Matthew Somma PT DPT MTC CSCS October 14 2017 Todays Highlights Understand the Significance of Low Back Pain Provide a Framework for Successfully Examining a Patient with Low Back Pain Ruling out Red Flags Consider Yellow Flags ID: 759732
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Slide1
Examination Strategies for Low Back Pain
Matthew Somma, PT, DPT, MTC, CSCS
October 14, 2017
Slide2Today’s Highlights
Understand the Significance of Low Back Pain
Provide a Framework for Successfully Examining a Patient with Low Back Pain
Ruling out Red Flags, Consider Yellow Flags
Determine a Working Diagnosis for the Patient
Slide3Opioid Epidemic
“Americans, constituting only 4.6% of the world’s population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply”
Manchikanti
L. Therapeutic Use, Abuse, and Nonmedical Use of Opioids: A Ten Year Perspective.
Pain Physician
. 2010; 13: 401-435.
Slide4Low Back Pain
1 year Incidence of first ever episode of back pain is between 6.3% and 15.4%Recurrence within 1 year is between 24% and 80%Incidence of low back pain is highest in its third decade of life
Hoy D et al. The epidemiology of low back pain.
Best
Pract
Res
Clin
Rheumatol
. 2010 Dec; 24(6): 769-781
Slide5Low Back Pain
Point Prevalence is 11.9% and 1-month prevalence at 23.2%Direct cost of low back pain is between $12 billion - $90 billionOn average 17% of this is related to physical therapy servicesIndirect cost lof low back pain is between $7 billion - $28 billion
Hoy D et al. A systematic review of global prevalence in low back pain. Arthritis Rheum. 2012; Jun 64(6):2028-2037
Dagenais
S et al. A systematic review of low back pain cost of illness studies in the United States and Internationally.
Spine
. 2008;8(1):8-20
.
Slide6Non-Specific Low Back Pain
Slide7Non-Specific Low Back Pain
“Patients with persistent low back pain often have misconceptions about what is going on, and may have given all sorts of speculative explanations for their symptoms resulting in anxiety and confusion”
Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews.
BMC Musculoskeletal Disorders
. 2017; 18: 188-211.
Slide8Non-Specific Low Back Pain
May reduce the patient’s confusionReassurance that the provider understands the patient’s conditionVisualizing the potential benefit of treatment directed at painful tissue
Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews.
BMC Musculoskeletal Disorders
. 2017; 18: 188-211.
Slide9Imaging Studies
False positive findings on imaging studies 32% of “asymptomatic subjects” had abnormal lumbar spinesOnly 47% subjects who were experiencing low back pain had abnormal imaging
Savage RA et al. The Relationship Between MRI appearance of the lumbar spine and low back pain, age and occupation in males.
Eur
Spine J
. 1997;6:106-114
Slide10Imaging Studies
Slide11Slide12Slide13Slide14Examination Strategies
Slide15Goal
Providing a working diagnosis, through better examination strategies, and reducing imaging will likely improve patient outcomes, reduce cost of care, provide treating providers better opportunity for success with the patient, ultimately leading to better patient satisfaction
Slide16Biopsychosocial Model
Puentedura
EJ, Louw A. A neuroscience approach to managing athletes with low back pain .
Phys
Ther
in Sport
. 2012: 1-11
Slide17Terminology
Specificity: If a test has a high specificity and is positive, you can be fairly certain they have the condition.
Sensitivity: If a test is highly sensitive and it is negative, you can be fairly certain they do not have the condition.
Likelihood Ratio: the greater the number the greater chance they have the condition. Generally over 2.0 can be considered
Slide18Clinical Red Flag Examination
The prevalence of findings a medical emergency in those with acute low back pain is 0.9%. The majority of findings are spinal fracture. 9% of patients not tested80% of patient with low back pain present with a red flag
Henschke
N et al. Prevalence and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain.
Arthritis and Rheumatism
. 2009;60(10):3072-3080.
Slide19Spinal Cancer
0.66% of the populationIf you are considering spinal cancer in your patient, consider the following variables:Previous history of cancer has a 0.98 specificityUnexplained weight loss has a 0.94 specificityFailure to improve after one month of therapy has a 0.90 specificityIf the patient is greater than 50 years of age, had a history of cancer, present with unexplained weight loss or failure of conservative therapy, then there is a 1.00 sensitivity
Deyo
RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies.
J Gen Intern Med
. 1988;3(3):230-238.
Slide20Spinal Infection
The prevalence of infection is extremely rare. 0.01%Most findings will come from the subjective history of the patient.Symptoms are more consistent with fever, chills, and night sweats. The pain is non-mechanical in nature and does not usually improve in the recumbent position.
Verhagen
AP et al. Red flags presented in current low back pain guidelines.
Eur
Spine J
. 2016;25:2788-2802.
Slide21Spinal Fracture
The prevalence of spinal fracture is 0.7% in acute low back painA diagnostic recommendation has been developed to aide in clinical decision making for spinal fracture: If a patient is a female, greater than 70 years of age, who reports minor or significant trauma, and report prolonged corticosteroid use, there is a high incidence of fracture. If three of the four tests are positive, the likelihood of a fracture can increase by 52%.
Henschke
N et al. Prevalence and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain.
Arthritis and Rheumatism
. 2009;60(10):3072-3080.
Slide22Cauda Equina Syndrome
Rare, occurs 0.1% of the timeThe etiology of cauda equina syndrome often includes lumbar disc herniation, spinal stenosis, and tumorIf a patient presents with both bowel or bladder dysfunction and saddle anesthesia, the specificity is 0.92 and the likelihood ratio is 3.46
Henschke N et al. Prevalence and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis and Rheumatism. 2009;60(10):3072-3080.
Raison NTJ et al. The reliability of red flags in spinal cord compression.
Arch Trauma Res
. 2014;3(1):e17850.
Slide23Differential Diagnosis
Slide24Facet Mediated Pain
Pain that is just off center of the spine. Referred pain down the thigh, the groin or into the buttocks. Does not travel distal to the knee. Pain with movement after prolonged posturing.Morning stiffness often exists. Patients will have a tendency to function in extension for general posturing and activities of daily living.
Allegri
et al. Mechanisms of lower back pain: a guide for diagnosis and therapy [version 2; referees: 3 approved] F1000 Research 2016, 5(F1000 Faculty Rev): 1530.
Slide25Facet Mediated Pain
Binder DS et al. The provocative lumbar facet joint.
Curr
Rev Musculoskeletal Med
. 2009;2:15-24
Slide26Binder DS et al. The provocative lumbar facet joint.
Curr
Rev Musculoskeletal Med
. 2009;2:15-24
Slide27Facet Mediated Pain
Findings to Rule in Facet Dysfunction: Extension Rotation TestFindings to Rule out Facet Dysfunction: centralization of symptoms, no relief with recumbencyLikelihood Ratio is 1.28
Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews.
BMC Musculoskeletal Disorders
. 2017; 18: 188-211.
Slide28Spondylolisthesis
Google Search: spondylolisthesis
Slide29Spondylolisthesis
Findings to Rule in a Spondylolisthesis:2 of the following variables – intervertebral slip by inspection or palpation, and segmental hypermobilitySpecificity: 0.81 – 0.99Likelihood Ratio: 2.4 – 12.8
Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews.
BMC Musculoskeletal Disorders
. 2017; 18: 188-211.
Slide30Spinal Stenosis
Acquired via degenerative changes to facet, disc, and hypertrophy of the ligamentum flavum or posterior longitudinal ligamentDiagnostic Criterion: 10-12mm in sagittal plan diameter on radiographs.Can have sensory or motor findings associated with extension based postures
1. Cook C, Brown C, Michael K, Isaacs R, Howes C, Richardson W, Roman M,
Hegedus
E.
The clinical value of a cluster of patient history and observational findings as a diagnostic support tool for lumbar spine stenosis
.
Physiother
Res Int
. 2011; 16(3): 170-8.
Slide31Spinal Stenosis
Google Search: Spinal Stenosis
Slide32Spinal Stenosis
Clinical Prediction Rule: 1. Bilateral symptoms 2. Leg pain > back pain 3. Pain during walking/standing 4. Pain relief upon sitting 5. > 48 years old
1. Cook C, Brown C, Michael K, Isaacs R, Howes C, Richardson W, Roman M,
Hegedus
E.
The clinical value of a cluster of patient history and observational findings as a diagnostic support tool for lumbar spine stenosis
.
Physiother
Res Int
. 2011; 16(3): 170-8.
Slide33Spinal Stenosis
Variables
Sensitivity
Specificity
+LR
-LR
+ Post-test
Prob
1
0.96
0.20
1.20
0.19
44.0%
2
0.68
0.62
1.80
0.51
55.0%
3
0.29
0.88
2.50
0.80
63.0%
4
0.06
0.98
4.60
0.95
76.0%
5
0.01
1.00
∞
0.99
99.0%
Slide34Discogenic Pain
Google Search: Discogenic back pain
Slide35Discogenic Pain
Insidious onset of symptoms (ie repetitive strain) or after an episode of bending, lifting or twisting with an audible “pop”. Pain is often described as central low back that may radiate into the glute. The pain reduces with extension, standing or lying supine. Pain is described as a dull ache that worsens with sitting, driving, flexion, bending, or twisting. Coughing and the Valsalva maneuver can increase or exacerbate symptoms. The pain generally worsens by the end of the day.
Simon J et al. Discogenic Low Back Pain.
Phys Med
Rehabil
Clin
N Am.
2014; 25(2):305-317.
Slide36Discogenic Pain
Findings to Rule in Intervertebral Disc Dysfunction: Centralization Likelihood Ratio 2.1
Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews.
BMC Musculoskeletal Disorders
. 2017; 18: 188-211.
Slide37Disc Herniation with Radiculopathy
Google Search: Disc Herniation
Slide38Disc Herniation with Radiculopathy
Findings to Rule in Nerve Root InvolvementPositive SLR for referred leg pain3 out of the 4 following findings: dermatomal pain in concordance with nerve root, corresponding sensory deficits, reflex and motor weaknessCrossed Straight Leg Raise TestSpecificity: .83-.94Likelihood Ratio: 2.2 – 5.0
Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews.
BMC Musculoskeletal Disorders
. 2017; 18: 188-211.
Slide39SI Joint Dysfunction
SI Distraction Test
SI Compression Test
Thigh Thrust Test
Gaenslen’s
Test (right and left)
Sacral Thrust Test
Slide40SI Joint Dysfunction
Laslett
M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint.
J Man Manip
. 2008; 16(3): 142-152.
Slide41SI Joint Dysfunction
Laslett
M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint.
J Man Manip
. 2008; 16(3): 142-152.
Slide42SI Joint Dysfunction
Likelihood Ratio: 4.00 It was also suggested that if all 6 tests were negative, then SI joint pathology may be ruled out
Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews.
BMC Musculoskeletal Disorders
. 2017; 18: 188-211.
Slide43Myofascial Pain
No clinical diagnostic rule currently presentSuggest a composite of 4 minimum criteria:Presence of palpable taut band within skeletal musclePresence of hypersensitive spot within taut muscle with an/or without distinct referred painPatient recognition of referred pain
Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews.
BMC Musculoskeletal Disorders
. 2017; 18: 188-211.
Slide44Central Sensitization
Increased responsiveness of nociceptive neurons in the central nervous system to their normal of subthreshold afferent inputCriterion 1: pain disproportionate to extent of injuryCriterion 2: bilateral pain, pain varying in location unrelated to the source of nociception, widespread pain, allodyniaCriterion 3: hypersensitivity of senses unrelated to the muscular system
Peterson T et al. Clinical classification in low back pain: best-evidence diagnostics rules based on systematic reviews.
BMC Musculoskeletal Disorders
. 2017; 18: 188-211.
Slide45Questions?
Matthew Somma, PT, DPT, MTC, CSCSmsomma@orthoassociates.com
October 14, 2017