PT529 Lecture+Lab Week 1: Lumbar Spine Differential Diagnosis

What are the different types of lumbar spine pathologies?

Lumbar Intervertebral Disc (IVD)

Lumbar Facet Dysfunction

Lumbar radiculopathy

Lumbar Instability (Spondylolysis, Spondylolisthesis)

Lumbar Stenosis (Spondylosis, DDD, DJD)

Lumbar Sprain & Strain/ Whiplash

what is OA of the lumbar spine?

lumbar stenosis

what happens when the IVD thins?

less space for nerves to travel

osteophytes can build up

what is spondylolysis?

fracture of pars interarticularis

what is spondylolisthesis?

Anterior sliding of one vertebrae over another that occurs from instability from the pars interarticularis fracture

will spinal stenosis always have radicular sx?

no

may just have generalized LBP or limited mobility

will facet joint dysfunction always have radicular sx?

no

could have mobility and/or neural sx

IVD: demographic information

30-50 y.o.

IVD: onset/MOI

Insidious, gradual.

Microtrauma with excessive flexion...prolonged sitting..repetitive bending

Could be traumatic (MVA, forced compression, lifting)

IVD: pain location

Central or unilateral LBP/ buttock (referred pain)

IVD: other sx

Pressure and pain with Valsalva (coughing, sneezing, working out)

Stiff

what does the valsalva maneuver cause pain with IVD?

causes pressure pushing against the spine and abdominals

causes a posterior force on the spine which pushes the disc further back onto the nerve root

IVD: nature/description

basically any type of pain

Achy, Dull, constant, Sharp intermittent, globally in a region (not localized)

IVD: aggravating factors

Prolonged sitting, repetitive bending, flexion based postures and movements

IVD: easing factors

Lying down (prone or supine with pillows under knees), walking, (maybe standing)

IVD: objective exam

may have Loss of lordosis

may have lateral shift

AROM: flexion most painful, can have end range extension pain,

SLR may be +

+ PAIVM (CPA/UPA)

+ axial unloading

+ prone press-up test

how do people with IVD problems usually sleep?

prone position

why can flexion or extension feel good for people with IVD problem?

depends on severity

if very severe -> flexion may feel better bc this opens up the space. extension closes it down and if it is very severe and inflamed, this will hurt

if not as severe -> extension may feel better bc it pushes the disc forward

pain from an IVD follows what pattern?

NOT DERMATOMAL

usually over lower back, butt, and upper posterior thigh

why does flexion feel better with facet dysfunction?

flexion opens up the space

facet dysfunction: demographic information

20-50y.o.

facet dysfunction: onset/MOI

Sudden, MOI- twisting (golf, volleyball, lifting), upon awakening (back locked up)

facet dysfunction: pain location

Unilateral LBP/ buttock

facet dysfunction: nature/description

Acute pain/ inflamm? Could respond to NSAIDS.

facet dysfunction: aggravating factors

Sidebending toward, extension based movements (standing, walking), twisting movements

facet dysfunction: easing factors

Lying, sitting

facet dysfunction: objective exam

AROM: Asymmetrical pain with ext, SB (L or R),

(+) CPA/ UPA

prone pressup (finding would be negative)

Quadrant motion (ext with SB) -> painful

why is extension painful with stenosis?

extension further closes the space -> this is painful with osteophytes

stenosis: demographic information

Older, Age over 50 y.o.

stenosis: onset/MOI

Onset/ MOI

Gradual, weeks to months

stenosis: pain location

Bilateral LBP, lower extremity (unilateral or bilateral)...neurogenic claudication

stenosis: other sx

Paresthesias (numbness, tingling), weakness in LE's

stenosis: nature/description

Achy, dull, stiff, heaviness in legs, could be sharp at times

stenosis:aggravating factors

Standing, walking, extension postures

stenosis: easing factors

Flexion based postures (sitting, walking uphill)

stenosis: objective exam

Excessive lumbar lordosis (contributory)/anterior pelvic tilt (feels worse) OR loss of lumbar lordosis/ posterior pelvic tilt (compensatory)

AROM: pain and limited with extension, Symmetrical loss of SB ROM

Pain and hypomobility with CPA at involved segments

(+) Thomas test, weak lower abdominals

what is neural claudication?

aching in leg bc of movement which causes more neural compression

why is the Thomas test positive with stenosis?

often in a flexed position which shortens the illiopsoas and rectus femoris

lumbar radiculopathy: demographic information

30-50 y.o.

lumbar radiculopathy: onset/MOI

Insidious or sudden (pick up object)

lumbar radiculopathy: pain location

Leg pain with/ without LBP (below knee)

lumbar radiculopathy: other sx

Numbness, tingling, paresthesia, burning

lumbar radiculopathy: nature/description

Shooting pain down leg (pressure on dural sheath/sleeve)

lumbar radiculopathy: aggravating factors

Flexion activities: bending, sitting, lifting

lumbar radiculopathy: easing factors

Extension activities: standing, lying

lumbar radiculopathy: objective exam

+ SLR and other neurodynamic testing

(+) neuro screen findings (loss sensation, hyporeflexia, weakness)

+ PAIVM (CPA/UPA)

+ axial unloading

+ prone press-up test

what is considered an instability disorder?

spondylolisthesis

weak muscles

spondylolosis

instability: demographic information

younger < 40 y.o., post partum moms

Could be older if degenerative spondylolisthesis

instability: onset/MOi

Gradual with repetitive motions (extension...gymnast, dancer, volleyball)

instability: pain location

Diffuse, central or bilateral (could be unilat.), could be localized

instability: other sx

Feeling of instability (radicular in severe spondylolisthesis)

instability: nature/description

Could be intermittent that doesn't last long followed by achy, diffuse, constant low level pain "sore", pain with positional changes, unsupported sitting

instability: aggravating factors

Extension based

instability: easing factors

flexion postures

instability: objective exam

(+) step deformity if "listhesis"

Increased lumbar lordosis (ant. Pelvic tilt)

AROM pain at end ranges (especially ext) + Aberrant movements

(+) CPA pain/ hypermobile

(+) SLR > 90 deg

(+) Beighton (4>9),

prone hip extension for extension (MSI)

lower abdominal testing -> stretch bc APT

hip flexor length -> tight bc APT

sprain/strain: demographic information

Any age

sprain/strain: onset/MOI

Sudden, MVA (whiplash) or fall

sprain/strain: pain location

(B) Lower back, mid back, possible neck pain

sprain/strain: other sx

Tightness, muscle guarding, "spasms"

sprain/strain: nature/description

"back is locked"

sprain/strain: aggravating factors

No clear pattern, Sudden movements

sprain/strain: easing factors

Lying, heat, meds

sprain/strain: objective exam

AROM limited throughout and painful,

pt. can be fearful to move

Palpation most positive over erector spinae muscle group

No clear "key segment" with CPA's

Neg neuro screen and SLR

does clinical dx determine tx?

no

what determines tx?

SINSS

what is acute LBP?

less than 6 weeks

what is chronic LBP?

more than 6 weeks

what disorders are often acute?

Mobility deficits

Movement Coordination Impairments

Related (Referred) LE pain

Radiating Pain

Related Cognitive or Affective Tendencies

what disorders are often chronic?

Movement Coordination Impairments

Related (Referred) LE Pain

Generalized Pain

acute LBP with mobility deficits: history

Acute low back, buttock, or thigh pain

Onset often linked to awkward movement or position

acute LBP with mobility deficits: presentation

Limited AROM of lower thoracic or lumbar spine

Pain reproduced with end-range motion and passive mobility testing

acute LBP with mobility deficits: treatment

Specific trunk activation training/stability

Core strengthening and endurance training

Joint mobilization/manipulation

Generalize exercise for back and hip mobility

Education on active lifestyle and self-management techniques

acute LBP with movement coordination impairments: history

Acute exacerbation of recurring LBP that is commonly associated with referred LE pain

Many episodes in recent years

acute LBP with movement coordination impairments: presentation

Pain in mid-range of motion that worsens towards end range

Pain with segmental joint mobility

Observable movement impairments

Decreased core strength/endurance

Mobility deficits or hypermobility

acute LBP with movement coordination impairments: treatment

Specific trunk activation training/stability

Core strengthening and endurance training

Joint mobilization/manipulation

Generalize exercise for back and hip mobility

Education on active lifestyle and self-management techniques

is acute or chronic LBP with movement coordination impairments hyper or hypo mobile?

can be either for both acute and chronic

is there nerve root involvement with LBP with referred LE pain

NO

pain is in the disc or facet, referring to the LE

what is the difference between referred and radicular pain in the lumbar spine?

referred: pain in LE from facet or disc

radicular: nerve root compression, causes pain in LE

acute LBP with referred LE pain: history

LBP often with referred buttock, thigh or leg pain, worse with flexion

Multiple low back-related lower extremity pain episodes

acute LBP with referred LE pain: presentation

LBP and LE pain can be centralized with positions, movements, manual procedures

Lateral shift, decreased lordosis, decreased lumbar extension mobility

Clinical presentation of mobility deficits

acute LBP with referred LE pain: treatment

*these are mostly for if the pain is in the disc not the facet

McKenzie techniques (mechanical diagnosis and therapy)

Traction

Progress to movement coordination interventions -> after pain has been centralized

can you have radicular and referred pain at the same time?

yes

acute LBP with radiating pain: history

Acute LBP with a narrow band of "lancinating" pain in lower extremity

Possible LE paresthesias, numbness, and weakness

acute LBP with radiating pain: presentation

Sx reproduced or aggravated with mid-range and worsened at end-range

+ SLR, slump

reduced myotomes, dermatomes, reflexes

**Can have sx of referred pain as well

acute LBP with radiating pain: treatment

General exercise training

Neural tissue mobilization

Mobilization and manipulation

Soft tissue techniques

Education of self-management techniques

acute LBP with related cognitive or affective tendencies: history

Acute or subacute low back pain and/or low back-related LE pain

acute LBP with related cognitive or affective tendencies: presentation

Clinical presentation of fear avoidance behaviors, pain catastrophizing, or depression.

High scores on any of the following: Psychosocial subscale of Star Back Screening, FABQ, Pain Catastrophizing Scale PHQ-9 or Beck Depression Inventory

acute LBP with related cognitive or affective tendencies: treatment

Address Biopsychosocial Contributors to Pain

Pain Neuroscience Education

General exercise and active lifestyle education

chronic LBP with movement coordination: history

Chronic, reoccurring LBP that is commonly associated with referred LE pain

chronic LBP with movement coordination: presentation

LBP or LE pain that worsens with sustained end-range movements/position

Observable movement impairments -> decreased quality of movement, increased compensations

Decreased core strength/endurance

Mobility deficits or hypermobility

chronic LBP with movement coordination: treatment

Specific trunk activation training/stability

Core strengthening and endurance training

Joint mobilization/manipulation

Generalize exercise for back and hip mobility

Education on active lifestyle and self-management techniques

chronic LBP with radiating pain: history

Chronic, reoccurring, mid-back and/or LBP with radiating pain

Possible c/o numbness, tingling, weakness, hyporeflexia

chronic LBP with radiating pain: presentation

Sx aggravated or reproduced with end-range neural tension tests (SLR, slump)

chronic LBP with radiating pain: treatment

General exercise training

Neural tissue mobilization

Mobilization and manipulation

Soft tissue techniques

Education of Active lifestyle and self-management techniques

chronic LBP with generalized pain: history

LBP and/or low back-related LE pain for > 3 months

Not consistent with any other sub-group

Thoughts or behaviors consistent with fear-avoidance, pain catastrophizing and/or depression

chronic LBP with generalized pain: presentation

High scores on any of the following: Psychosocial subscale of Star Back Screening, FABQ, Pain Catastrophizing Scale PHQ-9 or Beck Depression Inventory

chronic LBP with generalized pain: treatment

Address Biopsychosocial Contributors to Pain

Pain Neuroscience Education

General exercise and active lifestyle education

Cognitive functional therapy