Lumbar Instability (Clinical/Radiographic)

Lumbar Instability (Clinical/Radiographic)
Ryan Tauzell, MA, PT, Cert. MDT

Disclosures None

History 1944 Knuttson: Method of diagnosing segmental instability by measuring sagittal plane translation and rotation with lateral flexion/extension radiographs, then compared to normal ranges

History White and Panjabi: Defined criteria for diagnosing instability
1990 1944 White and Panjabi: Defined criteria for diagnosing instability -Sagittal translation > 4.5mm, or > 15% vertebral body width -Sagittal rotation > 15o at L1-2, L2-3, or L3-4, > 20o at L4-5 or 25o at L5-S1

History 1992 1990 1944 Panjabi: presents a conceptual model of the spinal stabilization system, the neutral zone and clinical instability

History 1992 Today 1990 1944 Multiple studies on lumbar clinical instability and its role in LBP How far have we come in nearly 70 years?

Definitions Clinical Instability (Panjabi, 1992)
“A significant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits so that there is no neurological dysfunction, no major deformity, and no incapacitating pain”

Stabilization System (3 Subsystems) Vertebrae Facets Discs Ligaments
Muscles Tendons Active Neural Control Passive The Stabilization System is divided into 3 subsystems that are in constant interaction. CNS Nerves Feedback System

Subsystem Dysfunction?
Active Neural Control Passive Compensatory response from other subsystems

Response to Subsystem Dysfunction
Active Neural Control Passive Response to Subsystem Dysfunction Conceptual Response Immediate successful compensation from other subsystems Long-term compensation from one or more subsystems Injury to one or more subsystems Conceptual Outcome Normal Function Normal function with altered stabilization system Overall system dysfunction, LBP

Definitions Clinical Instability (Panjabi, 1992)
“A significant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits so that there is no neurological dysfunction, no major deformity, and no incapacitating pain”

Neutral Zone “That part of the range of the intervertebral motion, measured from the neutral position, within which the spinal motion is produced with a minimal internal resistance.” (Panjabi) Zone of high flexibility or laxity Portion of the range of motion that is highly flexible

Elastic Zone “That part of the physiological intervertebral motion, measured from the end of the neutral zone up to the physiological limit.” Zone of high stiffness/resistance Portion of the ROM that is highly stiff

Diagram of IV movement(Biely et al.)
High Laxity Zone ROM Weakness or Injury Zone ROM Strengthening, Osteophytes, Fusion High Resistance Neutral Zone may increase with injury or weakness and may decrease by strengthening, osteophyte formation and surgical fusion. Neutral Zone + Elastic Zone = Physiological ROM

Theoretical Construct
Passive Active Neural

Definitions Radiographic Instability: No standardized definition

Radiographic Limitations
Lateral Flexion/Extension: No standardized procedure False positives Variation in asymptomatic subjects Variable limits for cutoff values to diagnose instability Slight variation in patient position of direction of beam can produce 10%-15% variation in displacement measure Provides no information about the active and neural components Provides no information on what is occurring within range Can not reliably correlate abnormal image to pain/disability Clinical instability can exist without radiographic evidence of instability A definition for radiographic instability in uncertain as is the measure of lateral flexion/extension radiograph due to several confounding factors. Therefore, the diagnosis of clinical instability can not solely be produced from imaging

Validity of Clinical Instability
ADTO Are assessment protocols/tools available to accurately/reliably diagnose clinical instability? Once clinical instability is diagnosed, is there agreement on an established treatment? What is the best treatment for lumbar instability? Spratt KF, Weinstein JN. Chapter 25: Measuring clinical outcomes. In: Weisel S, ed. The Lumbar Spine. 2nd ed. v. 2. Philadelphia: W.B. Saunders Co., 1996:

Prevalence Depending on the cutoff limits and the study 12% of patients manually assessed for lumbar segmental instability (Abbott JH, McCane B, Herbison P, Moginie G, Chapple C and Hogarty T. Lumbar segmental instability: a criterion-related validity study of manual therapy assessment. BMC Musculoskeletal Disorders. 2005;6:56. doi: / ) 57% patients referred for flex/ext radiographs based on suspicion of instability (Fritz JM, Piva SR, Childs JD. Accuracy of the clinical examination to predict radiographic instability of the lumbar spine. Eur Spine J. 2005;14: There is a wide range of prevalence dependent on assessment methods

Is Lumbar Instability a Valid Subgroup?
Abbott et al. (2006) concluded lumbar segmental mobility disorders are a valid means of defining sub-groups within NSLBP in a conservative care population of patients with recurrent CLBP Prospective cohort of 138 consecutive patients with RCLBP, Roland Morris and VAS scores obtained Sagittal angular rotation and translation of each lumbar segment was measured on radiograph then compared to reference range derived from a study of 30 asymptomatic volunteers Lumbar Segmental Mobility Disorder (LSMD) defined as 2sd from reference mean Normal reference intervals developed using 2 models (Gaussian, novel normalized within-subjects) Rotational Instability: 23% Translational Instability: 32% Radiographic metholody was identical for symptomatic and asymptomatic groups with high reliability

Is Lumbar Instability Associated with pain/disability?
LSMDs are a valid means of defining sub-groups within NSLBP Abbott et al.(2006): Among patients with RCLBP, presence of any LSMD, regardless of how defined, does not appear to be strongly associated with greater levels of pain or disability compared to patients with other forms of NSLBP without LSMDs Short answer: NO. +/- LSMDs, pain/disability is the same within the black box of NSLBP

Assessment to Diagnosis
Abdullah et al. Clinical Test to Diagnose Lumbar Segmental Instability: A Systematic Review Hicks et al. Interrater Reliability of Clinical Examination Measures for Identification of Lumbar Segmental Instability Hicks et al. Preliminary Development of a Clinical Prediction Rule for Determining Which Patients With LBP Will Repsond to a Stabilization Exercise Program Abbott et al. Lumbar Segemental Mobility Disorders: Comparison of Two Methods of Defining Abnormal Displacement Kinematics in a Cohort of Patients with NSLBP Demoulin et al. Lumbar Functional Instability: A Critical Appraisal of the Literature Fritz et al. Accuracy of the Clinical Examination to Predict Radiographic Instability of the Lumbar Spine Abbott et al. Lumbar Segmental Instability: A Criterion-Related Validity Study of Manual Therapy Assessment Cook et al. Subjective and Objective Descriptors of Clinical Lumbar Spine Instability: A Delphi Study Kasai et al. A New Evaluation Method for Lumbar Spinal Instability: Passive Lumbar Extension Test In an attempt to answer the question of consistently accurate diagnostics, I reviewed several studies

Study Mix Prospective Cohorts: 5
Single group repeated measure interrater reliability study: 1 Critical Appraisal of Literature: 1 Delphi Study: 1 Systematic Review: 1

Assessment to Diagnosis Tests/Criteria Available
History Passive Active Age less than 40 Beighton Ligamentous Laxity Scale Prone Instability Test “Giving way” “Giving out” “Catching” “Locking” Avg SLR > 91o Aberrant Motions Temp. Relief with bracing Passive Lumber Extension Test Total Flexion > 53o Self manipulator Posterior Shear Test Total Extension > 26o Pain with transitions PAIVM Sit to stand test Pain with sudden movement PPIVM (flexion) Instability Catch Sign Difficulty sitting unsupported PPIVM (extension) Painful Catch Sign Difficulty with static positions Step off Apprehension Sign Frequent muscle spasms Lack of hypomobility Gower’s Sign Fear with movement Segmental Hinging Recurrent episodes Reversal of Lumbopelvic Rhythm Progressively worsening

Assessment to Diagnosis Tests/Criteria with high +LR(Diagnostic Accuracy)
+LR Shift in Probability >10 Large 5-10 Moderate 2-5 Small 1-2 Very small History Passive Active Age less than 40 (3.7) Beighton Ligamentous Laxity Scale (2.5) Prone Instability Test (1.7) “Giving way” “Giving out” “Catching” “Locking” Avg SLR > 91o (3.3) Aberrant Motions (1.6) Temp. Relief with bracing Passive Lumber Extension Test (8.8) Total Flexion > 53o (1.3) Self manipulator Posterior Shear Test (1.1) Total Extension > 26o Pain with transitions PAIVM (2.4) Sit to stand test (infinite, selection bias) Pain with sudden movement PPIVM (flexion) (8.7, 95% CI: 0.6, 134.7) Instability Catch Sign (1.8) Difficulty sitting unsupported PPIVM (extension) (7.1, 95% CI: 1.7, 29.2) Painful Catch Sign (1.4) Difficulty with static positions Step off Apprehension Sign (1.6) Frequent muscle spasms Lack of hypomobility with PA (5.0) Gower’s Sign Fear with movement (1.4) Segmental Hinging Recurrent episodes Reversal of Lumbopelvic Rhythm Progressively worsening Wide CI indicates imprecision in the estimate

Assessment to Diagnosis Tests/Criteria with high reliability
History Passive Active Age less than 40 Beighton Ligamentous Laxity Scale Prone Instability Test (k= ) “Giving way” “Giving out” “Catching” “Locking” Avg SLR > 91o Aberrant Motion with Trunk Motion (k=-0.07,0.60) Temp. Relief with bracing Passive Lumber Extension Test (high test-retest reliability, however no k value) Total Flexion > 53o Self manipulator Posterior Shear Test (k=0.27) Total Extension > 26o Pain with transitions PAIVM hypermobile (k=0.48) hypo (k=0.38) Sit to stand test Pain with sudden movement PPIVM (flexion) (-0.02, 0.26) Instability Catch Sign Difficulty sitting unsupported PPIVM (extension) (-0.02, 0.26) Painful Catch Sign Difficulty with static positions Step off Apprehension Sign Frequent muscle spasms Lack of hypomobility with PA (k=0.30) Gower’s Sign Fear with movement Segmental Hinging Recurrent episodes Reversal of Lumbopelvic Rhythm Progressively worsening

Assessment to Diagnosis Tests/Criteria Available (Multivariate)
Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil 2005;86: Variables in the Clinical Prediction Rule (CPR) for success with stabilization treatment Age less than 40 y/o (+) Prone Instability Test(k=0.69, 0.87) (+) Aberrant Movements (k=0.07,0.60) Avg SLR > 91o (ICC ) No. of Variables Present +LR 1 or more 1.3 ( ) 2 or more 1.9 ( ) 3 or more 4.0 ( ) No reliability score available for 3 or more tests, however Kappa for PIT, SLR and Aberrant Motions listed above. If Aberrant Movements are among the 3 tests, reliability would decrease significantly, along with validity

Assessment to Diagnosis Tests/Criteria Available (Multivariate)
Hebert JJ, Koppenhaver SL, Magel JS, Fritz JM. The relationship of transversus abdominis and lumbar multifidus activation and prognostic factors for clinical success with a stabilization exercise program: a cross-sectional study. Arch Phys Med Rehabil 2010;91:78-85. Predictors of clinical success with a spinal stabilization exercise program (+) Prone Instability Test (k=0.69, 0.87) (+) Aberrant Movement (k=0.07,0.60) Avg. SLR > 90o (ICC ) (+) Hypermobility with PA (k=0.30) # of prognostic factors = LM activation No relation between prognostic factors and TrA No Sn/Sp calculated, No LRs No. + Prognostic Factors The role of LM in spinal stabilization is controversial

Assessment to Diagnosis Summary
The Passive Lumber Ext Test is not validated, however comes the closest General consensus of nearly all studies is that diagnosis should not occur with one clinical test, but rather a cluster of signs/tests Does using multiple unreliable, inaccurate tests add clarity? Lack of correlation between radiographic findings and clinical symptoms increases uncertainty If a diagnosis can not reliably and accurately be established, can there be agreement on treatment?

ADTO Are assessment protocols/tools available to accurately/reliably diagnose clinical instability? Once clinical instability is diagnosed, is there agreement on an established treatment? What is the best treatment for lumbar instability?

Diagnosis to Treatment Agreement on established treatment?
Several studies agree “Stabilization exercise” “Stabilizing Exercise” “Trunk Muscle Stabilization Training” How this is carried out varies considerably Concentric, Eccentric, Isometric Muscle Firing, Sequencing, Patterning Position, Resistance, Reps Progression Feedback: US, EMG, Tactile, Visual

Diagnosis to Treatment Agreement on established treatment?
The most frequently cited study for exercise protocol: Richardson CA, Jull GA. Muscle control – pain control. What exercises would you prescribe? Manual Therapy 1995;1:2-10. Isometric co-contraction of the TrA and Multifidus with a static neutral spine Focus on precise muscle action with re-education of this contraction in: Quadriped Prone Upright positions Eventual functional training

Diagnosis to Treatment
Diagnosis to Treatment Is Stabilization Exercise doing what we think it is? McGill et al. proposed that no single muscle is the best stabilizer of the spine. Multiple muscles are required dependent on the task. This muscle activation produces stability: Muscles acting as ‘guywires’ Compression/Loading through antagonistic activity Stokes et al. : Analytical study of a biomechanical model Spinal Stability increased with increased intra-abdominal pressure (IAP) Forced component activation of abdominals decreased lumbar stability IAP generates an extension moment Can this extension moment inadvertently have an effect?

Diagnosis to Treatment Summary
Spinal Stabilization Specific Muscle Activation/Recruitment/Firing Gross core activation Intra-Abdominal Pressure Other / All A general framework of treatment

ADTO Are assessment protocols/tools available to reliably diagnose clinical instability? Once clinical instability is diagnosed, is there agreement on an established treatment? What is the best treatment for lumbar instability?

Treatment to Outcome Diagnosed Radiographic Instability
O’Sullivan (1997): …patients with CLBP and radiologic diagnosis of spondylolysis or spondylolisthesis. Results: A “specific exercise” approach decreased pain/disability/pain medication use significantly more than other commonly prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis/spondylolisthesis. Kumar (2011):…patients with lumbar segmental instability. Results: Segmental stabilization exercise was more effective than placebo intervention in symptomatic lumbar segmental instability. O’Sullivan (2011) Editorial:…’instability’ should be reserved solely for ‘unstable fractures’ and ‘unstable spondylolisthesis’. Lets look at the outcome of a matching treatment to diagnosed instability or suspicion of instability. Subgrouping the subject population improved the outcome of the matched treatment

Treatment to Outcome Absence of Instability
Koumantakis (2005): …patients with RCLBP and no clinical signs suggesting spinal instability Conclusion: Stabilization exercises do not appear to provide additional benefit to patients with subacute or CLBP who have no clinical signs suggesting the presence of spinal instability Rachwitz (2006):…patients with acute, subacute and CLBP Conclusion: For LBP, segmental stabilizing exercises are more effective than treatment by GP (walking, stretching, swimming, education, active rest, out of work, traction, STM), but they are not more effective than other physiotherapy interventions. Macedo (2012):…patients with CLBP Conclusion: The results of this study suggest that motor control exercises and graded activity have similar effects for patients with chronic nonspecific low back pain.

Recurrence Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine 2001;26: 1 and 3 year follow-up of exercise group (Richardson,Jull) vs. control group after acute, first-episode LBP. 1 year after treatment: specific exercise recurrence was 30%, control was 84% 2-3 years after treatment: specific exercise recurrence was 35%, control was 75% Hides and others did a follow-up study to the original 1996 study to document the the natural course of LM recovery and the effectiveness of specific exercise on muscle recovery Patients of both groups most commonly reported precipitating incidents of recurrence related to lifting Lifting is a flexion-based movement DP was not ruled out initially Prevalence data shows that up to 90% of patient’s with acute LBP have a DP

ADTO Are assessment protocols/tools available to accurately/reliably diagnose clinical instability? Once clinical instability is diagnosed, is there agreement on an established treatment? What is the best treatment for lumbar instability?

Instability may be a valid subgroup
Cloudy ADTO Linkage Instability may be a valid subgroup Stabilization Exercise may be effective

Where do I start? With the suspicion of instability (history)
Cook C, Brismee JM, Sizer PS. Subjective and objective descriptors of clinical lumbar spine instability: a delphi study. Manual Therapy 2006;11:11-21 122 PTs with OCS and/or FAAOMPT training responded fully to create a consensus on the subjective and objective symptoms associated with clinical instability of the spine. Ranked lists of subjective and object reports were created Fritz (2005):…patients with LBP referred for flexion-extension radiographs due to suspicion of lumbar instability Conclusion: Prevalence is much higher in this study (57%) compared to other studies.

Top 10 subjective reports associated with clinical instability
Reports feeling of “giving way” or back “giving out” Self manipulator who feels the need to frequently crack or pop the back Frequent bouts or episodes of symptoms History of painful catching or locking during twisting or bending of the spine Pain during transitional activities (e.g. sit to stand) Greater pain returning to erect position from flexion Pain increased with sudden, trivial, or mild movements Difficulty with unsupported sitting and better with supported backrest Worse with sustained postures and a decreased likelihood of reported static position that is not painful Condition is progressively worsening (e.g. shorter intervals between bouts)

What Can I Do Monday? History that suggests instability, +/- radiographic diagnosis Catching / Locking / Giving out / Pain with sudden movements Rule out Directional Preference If DP can be ruled out, history suspicious of instability becomes more relevant Perform tests, use criteria with the best available evidence (diagnostic accuracy/reliability) Passive Lumbar Extension Test Age < 40 y/o Avg SLR > 91o Perform Lumbar Stabilization Exercise per Richardson and Jull Progress to patient specific functional limitations

References Nizard RS, Wybler M, Laredo JD. Radiologic assessment of lumbar intervertebral instability and degenerative spondylolisthesis. Radiol Clin North Am 2001;39:55-71 Cook C, Brismee JM, Sizer PS, Jr. Subjective and objective descriptors of clinical lumbar spine instability: a Delphi study. Manual Therapy 2006;11:11-21 Hides JA, Richardson CA, Jull G. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine 1996;21: Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine 2001;26:E243-E248 Fritz JM, Piva SR, Childs JD. Accuracy of the clinical examination to predict radiographic instability of the lumbar spine. Eur Spine J 2005;14: DOI: /s =0803-4 O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997;22: Kumar SP. Efficacy of segmental stabilization exercises for lumbar segmental instability in patients with mechanical low back pain: a randomized placebo controlled crossover study. N Am J Med Sci 2011;3: doi: /najms Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Physical Therapy 2005;85: O’Sullivan P. (Editorial) It’s time for change wit h the management of non-specific chronic low back pain. Br J Sports Med doi: /bjsm Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary Development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys med Rehabil 2005;86: McGill SM, Grenier S, Kavcic N, Cholewicki J. Coordination of muscle activity to assure stability of the lumbar spine. Journal of Electromyography and Kinesiology 2003;13: Wallwork TL, Stanton WR, Freke M, Hides JA. The effect of chronic low back pain on size and contraction of the lumbar multifidus muscle. Manual Therapy 2009;14: Biely S, Smith SS, Silfies SP. Clincial instability of the lumbar spine: diagnosis and intervention. Orthopaedic Practice 2006;18:11-18 Cook C, Brismee JM, Sizer PS. Subjective and objective descriptors of clinical lumbar spine instability: a delphi study. Manual Therapy 2006;11:11-21 Richardson CA, Jull GA. Muscle control-pain control. What exercises would you prescribe? Manual Therapy 1995;1:2-10 Stokes IAF, Gardner-Morse MG, Henry SM. Abdominal muscle activation increases lumbar spinal stability: analysis of contributions of different muscle groups. Clin Biomech 2011;26: Alqarni AM, Schneiders AG, Hendrick PA. Clinical tests to diagnose lumbar segmental instability: a systematic review. JOSPT 2011;41: Demoulin C, Destree V, Tomasella M, Crielaard JM, Vanderthommen M. Lumbar functional instability: a critical appraisal of the literature. Annales de Readaptation et de Medecine Physique 2007;50: Abbott JH, Fritz JM, McCane B, Shultz B, Herbison P, Lyons B, Stenfanko, Walsh RM. Lumbar segmental mobility disorders:comparison of two methods of defining abnormal displacement kinematics in a cohort of patients with non-specific mechanical low back pain. BMC Musculoskeletal Disorders 2006;7:1-11. doi: / Kasai Y, Morishita K, Kawakita E, Kondo T, Uchida A. A new evaluation method for lumbar spinal instability: passive lumbar extension test. Physical Therapy 2006;86:

References Leone A, Guglielmi G, Cassar-Pullicino VN, Bonomo L. Lumbar intervertebral instability:a review. Radiology 2007;245:62-77. Hayes MA, Howard TC, Gruel CR, Kopta JA. Roentgenographic evaluation of lumbar spine flexion-extension in asymptomatic individuals. Spine 1989;14: Danneels LA, Vanderstraeten GG, Cambier DC, Witvrouw EE, Bourgois J, Dankaerts W, DeCuyper HJ. Effects of three different training modalities on the cross sectional area of the lumbar multifidus muscle in patients with chronic low back pain. J Sports Med 2001;35: Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord 1992;5: Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord 1992;5: Abbott JH, McCane B, Herbison P, Moginie G, Chapple C, Hogarty T. Lumbar segmental instability: a criterion-related validity study of manual therapy assessment. BMC Musculoskeletal Disorders 2005;6:1-10. doi: / Rackwitz B, de Bie R, Limm H, von Garneir K, Ewert T, Stucki G. Segmental stabilizing exercises and low back pain. What is the evidence? A systematic review of randomized controlled trials. Clin Rehabil 2006;20: Hebert JJ, Koppenhaver SL, Magel JS, Fritz JM. The relationship of transversus abdominis and lumbar multifidus activation and prognostic factors for clinical success with a stabilization exercise program: a cross-sectional study. Arch Phys Med Rehabil 2010;91:78-85 Waddell G, Sommerville D, hendersonI, Newton M. Objective clinical evaluation of physical impairment in chronic low back pain. Spine 1992;17: Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability of clinical examination measures for identification of lumbar segmental instability. Arch Phys Med Rehabil 2003;84: Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. Arch Phys Med Rehabil 2005;86: Spratt KF, Weinstein JN. Chapter 25: Measuring clinical outcomes. In: Weisel S, ed. The Lumbar Spine. 2nd ed. v. 2. Philadelphia: W.B. Saunders Co., 1996:

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Lumbar Instability (Clinical/Radiographic)

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