Diagnostic and Treatment Approach to the Active Patient with Complex Spine Pathology

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1 Physical Therapy Diagnostic and Treatment Approach to the Active Patient with Complex Spine Pathology Scott Behjani, DPT, OCS

2 Introduction

4 Prevalence 1-year incidence of first-episode LBP ranges from 6.3% % 1 Reoccurrence ranges from 24% to 33% 2 Lifetime prevalence range from 60% and 80% 3 Nearly a 6% increase in chronic LBP from 1992 to WHO lists LBP as a top-10 condition with highest disease burden on society 5

5 Risk Factors Individual Genetic factors Gender Body morphology Strength Flexibility Psychological & psychosocial Depression Socioeconomic status Education Access to healthcare Activity Related Occupation Operating heavy equipment Physical Activity Lifestyle

6 Risk Factors Individual Genetic factors Gender Body morphology Strength Flexibility Psychological back pain 6 & psychosocial Depression Socioeconomic status Education Access to healthcare Activity Related Occupation Operating heavy equipment Current literature does not support a Physical definitive Activity cause for initial episodes of low back pain. Risk factors Lifestyle are multifactorial, population specific, and only weakly associated with the development of low

7 Pathoanatomical Features Any innervated structure in the lumbar spine can cause symptoms of low back and referred pain into the extremity or extremities 6 Muscles Ligaments Dura Mater Nerve roots Facet joint Annulus fibrosis Thoracolumbar fascia Vertebrae

8 Pathoanatomical Features7

9 Clinical Course8

10 Clinical Course8

11 Clinical Course 8 Patients that are followed for 1 year: 65% will report 1 additional episode 9 60 day (median) episode duration 9

12 Clinical Course Recurrent pain prognostic factors Previous episodes of LBP 10,11 Excessive spine mobility 12,13 Excessive mobility in peripheral joints 14 Chronic pain prognostic factors Symptoms below the knee 15 Psychological distress or depression 15 Fear of pain, movement, and reinjury or low expectations of recovery 16,17 Intense pain 18 Passive coping style 19

13 Clinical Course Recurrent pain prognostic factors Previous episodes of LBP 10,11 Excessive spine mobility 12,13 Excessive mobility in peripheral joints 14 Chronic pain prognostic factors Symptoms below the knee 15 Psychological distress or depression 15 Fear of pain, movement, and reinjury or low expectations of recovery 16,17 Intense pain 18 Passive coping style 19

14 Diagnosis Historical Identifying effective interventions for LBP has been largely unsuccessful 6 Interventions are ineffective or have marginal effects sizes Most intervention studies have treated LBP as a homogenous diagnosis Contemporary The best available evidence supports a classification system de-emphasizes the importance of identifying specific anatomical lesions after red flag screening 6 Interventions based on subgroup classification have the potential to enhance effect sizes over studies where the identical interventions were administered in a one-sizefits-all approach 20

15 Classification ICF ICD Low Back Pain with Mobility Deficits Lumbosacral segmental/somatic dysfunction Low Back Pain with Movement Spinal instabilities Coordination Impairments Low Back Pain with Related Flatback syndrome (Referred) Lower Extremity Pain Other specified intervertebral disc displacement Low Back Pain with Radiating Pain Lumbar radiculopathy Lumbago with sciatica Low Back Pain with Related Cognitive or Affective Tendencies Low back pain Disorder of central nervous system, specified as central nervous system sensitivity to pain Low Back Pain with Related Generalized Pain Low back pain Disorder of central nervous system, specified as central nervous system sensitivity to pain Persistent somatoform pain disorder ICF: International Classification of Functioning, Disability, and Health (ICF) impairment-based category ICD: International Statistical Classification of Diseases and Related Health Problems

16 Classification ICF Low Back Pain with Mobility Deficits Low Back Pain with Movement Coordination Impairments Low Back Pain with Related (Referred) Lower Extremity Pain Low Back Pain with Radiating Pain Low Back Pain with Related Cognitive or Affective Tendencies Low Back Pain with Related Generalized Pain Symptoms Low back, buttock or thigh pain Onset related to unguarded or awkward position or movement back stiffness Recurring or numerous episodes of low back pain that is commonly associated with referred LE pain LBP that is commonly associated with referred buttock, thigh, or leg pain Symptoms are often worsened with flexion activities and sitting LBP with associated radiating (narrow band of lancinating) pain in the involved LE LE paresthesias, numbness, and weakness Low back and/or low back-related LE pain Low back and/or low back-related LE pain with >3 month Sx duration Generalized pain not consistent with other impairment-based classification criteria

17 Examination Outcome measures Validated self-report questionnaires Identify baseline pain, function, disability Monitor for change Activity limitation and participation restriction measures Physical Exam Mental impairment measures Fear avoidance belief questionnaire Pain catastrophizing scale

18 ICF Exam Impairments Low Back Pain with Mobility Deficits ROM limitations and symptom reproduction with ROM Limited segmental mobility Symptom reproduction with segmental provocation Low Back Pain with Movement Coordination Impairments Low Back Pain with Related (Referred) Lower Extremity Pain Reproduction of pain with ROM Symptom reproduction with segmental provocation Segmental hypermobility Diminished trunk or pelvic-region muscle strength and endurance Presence of aberrant movements Symptoms that can be centralized and diminished with specific postures or repeated movements Reduced lumbar lordosis Limited lumbar extension mobility Low Back Pain with Radiating Pain LE radicular symptoms that are present at rest or with ROM Adverse neural tension testing Signs of nerve root involvement

19 Exam ICF Low Back Pain with Related Cognitive or Affective Tendencies Impairments Two positive responses to Primary Care Evaluation of Mental Disorders screen and affect consistent with an individual who is depressed High scores on the Fear-Avoidance Beliefs Questionnaire and behavioral processes consistent with an individual who has excessive anxiety or fear High scores on the Pain Catastrophizing Scale and cognitive process consistent with rumination, pessimism, or helplessness Low Back Pain with Related Generalized Pain Two positive responses to Primary Care Evaluation of Mental Disorders screen and affect consistent with an individual who is depressed High scores on the Fear-Avoidance Beliefs Questionnaire and behavioral processes consistent with an individual who has excessive anxiety or fear High scores on the Pain Catastrophizing Scale and cognitive process consistent with rumination, pessimism, or helplessness

20 Physical Exam Reference

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28 Physical Exam Trunk muscle power and endurance

Physical Exam Trunk Flexors The pt is in supine; the examiner elevates both of the pt s fully extended legs to the point at which the sacrum begins to rise off the table.

29 Physical Exam Trunk Flexors The pt is in supine; the examiner elevates both of the pt s fully extended legs to the point at which the sacrum begins to rise off the table. The pt is instructed to maintain contact of the low back with the table while slowly lowering extended legs to the table without assistance. The examiner observes and measures when the lower back loses contact with the tabletop due to anterior pelvic tilt. If patients demonstrate anterior pelvic tilt with hip flexion greater than 50 in males and 60 in females, they are more likely to have chronic low back pain 21

Physical Exam Trunk Extensors The pt is in supine; is instructed to extend at the lumbar spine and raise the chest off the table to approximately 30 and hold.

30 Physical Exam Trunk Extensors The pt is in supine; is instructed to extend at the lumbar spine and raise the chest off the table to approximately 30 and hold. The test is timed until the pt can no longer hold the position. Trunk extensor strength has been highly correlated with the development and persistence of low back pain 22 Males who are unable to maintain an isometric hold of 31 seconds (33 seconds for females) are significantly more likely to experience low back pain 22

31 Physical Exam Transversus Abdominis The pt is prone; over a pressure biofeedback unit that is inflated to 70 mmhg. The patient is instructed to draw in the abdominal wall for 10 seconds without inducing pelvic motion while breathing normally. The maximal decrease in pressure is recorded. A 4-mmHg decrease in pressure is established as normal, whereas the inability to decrease the pressure biofeedback device measure by 2 mmhg is associated with incidence of low back pain 23

32 Physical Exam Hip Abductors The pt is in side lying; with both legs fully extended. The pt is instructed to keep the leg extended and raise the top thigh and leg toward the ceiling, keeping the limb in line with the body. Patients are graded on quality of movement. The hip abduction test has demonstrated discriminative ability to predict patients who will develop pain with standing (+LR = ) 24

33 Physical Exam Hip Extensors The pt supine; with knees flexed to 90 and feet on the table. The pt is instructed to raise the pelvis off the table to a point where the shoulders, hips, and knees are in a straight line. The position is held and timed until the position can no longer be maintained. Mean duration of hold for patients with low back pain is 76.7 seconds compared to seconds in persons without low back pain

34 Interventions

35 Interventions Manual Therapy Clinical Prediction Rule 25 Symptoms <16 days No symptoms distal to knee Lumbar hypomobilty Hip IR >35 degrees FABQ-W <19 points 50% reduction in ODI within 2 visits

36 Interventions Trunk coordination, strengthening, and endurance exercises

37 Interventions Centralization and directional preference exercises

38 Interventions Nerve Mobilization

39 Interventions Traction

40 Interventions Patient education and counseling

41 Interventions Progressive endurance exercise and fitness activities

42 Interventions Dry needling Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain 26

43 ICF Interventions Primary Intervention Strategies Low Back Pain with Mobility Deficits Manual therapy to diminish pain and improve mobility Therapeutic exercise to improve ROM Patient education that encourages an active lifestyle Low Back Pain with Movement Coordination Impairments Neuromuscular re-education to promote muscular stability Therapeutic exercises to address strength and endurance deficits Self care and home management training programs Low Back Pain with Related (Referred) Lower Extremity Pain Therapeutic exercises, manual therapy, and traction procedures that promote centralization Patient education about promoting centralization Progress to therapeutic exercises to address strength and endurance deficits Low Back Pain with Radiating Pain Patient education in positions that reduce strain or compression to the involved nerve root(s) or nerves Traction Nerve mobility exercises

44 Interventions ICF Low Back Pain with Related Cognitive or Affective Tendencies Impairments Patient education and counseling to address specific classification exhibited by the patient (ie, depression, fear-avoidance, pain catastrophizing) Low Back Pain with Related Generalized Pain Patient education and counseling to address specific classification exhibited by the patient (ie, depression, fear-avoidance, pain catastrophizing) Low-intensity, prolonged (aerobic) exercise activities Appropriate to refer to multidisciplinary chronic pain management

45 Case History Symptoms aggravated with walking and improved with sitting Exam Limited and pain-reproduction with lumbar extension AROM Presence of adverse neural tension tests

46 ICF Exam Impairments Low Back Pain with Mobility Deficits ROM limitations and symptom reproduction with ROM Limited segmental mobility Symptom reproduction with segmental provocation Low Back Pain with Movement Coordination Impairments Low Back Pain with Related (Referred) Lower Extremity Pain Reproduction of pain with ROM Symptom reproduction with segmental provocation Segmental hypermobility Diminished trunk or pelvic-region muscle strength and endurance Presence of aberrant movements Symptoms that can be centralized and diminished with specific postures or repeated movements Reduced lumbar lordosis Limited lumbar extension mobility Low Back Pain with Radiating Pain LE radicular symptoms that are present at rest or with ROM Adverse neural tension testing Signs of nerve root involvement

47 ICF Interventions Primary Intervention Strategies Low Back Pain with Mobility Deficits Manual therapy to diminish pain and improve mobility Therapeutic exercise to improve ROM Patient education that encourages an active lifestyle Low Back Pain with Movement Coordination Impairments Neuromuscular re-education to promote muscular stability Therapeutic exercises to address strength and endurance deficits Self care and home management training programs Low Back Pain with Related (Referred) Lower Extremity Pain Therapeutic exercises, manual therapy, and traction procedures that promote centralization Patient education about promoting centralization Progress to therapeutic exercises to address strength and endurance deficits Low Back Pain with Radiating Pain Patient education in positions that reduce strain or compression to the involved nerve root(s) or nerves Traction Nerve mobility exercises

48 Intervention Education 27

49 Intervention Centralization and directional preference exercises

50 Intervention Nerve Mobilizations Traction

51 Intervention

Movement System Diagnoses. Movement System Impairment Syndromes of the Lumbar Spine. MSI Syndrome - Assumptions. Return From Forward Bending

Movement System Diagnoses. Movement System Impairment Syndromes of the Lumbar Spine. MSI Syndrome - Assumptions. Return From Forward Bending Movement System Diagnoses Kinesiopathologic Pathokinesiologic Movement System Impairment Syndromes of the Lumbar Spine Shirley Sahrmann, PT, PhD, FAPTA Washington University St. Louis School of Medicine