Lumbar Spine and P elvic Dysfunctions

1. Lumbar Spine andPelvic Dysfunctions Alex Wong Senior Physiotherapist Queen Elizabeth Hospital 19 September 2008

2. Contents Classification of Lumbo-sacral Dysfunctions Clinical Reasoning Practice Clinical Concerns Related to Reasoning Take Home Message

3. Vague Diagnosis of LBP 80% no structural diagnosis Limited evidence to support classification Vague complaints to relate pathology Poor understanding biomechanics Complicated treatment outcomes impairment, disability, capability psychosocial……….

4. Classification of Lumbo-sacral Dysfunctions Purpose Direct Specific and Effective Treatments to Homogenous Sub-group Ford et al, 2007

5. 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

6. Classification of Lumbo-sacral Dysfunctions McKenzie Approach Postural – symptoms after static position Dysfunctional – symptoms at end range Derangement – symptoms through range MeKenzie

7. 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

8. Classification of Lumbo-sacral Dysfunctions Physical Therapy Reviews 2007 Classification Dimensions Patho-anatomy (47%) Signs and Symptoms (58%) Psychological (51%) Social (14%) No clear guideline to classify Ford et al, 2007

9. Clinical Reasoning Practice

10. 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

11. 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

12. Clinical Reasoning Generate Patient Identified and Non-identified Problem Lists (S/E) Patient’s concerns Problems led to seek PT Layman information eg. inability to downstairs (PIP) contracture after knee amp. (NPIP) Rothstein, 2003

13. Clinical Reasoning Formulate Exam. Strategy Establish clinical hypothesis Base on pathoanatomic activities (pathology, physiology, anatomy, movement science and biomechanics) Change to clinical information Rothstein, 2003

14. Clinical Reasoning Conduct Examination and Analyze Test the tentative reasons Pathology extent and type not observable and measurable by PT Confirm or reject the hypotheses Rothstein, 2003

15. Clinical Reasoning Generate Working Hypotheses Working base for intervention Causes of problems usually due to impairment eg. joint stiffness, muscle weakness Causes sometimes relate to pathology eg. wound infection Rothstein, 2003

16. Clinical Reasoning Intervention Mainly base on examination findings (O/E) Usually focus on impairment and functional limitations eg. LBP PID (MRI confirmed) intervention not designed to change the pathology, but rather the impairment and disability that the pathology caused Sometimes attempt to eliminate a pathology, eg. eliminate the sepsis for wound healing Rothstein, 2003

17. Formulate Examination Strategy (base on clinical presentations)

18. Case 1 • C/O anterolateral thigh pain during walking • much more pain when up & downstairs • (likely hip problem) • Case 2 • C/O pain over posterior thigh when bending forward to lift • much relieved when squatting to lift • (likely hamstrings/neurodynamic problem) Formulate Examination Strategy (base on clinical presentations)

19. Conduct Examination, O/E (base on examination strategy) Intervention (base on examination, O/E, findings)

20. Clinical Concerns Related to Reasoning in Lumbo-sacral Dysfunctions

21. Pathological “Red Flags” Most clues are in history Not in physical examinations Wilk, 2004

22. Cauda Equina & Widespread Neurological Disorders Clinical Concerns Bladder dysfunction (rapid & immediate) Saddle anaesthesia Sphincter disturbance Progressive motor weakness Gait disturbance (spastic, clonus in stairs walking) UMNL tests positive (Hoffman’s, Babinski & Clonus) Surgical intervention within 48 hrs Wilk, 2004

23. Potential Tissue Injured Clinical Concerns Vascular Tissues: inflammatory signs appear within half hour after injury e.g. ligament, muscle, capsule…. Avascular Tissues: inflammatory signs appear after few hours following injury e.g. IV disc, meniscus…..

24. Facet Joint / Extension Syndrome Applied Anatomy & Physiology Lumbar facet joints orientation (sagittal plan) Increasing stress due to: - decreasing IVD height - short hip flexor muscles - decreased performance of abdominal and gluteal muscles - excessive use of hip flexor and paraspinal muscles Harris-Hayes, et al, 2005

25. Facet Joint / Extension Syndrome Clinical Concerns 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

26. Pathogenesis of Inter-vertebral Disc Applied Anatomy & Physiology Intrinsic Discogenic Disorder Avascular tissue Pain nerves over periphery After injury, ingrowth of vascular granulation tissues & nerves along torn fissures, extend from external layer of anulus fibrosus to nucleus pulposus Painful disc from injury and repair Peng, et al, 2006

27. Pathogenesis of Inter-vertebral Disc Applied Anatomy & Physiology Prolapsed Inter-vertebral Disc Fissures communicated, disc materials protruded Axilla / shoulder regions protrusion ipsilateral / contralateral Lx listing L5 nerve may be compressed by L4/5 or L5/S1 disc L5/S1 disc may compress L5 and /or S1 nerves Nerve compression irritation Neural tissues ischaemic inflammation Peng, et al, 2006

28. Pathogenesis of Inter-vertebral Disc Clinical Concerns 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

29. Sacral Iliac Joint Syndrome Applied Anatomy & Physiology Weight-bearing synovial joint Movement A-P translation : ~3 to 7 mm A-P rotation : ~3 to 5 degree Male: likely fused in late 40 Female in late 60 DonTigny, 1990 DeMann, 1997

30. Sacral Iliac Joint Syndrome Applied Anatomy & Physiology Stable with form and force closure Form closure: closely fit joint surface (sulcus) Force closure: muscles, ligaments & thoracolumbar fascia No direct prime mover muscle Strong dorsal / ventral SI & sacrotuberous ligaments Anterior dysfunction more likely One of common metastasis area DonTigny, 1990 DeMann, 1997

31. Inter-rater Reliability of SIJ Tests(Oldreive,1995)

32. 4 Tests: Gillet,stand flexion,sit flexion,supine to sit test Results: Sensitivity:8-44% Specificity:64-93% Negative predictive value:28-38% Positive predictive value:61-79% Reliability SIJ Tests(Freburger JK & Riddle DL,1999)

33. Reliability of SIJ Tests(Cibulka MT & Koldehoff R, 1999) • 4 clinical tests used together:stand flexion test,PSIS palpation,supine long sitting leg length test,prone knee flexion test • at least ¾ test should positive for positive • Result • Sensitivity :82% • Specificity: 86% • Negative predictive value: 84% • Positive predictive value: 86%

34. Sacral Iliac Joint Syndrome Clinical Concerns 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

35. Vascular Vs Spinal Claudication Applied Anatomy & Physiology Vascular (Intermittent Claudication) : - arterial insufficient of distal aorta, iliac or femoral arteries - ischemic symptoms Spinal (Spinal Stenosis): - IVF occlusion - mechanical constriction and irritation of spinal nerves - impinging spinal nerves usually in dynamic extension pattern Gray, 1999

36. Vascular Vs Spinal Claudication Clinical Concerns Vascular: Heavy smoker, > age 40 male Diabetes, obesity, coronary heart disease Common in calf, cramp, decrease dorsalis pedis pulse Symptoms appear after similar distance walk, fast symptoms relieve with rest, even slow walking or standing Worse in slope walking Gray, 1999

37. Vascular Vs Spinal Claudication Clinical Concerns Spinal: 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

38. Lumbar Dynamic Stability Applied Anatomy & Physiology Structural Defect (Spondylolisthesis) • Grade (I – III), likely at L4/L5 and L5/S1 • Review the flexion / extension x-ray view • Lumbar curvature kink • Usually associated with abdominus weakness / hamstring tightness

39. Lumbar Dynamic Stability Applied Anatomy & Physiology Neuromuscular Defect • Global Muscles larger torque producing muscles balance external loads spine: erector spinae • Intrinsic Muscles small local muscles control joint position & mov’t planes spine: multifidus; transversus abdominus

40. Lumbar Dynamic Stability Neutral Zone Neuromuscular Control Active Structures Passive Structures • A region of no or little resistance to motion in the middle of an IV joint’s ROM • Min. Passive Tissue Stiffness Panjabi, 1992 Gay et al, 2006

41. Lumbar Dynamic Stability Neutral Zone • A feature of natural ROM • Exists mainly in flexion / extension • Facet joint contribute much on NZ stability • Small change in torque gives moderate • change in position • Require complex control of IV joints by spinal muscles • Increase with increasing disc degeneration or injuries • Decrease with addition of muscle forces / spinal instrumentation Gay et al, 2006

42. Lumbar Dynamic Stability Clinical Concerns Chronic LBP • Studies demonstrated delay onset or poor motor control of the intrinsic muscles • Multifidus max contracts at upright standing in normal subjects, while max. in 25 forward stooping in LBP patients Hides, 1994; Lee et al, 2006

43. Lumbar Dynamic Stability Clinical Concerns • 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

44. Thoracolumbar Junction Syndrome Applied Anatomy & Physiology Transition zone between two regions of facet orientation Thoracic – coronal plane Lumbar – sagittal plan T12 - Superior facet inclined as Tx Inferior facet inclined as Lx T12 as an intermediate vertebrae during trunk rotation Sebastian, 2006

45. Thoracolumbar Junction Syndrome Clinical Concerns Symptoms at upper Lx and gluteal regions Considerable rotational stress in TL and LS junctions Associated with impact injury (slipped / fell with buttock landed) One of the common osteoporotic site Sebastian, 2006

46. Neurodynamic Dysfunction Applied Anatomy & Physiology Neuro- connective tissues involvement Dynamic mechanical irritation Circulation deficiency (extra / intraneural circulatory system Occasionally associated with neurogenic signs Common adhesion sites at C6, T6 and L4 (approximate points) SLR, Slump, ULTTs Bulter, 1992; Ko et al, 2006

47. Neurodynamic Dysfunction Clinical Concerns Relative dynamic mov’t of neuro-connective 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 - prefer for stable symptoms Bulter, 1992; Ko et al, 2006

48. Piriformis Syndrome Applied Anatomy & Physiology Sacral plexus L5, S1,2 Mainly hip external rotator Entrapment of sciatic nerve Comparable to sciatica Buttock pain with muscle trigger points Kuncewicz, et al, 2006

49. Piriformis Syndrome Clinical Concerns Symptoms similar to sciatica After fall / leg twisting injury, pyomyositis, fibrosis after deep injection Tight hip external rotator Supine lying with different hip rotation when compared on both sides Buttock pain on stretching the muscle Fair tolerance on SLS Kuncewicz, et al, 2006

50. Thoracic Outlet Syndrome Applied Anatomy & Physiology Non-specific label Vascular: obstruction of subclavian artery / vein due to: stenosis, cervical rib, thrombosis Neurogenic: brachial plexus compression due to: scared / tight scalene muscles Sanders et al, 2007