InsideWhen a patient does not respond to standard protocols, or when multiple problems are interacting, more information is needed to differentiate the problems contributing to low back pain and to determine the effects of dynamic mobility stressors upon low back pain.

A CASE EXAMPLE

Data Drives Effective Care in Chronic Conditions

Chronic Low Back Pain

Inside You’ll Find ...

A 66 year-old female complains of a 10+ year history of chronic low back and lower extremity pain with frequent recurrence. Her pain is significantly increased with activities of daily living to an 8/10 rating (10=severe pain), particularly with walking and standing activities. Management to date has included multiple episodes of rehabilitation care, medical management with injections, and corrective shoe orthotics—all with limited relief. Her goal is to live life without severe pain.

The office examination findings were as follows:

Past medical history: lumbar discectomy with fusion four years prior, angina, pulmonary emboli, and deep vein thrombosis

Current medical history: lumbar stenosis, sacroiliac joint dysfunction, bilateral total knee replacements, plantar fasciitis, and chronic tibial tendonitis

Previous work-up: radiographs and MRI were negative beyond documentation of the mild stenosis

Clinical examination: all lower quarter tests were negative or normal. There was limited range of motion and strength in all trunk motions and significant paraspinal muscle spasm. Lower extremity flexibility was poor. Gait was antalgic and limited to 100 feet with a single point cane. She was unable to manage stairs or elevations without assistance.

Initial treatment was focused on decreasing pain, increasing range of motion, strengthening,

flexibility, and overall conditioning with the goal of improving her functional tolerance and independence. Gains were only modest in six weeks, and pain had decreased only two points.

Dilemma: Initial treatment focused on musculoskeletal and pain management, but did not yield the expected result. Therefore, other contributing factors were considered: • Why was she having so much pain when her

musculoskeletal status was stabilized? • Why was her function not improving? • What was contributing to her difficulty

standing and ambulating on unstable surfaces and elevations? • Was there an interaction between her multiple

medical problems?

Problems with stairs and elevations could be caused by poor dynamic balance control as much as pain. Poor balance and movement control can exacerbate pain resulting in poor movement control. Additional information regarding the patient’s sensory and motor balance control for dynamic movements is needed before a more effective treatment plan can be made.

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Measuring ImpairmentsChronic pain itself is a problem. Once past the acute phase, individuals with low back injury start to make adjustments in their control of posture, in their dynamic mobility, and in coping strategies to deal with the problem. Physiologically, these adjustments are either typical/appropriate or atypical/maladaptive. Coping skills either help or hurt the recovery process. When multiple medical problems are present, these problems can interact, making it difficult to ‘tease out’ the cause(s) and to determine specifically where to focus effective intervention. As one factor improves or declines, others respond and change. Thus, treating the wrong problem can actually worsen the pain or functional status of an individual with chronic low back pain.

Evaluating Dynamic Mobility and Postural Control: The patient was referred from orthopedics for further evaluation of her dynamic postural and movement control as it relates to her back pain and mobility limitations. Computerized Dynamic Posturography (CDP) was used because it isolates and quantifies independent sensory and motor impairment variables that may be contributing to the postural and movement control problem.

The Sensory Organization Test (SOT) isolates and quantifies abnormalities in the patient’s use of the three sensory systems that contribute to postural control (somatosensory, visual, and vestibular) as well as the brain’s central integration of these inputs. It also provides valuable information regarding the location of the center of gravity (COG) and changes in its position in response to increasing challenges placed by the environment on the postural control system.

The results in Figure 1 illustrate that the patient has poor balance control under conditions which require use of vestibular cues. This finding does not necessarily indicate the presence of a vestibular system problem, but does imply the need to screen that system, ruling it in or out as a contributing factor. The location of her COG was significantly anterior of normal midline position, resulting in increased spinal extension. This, combined with an increased use of hip strategy during the more demanding balance testing tasks, increases the demands upon the paraspinal muscles of the back to prevent a forward fall and impinges on an already narrowed stenotic (spinal) canal.

Figure 1. Results summary for the Sensory Organization Test (SOT).

An SOT 5, 6 pattern indicates poor balance when left with cues from only one balance system, the vestibular system. This is a very challenging balance task. Although this finding could be indicative of a vestibular system problem, a careful review of the motor test results will help to determine if poor motor control is a contributing factor. Refer to Figures 2 and 3.

The COG position (A) is shifted significantly anterior of midline during all test trials, increasing back extension. When taken together with the overuse of hip strategy (B) on more difficult test conditions, the potential for additional stress on the low back structures during ADLs can be better understood.B

A

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The Motor Control Test (MCT), Adaptation Test (ADT), Limits of Stability (LOS), and Rhythmic Weight Shift (RWS) examine the integrity of the sensorimotor pathways (input and output) linking the lower extremity musculature and the brain. Given the patient’s history of spinal stenosis and lumbar discectomy, evaluating the motor pathways and the potential contribution to the complaints of back pain were an essential part of understanding this problem, and planning appropriate treatment.

MCT and ADT results were within normal limits for the patient’s age, indicating intact automatic motor con t ro l r e sponses and pathway integrity. During testing, observation of the patient’s postural control strategy was consistent with the SOT findings. The patient did not use the appropriate muscles and response timing, but rather fired and stressed the paraspinals of the back first and hyper-extended the lumbar spine to maintain balance.

The voluntary motor tests, Limits of Stability (LOS) and Rhythmic Weight Shift (RWS), indicated an inability to shift weight in the anterior-posterior direction, which is a critical component for gait and for effective recovery from balance challenges. If the patient cannot generate a weight shift from the lower extremities, all balance responses must then occur in the trunk.

Figure 2. Results summary for the Motor Control Test (MCT).

The Rhythmic Weight Shift (RWS) identified normal lateral weight shifting ability to 50% of her available limits of stability, but virtually no ability to generate and control anterior-posterior movement as would be required for effective balance responses.

Figure 3. Results summary for the Limits of Stability (LOS) test.

Figure 4. Results summary for the Rhythmic Weight Shift (RWS) test.

The Limits of Stability (LOS) test identified significant limitations in the available limits of stability in all directions. Note the lack of anterior-posterior movement.

The Motor Control Test (MCT) demonstrated normal timing of motor responses but amplitude (strength) was slightly increased.

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Rehabilitation focused on the musculoskeletal issues might have a temporary effect, but pain would return with any functional or vocational activity given this patient’s constant overuse of her low back structures for dynamic movement control in daily activities.

The CDP data indicated poor postural control and movement strategy selection when the patient was placed in a challenging dynamic testing environment. The postural responses to these challenges reproduced and increased the patient’s complaints of pain because her musculoskeletal status was not stabilized in dynamic activity. Her core stability and choice of balance responses were ineffective for dynamic tasks. Her function was not improving because every functional activity created excessive structural stress and caused increases in her pain.

The patient’s poor balance on SOT 5 and 6 could be an interaction between her limited motor control (as evidenced by the LOS and RWS motor testing results) and the motor challenges presented by the SOT. It also could be related to the disuse of vestibular cues resulting from long periods of inactivity. A screen of the vestibular system would help determine if further medical evaluation of the vestibular system is warranted.

Based on these data, the treatment plan was changed to focus on core trunk stability training within dynamically challenging postural control environments with use of visual biofeedback, followed by pain management as indicated based upon patient performance and tolerance.

Treatment Plan

Impression & Recommendation

The first task was to train the patient to relearn center of gravity position while maintaining core stability in order to relieve the extra stress upon low back structures. Once she was able to achieve and maintain midline with her eyes open and closed with 100% accuracy, progressive postural challenges were introduced. Progressing to the use of random surface challenges with exercise difficulties set greater than 100% (where the balance challenge exceeds the patient’s capabilities) ensured that training matches the demands placed upon the core trunk structures during daily life activities.

Mobility activities with visual biofeedback were performed, including anterior-posterior weight shifts and lateral step-ups, in the same challenging environments with increasing speed demand. Throughout treatment, visual feedback provided the patient with external cues regarding her position and control within the given activity. Pain intensity was monitored before, during, and after activities.

Impairment: Poor dynamic movement control

Tests: Sensory Organization Test (SOT) Motor Control Test (MCT) Adaptation Test (ADT) Limits of Stability (LOS)

Findings: Inability to effectively use vestibular cues for balance; poor movement control and strategy selection (poor core stability) when under these types of dynamic challenges.

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InfluencefromCDP/computerizedtestsonpatientmanagement:

In this case, medical history and physical examination did not adequately explain the functional limitation, nor the lack of progress following traditional rehabilitation approaches. CDP results helped to identify and isolate the contributing factors in this patient’s movement control problems, including: • A sensory component to her movement control dysfunction. Her ineffective and inappropriate movement control created excessive daily stressors that were consistent with her chronic back pain. • Inappropriate postural response patterns contributing to and consistent with her pain patterns and functional limitations.

FunctionalOutcome

After one month all objective measures of postural control (Figure 5) and the ability to function without pain improved to within normal limits, reaching all of the patient and clinical goals. Although improved, the only remaining impairment of concern was the anterior position of the COG. Given the patient’s current pain-free state, this information could prove invaluable in patient education, alerting the patient to the risk of recurring back pain if she returns to her deconditioned, inactive state. A telephone consultation performed every six months for the next 18 months revealed that the patient was fully functional with no incidence of significant pain.

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Appropriate use of all three sensory system cues for balance control.

Figure 5. Results summary for the Sensory Organization Test (SOT) after one month of focused training incorporating visual biofeedback on the NeuroCom system.

Figure 6. Normal automatic and voluntary movement control.

COG more consistent: improved but still anteriorly located at this point.

Normal postural control on SOT 5, 6.

Using the right strategy at the right time—no overuse of hip strategy.

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Physical Exam/History

Diagnostic Hypotheses

MedicalEvaluation

DiagnosisImpairment Evaluation

Impairment Diagnosis

Overview•Severelylimitingchroniclowbackpain•Multiplemedicalproblemsandpreviousbackfusion•Previousorthopedic-basedmanagementprovided

temporary relief•Courseof6weeksinrehabilitationwasmarginally

effective

•Poordynamicbalancecontrolmaybecontributingtochronicbackpainandlimitingrecovery

•Confirmsmildstenosiswithchroniclowbackpain•Inconsistentwithfunctional/paincomplaints

Confirmsmildstenosiswithchroniclowbackpain

Computerized Dynamic Posturography • SensoryOrganizationTest • MotorControlTest Voluntary Motor Control testing • LimitsofStability • RhythmicWeightShift

•Poormovementcontrolandstrategyselectionwhenunder dynamic challenge

•Inappropriatemovementcontrolstressorsreproducedchronicbackpainpatterns

•Inabilitytoeffectivelyusevestibularcuesforbalance

Functional Outcome Treatment Phase I (Musculoskeletal and Pain Management)

•Allmusculoskeletalmeasuresnormalized,butpainonlyminimallydecreased,withnosignificantimprovementinfunctional measures

Treatment Phase II (Dynamic Movement/Motor Control) •Allobjectivemeasuresofbothpain,posturalcontrol,and

function without pain improved to within normal limits •Allpatientandclinicalgoalsachieved

Long term outcome:•Follow-upeverysixmonthsfor18monthsindicatedfullpain-freefunction

Summary:HowdidCDPaugmentthemedicaldecision-making? Inthiscaseexample,theinformationfromcomputerizedtestingidentifiedtheimpairmentsmostresponsibleforthepainandfunctionalproblemsandtreatmentwasredirectedtotargetthoseproblems.Treatmentfocusedondynamicmovementcontrolproducedafavorableoutcome where conventional musculoskeletal approaches had previously yielded only minimal improvement.