1. 1 Alex Wong Senior Physiotherapist Queen Elizabeth Hospital 3 January 2009 Clinical Reasoning Lumbosacral Dysfunction Assessment & Treatment

2. 2 Contents Classification of Lumbo-sacral Dysfunctions Clinical Reasoning Practice Case Illustration Examination /Treatment Skills Take Home Message

3. 3 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……….

4. 4 Classification of Lumbo-sacral Dysfunctions Purpose Direct Specific and Effective Treatments to Homogenous Sub-group Ford et al, 2007

5. 5 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

6. 6 Classification of Lumbo-sacral Dysfunctions McKenzie Approach Postural – symptoms after static position Dysfunctional – symptoms at end range Derangement – symptoms through range MeKenzie

7. 7 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

8. 8 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

9. 9 Clinical Reasoning Practice

10. 10 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

11. 11 Clinical Reasoning Process Generate Patient Identified and Generate Patient Identified and Non-identified Problem Lists (S/E) Non-identified Problem Lists (S/E) Formulate Exam. Strategy Formulate Exam. Strategy Conduct Examination and Analyze (O/E) Conduct Examination and Analyze (O/E) Generate Working Hypotheses Generate Working Hypotheses Intervention Re-assessment Rothstein, 2003

12. 12 Subjective Complaint (generate the clinical hypothesis) Examination, O/E (confirm the clinical hypothesis) Intervention (base on the O/E, findings) Clinical Reasoning Process

13. 13 Case Illustration

14. 14 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

15. 15 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

16. 16 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

17. 17 Conduct Examination, O/E (base on clinical hypothesis) Case 1 O/E postural defect movement quality (L4,5) regular movement pattern quadrant palpation (extension)

18. 18 Treatment Choice (base on examination findings) Case 1 Treatment facet joint passive mobilization mobilize in extended position (L4,5) extension exercises

19. 19 Formulate Problem Lists (base on clinical presentations) 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 cant tolerate public transport (bus, mini-bus)

20. 20 Generate Clinical Hypothesis (base on clinical presentations) 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

21. 21 Nature of injury (F/Rot) Delayed symptoms after injury Sensitive to vibration Morning symptoms Increase symptoms on changing intra-abdominal pressure Restricted movt of neuro-tissues Lumbar listing (ipsilat. / contralat.) Diagnosed by MRI (match with sym) Discogenic Back Pain Peng, et al, 2006

22. 22 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

23. 23 Treatment Choice (base on examination findings) Case 2 Treatment listing correction rotation mobilization Mckenzie exercises extension with listing correction

24. 24 Formulate Problem Lists (base on clinical presentations) 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 cant tolerate cross leg sitting & pulling activities

25. 25 Generate Clinical Hypothesis (base on clinical presentations) 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

26. 26 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

27. 27 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

28. 28 Treatment Choice (base on examination findings) Case 3 Treatment leg traction posterior pelvic tilting hamstring strengthening (muscle energy)

29. 29 Formulate Problem Lists (base on clinical presentations) 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

30. 30 Generate Clinical Hypothesis (base on clinical presentations) 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

31. 31 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 Lumbar Dynamic Stability Hides, 1994; Lee et Al, 2006

32. 32 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

33. 33 Treatment Choice (base on examination findings) Case 4 Treatment supine traction prone traction abdominal exercises stabilization exercises

34. 34 Formulate Problem Lists (base on clinical presentations) 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

35. 35 Generate Clinical Hypothesis (base on clinical presentations) 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

36. 36 Neurodynamic Dysfunction Relative dynamic movt 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

37. 37 Conduct Examination, O/E (base on examination strategy) Case 5 (aggravating approach) O/E stable symptoms relative dynamic movt of neuroconnective tissues deficiency: - total length insufficiency, adhesion to sensitive structures, poor excursion / gliding movements ULTT, Slump

38. 38 Treatment Choice (base on examination findings) Case 5 Treatment hamstring stretching (cadual / cephelic direction) slump

39. 39 Formulate Problem Lists (base on clinical presentations) 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

40. 40 Generate Clinical Hypothesis (base on clinical presentations) 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

41. 41 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

42. 42 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

43. 43 Treatment Choice (base on examination findings) Case 6 Treatment crook lying traction rotation mobilization rotation with SLR abdominal strengthening

44. 44 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, OSullivan 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.

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