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. Oswestry Questionnaire Self Report of Performance Limitation Personal Hygiene Lifting Walking Sitting Standing Sleeping Social Activity Traveling Sex Life Pain Intensity Scale: 0 - 5Maximum Score = 50 No MaxDouble 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 IInability 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

51. Extension Worsens Supine Traction

52. Sidebending/Worsen Asymmetrical Sidebending –Cyriax Non Capsular Pattern Do Repeated Motions Worsen –Traction Syndrome

53. Sidebending/Improve Symmetrical (Capsular) Do Repeated Motions Improve? –Flexion Syndrome ACTIVE FLEXION –Extension Syndrome ACTIVE EXTENSION

54. Centralization Phenomenon Intensity will increase as pain centralizes Once no radicular symptoms ~2wks left Must re-introduce provocative motion once radicular symptoms are resolved

55. Improve with Extension What would the treatment look like?

56. Improve with Extension CASH Brace Worn 24hrs Wean Slowly

57. Improve with Extension Prone Press Ups

58. Self Correction for Extension Repeated Extension in Standing Performed every 30 minutes

59. Posterior/Anterior Glides Assessment Symptom Provocation Treatment

60. Flexion Improves What would the treatment look like?

61. Flexion Improves Flexion Exercise

62. Flexion Improves Flexion Postures

63. Flexion Mobilizations SNAGs with Belt

64. Status Quo

65. Sidebending/Status Quo Symmetrical (Capsular) Mobilization Syndrome –Passive Flexion General –Passive Extension General

66. Flexion Range is Decreased What would a treatment look like?

67. General Flexion Flexion Mobilizations Flex LE to desired levels Posterior Glide of LE on segments

68. General Flexion for Home Slouched sitting Flexion stretches Flexion activity –Rower –Bike

69. Extension is Limited What would the treatment look like?

70. General Extension PA Glides Begin in Neutral Progress to Extended Position

71. General Extension for Home Force Movement at Specific Levels Modified Press Up Exercise Extension at L3 Towel Roll to flex at L4/5

72. Sidebending/Status Quo Asymmetrical (Non capsular) No Pattern –General Mobilization Specific Pattern –Specific Mobilization

73. Opening Restriction What does the range loss look like?

74. Opening Restriction Forward Flexion –Deviation to the side of the Restriction Sidebending –Limitation to the contralateral side Combined Flexion and Contralateral SB’ing

75. Opening Mobilization Flex to desired level Lift Bilateral LE to ceiling to gap/open Opening on side on table Progression - Laterally flex table

76. Opening Mobilization Joint Glide in Flexion Look for deviation with forward flexion to determine where in range to mobilize

77. Closing Restriction What would the pattern look like?

78. Closing Restriction Extension –Deviation to contralateral side Sidebending –Limitation to the ipsilateral side Combined Extension and Ipsilateral SB’ing

79. Closing Mobilizations PA’s with unilateral support SNAG’s in Extension

80. Opening/Closing Manipulation Flex to level of involvement (Gap L4/5 to manipulate L4) Stabilize LE

81. Opening/Closing Manipulation Maximally Rotate Upper Body to end range Have Patient Exhale and relax abdominals Overpress gently with upper body rotation Closes side toward ceiling/Opens opp.

82. Maximize Gains with Home Programs Home Exercise of Towel Sitting Open- Contralateral Close- Ipsilateral

83. Lumbar Instability Immobilize/Stabilize What would the pattern look like?

84. Instability No range Restrictions Glitch in forward bending Need to support to return from flexed position

85. Joint Shear Testing

86. General Stabilization Pelvic Neutral with leg lowering

87. General Stabilization Side Lift –Quadratus –Obliques –Minimal LB stress

88. Lumbar Weakness/Instability High Intensity Electrical Stimulation to Lumbar Paraspinals 2500Hz Sine wave 75 burst/sec 15 on/ 50 off (3sec ramp) 15 contractions

89. Electrical Stimulation for Strengthening

90. Classification

92. Case 1 18 year old soccer player 6wk history of LBP Played until 1 week ago then too painful to overcome Dull aching right sided low back pain –Denies pain in any other location

93. Case 1 Soccer Player Pain is 0-7/10 Pain with Activity –shooting ball –cutting back and forth –right sidebending Pain improves –Rest –Ice –Relafen

94. Case 1 Soccer Player 3 of 4 SIJ tests (-) 50% reduction in Right Sidebending Good Forward Bending 50% reduction in Left Rotation Extension is 50% limited Quadrant Test or Max ? Test is +

95. Hypothesis What is wrong with this player? What group does he belong in?

96. Hypothesis Status Quo Closing Restriction Specific Mobilization How would you treat him? How long will it take?

97. Case 1 Soccer Player Outcome Performed manipulation on first treatment –Greater than 50% improvement in range –Joint mobilizations for closing –Home program Facet joint closing with towel under right buttock Prone press ups at home

98. Case 1 Soccer Player Outcome Next Treatment 60% improvement in pain and range Continued with closing mobilizations 4 th treatment return to full 100% painfree play

99. Case 2 60 year old with back and leg pain –Left buttock, anterior knee and big toe Symptoms provoked –Walking < 1 mile –Standing 10-15 minutes Symptoms increase –Squatting –Sitting

100. Case 2 60 year old Oswestry 16% LQS Left Quad and HS 4+/5 compared to R All other = B and Reflexes =B Sensation- Slight decrease L3 and S1 on Left

101. Movement Testing Asymmetrical sidebending (decreased L) –Recreates buttock pain Flexion and Extension 75% limited pain-free –Left deviation with forward flexion Repeated L sidebending increases tingling in toe –symptoms resolve on standing L Quadrant closing recreates foot symptoms –Symptoms resolve when return to standing

102. Joint Play L2 and L3 Hypomobile L4, L5 N L5/S1 Unilateral –Recreates buttock pain L4/5 Unilateral –Sore with empty end feel

103. Special Tests SLR (-) Slump Test (+) Left –Recreates Buttock Pain Palpation to piriformis –Recreates buttock c/o

104. Case 2 What do you suspect is wrong? What category does he fall into? What will his treatment program look like?

105. Case 2 Asymmetrical Sidebending Status Quo or Worsen Indication of Radiculopathy –May argue worsen with extension Closing Restriction

106. Case 2 Treatment Joint Mobs to Hypomoblie segments –Specific mobilizations Traction –Mechanical effects of intervetebral separation –Parameters to maximize

107. Treatment and Traction –130 lbs first day- progressing to 190 over 4 treatments –12 th treatment walk greater than 1 mile with no symptoms and raquetball with no symptoms –16 th treatment- could stand to lecture today –23 rd treatment- walked around campus 3x today Walking is fun –25 th treatment- great weekend but has buttock pain- + SIJ testing

108. Acute Lumbar Treatment Diagnosis Can Lead Intervention Classification Dictates Treatment Maximize Treatment Goals; In Clinic, Home, and Return to Work

109. Delitto et al Physical Therapy 75:6 1995 Greenwood et al JOSPT 27:4 1998 Fritz Physical Therapy 78:7 1998 McGill Physical Therapy 78:7 1998 Fritz et al Physical Therapy 78:8 1998