Lumbopelvic Pathology PDF

Lumbopelvic Pathology Adam Squires PT, DPT, Cert SMT, Cert DN Board Certified Specialist in Orthopedic Physical Therapy  Objectives Understand impairment-based classification of low back pain. Demonstrate understanding of common lumbopelvic pathologies. Definitio...

Lumbopelvic Pathology Adam Squires PT, DPT, Cert SMT, Cert DN Board Certified Specialist in Orthopedic Physical Therapy  Objectives Understand impairment-based classification of low back pain. Demonstrate understanding of common lumbopelvic pathologies. Definitions  Pathology Webster Online: “The structural and functional deviations from the normal that constitute disease or characterize a particular disease” “The study of the essential nature of diseases and especially of the structural and functional changes produced by them” Important to understand Even if pathology does NOT always equal pain or limitation  Lumbar Clinical Practice Guideline Published 2012, updated 2021 Impairment-based classifications for low back pain (not pathology) Low back pain with mobility deficits (acute, subacute, chronic) Low back pain with movement coordination impairments (acute, subacute, chronic) Low back pain with radiating pain (acute, subacute, chronic) Physical therapy diagnoses Pathology  Overview Serious/Systemic Pathology Bone Pathology Joint Pathology Disc Pathology Nerve Pathology Contractile Tissue Pathology Serious/Systemic Pathology  Overview Spondyloarthropathies Ankylosing Spondylitis Cauda Equina Abdominal Aortic Aneurysm (AAA) Cancer Fracture  Ankylosing Spondylitis Inflammatory condition of the spine Eventually results in fusion of the spine Men>women – starts in early adulthood (80% 3 cm (1.2 inches) 4-8% of older men, 0.5-1.5% of older women Symptoms Abdominal pain, backache Risk Factors Age, smoking, family history Diagnosis Palpation Imaging – Ultrasound, CT, MRI https://medlineplus.gov/ency/article/000162.htm  Compression Fracture Most frequently – T8, T12, L1, L5 Trauma Significant in young person Minor in older person Risk Factors Post-menopausal women Osteoporosis Long-term corticosteroid use https://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_spinal/x-ray_thoracolumbar_spine_fracture  Compression Fracture Symptoms Pain at site of fracture Limited motion Diagnosis X-ray Treatment Time Kyphoplasty Fusion https://my.clevelandclinic.org/health/procedures/kyphoplasty  Tumors Primary – rare Originates in spine Osteosarcoma, Multiple Myeloma Secondary – common Metastasizes from another area Breast, Lung, Thyroid, Kidney, Prostate BLT with Ketchup and Provolone Red Flags Unexplained weight loss, Pain not relieved with rest or position change, Night pain, Etc.  Tumors http://www.tumorlibrary.com/case/detail.jsp?image_id=5606 http://tcspinecenter.com/spine-conditions/thoracic-tumorinfection/ Bone Pathologies  Overview Spondylolysis Spondylolisthesis Schmorl’s Nodes  Spondylolysis Fracture of pars interarticularis without vertebral displacement Repeated or excessive end-range extension Dancers, gymnasts Signs/Symptoms Pain (acute vs chronic) Localized to low back https://twincitiespainclinic.com/conditions/spondylolysis/  Spondylolysis Diagnosis X-ray Scotty Dog collar sign Treatment Conservative Flexion bias Bracing Facet Time Pars Interarticularis Facet http://www.gentili.net/signs/images/200/spinescottynormal.JPG https://radiopaedia.org/articles/scottie-dog-sign-spine?lang=us  Spondylolisthesis Pars fracture with anterior displacement of the vertebral body CPG- Low back pain with movement coordination impairments Most common in lumbar region (esp. L5/S1) Etiology Congenital Arthritis Trauma Stress Fracture Diagnosis X-ray http://www.wyospine.com/spine_abnormalities.asp  Spondylolisthesis Meyerding Scale - 4 grades (according to % displacement/slippage) Grade 1 = 0 – 25% Grade 2 = 25 – 50% Grade 3 = 50 – 75% Grade 4 = 75 – 100 % Spondyloptosis = >100% http://www.eorthopod.com/lumbar-spondylolisthesis/topic/124  Spondylolisthesis Signs/Symptoms Pain (acute vs chronic) Neurological symptoms (higher grades) Step-off deformity Treatment Conservative (low grades) Flexion bias exercises Strengthening Careful with manual therapy Injections Surgical (high grades)  Schmorl’s Nodes Disc herniation through the vertebral endplate into the body of the vertebrae Usually asymptomatic http://radiopaedia.org/images/11068 https://www.spineinfo.com/conditions/schmorls- nodes-definition-causes-symptoms-and-treatment/ Joint Pathology  Overview CPG - Low back pain with mobility deficits Spondylosis, Degenerative Joint Disease (DJD), Osteoarthritis (OA), Facet arthropathy Different words for the same thing Contributing factors: Genetics, lifestyle factors, trauma Arthritic changes Osteophytes Cartilage loss Thickening of capsule  Facet Joint Signs/Symptoms https://link.springer.com/chapter/ Pain/Stiffness relieved by movement 10.1007/978-981-16-9547-6_4 Local and referred Limited ROM “Closed” positions most uncomfortable (e.g. standing, walking) Older individuals Treatment Conservative https://www.discspine.com /conditions/facets-arthritis/ Mobility, Manual therapy Injections Radiofrequency Ablation  SI Joint Usually related to hypermobility Peripartum women>men Hypermobile people Connective tissue disorders CPG: Low back pain with movement coordination impairments Signs/Symptoms Stiff, sharp, tingling symptoms Localized and/or generalized pain Sitting, sit to stand, inactivity Lifting, Running, shifting weight to affected side https://www.researchgate.net/figure/Typical-pain- referral-pattern-of-sacroiliac-joint-pain-illustration- Rogier-Trompert_fig1_233943128  SI Joint Treatment Conservative Bracing Manual Therapy Strengthening Injections RFA Surgery https://www.mayoclinic.org/diseases-conditions/sacroiliitis/multimedia/sacroiliac-injection/img-20007974 Disc Pathology  Overview Estimated prevalence of pain related to disc herniation: 1.6- 13.4% (Wong et al 2023) Degenerative Disc Disease (DDD) 88-96% of asymptomatic people between 60 and 80 years old have disc degeneration (Brinjikji 2015) Increases every decade of life from age 20 up Disc Herniation 69-84% of asymptomatic people between 60-80 years old have disc bulge (Brinjikji 2015)  Degenerative Disc Disease Decrease in proteoglycans leads to decrease in water imbibition into nucleus Decreased vertical height Increased facet joint loading Ligamentous laxity bulging into canal and foramina (stenosis) lig. flavum also thickens Loss of nutrients Strong genetic link Lifestyle factors? http://myspinedoc.com/conditions-diagnosis/conditions/degenerative-disc  Disc Herniation Posterolateral is most common Degeneration breakdown of inner rings no deformation of outer rings Prolapse bulging beyond normal annular margin, outer rings still intact http://www.nshdubai.com/wp-content/uploads/DiscDegeneration_labeled.jpg  Disc Herniation Extrusion nuclear material escapes but still in one piece portion of broken annulus may also extrude Sequestration nuclear material separates free from disc annular material may also break free http://www.nshdubai.com/wp-content/uploads/DiscDegeneration_labeled.jpg  Disc Herniation CPG - Low back pain with radiating pain Signs/Symptoms Back and radiating pain +/- Neurological signs Bending/twisting > standing/walking Nerve Mechanosensitivity Treatment Conservative – Time, direction specific exercises Injection Surgery Progressive or rapid neurological symptoms  Disc Herniation Can disc herniations heal without surgery? YES!! https://www.nejm.org/doi/full/10.1056/NEJMicm1511194 Nerve Pathology  Overview CPG - Low back pain with radiating pain Radiculopathy Stenosis Nerve Entrapment Nerve Mechanosensitivity “Double Crush” Syndrome https://www.spinalbackrack.com/what-is-nerve-compression-syndrome-in-the-back/  Radiculopathy Prevalence – 3-5% Age risk factor Men – 40s Women – 50-60s Degenerative Spondyloarthropathies Disc herniation Spondylolisthesis https://www.scoliosissos.com/blog/spondylosis-causes-prevention-and-treatment  Radiculopathy Signs/Symptoms True neurological deficits Dermatomes, Myotomes, Reflexes Lower Motor Neuron deficits Pain in area associated with nerve root +/- Limited ROM Nerve Mechanosensitivity Treatment Conservative Mobility, time Injection https://www.sportspainmanagementnyc.com/lumbar-radiculopathy/ Surgery  Spinal Stenosis Narrowing of a tube or canal Central Stenosis Narrowing of spinal cord space “Buckling”/thickening of PLL and ligamentum flavum https://regenexxpittsburgh.com/spinal-ligament-injuries-and-neck-pain/ https://vancouverspinedoctor.com/conditions/spinal-stenosis/  Central Stenosis Signs/Symptoms Bilateral LE symptoms Neurogenic claudication +/- true neurological signs Upper motor neuron deficits Treatment Conservative Direction specific Injections Surgery  Foraminal Stenosis Foraminal Stenosis Narrowing of foramen Facet hypertrophy Disc pathology https://caringmedical.com/prolotherapy-news/prolotherapy-spinal-stenosis/  Foraminal Stenosis Signs/Symptoms Unilateral symptoms Neurogenic Claudication +/- true neurological signs Lower Motor Neuron deficits Treatment Conservative Direction specific Injections Surgery  Nerve Entrapment Theory – Minor injuries to either the nerve or connective tissue may cause the connective tissues to: Adhere (referred to as “tethering”) Shorten Lose elasticity Resulting in pain and paresthesia along the affected nerve Nerves are quite robust But can become highly sensitized Especially with chemical irritation (e.g. inflammation)  Nerve Entrapment Better term – Nerve Mechanosensitivity Nerve is sensitized to mechanical forces E.g. stretch, compression Prevalence varies based on body area Carpal tunnel as high as 3.72% Signs/Symptoms Pain and paresthesia along nerve Not dermatomes +/- Motor deficits Not myotomes https://www.rehabmypatient.com/lumbar-spine/femoral-nerve-entrapment  “Double Crush” Compression or irritation in 2 or more distinct areas E.g. Sciatic nerve – L4 nerve root and piriformis http://miracledoc.com/blog/b_7151_carpal_tunnel_syndrome.html https://www.mountsinai.org/health-library/diseases-conditions/sciatica  Nerve Treatment Nerves like 3 things Space Movement Blood flow Space Direction Specific exercise? Surgery Movement https://www.sydneyhealthphysio.com.au/resources/sciatic-nerve-glide-in-sitting Nerve glides, manual therapy, exercise Blood flow Cardiovascular exercise Contractile Pathology  Contractile Pathology CPG - Low back pain with mobility deficits Can be overlooked as a pain generator in the lumbar spine Muscle Strain Acute or chronic overuse Develop myofascial pain Muscle Spasm Protective mechanism Contractile, joint, disc, or nerve injury/pain https://www.prophysiomt.com/blog?action=view&post_id=1815  Contractile Pathology Signs/Symptoms Sore, stiff Aching, sharp pain Localized to the lumbar musculature Decreased ROM Treatment Time Conservative Trigger point injections https://www.prevention.com/fitness/a20506161/5-stretches-to-ease-your-lower-back-pain/ Questions