Assessment and Treatment of Low Back Pain - A Comprehensive Approach
This article discusses the goals of individualized and efficient treatment for low back pain, as well as an overview of the physical exam process. Areas of focus include pain behavior, gait, motor strength, and muscle reflexes.
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1. Assessment and Treatment of Low Back Pain Steven Stanos, DO Medical Director Center for Pain Management Rehabilitation Institute of Chicago Asst. Professor, Dept. PM&R Northwestern University Medical School Feinberg School Of Medicine
2. Goals Individualized yet comprehensive Efficient Comfortable for patient Comfortable for clinician Build rapport Educate and prepare patient for treatment Monitor for inconsistencies
3. Physical Exam Overview Pain behavior Gait Motor strength Muscle stretch reflexes Dural tension testing Sacral iliac joint testing Myofascial assessment Kinetic Chain considerations
4. Anatomy of LumboSacral Spine Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum , 3 rd . Ed. Churchill Livingstone, 1999.
5. Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum , 3rd. Ed. Churchill Livingstone, 1999. Annulus Fibrosis
6. Lumbar Facets: zygapophysial joints z-joint Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum , 3rd. Ed. Churchill Livingstone, 1999.
7. Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum , 3rd. Ed. Churchill Livingstone, 1999. Degenerative Cascade
8. Definitions Somatome : field of somatic and autonomic innervation based on embryologic segmental origin of somatic tissues three basic elements : 1. Dermatome : cutaneous structures 2. Myotome : skeletal musculature 3. Sclerotome : bones, joints, and ligaments 8 Inman VT, Saunders J. J Nerv Ment Dis 1944;99:660-67.
9. Spinal stability Neural Control Unit Spinal Column Spinal Muscles Vertebral Position Spinal Loads Spinal Motions Muscle Activation Patterns Panjabi MM. J Electromyography Kinesiology 2003:12:371-9
10. Core muscle groups Abdominals (Front) Paraspinals and gluteals (Back) Diaphragm (Roof) Pelvic floor and hip muscles (Bottom) Richardson C, et al . Therapeutic exercise for spinal stabilization and low back pain . Edinburgh (Scotland): Churchill Livigstone1999.
11. Abdominals Local muscles (Slow twitch) Transversus abdominus Multifidi Internal oblique Pelvic floor Global Muscles (Fast-twitch) Erector spinae External oblique Rectus abdominus MULTIFIDI ERECTOR SPINAE Panjabi MM. J Electromyography Kinesiology 2003:12:371-9
12. the 15 minute rotisserie special
13. Pain Behaviors Grimace Groan Guarding Overreaction Inconsistencies Give-way weakness Shaking Equipment Cane Ice-packs, Heating pads Braces: collars
14. Gait Balance Base of support Arm swing/ trunk and shoulder rotation Cadence Leg: cicumduction, stance time, position Pain behavior
15. Static Stance Assessment (J. Rittenberg. Photos from practice & personal files used with permission) L4-L5 PSIS
16. Flexion Based Muscular Ligamentous Compression Fracture Discogenic Extension Based Stenosis Facet Spondylosis Central Disc Transitional Spondylolisthesis Sacroiliac Facet Differential Diagnosis
17. Facet Arthropathy Zygapophyseal (z-joint) Poor correlation with history and exam 1 Commonly pain with extension & rotation Referral patterns 2 1. Schwarzer AC, et al. Spine 1994;19:1132-7. 2. Slipman, C. Arch PM&R 81:334-338, 2000.
18. Myofascial Assessment
19. Myofascial Trigger Points Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual , Volume 2. Williams & Wilkins, Baltimore, 1992.
20. Muscle pain is not skin pain Jay Shah, MD
21. Myofascial Trigger Points (MTrPs) Active cause a clinical pain complaint or other abnormal sensory symptoms Latent show all the other characteristics of active MTrPs, except that theyre pain free
22. Muscle Pain Aching and cramping Difficult to localize and refers to other deep somatic tissues (fascia, muscle, joints) Muscle nociceptive activity is processed differently in the CNS Inhibited more strongly by descending pain-modulating pathways than cutaneous pain
23. Symptoms Local & referred pain Pain with iso contraction Stiffness, limited ROM Muscle weakness Paresthesia & numbness Propriocpetive disturbance Autonomic dysfunction Physical Findings Local Tenderness Single or multiple muscles Palpable nodules Firm or Taut Bands twitch response (LTR) Jump sign Muscle shortening Limited joint motion Muscle Weakness
24. Motor Strength Testing 5 = Normal, full ROM vs. gravity, max resistance 4 = Good, full ROM vs. gravity, moderate resistance 3 = Fair, full ROM vs. gravity, no resistance 2 = Poor, full ROM, gravity eliminated 1 = Trace 0 = No activity
25. Core Stabilization Testing
26. Muscle Stretch Reflexes Lower Limb Patella (L2, L3,L4) Medial hamstring (L5,S1) Achilles (S1, S2)
27. Muscle Stretch Reflexes 4 + = hyperactive with clonus 3 + = more brisk 2 + = normal response 1 + = decreased with facilitation 0 = no response
28. Radiculopathy Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum , 3rd. Ed. Churchill Livingstone, 1999. Sitting Standing Walking Bending Valsalva or cough
29. Dural Tension Signs Straight Leg Raise (SLR) Slump Seated Femoral Nerve Stretch (J. Rittenberg. Photos from practice & personal files used with permission)
30. Straight Leg Raise:
31. Epidural Space Contents: Loose areolar connective tissue Semiliquid fat Lymphatics Arteries Extensive plexus of veins Spinal nerve roots Segmented and discontinuous
33. Transforaminal Approach
34. Injection Techniques S1 Transforaminal Epidural Dr. Stanos personal files. Nelemans PJ, et al. Spine 2001;26:501-15.
35. Caudal Approach
38. Axial Low Back Pain Degenerative disc disease (DDD) Internal disc derangement (IDD) Facet dysfunction Myofascial dysfunction 2005 Rehabilitatio Institute of Chicago
40. Dorsal Rami Anatomy
44. Sacroiliac Joint and Pelvis
45. Integral Components of SIJ motion Form closure: joint surfaces congruently fit together Force closure: muscles & ligaments provide force to withstand load Motor control: timing & sequencing of muscle activation & release Emotion & awareness: emotions can influence motor control Vleeming A, et al. Spine 1990;15:133-5
46. Sacroiliac Joint Pain Referral Zones Buttocks 94% Thigh 48% Lower leg 28% Foot / ankle 13% Groin 14% Abdomen 2% Dreyfuss D, J Am Acad Ortho Surg 2004, 12.
47. SIJ Assessment (J.Rittenberg. Photos from practice & personal files used with permission)
48. Sacroiliac Joint Provocative Tests: SIJ border tenderness Patricks test Gaenslens test Prone hip extension Compression testing Fortin J, et al, Spine 1994;19:1475-82.
49. Sacroiliac Joint Injections Bogduk N, MJA 2004;19:79-83.
50. Lumbar Spinal Stenosis: Posture Akuthota, V. Pathogenesis of lumbar spinal stenosis pain. Phys Med Rehab Clin N Am 14:17-28, 2003. With permission. J. Rittenberg. Used with permission.
51. BI-Level Central Neurovascular Claudication Porter RW. Spine 1996;21:2046-52. Onset with walking Heavy sensation Variability Attempt to increase flexion Stooped posture
52. Lumbar Spinal Stenosis: Simian Stance Posterior pelvic tile Hips, knees flexed Hands face backwards Hip and psoas tight Gluteus and piriformis inhibited Gait: lumbar flexion
53. Geraci, M. Rehabilitation of the hip and pelvis. In: Kibler WB. Functional Rehab Sports Musculoskeletal Med; Aspen Publishers,1998. With permission. Weak and Inhibited Muscles
54. Finding Balance Underactive Overactive Shortened Stabiliser Synergist Antagonist Glut Medius TFL, QL, Pirif ormis Thigh adductors Glut Maximus Iliocast, Hamstring Iliopsoas, Rec Fem Lower Trapezius Levator Scapulae Pectoralis Major Upper trapezius Geraci, M. Rehabilitation of the hip and pelvis. In: Kibler WB. Functional Rehab Sports Musculoskeletal Med; Aspen Publishers,1998. With permission.
55. trapezius and cercival spine
56. Cervical & Scapular Dysfunction (Janda 2002)
57. APS: LBP Guidelines Categorize the condition Nonspecific low back pain? Back pain associated with neurologic deficits, radiculopathy or spinal stenosis? Back pain associated with an alternate cause? Identify patients who require urgent surgical evaluation Chou R, et al. Ann Intern Med . 2007;147:478-491.
58. Acute Low Back Pain Red Flags Cauda equina syndrome? Cancer? Infection? Fracture? Confirmation of red flag conditions may require Lab testing [complete blood count (CBC)/erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP)/ urinalysis (UA) and PSA when appropriate] Medical imaging [lumbosacral (LS) radiographs/computed tomography (CT)/magnetic resonance imaging (MRI)] Test results may indicate need for emergent surgical referral Chou R, et al. Ann Intern Med . 2007;147:478-491. Chou R, et al. Lancet . 2009;373:463-472.
59. Pharmacologic Interventions Acute Low Back Pain Drug Net benefit Level of evidence Acetaminophen Small to moderate Fair NSAIDs Moderate Good Skeletal muscle relaxants Moderate (for acute LBP only) Good Chou R, et al. Ann Intern Med . 2007;147:504-514.
60. Guideline Highlights
61. Chou R, et al. Ann Intern Med . 2007;147:478-491. Guideline Highlights 1. Conduct a focused history and physical examination Assess severity of baseline pain and functional deficits 2. Evaluation of psychosocial risk factors is essential to predict the risk for chronic, disabling low back pain 3. Limit use of diagnostic imaging and testing Except in patients with signs of severe or progressive underlying disease or those with neurologic deficits
62. Recommendation 6 ACP/APS Guidelines 2007 Clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy. For most patients, first-line medication options are acetaminophen or NSAIDs. (Strong recommendation, moderate-quality evidence) Chou R, et al. Ann Intern Med . 2007;147:504-514.
63. Pharmacologic Interventions Drug Net benefit Level of evidence Acetaminophen Small to moderate Fair NSAIDs Moderate Good Skeletal muscle relaxants Moderate (for acute LBP only) Good Tricyclic antidepressants Small to moderate (for chronic LBP only) Good Opioids and tramadol Moderate Fair Benzodiazepines Moderate Fair Antiepileptic medications Small ( for gabapentin in patients with radiculopathy only) Unable to estimate topiramate Fair for gabapentin to poor for topiramate Systemic steroids No benefit Good Chou R, et al. J Pain . 2009;10:113-130.
64. Summary Comprehensive, but focused Efficient Exam should be easy on you and the patient Great opportunity to initiate a therapeutic relationship and dialogue Use a good exam to improve outcomes and identify deficits or impairments