Lumbar Spine Dysfunction: Prevalence and Economic Impact

• Low back pain is defined by location and chronicity

• LBP is just pain or caused by muscle tension or stiffness localized below the costal margin and above the inferior gluteal fold (can be associated with or without leg pain)

• Acute: < 6 weeks

• Subacute: 6-12 weeks

• Chronic: > 12 weeks, more challenging to treat because of the multitude of components

Prevalence:

• LBP major problem throughout the world, highest prevalence among females (40-80 years)

• adjusting for methodologic variation, the worldwide point prevalence was estimated to be 11.9%

Chronic LBP:

• Prevalence: 4.2% (24-39 years) & 19.6% (20-59 years)

• Increases linearly from the 3rd decade of life until 60 years old (more prevalent in women)

• Related job pressures, psychological concerns and socioeconomic issues

LBP is a symptom not a disease…can result from unknown causes. There is insufficient evidence to support the existence of any specific causes of LBP beyond malignancy, fracture, infection or inflammatory disorder (ankylosing spondylitis)

“Is LBP self-limiting?”

• It is not a self-limiting problem but rather a recurrent/persistent disorder

• LBP “episodes” are short lived in a primary care setting

• Long-term ~12 months

Chance of Recurrence:

• 24.1%-58.6% at 2 years (self-report)

• Documented 9% @ 3 month and 77.1% @ 3 years

Most Robust Risk Factors:

• PF att baseline occupation

• Only included OR(Odds Ratio), RR (Relative Ratio) & HR (Hazard Ratio)

  • Obesity

  • Poor Health

  • Prior LBP

  • Poor back endurance

  • Lifting or carrying > 25 lbs

  • Awkward posture

  • Poor relationships at work

Patient History & Outcomes Measures:

• Intake Data

  • PRAPARE instrument

  • Self-perceived general health condition

  • Prior/on-going care

  • Activity level

  • Drug/Alcohol use

  • Common health conditions (*** good place to spend some time and gain a good understanding)

    • Comorbidity: presence of one or more secondary conditions co-occuring with the primary condition of interest

• Dedicated Patient History: recommended history taking and clinical examination process has had little formal scientific assessment of its validity…it is most supported in most guidelines

Patient History includes bothe Nonmechanical Patient History & Mechanistic History

• Mechanical History:

  • Mechanism of injury

  • Prior History of low back pain

  • Leg pain

  • Fear, Depression,Anxiety

  • Lifestyle

  • Behavior Condition

  • Irritability

  • Previous failed attempt

• Non-Mechanical History:

  • Night Pain

  • Prior History of Cancer

  • Psychosocial factor

  • Trauma

  • Bowel and Bladder problems

  • Compromised Bone density

  • Information has higher prevalence in some environments

Outcome Measures: part of patient history, gives us a perspective of the condition influences the patient

Core Outcomes Sets: LBP

• Physical function measure

• Pain Intensity measure

• Health-Related Quality of life

(3 should be gathered on all individuals)

• Lack of consensus for work ability and pain interference aspects of pain, sleep etc.….

Oswestry LBP Questionnaire

• Shown to be reliable and valid for LBP patients

• ~ 5mins to complete

• Rates level of disability

• Each of 10 sections, each scored 0-5

• If all completed (x/50) x 100= % of disability …..One section missing (x/45)

Numeric Pain Scale

• 0-10/11 point scale

• VAS or NPRS

• MCID is considered to be 1.3-2 for mechanical neck pain

PEG-3

• Captures pain interference and pain intensity

SF-12 or SF-36

• Looks at the Health-Related Quality of Life

• There is a cost associated with it

• Scored 0-100

• Veterans use a VR-12

Patient-Specific Functional Scale

• 3 Unique activities limitation assessment

• MCID = 2 points

• Target Patients activity interest/motive

• Mark 1-10, lower = higher difficulty

PHQ-2

• Signs of depression

• Understand how to proceed, where to refer and what "tools" to give/use

• Psychological considerations influence LBP recovery

Subgrouping Tools

• STarT Back tool: those who need less physical care and more cognitive-behavioral-based care

• Orebro Musculoskeletal Pain Questionnaire: helps to identify those at risk for long term problems (identifies prognostic factors)…region specific scale used to measure disability specifically

Constructs of PREMS

Have suggested capturing experiences measures such as

• Time invested for the particular care approach (including waiting time)

• Complications and suffering that incurred while receiving the care

• Sustainability of benefits

• Costs versus outcomes

Observation  Is conducted all throughout the appointment/evaluation..

• Is awkward posture associated with low back pain?

• Studies show that there is no causality but there are some positive & null associations

• (some support and some do not)

Work and Posture?

• Less associated with dysfunction than non-work environment

Changing Posture?

• Immediate pain reduction can be achieved by altering muscle-activation and movement patterns

• Combination for optimal success seems to be different for every individual

• Pain provocation tests help to "tune" the intervention…..suggests that patient classification schemes may need more refinement

• The Shift: Lumbar List

  • If present try to reduce it

  • If it reduces, then preform AROM exercises

  • Could be disc-genetic

  • Or number of other features

    • Instability

    • Facets problem

    • Sacroiliac joint disorder

Observational Examination:

• Side

• Posterior

• Anterior

• Range of rotation to each side

• Pain might be aggravated or relieved by the lumbar shift

• Shoulder level

• Arm distance to trunk (can be scoliosis)

• Pelvis height and level

• Flat low back (stenosis)

• Hyper-lordotic back

Pain Relation Behaviors

• BAT-Back: Behavioral Avoidance Test-Back Pain

  • avoidance behavior can be defined as behavior that prevents or postpones the occurrence of an aversive stimulus

• Expressive Behaviors: (communicative and protective behaviors) represent subsystems of behavior associated with pain …pain severity would be associated with decreased physical tolerance and heighted expression of pain behavior

Triage & Screening

• When looking for red flags remember that 80% of your patients will have at least 1 red flag

• So we need to rule out non-mechanical findings

Trigger for a Red Flag

• Do not actually screen but tend to manage findings

• Red flags symptomology negates the utility of clinical findings

• Leads to too many tests and extra referrals (dig too deep)

Rethink Red Flags (Category 1 = Immediate referral, Category 2, precautionary….possibly referral/co-treat, Category 3, not an emergency treat/exam as normal )

Propose to….

• Importance of watchful waiting

• Value-based care does not support examination driven by red flag symptoms

• Recognition that red flag symptoms may have a stronger relationship with prognosis than diagnosis

  Specific Red Flags

  • Non-mechanical pain distribution

  • Cauda equina dysfunction

  • Upper lumbar disc herniation in younger patients

  • Lumbar compression fracture

  • Spine cancer

  • Ankylosing Spondylitis

  • Pelvic fracture or tumor

  • Sacral Fracture

Remember that Non-Mechanical Pain …

• cannot be reproduced, changed or reproduced during examination

• the pain has an origin outside our practice capabilities

Cauda Equina (Refer out)

• Rapid onset of symptoms( 89% sensitive)

• History of back pain (94% sensitive)

• Loss of sphincter tone: (80% sensitivity)

• Loss of sacral sensation

• Sphincter disturbance ( reduced tone)

• fecal incontinence

• Gait Disturbance

Lumbar compression Fracture

• Age is greater than 50 (.84 sensitivity) or 70 (.96 specificity)

• Trauma (.85), in elderly trauma can be minor

• Corticosteroid Use (.995 specificity)

Spine Cancer

• Age greater than 50 (.77 sensitivity)

• Previous history (personal or family) (.98 specificity)

• Failure to improve in one month of therapy (.90 specificity)

• No relief with bed rest ( 0.90 sensitivity)

• Duration greater than 1 month (.81 specificity)

• Younger than the age of 50, no cancer history, unexplained weight loss or failure of corrective history ( 100% sensitivity)

• Gradual onset of constitutional symptoms

Ankylosing Spondylitis

• Age younger than 40 (100 sensitivity)

• Pain not relieved by supine (.80 sensitivity)

• Morning back stiffness (.64 sensitivity)

• Pain duration longer than 3 months

• 4/5 questions above (.82 specificity)

• Remember that it is improved by exercise

The Movement Examination of the Lumbar Spine

Pain Adaptivity Model/Behaviors

• Being pain adaptive means a person has the ability to modulate pain without the help of medical interventions

• Patients have their own internal mechanisms to modulate their own pain and are great candidates for pain modulations w/ movement (passive or active)

• people either have or do not have adaptive pain

• Examples of those who are not pain adaptive:

  • central sensitization

  • chronic pain syndrome

  • fibromyalgia

  • those addicted to painkillers

Concordant/Comparable sign (the anchor)

• Symptoms that is identified on a pain drawing and verified by the patient

• It is the issue that they are coming to see us for, main complaint that they are coming to us for treatment/diagnosis

• Discordant sign…painful movement that is not the pain or other symptoms identified on a pain drawing and verified as the main complaint

• Overall drives our examination

Active Physiological Movements (all ROMs of the area being examined)

• purpose: is to identify the concordant sign

• positive findings maybe used as treatment

• Overpressure is used to rule out joints

Centralization: pain-adaptive behavior

• pain centralizes during active movement, the outcome of therapy is typically very good

• great predictor of short-term outcome and eliminate chronic pain syndrome

Passive Physiological Movements

• purpose of passive physiological movements is to identify the concordant sign

• passive findings may be used as treatment (just like Active ROM)

• Central and Unilateral PA’s (posterior-anterior glides)

Palpation, Muscle Endurance and Physical Performance

Palpation is not very useful in LBP, the main benefit is patient bonding

Multifidus Lift Testing

• Patient bends arms and raises the contra-lateral arm towards the ceiling, then as the therapist palpates the multifidi at the L5 - S1 region you make a qualitative judgement as to whether the participant demonstrates normal or abnormal L-multifidus contraction

Endurance and Physical Performance Testing

Endurance

• Endurance is very important for LBP

• Has been shown to predict first-time and recurrent low back pain

• Has been associated with the chronification and severity of LBP

• Designed to measure the endurance of low back extensors

• Actually seeing what the patient is capable of rather than what they think they are capable of (tend to limit themselves)

Tests:

• Bering-Sorensen Endurance test

• Isometric Chest Raise

• Repetitive Arch-up test

• Side Plank

• Flexor-to-Extensor ratio

Physical Performance Tests

• self-report outcomes measures of disabilities are more influenced by the patients psychological status than performance-based measures

• Physical performance tests quantify activities that are typically influenced in individuals with LBP (bending, twisting, lifting, crouching, dressing, etc.)

Tests:

• Sock test (functional)

• Villiger test (step-up and down x96 in 3 mins)

• Prolonged Flexion Test (flexed and timed)

• Repeated Sit-Stand test (15-30 sec)

• Loaded (4.5 kg) functional reach test ( look up example***)

Aerobic-Based Tests

• useful to determine how pain influences activity in individuals with high degrees of severity (chronic low back pain with behavioral changes)

Tests:

• 50ft walk test

• Timed up and go

• 1 min stair climb

• 6 min walk test

• self-selected stair climbing test

Confirmation Based Special tests

• Quality of special test is that it allows us to differentiate b/w 2 different tissues…identify or determine the etiology of the disease or condition

Language of Diagnostic Accuracy

• Sensitivity: % of individuals who have the disease and test +

• Specificity: % of individuals who do not have the disease and test -

• Likelihood Ratios: +1, rules in the diagnosis

  • -1, probability of negative findings (rules out)

  • Value closer to 0 and rules out is best

Posttest Probability Change: probability of the target disorder after a diagnostic test result +/- is known

• pretest vs post test

• change ~ 25% is considered a large change

Lumbar Radiculopathy

What you would most likely see..

• Dermatomal patterns

• pain on cough, sneezing, straining

• More pain sitting

• Muscle weakness

• Subjective sensory loss

• Paresis

• +SLR & +Crossed-SLR

• Unilateral ankle reflex

SLR and SLUMP test are better as triage test, do not confirm Lumbar Radiculopathy

• sensitive tests, not specific

Cross SLR is a specificity test

Neurological Findings: Sensory, Reflexes and MMT

• mostly below clinical threshold

• neither specific or sensitive

• may see variability with reflexes

• sensation tests should compare both sides, improves with sharp/dull

• MMT is best, but only slightly

Usually these do not have diagnostic value and usually have inconclusive results

Centralization: 3 studies

• specificity = 94%

• high LR+ than LR-

• used to rule in and out the presence of discogenic disorder

Passive Lumbar Extension Test

• looking for possible fractures/mechanical damage…PAR’s, Spondylosis, etc.

• higher specificity than sensitivity

Lumbar Stenosis Rule

• bilateral symptoms

• leg pain more than back pain

• pain during walking/standing

• pain relief upon sitting

• older than 48 years

• Highly improved positive posttest probability (>25%)