Transcript Work Plan & Progress Report by Risk Management

Lumbar Spine and
Pelvic Dysfunctions
Alex Wong
Senior Physiotherapist
Queen Elizabeth Hospital
19 September 2008
1
Contents
 Classification of Lumbo-sacral
Dysfunctions
 Clinical Reasoning Practice
 Clinical Concerns Related to
Reasoning
 Take Home Message
2
Vague Diagnosis of LBP
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80% no structural diagnosis
Limited evidence to support
classification
Vague complaints to relate pathology
Poor understanding biomechanics
Complicated treatment outcomes
impairment, disability, capability
psychosocial……….
3
Classification of
Lumbo-sacral Dysfunctions
Purpose
Direct Specific and Effective
Treatments to Homogenous
Sub-group
Ford et al, 2007
4
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
5
Classification of
Lumbo-sacral Dysfunctions
McKenzie Approach
Postural – symptoms after static
position
Dysfunctional – symptoms at end
range
Derangement – symptoms
through range
MeKenzie
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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
7
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
8
Clinical Reasoning
Practice
9
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
10
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
11
Clinical Reasoning
Generate Patient Identified and Nonidentified 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
12
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
13
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
14
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
15
Clinical Reasoning
Intervention
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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
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Formulate Examination Strategy
(base on clinical presentations)
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Formulate Examination Strategy
(base on clinical presentations)
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)
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Conduct Examination, O/E
(base on examination strategy)
Intervention
(base on examination, O/E, findings)
19
Clinical Concerns
Related to Reasoning
in
Lumbo-sacral Dysfunctions
20
Pathological “Red Flags”
Most clues are in history
Not in physical
examinations
Wilk, 2004
21
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
22
Potential Tissue Injured
Clinical Concerns
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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…..
23
Facet Joint / Extension Syndrome
Applied Anatomy & Physiology
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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
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Facet Joint / Extension Syndrome
Clinical Concerns
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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
25
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
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Pathogenesis of
Inter-vertebral Disc
Applied Anatomy & Physiology
Prolapsed Inter-vertebral Disc
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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
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Pathogenesis of
Inter-vertebral Disc
Clinical Concerns
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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
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Sacral Iliac Joint Syndrome
Applied Anatomy & Physiology
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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
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Sacral Iliac Joint Syndrome
Applied Anatomy & Physiology
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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
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Inter-rater Reliability of SIJ Tests
(Oldreive,1995)
Test
% of Agreement
Iliac crest standing level
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Iliac crest level in sitting
41
PSIS level in standing
35
PSIS level in sitting
35
ASIS level in sitting
43
ASIS level in standing
38
Standing flexion test
43
Sitting flexion
50
Side-lying iliac approximation
76
Supine/long sitting test
40
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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%
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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%
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Sacral Iliac Joint Syndrome
Clinical Concerns
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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
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Vascular Vs Spinal Claudication
Applied Anatomy & Physiology

Vascular (Intermittent Claudication) :
- arterial insufficient of distal aorta,
iliac or femoral arteries
- ischemic symptoms
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Spinal (Spinal Stenosis):
- IVF occlusion
- mechanical constriction and
irritation of spinal nerves
- impinging spinal nerves usually
in dynamic extension pattern
Gray, 1999
35
Vascular Vs Spinal Claudication
Clinical Concerns
Vascular:
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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
36
Vascular Vs Spinal Claudication
Clinical Concerns
Spinal:
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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
37
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
38
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
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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
40
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
41
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
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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
43
Thoracolumbar Junction Syndrome
Applied Anatomy & Physiology
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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
44
Thoracolumbar Junction Syndrome
Clinical Concerns
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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
45
Neurodynamic Dysfunction
Applied Anatomy & Physiology
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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
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Neurodynamic Dysfunction
Clinical Concerns
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Relative dynamic mov’t of neuroconnective 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
Bulter, 1992; Ko et al, 2006
- prefer for stable symptoms
47
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
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Piriformis Syndrome
Clinical Concerns
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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
49
Thoracic Outlet Syndrome
Applied Anatomy & Physiology
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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
50
Thoracic Outlet Syndrome
51
Thoracic Outlet Syndrome
Clinical Concerns
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~ 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
52
Take Home Message

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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
53
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