1. By Kyle Schultz & Sarah Hoover

2. 42 y.o. male construction worker who
sustained a low back sprain/strain
injury on the job while lifting and
twisting a 60 lb load.
(the 3rd injury to his back)
His medical history is NEGATIVE for
any contributing factors including the
absence of any known spinal disease.

3. SUBJECTIVE
 10/10 back pain initially, reduced
to 6/10 (max) – 2/10 (best)
 Avg. pain (w/ pain meds): 3-4/10
 Pt. reports occasional pain
shooting down his R leg to his
toes, but no loss of sensation
 Pt. reports that he does not do
any regular exercise
 Pt. stated he did not receive lifting
training (except 5 minute verbal
instruction “years ago”)
OBJECTIVE
 Pt. is slightly overweight and
presents with a slightly foreword
flexed posture
 Lumbar spine shifted to the left
 Significant tenderness and edema
in bilateral lumbar paraspinals
(right > left), and R gluts
 Multiple trigger points in R gluts
 Palpation of trigger points reproduces
radiating pain down R posterior leg
 Unable to test core muscles due
to pain
 Pt. only able to isometrically contract
rectus abdominus

4. OBJECTIVE (CONT’D)
 Myotomal and neuro screens of
LE are negative
 Slump and SLR tests are positive
for reproducing pain
 Tight hamstrings noted during
SLR test:
 L LE: 0 – 40 degrees of hip
flexion
 R LE: 0 – 50 degrees of hip
flexion
 Lumbar AROM:
FF: -7  17 degrees
 Limited by pain and
deviates to the L
Ext: +7  0 degrees (neutral)
 Limited by pain
SB L: 15 degrees
SB R: 5 degrees (pain)
RR: 15 degrees
RL: 5 degrees (pain)

5. Question #1:
 Paraspinal muscular hypertrophy &
acute inflammation (poor lifting
technique + lack of abdominal bracing)
 Poor lifting technique, exponentially
increases the force exerted on the spine
 Rotation of the spine under this force caused
a lumbar strain/sprain
 Inflammation  radiating pain down sciatic
nerve root
 Left AIC Pattern
Shelly
Alex
What do you think are the most likely
anatomical causes of his back and RLE pain
based on his clinical exam? Why?

6. Question #2:
 E-Stim
 Thermotherapy
 Traction
 Myofascial Release
 Trigger Point Dry Needling
 Active Release Techniques
Shelly
Alex
What modalities would you choose and what
settings/parameters to reduce edema, pain, or
both?

7.  IFC
 Pain
 Edema
 Heat
 Pain
 Relaxing muscles and
supportive structures

8.  Form of
decompression
therapy that relieves
pressure on the spine
 Can be done manually
or mechanically

9.  MFR
 Highly specialized stretching technique used for a
variety of soft tissue problems

10.  What is dry
needling?
 What is a Trigger
Point?

11.  ART
 Similar to deep tissue
massage but uses the
patient’s natural body
mechanics to break up
adhesions and to
stretch tissue

12. Question #3:
 Contraindication: Acute Inflammatory
Phase
 Redness, edema, warmth of skin
 Wait at least 72 hours post-injury
 Traction could be beneficial for this patient
and reduce his pain by:
 Soft Tissue Stretching
 Muscle Relaxation
Ryan
Jesse
What traction setting would you use and why?
If you decide not to use traction, then why
would you not use it?

13.  Settings:
 Static traction (inflammation)
 Supine w/ hip flexion
 25% pts body weight (initially)
 Increased distance between
vertebral bodies/facet joints
 Increases length of soft tissues
in the area
 Increases spinal ROM
 Relaxation of the paraspinal
muscles
 Decreases pain

14.  P: 130 people (20-60 years of age) with chronic nonspecific LBP that were
referred for fitness-for-work evaluation to measure their physical ability to
safely engage in work-related activities
 I : Waddle signs (Questionnaire)
 8 physical signs to assess psychological factors that could negatively affect
performance of lifting activities
 C: Functional Capacity Evaluation (FCE)
 Determined the level of effort utilizing predetermined observational criteria
 3 FCE lifting tests (floor to waist, waist to shoulder, horizontal lifting)
 O: 53%-63% of participants who exhibited submaximal effort during FCE
tests also presented with Waddell signs. The contribution of submaximal
effort to an unsafe performance was greater than that of Waddell signs,
with a 20%-29% higher explained variance. Therefore, Waddell signs
should not be used independently to analyze an individuals ability to safely
engage in work-related activities.

15. Question #4:
 Poor Lifting = Low Back Pain
 Types and Causes
 How to avoid these injuries
 Proper lifting techniques and proper body
mechanics
 Compressive forces on the disc
Ryan
Jesse
What would you teach him initially about
lifting and body mechanics? Write out a brief
script.

16.  Types
 Muscle Strains
 Ligament Sprains
 Radiculopathy
 Disc Pathologies
 Causes
 Poor Physical Condition
 Poor Posture
 ExtraWeight
 Stress
 Over working (“pushing it”)
 Poor body mechanics

17.  Place objects higher
 Raise/lower shelves
 Body
management/conditioni
ng
 Reduce weight
 Use straps
 GET HELP!!

18.  Load
 Lever
 Lordosis
 Legs
 Lungs

19.  Standing: 100% of BW
 Supine: < 25%
 Side-lying: < 75%
 Standing and bending
forward: ~ 150%
 Supine with both knees
flexed: < 35%
 Seated in a flexed position:
~ 85%
 Bending forward in a flexed
posture and lifting: ~ 275%

20. Question #5:
 Myofascial Release
 Active Release Technique
 Dry Needling for trigger point release
 Ice cup massage to paraspinals
 Good for small area
 Decrease Pain and edema
 SLR with distraction
 Stretch soft tissues of the acetabulo-femoral
joint, as well as the hip extensors
Josh C
Rene
What manual therapy techniques could or
would you use to address the pain, edema
and trigger points? Why did you choose
these techniques?

21.  Patient Position: supine, close to edge of
table. Hip is flexed to loose-packed
position, keeping knee extended
(decrease hip flexion if symptoms
reproduced)
 Therapist Position: staggered stance,
applying force to increase dorsiflexion
and to maintain knee extension
 Mobilization: therapist applies a force
away from the patient’s hip for
traction/distraction (Grade III)
(Hensley, C.P. & Courtney, C.A, 2014)

22. Question #6:
 SF-36 / SF-12
 Roland-Morris Questionnaire (RMQ)
 Oswestry Low Back Paid Disability
Questionnaire
 Patient-Specific Measures
 Functional Capacity Evaluations (FCEs)
 ROM
 Manual Muscle Testing (MMT) scores
Josh C
Rene
What outcome measures/tools could you use
to follow his care and why could you use
them?

23.  Subdivided into 2
separate health
constructs
 Measures 8 different
health concepts
 Self-administered
 SF-12 is an
abbreviated version

24.  Most widely tested of
all disease-specific
measures
 Consists of 24
questions
 Scored on a scale of
0-24

25.  Self-administered
 Takes 5 mins to
complete
 Includes 10 sections
 Sections scored from 0-5
 First developed in 1980

26.  Patient selects up to
5 main activities
which they find
difficult
 Asked to rate ability
to complete the
activity on an 11
point scale
 Takes about 15 mins

27.  Highly specific to
individual’s job tasks
 To identify risk factors
associated with a
particular job or activity
 Administered to a
patient recovering from
injury before returning to
work

28.  To identify and set goals
based on measurements
 Identify where limitations
are
 Puts a reproducible
number that can be used
to evaluate progress

29.  Identifies which muscles
are weak
 Identifies compensatory
patterns
 Sets up interventions for
muscles with limitations
 Reproducible evaluation
to track progress

30. Question #7:
 SLR stretch
 Nerve glides
 Stretch HS
 Balance exercises
 To increase abdominal
strength and control
 Tandem & single leg
stance (advanced with
airex)
 Stretching on Foam Roll
 Decrease kyphosis of
thoracic spine, retract
shoulder girdles, PPT
 Add marching = balance
exercise
Erica
Monique
Describe at least three exercises in detail that
you would teach him early on in his therapy.
Why did you choose these three exercises?

31. He is cleared for full duty but you sense he is
not ready and have the supervising PT do a
reevaluation which shows continued core
weakness, that the patient still does NOT know
his lifting techniques without prompting, and he
still needs reminders about what exercises to
do. The PT gets the doctor to order a few more
sessions.

32. Question #8:
 Advanced Exercises
 “Proximal Stability for Distal Mobility”
 Stabilization Training
 Flexibility
 Cardiovascular conditioning
 Postural Restoration Institute (PRI)
exercises
Erica
Monique
What advanced exercises would you choose
at this point? Describe them and the rationale
for using them.

33.  Hamstring Stretch
 Pelvic tilt
 Arm/leg raises
 Exercise ball
bridges
 TA activation /
exercises

34.  Neck and shoulder
stretches
 Back exercise
stretches
 Hip and Gluteus
stretches

35.  Low-impact aerobic
exercises
 Benefits of aerobic
exercise for back
pain

36.  P: 42 y.o. male with low back sprain/strain
and history of mild back pain
 I: Standard physical therapy integrated with
PRI exercises
 C: Standard physical therapy with IFC,
Aquatic Therapy
 O: Using the Oswestry Disability Index for
comparison: IFC = 2.5% improvement,
Aquatic = 11% improvement, Standard with
PRI = 40% improvement

37.  90/90 Hip Lift
 With hip shift
 Right side lying left
adductor pull-back
 Left side lying knee-
toward-knee

39.  P: 101 sets of monzygotic (identical) twins (202 men, avg. age = 49.35)
with a history of LBP
 I : Behavioral, environmental, and constitutional factors leading to
paraspinal asymmetry
 C: Genetic Link of paraspinal asymmetry
 O: 57.92% of participants had erector spinae muscle asymmetry. This
asymmetry was found to be associated with handedness and the greater
CSA was found on the dominant side (usually the right). Greater asymmetry
was not always associated with greater LBP and there was a lack of
statistically significant data linking asymmetry and/or LBP with specific
factors that were investigated. The results did suggest that greater exercise
and sports participation may decrease the likelihood of paraspinal
asymmetry. It is unclear what accounted for the large portion of
unexplained variance in muscle asymmetry, but some degree of asymmetry
may be a naturally occurring phenomenon in human anatomy

40.  The human body is not symmetrical
 Ex: Asymmetry of the diaphragm
 PRI recognizes anatomical imbalances and
typical patterns associated with system
disuse, or weakness that develops because of
dominant side overuse (usually Right)
 When these imbalances are not regulated, a
strongly favored pattern emerges (Left AIC =
most common)
 Structural weaknesses
 Instabilities
 Musculo-skeletal pain syndromes
 Gait/Postural Deviations

41.  Difficulty rotating to one or both sides
 Elevated anterior ribs on the LEFT
 Influencing breathing patterns
 Lowered, depressed shoulder and
chest on the RIGHT
 LEFT pelvic is anteriorly tipped and
forwardly rotated
 Excessive hypertrophy of right lower
back muscle

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