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Clinical Pattern Recognition- Low back pain

From anatomy to discovering the patient!

Low back pain

  • 1-year incidence of a first-ever episode of low back pain to range between 6.3% and 15.3%, while estimates of the 1-year incidence of any episode of low back pain range between 1.5% and 36%.

  • Low back pain is the leading cause of activity, limitation and work absence throughout much of the world and is associated with an enormous economic burden.

  • Individuals who have experienced activity-limiting low back pain often experience reoccurring episodes with estimates ranging between 24% and 33%.

See more prevalence information in the Clinical Pattern Recognition: Orthopaedics app here

Meet the 6 common low back pain patients from the Clinical Practice Guidelines!

Clinical Pattern Recognition

Click on the pain pattern to learn about the patients and develop your clinical patterns!

1.     Lumbar degenerative joint disease/facet syndrome- Low back pain and mobility deficits (1 min video)

2. Sciatica/disc herniation- Low back pain and radiating pain (1 min video)

3. Lumbar strain/instabilities- Low back pain and movement coordination impairments (1 min video)

4. Sacroiliac joint sprain- Pelvic girdle mobility deficits(1 min video)

5. Spinal stenosis- Low back pain with radiating pain (1 min video)

6. Psychologic overlay Depression/Anxiety/Fear leading to Chronic pain or central sensitization- Low back pain with cognitive and associative tendencies leading to Generalized pain

Lumbar Facet Syndrome

Lower Back Pain with Mobility Deficits

Screen Shot 2018-10-22 at 10.34.01 PM.png

  • Do you have a patient who has pain extending back or with rotation? That pattern is similar to that of lumbar facet syndrome. Look below for some things to consider!

  • If you do not know the common clinical findings no problem! Click here

Anatomy

Picture1.png

Image via Complete Anatomy 2018 by 3D4 Medical

Common Movement Fault

A common movement fault seen with facet syndrome is extension rotation. Which means every time a person rotates their body to the R or the L they are also extending back which puts increased compression onto the facet joint. This will lead to irritation over time with repeated movements. (Click image to watch 1-2 minute video)

Special Tests

 The above test on the left is apart of the “Clinical Pattern Recognition (CPR) for lumbar facet syndrome.” This is a grouping of 5 measures that are highly predictive for ruling in lumbar facet syndrome. These measures include a facet that is over 50 years old, someone who feels best walking, feels best sitting, onset is next to the spine, and they have a positive quadrant test. This CPR has been designed to help the Physical Therapist better ascertain the likelihood of Lumbar Facet Syndrome as a diagnosis. (Click image to watch 1-2 minute video)

Treatment

Consider utilizing manipulations to reduce pain and disability in patients with mobility deficits who have acute low back pain. If all criteria from CPR are met consider using this technique. Check out the video above! (Click image to watch 1-2 minute video)

Therapeutic Exercise

Therapeutic exercises chosen should always closely match treatment give in clinic; in this case the manipulation would address the mobility deficit. However, if manipulation is not appropriate for treatment another method would be to increase mobility of the lumbar spine. Quadruped rock backs work to help create space between the facet joints which can help to ease pain. This exercise can help increase lumbar flexion range of motion! Do not forget to correct the movement fault to help prevent any future irritation of the facet joint. (Click image to watch 1-2 minute video)

 

Lumbar Muscle Strain

Lower Back Pain with Movement Coordination Impairments

Screen Shot 2018-10-22 at 11.37.52 PM.png

  •  Do you have a patient who has low back pain across their whole back? Do they have pain bending forward and extending back or have had multiple occurrences of their back “going out” on them over the past couple of years? That pattern is similar to that of lumbar muscle strains. Look below for some things to consider!

  • If you do not know the common clinical findings no problem! Click here

Anatomy

Picture1.png

Image via Complete Anatomy 2018 by 3D4 Medical

Common Movement Fault

A common mechanism of injury for lumbar strains are unaccustomed repeated movements of bending and lifting activities such as shoveling. This can be caused by is too much mobility from the lumbar spine and not enough mobility coming from the hip. (Click image to watch 1-2 minute video)

Special Tests


The above tests can be helpful to physical therapists to better ascertain the likelihood of lumbar muscle strain. A good way to “rule in” or “rule out” a muscle strain is if the muscle is 1) tender to palpation, 2) hurts when contracted, and 3) hurts when stretched. (Click images (Left/Right) to watch 1-2 minute video)

Treatment

Above are two treatment techniques that can be used for both acute and subacute patients. The video on the left can be used for a patient that has a high level of pain. The video on the right can be used to help alleviate trigger points, muscle spasms, or decrease pain. (Click images (Left/Right) to watch 1-2 minute video)

Therapeutic Exercise

Therapeutic exercises chosen should always closely match treatment give in clinic; in this case the above treatments would help to decrease pain and relax the paraspinal muscles. Consider using trunk coordination, and strengthening exercises to reduce low back pain and help with movement coordination impairments! (Click image to watch 1-2 minute video) 

Disc Herniation

Lower Back Pain with Radiating Pain

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  • Not to be confused with lower back pain with related leg pain; patients with a disc herniation will be more likely to have complaints of narrow shooting/burning type pain sometimes associated with numbness. It is important for the Physical Therapist to be able to make the distinction between the two.

  • If you do not know the common clinical findings no problem! Click here

Anatomy

Picture1.png

Image via Complete Anatomy 2018 by 3D4 Medical

Common Movement Fault

Similar to disc disorders due to displacement, typical mechanism of injury associated with discogenic herniation is bending forward to lift (often times heavy) objects. If the patient moves too readily through the lumbar spine and not enough through the hip (flexion movement fault), they are at a higher risk for back injury! (Click image to watch 1-2 minute video)

Special Tests


The straight leg raise is an excellent for ruling out disc herniation due to it’s high sensitivity (0.97)! (Click image to watch 1-2 minute video)

Treatment

It is important to note that in the early stages of disc herniation rehabilitation, the centralization procedures used for treating lower back pain with related leg pain may actually cause symptom exacerbation. Patient’s who present to clinic with an acute injury or high irritability may benefit from finding positions of comfort, maintaining neutral spine alignment, and slow restoration of normal lumbar spine lordosis. (Click the image to watch 1-2 minute video)

Therapeutic Exercise

The quadruped rock back is an excellent exercise for this patient population. It puts the lumbar spine in a gravity eliminated position and teaches the patient how to move through their hips while maintaining a neutral lumbar spine! (Click image to watch 1-2 minute video)

Discogenic Lower Back Pain

Lower Back Pain with Related Leg Pain

Screen Shot 2018-10-23 at 9.28.32 PM.png

  • Is your patient experiencing diffuse or difficult to pin point pain that can travel down their leg? Take a look at some common clinical findings for discogenic lower back pain to see if signs and symptoms match up!

  • If you do not know the common clinical findings no problem! Click here

Anatomy

Picture1.png

Image via Complete Anatomy 2018 by 3D4 Medical

Common Movement Fault

Typical mechanism of injury associated with discogenic lower back pain is bending forward to lift (often times heavy) objects. If the patient moves too readily through the lumbar spine and not enough through the hip (flexion movement fault), they are at a higher risk for back injury! (Click image to watch 1-2 minute video)

Special Tests


The above videos demonstrate how you can quickly screen for discogenic lower back pain via centralization phenomenon! (Click images (Left/Right) to watch 1-2 minute video)



Treatment/Therapeutic Exercise

Repeated extension in standing can be used as both a treatment and a therapeutic exercise that the patient can perform on their own. If patient is unable to perform in standing try prone on elbows! Lastly, do not forget to address the flexion movement fault not just in standing but sitting as well! (Click the images (Left/Right) to watch 1-2 minute video)