Evaluation and Treatment Lumbar/Sacral Spine: Manual Therapist Approach KAMERON IHRY HODEM PT, DPT, MTC, CERT. DN

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1 Evaluation and Treatment Lumbar/Sacral Spine: Manual Therapist Approach KAMERON IHRY HODEM PT, DPT, MTC, CERT. DN

2 Purpose Educate on the Evaluation of the lumbar/sacral spine using a manual therapy approach to identify common low back syndromes and impairments

3 Objectives Using the evaluation to identify impairments Identify common low back injuries/syndromes Identify impairments that could be causing/contributing to the syndrome/dysfunction Using impairments, syndromes, stages of healing & tissue reactivity to guide treatment plan Identify impairments that may need referral to primary or DPT

4 History and interview When did it happen, how did it happen, where did it happen? Where is your pain? How intense? Aggravating positons, movements, activities, or times of day? Relief with positions, movements, or times of day? Its effect on function? Co-morbidities/Past Medical History (PMI)? Functional Outcome Measures

5 Red Flags MOI Changes in bowel or bladder symptoms Diffused non-specific pain Pain at night Saddle paresthesia Loss of sensation* Weakness in extremity*

6 Observation/Structural Inspection Visual presentation Transitions Gait Standing posture Seated posture

for symmetry Iliac crest, PSIS, ASIS, greater trochanter, gluteal fold, fibular

7 Standing postural assessment Visual asymmetries Tone Hypertrophy/Hypotrophy Unilateral/bilateral Curvature of the spine Sagittal and frontal planes Palpate for symmetry Iliac crest, PSIS, ASIS, greater trochanter, gluteal fold, fibular head, Angle of inclination Foot, ankle, knee Structural or functional deformities

8 Seated postural assessment Changes in: Tone Curvature Symmetry Position relate to subjective complaints? Work or desk ergonomics and position?

9 AROM Quality Symmetries, deviations, hesitations Quantity Reproduction of pain Relief of pain Remember transitional zones Know and understand the biomechanics

10 Lumbar Biomechanics Lumbar spine facet biomechanics Flexion: B superior glide Extension: B inferior glide Right Sidebend: Right inferior glide, Left superior glide Left Sidebend: Right superior glide, Left inferior glide Right Rotation: Right Gapping, Left compression/inf Left Rotation: Left Gapping, Right compression/inf Lumbar spine Rules for Combined Motion Neutral Spine: side bend and rotation coupled in opposite Flexed or Extended spine: Side bend and rotation are in the same direction

11 Lumbar Biomechanics

12 AROM Lumbar Cont.

13 AROM Lumbar Cont.

14 AROM Lumbar Cont.

15 AROM Lumbar Cont. Determining Facet Restriction: Limited Right side bend Inferior glide right? Superior glide left? Limited Extension Inferior glide left? Inferior glide right? What is the common movement?

16 SI Biomechanics Forward Bend Sacral extension Innom anterior rotation Backward Bend Sacral Flexion Innom posterior rotation Rotation Sacral flexion contralateral Sacral extension ipsilateral side Innom s follow hips

17 AROM Sacroiliac joint Motions to Assess Posterior innom rotation Anterior inom-rotation Innom External Rotation/Outflare Innom Internal Rotation/Inflare Sacral flexion, extension, SB, Rotation Assessed by palpation due to small degree of motion Hypermobility/hypomobility

18 Palpation Condition Tone Temperature Edema Pain Hypertonic- spasm, hypertrophy, muscle holding (voluntary vs involuntary) Hypotonic- Wasting, fibrosis Myofasical Mobility Layers Muscle play Trigger points, taut bands

19 Palpation Cont. Palpation for position Spinous Process alignment Intervertebral Space Step deformity Pelvic alignment/position

20 Palpation Cont.

21 Passive Mobility Testing Lumbar Intervertebral Motion Testing Pelvic Passive motion testing End-feel Hard Firm Normal Loose No end-feel Pain

22 Strength Assessment Hip strength MMT Functional- Stork, Squat, SL Squat Core strength and stability Transverse abdominis activation with multifidi With SLR Quadruped instability Pelvic bridge Prone hip extension Sit-up and oblique testing

23 Special Tests SI Provocation Thigh thrust/shear test Gaenslen s Test Distraction/compression FABER Active SLR SLR w/ compression Lumbar Quadrant test Slump test Passive SLR Neural tension testing Instability tests Anterior Posterior Lateral Muscle Length Tests Thomas Ober Hamstring Length Rectus Femoris

24 Neurological Testing Dermatomes Myotomes Reflexes

25 Above and Below Clearing Hip ROM, strength, Joint mobility, and special tests to clear joint dysfunction/pathology Impact of motion dysfunction on SI and lumbar spine. Thoracic ROM, Joint mobility (facets, ribs)

26 Assessment Identify irritated tissue Culprit Victim Gathering Impairments, and functional loss Stages of Tissue Healing Acute Subacute Proliferative Remodeling Chronic Stages of Tissue Reactivity High reactivity Moderate Reactivity Low Reactivity No Reactivity Both Tissue and Subject

27 Common Diagnosis/Syndromes A working Diagnosis 1. Myofascial Syndrome Guarding Voluntary vs. Involuntary Adaptive shortening Adhession/Mobility/TP s Muscle strain 2. Postural Dysfunction -Asymmetry -Cross-Syndrome 3. Facet Dysfunction Synovitis/strain Stiffness/restriction Painful entrapment Mechanical block Degeneration/arthritis

28 Common Diagnosis/Syndromes 3. Sacroiliac Dysfunction Strain Hypermobility Hypomobility Fixed Displacement 4. Ligamentous weakness 5. Instability 6. Disc Dysfunction pre-discal Acute Settled chronic Disc Protrusion/Bulge Disc Herniation

29 Diagnosis/Syndromes 7. Spondylolysis 8. Spondylolisthesis 9. Stenosis 10. Complex lesion/layered

30 Plan of Care and Treatment List and prioritize impairments, and establish time frame Working dx as your guide Stage of healing and reactivity Determines frequency, duration Requires discussion with patient Match impairments with most appropriate interventions Interventions guided by stage of healing and reactivity

31 Case Example Subjective/History 19 y/o male with c/o back pain/stiffness for the past 1 ½ months. No significant PMH, or MOI. Reports stiffness in the morning, and soreness after resistive exercise program. Pain is in central to left low back pain at 4/10 at most Student and former football player that enjoys recreational exercise (strength program). Pain does not prevent or limit activity

32 Case Example Cont. Impairment lumbar lordotic posture pelvic inclination tone in paraspinals in standing, in prone Limit in R SB and L Rot. Firm end feel with superior glide and gapping L4/5 muscle mobility L L4-S1 paraspinals + Thomas test, +Ober in hip mobility (globally) Left inom anterior rot Abdominal control during SLR Interventions Education, stretching, strengthening, NMR Education, stretching, strengthening, NMR Bracing, taping, posture retrain, NMR Stretching/ROM, mobs, MET Stretching/ROM, mobs, manip, MET Stretching, STM, ASTM, Needling, MFR, etc Stretching, Soft tissue techniques Stretching, joint mobs, warm-up MET, Joint mob, stretching, ROM NMR, strengthening

33 Case Example Cont. Working Diagnosis? Facet Dysfunction: Stiffness/Restriction Postural Dysfunction Myofascial Dysfunction: Mobility

34 Case Example Cont. Invervention? Joint mobilization/manipulation Home stretch/rom Posture education Postural stretching Abdominal/TA re-ed

35 When to refer? Joint impairment Need for advanced manipulation Physical Therapist, Chiro, Osteopath Soft tissue dysfunction Need for other interventions; dry needling, strain counter strain, ASTYM, myofascial release, cranio-sacral Physical Therapist, Massage Therapist, Acupuncturist Discogenic with neuropathy Persisting neural sx s Primary, Physical Therapy Instabilities with neurological symptoms Red Flags as discussed earlier

36 Questions, Concerns, Comments

RN(EC) ENC(C) GNC(C) MN ACNP * MECHANISM OF INJURY.. MOST IMPORTANT *

RN(EC) ENC(C) GNC(C) MN ACNP *** MECHANISM OF INJURY.. MOST IMPORTANT *** HISTORY *** MECHANISM OF INJURY.. MOST IMPORTANT *** Age of patient - Certain conditions are more prevalent in particular age groups (Hip pain in children may refer to the knee from Legg-Calve-Perthes