Applying Clinical Reasoning in Spine Pain...Shah JP, Gilliams EA. Uncovering the biochemical milieu...

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Applying Clinical Reasoning in Spine Pain

In a Busy Clinical Environment

Donald R. Murphy, DC, FRCC

[email protected]

Clinical Assistant Professor, Dept of Family MedicineAlpert Medical School of Brown University

Adjunct Assistant Professor, Department of Physical TherapyUniversity of Pittsburgh

Certified Primary Spine Practitioner

Spine-Related Disorders

• Low back pain

• Thoracic pain

• Neck pain

• Radiculopathy

• Disc herniation

• Spinal stenosis

• Whiplash Associated Disorders

• Some types of headache

Virtually 100% of the population

Understanding Spine-Related Disorders

The Biopsychosocial Model

Not just a fancy word

Somatic factors(bio)

Pain/ Disability/Suffering

Experience

Psych factors

Neurophys factors(bio)

Social Context

The “Bio” -Somatic Factors

Adams M, Bogduk N, Burton K, Dolan P. The Biomechanics of Back Pain. Edinburgh: Churchill Livingstone, 2002

Bogduk N. Degenerative joint disease of the spine. Radiol Clin N Am 2012; 50:613-628.

Disc Derangement (Internal Disc Disruption)

mailto:[email protected]

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Joint dysfunction

Seaman DR, Winterstein JF. Dysafferentation a novel term to describe the neuropathophysiological effects of joint complex dysfunction a look at likely mechanisms of symptom generation. Journal of manipulative and physiological therapeutics. 1998;21(4):267-80.

Bakkum BW, et al. Preliminary morphological evidence that vertebral hypomobility induces synaptic plasticity in the spinal cord. J Manipulative Physiol Ther2007;30(5):336-42.

Quinn KP, et al. Neuronal hyperexcitability in the dorsal horn after painful facet joint injury. Pain. 2010 Nov;151(2):414-21.

Radiculopathy

Spinal Stenosis Disc Herniation

Myofascial Pain - Trigger Points

Simons DG, Travell JG, Simons LS. Myofascial Pain

and Dysfunction: The Trigger Point Manual. Volume 1. Baltimore: Williams and Wilkens; 1999

Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo

microdialysis: an application of muscle pain concepts to myofascial pain syndrome. J Bodyw Mov Ther.

2008;12(4):371-84.

The “Bio” –Neurophysiologic Factors

Impaired Motor Control / Instability

Impaired motor control: neuromuscular

Instability: ligamentous, etc

van Dieen JH, et al. Motor Control Changes in Low Back Pain: Divergence in

Presentations and Mechanisms. The Journal of orthopaedic and sports

physical therapy. 2019 Jun;49(6):370-9.

Spina N, et al. Defining Instability in Degenerative Spondylolisthesis: Surgeon View s. Clinical spine surgery. 2019 Dec;32(10):E434-E9.

Oculomotor Dysfunction(Cervical Patients)

Treleaven J. Sensorimotor disturbances in

neck disorders affecting postural stability,

head and eye movement control. Manual therapy. 2008 Feb;13(1):2-11.

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Nociplasticity(Nociceptive System Sensitization)

Hodges PW, Barbe MF, Loggia ML, Nijs J,

Stone LS. Diverse Role of Biological Plasticity in

Low Back Pain and Its Impact on Sensorimotor Control of the Spine. The Journal of orthopaedic

and sports physical therapy. 2019 Jun;49(6):389-401.

Kosek E, Cohen M, Baron R, Gebhart GF, MicoJA, Rice AS, et al. Do w e need a third

mechanistic descriptor for chronic pain states?

Pain. 2016 Jul;157(7):1382-6.

Psych Factors

• Fear

• Catastrophizing

• Passive coping

• Low self-efficacy

• Depressive sx’s

• Perceived Injustice

• Cognitive fusion

• Hypervigilance

• Anxiety

The “Big 5”

The “Social”

• Job satisfaction

• Work Disability

• Home life

• Social isolation

• Social disadvantage

• Relationships

Shaw WS, et al. Effects of workplace, family and cultural influences on low back pain: what opportunities exist to address social factors in general consultations? Best practice & research Clinical rheumatology. 2013 Oct;27(5):637-48

So What’s the Doc to Do?

Somatic Neurophysiological

Psychological Social

Clinical Reasoning in Spine Pain®

The CRISP® Protocols

Clinical Reasoning in Spine Pain® (CRISP®):

Applying the BPS Model to the Dx and Rx of SRDs

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CRISP® The Three Questions of Diagnosis

1. Do the presenting symptoms reflect a visceral disorder, or a serious or potentially life-threatening illness?

2. Where is the pain coming from?

3. What is happening with this person as a whole that would cause the pain experience to develop and persist?

CRISP®The Three Questions of Diagnosis

IOW:

1. Is the patient sick? Is additional investigation necessary?

2. Where is the pain coming from?

3. What are the perpetuating factors?

Question #1:Is the patient sick? Is additional investigation

necessary?

Disorder Detected by

Cancer Hx CA, no pos relief, fever, constit sx, wt loss, blood in stool

Benign tumor Local severe pain, no pos relief, relief w/ NSAID, px percussion

Infection Hx fever, chills, febrile, pt tender, red, heat

Fracture Hx trauma, hxosteoporosis, pxpercussion

Disorder Detected by

GI disease GI complaints, pain w/ food, abd exam

GU Disease GU complaints, bleed, spot,

discharge, GU exam

Myelopathy Gait, bowel/ blad, UMN, spast, sens

level

Cauda Equina Snd Bowel/ blad, saddle anesth, anal

sphincter tone

Seeking Answer to Dx Ques #1

• History

• Physical exam (esp neuro)

• Special tests or specialist consults

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Diagnostic Question #2:Where is the pain coming from?


With permission. Murphy DR. Conservative Management of Cervical Spine Syndromes. 2000 ©Donald R. Murphy

Dx Ques #2: Identify the Primary Pain Generator(s)

•Disc derangement

•Joint dysfunction

•Radiculopathy

•Myofascial trigger points


• Evidence-based history

• Evidence-based exam (pain provocation maneuvers)

With permission Murphy DR. Clinical Reasoning in Spine Pain Vol I. CRISP Education and Research, LLC ©2013

Question #3:What are the perpetuating factors?


Perpetuating Factors Believed to Be Important in Spine Related Disorders

• Impaired motor control

• Instability• Oculomotor

dysfunction• Nociplasticity

• Fear• Catastrophizing• Passive coping• Low self-

efficacy• Depressive

symptoms• etc


• Evidence-based history

• Evidence-based exam

• Relationship-centered care

• Data

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Management The management strategy is based on the Dx

Three Components

• In response to ques. #1: Further investigation

• In response to ques #2: Addressing pain generators

• In response to question #3: Addressing perpetuating factors

Diagnostic Question #1:Is the patient sick? Is additional

investigation necessary?

Referral Choices• Depend on:

• Pathology suspected• Comfort level of DC• Legal rights of DC (for now) Diagnostic Question #2:

Where is the pain coming from?


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Historical Factors Suggestive of Disc Pain -Lumbar

• Acute episode(s)

• Antalgia

• Pain with sitting

• Pain with sit-to-stand

• Pain with flexion

• Worse in AM

Young S, April l C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J 2003;3(6):460-5.

End Range Loading Exam (Directional Preference)

“Direction of Benefit”

With permission: Murphy DR. Clinical Reasoning in Spine Pain Volume I: Primary Management of Low Back Disorders. Pawtucket, RI: CRISP Education and Research; 2013.

Key: Painful obstruction!With permission: Murphy DR. Clinical Reasoning in Spine Pain Volume II: Primary Management of Cervical Disorders and Case Studies in Primary Spine Care. Pawtucket, RI: CRISP Education and Research 2016


• Moving spine in various directions• Extension

• Side Gliding

• Flexion

• Rotation

• Looking for painful obstruction that reproduces their pain

Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J. 2003;3(6):460-5.

Laslett M, et al. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine J. 2005;5(4):370-80.


• Repetitive movements in that direction

• Looking for reduction or centralization

• Sometimes overpressure or sustained loading is used

Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J. 2003;3(6):460-5.

Laslett M, et al. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine J. 2005;5(4):370-80.


End Range Loading Exam - Lumbar

ExtensionWith permission: Murphy DR. Clinical Reasoning in Spine Pain Volume I: Primary Management of Low Back Disorders. Pawtucket, RI: CRISP Education and Research; 2013.


Side gliding


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Flexion


Joint Dysfunction

Identifying Lumbar Facet Pain (Laslett criteria)History and exam

• Age≥50

• Best when walking

• Best when sitting

• Paraspinal location

• No pain on sit-to-stand

• Positive extension/rotation test

• Negative end range loading

Laslett M, et al. Clinical predictors of screening lumbar zygopophyseal joint blocks: development of clinical prediction rules. Spine J. 2006;6(4):370-9.

Extension-Rotation Test

• Age≥50

• Best when walking

• Best when sitting

• Paraspinal location

• No pain on sit-to-stand

• Positive ext/rot test

• Negative end range loadingLaslett M, et al. Clinical predictors of screening lumbar zygopophyseal joint blocks: development of clinical prediction rules. Spine J. 2006;6(4):370-9.

Historical Factors Suggestive of SI Pain

• Unilateral pain over SI/ butt

• Below L5

• No lumbar pain

• Pain on sit-to-stand

• Half have posterior thigh pain

• 1/3 lat hip/ thigh

• 10-15% groin pain

Young S, et al. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J 2003; 3: 460– 5.

Kennedy DJ, et al. Fluoroscopically Guided Diagnostic and Therapeutic Intra-Articular Sacroiliac Joint Injections: A Systematic Review. Pain medicine. 2015 Aug;16(8):1500-18.

Identifying SI Joint Pain (Laslett criteria)

Three or more of the following positive:

• Distraction

• Thigh thrust

• Gaenslen's test

• Compression

• Sacral thrust

• (FABER Test) Laslett M, et al. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther 2005;10:207-18.Telli H, et al. The Validity and Reliability of Provocation Tests in the Diagnosis of Sacroiliac Joint Dysfunction. Pain physician. 2018 Jul;21(4):E367-E76.

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However…

Rule Out Disc

Diagnostic yield of SI provocation tests greatly enhanced by doing ERL exam first

Laslett M, et al. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Aus J Physiother. 2003;49:89-97.

Radiculopathy

Disc herniationSpinal stenosis

Lumbar Radiculopathy - History

• Severe LE pain• Pain below knee• Claudication (stenosis)• Neuro symptoms• Severe LBP (herniation)• Worse with extension (stenosis)• Worse with flexion (herniation)• Worse with cough, sneeze, strain Verwoerd AJ, et al. Diagnostic accuracy of history taking to assess

lumbosacral nerve root compression. Spine J. 2014 Sep 1;14(9):2028-37.

Lumbar Neurodynamic Exam

van der Windt DA, Simons E, Riphagen, II, Ammendolia C, Verhagen AP, Laslett M, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. The Cochrane database of systematic reviews. 2010 Feb 17(2):CD007431.

Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: part 2 of 3: symptoms and signs of peripheral neuropathic pain in

patients with low back (+/- leg) pain. Man Ther 2012;17(4):345-51.

1.“Nerve root tension signs”

2.Structural differentiation

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• Watch for progressive motor loss

• Key: 3/5 rule

Neurologic Deficit• Dx Ques #1 suggests serious pathology

• Hx and exam do not clearly demonstrate the Dx

• Profound or progressive motor loss (3/5 rule)

• Considering ESI or surgery

• Unrelenting nerve root pain

When do we order an MRI?

Myofascial Trigger Points

Best to use "tender point in a taut band" and "predicted or recognized pain referral"

Tough EA, et al. Variability of criteria used to diagnose myofascial trigger point pain syndrome - evidence from a review of the literature. Clin J Pain 2007;23(3):278-86.

TrPs are often (Usually? Almost always?) secondary to other pain sources

Myofascial Trigger PointsRemember!

Adelmanesh F, et al. Is There an Association Between Lumbosacral Radiculopathy and Painful Gluteal Trigger Points?: A Cross-sectional Study. Am J Phys Med Rehabil. 2015 Oct;94(10):784-91.

Jarrell J. Endometriosis and abdominal myofascial pain in adults and adolescents. Current pain and headache reports. 2011 Oct;15(5):368-76.

Question #3:Diagnostic Ques #3:

What are the perpetuating factors?

Perpetuating Factors Believed to Be Important in Spine Related Disorders

• Impaired motor control

• Instability

• Oculomotor dysfunction (cervical)

• Nociplasticity (“NSS”, “Central sensitization”)

• Fear• Catastrophizing• Passive coping• Low self-efficacy• Depressive sx’s• etc

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Impaired Motor Control• Recurrent episodes of pain

• Pain aggravated by quick movements

• Feeling of “giving way” in the back

• Frequent self-manipulation for relief*

• Frequent painful “catching” during movements

• Pain when turning in bed

Lumbar Impaired Motor Control - History

Cook C, Brismee JM, Sizer PS. Subjective and objective descriptors of clinical lumbar spine instability: A Delphi study. Man Ther 2006;11:11-21

*Common innociplasticity

Lumbar Impaired Motor Control – Exam

Murphy D, et al. Interexaminer reliabil ity of the hip extension test for suspected impaired

motor control of the lumbar spine. JMPT 2006;29(5):374-7.

Arab AM, et al. Lumbar lordosis in prone position and prone hip extension test: comparison between subjects with and without low back pain.

Chiropractic & manual therapies. 2017;25:8.

Tateuchi H, et al. Balance of hip and trunk muscle activity is associated with increased anterior pelvic ti lt during prone hip extension. J Electromyogr Kinesiol. 2012 Jun;22(3):391-

7.

Carlsson H, Rasmussen-Barr E. Clinical screening tests for assessing movement control in non-specific low-back pain. A systematic review of intra- and inter-observer reliability

studies. Man Ther. 2013 Apr;18(2):103-10.

Bruno PA, et al. Patient-reported perception of difficulty as a clinical indicator of dysfunctional neuromuscular control during the prone hip extension test and active straight

leg raise test. Man Ther. 2014 Dec;19(6):602-7.

Hip Extension Test

Lumbar Impaired Motor Control – Exam

Hicks GE, et al. Interrater reliability of clinical examination measures for identification of lumbar segmental instability. Archives of physical medicine and

rehabilitation. 2003;84:1858-64

Hicks GE, et al. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med and Rehab. 2005;86:1753-62.

Denteneer L, et al. Inter- and Intrarater Reliability of Clinical Tests Associated With Functional Lumbar Segmental Instability and Impaired Motor Control in

Patients With Low Back Pain: A Systematic Review. Archives of physical medicine and rehabilitation. 2017 Jan;98(1):151-64 e6.

Vanti C, et al. The Relationship Between Clinical Instability and Endurance Tests, Pain, and Disability in Nonspecific Low Back Pain. JMPT 2016 Jun;39(5):359-68.

Ferrari S, et al. A literature review of clinical tests for lumbar instability in low back pain: validity and applicability i n clinical practice. Chiropr Man Therap.

2015;23:14.

Prone Instability Test

Impaired Motor Control – Exam

MensJM, et al. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine. 2001;26(10):1167-71.

MensJM, et al. Validity of the active straight leg raise test for measuring disease severity in patients with posterior pelvic pain after pregnancy. Spine.

2002;27(2):196-200.

MensJM, et al. The Active Straight Leg Raise test in lumbopelvic pain during pregnancy. Manual therapy. 2012 Aug;17(4):364-8.

O’Sullivan PB, et al. Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine. 2002;27(1):E1-E8.

Active Straight Leg Raise Test

Lumbar Instability

Ligament injury Degenerative Spondy

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Lumbar Instability

• History of severe trauma and/or;

• Older age

• Recurrent episodes of pain

• Pain aggravated by quick movements

• Feeling of “giving way” in the back

• Frequent painful “catching” during movements

• Pain when turning in bed

Clinical Tests for Lumbar Instability

• Passive Lumbar Extension Test1

• Low midline sill sign2

• Interspinous gap change2

1. Kasai Y, et al. A new evaluation method for lumbar spinal instability: passive lumbar extension test. Phys Ther. 2006 Dec;86(12):1661-7.

2. Ahn K, et al. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion-extension motion. BMC Musculoskelet Disord. 2015;16:97.

Flexion-extension radiographs

•Translation 3.0 to 4.5 mm or >15% of the vertebral body width

•Flex or ext > than 15% at L1-2, L2-3 or L3-4, > 20 degrees at L4-5 or > 25 degrees at L5-S1

White AA, Panjabi MM. Clinical Biomechanics of the Spine. 2nd ed. Philadelphia: Lippincott, 1990.

Even JL, et al. Imaging characteristics of "dynamic" versus "static" spondylolisthesis: analysis using magnetic resonance imaging and flexion/extension films. Spine J. 2014; 14(9):1965-9.

“Gold Standard” for instabilityNociplasticity

Nociplasticity – Smart Criteria

• Pain intensity and behavior disproportionate to injury or pathology

• Strong association with psych factors

• Atypical incr/ decr factors on Hx; “everything hurts”

• Pain on palpation virtually everywhere

Smart KM, et al. The Discriminative Validity of "Nociceptive," "Peripheral Neuropathic," and "Central Sensitization" as Mechanisms-based Classifications of Musculoskeletal Pain. Clin J Pain 2011, 27(8):655-663

Smart KM, et al. Mechanisms-based classifications of musculoskeletal pain: Part 1 of 3: Symptoms and signs of central sensitization in patients with low back (+ leg) pain. Man Ther 2012 17:336-344.

Frequent self-manipulation for relief

Nociplasticity – Waddell’s Nonorganic Signs

1. Tenderness

2. Simulation

3. Distraction

4. Regional Disturbances

5. Overreaction

Waddell G. Nonorganic signs. Spine. 2004;29(13):1393.

Apeldoorn AT, et al. The reliability of nonorganic sign-testing and the Waddell score in patients with chronic low back pain. Spine. 2008 Apr 1;33(7):821-6.

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Psychological Factors – the Big 5

• Fear

• Catastrophizing


• Passive Coping

• Depressive sx’s

Psychological Factors – and the rest

• Fear

• Catastrophizing

• Passive Coping


• Depressive symptoms

• Perceived injustice

• Cognitive fusion

• Hypervigilance

• Anxiety

Identifying Psych Factors

• It’s mostly in the relationship

• Relationship-Centered Care

STarT Back Screening Questionnaire

Items 5-9: Psych subscale

STarT Back Clinical Questionnaire

Items 5-9: Psych subscale

Self-Efficacy and Coping

Self-efficacy

Coping

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Management The management strategy is based on the Dx

Three Components• In response to ques. #1: Further investigation

• In response to ques #2: Addressing pain generators• Disc derangement• Joint dysfunction• Radiculopathy• Myofascial

• In response to question #3: Addressing perpetuating factors• Impaired motor control• Instability• Oculomotor dysfunction• Nociplasticity• Psych factors

But remember…

• Consider the whole clinical picture – incl factors related to Dxques #2 and #3

• How you communicate

• Result attribution

Context is everything!

Stilwell P, Harman K. Contemporary biopsychosocial exercise prescription for chronic low back pain: questioning core

stability programs and considering context. J Canad Chiropr Assoc 2017 Mar;61(1):6-17.







PSPN Toolbox

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• Self-efficacy

• Compliance

• Validate!




PSPN Toolbox

Impaired Motor Control, Nociplasticity and (possibly) Oculomotor are:

• Induced by acute nociception

• Perpetuated by:

• Chronic nociception• Distress• Low self-efficacy• Intramuscular changes?

Nijs J, et al. Nociception affects motor output: a review on sensory-motor interaction with focus on clinical implications. ClinJ Pain. 2012;28(2):175-81.

Hodges PW, et al. Diverse Role of Biological Plasticity in Low Back Pain and Its Impact on Sensorimotor Control of the Spine. JOSPT 2019

Jun;49(6):389-401.

With permission: ©Murphy DR. Clinical Reasoning in Spine Pain Volume I: Primary Management of Low Back Disorders. Pawtucket, RI:

CRISP Education and Research; 2013.

Question #1:Is the patient sick? Is additional

investigation necessary?

Referral Choices• Depends on:

• Pathology suspected• Comfort level of PSP• Legal rights of PSP (for now)

General Approaches

1. Patient ed2. Sort out sleep3. Respond to questions

a. Do I need injections?b. Do I need an MRIc. Do I need an opioid?d. Do I need to see a surgeon?

4. Plus…

Posture and Lifting

The secret for lumbar??

It’s all about lordosis!!

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The “Good Morning” Exercise Lifting while maintaining lordosis

Anti-inflammatory Diet(www.deflame.com)

• Eliminate ALL grains (OK, almost all), esp those with gluten (wheat, rye, couscous spelt, barley oats)

• Eliminate refined sugar

• Eliminate hydrog oils

• Limit soy and dairy (except cream)

• Don’t smoke (duhhh!)

Anti-Inflammatory Diet (cont)(www.deflame.com)

• Fruits and vegetables

• Nuts and certain seeds

• Dark Chocolate (75% or more cocoa)

• Cold water fish (salmon, mackerel, sardines)

• Meat, chicken – preferably grass fed and free range

• Spices

• Red wine and stout (assuming no HA trigger or alcoholism)

• Omega-3 eggs

• Olive oil, coconut oil, butter

Specific Management Decisions

Dx question 2• Disc derangement – end range loading, distraction

manipulation (lumbar)

• Joint dysfunction – self-mobilization, manipulation

• Radiculopathy –• Acute: watchful waiting, NSAID, oral steroid, ESI• Chronic: neurodynamics

• Trigger points – myofascial treatments

Lumbar Disc Derangement

• ER loading in direction that reduced/ centralized symptoms1 (“directional preference”)

• Distraction manip (Cox)2

1. Long A, et al. "Does it matter which exercise? A randomized controlled trial of exercise for low back pain." Spine 2004; 29(23): 2593-2602.

2. GudavalliM, et al. A randomized clinical trail and subgroup analysis to compare flexion-distraction with active exercise for chronic low back pain. Eur Spine 2005;15(7):1070-1082.


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Problematic because:

• Most expensive type of surgery in all of medicine: $40 billion per year, yet:

• Success rate 50-50 over short term

• Long term outcome no better than conservative management

• Indication often based on discogram which can cause worse problems – so can the surgery

Surgery - Fusion

Deyo RA. Fusion surgery for lumbar degenerative disc disease: still more questions than answers. Spine J. 2015 Feb 1;15(2):272-4.

Bhalla A, et al. The influence of subgroup diagnosis on radiographic and clinical outcomes after lumbar fusion for degenerative disc disorders revisited: a systematic review of the literature. Spine J. 2017 Jan;17(1):143-9.

Hedlund R, et al: The long-term outcome of lumbar fusion in the Swedish lumbar spine study. Spine J 2016, 16:579-587.

Mannion AF, et al: Consensus at last! Long-term results of all randomized controlled trials show that fusion is no better than non-operative care in improving pain and disability in chronic low back pain. Spine J 2016, 16:588-590.

Cuellar JM, et al. Does provocative discography cause clinically important injury to the lumbar intervertebral disc? A 10-year matched cohort study. Spine J. 2016 Mar;16(3):273-80.

• Self-mobilization

• Adjustment/ Manipulation

• No studies specifically on facet pain but manip shown to have mechanical and neurological effects on facet joints

Lumbar Facet Pain

Cramer GD, et al. Evaluating the relationship among cavitation, zygapophyseal joint gapping, and spinal manipulation: an exploratory case series. J Manipulative Physiol Ther 2011 Jan;34(1):2-14.

Pickar JG. Neurophysiological effects of spinal manipulation. Spine J. 2002;2(5):357-71.

Dagenais S, et al. NASS Contemporary Concepts in Spine Care: spinal manipulation therapy for acute low back pain. Spine J 2010;10(10):918-40.

Rubinstein SM, et al. Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine (Phila Pa 1976) 2011;36(13):E825-46.


• Self-mobilization

• Adjustment/ Manipulation

SI Joint Pain

Visser LH, et al. Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial. Eur Spine J.

2013 Oct;22(10):2310-7.

Stuge B, et al. The efficacy of a treatment program focusing on specific exercises for pelvic girdle pain after

pregnancy a randomized controlled trial. Spine. 2004;29(4):351-9.

Lumbar and Cervical Injections, RF neurotomy

• Very few pts need

• Some individuals seem to benefit so case by case basis

• Facet – MBB and decide about RF ablationJuch JNS, Maas ET, Ostelo R, Groeneweg JG, Kallewaard JW, Koes BW, et al. Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain: The Mint Randomized Clinical Trials. Jama. 2017 Jul 04;318(1):68-81.

Maas ET, Ostelo RW, Niemisto L, JousimaaJ, Hurri H, Malmivaara A, et al. Radiofrequency denervation for chronic low back pain. The Cochrane database of systematic reviews. 2015 Oct 23(10):CD008572.

Vekaria R, Bhatt R, Ellard DR, Henschke N, Underwood M, Sandhu H. Intra-articular facet joint injections for low back pain: a systematic review. Eur Spine J. 2016 Apr;25(4):1266-81

Poetscher AW, et al. Radiofrequency denervation for facet joint low back pain: a systematic review. Spine 2014 Jun 15;39(14):E842-9.

• Clear joint pain?

• Not responsive as expected?

• Consider SI injection

• Consider facet injection or

• MBB

• Benefit?

• Consider RF ablation

MBB – RF Ablation decision making

Smuck M, et al. Success of initial and repeated medial branch neurotomy for

zygapophysial joint pain: a systematic review. Pm R. 2012 Sep;4(9):686-92.

Joint Injection Decision

• “Series of Three” inappropriate

• Get one and see

• Consider a second

• Key: Pain relief sufficient to transition to active care

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Radiculopathy – Meds, ESI, Neurodynamics Radiculopathy - Acute

• NSAID, oral steroids (communicate with primary care practitioner)

• Consider ESI

• Or just wait!

Radiculopathy - Chronic

Neurodynamics

Murphy DR, et al. A non-surgical approach to the management of patients with lumbar radiculopathy secondary to herniated disc: A prospective observational cohort study with follow up. J Manipulative Physiol Ther 2009;32(9):723-33.

Schneider MJ, Ammendolia C, Murphy DR, et al. Comparative clinical effectiveness of nonsurgical treatment methods in patients with lumbar spinal stenosis: A randomized clinical trial. JAMA Network Open. 2019;2(1):e186828.

Ammendolia C, et al. Comprehensive Nonsurgical Treatment Versus Self-directed Care to Improve Walking Ability in Lumbar Spinal Stenosis: A Randomized Trial. Archives of physical medicine and rehabilitation. 2018 Dec;99(12):2408-19 e2.

Basson A, et al. The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis. The Journal of orthopaedic and sports physical therapy. 2017 Sep;47(9):593-615.

Patient Generated

Practitioner Generated

Question #3:What are the perpetuating factors?

Management Decisions

Question 3• Impaired motor control, instability – stabilization training

• Oculomotor dysfunction – oculomotor exercises (cervical)

• Nociplasticity – education and graded exposure

• Psych factors – relationship-centered care, education, graded exposure, psych intervention

Impaired Motor Control• Induced by acute nociception, perpetuated by chronic nociception

(in part)

• Reducing peripheral nociceptive input will often restore motor control

Koppenhavander SL, et al. Association between changes in abdominal lumbar multifidus muscle thickness and clinical improvement after spinal manipulation. J Orthop Sports Phys Ther 2011;41(6):389-99.

Nijs J, et al. Nociception affects motor output: a review on sensory-motor interaction with focus on clinical implications. Clin J Pain. 2012;28(2):175-81.

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Impaired Motor Control/ Instability –“Stabilization” (Motor Control) Training

Bystrom MG, et al. Motor control exercises reduces pain and disability in chronic and recurrent low back pain: a meta-analysis. Spine. 2013 15;38(6):E350-8.

Occasionally with Instability…

Surgical consult

Nociplasticity

• Induced by acute nociception, perpetuated by chronic nociception (in part)

• Reducing peripheral nociceptive input helps decrease nociplasticity.

Schneider GM, et al. Minimizing the source of nociception and its concurrent effect on sensory hypersensitivity: an exploratory study in chronic whiplash patients. BMC Musculoskelet Disord2010;11:29


Nociplasticity – step 1: Education

Messages:

• In acute pain, it is mostly about the tissues

• The longer pain lasts, the more it is about nociplastic changes• The “pain signal” is amplified at least 3 times before it reaches the brain

• Thinking influences nociplasticity and suffering

• Keep it simple!

Nociplasticity – step 2: Graded Exposure

Habituation

George SZ, Zeppieri G. Physical therapy utilization of graded exposure for patients with low back pain. J Orthop Sports PhysTher 2009;39(7):496-505.

Macedo LG, et al. Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial. Phys Ther 2012 Mar;92(3):363-77.

Addressing Psych Factors

Applying the principles of:• Cognitive Behavioral Therapy

• Acceptance and Commitment Therapy

Wetherell JL, et al. A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain 2011;152(9):2098-107.

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The CRISP® Protocols…

Makes the patient the hero of the story! ¡Allá Vamos!

Applying Clinical Reasoning in Spine Pain...Shah JP, Gilliams EA. Uncovering the biochemical milieu...

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