![Thou shouldst say to [the
patient]: ‘Extend now thy
two legs and contract both
again.’ When he extends
them he contracts them
both immediately because
of the pain he causes in the
vertebra of his spinal
column in which he suffers
van Middendorp (2010) Eur Spine J](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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Clinical tests for the Lumbar Spine
- 1. Clinical Tests for the Lumbar Spine John Doyle Physiotherapy Learning & Development Manager, Nuffield Health Extended Scope Physiotherapist, Frimley Health NHS Trust @JPTDoyle
- 2. Thou shouldst say to [the patient]: ‘Extend now thy two legs and contract both again.’ When he extends them he contracts them both immediately because of the pain he causes in the vertebra of his spinal column in which he suffers van Middendorp (2010) Eur Spine J
- 3. One who has a wrenching strain in the vertebral column of his lower back, this is a medical condition I can treat van Middendorp (2010) Eur Spine J
- 4. Are we any better than the ancient Egyptians at figuring out back pain?
- 5. We definitely know more than the Ancient Egyptians about … Pathology Epidemiology Pain Diagnostic Imaging Statistics
- 6. And we definitely have more clinical tests…
- 7. 162% increase in prevalence between 1992 and 2006
- 8. Days of sick certification 0 1000 2000 1950 1960 1970 1980 Male Female Waddell 1987
- 9. Back pain has always existed Disability has not!
- 10. For most serious pathology clinical tests are of questionable value Subjective questions are more valuable for screening Neurological examination Baseline assessment Onward referral Fairbank et al (2011) Evid Based Spine Care J Henscke et al (2013) Cochrane Database of Systematic Reviews
- 11. Spinal Stenosis
- 13. Study performed in tertiary referral centre Patients quite likely to have spinal stenosis
- 14. Index of suspicion Abnormal Neurological Examination Abnormal Romberg Test Treadmill Test Wide Based Gait
- 15. Index of suspicion Sign +ve LR -ve LR Absent Achilles Reflex 2.8 0.58 Decreased Pin Prick Sensation 2.5 0.90 Decreased Vibration Sense 2.1 0.69 Muscle Weakness 2.1 0.68 Abnormal Romberg Test 4.3 0.67 Earlier Onset Of Symptoms: Flat Treadmill 4.0 0.39 Longer Total Walking Time: Inclined Treadmill 6.3 0.54 Wide Based Gait 14 0.59 De Schepper et al (2013) Spine
- 17. Index of suspicion Pain on Palpation Abnormal Neurological Examination Straight Leg Raise Crossed Straight Leg Raise
- 18. Index of suspicion Sign Sensitivity Specificity Bell Test (palpation) 0.49 0.63 Straight Leg Raise 0.92 0.28 Crossed Straight Leg Raise 0.28 0.90 Van der Windt et al. Cochrane Database of Systematic Reviews 2010
- 20. Possibly the SIJ Maybe the disc Probably not the facet joints
- 21. Compression Sacral Thrust Gaenslen Thigh ThrustDistraction Laslett et al 2005 Manual Therapy
- 22. Index of suspicion Sign +ve LR -ve LR One positive test 1.78 0.00 Two positive tests 2.73 0.10 Three positive tests 4.29 0.80 Four positive tests 3.20 0.49 Five positive tests 2.13 0.84 Laslett et al 2005 Manual Therapy
- 23. Sensitivity Specificity 0.38 0.89 Centralisation of symptoms on repeated movements in the diagnosis of disc pain But….. What if there are no peripheral symptoms??? Hancock et al 2007 Eur Spine J
- 24. Can you differentiate between disc/ facet joint pain? Does it matter?So What?!?! Not just pathoanatomical focus Pain mechanisms approach Understand all contributing factors
- 26. ‘Don’t have any faith really, what I want to find out is what is causing the pain all through my body and I seem to meet a blank wall’ ‘My back was hurting. I tell the doctor what’s up. And he still won’t examine me to see if I’m telling the truth or not you can’t fix a car just by looking at it’ ‘Being believed is the most Important’
- 28. Strength and endurance deficits exist in some patients with low back pain ? Relevance of test position and contraction type? Simple baseline of patients exercise capacity?
- 29. Patients able to perform at least a 60 second hold on Biering-Sorensen endurance test
- 30. Is the best ‘clinical test’ done with a pen?
- 31. Pain Function Distress Return To Work Fear Avoidance
- 32. I’m a Mckenzoid Combined Movement Theory For All!!! We Want Cognitive Functional Therapy!!
- 34. Are we any better than the ancient Egyptians at figuring out back pain? Yes! But only if we take a wider thinking approach to the patient
- 35. Can you differentiate between disc/ facet joint pain? Does it matter? To be better than the ancient Egyptians Think pain mechanisms not just tissues Understand the contributing factors Try to understand the value of tests Use a variety of relevent tests to understand your patients function & disability
- 36. One who has a wrenching strain in the vertebral column of his lower back, this is a medical condition I can treat Treatment: You must lay him stretched out/prostrate and prepare for him... van Middendorp (2010) Eur Spine J
- 37. Can you differentiate between disc/ facet joint pain? Does it matter?Thanks! #Therapyexpo @JPTDoyle
Editor's Notes
- Patient therapist interaction Validating pain
- Patient therapist interaction Validating pain