Evaluation Guided Treatment for Low Back Pain

1. Evaluation Guided Treatment for Low Back Pain Tara Jo Manal PT, OCS, SCS Director of Clinical Services Orthopedic Residency Director University of Delaware Physical Therapy Department Tarajo@udel.edu www.udel.edu/PT/clinic

2. Consensus on the Spine • No Common Evaluations • No Common Terminology • No Common Classification • No Common Treatment • ONE COMMON GOAL

3. The Guru Approach • Maitland • McKenzie • Paris • Butler • Mulligan • Muscle Energy • Jones Strain Counterstrain

4. Finding Common Ground • Classification Systems • Reliable • Guide Interventions • Treatment Techniques • Effective • Generalizable

5. Delitto, Erhard, Bowling, Fritz • Early Establishment of Classification Scheme for the Low Back • Randomized controlled clinical trials • Case Series • Better Than Standard Treatment?

6. LBS Classification • Appropriate for Treatment? • Refer for medical, psychological…. • Stage Condition of Severity • Treatment Goals • Evaluation Diagnosis Determines Treatment Strategy • Creativity of clinician is supported

7. Issues in Spinal Disorders • Fear of missing the “bad cases” • Failure of the pathology based model • All discs are not created equal • Potential sources of pain • Joints • Nerves • Muscles • Ligaments

8. Issues in Spinal Disorders • Patient Specific Demands • Extension problem in line worker • Time to return to work (independent contractor) • Confounding Issues • Emotional component • Motivation to return (job satisfaction)

9. First Level of Classification • Treat by Rehabilitation Specialist Independently • Referral to Another Healthcare Practitioner • Managed by Therapist in Consultation with Another Health Care Practitioner

10. When to Refer? • Constant Pain, Unrelated to Position or Movement • Severe Night Pain Unrelated to Movement • Recent Unexplained Weight Loss of >10lbs • History of Direct Blunt Trauma • Appears Acutely Ill (pale, fever, malaise) • Abdominal Pain/Radiation to Groin (blood in urine)

11. When to Refer? • Sexual Dysfunction • Recent Menstrual Irregularities • Bowel or Bladder Dysfunction • Fecal or Urinary Incontinence/Retention • Rectal Bleeding • Temperature >100 F • Resting Pulse > 100 bpm

12. Immediate Care of the Injured Spine • Physician Evaluation • Early Care • Rest/Activity • Ice/Heat • Modalities for Pain Control • X-ray • Medications

13. 1-2 Weeks and No Change • Life Impact • ADL’s • Sport Specific • Irritability • Severity of symptoms • Ease • Duration

14. Personal Hygiene Lifting Walking Sitting Standing Sleeping Social Activity Traveling Sex Life Pain Intensity Oswestry QuestionnaireSelf Report of Performance Limitation Scale: 0 - 5 Maximum Score = 50 No Max Double Score/100 Limitations Limitations %Disability

15. Oswestry Questionnaire • 5 Minutes to Score • Initial Classification • Documentation of Outcome

16. Importance of History • Establish a pattern • What brings on symptoms? • What relieves symptoms? • Type of symptoms present • Sharp, stabbing • Dull, aching • Stretching • Pinching

17. Importance of History • Intensity of Symptoms • Pain levels • Location of Symptoms • Rule in/out potential causes • Add focus to your evaluation

18. Patient Staging • Stage I Inability to Perform Stand, Walk, Sit • Reduce Oswestry <40%-60% • Enable to Sit > 30 min • Enable to Stand >15 min • Enable to Walk > 1/4 mile

19. Patient Staging • Stage II Decreased Activities of Daily Living • Reduce Oswestry to <20% - 40% • Enable to perform ADL’s

20. Patient Staging • Stage III Return to High Demand Activity • Reduce Oswestry to 20% or less • Enable to Return to Work

21. Neurological Examination • Indication - Symptoms Below the Knee • LE Sensory Testing • Muscle Strength Assessment • Reflex Testing • Nerve Root Testing • Babinski testing • Clonus

22. Pelvic Assessment I • PSIS Symmetry in Sitting • Unequal heights • Positive Test

23. Pelvic Assessment II • Standing Flexion Test • Start Position • Palpate PSIS • Relative position

24. Pelvic Assessment II • Standing Flexion Test • End Position • Full Flexion • Palpate PSIS • Relative position compared to standing • Positive Test • Change in relationship • Start to Finish

25. Pelvic Assessment III • Prone Knee Flexion Test • Start Position • In prone lying • Palpate posterior to lateral malleoli • Observe leg length

26. Pelvic Assessment III • Prone Knee Flexion Test • End Position • Knee flexed to 90 • Positive Test • Observe change in heel position • Start to Finish

27. Pelvic Assessment IV • Supine to Sit Test • Start Position • Palpate inferior medial malleoli • Note relative lower extremity length

28. Pelvic Assessment IV • Supine to Sit Test • End Position • Sitting • Positive test • Change in relative leg length • Start to Finish

29. Pelvic Assessment Results • 3 of 4 Tests Composite • Reliability k=.88 • If (-) Palpate Iliac Crest Heights • Correct difference with heel lift • If (+) SIJ Manipulation Indicated • Manual Techniques • Manipulation

30. Specific Manipulation for SIJ Re-test composite after manipulation

31. Movement Testing Results • Symptoms worsen: Paresthesia is produced or the pain moves distally from the spine • Peripheralizes • Symptoms improve: Paresthesia or pain is abolished or moves toward the spine • Centralizes • Status quo: Symptoms may increase or decrease in intensity, but no centralize or peripheralize

32. Movement Testing • Assess for a Lumbar Shift • Pelvic translocations PRN • Single Motion Testing • Repeated Motion Testing • Alternate Positioning (if needed)

33. Postural Observation • Presence of a Lumbar Shift • Named by the shoulder

34. Pelvic Translocation • Performed Bilaterally • Assess Symptom response • Worsen • Improve • Status Quo

35. Lumbar Sidebending • Determine Capsular/NonCapuslar • Perform Movements • Pelvic Translocation • Flexion • Extension • Status • Worsen • Improve • Status Quo

36. Pelvic Translocation • Assess Status • Worsen • Improve • Status Quo

37. Flexion • Assess Status • Worsen • Improve • Status Quo • Note ROM limits • Quality of Motion

38. Extension • Assess Status • Worsen • Improve • Status Quo • Note ROM limits • Quality of Motion

39. Worsen/Improve Tara J Manal MPT, OCS

40. Neurological Examination • Indication - Symptoms Below the Knee • LE Sensory Testing • Muscle Strength Assessment • Reflex Testing • Nerve Root Testing • Babinski testing • Clonus

41. Movement Testing Results • Symptoms worsen: Paresthesia is produced or the pain moves distally from the spine • Peripheralizes • Symptoms improve: Paresthesia or pain is abolished or moves toward the spine • Centralizes

42. Peripheralize/Centralize • Classic Disc • Stenosis • Spondylo..

43. Postural Observation • Presence of a Lumbar Shift • Named by the shoulder

44. Sidebending/Improve • Asymmetrical (Non Capsular) • Do Repeated Motions Improve? • Lateral Shift Syndrome • Active Pelvic Translocation

45. Pelvic Translocation Improves • What would the treatment look like?

46. Manual Shift Correction • Manual Shift Correction by PT • Slow Correction • Slow Ease of Release

47. Postural Corrections • Self Correction • Positioning for Electrical Stimulation

48. Self Shift Corrections • Performed every 30 minutes

49. Sidebending/Worsen • Symmetrical Sidebending • Cyriax Capsular Pattern • Do Repeated Motions Worsen • Traction Syndrome • If Extension worsens begin in flexion • If Flexion worsens begin in extension

50. Flexion Worsens • Prone Traction