Lumbar Spine Differential Diagnosis. Jason Zafereo, PT, OCS, FAAOMPT

Transcription

1 Lumbar Spine Differential Diagnosis Jason Zafereo, PT, OCS, FAAOMPT Clinical i l Orthopedic Rehabilitation ti Education 1

2 Objectives Describe the relevant findings from the history and examination indicating the source of symptoms as: Contractile tissue Non-contractile tissue Nerve Spine Describe the relevant findings from the history and examination indicating a primary impairment of: Stiffness Weakness 2

3 3 CONTRACTILE TISSUE PATHOLOGY

4 Subjective Exam Findings Chief complaint: LBP Onset (QL): MVA or sustained walking boot use Aggravating: Rolling over in bed (QL), standing upright (Iliopsoas) and walking (QL), coughing - sneezing (QL), sit to stand (ES), stairs (ES) Easing (QL): pressure relief or short term corset use Travell and Simons

5 Subjective Exam Findings--Location Quadratus lumborum Iliopsoas Rectus Abdominus 5 Travell and Simons 1992, 1983

6 Subjective Exam Findings--Location Erector spinae External Oblique 6 Travell and Simons 1992, 1983

7 Objective Exam Findings 7 Test Response Alignment Elevated ipsilateral crest (QL); Forward trunk lean (Iliopsoas) ROM/Flexibility Restricted flexibility of involved muscle; Active and Passive ROM painful in opposite directions; LROM significantly limited sagittal plane and contralateral sidebending (QL); marked limitation of flexion (ES) Muscle Provocation ocation Testing Painful, possibly weak (no atrophy) Palpation 1) Focal tenderness with concordant sign reproduction (about 3kg of pressure) 2) Twitch response 3) Taut band 4) Often referred pain (non dermatomal) on continued (~5sec) pressure

8 8 NON-CONTRACTILE TISSUE PATHOLOGY

9 Nerve Cauda Equina Syndrome Disc Herniation with Radiculopathy Lumbar Spine Stenosis 9

10 Subjective Exam Findings Cauda Equina Syndrome Numbness around the buttocks Walking almost causes urination Burning sensation around the buttocks Numbness in the soles of both feet Numbness in both legs Numbness without pain +LRs 2, p < 0.05 Konno et al, BMC Musc Disorders,

11 Subjective Exam Findings HNP with Radiculopathy 11 Age Onset with lifting Pain aggravated with sitting, eased with standing/walking Pain with valsalva, cough, laugh, sit to stand Magee 2008

12 Subjective Exam Findings Lumbar Spine Stenosis 12 No pain or sx improved when sitting Age>48 years Leg pain>back pain Bilateral symptoms Pain during walking/standing -LR =.19, +LR = 4.6 Pre-test probability = 40% 4/5 = 76% 5/5 = 99+% Katz et al, Arth Rheum, 1995; Cook et al, 2011

13 Subjective Exam Findings--Location L4 L5 S1 13

14 Objective Exam Findings 14 Test Response ROM Active and Passive ROM equal and painful in same direction; Worsening pain with extension, improved with flexion (IVF); Worsening pain with sagittal plane motions, Centralization/peripheralization with repeated movements (disc) Special Testing Positive SLR/Slump p( (disc); Positive Two- Stage Treadmill test (IVF) Neurological exam Sensation, strength, and reflex may be reduced at key sensory/motor points (All) Palpation Tenderness over nerve trunks and involved segment

15 SLR Validity (pooled) SLR Sensitivity =.85, Specificity =.52 Crossed SLR Sensitivity =.29, Specificity it =.88 Reliability SLR K =.70 Rubinstein and van Tulder, Best Pract & Res Clin Rheum, van der Windt et al 2010

16 Two-Stage Treadmill Test 16 Walking on Treadmill for two 10 minute bouts One bout flat and one inclined 15 Walking speed 1.0 mph, adjusted to patient comfort Test termination at time or high symptom intensity Positive: Greater tolerance for walking in inclined position SP = 92.3%; SN = 50% for Stenosis Prolonged recovery time and earlier onset of symptoms after level walking (+LR = 14.5) Fritz, J Spinal Disord 1997

17 Joint/Disc Differential diagnosis is difficult Shared pain referral patterns Inconsistent lumbar coupling Key to diagnosis lies with cluster testing based on history, imaging, and ROM findings 17

18 Subjective Exam Findings--Joint 18 Age >65 Pain not worsened with Coughing Hyperextension Forward flexion Extension-rotation Rising from a chair Pain relieved by recumbency* 5 of 7 present suggests joint pain (+LR = , -LR = ) Revel et al, Spine, 1998 Laslett, BMC Musc Dis, 2004

19 Subjective Exam Findings--Joint 19 Positive Extension-Rotation test Age 50 Best when walking Best when sitting Pain is paraspinal 3 of 5 present suggest relief with ZJ block (+LR 9.7) Extension-Rotation otat o test (SN = 100%) Laslett et al, Spine J, 2006

20 Subjective Exam Findings Joint Location 20 Percent occurrence by location Groin 18% Buttocks 57% Thigh 72% Calf 42% Foot 39% Schwartzer et al, Spine 1994 Fukui et al 1997

21 Subjective Exam Findings--Disc Pain while rising from sitting Imaging Young et al 2003 Degenerative disc on MRI (-LR =.21) Imaging g suggestive of high intensity zone, endplate changes, or degeneration (+LR > 2) Hancock et al

22 Subjective Exam Findings Disc Location Referral patterns consistent with other somatic structures (low back and extremity) Distal extent of pain depends on intensity of stimulation Pain may extend below the knee O Neill et al, Spine

23 Objective Exam Findings Test ROM Special Tests Palpation Alignment Response Active and Passive ROM painful in same direction; 3-D combined movements most painful (Ext/Rot): Joint; Significant loss of extension, vulnerability during mid-range flexion/rotation, and centralization yields +LR of 6.7 for disc (Laslett et al. 2006) May have positive dural testing: Disc Tenderness over involved joints Presence of acute lateral shift or lumbar kyphosis: Disc 23

24 Repeated Movement Testing 24 Validity Centralization with repeated movements consistent with disc as the source of pain (+LR = ) Hancock et al, Eur Spine J, 2007 Laslett et al, Spine, 2006 Reliability K = on whether centralization occurred in a given patient Kilpkoski et al, Spine, 2002 Fritz et al, Arch, Phys Med Rehabil, 2000 K =.90 on directional preference Kilpkoski et al, Spine, 2002

25 25 PRIMARY STIFFNESS IMPAIRMENT

26 Objective Exam Findings 26 Objective Exam Variable Response ROM Limited it ROM Passive physiological movement Passive accessory movement Palpation Flexibility Capsular pattern; characteristic motion loss with firm end feel. Symmetrical loss of hip IR associated with LBP (Ellison et al 1990). Sagittal plane motion loss associated with DSM category R1 occurs before P1 Tenderness, tightness, and presence of positional fault (TP/facet rotation) Limited in muscles prone to hypertonicity

27 27 Lumbar ROM Diagram

28 28 Lumbar Cardinal Plane Patterns

29 Reliability of Palpation/Motion Testing 29 Reliability (pooled) ID of osseous structures t (K =.53) Motion assessment all levels (K =.17) Pain assessment all levels (K =.42) Stochkendahl et al, J Manip Phys Ther, 2006 Most hypomobile segment (K =.71) Most hypermobile segment (K =.29) Landel et al, PT 2008 Validity Poor agreement (K = 0-.04) with MRI Landel et al, PT 2008

30 Validity of Palpation/Motion Testing Segmental PA exam findings used to predict response to manipulation or stabilization treatments Findings of hypomobility Failure rates were 26% with manipulation, 74.4% with stabilization Findings of hypermobility Failure rates were 83.3% with manipulation, 22.2% with stabilization Fritz et al Arch Phys Med Rehabil,

31 Common Motor Patterns Ventral hyperactive musculature Hip adductors Rectus femoris TFL Iliopsoas Oblique abdominals Dorsal hyperactive musculature Triceps surae Hamstrings Lumbar erector spinae Quadratus lumborum 31

32 Regional Interdependence 32 Hip ROM cut scores <106deg flexion >6deg extension lag on Thomas test Unidirectional motion loss occurred 57.5% of time, with 78% DSM agreement Bidirectional motion loss occurred 25% of time, with 70% DSM agreement to most limited direction Zafereo et al, Arch PM&R, 2015

33 33 PRIMARY WEAKNESS IMPAIRMENT

34 Subjective Exam Findings Subjective Exam Variable Mechanism Response Remote history of trauma; frequent episodes of acute attacks Aggravating factors Sustained weight-bearing i posture; sharp pain with sudden movements; sleeping position dependent on DSM Easing factors Manipulation; Non-weight bearing; external support Associated factors Popping, clicking, locking, catching, giving way of the low back during movement 34

35 Objective Exam Findings 35 Objective Exam Variable Active movements Passive physiological og movement Passive accessory movement Response Full general mobility with aberrant motion; hinging, pivoting, fulcruming*. Greater ROM in lying than in sitting/standing Full with decreased eased resistance sta to end range. Lumbar pain with hip ROM testing*. Increased neutral zone and shear Special Testing Positive Prone instability test; Positive leg raise tests*; Positive BKFO* Strength testing Weakness/poor coordination TRA, multifidus, Hip extension/abduction (Nadler et al 2001) Palpation Atrophy of multifidus segmentally; Paraspinal muscle guarding/hypertrophy*

36 Defining Aberrant Movement Altered Lumbopelvic Rhythm Forward bending: Hip>lumbar in first third; lumbar>hip during last third Extension: Lumbar>hip in first third; hip>lumbar during last third Gower s sign Deviation from sagittal plane Instability catch, shake, or judder Painful arc of motion 36 Fair to excellent (K= ) agreement for individual signs Substantial (K=.65) agreement for at least 1 sign Biely et al, 2014

37 Identification of Radiographic Lumbar Instability 37 Age <37 years Total extension >26deg Any hypermobility of the lumbar spine Lack of hypomobility of the lumbar spine* Lumbar flexion >53deg* *+LR=128; 12.8; -LR =.72 Fritz et al., Eur Spine J 2005

38 Identification of Radiographic Instability 38 Spondylolysis One-legged hyperextension test had low to moderate sensitivity (50% 73%) and low specificity (17% 32%) Spondylolisthesis Lumbar SP palpation had high specificity (87% 100%) and moderate to high sensitivity (60 88) Algarni et al, 2015

39 Identification of Radiographic Lumbar Instability Passive lumbar extension test Pain reproduced with lifting legs 30cm from table with slight traction Best diagnostic test for instability Validity 84% sensitive and 90% specific for radiographic instability Reliability K= Rabin et al, 2013; Kasai et al, 2006; Ferrari et al, 2015

40 Prone Instability Test Reliability Ferrari et al, 2015; Rabin et al, 2013; Hicks et al., 2003 K= K= Validity Hicks et al, 2005; Ferrari et al, 2015 Likelihood of patient responding to stabilization program +LR = 1.7, -LR =.48 Fair diagnostic accuracy Spec =.57; Sens =.71 40

41 Common Motor Patterns Dorsal hypoactive musculature Gluteals Ventral hypotonic musculature Tibialis anterior Toe extensors Peronei Vasti Rectus abdominus 41

42 Motion Control Testing - Bent Knee Fall Out 42 Supine hooklying position Eccentric lowering into hip abduction/lateral rotation Pelvic rotation during first 50% of motion is positive testt If symptoms increased, pelvic stabilization should improve pain Reliability K = Luomajoki et al 2007; White and Thomas 2002; VanDillen 1998

43 Motion Control Testing Prone Leg Raise 43 Hip and back extensors Position: Prone, pillow as needed d Test: Lift leg 8-10 off table Assess: Neutral spine and firing pattern Transverse abdominus Ipsilateral Glut/hamstring Contralateral t l multifidus Ipsilateral multifidus Contralateral Erector spinae Ipsilateral erector spinae Sahrmann 2002 Oh et al, JOSPT 2007

44 Motion Control Testing Prone Leg Raise 44 Reliability of hip extension test K = for agreement on deviation in frontal, transverse, or sagittal plane Murphy et al 2006 Gluteus maximus time to contraction significantly reduced by ypelvic compression Takasaki et al 2008

45 Strength Testing-Hip Extensors 45 Static double leg bridging Reliability ICC=.84 Expected holds Patients with LBP = 76.7secs Patients without LBP=172.9secs (after 2 mins, unilateral) Schellenberg et al, Am J Phys Med Rehabil 2007

46 Motion Control Testing Sidelying Leg Raise Gluteus medius/minimus Position: Sidelying i with both legs fully extended, neutral hip, relaxed ankle, top arm off the table Test: Frontal plane hip ABD smooth and easy Substitutions: Uncontrolled and rapid, Flexion/IR of hip, and forward rolling of pelvis, trunk, shoulder 46

47 Motion Control Testing Sidelying Leg Raise 47 Interrater Reliability Reported as poor to acceptable Validity Rabin et al, JOSPT 2013; Davis et al, JOSPT LR in discriminating development of LBP in asymptomatic population Nelson-Wong et al, JOSPT 2009 and Clin Biomech 2008

48 Multifidus Dysfunction Identified with palpation of segmental atrophy and limitations on Supine ASLR test Significant relationship between % multifidus activation and number of factors present for stabilization CPR Hebert et al, Arch Phys Med Rehabil, 2010 However, post-treatment multifidus muscle thickness not predictive of response to stabilization program Zielinski et al,

49 Strength Testing-Trunk Extensors Prone double SLR highly correlated with development and persistence of LBP Males <30secs Females<29secs Prone chest raise cut scores Males >31secs Females >33secs Reliability (ICC=.90) 49 Arab et al, Clin Rehabil 2007

50 Motion Control Testing Supine Leg Raise Procedure Stabilizer to 40mmHg Drawing in with relaxed normal breathing Test Maintain pressure at 40-43mmHg with the following movements Heel slide 3 inch march SLR (8-10 ) Successful completion of this test not an indication of high TRA activation on US imaging Grooms et al,

51 Strength Testing - Transverse Abdominus 51 Procedure Stabilizer to 70mmHg Inferior edge at level of ASISs Drawing in with relaxed normal breathing 10sec x 10 reps Test results Normal = 4 mmhg pressure reduction Increased incidence of LBP=2mmHg reduction Reliability (ICC=.58) Costa et al, Physiother Res Int 2006 Validity Poor concurrent validity with superficial EMG in CLBP Limpa et al, 2012

52 Strength Testing Trunk Flexors 52 Double leg lowering Greater likelihood lih of CLBP if anterior pelvic tilt above 50deg hip flexion in males 60deg hip flexion in females Youdas et al, PT 2000 Prone planking Expected holds Patients with LBP = 28.3secs Patients without LBP=72.5secs Schellenberg et al, Am J Phys Med Rehabil 2007

53 Summary of Stabilization Findings Examples of Motion Control Testing Lumbopelvic rhythm Pattern of motion lumbar sidebending/rotation toward paraspinal bulk Passive Hip ROM Active leg raises (sagittal) Active leg raise (frontal) Bent knee fall out 3/6 positive findings used as criteria for prescribing stabilization program Significant improvements in pre-post testing, pain, disability Luomajoki et al