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M) Adult presenting with ongoing lumbar/LB back pain (Person (Narrative…

- - - - Cl is Relaxed, easy going, well dressed and presentable... Ongoing continue to remind of functional changes rather tha focus of pain. Be forward in expectations of Rx and progression - given previous PT experience. Rx choice and clinical reasoning must be clear and direct to ensure adherence.
  - - - HPC: Ongoing for 6/12 from deadlift, saw PT (advice/EPA) nil change. Pin and needles down left side since march. Symptoms have progressed
  - - - GP: contact if symptoms worsen or need for medication. Read the report from CT Scan - low/poor correlation with Cl presentation. EP: potential referral for ongoing Mx when improved.
- - - - ? L spine radiculopathy
        
        Thought Spinal Sx/SSx have only been for past 2-3/12 not since initial onset. Progressive stiffness in MM's may have led to a nerve compression from guarding, therefore leading to onset of nerve symptoms. More likely NSLBP w/ consequential onset. Rx as NSLBP and monitor symptoms progression. STOP
      - ? NSLBP w/ peripheral nerve entrapment from muscle tightness in LX spine.
        
        Thought: Consequential onset due to muscle guarding, should settle as pain response subsides and muscle activation is improved. NSLBP is multifactorial so Ax of abdominal control/activation is key in reduction of loading into Lx spine mm's along with education on the importance of movement in recovery.
        
        Rx/ 1. Education 2. Pelvic Tilt + rec ab activation w/ crunch 2x5 // Ext 60%, Flex 40% still (P) but improved, sitting is better. HHD L Hip add 193. Plan 8/52 beat your back pain plan. Detone psoas and increase abdominal activation to reduce loading of Lx spine
        
        Session #2: S/ Pt. seen a difference since last apt. Wants to see if differences are consistent today and continue as he commutes on the bus. O/ LX AROM Flex 40% mid thigh pulling & pt pulls to the R), Ext 40% still EROM. HIP ABD L 165 R 149 ADD L 149 R 167
        
        Thought AROM is improving since previous apt. Hence Rx is effective continue current course. Introducing loading of the HIP stabilisers in ER/IR will help to continue off loading Lx spine during movement / assist in load capacity.
        
        Rx 1. Education 2. PEvlic tilt + rec ab activation with crunch 2x5 3. Clams ER green TB 2x6 Left // Flex to patella, more comfortable
        
        1 more item...
      - Red flag - symptoms are unilateral not bilateral. No sign of sudden worsening. STOP
  - - - Exercise: Beneficial effect on LBP when compared to other Rx options. Strength / resistance and coordination / stabilisation training shown to have small but clinically significant effect. CV training nil direct effect demonstrated. -Searle, A., Spink, M., Ho, A., & Chuter, V. (2015). Exercise interventions for the treatment of chronic low back pain: A systematic review and meta-analysis of randomised controlled trials. Clinical Rehabilitation, 29(12), 1155-1167. doi:http://dx.doi.org.ezproxy1.library.usyd.edu.au/10.1177/0269215515570379
      - Massage / MT MT = no more effective than other Rx for LBP in increasing function or reducing pain, Massage = s/a of change in short term in pain and reported function compared to inactive methods, nil confidence in efficacy in Rx of LBP due to poor evidence quality and volume -Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW (2011) Spinal manipulative therapy for chronic low-back pain. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD008112. DOI: 10.1002/14651858.CD008112.pub2 & Furlan, A. D., Giraldo, M., Baskwill, A., Irvin, E., & Imamura, M. (2015). Massage for low-back pain. The Cochrane Database of Systematic Reviews, (9), CD001929.
      - Deactivation of abdominal muscles in LBP:Muscle Strength and Neuromuscular Control in Low-Back Pain: Elite Athletes Versus General Population. - Moreno Catalá, M., Schroll, A., Laube, G., & Arampatzis, A. (2018) - Athletes vs. gen pops. Demonstrated the same reduction in lumbar extensor strength & neuromuscular parameters of spine stability (higher damping & shorter onset times of trunk mm. control). - Therefore both may benefit from direct trunk muscle training when indicated.
    - - External obliques originiate on the outer 8 ribs, insert into the linea alba, pubic crest and iliac crest affecting th eRibs, Tx spine, L spine hips and SIJ. - These can assist in detoning psoas.
      - Internal obliques origiinate form lumbar facia, iliac crest and inguinal ligament. Insert into linea alba, pubic crest, last 3-4 ribs and costal margin. Act on Ribs, Tx spine, L spine hip and SIJ. Can also assist in detoning psoas
      - Rectus abdominis Originates pubic crst and synphysis. Inserts xyphoid process and coastal cartilage of ribs 5-7. Acts on ribs, Pelvis and sternum. Can assist in detoning psoas
      - Psoas major originates from transverse processes, bodies and disc of lumbar vertebrae and T12. Inserts into lesser trochanter of femur via iliopsoas tendon. Acts on Tx spine, L spine, Hips and SIJ. Can increase pevlic anterior tilt if tight/overtoned - hence increase Lx spine loading. Offloaded by lower ab tone - increase posterior pelvic tilt