Evaluation Guided Treatment for Low Back Pain Tara Jo Manal PT, OCS, SCS Director of Clinical Services Orthopedic Residency Director University of Delaware.

Evaluation Guided Treatment for Low Back Pain

Tara Jo Manal PT, OCS, SCS

Director of Clinical Services

Orthopedic Residency Director

University of Delaware Physical Therapy Department

Tarajo@udel.edu

www.udel.edu/PT/clinic

Consensus on the Spine

• No Common Evaluations

• No Common Terminology

• No Common Classification

• No Common Treatment

• ONE COMMON GOAL

The Guru Approach

• Maitland

• McKenzie

• Paris

• Butler

• Mulligan

• Muscle Energy

• Jones Strain Counterstrain

Finding Common Ground

• Classification Systems– Reliable– Guide Interventions

• Treatment Techniques– Effective– Generalizable

Delitto, Erhard, Bowling, Fritz

• Early Establishment of Classification Scheme for the Low Back

• Randomized controlled clinical trials

• Case Series

• Better Than Standard Treatment?

LBS Classification

• Appropriate for Treatment?– Refer for medical, psychological….

• Stage Condition of Severity– Treatment Goals

• Evaluation Diagnosis Determines Treatment Strategy

• Creativity of clinician is supported

Issues in Spinal Disorders

• Fear of missing the “bad cases”• Failure of the pathology based model

– All discs are not created equal

• Potential sources of pain – Joints– Nerves– Muscles– Ligaments

Issues in Spinal Disorders

• Patient Specific Demands– Extension problem in line worker– Time to return to work (independent contractor)

• Confounding Issues– Emotional component– Motivation to return (job satisfaction)

First Level of Classification

• Treat by Rehabilitation Specialist Independently

• Referral to Another Healthcare Practitioner

• Managed by Therapist in Consultation with Another Health Care Practitioner

When to Refer?

• Constant Pain, Unrelated to Position or Movement

• Severe Night Pain Unrelated to Movement• Recent Unexplained Weight Loss of >10lbs• History of Direct Blunt Trauma• Appears Acutely Ill (pale, fever, malaise)• Abdominal Pain/Radiation to Groin (blood

in urine)

When to Refer?

• Sexual Dysfunction

• Recent Menstrual Irregularities

• Bowel or Bladder Dysfunction– Fecal or Urinary Incontinence/Retention– Rectal Bleeding

• Temperature >100 F

• Resting Pulse > 100 bpm

Immediate Care of the Injured Spine

• Physician Evaluation

• Early Care– Rest/Activity– Ice/Heat– Modalities for Pain Control– X-ray– Medications

1-2 Weeks and No Change

• Life Impact– ADL’s– Sport Specific

• Irritability– Severity of symptoms– Ease – Duration

Oswestry QuestionnaireSelf Report of Performance Limitation

• Personal Hygiene• Lifting• Walking• Sitting• Standing

• Sleeping• Social Activity• Traveling• Sex Life• Pain Intensity

Scale: 0 - 5 Maximum Score = 50 No Max Double Score/100Limitations Limitations %Disability

Oswestry Questionnaire

• 5 Minutes to Score

• Initial Classification

• Documentation of Outcome

Importance of History

• Establish a pattern– What brings on symptoms?– What relieves symptoms?

• Type of symptoms present– Sharp, stabbing– Dull, aching– Stretching– Pinching

Importance of History

• Intensity of Symptoms– Pain levels

• Location of Symptoms– Rule in/out potential causes– Add focus to your evaluation

Patient Staging

• Stage I Inability to Perform Stand, Walk, Sit– Reduce Oswestry <40%-60%– Enable to Sit > 30 min– Enable to Stand >15 min– Enable to Walk > 1/4 mile

Patient Staging

• Stage II Decreased Activities of Daily Living– Reduce Oswestry to <20% - 40%– Enable to perform ADL’s

Patient Staging

• Stage III Return to High Demand Activity– Reduce Oswestry to 20% or less– Enable to Return to Work

Neurological Examination

• Indication - Symptoms Below the Knee– LE Sensory Testing– Muscle Strength Assessment– Reflex Testing– Nerve Root Testing– Babinski testing– Clonus

Pelvic Assessment I

• PSIS Symmetry in Sitting– Unequal heights

– Positive Test

Pelvic Assessment II

• Standing Flexion Test– Start Position

• Palpate PSIS – Relative position

Pelvic Assessment II

• Standing Flexion Test– End Position

– Full Flexion

• Palpate PSIS – Relative position

compared to standing

• Positive Test– Change in relationship

– Start to Finish

Pelvic Assessment III

• Prone Knee Flexion Test– Start Position

• In prone lying• Palpate posterior to

lateral malleoli• Observe leg length

Pelvic Assessment III

• Prone Knee Flexion Test– End Position

• Knee flexed to 90• Positive Test

– Observe change in heel position

– Start to Finish

Pelvic Assessment IV

• Supine to Sit Test– Start Position

• Palpate inferior medial malleoli

• Note relative lower extremity length

Pelvic Assessment IV

• Supine to Sit Test– End Position

• Sitting

• Positive test– Change in relative leg length– Start to Finish

Pelvic Assessment Results

• 3 of 4 Tests Composite– Reliability k=.88

• If (-) Palpate Iliac Crest Heights– Correct difference with heel lift

• If (+) SIJ Manipulation Indicated– Manual Techniques– Manipulation

Specific Manipulation for SIJ

Re-test composite after manipulation

Movement Testing Results• Symptoms worsen: Paresthesia is produced

or the pain moves distally from the spine

– Peripheralizes

• Symptoms improve: Paresthesia or pain is abolished or moves toward the spine– Centralizes

• Status quo: Symptoms may increase or decrease in intensity, but no centralize or peripheralize

Movement Testing

• Assess for a Lumbar Shift– Pelvic translocations PRN

• Single Motion Testing

• Repeated Motion Testing

• Alternate Positioning (if needed)

Postural Observation

• Presence of a Lumbar Shift

– Named by the shoulder

Pelvic Translocation

• Performed Bilaterally– Assess Symptom

response

– Worsen

– Improve

– Status Quo

Lumbar Sidebending• Determine

Capsular/NonCapuslar

• Perform Movements– Pelvic Translocation

– Flexion

– Extension

• Status– Worsen

– Improve

– Status Quo

Pelvic Translocation

• Assess Status– Worsen

– Improve

– Status Quo

Flexion

• Assess Status– Worsen

– Improve

– Status Quo

• Note ROM limits• Quality of Motion

Extension

• Assess Status– Worsen

– Improve

– Status Quo

• Note ROM limits• Quality of Motion

Worsen/Improve

Tara J Manal MPT, OCS

Neurological Examination

• Indication - Symptoms Below the Knee– LE Sensory Testing– Muscle Strength Assessment– Reflex Testing– Nerve Root Testing– Babinski testing– Clonus

Movement Testing Results• Symptoms worsen: Paresthesia is

produced or the pain moves distally from the spine– Peripheralizes

• Symptoms improve: Paresthesia or pain is abolished or moves toward the spine– Centralizes

Peripheralize/Centralize

• Classic Disc

• Stenosis

• Spondylo..

Postural Observation

• Presence of a Lumbar Shift

– Named by the shoulder

Sidebending/Improve

• Asymmetrical (Non Capsular)

• Do Repeated Motions Improve?– Lateral Shift Syndrome

• Active Pelvic Translocation

Pelvic Translocation Improves

• What would the treatment look like?

Manual Shift Correction

• Manual Shift Correction by PT

• Slow Correction• Slow Ease of Release

Postural Corrections

• Self Correction • Positioning for

Electrical Stimulation

Self Shift Corrections

• Performed every 30 minutes

Sidebending/Worsen

• Symmetrical Sidebending– Cyriax Capsular Pattern

• Do Repeated Motions Worsen– Traction Syndrome– If Extension worsens begin in flexion– If Flexion worsens begin in extension

Flexion Worsens

• Prone Traction

Extension Worsens

• Supine Traction

Sidebending/Worsen

• Asymmetrical Sidebending– Cyriax Non Capsular Pattern

• Do Repeated Motions Worsen– Traction Syndrome

Sidebending/Improve

• Symmetrical (Capsular)

• Do Repeated Motions Improve?– Flexion Syndrome

• ACTIVE FLEXION

– Extension Syndrome• ACTIVE EXTENSION

Centralization Phenomenon

• Intensity will increase as pain centralizes

• Once no radicular symptoms ~2wks left

• Must re-introduce provocative motion once radicular symptoms are resolved

Improve with Extension

• What would the treatment look like?

Improve with Extension

• CASH Brace• Worn 24hrs• Wean Slowly

Improve with Extension

• Prone Press Ups

Self Correction for Extension

• Repeated Extension in Standing

• Performed every 30 minutes

Posterior/Anterior Glides

• Assessment• Symptom Provocation• Treatment

Flexion Improves

• What would the treatment look like?

Flexion Improves

• Flexion Exercise

Flexion Improves

• Flexion Postures

Flexion Mobilizations

• SNAGs with Belt

Status Quo

Sidebending/Status Quo

• Symmetrical (Capsular)

• Mobilization Syndrome– Passive Flexion General– Passive Extension General

Flexion Range is Decreased

• What would a treatment look like?

General Flexion

• Flexion Mobilizations

• Flex LE to desired levels

• Posterior Glide of LE on segments

General Flexion for Home

• Slouched sitting

• Flexion stretches

• Flexion activity– Rower– Bike

Extension is Limited

• What would the treatment look like?

General Extension

• PA Glides• Begin in Neutral• Progress to Extended

Position

General Extension for Home

• Force Movement at Specific Levels

• Modified Press Up Exercise

• Extension at L3• Towel Roll to flex at

L4/5

Sidebending/Status Quo

• Asymmetrical (Non capsular)

• No Pattern– General Mobilization

• Specific Pattern– Specific Mobilization

Opening Restriction

• What does the range loss look like?

Opening Restriction

• Forward Flexion– Deviation to the side of the Restriction

• Sidebending– Limitation to the contralateral side

• Combined Flexion and Contralateral SB’ing

Opening Mobilization

• Flex to desired level

• Lift Bilateral LE to ceiling to gap/open

• Opening on side on table

• Progression - Laterally flex table

Opening Mobilization

• Joint Glide in Flexion

• Look for deviation with forward flexion to determine where in range to mobilize

Closing Restriction

• What would the pattern look like?

Closing Restriction

• Extension– Deviation to contralateral side

• Sidebending– Limitation to the ipsilateral side

• Combined Extension and Ipsilateral SB’ing

Closing Mobilizations

• PA’s with unilateral support

• SNAG’s in Extension

Opening/Closing Manipulation

• Flex to level of involvement (Gap L4/5 to manipulate L4)

• Stabilize LE

Opening/Closing Manipulation

• Maximally Rotate Upper Body to end range

• Have Patient Exhale and relax abdominals

• Overpress gently with upper body rotation

• Closes side toward ceiling/Opens opp.

Maximize Gains with Home Programs

• Home Exercise of Towel Sitting

• Open- Contralateral

• Close- Ipsilateral

Lumbar Instability

• Immobilize/Stabilize

• What would the pattern look like?

Instability

• No range Restrictions

• Glitch in forward bending

• Need to support to return from flexed position

Joint Shear Testing

General Stabilization

• Pelvic Neutral with leg lowering

General Stabilization

• Side Lift– Quadratus

– Obliques

– Minimal LB stress

Lumbar Weakness/Instability

• High Intensity Electrical Stimulation to Lumbar Paraspinals

• 2500Hz

• Sine wave

• 75 burst/sec

• 15 on/ 50 off (3sec ramp)

• 15 contractions

Electrical Stimulation for Strengthening

Classification

Case 1

• 18 year old soccer player

• 6wk history of LBP

• Played until 1 week ago then too painful to overcome

• Dull aching right sided low back pain– Denies pain in any other location

Case 1 Soccer Player

• Pain is 0-7/10• Pain with Activity

– shooting ball– cutting back and forth – right sidebending

• Pain improves– Rest– Ice– Relafen

Case 1 Soccer Player

• 3 of 4 SIJ tests (-)

• 50% reduction in Right Sidebending

• Good Forward Bending

• 50% reduction in Left Rotation

• Extension is 50% limited

• Quadrant Test or Max ? Test is +

Hypothesis

• What is wrong with this player?

• What group does he belong in?

Hypothesis

• Status Quo

• Closing Restriction

• Specific Mobilization

• How would you treat him?

• How long will it take?

Case 1 Soccer Player Outcome

• Performed manipulation on first treatment– Greater than 50% improvement in range – Joint mobilizations for closing– Home program

• Facet joint closing with towel under right buttock

• Prone press ups at home

Case 1 Soccer Player Outcome

• Next Treatment

• 60% improvement in pain and range

• Continued with closing mobilizations

• 4th treatment return to full 100% painfree play

Case 2

• 60 year old with back and leg pain– Left buttock, anterior knee and big toe

• Symptoms provoked– Walking < 1 mile– Standing 10-15 minutes

• Symptoms increase – Squatting – Sitting

Case 2 60 year old

• Oswestry 16%

• LQS

• Left Quad and HS 4+/5 compared to R

• All other = B and Reflexes =B

• Sensation- Slight decrease L3 and S1 on Left

Movement Testing

• Asymmetrical sidebending (decreased L)– Recreates buttock pain

• Flexion and Extension 75% limited pain-free– Left deviation with forward flexion

• Repeated L sidebending increases tingling in toe– symptoms resolve on standing

• L Quadrant closing recreates foot symptoms– Symptoms resolve when return to standing

Joint Play

• L2 and L3 Hypomobile

• L4, L5 N

• L5/S1 Unilateral– Recreates buttock pain

• L4/5 Unilateral– Sore with empty end feel

Special Tests

• SLR (-)• Slump Test (+) Left

– Recreates Buttock Pain

• Palpation to piriformis– Recreates buttock c/o

Case 2

• What do you suspect is wrong?

• What category does he fall into?

• What will his treatment program look like?

Case 2

• Asymmetrical Sidebending

• Status Quo or Worsen

• Indication of Radiculopathy– May argue worsen with extension

• Closing Restriction

Case 2 Treatment

• Joint Mobs to Hypomoblie segments– Specific mobilizations

• Traction – Mechanical effects of intervetebral separation– Parameters to maximize

Treatment and Traction

– 130 lbs first day- progressing to 190 over 4 treatments

– 12th treatment walk greater than 1 mile with no symptoms and raquetball with no symptoms

– 16th treatment- could stand to lecture today– 23rd treatment- walked around campus 3x today

• Walking is fun

– 25th treatment- great weekend but has buttock pain- + SIJ testing

Acute Lumbar Treatment

• Diagnosis Can Lead Intervention

• Classification Dictates Treatment

• Maximize Treatment Goals; In Clinic, Home, and Return to Work

• Delitto et al Physical Therapy 75:6 1995

• Greenwood et al JOSPT 27:4 1998

• Fritz Physical Therapy 78:7 1998

• McGill Physical Therapy 78:7 1998

• Fritz et al Physical Therapy 78:8 1998