For the below, in order to choose correctly directional preference can we assume since he is 8/10- 10/10 pain and right lateral shift that he has not “plateud” / directional preference is right lateral? My instinct was to go with a manip since his symptoms are no better worse in any direction ( no true perfrence outside of posturing) / acute pain onset + no sx distal to the knee makes him a good manip candidate?
You have been selected to be part of a new low back pain initiative being rolled out in your health system. One of the first tactics is to staff the emergency department with a physical therapist. You are working your first shift in the ED when you get a page to assess a patient complaining of severe low back pain. The patient is a 56-year-old male with a history of low back pain managed with exercise. He reports that he was removing siding from an old shed and started to notice his back getting tight. He pushed through the stiffness to complete the work, and then he went in the house to do his back exercises. When he bent down to get on the floor, his back became extremely tight followed by the most excruciating pain (10/10) he has ever felt. He states everything hurts: breathing, bending, walking, coughing, and sneezing. Current pain is 8/10. He reluctantly participated in a movement assessment out of fear he will experience another spasm. Grossly, his range of motion is limited 50-75% in all directions and he is visibly shifted to the right. He denies leg pain, numbness, tingling, or bowel or bladder changes. Neurological testing is unremarkable. You assess his lumbar spine mobility and he is extremely hypomobile. Hip range of motion is WNL. Special tests are inconclusive due to guarding.
Which of the following interventions would be most appropriate at this point in time?
a. Active rest
b. Directional preference exercises
Based on the current TBC (Alrwaily et al.), clinicians should prioritize directional preference exercises over mobilization/manipulation until the patient’s symptoms plateau.
You’re correct. This question was designed (intentionally sneaky) to remind test takers to take the information provided literal. 10/10 to 8/10 is subtle, but it should still be considered an improvement until stated otherwise.