My Lens Objectives Low Back Pain – What We Know Low Back Pain

4/26/2015
Eclectic Approach to Management of SI
Joint Dysfunction
Arkansas Athletic Trainers’ Association
Annual Meeting & Symposium
Conway, AR
April 25, 2015
My Lens
• Never sought to be a back/SIJ specialist
• Worked clinically treating knees for many years
• Moved into clinical role and now academia that
has forced me to work with clients with LBP
• Took several pieces of people I learned
from/courses attended and assembled them:
– Davies, Sahrmann, Butler, Mulligan, Kegerreis,
McKenzie, Greenman, Hesch, Falsone, Barnes, Cook,
Kiesel
Scott Lawrance, DHS, LAT, ATC, MSPT, CSCS
University of Indianapolis
Objectives
• Attendees will be able to assess pelvic joint
springs to determine alignment and dysfunction
• Attendees will be able to describe and manage
commonly seen patterns of sacroiliac joint
dysfunction and prioritize components of
treatment
• Attendees will understand how the use of an
eclectic manual therapy approach can be used to
treat sacroiliac dysfunction in an active individual
Low Back Pain – What We Know
• LBP is the second most common
cause of disability in US adults
• 149 million days of work per year
are lost because of LBP
• Total estimated costs are between
$100 and $200 billion annually
Low Back Pain – What We Know
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•
•
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30% people have never had LBP
46% have moderate LBP
24% have severe LBP
Incidence peaks in the 30’s and
prevalence increases until 60-65
and then gradually declines
• Risk Factors: job demands, cigarette/tobacco use,
educational status, stress, anxiety, depression
(Frymoyer, JBJS; Hoy, Clin Rheumatol )
What We Think We Know???
• Low back pain will get better regardless of what
we do if you wait long enough
• Biomechanics and anatomy can explain LBP
• Balancing the pelvis is important
– Symmetry in pelvic landmarks
• Core strengthening helps everyone
(Freburger, Arch Intern Med)
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What Evidence Tells Us
• When will my back pain get better?
– 60% of patients with acute LBP return to work within
one month and 90% percent return within three
months (Anderson, Spine)
– At 1-year follow-up, only 21% of individuals with
acute LBP and 12% with chronic LBP were pain free (Von
Korff, Spine)
• 14% (Acute LBP) and 20% (Chronic LBP) had high levels of
disability
What Evidence Tells Us
• Evaluation of pelvic landmarks?
– Motion assessment and static
palpation tests have very poor
reliability for either SIJ pain or
innominate torsions (Cleland, 2011)
• Interrater Kappa = 0.04 to 0.37
• Intrarater Kappa = 0.24 to 0.69
What Evidence Tells Us
• Biomechanics and anatomy = pathology?
– The pathomechanical
model may not
adequately explain LBP
(Savage, Eur Spine J)
• 47% of symptomatic
individuals had no
evidence of abnormality
• 32% of asymptomatic
individuals had
‘abnormal’ MRI’s
What Evidence Tells Us
• Can I strengthen the core and improve my
patient?
– Core stability programs have been shown to increase
strength and function, but no significant difference in
pain (Moon, Ann Rehabil Med)
– Clinical Prediction Rule for stabilization program predicts 50% improvement in disability if patient met
3 of 4: Age < 40, + Positive prone instability test ,
movement dysfunction, SLR < 91° (Hicks, Arch Phys Med Rehabil)
• + LR 4.0
But, Evidence Based Practice isn’t
all about the Literature!
Biopsychosocial Screening
• Not all pain is structural
• Important to screen patient’s lifestyle
• Screening form (Hurley, Clin J Pain) and good clinical
reasoning can help identify these individuals
– The Acute Low Back Pain Screening Questionnaire
correctly classified 74% of patients who received
more than six treatments and 80% of patients who
failed to return to work at the end of treatment
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Evaluation/Rehabilitation
Philosophy
• Start with gross movement assessment and
move to specific segmental movement
• Balance the pelvis to restore normal joint
springs not to correct leg length differences
• Correct/treat as you evaluation, but look for
the boulders in the river
• Be precise with your skills and have a system!
• Empower the patient
Evaluation/Treatment Algorithm
Squat Test
• Athlete stands with feet
shoulder width apart and arms
overhead
• Instruct them to squat and look
to see if they can maintain
upright posture, hip/knee/ankle
alignment and feet flat on the
floor
• Observe for pelvic “shift”
Evaluation/Treatment Algorithm
• Subjective History
– Important to be thorough
– Hallmark sign/symptom: difficulty with sit to stand
after prolonged period of sitting
– “Pain relieved by standing” is only question to
demonstrate diagnostic utility with +LR of 3.5
• Encourage use of self-report questionnaires, such
as the Oswestry Disability Index and the RolandMorris Disability Questionnaire
Evaluation/Treatment Algorithm`
• Gross Spinal Motion Assessment (Cook, 2010)
Note: quality of motion, amount of motion, degree of rotation,
complains of pinching with extension, diminishment or
exaggeration of spinal curves
(Cook, 2010)
Evaluation/Treatment Algorithm
Evaluation/Treatment Algorithm
Resisted Trendelenburg
Leg Length
• Athlete performs single
limb stance with hip flexed
to 90°
• Apply manual force to
thigh into hip extension
• Challenge the lateral
stability movement system
• Structural vs. Functional?
– Looking at pelvic ring for
positional faults
– Must clear the spine to
remove influences of
supine posture
– Have athlete bridge 1-3
times and PASSIVELY
extend legs
– Relative position of medial
malleolus
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Evaluation/Treatment Algorithm
• Assess Lumbar Sideglide
– Spring lumbar spine by
pushing on innominate side
to side and determining if
there is a restriction
– If restricted, treat with halfround roller under
innominate of restricted
side for 3-5 minutes (HEP)
(Hesch, 2011)
Evaluation/Treatment Algorithm
• Once Lumbar Sideglide is corrected or if normal,
then…
• Assess Pelvic Landmarks (ASIS, Pubic Symphysis,
PSIS)
– Most Common Pattern: (Hesch, 2011)
• L posterior pubic bone
• R innominate anterior rotation/inflare
• L innominate outflare
– Second Most Common Pattern: (Hesch, 2011)
• B innominate anterior rotation/inflare
Evaluation/Treatment Algorithm
• Assessment of Joint
Spring (Hesch, 2011)
– Innominate Ant-Post
– Innominate InferiorSuperior on Sacrum
– Sacrum Post-Ant
each side
Evaluation/Treatment Algorithm
Treating SI Joint Shear/Torsion
• Next…
– Treat any present shear first and
then torsion second
• Shear (upslip is most common):
treated with leg pull timed with
valsalva maneuver (Greenman, 2005)
• Torsion (ant rotation is most
common): treat with muscle energy
activation of glute max (Greenman, 2005)
Evaluation/Treatment Algorithm
Treating Pubic Symphysis
• If…
– Pelvic ring asymmetry present
and decreased spring also
present, treat pubic symphysis
first
• If symphysis has an anteriorposterior orientation, use the
pelvic shotgun (Chaitow, 1996)
• If symphysis has a superiorinferior orientation, use hip
adductor muscle energy on high
side (Greenman, 2005)
Evaluation/Treatment Algorithm
• For a patient that presents with an innominate
shear or torsion, treat with low-load, longduration stretches (HEP)
(Hesch, 2011)
Treatment for Left Upslip
Treatment for Right Anterior
Rotation
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Evaluation/Treatment Algorithm
Treating SI Joint Inflare/Outflare
• If an inflare is present and
symptomatic, this is typically
bilateral (Hesch, 2011)
• If the inflare is isolated
unilaterally, be sure to
recheck shears and torsions
as these are rarely
symptomatic
• Outflare commonly seen
with opposite side inflare
(windswept)
Evaluation/Treatment Algorithm
• Reassess/recheck joint springs prior to moving
forward
Treatment for Bilateral Inflare
– Innominate Ant-Post
– Innominate Sup on Sacrum
– Sacrum: Post-Ant
• At this point, pelvic ring should be balanced
– If not, recheck pubic symphysis
Treatment for Left Outflare
Evaluation/Treatment Algorithm
• If patient presents with decreased joint springs,
treat these with low-load, long-duration stretches
(HEP)
Evaluation/Treatment Algorithm
• Now that pelvis tensegrity is restored, check the
lumbar spine
– Common to have L5 segment dysfunction or lower
lumbar (L2-L5) group dysfunction
Treatment for Left Sacral
Rotation
Treatment for Right
Superior Pubic Bone
Evaluation/Treatment Algorithm
• Palpate transverse process of lumbar spine in
three positions (flexion, neutral, extension)
(Greenman, 2005)
Evaluation/Treatment Algorithm
• Group dysfunctions treated with therapeutic
exercises, modalities, manual therapy
• Segmental dysfunctions treated with Muscle
Energy
Note: relative position of the vertebra in each position by judging prominence
of transverse process, motion restriction, tissue texture changes
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Evaluation/Treatment Algorithm
• At this point…
– Pelvic ring is balanced
– Normal joint springs are present
– Lumbar spine is clear of
positional faults
• Look for that comparable sign!
• This is a good time to start a
core stability program…
Evaluation/Treatment Algorithm
Thoracic Spine Evaluation
• Observation/Assessment
– AROM screen
– PROM endfeel
– Quality of spinal curve
– PA mobility (hypomobile vs. hypermobile)
Evaluation/Treatment Algorithm
• At this point, let’s consider
the effects of the ripple
wave…
• Issues in the low back can
cause problems in other
areas and vice versa
• It’s common to have decreased thoracic spine
extension and/or decreased hip mobility in
combination with low back pain
Evaluation/Treatment Algorithm
• Thoracic Spine mobility
– Manual Therapy
• Grade V manipulations – must be trained, check state
practice act!
• PA and rotational glides – grade III/IV mobilizations
• Mulligan rotational MWM’s – great to use for decreased
rotation
– Therapeutic Exercise Series
• Exercise series athletes can be taught to do on their own
Evaluation/Treatment Algorithm
• Thoracic Spine mobility (HEP) (Cook, 2010)
Evaluation/Treatment Algorithm
• Thoracic Spine mobility (HEP)
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Evaluation/Treatment Algorithm
• Now your patient has…
– Pelvic ring balanced
– Normal joint springs
– Clean lumbar spine
– Improving core stability
– Improving thoracic spine mobility
Evaluation/Treatment Algorithm
• Treating decreased hip
extension
– Is this from tight musculature?
– Is this from a tight capsule?
– Is this from altered
arthrokinematics?
• Let’s check out the hip
Evaluation/Treatment Algorithm
• Start with treating capsule/
arthrokinematics (In Clinic
Treatment)
– Anterior joint mobilization (Hesch,
2011)
– Apply force at gluteal fold in
anterior direction
– Beware of pain in the low back! (may
need to flex the hip)
Hip Inferior Glide
• Inferior glide with hip flexed
places stress into posteriorinferior joint capsule
• Helps to increase hip flexion
and rotation
Hip Lateral Glide
• Good general
technique to loosen
capsule and improve
general mobility,
control pain
• Sit backward into hips,
but keep good stance
Hip Posterior Glide
• Increase hip flexion or
internal rotation
• Hip flexed, adducted,
and slightly externally
rotated
• Use hand across table to
apply downward into hip
toward table
Beware of pain in the groin! (may
need to abduct the hip)
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Evaluation/Treatment Algorithm
Hip Mobility Exercises
• Release Hip Flexor
– Find tender spot and hold
pressure for approximately 90
seconds
– Start with lighter pressure and
build as patient tolerates
– Can follow with ART and gentle
passive stretching (HEP)
Evaluation/Treatment Algorithm
• Now our patients have…
– Pelvic ring balanced
– Normal joint springs
– Clean lumbar spine
– Improving core stability
– Improving thoracic spine mobility
– Improving hip mobility
Evaluation/Treatment Algorithm
• Check for trigger points (Travell, 1998) commonly found
in piriformis, gluteus medius, or quadratus
lumborum (particularly with group lumbar spine
dysfunction) and treat as needed
Can work on at
the same time
• At this point, any remaining symptoms likely
coming from hypertonic trunk musculature
Progression through the algorithm
General Rules:
• No impact activity for 24-48 hours and no
unilateral impact activity for 3-5 days if there is SI
joint asymmetry
• Its typical to treat through the early portion of
the algorithm 2-3 times;
– If pattern doesn’t hold and symptoms decrease
significantly after 2-3 treatments - you’re missing
something!
Progression through the algorithm
General Rules:
• Once patient has normal SI joint springs for 2
days in a row, then start the core
activation/lumbar stabilization exercises (HEP)
• Introduce low impact conditioning as symptoms
allow
• Refer to other appropriate healthcare providers
as necessary
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Summary
Don’t Ever Mistake Activity for Achievement!
- John Wooden
• Very few examination or intervention
tests/techniques have good evidence
• Have a system and be precise with your SIJ and
lumbar spine evaluations so you have good
intrarater reliability
• My treatment is based on restoring normal joint
springs/mobility
• Include thoracic spine and hip in your thought
processes and management strategies
References/Suggested Readings
• Frymoyer JW, Pope MH, Clements JH, Wilder JG, MacPherson B, Ashikaga T. Risk
factors in low-back pain. An epidemiological survey. JBJS, 1983, 65 (2): 213-8.
• Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best
Pract Res Clin Rheumatol. 2010 Dec;24(6):769-81.
• Savage RA, Whitehouse GH, Roberts N. The relationship between the magnetic
resonance imaging appearance of the lumbar spine and low back pain, age and
occupation in males. Eur Spine J. 1997;6(2):106-14.
• Andersson GB, Svensson HO, Oden A. The intensity of work recovery in low
back pain. Spine. 1983;8:880–4.
• Von Korff M, Deyo RA, Cherkin D, Barlow W. Back pain in primary care.
Outcomes at 1 year. Spine. 1993;18:855-862.
• Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical
prediction rule for determining which patients with low back pain will respond
to a stabilization exercise program. Arch Phys Med Rehabil. 2005;86:1753-1762.
References/Suggested Readings
• Chaitow L, Liebenson C, Muscle Energy Techniques. Edinburgh, Churchill
Livingstone. 1996.
• Lenehan KL, Fryer G, McLaughlin P. The effect of muscle energy technique on
gross trunk range of motion. J Osteopath Med. 2003;6(1):13-18.
• Wilson E, Payton O, Donegan-Shoaf L, Dec K. Muscle energy technique in
patients with acute low back pain: a pilot clinical trial. J Orthop Sports Phys
Ther. 2003;33:502-512.
• Selkow NM, Grindstaff TL, Cross KM, Pugh K, Hertel J, Saliba S. Short term effect
of muscle energy technique on pain in individuals with non-specific
lumbopelvic pain: a pilot study. J Man Manip Ther 2009; 17(1): 14-18.
• Moon HJ, Choi KH, Kim DH, et al. Effect of lumbar stabilization and dynamic
lumbar strengthening exercises in patients with chronic low back pain. Ann
Rehabil Med. 2013 Feb;37(1):110-7.
References/Suggested Readings
• Freburger JK, Holmes GH, Agans RP, et al. The Rising Prevalence of Chronic Low
Back Pain. Arch Intern Med. 2009;169(3):251-258.
• Moon HJ, Choi KH, Kim DH, et al. Effect of lumbar stabilization and dynamic
lumbar strengthening exercises in patients with chronic low back pain. Ann
Rehabil Med. 2013 Feb;37(1):110-7.
• Greenman PE. Principles of Manual Medicine. (3rd Ed.). Lippincott Williams and
Wilkins:Philadelphia, 2005.
• Hurley DA, Dusoir TE, McDonough SM, Moore AP, Linton SJ, Baxter GD.
Biopsychosocial screening questionnaire for patients with low back pain:
preliminary report of utility in physiotherapy practice in Northern Ireland. Clin J
Pain. 2000 Sep;16(3):214-28.
• May T. Muscle Energy Techniques. Principles of Manual Sports Med. 2004;14:
27-31.
• Cook G. Movement: Functional Movement Systems – Screening, Assessment,
Corrective Strategies. Aptos, CA: On Target Publications; 2010.
References/Suggested Readings
• Hesch J. The HESCH Method of Treating Sacroiliac Joint Dysfunction. 2011.
Available at: www.heschinstitute.com
• Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point
Manual. LWW; 1998.
• Google Images
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Questions?
Thank you for attending!
Scott Lawrance, DHS, ATC, MSPT, CSCS
University of Indianapolis
(317) 788-3248
[email protected]
@SELawrance
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