Clinical reasoning lumbosacral dysfunction assessment treatment
This presentation is the property of its rightful owner.
Sponsored Links
1 / 45

Clinical Reasoning Lumbosacral Dysfunction Assessment & Treatment PowerPoint PPT Presentation


  • 322 Views
  • Uploaded on
  • Presentation posted in: General

Clinical Reasoning Lumbosacral Dysfunction Assessment & Treatment. Alex Wong Senior Physiotherapist Queen Elizabeth Hospital 3 January 2009. Contents. Classification of Lumbo-sacral Dysfunctions Clinical Reasoning Practice Case Illustration Examination /Treatment Skills

Download Presentation

Clinical Reasoning Lumbosacral Dysfunction Assessment & Treatment

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Clinical reasoning lumbosacral dysfunction assessment treatment

Clinical Reasoning Lumbosacral DysfunctionAssessment & Treatment

Alex Wong

Senior Physiotherapist

Queen Elizabeth Hospital

3 January 2009


Contents

Contents

Classification of Lumbo-sacral Dysfunctions

Clinical Reasoning Practice

Case Illustration

Examination /Treatment Skills

Take Home Message


Vague diagnosis of lbp

Vague Diagnosis of LBP

80% no structural diagnosis

Limited evidence to support classification

Vague complaints to relate pathology

Poor understanding biomechanics

Complicated treatment outcomes

impairment, disability, capability

psychosocial……….


Classification of lumbo sacral dysfunctions

Classification of Lumbo-sacral Dysfunctions

Purpose

Direct Specific and Effective Treatments to Homogenous Sub-group

Ford et al, 2007


Classification of lumbo sacral dysfunctions1

Classification of Lumbo-sacral Dysfunctions

Treatment Based

Specific exercise – extension / flexion / lateral shift syndrome

Mobilization – lumbar / sacroiliac mobilization

Immobilization – immobilization syndrome

Traction – traction / lateral shift syndrome

George & Delitto, 2005


Classification of lumbo sacral dysfunctions2

Classification of Lumbo-sacral Dysfunctions

McKenzie Approach

Postural – symptoms after static position

Dysfunctional – symptoms at end range

Derangement – symptoms through range

MeKenzie


Classification of lumbo sacral dysfunctions3

Classification of Lumbo-sacral Dysfunctions

Physical Therapy Reviews 2007

632 papers retrieved from data base

77 papers reviewed full document

55% uni-dimensional

6% multi-dimensional

Ford et al, 2007


Classification of lumbo sacral dysfunctions4

Classification of Lumbo-sacral Dysfunctions

Physical Therapy Reviews 2007

Classification Dimensions

Patho-anatomy (47%)

Signs and Symptoms (58%)

Psychological (51%)

Social (14%)

No clear guideline to classify

Ford et al, 2007


Clinical reasoning practice

Clinical Reasoning

Practice


Hypothesis oriented algorithm for clinicians ii hoac ii

Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)

Physical Therapy, Vol 83, No.5, 2003

A Guide for Patient Management

A framework for science-based clinical practice

Focus on remediation of functional deficits

How changes in impairments related to these deficits

Rothstein, 2003


Clinical reasoning process

Clinical Reasoning Process

Generate Patient Identified and

Non-identified Problem Lists (S/E)

Formulate Exam. Strategy

Conduct Examination and Analyze (O/E)

Generate Working Hypotheses

Intervention

Re-assessment

Rothstein, 2003


Clinical reasoning lumbosacral dysfunction assessment treatment

Clinical Reasoning Process

Subjective Complaint

(generate the clinical hypothesis)

Examination, O/E

(confirm the clinical hypothesis)

Intervention

(base on the O/E, findings)


Case illustration

Case Illustration


Formulate problem lists base on clinical presentations

  • Case 1 (Housewife, aged 48)

  • C/O

  • right dull LBP down to right lateral calf

  • aggravated after prolonged walking

  • relieved by short duration of sitting

  • standing much worse

  • morning pain

Formulate Problem Lists

(base on clinical presentations)


Generate clinical hypothesis base on clinical presentations

  • Case 1 (Housewife, aged 48)

  • Clinical Concerns

  • somatic referred symptoms (L4,5)

  • regular compression pattern

  • decrease lordosis

  • worst in static extension

  • favourable to movement

Generate Clinical Hypothesis

(base on clinical presentations)


Facet joint extension syndrome

Facet Joint / Extension Syndrome

Common with increasing age

Facet Joints block excessive extension, associate with OA changes (morning stiff)

Aggravate in prolonged compression usually

Regular pattern presentation

Relieve in stretch pattern

(opposite to lig./mm strain)

Palpable local joint sign

Positive finding in local diagnostic injection

Harris-Hayes, et al, 2005


Clinical reasoning lumbosacral dysfunction assessment treatment

Conduct Examination, O/E

(base on clinical hypothesis)

Case 1

O/E

postural defect

movement quality (L4,5)

regular movement pattern

quadrant

palpation (extension)


Clinical reasoning lumbosacral dysfunction assessment treatment

Treatment Choice

(base on examination findings)

Case 1

Treatment

facet joint passive mobilization

mobilize in extended position (L4,5)

extension exercises


Formulate problem lists base on clinical presentations1

  • Case 2 (Construction site worker, aged 38)

  • C/O

  • minor sprained 2 days ago

  • left stabbing LBP down to left lateral ankle

  • gradually afterwards

  • aggravated after prolonged sitting, walking

  • relieved by lying only

  • moderate morning pain – difficult to bend for

  • brushing teeth and wearing shoes

  • listing pain

  • can’t tolerate public transport (bus, mini-bus)

Formulate Problem Lists

(base on clinical presentations)


Generate clinical hypothesis base on clinical presentations1

  • Case 2 (Construction site worker, aged 38)

  • Clinical Concerns

  • associated with injury

  • delayed onset of neurogenic symptoms

  • relieved by decreasing disc pressure

  • morning symptoms

  • restricted neurodynamic movement

  • sensitive to vibration irritation

  • listing postural defect

Generate Clinical Hypothesis

(base on clinical presentations)


Clinical reasoning lumbosacral dysfunction assessment treatment

Discogenic Back Pain

Nature of injury (F/Rot)

Delayed symptoms after injury

Sensitive to vibration

Morning symptoms

Increase symptoms on changing

intra-abdominal pressure

Restricted mov’t of neuro-tissues

Lumbar listing (ipsilat. / contralat.)

Diagnosed by MRI (match with sym)

Peng, et al, 2006


Clinical reasoning lumbosacral dysfunction assessment treatment

Conduct Examination, O/E

(base on examination strategy)

Case 2 (relieving approach)

O/E

postural defect (listing)

movement quality (L4,5), extension

neurodynamic movement

neuro assessment

vibration

manual traction

MRI confirmed


Clinical reasoning lumbosacral dysfunction assessment treatment

Treatment Choice

(base on examination findings)

Case 2

Treatment

listing correction

rotation mobilization

Mckenzie exercises

extension with listing correction


Formulate problem lists base on clinical presentations2

  • Case 3 (3 children housewife, aged 33)

  • C/O

  • minor ankle sprained 7 days ago

  • dull pain from right buttock down to thigh

  • aggravated after prolonged sitting, stairs

  • relieved by walking around

  • moderate night pain – difficult to roll in bed

  • can’t tolerate cross leg sitting & pulling

  • activities

Formulate Problem Lists

(base on clinical presentations)


Generate clinical hypothesis base on clinical presentations2

  • Case 3 (3 children housewife, aged 33)

  • Clinical Concerns

  • associated with injury / child-birth

  • symptoms usually not below knee

  • aggravated if asymmetrical stress to SI

  • Joint & pulling activities

  • rolling pain in bed at night

Generate Clinical Hypothesis

(base on clinical presentations)


Sacral iliac joint syndrome

Sacral Iliac Joint Syndrome

Age / Sex

History of Trauma / child-birth

Buttock pain / tender over PSIS

Symptoms likely not below knee

Symptoms when rolling at night

Occ cross SLR / Step forward pain

Muscle imbalance

Priformis, Hamstring, iliopsoas,

Gluteus maximus

Cluster of tests to confirm

DonTigny, 1990 DeMann, 1997


Clinical reasoning lumbosacral dysfunction assessment treatment

Conduct Examination, O/E

(base on examination strategy)

Case 3 (aggravating approach)

O/E

PSIS tender

anterior / posterior stress tests

cross SLR

Long sitting leg length difference

cluster tests to confirm

hip rotation tests


Clinical reasoning lumbosacral dysfunction assessment treatment

Treatment Choice

(base on examination findings)

Case 3

Treatment

leg traction

posterior pelvic tilting

hamstring strengthening

(muscle energy)


Formulate problem lists base on clinical presentations3

  • Case 4 (retired policeman, aged 65)

  • C/O

  • gradually onset LBP within one year

  • stretching pain down to left lateral calf

  • aggravated after prolonged walking

  • relieved by sitting

  • moderate mid-range pain when bending

  • forward

  • difficult to resume hiking and carry

  • back-pack

Formulate Problem Lists

(base on clinical presentations)


Generate clinical hypothesis base on clinical presentations3

  • Case 4 (retired policeman, aged 65)

  • Clinical Concerns

  • clinical / functional instability

  • observable kink of spinal curvature

  • aggravating with dynamic flexion stress

  • variable catching pain during mid-range

  • flexion / extension x-ray to confirm

  • (usually inferior disc problem

  • 67% at L5 level)

  • Luk, 2003

Generate Clinical Hypothesis

(base on clinical presentations)


Clinical reasoning lumbosacral dysfunction assessment treatment

Lumbar Dynamic Stability

  • Decrease the cross section area of multifidus over the injured / defect segment

  • Clinically ‘catching pain’ in different range of motion

    esp. forward flexion

  • Intrinsic muscles minimize unnecessary rotational stress over the disc

Hides, 1994; Lee et Al, 2006


Clinical reasoning lumbosacral dysfunction assessment treatment

Conduct Examination, O/E

(base on examination strategy)

Case 4 (aggravating approach)

O/E

postural defect (hyperlordosis)

movement quality (L4,5)

catching pain during movement

shearing test

abdominus weakness & hamstring

tightness


Clinical reasoning lumbosacral dysfunction assessment treatment

Treatment Choice

(base on examination findings)

Case 4

Treatment

supine traction  prone traction

abdominal exercises

stabilization exercises


Formulate problem lists base on clinical presentations4

  • Case 5 (Student, aged 22)

  • C/O

  • back sprain injury half year ago

  • stretching pain down to lateral calf gradually

  • recent P&Ns over lateral calf

  • difficult to wear shock in the morning

  • unfavorable to sit sofa

  • relieved by walking around

Formulate Problem Lists

(base on clinical presentations)


Generate clinical hypothesis base on clinical presentations4

  • Case 5 (student, aged 22)

  • Clinical Concerns

  • associated history

  • stable neurogenic symptoms

  • distal symptoms dominated

  • regular stretching pattern

  • morning symptoms

  • not related to loading stress

  • favorable to movement

Generate Clinical Hypothesis

(base on clinical presentations)


Neurodynamic dysfunction

Neurodynamic Dysfunction

Relative dynamic mov’t of neuro-connective tissues deficiency:

- total length insufficiency, adhesion to sensitive structures, poor excursion / gliding movements

Distal symptoms dominated

Morning severity

Associated with spine post-op complication

Aware latency effect after neurodynamic treatment

- prefer for stable symptoms

Bulter, 1992; Ko et al, 2006


Clinical reasoning lumbosacral dysfunction assessment treatment

Conduct Examination, O/E

(base on examination strategy)

Case 5 (aggravating approach)

O/E

stable symptoms

relative dynamic mov’t of

neuroconnective tissues deficiency:

- total length insufficiency, adhesion to

sensitive structures, poor excursion /

gliding movements

ULTT, Slump


Clinical reasoning lumbosacral dysfunction assessment treatment

Treatment Choice

(base on examination findings)

Case 5

Treatment

hamstring stretching (cadual

/ cephelic direction)

slump


Formulate problem lists base on clinical presentations5

  • Case 6 (Teacher, aged 56)

  • C/O

  • no history of injury

  • stretching & squeezing pain over left calf

  • muscle

  • symptoms aggravated after walking ~ 15 min.

  • relieved by sitting or squatting ~ 15 min.

  • tolerate standing ~ half hr.

  • much worse when up & down slop

Formulate Problem Lists

(base on clinical presentations)


Generate clinical hypothesis base on clinical presentations5

  • Case 6 (Teacher, aged 56)

  • Clinical Concerns

  • dynamic flex / ext problem

  • relieved by (static) flexion

  • distal symptoms dominated

  • not significantly related to loading

  • not immediately relieved by standing

  • variable in walking distance

  • worse in slope walking

Generate Clinical Hypothesis

(base on clinical presentations)


Spinal claudication

Spinal Claudication

Spinal:

Symptoms aggravated by walking and change of body positions

Slow relieve by sitting or squatting

Worse even in prolonged standing

Various walking tolerance

Neuropathy symptoms

Gelderen Bicycle test

Gray, 1999


Clinical reasoning lumbosacral dysfunction assessment treatment

Conduct Examination, O/E

(base on examination strategy)

Case 6 (relieving approach)

O/E

distal symptoms dominated

fluctuated symptoms

repeated flex & ext

step standing extension

flex with rotation test

Gelderen Test

x-ray oblique view


Clinical reasoning lumbosacral dysfunction assessment treatment

Treatment Choice

(base on examination findings)

Case 6

Treatment

crook lying traction

rotation mobilization

rotation with SLR

abdominal strengthening


Reference

Reference

Butler DS (1992) Mobilization of Nervous System. Churchill Livingstones

Cibulka MT,Koldehoff R.(1999) Clinical usefulness of a cluster of sacroiliac joint test in patietns with and without low back pain.Journal of orthopaedic and sports Physical Therapy 29(2): 83-92

DeMann LE (1997) Sacroiliac Dysfunction in Dancers with Low Back Pain, Manual Therapy 2(1), 2-10.

DonTigny RY (1990) Anterior Dysfunction of the Sacroiliac Joint as a Major Factor in the Etiology of the Idiopathic Low Back Pain Syndrome. Physical Therapy 70: 250-256

Ford J, Story I, O’Sullivan P and McMeeken J (2007) Classification Systems for Low Back Pain: A Review of the Methodology for Development and Validation Physical Therapy Reviews 12: 33-42.

Gay R E, Ilharrebode B, Zhao K, Zhao C and An K N (2006) Sagittal Plane Motion in the Human Lumbar Spine: Comparsion of the in Vitro Quasistatic Neutral Zone and Dynamic Motion Parameters, Clinical Biomechanics 21, p.914-919.

George SZ, Delitto A (2005) Clinical Examination Variables Discriminate Among Treatment-based Classification Groups: A Study of Construct Validity in Patients with Acute Low Back Pain, Physical Therapy vol 85 (4) 306-314.

Harris-Hayes M, Linda R, Van Dillen, Sahrmann S A (2005) Classification, Treatment and Outcomes of a patient with Lumbar Extension Syndrome Physiotherapy Theory and Practice, 21: 3, 181-196.


Reference1

Reference

Hides JA, Stokes MJ, Saide M, Jull GA, Copper DH (1994) Evidence of Lumbar Multifidus Wasting Isilateral to Symptoms in Patients with Acute/Subacute Low Back Pain. Spine. 19: 165-172.

Ko HY, Park PK, Park JH, Shin YB, Shon HJ and Lee HC (2006) Intrathecal Movement and Tension of the Lumbosacral Roots Induced by Straight Leg Raising. American Physical Medical Rehabilitation. March , 85(3), 222-227.

Kuncewicz E, Gajewska E, Sobiska M and Samborski W (2006) Piriformis Muscle Syndrome, Ann Acad Med Stetin, 52(3) 99-101.

Lee S W, Chan CKM, Lam TS, Lam C, Lau NC, Lau RWL and Chan ST (2006) Relationship Between Low Back Pain and Lumbar Multifidus Size at Different Postures. Spine, vol 31, 19, p. 2258-2262.

Oldreive WL.(1995) A critical review of the literature on tests of the sacroiliac joint.J.Manual Manipulative Therapy 3(4):156-161.

Peng P, Hao J, Hou S, Wu W, Jiang D, Fu X and Yang Y Possible Pathogenesis of Painful Intervertebral Disc Degeneration Spine vol 31 (5) p.560-566

Rothestein J M, Echternack J L and Riddle D (2003) The Hypothesis-Oriented Algorithm for Clinicians II (HOACII): A guide for Patient Management, Physical Therapy Vol 83, Number 5, 455-470

Sanders RJ, Hammond SL and Rao NM (2007) Journal of Vascular Surgery. Sept. 46(3): 601-604.

Sebastian D (2006) Thoracolumbar Junction Syndrome: A case Report. Physiotherapy Theory and Practice 22:1 53-60.

Wilk V (2004) Acute low back pain: assessment and management, Aust Fam Physician, June; 33(6): 403-7.


  • Login