Is it really a back problem? Tools to identify the real issue

Transcription

1 Is it really a back problem? Tools to identify the real issue Thuy (Twee) Bridges Physiotherapist

2 BACKGROUND - The worst back pain may not be the scariest. Pain intensity does NOT correlate to severity of condition. - Pain is a symptom that reminds your body that something is not right, where the pain is located may feel quite severe but this may not actually be where the work or training needs to be done. - Muscle spasm, Trigger points (tiny muscle cramps) can be a typical source of extreme pain; these ARE NOT DANGEROUS but hinder participation in exercise and function. - A Symptomatic based Diagnosis is different to a Driver Diagnosis. A Driver is considered to be the instigator of the symptoms, treating the Driver will lead to a reduction in symptoms. - The aim of this presentation is to assist you with tools and strategies to understand driving forces for LBP that may not be in the low back itself. ANATOMY OF THE BACK - REVIEW - How does the back relate to the rest of the body with biomechanics and function Joints segments Cervico-vertebral joint (upper cervical spine) Mid cervical Thoracic cage Shoulder Lumbar Pelvis/Hips Knee Ankle Arch Metatarsals Primary or secondary curve? Function? Impact of dysfunction

3 COMMON BACK CONDITIONS Condition What is it? Symptoms to look for Sciatica Spondylolisthesis Arthritis Spondylosis Stenosis Slipped disc, Disc bulge Non Specific low back pain Causes Strategies Keep in mind that people can have NO PAIN despite imaging that shows: arthritic degeneration, herniated discs and structural problems such as stenosis and spondylolisthesis. SOME ORTHOPAEDIC TESTS PHYSIOTHERAPISTS USE Test How to perform the test What do the findings mean? Straight leg raise Prone knee bend Cervical Spine flexion Slump Reflexes Babinski Pelvic Thrust

4 RED FLAGS These are rare, but try not to miss these Red flag Symptoms to look out for: Condition Cancer Typical symptoms Cauda Equina Spinal Infection Abdominal Aneurysm Ankylosing Spondylitis Fracture Only 6% of LBP in older adults have a serious underlying cause. 5% of this is due to cancer, the remaining 1% is divided amongst the other serious cases. Enthoven WT et al. Prevalence and red flags regarding specified causes of low back pain in older adults presenting in general practice. Physical Therapy March. 96(3)

5 OTHER CAUSES OF LOW BACK PAIN Organ/visceral load Organ Location Symptom characteristics to look out for Kidney Aorta Appendix Gall Bladder Pancreas Spleen Intestine Pelvic floor Emotional load Disabling back pain can change for the better with a different narrative and coping strategies. Vibe- Fersum K et al. Efficacy of classification- based cognitive functional therapy in patients with non-specific chronic low back pain. A randomised controlled trial. Euro J Pain July 17(6): Thoughts drive feelings. Habits and style of thinking drive feelings. Feelings drive experiences. Emotion of fear and the reaction urge; Fear avoidance Anxiety- habituation and controlled de-sensitisation Emotional event connection Cultivating Helpful Thinking (healthymindsprogram.com) Event Emotion Reaction Urge Was it helpful?

6 BIOMECHANICAL LOAD ALGORITHM FOR SUCCESS 1A. Establish a Meaningful Movement MM aggravating/painful movement- irritable or stable? increased effort, or just not right if the task is complex, break it down into component movements This needs to be something that you can see or measure and something that they can feel or report on with a level of certainty 1B. If the client does not have a meaningful movement that can produce effort or symptoms. Or Everything hurts so picking one movement is too hard, you can implement additional testing to get a better understanding. Other Tests that you can try to get more clues Test How to perform the test What do the findings mean? A. Seated rotation test. Hand above head B. Standing rotation test C. Squat test D. Serratus punch test ASLR E. Windlass test F. Therapy band glut test Remember the goal to get a test that highlights to the client their symptoms in order to monitor if your management has been effective. 2. Establish the baseline in Neutral and the baseline for movement during MM Once you have your meaningful task Look for what is not normal/ideal at the start ie. Before they commence the MM. Know what is normal or ideal for that movement (MM)? Look for what gets worse or becomes abnormal or dysfunctional as they move into the task. Start with what goes wrong first. If you cannot see what goes wrong first, go with the most obvious dysfunctional movement

7 Option 3A. Local symptom management Test locally at site looking for local source to change to MM. eg Length and strength resource. Manage locally with tape, stretch or mechanical correction and look for impact on MM Compare to the original testing. What other region gets worse? You will need to follow this up next time What doesn t change? You may need to follow this up later Option 3B. Remote hierarchy management Based on looking for most dysfunctional/ obvious/ first deviation from expected normal movement. Test at remote site looking for source to change to MM. eg Length and strength resource. Manage locally with tape, stretch or mechanical correction and look for impact on MM. What other region gets worse? You will need to follow this up next time What doesn t change? You may need to follow this up later 4. Find the next correction that improves the MM Keep following the clues that the body gives you. It is OK to not get it quite right the first time so long as you keep following the clues, you will collect clues as you go. Change is always better than no change. 5. If the area is symptomatic then you will likely need to manage the local and remote sites Keep in mind there may be more than one driver ie. Two or more interacting forces that interact at the local site of symptoms. 6. Train according to the hierarchy that you have established. SUMMARY ALGORITHM FOR SUCCESS 1. Nominate the meaningful movement. The client performs the MM. Record Range, symptoms, restrictions and effort 2A. Complete what you notice at rest/in neutral 2B. Establish your baseline for movement during the MM 3A or B Nominate you focus on either the symptom or the hierarchy. Review your intervention against the MM. 4. Next session follow up what you missed or what went wrong 5. Local training to prevent symptoms worsening, Remote training for what is causing the problem or preventing the problem from completely resolving. 6. Educate the client that if they are short on time, training the top of the hierarchy gets the fasted results.