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
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
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