Lumbar Spine and SIJ Flashcards
Natural history of acute LBP
80% of patients with acute LBP have recovery in 6-8 weeks and may not require extensive treatment.
Characterized by periods of exacerbation and remission.
Flare ups are normal and do not necessarily represent a failure of treatments
Natural history of chronic LBP
Widely variable
1/3 of patients had full recovery at 12 month follow up
<5% have persistent symptoms with significant disability. High degrees of pain intensity and disability are unfavorable prognostic factors.
Relationship between work-related spinal loading, prolonged sitting, and/or participation in sports and recovery from LBP
No relationship
Therefore, these activities shouldn’t necessarily be limited for patients recovering from LBP
Determining pathoanatomical diagnosis
We cannot accurately determine specific tissue causing sxs for most patients.
This is likely ok since most spinal tissues work together and will be influenced by any treatment.
3 primary anatomic regions in nervous system which help to modulate pain
- Spinal cord (dorsal horn neurons have increased excitability and spontaneous discharge nociceptive info)
- Brain stem (Periaqueductal gray matter - opioidergic)
- Higher brain centers
Consistent recommendations for treatment of patients with acute LBP
- initiate early treatment that emphasizes resumption of activity and discourages bed rest
- Early recognition of psychologic and work related factors (yellow/blue/black flags)
Consistent recommendations for treatment of patients with chronic LBP
- Supervised exercises
- Cognitive behavioral therapy
(Recommendations for manual therapy vary) - Step care approach - rapid transition from passive to active treatments with encouragement and reassurance
- Final common pathway should include activity based approach that maximizes patient participation
Is a single red flag enough to warrant referral?
No. Nearly all patients have at least one red flag. About 1% of patients with LBP have serious pathology.
Key clinical features predicting metastatic neoplasm of lumbar vertebrae
- History of cancer
- Overall clinician judgment
(others include unexplained weight loss, >50 yo, <17 yo, failure to improve over predicted time interval following treatment, no relief with bed rest)
Strong predictors of vertebral fracture
- Contusion or abrasion on the back
- History of acute trauma
~3. Corticosteroid use
CPR - 3 more positive indicates high risk:
- > 70 yo
- Female
- Significant trauma
- Prolonged use of corticosteroids
National guidelines re: imaging and LBP
National guidelines call for restricting use of lumbar MRI in patients with nonspecific LBP
Lumbar MRI findings which are meaningfully associated with symptoms
- High intensity zone (HIZ) in the annular region of the disc > associated with diskogenic pain
- High T2 signil in and near vertebral end plate (Modic sign) > disruption of end plate with subsequent bone marrow edema> impaired diffusion of nutrients/waste products> may contribute to diskogenic pain
Physical exam test that increases likelihood of diskogenic pain
Centralization of sxs
Yellow flags
A patient’s personal mistaken beliefs about pain and injury
- Pain Catastrophizing Scale: Strong predictor of disability
- Fear-Avoidance Beliefs Questionnaire: Not good predictors of chronicity when used in isolation.
Blue flags
Patient’s perception of work and work conditions that may impair return to work
Black flags
Patient’s social and financial issues.
Self efficacy
Belief one can achieve future goals. Patient’s beliefs about how pain can be controlled appear to be a powerful predictor of disability.
Spinal manipulation therapy
- Recommended in most guidelines, early on in treatment of patient with acute (sometimes chronic).
- Unlikely that use of SMT in isolation will provide optimal benefit
Motor control exercises
Superior to minimal intervention at short- and long-term follow up
CPR for lumbar manipulation
- No sxs distal to knee
- Sxs <16 days
- Score of <19 on Fear-avoidance beliefs questionnaire
- At least 1 hypomobile segment
- At least 1 hip with greater than 35 deg of internal rotation
(Generalizability of this rule has been questioned)
Evidence for lumbar extensor strengthening
Not sufficient. Appears to be more effective than no treatment, no comparison to other exercise approaches.
Benefit of aerobic training
Appears to reduce increased awareness of neural stimulus (central sensitization)
Weight training and LBP
- Reduces frequency of acute LBP
2. Properly performed weight training is very unlikely to result in reinjury of spinal tissues
McKenzie Exercises
Likely to reduce pain and increase mobility in individuals with acute/ subacute/ chronic LBP
Patient education (Back pain)
Key component of care.
- Avoiding bedrest
- Understanding difference between god pain and bad pain
- Physiology of pain and neuroplasticity
Evidence for pain neuroscience education and dry needling
- No data for PNE
2. Data inconclusive for DN
Peripheral and central events that occur with spinal manual therapy
Peripheral: Increased diffusion of water within discs and skeletal muscle; maybe rapid changes in concentrations of inflammatory mediators.
Central: Activation of pain modulatory circuitry; autonomic responses e.g. changes in cortisol levels.
Which part of the disc contains most of the neurovascular structures?
Outermost annulus.
Sensory information from these nerves travels to spinal cord via two possible routes - possibly contributing to somewhat vague and diffuse spatial location of people with disc pain.
Tissue fluid exchange within discs
- Influenced by physical activity
2. Needed to synthesize collagen and proteoglycans
How common are findings of DDD on imaging?
Signs are present for most people by third decade of life. Almost universal by 7th/8th decades.
Relationship of smoking and heavy physical loading with DDD
Not meaningful etiologic factors.
In the absence of trauma, competitive weight lifters have a lower than expected degree of degeneration.
Strongest known predictors of DDD development
Genetic factors
Relationship between OA and DDD?
DDD has the highest prevalance in those people with OA involving the extremities.
Age-related changes in discs are similar to those observed in articular cartilage and are not necessarily related to pain.
What part of spine usually gets injured with axial trauma to the spine?
Vertebral end plate.
Disruptions in end plate have a strong correlation with DDD.
How to annular tears heal?
Limited capacity for healing.
Heal through inflammatory processes > poorly remodeled scars> Increased area of disc that is innervated > decreased threshold to stimulation of pain-sensitive fibers.
Heterogeneity in vascularization of healing annular tears may contribute to variations in recovery from LBP.
Process leading to development of spondylosis
DDD> dehydration of nucleus > decreased internal stiffness of disc > micromotion during loading and slackening of supporting tissues due to loss of disc height> facet overload> osteoblastosis
> Further loss of disc height and reduction in ROM > cycle that further reduces threshold for nociception during loading.
Exercise prescription for DDD depending on stage:
Mild/ early stage: No additional treatment precautions
Later stage: Avoid exercises that stress vigorous or sustained loading at the end of trunk ROM. Avoid early-morning lumbar flexion for approximately 2 hours. Avoid prolonged flexion including sitting. Work on improving hip ROM.
Why is delayed onset of pain common with DDD?
Swelling from micro-hemorrhage and associated edema
Are pelvic bones symmetrical?
No.
Primary intervention for SIJ dysfunction
Motor control.
Hip muscle activation can increase stiffness of SIJs.
Evidence for form closure theory
No real evidence to support this. There is better evidence to support the biotensegrity model.
Total SIJ and pubic symphysis motion with position changes
SIJ: Rotation = 1.15-2.5deg. Translation - 0.4-0.9mm
Pubic Symphysis: Rotation = 2 deg. Translation vertical = 0.8 mm males, 1.6 mm females. Translation AP = 0.5-0.7 mm
SIJ ligaments relevant to pain
Short posterior ligament is often a source of pain. Multidirectional fibers so most any motion can stress it.
Pain with palpation of long posterior (distal) ligament is highly sensitive.
Relationship between posture and sacrotuberous ligament
Optimal sitting posture engages the sacrotuberous ligament by positioning the sacrum in flexion (enabling stabilizing influence on SIJ).
SIJ innervation
Upper portion: L5
Lower portion: Sacral plexus
(SIJ can refer pain to L5 and sacral dermatomes)
Which parts of SIJ refer where?
Upper section: upper buttock, middle buttock, lateral thigh
Lower section: Middle buttock, lower buttock, thigh and lower leg
Groin pain also common for SIJ. SIJ rarely occurs above L5 region.
Note: Pain location not a reliable tool for identifying pain generating structure.
“Triangulation of forces” with three muscles at lumbar spine
Deep erector spinae
Quadratus lumborum
Psoas
(page 13 of current concepts)
Changes to multifidus with LBP
Fibrosis after surgery
Atrophy in relation to LBP
Quadratus lumborum
Highly involved with stabilization during every loading mode of the spine.
Importance of glute max in SIJ stabilization
Tensions thoracolumbar fascia ipsilaterally and contralaterally.
Glutes often inhibited with LBP. Hip extension becomes hamstring dominant.
An important muscle to strengthen for pubic hypermobility
Adductors due to working with contralateral rectus sheath.
Characteristics of “acute lbp with mobility deficits”
- Restricted spinal ROM and segmental mobility.
- LBP reproduced with provocation of involved segments
- Unilateral pain
- onset of sxs often linked to a recent unguarded/awkward movement or position
Characteristics of “subacute LBP with mobility deficits”
- May report sensation of back stiffness
- Unilateral pain
- Symptoms reproduced with end-range spinal motions
- Sxs reproduced with provocation of involved segments
- Demos at least 1: Limited thoracic ROM and associated segmental hypomobility, “ lumbar, “ lumbopelvic
Characteristics of “acute lbp with movement coordination impairments”
- Acute exacerbation of recurring lbp that is commonly associated with referred LE pain
- Pain at rest or produced with initial to mid-range movements
- Pain reproduced with provocation of involved segments
- Movement coordination impairments of lumbopelvic region with flexion/extension movements
Characteristics of “subacute lbp with movement coordination impairments”
- Subacute, recurring lbp that is commonly associated with referred LE pain
- Lumbosacral pain with mid range motions that worsens at end range
- Pain reproduced with provocation of involved segments
- Lumbar segmental hypermobility
- Decreased thoracic and/or lumbopelvic/hip mobility
- Decreased trunk and/or pelvic region muscle strength and endurance
- Movement coordination impairments while performing self-care/home management activities
Characteristics of “chronic lbp with movement coordination impairments”
- Chronic, recurring low back pain often with associated LE pain
At least one of the following: - Pain worsens with sustained end-range movements/positions
- Lumbar segmental hypermobility
- Thoracic and/or lumbopelvic/hip hypomobility
- Decreased trunk/pelvic strength and endurance
- Movement coordination impairments while performing community/work-related recreational or occupational activities.
Characteristics of “acute lbp with related/referred LE pain”
- Acute LBP + LE pain
- Sxs often worsened with flexion activities and sitting
- Centralization-
- Reduced lumbar lordosis
- Limited extension mobility
- Possible lateral trunk shift
- Clinical findings consistent with subacute or chornic LBP with movement coordination impairments.
Characteristics of “acute lbp with radiating pain”
- LBP and narrow band of lancinating pain in LE
- LE paresthesias, numbness, weakness possible
- Radicular sxs present at rest or produced with initial to mid-range spinal mobility, lower limb tension testing
- Signs of nerve root involvement may be present
(Common for these sxs and impairments to also be present in pts with related/referred LE pain)
Characteristics of “subacute LBP with radiating pain”
- Subacute, recurring back and LE pain
- Possible paresthesias, numbness, weakness
- Pain reproduced with mid-range and worsen with end-range lower limb tension tests
- Possible neuro deficits
Characteristics of “chronic lbp with radiating pain”
- Chronic, recurring back and LE pain
- Possible paresthsias, numbness, weakness
- Pain reproduced with sustained end-range lower limb tension tests
- signs of nerve root involvment may be present
Characteristics of “acute/subacute lbp with related cognitive or affective tendencies”
At least 2:
- 2 + responses to mental disorder screen, affect consistent with individual who is depressed
- High FABQ score, behavioral processes consistent with an individual who has excessive anxiety or fear
- High pain catastrophizing scores
- Exam doesn’t follow initial/mid-range/ end-range movement/pain relationship reflective of tissue stress/inflammation/ irritability
Characteristics of “chronic lbp with related generalized pain”
- LBP > 3 months
- Generalized pain not consistent with other impairment-based classification criteria
- At least 1: Positive responses on depression screen, high FABQ score, high pain catastrophizing scores.
- Exam doesn’t follow initial/mid-range/ end-range movement/pain relationship reflective of tissue stress/inflammation/ irritability
CPR for stabilization classification
- Age <40 yo
- Positive prone instability test
- Aberrant movements with motion testing
- SLR > 90 deg
Treatment for acute lbp with mobility deficits
- Manual therapy
- Therex for mobility
- Pt ed encouraging activity
Treatment for subacute lbp with mobility deficits
- Manual therapy
- Ther ex for mobility
- Ther ex (treat impairments) and education to prevent recurrence
Treatment for acute lbp with movement coordination impairments
- NMR for stability in mid-range positions
- Temporary external devices for restraint
- Self care/home management training
Treatment for subacute lbp with movement coordination impairments
- NMR and Ther ex for stability in mid-range positions and during self-care related functional activities
- Manual therapy/ ther ex for thoracic or hip mobility deficits
- Self care/ home management strategies maintaining the involved structures in mid-range positions
Tretament of chronic lbp with movement coordination impairments
- NMR and ther ex for stability at all ranges and during household, occupational, and recreational actvities
- Manual therapy for thoracic or hip mobility deficits
- Community work/ re-integration
Treatment for acute lbp with related/referred LE pain
- Ther ex, MT, traction to promote centralization and lumbar extension mobility
- Progress to interventions for subacute/chronic movement coordination impairment as able.
Treatment for acute lbp with radiating pain
- Pt education in positions that reduce strain or compression to involved nerve roots
- Manual or mechanical traction (prone?)
- MT to mobilize joints/soft tissues adjacent to the involved nerve root that has impaired mobility
- Nerve mobility exercises in pain-free non-symptomatic range
Treatment for subacute lbp with radiating pain
- MT to mobilize joints/soft tissues adjacent to the involved nerve root that has impaired mobility
- Traction
- Nerve mobility exercises in mid-end range
Treatment for chronic lbp with radiating pain
- MT and TE for thoracolumbar and LQ nerve mobility deficits
- Pt education on pain managemnet strategies.
Treatment for Acute/Subacute LBP with related cognitive or affective tendencies
- Pt education and counseling to address specific classification exhibited by patient
Treatment for chronic lbp with related generalized pain
- Pt education and counseling to address specific classification exhibited by patient
- Low-intensity, prolonged aerobic exercise activities.
Relationship between pelvic rotation and hip flex/ext
Anterior rotation + hip extension
Posterior rotation + hip flexion
Cluster of exam findings to diagnosis pubic joint hypermobility
- Excessive motion on 3 WB radiographs
- ASLR
- Tenderness of superior pubic ligament
Hip flexion test for pelvic fracture
ASLR. + = unable to complete.
Metrics for crossed SLR
97% specific for herniated disc or lumbar radiculopathy
Metrics for Fortin finger test
Sensitive, not specific.
Stork test for normal SIJ movement
Standing unilateral hip flexion. Should only see sagittal plane motion. Abnormal would be motion in other planes, e.g. hip hike or rotation.
Best imaging for pelvic fracture (traumatic)
CT
Risk factors for chronic destructive pyogenic sacroiliitis
IV drug use
Inflammatory bowel disease
Post-op infection
(can have insidious onset)
2 most useful criteria for ruling out zygapophyseal origin of pain
Absence of pain during coughing or sneezing
No pain when arising from a flexed seated posture
2 Laslett’s tests with highest sensitivity and specificity (should be performed first)
Thigh thrust
Distraction
What type of manipulations were most effective for SIJ pain?
SIJ manipulation combined with lumbar manipulation more effective than SIJ alone.
Manipulation improves muscle function and is effective when combined with stabilization exercises.
Purpose of shotgun approach after manipulation
Moving joint through passive, active, and resisted range of motion.
Principles of stabilization program
- Keep exercises bilateral and functional whenever possible.
- Train every muscle that works to stabilize SIJ/pelvis
- Focus on motor control and endurance over strength. Building strength can come at the end (phase 5)
Do SIJ belts decrease muscle activity?
No. There seems to be no change in muscle activity with belts. They act on the passive systems of the pelvis.
When to consider prolotherapy or surgery for SIJ dysfunction
After failed conservative treatment (and pain is consistent with SIJ pathology, e.g. positive but temporary response to SIJ injection).
Relationship between lumbar fusion and future SIJ degeneration
75% of patients with L45 and/or L5S1 fusion had SIJ degeneration unilaterally or bilaterally in 5 years. Fusion to sacrum increases rate of degeneration and likelihood that degeneration will be bilateral.
SIJ degeneration may be accelerated on side that had the iliac crest harvesting.
Ankylosing spondylitis diagnosis CPR
Berlin criteria
- Alternating buttock pain
- Pain with rest relieved with exercise
- PM pain in second half of night
- Morning stiffness >30 minutes
IBP criteria:
- <40 yo
- Insidious onset
- Improvement with ex
- No improvement with rest
- PM pain which improves with getting up
Lumbar stenosis diagnosis CPR
- Bilateral symptoms
- Leg pain > back pain
- Pain during walking/standing
- Pain relief upon sitting
- > 48 years old
Vertebral compression fracture CPR
- Age > 52 years
- No presence of leg pain
- Body mass index < 22
- Does not exercise regularly
- Female gende
