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Clinical Reasoning
Lumbosacral Dysfunction
Assessment & Treatment
Alex Wong
Senior Physiotherapist
Queen Elizabeth Hospital
3 January 2009
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Contents
 Classification of Lumbo-sacral
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Dysfunctions
Clinical Reasoning Practice
Case Illustration
Examination /Treatment Skills
Take Home Message
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Vague Diagnosis of LBP
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80% no structural diagnosis
Limited evidence to support
classification
Vague complaints to relate pathology
Poor understanding biomechanics
Complicated treatment outcomes
impairment, disability, capability
psychosocial……….
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Classification of
Lumbo-sacral Dysfunctions
Purpose
Direct Specific and Effective
Treatments to Homogenous
Sub-group
Ford et al, 2007
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Classification of
Lumbo-sacral Dysfunctions
Treatment Based
Specific exercise – extension / flexion
/ lateral shift syndrome
Mobilization – lumbar / sacroiliac
mobilization
Immobilization – immobilization
syndrome
Traction – traction / lateral shift
syndrome
George & Delitto, 2005
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Classification of
Lumbo-sacral Dysfunctions
McKenzie Approach
Postural – symptoms after static
position
Dysfunctional – symptoms at end
range
Derangement – symptoms
through range
MeKenzie
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Classification of
Lumbo-sacral Dysfunctions
Physical Therapy Reviews 2007

632 papers retrieved from data base
 77 papers reviewed full document
 55% uni-dimensional
 6% multi-dimensional
Ford et al, 2007
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Classification of
Lumbo-sacral Dysfunctions
Physical Therapy Reviews 2007
Classification Dimensions
 Patho-anatomy (47%)
 Signs and Symptoms (58%)
 Psychological (51%)
 Social (14%)
Ford et al, 2007
No clear guideline to classify
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Clinical Reasoning
Practice
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Hypothesis-Oriented Algorithm for
Clinicians II (HOAC II)
Physical Therapy, Vol 83, No.5, 2003
A Guide for Patient Management
 A framework for science-based
clinical practice
 Focus on remediation of functional
deficits
 How changes in impairments
related to these deficits
Rothstein, 2003
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Clinical Reasoning Process
Generate Patient Identified and
Non-identified Problem Lists (S/E)
Formulate Exam. Strategy
Conduct Examination and Analyze (O/E)
Generate Working Hypotheses
Intervention
Re-assessment
Rothstein, 2003
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Clinical Reasoning Process
Subjective Complaint
(generate the clinical hypothesis)
Examination, O/E
(confirm the clinical hypothesis)
Intervention
(base on the O/E, findings)
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Case Illustration
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Formulate Problem Lists
(base on clinical presentations)
Case 1 (Housewife, aged 48)
C/O
• right dull LBP down to right lateral calf
• aggravated after prolonged walking
• relieved by short duration of sitting
• standing much worse
• morning pain
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Generate Clinical Hypothesis
(base on clinical presentations)
Case 1 (Housewife, aged 48)
Clinical Concerns
• somatic referred symptoms (L4,5)
• regular compression pattern
• decrease lordosis
• worst in static extension
• favourable to movement
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Facet Joint / Extension Syndrome
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Common with increasing age
Facet Joints block excessive
extension, associate with OA
changes (morning stiff)
Aggravate in prolonged
compression usually
Regular pattern presentation
Relieve in stretch pattern
(opposite to lig./mm strain)
Palpable local joint sign
Positive finding in local
diagnostic injection
Harris-Hayes, et al, 2005
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Conduct Examination, O/E
(base on clinical hypothesis)
Case 1
O/E
• postural defect
• movement quality (L4,5)
• regular movement pattern
• quadrant
• palpation (extension)
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Treatment Choice
(base on examination findings)
Case 1
Treatment
• facet joint passive mobilization
• mobilize in extended position (L4,5)
• extension exercises
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Formulate Problem Lists
(base on clinical presentations)
Case 2 (Construction site worker, aged 38)
C/O
• minor sprained 2 days ago
• left stabbing LBP down to left lateral ankle
gradually afterwards
• aggravated after prolonged sitting, walking
• relieved by lying only
• moderate morning pain – difficult to bend for
brushing teeth and wearing shoes
• listing pain
• can’t tolerate public transport (bus, mini-bus)
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Generate Clinical Hypothesis
(base on clinical presentations)
Case 2 (Construction site worker, aged 38)
Clinical Concerns
• associated with injury
• delayed onset of neurogenic symptoms
• relieved by decreasing disc pressure
• morning symptoms
• restricted neurodynamic movement
• sensitive to vibration irritation
• listing postural defect
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Discogenic Back Pain
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Nature of injury (F/Rot)
Delayed symptoms after injury
Sensitive to vibration
Morning symptoms
Increase symptoms on changing
intra-abdominal pressure
Restricted mov’t of neuro-tissues
Lumbar listing (ipsilat. / contralat.)
Diagnosed by MRI (match with sym)
Peng, et al, 2006
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Conduct Examination, O/E
(base on examination strategy)
Case 2 (relieving approach)
O/E
• postural defect (listing)
• movement quality (L4,5), extension
• neurodynamic movement
• neuro assessment
• vibration
• manual traction
• MRI confirmed
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Treatment Choice
(base on examination findings)
Case 2
Treatment
• listing correction
• rotation mobilization
• Mckenzie exercises
• extension with listing correction
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Formulate Problem Lists
(base on clinical presentations)
Case 3 (3 children housewife, aged 33)
C/O
• minor ankle sprained 7 days ago
• dull pain from right buttock down to thigh
• aggravated after prolonged sitting, stairs
• relieved by walking around
• moderate night pain – difficult to roll in bed
• can’t tolerate cross leg sitting & pulling
activities
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Generate Clinical Hypothesis
(base on clinical presentations)
Case 3 (3 children housewife, aged 33)
Clinical Concerns
• associated with injury / child-birth
• symptoms usually not below knee
• aggravated if asymmetrical stress to SI
Joint & pulling activities
• rolling pain in bed at night
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Sacral Iliac Joint Syndrome
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Age / Sex
History of Trauma / child-birth
Buttock pain / tender over PSIS
Symptoms likely not below knee
Symptoms when rolling at night
Occ cross SLR / Step forward pain
Muscle imbalance
Priformis, Hamstring, iliopsoas,
Gluteus maximus
Cluster of tests to confirm
DonTigny, 1990 DeMann, 1997
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Conduct Examination, O/E
(base on examination strategy)
Case 3 (aggravating approach)
O/E
• PSIS tender
• anterior / posterior stress tests
• cross SLR
• Long sitting leg length difference
• cluster tests to confirm
• hip rotation tests
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Treatment Choice
(base on examination findings)
Case 3
Treatment
• leg traction
• posterior pelvic tilting
• hamstring strengthening
(muscle energy)
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Formulate Problem Lists
(base on clinical presentations)
Case 4 (retired policeman, aged 65)
C/O
• gradually onset LBP within one year
• stretching pain down to left lateral calf
• aggravated after prolonged walking
• relieved by sitting
• moderate mid-range pain when bending
forward
• difficult to resume hiking and carry
back-pack
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Generate Clinical Hypothesis
(base on clinical presentations)
Case 4 (retired policeman, aged 65)
Clinical Concerns
• clinical / functional instability
• observable kink of spinal curvature
• aggravating with dynamic flexion stress
• variable catching pain during mid-range
• flexion / extension x-ray to confirm
(usually inferior disc problem
67% at L5 level)
Luk, 2003
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Lumbar Dynamic Stability
 Decrease the cross section
area of multifidus over the
injured / defect segment
 Clinically ‘catching pain’ in
different range of motion
esp. forward flexion
 Intrinsic muscles minimize
unnecessary rotational stress
over the disc
Hides, 1994; Lee et Al, 2006
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Conduct Examination, O/E
(base on examination strategy)
Case 4 (aggravating approach)
O/E
• postural defect (hyperlordosis)
• movement quality (L4,5)
• catching pain during movement
• shearing test
• abdominus weakness & hamstring
tightness
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Treatment Choice
(base on examination findings)
Case 4
Treatment
• supine traction  prone traction
• abdominal exercises
• stabilization exercises
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Formulate Problem Lists
(base on clinical presentations)
Case 5 (Student, aged 22)
C/O
• back sprain injury half year ago
• stretching pain down to lateral calf gradually
• recent P&Ns over lateral calf
• difficult to wear shock in the morning
• unfavorable to sit sofa
• relieved by walking around
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Generate Clinical Hypothesis
(base on clinical presentations)
Case 5 (student, aged 22)
Clinical Concerns
• associated history
• stable neurogenic symptoms
• distal symptoms dominated
• regular stretching pattern
• morning symptoms
• not related to loading stress
• favorable to movement
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Neurodynamic Dysfunction
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Relative dynamic mov’t of neuroconnective tissues deficiency:
- total length insufficiency, adhesion to
sensitive structures, poor excursion /
gliding movements
Distal symptoms dominated
Morning severity
Associated with spine post-op
complication
Aware latency effect after neurodynamic
treatment
Bulter, 1992; Ko et al, 2006
- prefer for stable symptoms
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Conduct Examination, O/E
(base on examination strategy)
Case 5 (aggravating approach)
O/E
• stable symptoms
• relative dynamic mov’t of
neuroconnective tissues deficiency:
- total length insufficiency, adhesion to
sensitive structures, poor excursion /
gliding movements
• ULTT, Slump
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Treatment Choice
(base on examination findings)
Case 5
Treatment
• hamstring stretching (cadual
/ cephelic direction)
• slump
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Formulate Problem Lists
(base on clinical presentations)
Case 6 (Teacher, aged 56)
C/O
• no history of injury
• stretching & squeezing pain over left calf
muscle
• symptoms aggravated after walking ~ 15 min.
• relieved by sitting or squatting ~ 15 min.
• tolerate standing ~ half hr.
• much worse when up & down slop
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Generate Clinical Hypothesis
(base on clinical presentations)
Case 6 (Teacher, aged 56)
Clinical Concerns
• dynamic flex / ext problem
• relieved by (static) flexion
• distal symptoms dominated
• not significantly related to loading
• not immediately relieved by standing
• variable in walking distance
• worse in slope walking
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Spinal Claudication
Spinal:
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Symptoms aggravated by walking
and change of body positions
Slow relieve by sitting or squatting
Worse even in prolonged standing
Various walking tolerance
Neuropathy symptoms
Gelderen Bicycle test
Gray, 1999
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Conduct Examination, O/E
(base on examination strategy)
Case 6 (relieving approach)
O/E
• distal symptoms dominated
• fluctuated symptoms
• repeated flex & ext
• step standing extension
• flex with rotation test
• Gelderen Test
• x-ray oblique view
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Treatment Choice
(base on examination findings)
Case 6
Treatment
• crook lying traction
• rotation mobilization
• rotation with SLR
• abdominal strengthening
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Reference
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DeMann LE (1997) Sacroiliac Dysfunction in Dancers with Low Back Pain,
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DonTigny RY (1990) Anterior Dysfunction of the Sacroiliac Joint as a Major
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Reference
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