Lumbopelvic

S.I.N.S.S. Construct

• A systematic strategy used to assess a patient's symptoms.
• An acronym standing for Severity, Irritability, Nature, Stage, and Stability.
• Each variable should be determined to evaluate the intensity of the physical examination, treatment options and likely prognosis.

Severity

• Pain intensity, often rated on a scale from 0 to 10.
• Also considers the effects of symptoms on daily activities.
• Minimal severity is pain ranging from 0 to 3 and doesn't limit daily activities.
• Moderate severity is pain ranging from 4 to 7, impacting daily/work activities moderately.
• Maximal severity is pain ranging from 8 to 10, heavily impacting daily activities and possibly limiting self-care and work ability.

Irritability

• Symptom's irritability level, not the patient's.
• Considers the type/amount of activity that aggravates/eases symptoms.
• Minimal irritability is when high repetition, intense activities/sustained postures are tolerated before symptoms appear and symptoms ease quickly by stopping activity or changing positions.
• Moderate irritability is tolerance of a moderate activity amount.
• Maximum irritability is the ease with which the symptoms are aggravated and the length of time taken to subside.

Nature

• Pain type and symptom characteristics.
• Broad categories include musculoskeletal or non-musculoskeletal.
• Musculoskeletal pain is classified as either mechanical or non-mechanical.

Stage

• Clinician's assessment focused on the timeframe of the condition.
• Acute stage is of recent onset.
• Subacute stage is typically from three to six weeks.
• Chronic stage is typically longer than six weeks.
• Acute on chronic is an underlying chronic issue with an acute exacerbation.
• Subacute on chronic is an underlying chronic condition with a subacute exacerbation.

Stability

• Progression of symptoms over time; related to current episode or history.
• Improving symptoms are decreasing in intensity, frequency, or location.
• Worsening ones are increasing in intensity, frequency, or location.
• Not changing symptoms stay the same since onset.
• Waxing and waning symptoms are at times better, improving and worsening.

Joint Mobilization Grades (Maitland Grades)

• Used to treat joint pain.
• Based on amplitude of movement; whether movement is performed into or out of resistance.
• Grade I is a small amplitude movement out of resistance, used to decrease pain.
• Grade ll is a large amplitude movement out of resistance, used to decrease pain.
• Grade lll is a large amplitude movement into resistance, used to improve motion and decrease the pain.
• Grade IV is a small amplitude movement into resistance and improves motion.
• Grade V is a high velocity, low amplitude thrust into the resistive barrier and improve motion and decrease pain.
• Mobilization grade depends on the dominant symptoms.
• If pain is the dominant feature, begin treatment on accessory motions in open pack with Grade I or II mobilizations, then progress to physiological motions with Grades I through III if tolerated.
• If stiffness is the dominant feature, begin treatment on physiological at end range motion using Grade IV mobilizations, and potentially Grade V, or accessory motions at end range using Grade IV mobilizations.
• If the presentation is stiff>pain, begin with large physiological at end range motions (Grade III), progressing to accessory and physiologic end range motions using Grade IV if pain decreases.
• If presentation is pain>stiff, begin using Grade l-ll accessory motions, progressing to Grade ll-lll physiological as tolerated.
• Assess the patient's joint mobility to confirm hypomobility, mobility/hypermobility, but do not grade it until after treatment

End-Feel

• Summarizes normal/abnormal end-feels with examples.
• Normal bone to bone end-feel is an abrupt and hard stop, for example, at elbow extension.
• Normal soft tissue approximation is soft and yielding, for example, at knee flexion.
• Normal tissue stretch is springy with some resistance; example is shoulder external rotation, finger extension.
• Abnormal soft feel is a boggy sensation; example is soft tissue edema.
• Abnormal firm feel is increased muscular tone or muscular, ligamentous, or fascial shortening.
• Abnormal hard end feel can be bone-on-bone or a rigid block.
• Abnormal empty feel is when pain prevents end of range motion and no real resistance is felt.
• Abnormal end-feel can occur sooner/later instead of as expected.
• Compare symptomatic to unaffected side.
• Delay passive range assessment if symptoms are highly irritable.

Self-Report Measures

• Summary of self-report measures with purpose, scoring and key characteristics.
• NPRS (Numeric Pain Rating Scale) measures pain intensity and uses 0-10 scale with 0/no and 10/worst pain. MDC is 2 points in low back pain and 1.25 in spinal stenosis.
• Patient-Specific Functional Scale (PSFS) assesses ability to complete specific activities; a total score is summed activity scores/number of activities. MDC is 2 points for average score and MDC is 3 points for single activity score..
• Roland-Morris Disability Questionnaire (RMDQ) gauges whether item is possible; scored out of 24, with higher scores meaning more disability, it's raw score MCID is 5 points out of 24.
• Oswestry Disability Index (ODI) has 10 items each scored from 0-5. A total is expressed as a percentage and higher scores mean greater low back pain disability. The MCID is 10 points out of 100.
• Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ) identifies if any of psychosocial "yellow flags" exist. Summed scored items make score from 0-210- higher scores mean risk of poor outcome. MDC is 12 points and a score > 130 predicts risk of disability.
• STarT Back Screening Tool (SBST) identifies subgroups of low back pain patients to allocate best treatment. Used to determine the best treatment pathway.
• Fear-Avoidance Beliefs Questionnaire (FABQ) assesses fear-avoidance beliefs with 4-item physical activity scale (FABQ-PA) ranging from 0 to 24 and 7 item work scale (FABQ-W; ranging from 0-42). Higher scores mean higher levels of fear-avoidance beliefs.
• Pain Catastrophizing Scale (PCS) assesses catastrophic thinking, it's 13 items range from 0-52, and higher scores mean more pain catastrophizing.
• Tampa Scale of Kinesiophobia (TSK) assesses kinesiophobia (fear of movement) with 17 items, each scored from 1-4. High scores mean kinesiophobia.

Minimal Detectable Change (MDC)

• Minimum change required on an outcome measure to exceed anticipated measurement error and variability.
• Helps you know whether the change in score means a real change/simply error during measurement.

Minimal Clinically Important Difference (MCID)

• Represents minimum amount of change on an outcome measure that has perceived benefit.
• Determines if change is significant and a real improvement that will be noticed and valued..
• MDC and MCID are important tools to help interpret self assessment results.

Red Flags

• Red flags mean immediate consultation with a medical specialist due to high risk of serious disorders
• Saddle anaesthesia, bladder or bowel dysfunction and severe neurological deficit in unilateral/bilateral legs (LA-S1) needs emergency/urgent referral/attention.
• Major trauma and osteoporosis can cause spinal fracture in the thoracolumbar region; requires emergency/urgent referral.
• Past history of cancer, weight loss, unrelenting night pain and failure to improve, potentially malignancy.
• Fever, chills, immunosuppression, recent spinal infection or surgery may cause spinal infection and requires referral.
• Abdominal/back pain with groin and flank pain; pulsating abdomin is Abdominal Aortic Aneurysm, requires investigation.

Yellow Flags

• May need referral or consultation with a medical/mental health provider.
• Unhelpful beliefs about pain.
• Avoidance of activities due to expectation of pain or possible re-injury.
• Psychosocial factors identified by OMPSQ/SBST may require a referral to a mental health professional.
• Stress/anxiety are risks for the development, duration, and severity of low back pain.
• Screening assesses signs/symptoms of possible depression.
• Red Flag use requires consideration of clinical patient profile.
• When screening look for 1. appropriate for physical therapy, 2. appropriate for physical therapy and consultation with another provider, 3. not appropriate for physical therapy and referral to another health provider.
• If there are no red flags then proceed with management.

Facet Joint Pain

• Category described as pain with lifting or twisting.
• Presentation is unilateral low back pain, may refer to ipsilateral buttock and upper leg, worsened by lumbar extension, with reduced movement, pain with passive mobility.
• Body chart show localized and sharp pain.
• Management; mobilizations/manipulations, self exercises/stretches.

Spondylosis

• Is a generic term referring to degenerative alterations.

Spondylolysis

• A bone defect in the pars interarticularis (vertebral arch).
• Often at L4-L5 and L5-S1.
• The clinical presentation of it not radiating is unilateral lower back pain w/ loading at the area.
• Oblique view radiographs show the collar on the Scottie Dog.
• The management activity should be modified/restricted, bracing, exercising and flexibility.

Spondylolisthesis

• Is where one vertabae body is slipping on the vertebral body below because of a bilateral pars fracture.
• Grading of the the slip 1 = <25%, 2 is at 50%, 3 and 75 and 4 means at 100%.
• Epidemology is at 3 to 6% , most notably young athletes.

Scoliosis

• Is a curvature of the spine and is determined if is flexible or not.
• Most commonly idiopathic (80%).
• Imaging determines structural vs non stuctural. and course of management.
• Treatment depends on the course of treatment and curvature size.

Osteoporosis

Categories: definition, including primary (age-related) and secondary.

• Risk factors, including estrogen deficiency, low body composition, family history, current smoker and gender.
• X-rays do not show until 30% bone loss, DEXA is preferred and with low body levels of osteopenia.

Lumbopelvic Pathologies

• Including description, clinical presentation, prevalence, treatment.
• Facet Joint Pain:
  • Typically presents as unilateral low back pain.
  • Symptoms are typically incited by lumbar extension or side flexion (reduced movement during same side motions).
• Spondylosis is where symptomatic joint depends or the pain-generating structure such as lower spinal sternosis.
• Forward displacements (Spondylolisthesis) cause some radiation into lower extremities and less loading of flexion symptoms.
• Scoliosis has curves within the spine.

Sacroiliac joint

• Sacroiliac joint may occur where there's pain in the glutes, or lower limb.
• May vary by movement, sit-to-stand or stair climbing.

Intervertebral disc

• Compression from from flexion and rotation or sidebending.

Lumbar

• More commonly nerve pain that's achey.

Spinal

• Is narrowed with tissue,
• Causes pain to the extremities that's relieved during flexed positioned

Lumbar muscle

• Is specific in a strain
• Causes referred symptoms that's hard to palpate.

Spinal Stenosis Treatment

• Nonsteroidal anti-inflammatory drugs.
• Corticosteroid steroid injections
• Exercising

Special Test Procedure

• Sign of the Buttock : passively flexing hip, test equal extension.
• Instability,prone: CPA one leg.
• Lumbar Extension : legs off the floor.
• Test extends both extremities.
• Quadrant Test, Flex and extend.
• Thomas: Stabilize and asses.
• Straight Leg Raises leg with knee.

Action of myotome levels

• Myotome levels indicate area of weakness and integrity of nervous activity.
• Ankle plantarflexion, and medial malleolus
• Myotomes are groups of muscles intervened by a single spinal nerve. And dermatomes are sections of the skin with single regions nerve

SIJ Test & Precautions

• Examinees leg position with the patient supine.
• The provider places hands on either side and distracts from front of the patient
• Patient is side lying, and provider presses down.
• Patient raises the test against resistance.
• Patient will provide push by provider.

Neurodynamic Testing

• Positive findings are a indicator of related dysfunction in neural tissue/structure.
• Assess is done by tensioning nerve or slacking it.
• In some patients, just slacking is sufficient to relieve them if their levels are low.
• Each assessment provides key points about how the joint tested responds/reacts to any applied stimuli.

ICF Category

• Patient may have range and reduced passive movement or pain .
• Pain patient may have a positive straight leg raise test of 91 degrees.
• Patient in low extremity pain or buttock is from lack of flexed movement.

Treatment-Based Classification

• Patients with acute exacerbation, they may need to take over the manipulation to manage some pain or anxiety-related episodes. However, it is essential to have some type of plan in place to support.
• Treatment based method describing a plan
• Important to also consider SINSS
• Look at manipulation. stabilization and specific exercise

Bone

• Pathology, surgical history due to fusion.

Spinal

• Surgery infection in some cases in is always caused by cancer as well.

Directional Preference

• Aggrevated while sitting , but at at other positions.

Pains

• Are not that localized.

Extremit

• Causes referred symptoms.

Lumbar

• Stenosis and the disc herniation are known to cause mechanical disruptions.

Management

• Involves with hip rotations, and general mobility.
• Demographics
• Specific symptoms for the spine
• Lower symptoms is to calf issues with walking.
• Provide specific activities and functions
• Disc disruptions with lateral shifts.

Sacroiliac Joint Dysfunction

• Not to stable during a pain event.
• Joint injections occur here

Spinal Compression Indications

• If one has low back pain and radiating pain due to a space issue that disrupts the way its working it is considered after more conservative methods.
• The timeline can last up months.