Improving Decision-Making in Low Back Pain: How to Target the Right Treatment at the Right Patient

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Sharlene Small
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Evidence Based Examination Stats No not stats Patient

'SeNsitive' test, when Negative rules OUT disease

Individual Clinical Expertise EBM Best External

when Positive, rules IN disease (SP-P-IN) +LR -LR

you the odds of the condition increasing when the

Negative Likelihood Ratios Tells you the odds of the

FABQ Oswestry Disability Index Self Report Measures

people with chronic LBP have depression Two Question

bothered by feeling down, depressed, or hopeless?

1 Evidence Based Examination Stats No not stats Patient Values & Expectations SNNOUT Sensitivity a highly 'SeNsitive' test, when Negative rules OUT disease (SN-N-OUT). Individual Clinical Expertise EBM Best External Evidence SPPIN Specificity A highly SPecific test, when Positive, rules IN disease (SP-P-IN) +LR -LR Stats No not stats Positive Likelihood Ratios Tells you the odds of the condition increasing when the test is positive. Negative Likelihood Ratios Tells you the odds of the condition decreasing when the test is negative. FABQ Oswestry Disability Index Self Report Measures Global Rating of Change Numeric Pain Scale 54% of people with chronic LBP have depression Two Question Screen During the past moth have you often been bothered by feeling down, depressed, or hopeless? During the last month have you often been bothered by little interest or pleasure in doing things? copied or otherwise used without express written permission of the authors. 1

Two Question Screen Sensitivity.97 Specificity.67 -LR.

Over the age of 50 Previous History of Cancer Unexplained wt.

Extension Combined extension, side bending, and rotation

L2- Anterior mid-thigh L3- Distal anterior thigh L4- Medial

S2- Plantar surface of foot S3- Groin S4- Perineum/genitals

Extensors L4 = Ankle Dorsiflexors L5 = Hallux Extension

L4 = Quadriceps S1 = Achilles Upper Motor Neuron Screen

2 Two Question Screen Sensitivity.97 Specificity.67 -LR.05 +LR 2.9 What about the BIG C? Over the age of 50 Previous History of Cancer Unexplained wt. loss Physical Examination Standing Active ROM Flexion Extension Combined extension, side bending, and rotation Side Bending Trunk Rotation Shearing L1 - Inguinal region L2- Anterior mid-thigh L3- Distal anterior thigh L4- Medial lower leg/foot L5- Lateral leg/foot S1- Lateral side of foot S2- Plantar surface of foot S3- Groin S4- Perineum/genitals Dermatomes Myotomes L2-L3 = Hip Flexor L3-L4 = Knee Extensors L4 = Ankle Dorsiflexors L5 = Hallux Extension L5-S1 = Ankle Plantarflexors S1-S2 = Ankle Evertors Reflexes L4 = Quadriceps S1 = Achilles Upper Motor Neuron Screen Babinski Hoffman Clonus Romberg Neurological Screen copied or otherwise used without express written permission of the authors. 2

Seated Examination Supine Examination Seated Trunk Rotation SLUMP

decreased tension from cervical extension.

groin or buttock pain s for SIJ region pain or hip pathology

6 (based on anesthetic block of the SIJ) FABER Flexion Adduction

s for hip pathology i.e. labral tears Sensitivity =.75 Specificity =.

58 Positive test reproduces pain in the back or leg at < 40 degrees or

Straight Leg Raise Positive if it reproduces pain in the involved leg

3 Seated Examination Supine Examination Seated Trunk Rotation SLUMP Order spinal flexion, neck flexion, knee extension and ankle DF with decreased tension from cervical extension. Diagnostic Accuracy unknown Hip ROM FABER FADDIR SLR Positive test = groin or buttock pain s for SIJ region pain or hip pathology Sensitivity =.71 Specificty = LR = 0 - LR =.23 Reliability.6 (based on anesthetic block of the SIJ) FABER Flexion Adduction Internal Rotation FADDIR Positive test = pain in the piriformis region s for hip pathology i.e. labral tears Sensitivity =.75 Specificity =.43 + LR = LR =.58 Positive test reproduces pain in the back or leg at < 40 degrees or less for the presence of a disk herniation Straight Leg Raise Crossed Straight Leg Raise Positive if it reproduces pain in the involved leg Assessing disc pathology on the opposite side Sensitivity =.29 Specificity =.88 +LR = LR =.8011 copied or otherwise used without express written permission of the authors. 3

Prone Assessment Joint Mobility Assessment (P.

Internal rotation performed in the CPR for

Distraction Drop Sacral Thrust Sacroiliac

4 Prone Assessment Joint Mobility Assessment (P.A.s) Positive if pain provoking. Grade hypomobile, normal or hypermobile Specificity =.95 Sensitivity =.43 -LR =.6 +LR = 8.6 Reliability Prone Instability Hip Assessment Hip ROM Internal rotation performed in the CPR for Acute LBP Sensitivity =.72 -LR =.48 Specificity =.58 +LR = 1.7 Femoral nerve mobility Sacroiliac Joint s Distraction Drop Sacral Thrust Sacroiliac Joint s Thigh Thrust Gaenslen s What Do We Know? Compression copied or otherwise used without express written permission of the authors. 4

Hip OA vs. LBP Cluster 1 Cluster 2 If all 3 components of a test cluster are present LR +3.4 and if not present LR -.

The reliability and construct validity of the Neck Disability Index and Patient Specific Functional Scale in patients with cervical radiculopathy. Spine 2006;31:598-602. Fritz JM, Irrang JJ.

Measurment of health status: Ascertaining the minimal clinically important difference. Controlled Clinical Trials 1989;10:407-15. Jacob T, Baras M, Zeev A et al.

5 Hip OA vs. LBP Cluster 1 Cluster 2 If all 3 components of a test cluster are present LR +3.4 and if not present LR -.19 Hip Pain Painful with hip IR Hip IR < 15 degrees >50 years old Hip flexion< 115 degrees AM hip stiffness <60 minutes Cleland JA, Fritz JM, Whitman JM et al. The reliability and construct validity of the Neck Disability Index and Patient Specific Functional Scale in patients with cervical radiculopathy. Spine 2006;31: Fritz JM, Irrang JJ. A comparison of a modified Oswestry Low Back Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther 2001;81: Jaeschke R, Singer J, Guyatt GH. Measurment of health status: Ascertaining the minimal clinically important difference. Controlled Clinical Trials 1989;10: Jacob T, Baras M, Zeev A et al. Low back pain: reliability of a set of pain measurement tools. Arch Phys Med Rehabil 2001;82: Andersson GBJ. Epidemiological features of chronic low-back pain. The Lancet. 1999;354(9178): Arroll B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ 2003;327: Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med. 1988;3(3): Broadhurst NA, Bond MJ. Pain provocation tests for the assessment of sacroiliac joint dysfunction. J Spinal Disord. 1998;11(4): Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy. 2003;49(2): Narvani AA, Tsiridis E, Kendall S, Chaudhuri R, Thomas P. A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain. Knee Surgery, Sports Traumatology, Arthroscopy. 2003;11(6): Fishman LM, Dombi GW, Michaelsen C, et al. Piriformis syndrome: Diagnosis, treatment, and outcome [mdash] a 10-year study. Archives of physical medicine and rehabilitation. 2002;83(3): Jari S, Paton RW, Srinivasan MS. Unilateral limitation of abduction of the hip. A valuable clinical sign for DDH? J Bone Joint Surg Br. 2002;84(1): Flynn T, Cleland J, Whitman J. Users Guide to Musculoskeletal Management. Buckner, KY; Evidence in Motion;2008. Fritz JM, Piva SR, Childs JD. Accuracy of the clinical examination to predict radiographic instability of the lumbar spine. Eur Spine J. 2005;14(8): Binkley J, Stratford PW, Gill C. Interrater reliability of lumbar accessory motion mobility testing. Physical Therapy. 1995;75(9):786. Maher CG, Latimer J, Adams R. An investigation of the reliability and validity of posteroanterior spinal stiffness judgments made using a reference-based protocol. Physical Therapy. 1998;78(8):829. Devillé WL, van der Windt DA, Dzaferagić A, Bezemer PD, Bouter LM. The test of Lasègue: systematic review of the accuracy in diagnosing herniated discs. Spine. 2000;25(9): Broadhurst NA, Bond MJ. Pain provocation tests for the assessment of sacroiliac joint dysfunction. J Spinal Disord. 1998;11(4): Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy. 2003;49(2): Broadhurst NA, Bond MJ. Pain provocation tests for the assessment of sacroiliac joint dysfunction. J Spinal Disord. 1998;11(4): Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy. 2003;49(2): Cibulka MT, Koldehoff R. Clinical usefulness of a cluster of sacroiliac joint tests in patients with and without low back pain. Journal of Orthopaedic and Sports Physical Therapy. 1999;29: copied or otherwise used without express written permission of the authors. 5

6 Cibulka MT, Koldehoff R. Clinical usefulness of a cluster of sacroiliac joint tests in patients with and without low back pain. Journal of Orthopaedic and Sports Physical Therapy. 1999;29: Brown MD, Gomez-Marin O, Brookfield KFW, Li PS. Differential diagnosis of hip disease versus spine disease. Clinical orthopaedics and related research. 2004;419:280. Altman R, Alarcon G, Appelrouth D, Bloch D, Borenstein D, Brandt K et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arth Rheum 1991; 34(5): Waddell G, Newton M, Henderson I, Somerville D, Main CJ. Fear- Avoidance Beliefs Questionnaire (FABQ) and the role of fearavoidance beliefs in chronic low back pain and disability. Pain. 1993;52(2): copied or otherwise used without express written permission of the authors. 6

Straight Leg Raising Test a snapshot summary of evidence (May 2013) Key messages

Straight Leg Raising Test a snapshot summary of evidence (May 2013) Key messages The passive straight leg raising test (PSLR) is commonly used as an aid to the diagnosis of Lower Back Pain and is considered