PTMMD Unit 2 Transcripts - Lumbopelvic Medical Screening PDF

PHT 5452: Lumbopelvic Medical Screening The following presentation will review medical screening for the thoracolumbar and lumbar pelvic regions of the spine to determine the need for outside referral and the appropriateness of physical therapy interventions. We'll start by looking at the physical therapist management process, the subjective and objective examinations are conducted and then we will evaluate our findings to determine the need for outside referral or consultation. This first step is extremely important to determine the appropriateness of physical therapy services and whether urgent referral must take place or a collaborative approach with other healthcare professionals is warranted. Once we determine whether there is a need for additional resources, we then move on to the diagnosis and prognosis stage to establish appropriate interventions. As a quick reminder, red flags are warning signs that may indicate the need for RE evaluation by medical specialist and yellow flags are warning signs specifically to assess pain associated psychological distress which may indicate higher risk for delayed recovery or the development of a chronic condition that may require referral for psychological evaluation and counseling for serious medical conditions that may present as low back pain. We will review viscerogenic conditions such as neoplasm, including metastatic spinal cord compression, spinal infection and abdominal aortic aneurysm. We will also look at serious neuromusculoskeletal conditions that would require medical referral including spinal fracture or cauda Iquana syndrome. The prevalence of neoplasm for patients presenting with low back pain has been reported between.1% to 3.5%. 1 Significant clinical findings that would indicate the potential for neoplasm include age greater than 50, history of cancer, especially lung, breast or prostate cancer due to their high rate of metastasis to the spinal column. Unexplained weight loss defined as greater than £10 / 3 months without change in diet or other known causes of weight loss. Failure of conservative therapy after one month, and unrelenting night pain. While pain at night can be a red flag for metastatic bone disease, it is also often present in patients with benign low back pain. To increase the index of suspicion for neoplasm, patients should have low back pain that worsens with lying down. Instead of alleviating, they will report a need to get up and walk to E symptoms and may be unable to sleep lying flat, requiring them to sleep upright sitting in a chair. A cluster of exam findings found to be useful in cancer screening has been developed. It includes the combination of age greater than 50, history of cancer, unexplained weight loss and no improvement after one month of conservative care. This diagnostic cluster was found to have 100% sensitivity, meaning in the absence of all of these findings. So the patients younger than 50, they have no history of cancer or unexplained weight loss and symptoms improve over a month of conservative care. Cancer is less likely cause of the patient's symptoms. Therefore these items function well as a screen for malignancy in patients with low back pain. Diagnostic utility of additional clinical features for the identification of cancer have also been studied. History of cancer Elevated erythrocytes sedimentation rate, reduced hematocrit levels, and overall clinical judgment increase the probability in the patient having malignancy based on the reported psychometrics. 2 These are some of the most useful clinical features to rule in malignancy. Metastatic spinal cord compression is a neoplastic condition of the spine that leads to vertebral body collapse or direct tumor growth that can cause irreversible neurological damage. Patients can experience pain and structural spinal instability and it can eventually lead to paraplegia, quadriplegia, and bowel and bladder incontinence. The most common cancers to metastasize to the spine are breast, prostate and lung, making up about 50% of cases, though other cancers can also metastasize like colorectal cancer and lymphoma. While the absence of a history of cancer can be a useful clinical feature to help screen for metastatic disease. Approximately 25% of patients will have metastatic spinal cord compression as the first sign of cancer while early signs include intensifying pain over time, worse with increased abdominal pressure like during coughing, sneezing and straining during bowel movements as well as worse with lying supine which is unusual for patients but non mechanical low back pain. The index of suspicion should be elevated if patients have a known cancer diagnosis or severe unremitting pain, especially if localized over the cervical and thoracic spine or aggravated with increased intra abdominal pressure. The pneumonic red flags was developed to assist clinicians in recognizing metastatic spinal cord compression quickly as delayed diagnosis and treatment can have significant impact on prognosis. These red flags include refer to radiating pain that is multi segmental or band like escalating pain which is poorly responsive to treatment, different character or site to previous symptoms. Funny feelings, odd sensations or heavy legs. Lying flat increases low back pain, agonizing pain causing anguish or despair, Gait disturbances unsteadiness especially on stairs, not just a antalgic limp sleep grossly disturbed due to pain being worse at night. 3 A single red flag may only require you to continuously monitor the patient. The greater the number of red flags should increase your level of suspicion and impact the urgency of medical referral. Additional red flags for metastatic spinal cord compression include the following limb weakness, difficulty walking, sensory loss, bladder and bowel dysfunction, Neurological signs progressive unremitting lumbar, spine pain, cervical or thoracic pain. Pain increase with straining and night pain. Another viscerogenic condition that should be considered as a part of medical screening in patients with low back pain is spinal infection. Potential infections that occur in the lumbar spine include tuberculosis, discitis, and spinal Abscess. These are rare occurrences, representing.01% of patients with low back pain presenting to primary care. Due to this rare occurrence, it is often overlooked as a potential differential diagnosis. Patients who may be presenting with spinal infection include those with progressive low back pain who may have a fever, though the absence of fever does not rule out infection and may or may not have neurological dysfunction. They often have a history of recent infections like urinary tract infections or skin infections, immunosuppressive disorders, comorbidities that suppress the immune system such as diabetes, HIV, long term steroid use and smoking. Socio economic and environmental factors like IV drug use, obesity, migrants from tuberculosis, endemic countries or a family history of tuberculosis and poor living conditions increase the risk for infection. Finally, recent spinal surgery is a key risk factor, especially the more complex multi level lumbar surgeries. If you suspect a patient has a spinal infection, it is important that you seek immediate medical referral as this condition can quickly progress to a disabling or life threatening condition. 4 Screening for vascular causes of low back pain should also occur, including for abdominal aortic aneurysm or AAA. AAA can present with back, abdominal and groin pain patients with peripheral vascular disease and coronary artery disease and their associated risk factors are at greatest risk for developing an aneurysm. Patients with an abdominal girth less than 100 centimeters have a positive likelihood ratio of 2.5 indicating a small shift in probability. They have AAA and those who have abdominal girth that is greater than 100 centimeters have a moderate shift in probability that they do not have a AAA presenting as low back pain. The absence of a palpable abnormal aortic pulse as well as a pulse with less than 4 centimeters can also help rule out AAA. If the patient is suspected of having an abdominal aortic aneurysm, they should be referred for medical evaluation and if you suspect the aneurysm has ruptured and this is an immediate urgent referral as this is a life threatening situation. Spinal fracture is another condition that clinicians must consider in patients with low back pain to ensure timely referral for imaging occurs. Desire to avoid unnecessary imaging referrals in patients with low back pain has LED some to criticize the reported red flag features for fracture in this area. Due to the number of false positives that are often generated, it is important that we do our due diligence in determining those that need imaging and those that do not. Some red flag consideration should include those with a history of trauma, prolonged steroid use, and age greater than 70 years. The combination of these factors being present represent a large shift in probability The patient has a spinal fracture. A diagnostic cluster has been developed to assess for spinal compression fracture. Researchers identified 5 items predictive of compression fracture. 5 These include age greater than 52 years, no presence of lower extremity, pain body mass index less than 22, someone who does not regularly exercise and is a female gender. If one or less of these findings is present, then the negative likelihood ratio is 0.16, indicating A moderate shift in probability. The patient does not have a compression fracture. If the patient exhibits 4 or more of these items from the cluster, the positive likelihood ratio is 9.6, indicating A moderate shift in probability. The patient does have a compression fracture and should be referred for imaging. Another neuromusculoskeletal condition that should be screened for in all patients with low back pain, especially those with concurrent lower extremity symptoms, is called Aquana syndrome. Called Aquana syndrome is a lower motor neuron lesion where the lumbosacral nerve roots have been compromised and the patient is experiencing the loss of sensory, motor and reflex function. This most often occurs due to a large central disc herniation at L45 or L5 S, one that can also be caused by any space occupying lesion of the central canal below the Conus medullaris at approximately L1. These include traumatic spinal fractures, tumors or metastatic disease causing pathological fracture, central canal stenosis caused by spondylolisthesis, and spinal Abscess or infection. These patients will present with a combination of bowel and bladder dysfunction, which can include fecal incontinence and urinary retention, saddle paresthesia or anaesthesia, sexual dysfunction, bilateral radicular pain and multi level weakness and sensory loss, often in the L4 L5 S1 distribution of the feet and perianal pain. Urinary retention caused by a hyporeflexive bladder that can eventually become overflowing continence can be an important predictor of Cauda Quanta syndrome. 6 The positive likelihood ratio indicates a large shift in probability they have Cauda Quana syndrome if urinary retention is present and the negative likelihood ratio represents A moderate shift in probability that they do not have Cauda Quana syndrome if it is not present. As a result of Cauda Quana syndrome being a lower motor neuron lesion affecting multiple nerve roots within the central canal of the lumbar spine, patients can have impaired multi level bilateral lower extremity reflexes, myotomes and dermatomes. One of the differential diagnosis that can also present with bowel and bladder dysfunction and lower extremity sensory and motor impairments is cervical myelopathy, but since it is a condition of the spinal cord and not the nerve roots, it would present as an upper motor neuron lesion. Because of this, it is important that a complete lower quarter neurological exam including pathological reflexes is performed as a part of your comprehensive medical screen. If cauda quanta is suspected, it is important to immediately refer the patient for imaging in surgical consult as urgent decompression is necessary to preserve neurological function. Delayed referral could lead to permanent loss of bowel and bladder control, sexual dysfunction and lower extremity weakness or paralysis. It is important to provide patient education to those that are at risk for cauda quanta syndrome. Providing patients with specific symptoms to be aware of during self-care and daily activities can lead to a timely diagnosis and intervention to prevent permanent disability. Handouts like this one from the United Kingdom National Health Service can serve as reminders to patients. Once we've determined the patient is likely presenting with a neuromusculoskeletal condition that is safe and appropriate for physical therapy management, we will continue our examination to identify impairments in body function and structure, along with activity limitations and participation restrictions that require PT intervention. 7 However, we should continue to evaluate and monitor for signs and symptoms of serious pathology as a condition involves over time or a new presentation emerges. This may then require outside consultation and referral. 8 PHT 5452: Low Back Pain with Mobility Deficits In this presentation, we will review the impairment based diagnosis low back pain with mobility deficits. When considering the underlying cause of the patient's condition, it's important to remember that direct patho anatomical causes for low back pain are rarely truly identifiable. All innervated structures in the lumbar spine can be a source of nociception, which includes the facet joints, vertebra muscles, ligaments, nerves, and discs. Low back pain may be associated with the degenerative process or pathology identified during imaging, but the specific tissue causing the patient's symptoms is often unknown. It is common to have abnormal imaging findings in patients without low back pain and a lack of progressive changes in those who develop it, while only fewer than 15% of low back pain cases can be confidently linked to a true pathoanatomical source. Despite this lack of knowledge, we may hypothesize what tissues are being affected that we must continue to remember these limitations. Also because of this, it is important that we utilize an impairment based model when considering potential diagnosis and determining the best treatment approach. Low back pain with mobility deficits. It's an impairment based diagnosis that is caused by impairments to the facet, joint and periarticular soft tissue. The pathoanatomy can be categorized into to broad conditions, Spondylosis, A gradual progression of age-related changes to the spinal elements that allow for movement, or a spraying strain to the facet joint and surrounding soft tissue caused by a sudden, awkward movement. 1 Both of these conditions will result in a loss of active and passive range of motion and will respond favorably to manual therapy and exercise, but they have different time frames to onset and different underlying causes for the resulting loss of motion. Medical screening should include a consideration of viscerogenic diagnosis as well as serious neuromusculoskeletal conditions including spinal fracture and Cauda acquana syndrome. Differential diagnosis for low back pain with movement coordination impairment should include other impairment based diagnosis. This list is not exhaustive but should encourage you to consider the potential for other conditions. There may be overlap with these conditions or patients may transition from another impairment based diagnosis to movement coordination impairments. When there is significant overlap, the diagnosis should be based on which of the impairments are most responsible for limiting the patient's activity and participation and on patient values. Or in some cases, it's appropriate to start treating multiple impairments or the transition from 1 diagnosis to another may happen quickly. For example, once you've had a positive influence on patients with cognitive and affective tendencies. These patients may also present with movement coordination impairments and would benefit from treatment targeting these. If that is the case. Take care with your language when explaining the condition or the purpose of your interventions. It is also common for patients with referred or radiating pain to progress to movement coordination impairments classification once positive progress has been made towards centralizing their lower extremity pain. 2 This is not a guarantee though and patients should be re examined for these impairments when it's once it's appropriate to do so. The nature of the condition involves the musculoskeletal system with the impairment in body structures that are often involved, including the zygopophyseal, joint and periticular soft tissue. The dominant pain mechanism is no susceptive even in the presence of somatic referred pain from the facet joints and ligaments. When the condition involves a sudden awkward movement resulting in a spring strain, we should consider healing time frames for muscle and ligaments. General subjective reports will include central or unilateral low back pain that may be a dull ache at rest but become sharp with movements that load the involved structures, particularly at in range. The major differences between a Spondylosis and a sprained strain are the time frames to onset and the presence of a mechanism of injury. Spondylosis involves more gradual progressive worsening over time where a sprained strain is more immediate onset with a clear mechanism of injury, with a likely dominant pain mechanism being no susceptive. The patients aggravating and easing factors will have a clear proportionate mechanical nature with localized symptoms, though pain can refer into the lower extremity. Pain is often more of a dull ache across the low back, but can be sharp and very localized with movement. These patients have a typical 24 hour pain pattern and may have a positive response to simple analgesics. Common aggravating factors include inactivity, which will result in reported stiffness, loss of motion, and a dull ache. Certain active movements that load the involved structures towards N range may be painful, for example with intraarticular facet conditions. 3 Movements that involve a down glide or facet compression like an extension, ipsilateral side bending, and contralateral rotation may be painful on the involved side due to the increased stress to the joint surfaces with extra articular or periarticular soft tissue and facet conditions. Movements that involve an up glide or facet gapping, like in flexion, contralateral side bending, and ipsilateral rotation may be painful due to the tensile forces placed on the tissues. Easing factors include progressive spinal movement. Staying active along with progressive range of motion during periods of pain and stiffness will help alleviate the pain the patient's chief complaint and improve range of motion. Because of the lack of activity and movement while they sleep, patients may wake up stiff and achy until they get up and move around. The rest of the day will be variable depending on the amount of inactivity or activities that require moving into painful positions. Depending on symptoms, severity, and irritability, as well as the ability to find positions of comfort, patients may or may not have difficulty sleeping. If they do, it's important to problem solve positioning to improve sleep, as poor sleep hygiene can negatively impact rehab. The first step of any patient examination is to determine if the patient is appropriate for physical therapy or if they require additional medical evaluation. This should influence your chosen tests and measures in the objective examination and are based on the outcome of this objective exam. It is best practice to assess vitals on all patients, especially if they have comorbidities that warrant an understanding of their baseline status that would allow for monitoring over time. 4 One of the best ways to determine the mechanical nature of a patient's condition is to have to assess if it behaves mechanically throughout your exam, therefore monitoring for this essential part of medical screening. If the patient has symptoms in the extremities that you believe could be related or report symptoms that suggest Caudaquana syndrome or radiculopathy, then a full lower quarter neurological exam should be conducted including sensation, motor reflexes and pathological reflexes. If cervical myelopathy or other upper motor neuron lesion presenting with symptoms into the lower extremity is suspected, then a full upper quarter neurological exam should also be included. Hallmark objective findings for patients with mobility deficits are limited active range of motion with consistent reproduction of symptoms at the end of range with certain motions. They will also have joint mobility restrictions and symptom reproduction, including local and somatic referred pain with a passive intervertebral motion assessment at the involved segment or segments. Patients may also have gross hypomobilities throughout the lumbo pelvic hip complex central posterior to anterior passive accessory. Inner vertebral motion testing has been shown to have moderate iterator reliability for pain provocation and fair iterator reliability for the assessment of segmental hypomobility. The Lumbar Quadrant test, which involves active or passive lumbar extension, ipsilateral side bending, and ipsilateral rotation with the patient in standing, has been identified as a good screening assessment for lumbar facet joint pain with a negative likelihood ratio of less than 0.00 with fair iterator reliability. However, it does not perform well at ruling in facet joint pain with a positive likelihood ratio of only 1.3 as there are other reasons the patient may experience a reproduction of pain such as increased reticular pain in patients with lateral foraminal stenosis because of the closure of the foramen on that side. 5 In all patients with low back pain, hip active and passive range of motion should be examined. Limited hip flexion and extension can translate into the lumbar spine during sagittal plane motions and positions. For example, patients with limited hip extension will require increased lumbar extension range of motion in order to come to a fully upright position. Patients who have increased pain with lumbar extension benefit with improved hip extension to reduce the amount of lumbar extension that is needed for standing and walking hip Internal rotation Range of motion is a part of a clinical prediction rule to determine patients with low back pain that are likely to respond to thrust manipulation to the lumbar spine. The inner rater reliability of hip rotation. Range of motion measurements assessed with an inclinometer and prone have almost perfect inner rater agreement for patients experiencing pain over the sacroiliac joint, typically over Fortin's.1 centimeter inferior medial to the PSIS. For symptom provocation, the Lazat cluster is utilized prior to performing these provocation tests. It's important to rule out the lumbar spine first since referred in radicular pain to this area is very common and could lead to false positive tests. This lumbar screen should include tests and measures that attempt to provoke or alleviate symptoms from the thoracolumbar and lumbosacral segments from T1011 to L5 S one. This would include active range of motion, repeated motions or sustained positions assessing for centralization or peripheralization, passive accessory intervertebral motion testing, and neuro dynamic testing. Once the lumbar spine is clear, greater confidence in the Laszlo cluster is achieved. 6 This is seen statistically with an improvement in the positive likelihood ratio from 4.25 to 6.9 when symptoms do not centralized, moving from a small shift in probability to a moderate shift that the source of symptoms is the sacroiliac joint. The original Laszloc cluster had six items with three positive tests indicating a positive test item cluster. Follow up studies found that gainless in right and gainless in left only provide a small improvement to the likelihood ratio and that removing them did not have a negative impact on its clinical utility. With a reduced number of provocation tests, the updated for item cluster includes to be performed in this order Thigh thrust, the most sensitive test, ASIS distraction, the most specific test, ASIS compression and sacral thrust. Once there are two positives, there is no need for further testing and SI joint pain can be suspected, though the positive likelihood ratio is only 4.0, a small shift in probability which does improve if you have adequately ruled out the lumbar spine. If only one test is positive, the negative likelihood ratio is 0.16, a moderate shift in probability. The patient does not have SI joint pain, and if all tests are negative, the likelihood ratio is less than.0. A large shift in probability. The SI joint is not the source of symptoms and can be ruled out. As with all provocation tests, it's important to remember in patients with high irritability, the test should be reserved for once symptoms are less irritable or a high number of false positives are possible. Muscle performance Testing of the lumbar pelvic hip musculature often reveals limited length that affects mobility along with impaired muscle coordination, endurance, and strength, and should be assessed and addressed as necessary. Palpation may also reveal increased muscle tone and active or latent trigger points that may contribute to pain and muscle performance deficits. 7 Once the primary impairments of body function have been assessed and prioritized, additional muscle performance testing should occur and these should be addressed as necessary over time to complete a comprehensive rehabilitation plan of care. With a lifetime prevalence of 70 to 80%, low back pain is one of the most common conditions anyone will ever experience. It is a leading cause of disability globally in one of the most costliest medical conditions. The overall prognosis and Natural History of acute low back pain is favorable, with 90% of patients experiencing recovery by six weeks. With a significant reduction in symptoms noted at four weeks, The residual less severe pain may persist up to three months. The recurrence rate of low back pain has been reported as high as 80% and this can complicate the Natural History of subsequent episodes. The expected clinical course for chronic low back pain is much more variable and less favorable than acute low back pain. Given the high prevalence of recurrent and chronic low back pain and the associated calls, clinicians should place high priority on interventions that prevent the recurrence in the transition to chronic low back pain. Factors associated with higher prevalence of low back pain are female gender, older age, educational status, physically demanding occupation, hypertension, lifestyle factors like smoking or having obesity, and either extremely high levels of activity or being sedentary. Factors associated with the risk of recurrence are previous low low back pain episodes, excessive spinal mobility and excessive mobility and other joints. There is inconclusive evidence for relationship between trunk muscle strength or mobility of the lumbar spine and the risk of low back pain. These factors should be considered when determining the likelihood of developing a new onset of low back pain or the recurrence of a previous episode of low back pain. 8 Factors that may have an impact on prognosis include symptoms below the knee, psychological distress or depression, low expectations of recovery, fear avoidance beliefs and behaviors, higher pain intensity, and passive coping styles. Clinicians should consider these factors when determining prognosis and developing strategies to prevent the progression to clinicity. When determining stage of condition, it is important to consider multiple factors, not just time since injury. This can become even more challenging in the face of the high rate of recurrence of low back pain. Time based staging alone can have little value for intervention selection in most situations. In the presence of known trauma, stage of healing should be considered to avoid overloading healing tissues. In the absence of known trauma, a better judgement of stage and condition may be severity and irritability of the condition. For all stages of low back pain. Patient education is extremely important. In general, clinicians should not utilize patient education and counseling strategies that either directly or indirectly increase the perceived threat or fear associated with low back pain, such as education and counseling strategies that promote extended bed rest or provide in depth path of anatomical explanations for the specific cause of the patient's low back pain. Patient education and counseling strategies for patients with low back pain should emphasize the promotion of the understanding of the anatomical structural strength inherent in the human spine, the neuroscience that explains pain perception, the overall favorable prognosis of low back pain, the use of active pain coping strategies that decrease fear and catastrophizing thoughts, the early resumption of normal or vocational activities even when still experiencing pain, and the importance of improvements in activity levels, not just pain relief acutely. 9 The goal for selected intervention should initially be pain control to keep the patient as active as possible. Patients should receive education on the favorable Natural History of acute low back pain and should be encouraged to participate. In general, exercise promotes mobility, and to maintain an active lifestyle. Patients may need reassurance that this will not worsen the condition and that experiencing some pain during activity does not mean they are causing harm. But if there's an exacerbation of symptoms that remains, then they should adjust activity levels accordingly. Exercise should include activities that promote range of motion, endurance, strength and flexibility that addresses identified impairments throughout the lower quarter. Those specifically limiting spinal and hip mobility should be prioritized. Manual therapy should include both thrust and non thrust, manipulation of the thoracolumbar and lumbar, pelvic spine and hip. The use of thrust spinal manipulation has strong evidence to support its use in the acute stage, especially for those with mobility deficits. In the sub acute phase, these same interventions should be carried over but with more emphasis on movement control, including spine and hip mobility, lower quarter flexibility and continued progression of activity levels. In the chronic stage, less emphasis should be placed on pain control with interventions directed at functional optimization. Promotion of an active lifestyle should continue with additional education on the neuroscience of pain. Pain education should be patient specific and targeted concepts identified as being misunderstood. This education should be directed at helping patients understand why they still have pain beyond normal tissue healing Time frames the biopsychosocial contributors to their 10 pain activity, pacing, and an understanding of how graded exposure to activity and exercise can reduce their pain. Despite not changing pathoanatomy. Pain neuroscience education should not be provided in isolation and should occur alongside exercise and manual therapy interventions. A mix of exercise approaches can be utilized to address impairments in trunk strength, endurance, movement control, mobility and specific trunk muscle activation and other muscle performance deficits identified in the objective exam. Manual therapy should include lumbar, pelvic hip thrust and non thrust joint manipulation and soft tissue manipulation to reduce pain and disability and to restore mobility. Dry needling can also be utilized in these patients to inhibit pain and improve function. In 2002, Flynn ET al. Developed a clinical prediction rule to identify those patients with low back pain most likely to respond to lumbosacral thrust. Manipulation success was defined as a 50% improvement on the Oswestry Disability Index within one to two visits. In addition to spinal manipulation, spinal range of motion exercises were also included in the treatment. There are five items including symptoms less than 16 days. No Symptoms Distal to the Knee Fear Avoidance Belief Questionnaire Work subscale less than 19, hip internal rotation of at least one hip greater than 35°, and at least one hypomobile segment in the lumbar spine identified during posterior anterior accessory testing. If at least four of the five items are present, the patient has a 95% probability of having at least a 50% improvement in the Oswestry within one to two visits. As a part of widespread clinical adoption process in 2004, Childs and colleagues were able to validate the rule during a multi center randomized controlled trial. 11 The chance of success for those that met the rule in this study was 92%, with improvements lasting out to six months. In a follow up study by Fritz ET al. In 2005, the authors identified 2 factors that were predictive of success, including the presence of both symptoms less than 16 days and no symptoms distal to the knee. The presence of both factors resulted in a positive likelihood ratio of 7.2, indicating A moderate shift in probability the patient will have success with spinal manipulation. The results of this study in previous studies indicates that patients with acute low back pain without signs of nerve root involvement are likely to respond well to early thrust manipulation to the lumbar spine and it should be considered as a part of a comprehensive treatment plan. It's important to remember that meeting the clinical prediction rule is only one factor in the decision making to use lumbar thrust manipulation, which should also include patient values, your skill level, and patient safety. Patients should only undergo imaging studies if they develop progressive neurological compromise, a non musculoskeletal condition is suspected, or the results are likely to change the management of the condition. Medical intervention may include NSAIDs, facet injections or radiofrequency ablation, though these typically have short term benefits if at all. If patients are receiving these medical interventions, it would be beneficial to receive concurrent physical therapy instead of in isolation. Otherwise non cervical conservative management is strongly recommended. 12 PHT 5452: LBP with Movement Coordination Impairments In this presentation, we will review the impairment based diagnosis low back pain with movement coordination impairments. When considering the underlying cause of the patient's condition, it's important to remember that direct pathoanatomical causes for low back pain are rarely truly identifiable. All innervated structures in the lumbar spine can be a source of nociception, which includes the facet joints, vertebra muscles, ligaments, nerves, and discs. Low back pain may be associated with the degenerative process or pathology identified during imaging, but the specific tissue causing the patient's symptoms is often unknown. It is common to have abnormal imaging findings in patients without low back pain and a lack of progressive changes in those who develop it, while only fewer than 15% of low back pain cases can be confidently linked to a true pathoanatomical source. Despite this lack of knowledge, we may hypothesize what tissues are being affected that we must continue to remember these limitations. Also because of this, it is important that we utilize an impairment based model when considering potential diagnosis and determining the best treatment approach. In 1992, Panjabi proposed that spinal stability is the ability of the spine under physiologic loads to maintain its pattern of displacement, so that no neurologic damage or irritation, no development of deformity, and no incapacitating pain occur. He described 3 subsystems that contributed to spinal control and coordination. The passive system, which includes all passive structures including bone, joint, ligament, disc, and the passive resistance from an elongated muscle tendon. The active subsystem, which is made of the spinal muscles and tendons that provide active control of the vertebral segments, and the neural subsystem, which is composed 1 of all of the neurological structures responsible for coordinating muscle contraction throughout the central and peripheral nervous system, Panjabi proposed The spine had two zones, the neutral zone, the mid portion of the range with the least amount of passive resistance, similar to loose pack position, which requires the active and neural subsystem to contribute most to spinal control in the elastic zone. The portion of the range with the most passive resistance where much of the control that occurs here is through the passive subsystem. The term clinical instability was coined to describe what occurs in the presence of a large neutral zone, either congenital such as in hypermobility syndromes, or acquired through a loss of the integrity of the passive structures, like after the development of ligamentous laxity through prolonged sustain load, the after effects of disk herniations, or in cases of bilateral pars articularis fractures or facet degeneration causing spondylolisthesis. This leads to a reduction in passive resistance in the presence of a dysfunctional active and neural subsystem which cannot fully compensate during movement through an enlarged neutral zone. In cases where the spine stiffens up, the neutral zone decreases and the elastic zone increases, resulting in an increase in passive resistance and less reliance on the active and neural subsystems for control. In the lumbar spine. Recurrent sprain strains resulting in increased extensibility of the passive structures in the presence of muscle performance deficits are the likely impairments in body structure and function that are contributing to this patient's symptoms. These patients often report symptoms related to uncoordinated movement through the neutral zone, sustained loading of the passive structures at N range, and fatigue and increased resting tone of the global muscles. This recurrent loading can also weaken the outer annulus and preclude A herniated nucleus, propulsa or the sequila of a disk Herniation may lead to a loss of passive stability and muscle performance. 2 Deficits in the local musculature due to pain inhibition, a loss of passive stability can also occur in cases of spondylolysis or spondylolisthesis. Spondylolysis most often occurs after a hyperextension injury to the lumbar spine. A spondylolisthesis or slippage of the vertebra on an adjacent vertebra can occur after bilateral parserticularis fractures or in cases of bilateral facet degeneration. Depending on the degree of the spondylolisthesis, neurological compromise in the central canal or foramen can occur, such as in stenosis. If this is the case, the radiating pain should be addressed first and then the movement coordination impairments. Muscle performance deficits of the local spinal muscles including the lumbar multifidus posteriorly, the transverse abdominis anteriorly are the primary impairments in body function that should be treated initially. These muscles often demonstrate deficits and endurance and coordination that should be addressed early with an exercise approach that isolates and targets these muscles. Specifically, muscle performance deficits of the global muscles, including impaired coordination with the local muscles, endurance and increased resting tone may need to be addressed. However, many times after addressing local muscle impairments, muscle performance deficits of the global muscles resolve once the foundation of local muscle control has been established. Coordinating local and global muscles is essential for successful rehabilitation. Ongoing assessment of these impairments and their response to treatment over the course of care is necessary to determine what intervention should be included. Medical screening should include a consideration of viscerogenic diagnosis as well as serious neuromusculoskeletal conditions including spinal fracture and Cauda Acquana syndrome. Differential diagnosis for low back pain with movement coordination impairment should include other impairment based diagnosis. 3 This list is not exhaustive but should encourage you to consider the potential for other conditions. There may be overlap with these conditions or patients may transition from another impairment based diagnosis to movement coordination impairments. When there is significant overlap, the diagnosis should be based on which of the impairments are most responsible for limiting the patient's activity and participation and on patient values. Or in some cases, it's appropriate to start treating multiple impairments or the transition from 1 diagnosis to another may happen quickly. For example, once you've had a positive influence on patients with cognitive and affective tendencies. These patients may also present with movement coordination impairments and would benefit from treatment targeting these. If that is the case, take care with your language when explaining the condition or the purpose of your interventions. It is also common for patients with referred or radiating pain to progress to movement coordination impairments classification once positive progress has been made towards centralizing their lower extremity pain. This is not a guarantee though and patients should be re examined for these impairments when it's once it's appropriate to do so. The nature of the condition includes A neuromusculoskeletal system involving the bones, muscles, tendon, ligaments, discs and nervous system. The most likely dominant pain mechanism is Noceception. When treating the after effects of a disc herniation, it can take 10 to 12 weeks for the annulus to heal, and in an acute spondylolysis, bone healing can take 6 to 8 weeks. Otherwise, tissue trauma may not be present and therefore not a consideration in patient management. 4 Common subjective reports include recurrent low back pain that can refer into the lower extremity with a possible history of remote or recent trauma, such as in cases of disc herniation or parserticularis fractures. Patients have often had multiple episodes of worsening low back pain that are becoming more frequent and take longer to recover. They may report incidences of their back giving out or giving way, locking or catching that may be accompanied by muscle spasm. Patients will report dull pain, fatigue and tightness with the maintenance of static upright postures either sitting or standing that requires them to change positions frequently. It is common that this progressively worsens throughout the day. They may also have sharp pain with quick unguarded movements or transitions like set to stand. They may find forward bending difficult, especially on the return to being upright that may require upper extremity assistance, also known as a Gower sign. Patients will report that external support like the back of a chair or back brace may provide some relief. These patients may also find relief in supported lying positions and may find it helpful to achieve passive spinal neutral through placing their hips and knees in a 9090 position while lying supine on the floor. It's also common that they frequently self manipulate to reduce pain, resting muscle tone and spasm, with the likely dominant pain mechanism being no susceptive. The patient's aggravating and easing factors will have a clear proportionate mechanical nature with localized symptoms, though pain can refer into the lower extremity. Pain is often more of a dull ache across the low back, but can be sharp and very localized with movement. These patients have a typical 24 hour pain pattern and may have a positive response to simple analgesics. 5 Common aggravating factors include static weight bearing positions such as prolonged sitting or standing, especially unsupported. These prolonged positions involve the patient loading in range passive structures that become painful over time. It also results in an increase in global muscle tone and fatigue because of a lack of segmental control from the local muscles as the day progresses, which also contributes to their symptoms. When questioning these patients, it's important to make sure that you know how both static sitting or sustained lumbosacral flexion and static standing sustained lumbosacral extension impacts their symptoms as it's both sustained positions that are aggravating not just one or the other, though they may only report one initially before further questioning. Also, a change in position can be alleviating as they are unloading the sensitive tissues, so they may report after sustained sitting that initially standing eases their symptoms or after sustained standing, sitting eases their symptoms. But it is the change of position that is reducing pain, not the position itself, and if they maintain those different positions they would also become painful. Patients may also report pain with uncontrolled movements and transitional movements, especially within the sagittal plane, as they are moving through the neutral zone in an uncontrolled manner without the assistance of the passive subsystem and a dysfunctional active and neural subsystem. This involves abnormal loading of the tissues during the range of motion which results in symptom reproduction which can be sharp. Easing factors include change of positions including standing after sitting or sitting after standing to change spinal position from flexion to extension or extension to flexion. If they are unable to completely change positions then they may go from a posterior pelvic tilt to an anterior pelvic tilt or vice versa, or shift around in their chair while sitting, or shift weight from one leg to the other while standing. 6 Non weight bearing positions such as reclining or lying supine can alleviate symptoms by supporting the trunk, requiring less active support and allows for passive positioning of the lumbar spine into neutral supine with the hips and knees at 9090 to passively place the lumbar spine and neutral while in a supported position is common. This has the benefit of placing all the sensitive passive structures on slack while requiring little active support. General lumbar movement like hook line rocking or stretching the paraspinals through double knee to chest or child's pose is also common, especially at the end of the day when resting muscle tone is high. Self manipulation is also common which temporarily reduces pain in muscle tone. Patients will frequently self manipulate because of this temporary relief. Back braces may offer temporary relief and reduce activity limitations and participation restrictions, but this should be discontinued quickly to allow for more active engagement of the local muscles. Knowing these easing factors will not only help you with differential diagnosis, but these may also be troubleshooting strategies that the patient has identified that may reduce barriers to activity and participation. For example, knowing that the patient has to stand to enjoy a concert, you could educate the patient to place one foot on a step to flex the hip and place the lumbar spine in neutral, or teach a posterior pelvic tilt which may quickly allow them to return to that activity and reduce perceived disability. These patients will often wake up with the least amount of low back pain of the day, but this will progressively worsen throughout the day with sustained weight bearing positions, with the end of the day frequently reported as the worst. The patient may report a reduction in symptoms when they lay in a recliner or in bed Due to the external support of these non weight bearing positions, these patients may be able to sleep without any issues unless their severity and irritability are high. The first step of any patient examination is to determine if the patient is appropriate for physical therapy or if they require additional medical evaluation. 7 This should influence your chosen tests and measures in the objective examination and are based on the outcome of this objective exam. It is best practice to assess vitals on all patients, especially if they have comorbidities that warrant an understanding of their baseline status that would allow for monitoring over time. One of the best ways to determine the mechanical nature of a patient's condition is to have to assess if it behaves mechanically throughout your exam, therefore monitoring for this essential part of medical screening. If the patient has symptoms in the extremities that you believe could be related or report symptoms that suggest Caudaquana syndrome or radiculopathy, then a full lower quarter neurological exam should be conducted including sensation, motor reflexes and pathological reflexes. If cervical myelopathy or other upper motor neuron lesion presenting with symptoms into the lower extremity is suspected, then a full upper quarter neurological exam should also be included. During the structural inspection, a step may be palpated indicating a possible spondylolisthesis. The Kappa for inner rater reliability for this palpation is fair to moderate agreement and the likelihood ratios indicate a small shift in probability. The patient does or does not have a spondylolisthesis, depending on whether it is present or not. You may also perform the lumbar posterior shear test in this position to assess for translation of the segment. The Kappa for inner rater reliability has been found to be fair, but the validity of this test indicates it is not very good at ruling in or ruling out spondylolisthesis. These patients may also present with increased paraspinal muscle tone and horizontal muscle banding at the involved segment. 8 It is important to note that these tests have limited utility on their own and must be combined with the rest of the physical exam to be meaningful to assess for movement coordination impairments. The first thing we should do is look at active movement and determine the amount of motion and how well it is coordinated. During this portion of the exam, we could see aberrant motions, poor recruitment and disassociation of the lumbar pelvic region, lack of smooth movement, which could include hinging, pivoting and fulcruming during active range of motion, especially during sagittal plane motions. An observation of a variant motions, a hallmark of movement coordination impairment, should occur. These include altered lumbar pelvic rhythm, Gower sign, deviation from the sagittal plane during flexion and extension, instability, catch shaking or juttering, including sudden acceleration, stopping or decelerations, and a painful arc. Collectively assessing for aberrant motions has moderate agreement with the painful arc being the most reliable during the passive inner vertebral motion exam. Identification of hypermobilities is common, with symptom reproduction occurring at the involved segment. In the lumbar pelvic region. Adjacent hypomobilities in the lower thoracic and lumbar spine, as well as the hip may be present. The central posterior to anterior passive accessory test has moderate reliability to identify hypermobilities with a small shift in probability of the presence of an instability. This same assessment has moderate agreement for pain propagation and fair agreement for segmental hypermobility. Orthopaedic examination tests should include the prone instability test and the prone lumbar extension test. 9 The prone instability test is a reliable test with substantial iterator agreement, but for the purpose of diagnosing segmental instability as an isolated test, it is not very valid. When using it to determine the likelihood of patient will or will not respond to neuromuscular reeducation exercises, either as an individual test or as a part of a clinical prediction rule, it performs much better. The prone lumbar extension test has moderate to substantial reliability and is good at ruling in or out segmental instability with a moderate shift in probability if positive or negative. For patients experiencing pain over the sacroiliac joint, typically over Fortin's.1 centimeter infer medial to the PSIS. For symptom provocation, the Lazat cluster is utilized prior to performing these provocation tests. It's important to rule out the lumbar spine first since referred in radicular pain to this area is very common and could lead to false positive tests. This lumbar screen should include tests and measures that attempt to provoke or alleviate symptoms from the thoracolumbar and lumbosacral segments from T1011 to L5 S ONE. This would include active range of motion, repeated motions or sustained positions assessing for centralization or peripheralization, passive accessory intervertebral motion testing, and neuro dynamic testing. Once the lumbar spine is clear, greater confidence in the laszloc cluster is achieved. This is seen statistically with an improvement in the positive likelihood ratio from 4.25 to 6.9 when symptoms do not centralized, moving from a small shift in probability to a moderate shift that the source of symptoms is the sacroiliac joint. The original Laszloc cluster had six items with three positive tests indicating a positive test item cluster. 10 Follow up studies found that gainless in right and gainless in left only provide a small improvement to the likelihood ratio and that removing them did not have a negative impact on its clinical utility. With a reduced number of provocation tests, the updated for item cluster includes to be performed in this order Thigh thrust, the most sensitive test, ASIS distraction, the most specific test, ASIS compression and sacral thrust. Once there are two positives, there is no need for further testing and SI joint pain can be suspected, though the positive likelihood ratio is only 4.0, a small shift in probability which does improve if you have adequately ruled out the lumbar spine. If only one test is positive, the negative likelihood ratio is 0.16, a moderate shift in probability. The patient does not have SI joint pain, and if all tests are negative, the likelihood ratio is less than.0. A large shift in probability. The SI joint is not the source of symptoms and can be ruled out. As with all provocation test, it's important to remember in patients with high irritability the test should be reserved for once symptoms are less irritable or a high number of false positives are possible. Testing of muscle performance, specifically neuromuscular control and endurance, is one of the primary assessments in this patient population and should first involve the assessment of isolated transverse abdominis in lumbar multivitus. Common tests and measures to assess muscle performance in the lumbar spine are supine hook line lumbar pelvic control tests, prone transverse abdominis test, prone hip extension neuromuscular control test, and the active straight leg raise test. Once we have assessed and developed a foundation of neuromuscular control and endurance of the local muscles, we will later assess and address strength and endurance deficits of the whole lumbo pelvic hip complex. 11 These assessments should include the Leg Lowering test, prone Lumbar Extension Endurance test, Modified side Plank test, Hip Abduction Neuromuscular control Test, Trendeling Bird test and the supine bridge endurance Test. Other clinical tests for muscle performance include tests for flexibility and palpation for tenderness and tone of the surrounding lumbar, pelvic and lower extremity musculature for the diagnosis of a structural spinal instability in the lumbar spine. Fritz had all found that either lumbar active range of motion greater than or equal to 53° measured with a double inclinometer or a lack of hypomobility identified during central, posterior and anterior accessory testing resulted in a positive likelihood ratio of 4.3, indicating a small shift in probability. The patient has a structural spinal instability and if both are positive, the positive likelihood ratio goes up to 12.8, a large shift in probability. These findings were confirmed using flexion and extension radiographs assessing for in translation at in range. By combining the results from this test item cluster along with the passive lumbar extension test, which has a positive likelihood ratio of 8.84. If all three are positive, there is an increased likelihood the patient has a structural spinal instability, though negative findings don't necessarily rule it out. With a lifetime prevalence of 70 to 80%, low back pain is one of the most common conditions anyone will ever experience. It is a leading cause of disability globally and one of the most costliest medical conditions. The overall prognosis and Natural History of acute low back pain is favorable with 90% of patients experiencing recovery by six weeks, with a significant reduction in symptoms noted at four weeks. The residual less severe pain may persist up to three months. The recurrence rate of low back pain has been reported as high as 80% and this can complicate the Natural History of subsequent episodes. 12 The expected clinical course for chronic low back pain is much more variable and less favorable than acute low back pain. Given the high prevalence of recurrent and chronic low back pain and the associated calls, clinicians should place high priority on interventions that prevent the recurrence and the transition to chronic low back pain. Factors associated with higher prevalence of low back pain are female gender, older age, educational status, physically demanding occupation, hypertension, lifestyle factors like smoking or having obesity, and either extremely high levels of activity or being sedentary. Factors associated with the risk of recurrence are previous low back pain episodes, excessive spinal mobility, and excessive mobility in other joints. There is inconclusive evidence for relationship between trunk muscle strength or mobility of the lumbar spine and the risk of low back pain. These factors should be considered when determining the likelihood of developing a new onset of low back pain or the recurrence of a previous episode of low back pain. Factors that may have an impact on prognosis include symptoms below the knee, psychological distress or depression, low expectations of recovery, fear avoidance beliefs and behaviors, higher pain intensity, and passive coping styles. Clinicians should consider these factors when determining prognosis and developing strategies to prevent the progression to clinicity. When determining stage of condition, it is important to consider multiple factors, not just time since injury. This can become even more challenging in the face of the high rate of recurrence of low back pain. Time based staging alone can have little value for intervention. Selection in most situations. In the presence of known trauma, stage of healing should be considered to avoid overloading healing tissues. 13 In the absence of known trauma, a better judgment of stage and condition may be severity and irritability of the condition. For all stages of low back pain, patient education is extremely important. In general, clinicians should not utilize patient education and counseling strategies that either directly or indirectly increase the perceived threat or fear associated with low back pain, such as education and counseling strategies that promote extended bed rest or provide in depth patho anatomical explanations for the specific cause of the patient's low back pain. Patient education and counseling strategies for patients with low back pain should emphasize the promotion of the understanding of the anatomical structural strength inherent in human spine, the neuroscience that explains pain perception, the overall favorable prognosis of low back pain, the use of active pain coping strategies that decrease fear and catastrophizing thoughts, the early resumption of normal or vocational activities even when still experiencing pain, and the importance of improvements in activity levels, not just pain relief. The primary treatment goal in the acute phase is pain control with reassurance and educational remaining active. The initiation of low intensity exercise, manual therapy and biophysical agents as needed to keep the patient moving acutely. Education should include advice to remain active and limit bed rest. It should also include the favorable Natural History and prognosis of acute low back pain. Self management strategy should focus on pain management, including assuming postures or performing movements that promote neutral spinal positions to reduce load on sensitive passive structures. Temporary use of external support like a back brace or SI joint belt may be utilized to help reduce strain on painful structures, but a trial should be undertaken to assess its effectiveness and should be used for a limited time and only as needed. 14 A home exercise program should be provided that is designed to initiate improvements in movement coordination. Clinical exercises should be prescribed for specific trunk activation to promote dynamic spinal control including transverse abdominis and multifidus to help maintain mid range less symptomatic spinal positions. Additionally, once foundational local muscle control has been initiated, lumbar pelvic hip strengthening and endurance exercises can also be included. Based on the identified impairments in muscle performance, manual therapy can be a very effective way to treat these patients through inhibition of pain and resting resting muscle tone, which can help remove activity limitations and improve muscle performance. It can also be used to improve joint mobility in the thoracolumbar spine and lumbar pelvic hip complex, which can reduce stress and load on the involved segments. The goal of the subacute phase should begin to focus on movement control through a targeted individualized home program exercise to promote dynamic spinal control and flexibility and joint mobility to reduce segmental stressors and allow the patient to change spinal positions during activities. Patients should be encouraged to continue to progress their activity levels and should not be using external support at this time. A progressive home program should include therapeutic exercise and activities that promote neuromuscular control. In this subacute phase, exercises should continue to address movement and coordination impairments but with a focus on self-care and possibly work activities. Manual therapy should be utilized in this phase to address impairments in body functions such as pain, global muscle tone, and joint mobility. Primary treatment goals for the chronic stage are to optimize function with less emphasis placed on pain control. 15 It's important to take a holistic approach to care at this stage, including counseling and resources on sleep, hygiene, nutrition, stress reduction and the management of comorbidities. Patients with chronic low back pain with movement coordination impairment should be encouraged to live active lifestyles even in the presence of some pain. Emphasis should be placed on the ability to achieve positions and postures that reduce stress on structures that can become pain sensitive during community and vocational activities. This may include advice to change positions regularly such as standing after sitting or vice versa, and the ability to change lumbar pelvic positions in sitting or standing. These types of problem solving strategies can be important to remove barriers that limit activity and participation. Exercises should be geared towards dynamic control during household, occupational or recreational activities related to the patient specific activity limitations. General trunk strengthening and endurance should also be included to this stage and progress disabled. This should address not only dynamic spinal control, but also the ability to change lumbar pelvic positions and sitting and standing as well as general fitness and resiliency. Manual therapy should be included as needed to enhance patient participation in the prescribed therapeutic exercise program and improve joint mobility to reduce load placed on the involved spinal segments. A clinical prediction rule was developed by Greg Hicks in 2005 to identify those patients most likely to respond to a stabilization exercise approach. Patient characteristics that increase the likelihood of success include a positive prone instability test, the presence of aberrant motion aged less than 41 years, and a straight leg raise greater than 91°. 16 If three or more positive findings out of the four variables were present, then the positive likelihood ratio for probability of success was 4 point OA. Small shift in probability the patient will have success with a stabilization program. Success was defined as having a 50% improvement on the Oswestry at 8 weeks. The most predictive of success was aged less than 41 years later. A validation study was conducted by Revit ET al. In 2014 to compare stabilization exercises to thrust and non thrust manipulation for those patients that either met the rule or did not meet the rule. For this study, a modified clinical prediction rule was established, including Everett motions and positive prone instability test. This study was unable to validate the CPR or the modified CPR, but also did not invalidate them. Future research with a larger sample is necessary to determine the appropriateness of widespread adoption into clinical practice. Hicks also identified factors that predicted failure with a lumbar stabilization program. These include a negative prone instability test, any lumbar hypomobility with passive accessory intervertebral motion testing. Aberrant motions were absent and an FABQ physical activity subscale less than or equal to 9. If any two of these are positive, then the positive likelihood ratio is 6.54, indicating A moderate shift in probability the patient will fail. A stabilization approach, the negative likelihood ratio indicates that if less than two are present, then there's a moderate shift in probability the patient will not fail a stabilization program. 17 As with all clinical prediction rules, caution should be taken in applying this to clinical practice, especially when it has not been validated or stood up to the appropriate scrutiny. It is important to remember that they have significant limitations. Their utility has been called into question and should be used with caution. Also keep in mind that they do not explain causation, so be careful how you interpret them. Finally, meeting a clinical prediction rule is only one factor in the decision making to use lumbar stabilization exercises, which should also include patient values, your skill level, and patient safety. For the diagnosis of anterior or posterior structural spinal instability due to a spondylolisthesis and for surgical planning, a flexion extension radiograph may be used. However, it does not yield information about quantity and quality of motion that occurs in the neutral zone, which limits value of radiographs for diagnosis of functional instabilities. Patients should only undergo imaging studies if they develop severe progressive neurological deficits. A non musculoskeletal condition is suspected or the results are likely to change the management of the condition. Routine imaging does not result in clinical benefit and may lead to harm. Medical interventions may include NSAIDs, muscle relaxers or injections and in the case of severe neurological compromise, a lateral or anterior lumbar inner body fusion may be indicated. Otherwise non surgical conservative management is strongly recommended. 18 Low Back Pain with Referred Pain Pathoanatomy What is the proposed underlying cause of the condition? Pathoanatomy ▪ There are numerous anatomical structures in the spine that can be sources of nociception, including zygapophyseal joints, vertebrae, muscles, ligaments, nerves and the intervertebral disc.1,2 ▪ Despite advances in imaging technology, challenges remain in identifying a single source of symptoms in the majority of patients with low back pain.1,2 ▪ False positive imaging findings are common for those without low back pain and patients who develop low back often have no pathoanatomical changes in longitudinal imaging studies.1,2 Pathoanatomy What is the proposed underlying cause of the condition? ▪ Lumbar discogenic pain3,4,5 ▪ Degenerative changes to the disk ▪ Aging, genetics, and prolonged exposure to hypo- or hyper- loading correlates with disc degeneration ▪ Ingrowth of nerve fibers deep into the disk and endplate cause pain sensitization ▪ This exposure of the inner disk to the outer annulus and neuronal tissue attracts inflammatory mediators ▪ Hyperinnervation and hyperalgesia occur as a result of the release of proinflammatory cytokines ▪ Nociceptive information is then transmitted from deep within the disk Medical Screening What other conditions should be considered with this patient presentation? ▪ Medical Screening1,2 ▪ Viscerogenic ▪ Neoplastic conditions ▪ Inflammatory or systemic disease ▪ Spinal infection ▪ Cardiovascular/gastrointestinal/urogenital ▪ Neuromusculoskeletal ▪ Spinal fracture ▪ Cauda equina syndrome Differential Diagnosis What other conditions should be considered with this patient presentation? ▪ Differential Diagnosis1,2 ▪ Neuromusculoskeletal ▪ Low back pain with radiating pain ▪ Low back pain with mobility deficits ▪ Low back pain with movement coordination impairments ▪ Low back pain with cognitive and affective tendencies ▪ Low back pain with generalized pain Subjective Examination What system, structure, pain mechanism, and phases of healing are unique to this patient presentation? ▪ System ▪ Musculoskeletal ▪ Structure ▪ Disk ▪ Pain mechanism1 ▪ Nociceptive ▪ Phase of healing5 ▪ Disk/annulus tear 10-12 weeks Subjective Examination Subjective What are common subjective reports for patients with referred pain? Examination Nociceptive pain1 Clear, proportionate mechanical/anatomic nature to aggravating and easing factors Localized pain with/without somatic referral Usually rapidly resolving in accordance with expected recovery times Often intermittent and sharp with movement/mechanical provocation May have more constant dull ache or throb at rest Responsive to simple analgesics/NSAIDs Clear diurnal or 24-hr pain pattern Subjective Examination What are common subjective reports for patients with referred pain? ▪ Low back pain with referred pain ▪ May be gradual or immediate onset of local and somatic referred low back pain and lower extremity pain ▪ Dull ache in the low back that extends down the thigh and below the knee ▪ Frequently presents with a history and symptoms consistent with low back pain with movement coordination impairments Subjective Examination What are common subjective reports for patients with referred pain? ▪ Low back pain with referred pain1,2 ▪ Aggravating factors (peripheralization of referred symptoms) ▪ Lumbosacral flexion ▪ Sitting ▪ Bending forward ▪ Easing factors (centralization of referred symptoms) ▪ Lumbosacral extension ▪ Standing and walking ▪ Prone lying Subjective Examination What are common subjective reports for patients with referred pain? ▪ Low back pain with referred pain1,2 ▪ 24-hour pain behavior ▪ Morning ▪ Sleeping in flexion they may wake up with leg pain ▪ May have difficulty coming up into full lumbar extension initially ▪ Noon to evening ▪ Symptoms may vary throughout the day depending on the patient's activities ▪ Night ▪ Sleeping in they may wake up with leg pain ▪ May have disrupted sleep Physical Examination What are the key examination procedures for patients with referred pain? ▪ Low back pain with referred pain1,2 ▪ Systems review (as indicated from the subjective exam) ▪ Cardiopulmonary ▪ Vitals ▪ BP, HR, auscultate, distal pulses Urogenital/Gastrointestinal Assess for mechanical reproduction of symptoms and/or adverse response to movement AROM, PIVM, compression/distraction, neurodynamic tests ▪ Neuromusculoskeletal ▪ Reflexes/pathological reflexes ▪ Dermatomes/myotomes Physical Examination What are the key examination procedures for patients with referred pain? ▪ Low back pain with referred pain1,6 ▪ Specific Tests and Measures ▪ Neurological examination ▪ Deep tendon reflexes ▪ Quadriceps (+LR 3.0, -LR 0.9), Achilles (+LR 7.9, -LR 0.2) ▪ Dermatomes (light touch and/or sharp/dull) ▪ L3-S1 ▪ Sharp/dull (+LR 0.3 to 5.5, -LR 0.5 to 2.0) ▪ Myotomes ▪ L3-S1 ▪ (+LR 0.8 to 5.9, -LR 0.3 to 1.1) ▪ Cluster of dermatomes, myotomes, and reflexes ▪ (+LR ∞, -LR 0.9) Physical Examination What are the key examination procedures for patients with referred pain? ▪ Low back pain with referred pain1,6 ▪ Specific Tests and Measures ▪ Movement and provocation examination ▪ Active range of motion ▪ Range of motion limitations and symptom provocation will depend on individual patient presentation Extension loss +LR 2.0, -LR 0.8 Centralization +LR 6.7, -LR 0.6; k= 0.70 to 0.90 Aberrant motions k= 0.60 ▪ Passive intervertebral motion ▪ Hypomobility and symptom reproduction at the involved segment(s) ▪ Possible hyper- or hypomobility at adjacent segments Physical Examination What are the key examination procedures for patients with referred pain? ▪ Low back pain with referred pain1,6 ▪ Specific Tests and Measures ▪ Neurodynamic testing (HNP) ▪ Straight leg raise ▪ Slump test ▪ Femoral nerve tension test (Ely’s Test) Prognosis What is the prognosis of the condition? ▪ Low back pain (general)2 ▪ Clinical course and prognosis ▪ Lifetime incidence of at least one episode of low back in adults is 75% and 70- 80% for adolescents. ▪ Acute low back pain is self-limiting with 90% of patients recovering within 6 weeks. ▪ Recurrence rates from 40% to 80% have been reported. ▪ Chronic low back has more variable clinical course with a less favorable prognosis. Prognosis What is the prognosis of the condition? Prognosis ▪ Low back pain (general)2 ▪ Factors that may impact new onset or recurrence ▪ Female gender ▪ History of previous episodes ▪ Older age ▪ Excessive spine mobility ▪ Educational status ▪ Excessive mobility in other joints ▪ Physically demanding occupation ▪ Cardiovascular hypertension ▪ Lifestyle (smoking, overweight/obesity) ▪ High activity/sedentary Prognosis What is the prognosis of the condition? Low back pain with referred pain2 Factors that may impact prognosis Symptoms below the knee Fear of pain, movement, or reinjury Psychological distress or depression Higher pain intensity Low expectations of recovery Passive coping style Stage of Condition How does this present differently based on stage of condition? ▪ Acute2 ▪ Severity and irritability are often high ▪ Pain at rest or with initial to mid-range spinal movements: before tissue resistance ▪ Pain control is often the intervention goal at this stage ▪ Subacute2 ▪ Severity and irritability are often moderate ▪ Pain experienced with mid-range motions that worsen with end-range spinal movements: at tissue resistance ▪ Movement control is often the intervention goal at this stage ▪ Chronic2 ▪ Severity and irritability are often low ▪ Pain that worsens with sustained end-range spinal movements or positions: overpressure into tissue resistance ▪ Functional optimization is often the intervention goal at this stage Interventions What interventions are recommended for this condition by the clinical practice guidelines? Interventions General education2 Should Not Should Increased the perceived threat or fear Promote the inherent strength of the spine Promote extended bed rest Neuroscience that explains pain perception Provide in-depth anatomical explanations Favorable prognosis Active coping strategies Early resumption of activities Importance of improvement in activity levels Interventions What are interventions recommended by the clinical practice guidelines based on stage of condition? Interventions Acute2,9 Classification Mechanical Diagnosis and Therapy or Treatment-based Classification Education Advice to remain active, pursue an active lifestyle, and self management Favorable natural history of acute low back pain Exercise Trunk strengthening, endurance, and specific trunk activation training Manual therapy Thrust and non-thrust manipulation and soft tissue mobilization to reduce pain and disability Interventions What are interventions recommended by the clinical practice guidelines based on stage of condition? Interventions Subacute2,9 Classification Mechanical Diagnosis and Therapy or Treatment-based Classification Education Advice to remain active, pursue an active lifestyle, and self management Favorable natural history of subacute low back pain Exercise Trunk strengthening, endurance, and specific trunk activation training Manual therapy Thrust and non-thrust manipulation and soft tissue mobilization to reduce pain and disability Interventions What are interventions recommended by the clinical practice guidelines based on stage of condition? Interventions Chronic2,9 Classification Mechanical Diagnosis and Therapy or Treatment-based Classification Education Advice to remain active, pursue an active lifestyle, and self management Pain neuroscience education Exercise Trunk strengthening, endurance, specific trunk activation and movement control training Manual therapy Thrust and non-thrust manipulation and soft tissue mobilization to reduce pain and disability Interventions What additonal interventions are recommended? Interventions Mechanical Diagnosis & Therapy (MDT)1,2,9 Assessment and treatment utilizing the patient's directional preference for symptom centralization Low back pain with referred pain classified as ”derangement” syndrome Repeated motions or sustained position to promote centralization Disk related conditions often respond to an extension–oriented (sagittal plane) program May have to address the frontal plane (shift correction) prior to sagittal plane Interventions When should we consider interprofessional referral and what are other treatment options? ▪ Imaging1,2 ▪ MRI ▪ Preferred modality for patient who do not respond to conservative care ▪ Medical Intervention ▪ Medications/injections ▪ NSAIDs & muscle relaxers ▪ Spinal injections ▪ Surgical ▪ Radiofrequency ablation ▪ Discectomy ▪ Lumbar interbody fusion References 1. Olson, KA. Manual Physical Therapy of the Spine, 3rd ed. Saunders/Elsevier; 2022. 2. Delitto A, George SZ, Van Dillen L, et al. Low back pain. J Orthop Sports Phys Ther. 2012;42(4):A1-A57. doi:10.2519/jospt.2012.42.4.A1 3. José García-Cosamalón et al. Intervertebral disc, sensory nerves and neurotrophins: who is who in discogenic pain? J Anat. 2010 July; 217(1): 1–15. 4. Fukui S et al. Intradiscal Pulsed Radiofrequency for Chronic Lumbar Discogenic Low Back Pain: A One Year Prospective Outcome Study Using Discoblock for Diagnosis. Pain Physician 2013. 5. Pathak S, Conermann T. Lumbosacral Discogenic Syndrome. StatPearls Publishing; 2023. 6. Cook CE, Hegedus EJ. Orthopaedic Physical Examination Tests; An Evidence Based Approach. Pearson Prentice Hall; 2008. 7. Casey E. Natural history of radiculopathy. Phys Med Rehabil Clin N Am. 2011;22(1):1-5. 8. Cribb GL, Jaffray DC, Cassar-Pullicino VN. Observations on the natural history of massive lumbar disc herniation. J Bone Joint Surg Br. 2007;89(6):782-784. 9. George SZ, Fritz JM, Silfies SP, et al. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. J Orthop Sports Phys Ther. 2021;51(11):CPG1-CPG60. PHT 5452: Low Back Pain with Radiating Pain In this presentation, we will review the impairment based diagnosis. Low back pain with radiating pain. Low back pain with radiating pain can primarily be caused by three separate pathway anatomical conditions. First, lumbar radiculopathy can be caused by a herniated nucleus propulsa as a part of the sequela of disk degeneration, the annulus fibrosis can weaken. This loss of structural integrity predisposes the patient to disc injury during sudden unguarded movements involving flexion and rotation. This can result in a protrusion or exclusion into the neural canal, intervertebral foramen, or lateral to the foramen. This leads to inflammation in nerve sensitization, causing radicular pain, which can progress to an impairment in neurological function. There are multiple classification systems used to describe the severity of a discogenic condition. McNabb classified these conditions into disk protrusions and disk radiations. He further described different types of each, including protrusions with either localized versus diffused bulges and herniations with either a prolapse extrusion or a completely sequestered nucleus. The American Academy of Orthopaedic Surgeons classifieds discogenic presentations as either degenerative, A bulge, A protrusion, or an extrusion, which can be further divided into sub ligamentous, trans ligamentous, or sequestered. Low back pain with radiating pain can also be caused by a space occupying lesion within the lateral foramena, which would result in unilateral radiating lower extremity 1 pain made worse by further closure of the foramen, such as during lumbar extension and ipsilateral side bending. This narrowing of the foraminal opening can be due to degenerative changes in the facet and intervertebral disc, including changes in disc height or osteophyte formation, or the development of a spondylolisthesis. Patients can also develop stenosis of the central canal which would present with bilateral lower extremity radiating pain made worse by further narrowing of the central canal like during lumbar extension required for walking. Medical screening should include a consideration of this phosphogenic diagnosis as well as serious neuromusculoskeletal conditions including spinal fracture and cauda iquana syndrome. Differential diagnosis for low back pain with radiating pain should include other impairment based diagnosis. This list is not exhaustive but should encourage you to consider the potential for other conditions. The nature of the condition includes the neuromusculoskeletal system in the painful structures involved are the nerve root and disk. If an HMP is the cause, the dominant pain mechanism for the extremity symptom is neuropathic, but in the case of a disc herniation, there may also be no susceptive pain at the low back and overlapping somatic referred pain into the extremity. When a disc herniation has occurred, we should take into account normal tissue healing time frames for the outer annulus, which is vascular and can heal. Also, with prolonged compression of the nerve root, injury to the neural tissue can occur. Healing time frames are dependent on the severity of the injury and the location along the neuron. In general, most compression injuries like what would be seen in radiculopathies are Grade 1 neuropraxia and will recover at a rate of 2 to 3mm per day. 2 Patients with neuropathic pain may report symptoms consistent with what is expected of neurological involvement, like burning, shooting, electric shock. Like though it's important to remember that it can also be described as sharp or just an ache. Patients may have paresthesias, numbness, or reported weakness, but not always. Sometimes it's just pain. Neuropathic pain from the nerve root can vaguely follow a dermatomal pattern and in general has high severity and irritability with spontaneous intensification and does not typically respond well to insects. Important to note, neuropathic pain may have a delayed onset or latent response to movement and testing, sort of like delayed onset muscle soreness. Therefore, it can be hard to predict how the patient may respond to your exam and treatment because it may worsen later than during the examination, manual therapy, or exercise. Caution is warranted in patients with neuropathic pain until you know how the patient may respond. These patients often report sleep disturbances, and the overall distress caused by neuropathic pain can have effect on their psychological status, both which can negatively affect pain intensity and rehab. Common subjective reports can differ based on the underlying cause. In patients with lateral framinal stenosis, symptoms tend to be more gradual onset due to the slowly developing degenerative changes. Patients with disc herniations often report a more immediate or quickly evolving onset. Aggravating factors for patients with disc herniations often involve positions of lumbar flexion that occur during sitting or bending forward. These positions increase tensile forces on the posterior annulus and neural tissue, which is aggravating to the disc and nerve root, causing a peripheralization of 3 neuropathic pain from the nerve root with overlapping somatic referred pain from the disk. These patients will also have an increase in symptoms with positions that mimic lower extremity neuro dynamic positions similar to the slump test. Easing factors may include positions that reduce tension on the posterior anulus, such as in the lumbar extension during standing, walking, or prone line. If a patient reports a peripheralization of symptoms while sitting and a centralization of symptoms when they stand and walk, they are said to have a directional preference towards extension. A quick note, patients with a disk herniation who have a lateral shift may not present with this specific pattern of positions that promote centralization or peripheralization of symptoms. Patients with a lateral shift may have the exact opposite pattern, or they may be in no position that centralizes symptoms. Once the shift is corrected, they will often resume this expected pattern for symptoms centralization. The 24 hour pain pattern is often dependent on time spent in lumbosacral flexion, such as sleeping in a fetal position or soft bed or prolonged sitting during work. If the patient has been in flexion for a prolonged period of time, they may have difficulty coming back up into a full upright position initially because of a significant loss of lumbar extension. Once these patients work on achieving lumbar extension, this will quickly improve. They will also have peripheralizing leg pain that will centralized as they restore their lordosis. Symptoms can also worsen with lower extremity positioning during Adls and work related activities that place tension on the nerve root. Educating these patients on sitting in an increased lumbar lordosis or working from a standing desk can promote lumbar extension and will allow them to work with less pain. 4 Sleep is often interrupted simply due to the neuropathic nature of the condition, but addressing sleeping position, like lying and prone or placing a towel under the lumbar spine with hips and knees extended, or educating on leg position may help. Aggravating activities for patients with lateral foraminal and central canal stenosis frequently involve movements or positions that decrease the space of the intervertebral foramen or the central canal, therefore increasing the mechanical load on the nerve root, including the lumbar extension required for standing and walking. These movements or positions will cause a peripheralization of symptoms in one limb if the patient has lateral foraminal stenosis in both limbs. If the patient has central stenosis. Easing factors include movements and positions that increase the space in the foramen or central canal as long as it doesn't add increased tension to the nerve root, therefore reducing mechanical load to the nerve root, including the lumbar flexion that occurs during sitting and this centralizes the patient's extremity symptoms. The 24 hour pain pattern for lateral, foraminal and central stenosis is primarily dependent on the amount of time spent in positions that narrow the foramen or central canal or places the nerve root on tension. Neuropathic pain can be worse at night and may disrupt sleep. Educating patients on sleeping position for the lumbar spine and lower extremity can assist in improving sleep hygiene, which is important for recovery. The first step of any patient examination is to determine if the patient is appropriate for physical therapy or if they require additional medical evaluation. This should influence your chosen tests and measures in the objective examination. Inter based on the outcome of this objective exam, it is best practice to assess vitals on all patients, especially if they have comorbidities that warrant an understanding of their baseline status that would allow for monitoring over time. One of the best ways to determine the mechanical nature of a patient's condition is to have to assess if it behaves mechanically throughout your exam. 5 Therefore, monitoring for this essential part of medical screening. If the patient has symptoms in the extremities that you believe could be related or report symptoms that suggest Caudaquana syndrome or radiculopathy, then a full lower quarter neurological exam should be conducted including sensation, motor reflexes and pathological reflexes. If cervical myelopathy or other upper motor neuron lesion presenting with symptoms into the lower extremity is suspected, then a full upper quarter neurological exam should also be included. The neurological examination for patients with suspected lumbar radiculopathy is extremely important. Establishing A baseline status of the functioning of the nervous system not only allows for assisting in confirming your hypothesis, but also allows for monitoring for progressive neurological decline. When a patient presents with progressive worsening of neurological function, this requires A referral for medical evaluation and potential surgical consultation. Failure to address this in an appropriate amount of time can result in permanent loss of strength and sensation. It is important to note the utility of the neurological exam as it pertains to diagnostics. Overall, based on the reported likelihood ratios, the validity of these tests and measures is better at ruling in lumbar radiculopy than it is at ruling out with variable likelihood ratios reported. As is the case with many objective tests, clustering the findings of dermatomes, myotomes, and reflexes does improve the positive likelihood ratio to a large shift in probability. The patient does have a lot a lumbar radiculopathy. If present, these lower motor neuron findings will include a reduction in sensation in a dermatomal pattern, a reduction in strength in a myotomal pattern, and hyper reflexia, all in the distribution of the involved nerve root. 6 The movement provocation examination should include active range of motion, which will likely result in a loss of range of motion and symptom reproduction of low back and lower extremity symptoms. The movements and positions that result in peripheralizing or centralizing leg pain should be noted and will depend on whether the patient has a disc herniation or stenosis. Patients with HMPS will have symptoms that peripheralize with lumbar flexion and centralized with lumbar extension. It is worth noting that in certain situations like when they have a lateral shift or when symptoms are highly irritable, symptoms may not immediately centralized with extension. Also, a hallmark of patients with HMP is they initially have a significant loss of extension that will rapidly restore once they report perform repeated or sustained lumbar extension. Extension loss has been directly tied to discogenic conditions and the presence of lumbar extension loss has a positive likelihood ratio of 2.0. Also, centralization of symptoms with an extension oriented assessment has a positive likelihood rat

PTMMD Unit 2 Transcripts - Lumbopelvic Medical Screening PDF

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