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Low Back PainSubjective - Objective - Treatment Options
Alli Ferris and Matt McCutcheon
What are we trying to achieve today??● To simplify low back pain and classification of low back pain to enable a more
universal approach across practitioners● To conduct a thorough subjective assessment and use clues within it to guide
your objective assessment.● Movement away from the “push on it” approach or “extend it” approach to look
at the bigger picture - understand WHY we are prescribing certain movements/positions/restrictions
● To create consistency with regard to use of neurological examination/neurodynamic testing
● To understand the importance of screening tests/special tests and when they are indicated and when to refer on.
● To Learn plenty of hot tips and tricks from each other
OUTCOMESBe able to classify patients into management groups and assign interventions appropriately.
Collective agreement on how we do a neuro exam, when and why?
What Special Tests should we use in our assessment of the lumbar spine and what are the indications?
Consistency in palpatory skills between all Physio’s at SL.
Consistency on the identification, and the correction of faulty functional tasks related to LBP.
The Plan:Subjective
Objective
And some treatment tips if we have time.
Initial Assessment - What are we aiming for?● Identification of:
○ Red Flags○ Yellow Flags○ Candidate for physio??○ Risk factors for poor prognosis○ Degree of pain and functional disability
● Establish baseline measures that we can reassess○ Rule In/Rule Out other structures, areas○ Questionnaires - do we need these??
● Take your time
Subjective History
What information do we need???
● Age● HPI/Mechanism - overload, trauma, insidious● Body Chart● Current Status: Aggs/Eases, irritability, mechanical pain, functional “instability”/lack of motor control, trend of injury
(getting better or worse), sleep, immediate physical requirements (work, family, sport), current function (sit, walk, standing tolerance), PSFS
● 24/24● Past history – episodes, surgery, contributing injuries● Attitudes of injury – beliefs, fear avoidance, ignorance● Pain (site intensity nature) nociception, somatic referred, neurological, inflammatory● Stage of tissue healing - pathoanatomy● Current disabilities or activity limitations (work, life, sport, pain)● Patients expectations
What do we use it for?● Understand current limitations● Initiate hypothesis of direction of preference and motion impairment● Guide Objective Exam: Systematic approach● Grade treatment (based on irritability, patients attitudes, expectations)● Refer ● Commence data collection to enable subgroup classification
○ Recommendation for pain relieving exercises○ Better outcomes ○ Guide functional restoration○ Prognosis
● Identify if misinformation or unrealistic expectations exist
CLINICAL REASONING
Hypotheses Categories (Jones and Rivett 2004)Activity and Participation capability/restriction - difficulty performing activity, functional restrictions, participation in life, sport, caring for family → Use these to create goals.
● Capabilities are also important as a starting point for intervention, what CAN they do.
Patients perspective on their experience - understanding, feelings, beliefs. Can be a barrier to recovery eg. pain = damage = avoiding movement, also need to understand WHY they have this perspective.
Pathobiological Mechanisms - Issue in the tissue +/- pain mechanisms. Need to consider both and how it affects management.
Hypotheses Categories contPhysical Impairments - specific abnormalities detected through P.E. Use subjective to guide this. Should be measureable.
Pathoanatomical Source of Symptoms - actual structure that the symptoms/signs are from. Careful with more complex pains states. DIFFERENTIAL DIAGNOSIS
Contributing Factors: environmental, psychosocial, behavioural, physical/biomechanical, hereditary
Contraindications and Precautions: Consider irritability, red flags - will guide the P.E so NEED TO ASK
Management and Treatment: Guided by the previous categories. Need to address all contributing factors to manage appropriately
Prognosis
Hypotheses CategoriesActivity and Participation capability/restriction
Patients perspective on their experience
Pathobiological Mechanisms
Physical Impairments
Pathoanatomical Source of Symptoms
Contributing Factors
Contraindications and Precautions
Management and Treatment
Prognosis
TASK…Using the categories discussed, and the case study attempt to fill in the blanks…
Which categories are the most important for your patient?
Some may be very relevant, some may not apply at all.
What can we use this information for? Is it a useful approach?
Questionnaires?McGill Pain Questionnaire (MPQ)
● Subjective pain experience - self rating ● Category scores >16 or marking of items
in categories 11-16 = severe or excessive emotional reaction to pain
● Reliable, valid and consistent
Roland Morris Disability Questionnaire (modified) (mRMDQ)
● Assessment of physical disability due to back pain
● Scores 0 (no disability) - 24 (max disability)
Orebro Musculoskeletal Pain Questionnaire (OMPQ)
● Screening questionnaire to identify patients with acute or subacute musculoskeletal pain at risk of a delayed recovery
● Workers Comp/CTP patients● Scoring more complex
Patient Specific Functional Scale (PSFS)
● Self explanatory
Classification Systems for LBPMackenzie
Maitland
O’Sullivan: CBT
Wadell : Mechanical, Nerve Root, SSP
Clinical Prediction Rules: manipulation, stability
Multidimensional Classification System (O’Sullivan 2012): CB-CFT
So how do WE classify them???
SIMPLY...RED FLAGS/Serious Spinal Pathology
Neurological Compromise
NSLBP
But then what??
O’Sullivan Multidimensional Classification System
STAGE OF DISORDERAcute (1-4 weeks)
Subacute (4-12 weeks)Chronic (>12 weeks)Recurrent episodic
SPECIFIC LBP
Pathoanatomical Diagnosis
● Lateral Canal Stenosis
● Central Stenosis● Disc prolapse● Modic changes● Spondylolisthesis
Radiology must correlate with clinical presentation
RED FLAG DISORDERS
CancerInflammatory DisordersInfectionsFractures
NON-SPECIFIC LBP
No clear pathoanatomical diagnosis
Based on Clinical exam and review of available radiology
Red Flag Conditions SPINAL FRACTURE
● Long term steroid use● Age 70+● Female● Trauma
MALIGNANCY
● Past history Cancer
** Increase suspicion when “red flags” identified in history: unexplained weight loss, age (<20/>50), failure to improve after 1 month
INFECTION: Discitis, Osteomyelitis
(<0.01% prevalence)
Indications: slow onset, non responsive to treatment, back pain, low grade temp
Risk Factors: systemic infection (current/recent), recent penetrating trauma, immune system compromise
Red Flag ConditionsCAUDA EQUINA
● Acute onset urinary retention or overflow incontinence
● Loss of anal sphincter tone or faecal incontinence
● Saddle anaesthesia● Widespread progressive LL weakness or
gait disturbance● Altered sensation
INFLAMMATORY BACK PAIN
1. Age <40 years2. Insidious onset3. Improvement with exercise, 4. No improvement at rest5. Night pain
** if >4 /5 present sensitivity 77%, specificity 91.7% (Sieper et al 2009)
● Constant, progressive, non mechanical● Morning stiffness● Peripheral joint/tendon involvement● Iritis, rashes, colitis, urethral discharge● Family history of arthritis
Red Flag ConditionsSeronegative Spondyloarthropathies
Ankylosing Spondylitis: SIJ, ankylosing
Reactive Arthritis: preceding urogenital arthritis
Psoriatic Arthritis : psoriasis
Enteropathic Arthritis: inflamm bowel disease
Refer on...
Can we/should we still make/consider a pathoanatomical diagnosis??
● = SPECIFIC LBP● More often in acute scenario● Absolutely● But have to consider it in context - how does it feed back into the overall
management of the patient?● Consider stage of tissue healing before implementing management strategies● Pacing to avoid exacerbations● Graded activity program
(Ford et al 2017)
Neurological Compromise/ RadiculopathyRadicular Pain (Nerve Root)
● Positive Neuro● Positive Neurodynamics
Limited diagnostic accuracy in detecting disc herniation with suspected radiculopathy (Al Nezari et al 2013)
All tests had low sensitivity and moderate specificity
Tawa et al 2017All cause radiculopathy, not disc herniation alone, compared to MRI
● Sensory: light touch and pain sensitivity - high specificity● Motor: not ideal for ruling out radiculopathy (inconsistencies in execution) ,
highest specificity for S1 NR● Reflexes (achilles/patella): good specificity and moderate sensitivity. Use as
confirmatory tests for radiculopathy● Neurodynamic testing: SLR (sacral plexus), Fem nerve (lumbar plexus)
○ Discrepancy between purpose of test: detection of increased mechanosensitivity or nerve root compromise due to disc herniation (Lassegues sign)
○ Tests more sensitive than specific therefore ideal for RULING OUT = screening
PAIN WITH NON-MECHANICAL BEHAVIOUR
Spontaneous, constant, generalised
No clear anatomical focus either unrelated to mechanical factors or a disproportionate exaggerated and sustained pain response to minor mechanical triggers (absence of peripheral nociceptor drive)
Dominant central drive
PAIN WITH MECHANICAL BEHAVIOUR
Clear and consistent anatomical focus
Proportionate mechanical behaviour
Provoked and relieved with specific activities and postures
MIXED PRESENTATION
Consider pain type: nociceptive, inflammatory, functional,neuropathic
Cognitive and psychosocial FactorsQuestioning:
● Beliefs● Fears● Stress and Anxiety● Mood● Coping Strategies● Work/Home● Co-Morbidities
THOROUGH SUBJECTIVE
Lifestyle and Individual FactorsQuestioning:
● Physical Activity levels and preferences● Work related factors● Sleep related problems● Lifestyle● Goal Setting regarding lifestyle factors, activities of enjoyment, barriers,
realistic expectations
Pain Related Movement BehavioursIdentify and Examine Primary Pain provocative functional Impairments
Identify the postural +/- control strategy adopted with the activity
Identify pain behaviours eg. avoidance, propping, breath holding
Identify levels of body relaxation, breathing control, body control, awareness
Pain Related Movement Behaviours contIs the adopted strategy:
● Provocative (Mal-adaptive) : overprotective movement patterns → ongoing abnormal tissue loading and mechanically provoked pain
● Protective (Adaptive)
I.e. Does re-inforcing the patient's strategy provoke their pain?
Pain Related Movement Behaviours contHow do these behaviours relate to patients cognitive and psychosocial factors
Can an alternative movement or postural control strategy be found to reduce pain and facilitate functional capacity??
Consider levels of conditioning, muscle strength and endurance
Movement Impairment BehaviourPain associated with movement or loading in a specific direction or postural task.
Movement impairment (guarding) in direction of pain provocation - EOR pain or difficulty moving. Loss of ROM
Graduated movement exposure into the direction of pain provocation with controlled motor relaxation reduces pain and enhances functional capacity during the provocative task.
DIRECTIONS: Extension, Flexion, Multi Directional sensitivity
Control Impairment BehaviourPain with movement and or loading in a specific movement direction or postural task.
NO MOVEMENT IMPAIRMENT in direction of pain provocation during provocative activity and/or postural task. Through ROM pain, loading pain (due to non-physiological loading, EOR pain or over-strain.
Adaptation of movement/control strategy to reduce focal spinal loading during the provocative task reduces the pain and enhances functional capacity.
DIRECTIONS: Flexion, Extension, multidirectional
Passive or active Extension pattern/Flexion Pattern
http://www.aspetar.com/journal/viewarticle.aspx?id=220#.WTaOjGiGPD4
Active Extension Pattern
Treatment: The Evidence...ACUTE LBP (Koes et al 2010)
● Reassurance (favourable prognosis)
● Stay Active - discourage bed rest.
● Medications - paracetamol → NSAID --? Muscle relaxant, opioid, antidepressant, anticonvulsive (pain relief)
● Do not advise supervised exercise program
CHRONIC LBP
● No modalities● Short term meds/manipulation● Supervised Exercise Therapy● CBT● Multidisciplinary
What are our options?
What tools do we have?Mobilisation/Manipulation: PPIVMs, PAIVMs, MWMs
Soft Tissue release - needling, trigger point
Neurodynamics
Exercise
Motor Control
Pain Education
Clinical Pilates
CBT
Classification Based - Cognitive Functional
TherapySpecific targeted intervention aimed at intrinsic and
extrinsic contributing factors
Study: Fersum et al 2012Classification based cognitive functional therapy vs Manual Therapy/Exercise:
● Significant superior outcomes in the CB-CFT group with regard to:○ Pain○ Disability○ Days reported sick leave○ Fear beliefs○ Mood
How do we decide?
Prognosis● Future episodes of LBP predicted by factors such as depression, stress,
lifestyle, cognitive factors NOT pathoanatomical diagnosis (Jarvik et al 2005)
Imaging● MRI - diagnostic tool of choice
○ Follows the patho-anatomical model○ Radiculopathy not always mechanically mediated (Tawa et al 2017)
● What if they aren’t getting better?
When do we image??NOT indicated in absence of:
● Red flags● Trauma● Progressive Neurological deficit
(Deyo et al 2013, Jarvik et al 2005)
Abnormal MRI in pain free population
(McCullough et al 2012)
Classification: Take Home Message
NSLBP associated with a complex combination of
● physical ● behavioural, ● lifestyle, ● neuro-physiological (peripheral and central nervous system changes),● psychological/cognitive and ● social factors.
→ maladaptive cognitive behaviours, pain behaviours and movement behaviours, → vicious cycle of pain sensitisation and reinforcing disability
(O’Sullivan 2012)
● Changes in immune and neuroendocrine function linked to altered stress responsiveness + activation of the pain neuromatrix in the brain → tissue hyperalgesia and altered neuromuscular responses.
● Mediated by environmental/genetic interactions. ● The balance and contribution of these different factors will likely vary for each
individual.
What do we need to do better?● Understand multidimensional nature of LBP● Differentiate specific pathology as pain driver early● Develop our subjective questioning skills to explore patients,attitudes, beliefs,
fears, stresses,pain behaviours, impairments and goals● Identify maladaptive cognitive behaviours● Identify neurophysiological responses (central sensitisation)● Identify pain and movement behaviours - are they adaptive (protective)or
maladaptive (provocative)● Develop interventions/strategies targeted at each of the above - or refer on!● Multidisciplinary
(O’Sullivan 2012)
What about athletes?● No different● Identify athlete’s MOI:
○ Knowledge of sport○ Understand symptoms and signs○ Assessment in specific pain provocative tasks - sport specific
● Must consider ALL intrinsic and extrinsic factors relevant to your athlete● “Contributing factors”● Balance:
○ Stability/control vs compressive force○ Respiratory demands vs control demands (intra-abdominal pressure)○ Postural demands vs sport demands
Neurological Testing
Clinical Reasoning:CB-CFTTreatment targeted at each of the relevant identified factors: **SIGNS **
Intervention targeted at changing maladaptive movement strategies to unload sensitised spinal structures using motor learning.
Need to teach pain control whilst altering maladaptive strategies in a functional capacity (CB-CFT)
When do we test?● Any symptoms below gluteal fold● Subjective description of weakness, giving way, gait disturbances
???? Do we do this routinely in the clinic? Why/Why not?
What are the clinical features of somatic referred pain?
What do we test??Sensation - vibration, light touch --> pin prick. Map out dermatome/peripheral nerve fields
Power: motor loss
Reflexes: L3/4 Knee jerk, S1/S2 Ankle jerk
(Upper Motor Neuron: Babinski/Clonus)
App - Nerve Wiz
What are we testing?Altered Conduction
● Abnormalities in conduction of the peripheral nervous system (lower motor neuron)
● Nerve root vs. peripheral nerve (where possible)● Level of nerve root involvement● Assess sensory response in terms of pain mechanisms (hyperalgesia,
hyperaesthesia, allodynia), central pain mechanisms with neuropathic component
● Re-Assessment Tool
Then what???When do we refer on?
● Red Flag Conditions: cauda equina● Cord Compromise
Neurodynamic Testing
What are we testing?Increased sensitivity of the nervous system
Combination of joint angulation and anatomical destination of the nerve → cause neuromechanical response in the nerve.
Tension is transmitted to the nerve by stressing the structure in which it terminates.
ORDER of sensitisation is therefore important; Neural movement further from the joint will occur only once the slack along the nerve has been taken up.
Nerves move toward the joint that is currently being moved.
Greater strain in nerves occurs where force is applied first and most strongly.
What does it look like?Subjective Clues:
Pain worse in morning
Pain worse when neural pathway placed in stretched position
Neurodynamic TestingMECHANICAL RESPONSES
● Neural sliding● Tension● Intraneural pressure changes● Alterations in cross sectional shape● Viscoelastic function
PHYSIOLOGICAL RESPONSES
● Alterations in:○ Intraneural blood flow○ Impulse traffic○ Atonal transport
● SYmpathetic activation
(Shacklock 1995)
When do we test?Routinely?
Symptoms below gluteal fold?
Clues from subjective history?
What do we test?Slump
Prone Knee Bend
SLR
+ Sensitisations
Movements must be passive
What sensitisations do we use clinically - what do they tell us?
What is a positive test?Pain
ROM
Resistance
MUST COMPARE TO ASYMPTOMATIC SIDE
Objective
Classification of Pain Related Movement BehaviourAdaptive
Maladaptive
Movement Impairment
Control Impairment
In what direction??? Flex/Ext/LF/Rotation/Multidirectional
How do we figure it out??
PracticalAgreement on objective examination skills;
● Neuro exam● Functional assessment● Qualitative assessment of spinal motion● Special tests (stork, quadrant, SLE, Laslett, thomas, ASLR, Hip, Tx spine)● Static osseous alignment of pelvis● Palpation
Objectives of Objective exam;
1. Confirm what you already know from subjective. Don’t re-write the story!2. Identify contributing factors of injury.
Neuro exam pracMotor / power testing
Sensation testing
Reflex testing
Neurodynamics
In groups of 3;
In groups of 3 assess the clinical functioning of the L5 nerve.
Qualitative assessment of motionIn groups of 3 assess and consider video of movement quality
● Flexion● Extension● Lateral flexion
Based on the movement characteristics which spinal levels (approximately) would you focus your palpatory assessment on to confirm;
1. joint hypomobility2. pain
Which muscles would you expect to find increased tone in?
PalpationStatic osseous alignment - Do the features fit?
Muscle tone - TFL, QL, iliopsoas, hams, glutes, ribs
PAIVMS
In groups of 3 assess each other, take notes of the features you see most significant ie. muscle tone, joint hypomobility, static pelvic asymmetry and compare with your partners. Justify your findings, consider how to improve your assessment!
Functional Assessment - sitting Maladaptive patterns to flexion related pain in sitting
Control impaired, movement impaired and correct sitting.
FunctionIn your group recount and re-enact the best examples of;
1. Control impairment to flexion related pain in squatting2. Movement impairment to flexion related pain in lifting3. Movement impairment to extension related pain in standing4. Control impairment to extension related pain in walking
Discuss what was wrong with these strategies
Discuss cues and strategies to rehabilitate these maladaptive patterns.
Confirm contributing factorsAs a group discuss for your assigned functional task;
1. The common possible impairments contributing to pain in that situation2. Describe tests to confirm or exclude those impairments ie. stork test, ASLR,
hip ROM, Tx ROM, thomas, hamstring length, Laslett tests ect…..3. A simple and practical patient remedial exercise strategy to correct the
impairment
Special testsLaslett SI tests
McKenzie repeated movements
Static Osseous alignment
Stork test
Thomas test
ASLR + compression
Muscle length tests
Core stability tests
Movement analysis
Functional movement screening
Funky PAIVM’s, PPIVM’s and OP’s
What should be apart of SL’s assessment procedures???
OUTCOMESBe able to classify patients into management groups and assign interventions appropriately.
Collective agreement on how we do a neuro exam, when and why?
What Special Tests should we use for LBP and what are the indications?
Consistency on palpatory skills between all Physio’s at SL.
Consistency on the identification, and the correction of faulty functional tasks related to LBP.