Lumbopelvic Case presentation and discussion

1. GROUP BRAVO Andreas Barth, PT, CSCS Brett Crowe, DPT Jon Evans, DPT Mike Jones, PT, MHS, OCS, MTC Tim Lonergan, DPT Lumbopelvic Case presentation and discussion EIM-103 Management of Lumbopelvic Disorders Section 5

2. Subjective Examination • What structures must be examined and/or ruled out? • Joints1,2 • Lumbar spine • Lower thoracic spine and rib cage • Sacroiliac/Pelvis • Hips

3. Subjective Examination • What structures must be examined and/or ruled out? • Muscle groups3,4 • Longissimusthoracis and lumborum • Iliocostalisthoracis and lumborum • Quadratuslumborum • Multifidi • Piriformis • Other deep hip lateral rotators • Gluteus maximus • Gluteus medius

4. Subjective Examination • What structures must be examined and/or ruled out? • Muscle groups3,4 continued…. • Gluteus minimus • Rectus abdominis • Transverse abdominis • Iliopsoas • Semitendinosus • Semimembranosus • Biceps femoris

5. Subjective Examination • What structures must be examined and/or ruled out? • Neurovascular structures • Lumbar and sacral nerve roots • Neurodynamics of femoral nerve (due to upper lumbar pain) • Neurodynamics of sciatic nerve

6. Subjective Examination • What are your key subjective asterisks (findings) for this patient? • Repeated trunk motions • Lifting > 10 pounds • Standing and marching > 30-45 minutes • Transferring from sit to stand • Trunk Flexion/Extension • Squatting • Possibly running, but not specifically known as she has avoided this activity since onset of current episode

7. Subjective Examination • Based on the history, identify the patient’s symptoms (P1 and P2) in terms of SINSS.   • P1 complaint • Severity = Moderate, patient never without symptoms, range of 4-8/10, average of 6/10 • Irritability = Minor, resolution ranges from immediate to 15 minutes • Nature = Lumbar Instability • Stage = Subacute with respect to chronicity and effects on function • Stability = Stable, no change since onset

8. Subjective Examination • Based on the history, identify the patient’s symptoms (P1 and P2) in terms of SINSS.   • P2 complaint • Severity = Mild , range of 0-6/10, average of 3/10 • Irritability = Minor, aggravation after 30-45 min or sooner if repetitive, resolution ranges from immediate to 40 minutes • Nature = Muscular • Stage = Subacute with respect to current episode and effects on function; chronic with respect to previous bouts • Stability = Unstable, intermittent, improved since initial onset of current episode

9. Subjective Examination • Will these symptoms limit your examination? Why or why not? • Although P1 severity is moderate, irritability of P1 and P2 is minor. • Due to relatively quick resolution, there should be no hesitation to reproduce symptoms. • As such, these symptoms should not limit the examination.

10. Subjective Examination • Are there contraindications or precautions (red/yellow flags) to your objective exam? • No obvious red flags are present • Little concern regarding yellow flags • Fear-avoidance beliefs • FABQpa < 15, which has been proposed as cut-off score for classifying fear-avoidance beliefs as being elevated5 • Additionally, FABQpa and FABQw scores have not been demonstrated to be prognostic indicators in patient not receiving worker’s compensation6 • Activity avoidance does not appear to be severely maladaptive as patient continues to participate in school activities

11. Subjective Examination • Do you expect a comparable sign for all pain areas to be hard or easy to reproduce? • P1: Easy (repeated trunk motions, lifting) • P2: Easy (repeated trunk extension, sit to stand transfer, bending, or squatting) • P3: Relatively difficult to establish comparable sign, but may become apparent with comparable signs of P1 due to possible association

12. Subjective Examination • What is your primary working hypothesis? • Lumbar instability • Young age • Recurrent bouts of symptoms • Periodic sharp P1 • Short-term relief with manipulation during prior episodes • Minimal improvement with mobility exercises during prior episodes • Pain with positions of extension and flexion with no apparent directional preference

13. Objective Examination and Treatment Planning • What are your key objective asterisks (findings) for this patient? • Sit to stand • 3/4 squat • Trunk ROM • Flexion AROM with positive Gower’s sign • Extension AROM decreased by 25% • Right side bending with overpressure • Trunk extension quadrants (local back pain) • Thomas test bilaterally • Hip extension ROM with overpressure bilaterally • Palpation of left piriformis and SI region

14. Objective Examination and Treatment Planning • What are your key objective asterisks (findings) for this patient? • PAVIMs • Central • Stiff T12-L1 • P1 and stiff L5 • Unilateral • Stiff left > right L1-2 • Pain left > right L2-3 and L3-4 • Pain and stiff left L5-S1 > L4-5 • Mild pain right L5-S1 • Ely test bilaterally • Left SI spring test

15. Objective Examination and Treatment Planning • What is/are your revised diagnosis(es)? • Recurrent strain of lumbar instability • Classification according to Treatment-based Classification Approach7 • Primary: Manipulation • Secondary: Stabilization

16. Objective Examination and Treatment Planning • What is/are your revised diagnosis(es)? Criteria as applies to patient outlined in red (Adapted from Fritz et al7)

17. Objective Examination and Treatment Planning • Assuming manual physical therapy interventions are appropriate for this patient, what area/joint will you target first with your interventions and why? • Lumbar spine manipulation • Overall, the patient is positive on the clinical prediction rule proposed by Flynn et al8 as validated by Childs et al9 indicating the patient is likely to demonstrate a positive response to manipulation • Such intervention will be directed at the left lower lumbar spine due to the predominance of symptom complaints in this region and correlating stiffness and reproduction of pain when testing PAVIMs

18. Objective Examination and Treatment Planning • What specific manual therapy intervention(s) will you use and what impairments are you targeting? Is there any evidence to support your choice of treatment? • First choice • Right sidelying neutral gap rotational manipulation localized to left lower lumbar spine to address stiffness and pain assessed at L4-5 and L5-S1 levels (From Cleland et al10)

19. Objective Examination and Treatment Planning • What specific manual therapy intervention(s) will you use and what impairments are you targeting? Is there any evidence to support your choice of treatment? • First choice • The choice of this technique is supported by the findings of Cleland et al10 who found similar results with this manipulation as compared to a supine regional lumbopelvic manipulation in patients with low back pain found to be positive on the clinical prediction rule guiding the use of manipulation in the treatment of low back pain

20. Objective Examination and Treatment Planning • What specific manual therapy intervention(s) will you use and what impairments are you targeting? Is there any evidence to support your choice of treatment? • First choice • Additionally, though difficult to justify with specific literature, it seems the side lying technique may potentially allow for the protection of the hypermobile segment assessed to be present in the upper lumbar region

21. Objective Examination and Treatment Planning • What specific manual therapy intervention(s) will you use and what impairments are you targeting? Is there any evidence to support your choice of treatment? • Alternatives • Supine lumbopelvic regional manipulation directed toward left side8-10 (From Flynn et al8)

22. Objective Examination and Treatment Planning • What specific manual therapy intervention(s) will you use and what impairments are you targeting? Is there any evidence to support your choice of treatment? • Alternatives • Prone central (T12-L1, L5-S1) and unilateral (bilateral L1-2, left L4-5 and L5-S1) PA non-thrust mobilization • Possible option if patient apprehensive regarding thrust manipulation although Cleland et al10 supports the use of thrust over non-thrust manipulation (From Cleland et al10)

23. Objective Examination and Treatment Planning • After treating the area with your intervention that you have chosen, what will you reassess to determine the effectiveness of your treatment? • Sit to stand • 3/4 squat • Trunk flexion AROM, extension AROM, and right side bending with overpressure • Trunk extension quadrants (local back pain)

24. Objective Examination and Treatment Planning • What home exercises will you give this patient following day 1 treatment and what are the goals of these exercises? • Supine lumbar AROM with pelvic tilting8,9 to maintain and improve upon gains in lumbar ROM achieved with manipulation

25. Objective Examination and Treatment Planning • What home exercises will you give this patient following day 1 treatment and what are the goals of these exercises? • Initiate stabilization exercise program per Hicks et al11 to improve strength/motor control of lumbopelvic stabilizers (From Hicks et al11)

26. Objective Examination and Treatment Planning • Assume your interventions above lead to improvements in the patient’s symptoms. How will you progress this patient in 3-5 subsequent visits? (Consider OMPT and exercise progressions) • OMPT • Repeat manipulation performed at initial visit • Seated rotational manipulation at T12-L1 • Potentially add non-thrust mobilization at any remaining stiff or stiff and painful spinal segments • Prone central PA (T12-L1, L5-S1) • Prone unilateral PA(bilateral L1-2, left L4-5 and L5-S1)

27. Objective Examination and Treatment Planning • Assume your interventions above lead to improvements in the patient’s symptoms. How will you progress this patient in 3-5 subsequent visits? (Consider OMPT and exercise progressions) • OMPT • Potentially incorporate anterior glide of hip joints or grade V longitudinal hip distraction to improve hip extension mobility • Manually stretch hip flexors with an emphasis upon rectus femoris

28. Objective Examination and Treatment Planning • Assume your interventions above lead to improvements in the patient’s symptoms. How will you progress this patient in 3-5 subsequent visits? (Consider OMPT and exercise progressions) • Therapeutic exercise • Progress stabilization exercises per quota-based protocol11 • Add self-stretching of hip flexors including rectus femoris if able to stabilize lumbar spine preventing pain and/or compensatory movement

29. Objective Examination and Treatment Planning • Assume your interventions above lead to improvements in the patient’s symptoms. How will you progress this patient in 3-5 subsequent visits? (Consider OMPT and exercise progressions) • Therapeutic exercise • Incorporate functionally-oriented exercise progressions while incorporating co-contraction of transversusabdominus and multifidi • Sit to stand exercise to progressively increased depths until able to perform without pain at height of normal chair • Dynamic activity such as marching and/or lunging with and without upper extremity resistance • Free squatting progressed to lifting until able to lift pain free with loads required for daily activities • Progression of walking to jogging to running

30. THANKS FOR ROCKING OUT WITH US!!!

31. References • Feinstein B, Langton JN, Jameson RM, Schiller F. Experiments on pain referred from deep somatic tissues. J Bone Joint Surg Am. 1954 Oct;36-A(5):981-97. • Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007 Nov;37(11):658-60. • Simons DG, Travell JG, Simons LS. Travell and Simons' Myofascial Pain and Dysfunction. The Trigger Point Manual, The Upper Half of the Body. Vol. 1. 2nd ed. Baltimore, MD: Williams & Wilkins; 1999. • Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, The Lower Extremities. Volume 2. Philadelphia, PA: Williams & Wilkins; 1993.

32. References • Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999 Mar;80(1-2):329-39. • Cleland JA, Fritz JM, Brennan GP. Predictive validity of initial fear avoidance beliefs in patients with low back pain receiving physical therapy: is the FABQ a useful screening tool for identifying patients at risk for a poor recovery? Eur Spine J. 2008 Jan;17(1):70-9. • Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007 Jun;37(6):290-302.

33. References • Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine (Phila Pa 1976). 2002 Dec 15;27(24):2835-43. • Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004 Dec 21;141(12):920-8.

34. References • Cleland JA, Fritz JM, Kulig K, Davenport TE, Eberhart S, Magel J, Childs JD. Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial. Spine (Phila Pa 1976). 2009 Dec 1;34(25):2720-9. • Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005 Sep;86(9):1753-62.