Physical Therapy Protocols for Conditions of the Low Back Region

Red Flags for Potential Serious Conditions in Patients with Low Back Problems

Condition Back related tumor 1,2

Back related infection (Spinal osteomyelitis) osteomyelitis) 3

Cauda equina syndrome1,4

Spinal fracture 1,5

Abdominal aneurysm6,7

Red Flags for the Low Back Region Red Flag Red Flag Data obtained during Interview/History Data obtained during Physical Exam Age over 50 Ambiguous presentation in early stages. History of cancer Constant pain not affected by position or Unexplained weight loss activity; worse with weight-bearing, Failure of conservative therapy worse at night. Age over 50 of history of cancer or failure Neurological signs in lower extremities or conservative therapy Recent infection (e.g., urinary tract or skin Deep constant pain, increases with weight infection) bearing; may radiate Intravenous drug user/abuser Fever, malaise, and swelling Concurrent immunosuppressive disorder Spine rigidity; accessory mobility may be limited Urine retention or incontinence Sensory deficits in the feet (L4, L5, S1 areas) Ankle dorsiflexion, toe extension, and ankle Fecal incontinence plantarflexion weakness Saddle anesthesia Global or progressive weakness in the lower extremities History of trauma trauma (including minor falls or heavy lifts for osteoporotic or elderly individuals) Prolonged use of steroids Age over 70 Loss of function or mobility Back, abdominal, or groin pain Presence of peripheral vascular disease or coronary artery disease & associated risk factors (>50, Smoker, HTN, DM) Symptoms not related to movement stresses associated with somatic LBP Unilateral flank or low back pain Difficulty with initiating urination, painful urination, or blood in the urine Recent of coexisting urinary tract infection Past episodes of kidney stone

Point tenderness over site of fracture Exquisitely tender with palpation over fracture site Increased pain with weight-bearing Edema in local area Abnormal width of aortic or iliac arterial pulses Presence of a bruit in the central epigastric area upon auscultation

Kidney disorders 8 Positive fist percussion test over the kidney pyelonephritis nephrolithiasis renal cell carcinoma References: 1. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. December 1994. 2. Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical clinical presentation, presentation, and diagnostic diagnostic strategies. strategies. J Gen Intern Med 1988;3:230-238. 3. Lew DP, Waldvogel FA. Osteomyelitis. N Engl J Med 1997;336:999-1007. 4. Hakelius A, Hindmarsh Hindmarsh J. The comparative reliability of preoperative diagnostic methods methods in lumbar disc surgery. Acta Orthop Scand 1972;43:234-238. 5. Deyo RA, Rainville Rainville J, Kent DL. What can the history and physical examination tell tell us about low back pain? JAMA 1992;268:760-765. 6. Halperin JL. Evaluation of patients with peripheral vascular disease. Thrombosis Research. 2002;106:V303V311. 7. Krajewski LP, Olin JW. Atherosclerosis of the aorta and lower extremities extremities arteries. arteries. In: Young JR, Olin JW, nd Bartholomew JR, editors. Peripheral Vascular Diseases. 2 ed . St. Louis: Yearbook Medical Publishing, 1996. 8. Bajwa ZH. Pain patterns patterns in patients patients with with polycystic polycystic kidney disease. Kidney Int . 2004;66:1561-1569.

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

LOW BACK PAIN MEDICAL SCREENING QUESTIONNAIRE NAME: ___________________________ ________________________________________ _____________ Medical Record #: _________________________

DATE: _____________

Yes

No

1. Have you recently had a major trauma, such as a vehicle accident or a fall from a height? 2. Have you ever had a medical practitioner tell you that you have osteoporosis? 3. Do you have a history of cancer? 4. Does your pain ease when you rest in a comfortable position? 5. Have you recently had a fever? 6. Have you recently lost weight even though you have attempting to eat less or exercise more?

not

been

7. Have you recently taken antibiotics or other medicines for an infection? 8. Are you currently taking steroids or have you been on prolonged steroid therapy? 9. Have you been diagnosed with an immunosuppressive immunosuppressi ve disorder? 10. Have you noticed a recent onset of difficulty with retaining your urine? 11. Have you noticed a recent need to urinate more frequently? 12. Have you noticed a recent onset of numbness in the area of your bottom where you would sit on a bicycle seat? 13. Have you recently noticed your legs becoming weak while walking or climbing stairs?

Adapted from Bigos et al. AHCPR Clinical Practice Guideline. No. 95-0642



Pelvic Girdle Mobility Deficits ICD-9-CM code: ICF codes:

846.1

Sprain of sacroiliac ligament

Activities and Participation Domain code: d4106 Shifting the body’s centre of gravity (Adjusting of moving the weight of the body from one position to another while sitting, standing or lying, such as moving from one foot to another while standing.) Body Structure code: s76003 Sacral vertebral column Body Functions code: b7201 Mobility of pelvis

Common Historical Findings: Unilateral sacroiliac, buttock, and/or groin pain Symptoms worsen with lower extremity weight bearing and weight shifting activities Onset related to fall onto buttock; misstep or abrupt weight bearing onto straightened leg; pregnancy, or child-bearing strain Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Restricted innominate mobility (e.g., positive march test) Asymmetrical bony landmarks, (e.g., Posterior Superior Iliac Spines –PSIS's; Anterior Superior Iliac Spines- ASIS's) Symptom reproduction with palpation of sacroiliac ligaments (e.g., long posterior sacroiliac ligaments, short posterior sacroiliac ligaments; sacrotuberous ligaments) Physical Examination Procedures:

March Test Posterior Rotation of the Left Innominate

March Test Anterior Rotation of the Left Innominate

Performance Cues: The march test is utilized to examine the active mobility of the innominate bone (PSIS) relative to the sacrum (S1-S2 area) via full active hip flexion while standing


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Palpate the inferior aspect of the left PSIS and the most prominent S1 or S2 spinous process when assessing left innominate mobility Allow the patient to touch the tabletop for balance assist “Lift your left knee toward your chest and now your right knee” Ensure that enough active flexion occurs to recruit motion in to the innominate Palpate the inferior aspect of the right PSIS and the most prominent S1 or S2 spinous process when assessing right innominate mobility

PSIS Palpation for Symmetry

ASIS Palpation for Symmetry

Performance Cues: "Center" Patient on the table Gently "lift" and lower pelvis Stand on same side of table as your dominant eye Align thumbs symmetrically on the same part of the inferior aspect of the PSIS (the inferior "foothill") with the patient prone Palpation of the posterior SI ligaments (described below) at this time speeds the evaluation Palpate the ASIS's with the patient supine using similar tactics

Long Posterior Sacroiliac Ligament Performance Cues: Palpate directly inferior to the prominence of the PSIS


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Determine symptom response Tenderness is associated with innominate functioning toward end range of anterior rotation

Short Posterior Sacroiliac Ligament Performance Cues: Palpate directly medial to the PSIS Determine symptom response If low level of symptoms - deep palpation is required to "clear" the SI ligaments Tenderness is associated with most SIJ movement dysfunctions

Sacrotuberous Ligament Performance Cues: Palpate approximately one inch from coccyx- inferior and medial to gluteus maximus – pressure in direction laterally and superiorly (toward iliac crest) Determine symptom response Determine tautness of ligament compared to exact location and amount of pressure given to opposite side Tenderness and tautness associated with innominate functioning toward end range of posterior rotation


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Pelvic Girdle Mobility Deficits: Description, Description , Etiology, Stages, and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Sacroiliac Ligament Strain”

Description: Dysfunction of the movement and stability of the innominate bones relative to the sacrum resulting from and/or producing a strain of the sacroiliac ligaments. Etiology: Sacroiliac ligament sprains result from stresses imparted to either the sacrum or the innominates. Stresses imparted to the sacrum commonly originate from lumbar spine bending, twisting, or lifting movements as well as the stresses associated with some spinal postures such as prolonged slump sitting. Stresses imparted to the innominates commonly originate from falls onto the ischial tuberosity or from forces transmitted through the legs to the innominates such as stepping off a curb or into a hole and landing with a straightened leg. Additionally, sacroiliac ligaments are commonly strained during pregnancy and childbirth. The hormone relaxin, which is secreted to relax the pelvic girdle ligaments in preparation for childbirth, makes women especially vulnerable to sacroiliac ligament sprains.

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7201.3 SEVERE impairment of mobility of pelvis •

•

•

•

•

•

Low back pain unilateral/bilateral region of the posterior-superior iliac spine with/without buttock/groin pain, but usually not below the knee Asymmetrical position of one posterior, superior iliac spine (PSIS) relative to the contralateral PSIS and/or asymmetrical position of one anterior, superior iliac spine (ASIS) relative to the contralateral contralateral ASIS Restricted innominate motion relative to the sacrum – as measured by either the March Test or the Forward Bending Test Pain with end range hip motions that stress the involved sacroiliac ligament. For example, end range hip flexion will cause innominate posterior rotation and place stress on the ipsilateral sacrotuberous ligament – or – end range hip extension will cause innominate anterior rotation and place stress on the ipsilateral long, posterior sacroiliac ligament. Passive movements to the innominate that stress the involved ligament will provoke the patient’s reported symptoms. (Passive movements commonly commonly tested are innominate anterior rotation, posterior rotation, external rotation, internal rotation, superior translation, and inferior translation.) Provocatory palpation of the involved ligament will reproduce the patient’s reported symptoms. (Three sacroiliac ligaments are easily palpated. These are the long posterior sacroiliac ligament, the short posterior sacroiliac ligament and the sacrotuberous ligament.)


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The presence of four of five variables in the present in the clinical examination increased the likelihood of success with manipulation from 45% to 95%. Duration of symptoms less that 16 days Fear-avoidance belief questionnaire work scale score less than 19 At least one hip with greater than 35 degree of IR ROM (when measured prone lying) Hypomobility in the lumbar spine with posterior-to-anterior glides No symptoms distal to the knee

• • •

• •

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7201.2 MODERATE impairment of mobility of pelvis •

•

•

Improved symmetry of the PSIS’s and ASIS’s is commonly associated with improving symptomatology Improved innominate active mobility is commonly associated with improving symptomatology As the strain is relieved from the involved ligament, it becomes less tender to provocatory palpation

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7201.1 MILD impairment of mobility of pelvis Now when less acute – examine for muscle flexibility and strength deficits that may predispose the patient to future injury - for example: The ipsilateral hip flexors commonly exhibit flexibility deficits in patients with an innominate held at end range of anterior rotation – producing a strain to the long posterior sacroiliac ligament. The ipsilateral hip extensors commonly exhibit flexibility deficits in patients with an innominate held at end range of posterior rotation – producing a strain on the sacrotuberous ligament. The ipsilateral quadratus lumborum commonly exhibit flexibility deficits in patients with an innominate held at end range of superior translation – producing a strain on the short posterior sacroiliac ligament. The ipsilateral hip extensors and abdominals are commonly weak in patients with long posterior sacroiliac ligament sprains. The ipsilateral hip flexors and back extensors are commonly weak in patients with sacrotuberous ligament sprains. The ipsilateral hip abductors are also commonly weak in patients with short posterior sacroiliac ligament sprains.


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Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Alleviate pain with active lumbar spine/sacral movements Alleviate pain with weight bearing activities such as standing and walking short distances. •

•

•

•

Physical Agents: Ultrasound, phonophoresis, TENS, and ice to the sacroiliac region Manual Therapy Isometric mobilization and/or passive joint mobilization procedures to restore innominate symmetry External Devices (Taping/Splinting/Orthotics) Sacroiliac braces may be implemented to maintain the pelvic alignment gained from the mobilization procedures Sacroiliac supports/braces are also indicated when ligamentous hypermobility is suspected – such as in pregnant and postpartum patients Re-injury Prevention Instruction Avoid postures or movements that place strain on the involved ligament

Sub Acute Stage / Moderate Condition Goals: Maintain corrected pelvis position and painfree status for extended periods (i.e., several days) Improve tolerance to repeated active spinal/sacral movements and weight bearing activities (i.e., ability to walk 15 minutes or more without pain). •

•

•

•

Approaches / Strategies listed above Manual Therapy Soft tissue mobilization to shortened hip flexors, extensors, or quadratus lumborum Therapeutic Exercises Instruct in exercises and/or movements to maintain the improvements in innominate symmetry gained with the soft tissue and joint manipulations Neuromuscular Re-education: Promote efficient, pain-free motor control of the trunk, pelvis, and lower extremities with bending movements, lifting maneuvers and weight bearing activities


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Settled Stage / Mild Condition Goals: Unrestricted Unrestricte d with performance of normal ADL and walking Normalize lumbar, pelvis, and hip muscle flexibility and strength deficits •

•

•

Approaches / Strategies listed above Therapeutic Exercises Instruct in stretching exercises to address the patient’s specific muscle flexibility deficits Instruct in strengthening exercises to address the patient’s specific muscle strength deficits Neuromuscular Re-education: Promote efficient, pain-free motor control of the trunk, pelvis, and lower extremities with bending movements, lifting maneuvers and weight bearing activities

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities •

•

Approaches / Strategies listed above Therapeutic Exercises Provide endurance exercises to maximize muscle performance of the lumbar, abdominal, and lower extremity musculature to perform the desired occupational or recreational activities Encourage participation in regular low stress aerobic activities as a means to improve fitness, muscle strength and prevent recurrences

Selected References Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. Which patients with low back pain benefit from spinal manipulation? validation of a clinical prediction rule. Ann Intern Med . 2004;141:920-928. Cibulka MT, Delitto A. A comparison of two different different methods to to treat hip pain in runners. J Orthop Sports Phys Ther . 1993;17:172-176. Cibulka M, Delitto A, Kondehoff R et al. Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain. Phys Ther .1988;68:1359-1363 .1988;68:1359-1363 Cibulka M, Koldehoff R et al. Clinical usefulness of cluster of sacroiliac joint tests in patients with and without low back pain. J orthop sports Phys ther 1999;29:83-92


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Delitto A, Cibulka MT, Erhard RE, Bowling RW, Tenhula JA: Evidence for use of an extension mobilization category in acute low back syndrome: A prescriptive validation pilot study. Phys Ther . 73:4;216-223, 1993. Ellison JB, Rose SJ, Sahrmann SA. Patterns of hip rotation range of motion: comparison comparison between healthy subjects and patients with low back pain. Phys Ther . 1990;70:537-541. Erhard RE, Delitto A, Cibulka Cibulka MT. Relative effectiveness of an extension extension program and a combined combined program of manipulation and flexion and extension exercises in patients with acute low back pain. Phys 1994;74:1093-1100. Ther . 1994;74:1093-1100. Flynn T, Fritz J, Withman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, and Allison S. A clincal prediction rule for classifying patients with low back pain who demonstrate short- term improvement with spinal manipulation. Spine. 2002;27:2835-2843 Godges JJ, Varnum DR, Sanders KM. Impairment-based examination and disability management of an elderly woman with sacroiliac region pain. Phys Ther . 2002;82:812-821. Greenman PE. Innominate shear dysfunction dysfunction in the sacroiliac sacroiliac syndrome. Manual Medicine . 1986;2:114121. Herzog W, Read LJ, Conway, JW, et al. Reliability of motion palpation procedures to detect sacroiliac joint fixations. J Manipulative Physiol Ther . 1989;12:86-92. Jackson R. Diagnosis and Treatment Treatment of Pelvic Girdle Dysfunction. Dysfunction. Orthopaedic Physical Therapy Clinics of North America. 1998;7:413-445. Lee D. The Pelvic Girdle. 2nd ed. Edinburg, Scotland. Scotland. Churchill Livingstone; Livingstone; 1999:69,71,136-141. 1999:69,71,136-141. Levangie PK. Four clinical tests tests of sacroiliac joint joint dysfunction: The association of test results with innominate torsion among patients with and without low back pain. Phys Ther . 1999;79:1043-1057. Riddle DL, Freburger JK, NAOR. Evaluation of the presence if sacroiliac joint region dysfunction using a combination of tests: A multicenter intertester rereliability study. Phys Ther 2002; 82:772-781 Vleeming A, Pool-Goudzwaard AL, Hammudoghlu Hammudoghlu D, Stoeckart R, Snijders C, Mens JMA. The function of the long dorsal sacroiliac ligament. Spine. 1996;21(5):556-62. Vleeming A, Stoeckart R, Volkers Volkers AC, Snijders CJ. Relation between form and function in the sacroiliac joint. Part I: clinical clinical anatomical anatomical aspects. Spine 1990;15:130-2. Vleeming A, Volkers Volkers ACW, Snijders CJ, Stoeckart R. Relation between form and function in the sacroiliac joint. joint. Part II: Biomechanical Biomechanical aspects. aspects. Spine. 1990;15(2):133-6.


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Manual Therapy For Common Pelvic Girdle Disorders Impairment: Restricted Innominate Inferior Translation Joint Mobilization: Mobilizatio n:

using femoral traction direct passive mobilization bilateral adductor contractions

Soft Tissue mobilization:

quadratus lumborum

Therapeutic Exercises:

ipsilateral posterior pelvic depression contralateral anterior pelvic elevation

Movement Re-Education:

ipsilateral trunk elongation during daily activities

Impairment: Restricted Innominate Posterior Rotation Joint Mobilization: Mobilization :

using gluteus maximus direct passive mobilization bilateral adductor contractions

Soft Tissue Mobilization: Mobilizati on:

iliacus


hip extensor strengthening hip flexor stretching

Movement Re-Education:

promote hip extensor and abdominal control during functional activities

Impairment: Restricted Innominate Anterior Rotation Joint Mobilization:

using hip flexors using adductors using passive mobilization bilateral adductor contractions

Soft Tissue Mobilization: Mobilizati on:

gluteal myofascia


isometric hip flexor contractions gluteal and hamstring stretching

Movement Re-Education Options:


neutral standing posture allow limb to fully trail trunk (into hip extension and anterior innominate rotation) during terminal stance/pre-swing

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Quadratus Lumborum Soft Tissue Mobilization

Pelvic Pattern Contract/Relax Stretch and Re-education

Iliacus Soft Tissue Mobilization


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Impairments: Pelvic Girdle Positional Asymmetry Limited Innominate Inferior Translation

Innominate Inferior Translation – leg pull

Innominate Inferior Translation – prone direct mobilization Cues: Generate inferior translation via force through lower extremity or via direct force on ilium Ensure that hip, thigh, knee and leg are free of pathology prior to applying inferior traction to tibia Symptom level and response to initial mobilization determine the amplitude and speed of the mobilization The following references provide additional information regarding this procedure: Diane Lee MCPA, COMP: The Pelvic Girdle, p. 115-116, 1989 Godges JJ, Varnum DR, Sanders KM. Impairment-based examination and disability management of an elderly woman with sacroiliac region pain. Phys Ther . 2002;82:812-821.


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Impairments: Innominate Positional Asymmetry Limited Left Innominate Anterior Rotation -orLimited Right Innominate Posterior Rotation

Innominate Isometric Mobilization using hip flexors and extensors: Left Innominate Anterior Rotation Right Innominate Posterior Rotation Cues: Utilize iliacus and rectus femoris on the left, gluteus maximus and hamstrings on the right Having both feet off the table lessens undesired antagonist co-contraction Manually contact the appropriate surface required to elicit the desired agonist contraction Slow build-up of force - maximal, painfree contraction - full relaxation Use compression/support on top of knees to facilitate relaxation Repeat contraction - relaxation cycle 3 to 5 times “Balance” pubes via bilateral adductor contractions following every innominate mobilization or manipulation

The following references provide additional information regarding this procedure: Richard Jackson PT, OCS: Diagnosis and Treatment of Pelvic Girdle Dysfunction. Orthopaedic Physical Therapy Clinics of North America, Volume 7, No. 3, p. 441-442, 1998 Godges JJ, Varnum DR, Sanders KM. Impairment-based examination and disability management of an elderly woman with sacroiliac region pain. Phys Ther . 2002;82:812821.


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Impairments: Innominate Positional Asymmetry Limited Inferior Translation of Left Innominate (Left Pube) Limited Left Innominate Anterior Rotation

Innominate Isometric Mobilization using hip adductors and extensors: Left Pube Inferior Translation Left Innominate Anterior Rotation Right Innominate Posterior Rotation Cues: Utilize adductors on the left, gluteus maximus and hamstrings on the right Stand on patient’s right side to provide an efficient force application (lean) into left adductors and right tibia


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Impairment:

Limited Innominate Posterior Rotation

Innominate Posterior Rotation Cues: Stand in front of patient Utilize force couple on the innominate – mobilizing the ASIS posteriorly, mobilizing the ischial tuberosity anteriorly The following references provides additional information regarding this procedure: Carolyn Wadsworth MS, PT: Manual Examination and Treatment of the Spine and Extremities, p. 87, 1988 Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 111, 1993 Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 365, 1996


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Impairment:

Limited Innominate Anterior Rotation

Innominate Anterior Rotation Cues: Location of the foot placement on the floor and the height of the table determine the amount of posterior rotation on the contralateral innominate Utilize ipsilateral passive hip extension to create innominate anterior rotation To isolate mobilizing force to the sacroiliac and pubic articulations, manually stabilize the sacrum Create mobilizing and stabilizing forces with a lateral trunk lean The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 110, 1993


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Impairments: Limited Innominate Mobility Limited Sacral Mobility

Lumbopelvic Region Manipulation Cues: Flex, and sidebend thorax to the same side as the involved SI, and rotate thorax and lumbar spine away from the involved side – recruiting movement into the sacrum Through the ASIS, apply a posterior and slightly lateral mobilization or manipulation to the innominate The following research publications provide additional information regarding this procedure: Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. Which patients with low back pain benefit from spinal manipulation? validation of a clinical prediction rule. Ann Intern Med . 2004;141:920-928. Cibulka MT, Delitto, A Koldehoff LM. Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain: an experimental study. Phys Ther . 1988;68:1359-1363. Cibulka MT. The treatment of the sacroiliac joint component to low back pain: a case report. Phys Ther. 1992;72:917-922. Erhard RE, Delitto A, Cibulka MT. Relative effectiveness of an extension program and a combined program of manipulation and flexion and extension exercise in patients with acute low back syndrome. Phys Ther. 1994;74:1093-1100. Flynn T, Fritz J, Whitman J, Wainer R, Magel J, Redeiro D, Butler B, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate shortterm improvement with spinal manipulation. Spine. 2002;27:2835-2843.


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Lumbar Spine Mobility Deficits ICD-9-CM code: ICF codes:

724.2 Lumbago (low back pain, low back syndrome, lumbalgia)

Activities and Participation Domain code: d4105 Bending (Tilting the back downward or to the side, at the torso, such as in bowling or reaching down for an object) Body Structure code: s76002 Lumbar vertebral column Body Functions code: b7101 Mobility of several joints

Common Historical Findings: Felt "catch" in low back following a misstep, fall, bending, twisting, or lifting activity Unilateral pain in low back, buttock, or posterior thigh (depending on level of segmental involvement) If subacute, may report stiffness Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Increase in pain at end range of sidebending left or sidebending right Symptoms reproduced with unilateral posterior-to-anterior pressure over the involved spinal segment Physical Examination Procedures:

Lumbar Side Bending Performance Cues: "Do you have any discomfort at this moment?" Demonstrate as you say "Bend to the side as far as you comfortably can and return" "Did that motion cause an increase in your pain?" "WHEN during the movement did you notice an increase in your pain?"


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Unilateral Posterior-to-Anterior Posterior-to-Anterior Pressures Performance Cues: Localize pressure to one transverse process Sink deep enough to incriminate or "clear" the segment When using thumbs - contact same side When using a “dummy” thumb under pisiform - contact opposite side - fingers face away from iliac crest – using a flat, relaxed hand Other physical examination procedures to identify the involved segment:

TP Assessment in flexion Performance Cues: Ensure that spinal extensors are relaxed ("Let your arms hang toward the floor") Keep thumbs at same level of the segment’s transverse process Match right and left thumb PA pressure intensity Determine symmetry of depth Determine symmetry of resistance Determine symptom response


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TP Assessment in Extension Performance Cues: Ensure that the spinal extensors are relaxed ("Let your chin rest in your hands") Remember to line up your dominant eye Lumbar Spine Mobility Deficits: Description, Descriptio n, Etiology, Stages, and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Lumbar Facet Syndrome”

Description: Dysfunction of the movement of the one vertebrae of the lumbar spine relative to its adjacent vertebrae – commonly due to facet irregularities, muscle imbalances or trauma. Etiology: The suspected cause of this disorder is a movement abnormality where one segment of the spine is unable to either flex, extend, side bend or rotate in a normal pain free manner on its adjacent vertebrae. There is anatomical evidence that this movement movement abnormality is caused by either a displacement of fibro-fatty tissue within the outer borders of the facet capsule or posttraumatic fibrosis of the facet capsule. The cause of the movement abnormalities and the associated pain is believed to be an awkward, sudden, twisting or bending motion, (resulting in a reversible displacement of fibro-fatty tissue) or healing of the a posttraumatic facet capsule with its accompanying capsular contracture and shortening of the adjacent segmental myofascia.

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101.3 SEVERE impairment of mobility of several joints •

•

• •

• •

The patient’s reported complaint of unilateral low back and/or buttock pain increases at the end ranges of left or right sidebending Repeated flexion and extension movements do not improve or worsen the patient’s baseline level of pain Limited or pain-limited lumbar inclinometer measures are common Unilateral posterior-to-anterior pressures at the involved segment reproduce the patient’s pain complaint Motion restrictions are present at the involved segment Myofascia associated with the involved segment is usually hypertonic and painful


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Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101.2 MODERATE impairment of mobility of several joints As above with the following differences The patient’s unilateral symptoms are reproduced only with overpressures at end ranges of left or right sidebending Improved segmental mobility is commonly associated with improving symptomatology

•

•

Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101.1 MILD impairment of mobility of several joints As above with the following differences The patient’s unilateral symptoms are reproduced only with end range overpressures in either a combined extension and sidebending motion or a combined flexion and sidebending motion

•

Now when less acute – examine for muscle flexibility and strength deficits that may predispose the patient to future injury. For example: •

•

Muscles that commonly exhibit flexibility deficits in patients with facet abnormalities are latissimus dorsi/thoracolumbar fascia, hip flexors, hamstrings/sciatic nerve, and the gastrocsoleus complex Muscles that are commonly weak are the trunk extensors, trunk flexors, hip flexors, hip extensors, and hip abductors

Intervention Approaches / Strategies Acute Stage / Severe Condition Goal: Restore painfree active spinal mobility •

•

Physical Agents Electrical stimulation, ice (or heat) to provide pain relief and reduce muscle guarding Manual Therapy Soft tissue mobilization primarily to multifidus and rotatores of the involved segment Joint mobilization/manipulation using isometric mobilization and contract/relax procedures to the involved segment to reduce associated rotatores or multifi muscle guarding Passive stretching procedures to restore normal lumbar segmental mobility to the involved segment


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•

•

Therapeutic Exercise Instruct in exercise and functional movements to maintain the improvements in mobility gained with the soft tissue and joint manipulations Re-injury Prevention Instruction Instruct the patient in efficient, painfree, motor performance of movements that are related by the patient to be the cause of the current episode of low back pain

Sub Acute Stage / Moderate Condition Goal: Restore normal, painfree response to overpressures at end ranges of sidebending •

Approaches / Strategies listed above – focusing on soft tissue mobilization and joint mobilization/manipulation to normalize segmental mobility followed by mobility exercises to maintain the improvements gained from the manual procedures

Settled Stage / Mild Condition Goal: Restore normal, painfree responses to overpressures of combined extension and sidebending and/or combined flexion and sidebending Normalize lumbar, pelvis, and hip muscle flexibility and strength deficits •

•

Approaches / Strategies listed above Therapeutic Exercises Instruct in stretching exercises to address the patient’s specific muscle flexibility deficits Instruct in strengthening exercises to address the patient’s specific muscle strength deficits

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities •

•

Approaches / Strategies listed above Therapeutic Exercises Encourage participation in regular low stress aerobic activities as a means to improve fitness, muscle strength and prevent recurrences


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Selected References Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. Which patients with low back pain benefit from spinal manipulation? validation of a clinical prediction rule. Ann Intern Med . 2004;141:920-928. Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain. Spine. 2003;28:1363-1372. Assendelft WJ, Morton SC, Yu EL, Suttorp MJ, Shekelle PG. Spinal manipulatative therapr for low back pain. A meta-analysisis of effectiveness relative to other therapies. Ann Intern Med. 2003;138:871-881 Bronfort G. Spinal manipulations: current state of research and its indications. Neurologic Clinics 1999;17:91-111. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for lowback pain. Annals of Internal Medicine 1992; 117:590-8. New Zealand Acute Low Back Pain Guide. Wellington, NZ: ACC and National Health Committee, 1997. http://www.nzgg.org.nz/library/gl_complete/backpain1/index.cfm#contents VHA/DoD Clinical Practice Guideline for the Management of Low Back Pain or Sciatica in the Primary Care Setting. The Low Back Pain Workgroup with support from: The Office of Performance and Quality. VHA Headquarters, Washington, DC; Quality Management Directorate, United States Army MEDCOM; The External Peer Review Program. West Virginia Medical Institute, Inc. Birch & Davis Associates, Inc. 1999. http://www.cs.amedd.army.mil/qmo/lbpfr.htm Bigos S, Bowyer O, Braen G, Brown K, Deyo R, Haldeman S. Acute Low Back Problems in Adults. Rockville, Maryland: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, 1994. http://text.nlm.nih.gov/ftrs/pick?collect=ahcpr&dbName=lbpc&cd=1&t=919360476 Tannenbaum H, Davis P, Russell AS, et al. An evidence-based approach to prescribing NSAIDs in musculoskeletal disease: a Canadian consensus. Canadian NSAID Consensus Participants. CMAJ 1996; 155:77-88. http://www.rcgp.org.uk/rcgp/clinspec/guidelines/backpain/backpain5.asp#Guideline Jackson, Roger P. "The Facet Syndrome: Myth or Reality?" Clinical Orthopedics and Related Research. June, 1992.


6


Manual Therapy for Lumbar Spine Segmental Motion Impairments Flexion (opening) Impairment Impairment Examination

Active ROM – Sidebending movement/pain relation Position – TP provocation/symmetry in sitting flexion Passive ROM – Unilateral PA’s movement/pain relation Palpation – Segmental myofascial hypertonicity/tenderness Passive ROM – Segmental (physiologic) motion tests

Treatment

Soft Tissue Mobilization:

Quadratus Lumborum Erector Spinae/Thoracolumbar Fascia Segmental Myofascia

Joint Mobilization/Manipulati Mobilizati on/Manipulation: on:

Lumbar Sidebending in Neutral Lumbar Sidebending/Rotation in Flexion

Extension (closing) Impairment Impairment Examination

Active ROM – Sidebending movement/pain relation Position – TP provocation/symmetry in prone extension Passive ROM – Unilateral PA’s movement/pain relation Palpation – Segmental myofascial hypertonicity/tenderness

Treatment

Soft Tissue Mobilization:

Psoas

Joint Mobilization/Manipulati Mobilizati on/Manipulation: on:


7

Lumbar Rotation in Neutral Lumbar Sidebending/Rotation in Extension


Quadratus Lumborum Soft Tissue Mobilization

Psoas Soft Tissue Mobilization

Lumbar Segmental Myofascia STM


8


Impairment:

Limited Lumbar Segmental Rotation

Forward Bend up to Involved Segment

Rotate Down to the Involved Segment


9


Lumbar Rotation in Neutral Cues: Forward bend to midrange of involved segment Rotate until motion just begins at the involved segment Keeping involved segment perpendicular Ensure that forces and contacts on the rib cage (not humerus) and ilium (not trochanter) are comfortable Contract/relax, oscillation, and high velocity-low amplitude procedures can be employed as indicated Utilize compression, slight lumbar sidebending, slight lumbar flexion or extension to create a “crisp” barrier at the involved segment prior to manipulation procedures The following references provides additional information regarding this procedure: Stanley Paris PT: Spinal Manipulative Therapy. Clinical Orthopaedics and Related Research, Volume 179, p. 55-61, 1983. Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 134, 137, 1993 John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 184185, 1992 Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 294-295, 1996


10


Impairment:

Limited Lumbar Segmental Flexion, Left Sidebending, and Left Rotation

Lumbar Left Rotation/Sidebending in Flexion Cues: Position the upper knee anterior to the bottom knee to allow the pelvis to rotate Flex up from below to the involved segment Flex down from above to the involved segment Retract the upper shoulder (don’t pull the bottom arm) Keep the involved segment perpendicular to the table Push the pelvis superiorly and anteriorly to promote the sidebending and rotation

The following references provides additional information regarding this procedure: John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 178, 1992 Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 288–289, 1996


11


Impairment:

Limited Lumbar Segmental Extension, Left Sidebending, and Left Rotation

Lumbar Left Rotation/Sidebending in Extension Cues: A sheet between the patient and the table reduces friction during the set-up Localize to the involved segments by 1) anterior translation of spine, 2) extension of the leg near table, 3) extension of the trunk, 4) simultaneous counter rotation with sidebending of the trunk and pelvis (maintain perpendicular at the involved segment) The following references provides additional information regarding this procedure: Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 161-162, 1993 John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 180182, 1992 Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 291-292 and 298-299, 1996


12


Lumbar Muscle Power Deficits ICD-9-CM codes:

847.2

Lumbar sprains and strains

ICF codes: Activities and Participation Domain codes: d4105 Bending (Tilting the back downward or to the side, at the torso, such as in bowling or reaching down for an object) d4305 Putting down objects (Using hands, arms or other parts of the body to place an object down on a surface or place, such as when lowering a container of water to the ground.) Body Structure code: s7601 Muscles of trunk Body Functions code: b7300 Power of isolated muscles and muscle groups Common Historical Findings

Recent unaccustomed, repetitive bending or lifting activities (e.g., shoveling) Sudden or unexpected strain – usually while lifting or pushing Direct, blunt trauma to low back Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:

Pain with contraction of lumbar extensors (e.g., "torturous" return from forward bending) Symptoms reproduced with palpation of erector spinae, quadratus lumborum, or psoas trigger points Physical Examination Procedures:

Painful Contraction of Lumbar Extensors Performance Cues: Assess ability to return to erect standing from full forward bending - e.g., use of hands on bent knees and thighs; expressions and vocalizations of discomfort

Joe Godges, DPT, MA, OCS


Quadratus Lumborum Palpation Performance Cues: Palpate for symptomatic taut bands superior to iliac crest, anterior to erector spinae myofascia, and inferior to 12th rib

Psoas Palpation Performance Cues: To palpate psoas: Fully flex hip to relax abdominals. Sink slowly Use a "flat" hand Extend hip to allow the patient’s foot to rest on table Palpate for psoas contraction when asking patient to “raise knee a quarter inch toward the ceiling and relax” Palpate from L1 to L4 for taut bands which reproduce the symptomatic complaints If it does not contract with hip flexion - it is not psoas myofascia



Lumbar Muscle Power Deficits: Description, Etiology, Stages, and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with the vernacular term "Lumbar Muscle Strain"

Description: Injury to the muscles of the low back. The muscles that commonly produce lumbar pain are quadratus lumborum, psoas major, iliocostalis lumborum, and the multifidi. Etiology: Lumbar muscle strain occurs with a trauma to the low back region that is a result of a contusion, stretching or tearing tearing of the muscluature. muscluature. Lumbar muscle strain can also occur secondary to micro tears in muscle and fascial tissue caused by repetitive stress. This typically occurs when an unaccustomed activity is performed – such as shoveling snow for the first time in winter, gardening for the first time in spring, or moving furniture and boxes during d uring a home improvement project.

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7300.3 SEVERE impairments of muscle power •

• •

Pain with activities that require contraction of lumbar lumba r musculature (e.g., when returning to upright from a bent over position) Pain with activities that stretch the involved invo lved lumbar musculature Palpatory provocation of the involved muscles reproduce the reported symptoms

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7300.1 MILD impairments of muscle power • •

As above – but symptoms are less intense and more difficult to provoke Muscle flexibilty and strength deficits in the hip, pelvis and lumbar regions

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease pain Limit further tissue injury •

Physical Agents Ice packs, ice massage Ultrasound Electrical stimulation Whirlpool



•

•

•

Manual Therapy Soft tissue mobilization and gentle manual stretching to the involved myofascia and myofascial trigger points Therapeutic Exercises Active mobility exercises to involved muscle – i.e., midrange painfree contractions of the involved muscles Gentle stretching of the involved muscles Re-injury Prevention Instruction Provide instructions in proper body mechanics for lifting, bending or other potentially injurious activities routinely performed by the patient

Sub Acute Stage / Moderate Condition Goals: As above Return to near-normal activities •

•

Approaches / Strategies listed above Therapeutic Exercises Increase intensity and duration of the mobility and stretching exercises

Settled Stage / Mild Condition Goals: Normalize muscle flexibility Normalize pelvic girdle and trunk strength Return to normal activities •

•

Approaches / Strategies listed above Therapeutic Exercises Increase intensity and duration of the mobility and stretching exercises Stretching exercises for relevant tight musculature Strengthening exercises for relevant weak musculature

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or recreational activities •

Approaches / Strategies listed above



•

•

Therapeutic Exercises Add muscular and cardiovascular endurance activities to the current exercise program Ergonomic Instruction Provide job/sport specific training to lessen strain on the lumbar spine and to maximize activity tolerance

Selected References Drezner JA, Herring SA: Managing low-back pain. Physician & Sports Medicine. 2001;29, (8) Philadelphia panel evidence- based clinical practice guidelines on selected rehabilitation intervention: overview and methodology: low back pain. Phys Ther . 2001;81:(10) Schenk RJ, Doran RL, Stachura JJ. Learning effects of a back education program. Journal of Manipulative & Physiological Therapeutics. 1997;20:(7) Smith D, McMurray N, Disler P. Early intervention for acute back injury: can we finally develop an evidence-based approach? Clinical Rehabilitation. 2002;(10)



Lumbar Spine Movement Coordination Deficits ICD-9-CM code: ICF codes:

846.0

Lumbosacral ligament sprain

Activities and Participation Domain code: d4159 Maintaining a body position, unspecified Body Structure code: s76002 Lumbar vertebral column Body Functions code: b7601 Control of complex voluntary movements

Common Historical Findings: Trauma, such as a vehicular accident Bending/twisting Bending/twisting strain Pain with sustained, end-range postures - relief with position change Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Pain worsens with sustained positions that put an end range strain on the involved structures Segmental hypermobility with manual examination procedures such as posterior-toanterior pressures over the lumbar spinus processes Physical Examination Procedures:

Overpressure in Flexion Performance Cues: Intensity of symptoms in mid-range position are compared with sustained end-range positions With high level of symptoms - gentle overpressures will reproduce complaints With low level of symptoms - strong, sustained overpressures are required to reproduce the complaints


1


Central Posterior-to-Anterior Pressures Performance Cues: Localize pressure to one spinus process Assess amount of mobility and resistance to the manually applied pressure Assess for the presence of pain, type of pain with regards to the patient’s reported symptoms, and the relation of the onset of the pain to the onset of resistance

Lumbar Spine Movement Coordination Deficits: Description, Etiology, Stages, and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Lumbar Instability or Lumbar Ligament Strain”

Description: A sprain is a stretch and/or tear of a ligament, the fibrous band of connective tissue that joins the end of one bone with another. In the lumbar spine, ligaments produce pain when they are held at end range. An abnormal end range stress to a lumbar ligament for a short period of time will produce pain. Or, a normal end range stress held for and abnormal amout of time will produce pain. And thirdly, a normal stress for a short period of time to abnormal tissue will also produce pain. These stress/time relationships help define Robin McKenzie’s classification of Postural Syndrome and Dysfunction Syndrome. The outer fibers of the annulus fibrosis serve the same physiological function as other ligaments of the lumbar spine (such as the posterior longitudinal ligament, interspinous ligaments, or supraspinus ligaments). Thus, abnormal stresses to the annulus fibrosis may be the actual tissue that is the source of the low back pain for many patients within this diagnostic category. In any case, the intervention is essentially the same – avoid the end range, pain-producing positions. Etiology: Lumbar ligaments are “sprained” secondary to 1) trauma, bending / twisting, and 2) sustained end ranges postures or positions, such as prolonged sitting. Most of the ligaments of the lumbar spine, as well as the annulus fibrosis, function to limit anterior shearing with forward bending. Thus, forward bending positions appear to be the most pain producing positions for patients with ligament disorders.


2


Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7601.3 SEVERE impairment of motor control/coordination of complex voluntary movements •

•

• • •

•

•

Pain limits movements into end ranges of motion of the lumbar spine – especially flexion Central posterior-to-anterior pressures onto the involved segment reproduce the patient’s symptoms Guarding/hypertonicity of the muscles adjacent to the involved segment Proprioceptive deficits (i.e., inability to single leg stand with eyes closed) Poor trunk control – including poor control of the muscles that stabilize the involved lumbar spine segment(s) (i.e., multifidus and transversus abdominus) Muscle flexibility deficits in regions above and below the lumbar spine (that result in excessive compensatory movement taking place at the lumbar segments) Nerve mobility deficits in regions adjacent to the lumbar spine

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7601.2 MODERATE impairment of motor control/coordination of complex voluntary movements As above with the following differences •

Manual overpressure movements into end ranges of motion of the lumbar spine – especially flexion – reproduce symptoms. Symptoms are eased when overpressure is relieved

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7601.1 MILD impairment of motor control/coordination of complex voluntary movements As above with the following differences •

Sustained postures held at end ranges of motion of the lumbar spine – especially flexion – reproduce symptoms. Symptoms are eased when the patient repositions him/herself into a more neutral position.

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease pain Ability to stabilize lumbar spine during basic daily activities, such as transitional movements •

Physical Agents


3


Cold pack Electric stimulation •

•

•

External Devices (Taping/Splinting/Orthotics) Consider using taping or a brace or issue a lumbar roll to remind the patient to maintain his/her lumbar spine neutral positions during daily activities and limit forward bending Re-injury Prevention Instruction Take caution to avoid end range positions that reproduce the symptoms Patient education in correct posture, body mechanics and ergonomics. Therapeutic Exercises Directionally biased, repetitive end-range movements if required for centralization of symptoms Trunk isometric exercises in neutral positions (e.g., abdominal sets, back extensor sets) and maintenance of the contractions during transitional movements such as supine-sit, and sit-stand Aquatic therapy Lumbar segmental contract/relax (muscle energy techniques) as appropriate for symptom reduction. Initiate stretching exercises to muscles (e.g., hamstrings) with flexibility deficits.

Sub Acute Stage / Moderate Condition Goals: Increase trunk strength Increase activity tolerance •

•

Approaches / Strategies listed above Therapeutic Exercises Add resistance to trunk isometric exercises in neutral positions (e.g., leg sliding, leg lowering, bridging, quadruped alternate arm/leg lifts) Initiate proprioceptive exercises (e.g., single leg standing with a neutral foot positions) Promote participation in aerobic conditioning exercises (e.g., walking)

Settled Stage / Mild Condition Goals: As above Increased tolerance to perform lumbar flexion activities •



4


•

•

Therapeutic Exercises Progress resistance to trunk isometric and isotonic exercises in neutral or nearneutral positions Progress proprioceptive exercises Progress in aerobic conditioning Initiate stretching exercises to muscles (e.g., hamstrings) with flexibility deficits Initiate mobility exercises exercises to nerves (e.g., sciatic) with flexibility deficits Re-injury Prevention Instruction Promote self-efficacy with exercise body mechanics, ergonomics and correct posture durning daily activities for symptom control Promote maintenance of optimal fitness and weight control

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goals: Return patient to optimal activity level for performance of desired occupational and recreational activities Avoid re-injury •

•

•

Approaches / Strategies listed above Therapeutic Exercise Progress stretching, strengthening, and proprioception and nerve mobility exercises Maximize muscle performance of the relevant lower quadrant (hip, knee, ankle and lumbar) muscles or upper quadrant (scapular, shoulder, elbow, and forearm) required to perform the desired occupational or recreational activities Ergonomic Instruction Provide job/sport specific training to lessen strain on the lumbar spine and to maximize activity tolerance

Selected References rd Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum, 3 Ed . Edinburgh: Churchill Livingstone; 1997:203-225.

Bullock-Saxton JE, Janda V, Bullock MI. Reflex activation of gluteal muscles in walking. An approach to restoration of muscle function for patients with low-back pain. Spine. 1993;18:704708. Bullock-Saxton JE. Local sensation changes and altered hip muscle function following severe ankle sprain. Phys Ther . 1994 ;74:17-31.


5


Cresswell AG, Oddsson L, Thorstensson A. The influence of sudden perturbations on trunk muscle activity and intra-abdominal pressure while standing. Experimental Brain Research. 1994;98:336-341 Godges JJ, MacRae PG, Engelke KA. Effects of exercise on hip range of motion, trunk muscle muscle performance, and gait economy. Phys Ther. 1993;73:468-477. Godges JJ, Varnum DR, Sanders KM. Impairment-based examination and disability management of an elderly woman with sacroiliac region pain. Phys Ther . 2002;82:812-821. Hayes MA, Howard TC, Gruel CR, Kopta JA. Roentgenographic evaluation of lumbar spine flexion-extension in asymptomatic individuals. Spine. 1989;14:327-331. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic following resolution of acute first episode low back pain. Spine. 1996;21:2763-2769. Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. Clin Orthop. 1982;165:110-123. La Rocca H, MacNab I. Value of pre-employment radiographic assessment of the lumbar spine. Ind Med Surg. 1970;39:31-36. Mc Kenzie, RA: The Lumbar spine: Mechanical Diagnosis and Therapy. Waikanae, New Zealand, Spinal Publications Ltd., 1981 O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. 1997;22:2959-2967. Paris SV. Physical signs of instability. Spine 1985;10:277-279. Richardson C, Jull G, Hodges P, Hides J. Therapeutic Exercise for Spinal Stabilization in Low Back Pain. Edinburgh: Churchill Livingstone; 1999:41-59. Weiler PJ, King GJ, Gertzbein SD. Analysis of sagittal plane instability of the lumbar spine in vivo. Spine 1990;15:1300-1306. Wilke HJ, Wolf S, Claes LE, Arand M. Stability increase of the lumbar spine with different muscle groups: a biomechanical in vitro study. Spine. 1995;20:192-198. Wilson E, Payton O, Donegan-Shoaf L, Dec K. Muscle energy technique in patients with acute low back pain: a pilot clinical trial. J Orthop Sports Phys Ther . 2003;33:502-512.


6


Exercise and Movement Re-Education Interventions for Patients with Lumbar Spine Impairments Body Function Label

Lumbar Spine Mobility Deficits

Critical Impairments

Other Supportive Criteria Acute low back pain

ROM limitations limitations

Minimal/no previous history of LBP

Symptoms reproduced with sustained end range positions

Long history of progressively worsening symptoms (i.e., less tolerance to end range positions – such as sitting)

Isometric mobilizations to normalize pelvic girdle symmetry. Ergonomic cuing to maintain mid-range lumbar and pelvic girdle positions. Proprioceptive Proprioceptive training and trunk/pelvic girdle strengthening to improve ability to stay in midrange positions. Taping or bracing as indicated.

Location of symptoms move centrally with repeated lumbar extension or with repeated lateral trunk shifts

Difficulty with sitting and forward bending Multiple previous episodes of LBP (progression of “Ligamentous Instability”) Observable reduced lumbar lordosis – may have lateral trunk shift

Manual procedures, postures, or exercises that centralize the symptoms. Ergonomic cuing to maintain lumbar lordosis prevent peripheralization. Progress to treatment of underlying segmental instability.

Narrow band of lancinating pain

Nerve mobility deficits with lower limb tension testing

Dural and nerve mobility exercises as indicated to address the patient’s key impairments Soft tissue and/or joint mobilization to areas of potential spinal and peripheral nerve entrapments

“Facet Syndrome” Mobilization Exercises

Other vernacular terms: “Ligamentous Instability”

Symptoms eased with neutral positions and midrange movements

Stabilization Exercises

Lumbar Spine and Related Lower Limb Pain Other vernacular terms: “Disc Derangement” Extension Exercise, or Specific Exercise Group

Lumbar Spine and Related Lower Extremity Radicular Pain “Nerve Root Adhesion” or “Dural Adhesion” Nerve Mobility Exercises


End-range stretching to maintain segmental ROM gained from manipulative procedures. Ergonomic instruction, trunk & pelvic girdle strengthening & stretching, as indicated, to prevent future disability.

End-range pain

Other vernacular terms:

Lumbar Spine Stability Deficits

Interventions

Symptoms reproduced with SLR and/or slump testing

7


References Mobilization Exercises 1. Deyo R, Hiehl A, Rosenthal M. M. How many days of bed rest for acute low back pain? a randomized randomized clinical clinical trial. trial. N Engl J Med. 1986;315:1064-70. 2. Delitto A, Erhard RE, Bowling Bowling RW. RW. A treatment-based treatment-based classification classification approach approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther. 1995;75:470-489. 3. McGill SM. Low back exercises: evidence for improving exercise regimens. Phys Ther. 1998:78:754-765. 4. Godges JJ, MacRae H, Longdon C, Tinberg C, MacRae P. The effects of two stretching procedures procedures on hip range of motion motion and gait economy. J Ortho Sports Phys Ther . 1989;10:350-357. 1989;10:350-357. Stabilization Exercises 5. Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum, 3 rd Ed . Edinburgh: Churchill Livingstone; 1997:203-225. 6. Kirkaldy-Willis Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. Clin Orthop. 1982;165:110-123. 7. Paris SV. Physical signs of instability. Spine 1985;10:277-279. 8. La Rocca H, MacNab MacNab I. Value of pre-employment pre-employment radiographic radiographic assessment of the the lumbar lumbar spine. spine. Ind Med Surg . 1970;39:31-36. 9. Hayes MA, Howard TC, TC, Gruel CR, Kopta Kopta JA. Roentgenographic Roentgenographic evaluation of lumbar lumbar spine flexion-extension in asymptomatic asymptomatic individuals. Spine. 1989;14:327-331. 10. Weiler PJ, King King GJ, Gertzbein Gertzbein SD. Analysis of sagittal plane instability of the lumbar lumbar spine in vivo. Spine 1990;15:1300-1306. 11. Wilke HJ, Wolf S, Claes LE, Arand Arand M. Stability increase of the lumbar lumbar spine with different different muscle groups: a biomechanical biomechanical in vitro study. Spine. 1995;20:192-198. 1995;20:192-198. 12. Hides JA, Richardson CA, Jull Jull GA. Multifidus muscle muscle recovery is not automatic automatic following resolution resolution of acute first episode low back pain. Spine. 1996;21:2763-2769. 13. Cresswell AG, Oddsson Oddsson L, Thorstensson A. The influence of sudden perturbations on trunk muscle activity activity and intra-abdominal intra-abdominal pressure while standing. Experimental Brain Research. 1994;98:336-341 1994;98:336-341 14. Richardson C, Jull G, Hodges Hodges P, Hides J. Therapeutic Exercise for Spinal Stabilization in Low Back Pain. Edinburgh: Churchill Livingstone; 1999:41-59. 15. Godges JJ, Varnum DR, Sanders KM. Impairment-based Impairment-based examination and disability management of an elderly woman woman with sacroiliac region pain. Phys Ther . 2002;82:812-821. 16. Bullock-Saxton JE, Janda V, Bullock Bullock MI. Reflex activation of of gluteal muscles in in walking. An approach to restoration restoration of muscle muscle function for patients with low-back pain. Spine. 1993;18:704-708. 17. Bullock-Saxton JE. Local sensation changes and altered altered hip muscle muscle function following severe ankle sprain. sprain. Phys Ther . 1994 ;74:1731. 18. Godges JJ, MacRae PG, Engelke Engelke KA. Effects of exercise on hip hip range of motion, motion, trunk muscle muscle performance, and gait economy. Phys Ther. 1993;73:468-477. 19. O’Sullivan PB, Twomey Twomey LT, Allison GT. Evaluation Evaluation of specific stabilizing stabilizing exercise in the treatment of chronic chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. 1997;22:2959-2967. Extension Exercises and Lateral Shift Correction/Exercises 20. Delitto A, Cibulka Cibulka MT, Erhard RE, Bowling RW, RW, Tenhula JA: Evidence for use of an extension extension mobilization category category in acute low back syndrome: A prescriptive validation pilot study. Phys Ther. 1993;73;216-223. 21. Fritz J, George S. The Use of a Classification Classification Approach to Identify Subgroups Subgroups of Patients Patients With Acute Low Back Pain: Interrater Reliability and Short-Term Treatment Outcomes. Spine. 2000;25:106-114. 2000;25:106-114. 22. Donelson RG. The reliability reliability of centralized centralized pain response. Arch Phys Med Rehabil. 2000;81:999-1000. 23. Donelson R, Silva G, Murphy K. Centralization phenomenon: its usefulness in evaluating and treating referred pain. Spine 1990;15:211-213. 24. Donelson R, Grant Grant W, Kamps C, C, Medcalf R. Pain response to sagittal end-range spinal spinal motion: motion: a prospective, randomized, randomized, multicentered trial. Spine. 1991;16(6):S206-S212. 25. Erhard RE, Delitto Delitto A, Cibulka Cibulka MT. Relative effectiveness of an extension program program and a combined combined program of manipulation manipulation and flexion and extension exercises in patients with acute low back pain. Phys Ther. 1994;74:1093-1100. 26. Stankovic R, Johnell O: Conservative treatment treatment of acute low-back pain. A prospective randomized trial: trial: McKenzie method of treatment versus patient education in “mini back school”. Spine 1990 Feb;15:120-123. 27. Sufka A, Hauger B, Trenary M, Bishop Bishop B, Hagen A, Lozon Lozon R, Martens B. B. Centralization of of low back pain and perceived functional functional outcome. J Ortho Sports Phys Ther. 1998;27:205-212. 28. Saal JA, Saal JS. Nonoperative Nonoperative treatment treatment of herniated lumbar lumbar intervertebral intervertebral disc with radiculopathy: radiculopathy: an outcome study. study. Spine. 1989;14:431-437. 29. Stankovic R, Johnell Johnell O: Conservative treatment treatment of acute low back pain. A 5-year follow-up study study of two methods methods of treatment. treatment. Spine. 1995;15;20:469-72. 30. Williams MM, MM, Hawley JA, McKenzie McKenzie RA, Van Wijmen Wijmen PM: A comparison of the effects of two sitting sitting postures on back and referred pain. Spine. 1991;16:1185-1191. 1991;16:1185-1191. Nerve Mobility Exercises 31. Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum, 3 rd Ed . Edinburgh: Churchill Churchill Livingstone; 1997:187-191. 1997:187-191. 32. George SZ. Characteristics of patients with with lower extremity extremity symptoms symptoms treated with slump stretching: stretching: a case series. J Orthop Sports Phys Ther. 2002;32:391-398 33. Howe JF, Loeser JD, Calvin WH. Mechanosensitivity of dorsal root ganglia ganglia and chronically chronically injured axons: axons: a physiological physiological basis for the radicular pain of nerve root compression. Pain. 1977;3:25-41. 34. El Mahdi MA, Latif FYA, Janko M. M. The spinal nerve root root irritation, irritation, and a new concept of of the clinicopathological clinicopathological interrelations interrelations in back pain and sciatica. Neurochirurgia. 1981;24:137-141. 35. Smyth MJ, MJ, Wright V. Sciatica and the intervertebral intervertebral disc. An An experimental experimental study. J Bone Joint Surg. 1959;40A:1401-1418.


8


Lumbar Spine and Related Lower Limb Pain ICD-9-CM code:

ICF codes:

722.10

Displacement of lumbar intervertebral intervertebr al disc without myelopathy

Activities and Participation Domain code: d4153 Maintaining a sitting position (Staying in a seated position, on a seat or the floor, for some time as required, such as when sitting at a desk or table.) Body Structure code: s76002 Lumbar vertebral column Body Functions code: b28013 Pain in back b28015 Pain in lower limb

Common Historical Findings: Recurring episodes of low back pain (> one year) Recent episode precipitated by bending/twisting or lifting strain Symptoms worse with prolonged sitting or repetitive forward bending activities Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: "Flat" back (reduction in normal lumbar lordosis) May have lateral shift of thorax Location of symptoms peripheralize or centralize following a specific repeated movement Physical Examination Procedures:

Right Lateral Shift

Repeated Forward Bending

Performance Cues: Establish baseline location of symptoms - remember to ask "Anywhere else?"


1


Demonstrate as you say "Slide your hands down your thigh and bend forward as far as you comfortable can and return" After returning to the standing position inquire, "Did that motion cause a change in your pain (or symptoms?)" If yes, "At this moment, WHERE is your pain (or symptoms)? Anywhere else?" If the location of symptoms moves peripherally - perform one more repetition to verify If the location of symptoms moves centrally - perform five more repetitions to verify If the location of symptoms does not change - perform five more repetitions to verify

Repeated Backward Bending Performance Cues: Re-establish baseline Demonstrate and say "Spread your feet apart, place your hands on your buttocks, and bend backward as far as you comfortable can then return back up." Utilize standard inquires (above in forward bending cues) to determine if the location of symptoms peripheralized or centralized following completion of the motion(s)

Lumbar Spine and Related Lower Limb Pain: Description, Etiology, Stages, and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Lumbar Disc Disorder”

Description: As the degeneration of the intervertebral disc progresses the outer layers of the disc (annulus fibrosus) becomes weak and allow protrusion or extrusion of the inner portion of the


2


disc (nucleus pulposus). The bulging disc can produce low back and leg pain. The bulging disc may also put pressure on the spinal cord or any of the nerve roots that branch from it – thus producing a lumbar radiculopathy Etiology: Traumatic onset such as with awkward and/or heavy lifting using poor body mechanics may initiate the slow process of disc degradation – which may take years before symptoms are noted. Non-traumatic onset, associated with prolonged sitting and repetitive flexion/bending activities, may also create degenerative changes in the disc over time.

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28013.3 SEVERE pain in back; and b28015.3 SEVERE pain in lower limb • • • •

•

Reduced lumbar lordosis May have a lateral trunk shift Repeated flexion movement worsen or peripheralize the patient’s symptoms Central posterior-to-anterior pressures on the involved segment reproduce the reported symptoms Limited straight leg raise (SLR) due to mobility deficits in the sciatic nerve or hamstrings

Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28013.2 MODERATE pain in back; and b28015.2 MODERATE pain in lower limb •

•

As above Specific repeated movements, commonly extension or lateral shift movements, may centralize or reduce the patient’s symptoms

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28013.1 MILD pain in back; and b28015.1 MILD pain in lower limb •

As above

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease pain Centralize symptoms


3


•

•

•

•

•

Physical Agents Ice Electrical stimulation (e.g., interferential or TENS) Re-injury Prevention Instruction Educate patient to avoid activities (typically flextion activities) that aggravate the low back or leg pain – especially avoid movements and positions that peripheralize the patient’s symptoms External Devices (Taping/Splinting/Orthotics) Consider using taping or a brace to remind the patient to maintain his/her lumbar lordosis during daily activities and limit forward bending Therapeutic Exercise Instruct in positions or exercises (typically lumbar extension postures or exercises) that centralize the symptoms Manual Therapy Lateral shift procedures, manual traction, or mechanical traction may allow centralization of symptoms when positions/exercises are ineffective in centralizing the symptoms

Sub Acute Stage / Moderate Condition Goals: As above Improve activity tolerance for performing normal ADL’s •

•

•

Approaches / Strategies listed above Therapeutic Exercise Initiate lumbar stabilization exercises (i.e., trunk flexor and extensor strengthening to maintain the lumbar spine in its neutral positions during performance of daily activities Initiate stretching exercises to myofascia with flexibility deficits (e.g., hamstrings) Initiate nerve mobility exercises the nerve with mobility limitations (e.g., sciatic nerve) Promote daily performance of low-stress aerobic activity (e.g., walking) Neuromuscular Re-Education Provide verbal, proprioceptive and manual cues for maintenance of neutral lumbar spine postitions during daily activites


4


Settled Stage / Mild Condition Goals: Improve activity tolerance for performing normal ADL’s Return to desired level of activity, including occupational and recreational activities.

Intervention for Higher Performance / High Demand Function in Workers or Athletes Goal: Return patient to optimal activity level for performance of desired occupational and recreational activities •

•

•

Avoid re-injury Approaches / Strategies listed above Therapeutic Exercise Progress stretching, strengthening, and proprioception and nerve mobility exercises Maximize muscle performance of the relevant lower quadrant (hip, knee, ankle and lumbar) muscles or upper quadrant (scapular, shoulder, elbow, forearm) required to perform the desired occupational or recreational activities Ergonomic Instruction Provide job/sport specific training to lessen strain on the lumbar spine and to maximize activity tolerance

Selected References Stankovic R, Johnell O. Conservative treatment of acute low back pain; a prospective randomized trial: McKenzie method versus patient education in “mini back school”. Spine. 1990;15:120-3. Donelson R, Grant W, Kamps C, Medcalf R. Pain response to sagittal end-range spinal motion: a prospective, randomized, multicentered trial. Spine. 1991;15(6suppl):S206-212. Zylbergold RS, Piper MC. Lumbar disc disease: comparative analysis of physical therapy treatments. Arch Phys Med Rehab. 1981;62:179-179. Saal JA. Natural history and nonpoerative treatment of lumbar disc herniation. Spine. 1996;21(24s):2S-9S. Koury MJ, Scarpelli E. A manual therapy approach to evaluation and treatment of a patient with a chronic lumbar nerve root irritation. Phys Ther. 1994;74:548-560. Weber H. Lumbar disc herniation: a comtrolled, prospective study with ten years of observation. Spine. 1983;8:131-139.


5


Donelson R, Aprill C, Medcalf R, Grant W. A prospective study on centralization of lumbar and referred pain. Spine. 1997;22:1115-1122. Donelson R, Silva G, Murphy K. Centralization Phenomenon: its usefulness in evaluation and treating referred pain. Spine. 1990;15:211-213. Sufka A, Hauger B, Trenary M, Bishop B, Hagen A, Lozon R, Martens B. Centralization of low back pain and perceived functional outcome. J Orthop Sports Phys Ther. 1998;27:205-212. Sanders M, Stein K. Conservative management of herniated nucleus pulposus: treatment approaches. J Manip Physiol Ther . 1988;11:309-313. Delitto A, Erhard EE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther . 1995;75:470485. Barstow IK, Gilliam J, Bishop M. Management of patients with low back pain. Orthopaedic Physical Therapy Clinic of North America. 1998;7:447-488.


6






















Lumbar Spine and Related Lower Extremity Radicular Pain Other vernacular terms: “Nerve Root Adhesion” or “Dural Adhesion” Nerve Mobility Exercises



End-range pain



Interventions


7


References Mobilization Exercises 1. Deyo R, Hiehl A, Rosenthal M. M. How many days of bed rest for acute low back pain? a randomized randomized clinical clinical trial. trial. N Engl J Med. 1986;315:1064-70. 2. Delitto A, Erhard RE, Bowling Bowling RW. RW. A treatment-based treatment-based classification classification approach approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther. 1995;75:470-489. 3. McGill SM. Low back exercises: evidence for improving exercise regimens. Phys Ther. 1998:78:754-765. 4. Godges JJ, MacRae H, Longdon C, Tinberg C, MacRae P. The effects of two stretching procedures procedures on hip range of motion motion and gait economy. J Ortho Sports Phys Ther . 1989;10:350-357. 1989;10:350-357. Stabilization Exercises 5. Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum, 3 rd Ed . Edinburgh: Churchill Livingstone; 1997:203-225. 6. Kirkaldy-Willis Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. Clin Orthop. 1982;165:110-123. 7. Paris SV. Physical signs of instability. Spine 1985;10:277-279. 8. La Rocca H, MacNab MacNab I. Value of pre-employment pre-employment radiographic radiographic assessment of the the lumbar lumbar spine. spine. Ind Med Surg . 1970;39:31-36. 9. Hayes MA, Howard TC, TC, Gruel CR, Kopta Kopta JA. Roentgenographic Roentgenographic evaluation of lumbar lumbar spine flexion-extension in asymptomatic asymptomatic individuals. Spine. 1989;14:327-331. 10. Weiler PJ, King King GJ, Gertzbein Gertzbein SD. Analysis of sagittal plane instability of the lumbar lumbar spine in vivo. Spine 1990;15:1300-1306. 11. Wilke HJ, Wolf S, Claes LE, Arand Arand M. Stability increase of the lumbar lumbar spine with different different muscle groups: a biomechanical biomechanical in vitro study. Spine. 1995;20:192-198. 1995;20:192-198. 12. Hides JA, Richardson CA, Jull Jull GA. Multifidus muscle muscle recovery is not automatic automatic following resolution resolution of acute first episode low back pain. Spine. 1996;21:2763-2769. 13. Cresswell AG, Oddsson Oddsson L, Thorstensson A. The influence of sudden perturbations on trunk muscle activity activity and intra-abdominal intra-abdominal pressure while standing. Experimental Brain Research. 1994;98:336-341 1994;98:336-341 14. Richardson C, Jull G, Hodges Hodges P, Hides J. Therapeutic Exercise for Spinal Stabilization in Low Back Pain. Edinburgh: Churchill Livingstone; 1999:41-59. 15. Godges JJ, Varnum DR, Sanders KM. Impairment-based Impairment-based examination and disability management of an elderly woman woman with sacroiliac region pain. Phys Ther . 2002;82:812-821. 16. Bullock-Saxton JE, Janda V, Bullock Bullock MI. Reflex activation of of gluteal muscles in in walking. An approach to restoration restoration of muscle muscle function for patients with low-back pain. Spine. 1993;18:704-708. 17. Bullock-Saxton JE. Local sensation changes and altered altered hip muscle muscle function following severe ankle sprain. sprain. Phys Ther . 1994 ;74:1731. 18. Godges JJ, MacRae PG, Engelke Engelke KA. Effects of exercise on hip hip range of motion, motion, trunk muscle muscle performance, and gait economy. Phys Ther. 1993;73:468-477. 19. O’Sullivan PB, Twomey Twomey LT, Allison GT. Evaluation Evaluation of specific stabilizing stabilizing exercise in the treatment of chronic chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. 1997;22:2959-2967. Extension Exercises and Lateral Shift Correction/Exercises 20. Delitto A, Cibulka Cibulka MT, Erhard RE, Bowling RW, RW, Tenhula JA: Evidence for use of an extension mobilization mobilization category category in acute low back syndrome: A prescriptive validation pilot study. Phys Ther. 1993;73;216-223. 21. Fritz J, George S. The use of a classification classification approach to identify identify subgroups subgroups of patients with acute low back pain: pain: interrater reliability reliability and short-term treatment outcomes. Spine. 2000;25:106-114. 2000;25:106-114. 22. Donelson RG. The reliability reliability of centralized centralized pain response. Arch Phys Med Rehabil. 2000;81:999-1000. 23. Donelson R, Silva G, Murphy K. Centralization phenomenon: its usefulness in evaluating and treating referred pain. Spine 1990;15:211-213. 24. Donelson R, Grant Grant W, Kamps C, C, Medcalf R. Pain response to sagittal end-range spinal spinal motion: motion: a prospective, randomized, randomized, multicentered trial. Spine. 1991;16(6):S206-S212. 25. Erhard RE, Delitto Delitto A, Cibulka Cibulka MT. Relative effectiveness of an extension program program and a combined combined program of manipulation manipulation and flexion and extension exercises in patients with acute low back pain. Phys Ther. 1994;74:1093-1100. 26. Stankovic R, Johnell O: Conservative treatment treatment of acute low-back pain. A prospective randomized trial: trial: McKenzie method of treatment versus patient education in “mini back school”. Spine 1990 Feb;15:120-123. 27. Sufka A, Hauger B, Trenary M, Bishop Bishop B, Hagen A, Lozon Lozon R, Martens B. B. Centralization of of low back pain and perceived functional functional outcome. J Ortho Sports Phys Ther. 1998;27:205-212. 28. Saal JA, Saal JS. Nonoperative Nonoperative treatment treatment of herniated lumbar lumbar intervertebral intervertebral disc with radiculopathy: radiculopathy: an outcome study. study. Spine. 1989;14:431-437. 29. Stankovic R, Johnell Johnell O: Conservative treatment treatment of acute low back pain. A 5-year follow-up study study of two methods methods of treatment. treatment. Spine. 1995;15;20:469-72. 30. Williams MM, MM, Hawley JA, McKenzie McKenzie RA, Van Wijmen Wijmen PM: A comparison of the effects of two sitting sitting postures on back and referred pain. Spine. 1991;16:1185-1191. 1991;16:1185-1191. Nerve Mobility Exercises 31. Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum, 3 rd Ed . Edinburgh: Churchill Churchill Livingstone; 1997:187-191. 1997:187-191. 32. George SZ. Characteristics of patients with with lower extremity extremity symptoms symptoms treated with slump stretching: stretching: a case series. J Orthop Sports Phys Ther. 2002;32:391-398 33. Howe JF, Loeser JD, Calvin WH. Mechanosensitivity of dorsal root ganglia ganglia and chronically chronically injured axons: axons: a physiological physiological basis for the radicular pain of nerve root compression. Pain. 1977;3:25-41. 34. El Mahdi MA, Latif FYA, Janko M. M. The spinal nerve root root irritation, irritation, and a new concept of of the clinicopathological clinicopathological interrelations interrelations in back pain and sciatica. Neurochirurgia. 1981;24:137-141. 35. Smyth MJ, Wright V. Sciatica and the intervertebral disc. An experimental study. J Bone Joint Surg. 1959;40A:1401-1418.


8


Lumbar Spine and Related Lower Extremity Radiating Pain ICD-9-CM code: ICF codes:

724.3

Sciatica

Activities and Participation Domain code: d4104 Standing (Getting into and out of a standing position or changing body position from standing to any other position, such as lying down or sitting down) Body Structure codes: s76002 Lumbar vertebral column s7508 Structure of the lower extremity, other specified Body Functions code: b28013 Pain in back b2803 Radiating pain in a dermatome

Common Historical Findings: Shooting, narrow band of pain - usually below the knee Paresthesias Numbness Weakness Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: May adopt postures or positions found to relieve nerve tension Symptoms are reproduced with SLR or other lower limb tension tests May have sensation deficits over medial calf, dorsal web space between 1st and 2nd metatarsals, or lateral foot to light touch or sharp/dull May have strength deficits of gastrocnemius/soleus complex (single leg heel raise), extensor hallucis longus (EHL manual muscle test), or tibialis anterior (TA manual muscle test) Physical Examination Procedures:

Straight Leg Raising/Ankle Dorsiflexion Performance Cues: Raise leg until symptoms are slightly reproduced


1


Determine symptom alteration with hip flexion and extension; ankle dorsiflexion and plantarflexion

Sensation Testing Performance Cues: Utilize light touch or sharp/dull testing:

L4 = Medial lower leg L5 = Dorsal web space S1 = Lateral foot (5th metatarsal) Assess perianal region if you suspect cauda equina involvement

Segmental Muscle Strength Testing Single Leg Heel Raise Performance Cues: Provide hand to hand contact to assist bal First - perform bilateral heel raise and note amount of ankle plantarflexion Second - perform single leg heel raise and determine if full ankle plantarflexion is achieved Gastrocnemius/Soleus muscles = S1


2


Segmental Muscle Strength Testing Tibialis Anterior Performance Cues: “Raise your foot and ankle up and in and hold it there” Note ability to resist opposing manual force Tibialis anterior = L4

Extensor Hallucis Longus Manual Muscle Tests Performance Cues: "Raise your big toes to the ceiling and hold" Note ability to resist opposing manual force May resist bilaterally and compare ability to resist Extensor hallucis longus = L5

Lumbar Spine and Related Lower Extremity Radiating Pain Description, Etiology, Stages, and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Lumbar Radiculopathy”

Description: Lumbar radiculopathy is a disorder of the nerve root at the central canal involving a portion of the cauda equina or at the lateral forminal canal involving one or more nerve roots. The patient presentation is usually involves pain, numbness or paresthesia, and weakness of the lower extremities. The pain is typically described as a lancinating, narrow band or pain that radiates distally. Etiology: Lumbar radiculopathy is suspected to occur as a result of arthritic spurs, displacement of the lumbar disc, fractures of the spine, and other pathology such as neoplasms. It is commonly believed that these disorders compress the nerves exiting the spinal cord producing impaired conduction of the involved nerves. In many patients, the inflammatory process around


3


the nerve root is believe to be the major cause of the pain and nerve conduction disturbances – because the anatomical abnormalities persist (upon follow-up imaging) even after the symptoms have been alleviated.

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28013.3 SEVERE pain in back; and b2803.3 SEVERE radiating pain in a dermatome •

• •

•

•

Radicular pain limits movements are commonly seen that create a stretch to the involved nerve root – such as lumbar and hip flexion with a straightened knee Postures to limit the tension on the (such as a lateral shift) may be present Muscles associated with the level of the injury will often present with guarding/spasming o Positive straight leg raising (SLR) where radicular pain is reproduced at about 30 of SLR and worsens with ankle dorsiflexion Positive contralateral SLR

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28013.2 MODERATE pain in back; and b2803.2 MODERATE radiating pain in a dermatome • • •

As above with the following differences Radicular pain typically diminishes as the inflammation is reduced Patient reports less pain in mid range/neutral postures and but pain remaines with end range movement

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28013.1 MILD pain in back; and b2803.1 MILD radiating pain in a dermatome • •

As above with the following differences The patient’s radicular symptoms are reproduced only at the extreme end ranges of SLR or forward bending while standing

When less acute the therapist should re-assess for strength and flexibility deficits that may be present and predispose the patient to repeated or further injury.

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Alleviate radicular symptoms Improve active movement range for the lumbar spine and lower extremities


4


•

•

•

Patient Education/Re-injury Prevention Establish a movement or position that best relives the patient’s radicular symptoms. (Positions that reduce nerve entrapment at the lateral forminal canal are typically slight flexion, sidebending opposite the painful side, and slight rotation away from the painful side.) This positioning is usually done with the patient sidelying on a treatment or mat table – mimicking the patient’s bed positions Advise the patient to follow the medication instructions provided by her/his physician – specifically emphasize the importance of proper administration of steroidal or non-steroidal antiflammatory medications in addressing the inflammation around the nerve root Instruct the patient to avoid movements that may exacerbate their symptoms Therapeutic Exercises Nerve mobility exercises for the involved lower extremity in the painfree ranges (e.g., ankle dorsiflexion/plantarflexion in painfree ranges – with varying amounts of knee extension) Physical Agents Ice Electrical stimulation

Sub Acute Stage / Moderate Condition Goal: Restore painfree active spinal and lower extremity movement •

•

•

Approaches / Strategies listed above Therapeutic Exercises Progress nerve mobility exercises for the involved lower extremity in the painfree ranges If the patient is suspected to have an underlying disc disorder, attempt to centralizes the patient’s pain in the lower extremity through the use of positions and repeated movements/exercises (usually lateral shift maneuvers combined with extension exercises) Manual Therapy Manual overpressures or mobilization techniques may be utilized to facilitate and maintain the centralization of lower extremity pain

Settled Stage / Mild Condition Goals: Restore normal, painfree active spinal movement to enable the patient to perform activities of daily living


5


Normalize lumbar, pelvis, hip, knee and ankle strength and flexibility •


When less acute the therapist should re-assess for strength and flexibility deficits that may be present and predispose the patient to repeated or further injury. •

Therapeutic Exercises Continue to progress nerve mobility exercises for the involved lower extremity in the painfree ranges Continue to progress the use of positions and repeated movements/exercises that centralize the patient’s symptoms Stretching exercises for relevant tight musculature Strengthening exercises for relevant weak musculature

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or recreational activities •

•

•

Approaches / Strategies listed above Therapeutic Exercises Add muscular and cardiovascular endurance activities to the current exercise program Ergonomic Instruction Provide job/sport specific training to lessen strain on the lumbar spine and to maximize activity tolerance

Selected References George SZ. Characteristics of patients with lower extremity symptoms treated with slump stretching: a case series. J Orthop Sports Phys Ther. 2002;32:391-398 Stankovic R, Johnell O: Conservative treatment of acute low-back pain. A prospective randomized trial: McKenzie method of treatment versus patient education in “Mini Back School”. Spine 15:2,1990. Sufka, A et al. Centralization of low back pain and perceived functional outcome. J Ortho Sports Phys Ther. 1998. 27:205-212. Williams MM, Hawley JA, McKenzie RA, Van Wijmen PM: A comparison of the effects of two sitting postures on back and referred pain. Spine. 1991;16:1185-1191.


6






















Lumbar Spine and Related Lower Extremity Radicular Pain Other vernacular terms: “Nerve Root Adhesion” or “Dural Adhesion” Nerve Mobility Exercises



End-range pain



Interventions


7


References Mobilization Exercises 1. Deyo R, Hiehl A, Rosenthal M. M. How many days of bed rest for acute low back pain? a randomized randomized clinical clinical trial. trial. N Engl J Med. 1986;315:1064-70. 2. Delitto A, Erhard RE, Bowling Bowling RW. RW. A treatment-based treatment-based classification classification approach approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther. 1995;75:470-489. 3. McGill SM. Low back exercises: evidence for improving exercise regimens. Phys Ther. 1998:78:754-765. 4. Godges JJ, MacRae H, Longdon C, Tinberg C, MacRae P. The effects of two stretching procedures procedures on hip range of motion motion and gait economy. J Ortho Sports Phys Ther . 1989;10:350-357. 1989;10:350-357. Stabilization Exercises 5. Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum, 3 rd Ed . Edinburgh: Churchill Livingstone; 1997:203-225. 6. Kirkaldy-Willis Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. Clin Orthop. 1982;165:110-123. 7. Paris SV. Physical signs of instability. Spine 1985;10:277-279. 8. La Rocca H, MacNab MacNab I. Value of pre-employment pre-employment radiographic radiographic assessment of the the lumbar lumbar spine. spine. Ind Med Surg . 1970;39:31-36. 9. Hayes MA, Howard TC, TC, Gruel CR, Kopta Kopta JA. Roentgenographic Roentgenographic evaluation of lumbar lumbar spine flexion-extension in asymptomatic asymptomatic individuals. Spine. 1989;14:327-331. 10. Weiler PJ, King King GJ, Gertzbein Gertzbein SD. Analysis of sagittal plane instability of the lumbar lumbar spine in vivo. Spine 1990;15:1300-1306. 11. Wilke HJ, Wolf S, Claes LE, Arand Arand M. Stability increase of the lumbar lumbar spine with different different muscle groups: a biomechanical biomechanical in vitro study. Spine. 1995;20:192-198. 1995;20:192-198. 12. Hides JA, Richardson CA, Jull Jull GA. Multifidus muscle muscle recovery is not automatic automatic following resolution resolution of acute first episode low back pain. Spine. 1996;21:2763-2769. 13. Cresswell AG, Oddsson Oddsson L, Thorstensson A. The influence of sudden perturbations on trunk muscle activity activity and intra-abdominal intra-abdominal pressure while standing. Experimental Brain Research. 1994;98:336-341 1994;98:336-341 14. Richardson C, Jull G, Hodges Hodges P, Hides J. Therapeutic Exercise for Spinal Stabilization in Low Back Pain. Edinburgh: Churchill Livingstone; 1999:41-59. 15. Godges JJ, Varnum DR, Sanders KM. Impairment-based Impairment-based examination and disability management of an elderly woman woman with sacroiliac region pain. Phys Ther . 2002;82:812-821. 16. Bullock-Saxton JE, Janda V, Bullock Bullock MI. Reflex activation of of gluteal muscles in in walking. An approach to restoration restoration of muscle muscle function for patients with low-back pain. Spine. 1993;18:704-708. 17. Bullock-Saxton JE. Local sensation changes and altered altered hip muscle muscle function following severe ankle sprain. sprain. Phys Ther . 1994 ;74:1731. 18. Godges JJ, MacRae PG, Engelke Engelke KA. Effects of exercise on hip hip range of motion, motion, trunk muscle muscle performance, and gait economy. Phys Ther. 1993;73:468-477. 19. O’Sullivan PB, Twomey Twomey LT, Allison GT. Evaluation Evaluation of specific stabilizing stabilizing exercise in the treatment of chronic chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. 1997;22:2959-2967. Extension Exercises and Lateral Shift Correction/Exercises 20. Delitto A, Cibulka Cibulka MT, Erhard RE, Bowling RW, RW, Tenhula JA: Evidence for use of an extension extension mobilization category category in acute low back syndrome: A prescriptive validation pilot study. Phys Ther. 1993;73;216-223. 21. Fritz J, George S. The use of a classification classification approach to identify identify subgroups subgroups of patients with acute low back pain: pain: interrater reliability reliability and short-term treatment outcomes. Spine. 2000;25:106-114. 2000;25:106-114. 22. Donelson RG. The reliability reliability of centralized centralized pain response. Arch Phys Med Rehabil. 2000;81:999-1000. 23. Donelson R, Silva G, Murphy K. Centralization phenomenon: its usefulness in evaluating and treating referred pain. Spine 1990;15:211-213. 24. Donelson R, Grant Grant W, Kamps C, C, Medcalf R. Pain response to sagittal end-range spinal spinal motion: motion: a prospective, randomized, randomized, multicentered trial. Spine. 1991;16(6):S206-S212. 25. Erhard RE, Delitto Delitto A, Cibulka Cibulka MT. Relative effectiveness of an extension program program and a combined combined program of manipulation manipulation and flexion and extension exercises in patients with acute low back pain. Phys Ther. 1994;74:1093-1100. 26. Stankovic R, Johnell O: Conservative treatment treatment of acute low-back pain. A prospective randomized trial: trial: McKenzie method of treatment versus patient education in “mini back school”. Spine 1990 Feb;15:120-123. 27. Sufka A, Hauger B, Trenary M, Bishop Bishop B, Hagen A, Lozon Lozon R, Martens B. B. Centralization of of low back pain and perceived functional functional outcome. J Ortho Sports Phys Ther. 1998;27:205-212. 28. Saal JA, Saal JS. Nonoperative Nonoperative treatment treatment of herniated lumbar lumbar intervertebral intervertebral disc with radiculopathy: radiculopathy: an outcome study. study. Spine. 1989;14:431-437. 29. Stankovic R, Johnell Johnell O: Conservative treatment treatment of acute low back pain. A 5-year follow-up study study of two methods methods of treatment. treatment. Spine. 1995;15;20:469-72. 30. Williams MM, MM, Hawley JA, McKenzie McKenzie RA, Van Wijmen Wijmen PM: A comparison of the effects of two sitting sitting postures on back and referred pain. Spine. 1991;16:1185-1191. 1991;16:1185-1191. Nerve Mobility Exercises 31. Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum, 3 rd Ed . Edinburgh: Churchill Churchill Livingstone; 1997:187-191. 1997:187-191. 32. George SZ. Characteristics of patients with with lower extremity extremity symptoms symptoms treated with slump stretching: stretching: a case series. J Orthop Sports Phys Ther. 2002;32:391-398 33. Howe JF, Loeser JD, Calvin WH. Mechanosensitivity of dorsal root ganglia ganglia and chronically chronically injured axons: axons: a physiological physiological basis for the radicular pain of nerve root compression. Pain. 1977;3:25-41. 34. El Mahdi MA, Latif FYA, Janko M. M. The spinal nerve root root irritation, irritation, and a new concept of of the clinicopathological clinicopathological interrelations interrelations in back pain and sciatica. Neurochirurgia. 1981;24:137-141. 35. Smyth MJ, MJ, Wright V. Sciatica and the intervertebral intervertebral disc. An An experimental experimental study. J Bone Joint Surg. 1959;40A:1401-1418.


8


Algorithm #1 Lumbo-Pelvic Region Examination Negative Findings

Red Screen for Potentially Serious Conditions (i.e., Red Flags) including Neurologic Examination when indicated

• • • • •

Clinical Prediction Rule Screening: Duration of symptoms <16 days No symptoms distal to knee FABQ work score < 19 Detection of lumbar hypomobility o > 35 hip internal rotation

Lumbopelvic Region Manipulation

At Least 3 of 5 Variables Present

Favorable Response Less Than 3 of 5Variables Present Less Than Favorable Response Positive Findings

Positioning and/or Repeated Movements for Centralization (if indicated)

Consultation with Appropriate Healthcare Provider

To Algorithm #2 Pelvic Girdle Sagittal Plane Examination

Centralization/Favorablee Response Centralization/Favorabl Symptoms Do Not Centralize

Lumbar Spine Repeated Movement Exam

Lumbar Single Plane Active Mobili Mobilitt Examin Examinati ation on

Pain Does Not Limit Motion in Available Ranges and/or Pain at End Range Does Not Produce Peripheral Symptoms To Algorithm #2

Pain During Movement, Pain Limits Motions in Available Ranges, or Movement Produces Peripheral Symptoms Lateral Shift Procedures and Exercises

Flexion Procedures and Exercises

Extension Procedures and Exercises

Lumbar Stabilization /Modality Procedures

Pain Limited Nerve Mobility (SLR or Slump)

Nerve Entrapment Reduction Procedures



Algorithm #2 Pelvic Girdle Sagittal Plane Examination Limited Anterior Innominate Rotation

Pelvic Girdle Motion Testing

Limited Posterior Innominate Rotation

Negative

Ipsilateral ASIS Superior PSIS Equal

Or

Ipsilateral ASIS Superior Ipsilateral PSIS Inferior

Pelvic Girdle Positional Testing

Ipsilateral ASIS Inferior Ipsilateral PSIS Superior

Or

ASIS Equal Ipsilateral PSIS Superior

Negative

Provocation of Sacrotuberous, and/or Short Posterior Sacroiliac Ligaments

Provocation of Sacrotuberous and/or Short Posterior Sacroiliac Ligaments

Pelvic Girdle Ligament Provocation Testin

Negative

Provocation of Long and/or Short Posterior Sacroiliac Ligaments

Provocation of Long Posterior Sacroiliac Ligaments and/or Short Posterior Sacroiliac Ligaments

Algorithm #2 Pelvic Girdle Sagittal Plane Examination Limited Anterior Innominate Rotation

Pelvic Girdle

Limited Posterior Innominate Rotation

Motion Testing

Negative

Ipsilateral ASIS Superior PSIS Equal

Ipsilateral ASIS Superior Ipsilateral PSIS Inferior

Or


Ipsilateral ASIS Inferior Ipsilateral PSIS Superior

Or

ASIS Equal Ipsilateral PSIS Superior

Negative

Provocation of Sacrotuberous, and/or Short Posterior Sacroiliac Ligaments

Provocation of Sacrotuberous and/or Short Posterior Sacroiliac Ligaments

Pelvic Girdle Ligament Provocation Testin

Provocation of Long and/or Short Posterior Sacroiliac Ligaments

Provocation of Long Posterior Sacroiliac Ligaments and/or Short Posterior Sacroiliac Ligaments

Negative

Inferior Innominate Translation with Anterior Innominate Mobilization Pattern

Anterior Innominate Mobilization Pattern

Go To Algorithm #3 Pelvic Girdle Transverse Plane Examination Algorithm

Posterior Innominate Mobilization Pattern

Inferior Innominate Translation with Posterior Innominate Mobilization Pattern

***Must have 2 out of 3 Square Boxes for greater specificity to Treatment Category



Algorithm #3 Pelvic Girdle Transverse Plane Examination

Limited Innominate External Rotation (Inflare)

Pelvic Girdle Active Motion Testing (Leg Rotation Test)

Limited Innominate Internal Rotation (Outflare)

Negative

Ipsilateral ASIS Medial


Ipsilateral ASIS Lateral

Negative

Positive ASIS Compression Test Provocation of Short Posterior SI Ligament

Pelvic Girdle Ligament Provocation Testing

Positive ASIS Distraction Test (Suspect Anterior SI Ligament Involvement)

Algorithm #3 Pelvic Girdle Transverse Plane Examination

Limited Innominate External Rotation (Inflare)

Pelvic Girdle Active Motion Testing (Leg Rotation Test)

Limited Innominate Internal Rotation (Outflare)

Negative

Ipsilateral ASIS Medial


Ipsilateral ASIS Lateral

Negative

Positive ASIS Compression Test Provocation of Short Posterior SI Ligament

Pelvic Girdle Ligament Provocation Testing

Positive ASIS Distraction Test (Suspect Anterior SI Ligament Involvement)

Negative

Innominate Outflare Mobilization Pattern

Go To Algorithm #4 Lumbar Mobility Examination

Innominate Inflare Mobilization Pattern



Algorithm #4

Lumbar Spine Segmental Mobility Examination To Algorithm #5

No pain group

Movement/Pain Relationship with Active Side-Bending

Flexion Manipulation Group (Contralateral Lumbar Pain)

Extension Manipulation Group (Ipsilateral Lumbar Pain)

Transverse Process Symmetry

Sitting Flexed Position Palpable positional asymmetry on Left Right

Prone Extended Position Palpable positional asymmetry on Left Right

Algorithm #4

Lumbar Spine Segmental Mobility Examination To Algorithm #5

Movement/Pain Relationship with Active Side-Bending

No pain group

Flexion Manipulation Group

Extension Manipulation Group

(Contralateral Lumbar Pain)

(Ipsilateral Lumbar Pain)

Transverse Process Symmetry

Sitting Flexed Position

Prone Extended Position

Palpable positional asymmetry on Left Right

Palpable positional asymmetry on Left Right

Resistance with P-A Pressures Unilat PA’s Reproduce Symptoms no resistance Hypermobile

Resistance/ Hypomobile Segment

Resistance/ Hypomobile Segment

no resistance Hypermobile

Segmental Muscle Hypertonicity

No

Yes

Add STM if Present

Neutral and/or Flexion/SB/Rot Spinal Manipulation Procedures

Yes

No

Neutral and/or Extension/SB/Rot Spinal Manipulation Procedures

To Algorithm #5



Algorithm #5

Associated Impairments Provide intervention intended to normalize impairments felt to be strongly associated with the patient’s symptoms or functional limitations Mobility/Flexibility Mobility/Flexibility Deficits Lumbar Extension ROM Lumbar Flexion ROM

Hip Flexors Hip Extensors Hip Internal Rotators Hip External Rotators Piriformis

Sciatic Nerve Femoral Nerve Dural Structures

Muscle Strength/Motor Control Deficits Upper Abdominals Lower Abdominals

Trunk Extensors Trunk Rotators

Transverse Abdominus

Multifidi

Hip Extensors Hip Abductors

Low Aerobic Capacity

Coordination Deficits Lower Extremity Proprioceptive Deficits


Balance Disorders

Poor Ergonomic Functioning


1

Lumbar Microdiscetomy and Rehabilitation Rehabilitation Surgical Indications and Considerations Anatomical Considerations: Unfortunately, Unfortunatel y, because the disc covering has a poor blood supply, healing of the hole where the inner core of the disc extruded may take three to four months to scar over. Therefore, restricting a patient’s activity for six weeks after microdiscectomy back surgery will not necessarily prevent a recurrence. Pathogenesis: A sudden heavy strain or increased pressure to the lower back. Sometimes a sudden twisting movement or even a sneeze will force some of the nucleus out through the disc's outer layer the annulus. Activities that are repetitious may stress the lower back, including poor lifting habits, prolonged exposure to vibration, or sports-related sports-relat ed injuries. A herniated disk fragment comes from the nucleus pulposus of the disc. In the normal condition, this nucleus is in the disk center securely contained by the annulus fibrosis. When a fragment of nucleus herniates, it irritates and/or compresses the adjacent nerve root. This can cause the pain

1

Lumbar Microdiscetomy and Rehabilitation Rehabilitation Surgical Indications and Considerations Anatomical Considerations: Unfortunately, Unfortunatel y, because the disc covering has a poor blood supply, healing of the hole where the inner core of the disc extruded may take three to four months to scar over. Therefore, restricting a patient’s activity for six weeks after microdiscectomy back surgery will not necessarily prevent a recurrence. Pathogenesis: A sudden heavy strain or increased pressure to the lower back. Sometimes a sudden twisting movement or even a sneeze will force some of the nucleus out through the disc's outer layer the annulus. Activities that are repetitious may stress the lower back, including poor lifting habits, prolonged exposure to vibration, or sports-related sports-relat ed injuries. A herniated disk fragment comes from the nucleus pulposus of the disc. In the normal condition, this nucleus is in the disk center securely contained by the annulus fibrosis. When a fragment of nucleus herniates, it irritates and/or compresses the adjacent nerve root. This can cause the pain syndrome known as sciatica and, in severe cases, dysfunction of the nerve. Epidemiology: Lumbar microdiscectomy are more common in males that females and has the maximal incidence in the third and fourth decades of life. First-degree relatives of patients with disc herniations have an increased prevalence of disc herniations. Other risk factors include prolonged driving of motor vehicles, frequent lifting of heavy objects, and repetitive twisting. Diagnosis:

Laboratory and Imaging CT/Myelography: Excellent when combined with CT for defining disc herniation and bony changes in relationship to the soft tissue abnormality. False negatives usually at the L5-S1 level, where there is a large space between the anterior dural edge and the posterior bony spine. False positives are greater in patients over the age of 55 because of hypertrophic osteoarthritic degenerative changes. MRI: The current imaging study of choice to demonstrate herniated disc due to noninvasive nature. EMG: Useful only if diagnosis of neuropathy or primary muscle disease is possible. May have utility in clarifying multi-level multi-level disease Non-operative Verses Operative Management When Lumbar Microdiscectomy is NOT an Option The severity of the symptoms (pain, weakness, lack of mobility), the patient’s general health and physical condition play an important part in determining when surgery is not an option. In general, surgery is not an option when (1) the back and leg pain is not caused by a ruptured disc; (2) there are mimimal leg symptoms, (3) a medical condition which prevents the surgery, and/or (4) physical therapy could improve reduce the symptoms.

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs


2 When Lumbar Microdiscectomy IS an Option Lumbar microdiscectomy is usually recommended when specific conditions are met. In general, surgery is recommended when: (1) a ruptured disc is pinching one or more spinal nerve roots, (2) there is leg pain which limits normal daily activities, (3) there is leg weakness or numbness, and/or there is impaired bowel or bladder functioning. Surgical Procedure: A microdiscectomy is performed through a small (1 inch to 1 1/2 inch) incision in the midline of the low back. First, the back muscles erector spinae are lifted off the lamina of the spine. Since these back muscles run vertically, they can be moved out of the way rather than cut. The surgeon is then able to enter the spine by removing the ligamentum flavum, and uses either operating glasses or an operating microscope to visualize the nerve root. Often, a small portion of the inside facet joint is removed both to facilitate access to the nerve root and to relieve pressure over the nerve. The nerve root is then gently moved to the side and the disc material is removed from under the nerve root.

Advantages of microdiscectomy or traditional laminectomy: Microdiscetomy Microdisceto my results in essentially no destabilizing effect from the removal of the lamina and unilateral ligamentum flavum. Preoperative Rehabilitation: Usually, a microdiscectomy procedure is performed on an outpatient basis or with one overnight stay in the hospital. Some surgeons restrict a patient from bending, lifting, or twisting for the first six weeks following surgery. However, since the patient's back is mechanically the same, it is also reasonable to return to a normal level of functioning immediately following surgery. Patient is educated on proper wound care and is instructed to keep the wound dry and clean. Change bandages when the dressing gets soiled or wet. Review techniques as to get in and out of bed properly, sleeping positions, sitting, walking and lifting. Patients are usually advised to not lift heavy objects above 10kg for 12 weeks following the surgery.

POSTOPERATIVE REHABILITATION

Note: The following rehabilitation protocol is a summary of guidelines for post-operative articular cartilage procedures provided by Post Surgical Rehabilitation Protocols for the Thoraco-Lumbar Spine: Arthroscopic Microdisectomy Clinical Guidelines. Developed st by Measurement Driven Rehabilitation Systems Inc. 1 edition) Phase I - Initiation of Spine and Trunk Rehabilitation: Weeks 1-4

Goals: Control pain symptoms Minimize loss of range or motion in a pain free zone Patient education on self-care techniques Educate patient on postural stability and proper positioning



3 Intervention: • •

•

•

Modalities for pain management, such as TENS, ice or heat Gentle stretching exercises should be done in the early postoperative period to minimize the any development of postsurgical scarring of the nerve root: The stretching should be done about 5 to 6 times a day The safest way to stretch is to lie down and maximally flex the hips and gradually extend the knee. This maneuver will also stretch the hamstring muscles, which is important for rehabilitation of the back It is generally advisable to do the stretching exercises frequently and gently. Stretching too hard may result in pain, and one should only take the stretch to the to just before the initial point of pain, and not beyond, to avoid inflaming the nerve Patient education on proper posture, assisting the patient in finding their neutral spine position Isometric exercises of “abdominal draw in,” “head flexion in supine,” “bridges,” and “superman”

Phase II - Spine and Trunk Rehabilitation: Weeks 4-8

Goals: Pain control Minimize loss of trunk strength Minimize deconditioning by implementing low-impact aerobic conditioning Intervention: •

Therapeutic exercises: At least about 15 minutes of appropriate stretching and strengthening exercises per day “Stabilization exercises” form the basis of the exercises, such as the quadruped arm and leg extensions, as well as transverses and lower oblique abdominal exercise progressions Aquatic therapy is an option for patients with a great deal of pain Walking at a sustained pace for a twenty minutes or more is a mainstay of most back rehabilitation programs Stationary biking is also an exercise option for patients who are more comfortable positioned leaning forward

Phase III – Spine and Trunk Rehabilitation: Weeks 8-12

Goals: Pain control Prevention of future episodes of low back pain an associated disability



4

Intervention: • •

•

Continue use of modalities as needed for pain control Progress trunk condition exercises – adding proprioception and motor reprogramming of lower extremity afferents and core stabilization muscles Progress intensity and duration of cardiovascular condition exercises such as walking, jogging, running, cycling, skating, cross country skiing, or swimming

Selected References: Donatelli A. Robert, Orthopaedic Physical Therapy. Philadelphia. 2001. Churchill Livingstone. Esses I. Stephen. Textbook of Spinal Disorders. Philadelphia. 1995. J. B. Lippincott Company. Dolan P, Greenfield K, Nelson RJ, Nelson IW. Can exercise therapy improve the outcome of microdiscectomy? Spine. 2000 Jun 15;25(12):1523-32. Yilmaz F, Yilmaz A, Merdol F, Parlar D, Sahin F, Kuran B. Efficacy of dynamic lumbar stabilization exercise in lumbar microdiscectomy. J Rehabil Med . 2003 Jul;35(4):163-7. http://www.spine-health.com/topics/surg/overview/lumbar/lumb03.html



1

Lumbar Spine Fusion Anatomical Considerations: The lumbar facet joints have a sagittal plane orientation that favors flexion/extension flexion/exten sion motions at the expense of axial rotation. A large flexion torque delivered to the thorax may concentrate an excessive hyperflexion stress at the extreme upper lumber region. Orientation of the lumbosacral junction facets and sacrohorizontal angle increases a shearing effect. Hyper-mobility in the lumbar segments occurs due to thoracic spine rigidity and sacral/pelvis sacral/pelvi s stability. The increased motion is disbursed only across the five intervertebral intervertebr al junctions. Due to increased motion, motion, the lumbar discs can degenerate, which can lead to disc herniations, nerve root impingements, and vertebral instability. A leading cause of disc degeneration and instability may be from poor postural control. Pathogenesis: Lumbar vertebrae and/or discs can be structurally compromised by many different factors. Instability can come from trauma directly to the spinal vertebrae/discs or peripherally that may affect the pull on the vertebras. Infections or tumors of the vertebral column can greatly affect alignment. Inherited or idiopathic scoliosis causes a cascade of muscle muscle imbalance and structural changes. Spondylolisthesis Spondylolisth esis occurs from anatomical mal-alignment and/or inadequate postural control. These listed conditions tend to be the primary pathologies indicating a spinal fusion. Conditions still under debate for indications are age related physiological changes such as disc dehydration which can contribute to disc degeneration and/or herniation, and conditions such as spondylolysis, or spondylosis. Epidemiology: Degeneration of the spine sometimes has a hard delineation of cause. It can be inherited or acquired. The largest contributing factor to both origins is poor postural control and improper biomechanical loading. Lumbar disc herniations or internal disc disruption, are one of the most frequent herniation sites in the spine, with approximately (85%) occurring at the L4-L5 level. Disc herniations usually are the result of two different mechanisms. One, from a large, sudden compression force delivered over the lumbar spine that is flexed or flexed and axially rotated, and is usually associated with a single event. The second resulting from a series of multiple, low magnitude compression forces, often imposed over a flexed lumbar spine and usually occurs gradually from cumulative microtrauma (poor posture with loading). If a disc disruption leads to significant instability, surgical fusion may be attempted (Note: Not all surgeons agree that internal disc disruptions are an indication for spinal fusion). Another source of degeneration is primary OA, which cause is unknown, however, it is termed as the wear and tear arthritis. Articular cartilage breaks down because of an imbalance between the mechanical stresses and the ability of the joint structures to handle the loads put upon them. Once the cartilage begins to breakdown, a cascade of tissue failure follows contributing to spinal instability. instability . Spondylolysis can occur from stress fractures caused by a traumatic event, from systemic dysfunction, or from surrounding structural imbalances usually affecting the zygapophysial joints. If this area of the vertebra is unable to handle the forces put upon them, compensatory movements will facilitate other sites of instability. Spondylolysthesis can occur from the plane shearing effect caused by anatomical structure and poor postural control contributions. Degenerative scoliosis, whether an inherent factor or idiopathically developed may be fused if a 30 degree curvature or more has occurred.



2 Diagnosis: • Patients’ clinical presentation may include low back pain with radiculopathy down the lower extremity, weakness of the legs or feet, numbness of the legs, feet, or toes, and/or loss of bowel and bladder control. • MOI of a single event of bending down to lift or lower a heavy object (with or without twisting), immediately feeling pain in their low back of varying degrees of severity. • Clinical evaluation using the single leg raise may indicate a herniated disc. As well as using dermatomal patterns and deep tendon reflexes to help identify nerve root involvement. • With degenerative disc disease and/or stenosis, patients may complain of an insidious onset of back pain or a sudden onset, with or without radicular symptoms due to the severity of resulting impingement. • X-ray to reveal amount of joint space narrowing, osteophyte formation/location, and healing confirmation in stress fractures. • MRI scan to reveal location and severity of disc protrusion and/or nerve root impingement. • A CT scan also may be used. • An nerve conduction velocity test may be done to detect signs of nerve damage or to determine the exact nerve roots that are involved Non-operative Versus Operative Management: Surgical fusion of the lumbar spine is typically recommended for patients who have unsuccessfully completed conservative therapy. This can include postural training, increasing flexibility, and improving strength within the trunk and lower extremities in an attempt to take mechanical stresses off the affected vertebral joints. Such therapy should be consistent for at least six weeks before considering surgery. Included in conservative therapy is the use of modalities such as the use of heat, cold, ultrasound, and electrical stimulation to reduce pain and muscle spasm. Hands-on treatments such as specialized forms of soft-tissue mobilization, spinal manipulation, and lumbar traction may be included. The primary purpose of therapy is to educate the patient on an independent program that facilitates proper body alignment/mechanics to ensure that muscle imbalance no longer contributes to structural changes.

The severity of the patient’s pain and increased loss of function is the deciding factor of whether surgery for spinal fusion will take place. There is no guarantee that surgical intervention will fix the problem completely. There is always the possibility that complete immobilization immobilization of the fused vertebral levels will result in further degeneration/stenosis/disc herniation or spondylolysthesis spondylolysth esis occurring at surrounding vertebral levels. Instability Instabilit y at adjacent levels is likely to occur if proper biomechanics have not been adopted. There is also the risk of surgical damage or infection to the vertebral column or spinal cord that can cause much greater problems. Proper patient selection for spinal fusions is critical for two reasons. One, healing from a fusion procedure takes a long time (about 3 to 6 months, and up to 18 months), and two, the fusion forever changes the biomechanics of the back by increasing the stress placed on the other (nonfused) joints in the spine. Fusions are generally not recommended until a patient has tried 6 to12 months of adequate conservative care, such as physical therapy, medications, or steroid injections.



3

Even when conservative treatments have failed, physicians remain to have difficulty categorizing when a surgical fusion is indicated. Cumulative research shows that fusion for spondylolisthesis has excellent outcomes, but indication for other routine applications fall short. To help prove this point, a study done where nineteen spine surgeons reviewed 30 potential spinal fusion cases. Outcomes revealed that 66% of that caseload was broad disagreement as to the indication for fusion. The cases they agreed to fusions on where for patients with spondylolisthesis and scoliosis. Disagreeable cases where for patient with moderate multilevel radiographic abnormalities. Physicians debated over if indication for fusion be determined by severity of radiographic findings or relevant clinical findings. Most literature states indication for lumbar fusion as a treatment for back pain is an option for patients who: Have failed to get better after extensive conservative treatment Continue to have back pain that limits their ability to function Have received a diagnosis that a specific disc space is the pain generator. Host factors that have a negative impact on obtaining a fusion include: o Smoking (nicotine) o Obesity o Osteoporosis o Chronic steroid use o Diabetes mellitus or other chronic illnesses o Prior back surgery or attempted fusion o Malnutrition Of all these factors, the one that most negatively affects the fusion rate and is under the control of the patient is smoking. smoking. Nicotine has been shown to be a bone toxin and it inhibits the ability of the bone growing cells (osteoblasts), (osteoblasts ), to grow bone. A fusion is basically a race between the bone growing cells and the bone eating cells (osteoclasts). Continuing to smoke after a fusion procedure, especially immediately after surgery, favors the osteoclasts and significantly undermines the fusion process. Since almost all fusion procedures for back pain are elective, it only makes sense for patients to make a concerted effort to quit smoking to give the best chance possible of allowing the bone to heal. Surgical Procedures: Posterior Spinal Fusion: An incision is made along the posterior aspect of the chosen lumbar region. To prepare the area to be fused, the surgeon shaves a layer or completely removes the lamina and/or the spinous process off the lumbar segments. The cut bone bleeds. The surgeon then may make a second incision at the hip where small small strips of bone are removed removed from the top rim of the pelvis. This is used as the bone graft. The surgeon lays the bone strips over the back of the spinal column. When the bone graft contacts the bleeding area, the healing process and fusion of the bones together can occur just as it would a fractured bone. During the posterior spinal fusion, the surgeon also fixes the bones in place using a combination of metal screws, rods, and plates. This instrumentation or hardware holds the vertebrae to be fused together and prevents them from moving. The less motion there is between two bones trying to heal, the higher the chance they will successfully fuse. The use of instrumentation has increased the success rate of spinal fusions considerably.



4

Anterior lumbar fusion: Also known as anterior lumbar interbody fusion (ALIF). In this procedure, the surgeon approaches the spine from the front. Taking special care in moving vital organs, especially the abdominal aorta and inferior vena cava, as these vessels lie directly anterior to the lumbar vertebrae until they bifurcate at about L4. These great vessels are moved over to the left side in order to stretch the aorta as little as possible. The surgeon measures measures the depth and height between the two vertebrae, this can be done off the patients radiograph or the patient itself. Bone used to create the graft can be taken from the patients hip or from an allograph. The graft is measured measured to fit snugly in the space where the disc was taken out. The surgeon uses a traction device to spread the two vertebrae apart, and the graft is tamped into place. The goal of the procedure is to stimulate the vertebrae to grow together into one solid bone. Fusion creates a rigid and immovable column of bone in the problem section of the spine in attempt to reduce the patients back pain and other symptoms. Combined fusion: Most surgeons apply some form of instrumentation to prevent movement between the vertebrae. Instrumentation protects the graft so it can heal better and faster. One option involves screwing a strap of metal across the front surface of the spine over the area where the graft rests. A second method method involves additional surgery through the low back, either on the same day or during a later surgery. In this operation, metal plates and screws are applied through the back of the spine, locking the two vertebrae and preventing them from moving. By locking the vertebrae from the front and back, some surgeons believe the graft stays solid and is prevented from collapsing. Results do show improved fusion of the graft. Debate is present on whether patients fare as equally well with other methods of fusion. With all spinal fusion surgeries, the fusion itself is not completed at the time of surgery. Instead, the conditions for the spine to fuse are created and the fusion will set up over a 3 to 6 month (and up to 18 month) period of time following the spinal surgery. Preoperative Rehabilitation: Preoperative treatment is to establish a conditioning program for surgery. Included in the program is keeping the affected joint from excessive mechanical forces and instruction on proper postural body mechanics for everyday movement and an exercise program to improve flexibility and core strengthening. Medications such as non-steroidal antiinflammatory drugs, acetaminophen, muscle relaxants, and possibly narcotics are prescribed for pain control. Spinal injections can be used for both treatment and diagnostic purposes. There are several different types of spinal injections. These injections usually use a mixture of an anesthetic and some type of cortisone preparation. preparatio n. The anesthetic numbs the area where it is injected. If the injection takes away the pain immediately, this reveals important information suggesting that the injected area is indeed the source of pain. The cortisone decreases inflammation and can reduce the pain from an inflamed nerve or joint for a prolonged period of time. Types of injections include; epidural steroid injection (ESI), selective nerve root injection, facet joint injections, and trigger point injections



5

POSTOPERATIVE REHABILITATION

Note: The following rehabilitation progression is a combination of guidelines provided by O’Sullivan,Bardin, Kim and Todd. Refer to their publications in the reference section to obtain details.

Part I: At the Hospital: one to five days

Goals: Control pain Protect repair Instill proper alignment through positioning and controlled movement Intervention: • •

•

TLSO brace to ensure minimal lumbar motion with routine movement. Educate and demonstrate controlled mobility with neutral spine precautions for function (bed mobility, transfers, gait) Bed level and bedside exercises to address muscular atrophy, i.e: quad sets, glut sets, heel slides, mini-squats, heel raises.

Part II: After discharge: Post-Op to 6-8 weeks

Goals: Continue to control pain Continue to protect fusion Increase endurance Intervention: • • •

Reinforce neutral spine/proper body mechanics with all functional activities Encourage low impact aerobic activity, i.e. walking, swimming Gentle active neural mobilization, SLR and progressive walking program

Part III: Outpatient physical therapy reconditioning program - 3 phases Phase I: Cognitive stage: 3-6 weeks

Goals: Pain and inflammation control Kinesthetic training for maintaining neutral spine Activation of transverse abdominus and multifidi muscles in sitting and standing Demonstration of proper body mechanics with all functional activities (sitting, standing,



6 bending, lifting) Improve flexibility of the hip and region Intervention: • • • • •

Ice, electrical stimulation, soft tissue mobilization if indicated Education and continued practice of obtaining and maintaining neutral spine Dynamic lumbar stabilization exercises Functional activities training in proper alignment Active and passive stretches for the lower extremities

Phase II: Motor learning stage: (8 weeks – 4 months before becoming automatic)

Goals: Spontaneous activation of ‘internal corset’ with all dynamic activity Progress dynamic lumbar stabilization Progress aerobic activity (speed, length, and duration) Sport simulation/controlled environment Intervention: • • • •

“Core” trunk strengthening Extremity strengthening – while maintaining a neutral trunk alignment Functional training Treadmill walking, elliptical rider, bicycle, swimming.

Phase III: Autonomous stage: (On-going)

Goals: Return to high level/high intensity activities for prolonged periods of time Intervention: • •

Work hardening/conditioning Dynamic co-ordination and balance activities

These post-surgical exercises are the same exercises used to prevent surgery and have been shown to be an effective treatment with long-term reductions in pain and functional disability in subjects diagnosed with lumbar segment instability instabilit y and chronic low back pain. For operative or for non-operative patients the approach is the same, it is based on a motor learning model where faulty movement patterns are identified and components of movement are isolated so they can be retrained into functional tasks.



7

Selected References: Bardin L. Physiotherapy management of accelerated spinal rehabilitation in an elite level athlete following L4-S1 instrumental spinal fusion. Physical Therapy in Sport . 2003;40-45. Glassman S. et al. The difficulty in categorizing indication for lumbar fusion. The Spine Journal. 2003;67S-171S. Kim D. Update on use of instrumentation in lumbar spine disorders. Best Practice & Research Clinical Rheumatology. 2002;123-140. Medical multimedia group. Spine-Lumbar Topics. eorthopod.com. 6/30/04. O’Sullivan P. Lumbar segmental ‘instability’: ‘instabili ty’: clinical presentation and specific stabilization stabilizati on exercise management. Manual Therapy. 2000;2-12. 2000;2-12. O’Sullivan P., Twomey A. Dynamic stabilization of the lumbar spine. Critical Review of Physical and Rehabilitation Medicine.1997;315-330.



Physical Therapy Protocols for Conditions of the Low Back Region

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