where is pain the worst? is pain constant or intermittent? back

Where is pain the worst?

Is pain constant or intermittent?

Back Dominant Leg Dominant

Since the start of your back trouble, has there been a change in your bowel or bladder function?

What can’t you do now that you could do before you were in pain and why?

What are the relieving movements or positions?

Have you had this same pain before?

What treatment have you had in the past, and did it work?

Are you experiencing morning stiffness in your back that lasts greater than 30 minutes?

Pattern 1

Constant or Intermittent Pain

Worse with flexionBetter with Prone

Extension - PEPWorse with Prone Extension – PEN

Pattern 2

Intermittent PainWorse with extensionSame or better with

flexion

Pattern 3

Constant painPositive Neurologic

Pattern 4

Intermittent PainWorse in Flexion

FA-Flexion Aggravated

Worse with activity in extension (walking) Better in Flexion –

FR- Flexion RelievedExam usually normal

History must be supported by physical exam

Does bending forward make your typical pain worse?

Version 5.1 – December 2015

Where is your pain the worst? You must determine if the pain is back or leg dominant. Back symptoms usually involve both the back and the leg but one site will predominate. That distinction is essential for pattern recognition. Back dominant pain is referred pain while leg dominant pain is radicular pain. The pain is considered back dominant if it is worst in the low back, buttocks, coccyx, and groin or over the outer aspects of the hips. The pain is considered leg dominant when the pain is worst around and below the lower buttocks at the gluteal fold, in the thigh, calf or foot. It may be easier to determine the dominant location by stating that only one site will be treated and asking which pain the patient wants abolished. Axial (back dominant) pain arises from a spinal structure but

may have accompanying referred pain into the leg. When

forced to choose, patients with axial pain will acknowledge that

the back pain is worse. Radicular (leg dominant) pain indicates

direct nerve root involvement in addition to the mechanical

malfunction. Again, patients often report pain in the back as

well as in the leg; but for those with radicular pain, leg pain

below the buttock will be the chief complaint.

Is your pain constant or intermittent?

Determining if the pain is constant or intermittent can be equally or more difficult. Most patients who endure prolonged discomfort describe their symptoms as constant. The inquiry, therefore, must be clear and specific. It is best asked in two parts:

“Is there ever a time during the day when your pain stops, even for a brief moment and even though it may quickly return?”

“When your pain stops, does it disappear completely; is it totally gone?” Truly intermittent back dominant pain is never the result of spinal malignancy or active infection. The power of these questions, properly asked and answered, is enormous. They can eliminate the chance of the clinician missing a sinister pathology, one of the commonest concerns about relying so heavily on the history and physical examination.

The Pattern question:

“Does bending forward make your typical pain worse?”

This is the essential element of the broader question, “What are the aggravating movements or positions?” It is the specific pain producing movement that confirms pattern recognition for Patterns 1, 2 and 3. Pattern 4 is identified on history alone but separating Pattern 4 FA from FR depends on the response to flexion.

In the physical exam, it is the determining question to differentiate between:

Pattern 1 Pain is reproduced or increased in back flexion.

Prone Extension Positive PEP

Pain is reduced after the patient performs up to ten prone passive

back extensions. Raise the upper body by pushing up with the arms.

Move the hands far enough forward to fully extend the arms and lock

the elbows while the hips remain down.

There is a “directional preference”.

Prone Extension Negative PEN

Pain is either unchanged or increased after the patient performs up

to ten prone passive back extensions.

There is no “directional preference”.

Pattern 2

Pain is reproduced or increased in back extension.

Pain is never increased in back flexion.

Pattern 3

Leg pain is affected by position and all back movements including

flexion.

Pattern 4

Flexion Aggravated FA

Leg pain is worse with flexion.

Flexion Relieved FR

Leg pain is relieved with rest in flexion.

Leg pain is increased with activity in extension.

Bowel or Bladder function change?

The fourth mandatory question is, “Since the start of your back trouble, has there been a change in your bowel or bladder function?” Asking the question in this way avoids confusion with long

standing and unrelated urinary or GI problems. The changes

that suggest a possible Acute Cauda Equina Syndrome are:

urinary retention followed by insensible overflow

faecal incontinence

o perineal numbness is the other significant finding Rather than initially searching for a detailed description, the query is deliberately vague in nature. Specifying changes only since the start of the attack avoids unnecessary worry about previous, unrelated disorders. A report of “no change” removes the necessity to go further. Any positive response requires a more thorough investigation. Urinary retention followed by insensible, uncontrolled overflow and fecal incontinence is indicative of an acute cauda equina syndrome: a surgical emergency.

Five remaining questions

Five remaining questions complete the clinical picture and establish a link to the past history and the level of present disability:

1. “What can’t you do now that you could do before you were in pain and why?”

The reason for the limitation (“why?”) should be the same as the response to the first question, “Where is your pain the worst?”

2. “What are the relieving movements or positions?” 3. “Have you had this same pain before?” 4. “What treatment have you had before, and did it work?” 5. If patient under 40 yrs. old, “Are you experiencing morning

stiffness in your back that lasts greater than 30 minutes?”

Mechanical back pain is responsive to movement and position. Discovering the aggravating and relieving factors helps identify the syndrome and suggests a pain control strategy. Inflammatory back pain is suggested by the last question and should be investigated further. Other symptoms include:

Morning stiffness >1hr diagnostic if age < 40yr old

Persistence of pain in spite of treatment over several months

Disproportionate night pain

Onset usually <40 years of age

Peripheral joint involvement

Other systemic symptoms (e.g. iritis) Consider: Sacroiliitis, Iritis, IBD, Enthesitis, Psoriasis, Family History of Ankylosing Spondylosis/Rheumatoid or Spinal Osteo Arthritis Back pain is a recurrent complaint that tends to worsen with time. In a survey of patients seeking care, over half had suffered more than 10 attacks and over 60% believed that their present attack was, in at least one respect, worse than the preceding one. The degree of physical limitation and the value of past therapies influence the current choices.

The Physical Examination The physical examination is not an independent event. It should be designed to verify or refute the history.

Performing the examination in the most efficient manner usually means starting with the patient standing then

progressing to kneeling, sitting on a chair, sitting on the examining table, lying supine and lying prone. Select the

optimum position for each test.

Observation:

General activity and behaviour

Back specific:

Gait

Contour – subtle malalignments are not relevant

Colour – areas of obvious inflammation

Scars

Palpation:

Of limited value – briefly palpate for tenderness and gross deformity

Movement:

Flexion – reproduction of the typical back pain and rhythm of movement

Extension – reproduction of the typical back pain and rhythm of movement

Prone passive extensions – up to 10 when suggested by the history

Other spinal movements – when suggested by the history

Pain is reduced after the patient performs five prone passive back extensions. Raise the upper

body by pushing up with the arms. Move the hands far enough forward to fully extend the arms

and lock the elbows while the hips remain down.

There is a “directional preference”.

Nerve root irritation tests:

Straight leg raise test

Patient lies with the other hip and knee flexed

Passive test - the examiner lifts the leg

Reproduction or exacerbation of the typical leg pain

Reproduction of back pain is not relevant

Produced at any degree of leg elevation

Femoral stretch test – when suggested by the history

Passive test - the examiner lifts the leg

Patient prone with the knee extended

Reproduction or exacerbation of the anterior thigh pain

Back pain is common but not relevant

Nerve root conduction tests: The first test in each group (in italics) is all that is required for a basic screen.

L3-L4 Knee reflex

Test with the patient seated, lower leg hanging free

Quadriceps power

Test with patient seated – extend knee against resistance

L5 Extensor hallucis longus

Test with the patient seated, foot on floor – elevate great toe against resistance

Heel walking (L4)

Walk five steps at maximum elevation

Ankle dorsiflexion (L4)

Test with the patient seated, foot on floor – elevate forefoot against resistance

Hip abduction

Trendelenburg test – the patient stands on one leg and then on the other. The hip abductors

are tested for the leg on which the patient is standing. The movement of the contralateral crest

is the marker. A normal test is symmetrical.

S1

Flexor hallucis longus

Test with the patient seated, foot on floor – curl great toe against resistance

Toe walking

Walk five steps at maximum elevation

Plantar flexion

Toe raise on both feet and then on the affected side – examiner supplies balance

Ankle reflex

Test with the patient kneeling

Gluteus maximus muscle tone

Test with patient prone – palpate buttocks as patient tenses and relaxes

Mandatory tests:

Upper motor tests

Plantar response, clonus – any upper motor finding negates a low back mechanical diagnosis.

Saddle sensation

Lower sacral (S2,3, 4) nerve root test – the same roots that supply saddle sensation supply bowel and

bladder function.

Tested in the mid-line between the upper buttocks

Sensory testing:

Optional – for confirmation of root level – when suggested by the history

Ancillary testing:

Hip examination – typical pain on flexion-internal rotation– when suggested by the history

Peripheral pulses– when suggested by the history

Abdominal examination– when suggested by the history

16 Journal of Current Clinical Care Educational Supplement • January 2013

The PaTienT wiTh newly DiagnoseD UlceraTive coliTis

Making SenSe of Low Back Pain

Figure 1:Physical Examination to Assess Low Back Pain

Observation

Sitting

StandingExtension

Hip Abduction(Trendelenburg)

Test (L5 NerveRoot Conduction)

Heel Walking Test(L4-L5 Nerve Root Conduction)

Toe Walking Test(S1 Nerve Root Conduction)

Normal Abnormal

Ankle Dorsi�exion Test(L4 and L5 Nerve Root

Conduction)

Great ToeExtension Test(L5 Nerve Root

Conduction)

Flexion

Gait

Movement toReproduce Pain

Great ToeFlexion Test

(S1 Nerve RootConduction)

Upper MotorTest

NormalAbnormal

* 5 steps at maximum elevation

Journal of Current Clinical Care Educational Supplement • November 2012 17

Making SenSe of Low Back Pain

Classi�cation of Mechanical Patterns of Low Back Pain

ReportedPain Location

Pain Constancy Pain Improved Pain Worsened NeurologicalFindings

1 Constant orintermittent

One of 2 cohorts willimprove on extension

Unaected or may beimproved on �exion

By immobility andrecumbent rest

By all back movement, usually more by�exion

Back, buttocksor around hips

Back dominant

Leg dominant

Leg dominant

Forward �exion,one of the 2 cohorts’pain also worsens onextension

Worsens on extension

Activity in extension(walking)

May havepositiveconduction test;no irritative test.

Relieved by rest in�exion (sitting)

Normal

Normal

Positiveirritative test and/or conduction loss

PainOrigin

Most likely discogenic

Most likely posterior spinalelements

Sciatic (or occasionallyfemoral) nerveroot irritation

Neurogenicclaudication, often mislabelledspinal stenosis

Constant

Intermittent

Intermittent

2

3

4

Hip Extension Test(Palpate Gluteus Maximus Tone)

(S1 Nerve Root Conduction)

SaddleSensation Test

(Lower SacralNerve Roots)

Ankle Re�exTest

(S1 Nerve RootConduction)

Straight Leg Raise Test(Sciatic Nerve Root Irritation)

Femoral Stretch Test(Femoral Nerve Root Irritation)

Kneeling

Lying Prone

Lying Supine

Pattern 1: Back Dominant Pain Aggravated by Flexion Descriptive Symptoms

Low back dominant pain: felt most intensely in the back, buttock, over the trochanter or in the groin. Pain is always intensified by forward bending or sustained flexion. Pain may be constant or intermittentNo relevant neurological symptoms

Findings on Objective Assessment This pattern is divided into two groups:

PEP (Prone Extension Positive): Increased pain on flexion and relief with up to ten prone passive lumbar extensions. PEN (Prone Extension Negative): Increased pain on flexion and unchanged or increased with up to ten prone

extensions. Initial Treatment 1. Handout: Back Pain: Patient Information and Pattern 1: Patient Handout2. Follow appropriate treatment schedule: position, movement, pharmacology and adjunct therapies

Positions:PEN: Constant Pain:

“Z” lie Knees to Chest Lie prone: pillow under pelvis

PEN: Intermittent Pain:”Z” lie Minimal lumbar support Lumbar night roll Prone Lie

PEP:”Z” lie Use lumbar support when sitting Place one foot on stool when standing

Movement:PEN: Constant Pain:

Progress to Sloppy Pushup Avoid loaded flexion

PEN: Intermittent Pain:Progress to Sloppy Pushup

PEP:Sloppy Pushup is mainstay of activity (Perform 10 reps every hour as the benefits are short- lived).

Typical Therapy Options:Pharmacologic Therapy Non-Pharmacologic (Adjunct) Therapy

Acetaminophen NSAIDS

Spinal Manipulation Exercise Therapy Massage Acupuncture

Yoga Apply Ice/Heat Progressive Relaxation

Schedule 1: Follow Up: One to two days after beginning therapy 1. Has there been clinical improvement?

Significant ImprovementIt is anticipated that there will be considerable resolution of symptoms within seven days. If necessary, consider gradual return to work program

Limited Improvement Continue to treat – see Schedule 2 If experiencing intermittent pain at reassessment continue to treat as Fast Responders

No Improvement Patients with increased pain or radiation of pain into the legs should be reassessed.

Schedule 2: For patients with limited improvement in first week of treatment

Positions:PEN

Maintain a rigid schedule of rest and movement

Movement:PEN

In addition to initial therapies add asymmetric movements and core stability exercises (Back Pain: Patient Information) Avoid flexion

PEPIncrease lumbar support Use lumbar support when recumbent

PEPImprove techniques and increase frequency Schedule Sloppy Pushup

A Pure Solution for those with chronic back and neck pain734.404.7300 | [email protected] | PureHealthyBack.com

Other General Recommendations• Your back will feel better when you walk or stand

rather than sit. Schedule ________ minutes of walking every ________ hour(s).

• When standing, place one foot on a stool to relieve pressure on your back. Switch feet every 5 to 15 minutes. Maintain good posture.

• Avoid rolling your spine forward. This may put more pressure on the painful areas and increase your discomfort.

Rest Positions and ExcercisesThe rest positions and excercises outlined in this handout can be used to reduce your pain. Your physical therapist will check the boxes next to each recommendation and cross out the rest positions and excercises that are not suitable for your diagnosis and treatment.

>

>

>

>

PATTERN 1 BACK PAIN:At-Home Exercises

Pure HealthyBack (PHB) is committed to providing you an exceptional experience and improving your health. To diagnose and best treat you, we use a simple and elegant method called Patterns of Pain (POP), which was created by world-renowned spine surgeon and best-selling back and neck pain author Hamilton Hall, MD, FRCSC, who is PHB’s medical director. The POP method has been shown to be effective because it allows us to focus on the symptoms you have identified and the problems as you describe them.

Patterns of Pain include four distinct patterns for patients with chronic back pain and four for those with neck pain. You are receiving treatment according to your distinct Pattern of Pain.

Physical Therapist Comments to Patient:

Pattern 1 SymptomsYou’ve been diagnosed as having Pattern 1 symptoms, including:• Pain is worst in the back, buttocks, around the hips,

or in the groin but may radiate to the legs.• Pain may be constant or intermittent.• Pain is worse when sitting or bending forward.• Pain may be eased by bending backwards. Walking

and standing are better than sitting.

Your physical therapist may prescribe other exercises and stretches. Please see the General Recommendations for Maintaining a Healthy Back Patient Information handout.

Committed to Your CareIf you have any questions, please ask a member of your health care team, call, or email us at [email protected]. We are each committed to providing you an exceptional experience and improving your health.

Consult your physical therapist before you begin an exercise program.

R PRONE LIE

Lie on your stomach and use three pillows to support your hips (you may also support your head with pillows). Sometimes just lying on your stomach without any pillows feels best.Rest for ________ minutes every ________ hour(s).

R LUMBAR ROLL: SITTING

Use a straight-backed chair and ___ -inch lumbar roll to support the curve of your back.Rest for ________ minutes every ________ hour(s).

R “Z’ LIE

• Lie with your back flat on the floor and support your head with a pillow (you may also support your buttocks with a pillow).

• Place your feet on a chair with your knees bent at more than a 90-degree angle.

Rest for ________ minutes every ________ hour(s).

R SLOPPY PUSH-UP

• Lie on your stomach with your hands on either side of your head.

• Keep your lower body on the floor and use your arms to slowly raise your upper body. (Your hands may need to be positioned above your head to fully extend your elbows, and your pelvis should remain on the floor.)

• Keep your back muscles relaxed.• Move slowly up. Lock elbows. Sag back. Down.• Do not hold the position.Repeat ______ times every ______ hour(s) during the day.

Start SlowlyFor the first few days, you may only be able to lie on your stomach (see Prone Lie below) and then progress to prone extension using your arms at your physical therapist’s recommendation.

R LUMBAR ROLL: LYING DOWN

Lie on a long sponge roll running across your body between your hips and your ribs to support your back and stop it from sagging.R PRONE LIE ON ELBOWS

• Lie face down on the floor or bed.• Bend your elbows and relax.Rest for ________ minutes every ________ hour(s).

>

Positions: Movement: ”Z” Lie Supine knees to chest Correct sitting and standing postures

Typical Therapy Options:

Repeated supine flexion (Knees to chest) Repeated seated flexion (Use hands on thighs to push upper body into

upright position) Avoid extension as required

Pattern 2: Back Dominant Pain Aggravated by Extension Descriptive Symptoms

Low back dominant pain; felt most intensely in the back, buttock, over the trochanter or in the groin. Pain is never intensified with flexion. Pain is always intensified by extension Pain is always intermittent. No relevant neurological symptoms.

Findings on Objective Assessment Increased or reporduced pain on back extensionPain is unchanged or reduced in back flexionThe neurological examination is normal or non-contributory

Initial Treatment 1. Handout: Back Pain: Patient Information and Pattern 2: Patient Handout2. Instruct patient to follow appropriate treatment schedule: position, movement, pharmacology and adjunct therapies.

Pharmacologic Therapy Non-Pharmacologic (Adjunct) Therapy


Spinal Manipulation Exercise Therapy Massage Acupuncture Yoga Apply Ice/Heat

Follow Up: One to two days after beginning therapy 1. Assess treatment response

Assess pain medication and treatment modalities Assess improvement:

Better = decreased pain or pain is becoming more centralized Worse = increased pain or pain moving towards the periphery

2. Has there been clinical improvement?

Significant Improvement

Movement should begin to restore within one or two days. Full function is expected in two to three weeks If necessary, consider gradual return to work program

Limited Improvement Continue treatment. Use Pattern 1: Slow Responder Improve techniques Introduce manual therapies

No Improvement Reconsider pattern selection If patient has no improvement, reassess





>

>



Rest Positions and ExcercisesThe rest positions and excercises outlined in this handout can be used to reduce your pain. Your physical therapist will check the boxes next to each recommendation and cross out the rest positions and excercises that are not suitable for your diagnosis and treatment.

>

Pattern 2 SymptomsYou’ve been diagnosed as having Pattern 2 symptoms, including:• Pain is worst in the back, buttocks, around the hips,

or in the groin but may radiate to the legs.• Pain is always intermittent.• Pain is worse when bending backward and when

standing or walking for extended periods.• Bending forward or sitting may ease pain.


R KNEES TO CHEST

• Lie on your back with your knees bent and your feet flat on the floor.

• Raise one knee to your chest and slowly raise the other to meet it (you may use your hands to lift your knees if necessary).

• Wrap your arms behind your knees and gently pull both knees toward your chest.

• Hold for a few seconds, relax, and repeat.Repeat ______ times every ______ hour(s) during the day.

R TRUNK FLEXION STRETCH (SUSTAINED FLEXION)

• Kneel on your hands and knees.• Tuck in your chin and let your back bend forward.• Slowly sit back on your heels while dropping your

shoulders toward the floor.Hold for ______ seconds. Repeat ______ times every ______ hour(s) during the day.

R SITTING FLEXION

• Sit with your feet flat on the floor about hip-width apart.• Lean forward and allow your head and shoulders to drop

between your knees.• For added stretch, grab your ankles and pull down.• With your hands on your knees, use your arms to raise

your upper body.• Hold the stretch for a few seconds, sit up, and repeat.Repeat ______ times every ______ hour(s) during the day.

> Other General Recommendations• When standing, reduce unnecessary load on the spine

by using your arms on your thighs to push your upper body into an upright position.

• Avoid extension: Do not bend your back backward. This may cause more pain.

Your physical therapist may prescribe other exercises and stretches. Please see the General Recommendations for Maintaining a Healthy Back Patient Information handout.

Pattern 3: Constant Leg Dominant Pain Descriptive Symptoms

Leg dominant pain: felt most intensely below the gluteal fold above and can extend to the thigh, calf, ankle, foot. Pain is always constant and is affected by back movement or position.Neurological symptoms must be present

Findings on Objective Assessment Neurological examination must be positive for either an irritative test or a newly acquired focal conduction deficit.

Initial Treatment NOTE: Pattern 3 will not respond to exercise. Treatment consists of prescribed REST positions. Track progress over six weeks (Neurological deficit beyond seven days does not happen unless it is Cauda Equina Syndrome).

1. Handout: Back Pain: Patient Information and Pattern 3: Patient Handout2. Follow appropriate treatment schedule: position, pharmacology and adjunct therapies.

Positions: Basis of treatment is scheduled rest: 20-40 minutes every hour

“Z” lie Prone lying on pillows Prone lying on elbows Rest on hands and knees Lumbar support Night roll

Typical Therapy Options: Pharmacologic Therapy Non-Pharmacologic (Adjunct) Therapy

Acetaminophen NSAIDS Tramadol, Opiods

Massage Acupuncture Apply Ice/Heat

Progressive Relaxation Professionally administered invasive therapies Spinal Manipulation(if there is no inflammation)

Follow Up: One to two weeks after beginning therapy

1. Assess treatment response Assess pain medication and treatment modalities Assess improvement:

Better = decreased leg pain Worse = increased leg pain


Significant Improvement Focus on symptom reduction for up to six weeks. Pain should begin to resolve within four weeks Once leg symptoms become intermittent or pain becomes back dominant continue treatment as per Pattern 1.

No Improvement If no improvement, reassess



Pure HealthyBack (PHB) is committed to providing you an exceptional experience and improving your health. To diagnose and best treat you, we use a simple and elegant method called Patterns of Pain (POP), which was created by world-renowned spine surgeon and best-selling back and neck pain author Hamilton Hall, MD, FRCSC, who is PHB’s medical director. The POP method has been shown to be effective because it allows us to focus on the symp-toms you have identified and the problems as you describe them.


>

>



Rest PositionsThe rest positions outlined in this handout can be used to reduce your pain. Your physical therapist will check the boxes next to each recommendation and cross out the rest positions that are not suitable for your diagnosis and treatment.

>

Pattern 3 SymptomsYou’ve been diagnosed as having Pattern 3 symptoms, including:• Pain is mainly in the legs but back pain may be present.• Pain is constant.• Pain is often worse when sitting or bending but in the

acute stage can be made worse by any movement.• Pain may be lessened in some resting positions.


Your physical therapist may prescribe other exercises and stretches once the acute leg pain has subsided. Please see the General Recommendations for Maintaining a Healthy Back Patient Information handout.

R “Z’ LIE• Lie with your back flat on the floor and support your

head with a pillow (you may also support your buttocks with a pillow).



R PRONE LIELie on your stomach and use pillows to support your hips to find the position that reduces the leg pain (you may also support your head with a pillow).Rest for ________ minutes every ________ hour(s).

R PRONE LIE ON ELBOWS• Lie face down on the floor or bed.• Bend your elbows and relax.Rest for ________ minutes every ________ hour(s).

R REST ON HANDS AND KNEES

Kneel on your hands and knees on the floor or bed.Rest for ________ minutes every ________ hour(s).

R LUMBAR ROLL: SITTING

Use a straight-backed chair and ___ -inch lumbar roll to support the curve of your back. Sitting is usually very painful for Pattern 3 patients.

R LUMBAR ROLL: LYING DOWN

Lie on a long sponge roll running across your body between your hips and your ribs to support your back and stop it from sagging.

Other General RecommendationsThe best treatment is to schedule rest periods throughout the day. Lie down for ________ minutes and find the rest position(s) that best reduce(s) your leg pain. Long-term bed rest is not recommended and can hinder recovery. The best position is the one that most reduces the leg pain. There is no place for exercises or repeated movements during the acute attack.

>

Pattern 4: Intermittent Leg Dominant Pain

FA - Flexion Aggravated (residual nerve root involvement) Descriptive Symptoms and Physical Exam

Leg dominant pain: felt most intensely below the gluteal fold above or below the knee. Leg pain is worse with flexion. Pain is always intermittent. May have a positive irritative test and/or a conduction loss. Always better with unloaded back extension movement or position: (leg dominant pain that responds to mechanical back Tx) – Prone extension will reduce the pain.

FR – Flexion Relieved (neurogenic claudication) Descriptive Symptoms and Physical Exam

Pain is leg dominant Leg pain is intermittent Leg pain is increased with activity in extension Leg pain is relieved with rest in flexion. The irritative tests are always negative

May be a conduction loss in long standing cases: prone extension will aggravate the symptoms

Initial Treatment 1. Handout: Back Pain: Patient Information and Pattern 4: Patient Handout 2. Follow appropriate treatment schedule: position, movement, pharmacology and adjunct therapies 3. Because it is leg dominant, radicular pain, a gentle, gradual approach is recommended.

Positions: Movement:

Generally relieved rapidly with rest and flexion Pelvic tilt Correct sitting and standing postures

Modification of daily routine

Regular, continued flexion-strengthening exercises is the most effective physical treatment Increase trunk strength in the abdominal oblique and paraspinal muscles

Typical Therapy Options: Pharmacologic Therapy Non-Pharmacologic (Adjunct) Therapy


Exercise Therapy Massage Acupuncture Yoga Apply Ice/Heat Progressive Relaxation

Follow Up: Treat for one to two months before follow-up 1. Assess treatment response

Assess pain medication and treatment modalities

Assess improvement:

Better = Increased walking distance Worse = Decreased walking distance


Significant Improvement Treatment requires an extended period of increasing strength and range of motion Should have a quick return to work with no modification or review

Limited Improvement Continue with treatment

Improve exercise techniques

Stationary cycling in flexion

Increase frequency of rest/exercise cycles

No Improvement If patient has no improvement, reassess



Positions and ExcercisesThe following rest positions and exercises can be used to reduce your pain. For example, the leg pain should be relieved quickly with rest in a flexed position. When the leg pain occurs, sit in a chair and bend forward until it subsides (See Sitting Flexion). Your physical therapist will check the boxes next to each recommendation and cross out the rest positions and exercises that are not suitable for your diagnosis and treatment.

>

>>





Pattern 4 SymptomsYou’ve been diagnosed as having Pattern 4 symptoms, including:• Pain is worst in legs and can be described as

heaviness or aching.• Pain is intermittent and is made worse by activity

with the back extended (often walking).• Pain is relieved by resting in a forward bent, flexed,

position (often sitting down).

Pattern 4 Flexion Aggravated (FA)

www.pspbc.caCourtesy of Dr Hamilton Hall, CBI Heath Group, Pure Healthy Back,

PRONE LIE

Lie on your stomach and use three pillows to support

your hips (you may also support your head with pillows). Sometimes just lying on your stomach without any pillows feels best.Rest for ________ minutes every ________ hour(s).

LUMBAR ROLL: SITTING

Use a straight-backed chair and ___ -inch lumbar roll to support the curve of your back.Rest for ________ minutes every ________ hour(s).

“Z’ LIE

• Lie with your back flat on the floor and support your head with a pillow (you may also support your buttocks with a pillow).



SLOPPY PUSH-UP

• Lie on your stomach with your hands on either side of your head.

• Keep your lower body on the floor and use your arms to slowly raise your upper body. (Your hands may need to be positioned above your head to fully extend your elbows, and your pelvis should remain on the floor.)

• Keep your back muscles relaxed.• Move slowly up. Lock elbows. Sag back. Down.• Do not hold the position.Repeat ______ times every ______ hour(s) during the day.

NIGHT ROLL: LYING DOWN

Lie on a long sponge roll running across your body between your hips and your ribs to support your back

and stop it from sagging.

PRONE LIE ON ELBOWS

• Lie face down on the floor or bed.• Bend your elbows and relax.


A) It is the leg pain that is the focus and which will decrease with the sloppy push-ups.

B) Because it is leg dominant, radicular pain, a gentle, gradual approach is recommended.

Pattern 4 Flexion Relieved (FR)

www.pspbc.ca

SINGLE LEG ABDOMINAL PRESS• Lie on your back with your knees bent.• Keep your back in a neutral position and tighten

your abdominal muscles.• Lift one leg so your knee and hip are at a 90-degree angle.• Press one hand against your knee while pulling it toward

the hand. Keep your elbow straight.Hold for ________ seconds. Return to start position and repeat with your opposite leg. Do ________ repetitions.

PARTIAL SIT-UP OR CRUNCH • Lie on your back with your knees bent, feet flat on

the floor, and arms crossed over your chest.• Using your lower stomach muscles, raise your head

and shoulder slightly until your shoulder blades are just off the floor (you may not be able to get up this far in the beginning).

Hold for ________ seconds. Do ________ repetitions.

SITTING FLEXION• Sit with your feet flat on the

floor about hip-width apart.• Lean forward and allow your

head and shoulders to drop between your knees.


PELVIC TILT• Lie on your back with your knees bent and your

arms on your chest or at your side.• Place your feet flat on the floor, hip-width apart, with

your knees slightly closer together than your feet.• Tighten your abdominal muscles.• Press the small of your back against the floor causing

the front of your pelvis to tilt forward.Hold for ________ seconds. Do ________ repetitions.

CAT/CAMEL • Kneel on your hands and knees.• Arch your back, letting your head drop slightly.• Keep your abdomen and buttock muscles tightened.Hold for ________ seconds.• Let your back sag toward the floor while keeping your

arms straight and your weight evenly distributed between your legs and arms.


The most effective treatment for your condition is a long-term regular exercise program focused on increasing strength in core muscles. Your physical therapist may prescribe additional exercises and stretches.

Courtesy of Dr Hamilton Hall, CBI Heath Group, Pure Healthy Back,

PRONE LIE

REST ON HANDS & KNEES

SINGLE LEG ABDOMINAL PRESS

“Z” LIE

PRONE LIE ON ELBOWS

NIGHT ROLL: LYING DOWN

LUMBAR ROLL: SITTING

PARTIAL SIT-UP OR CRUNCH SITTING FLEXION

www.pspbc.ca

PELVIC TILT

LUMBAR ROLL: CAT & CAMEL

Pattern 3

Pattern 1(Exercises)

Pattern 4

courtesy of Pure Healthy Back

SLOPPY PUSH-UP

A) It is the leg pain that is the focus and which will decrease with the sloppy push-ups.

B) Because it is leg dominant, radicular pain, a gentle, gradual approach is recommended.

before after

FA

FR

where is pain the worst? is pain constant or intermittent? back

Documents