9.50 - 10.35 Mark Laslett Patho-Anatomic Sources

Sources and Causes of Chronic Low Back and Referred Leg Pain

Mark LaslettMark LaslettPT, PhD, Dip.MT, Dip.MDTPT, PhD, Dip.MT, Dip.MDT

PhysioSouth, Christchurch, New ZealandPhysioSouth, Christchurch, New Zealand

2006 Congress Danish Physiotherapy Association2006 Congress Danish Physiotherapy AssociationOdense, Denmark. March 24Odense, Denmark. March 24--2525

© Mark Laslett 2006

Sources of Back & Leg PainSources of Back & Leg Painendplate

annularfailure

annularfissure

Z-jointcapsule

Intervertebral DiscIntervertebral DiscNerve Root / duraNerve Root / duraZZ--JointJointSacroiliac JointSacroiliac JointButtock & HipButtock & HipMusclesMuscles


Causes of Back and Leg PainCauses of Back and Leg Pain

InjuryInjurySustained loadingSustained loadingGradual tissue Gradual tissue degradationdegradationSpinal stenosisSpinal stenosisPeripheral artery diseasePeripheral artery diseaseNeoplasmsNeoplasmsInstabilityInstabilityRheumatic diseaseRheumatic disease


PrevalencePrevalence

10%

Nerve Root

15%Z-Joint

13%SIJ

2%Stenosis

21%

? & others

39%Disc

DiscNerve RootZ-JointSIJStenosis? & others


Discogenic painDiscogenic pain

Reacts to Reacts to preferentially to preferentially to specific loading specific loading (directional (directional preference)preference)

Reacts nonReacts non--preferentially to preferentially to loading

Mechanically mediatedMechanically mediated

Chemically mediatedChemically mediated

loading


Directional PreferenceDirectional Preference

Can be identified using:Can be identified using:repeated movementsrepeated movementssustained loadingsustained loadingMDT assessment (McKenzie)MDT assessment (McKenzie)

One direction progressively increases or One direction progressively increases or peripheralizes pain distributionperipheralizes pain distributionAnother direction progressively reduces or Another direction progressively reduces or centralizes pain distributioncentralizes pain distribution


Directional PreferenceDirectional Preference

Common Common (Donelson R et al 1991)(Donelson R et al 1991)

43% respond preferentially to extension43% respond preferentially to extension11% respond preferentially to flexion11% respond preferentially to flexion11% respond preferentially asymmetric extension or 11% respond preferentially asymmetric extension or lateral flexionlateral flexion

CentralizationCentralizationAt least 20% in chronic cases (single assessment)At least 20% in chronic cases (single assessment)Over 50% in general LBP (over 3Over 50% in general LBP (over 3--5 days)5 days)


MDT AssessmentMDT Assessment

Test movements / Test movements / positions are positions are standardizedstandardizedTherapist Therapist overpressure, overpressure, mobilization and mobilization and manipulation used as manipulation used as methods to increase methods to increase loading in a specified loading in a specified directiondirection


PeripheralizationPeripheralizationCentralizationCentralization


Validity of clinical findingsValidity of clinical findingsagainst provocation discographyagainst provocation discography

VariableVariable % Sensitivity% Sensitivity % Specificity% Specificity LR+LR+

CentralizationCentralization 4040 9494 6.96.9

Directional preferenceDirectional preference 4949 9191 5.75.7

Moderate or minor Moderate or minor extension lossextension loss

2727 8787 2.02.0

‘vulnerable in the neutral ‘vulnerable in the neutral zone’zone’

4141 8383 2.52.5

History of persistent pain History of persistent pain between episodesbetween episodes

3232 9292 4.14.1


Cecil MCecil MMale, age 39Male, age 39

9yrs pain worsening. Fell 2 9yrs pain worsening. Fell 2 metresmetres. .

Severely disabled. DRAM “distressed Severely disabled. DRAM “distressed somatic”somatic”

VAS: Now 99, best 4, worst 99VAS: Now 99, best 4, worst 99

Poor historian, speech impediment. Poor historian, speech impediment. Taking Taking VicodinVicodin


Cecil MCecil MLeft lateral shiftLeft lateral shift

Negative SIJ tests except sacral Negative SIJ tests except sacral thrust. Spring tests positive L5,4,3thrust. Spring tests positive L5,4,3

Neurological testing negative Neurological testing negative normal, Nerve tension tests negativenormal, Nerve tension tests negative

CentralisationCentralisation, DP to shift correction , DP to shift correction and extensionand extension


L5/S1 L4/5 L3/4


Beverly MBeverly MFemale, age 42Female, age 42

2yrs pain unchanging. Motor vehicle 2yrs pain unchanging. Motor vehicle accident restrained. accident restrained.

Moderately disabled. DRAM ‘at risk’. Moderately disabled. DRAM ‘at risk’.


PT (5/12) NE, epidural and SIJ PT (5/12) NE, epidural and SIJ injections no benefitinjections no benefit


Beverly MBeverly MPositive Extension / Rotation testsPositive Extension / Rotation tests

One positive SIJ test, Spring test One positive SIJ test, Spring test positive L5positive L5

Nerve tension tests essentially Nerve tension tests essentially normal. Absent left TA reflex. normal. Absent left TA reflex. Normal muscle testsNormal muscle tests

peripheralisationperipheralisation


Chemically Mediated Chemically Mediated Discogenic painDiscogenic pain

Trauma Trauma –– acute & subacute painacute & subacute pain? Infection / discitis? Infection / discitis? Auto? Auto--immune reactionimmune reaction


George LGeorge LMale, age 52Male, age 52

5yrs pain worsening. Lifting lawnmower. 5yrs pain worsening. Lifting lawnmower.

Moderately DisabledModerately Disabled

DRAM ‘at risk’. DRAM ‘at risk’.


PT (2/12) worse, epidural 2/7 relief, facet PT (2/12) worse, epidural 2/7 relief, facet injections/RF no benefitinjections/RF no benefit


George LGeorge LPositive Extension/Rotation testsPositive Extension/Rotation tests

Negative SIJ. Spring +Negative SIJ. Spring +veve L4 onlyL4 only

Neurologically normal, Nerve tension Neurologically normal, Nerve tension tests normaltests normal

No No centralisationcentralisation, peripheralisation, , peripheralisation, Directional PreferenceDirectional Preference


ZygapophysealZygapophyseal jointjoint

10%

Nerve Root

13%SIJ

2%Stenosis

21%

? & others

39%Disc

15%Z-Joint


Zygapophyseal joint painZygapophyseal joint pain

16% have Z16% have Z--joint pain (Jackson et joint pain (Jackson et al 1988)(Schwarzer et al 1994)al 1988)(Schwarzer et al 1994)40% of older patients have Z40% of older patients have Z--Joint Joint pain (pain (ManchikantiManchikanti L et al 1999)L et al 1999)True prevalence is probably between True prevalence is probably between 55--10%10%


Zygapophyseal joint painZygapophyseal joint pain

There is no clinical facet / ZJ There is no clinical facet / ZJ ‘syndrome’‘syndrome’

Can only be diagnosed by controlled Can only be diagnosed by controlled ZJ blocks under fluoroscopic ZJ blocks under fluoroscopic guidanceguidance


Prediction of 95% pain reduction after Z joint block Prediction of 95% pain reduction after Z joint block Laslett M et al Laslett M et al –– in press)in press)

VariableVariable % % SensSens % Spec% Spec +LR+LR

Age>49Age>49 6262 7777 2.62.6

Onset pain Onset pain paraspinalparaspinal

7575 7272 2.72.7

Best walkingBest walking 3131 9292 3.63.6

Best sittingBest sitting 3333 9090 3.23.2

Positive ER testPositive ER test 100100 2222 1.31.3

SomatizationSomatization 4646 7070 1.51.5

NonNon--centralisationcentralisation 100100 1414 1.11.1


Clinical Prediction Rules of screening ZJ blockClinical Prediction Rules of screening ZJ blockNote: pretest odds approx 0.11 (prevalence 11%)Note: pretest odds approx 0.11 (prevalence 11%)

Clinical Prediction RuleClinical Prediction Rule %%SensSens %Spec%Spec

2 of 6 (excluding use of 2 of 6 (excluding use of centralisation data)centralisation data)

100100 3636

4 of 74 of 7 100100 5050

91913 of 5 (excluding MSPQ 3 of 5 (excluding MSPQ questionnaire and CP data)questionnaire and CP data)

8585


If Rule satisfied:If Rule satisfied:11%11%-->55% chance>55% chance

If Rule not satisfied:If Rule not satisfied:11% 11% -->2% chance>2% chance

Five fold improvement in probability of Five fold improvement in probability of a 95% pain reduction or not using the a 95% pain reduction or not using the rule.rule.

Pretest probability

Posttest probabilityLikelihood ratio

Fagan’s Fagan’s NomogramNomogram for 3 of 5for 3 of 5


Billie RBillie RMale 72ysMale 72ys4 months since chair broke and landed on 4 months since chair broke and landed on buttocks. buttocks. Severely disabled. DRAM ‘distressed Severely disabled. DRAM ‘distressed depressed’depressed’VAS 80 (now) 48 (best) 95 (worst)VAS 80 (now) 48 (best) 95 (worst)RF right facets 4 weeks ago abolished RF right facets 4 weeks ago abolished right sided pain. (R) THR, some (L)OA hipright sided pain. (R) THR, some (L)OA hip


Billie RBillie R

Positive Extension / Rotation testsPositive Extension / Rotation testsSIJ tests negative. Spring tests L3,4,5 SIJ tests negative. Spring tests L3,4,5 positive. Capsular pattern left hippositive. Capsular pattern left hipNormal nerve tension tests, LBP with left. Normal nerve tension tests, LBP with left. Absent left TA reflex, weak left quads and Absent left TA reflex, weak left quads and EHL.EHL.Only partial MDT exam because of OA hip Only partial MDT exam because of OA hip and THRand THR


Billie RBillie R

initialinitialpain drawingpain drawing

(pre(pre--examination)examination)


Billie RBillie R

(post(post--examination)examination)


Billie RBillie R

left L3 superior left L3 superior articular process at articular process at its junction with the its junction with the transverse process. transverse process.

Aspiration recovered Aspiration recovered no blood. ¼ cc no blood. ¼ cc

IohexolIohexol was instilled. was instilled. The contrast spread The contrast spread

at the base of the at the base of the SAP at the target SAP at the target

location for left L2 location for left L2 medial branch.medial branch.


Billie RBillie R

Post MBB L2,3Post MBB L2,3


Sacroiliac jointSacroiliac joint

2%Stenosis

21%

? & others

39%Disc

15%Z-Joint

10%

Nerve Root

13%SIJ


Sacroiliac joint syndromeSacroiliac joint syndrome

13% have SIJ pain 13% have SIJ pain (Bogduk 1997)(Bogduk 1997)

22.5% have SIJ pain 22.5% have SIJ pain (Bernard et al 1991)(Bernard et al 1991)

30% have SIJ pain 30% have SIJ pain (Schwarzer et al 1995)(Schwarzer et al 1995)

7% have SIJ pain 7% have SIJ pain (Laslett 1997)(Laslett 1997)

probably much lower ? 5% in chronic LBPprobably much lower ? 5% in chronic LBP

depends on sample depends on sample

PGP in pregnant women 21% (Albert H et al 2002)PGP in pregnant women 21% (Albert H et al 2002)


Composite pain drawings Composite pain drawings DreyfussDreyfuss et al 1996et al 1996

Patients with negative Patients with negative Patients with positive Patients with positive arthrogramsarthrograms arthrogramsarthrograms


Reliability of SIJ testsReliability of SIJ tests

% agreement% agreement KappaKappa value (Landis et al)value (Landis et al)

DistractionDistraction 88.288.2 0.690.69 substantialsubstantialTorsion (R)Torsion (R) 88.288.2 0.750.75 substantialsubstantialTorsion (L)Torsion (L) 88.288.2 0.720.72 substantialsubstantialThigh thrustThigh thrust 94.194.1 0.880.88 almost perfectalmost perfectCompressionCompression 88.288.2 0.730.73 substantialsubstantialSacral thrustSacral thrust 78.078.0 0.520.52 moderatemoderateCranial glideCranial glide 84.384.3 0.610.61 substantialsubstantial

Laslett M, Williams M. Spine 1994Laslett M, Williams M. Spine 1994


SIJ SIJ -- validity of test clustersvalidity of test clusters

Statistic 1 or more

positive tests

2 or more

positive tests

3 or more positive

tests

4 or more

positive tests

5 or more

positive tests

Sensitivity 1.00 0.9 0.9 0.6 0.27

Specificity 0.4 0.7 0.8 0.81 0.88

+LR 1.8 2.7 4.3 3.2 2.1

Laslett, Young, Aprill & McDonald, Manual Therapy 2005

Van derWurff2006

0.85

0.79

4.02


SIJ. Validity of >2 positive tests in non SIJ. Validity of >2 positive tests in non centraliserscentralisers

StatisticEstimate

Low 95% CI

High 95% CI

Sensitivity 0.91 0.62 0.98

Specificity 0.87 0.68 0.96

Positive Likelihood Ratio

6.97 2.70 20.27

Negative Likelihood Ratio

0.11 0.02 0.44

Laslett, Young, Aprill & McDonald, AJP, June 2003


Kristi GKristi GFemale, age 37 Female, age 37

2.5yrs pain worsening. Slipped & fell 2.5yrs pain worsening. Slipped & fell onto right hiponto right hip

Severely disabled. DRAM ‘distressed Severely disabled. DRAM ‘distressed depressed’depressed’


PT/MT unchangedPT/MT unchanged


Kristi GKristi GPositive Extension / Rotation testsPositive Extension / Rotation tests

SIJ all strongly positive. Spring tests all SIJ all strongly positive. Spring tests all positivepositive

R SLR 80º R butt pain L SLR 85º no pain.. R SLR 80º R butt pain L SLR 85º no pain.. Neurologically normalNeurologically normal

Hip: full ROM but all movements painful. Hip: full ROM but all movements painful. FABER test +FABER test +veve..

no centralization, peripheralisation, no centralization, peripheralisation, Directional PreferenceDirectional Preference


Kristi GKristi G

Initial pain Initial pain drawingdrawing

(pre (pre examination)examination)


SIJ SIJ arthrogramarthrogram

Dorsal joint Dorsal joint capsulecapsule

Ventral joint Ventral joint capsulecapsule


Kristi GKristi G

pre &pre &post SIJpost SIJinjectioninjection

pain pain drawingdrawing


Kristi GKristi GRight SIJ fusion March 2002Right SIJ fusion March 2002

As of March 2003As of March 2003

good solid fusion CT demonstratedgood solid fusion CT demonstrated

usual pain abolishedusual pain abolished

functionally normalfunctionally normal

recurring R buttock ache (different) recurring R buttock ache (different) apparently coincident with menstrual apparently coincident with menstrual cyclecycle


Sacroiliac joint criteriaSacroiliac joint criteriano centralizationno centralization3 or more pain provocation tests provoke 3 or more pain provocation tests provoke familiar painfamiliar painLaslett & Williams 1994Laslett & Williams 1994Laslett, Young, Aprill, McDonald 2003Laslett, Young, Aprill, McDonald 2003Van Van derder WurffWurff P et al 2006P et al 2006


The sacroiliac joint testsThe sacroiliac joint tests

DistractionDistractionThigh thrustThigh thrustCompressionCompressionSacral thrustSacral thrustGaenslen’sGaenslen’s testtestPatrick’s FABER testPatrick’s FABER test


DistractionDistraction


CompressionCompression


Thigh ThrustThigh Thrust


Gaenslen’s Gaenslen’s testtest


Sacral thrustSacral thrust


Nerve Root (Radicular) PainNerve Root (Radicular) Pain

13%SIJ

2%Stenosis

21%

? & others

39%Disc

15%Z-Joint

10%

Nerve Root


Stacie LStacie LFemale, age 22Female, age 22

Dominant pain: right buttock. Onset: Dominant pain: right buttock. Onset: same areasame area

3 months pain unchanging. Struck 3 months pain unchanging. Struck by moped while walkingby moped while walking

Severely disabled. DRAM ‘at risk’Severely disabled. DRAM ‘at risk’


PT (4/52) worse. MRI. No surgeryPT (4/52) worse. MRI. No surgery


Stacie LStacie LPositive Extension / Rotation testsPositive Extension / Rotation tests

SIJ: Gaenslen’s positive all others negative. SIJ: Gaenslen’s positive all others negative. Spring tests positive at L5 & L4Spring tests positive at L5 & L4

R & L SLR +R & L SLR +veve 30º causing R leg pain, 30º causing R leg pain, absent R TA reflex. Normal muscle testsabsent R TA reflex. Normal muscle tests

Peripheralisation. Temporary & slight Peripheralisation. Temporary & slight centralisingcentralising effect. Not a effect. Not a centralisercentraliser..


Initial pain drawing

Pain VAS

Now: 72Best: 59Worst: 83


Disc extrusionL5 and S1 rootlets


Extruded material behindL5 vertebral body

Extruded material at the level of L4/5 disc


Lynn MLynn MFemale, age 59Female, age 59

8 months pain unchanging. Onset: NAR. 8 months pain unchanging. Onset: NAR. Midline LBP, but L groin pain doing Midline LBP, but L groin pain doing lunges. Dominant groin painlunges. Dominant groin pain

Severely disabled, Zung 14, MSPQ 1, Severely disabled, Zung 14, MSPQ 1, DRAM ‘normal’DRAM ‘normal’


4/52 PT unchanged. MRI lumbar spine4/52 PT unchanged. MRI lumbar spine


Lynn MLynn Mworst standing / walking, best sitting. worst standing / walking, best sitting.

Positive extension rotation tests. SIJ: all Positive extension rotation tests. SIJ: all negative. Spring all negativenegative. Spring all negative

Neurologically normalNeurologically normal

Hip: nonHip: non--capsular pattern. Flex & lat capsular pattern. Flex & lat rotation most painful & limitedrotation most painful & limited

Repeated movementsRepeated movementsDirectional preference to repeated extensionDirectional preference to repeated extension


Lynn MLynn M

Initial pain Initial pain drawingdrawing

(pre examination)(pre examination)


Left hip Left hip arthrogramarthrogram


Mary CMary C

pre &pre &post hippost hipinjectioninjection

pain pain drawingdrawing


SummarySummary

There is no clinical ‘facet’ joint syndromeThere is no clinical ‘facet’ joint syndromeClinical diagnosis is possible for:Clinical diagnosis is possible for:

About 50% of discogenic pain (mechanical)About 50% of discogenic pain (mechanical)SIJ painSIJ painNerve root (radicular) painNerve root (radicular) painSpinal stenosisSpinal stenosisPeripheral vascular diseasePeripheral vascular disease


SummarySummaryZZ--joint pain can only be diagnosed using joint pain can only be diagnosed using controlled blocks but:controlled blocks but:

There are clinical indicators for positive and negative There are clinical indicators for positive and negative responses responses –– useful for patient selection of invasive useful for patient selection of invasive testingtesting

SIJ diagnosis confirmed only with double blocksSIJ diagnosis confirmed only with double blocksDiscogenic pain best diagnosed by provocation Discogenic pain best diagnosed by provocation discography, but this controversialdiscography, but this controversialSpinal stenosis Spinal stenosis confirmedconfirmed only by CT or MRIonly by CT or MRIPeripheral vascular disease confirmed by Peripheral vascular disease confirmed by angiographyangiography


Agreement between clinical Agreement between clinical diagnoses and available reference diagnoses and available reference

standardsstandards

BMC J Musculoskeletal Disorders 6:28,2005BMC J Musculoskeletal Disorders 6:28,2005216 patients. Chronic, disabled and distressed216 patients. Chronic, disabled and distressedSingle Single pathopatho--anatomic diagnosis in 66% by anatomic diagnosis in 66% by available reference standardsavailable reference standards13% chance of physiotherapist guessing correct 13% chance of physiotherapist guessing correct diagnosisdiagnosisClinical agreement achieved in 57%Clinical agreement achieved in 57%


ConclusionConclusion

The clinical examination is The clinical examination is useful, important, validuseful, important, valid

9.50 - 10.35 Mark Laslett Patho-Anatomic Sources

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