1. Clinical Reasoning
Lumbosacral Dysfunction
Assessment & Treatment
Alex Wong
Senior Physiotherapist
Queen Elizabeth Hospital
3 January 2009
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2. Contents
 Classification of Lumbo-sacral
Dysfunctions
 Clinical Reasoning Practice
 Case Illustration
 Examination /Treatment Skills
 Take Home Message
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3. Vague Diagnosis of LBP
 80% no structural diagnosis
 Limited evidence to support
classification
 Vague complaints to relate pathology
 Poor understanding biomechanics
 Complicated treatment outcomes
impairment, disability, capability
psychosocial……….
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4. Classification of
Lumbo-sacral Dysfunctions
Purpose
Direct Specific and Effective
Treatments to Homogenous
Sub-group
Ford et al, 2007
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5. Classification of
Lumbo-sacral Dysfunctions
Treatment Based
Specific exercise – extension / flexion
/ lateral shift syndrome
Mobilization – lumbar / sacroiliac
mobilization
Immobilization – immobilization
syndrome
Traction – traction / lateral shift
syndrome
George & Delitto, 2005
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6. Classification of
Lumbo-sacral Dysfunctions
McKenzie Approach
Postural – symptoms after static
position
Dysfunctional – symptoms at end
range
Derangement – symptoms
through range
MeKenzie
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7. Classification of
Lumbo-sacral Dysfunctions
Physical Therapy Reviews 2007
 632 papers retrieved from data base
 77 papers reviewed full document
 55% uni-dimensional
 6% multi-dimensional
Ford et al, 2007
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8. Classification of
Lumbo-sacral Dysfunctions
Physical Therapy Reviews 2007
Classification Dimensions
 Patho-anatomy (47%)
 Signs and Symptoms (58%)
 Psychological (51%)
 Social (14%) Ford et al, 2007
No clear guideline to classify
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9. Clinical Reasoning
Practice
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10. Hypothesis-Oriented Algorithm for
Clinicians II (HOAC II)
Physical Therapy, Vol 83, No.5, 2003
A Guide for Patient Management
 A framework for science-based
clinical practice
 Focus on remediation of functional
deficits
 How changes in impairments
related to these deficits
Rothstein, 2003
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11. Clinical Reasoning Process
Generate Patient Identified and
Non-identified Problem Lists (S/E)
Formulate Exam. Strategy
Conduct Examination and Analyze (O/E)
Generate Working Hypotheses
Intervention
Re-assessment
Rothstein, 2003
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12. Clinical Reasoning Process
Subjective Complaint
(generate the clinical hypothesis)
Examination, O/E
(confirm the clinical hypothesis)
Intervention
(base on the O/E, findings)
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13. Case Illustration
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14. Formulate Problem Lists
(base on clinical presentations)
Case 1 (Housewife, aged 48)
C/O
• right dull LBP down to right lateral calf
• aggravated after prolonged walking
• relieved by short duration of sitting
• standing much worse
• morning pain
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15. Generate Clinical Hypothesis
(base on clinical presentations)
Case 1 (Housewife, aged 48)
Clinical Concerns
• somatic referred symptoms (L4,5)
• regular compression pattern
• decrease lordosis
• worst in static extension
• favourable to movement
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16. Facet Joint / Extension Syndrome
 Common with increasing age
 Facet Joints block excessive
extension, associate with OA
changes (morning stiff)
 Aggravate in prolonged
compression usually
 Regular pattern presentation
 Relieve in stretch pattern
(opposite to lig./mm strain)
 Palpable local joint sign
 Positive finding in local
diagnostic injection
Harris-Hayes, et al, 2005
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17. Conduct Examination, O/E
(base on clinical hypothesis)
Case 1
O/E
• postural defect
• movement quality (L4,5)
• regular movement pattern
• quadrant
• palpation (extension)
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18. Treatment Choice
(base on examination findings)
Case 1
Treatment
• facet joint passive mobilization
• mobilize in extended position (L4,5)
• extension exercises
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19. Formulate Problem Lists
(base on clinical presentations)
Case 2 (Construction site worker, aged 38)
C/O
• minor sprained 2 days ago
• left stabbing LBP down to left lateral ankle
gradually afterwards
• aggravated after prolonged sitting, walking
• relieved by lying only
• moderate morning pain – difficult to bend for
brushing teeth and wearing shoes
• listing pain
• can’t tolerate public transport (bus, mini-bus)
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20. Generate Clinical Hypothesis
(base on clinical presentations)
Case 2 (Construction site worker, aged 38)
Clinical Concerns
• associated with injury
• delayed onset of neurogenic symptoms
• relieved by decreasing disc pressure
• morning symptoms
• restricted neurodynamic movement
• sensitive to vibration irritation
• listing postural defect
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21. Discogenic Back Pain
 Nature of injury (F/Rot)
 Delayed symptoms after injury
 Sensitive to vibration
 Morning symptoms
 Increase symptoms on changing
intra-abdominal pressure
 Restricted mov’t of neuro-tissues
 Lumbar listing (ipsilat. / contralat.)
 Diagnosed by MRI (match with sym)
Peng, et al, 2006
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22. Conduct Examination, O/E
(base on examination strategy)
Case 2 (relieving approach)
O/E
• postural defect (listing)
• movement quality (L4,5), extension
• neurodynamic movement
• neuro assessment
• vibration
• manual traction
• MRI confirmed
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23. Treatment Choice
(base on examination findings)
Case 2
Treatment
• listing correction
• rotation mobilization
• Mckenzie exercises
• extension with listing correction
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24. Formulate Problem Lists
(base on clinical presentations)
Case 3 (3 children housewife, aged 33)
C/O
• minor ankle sprained 7 days ago
• dull pain from right buttock down to thigh
• aggravated after prolonged sitting, stairs
• relieved by walking around
• moderate night pain – difficult to roll in bed
• can’t tolerate cross leg sitting & pulling
activities
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25. Generate Clinical Hypothesis
(base on clinical presentations)
Case 3 (3 children housewife, aged 33)
Clinical Concerns
• associated with injury / child-birth
• symptoms usually not below knee
• aggravated if asymmetrical stress to SI
Joint & pulling activities
• rolling pain in bed at night
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26. Sacral Iliac Joint Syndrome
 Age / Sex
 History of Trauma / child-birth
 Buttock pain / tender over PSIS
 Symptoms likely not below knee
 Symptoms when rolling at night
 Occ cross SLR / Step forward pain
 Muscle imbalance
Priformis, Hamstring, iliopsoas,
Gluteus maximus
 Cluster of tests to confirm
DonTigny, 1990 DeMann, 1997
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27. Conduct Examination, O/E
(base on examination strategy)
Case 3 (aggravating approach)
O/E
• PSIS tender
• anterior / posterior stress tests
• cross SLR
• Long sitting leg length difference
• cluster tests to confirm
• hip rotation tests
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28. Treatment Choice
(base on examination findings)
Case 3
Treatment
• leg traction
• posterior pelvic tilting
• hamstring strengthening
(muscle energy)
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29. Formulate Problem Lists
(base on clinical presentations)
Case 4 (retired policeman, aged 65)
C/O
• gradually onset LBP within one year
• stretching pain down to left lateral calf
• aggravated after prolonged walking
• relieved by sitting
• moderate mid-range pain when bending
forward
• difficult to resume hiking and carry
back-pack
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30. Generate Clinical Hypothesis
(base on clinical presentations)
Case 4 (retired policeman, aged 65)
Clinical Concerns
• clinical / functional instability
• observable kink of spinal curvature
• aggravating with dynamic flexion stress
• variable catching pain during mid-range
• flexion / extension x-ray to confirm
(usually inferior disc problem
67% at L5 level)
Luk, 2003
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31. Lumbar Dynamic Stability
 Decrease the cross section
area of multifidus over the
injured / defect segment
 Clinically ‘catching pain’ in
different range of motion
esp. forward flexion
 Intrinsic muscles minimize
unnecessary rotational stress
over the disc
Hides, 1994; Lee et Al, 2006
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32. Conduct Examination, O/E
(base on examination strategy)
Case 4 (aggravating approach)
O/E
• postural defect (hyperlordosis)
• movement quality (L4,5)
• catching pain during movement
• shearing test
• abdominus weakness & hamstring
tightness
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33. Treatment Choice
(base on examination findings)
Case 4
Treatment
• supine traction  prone traction
• abdominal exercises
• stabilization exercises
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34. Formulate Problem Lists
(base on clinical presentations)
Case 5 (Student, aged 22)
C/O
• back sprain injury half year ago
• stretching pain down to lateral calf gradually
• recent P&Ns over lateral calf
• difficult to wear shock in the morning
• unfavorable to sit sofa
• relieved by walking around
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35. Generate Clinical Hypothesis
(base on clinical presentations)
Case 5 (student, aged 22)
Clinical Concerns
• associated history
• stable neurogenic symptoms
• distal symptoms dominated
• regular stretching pattern
• morning symptoms
• not related to loading stress
• favorable to movement
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36. Neurodynamic Dysfunction
 Relative dynamic mov’t of neuro-
connective tissues deficiency:
- total length insufficiency, adhesion to
sensitive structures, poor excursion /
gliding movements
 Distal symptoms dominated
 Morning severity
 Associated with spine post-op
complication
 Aware latency effect after neurodynamic
treatment
- prefer for stable symptoms Bulter, 1992; Ko et al, 2006
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37. Conduct Examination, O/E
(base on examination strategy)
Case 5 (aggravating approach)
O/E
• stable symptoms
• relative dynamic mov’t of
neuroconnective tissues deficiency:
- total length insufficiency, adhesion to
sensitive structures, poor excursion /
gliding movements
• ULTT, Slump
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38. Treatment Choice
(base on examination findings)
Case 5
Treatment
• hamstring stretching (cadual
/ cephelic direction)
• slump
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39. Formulate Problem Lists
(base on clinical presentations)
Case 6 (Teacher, aged 56)
C/O
• no history of injury
• stretching & squeezing pain over left calf
muscle
• symptoms aggravated after walking ~ 15 min.
• relieved by sitting or squatting ~ 15 min.
• tolerate standing ~ half hr.
• much worse when up & down slop
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40. Generate Clinical Hypothesis
(base on clinical presentations)
Case 6 (Teacher, aged 56)
Clinical Concerns
• dynamic flex / ext problem
• relieved by (static) flexion
• distal symptoms dominated
• not significantly related to loading
• not immediately relieved by standing
• variable in walking distance
• worse in slope walking
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41. Spinal Claudication
Spinal:
 Symptoms aggravated by walking
and change of body positions
 Slow relieve by sitting or squatting
 Worse even in prolonged standing
 Various walking tolerance
 Neuropathy symptoms
 Gelderen Bicycle test
Gray, 1999
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42. Conduct Examination, O/E
(base on examination strategy)
Case 6 (relieving approach)
O/E
• distal symptoms dominated
• fluctuated symptoms
• repeated flex & ext
• step standing extension
• flex with rotation test
• Gelderen Test
• x-ray oblique view
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43. Treatment Choice
(base on examination findings)
Case 6
Treatment
• crook lying traction
• rotation mobilization
• rotation with SLR
• abdominal strengthening
43

44. Reference
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DeMann LE (1997) Sacroiliac Dysfunction in Dancers with Low Back Pain,
Manual Therapy 2(1), 2-10.
DonTigny RY (1990) Anterior Dysfunction of the Sacroiliac Joint as a Major
Factor in the Etiology of the Idiopathic Low Back Pain Syndrome. Physical
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Treatment and Outcomes of a patient with Lumbar Extension Syndrome
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45. Reference
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Lumbar Multifidus Wasting Isilateral to Symptoms in Patients with
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