ページ3:

Rule out
for space occupying
lesions
Rule in
Space occupying
lesions
• PSLR (Passive Straight-Leg Raise)
Very highly sensitive for a space occupying lesion
1-s
-
Sn
= 0.90
= back pain/leg pain <450
m
• Crossed SLR
Similar to PSLR
but moving the contralateral leg
7 - Specific for a space occupying lesion.
= back pain/leg pain
D
Stump
down
.
Slump test..
③
Place hands
behind back
c-spine flexion.
D
④knee
ext.
ankle DF
very
Sensitive to rule out space
occupying lesions.
Sh= 0.84
= back pain/leg pain.
looking at neurodynamics/
heuro compressive forces

ページ4:

"Red Flag Assessments
Pain
.
un controlled with analgesics
• not reproduced exacerbated by evaluations.
• worsen at night/rest
exacerbates with general activity
bilateral
encompasses several dermatomes
Constitutional
• any changes in the bowel/bladder functions.
1. any recent infections.
•
nausea
vomiting
Shortness of
Breath
Where
Tendons
Ligaments
attach to bones
Systemic
Pathology
Signs
Seribus
of
Pathology
Ankylosing spondylitis.
chronic inflammatory arthritis
affecting the spine/SI Jt.
*- Pn with rest, Pn with physical activity
♥-morning stiffness > 30 mins.
- advanced
the vertebrae fuse together.
<45 yo; M > F.
(4)

ページ5:

Pain
Beliefs
Emotional
responses
behavior
common in
brain &abdomen
•
Aneurysm
- a
bulge in the wall of the blood vessel.
• Kidney stone
• Cancer
•
Infection
Cauda equina
Yellow Flag Assessment,
Injury is
uncontrollable
No treatment
is gonna help
No motivation
o
to return to work
Canxiety
fear.
7
7
-Avoidance of activities to possible reinjury
-Overreliance on passive treatments.

ページ6:

0
O
O
"Clinical Decision Making,
Red Flag Referral/consult with Dr.
↑
if not getting better.
Yellow Flog
→Continue treatment, but
Lumbar Imaging
.
monitor closely
In athletic population,
early lumbar
imaging is very important for
the young athletes.
In general
Population,
not so much.

ページ7:

0
Ch2. Lumbar Conditions and
Treatment-Based Classification
Treatment-Based Classification Model,
Manipulation/Mobilization.
①Direction Specific Exercise
③Stabilization.
④Noci plastic Pain.
This categorization helps to determine
what type of treatment works best for
Ithe desired functional outcome.
C
How to
tule in/out?
Manipulation/Mobilization category
a) Positive clinical predictive rule.
acute → < 16 days
no heuroissues. No s/s below the knee.
no fear
←
'
FABQ Score <19
> one hypomobile L-spine (PA glide)
> one hip with >35° Passive IR
tight L-spine,
hot hip Je

ページ8:

30-45
(b) Clear closing pattern.
- limitation/pain with:
ext., ipsilateral rot. / side bending
c) SI Jt. dysfunction.
• unilateral PSIS region pain.
Patients can point with one finger
(Fortin Sign
Sn = 0.76
*
Sp=0.47
"groin pain (Sp = 0.63)
-buttocks
pain
(So= 0.80)
PSIS +groin pain = Sp 0.85
- ④> ³/s of =
Distraction test.
Thigh thrust
Compression test
Sacral thrust
Gaenslen's test.
2
ASIS
distraction.
thigh thrust
Support the
Sacrum.
S2
Compression
Sacral thrust
lay down on no es side.
hip J+ 45°
Jenee Je 900.
Goenslen's
test.
8

ページ9:

01
0
C
- Specific conditions
• facet impingement
Llocalized symptoms.
imaging
.
jt hypomobility .
• lumbar strain/sprain
L localized symptoms.
imaging
muscle guarding/trigger points ④
Sacroiliac dysfunction.
PSIS pain
How to
rule in/out?
groin pain
P.②
3/5 Tests ④
Direction-Specific Exercise category.
(a) Repeated movement testing.
*- Centralization →→Sp = 0.94.
& B
specific to positive
discography.
-LBP
radiating to
the leg
Set the
base line
-Pn &location

ページ10:

Centralization
11
very good
Prognosis
-
Goal of repeated movement test
.
find the specific directions that
Pn, I ROM, & centralizes symptoms.
/Ext. responder
Flex. responder
→
→
Lat. responder.
Bulging/
Hernia
Lumbar
Stenosis
←
eg) bulging disc,
eg)
) Stenosis
Spondylolysis
Spondylolisthesis
eg) lat bulging
•Flex. ↑ Pn & radicular symptoms.
•Repeated movement test ④
(Ext. centralizes the symptoms)
Ext. Pn radicular symptoms
Repeated movement test ④
(Flex. centralizes the symptoms)
Spondylolysis → Ext. Po
Radiographic evidence of
bony lesion
(10)
2

ページ11:

How to
rule in/out?
Stabilization category
a) Clinical prediction rule:
Age <40
• SLR >90°
primarily have
motor control issue,.
not mobility issue.
O
O
3/4+
LR4.0
• Abnormal movements,
eg)
Catching in the back
Prone instability test
walking hands up their
leg to get bock up when
bending forward.
b) Abnormal (aberrant) movements are:
Painful arc (mid-range pain)
☹ Instability catch/lock.
③Gowers' sign (thigh climbing)
↓
poor lumbar
Segmental
Contro
c) Prone instability test:
PA glide on the L-spine.
If PhD, PA glide on the L-spine.
(eg: 24).
D
O
Toes
ontheground
(
⑪
1~2cm.
If pain
11.
instability

ページ12:

all category
*Beighton
Score.
all athletes will filter to
local motor control.
&
neurodevelopmental stabilization exs.
OR. begin with this category if there is no
clear direction preference or mobility dysfunction.
• Prone instability test ℗
Aberrant movements +
Segmental
hands flat on
the floor
Instability
Congenital
Hypermobility
• Motor control dysfunction④
. "Beighton criteria (>5/9)
hyper ext.
thumb- forearm
Pinky@900
to the back
of your hand.
④Nociplastic pain category.
IASP criteria (International Association for the
Study of Pain)
- Po 73m.o.
Regional pain distribution (not localized)
- Pn that cannot be explained by nociceptive or
heuropathic pathways
- Hypersensitivity in the region of the pain.
• High level of disability on
Oswestry Disability Index (>50%)
- Örebro Musculoskeltal Pain Questionnaire (>105)
Central Sensitization Inventory (40/100)
(12)

ページ13:

CCC
• Nociplastic Pain is :
Pain arises from altered nociception.
despite no tissue damage.
"
eg).. Injury (long time ago)
↓
- healed (no pathology, any more)
-
but,
hociceptors
activation
causing
widespread / intense.
-multifocal pain
-CNS-derived symptoms
fatigue
sleep problems
memory problems
eg). - Fear of reinjury
mood problems.
psychological consequences may persist
even after completely physically rehabilitated.
Fear
Avoidance
Behavior
Injury
Pain &
Altered Motor
Control
Kinesiophobia
13
Be ready
physically as wellas
psychologically

ページ14:

after classified
into 4 category.
-hip
"Movement Assessment
ankle
upper back
etc...
• LBP recurrence ^^.
Address the factors leading to "why the patient
1 had back pain" with movement assessment.
reduce
rate
recurrence
P
•Maltisegmental flex.
-hamstring flex.
hip flex
spine flex
· pelvic & core stability.
•Malti segmental ext
-hip ext.
-T/L-spine extension.
• Multisegmental rot.
-hip rot.
M
Q
Deep SQ
-ankle D.F.
•Single-leg Stance
hip & core
Stability
(

ページ15:

Ch3. Medical Diagnosis & Imaging
Differential Diagnosis
Fit really
is "cely int
this differential
diagnosis.
• mechanical back pain.
.
8
。
Spondylolysis
Scheuermann's kyphosis
• acute disc herniation.
.
discitis/osteomyelitis
• Liver (L) <
• Spleen (s)
Sometimes
mimicking
like C6
close proximity
to diaphragm.
Gallbladder (G)
right under
Scapula.
synapsing
afferents on
Second-order neurons
In Cord atⓇ
lower T-spine.
retroperitoneal
Organ
↑
Stomach (st)
Bowel (B)
sensitive to
what,
F
when, have eaten.
Worse with
eating/
haven't eaten
• Pancreas (P) < lying back
Pn.&
>• Kidney (K) upright & Pn.
rhythmic P
(ureter).
•Neoplasm (tumor)
(15)

ページ16:

belly
Red Flags
*. Poor
response
to conservative care
*Unexplained change in bowel/bladder conditions
*. Symptoms not consistent with mechanical cause
.
of pain.
• Blood in sputum.
• Nonhealing sores / wounds
• Unexplained significant UE/LE weakness
Progressive neurological deficit
Medical Screening,
.
.
Upper Motor Neuron (UMN) testing
- Upper/Lower quadrants screen.
Temp. of the extremities / skin discoloration.
Auscultation
Abdominal exam (palpation)
Ask questions & more questions & more..
Important to try & sort out!
(16)
lungs
-heart
know the normal
sound
2
2

ページ17:

Diagnosis of Extension Pains
札
• One-legged hyperextension test
neither specific nor sensitive....
• Lumbar spinous process palpation test
A too difficult to reproduce pain.
Spondylolisthesis test.
look for the step-off
(Sp = 85
=85~100
/
Sn = 60~88)
but, doesn't mean "no problem".
201
It can show
Imaging
· X-ray
→ see a stress injury
or spondylolisthesis?
Yes No
.
•CT scan
Bone Scan
'
MRI
K
edema/Swelling
in the bone itself
(= acute stress
injury)
→ Surgery.
more dominant to look for
e acute stress injuries than
No
Bone scan.
V = Bone is normal.
(mechanical backpain).
go rehab.
17
Grade it to look
for any potential
to heal
(early? progressive?
Terminal?)
no healing.

ページ18:

people with
this often
return to
ports without
complete healing
(without pain)
"Treatment Extension
.
Conservative treatment (bracing/rest/rehab etc)
Surgical treatment.
Outcome variables were:
-Healing
Self-reported result
Return to sport
"Outcome Extension
If bracing
M-12 wk (8~32 wk))
2
2
2
•
Unilateral lesion
←
healing up to 100%.
• Bilateral terminal lesion →
A
healing as
as low as 0%.
2
However,
.
Both of them can get back to sport with.
the appropriate rehab.
2
2
2
2
2
)
)