Ortho I: Lumbopelvic Spine Examination

Limiting factors during lumbar flexion

-PLL

-ligamentum flavum

-interspinous

-supraspinous

-intertransverse

-anterior disc compression

Limiting factors during lumbar extension

-ALL

-posterior disc compression

Fryette's laws: if the segments are in full flexion or full extension, rotation and side bending are in what direction?

if the segments are in full flexion or full extension, rotation and side bending are in the same direction

Fryette's Laws: if the motion is introduced into a segment in any plane,

if the motion is introduced into a segment in any plane, motion in the other planes is reduced

Fryette's Laws: if the segments are in neutral, rotation and side bending are in what direction?

if the segments are in neutral, rotation and side bending are opposite

Why should caution be used when applying Fryette's laws in treatment?

due to inconsistency in reported patterns of coupled motions

Form closure in the pelvis

pelvis has significant form closure because of the shape of the sacrum creates natural stability in standing and with the influence of gravity

Force closure

additional stability provided by ligaments, muscles, and fascia that crosses a joint

Sagittal plane motion at the SIJ occurs about a transverse axis at the

2nd sacral body

Nutation

sacral flexion

-sacral base moves anteriorly and inferiorly

-iliacs approximate

-ischial tubs separate

Counternutation

sacral extension

-base moves posteriorly and superiorly

-iliacs move apart

-ischial tuberosities approximate

Sacral torsions occur around the ___________ axes

oblique

Forward sacral torsion

sacral sulcus moves anteriorly and contralateral ILA moves posteriorly

-LOL or ROR

Backward sacral torsion

sacral sulcus moves posteriorly and contralateral ILA moves anteriorly

-LOR or ROL

Contractile and fascial influences on the pelvic girdle during posterior rotation - innominate

abdominals, gluteus maximus, hamstrings (esp biceps femoris)

Contractile and fascial influences on the pelvic girdle during anterior rotation - innominate

iliopsoas, rectus femoris, TFL

Contractile and fascial influences on the pelvic girdle during transverse shear

pelvic floor fascia

Contractile and fascial influences on the pelvic girdle during anterior rotation - pelvis

erector spinae, lat dorsi (via fascia) and thoracolumbar fascia

Contractile and fascial influences on the pelvic girdle during flexion - sacrum

piriformis

Contractile and fascial influences on the pelvic girdle during inferior shear - pubis

hip adductors

Contractile and fascial influences on the pelvic girdle during lateral pelvic tilt

TFL

___________ _________is necessary for effective load transfer through the pelvic girdle

joint stability

Lumbopelvic functional considerations

-lumbopelvic rhythm

-lumbopelvic mobility

-lumbar disc mechanics

How is epidemiological data useful in patient care?

clinical reasoning and using likelihood ratios

What is the difference between incidence and prevalence?

-incidence is number of new cases in a time period/population at risk

-prevalence is number of existing cases at a point in time/population at risk

Example: Lots of new cases but ending in death means there's ________ incidence but ________ prevalence

high incidence but low prevalence

__________ and ________ pain are the leading cause of global disability in years lived with disability (increasing burden from 1990 and 2005)

LBP and neck pain

Annual prevalence of occupational LBP

2-8% of workforce affected by LBP

Chronic low back pain (CLBP) has increased from

3.9% to 10.2%

Lifetime prevalence of LBP

50-80% have at least 1 episode in a lifetime

Epidemiology of LBP: estimated between ___-___% have SIJ pain

13-30% (recurrence rate? ..no studies)

Annual incidence of developing an episode of LBP is

4-93%

What is a strong predictor of future episodes of LBP?

prior episodes (recurrent episodes are common)

LBP is a multifactorial disorder predominantly _________ and ___________

occupational and psychosocial

Risk factors of LBP

1. comorbidities

2. psychological factors

3. occupational factors

4. lifestyle/social demographic

5. age

6. gender

Risk factors of LBP: comorbidities

-increased cost and disability: diabetes, RA, anxiety, psychiatric illness, and depression

-risk comorbidity prevalence highest for anxiety (depression 5th)

Risk factors of LBP: psychological

anxiety, depression, catastrophizing, kinesiophobia, and somatization

Risk factors of LBP: occupational

-heavy lifting, pushing, pulling

-physical workload

-job demands

-stressful and monotonous work

-dissatisfaction with work

Risk factors of LBP: lifestyle/social demographic

-BMI - increased risk with obesity

-smoking 47 studies reviewed; favor a causal link

-BMI and smoking

-male and African American are significant predictors for claims related LBP

-lower education

-social class

-lower income

-overindebtedness 11x increase in probability of LBP

Risk factors of LBP: age

-"wear and tear"

-DDD

-higher rates of LBP in those >65

-highest frequency of LBP sxs from 35-55 (sickness, absence, symptom duration increase with age)

Risk factors of LBP: gender

-females > males

-more than 2/3 pregnant women report LBP

-LBP during pregnancy

Prognostic factors of lumbar disc herniation: favorable factors

-absence of crossed SLR

-spinal motion in extension that does not reproduce leg pain

-large extrusion or sequestration

-relief of >50% reduction in leg pain within the first 6 weeks onset

-positive response to corticosteroid treatment

-limited psychosocial issues

-self employed

-motivated to recover and return to function

-educational level >12 years

-good fitness level

-motivated to exercise and participate in recovery

-absence of spinal stenosis

-progressive return from neurologic deficit within the first 12 weeks

Prognostic factors of lumbar disc herniation: unfavorable factors

-positive crossed SLR

-leg pain produced in spinal extension

-subligamentous contained LDH

-lack of >50% reduction in leg pain within the first 6 weeks of onset

-negative response to corticosteroid treatment

-overbearing psychosocial issues

-worker's compensation

-unmotivated to return to function

-educational level <12 years

-illiteracy

-unreasonable expectation of recovery time frames

-poorly motivated and passive in recovery process

-concomitant spinal stenosis

-progressive neurologic deficit

-cauda equina syndrome

Prognostic factors of lumbar disc herniation: neutral factors

-degree of SLR

-response to bed rest

-response to passive care

-gender

-age

-degree of neurologic deficit (except progressive deficit and cauda equina syndrome)

Prognostic factors of lumbar disc herniation: questionable factors

-actual size of LDH

-canal position of LDH

-spinal level of LDH

-multi level disc abnormalities

-LDH material

Why is differential diagnosis difficult?

-functionally independent on adjacent joints

-joint mobility is minimal; radiographs are not helpful

-poor inter rater and intra reliability for positional and mobility clinical testing

-no true "gold standard" for diagnosis

Musculoskeletal causes of LBP

any innervated structure in the lumbar spine can cause symptoms of low back and referred pain into extremities

What makes associating anatomy with symptoms so difficult?

high rate of false positive findings with imaging studies

Non musculoskeletal causes of LBP

-visceral

-neurogenic

-vasculogenic

-spondylogenic

-psychogenic

-primary/secondary cancer

Lumbopelvic exam sequencing

-patient first

-test uninvolved/less involved side/direction first

-active motions done before passive, passive before resistive

-painful/provocative testing should be done towards the end of the exam

-special orthopedic testing done after motion and strength assessments

-do not repeat testing unnecessarily

-consider positional changes of the patient

Red flag indications

Cauda equina syndrome/widespread neurologic disorder indications

-difficulty with micturition

-loss of anal sphincter tone or fecal incontinence

-saddle anesthesia about the anus, perineum or genitals

-widespread (>one nerve root) or progressive motor weakness in the legs or gait disturbance

-sensory level

Inflammatory disorders (ankylosing spondylitis and related disorders) indications

-gradual onset before age 40

-marked morning stiffness

-persisting limitation of spinal movements in all directions

-peripheral joint involvement

-iritis, skin rashes (psoriasis), colitis, urethral discharge

-family history

Lumbopelvic examination viscerogenic: cancer

-prostate, testicular, and pancreatic cancer

-metastatic lesions

Lumbopelvic examination viscerogenic: cardiac

-abdominal aortic aneurysm (AAA)

-endocarditis

Lumbopelvic examination viscerogenic: renal

kidney involvement including UTI

Lumbopelvic examination viscerogenic: GI

-ulcerative colitis

-neoplasms and obstructions

-irritable bowel syndrome and Crohn's disease

-colon cancer

Lumbopelvic examination viscerogenic: other

-spinal tuberculosis

-reiter's syndrome (reactive arthritis)

-ankylosing spondylitis

-pagets disease

Red flags with the highest positive LR for cancer

1. age ≥ 50

2. failure to improve after 1 month of therapy

3. previous history of cancer

4. unexplained weight loss (more than 4.5 kg in 6 months)

*absence of all 4 confidently R/O malignancy

Red flags that may increase the likelihood of metastatic cancer

-history of cancer

-night pain or pain at rest

-unexplained weight loss

-age > 50 or < 17

-failure to improve over the predicted time interval following treatment

Red flags that may suggest the presence of an infection within the disc or vertebra

-patient is immunosuppressed

-a prolonged fever with a temp over 100.4 F

-history of intravenous drug abuse

-history of a recent UTI, cellulitis, or pneumonia

Red flags suggesting an undiagnosed vertebral fracture

-prolonged use of corticosteriods

-mild trauma > age 50 years

-age > 70 years

-a known history of osteoporosis

-recent major trauma at any age (motor vehicle accident or a fall from greater than 5 ft

-bruising over the spine following trauma

Red flags that may indicate a dangerous abdominal aortic aneurysm

-a pulsating mass in the abdomen

-a history of atherosclerotic vascular disease

-a throbbing, pulsing back pain at rest or with recumbency

-age > 60

Is cauda equina syndrome an emergency?

Yes, surgical emergency

Cauda equina syndrome

-progressive neurological deficits

-urine retention or incontinence

-fecal incontinence

-bilateral sciatica

-global or progressive LE weakness

-numbness in saddle distribution

-sensory deficits in the feet L4, L5, S1

-ankle DF, toe extension, and ankle PF weakness

Yellow flags are predictors of

chronicity - first 6 to 8 weeks

Yellow flags

-nerve root pain or specific spinal pathology

-reported severity of pain at the acute stage

-beliefs about pain being work related

-psychological distress

-psychosocial aspects of work

-compensation

-time off work

-the longer someone is off work with back pain, the lower the probability that they will return to work

Psychosocial barriers to recovery

-belief that pain and activity are harmful

-"sickness behaviors" such as extended rest

-low or negative moods, social withdrawl

-treatment that does not fit best practice

-problems with claim and compensation

-history of back pain, time off and other claims

-problems at work, poor job satisfaction

-heavy work, unsociable hours

-overprotective family or lack of support

Other associated symptoms with lumbopelvic pain

-paresthesias

-weakness

-crepitus

-swelling

-discoloration

-PM pain

-changes with eating

-B and B changes

Non mechanical LBP

-typically not made worse with loading

-referred (pelvis/abdomen)

-neoplasm

-vascular

-other medical

Mechanical LBP

-decreased pain with rest or unloading

-pain pattern with activity, motion, load

-pain provocation with specific motion, load, positioning

-usually cyclic

-low back pain is often referred to the buttocks and thighs

-morning stiffness or pain is common

-start pain (i.e. when starting movement) is common

-there is pain on forward flexion and often also on returning to the erect position

-pain is produced or aggravated by extension, side flexion, rotation, standing, walking, sitting, and exercise in general

-pain becomes worse over the course of the day

-pain is relieved by a change of position

-pain is relieved by lying down, especially in fetal position

Risk factors for development of recurrent LBP

-history of previous episodes

-excessive mobility in the spine

-excessive mobility in other joints

Risk factors for development of chronic pain

-presence of symptoms below the knee

-psychological distress or depression

-fear of pain, movement, and re injury or low expectations of recovery

-pain of high intensity

-passive coping style

Fear avoidance beliefs questionnaire

-16 item questionnaire

-2 sub scales: physical activity and work

Reliability and internal consistency of fear avoidance belief questionnaire

ranged between moderate and substantial

__________ relationships between measures of fear and avoidance beliefs and pain/disability among patients with mechanical neck pain as compared to patients with LBP

weaker

Scoring of fear avoidance beliefs questionnaire

0-6 points/item

-work max = 42 points

-physical activity max = 24 points

*higher the score the greater degree of fear and avoidance beliefs

Lower fear avoidance belief questionnaire predict what?

better functional outcome and less LBP in chronic unilateral radiculopathy

Work FABQ and depression were significant variables in predicting what?

short term pain and disability following lumbar disc surgery

Fear avoidance beliefs in LBP <6 months resulted in what outcomes?

-greater disability, higher pain and delayed RTW

-decreasing fear avoidance beliefs results in improved outcomes

-early treatment in patients with higher fear avoidance beliefs may result in less chronicity and better outcomes, if treatment addresses fear avoidance beliefs

Indication scores of poor return to work status in FABQ with patients with acute occupational LBP

>29 in working population or >22 in non working

Indication scores of poor outcomes in patients seeking care from PCP

>14

2 separate PT clinical trials found FABQ-W cutoff >_____ better predictor of self reported disability at 6 months

>29

Subgrouping and targeting treatment (STarT back screening questionnaire)

STarT back screening tool created by Keele University

Roland Morris Low back pain and disability questionnaire

Modified Oswestry Low Back Pain Disability Questionnaire

10 sections:

1. pain intensity

2. personal care

3. lifting

4. walking

5. sitting

6. standing

7. sleeping

8. social life

9. traveling

10. employment/homemaking

scored 0-5 pts; total 50 pts

Clinical prediction tool for prediction of poor 2 year outcome in persistent LBP

1. (+) feeling everything is an effort

2. (+) difficulty getting breath

3. (+) hot/cold spells

4. (+) numbness/tingling in parts of body

5. (+) pain in heart/chest

Overpressure rules: If patient has full painfree AROM,

apply OP at end range in standing

Overpressure rules: if patient has full AROM but is painful,

move the lumbar spine passively through the full ROM in sidelying and OP at end range to assess effect of motion on pain

Overpressure rules: if patient does not have full AROM,

move the lumbar spine passively and find if there is a difference in quantity of motion and pain; check end feel with OP

Neurodynamic tests

1. passive neck flexion

2. slump test

3. straight leg raise

4. crossed straight leg raise

5. prone knee bend

Special tests lumbar stability: prone instability test

-test is positive if pain is present in first part but subsides in second part

-has been used for CPR for lumbar instability: <40, (+) PIT, aberrant flexion AROM, ("instability catch"), SLR > 91 degree; if >2 present = (+) LR 4.0

Special tests lumbar stability: stork standing test is positive for

(+) for pars interarticularis defect

Special tests for SIJ/innominate dysfunction

-upslip/downslip

-ant/post rotations

-forward torsions

-backward torsions

-flexed/extended sacrum

Gillet test technique

-palpate inferior PSIS with one thumb and S2 with the other thumb

-patient actively flexes ipsilateral hip greater than 90 degrees

Gillet test is positive when

no inferior movement of thumb on PSIS

Alternate gillet test technique

-palpate the innominate bone, PSIS, and sacrum by placing the R thumb directly on the R PSIS with the rest of the R hand contacting the R innominate bone; palpates the S2 spinous process with the L thumb

-patient actively flexes the contralateral hip into 90 degrees of hip flexion and 90 degrees of knee flexion

Alternate gillet test is positive when? and negative when?

(+) when R PSIS moves cephalad; (-) if it remains unchanged

Standing forward flexion test technique

-patient standing. examiner palpates inferior PSIS with one thumb and S2 with the other thumb

-patient actively forward flexes