TIS

Chapter 19
Clinical Science Issues That Relate to the Lumbar Spine


ASSESSMENT

  1. Problem list
    1. musculoskeletal problem or not?
      1. structural impairment of the spine?
      2. abnormal motion?
      3. malalignment?
      4. "non-neurological" muscular weakness?
    2. true neurological impairment?
    3. associated problems: precautions, contraindications?
    4. risk factors: occupational, recreational
      1. habitual activities which influence pain?
      2. stress level?
      3. secondary gain?
      4. health attitude?
          - nutrition, smoking
    5. level of irritability
    6. classification

  2. Patient goals

  3. Treatment goals: (are they measurable?)
    1. short-term: treat pain or not?
      1. if so, reduce and centralize pain
      2. increase functional capacity
      3. reduce risk factors
    2. long-term goals
      1. maximize functional capacity
      2. eliminate risk factors
      3. commitment to health and fitness
        1. normal motion
        2. muscular strength
        3. cardiovascular fitness

  4. issues of reassessment
    1. pain vs. activity?
    2. when to modify treatment
SUBJECTIVE EXAM

In my opinion, the subjective exam is the single most important event in our association with the patient who presents with low back pain. A veteran clinician once said, "your patient will tell you not only his problem but also it's solution if you let him."

  1. Goals of the subjective exam for LBP
    1. establish patient's identity, lifestyle, daily stresses
    2. cc symptoms
    3. past medical history, current medical/surgical problems
    4. patient goals

  2. Suggested procedure
    1. age, occupation, recreation
    2. current cc
      1. location of pain: central vs peripheral
      2. * behavior: "what makes it better, what makes it worse"
      3. functional questions: walking, standing, sitting, sit to stand unique occupational demands: rotation, vibration, forward bending, disabled or not? (A useful tool for this is the Oswestry Low Back Pain Questionnaire, see Appendix)
      4. potential of nerve root compression: true weakness, anesthesia, bowel and bladder problems
    3. onset of pain
      1. when?
      2. single traumatic episode:
        1. radiographs?
        2. associated injuries?
        3. care of associated injuries?
      3. gradual onset
        1. postural stresses?
        2. potential for non-musculoskeletal cause?
      4. behavior since onset
        1. better or worse?
        2. previous care?
      5. previous back problems?
    4. past and current medical/surgical history
      1. chronic diseases: DM, RA, heart disease, HT, lung disease
      2. other: seizure disorder, PVD, connective tissue disease
      3. any systemic inflammatory disease
      4. osteoporosis
      5. surgeries: spinal, hysterectomy, cancer
      6. medications: steroids, opiates, psychotrophic, tricylics, NSAIDS
    5. patient goals
      1. measurable
      2. reasonable
    6. Examiner's impression
      1. disabled or not?
      2. level of irritability?
      3. reliability?
      4. precautions and contraindications?
      5. potential for non-PT related problems?

OBJECTIVE EXAM

  1. Goals of the objective exam for LBP
    1. identify structural abnormalities
    2. identify movements and positions which reproduce the patient's symptoms
    3. identify the presence of neuromuscular impairment

  2. General considerations
    1. consider level of irritability
    2. the "Gold Standard"
    3. the "Safety Valve"

  3. Suggested procedure
    1. exam maneuvers are performed in the following sequence of positions:
      1. standing
      2. sitting
      3. supine
      4. prone and if indicated, sidelying
    2. Positions and relevant tests:
      1. Standing
        1. inspection
          1. iliac crest height
          2. symmetry of trunk and lower extremities
        2. patient identifies painful area
        3. ROM of trunk
          1. forward bending
          2. backward bending
          3. side bending
          4. three dimensional
          5. repeated motions
        4. special tests
          1. unilateral leg stand (L4,5)
          2. heel raise (S1, 2)
      2. Sitting
        1. sitting posture, effect of correction
        2. ROM: rotation
      3. Supine
        1. inspection
          1. leg length
          2. alignment of LE's
          3. symmetry of soft tissue
          4. skin condition
        2. ROM
          1. hip flexion
          2. hip rotation
          3. Patrick's test
          4. knee extension
          5. SLR
          6. ankle dorsi flexion (Homan's)
        3. Motor
          1. hip flexion (L2,3)
          2. knee extension (L3,4)
          3. ankle dorsi flexion (L4,5)
          4. sub-talar eversion (L5,S1)
          5. great toe extension (L5)
          6. great toe flexion (S1)
        4. Sensory and reflex
          1. light touch L2-S2
          2. patellar tendon (L3,4)
          3. achilles tendon (S1,2)
          4. Babinski, Clonus
        5. Palpation
          1. ASIS, pubic tubercles, femoral head
          2. psoas major
          3. pulses: femoral, popliteal, posterior tibial, dorsalis pedis
        6. Special tests
          1. SI compression and distraction
          2. spinal distraction
        7. Prone
          1. inspection: spine and buttock soft tissues
          2. ROM
              knee flexion (femoral nerve stretch test)
          3. motor
            1. knee flexion (S1,2)
            2. hip extension (L4,5;S1,2)
          4. palpation (static)
            1. bony
              1. iliac crest, PSIS, sacrum, ischial tuberosity, greater trochanter
              2. spinous processes L5-T12
            2. soft tissue
              1. ligamentous: sacrotuberous ligament, supraspinious ligament
              2. muscles and fascia
                1. buttock: TFL, gluteus max, min, piriformis, quadratus femoris
                2. spinal: lateral abdominals, quadratus lumborum, erector spinae
          5. palpation (dynamic)
            1. articular: PA pressures
            2. soft tissue mobility
      4. Sidelying
        1. palpation (dynamic)
          1. spinal joints
            1. distraction
            2. flexion
            3. extension
            4. side-bending
            5. rotation
          2. sacro-iliac joint
            1. upward rotation
            2. downward rotation
        2. special tests
            Ober's test

Treatment approaches

Countless forms of physical therapy treatment for patients with LBP have been described. While some treatments have been shown to be of value it should be remembered that the fundamental theme of treatment of the patient with LBP is rehabilitation, i.e. "the process of restoring the patient to useful life." This involves not only regaining full, painfree ROM but also effecting a behavioral change in the patient. This is accomplished by patient education. The patient must become responsible for his own care, hence the dependency of the patient on his therapist must be avoided. As a result, "passive" treatments such as TENS, massage, etc. should be used only as adjuncts to self-administered "active" treatments.

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