Lumbar Spine Differential Diagnosis

Jason Zafereo, PT, OCS, FAAOMPTCli i l O th di R h bilit ti Ed tiClinical Orthopedic Rehabilitation Education

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Objectives

Describe the relevant findings from the history and examination indicating the source of symptoms as:examination indicating the source of symptoms as:

– Contractile tissue – Non-contractile tissue

Nerve Spine

Describe the relevant findings from the history andDescribe the relevant findings from the history and examination indicating a primary impairment of:

– StiffnessWeakness– Weakness

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CONTRACTILE TISSUE PATHOLOGY

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Subjective Exam Findings

Chief complaint: LBP Onset (QL): MVA or sustained Onset (QL): MVA or sustained

walking boot use Aggravating: Rolling over in

bed (QL) standing uprightbed (QL), standing upright (Iliopsoas) and walking (QL), coughing - sneezing (QL), sit to stand (ES), stairs (ES)to stand (ES), stairs (ES)

Easing (QL): pressure relief or short term corset use

– Travell and Simons 1992Travell and Simons 1992

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Subjective Exam Findings--Location

Quadratus lumborum Iliopsoas Rectus Abdominus

Travell and Simons 1992, 19835

Subjective Exam Findings--Location

Erector spinae External Oblique

Travell and Simons 1992, 19836

Objective Exam Findings

Test ResponseAlignment Elevated ipsilateral crest (QL); Forward trunk g p ( );

lean (Iliopsoas)ROM/Flexibility Restricted flexibility of involved muscle; Active

and Passive ROM painful in opposite directions; LROM significantly limited sagittal plane and contralateral sidebending (QL); marked limitation of flexion (ES)

M scle Pro ocation Testing Painf l possibl eak (no atroph )Muscle Provocation Testing Painful, possibly weak (no atrophy)Palpation 1) Focal tenderness with concordant sign

reproduction (about 3kg of pressure)2) Twitch response2) Twitch response3) Taut band4) Often referred pain (non dermatomal) on

continued (~5sec) pressure7

NON-CONTRACTILE TISSUE PATHOLOGY

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Nerve

Cauda Equina S dSyndrome

Disc Herniation with R di l thRadiculopathy

Lumbar Spine StenosisStenosis

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Subjective Exam Findings—Cauda Equina Syndrome

Numbness around the buttocks Walking almost causes urination Walking almost causes urination Burning sensation around the buttocks Numbness in the soles of both feet Numbness in both legs Numbness without pain +LRs ≥ 2, p < 0.05p

– Konno et al, BMC Musc Disorders, 2007

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Subjective Exam Findings—HNP with Radiculopathy

Age 15-40O t ith lifti Onset with lifting

Pain aggravated with sitting easedwith sitting, eased with standing/walking

Pain with valsalva, cough, laugh, sit to standstand– Magee 2008

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Subjective Exam Findings—Lumbar Spine Stenosis

No pain or sx improved when sittingsitting

Age>48 years Leg pain>back pain Bilateral symptoms Pain during walking/standing

-LR = 19 +LR = 4 6– -LR = .19, +LR = 4.6 – Pre-test probability = 40%– 4/5 = 76%

5/5 = 99+%– 5/5 = 99+%Katz et al, Arth Rheum, 1995; Cook et

al, 201112

Subjective Exam Findings--Location

L4 L5 S1

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Objective Exam Findings

Test ResponseROM Active and Passive ROM equal and painful in

same direction; Worsening pain with extension, improved with flexion (IVF); Worsening pain with sagittal plane motionsWorsening pain with sagittal plane motions, Centralization/peripheralization with repeated movements (disc)

Special Testing Positive SLR/Slump (disc); Positive Two-p g p ( );Stage Treadmill test (IVF)

Neurological exam Sensation, strength, and reflex may be reduced at key sensory/motor points (All)

Palpation Tenderness over nerve trunks and involved segment

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SLR

Validity (pooled)SLR S iti it 85– SLR Sensitivity = .85, Specificity = .52

– Crossed SLR Sensitivity 29 S ifi it 88= .29, Specificity = .88

Reliability– SLR K = .70

– Rubinstein and van Tulder, Best Pract & Res Clin Rheum, 2008

– van der Windt et al 201015

Two-Stage Treadmill Test

Walking on Treadmill for two 10 minute boutsbouts

One bout flat and one inclined 15° Walking speed 1.0 mph, adjusted to patient

comfortcomfort Test termination at time or high symptom

intensityP iti G t t l f lki i Positive: Greater tolerance for walking in inclined position

SP = 92.3%; SN = 50% for Stenosis Prolonged recovery time and earlier onset of

symptoms after level walking (+LR = 14.5)– Fritz, J Spinal Disord 199716

Joint/Disc

Differential diagnosis is difficultdifficult

– Shared pain referral patterns– Inconsistent lumbar coupling

Key to diagnosis lies with cluster testing based on history imaging and ROMhistory, imaging, and ROM findings

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Subjective Exam Findings--Joint

Age >65P i t d ith Pain not worsened with

– Coughing– Hyperextensionyp– Forward flexion– Extension-rotation

Rising from a chair– Rising from a chair

Pain relieved by recumbency*– 5 of 7 present suggests joint pain (+LR = 2.6-2.8, -LR = .06-

.88) Revel et al, Spine, 1998 Laslett, BMC Musc Dis, 200418

Subjective Exam Findings--Joint

Positive Extension-Rotation testtest

Age ≥ 50 Best when walking Best when walking Best when sitting Pain is paraspinal

– 3 of 5 present suggest relief with ZJ block (+LR 9.7)

– Extension-Rotation test (SN = te s o otat o test (S100%)

– Laslett et al, Spine J, 200619

Subjective Exam Findings—Joint Location

Percent boccurrence by

locationGroin 18%– Groin 18%

– Buttocks 57%– Thigh 72%Thigh 72%– Calf 42%– Foot 39%

Schwartzer et al, Spine 1994 Fukui et al 199720

Subjective Exam Findings--Disc

Pain while rising from sittingsitting

Young et al 2003

Imaging– Degenerative disc on MRI

(-LR = .21) – Imaging suggestive of g g gg

high intensity zone, endplate changes, or degeneration (+LR > 2) Hancock et al 2007

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Subjective Exam Findings—Disc Location

Referral patterns consistent with otherconsistent with other somatic structures (low back and extremity)

Distal extent of pain Distal extent of pain depends on intensity of stimulation

Pain may extend below the knee

– O’Neill et al, Spine 2002

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Objective Exam Findings

Test ResponseROM Active and Passive ROM painful in same

direction; 3-D combined movements most painful (Ext/Rot): Joint; Significant loss of

t i l bilit d i idextension, vulnerability during mid-range flexion/rotation, and centralization yields +LR of 6.7 for disc (Laslett et al. 2006)

Special Tests May have positive dural testing: DiscSpecial Tests May have positive dural testing: DiscPalpation Tenderness over involved jointsAlignment Presence of acute lateral shift or lumbar

kyphosis: Disckyphosis: Disc

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Repeated Movement Testing

Validity– Centralization with repeated– Centralization with repeated

movements consistent with disc as the source of pain (+LR = 2.8-6.7) Hancock et al, Eur Spine J, 2007 Laslett et al, Spine, 2006

Reliability– K =.70-.82 on whether centralization

occurred in a given patient Kilpkoski et al, Spine, 2002 Fritz et al, Arch, Phys Med

Rehabil, 2000– K =.90 on directional preference

Kilpkoski et al, Spine, 200224

PRIMARY STIFFNESS IMPAIRMENT

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Objective Exam Findings

Objective Exam Variable ResponseROM Li it d ROMROM Limited ROMPassive physiological movement Capsular pattern; characteristic

motion loss with firm end feel. Symmetrical loss of hip IR associatedSymmetrical loss of hip IR associated with LBP (Ellison et al 1990). Sagittal plane motion loss associated with DSM category

Passive accessory movement R1 occurs before P1Palpation Tenderness, tightness, and presence

of positional fault (TP/facet rotation)p ( )Flexibility Limited in muscles prone to

hypertonicity26

Lumbar ROM Diagram

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Lumbar Cardinal Plane Patterns

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Reliability of Palpation/Motion Testing

Reliability (pooled)ID f t t (K 53)– ID of osseous structures (K = .53)

– Motion assessment all levels (K = .17)– Pain assessment all levels (K = .42)

Stochkendahl et al, J Manip Phys Ther, 2006

– Most hypomobile segment (K = .71)– Most hypermobile segment (K = .29)

Landel et al, PT 2008

Validity Validity– Poor agreement (K = 0-.04) with MRI

Landel et al, PT 2008 29

Validity of Palpation/Motion Testing

Segmental PA exam findings used to predict response to p pmanipulation or stabilization treatments

– Findings of hypomobility Failure rates were 26% with

manipulation, 74.4% with stabilization

– Findings of hypermobilityg y y Failure rates were 83.3% with

manipulation, 22.2% with stabilization

– Fritz et al Arch Phys Med Rehabil, y ,2005

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Common Motor Patterns

Ventral hyperactive

Dorsal hyperactive musculaturehyperactive

musculature– Hip adductors

musculature– Triceps surae– Hamstrings

– Rectus femoris– TFL– Iliopsoas

– Lumbar erector spinae

– Quadratus Iliopsoas– Oblique

abdominals

lumborum

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Regional Interdependence

Hip ROM cut scores<106d fl i– <106deg flexion

– >6deg extension lag on Thomas test

Unidirectional motion loss occurred 57.5% of time, with 78% DSM agreement78% DSM agreement

Bidirectional motion loss occurred 25% of time, with 70% DSM t t t70% DSM agreement to most limited direction

– Zafereo et al, Arch PM&R, 201532

PRIMARY WEAKNESS IMPAIRMENT

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Subjective Exam Findings

Subjective Exam Variable ResponseMechanism Remote history of trauma; frequent

episodes of acute attacksA ti f t S t i d i ht b i tAggravating factors Sustained weight-bearing posture;

sharp pain with sudden movements; sleeping position dependent on DSM

Easing factors Manipulation; Non-weight bearing; g p ; g g;external support

Associated factors Popping, clicking, locking, catching, giving way of the low back during movementmovement

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Objective Exam Findings

Objective Exam Variable ResponseActive movements Full general mobility with aberrant motion;Active movements Full general mobility with aberrant motion;

hinging, pivoting, fulcruming*. Greater ROM in lying than in sitting/standing

Passive physiological Full with decreased resistance to end range. ass e p ys o og camovement

u t dec eased es sta ce to e d a geLumbar pain with hip ROM testing*.

Passive accessory movement

Increased neutral zone and shear

Special Testing Positive Prone instability test; Positive leg raise tests*; Positive BKFO*

Strength testing Weakness/poor coordination TRA, multifidus, g g pHip extension/abduction (Nadler et al 2001)

Palpation Atrophy of multifidus segmentally; Paraspinal muscle guarding/hypertrophy*35

Defining Aberrant Movement

Altered Lumbopelvic RhythmForward bending: Hip>lumbar in first third; lumbar>hip during last– Forward bending: Hip>lumbar in first third; lumbar>hip during last third

– Extension: Lumbar>hip in first third; hip>lumbar during last third Gower’s sign Gower s sign Deviation from sagittal plane Instability catch, shake, or judder

P i f l f ti Painful arc of motion

Fair to excellent (K=.35-.89) agreement for individual signs Substantial (K=.65) agreement for at least 1 sign Biely et al, 201436

Identification of Radiographic Lumbar Instability

Age <37 years Total extension >26deg Any hypermobility of

the lumbar spinethe lumbar spine Lack of hypomobility of

the lumbar spine* Lumbar flexion

>53deg** +LR = 12 8; LR = 72* +LR = 12.8; -LR = .72

Fritz et al., Eur Spine J 200537

Identification of Radiographic Identification of Radiographic Instability

SpondylolysisO l d– One-legged hyperextension test had low to moderate sensitivity (50% 73%)sensitivity (50%–73%) and low specificity (17%–32%)

Spondylolisthesis Spondylolisthesis– Lumbar SP palpation had

high specificity (87%–100%) d d t t100%) and moderate to high sensitivity (60–88)

Algarni et al, 201538

Identification of Radiographic Lumbar Instability

Passive lumbar extension test– Pain reproduced with lifting legs 30cm from table

with slight traction“Best” diagnostic test for instability– Best diagnostic test for instability

– Validity 84% sensitive and 90% specific for radiographic

instability

– Reliability K= 76 K= .76

Rabin et al, 2013; Kasai et al, 2006; Ferrari et al, 201539

Prone Instability Test

Reliability Ferrari et al, 2015; Rabin et al, 2013; Hicks et al 20032013; Hicks et al., 2003

– K=.67-.80– K=.04 - .87

Validity Hicks et al, 2005; Ferrari et al, 2015– Likelihood of patient responding to

stabilization program +LR = 1.7, -LR = .48

– Fair diagnostic accuracy Spec = 57; Sens = 71 Spec = .57; Sens = .71

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Common Motor Patterns

Dorsal hypoactive musculaturemusculature

– Gluteals

Ventral hypotonic musculature

– Tibialis anterior– Toe extensors– Peronei– Vasti

Rectus abdominus– Rectus abdominus

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Motion Control Testing - Bent Knee Fall Out

Supine hooklying positionE t i l i i t hi– Eccentric lowering into hip abduction/lateral rotation

– Pelvic rotation during first 50% f ti i iti t t50% of motion is positive test

– If symptoms increased, pelvic stabilization should improve

ipain

Reliability– K = .38-.60

Luomajoki et al 2007; White and Thomas 2002; VanDillen 199842

Motion Control Testing – Prone Leg Raise

Hip and back extensorsP iti P ill d d– Position: Prone, pillow as needed

– Test: Lift leg 8-10” off table– Assess: Neutral spine and firing

pattern Transverse abdominus Ipsilateral Glut/hamstring

C t l t l ltifid Contralateral multifidus Ipsilateral multifidus Contralateral Erector spinae Ipsilateral erector spinaeIpsilateral erector spinae

– Sahrmann 2002– Oh et al, JOSPT 200743

Motion Control Testing – Prone Leg Raise

Reliability of hip extension testextension test

– K = .72-.76 for agreement on deviation in frontal, t itt ltransverse, or sagittal plane Murphy et al 2006

Gluteus maximus time to contraction significantly reduced by pelvic y pcompression

– Takasaki et al 200844

Strength Testing-Hip Extensors

Static double leg b id ibridging– Reliability

ICC= 84 ICC=.84

– Expected holds Patients with LBP =

76.7secs Patients without

LBP=172.9secs (after 2 mins, unilateral)

– Schellenberg et al, Am J Phys Med Rehabil 200745

Motion Control Testing – Sidelying Leg Raise

Gluteus medius/minimusP iti Sid l i ith b th– Position: Sidelying with both legs fully extended, neutral hip, relaxed ankle, top arm off the tableoff the table

– Test: Frontal plane hip ABD smooth and easyS b tit ti U t ll d– Substitutions: Uncontrolled and rapid, Flexion/IR of hip, and forward rolling of pelvis, trunk shouldertrunk, shoulder

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Motion Control Testing – Sidelying Leg Raise

Interrater Reliability– Reported as poor to

acceptable Rabin et al, JOSPT 2013; ab et a , JOS 0 3;

Davis et al, JOSPT 2011

Validity– +LR 2.68-4.59 in

discriminating development of LBP in pasymptomatic population Nelson-Wong et al, JOSPT

2009 and Clin Biomech 200847

Multifidus Dysfunction

Identified with palpation of segmental atrophy

However, post-treatment multifidus muscle thicknessof segmental atrophy

and limitations on Supine ASLR test

Significant relationship

multifidus muscle thickness not predictive of response to stabilization program

– Zielinski et al, 2013 Significant relationship between % multifidus activation and number of factors present for

,

pstabilization CPR

– Hebert et al, Arch Phys Med Rehabil, 20102010

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Strength Testing-Trunk Extensors

Prone double SLR highly correlated with developmentcorrelated with development and persistence of LBP

– Males <30secs– Females<29secs

Prone chest raise cut scoresMales >31secs– Males >31secs

– Females >33secs

Reliability (ICC=.90)

– Arab et al, Clin Rehabil 2007

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Motion Control Testing – Supine Leg Raise

ProcedureSt bili t 40 H

Successful completion of this test not an indication of– Stabilizer to 40mmHg

– Drawing in with relaxed normal breathing

this test not an indication of high TRA activation on US imaging

Grooms et al 2013 Test

– Maintain pressure at 40-43mmHg with the

– Grooms et al, 2013

gfollowing movements Heel slide 3 inch march SLR (8-10”)

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Strength Testing - Transverse Abdominus

ProcedureSt bili t 70 H

Reliability (ICC=.58) Costa et al Physiother Res– Stabilizer to 70mmHg

– Inferior edge at level of ASISs

– Costa et al, Physiother Res Int 2006

ValidityP t lidit ith– Drawing in with relaxed

normal breathing– 10sec x 10 reps

– Poor concurrent validity with superficial EMG in CLBP Limpa et al, 2012

Test results– Normal = 4 mmHg

pressure reductionpressure reduction– Increased incidence of

LBP=2mmHg reduction51

Strength Testing – Trunk Flexors

Double leg loweringG t lik lih d f CLBP if– Greater likelihood of CLBP if anterior pelvic tilt above 50deg hip flexion in males

60d hi fl i i f l 60deg hip flexion in females– Youdas et al, PT 2000

Prone planking– Expected holds

Patients with LBP = 28.3secs Patients without

LBP=72.5secs– Schellenberg et al, Am J Phys Med

Rehabil 200752

Summary of Stabilization Findings

Examples of Motion Control Testing

3/6 positive findings used as criteria for prescribingControl Testing

– Lumbopelvic rhythm– Pattern of motion lumbar

as criteria for prescribing stabilization program

Significant improvements sidebending/rotation toward paraspinal bulk

– Passive Hip ROM

g pin pre-post testing, pain, disability

Luomajoki et al 2010– Active leg raises (sagittal)– Active leg raise (frontal)– Bent knee fall out

– Luomajoki et al 2010

Bent knee fall out

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