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Low Back Pain Subjective - Objective - Treatment Options Alli Ferris and Matt McCutcheon

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Page 1: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

Low Back PainSubjective - Objective - Treatment Options

Alli Ferris and Matt McCutcheon

Page 2: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 3: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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.

Page 4: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

The Plan:Subjective

Objective

And some treatment tips if we have time.

Page 5: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 6: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 7: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 8: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

CLINICAL REASONING

Page 9: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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.

Page 10: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 11: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 12: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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?

Page 13: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 14: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 15: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

So how do WE classify them???

Page 16: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

SIMPLY...RED FLAGS/Serious Spinal Pathology

Neurological Compromise

NSLBP

Page 17: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

But then what??

Page 18: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

O’Sullivan Multidimensional Classification System

Page 19: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

STAGE OF DISORDERAcute (1-4 weeks)

Subacute (4-12 weeks)Chronic (>12 weeks)Recurrent episodic

Page 20: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 21: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 22: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 23: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

Red Flag ConditionsSeronegative Spondyloarthropathies

Ankylosing Spondylitis: SIJ, ankylosing

Reactive Arthritis: preceding urogenital arthritis

Psoriatic Arthritis : psoriasis

Enteropathic Arthritis: inflamm bowel disease

Page 24: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

Refer on...

Page 25: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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)

Page 26: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct
Page 27: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct
Page 28: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct
Page 29: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 30: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 31: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 32: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

Cognitive and psychosocial FactorsQuestioning:

● Beliefs● Fears● Stress and Anxiety● Mood● Coping Strategies● Work/Home● Co-Morbidities

THOROUGH SUBJECTIVE

Page 33: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 34: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 35: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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?

Page 36: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 37: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 38: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 39: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

http://www.aspetar.com/journal/viewarticle.aspx?id=220#.WTaOjGiGPD4

Active Extension Pattern

Page 40: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct
Page 41: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 42: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

What are our options?

Page 43: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 44: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

Classification Based - Cognitive Functional

TherapySpecific targeted intervention aimed at intrinsic and

extrinsic contributing factors

Page 45: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 46: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

How do we decide?

Page 47: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

Prognosis● Future episodes of LBP predicted by factors such as depression, stress,

lifestyle, cognitive factors NOT pathoanatomical diagnosis (Jarvik et al 2005)

Page 48: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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?

Page 49: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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)

Page 50: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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)

Page 51: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

● 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.

Page 52: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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)

Page 53: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 54: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct
Page 55: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

Neurological Testing

Page 56: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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)

Page 57: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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?

Page 58: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 59: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 60: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

Then what???When do we refer on?

● Red Flag Conditions: cauda equina● Cord Compromise

Page 61: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

Neurodynamic Testing

Page 62: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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.

Page 63: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

What does it look like?Subjective Clues:

Pain worse in morning

Pain worse when neural pathway placed in stretched position

Page 64: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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)

Page 65: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

When do we test?Routinely?

Symptoms below gluteal fold?

Clues from subjective history?

Page 66: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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?

Page 67: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

What is a positive test?Pain

ROM

Resistance

MUST COMPARE TO ASYMPTOMATIC SIDE

Page 68: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

Objective

Page 69: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

Classification of Pain Related Movement BehaviourAdaptive

Maladaptive

Movement Impairment

Control Impairment

In what direction??? Flex/Ext/LF/Rotation/Multidirectional

Page 70: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

How do we figure it out??

Page 71: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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.

Page 72: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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.

Page 73: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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?

Page 74: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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!

Page 75: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

Functional Assessment - sitting Maladaptive patterns to flexion related pain in sitting

Control impaired, movement impaired and correct sitting.

Page 76: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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.

Page 77: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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

Page 78: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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???

Page 79: Low Back Pain Alli Ferris and Matt McCutcheon€¦ · To simplify low back pain and classification of low back pain to enable a more universal approach across practitioners To conduct

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.