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Assessment and Treatment of Low Back Pain Steven Stanos, DO Medical Director Center for Pain Management Rehabilitation Institute of Chicago Asst. Professor, Dept. PM&R Northwestern University Medical School Feinberg School Of Medicine Goals • Individualized yet comprehensive • Efficient • Comfortable for patient • Comfortable for clinician • Build rapport • Educate and prepare patient for treatment • Monitor for inconsistencies Physical Exam Overview – Pain behavior – Gait – Motor strength – Muscle stretch reflexes – Dural tension testing – Sacral iliac joint testing – Myofascial assessment – Kinetic Chain considerations Anatomy of LumboSacral Spine Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999. Annulus Fibrosis Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999. Lumbar Facets: zygapophysial joints “z-joint” Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999. Degenerative Cascade Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999. Definitions • Somatome: field of somatic and autonomic innervation based on embryologic segmental origin of somatic tissues three basic elements: 1. Dermatome: cutaneous structures 2. Myotome: skeletal musculature 3. Sclerotome: bones, joints, and ligaments 8 Inman VT, Saunders J. J Nerv Ment Dis 1944;99:660-67. Spinal “stability” Neural Control Unit Spinal Column Spinal Muscles Vertebral Position Muscle Spinal Loads Activation Patterns Spinal Motions Panjabi MM. J Electromyography Kinesiology 2003:12:371-9 “Core” muscle groups – Abdominals (Front) – Paraspinals and gluteals (Back) – Diaphragm (Roof) – Pelvic floor and hip muscles (Bottom) Richardson C, et al .Therapeutic exercise for spinal stabilization and low back pain. Edinburgh (Scotland): Churchill Livigstone1999. Abdominals Local muscles (Slow twitch) • Transversus abdominus • Multifidi • Internal oblique ERECTOR SPINAE • Pelvic floor Global Muscles (Fast-twitch) • Erector spinae • External oblique • Rectus abdominus Panjabi MM. J Electromyography Kinesiology 2003:12:371-9 MULTIFIDI the “15 minute rotisserie special” Pain Behaviors • • • • • • • Grimace Groan Guarding Overreaction Inconsistencies Give-way weakness Shaking • • • • • Equipment Cane Ice-packs, Heating pads Braces: collars Gait • • • • • • Balance Base of support Arm swing/ trunk and shoulder rotation Cadence Leg: cicumduction, stance time, position Pain behavior Static Stance Assessment L4-L5 PSIS (J. Rittenberg. Photos from practice & personal files used with permission) Differential Diagnosis Flexion Based Muscular Ligamentous Compression Fracture Discogenic Extension Based Stenosis Facet Spondylosis Central Disc Transitional Spondylolisthesis Sacroiliac Facet Facet Arthropathy • Zygapophyseal (z-joint) • Poor correlation with history and exam1 • Commonly pain with extension & rotation • Referral patterns2 1. Schwarzer AC, et al. Spine 1994;19:1132-7. 2. Slipman, C. Arch PM&R 81:334-338, 2000. Myofascial Assessment Myofascial Trigger Points Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2. Williams & Wilkins, Baltimore, 1992. “Muscle pain is not skin pain” Jay Shah, MD Myofascial Trigger Points (MTrPs) Active – cause a clinical pain complaint or other abnormal sensory symptoms Latent – show all the other characteristics of active MTrPs, except that they’re pain free Muscle Pain • Aching and cramping • Difficult to localize and refers to other deep somatic tissues (fascia, muscle, joints) • Muscle nociceptive activity is processed differently in the CNS • Inhibited more strongly by descending pain-modulating pathways than cutaneous pain Symptoms • Local & referred pain • Pain with iso contraction • Stiffness, limited ROM • Muscle weakness • Paresthesia & numbness • Propriocpetive disturbance • Autonomic dysfunction Physical Findings • Local Tenderness • Single or multiple muscles • Palpable nodules • Firm or Taut Bands • “twitch response” (LTR) • Jump sign • Muscle shortening • Limited joint motion • Muscle Weakness Motor Strength Testing • 5 = Normal, full ROM vs. gravity, max resistance • 4 = Good, full ROM vs. gravity, moderate resistance • 3 = Fair, full ROM vs. gravity, no resistance • 2 = Poor, full ROM, gravity eliminated • 1 = Trace • 0 = No activity Core Stabilization Testing Muscle Stretch Reflexes Lower Limb – Patella (L2, L3,L4) – Medial hamstring (L5,S1) – Achilles (S1, S2) Muscle Stretch Reflexes 4 + = hyperactive with clonus 3 + = more brisk 2 + = normal response 1 + = decreased with facilitation 0 = no response Radiculopathy Sitting • Standing • Walking • Bending • Valsalva or cough • Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999. Dural Tension Signs • Straight Leg Raise (SLR) • Slump Seated • Femoral Nerve Stretch (J. Rittenberg. Photos from practice & personal files used with permission) Straight Leg Raise: Epidural Space • Contents: – Loose areolar connective tissue – Semiliquid fat – Lymphatics – Arteries – Extensive plexus of veins – Spinal nerve roots • Segmented and discontinuous Transforaminal Approach Injection Techniques S1 Transforaminal Epidural Nelemans PJ, et al. Spine 2001;26:501-15. Dr. Stanos’ personal files. Caudal Approach Axial Low Back Pain • • • • Degenerative disc disease (DDD) Internal disc derangement (IDD) Facet dysfunction Myofascial dysfunction © 2005 Rehabilitatio Institute of Chicago Dorsal Rami Anatomy Sacroiliac Joint and Pelvis Integral Components of SIJ motion • Form closure: joint surfaces congruently fit together • Force closure: muscles & ligaments provide force to withstand load • Motor control: timing & sequencing of muscle activation & release • Emotion & awareness: emotions can influence motor control Vleeming A, et al. Spine 1990;15:133-5 Sacroiliac Joint Pain Referral Zones Buttocks Thigh Lower leg Foot / ankle Groin Abdomen Dreyfuss D, J Am Acad Ortho Surg 2004, 12. 94% 48% 28% 13% 14% 2% SIJ Assessment (J.Rittenberg. Photos from practice & personal files used with permission) Sacroiliac Joint Provocative Tests: • SIJ border tenderness • Patrick’s test • Gaenslen’s test • Prone hip extension • Compression testing Fortin J, et al, Spine 1994;19:1475-82. Sacroiliac Joint Injections Bogduk N, MJA 2004;19:79-83. Lumbar Spinal Stenosis: Posture Akuthota, V. Pathogenesis of lumbar spinal stenosis pain. Phys Med Rehab Clin N Am 14:17-28, 2003. With permission. J. Rittenberg. Used with permission. Neurovascular Claudication • • • • Onset with walking “Heavy” sensation Variability Attempt to increase flexion • Stooped posture BI-Level Central Porter RW. Spine 1996;21:2046-52. Lumbar Spinal Stenosis: Simian Stance • • • • • Posterior pelvic tile Hips, knees flexed Hands face backwards Hip and psoas tight Gluteus and piriformis inhibited • Gait: lumbar flexion Weak and Inhibited Muscles Geraci, M. Rehabilitation of the hip and pelvis. In: Kibler WB. Functional Rehab Sports Musculoskeletal Med; Aspen Publishers,1998. With permission. Finding Balance Underactive Stabiliser Overactive Synergist Shortened Antagonist Glut Medius TFL, QL, Piriformis Thigh adductors Glut Maximus Iliocast, Hamstring Iliopsoas, Rec Fem Lower Trapezius Levator Scapulae Upper trapezius Pectoralis Major Geraci, M. Rehabilitation of the hip and pelvis. In: Kibler WB. Functional Rehab Sports Musculoskeletal Med; Aspen Publishers,1998. With permission. trapezius and cercival spine Cervical & Scapular Dysfunction (Janda 2002) APS: LBP Guidelines • Categorize the condition – Nonspecific low back pain? – Back pain associated with neurologic deficits, radiculopathy or spinal stenosis? – Back pain associated with an alternate cause? • Identify patients who require urgent surgical evaluation Chou R, et al. Ann Intern Med. 2007;147:478-491. Acute Low Back Pain ‘Red Flags’ • • • • Cauda equina syndrome? Cancer? Infection? Fracture? – Confirmation of red flag conditions may require • Lab testing [complete blood count (CBC)/erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP)/ urinalysis (UA) and PSA when appropriate] • Medical imaging [lumbosacral (LS) radiographs/computed tomography (CT)/magnetic resonance imaging (MRI)] • Test results may indicate need for emergent surgical referral Chou R, et al. Ann Intern Med. 2007;147:478-491. Chou R, et al. Lancet. 2009;373:463-472. Pharmacologic Interventions Acute Low Back Pain Drug Net benefit Level of evidence Acetaminophen Small to moderate Fair NSAIDs Moderate Good Skeletal muscle relaxants Moderate (for acute LBP only) Good Chou R, et al. Ann Intern Med. 2007;147:504-514. Guideline Highlights Guideline Highlights 1. Conduct a focused history and physical examination – Assess severity of baseline pain and functional deficits 2. Evaluation of psychosocial risk factors is essential to predict the risk for chronic, disabling low back pain 3. Limit use of diagnostic imaging and testing – Except in patients with signs of severe or progressive underlying disease or those with neurologic deficits Chou R, et al. Ann Intern Med. 2007;147:478-491. Recommendation 6 ACP/APS Guidelines 2007 • Clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy. For most patients, first-line medication options are acetaminophen or NSAIDs. (Strong recommendation, moderate-quality evidence) Chou R, et al. Ann Intern Med. 2007;147:504-514. Pharmacologic Interventions Drug Net benefit Level of evidence Acetaminophen Small to moderate Fair NSAIDs Moderate Good Skeletal muscle relaxants Moderate (for acute LBP only) Good Tricyclic antidepressants Small to moderate (for chronic LBP only) Good Opioids and tramadol Moderate Fair Benzodiazepines Moderate Fair Small (for gabapentin in patients Fair for gabapentin to poor for topiramate Antiepileptic medications Systemic steroids with radiculopathy only) Unable to estimate topiramate No benefit Chou R, et al. J Pain. 2009;10:113-130. Good Summary • Comprehensive, but focused • Efficient • Exam should be easy on you and the patient • Great opportunity to initiate a therapeutic relationship and dialogue • Use a “good” exam to improve outcomes and identify deficits or impairments Thanks