Spine ICF - LBP with Related (Referred) Lower Extremity Pain

Background

• Also known as LBP w leg pain w directional preference

  • Lumbar and related peripheral leg pain centralizes w repeated movements in a preferred direction based on pathology in spine

    • Extension syndrome

    • Flexion syndrome

    • Lateral shift

• McKenzie protocol is used to identify directional preference and centralization

Test movements used in a McKenzie AROM exam

1. Side bending in standing

2. Flexion in standing

3. Repeated flexion in standing

4. Extension in standing

5. Repeated extension in standing

6. Sustained extension in standing

7. Pelvic translocation in standing

8. Extension in prone

9. Sustained extension in prone

10. Sustained extension with pelvic translocation in prone

11. Repeated flexion in sitting

12. Flexion in quadruped

13. Repeated flexion in quadruped

Centralization vs peripheralization

• Centralization: repeated lumbar movements/postures cause pain to recede toward lumbar midline (good prognosis for response to conservative treatment)

• Peripheralization: repeated lumbar movements/postures cause pain to spread laterally or distally from lumbar spine to foot (poor prognosis for response to conservative treatment)

• w McKenzie method, treatment of LBP w referred LE pain should be governed by the centralization/peripheralization phenomena

• Repeated exercises and movements should be given such that the pain does not peripheralize

• McKenzie has speculated that the bending direction that causes centralization of pain will correspond w the direction that the nuclear content of the disc has moved to general referred symptoms by mechanically stimulating the nerve root or annulus

• Directional preference:

  • 1. A specific direction of trunk movement or posture noted during the physical exam

  • 2. A specific aggravating or easing factor reported by the pt during the subjective history that alleviated or decreases the pt’s pain, w or w/o the pain having changed location or increased pt’s lumbar ROM

Extension syndrome

• Presentation

  • Pts who exhibit a directional preference toward lumbar extension may exhibit a symptomatic IV disc w an intact annulus

• Clinical exam findings

  • Spinal ext/backward bending causes symptoms to centralize

  • Spinal flexion/forward bending causes symptoms to peripheralize

McKenzie prone extension exercise sequence

Prone over two pillows

Prone over one pillow

Prone lying

Prone on elbows

Prone press up

Standing backward bending

Flexion syndrome

• Presentation

  • Lumbar spinal stenosis

    • Narrowing of spinal canal or IV foramen

    • Age-related degenerative changes (>50)

    • Present on imaging

  • 7 history items to look for

    • Leg or buttock pain while walking

    • Forward bending alleviates symptoms

    • Relief when using shopping cart

    • Motor/sensory disturbance while walking

    • Normal and symmetric foot pulses

    • LE weakness and fatigue

    • LBP

• Clinical exam findings

  • Spinal flexion/forward bending centralizes pain

  • Spinal ext/backward bending exacerbates leg symptoms (peripheralization)

  • Limited extension ROM

  • Neurogenic claudication

    • Pain/paresthesia/cramping of LEs caused by walking

    • Compression of vertebral venous plexus results in ischemic pain and fatigue in LEs

    • If +, these pts prefer walking on an incline. Sitting alleviates symptoms

• Intervention: Flexion-based exercise program, address hip dysfunctions, balance

Flexion exercises

• Quadruped cat back flexion

• Quadruped trunk flexion

• Supine single knee to chest

• Physioball bilateral knees to chest

Lateral shift

• Presentation

  • Visible frontal plane deviation of shoulders relative to pelvis

  • Can be due to herniated disc or facet, pelvic, and/or myofascial dysfunctions

• Clinical exam findings

  • LE symptoms centralize to lower back w lumbar side-glide and backward bending

• Intervention: Lateral shift correction (lumbar side-glide), address myofascial and/or pelvic dysfunction

Lateral shift exercise

• Pt should exercise shifting their trunk towards the side that centralizes their pain

Treatment outcomes

• Pts who exhibit a directional preference in exercise should have an exercise treatment that incorporates these preferences because

  • Exercises performed w direction preference are correspondent w better overall results

• These exercises should be done in coordination w:

  • Manual therapy techniques

  • Instruction in positioning aiding in the pt’s directional preference for centralization

• Once the pt’s symptoms have been improved from directional exercise, they might benefit from:

  • Spinal mobility in all directions

  • General conditioning

  • Movement control programs

  • Strengthening programs