2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...
Transcript of 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...
![Page 1: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/1.jpg)
Osteopathic Approach To
Low Back PainRobert Kim, DO
FM PGY-22019 FOMA Convention
![Page 2: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/2.jpg)
LBP Epidemiology
- Affects 5.6% of US adults daily- 18% of US adults report having LBP in the past month- Lifetime prevalence 60-70%- 25% of patients w/ LBP seek medical attention- 1 of 3 top 3 reasons for FM physicians - FM physicians see more LBP than any other specialist
![Page 3: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/3.jpg)
Differential Diagnosis (DDx) Mechanical
- Lumbar spondylosis- Disk herniation- Spondylolisthesis- Spinal stenosis- Fractures (osteoporotic)- Nonspecific (idiopathic)Neoplastic
- Primary- Metastatic
Inflammatory- Spondyloarthropathies
Infectious- Vertebral osteomyelitis- Epidural abscess- Septic diskitis- Herpes Zoster
Metabolic- Osteoporotic compression fracture- Paget’s disease
Referred Pain to Spine- Viscera, retroperitoneal structures, urogenital
system, aorta, or hip
![Page 4: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/4.jpg)
DDx - Lower Back Pain Mechanical 97%- Degenerative Joint Disease (DJD)- Disk Herniation- Osteoporotic Compression Fracture- Spinal Stenosis 3%- Spondylolisthesis 2%- Remaining majority %? no medical cause
- Nonspecific LBP… lumbar sprain/strain, somatic dysfunction
![Page 5: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/5.jpg)
DDx - Red FlagsFracture of the Spine
- Significant trauma- Prolonged glucocorticoid use- Age > 50 yrs
Infection or Cancer- Hx of cancer- Unexplained/unintentional weight loss- Immunosuppression- IVDU- Nocturnal Sx or pain- Age > 50 yrs
Cauda Equina Syndrome- Urinary retention- Overflow incontinence- Fecal incontinence- b/l or progressive motor deficit- Saddle anesthesia
Spondyloarthropathies- Morning stiffness- Pain improvement w/ exercise- Pain during second half of night- Alternating buttock pain- Age < 40 yrs
< 5 % of LBP
![Page 6: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/6.jpg)
Physical Exam (PE)Visual Inspection
- Posture from behind & from the side of the pt
Active & Passive ROM- Flexion Extension- Sidebending- Single-leg extension
Palpation: spine & paraspinal muscles- Spinous & transverse processes- Apophyseal joints - Sacroiliac (SI) joints- Iliolumbar ligament- Paraspinal muscles- Quadratus lumborum (QL)- Gluteal muscles
Neurologic assessment of nerve roots - L4, L5, S1 nerve roots
Special Tests - Unilateral straight leg raise test (Lasegue)- Crossed straight leg raise test (Well straight leg raise)- Femoral nerve stretch test- FABER/Patrick test- SI joint tests: distraction, shear, compression- Gaenslen’s test- Single leg extension- Centralization test
Osteopathic Exam
![Page 7: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/7.jpg)
PE - Neurological AssessmentHip Flexion (Iliopsoas) - L1 - L2, 3, 4 (Femoral N)
Knee Extension (Quadriceps)- L2, 3, 4 (Femoral N) - DTR… L4
Knee Flexion (Hamstrings)- (L4), 5, S1, 2, (3) (Sciatic N; Tibial N)
Ankle Dorsiflexion (Tibialis Anterior)- L4, 5 (Deep Fibular/Peroneal N)
Great Toe Extension (Extensor Hallucis Longus)- L5, S1 (Deep Fibular/Peroneal N)
Ankle Plantar Flexion (Gastrocnemius)- S1, S2 (Tibial N) - DTR… S1
![Page 8: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/8.jpg)
PE - Special Tests Straight Leg Raise (Lasegue) Test- Sciatic Nerve Compression ~80% sensitivity
- Patient supine, lift leg while maintaining knee extension- Lower raised leg when pt experiences pain/tightness until pain resolution- dorsiflex ankle & instruct the pt to flex neck
Positive- Pain at 30-60°, radiating down raised leg- indicates sciatic n root irritation- Pain at > 70°… muscle stretching, SI or lumbar facet joint pain
Crossed Straight Leg Raise Test
Positive- pain radiation down side of contralateral raised leg- indicates n root irritation 2/2 herniated intervertebral disc
![Page 9: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/9.jpg)
PE - Special Tests Femoral Nerve Stretch Test- N root impinge of L2, 3, 4 (Femoral N)
- Pt prone w/ pillow placed under abdomen- Examiner stabilizes pt’s hand over PSIS of pt’s far hip- Extend far hip while maintaining knee flexion at 90
Positive- pain in anterior & lateral thigh
![Page 10: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/10.jpg)
PE - Special Tests FABER/Patrick Test- Assess pathology of hip joint, iliopsoas spasm, or SI joint dysfunction
- Pt supine, examiner passively flexes, ABducts, & externally rotates leg while stabilizing contralateral ASIS- Rest pt’s foot on top of contralateral knee- Examiner slowly brings tested leg knee toward table
Positive- pain w/ tested &/or tested leg is unable to be ABducted below lvl of contralateral leg - Limited ROM, groin or side hip pain?
- Hip arthritis, femoroacetabular impingement, or other hip pathology- Iliopsoas strain or bursitis
- Posterior pain in back?- SI joint dysfunction or sacroiliitis
![Page 11: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/11.jpg)
PE - Special Tests Sacroiliac Distraction Test- anterior SI ligament dysfunction
- Pt supine w/ forearms under lower back & pillow under knees- Examiner crosses arms w/ elbows straight & places heels of hands on pt’s ASIS- apply slow steady posterior force on pt
Positive- Unilateral pain at SI joint or gluteal/leg region
Sacroiliac Shear Test- sacrospinous ligament dysfunction
- Pt supine w/ tested hip flexed to 90° & knee fully flexed- Examiner stabilizes OPP ASIS & applies pressure through axis of femur
Positive- pain in the posterior buttock
![Page 12: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/12.jpg)
PE - Special Tests Sacroiliac Compression Test - SI joint pathology, w/ possible posterior SI ligament dysfunction
- Pt in lateral recumbent position w/ pillow b/t knees- Examiner stands behind pt & places hands on top of pt’s iliac crest then exerts downward pressure
Positive- Reproduction of pain
Gaenslen’s Test- differentiate b/t lumbar spine & SI joint dysfunction
- Pt supine w/ tested leg off table. Pt actively flexes OPP hip & knee. - Examiner assists pt w/ stabilizing flexed leg & applies pressure to tested leg inducing further extension & ADduction- * begin w/ unaffected side first
Positive - SI joint problem, pubic symphysis instability &/or L4 n root
![Page 13: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/13.jpg)
PE - Special Tests Centralization Test- Determine whether flexion or extension increases or decreases Sx & if centralization is occurring
- Identify pt’s baseline Sx locations in standing position; emphasis on most distal Sx - Instruct pt to bend forward as far as possible w/ a return to starting position. Note any effect of movement on Sx- Repeat 10-12x, ask pt to report any lasting changes in location or change in intensity of Sx- Repeat assessment w/ standing extension, recumbent flexion, & prone extension
Positive- pain Sx moves from distal to proximal (centralization)- indicates Sx 2/2 internal disk disruption- centralization is commonly related to single direction of movement; Sx likely to improve w/ flexion or extension based exercises
![Page 14: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/14.jpg)
PE - Osteopathic Exam Sacroiliac DiagnosisSeated Flexion Test +
![Page 15: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/15.jpg)
PE - Osteopathic Exam Sacroiliac Diagnosis
Negative seated flexion test- no sacroiliac dysfunction- Bilateral flexion or extension- False negative 2/2 iliosacral decompression
Negative seated flexion & ILAs equal
Sulci deepNegative spring test- B/l sacral flexion
Sulci shallowPositive spring test- B/l sacral flexion
![Page 16: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/16.jpg)
OMT - Sacral Torsion
![Page 17: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/17.jpg)
OMT - Sacral Shear
![Page 18: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/18.jpg)
OMT - Sacral Shear
![Page 19: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/19.jpg)
PE - Osteopathic Exam Seated Flexion Test
OrAP Compression Test
Left or RLeft or Right
Superior ASIS Inferior ASIS Medial ASIS Lateral ASIS
Superior PSIS
Superior Innominate
Shear
Inferior PSIS
Anterior Innominate
Rotation
Lateral PSIS
Innominate Inflare
Medial PSISInnominate
Outflare
Inferior PSISInferior
Innominate Shear
Superior PSIS
Posterior Innominate
Rotation
Iliosacral Diagnosis
![Page 20: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/20.jpg)
OMT - Innominate Shear
![Page 21: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/21.jpg)
OMT - Innominate Rotation
![Page 22: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/22.jpg)
OMT - Innominate Flare
![Page 23: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/23.jpg)
PE - Osteopathic Exam Iliosacral Dysfunction
Pubic Rami
Inferior RamusSuperior ramus
Superior pubic shear Inferior pubic shear
Equal Rami
Compressed pubic symphisis
![Page 24: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/24.jpg)
OMT - Pubic Shear
![Page 25: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/25.jpg)
Osteopathic Manipulative Treatment- Myofascial release & soft
tissue technique- Counterstrain- Muscle Energy- BLT- HVLA- Still Technique
![Page 26: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/26.jpg)
OMT - Counterstrain
![Page 27: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/27.jpg)
OMT - Muscle Energy
![Page 28: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/28.jpg)
OMT - Balanced Ligamentous Tension
![Page 29: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/29.jpg)
OMT - HVLA
![Page 30: 2019 FOMA Convention FM PGY-2 Osteopathic Approach To Low ...](https://reader033.fdocuments.in/reader033/viewer/2022042519/6261e4d5b495ae6227288ef0/html5/thumbnails/30.jpg)