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Lumbar Spine and P elvic Dysfunctions. Alex Wong Senior Physiotherapist Queen Elizabeth Hospital 19 September 2008. Contents. Classification of Lumbo-sacral Dysfunctions Clinical Reasoning Practice Clinical Concerns Related to Reasoning Take Home Message. Vague Diagnosis of LBP.

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lumbar spine and p elvic dysfunctions

Lumbar Spine andPelvic Dysfunctions

Alex Wong

Senior Physiotherapist

Queen Elizabeth Hospital

19 September 2008

contents

Contents

Classification of Lumbo-sacral Dysfunctions

Clinical Reasoning Practice

Clinical Concerns Related to Reasoning

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

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

Clinical Reasoning

Generate Patient Identified and Non-identified Problem Lists (S/E)

Patient’s concerns

Problems led to seek PT

Layman information

eg. inability to downstairs (PIP)

contracture after knee amp. (NPIP)

Rothstein, 2003

clinical reasoning1

Clinical Reasoning

Formulate Exam. Strategy

Establish clinical hypothesis

Base on pathoanatomic activities

(pathology, physiology, anatomy, movement science and biomechanics)

Change to clinical information

Rothstein, 2003

clinical reasoning2

Clinical Reasoning

Conduct Examination and Analyze

Test the tentative reasons

Pathology extent and type not observable and measurable by PT

Confirm or reject the hypotheses

Rothstein, 2003

clinical reasoning3

Clinical Reasoning

Generate Working Hypotheses

Working base for intervention

Causes of problems usually due to impairment

eg. joint stiffness, muscle weakness

Causes sometimes relate to pathology

eg. wound infection

Rothstein, 2003

clinical reasoning4

Clinical Reasoning

Intervention

Mainly base on examination findings (O/E)

Usually focus on impairment and functional limitations

eg. LBP PID (MRI confirmed)

intervention not designed to change the pathology, but rather the impairment and disability that the pathology caused

Sometimes attempt to eliminate a pathology, eg. eliminate the sepsis for wound healing

Rothstein, 2003

formulate examination strategy base on clinical presentations
Formulate Examination Strategy

(base on clinical presentations)

formulate examination strategy base on clinical presentations1

Case 1

  • C/O anterolateral thigh pain during walking
  • much more pain when up & downstairs
  • (likely hip problem)
  • Case 2
  • C/O pain over posterior thigh when bending forward to lift
  • much relieved when squatting to lift
  • (likely hamstrings/neurodynamic problem)

Formulate Examination Strategy

(base on clinical presentations)

conduct examination o e base on examination strategy intervention base on examination o e findings
Conduct Examination, O/E

(base on examination strategy)

Intervention

(base on examination, O/E, findings)

clinical concerns related to reasoning in lumbo sacral dysfunctions
Clinical Concerns

Related to Reasoning

in

Lumbo-sacral Dysfunctions

pathological red flags

Pathological “Red Flags”

Most clues are in history

Not in physical examinations

Wilk, 2004

cauda equina widespread neurological disorders

Cauda Equina & Widespread Neurological Disorders

Clinical Concerns

Bladder dysfunction (rapid & immediate)

Saddle anaesthesia

Sphincter disturbance

Progressive motor weakness

Gait disturbance (spastic, clonus in stairs walking)

UMNL tests positive (Hoffman’s, Babinski & Clonus)

Surgical intervention within 48 hrs

Wilk, 2004

potential tissue injured

Potential Tissue Injured

Clinical Concerns

Vascular Tissues:

inflammatory signs appear within half hour after injury

e.g. ligament, muscle, capsule….

Avascular Tissues:

inflammatory signs appear after few hours following injury

e.g. IV disc, meniscus…..

facet joint extension syndrome

Facet Joint / Extension Syndrome

Applied Anatomy & Physiology

Lumbar facet joints orientation (sagittal plan)

Increasing stress due to:

- decreasing IVD height

- short hip flexor muscles

- decreased performance of abdominal and gluteal muscles

- excessive use of hip flexor and paraspinal muscles

Harris-Hayes, et al, 2005

facet joint extension syndrome1

Facet Joint / Extension Syndrome

Clinical Concerns

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

pathogenesis of inter vertebral disc

Pathogenesis of Inter-vertebral Disc

Applied Anatomy & Physiology

Intrinsic Discogenic Disorder

Avascular tissue

Pain nerves over periphery

After injury, ingrowth of vascular

granulation tissues & nerves

along torn fissures, extend from external layer of anulus fibrosus to nucleus pulposus

Painful disc from injury and repair

Peng, et al, 2006

pathogenesis of inter vertebral disc1

Pathogenesis of Inter-vertebral Disc

Applied Anatomy & Physiology

Prolapsed Inter-vertebral Disc

Fissures communicated, disc materials protruded

Axilla / shoulder regions protrusion

ipsilateral / contralateral Lx listing

L5 nerve may be compressed by L4/5 or L5/S1 disc

L5/S1 disc may compress L5 and /or S1 nerves

Nerve compression irritation

Neural tissues ischaemic inflammation

Peng, et al, 2006

slide28

Pathogenesis of Inter-vertebral Disc

Clinical Concerns

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

sacral iliac joint syndrome

Sacral Iliac Joint Syndrome

Applied Anatomy & Physiology

Weight-bearing synovial joint

Movement

A-P translation : ~3 to 7 mm

A-P rotation : ~3 to 5 degree

Male: likely fused in late 40

Female in late 60

DonTigny, 1990 DeMann, 1997

sacral iliac joint syndrome1

Sacral Iliac Joint Syndrome

Applied Anatomy & Physiology

Stable with form and force closure

Form closure: closely fit joint surface (sulcus)

Force closure: muscles, ligaments & thoracolumbar fascia

No direct prime mover muscle

Strong dorsal / ventral SI

& sacrotuberous ligaments

Anterior dysfunction more likely

One of common metastasis area

DonTigny, 1990 DeMann, 1997

reliability sij tests freburger jk riddle dl 1999
4 Tests:

Gillet,stand flexion,sit flexion,supine to sit test

Results:

Sensitivity:8-44%

Specificity:64-93%

Negative predictive value:28-38%

Positive predictive value:61-79%

Reliability SIJ Tests(Freburger JK & Riddle DL,1999)
reliability of sij tests cibulka mt koldehoff r 1999
Reliability of SIJ Tests(Cibulka MT & Koldehoff R, 1999)
  • 4 clinical tests used together:stand flexion test,PSIS palpation,supine long sitting leg length test,prone knee flexion test
  • at least ¾ test should positive for positive
  • Result
    • Sensitivity :82%
    • Specificity: 86%
    • Negative predictive value: 84%
    • Positive predictive value: 86%
sacral iliac joint syndrome2

Sacral Iliac Joint Syndrome

Clinical Concerns

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

vascular vs spinal claudication

Vascular Vs Spinal Claudication

Applied Anatomy & Physiology

Vascular (Intermittent Claudication) :

- arterial insufficient of distal aorta, iliac or femoral arteries

- ischemic symptoms

Spinal (Spinal Stenosis):

- IVF occlusion

- mechanical constriction and irritation of spinal nerves

- impinging spinal nerves usually in dynamic extension pattern

Gray, 1999

vascular vs spinal claudication1

Vascular Vs Spinal Claudication

Clinical Concerns

Vascular:

Heavy smoker, > age 40 male

Diabetes, obesity, coronary heart disease

Common in calf, cramp, decrease dorsalis pedis pulse

Symptoms appear after similar distance walk, fast symptoms relieve with rest, even slow walking or standing

Worse in slope walking

Gray, 1999

vascular vs spinal claudication2

Vascular Vs Spinal Claudication

Clinical Concerns

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

slide38

Lumbar Dynamic Stability

Applied Anatomy & Physiology

Structural Defect (Spondylolisthesis)

  • Grade (I – III), likely at L4/L5 and L5/S1
  • Review the flexion / extension

x-ray view

  • Lumbar curvature kink
  • Usually associated with abdominus weakness / hamstring tightness
slide39

Lumbar Dynamic Stability

Applied Anatomy & Physiology

Neuromuscular Defect

  • Global Muscles

larger torque producing muscles

balance external loads

spine: erector spinae

  • Intrinsic Muscles

small local muscles

control joint position & mov’t planes

spine: multifidus; transversus abdominus

slide40

Lumbar Dynamic Stability

Neutral Zone

Neuromuscular Control

Active Structures

Passive Structures

  • A region of no or little resistance to motion in the middle of an IV joint’s ROM
  • Min. Passive Tissue Stiffness

Panjabi, 1992

Gay et al, 2006

slide41

Lumbar Dynamic Stability

Neutral Zone

  • A feature of natural ROM
  • Exists mainly in flexion / extension
  • Facet joint contribute much on NZ stability
  • Small change in torque gives moderate
  • change in position
  • Require complex control of IV joints by spinal muscles
  • Increase with increasing disc degeneration or injuries
  • Decrease with addition of muscle forces / spinal instrumentation

Gay et al, 2006

slide42

Lumbar Dynamic Stability

Clinical Concerns

Chronic LBP

  • Studies demonstrated delay onset or poor motor control of the intrinsic muscles
  • Multifidus max contracts at upright standing in normal subjects, while max. in 25 forward stooping in LBP patients

Hides, 1994; Lee et al, 2006

slide43

Lumbar Dynamic Stability

Clinical Concerns

  • 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

thoracolumbar junction syndrome

Thoracolumbar Junction Syndrome

Applied Anatomy & Physiology

Transition zone between two regions of facet orientation

Thoracic – coronal plane

Lumbar – sagittal plan

T12 - Superior facet inclined as Tx

Inferior facet inclined as Lx

T12 as an intermediate vertebrae during trunk rotation

Sebastian, 2006

thoracolumbar junction syndrome1

Thoracolumbar Junction Syndrome

Clinical Concerns

Symptoms at upper Lx and gluteal regions

Considerable rotational stress in TL and LS junctions

Associated with impact injury

(slipped / fell with buttock landed)

One of the common osteoporotic site

Sebastian, 2006

neurodynamic dysfunction

Neurodynamic Dysfunction

Applied Anatomy & Physiology

Neuro- connective tissues involvement

Dynamic mechanical irritation

Circulation deficiency (extra / intraneural circulatory system

Occasionally associated with neurogenic signs

Common adhesion sites at C6, T6 and L4 (approximate points)

SLR, Slump, ULTTs

Bulter, 1992; Ko et al, 2006

neurodynamic dysfunction1

Neurodynamic Dysfunction

Clinical Concerns

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

piriformis syndrome

Piriformis Syndrome

Applied Anatomy & Physiology

Sacral plexus L5, S1,2

Mainly hip external rotator

Entrapment of sciatic nerve

Comparable to sciatica

Buttock pain with muscle trigger points

Kuncewicz, et al, 2006

piriformis syndrome1

Piriformis Syndrome

Clinical Concerns

Symptoms similar to sciatica

After fall / leg twisting injury, pyomyositis, fibrosis after deep injection

Tight hip external rotator

Supine lying with different hip rotation when compared on both sides

Buttock pain on stretching the muscle

Fair tolerance on SLS

Kuncewicz, et al, 2006

thoracic outlet syndrome

Thoracic Outlet Syndrome

Applied Anatomy & Physiology

Non-specific label

Vascular: obstruction of subclavian artery / vein

due to: stenosis, cervical rib, thrombosis

Neurogenic: brachial plexus compression

due to: scared / tight scalene muscles

Sanders et al, 2007

thoracic outlet syndrome2

Thoracic Outlet Syndrome

Clinical Concerns

~ 90% neurogenic

Adson Test minimum clinical value

Neck rotation, head tilting elicit symptoms over contralateral arm

Abducting arm to 90in external rotation leads to symptoms within 60 sec

Symptoms with carrying low weight

Symptoms during sleeping

Sanders et al, 2007

take home message

Take Home Message

Make use of anatomy, physiology, pathology, movement sciences and biomechanics knowledge to analyze pathoanatomic activities

Integrate into clinical context

Test your clinical hypotheses

Looking for physical problems to treat

Confirm with patient’s response

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.