11

Alex WongSenior Physiotherapist

Queen Elizabeth Hospital3 January 2009

Clinical Reasoning Clinical Reasoning Lumbosacral DysfunctionLumbosacral Dysfunction

Assessment & TreatmentAssessment & Treatment

22

ContentsContents

Classification of Lumbo-sacral Dysfunctions

Clinical Reasoning Practice Case Illustration Examination /Treatment Skills Take Home Message

33

Vague Diagnosis of LBPVague Diagnosis of LBP

80% no structural diagnosis Limited evidence to support classificat

ion Vague complaints to relate pathology Poor understanding biomechanics Complicated treatment outcomes

impairment, disability, capabilitypsychosocial……….

44

Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions

Purpose

Direct Specific and Effective Treatments to Homogenous Sub-group

Ford et al, 2007

55

Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions

Treatment Based Specific exercise – extension / flexion / lateral shift syndromeMobilization – lumbar / sacroiliac mobilizationImmobilization – immobilization syndromeTraction – traction / lateral shift syndrome

George & Delitto, 2005

66

Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions

McKenzie ApproachPostural – symptoms after static positionDysfunctional – symptoms at end range Derangement – symptoms through range

MeKenzie

77

Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions

Physical Therapy Reviews 2007 632 papers retrieved from data base 77 papers reviewed full document 55% uni-dimensional 6% multi-dimensional

Ford et al, 2007

88

Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions

Physical Therapy Reviews 2007Classification Dimensions

Patho-anatomy (47%) Signs and Symptoms (58%) Psychological (51%) Social (14%)

No clear guideline to classifyFord et al, 2007

99

Clinical Reasoning

Practice

1010

Hypothesis-Oriented Algorithm for Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)Clinicians II (HOAC II)

Physical Therapy, Vol 83, No.5, 2003A Guide for Patient Management A framework for science-based clini

cal practice Focus on remediation of functional

deficits How changes in impairments relate

d to these deficits

Rothstein, 2003

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Clinical Reasoning ProcessClinical Reasoning ProcessGenerate Patient Identified and Generate Patient Identified and

Non-identified Problem Lists (S/E)Non-identified Problem Lists (S/E)

Formulate Exam. Strategy Formulate Exam. Strategy

Conduct Examination and Analyze (O/E)Conduct Examination and Analyze (O/E)

Generate Working HypothesesGenerate Working Hypotheses

InterventionInterventionRe-assessment

Rothstein, 2003

1212

Subjective Complaint(generate the clinical hypothesis)

Examination, O/E (confirm the clinical hypothesis)

Intervention

(base on the O/E, findings)

Clinical Reasoning ProcessClinical Reasoning Process

1313

Case Illustration

1414

Formulate Problem Lists

(base on clinical presentations)

Case 1 (Housewife, aged 48) C/O • right dull LBP down to right lateral calf• aggravated after prolonged walking• relieved by short duration of sitting• standing much worse• morning pain

1515

Generate Clinical Hypothesis

(base on clinical presentations)

Case 1 (Housewife, aged 48)

Clinical Concerns• somatic referred symptoms (L4,5)• regular compression pattern• decrease lordosis• worst in static extension• favourable to movement

1616

Facet Joint / Extension SyndromeFacet Joint / Extension Syndrome

Common with increasing age Facet Joints block excessive e

xtension, associate with OA changes (morning stiff)

Aggravate in prolonged compression usually

Regular pattern presentation Relieve in stretch pattern

(opposite to lig./mm strain) Palpable local joint sign Positive finding in local diagnos

tic injection Harris-Hayes, et al, 2005

1717

Conduct Examination, O/E (base on clinical hypothesis)

Case 1O/E • postural defect • movement quality (L4,5)• regular movement pattern • quadrant • palpation (extension)

1818

Treatment Choice

(base on examination findings)

Case 1

Treatment • facet joint passive mobilization • mobilize in extended position (L4,5)• extension exercises

1919

Formulate Problem Lists

(base on clinical presentations) Case 2 (Construction site worker, aged 38) C/O • minor sprained 2 days ago • left stabbing LBP down to left lateral ankle gradually afterwards• aggravated after prolonged sitting, walking• relieved by lying only • moderate morning pain – difficult to bend for brushing teeth and wearing shoes• listing pain• can’t tolerate public transport (bus, mini-bus)

2020

Generate Clinical Hypothesis

(base on clinical presentations) Case 2 (Construction site worker, aged 38)Clinical Concerns• associated with injury • delayed onset of neurogenic symptoms• relieved by decreasing disc pressure• morning symptoms• restricted neurodynamic movement• sensitive to vibration irritation• listing postural defect

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Nature of injury (F/Rot) Delayed symptoms after injury Sensitive to vibration Morning symptoms Increase symptoms on changing

intra-abdominal pressure Restricted mov’t of neuro-tissues Lumbar listing (ipsilat. / contralat.) Diagnosed by MRI (match with sym)

Discogenic Back PainDiscogenic Back Pain

Peng, et al, 2006

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Conduct Examination, O/E

(base on examination strategy)

Case 2 (relieving approach)O/E• postural defect (listing)• movement quality (L4,5), extension• neurodynamic movement• neuro assessment• vibration • manual traction• MRI confirmed

2323

Treatment Choice

(base on examination findings)

Case 2Treatment • listing correction• rotation mobilization• Mckenzie exercises• extension with listing correction

2424

Formulate Problem Lists

(base on clinical presentations)

Case 3 (3 children housewife, aged 33) C/O • minor ankle sprained 7 days ago • dull pain from right buttock down to thigh• aggravated after prolonged sitting, stairs• relieved by walking around • moderate night pain – difficult to roll in bed• can’t tolerate cross leg sitting & pulling activities

2525

Generate Clinical Hypothesis

(base on clinical presentations)

Case 3 (3 children housewife, aged 33)Clinical Concerns• associated with injury / child-birth • symptoms usually not below knee• aggravated if asymmetrical stress to SI Joint & pulling activities• rolling pain in bed at night

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Sacral Iliac Joint SyndromeSacral Iliac Joint Syndrome

Age / Sex History of Trauma / child-birth Buttock pain / tender over PSIS Symptoms likely not below knee Symptoms when rolling at night Occ cross SLR / Step forward pain Muscle imbalance

Priformis, Hamstring, iliopsoas, Gluteus maximus

Cluster of tests to confirm DonTigny, 1990 DeMann, 1997

2727

Conduct Examination, O/E (base on examination strategy)

Case 3 (aggravating approach)O/E • PSIS tender• anterior / posterior stress tests• cross SLR• Long sitting leg length difference• cluster tests to confirm• hip rotation tests

2828

Treatment Choice

(base on examination findings)

Case 3Treatment • leg traction• posterior pelvic tilting• hamstring strengthening (muscle energy)

2929

Formulate Problem Lists

(base on clinical presentations)

Case 4 (retired policeman, aged 65) C/O • gradually onset LBP within one year • stretching pain down to left lateral calf• aggravated after prolonged walking • relieved by sitting • moderate mid-range pain when bending forward• difficult to resume hiking and carry back-pack

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Generate Clinical Hypothesis

(base on clinical presentations)

Case 4 (retired policeman, aged 65)Clinical Concerns• clinical / functional instability • observable kink of spinal curvature • aggravating with dynamic flexion stress• variable catching pain during mid-range• flexion / extension x-ray to confirm (usually inferior disc problem 67% at L5 level)

Luk, 2003

3131

Decrease the cross section area of multifidus over the injured / defect segment

Clinically ‘catching pain’ in different range of motionesp. forward flexion

Intrinsic muscles minimize unnecessary rotational stress over the disc

Lumbar Dynamic StabilityLumbar Dynamic Stability

Hides, 1994; Lee et Al, 2006

3232

Conduct Examination, O/E (base on examination strategy)

Case 4 (aggravating approach)O/E • postural defect (hyperlordosis)• movement quality (L4,5)• catching pain during movement• shearing test• abdominus weakness & hamstring tightness

3333

Treatment Choice

(base on examination findings)

Case 4Treatment • supine traction prone traction• abdominal exercises• stabilization exercises

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Formulate Problem Lists

(base on clinical presentations)

Case 5 (Student, aged 22) C/O • back sprain injury half year ago • stretching pain down to lateral calf gradually• recent P&Ns over lateral calf • difficult to wear shock in the morning • unfavorable to sit sofa• relieved by walking around

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Generate Clinical Hypothesis

(base on clinical presentations)

Case 5 (student, aged 22)Clinical Concerns• associated history• stable neurogenic symptoms • distal symptoms dominated • regular stretching pattern• morning symptoms• not related to loading stress• favorable to movement

3636

Neurodynamic DysfunctionNeurodynamic Dysfunction

Relative dynamic mov’t of neuro-connective tissues deficiency:- total length insufficiency, adhesion to sensitive structures, poor excursion / gliding movements

Distal symptoms dominated Morning severity Associated with spine post-op complicati

on Aware latency effect after neurodynamic

treatment- prefer for stable symptoms

Bulter, 1992; Ko et al, 2006

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Conduct Examination, O/E

(base on examination strategy)

Case 5 (aggravating approach)O/E• stable symptoms• relative dynamic mov’t of neuroconnective tissues deficiency: - total length insufficiency, adhesion to sensitive structures, poor excursion / gliding movements• ULTT, Slump

3838

Treatment Choice

(base on examination findings)

Case 5Treatment • hamstring stretching (cadual

/ cephelic direction)• slump

3939

Formulate Problem Lists

(base on clinical presentations)

Case 6 (Teacher, aged 56) C/O • no history of injury• stretching & squeezing pain over left calf muscle • symptoms aggravated after walking ~ 15 min.• relieved by sitting or squatting ~ 15 min.• tolerate standing ~ half hr.• much worse when up & down slop

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Generate Clinical Hypothesis

(base on clinical presentations)

Case 6 (Teacher, aged 56)Clinical Concerns• dynamic flex / ext problem• relieved by (static) flexion• distal symptoms dominated• not significantly related to loading • not immediately relieved by standing• variable in walking distance• worse in slope walking

4141

Spinal ClaudicationSpinal Claudication

Spinal: Symptoms aggravated by walking a

nd change of body positions Slow relieve by sitting or squatting Worse even in prolonged standing Various walking tolerance Neuropathy symptoms Gelderen Bicycle test

Gray, 1999

4242

Conduct Examination, O/E (base on examination strategy)

Case 6 (relieving approach)O/E• distal symptoms dominated• fluctuated symptoms• repeated flex & ext• step standing extension• flex with rotation test• Gelderen Test• x-ray oblique view

4343

Treatment Choice (base on examination findings)

Case 6Treatment • crook lying traction• rotation mobilization• rotation with SLR• abdominal strengthening

4444

ReferenceReferenceButler DS (1992) Mobilization of Nervous System. Churchill LivingstonesCibulka MT,Koldehoff R.(1999) Clinical usefulness of a cluster of sacroiliac joint test in patietns with and without low back pain.Journal of orthopaedic and sports Physical Therapy 29(2): 83-92DeMann LE (1997) Sacroiliac Dysfunction in Dancers with Low Back Pain, Manual Therapy 2(1), 2-10. DonTigny RY (1990) Anterior Dysfunction of the Sacroiliac Joint as a Major Factor in the Etiology of the Idiopathic Low Back Pain Syndrome. Physical Therapy 70: 250-256 Ford J, Story I, O’Sullivan P and McMeeken J (2007) Classification Systems for Low Back Pain: A Review of the Methodology for Development and Validation Physical Therapy Reviews 12: 33-42.Gay R E, Ilharrebode B, Zhao K, Zhao C and An K N (2006) Sagittal Plane Motion in the Human Lumbar Spine: Comparsion of the in Vitro Quasistatic Neutral Zone and Dynamic Motion Parameters, Clinical Biomechanics 21, p.914-919.George SZ, Delitto A (2005) Clinical Examination Variables Discriminate Among Treatment-based Classification Groups: A Study of Construct Validity in Patients with Acute Low Back Pain, Physical Therapy vol 85 (4) 306-314. Harris-Hayes M, Linda R, Van Dillen, Sahrmann S A (2005) Classification, Treatment and Outcomes of a patient with Lumbar Extension Syndrome Physiotherapy Theory and Practice, 21: 3, 181-196.

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ReferenceReferenceHides JA, Stokes MJ, Saide M, Jull GA, Copper DH (1994) Evidence of Lumbar Multifidus Wasting Isilateral to Symptoms in Patients with Acute/Subacute Low Back Pain. Spine. 19: 165-172.Ko HY, Park PK, Park JH, Shin YB, Shon HJ and Lee HC (2006) Intrathecal Movement and Tension of the Lumbosacral Roots Induced by Straight Leg Raising. American Physical Medical Rehabilitation. March , 85(3), 222-227.Kuncewicz E, Gajewska E, Sobiska M and Samborski W (2006) Piriformis Muscle Syndrome, Ann Acad Med Stetin, 52(3) 99-101.Lee S W, Chan CKM, Lam TS, Lam C, Lau NC, Lau RWL and Chan ST (2006) Relationship Between Low Back Pain and Lumbar Multifidus Size at Different Postures. Spine, vol 31, 19, p. 2258-2262.Oldreive WL.(1995) A critical review of the literature on tests of the sacroiliac joint.J.Manual Manipulative Therapy 3(4):156-161.Peng P, Hao J, Hou S, Wu W, Jiang D, Fu X and Yang Y Possible Pathogenesis of Painful Intervertebral Disc Degeneration Spine vol 31 (5) p.560-566 Rothestein J M, Echternack J L and Riddle D (2003) The Hypothesis-Oriented Algorithm for Clinicians II (HOACII): A guide for Patient Management, Physical Therapy Vol 83, Number 5, 455-470Sanders RJ, Hammond SL and Rao NM (2007) Journal of Vascular Surgery. Sept. 46(3): 601-604.Sebastian D (2006) Thoracolumbar Junction Syndrome: A case Report. Physiotherapy Theory and Practice 22:1 53-60.Wilk V (2004) Acute low back pain: assessment and management, Aust Fam Physician, June; 33(6): 403-7.