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14438537 Physical Therapy Protocols for Conditions of the Low Back Region[1]

14438537 Physical Therapy Protocols for Conditions of the Low Back Region[1]

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Published by: tinadasilva on Nov 13, 2009
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 Red Flags for Potential Serious Conditions in Patients with Low Back Problems
Red Flags for the Low Back RegionConditionRed FlagData obtained during Interview/HistoryRed FlagData obtained during Physical Exam
Back related tumor
Age over 50History of cancerUnexplained weight lossFailure of conservative therapyAge over 50 of history of cancer or failureor conservative therapyAmbiguous presentation in early stages.Constant pain not affected by position oractivity; worse with weight-bearing,worse at night.Neurological signs in lower extremitiesBack related infection(Spinal osteomyelitis)
 Recent infection (e.g., urinary tract or skininfection)Intravenous drug user/abuserConcurrent immunosuppressive disorderDeep constant pain, increases with weightbearing; may radiateFever, malaise, and swellingSpine rigidity; accessory mobility may belimitedCauda equinasyndrome
Urine retention or incontinence
incontinenceSaddle anesthesiaGlobal or progressive weakness in thelower extremitiesSensory deficits in the feet (L4, L5, S1 areas)Ankle dorsiflexion, toe extension, and ankleplantarflexion weaknessSpinal fracture
History of trauma (including minor fallsor heavy lifts for osteoporotic orelderly individuals)Prolonged use of steroidsAge over 70Loss of function or mobilityPoint tenderness over site of fractureExquisitely tender with palpation overfracture siteIncreased pain with weight-bearingEdema in local areaAbdominal aneurysm
Back, abdominal, or groin painPresence of peripheral vascular disease orcoronary artery disease & associatedrisk factors (>50, Smoker, HTN, DM)Symptoms
related to movementstresses associated with somatic LBPAbnormal width of aortic or iliac arterialpulsesPresence of a bruit in the central epigastricarea upon auscultationKidney disorders
pyelonephritisnephrolithiasisrenal cellcarcinomaUnilateral flank or low back painDifficulty with initiating urination, painfulurination, or blood in the urineRecent of coexisting urinary tract infectionPast episodes of kidney stonePositive fist percussion test over the kidneyReferences:1. Bigos S, Bowyer O, Braen G, et al.
 Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642
. Rockville, MD: Agency for Health Care Policy and Research, Public HealthService, U.S. Department of Health and Human Services. December 1994.2. Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies.
 J Gen Intern Med 
1988;3:230-238.3. Lew DP, Waldvogel FA. Osteomyelitis.
 N Engl J Med 
1997;336:999-1007.4. Hakelius A, Hindmarsh J. The comparative reliability of preoperative diagnostic methods in lumbar discsurgery.
 Acta Orthop Scand 
1972;43:234-238.5. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain?
1992;268:760-765.6. Halperin JL. Evaluation of patients with peripheral vascular disease.
Thrombosis Research
. 2002;106:V303-V311.7. Krajewski LP, Olin JW. Atherosclerosis of the aorta and lower extremities arteries. In: Young JR, Olin JW,Bartholomew JR, editors.
Peripheral Vascular Diseases. 2
. St. Louis: Yearbook Medical Publishing, 1996.8. Bajwa ZH. Pain patterns in patients with polycystic kidney disease.
Kidney Int 
. 2004;66:1561-1569.
Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency
 NAME: ________________________________________ DATE: _____________Medical Record #: _________________________
Yes No1. Have you recently had a major trauma, such as a vehicle accident or afall from a height?2. Have you ever had a medical practitioner tell you that you haveosteoporosis?3. Do you have a history of cancer?4. Does your pain ease when you rest in a comfortable position?5. Have you recently had a fever?6. Have you recently lost weight even though you have
beenattempting to eat less or exercise more?7. Have you recently taken antibiotics or other medicines for aninfection?8. Are you currently taking steroids or have you been on prolongedsteroid therapy?9. Have you been diagnosed with an immunosuppressive disorder?10. Have you noticed a
onset of difficulty with retaining your urine?11. Have you noticed a
need to urinate more frequently?12. Have you noticed a recent onset of numbness in the area of yourbottom where you would sit on a bicycle seat?13. Have you recently noticed your legs becoming weak while walking orclimbing stairs?
 Adapted from Bigos et al. AHCPR Clinical Practice Guideline. No. 95-0642
Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency
Pelvic Girdle Mobility Deficits
 ICD-9-CM code
: 846.1 Sprain of sacroiliac ligament
 ICF codes
: Activities and Participation Domain code:
Shifting the body’s centre of gravity (Adjusting of moving the weight of the body fromone position to another while sitting, standing or lying,such as moving from one foot to another while standing.)Body Structure code:
Sacral vertebral columnBody Functions code:
Mobility of pelvis
Common Historical Findings
:Unilateral sacroiliac, buttock, and/or groin painSymptoms worsen with lower extremity weight bearing and weight shifting activitiesOnset related to fall onto buttock; misstep or abrupt weight bearing onto straightened leg;pregnancy, or child-bearing strain
Common Impairment Findings
Related to the Reported Activity Limitation or Participation Restrictions:
 Restricted innominate mobility (e.g., positive march test)Asymmetrical bony landmarks, (e.g., Posterior Superior Iliac Spines –PSIS's; AnteriorSuperior Iliac Spines- ASIS's)Symptom reproduction with palpation of sacroiliac ligaments (e.g., long posterior sacroiliacligaments, short posterior sacroiliac ligaments; sacrotuberous ligaments)
Physical Examination Procedures
:March Test March TestPosterior Rotation of the Anterior Rotation of theLeft Innominate Left InnominatePerformance Cues:The march test is utilized to examine the active mobility of the innominate bone (PSIS)relative to the sacrum (S1-S2 area) via full active hip flexion while standing
Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency

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