Lumbar Spine Somatic Dysfunction Lecture Flashcards
Incidence of Lower Back Pain
- 85% of the General Population will have Lower Back Pain
- 2 to 5% of the general population reports LBP yearly
- Back pain occurs in 35% of Adolescent athletes
- Overuse back injuries are prone to recurrence
- 26% males/ 33% females
- 27% of back pain in Adults is due to Musculoskeletal Strains
General Consideration
- LBP is the #2 reason patients of to the doctor
- Majority of causes DO NOT REAUIRE Surgical Intervention
- Causes a Massive financial burden
a) Cost of Treatment
b) Expense of Lost work
c) Legal costs (Workmans comp, Disability, Person Injury) - Emotion burden as well
a) Increased Stress
b) Depression - $100 BILLION IN TOTAL COSTS/ YEAR!!!!!11
- 75% of total cost is attributed to Less than 5% of patients with LBP
- This means we spend to most money on a very small percentage of patients with LBP ($75 Billion on 5% of LBP patients)
- Majority of pain is due to MECHANICAL DYSFUNCTION
- Lumbar spine is Frequent site of:
a) Strain
b) Pain
c) Disability
Anatomy
- Vertebrae are built to support heavy loads in a fairly Neutral Plane
- Structure allows for fair amount of FLEXION and EXTENSION
- Less of Sidebending and Rotation due to SAGITTAL ORIENTATION of FACETS
Anatomic Variants
- SACRALIZATION of L5!!!!!!!!!!
- Lumbarisation of S1!!!!!!!!!!!!!!!!!!
- Spondylolysis: Fracture in PARS INTERARTICULARIS!!!!
- Lumbar Herniated Disc!!!!
Etiologies
1) MECHANICAL
- Arthritis
- Spondylosis/ Spondylolysis/ Spondylolisthesis
- Degenerative Disc Disease
- Somatic Dysfunction
2) NON-MECHANICAL
a) VISCEROGENIC
- Ex: Renal Colic, Endometriosis
b) VASCULOGENIC
- Ex: Abdominal Aortic Aneurysm
3) INFECTION
- Osteomyelitis
- Diskitis
4) TUMORS
- Primary: MYELOMA
- Metastatic:
a) Breast
b) Prostate
c) Lung
d) Kidney
5) METABOLIC
- Osteoporosis
6) Rheumatologic
- Rheumatoid Arthritis
Red Flags in Low Back Pain
- Major Trauma Mechanism
- Age > 50 or
Example of Mechanical Etiology: Spina Bifida
- Recall that the spinous process is formed from LAMINAE
- FAILURE of FUSION —> Spina Bifida (“Split Spine’)
- Neural Tube Defects: DECREASED incidence with FOLATE Supplementation
Spina Bifida 3 types
1) Spina Bifida Occulta
- Congenital
- Common L5-S1
- Asymptomatic
- May have patch of coarse her over site
* **NO SPINAL PROTRUSION
2) Meningocele
- Meninges FORCED OUT between Vertebral Spaces
3) Myelomeningocele
- MOST COMMON TYPE
- Unfused portion of the Spinal Column allows Spinal Cord to PROTRUDE through an OPENING!!!
Example of Mechanical Etiology: SPINAL STENOSIS
- The spinal canal contains the CONUS MEDULLARIS, FILUM TERMINALE, and CAUSE EQUINA
- Cord terminates at the level of L1-2
- Diameter can become COMPROMISED —> “Stenotic”
- The diameter also Normally DECREASES with Age
Causes of Compromise:
- Hypertrophy of Posterior Longitudinal Ligament
- Thickening of Ligamentum Flavum
- Osteoarthritis
- Exostoses
- Tumors
- Disc Rupture
Cauda Equina Syndrome
Multiple Etiologies:
- Infection/ Inflammation
- Herniated Disc
- Metastasis
- Spinal Stenosis
- **These all place pressure on the CAUDA EQUINA
Causes:
- Pain, numbness, or tingling in low back/ Lower extremity
- Progressive weakness and Paralysis of Lower Extremity
- Bladder and Bowel incontinence, Sexual Dysfunction
- This is often a SURGICAL EMERGENCY!!!!!
So, How do we figure out the Problem?
** A THOROUGH H&P!!!!!!!!
Especially the ROS!!!!!
Examination
- Observation
- Palpation
- Motion Testing
- Neuromuscular Exam: Strength and Sensation
- Vascular Assessment
Lumbar Exam
1) Range of Motion
- Patient seated/ Standing
2) Screen with Fingers
- Note skin changes, tenderness, etc
- TART
- Hip Drop Test for Lumbar SB
- hone in on these areas for further examination
a) Gross motion testing (Flexion, Extension, Rotation, Sidebend)
b) Single segment motion
Barrier Concept
1) Anatomic Barrier (Passive ROM)
2) Physiologic Barrier (Active ROM)
3) Pathologic Barrier (Loss of Motion)
- This is where the complaint lies
- This is where you will be working with your patients
Mechanics
Lumbar Spine
- Just like Thoracic Spine
- Follows TYPE I mechanics in NEUTRAL POSITION
- Follows TYPE II mechanics in NON-NEUTRAL Position
- This is the rule in Normal Mechanics and Dysfunction
- Lumbar SP and TPs are at the SAME LEVEL!!!!
Lumbar Exam
- Patient either prone or seated
- Induced an ANTERIOR FORCE on the Right Transverse Process (LEFT ROTATION)
- Repeat for the Left (RIGHT ROTATION)
- Repeat Rotation Test with Flexion, then Extension, and compare to Neutral
Type I Mechanics
TONGO (Maintained by LONG RESTRICTOR MUSCLES!!!!!!!)
- Predominantly in the NEUTRAL SPINE
- Sidebending and Rotation occur in the OPPOSITE Directions
L3-5 N RR SL
**SIDBENDING OCCURS FIRST!!!!!!!
Type II Mechanics
- Predominantly in the FLEXED or EXTENDED Spine
- Rotation and Sidebending occur in the Same Direction
L4 F RR SR
***ROTATION occurs FIRST!!!!!!
- Maintained by SHORT RESTRICTORS!!!!!!
a) Intertransversarii
b) Multifidus
c) Rotatores
Nomenclature
- Named for position of ANTERIOR ASPECT of Superior/ Cephalic Bone in relation to Inferior/ Caudad Bone (Relationship of L4 to L5)
Description:
1) Level of Dysfunction
2) Neutral of Flex/Ext
3) Type:
a) Type I: SIDEBENDING FIRST, then Rotation
b) Type II: ROTATION FIRST, then Sidebending
Lumbar Exam
1) If motion is roughly the same in both Flexion and Extension:
- Neutral Dysfunction
- Follows Type I Mechanics
2) If motion is more restricted in Flexion or Extension:
- It is a Flexion/ Extension Dysfunction
- Follows Type II Mechanics
3) The Flexion/ Extension component of the POSITION DIAGNOSIS is the plane in which the Restriction move MORE FREELY!!!
Lumbosacral Mechanics
- Sacrum and Lumbar spine move in Opposite Directions
***LUMBAR FLEXION —-> SACRAL EXTENSION
***LUMBAR EXTENSION—–> SACRAL FLEXION
Viscerosomatic Reflexes
- Also called “Segmental Facilitation”
- Our visceral organs are innervated by Nerves Originating from different segments of the Spinal Cord
1) SYMPATHETIC —-> THORACOLUMBAR Region
2) PARASYMPATHETIC —-> CRANIOSACRAL REGION
- Dysfunction in these Organs can cause Palpable Somatic Dysfunctions at these associated Segments
- VIscerosomatic = From VISCERA —> SOMA!!!
Viscerosomatic Reflexes
1) Pancreas: T6-9 Bilaterally
2) Kidney, Ureters: T10-L1 on Corresponding side
3) Ovaries, TEstes: T10-L1 on Corresponding side
4) Adrenals: T10-L1
5) Appendix: T11- L2 on RIGHT with associated Ribs
6) Uterus: T10-L2
7) Urinary Bladder, Prostate: L1-2
8) Colon: T8-L2, Ascending RIGHT Side, Descending LEFT SIDE
9) Rectum, Anus: L1-2
Chapman’s Reflex
- FRANK CHAPMAN D.O
- Tender point “CLUES” used for Dx of Visceral Dysfunction
- Anterior and Posterior Points
- Tender point is PALPABLE as a Small Smooth Firm Nodule (2-3 mm) —> Like a Pea
- Good inter examiner reliability and correlates with Discharge Diagnoses
Chapman’s Reflexes
Anterior Points
1) Periumilical: Adrenal, Kidney, Bladder
2) 5th ICS: Stomach (left), Liver (right)
3) 6th ICS: Stomach (left), Liver/ Gallbladder (Right)
4) 7th ICS: Spleen (Left), Pancreas (Right)
Chapman’s Reflexes
Poster Points
1) Kidney
2) Bladder
3) Urethra
4) Uterus
5) Colon
6) Pelvic Organs
Management
- Address the cause
- Use OMT to adress Mechanical causes and Help in VISCERAL CAUSES
Medical Management:
1) NSAIDS: Caution with Renal Insufficiency or GERD
2) Muscle Relaxants
3) Tricyclic Antidepressants
4) Narcotics JUDICOUSLY!!!!!
- Surgical Management if indicated
Note of Prescribing Narcotics from CDC
- Each day 46 people die from an overdose of Prescription Painkillers in the US
- Health care wrote 259 million prescriptions for Painkillers in 2012, enough for every American adult to have a bottle of pills
- 10 of highest prescribing states for Painkillers are in the South
What can we (Healthcare providers) do?
- Use monitoring programs to ID patents who may be misusing their prescription drugs
- Follow best practices for responsible Painkiller prescribing:
1) Screen for substance abuse and mental health problems
2) Avoiding combinations of prescription painkillers and sedatives unless theres is a specific medical indication
3) Prescribe the LOWEST EFFECTIVE DOSE and only the Quantity needed - Talk with out patients
- Discuss risks and benefits of pain treatment options, including those that don’t include prescription Painkillers (Like OMM)!!!!!!
