Osteopathic Approach To

Low Back PainRobert Kim, DO

FM PGY-22019 FOMA Convention

LBP Epidemiology

- Affects 5.6% of US adults daily- 18% of US adults report having LBP in the past month- Lifetime prevalence 60-70%- 25% of patients w/ LBP seek medical attention- 1 of 3 top 3 reasons for FM physicians - FM physicians see more LBP than any other specialist

Differential Diagnosis (DDx) Mechanical

- Lumbar spondylosis- Disk herniation- Spondylolisthesis- Spinal stenosis- Fractures (osteoporotic)- Nonspecific (idiopathic)Neoplastic

- Primary- Metastatic

Inflammatory- Spondyloarthropathies

Infectious- Vertebral osteomyelitis- Epidural abscess- Septic diskitis- Herpes Zoster

Metabolic- Osteoporotic compression fracture- Paget’s disease

Referred Pain to Spine- Viscera, retroperitoneal structures, urogenital

system, aorta, or hip

DDx - Lower Back Pain Mechanical 97%- Degenerative Joint Disease (DJD)- Disk Herniation- Osteoporotic Compression Fracture- Spinal Stenosis 3%- Spondylolisthesis 2%- Remaining majority %? no medical cause

- Nonspecific LBP… lumbar sprain/strain, somatic dysfunction

DDx - Red FlagsFracture of the Spine

- Significant trauma- Prolonged glucocorticoid use- Age > 50 yrs

Infection or Cancer- Hx of cancer- Unexplained/unintentional weight loss- Immunosuppression- IVDU- Nocturnal Sx or pain- Age > 50 yrs

Cauda Equina Syndrome- Urinary retention- Overflow incontinence- Fecal incontinence- b/l or progressive motor deficit- Saddle anesthesia

Spondyloarthropathies- Morning stiffness- Pain improvement w/ exercise- Pain during second half of night- Alternating buttock pain- Age < 40 yrs

< 5 % of LBP

Physical Exam (PE)Visual Inspection

- Posture from behind & from the side of the pt

Active & Passive ROM- Flexion Extension- Sidebending- Single-leg extension

Palpation: spine & paraspinal muscles- Spinous & transverse processes- Apophyseal joints - Sacroiliac (SI) joints- Iliolumbar ligament- Paraspinal muscles- Quadratus lumborum (QL)- Gluteal muscles

Neurologic assessment of nerve roots - L4, L5, S1 nerve roots

Special Tests - Unilateral straight leg raise test (Lasegue)- Crossed straight leg raise test (Well straight leg raise)- Femoral nerve stretch test- FABER/Patrick test- SI joint tests: distraction, shear, compression- Gaenslen’s test- Single leg extension- Centralization test

Osteopathic Exam

PE - Neurological AssessmentHip Flexion (Iliopsoas) - L1 - L2, 3, 4 (Femoral N)

Knee Extension (Quadriceps)- L2, 3, 4 (Femoral N) - DTR… L4

Knee Flexion (Hamstrings)- (L4), 5, S1, 2, (3) (Sciatic N; Tibial N)

Ankle Dorsiflexion (Tibialis Anterior)- L4, 5 (Deep Fibular/Peroneal N)

Great Toe Extension (Extensor Hallucis Longus)- L5, S1 (Deep Fibular/Peroneal N)

Ankle Plantar Flexion (Gastrocnemius)- S1, S2 (Tibial N) - DTR… S1

PE - Special Tests Straight Leg Raise (Lasegue) Test- Sciatic Nerve Compression ~80% sensitivity

- Patient supine, lift leg while maintaining knee extension- Lower raised leg when pt experiences pain/tightness until pain resolution- dorsiflex ankle & instruct the pt to flex neck

Positive- Pain at 30-60°, radiating down raised leg- indicates sciatic n root irritation- Pain at > 70°… muscle stretching, SI or lumbar facet joint pain

Crossed Straight Leg Raise Test

Positive- pain radiation down side of contralateral raised leg- indicates n root irritation 2/2 herniated intervertebral disc

PE - Special Tests Femoral Nerve Stretch Test- N root impinge of L2, 3, 4 (Femoral N)

- Pt prone w/ pillow placed under abdomen- Examiner stabilizes pt’s hand over PSIS of pt’s far hip- Extend far hip while maintaining knee flexion at 90

Positive- pain in anterior & lateral thigh

PE - Special Tests FABER/Patrick Test- Assess pathology of hip joint, iliopsoas spasm, or SI joint dysfunction

- Pt supine, examiner passively flexes, ABducts, & externally rotates leg while stabilizing contralateral ASIS- Rest pt’s foot on top of contralateral knee- Examiner slowly brings tested leg knee toward table

Positive- pain w/ tested &/or tested leg is unable to be ABducted below lvl of contralateral leg - Limited ROM, groin or side hip pain?

- Hip arthritis, femoroacetabular impingement, or other hip pathology- Iliopsoas strain or bursitis

- Posterior pain in back?- SI joint dysfunction or sacroiliitis

PE - Special Tests Sacroiliac Distraction Test- anterior SI ligament dysfunction

- Pt supine w/ forearms under lower back & pillow under knees- Examiner crosses arms w/ elbows straight & places heels of hands on pt’s ASIS- apply slow steady posterior force on pt

Positive- Unilateral pain at SI joint or gluteal/leg region

Sacroiliac Shear Test- sacrospinous ligament dysfunction

- Pt supine w/ tested hip flexed to 90° & knee fully flexed- Examiner stabilizes OPP ASIS & applies pressure through axis of femur

Positive- pain in the posterior buttock

PE - Special Tests Sacroiliac Compression Test - SI joint pathology, w/ possible posterior SI ligament dysfunction

- Pt in lateral recumbent position w/ pillow b/t knees- Examiner stands behind pt & places hands on top of pt’s iliac crest then exerts downward pressure

Positive- Reproduction of pain

Gaenslen’s Test- differentiate b/t lumbar spine & SI joint dysfunction

- Pt supine w/ tested leg off table. Pt actively flexes OPP hip & knee. - Examiner assists pt w/ stabilizing flexed leg & applies pressure to tested leg inducing further extension & ADduction- * begin w/ unaffected side first

Positive - SI joint problem, pubic symphysis instability &/or L4 n root

PE - Special Tests Centralization Test- Determine whether flexion or extension increases or decreases Sx & if centralization is occurring

- Identify pt’s baseline Sx locations in standing position; emphasis on most distal Sx - Instruct pt to bend forward as far as possible w/ a return to starting position. Note any effect of movement on Sx- Repeat 10-12x, ask pt to report any lasting changes in location or change in intensity of Sx- Repeat assessment w/ standing extension, recumbent flexion, & prone extension

Positive- pain Sx moves from distal to proximal (centralization)- indicates Sx 2/2 internal disk disruption- centralization is commonly related to single direction of movement; Sx likely to improve w/ flexion or extension based exercises

PE - Osteopathic Exam Sacroiliac DiagnosisSeated Flexion Test +

PE - Osteopathic Exam Sacroiliac Diagnosis

Negative seated flexion test- no sacroiliac dysfunction- Bilateral flexion or extension- False negative 2/2 iliosacral decompression

Negative seated flexion & ILAs equal

Sulci deepNegative spring test- B/l sacral flexion

Sulci shallowPositive spring test- B/l sacral flexion

OMT - Sacral Torsion

OMT - Sacral Shear

OMT - Sacral Shear

PE - Osteopathic Exam Seated Flexion Test

OrAP Compression Test

Left or RLeft or Right

Superior ASIS Inferior ASIS Medial ASIS Lateral ASIS

Superior PSIS

Superior Innominate

Shear

Inferior PSIS

Anterior Innominate

Rotation

Lateral PSIS

Innominate Inflare

Medial PSISInnominate

Outflare

Inferior PSISInferior

Innominate Shear

Superior PSIS

Posterior Innominate

Rotation

Iliosacral Diagnosis

OMT - Innominate Shear

OMT - Innominate Rotation

OMT - Innominate Flare

PE - Osteopathic Exam Iliosacral Dysfunction

Pubic Rami

Inferior RamusSuperior ramus

Superior pubic shear Inferior pubic shear

Equal Rami

Compressed pubic symphisis

OMT - Pubic Shear

Osteopathic Manipulative Treatment- Myofascial release & soft

tissue technique- Counterstrain- Muscle Energy- BLT- HVLA- Still Technique

OMT - Counterstrain

OMT - Muscle Energy

OMT - Balanced Ligamentous Tension

OMT - HVLA