Mechanical LBP &

The Frequent Flyer

NIKKI BRADLEY, PT, MPT, OCS, CERT MDT

Objectives

Participants will be able to:

Identify mechanical low back pain

Use Mechanical Diagnosis & Therapy (MDT) classification system to

subgroup LBP and subsequently guide treatment

Differentiate between a lateral shift and a relevant lateral component

Treat a lateral component using MDT principles

Understand common practice errors in mechanical therapy

Discuss clinical decision making in mechanical therapy as applied to

patient cases

Case 1-

Larry

Referring Dx:

L Hip pain

History:

55 y.o. male

Constant L buttock pain

No Numbness/ tingling.

Typically has ~ 5 episodes a year of back pain. Sees chiropractor.

Current symptoms began 1 month ago after 3-day road trip

Aggravating factors: Sitting, standing, rising from chair, walking, lying down

Relieving factors: Oxycodone

Current Baselines:

6/10 L buttock pain

Concordant sign: Increased pain with rising from chair

Neuro Screen (-)

Hip tests (-)

Case 1-

Larry

Current Baseline:

6/10 L buttock pain

Concordant sign:

Increased pain with

rising from chair

Provisional classification:

Derangement

Directional Preference-

Extension

Mechanical Exam:

Repeated Extension in Lying (REIL, or press ups): Increases buttock pain during// better after

Improved ROM Extension, Improved concordant sign

Visit 1 Issue HEP: REIL (press ups) 10 reps every 2-3 hours.

Education on self –monitoring symptoms, precautions (when to stop), posture.

Visit 2: Pt reports pain peripheralized to thigh. Pt worse; stopped HEP after 2nd day.

Worse with Extension. Now what??

Case 2-

Lisa

Referring dx:

Hamstring Strain

History:

27 y.o. female

Intermittent R posterior thigh pain above knee. Denies LBP. No Numbness/ tingling.

Began 4 months ago when increasing running

distance, adding hills

Currently not running due to pain

Aggravating factors: Driving, Running, Sitting

Relieving factors: StandingCurrent Baselines:

0/10 R thigh pain

Concordant sign: Pain with driving > 20 min

Neuro Screen (-)

Resisted Hamstring testing: Strong Painfree

Palpation: (-)

Case 2-

Lisa

Mechanical Exam:

Repeated Flexion in Stand: Produced thigh// worse

Repeated Extension in Lying (REIL, or “press ups”): Decreased thigh// No better

Visit 1 Issue HEP:

REIL (press ups) 10 reps every 2-3 hours

Visit 2: Pt reports symptoms/ function are SAME.

Pt unchanged with Extension. Now what??

Current Baseline:

0/10 R thigh pain currently

Provisional Classification:

Derangement

Directional Preference-

Extension

Do not accurately

describe the

frequent flyer

Do not help guide

treatment

“Acute”

“Chronic”

The “Frequent Flyer” =

Recurrent episodic

The Difficulty with

Common LBP

Assessment/

Treatment

Pathoanatomic diagnosis does not explain the behavior of the pain

Known lack of correlation between imaging findings and severity of pain

Tousignant-Laflamme Y, Longtin C, Brismée JM. How radiological findings can help or

hinder patients' recovery in the rehabilitation management of patients with low back

pain: what can clinicians do?. J Man Manip Ther. 2017;25(2):63–65.

Imaging findings in Asymptomatic

Patients

Caution when interpreting the

clinical significance of imaging

findings

We cannot rely on imaging to

guide treatment

Pathoanatomic model is not a

reliable guide for developing

effective treatment plan

Brinjikji W. Systematic literature review of imaging features of spinal

degeneration in asymptomatic populations. AJNR Am J Neuroradiol

2015 Apr;36(4);811-6

Mechanical Treatment: Evidence for

Reliability & Treatment Efficacy

97% of all back pain is Mechanical

Subgrouping is the key to successful management

Review evaluated 22 systems that classify populations with low back-related leg pain. Mechanical Diagnosis and Therapy (MDT) scored the highest of any system, with criteria based upon purpose, validity, feasibility, reliability and generalizability.

It was recommended that clinicians should use specific repeated movements to promote centralization in patients with acute, subacute or chronic low back pain, with the recommendation based on Grade A, ‘strong evidence’.

Long et al- Establishing directional preference (DP) and matching specific exercises based upon these findings resulted superior outcomes in the matched group including pain, function and medication use.

Stynes S, et al. Classification of patients with

LB-related leg pain: a systematic review. BMC

MSK Disorders 17:226. 2016

May S, Alessandro A. Centralisation and

directional preference: a systematic review.

Manual Therapy 17. 2012

Long A, et al. Does it matter which

exercise? A RCT of exercises for

LBP. Spine. 29:2593-2602. 2004

Chien JJ. Bajwa ZH What is mechanical back

pain and how best to treat it? Curr Pain

Headache Rep 2008 Dec;12(6) 406-11.

Nociceptors transmit 3 types of pain

CHEMICAL

Inflammatory process following

trauma, injury

Inflammatory or infective disease

MECHANICAL

Structures are compressed,

deformed, pulled taut

THERMAL

Relay hot/ cold

sensations

Americanpainsociety.org

Dubin AE, Patapoutian A.

Nociceptors: the sensors of the

pain pathway. J Clin Invest. 2010;120(11):3760–3772.

What structures in the spine are innervated?

Potential sources of pain-

Intervertebral disc (outer annulus)

Facet capsules

Interspinous ligament

Longitudinal ligament

Vertebral Bodies

Dura mater

Nerve root sleeve

Nerve connective tissues

Blood vessels

Local muscles

Cannot selectively stress

individual structure with

clinical tests

Kuslich et al found the predominant

source of back pain to be the disc,

and the source of sciatica to be

compressed nerve roots. (provocative

testing under conscious sedation)

Bogduk 1993, 1994, Kuslich et al 1991, Rankine et al 1998, Schwarzer et al 1994, 1995

Differentiating Mechanisms of Pain

CHEMICAL PAIN

Inflammatory process

Constant

Recent onset (injury or insidious)

Typical signs may include redness, heat, swelling, tenderness

Relative easing factors: rest, NSAID

All movements lastingly aggravate pain

No movement/ position can be found to abolish pain

MECHANICAL PAIN

Typically intermittent

Can be constant

Symptoms are affected by movement, posture, body position

Often variable function day to day

Loss of ROM correlates with symptoms

Better with movement in one direction

Worse with movement in opposite direction

→ Activity modification, NSAID’s, Medical Rx → Movement, Posture ed, Exercise

What is MDT?

Mechanical Diagnosis & Therapy

Classification system

Evidence based assessment and treatment

Seeks to differentiate between mechanical and non-mechanical sources of

pain and functional limitation

Mechanical changes are assessed using repeated end range movements and

sustained positions

Guides clinician to required management strategy

What MDT is not:

Not reliant on a pathoanatomical diagnosis

Not a cookbook approach

Treatment value lies in individualized assessment- using an algorithm to

determine a pattern, guide treatment and predict prognosis

Not just exercise

Includes Manual Therapy where indicated

Includes posture advice and lifestyle changes

Not just Extension

Other loading strategies include Lateral forces, Flexion, Contractile

forces (Extremities)

Mechanical Diagnosis & Therapy

Focus:

Patient education

Self directed treatments

Reduce dependency on Clinician

Empower the patient to control his/ her symptoms

Exercise + Lifestyle Modifications (posture; movement competency)

Manual techniques??

When self generated treatment is not successful, the use of manual techniques is considered

Hands on techniques are used to enable patient to return to self treatment

Mechanical Classification

Derangement

Specific Presentation

Specific Treatment

Dysfunction

Specific Presentation

Specific Treatment

Posture

Specific Presentation

Specific Treatment

Classification:

Derangement

Internal derangement causing

anatomical disturbance in the normal

resting position of the joint

Obstruction of movement due to

internal displacement of articular tissue

Treatment: Loading strategies to reduce, abolish, centralize symptoms

and normalize mechanics (ROM)

Expected time: Improvement in

baselines immediately/ within hours

Classification:

Dysfunction

Structurally impaired soft tissues

Contraction, scarring, adherence,

adaptive shortening

Pain is caused by mechanical

deformation of these structurally

impaired tissues

Trauma, inflammatory, degenerative

process

Pain will persist until remodeling has

occurred

Treatment: Repeatedly stress the tissue

Expected time: Several weeks for

remodeling to occur

Classification:

Posture

Mechanical deformation of soft tissues

or vascular insufficiency

Prolonged positional stress affecting

articular structures, contractile structure,

joint capsule/ ligament

NO loss of ROM

Treatment: Posture training

Expected time: within minutes, correction of posture abolishes

symptoms

Centralization

In response to therapeutic loading strategies pain is progressively abolished in a distal to proximal direction, with each progressive abolishing being retained over time until all symptoms are abolished and remain better

If back pain only is present this moves from a widespread to a more central location and then is abolished

Centralization refers to PAIN

Centralization requires Directional Preference

Directional Preference does not require symptoms - can use other baselines in the absence of symptoms

Peripheralization= Pain emanating from the spine spreads distally into or further into the limb as a result of loading strategies - and remains worse- Lasting change.

Copyright to McKenzie Global Holdings Limited (MGHL)

Centralization & Prognosis

Predicting Outcomes

The McKenzie Method also has a proven ability to predict patient outcomes

through classification and the determination of Centralization or Directional

Preference.

If a patient with spinal pain is classified as a Derangement and can centralize

their symptoms in a short time after initiating MDT, the prognosis for a rapid and

lasting improvement is very good.

Werneke M, Hart DL. Centralization phenomenon as a prognostic factor for chronic LBP and disability. Spine. 26;7:758-65. 2001

Skytte L, et al. Centralization: Its prognostic value in patients with referred symptoms and sciatica. Spine. 30;11:E293-9. 2005

Werneke M, et al. Association Between Directional Preference and Centralization in Patients with Low Back Pain. J. Ortho. Sports Phys. 41:22-31. 2014

Heidar Abady A, et al. Application of the McKenzie system of Mechanical Diagnosis and Therapy (MDT) in patients with shoulder pain; a prospective longitudinal study. J Man Manip Ther 25:5:235-243. 2017

Mechanical Classification

Used with permission- Copyright to McKenzie Global Holdings Limited (MGHL)

4 Phases of Treatment - Derangement

1. REDUCE

DERANGEMENT

2. MAINTAIN

REDUCTION

3. RECOVER

FUNCTION

4. PREVENTION

Derangement:

Clinical

presentation

History:

Symptom variability; Inconsistent Pattern

•“Some days I can bend over and other days I cannot”

Known Aggravating & Relieving Factors

Symptoms change with Movement & Position

Constant or Intermittent Pain

+/- symptoms into LE

Often recurrences of pain over time with worsening disability

Derangement:

Clinical

Presentation

Exam:

Loss of movement

• ROM limited by Obstruction

• and/or ROM limited by Pain

Pain during movement

Deviation with movement

Repeated movements: Symptoms can be made better or worse. Mechanics change concomitantly.

Dysfunction:

Clinical

Presentation

History:

Chronic, without specific incident

Symptoms are always local

(-) LE symptoms -No radiculopathy

Symptoms are always intermittent

• Produced when tight structures are loaded

Consistent pattern to pain

• “Every time I reach, I feel it”

Dysfunction:

Clinical

Presentation

Exam:

Loss of mobility and/ OR pain with ROM exam

Pain is at ENDRANGE

No peripheralization

Repeated movements:

• Symptoms will be Produced// No worse (in the restricted plane)

Posture:Clinical

Presentation

Intermittent pain brought on by prolonged static loading of normal tissues

No pathological changes

Pain is always local

Typically provoked with poor sitting posture & abolished with change of position

No loss of movement

Repeated movements: No Effect

MECHANICAL EXAM1. Identify Clear Baselines

MECHANICAL

ROM

LIMITED DUE TO PAIN OR STIFFNESS?

SYMPTOMATIC

CONSTANT OR INTERMITTENT?

INTENSITY

LOCATION

BE SPECIFIC

IDENTIFY MOST DISTAL SYMPTOM

FUNCTIONAL

CONCORDANT SIGN

WHAT IS IMPORTANT TO THE PATIENT?

RISE FROM CHAIR

GAIT

TIE SHOES

NEUROLOGICAL

MYOTOMES

DERMATOMES

REFLEXES

NEUROTENSION

2. Repeated Movements

KEY TO MECHANICAL

EXAM IS REPEATED

MOVEMENTS→

NEEDED FOR SUBGROUPING

WHY REPEATED MOVEMENTS?

DO ENOUGH TO EXPOSE A

DIRECTIONAL PREFERENCE

PARADOXICAL RESPONSE TO MOVEMENT IS

COMMON

INITIALLY DIRECTION

THAT IS MOST PAINFUL IS THE THERAPEUTIC MOVEMENT

BUILT IN SAFETY MECHANISM

Why Repeated

Movements?

Single movement testing can be misleading

and result in misinterpretation of Directional

Preference

One rep may relieve the pain temporarily

With repetition: Worse as progressive obstruction occurs

Flexion

Initially obstructed and painful

With repetition: Better as reduction occurs

Extension

Mechanical

Baselines

Deviation?

Willingness to move?

What limits movement: Pain or Stiffness?

Pain DURING movement? → indicates Derangement

Pain at ENDRANGE of movement?

If symptoms are unchanged → PT adds Overpressure

Note Side GLIDE (not lateral flexion)

MDT Repeated Movement Exam

Assessment: Loading Response

Peripheralized, Worse →

Change Position/ Load

Change Direction

Centralized, Better →

Continue

Increase// No worse

Decreased// No better →

More repetitions (test over a few days)

Progress Forces

Consider lateral

DURING

Increase

Decrease

Produce

Abolish

Centralizing

Peripheralizing

No effect

AFTER

Worse

No Worse

Better

No Better

Centralized

Peripheralized

No Effect

Force Progression

Concept of force progression in MDT:

Patient Applied forces → → → progressing to Therapist applied forces

Ensures Safety: tissue response is monitored at progressive levels of force

Empowers the patient (Use the least amount of force necessary)

When to progress forces?

Pt is improved, but not completely

Plateau in progress over a few days

Inconclusive response “Yellow light”

Increase/ No better - OR - Decrease// No worse

Midrange End rangeEnd range + self OP

End range + PT OP

Mobilization Manipulation

Role of Overpressure

Press Up

Painful

Press up with OP

Decreases pain= Derangement

Repeated movement with overpressure (OP)

can help confirm classification

Lateral Shift

vs.

Lateral

Component?

Lateral Shift vs.

Relevant Lateral Component

Lateral Shift

Postural Deformity

Obvious

Exists when vertebra above has laterally flexed in the relation to vertebra below, carrying the trunk with it

Often Kyphotic deformity also present

Contralateral or Ipsilateral

Named by shoulders

Lateral Component

Not a deformity

Not seen in standing observation

Will be exposed during movement exam

Exposed/ Confirmed with a failure to

respond to Extension

Repeated or Sustained Extension: Worse

Lateral Shift Deformity

UnmistakableOnset of shift

occurred with pain Patient can’t

correct voluntarily

Pt can’t maintain correction

Correction affects intensity of symptoms

Correction causes centralization or

worsening of peripheral symptoms

Relevant Lateral Component

Not visible Unilateral/

Asymmetrical Symptoms

Worse with Sitting

&

Worse with Standing

Loss of Frontal plane ROM

SideGLIDE

Sagittal plane movements:

No improvement OR Worse

Improvement with lateral movements

Lateral Shift Deformity: Treatment

Lateral Shift Correction at wall

PT Manual shift correction

Lumbar Rotation in Flexion

Work toward being able to return

to self-generated correction at

wall, then restore sagittal

If unable

If unable

Lateral Component - Treatment

Lateral component often reduces

with sagittal plane

Exhaust Sagittal plane first before

Frontal plane movements:

Progression of Forces

Sustained Extension

Procedure Overview

Extension Principle

+ Progression of Force as needed

Extension Principle + lateral component

+ Progression of Force as needed

Lateral Principle

Lumbar Flex Rotation

Goal is always to return to sagittal plane

Indication

for Lateral

Procedures

Asymmetrical Symptoms

Flexion and Extension BOTH aggravate symptoms

Loss of Side Glide ROM

Sagittal plane: Peripheralized, Worse, or Unchanged

Plateau with sagittal plane

Continue to get Increase// No worse or Decrease// No Better response with Extension progression of forces

Extension Principle

Legs wide

Glutes/ Trunk extensors relaxed

Achieve End range

Progression of Forces

IF Increase// No worse OR Decrease// No better

Extension in Lying with self Overpressure -

Lock elbow/ Exhale/ sag hips

Belt Fixation

Extension in Lying with PT Overpressure

Extension mobilization

Extension manipulation

Force Alternative: Sustained Extension

Load Alternative: Extension in standing

Extension Principle with lateral

component

Progression of Forces

Extension in lying with hips off center

Extension in lying with hips off center with PT Over Pressure

Sagittal plane overpressure

Frontal plane overpressure

Extension mobilization with hips off center

Rotation mobilization in extension

Rotation manipulation in extension

Lateral Procedures: Side Glide in Stand

Correct performance

- Shoulder stays against wall

- Elbow at ribs

- Feet together

- Pelvis should not touch the wall

- Watch for transverse plane compensation

- Watch posture in sagittal plane

- Achieve End range

- Maintain progressive improvements in range

Lateral Principle

Use for

1. Lateral shift deformity - to correct the shift

2. Derangement that worsens with Extension

3. Derangement that is unchanged with Extension over 1-3 day trial (with

Progression of Forces)

Common

Pitfalls:

Unclear Baselines

Clearly identify starting point

Symptoms: Specific location, Intensity

Mechanics (ROM)

Concordant Functional Sign

Neuro signs

Repeat initial baselines back to patient

“Remember how that feels. We’ll be

rechecking that movement to monitor for

change throughout the exam”

Consider using white board to involve patient

in exam findings

Common

Pitfalls

Unclear Classification

Derangement vs Dysfunction vs Posture

Classifications have differing treatment

strategies; Differing expectations

Day 1: Make a Provisional Classification

and Directional Preference

Day 1 hypothesis will be proven/ unproven

over next few days

You can’t treat what you don’t understand

Common

Pitfalls

Fear of making patient worse

If unclear response, consider provocative testing

Don’t be afraid to move them

Confirm Classification + Directional preference- mechanical clinician’s #1 goal

If you suspect posterior derangement but unable to confirm, use repeated flexion for 1-2 days. IF worse, now you know what you have and can effectively treat.

Most challenging scenario is pt coming back the same (yellow light)

Common

Pitfalls

Failure to Exhaust Sagittal plane

Abandoning Extension too quickly

Follow Progression of Forces

Consider Force alternatives (sustained)

When to progress forces?

Increase pain// No worse

Decreased pain// No better

“Yellow light” → Progress forces

Common

Pitfalls

Failure to Achieve Endrange

“Further, further, further”

Achieving end range too soon

Significant derangement may need time

to work through reduction

Not enough repetitions

“Give it heaps”

Lateral shifts often need several repetitions

consistently repeated over time

Common

Pitfalls

Wrong load

Standing vs Lying vs Sitting

Extension responders often need unloaded

(prone)

Ex: may respond poorly to Extension in

Stand but reduce with Extension in Lying

More likely to achieve end range in lying

position

Lateral responders often need loaded

position (standing)

Produce// No worse OR Decrease// NO

better? Consider Load modification

Common

Pitfalls

Failure to identify a lateral component

Presentation of Lateral component:

Extension increases, peripheralizes, and

worsens symptoms

OR

Plateau over several days with Extension

Mechanics not changing

Symptoms not further improving

Common

Pitfalls

Choose 1 Direction

Don’t add other exercises before

confirming Classification & Directional Preference→

Confounds the mechanical response

Limit other variables initially until

mechanical response is clear

This includes pt’s daily activities

Goal is to empower the patient to

ultimately self manage

Common

Pitfalls

Unclear Instructions to patient

4 Phases of Treatment

Self monitoring baselines

Often stiffness precedes an episode of

pain

Manage stiffness to prevent development

of pain

Perform reductive exercise as first aid

when symptoms first arise

Perform reductive exercise before/ after

potential aggravating activity

“Use your reductive exercise as you would

a pain pill.”

Common

Pitfalls

Insufficient frequency of HEP

Frequency of HEP is necessary to understand mechanical response

Every 2-3 hours and additionally upon onset of symptoms

“If you only do these 1x a day, it likely will not be enough to understand the pattern of how your pain behaves.”

Just like a pain pill, Need correct medication & correct dosage

Frequency of HEP is necessary to achieve and maintain reduction

Necessary frequency per day may vary based on daily activity and symptoms

How much sitting, standing, bending did you do today?

Common

Pitfalls

Failure to Avoid Aggravating factors

Is pt compliant with HEP but continuing to

slouch, bend poorly?

Clinician failure to help patient make

connection between Movement

competency → Symptoms

“I did my exercises and I’m no better…

I also spread 90 loads of mulch this

weekend.”

Case 1- Larry

Derangement? Yes

Lateral component?

Asymmetrical symptoms

Loss of Left Side Glide

Peripheralized & Worse with Extension

Visit 2:

Check HEP compliance [Satisfactory]

Check HEP form [Correct]

Review pt’s other activities--

Overuse of flexed postures? [No]

Case 1- Larry

Baselines: 6/10 L buttock & lateral

thigh pain

Concordant sign:

Increased pain with rising

from chair

Visit 2

Lateral procedures:

Repeated Extension in Lying with hips offset to R:

Increase thigh pain// Worse

Repeated L Side Glide at wall: Decreased

thigh// better. Improved L Sideglide ROM.

Improved Extension ROM.

Case 1- Larry

Baselines: 2/10 L buttock pain

Concordant sign:

Increased pain with rising

from chair

Visit 3:

Pt returns better.

L Sideglide ROM: Now painfree and full

Repeated Extension in Lying: Decreased buttock// Better. Improved

Extension ROM. Improved concordant

sign.

Transition back to sagittal plane:

HEP:

REIL 10x, every 2-3 hours + Additionally

as needed to manage inc in symptoms.

Posture correction

Case 1- Larry

Classification:

Derangement

Relevant Lateral

component

Restored Frontal Plane

Progressed back to

sagittal plane

Visits 4-5:

Maintain reduction of Derangement (posture + frequent HEP)

After 2 weeks of consecutive days without symptoms→ Recover Function

Core stabilization in Neutral Spine

Visit 6: Teach Prophylaxis program→

Extension program 2x a day

Lumbar roll with sitting

Frequent change of position

Self monitor baselines

Increase frequency of HEP PRN for

episodic symptoms

Case 2- Lisa

Current Baselines: 0/10 R posterior thigh pain

Concordant sign: Pain

prod with driving >20 min

Visit 2

Progression of Forces:

Repeated Extension in Lying with self OP:

No effect

Repeated Extension in Lying with PT OP:

Produced thigh// No worse

Extension mobilization: Produced thigh// Better.

Restored Flexion without pain

REIL with self OP: No Effect- maintained

improved baselines

Case 2- Lisa

Current Baselines: 0/10 R posterior thigh

pain

Concordant sign:

Resolved. No pain with

driving.

Visit 3

Pt returns better.

Continue with current HEP: REIL with self OP

every 3-4 hours

Maintain reduction of derangement

Reiterate sitting posture with lumbar roll

Limit frequency of flexion

Reinforce hip hinge training

Case 2- Lisa

Classification:

Derangement

Directional Preference:

Extension

Needed Progression of Forces

Needed therapist manual

techniques to improve

effectiveness of self treatment

Needed to utilize mechanical

baselines as symptoms not present at eval

Visits 4:

Recover Function

Return to running program

Visit 5: Teach prophylaxis program→

Extension program 2x a day

Lumbar roll with sitting & driving

Frequent change of position

Self monitor baselines

Increase frequency of HEP PRN for

episodic symptoms

HEP Prior/ After potentially aggravating

activity (running)

When Extension

doesn’t work…

Do you know what you have?

[Classification]

Have you progressed forces?

Have you tried going lateral?

Have you addressed & reinforced

lifestyle factors?

Posture, Movement competency,

Frequency of flexion

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Re-current Low Back Pain: It’s Not a Low Back Problem

Matthew VanderKooi PT, MS, OCS, COMT, FAAOMPT, FAFS

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Is the Best Provider Managing Care? Musculoskeletal education is lacking in medical Schools

It is NOT improving!

Average test scores remain at 51%.The only sub-group close to a passing grade of 70% were students taking an elective

musculoskeletal course (average score = 67.5%).(J Bone Joint Surg Am 2012 Oct 3; 94(19):e146(1-7).)

Choice of providers matters!Timing of interventions matters!How movement is managed matters!

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Risk is Driven by Imbalance

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Dynamic Systems Theory

movement patterns emerge from the interplay of the constraints between and within the elements of the system.

A dynamic system is composed of multiple interacting components

The movement is either efficient and sustainable, or inefficient and unsustainable leading to injury.

Holt KG, Wagenaar RO, Saltzman E. A dynamic systems/constraints approach to rehabilitation. Rev Bras Fisioter. 2010 Dec;14(6):446-463

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Regional Interdependence Any condition or disorder initiates a series of

responses that involves multiple systems of the body-musculoskeletal, neurophysiological somatovisceral, and biopsychosocial .

Definition- “a patient’s primary musculoskeletal symptoms may be directly or indirectly related or influenced by impairment form various body regions and systems regardless of proximity to the primary symptoms.” Sueki et al. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Journal of Manual and Manipulative Therapy; 2013, vol. 21 no 2

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Regional Interdependence

Eg.• Interventions at the thoracic spine have been found to

affect cervical spine, shoulder and elbow Sx Cleland et al., Berglund et al.

• Interventions the hip have been found to affect knee symptoms. Souza and Powers

• Relationship between ankle impairment and low back pain Brantingham et al.

Sueki et al. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Journal of Manual and Manipulative Therapy; 2013, vol. 21 no 2

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Regional Interdepedence

Fear avoidance, pain catastrophizing and anticipation can impact function and pain.

Education on pain can alter CNS function “An integrative model that eliminates the dichotomy

of having to choose between a biomedical, neurophysiclogical, or biopsychosocial models.”

Sueki et al. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Journal of Manual and Manipulative Therapy; 2013, vol. 21 no 2

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Can I find the lesion?

“. . . Identifying relevant pathology in patients with LBP has proved elusive and is identified in less than 10% of cases.”

• Fritz, JM et al. Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy. JOSPT June 2007, Volume 37, Number 6.

We’re not as good as we thought we were!!

This presentation does not fit the text book!!

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The Goal of Clinical Decision Making

Find the constraints or limitation in the dynamic resources (physical, psychological, social) of the individual to accomplish the desired task in the necessary environment.

The tissue in lesion or pathological tissue (Patient identified problem) may be the most significant constraint leading to the functional limitation, but likely not the only one, especially if tissue lesion onset was gradual in nature.

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Observe patient identified activity limitation, or activity that increases pain (Task/Environment).

Lumbar Scan Neurological scan/screening test Special Tests Clinical Prediction Rule criteria

Examination Strategy

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Task Observation-Finding body structure and function limitation (constraints)

Too much or too little motion at body region Lack of Dynamic Control of motion at body region. A breakdown in complexity, or a loss of variability, in the movement process

is viewed as a sign of dysfunction.

Holt KG, Wagenaar RO, Saltzman E. A dynamic systems/constraints approach to rehabilitation. Rev Bras Fisioter. 2010 Dec;14(6):446-463

Isolation of a body segment when task does not demand it (as opposed to

integrated movement up and down the movement chain) is a sign of dysfunction. Applied functional Science The Gray Institute

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Example-What should I see?

Walking stance position reaching with bilateral hands to floor• Calcaneal eversion, ankle dorsiflexion, tibial internal

rotation, knee abduction, knee flexion, hip internal rotation, adduction, and flexion, lumbar relative extension to pelvis followed by flexion (sacral nutation-counter nutation)

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Test the Hypothesis

Every treatment tests the hypothesis. Hypothesis needs to be continually reformed based

on results of testing. Asterisk sign Continuous process. Hypothetical question-treatment models.

Christensen, Nicole and Jones, Mark A Current concepts of Orthopaedic Physical Therapy 2nd Edition Independent Study course 16.2.1 APTA

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Psychosocial

Prognosis affected by: Depression Nonspecific physical problems (Mx areas) Rumination- compulsively focused attention on the symptoms

of one's distress, and on its possible causes and consequences Catastrophizing Stress at baseline Should be documented in assessment of evaluation

Hill and Fritz, Psychosocial influences on Low Back Pain, Disability and Response to treatment Physical Therapy Vol: 91:5 May 2011 pp 712-719

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Psychosocial

Mediators (link between intervention &desired outcome) Perceived control of pain Self efficacy (measure of one's own ability to complete tasks

and reach goals)Hill and Fritz, Psychosocial influences on Low Back Pain, Disability and Response to treatment Physical

Therapy Vol: 91:5 May 2011 pp 712-719

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Occupational

Prognosis affected by: Heavy physical demands Ability to modify work Job stress Social support Job satisfaction RTW expectations Fear of Re-Injury

Shaw WS et al. Addressing Occupational Factors in the Management of Low Back Pin: Implications for Physical Therapist Practice Physical Therapy Vol 91, 5 May 2011 pp 777-789

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Summary of Different Types of Flags.

Nicholas M K et al. PHYS THER 2011;91:737-753©2011 by American Physical Therapy Association

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Psychosocial Treatment considerations

Treatment needs to consider flags (yellow) Active PT-aerobic fitness and low back strength positive outcome for pain

catastrophizing. Education in understanding of condition

• (Low back how)

Educate on Perception of symptom legitimization Educate on Personal control of symptoms

Hill and Fritz, Psychosocial lnfluences on Low Back Pain, Disability and Response to treatment Physical Therapy Vol: 91:5 May 2011 pp 712-719

© 2017 solveglobal

Psychosocial Treatment considerations

Treatment needs to consider flags (yellow) Evidence-resume activities despite the presence of pain Decrease emphasis on anatomical structures as cause of pain Emphasis on pain management not relief Learn to live an active life in spite of pain Focus on Activity and Participation not pathology and impairment (ICF)

Need to collaborate with patient-pt. active role

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Psychosocial Treatment considerations

Treatment needs to consider flags (yellow) Explore patient beliefs and refer to them in explanation of patients pain. Graded activity or graded exposure Graded activity is quota based exercise in spite of symptoms Graded exposure is gradually exposing patient to activity that is feared starting at

lower level of intensitiesNicholas MK, and George SZ, Pscychologically Informed Interventions for Low Back Pain: An Update forPhysical Therapists Physical Therapy Vol

91, 5 May 2011 pp765-776

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Occupational Considerations

Treatment needs to consider flags (blue) Don’t ignore Advice that RTW is therapeutic-better outcomes if stay at work. Focus on Participation rather than impairment Challenge negative thoughts Problem solve with client having a central role in decision making process while

taking their perceptions into accountShaw WS et al. Addressing Occupational Factors in the Management of Low Back Pin: Implications for Physical Therapist Practice Physical

Therapy Vol 91, 5 May 2011 pp 777-789

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Readiness for Change

Clinical decision making in the context of readiness for change

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TAKE HOME –Identify Classification, address the symptom, but Treat the impaired movement (Regional

Interdependence) with in the context of the individual, (biological, psychological, sociological) task, and

environment

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Questions?

Thank you!

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Recurrent Lower Back Pain: Treating the Frequent Flyer

DAN RUSSO, PT, CIMT

UW HEALTH

When the Mechanics Approach Alone isn’t Working

“Frequent Flyers” What’s in a name?

The Term “Frequent Flyer,” implies that something isn’t working.

If we are doing our jobs well, patients don’t come back.

“You didn’t fix me the first time.”

“I keep getting hurt.”

“Something really complicated is going on here.”

“Maybe I have cancer.”

Etc…

So how do we approach this?

Refer to a physician for medication?

Call your favorite CI?

OR

Disagree with the Patient?

Tell them how good we are at our jobs?

Maybe…

New Zealand acute low back pain guide

2004 published guidelines

https://www.healthnavigator.org.nz/media/1006/nz-acute-

low-back-pain-guide-acc.pdf

2/3 of guide = Assessing Psychosocial Yellow Flags

Many Options to Consider

David S. Butler &

G. Lorimer Moseley

https://www.noigroup.com/

bodyinmind.org

Many Options to Consider

Adriaan Louw, PT, PhD

The International Spine and Pain Institute (ISPI)

https://www.ispinstitute.com/

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Many Options to Consider

CSM 2019

Pain Talks: Conversations with Pain Science Leaders on the Future of the

Field

Carolyn McManus, MPT, MA

Kathleen Sluka, PT, PhD

Steve George, PT, PhD

Carol Courtney, PT, PhD

Adriaan Louw, PT, PhD

Well, There’s No Protocol for That: Physical Therapy in a Trauma Setting

Daniel W. Flowers, PT, DPT; Sharon Dunn, PT, PhD; Megan Flavin, PT, DPT; Amanda Mahoney, PT, DPT; Erin McCallister, PT, DPT; Margaret Olmedo, MD

New Zealand acute low back pain guide

2004 published guidelines

https://www.healthnavigator.org.nz/media/1006/nz-acute-

low-back-pain-guide-acc.pdf

2/3 of guide = Assessing Psychosocial Yellow Flags

New Zealand…guide:“Ongoing management”

Review the patient’s progress each week until they have returned to

usual activities

Give the Green Light to be active at each review

Identify and address potential barriers to recovery at each review

Agree on a plan – and encourage autonomy and self-

management

If progress is delayed, reassess Red and Yellow Flags at 4 and 6

weeks

Consider specialist referral at 4-8 weeks to prevent ongoing

problems

Pain assessment: Patient

Great Resource from:

bodyinmind.org

Inactive as of Aug, 2019 – still a great

resource

Types of Pain

Tissue pain (Nociceptive)

Joints, muscle, ligaments, etc…

Peripheral Neuropathic

Central Sensitization

Centrally Driven

Central Sensitization

Tissue Pain (Nociceptive):Mechanical Problem*

Did something happen?

Was there an “injury?”

ACL: contact versus non-contact injuries

Common sense: If nothing happened → tissues not disrupted

If that’s the case, pain is likely due to something else.

Muscle spasm

Neural tension

Central sensitivity

Etc…

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Tissue Pain (Nociceptive):Mechanical Problem*

Don’t repeat what didn’t work last time

Change approach: What are you missing, what’s the “driver”?

Driver = behavior, biomechanics, weakness, etc… that is causing

the symptoms set

Treating wrong tissue?

Stabilization vs mobilization? (or vice versa)

Is a BEHAVIOR driving the symptom(s)?

OR is the driver more complex?

Peripheral Neuropathic & Centrally Driven (includes Central Sensitization)*

Multiple area sensitivity, light touch allodynia, Cold Hyperalgesia, pressure hyper-sensitivity,

Report of High disability levels, and of high pain levels

Pain behaviors.

Pain flare ups, unpredictable pain episodes. Socially modified pain reports

Self report of fears, anger, catastrophizing, anxiety, depressed mood, injustice, jealousy.

Poor pain concept, poor body perception concept

Thought driven report of pain, thought driven aberrant muscle activity

General guide to

contributing mechanisms

PCS = Pain Catastrophizing scale;

PKQr = Revised Pain knowledge

questionnaire;

FABQ = Fear Avoidance beliefs

questionnaire.

Patient Cases

Some Takeaways

Words Matter: Our ability to explain our diagnosis to patients has a

direct link to their outcome.

Treat the source of the problem.

Don’t prescribe press ups for ankle pain (unless is radicular)

If the issue is fear and inactivity, reassure them & get them moving.

MOVE:

Fairly unanimous in research I have seen: Patients do better when the

move more.

Patients are NOT “crazy”

They are in REAL pain and often unaware that they are compensating.

Pitfalls of Treating the Flyer

Manual therapy:

Touch patients: they will do much better

Manual therapy after 2wks or 4 visits (same approach) should raise your alarm

Pivot to education and movement

Posture:

Pay close attention to “induced scoliotic curves”

Correct with external cues

Don’t Rush & Take Time to Listen

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References:

1. New Zealand acute low back pain guide : incorporating the Guide

to assessing psychosocial yellow flags in acute low back pain. New

Zealand Guidelines Group; Accident Compensation Corporation

(NZ). [Wellington, N.Z.] : New Zealand Guidelines Group, 2004.

2. Body in Mind. https://bodyinmind.org/