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LBP again...
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LBP again... - February 6, 2001 6:21:00 AM
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davidspt
Posts: 3
Joined: February 4, 2001
From: Australia
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59 y/o patient who is experiencing pain at the low back,dull aching on the right leg(anterior part).R side flexion is markedly limited,R rotation is markedly limited, the rest of ROM is WNL.Pain is worst upon getting up on bed.MRI shows hypertropic spurring at the facet joints at L4-L5,L5-S1 levels, more the R side. SLR is ok. What is the best exercise for this patient???? What are the movements or exercises that may aggravate his pain??
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Re: LBP again... - February 8, 2001 10:24:00 AM
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scriss
Posts: 40
Joined: April 14, 1999
From: Columbus, IN USA
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Now, now Nic, be nice...a little encouragement goes a longer way than being harsh. David is a student, just learning, remember when you were there?
OK, think about the structure of the spine and how the facets fit on one another. If you have hypertrophic changes on the facets, what does that mean? If you treat with extension, what will the facet joints do? If you treat with flexion, what will the facet joints do? Relate that to the diagnosis and you will have your answer, all thought out and probably right! This will help your patient, I am sure of it! If you have other questions, fire away!! Good luck!
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Re: LBP again... - February 8, 2001 4:29:00 PM
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David Adamczyk
Posts: 302
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From: Cleveland
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The comment immediately following david's question has been removed due to its excessively negative tone.
Thank you SCRISS for your comments.
The RehabEdge Forum encourages all members to post questions and comments with an expectation that the discussion will be constructive. If criticism is warranted, please do so in a professional manner.
David Adamczyk, MS, PT
Administrator
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Re: LBP again... - February 8, 2001 7:15:00 PM
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mcap
Posts: 652
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Davidspt:
You are asking us how to treat a back patient. This is a complex issue and many of us won't be able to help without actually seeing the patient.
A few things to consider with this patient:
1. Is there a neurological deficit?
2. How long has he had the pain?
3. What is his functional status?
4. What is his social status?
5. Beware of treating patients with LBP by diagnosis. Hypertrophic scarring of the facet joints could be a false positive and not the source of the pain. There is no way to tell short of diagnostic injections - and even those are problematic. You don't have discount his dx but you have to monitor the effect of his dx on his beleifs and behaviors.
There are far too many choices and directions to go here. You will need to decide on what direction to go. If you are to treat back patients regularly, you need to read. I recommend the Richardson book and of course, the Waddell book. Also, the findings of the Paris Task Force provide a nice summary of the effect of exercise on LBP. Some kind of active exercise (doesn't even have to be specific) is usually appropriate for chronic patients.
Good luck......
mcap
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Re: LBP again... - February 8, 2001 7:23:00 PM
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mcap
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Scriss:
I would caution you about picturing facet joints and choosing flexion or extension.
If I read your post correctly, I can infer that you beleive extension would exacerbate a facet joint problem. Many PTs would concur. But there is no research to support this at all!!
Check out this study:
Revel, M., Poiraudeau, S., Auleley, G., et al. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine. 1998 Sep15;23(18):1972-6. discussion 1997.
In this study......The only study to characterize the clinical picture of patients with facet joint sydrome......patients with positive facet injections were evaluated to determine their clinical characteristics.
The findings.....patients with positive facet injections did not have pain during extension in standing and did not have pain during extension in standing WITH ROTATION. Yes this does not seem to make sense anatomically and it does not jibe with what we learned in PT school. Furthermore, more research is needed.
But it should make us pause!!!!!!!!'
mcap
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Re: LBP again... - February 8, 2001 10:50:00 PM
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nicaragua
Posts: 28
Joined: July 10, 2000
From: Australia
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Sorry Davidspt
I did not know that you were a student. Any questions feel free to ask me. my email is wernerspine@yahoo.com
About removing someone comments! Just like the Nazis. I thought this was an open forum of ideas negatives, positives and neutral. [QUOTE]Originally posted by mcap:
Scriss:
I would caution you about picturing facet joints and choosing flexion or extension.
If I read your post correctly, I can infer that you beleive extension would exacerbate a facet joint problem. Many PTs would concur. But there is no research to support this at all!!
Check out this study:
Revel, M., Poiraudeau, S., Auleley, G., et al. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine. 1998 Sep15;23(18):1972-6. discussion 1997.
In this study......The only study to characterize the clinical picture of patients with facet joint sydrome......patients with positive facet injections were evaluated to determine their clinical characteristics.
The findings.....patients with positive facet injections did not have pain during extension in standing and did not have pain during extension in standing WITH ROTATION. Yes this does not seem to make sense anatomically and it does not jibe with what we learned in PT school. Furthermore, more research is needed.
But it should make us pause!!!!!!!!'
mcap[/QUOTE]
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Re: LBP again... - February 9, 2001 12:03:00 AM
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davidspt
Posts: 3
Joined: February 4, 2001
From: Australia
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Thank's for your reply guys... I just hope you'll take some considerations on members posting messages for help.I'm sure that you had been also on this stage where you need to find some answers to your questions which you can't have at the corners of your classroom.
@MCAP: Can I have the full details of the books which you had mentioned? Thank's!
@NIC:Why should I seek some help to an "inconsiderate" person when there are a lot of considerate professional PTs there willing to help neophytes like me?????
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Re: LBP again... - February 9, 2001 11:10:00 AM
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scriss
Posts: 40
Joined: April 14, 1999
From: Columbus, IN USA
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mcap -
Good point on the research and comments. I was just trying to get him started in a direction and to think about structure and function. Most of us would agree that if the flexion path was not working, try the extension path and see which reduced symptoms most effectively?! I may have (upon examination) started with the extension path because ROM into extension reduced symptoms. I also disagree with treating someone according to diagnosis rather than objective clinical findings upon examination (how many physicians do you know that get it right every time??).
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Re: LBP again... - February 10, 2001 6:36:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
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Scriss:
It's amazing. Despite what the research tells us about how difficult it is to diagnose patients - most physicians seem to be able to come up with an exact diagnosis and very quickly. How do they do it [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
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Re: LBP again... - February 10, 2001 6:40:00 AM
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mcap
Posts: 652
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Davidspt:
Book 1 - THE BEST!!!!! The Back Pain Revolution by Dr. Gordon Waddell. Available through amazon or B&N. This is a great overview of the biopsychosocial approach. It is not specific to P.T. but I think therapists would benefit from reading what the rest of the medical community is.
Book 2 - Therapeutic exercises for Spinal segmental stabilization. Richardson, Hides, Hodges and Jull. Should also be on Amazon. Great book summarizing their method. A great summary of their work is the article:
Richardson C., Jull G. Muscle control - pain control. What exercises would you prescribe? Manual Therapy 1995 1,2-10.
You can go to the suggested reading portion of my website where all of these books are listed.
[URL=http://www.thebackpage.net/]http://www.thebackpage.net/[/URL]
Later,
mcap
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Re: LBP again... - February 10, 2001 6:49:00 AM
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davidspt
Posts: 3
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From: Australia
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Thank's again for your answers guys.My point is, will extension exercise not aggravate his condition since it will produce approximation of the facet jts.?
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Re: LBP again... - February 10, 2001 1:05:00 PM
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mcap
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David:
As I said previously, extension probably does not approximate the facet joints in the L-Spine. Where is everyone learning this?
If someone has particularly wide interspinous spaces, then the IAF may impact upon the lamina below. But, in most people, Extension is limited by approximation of the Spinous processes, not the facet joints. Yes the facets do bear more weight in extension. But "resection of the zygopohysial joints has little impact on the capacity of a lumbar segment to bear an extension load"
- Bogduk
If the scarring or degeneration is severe enough, then yes it can impact your treatment. But, in most cases, as we said, you shouldn't treat based on diagnosis. I know it is difficult to do but you may need to step away from the facet joint and examine the entire patient!!!
By the way......if you are an SPT, what does your CI say about this patient and it should be a good time for his/her guidance.
mcap
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Re: LBP again... - February 10, 2001 1:07:00 PM
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mcap
Posts: 652
Joined: February 8, 2000
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Let me revise my previous post.....
The facet joint approaches closer approximation in extension but in most cases the joint surfaces don't fully approximate.
mcap
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Re: LBP again... - February 10, 2001 6:56:00 PM
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chrishkpt
Posts: 23
Joined: January 29, 2001
From: hong kong SAR
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mcap, seems you are encouraging david the use of stabilisation exercise for his back patient. This remind me something that i wana ask all of you concerning the instability;
from many journal about Lx instability, they mentioned that no accurate test can be found to diagnose Lx instability so far, but likely patient with Lx instability may have trouble in the mid-range movement with a characteristic 'instability catch'
However, i couldn't see any explanation of mid-range mvt deficit or instability catch from the journals.
So, here i want to ask for your opinion.
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Re: LBP again... - February 11, 2001 3:47:00 AM
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PYH
Posts: 1
Joined: January 22, 2001
From: Singapore
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Dear David,
Rather than indulging in the pathoanatomical/"guess the tissue" game, why not adopt a pathokinesiological approach to LBP classification and management?
The following two articles should provide you some fresh perspectives.
Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment.
Phys Ther. 1995 Jun;75(6):470-85; discussion 485-9.
Maluf KS, Sahrmann SA, Van Dillen LR.
Use of a classification system to guide nonsurgical management of a patient with chronic low back pain
Phys Ther. 2000 Nov;80(11):1097-111.
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Re: LBP again... - February 11, 2001 9:55:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
Status: offline
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Chrishk:
The instability debate continues! The truth is that even gross instability with significant movement can be difficult to deliniate. In people with gross instability, a series of X-rays can be taken in flexion and extension and then a calculation can be performed to see if it is in the "norms."
PTs seem to hang their hats on a more subtle "instability" that has yet to be proven or quantified. There is no study, to my knowlege that successfully identifies these patients and there is certainly no validated clinical test. I am not saying that this doesn't exist, only that we haven't proven it yet.
So....the excellent question you pose???? Why stabilization training??? The answer is perhaps that it should not be called that. People with chronic LBP and even those that are more acute develop deficits in specific muscle groups. With this program we are simply trying to restore those deficits...thats it!! In research, this program has worked well so far.
What is actually happening....who knows. We know that the spine is inherently unstable without muscle control. For example, the multfidus is responsible for 2/3 of the stiffness at the L4-L5 segment. You can guess that a deficit within would compromise the stability of the segment. Also, patients with DJD of the spine demonstrate instant centers of rotation that vary much more than in spines without. So perhaps by improving the motor control of segmental muscles we are helping to reduce aberant motion. Who knows??????? [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
Take care,
Mcap
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Re: LBP again... - February 14, 2001 7:44:00 AM
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edilling
Posts: 139
Joined: January 10, 2000
From: pullman,wa,usa
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Your patient sounds relatively straight forward (maybe because they are not right in front of me).
Hypertrophic spurring of the Z-joint (facet) is likely due to increased loading of this joint. Why else would the body feel the need to make it bigger and stronger. According to Bogduk this is due to diminished disk height. If there is spurring at the Z-joint there is likely some foraminal stenosis which would account for the radicular symptoms.
Repeated flexion in painfree positions is called for. Active extension through PAINFREE range avoiding R ext producing or exacerbating symptoms. Teach the patient to avoid activities such as reaching up and twisting right or weedeating on a hillside (sideflexed right and rotating right). Also teach the patient how to avoid right rot and right sideflex when getting out of bed.
If this does not make sense get out the model of the spine and put it through the proposed motions.
Good luck and let us know what you did and what worked.
Erik
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Re: LBP again... - February 15, 2001 11:46:00 AM
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scriss
Posts: 40
Joined: April 14, 1999
From: Columbus, IN USA
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mcap -
Sorry it has taken me so long to reply....been sick with a bug! Well, I think it is just amazing that the physicians can be so precise in diagnosing with the use of MRI, x-ray, etc. (You know that they think that whatever pathology they find is the symptom-producing mechanism!!) I have just found that instead of "trusting" the diagnosis, I approach it from a function/deficit point of view - treat what you see basically. I have been fortunate that this has produced good outcomes with patient care. We, as PT's, should always think function, function, function!!
Oh, and by the way, has anyone ever heard of an Orthopedic physician putting a patient in a cast for 4 weeks for extensor carpi ulnaris tendinitis?!!?!?!??! I didn't think so.
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