Physio Charlie - lx

Red Flags

noreply@blogspirit.com (PhysioCharlie) — Thu, 15 Oct 2009 23:01:32 +0200

I was reading iCSP today and came across a debate about red flags. Something that came up was a "band of pain" across the abdomen and back as a red flag. See articles below:

Henschke, N., Maher, C. G. and Refshauge, K. M. (2007). "Screening for malignancy in low back pain patients: a systematic review." Eur Spine J 16(10): 1673-9.
Henschke, N., Maher, C. G. and Refshauge, K. M. (2008). "A systematic review identifies five "red flags" to screen for vertebral fracture in patients with low back pain." J Clin Epidemiol 61(2): 110-118.
Jarvik, J. G. and Deyo, R. A. (2002). "Diagnostic evaluation of low back pain with emphasis on imaging." Ann Intern Med 137(7): 586-97.
Mylona, E., Samarkos, M., Kakalou, E., Fanourgiakis, P. and Skoutelis, A. (2009). "Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics." Semin Arthritis Rheum 39(1): 10-17.

Systematic review of tests to identify the disc,

noreply@blogspirit.com (PhysioCharlie) — Wed, 22 Jul 2009 00:57:00 +0200

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2078309&blobtype=pdf

M. J. Hancock, C. G. Maher, J. Latimer, M. F. Spindler, J. H. McAuley, M. Laslett, N. Bogduk

This is a good review suggesting just how hard it is for any test to accurately diagnose pathology. It states that a combination of SI jt tests are relevant and that clinical reasoning is important...nothing we didn't already know really.

New website!!

noreply@blogspirit.com (PhysioCharlie) — Mon, 09 Mar 2009 19:22:00 +0100

I have a new website!!

http://physiocharlie.vpweb.co.uk

Psoas Massage

noreply@blogspirit.com (PhysioCharlie) — Wed, 18 Feb 2009 21:26:48 +0100

http://www.youtube.com/watch?v=_1RARwli_Zs&feature=related

Chronic Non Specific LBP

noreply@blogspirit.com (PhysioCharlie) — Wed, 21 Jan 2009 11:24:00 +0100

I did this IST a while ago:

CNSLBP

Recent systematic reviews = small, short-term benefits when compared to no treatment or sham treatment:
• Acupuncture
• Exercise
• Psychological
• Manual therapy
• Electrical stimulation

No treatment seems to be superior to any other intervention, including usual GP care & none of the cited interventions can be truly said to offer a solution to the problem of CNSLBP. (Wand et al, 2008)

Why Is Current Rx Ineffective in CNSLBP?

Recent evidence suggests changes in the brain:

Brain degeneration.
Cortical reorganisation - maladaptive plasticity
Brain biochemistry change
Wand and O’Connell, 2008

There is growing evidence that the brains of patients with CNSLBP are different to those of normal subjects, Apkarian et al (2004)

Patients with CBP showed 5–11% less neocortical gray matter volume than control subjects

Thalamic atrophy in CBP is important, because it is a major source of nociceptive inputs to the cortex

Brain Function

Flor et al 1997, evoked magnetic fields in the brain in response to electrical stimulation of the back.

NSCLBP subjects showed activity in the primary somatosensory cortex (S1) was shifted more medially and the S1 representation of the back was expanded

Chronic pain = cortical reorganization or “Maladaptive” plasticity ie; Phantom limb pain, tinitus….can be beneficial in the blind or CVA

Brain Biochemistry.

MR spectroscopy to discriminate subjects with persistent low back pain from control subjects with accuracies of 97%–100% based on regional brain biochemistry. (Siddall et al 2006)
Major step toward having an objective diagnostic technique in the assessment of persistent pain.

Mx Plan

Training the brain = Influence cortical function

Sensory discrimination
Visual feedback - Mirrors - Graded motor imagery
Sensory motor feedback
Proprioception
Exercise needs to be challenging

References

See Lx Anatomy IST for refs

Spinal surgery, an X stop procedure

noreply@blogspirit.com (PhysioCharlie) — Thu, 15 Jan 2009 12:01:46 +0100

I had a patient today who had spinal surgery, an X stop procedure:

What is the X STOP®?

The X STOP is a titanium metal implant designed to fit between the spinous processes of the vertebrae in your lower back. It is designed to remain safely and permanently in place without attaching to the bone or ligaments in your back. The oval spacer fits between the spinous processes and the wings are designed to prevent the implant from moving. Warning: The X STOP implant is manufactured from a titanium alloy of metal. Please inform your doctor if you think you are allergic to titanium or titanium alloy. Caution: The X STOP is manufactured from a titanium alloy which is known to produce artifacts if you undergo an MRI exam. If you have an MRI exam, after you have had X STOP surgery, inform your doctor that you have the X STOP. Failure to inform your doctor may affect the quality of diagnostic information obtained from these scans. The X STOP is MRI safe.

Kinetic Control Course Feedback

noreply@blogspirit.com (PhysioCharlie) — Fri, 28 Nov 2008 14:02:27 +0100

This was the IST by my colleague Ruth:

Kinetic Control Course Feedback

20/11/08

TOPIC: The Integrated Local Cylinder

The muscles constituting the Integrated Local Cylinder are:

1. Respiratory Diaphragm
2. Pelvic Floor
3. Posterior fasciculus of Psoas
4. Segmental Multifidus
5. Transverse Abdominis

The function of the Integrated local Cylinder is to control translation in the lumbar spine – flexion, extension and rotation.

The rationale behind testing the low threshold voluntary recruitment of these muscles is to find the ones that need to be reactivated/ rehabilitated.

When testing these muscles the following principles should be remembered:
1. Test in the neutral training position
2. VAK ( visual, auditory and kinaesthetic feedback is vital)
3. Low load, slow speed, consistent holding time

Finding the Neutral Training Region:

Gandevia et al (1992) state that proprioception relates to 3 key sensations: sensation of position and movement of joints; sensation of force, effort and heaviness of workload; and sensation of the perceived timing of muscle contraction. There are few reliable studies examining proprioceptive deficits associated with low back pain ( more so of shoulder and cervical spine): Gill and Callaghan(1998), Taimela et al (1999) and Brumagne et al (1999) report a significant decrease in repositioning ability in patients with low back pain.

Bear the above in mind when finding the neutral training region. Lots of VAK! The neutral training region is a relative region within the patient’s joint mid – range where there is minimal support or restraint of motion from the passive restraints.

Practical ( make personal notes if need to)

Respiratory Diaphragm:

Ideal recruitment
Fully elevate ribs with inspiration and maintain basal rib elevation and prevent rib depression during1/2 expiration.

Check if able to do in sitting, maintaining neutral, no substitutions. The benchmark is 15 secs x 2, feels easy, no VAK.

Substitutions to watch for – Tx flexion during expiration (using rectus abdominis); spinal extension during expiration (inefficient rib elevation); ribcage depression (external oblique dominance); breath holding (global co contraction rigidity).

Pelvic Floor:

Some prelimary studies indicate that some muscles of the pelvic floor complex may have an anticipatory recruitment pattern suggesting a stability role.

There should be sensory discrimination between high and low threshold pelvic floor recruitment strategies.

Examples of high threshold recruitment is: stopping the flow of urine midstream, the “lift”, maintaining a closed sphincter when bracing or bearing down. These high threshold strategies may be useful to train in conjunction with low threshold strategies and is sometimes the only option.

Low threshold facilitation strategies ( NB for motor control of translation of pelvic joints and continence)

1. Front to back

2. Side to side

3. 4 Points to the middle

4. Pelvic Zipper

5. Perineal lift
Ideal function:
In crook lying the patient should have a definite sensation of low force contraction of the pelvic floor. In patients with no SIjt or pelvic floor dysfunction there is usually a good sensory discrimination between being lower or higher, more anterior or posterior, consistency of the contraction, symmetry.

Posterior Fasciculus of Psoas

The Psoas has segmental attachments posteriorly to all lumbar transverse processes. Anteriorly at all lumbar vertebral bodies and to all lumbar discs except L5/S1. The posterior fasciculii fibres are approx 3 – 5cm in length.

“ It has a primary stability role at the lumbar spine for axial compression and it has minimal movement function on the lumbar spine. (Bogduk 1997)”

“It demonstrates a significant decrease in cross sectional area at a segmental level in patients with sciatica. (Dangaria and Naesh 1998)”

“ Psoas is clinically deficient in that it fails to segmentally resist displacement at the level of pain in patients who have segmental lumbar dysfunction.”

“Specific segmental psoas facilitation improves lumbar segmental control of induced displacement. (Cromerford and Emerson 1998).”

Action to facilitate:
The local stability role of the psoas is to longitudinally pull the head of the femue into the acetabulum with the spine fixed and supported in neutral alignment to produce axial compression along its line of pull.

Asess and rate voluntary low threshold recruitment: (palpation of segmental loss of translation stiffness)
VAK –describe where muscle is and its function, holding stack of books which you compress to turn on its side, sucking into socket …
Correct activation, sustained contraction, control of neutral position, benchmark 15 secs x 2, no added feedback, good symmetry.

Substitutions to watch for: pelvic hitching (QL and iliocostalis); pelvic rotation (internal and external obliques); hip MR (TFL and gracilis); PPT/Lx F (ant part of Psoas); APT/LxE (iliocostalis); knee F (hamstrings); knee hyperE (quads); co contraction rigidity.

Facilitation strategies:

No cluers – use movement and load facilitators
1. Side Lying rotation to neutral (can use “waggling” as well)

2. Hand Knee Diagonal Push (multifidus reactivation as well)

3. Sitting Manual Trunk Distraction

Some Idea – specific unloaded facilitation
1. Side Lying

2. Supine

3. Standing on step

Transversus Abdominis

“Activates prior to movement of limbs or trunk in anticipation of load to increase stiffness and stability of the spine.”

“A motor control deficit is present in all subjects with back pain.”

“The normal anticipatory activation of TA is significantly delayed in low back pain subjects.”

Action to facilitate: - hollowing of lower abdominal wall without excessive overflow to the upper abdominal wall.

Assess and rate voluntary low threshold recruitment efficiency:

Crook lying. Cough, laugh, forced expiration can demonstrate that muscles are under voluntary control, but these are phasic contractions. Describe where muscle is and its function. Corset. Moving ASIS together. Maintain control of neutral. Benchmark 15secs x 2. Good symmetry.

Substitutions to avoid – no palpable contraction (more effort); abdominal wall bulge ( internal obliques or intra abdominal pressure); spinal movement (global substitution); pelvic tilt (global muscles); ribcage depression (external obliques); bracing ( co contraction rigidity, intra abdominal pressure); breath holding (global rigidity); inspiration( passive hollowing)

No Idea at All! – sensory mechanical pre load
1. Lattisimus Dorsi Facilitation

Clues? – movement and load facilitators (these load thoraco lumbar fascia)
1. Four point kneeling
2. Prone on elbows ( not for patients with extension related pain)

Some Idea – specific unloaded facilitation
1. Tactile feedback
2. Low abdominal sling
3. Counting

Psoriatic Arthritis

noreply@blogspirit.com (PhysioCharlie) — Wed, 26 Nov 2008 12:25:00 +0100

I had a patient today with psoratic arthritis. I needed to recap my knowledge on this:

http://www.arc.org.uk/arthinfo/patpubs/6029/6029.asp

http://www.psoriasis-association.org.uk/arthritis.html

http://www.psoriasis-association.org.uk/PsA4.pdf

Psoriatic arthritis is an inflammatory joint disease associated with psoriasis. Like all arthritis, psoriatic arthritis can cause stiffness, pain and lack of movement in affected areas. It most commonly affects the joints in the hands and feet, but can also cause inflammation, swelling and pain in larger joints, including the knees, elbows, hips and the spine. The inflammation in psoriatic arthritis can also affect the tendons (the fibrous tissue that attaches the muscle to the bone).

Multifidus

noreply@blogspirit.com (PhysioCharlie) — Fri, 21 Nov 2008 15:16:47 +0100

This is my colleague Cath's IST this week:

Ms/Mnth:Multifidus

Anatomy:

Multifidus lies deep to semispinalis and erector spinae in the groove between the transverse and spinous processes of the sacrum to C2; it consists of a series of fleshy and tendinous fascicles.

Proximal Attachment

• It arises inferiorly from the dorsal surface of the sacrum as low as the fourth sacral foramen (deep to the tendon of erector spinae), the aponeurosis of erector spinae, the posterior superior iliac spine and posterior sacro-iliac ligament. In the lumbar region it arises from the mamillary processes of L1 to L5, in the thoracic region from the transverse processes of T1 to T12 and in the cervical region from the articular processes of C4 to C7.

Distal Attachment

• The fascicles pass obliquely supero-medially to attach to the whole length of the spinous processes of C2 to L5. The muscle is arranged in three layers: the deepest layer attaches to adjacent vertebrae, the intermediate layer to the second or third vertebra above and the superficial layer to the third or fourth vertebra above.

Actions:

• The precise actions of multifidus as well as those of the other short muscles in the back are not fully understood. It is thought that its main role is as a stabilizer of the vertebral column, which is probably of greater functional significance than its role in producing movement. Bogduk (1997) believes that in the lumbar spine; the obliquely orientated fibres of the deepest portion of multifidus; do not play a role in the production of spinal rotation as the lumbar spine has minimal range of rotation. He states the primary role of these deepest fibres is to resist the rotation generated by the obliques, therefore providing segmental stability. Globally the muscles are thought to play a role in extension, lateral flexion and rotation the vertebral column, acting as a series of extensible ligaments, adjusting their length to stabilize adjacent vertebrae (interactive spine).

Assessment:

Looking at:

Muscle atrophy
Consistency of muscle fibre i.e.: internal structure.
Contraction: whether it is a) symmetrical

b) at adjacent levels

c) Fatigue levels: gold standard to hold contraction for 15sec x 2

Ultrasound Imaging:

Changes in consistency of the multifidus can be easily observed using ultrasound imaging. The ultrasound appearance of muscle is usually dark because of its high fluid content (blood). The presence of fatty infiltration, fibrous changes or scar tissue (non-contractile tissue) leads to a change in the appearance as non contractile tissue is white in appearance. These changes can be seen at specific vertebral levels and are not difficult for the clinician to detect using ultrasound imaging.
In contrast, measurement of the multifidus cross-sectional area requires extensive training and practice to become proficient. Care should be taken as measurement error may be greater than the changes measured with rehabilitation; therefore not reflecting the actual changes (Richardson et al, 2004).

Clinical Assessment:

Palpation of the muscle at each segment with the patient relaxed in prone position.

(Page 195 - 196: Richardson et al, 2004)

The muscle is palpated adjacent to the spinous process.
Side-to-side comparison is made at each level.
Comparison is made of the segments above and below.
Feel for any loss in muscle consistency at each segment (spongy feeling).

For stabilization and joint protection, it is the activation of the deep multifidus fascicles that need to be particularly tested. They contract isometrically and segmentally. Therefore for assessment an isometric and segmental contraction must be used.

Procedure

(Page:196 Richardson et al, 2004)

Encourage the patient to visualise multifidus as deep triangles running down from every spinous process. Demonstrate a contraction of a muscle e.g.: swelling of the forearm with making a fist.

(A: deep and B: Superficial fibres Lumbar multifidus)

A variety of hand positions can be used to perform the test. Thumbs, index or middles fingers or your thumb and index finger either side of the segment.
It is important to sink your fingers in firmly before asking the patient to contract (swell) their muscles. But it is also important for the clinician to release the pressure as the patient contracts the muscle, otherwise, the compressive force could inhibit the contraction.
Prompts to the patient: ‘gently swell your muscles under my fingers without moving anything else, and breathe normally’…..
Ideally the muscle will harden as it generates tension. There should be a similar contraction between adjacent segmental levels and there should be symmetrical contraction between left and right sides at the same segmental level.
As a gold standard this contraction should be able to be held for 15 seconds and consistently repeated 2 times.
The inability to segmentally activate a symmetrical contraction indicates a loss of control of the deep segmental fibres of Lumbar multifidus (Richardson et al, 2004).

Phasic facilitators: if the patient is struggling to elicit any contraction.

These manoeuvres can be used to demonstrate the muscles action:

Cough

Laugh

Forced expiration

Lift, push or pull against resistance.

However, this type of contraction employs predominately phasic recruitment and is not appropriate for motor control stability re-training!

Optimal facilitation and re-training requires achieving control at an appropriate low load facilitation and feedback.

The prone position is not necessarily the best position to teach or facilitate the activation of lumbar multifidus if it is dysfunctional. It is unloaded and there is no weight-bearing facilitation and so could be considered a motor challenge. For the majority of patients, upright postures, such as sitting or standing, are the positions where it is easiest to facilitate and teach the correct activation of lumbar multifidus.

During active re-training of lumbar multifidus it is also essential to identify and eliminate various substitution strategies and faults.

Substitutions to be avoided

OBSERVATION	IMPLICATION
No palpable contraction	More effort required
Spinal movement	Global substitution
Pelvic movement	Global substitution
Bracing	Global co-contraction rigidity & excess IAP
Pushing back from hips and legs	Global substitution

Clinically, it seems acceptable to feel a definite contraction of the oblique abdominals, transverse abdominis and a sensation of bracing during segmental multifidus facilitation.

Re-training of Multifidus

Re-training must be facilitated in a pain-free posture or position.
The neutral spine posture is an ideal position for this.
The simple process of achieving a neutral spine posture may significantly activate transverse abdominis and lumbar multifidus in some subjects with low back pain.

Specific unloaded facilitation

Tactile feedback

Sit with the spine in neutral alignment. Place fingers / thumbs on the muscles just to the side of the vertebrae and let them sink firmly into the muscle.
Lean slightly forward from the hips (keeping the spine neutral) and feel the muscle tension.
Then lean slightly back from the hips until the trunk is directly over the centre of gravity and the muscles relax.
In this position with the muscle initially relaxed, instruct the patient to locally (or swell) the muscles into the finger and thumb.
Ideally the muscle will harden as it generates tension. There should be a similar contraction between adjacent segmental levels and there should be symmetrical contraction between left and right sides at the same segmental level.
The contraction should be able to be maintained for 10seconds 10 times.

Movement and load facilitators

Contra-lateral arm lift

Start in sitting and progress to standing.
Palpate the dysfunctional multifidus with one hand and lift the opposite arm forward and away from the body. Repetitively lift and lower the arm from neutral to 90º flexion and back to the side. Do not allow the spine or pelvis to move.
The contra-lateral multifidus activates automatically to counter-balance the spinal movement of the arm loading during concentric lifting and eccentric lowering of the arm.
There are 2 points during the repetitive flexion when multifidus activity diminishes (i.e.: when no load to counter-balance). 1) When the arm is hanging by the side and 2) When the movement changes from lifting to lowering.
The motor challenge and therefore the re-training exercise is to sustain the contraction during the points when multifidus activity decreases. Maintained for 10 seconds of repetitive movements 10 times.
To progress also you can make the arm movements faster.

Clinically, this is useful for low back pain associated with upper quadrant loading e.g.: throwing, swimming and racquet sports.

Walk Stance: Forward weight transfer

Stand with one foot in front of the other as in normal gait and with full weight on the rear foot. Palpate the dysfunctional multifidus on the rear foot side and move the body weight forward onto the front foot.
The muscle will activate during forward and lateral weight transfer away from the rear foot because it is load facilitated in preparation to support that side of the pelvis and control pelvic rotation during the swing phase of gait.
Multifidus should activate just after heel lift. If it does not activate until the weight is fully on the front foot the timing is late. Timing may be delayed for several reasons:

1) Pelvic sway

Pelvic sway is a powerful inhibitor of lumbar multifidus and if pelvic sway leads the weight shift multifidus activates late, if at all. Correction is achieved by leading weight transfer with the sternum.

2) Over rotation of the pelvis

Bogduk (1997) suggests the role of the segmental or oblique fibres of multifidus are to counter-act the rotation moment of the oblique abdominals. If, during weight transfer, the pelvis over-rotates away from the front foot then the oblique abdominals are not activating efficiently to control pelvic rotation. Consequently, multifidus also is not activated efficiently. Correction is achieved by controlling pelvic rotation and ensuring that the pelvis faces the direction of weight transfer.

3) Rear foot gluteal inefficiency

The front leg pulls the weight forward instead of the gluteal muscles on the rear leg pushing the body forward. Correction is achieved by conscious activation of the rear foot gluteals to push the body forward.

The motor control challenge and therefore the re-training exercise is to try to sustain the contraction during the points when multifidus activity decreases. Try to maintain active muscle tension during slow transferral of weight back from the front foot to the rear, just prior to heel touch. Sustain contraction while repeating forward and backward movement for 10seconds 10 times.

Clinically useful for low back pain associated with gait e.g.: walking, running.

References:

Bogduk: 1997. Clinical anatomy of the lumbar spine and sacrum. Edinburgh. Churchill Livingstone: 1-261

Richardson, Hodges and Hides: 2004. Theraputic exercise for lumbar stabilization: A motor control approach for the treatment and prevention of low back pain. Churchill Livingstone.

Interactive spine: http://www.owlnet.rice.edu/~kine351/spine_biomechanics.pdf

Lx Anatomy IST

noreply@blogspirit.com (PhysioCharlie) — Fri, 21 Nov 2008 09:54:01 +0100

I did this IST last week:

Lx Anatomy

l 1. How much of the general population suffer from back pain during their lifetime?

• A) Up to 78%

• B) Above 90%

• C) Most people

• D) Up to 50%

• E) Up to 84%

l 2. How many people with back pain go on to develop chronic, disabling LBP?

• A) 20%

• B) 1%

• C) 10%

• D) 5%

Name the structures of a typical lumbar vertebrae

l Spinous

l Transverse processes

l Joints

• facet (zygopophyseal)

• interbody

l Pedicles

l Body

l Lamina

l 3. How many degrees of rotation are available at the lumbar segment?

• A)2 B)3 C)4 D)5

l 4. Which movements make the Lx more vulnerable to injury?

• A) Flexion

• B) Flexion and side flexion

• C) Flexion and rotation

• D) Extension and side flexion

l 5. Name the Lx ligaments

l 6. The nerve root occupies how much of the space in the intervertebral foramen?

• A) 1/3

• B) 1/4

• C) 2/3

• D) 1/2

l 7. The spinal cord extends in the vertebral canal to the level of the….?

• A) L1 vertebrae

• B) T12/L1 disc space

• C) L1/2 disc space

• D) L2 vertebrae

l 84% of the general population suffer from back pain during their lifetime

l 10% will go on to develop chronic disabling LBP

l Most cases (90%) are best described as non-specific low back pain (NSLBP)

l The cost of healthcare for Chronic LBP has been estimated at £1623 million

Structure of a typical lumbar vertebrae

l Spinous

l Transverse processes

l Joints

• facet (zygopophyseal)

• interbody

l Pedicles

l Body

l Lamina

Structure lumbar vertebrae

l Large discs for weight bearing and shock absorbing

l Large Joints that limit movement - rotation is about 1 degree per level in each direction

l Small range of overall movement

l Vulnerable in flexion and rotation

Intervertebral foramen

l Foramen

• formed between pedicles above & below

• the vertebral body and discs in front

• the joint behind

l Contains

• nerve root and sinuvertebral nerve

• blood vessels

• lymphatic vessels

• fat

Ligaments

l Anterior Longitudinal

l Posterior Longitudinal

l Ligamentum Flava

l Interspinous Ligts

l Supraspinous Ligts

l Intertransverse Ligts

l Transforaminal Ligts

l Iliolumbar Ligts

Intervertebral foramen

l Nerve root occupies…

l … 1/3 of the space in the intervertebral foramen

l Contains the dorsal root ganglion

l Stenosis of the foramen can occur through…?

Cauda Equina

l The spinal cord extends in the vertebral canal to the level of…

l … L1/2 disc space

l Below this level the cauda eqiuna is formed

Movements

Flexion

l Movement occurs at the upper lx levels, limited by the joint capsules.

l Range = 40°

Extension

l Limited by impact of spinous processes or inferior articular processes on underlying lamina.

l Range = 30°

Rotation

l Very limited in Lumbar spine

l Tx has approximately 4 ´ the range available in the lx

l 1.5° rotation available in each direction from neutral

l Limited by the joint on the side opposite to that of the direction of rotation

Lateral flexion

l Complex movement that involves rotation as in Cx

l 20 - 30° in each direction

QUIZ Answers

l 1. E) Up to 84%

l 2. C) 10%

l 3. B) 3

l 4. C) Flexion and rotation

l 5. Anterior Longitudinal, Posterior Longitudinal, Ligamentum Flava, Interspinous Ligts, Supraspinous Ligts, Intertransverse Ligts, Transforaminal Ligts, Iliolumbar Ligts

l 6. A) 1/3

l 7. C) L1/2 disc space

The Aim Of The Clinical Ax Is:

l Exclude Red Flags

l Identify any neurological deficit requiring urgent specialist management

l Ax functional limitations caused by the pain

l Ax for Yellow flags – barriers to recovery

l Determine clinical management options

RED FLAGS

• Cauda Equina Syndrome

• History of cancer

• Age of onset < 20 or > 50

• New symptom onset

• Violent trauma, Minor in OP

• Fever (TB, infection – epidural abcess, osteomyelitis etc)

• Recent bacterial infection

• Severe, unremitting night pain

• Thoracic pain (Potts disease-TB, HIV) (Tx aortic anuerysm)

• Systemic steroids

• Drug abuse, HIV

• Systemically unwell

• Weight loss

• Severe restrict. of lumbar flx

• Widespread neurology

• Structural deformity

• Pain worse in supine

Yellow Flags

Yellow Flags indicate psychosocial barriers to recovery:

l Belief that pain and activity are harmful

l ‘Sickness behaviours’ (like extended rest)

l Low or negative moods, social withdrawal

l Treatment that does not fit best practice

l Problems with claim and compensation

l History of back pain, time-off, other claims

l Problems at work, poor job satisfaction

l Heavy work, unsociable hours

l Overprotective family or lack of support

New Zealand Acute LBP guidelines

ACUTE LBP

l Pain that has persisted for 5–11 days

l Explanation, assurance, allay fears, avoid passive therapies. (Koes et al 2001)

l Advice to stay active (Van Tulder et al 2000, Hayden et al 2005).

l Over 70% of patients can expect to become pain-free, with a recurrence rate of less than 25%. (Koes et al 2001)

SUB-ACUTE

l Pain that has persisted for up to 12 weeks

l Evidence of effectiveness of a graded activity exercise program in occupational settings. (Hayden et al 2005).

l An exercise programme led by a physiotherapist in the community and based on cognitive behavioural principles helped patients to cope better with their pain and function better even one year later. (Moffett et al. 1999)

CHRONIC Non Specific LBP (CNSLBP).

l Pain that has persisted for longer than 3 months

l Daily multidisciplinary bio psychosocial rehabilitation ( > 100 hours of therapy) with functional restoration. (Guzman et al. 2001) ? Useful in PC

l Exercise is at least as effective as other conservative treatments. (Hayden et al. 2005)

l A general exercise program reduced disability in short term more than a stabilization exercise approach. (Koumantakis et al. 2005)

l Return to Work programmes, single studies show efficacy (Watson et al., 2004).

CNSLBP

l Recent systematic reviews = small, short-term benefits when compared to no treatment or sham treatment:

• Acupuncture

• Exercise

• Psychological

• Manual therapy

• Electrical stimulation

l No treatment seems to be superior to any other intervention, including usual GP care & none of the cited interventions can be truly said to offer a solution to the problem of CNSLBP. (Wand et al, 2008)

Why Is Current Rx Ineffective in CNSLBP?

Recent evidence suggests changes in the brain:

l Brain degeneration.

l Cortical reorganisation - maladaptive plasticity

l Brain biochemistry change

Wand and O’Connell, 2008

l There is growing evidence that the brains of patients with CNSLBP are different to those of normal subjects, Apkarian et al (2004)

l Patients with CBP showed 5–11% less neocortical gray matter volume than control subjects

l Thalamic atrophy in CBP is important, because it is a major source of nociceptive inputs to the cortex

Brain Function

l Flor et al 1997, evoked magnetic fields in the brain in response to electrical stimulation of the back.

l NSCLBP subjects showed activity in the primary somatosensory cortex (S1) was shifted more medially and the S1 representation of the back was expanded

l Chronic pain = cortical reorganization or “Maladaptive” plasticity ie; Phantom limb pain, tinitus….can be beneficial in the blind or CVA

Brain Biochemistry.

l MR spectroscopy to discriminate subjects with persistent low back pain from control subjects with accuracies of 97%–100% based on regional brain biochemistry. (Siddall et al 2006)

l Major step toward having an objective diagnostic technique in the assessment of persistent pain.

Mx Plan

Training the brain = Influence cortical function

l Sensory discrimination

l Visual feedback - Mirrors - Graded motor imagery

l Sensory motor feedback

l Proprioception

l Exercise needs to be challenging

REFERENCES

Moore et al (2000) A randomized trial of a cognitive-behavioral program for enhancing back pain self care in a primary care setting, Pain 88 (2000) 145±153

Boduck N (2004) Management of chronic low back pain MJA 2004; 180: 79–83

Koes BW, can Tulder M, Ostelo R, et al. (2001) Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine; 26: 2504-2513

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