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___________________________________ ___________________________________ Ryan Tauzell, MA, PT, Cert. MDT
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___________________________________ Who is this patient? Symptoms successfully treated Not able or not fully prepared to return to usual highlevel activity
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___________________________________ Goal of this stage Achieve the desired volume of functional activity in realtime, pain free and with enough strength, endurance and motor control to protect against recurrence
Decrease fear associated with return to activity
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___________________________________ How to achieve goal Multiple modes of treatment utilized
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Gym program
Concentric/Eccentric/Isometric
Aerobic/Anaerobic exercise Work simulation Aquatics
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Plyometrics Varied Environmental Factors Pilates Yoga
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___________________________________ Precision Counts Precise treatments for a non-precise group produces nonprecise outcomes Koumantakis (2005): …patients with RCLBP and no clinical signs suggesting spinal instability
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Conclusion: Stabilization exercises do not appear to provide additional benefit to patients with
subacute or CLBP who have no clinical signs suggesting the presence of spinal instability
Precise treatments for a precise group produces precise outcomes O’Sullivan (1997): …patients with CLBP and radiologic diagnosis of spondylolysis or spondylolisthesis.
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Conclusion: A “specific exercise” approach appears more effective than other commonly
prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis/spondylolisthesis.
Treatment must be precise to the individual patient’s activities
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___________________________________ Determine Physical Demands Formal Physical Demands Analysis, Industrial Accident Prevention Program
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http://www.iapa.ca/main/documents/pdf/FreeDownloads_PDA.pdf
Informal Precise questioning about physical requirements List the patient’s concerns regarding return to activity
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___________________________________ Determine Fears Level of fear will determine a primary graded activity or graded exposure approach Formal Fear Avoidance Belief Questionnaire Physical Activity Subscale (FABQPA) Fear Avoidance Belief Questionnaire Work Subscale (FABQW) Informal List the patient’s fears regarding return to activity Precise questioning regarding fear of damage/harm
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___________________________________ Treatment Provide an active treatment progression that best matches the identified physical demands within available resources
Address patient’s concerns and fears with instruction and education on how to respond to these challenges Progress from matched exercise to dynamic multi-joint
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movements with motor learning emphasis Engram motor programming Unconscious competence
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Case Study (History)
34 yo male Work: Light duty. Fire Fighter/EMT Leisure: Has a farm with multiple animals (large and small), Married Worst Pain: 8/10 NPRS (prolonged sitting or standing) Least Pain: 2/10 NPRS Onset: 2 weeks, stable recently Symptoms at onset: Low Back only Incident: Loading obese patient into ambulance Functional Restrictions: sleep, bed mobility, transfers, forward bending, dressing, lifting Worse: transfers, sneezing Better: walk Sleep: Disturbed due to pain, no night sweats Bowel/Bladder: Normal Body weight: Stable Accidents/Falls: No Imaging: X-ray, MRI (L4-5 annular tear, L5-S1 HNP) Perceived general health: Good Recent of major surgeries: None Medications: None Previous episodes: None
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Case Study (Treatment Summary)
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Day 1: DP established: Extension Day 2: Pain centralized to low back, DP corrected to R posterolateral due to motion loss of SG R
Day 3: Centralization maintained, Gym activation started (Row, Back Ext, Lat Pulldown, OH Press)
High reps, Low weights (able to perform with proper technique, 15-30 reps) Theme of lordosis maintenance maintained throughout activation, manual/verbal cues PRN
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Day 4: Progress activation to include hip abduction/adduction and air squats (eventual
application to deadlift), Established work related physical requirements Day 5: Restoration of flexion initiated via slouch overcorrection, progress activation workload Day 7: Add quadriped APT/PPT for restoration of function / Introduce lifts as work simulation Day 8-10: Continually progressing baseline gym program workload Day 11: Added partial range sumo deadlift to a high pull on cable column, 10-45 lbs. progression with emphasis on motor control. Continued gym progression. Correlate lifts to work simulation Day 16: Added full range sumo deadlift, 30-50lbs (5 lb increments, 8 sets, 5 reps).
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Lordosis maintenance, motor control emphasis Establish work related concerns/fears (Best when RTW is realistic, too early is counterproductive)
Day 17: Goblet squat added, 40lbs for 5 reps (high center of gravity anterior loading) Day 18: Added Floor-to-waist lift from ½ kneeling position (work sim problem solving session) Day 19: Added bar loaded deadlift from knee level (75lb x 3, 95lb 2x3, 105lb 3x2)
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Day 20 (DC): Increased deadlift to 115lb, then jog 200 ft perform dead lift x 3, 6 rounds Next day released to work full duty, continues to work full-time today. Phone follow-up last week
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___________________________________ Exercises Sumo Deadlift
HighPull
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Deadlift
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___________________________________ Exercises Goblet Squat
½ Kneeling Lift
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___________________________________ Progression (88 days total) All progressions based on ability to maintain centralization Restoration of flexion initiated early to promote function Activation initiated early Gym program session 3 Work related physical demands established early Specific work task questioning: Session 4 From this point, lifting activities were related back to work environment Work related fears/concerns established as early as relevant Session 16, earlier was unrealistic for RTW
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___________________________________ References 1. 2. 3. 4.
5. 6.
Liebenson, C. Rehabilitation of the Spine. A Practitioner's Manual. 2nd Edition. Lippincott Williams&Wilkins 2007.p 612-652. O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997;22:2959-2967 Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Physical Therapy 2005;85:209-225. George SZ, Zeppieri G. Physical therapy utilization of graded exposure for patients with low back pain. Journal of Orthopaedic & Spine Physical Therapy 2009;39(7):496-505. Smeets RJEM, Vlaeyen JWS, Kester AD, Knottnerus JA. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. The Journal of Pain 2006;7(4):261-271. Nicholas MK, Linton SJ, Watson PJ, Main CJ. Early identification and management of psychosocial risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Physical Therapy 2011;91:737-753.
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Thank You
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