressing to full gravity with reduced external support.

Early Transversus Abdominis Activation Exercises

• Activation/Deactivation Focus: Learning to activate and deactivate abdominal/back muscles is often more crucial than isolated transversus abdominis activation, as abdominal and back muscle engagement can reduce pain in the shorter term.
• Emphasis on controlling the abdominal and spinal region, reducing pain and facilitating movement.

Early Multifidus Activation Exercises

• Positioning: Prone, side-lying, or standing positions.
• Manuever: Utilize the abdominal drawing-in maneuver.
• Instructions: Focus on activating the muscles as if lifting a leg or arm.

Progressive Isometrics

• Application: Beneficial for patients with chronic symptoms, but likely less beneficial right after acute activation exercises.

• Examples: Side plank (knees), prone plank (knees), other variations of abdominal and lumbar muscle isometric exercises.

Hooklying/Quadruped/Full Gravity Examples

• Progresses difficulty by maintaining the lumbar positioning while moving limbs outside the base of support (e.g., arms, legs).
• Quadruped: Abdominal bracing while alternating arm and leg movements, emphasizing neutral spine maintenance.
• Hooklying: Abdominal bracing and limb movement progression, graduating towards unassisted (tabletop) positions.
• Physioball: Arm and leg movement coupled with abdominal contraction on an unstable surface with full gravity. Resistance bands could be added in late phases.

Pre-Functional Training Considerations

• Joint dissociation/coordination: Important to address if the patient cannot dissociate or coordinate movements between the lumbar spine and adjacent regions (e.g., hips, thorax). Assessment on whether a patient can move their hip without moving their lumbar spine, or vice versa.

Lumbopelvic-hip Dissociation

• Examples: Clamshells, monster walks, and exercises to control movement between the hips and pelvis. Exercises are performed against resistance while maintaining a neutral pelvis and spine posture.

Lumbar Functional Exercise Progression

• Progression: Start with light weights, short ranges of motion, and progress gradually to heavier weights, longer ranges, and tasks that mimic daily activities.

• Goal: Integrate learned skills into daily activities (ADLs).

Return to Function

• Recall activities: Assess the patient's desired activities for return to function.
• Progression: Exercises progress alongside these activities, mimicking the desired activities.
• Discharge: Patient should consistently perform these activities or variations prior to discharge.

Functional Exercise Examples

• Examples provided of exercises that mimic common daily tasks (e.g., gardening, carrying groceries, lifting from floor). Focus on skill, strength, and confidence to support return-to-function.

Integrating Learned Skills

• Push/pull: Sled pushes, cable rows, presses.
• Reaching: Overhead lifts, cable punches.
• Lifting/lowering: Deadlifts, squats.
• Trunk twisting: Palloff press with rotation, chops.

Chronic Non-Specific LBP Management

• "Features don't fit": What to do when symptoms don't fit a common pattern for low back pain assessment. This is often the case in non-specific low back pain.
• LBP with Cognitive/Affective Tendencies: Two or more positive responses on mental health assessments, high fear-avoidance/anxiety, high pain catastrophizing scores (helplessness, rumination).
• LBP with Generalized Pain: Low back and/or lower extremity pain lasting greater than 3 months for nonspecific low back pain. Associated with symptoms like depression, fear avoidance, or catastrophizing.

Clinical Practice Guidelines Recommendations - Chronic LBP

• Grade B: Use standard education about exercise and activity for chronic LBP (not as a stand-alone treatment).
• Grade A: Incorporate pain neuroscience education (PNE). Offer active treatments (e.g., yoga, stretching, Pilates, and strength training) for chronic LBP.
• Grade A: Combine low-intensity fitness/endurance activities with pain management/health promotion for generalized pain.

Clinical Practice Guidelines Recommendations - Chronic LBP (continued)

• Yellow Flags (Psychosocial Risk): Medium-to-high risk may require different strategies beyond exercises.
• Patient Self-Report Measures: Utilize measures like the STarT Back Tool, Pain Catastrophizing Scale, Fear Avoidance Beliefs Questionnaire, and Orebro Musculoskeletal Pain Screening Questionnaire.

Potential Physical Examination Findings

• Pain disproportionate to test/response: Pain may not correlate strongly with test results.
• Neurological Testing (and more): Assess for possible abnormal neurological response, hyperalgesia (excessive sensitivity to pain), and allodynia (pain from non-painful stimuli).
• Palpation and Widespread Pain: Diffuse, non-anatomical pain or widespread pain outside a specific area.

Exercise Dosing Considerations

• Activation: High repetitions (15-20), multiple sets per day.
• Contraction with limb motion: High reps (15-20), 1-4 sessions per week.
• Functional exercises: Repetitions and sets vary depending on goal; may continue endurance or transition to strength/power training. 2-3 sessions/week.

Exercise Options (with examples)

• Trunk strength/endurance
• Specific trunk activation exercises
• Aerobic exercise
• Aquatic exercise
• General exercise

Pain Neuroscience Education (PNE)

• Reconceptualize pain: Focus on reducing patient's perceived threat of pain.
• Nociception vs pain: Differentiate between pain signals and pain experience.
• Protective mechanism: Emphasize pain as a protective mechanism, not necessarily associated with tissue damage.
• Biopsychosocial approach: Present a pain biology that supports a biopsychosocial view.

Cognitive Functional Therapy (CFT)

• Model: Combines PNE with strategies to manage pain, develop healthy coping strategies, and adapt lifestyle.
• Aims: Understanding pain experience, challenging pain-related thoughts, gradually exposing patients to valued activities, and adapting lifestyle to better handle pain.

Impact of Language

• Avoid language: Avoid use of phrases like, "chronic degenerative changes," "instability," "bone on bone arthritis."
• Use more fitting language: Instead use terms like normal age-related changes, strength and control/coordination, narrowing or tightness, respectively.

Sacroiliac Joint Management

• Pelvis function: Force transfer between the trunk and lower extremities. Increased mobility (e.g., during pregnancy).
• Ligaments: Provide significant passive support including iliolumbar, anterior sacroiliac; interosseous/posterior sacroiliac, sacrotuberous, sacrospinous ligaments.

Physical Examination Findings (SIJ)

• Anterior/posterior innominate rotation: Long-sitting (supine to sitting) may identify these issues, but has low reliability for repeated use. Testing of SIJ includes thigh thrust, sacral thrust, compression and distraction.
• SIJ hypermobility/hypomobility: Active straight leg raise is often used to test for hypermobility.

SI Joint Mobilization: Anterior/Posterior Rotation Corrections

• Anterior rotation: Superior leg fully flexed, clinician blocks hip into flexion, applies pressure to ASIS and ischial tuberosity for posterior rotation.
• Posterior rotation: Clinician lifts involved leg into end-range hip extension, blocks iliac crest, applies pressure, creating anterior rotation, and holds for ~30 seconds. This is done while patient engages abdominals to minimize spine movement.

Hypomobile/Hypermobile SI Joint Interventions

• Hypomobility: Supine lumbopelvic manipulation (SI regional manipulation) is used to improve mobility. These techniques target the lumbopelvic region.
• Hypermobility: SI lock/joint belt is used to create compression; the belt is positioned above the greater trochanter to better support the posterior SI ligaments.

Medical Interventions/Post-operative Considerations

• No high/moderate certainty: Pharmacological interventions show no large or medium effect on pain intensity compared to placebos.
• NSAIDs/muscle relaxants: May have small effect for acute LBP (but no significant difference to placebo in terms of risk of adverse events)
• Opioids: May have small effect on pain for chronic LBP, but linked to increase adverse event risk.
• Injections (considerations): Facet joint/transforaminal epidural steroid injections may be diagnostic; interventions need to consider the "symptom modulation window."
• Lumbar Surgeries: Microdiscectomy, spinal decompression, spinal fusion, artificial disc replacement – options for chronic LBP unresponsive to other interventions, or severe injuries, instability, symptoms/deficits due to lesions.

Lumbar Surgeries: Rehabilitation Considerations

• Early walking: Early walking is often part of the regimen for patients after surgery.
• Restrictions: Restrictions may be placed on lumbar flexion, rotation, and heavy lifting.
• Education: Education on body mechanics is usually offered.
• Gradual return to activity: A gradual return to activity over time may be recommended.

Post-operative Complications

• Wound complications: Rare, but possible.
• Venothromboembolic complications: Rare but possible complication, including deep vein thrombosis/pulmonary embolism.
• Neurological complications: Less common, but possible.

Sync Session - Major Concepts

• Stability: The spine's inherent stability is important to understand. Injuries may change movement and muscle activation, which is the focus of the intervention.
• Sacroiliac Joints: Importance to understanding SIJ stability and mobiliy. Treatment strategies focus on hypermobility, or hypomobility.
• Pain: Not all patients benefit from pain neuroscience education; but this kind of education paired with other interventions can be very beneficial.
• Medical Interventions: Indications and precautions should be considered for lumbar surgeries, and implications of medications for rehab should be understood.
• Special tests: One piece of a bigger picture; use in conjunction with the total clinical picture (not in isolation) to better understand a patient's condition.