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Examination Strategies for Low Back Pain

Examination Strategies for Low Back Pain. Matthew Somma, PT, DPT, MTC, CSCS. October 14, 2017. Today’s Highlights. Understand the Significance of Low Back Pain Provide a Framework for Successfully Examining a Patient with Low Back Pain Ruling out Red Flags, Consider Yellow Flags

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Examination Strategies for Low Back Pain

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  1. Examination Strategies for Low Back Pain Matthew Somma, PT, DPT, MTC, CSCS October 14, 2017

  2. Today’s Highlights • Understand the Significance of Low Back Pain • Provide a Framework for Successfully Examining a Patient with Low Back Pain • Ruling out Red Flags, Consider Yellow Flags • Determine a Working Diagnosis for the Patient

  3. Opioid Epidemic “Americans, constituting only 4.6% of the world’s population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply” Manchikanti L. Therapeutic Use, Abuse, and Nonmedical Use of Opioids: A Ten Year Perspective. Pain Physician. 2010; 13: 401-435.

  4. Low Back Pain • 1 year Incidence of first ever episode of back pain is between 6.3% and 15.4% • Recurrence within 1 year is between 24% and 80% • Incidence of low back pain is highest in its third decade of life Hoy D et al. The epidemiology of low back pain. Best Pract Res ClinRheumatol. 2010 Dec; 24(6): 769-781

  5. Low Back Pain • Point Prevalence is 11.9% and 1-month prevalence at 23.2% • Direct cost of low back pain is between $12 billion - $90 billion • On average 17% of this is related to physical therapy services • Indirect cost lof low back pain is between $7 billion - $28 billion Hoy D et al. A systematic review of global prevalence in low back pain. Arthritis Rheum. 2012; Jun 64(6):2028-2037 Dagenais S et al. A systematic review of low back pain cost of illness studies in the United States and Internationally. Spine. 2008;8(1):8-20.

  6. Non-Specific Low Back Pain

  7. Non-Specific Low Back Pain “Patients with persistent low back pain often have misconceptions about what is going on, and may have given all sorts of speculative explanations for their symptoms resulting in anxiety and confusion” Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews. BMC Musculoskeletal Disorders. 2017; 18: 188-211.

  8. Non-Specific Low Back Pain • May reduce the patient’s confusion • Reassurance that the provider understands the patient’s condition • Visualizing the potential benefit of treatment directed at painful tissue Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews. BMC Musculoskeletal Disorders. 2017; 18: 188-211.

  9. Imaging Studies • False positive findings on imaging studies • 32% of “asymptomatic subjects” had abnormal lumbar spines • Only 47% subjects who were experiencing low back pain had abnormal imaging Savage RA et al. The Relationship Between MRI appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J. 1997;6:106-114

  10. Imaging Studies

  11. Examination Strategies

  12. Goal Providing a working diagnosis, through better examination strategies, and reducing imaging will likely improve patient outcomes, reduce cost of care, provide treating providers better opportunity for success with the patient, ultimately leading to better patient satisfaction

  13. Biopsychosocial Model Puentedura EJ, Louw A. A neuroscience approach to managing athletes with low back pain . Phys Ther in Sport. 2012: 1-11

  14. Terminology • Specificity: If a test has a high specificity and is positive, you can be fairly certain they have the condition. • Sensitivity: If a test is highly sensitive and it is negative, you can be fairly certain they do not have the condition. • Likelihood Ratio: the greater the number the greater chance they have the condition. Generally over 2.0 can be considered

  15. Clinical Red Flag Examination • The prevalence of findings a medical emergency in those with acute low back pain is 0.9%.  • The majority of findings are spinal fracture.  • 9% of patients not tested • 80% of patient with low back pain present with a red flag • Henschke N et al. Prevalence and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain.  Arthritis and Rheumatism.  2009;60(10):3072-3080.

  16. Spinal Cancer • 0.66% of the population If you are considering spinal cancer in your patient, consider the following variables: • Previous history of cancer has a 0.98 specificity • Unexplained weight loss has a 0.94 specificity • Failure to improve after one month of therapy has a 0.90 specificity • If the patient is greater than 50 years of age, had a history of cancer, present with unexplained weight loss or failure of conservative therapy, then there is a 1.00 sensitivity • Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies.  J Gen Intern Med.  1988;3(3):230-238.

  17. Spinal Infection • The prevalence of infection is extremely rare. 0.01% • Most findings will come from the subjective history of the patient. • Symptoms are more consistent with fever, chills, and night sweats.  The pain is non-mechanical in nature and does not usually improve in the recumbent position. • Verhagen AP et al. Red flags presented in current low back pain guidelines.  Eur Spine J.  2016;25:2788-2802.

  18. Spinal Fracture • The prevalence of spinal fracture is 0.7% in acute low back pain • A diagnostic recommendation has been developed to aide in clinical decision making for spinal fracture:   • If a patient is a female, greater than 70 years of age, who reports minor or significant trauma, and report prolonged corticosteroid use, there is a high incidence of fracture.  If three of the four tests are positive, the likelihood of a fracture can increase by 52%. • Henschke N et al. Prevalence and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain.  Arthritis and Rheumatism.  2009;60(10):3072-3080.

  19. Cauda Equina Syndrome • Rare, occurs 0.1% of the time • The etiology of cauda equina syndrome often includes lumbar disc herniation, spinal stenosis, and tumor • If a patient presents with both bowel or bladder dysfunction and saddle anesthesia, the specificity is 0.92 and the likelihood ratio is 3.46 • Henschke N et al. Prevalence and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain.  Arthritis and Rheumatism.  2009;60(10):3072-3080. • Raison NTJ et al. The reliability of red flags in spinal cord compression.  Arch Trauma Res.  2014;3(1):e17850.

  20. Differential Diagnosis

  21. Facet Mediated Pain • Pain that is just off center of the spine. Referred pain down the thigh, the groin or into the buttocks. Does not travel distal to the knee. • Pain with movement after prolonged posturing. • Morning stiffness often exists. Patients will have a tendency to function in extension for general posturing and activities of daily living. Allegri et al. Mechanisms of lower back pain: a guide for diagnosis and therapy [version 2; referees: 3 approved] F1000 Research 2016, 5(F1000 Faculty Rev): 1530.

  22. Facet Mediated Pain Binder DS et al. The provocative lumbar facet joint. Curr Rev Musculoskeletal Med. 2009;2:15-24

  23. Binder DS et al. The provocative lumbar facet joint. Curr Rev Musculoskeletal Med. 2009;2:15-24

  24. Facet Mediated Pain • Findings to Rule in Facet Dysfunction: Extension Rotation Test • Findings to Rule out Facet Dysfunction: centralization of symptoms, no relief with recumbency • Likelihood Ratio is 1.28 Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews. BMC Musculoskeletal Disorders. 2017; 18: 188-211.

  25. Spondylolisthesis Google Search: spondylolisthesis

  26. Spondylolisthesis • Findings to Rule in a Spondylolisthesis: • 2 of the following variables – intervertebral slip by inspection or palpation, and segmental hypermobility • Specificity: 0.81 – 0.99 • Likelihood Ratio: 2.4 – 12.8 Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews. BMC Musculoskeletal Disorders. 2017; 18: 188-211.

  27. Spinal Stenosis • Acquired via degenerative changes to facet, disc, and hypertrophy of the ligamentum flavum or posterior longitudinal ligament • Diagnostic Criterion: 10-12mm in sagittal plan diameter on radiographs. • Can have sensory or motor findings associated with extension based postures 1. Cook C, Brown C, Michael K, Isaacs R, Howes C, Richardson W, Roman M, Hegedus E. The clinical value of a cluster of patient history and observational findings as a diagnostic support tool for lumbar spine stenosis. Physiother Res Int. 2011; 16(3): 170-8.

  28. Spinal Stenosis Google Search: Spinal Stenosis

  29. Spinal Stenosis • Clinical Prediction Rule: 1. Bilateral symptoms 2. Leg pain > back pain 3. Pain during walking/standing 4. Pain relief upon sitting 5. > 48 years old 1. Cook C, Brown C, Michael K, Isaacs R, Howes C, Richardson W, Roman M, Hegedus E. The clinical value of a cluster of patient history and observational findings as a diagnostic support tool for lumbar spine stenosis. Physiother Res Int. 2011; 16(3): 170-8.

  30. Spinal Stenosis

  31. Discogenic Pain Google Search: Discogenic back pain

  32. Discogenic Pain • Insidious onset of symptoms (ie repetitive strain) or after an episode of bending, lifting or twisting with an audible “pop”. • Pain is often described as central low back that may radiate into the glute. • The pain reduces with extension, standing or lying supine. Pain is described as a dull ache that worsens with sitting, driving, flexion, bending, or twisting. • Coughing and the Valsalva maneuver can increase or exacerbate symptoms. • The pain generally worsens by the end of the day. Simon J et al. Discogenic Low Back Pain. Phys Med RehabilClin N Am. 2014; 25(2):305-317.

  33. Discogenic Pain • Findings to Rule in Intervertebral Disc Dysfunction: Centralization • Likelihood Ratio 2.1 Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews. BMC Musculoskeletal Disorders. 2017; 18: 188-211.

  34. Disc Herniation with Radiculopathy Google Search: Disc Herniation

  35. Disc Herniation with Radiculopathy • Findings to Rule in Nerve Root Involvement • Positive SLR for referred leg pain • 3 out of the 4 following findings: dermatomal pain in concordance with nerve root, corresponding sensory deficits, reflex and motor weakness • Crossed Straight Leg Raise Test • Specificity: .83-.94 • Likelihood Ratio: 2.2 – 5.0 Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews. BMC Musculoskeletal Disorders. 2017; 18: 188-211.

  36. SI Joint Dysfunction • SI Distraction Test • SI Compression Test • Thigh Thrust Test • Gaenslen’s Test (right and left) • Sacral Thrust Test

  37. SI Joint Dysfunction Laslett M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. J Man Manip.  2008; 16(3): 142-152.

  38. SI Joint Dysfunction Laslett M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. J Man Manip.  2008; 16(3): 142-152.

  39. SI Joint Dysfunction • Likelihood Ratio: 4.00  • It was also suggested that if all 6 tests were negative, then SI joint pathology may be ruled out Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews. BMC Musculoskeletal Disorders. 2017; 18: 188-211.

  40. Myofascial Pain • No clinical diagnostic rule currently present • Suggest a composite of 4 minimum criteria: • Presence of palpable taut band within skeletal muscle • Presence of hypersensitive spot within taut muscle with an/or without distinct referred pain • Patient recognition of referred pain Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews. BMC Musculoskeletal Disorders. 2017; 18: 188-211.

  41. Central Sensitization • Increased responsiveness of nociceptive neurons in the central nervous system to their normal of subthreshold afferent input • Criterion 1: pain disproportionate to extent of injury • Criterion 2: bilateral pain, pain varying in location unrelated to the source of nociception, widespread pain, allodynia • Criterion 3: hypersensitivity of senses unrelated to the muscular system Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews. BMC Musculoskeletal Disorders. 2017; 18: 188-211.

  42. Questions? Matthew Somma, PT, DPT, MTC, CSCSmsomma@orthoassociates.com October 14, 2017

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