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How long does 90% of all acute LBP resolve? 4-6 weeks
Von Korff study: @ 1 month ___% of NP & LBP pts were pain free. @ 1 yr, __% reported ___ @ 1 month: 30% pts were pain free, @ 1 yr 50% reported recurrent of persistent pain
Croft, @ 3 months __% of pts stopped ___, but only ___ had ___. @ 1 yr only __% completely recoverd @ 3 months 91% pts stopped consulting DR but only 21% had completely recovered. @ 1 yr only 25% had completely recovered
What time span is considered subacute? 6-12 weeks
What are pts with subacute back pain @ high risk for? chronicity (extended for radiculopathy)
What is not responding in pts that are non responsive to care? function
What 3 areas should you focus on with subacute LBP 1. re-assess, 2. advise pt to stay active 3. tx
What 5 things should be re-assessed? 1. dx triage - red flag search. 2. re-eval dx 3. consider imaging, lab test, 4. functional eval, 5. psychosocial eval (yellow flags)
Pts with a preponderance of yellow flags are at a risk for what? chronic LBP
What are some sx of yellow flags? duration, sciatica, severe pain (3-8 wks), widespread pain, physdemand job, hate job, disability within past 12 yrs, neg fam/workplace, inc # of kids cared for.
what are functional findings of yellow flags moderate or higher disabilty score on oswestry, and sleep neg affected by pain.
what are psychosocial factors assoicated with yellow flags self rate health as poor, - fear avoidance beliefs, - anxiety, - catastrophizing, -distress/depression, -low expectation of recovery
what are work related yellow flags involved in compensation, and involved in litigation.
phsyical exam findings of yellow flags +SLR, +neuro exam
What txs are best for one with subactuce LBP manipulation, and exercise (esp stabilization!!, isotonic, and mckenzie. Active > passive care
Definition of chronic LBP > 3 months
What three things should be done with chronic LBP of 3-6 months 1. continue managemant as per subacute. 2. consider 2nd opinion, 3. consider referral to active rehab specialist.
What two things should be done with a pt with chronic LBP >6 months 1. consider referral to multidisciplinary rehab center, 2. consider formal cog-behavioral therapy
Why would cognitive behavioral therapy be good for a >6 month chronic case 1. licensed mental health prof, usually private office. 2. address psychological comorbities that may impede recovery, 3. these comorbidites may be a factor contributing to LBP or d/t LBP.
Minor or major inuries occur when applied load exveeds? tissue tolerance
What 6 things is lumbar spine injury a function of? 1. load magnitude & cumulative load, 2. direction of load, 3. spine posture, 4. hyrdation level & time of day, 5. motor control and instantaneous stability, 6. age & gender.
Few LB injuries happen from a ___ single event involving high load
Most LB injuries are the result of accumulated trauma that gradually reduces the level of tolerance to tissue failure such as... 1. repetitive low-load 2. sustained low load
in regards to loading what can be done to cause an adaptive response which increases tolerance of a tissue? when loading is followed by a period of rest.
What 3 directions of load have the greatest risk of injury? 1. compression, 2. shear, 3. twisting.
what helps to reduce shear affects on the spine when lifting? keeping a neutral spine (using hip hindge)
how does active twisting affect the spine? d/t mm contraction - greater mm contraction, greater the compression.
Problem with repeat flexion to a fully flexed posture progressive tracking of the disc nucleus posteriorly thru the annulus, eventually resulting in herniation. Fewer cycles of flexion are needed with simultaneous compressive loads.
Ligaments, joint capsule and discs provide stability to each spinal motion, mostly when? at the end range of motion
W/o mms when would the spine buckle? @ a load of only 20 lbs (90 newtons)
co-contraction def the simultaneous contraction of antag mms
what does co-contraction do? increases stiffness of the spine and therefore stability.
whats mms are included in the local mm system? multifidus, QL, intertransversarii
what does the local mm system stabilize? the spinal motion segment (3 joint complex)
global mms include? ES, Rect Ab, int obliq, ext obli, transvese abb
what do the global mms stabilize/ the spinal column as a whole
What are the 3 subsystems of spinal stabilizing systems? 1. passive osteoligamentous subsystem, 2. active mm subsytem, 3. neural control system
neural control subsyst receives senory info from? mechanoreceptors in the ligs of the passive subsystem
neural control subsyst determines what? the specific requirements for spinal stability.
neural control subsystem coordinates what? mm response from the active subsystem to acheive stability.
stiffness & stability of the spine is not ____, but varies with ___ is not constant but varies with applied loads
trunk mm co contraction is increased with? increased during more demanding tasks when more stability is needed
trunk mm cocontraction is decreased when? during less demanding tasks when less stability is needed
when is risk of segmental instability greatest during (2)? 1. high load tasks, and 2. extremely low load situations
what is transient segmental instability and buckling/ a transient loss of coordination or motor control of 1 or more interseg mms (local mms) results in temporary instability @ segment allwing vertebra to briefly exceed its safe & pain free range - w/c can injure soft tis.
When will segment instability occur during high load tasks? insufficient activation of intersegmental mms which is needed to balancethe high forces that are developed by the large global mms.
how does segmental instability and buckling occur from extremely low load situations? d/t low levels of co activation of the global and local mms therefore spinal stability is at its lowest. Therefore an error in motor control of the intersegmental mms during this can result in segmental instability. Can be single event, or repetitive inj
What are 6 risk factors for transient instability and buckling? 1. deconditioning of trunk mms, 2. deconditioning of neural subsyst, 3. inj to passive soft tis, 4. unexpected perturbations, 5. challenging aerobic times, 6.increase in the neutral zone.
what does injury to passive soft tissues (ligs, disc) result in? abnormal sensory info from mechanoreceptors
What is the motor system conflict during challenging aerobic circumstances should the torso mms maintain contraction for spine stability,OR rhythmically contract and relax to assist in active expiration (and sacrifice spine stability)
What is the neutral zone? the central part of the ROM where there is almost no resistance from ligaments or the disc to intervertebral motion. (vertebra can move w.o much resistance)
outside the neutral zone there is ____ resistance to movt increasing
What happens if the neutral zone is too large? the margin of safety is smaller, and greater demands are placed on the stabilizing mms.
What are 4 causes of an increased neutral zone? 1.cognential, 2.acute or repeat trauama that strecthes the ligs, 3.maintaining prolonged flexed position, 4.degen changes, esp the discs.
After ___min of full flexion, ligs creep and laxity occurs w/c persist even after __min of rest. 20 min, 30 min.
Functinal deficits were found more in who? LBP pts as compared to aSX pts, but not sure if deficit was cause or result of LBP.
relationship of decreased trunk extensors and LBP it correlates with LBP, and predicts recurrences as well as first time onset of episodes.
what was the only physical capacity measurement that indicated an increased risk of developing LBP as per age, sex and occupation static back endurance
where was mutlifidus atropy in pts with LBP, post surgery for NR problems, and compression caused by herniated discs? ipsilateral to the pain and @ the same segmental level as palpable joint dysfunction.
In healthy controls, when the resistance suddently and unexpectedly released what happened with the agonist and antagonist mm relationship? the agonist mm shut off BEFORE antagonist mms switched on.
In a pt with CLBP when the resistance suddently and unexpectedly released what happened with the agonist and antagonist mm relationship? agonists and antags stayed contracted longer than in healthy controls - agonists were still active when antags were switched on.
What happens with unexpected loads in CLBP pts? stability is compromised d/t antag-agonist coactivation disturbance.
what happens with transverse ab in CLBP pts? contracts after limb movt initiated, when should start before, thus spine less stabilized.
What did traditional rehab emphasize, and what were the results? emphasized increased mm strength and ROM (quantity of motion), but it did not reduce back troubles & even possible negative outcomes.
what are 4 things that stabilization exercises look to accomplish?? 1.inc endurance, not stregth, 2. challange the mm system w/o excessive load that can exacerbate the spine, 3.maintain a neutral spine under load, 4. encourage ab co-contraction & bracing in functional way.
What mm is most important stabilizer of lumbar torso? no 1 is most important, b/x all play dif roles w/ dif activities. they're all important.
which mms act both as global and local stabilizers of the lumbar torso? QL, int oblique,
what are the local stabilizers of the lumbar torso? intertransversarii, multifius, longissimus (lumbar) ,iliocostalis (lumbar), QL, transverse AB, internal oblique
what are the global stabilizers of the lumbar torso? longissimus (thoracic), ilicostalis (thoracic), QL, rect Ab, ext oblique, int oblique
what defines a local stabilizer? stabilize intersegmental joints, and must have direct connection to vertebra
what defines a global stabilizer? don't connect to the spine (don't have to)
What is the NIOSH set limit for compression of the spine>? 3300 newtons (above this linked to higher injury rates in workers)
what is the optimal technique to maximize activation of the QL, but minimize the spine load? Side bridge!
beginner side bridge technique and compression on spine on knees, <2000 N
advanced side bridge technique, and compression on spine from feet, compression on spine is 2600 N, 50% activation of QL closet to the floor.
what is the compression of a 1 leg wuardruped raise for back extensors? 2500 N
what is a the compressive force of 1 leg 1 arm quardruped? 3000 N
Why should you not perform prone trunk and leg extensions? 4000-6000 N spinal compression
why should you not perform roman chair extensions? 4000 N spinal compression
How much compression is on sine and % MVC for curl-up, ft free? 2000 N, with 65 % mvc
when can you add a dead bug after curl ups? after curl up has progressed to the highest level.
what exercises should not be performed for rect ab? straight-leg sit up (3500 N on spine, 121 MVC). or bent leg sit up (3350 N on spine, and 103MVC).
What exercsies can a beginngers program consist of, which would be sufficient for the daily healthy spine? cat-camel (5 cycles), one legged squats, side bridge, leg extensions and birddog, dead bug/curl ups.
What type of surfaces should rehab begin on as oppsed to labile? stabile surfaces b/c labile surfaces create elevated spine loads.
What is the definition of a theurapeutic exercise? indicates that the purpose of the exercise is for the tx of a specific medical condition rather than recreation.
85-90% LBP d.t? mechanical
<10% LBP dt? radiculopathy
<2% LBP dt? serious pathology
Reassurance phase of acute LBP should consist of? explain what is causing pain (functional usually), assure pt no dz, identify back related worries & fears & pt goals, give prognosis
pain relieving positions for acute lbp supine w/ pillow under knees, and lateral w/ pillow between knees.
Who might flexion exercises be good for with acute lbp? 1.tight or spasm extensors, 2.facet syndrome, or facet compression, 3. flexion bias (sx that improves w/ flexion & worse with extension)
who are flexion exercises contraindicated for with acute lbp? pt with suspected or confirmed disc herniation
what time of day are discs most hydrated? 1st hr after rising from bed - annulus under much greater stress when bending.
extension exercises good for who with acute lbp? disc lesions, and extension bias
Extension exercises may exacerbate pts with what? large central disc lesinos, foraminal stenosis, foraminal herniation, and facet syndrome
who are extension exercises contraindicated in? pts with a posterior arch lesion (spondylilisthesis)
who are lumbar glides useful for? pts with antalgic postures,
centralization? reduction if dustak referred sx and subsequently any remaining spinal pain
peripheralization? should be avoided. When distal referred sx increase in response to a particular movt or posture.
mckenzie method inclues what? assessment and intervention - uses mechanical loading to find direction that results in centralization
What are the 3 classifcations of pt mechanical syndromes? derangement, dysfunction, and postural.
derangement (what, charact, tx) pts with disc derangements, characterized by end range limited pain, not restriction. Tx - avoid that direction while performing endrange loading in opp direction
dysfunction (what, charact, tx) seen in pts with joint dysfun. Charact - pain produced only @ endrange of restricted movt. Tx - repeated endrange loading in the same direction as restriction that eventually restores flexibility to the tissue and allows normal pain free motion
postural (what, charact, tx) what-pts sustained end-range flexion postures(ex slouched) charact-full and painfree ROM w/ pain only elicited by sustained endrange loading that ceases only when endrange loading is removed. Tx - posture correction
What are two types of reactivation advice? bed rest and relative rest
bed rest should be no longer than? 1-3 days
relative rest, to try and resume normal activites bc? speeds recovery and avoids deconditioning
Why golfers lift for very light objects? minimuze low back motion and loads. Leg cantilevers behind and acts as a counter wt.
define neutral spinr position in which the joints surrounding passive tissues are in elastic equilibrium and thus @ an angle of minimal joint load. The spine is neighter flexed nor extended
what is an ab brace? isometric contraction of ab mms, produces an automatic cocontraction of the lumbar multifidi mms w/c stiffens and stabilizes lspine
Created by: margaretrhager