Wk4.pdf PDF - Treatment Principles for Lumbar Spine & Pelvis

4.1 Treatment Principles for the Lumbar Spine & Pelvis Ask these clarifying questions 1. what want to accomplish during PT 2. types of things unable to do now that could 3. what brings you to PT 4. what is the most important do before (task,activity,etc) for you to accomplish L - PT - POC incorporat...

4.1 Treatment Principles for the Lumbar Spine & Pelvis Ask these clarifying questions 1. what want to accomplish during PT 2. types of things unable to do now that could 3. what brings you to PT 4. what is the most important do before (task,activity,etc) for you to accomplish L - PT - POC incorporate functional/meaningful activities - E pic = movements that pts often feel that trigger pain > (transitional mvmts) consider category/calssification hypomob issue? hypermo issue? instability issue? condition inflammatory? what are the suspected pain generators are they a hands on or hands off pt rely on your manual therapy can do self management Big Picture are they resistant to move do they move too much is the pain local does the pain radiate dont get caught up in special test! Chronicity how long have they had the symptoms what are the contributing factors - adjacent joints (too mobile/too stiff) - occupational hazzard - posture - psychosocial (scared to move, scared to get better, scared to come in) Prognosis use knowledge on stages of healing to determine if you can make them better support your statement (talk to pt about it) comes with experience not everyone will have 100% recovery Exercise prescription exercise may be new to the pt choose something you know the pt will do (nothing wild, could be walking or sit to stand) make it specific to current presentation NOT diagnosis (no cookie cutter) choose 3 exercises, no more than 5 HEP (will not stick to it if too much or change a lot) suggest accountability techniques (diary, check ins) Educations & Safety educate on current status discuss activities encourage and those to avoid provide safety mechanisms & document did this Alternate methods aquatic exercise may be appropriate (takes weight off pelvis and low back, more fluid) braces/belts considered for stabilization warn not to be into long bc can fatigue and be harder on land no one is born knowing how to work out, we are specialists and we know how a person should approach their tx program, exercise, and return to activities summary intervention should be specific to pt not diagnosis provide education, prognosis, and safety measures make the exercise practical w/ goal of lifestyle & compliance * 4.2 HYPOmobility for Lumbar spine and Pelvis Recognize interventions for hypomobility Develop an approach Directional preference What is more comfortable: FLX or EXT Stick to basic Exercises Gradual increase in mobility Physiological movements>>assessment is also treatment FLX EXT Sidebend gapping between vertical segments sidelying Hypomobility- LACK of movement contributing factors include: Facet issues Muscle tension Neural Tension Inflammatory issues Pain Lifespan/age consideration Compensatory Movements Mobilization Return to asterisks, what movement hurts them Treat with appropriate grade III and IV move into resistance then gain range Prepositions Can do mobilization in combined movement Pelvis Mobilization mobilize the hemi pelvis in sidelying Manipulation Impart a force on low lumbar region or SI Get Consent Screen Hypermobility is contraindication Lumbar Roll Screen/consent Gapping in lumbar area Rotation of thoracic spine Be Specific, a pop doesnt mean it worked. a pop could mean just popping what is already mobile Soft Tissue Mobilization Be selective treat restricted area Be Purposeful Traction produce a gapping Do manual traction first Teach self traction techniques Self Management Self massage Stretches Yoga HEP compliance Selective Stretching Understand better positions for different stretches for the same muscles 4.3 Hypermobility - Treatment for the Lumbar Spine & Pelvis Hypermobility - If one segment is out of alignment, can cause biomechanics shift for the rest of spine - Excessive Movement - Constantly changing/shifting - Trauma or contributing factors such as pregnancy SI Instability - Trauma - Hormonal or Pregnancy - Pain can be located in buttocks, hip, groin - Transitional movements & walking are uncomfortable Form & Force Closure - Perform active SLR - Form Closure - Compression of innominate bones - Sacrum wedged b/w two hemi pelvis, possibly relief performing SLR - Force Closure - Resisted flexion & rotation toward side of SLR Muscle Energy Technique (MET) - To see if there is symmetry - Need to assess if the ASIS are level in supine - Can also do activation of hamstrings/hip flexors to correct rotation - Correction - Patient themselves can correct to have good pelvic symmetry - Correction is easy to do and can easily be taught to the client - Its critical to have symmetry in pelvis when considering loading bilaterally or single leg - (Ex. Stepping up/down curb, stairs) - Self-Correction (Whatever thumb is closer the ground when checking ASIS) - Anterior Rotated Pelvis - Palpate ASIS - Pull leg up of the side that is anterior rotated - Provide resistance w/ hand as you push out toward wall - Hold sub-max contraction 10 sec, do this 3 times - Recheck ASIS levels - Posterior Rotated Pelvis - Want to activate hip flexors - Can use assistive device to do both sides at the same time Anterior Neutral Spine or ‘Pelvis Neutral' - Extensors of back are in passive/lengthened position, ineffective for contraction - Teach people how to sit properly & maintain normal lordotic curve Local Vs. Global Muscles - Muscle activation should be segmental (local) - Want local muscles to assist, not have global muscles take over - Global muscles willl not assist segmental instability - Teach in various positions - Activation of transverse abdomens will then facilitate multifidus - Emphasis should be ‘up & in’ not flat back or posterior pelvic tilt ↳ Both Lumbar Stabilization - Stabilization training is combination of motor control, neural input (correct timing), passive restraints - Sub-Maximal training that should become subconscious - Training should adapt to static & dynamic movements - Teach in multiple positions - Normal breathing so this becomes natural > Progression - Start w/ basics: Activation - Muscle activation in supine position, contracting transverse abs - Ex. Sucking through straw, wearing tight pants - Dynamically challenge stability - See if they can move feet off ground 1 at a time - Progress to multiple postures - Make it functional Challenge the Core - Instrumentation can be used for objective monitoring of stabilization - Chattanooga Stabilizer (Sophisticated blood pressure cuff) - Can train lumbar stabilizers, pump device up to certain degree - Do dynamic exercises while maintaining certain pressure - Use dynamic movements that increase cardio - Chop & lift in diagonal fashion activating core, maintaining good posture - Increases HR, cardiovascular exercise which is also good Multi-Modal Exercise - Trunk ACtivation - Muscle Strength - Muscle Endurance - Trunk Coordination - Pilates - Does not always need to use equipment, can use mats Assistive Devices - SI Belt - Triangular piece over sacrum - Worn low around hips, around S2 to provide stability to SI joints - Lumbar Corset or Support - Would replace abdominal corset of musculature they’re lacking - Come w/ extra straps that velcro to the front 4.4 tx approach for radicular pain neural tension radicular pain 1. peripheralization 2. can be caused by disc (not always) 3. stenosis can cause leg pain ant: thigh/ankle post: lower back, L (all leg) & foot R side- all leg except popliteal space ppl often time confuse it w sciatic standing techniques assessment or tx ex: disc herniation or n root irritation correction of shift repeated mvmnts -flex: most difficulty -extL pts do more do 10x goal is to centralize or reduce leg pain prone press ups pt may start w prone on elbows (POE) instructions: press up breathe out relax guts & sag hips “look up and press up” then hold pain should reduce in leg & may increase in back prone press up w assist & HEP PT 1. help in ext as they press & look up 2. put hands on pt to stabilize ext (hands on sides or at diff levels) 3. home: pt strapped to iron board to mimic pressing down to straighten neural tension restriction of nerve sliding & gliding thru tissue tugging/pulling sensation may report sensation of fatigue ( if chronic) may lead to pain and altered mvmnt special tests 1. SLR when leg raised up back pain is triggered straight leg raise accentuated w DF./neck raised 7 *considered adverse neural tension 2. slump 3. long sit slump 4. sidelying slump varies bw pt ex: 1 pt can have pain in “c” position (photo) but in “D” position doesnt have pain SLR variation tibial n: knee extension & DF sural n: knee ext, DF, inversion peroneal n: knee ext, PF, inversion intervertebral disc (opposite leg) sacral plexus: med rot, ADD look here!! slump more aggressive than SLR due to compression w sitting (disc and neural structures) perform in sequence w assessment each time you add component + is a ‘change’ of symptoms w sensitizing maneneuver 1. alternation in ROM 2. difference side to side 3. reproducing their symptoms flossing getting nerve to move thru “container”/ adverse soft tissue causing issue ↳ have them start in supine hold leg in 90 degrees pt kicks leg up could add cervical flex saves pts post opp bc of scarring summary 1. radicular pain can also be referred to as peripheralization 2. goal of therapy intervention is centralization of pain 3. neural tension is the inability of the nerve to slide and glide through the tissue 4. flossing is a technique that can reduce adverse neural tension Be careful w/ nerve pain bc of latency! If goal is to increase ROM mobilize in end range Radicular start in laying position or sitting then have pt do repeated extension let hips sag, don’t let glutes help can also do this in standing or prescribe as exercise for traction stenosis - like flexion acetabular inclination normal: 33-38 degrees dysplastic: >47 acetabular index- assessed on. an anterior posterior radiograph greater angle=more dysplastic acetabular index acetabular roof angle acetabluar inclination- evaluated degree of upward slope of hip socket normal: 3-13 degrees -he said 10 in his lecture so idk which to go by.. 10 or 13? under coverage: >13 (DDH) over coverage 25 degrees slightly abnormal 20-25 severely abnormal 35) fossa acetabuli is medial to kohler’s line (deep socket) acetabular protrusion -femoral head is medial to kohler’s (ilioischial) line protrusio acetabuli: shallow socket alpha angle transverse plane angle formed by a line parallel to femoral neck axis and line from center of femoral head to transition of femoral head into femoral neck (neck radius exceeds head radius) femoral neck deformity cam impingement femoral head/neck profile exceeds the radius curvature of acetabulum alpha angle >60 indicator of size of bony anomaly no absolute cut-off value high alpha angle in an asymptomatic pt should be considered an incidental finding head neck offset ration