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Alex WongSenior Physiotherapist

Queen Elizabeth Hospital3 January 2009

Clinical Reasoning Lumbosacral Dysfunction

Assessment & Treatment

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Contents

Classification of Lumbo-sacral Dysfunctions

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

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Vague Diagnosis of LBP

80% no structural diagnosis Limited evidence to support

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

impairment, disability, capabilitypsychosocial……….

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Classification of Lumbo-sacral Dysfunctions

Purpose

Direct Specific and Effective Treatments to Homogenous Sub-group

Ford et al, 2007

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Classification of Lumbo-sacral Dysfunctions

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

George & Delitto, 2005

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Classification of Lumbo-sacral Dysfunctions

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

MeKenzie

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Classification of 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

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Classification of 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

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Clinical Reasoning

Practice

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Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)

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

clinical practice Focus on remediation of functional

deficits How changes in impairments

related to these deficits

Rothstein, 2003

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Clinical Reasoning ProcessGenerate Patient Identified and

Non-identified Problem Lists (S/E)

Formulate Exam. Strategy

Conduct Examination and Analyze (O/E)

Generate Working Hypotheses

InterventionRe-assessment

Rothstein, 2003

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Subjective Complaint(generate the clinical hypothesis)

Examination, O/E (confirm the clinical hypothesis)

Intervention

(base on the O/E, findings)

Clinical Reasoning Process

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Case Illustration

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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

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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

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Facet Joint / Extension Syndrome

Common with increasing age Facet Joints block excessive

extension, 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

diagnostic injectionHarris-Hayes, et al, 2005

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

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

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Treatment Choice

(base on examination findings)

Case 1

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

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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)

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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 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

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Treatment Choice (base on examination findings)

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

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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

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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 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 confirmDonTigny, 1990 DeMann, 1997

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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

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Treatment Choice (base on examination findings)

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

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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

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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 Stability

Hides, 1994; Lee et Al, 2006

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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

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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

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Neurodynamic 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

complication 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

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Treatment Choice

(base on examination findings)

Case 5Treatment • hamstring stretching (cadual

/ cephelic direction)• slump

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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

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Spinal Claudication

Spinal: Symptoms aggravated by walking

and 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

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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

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Treatment Choice (base on examination findings)

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

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ReferenceButler 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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ReferenceHides 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.