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Whats your lumbar evaluation method
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Whats your lumbar evaluation method - April 6, 2005 5:43:00 PM
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tf8560
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From: miami
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Given all the various schools of thought on lumbar evaluation ie mckenzie controlled movement/loading, biomechanical, osteopathic etc...what have you guys found to be the best for you. What are some of the important things you look for.
as for me, I have been through all the Mckenzie courses (several times)and after 18 years of practice dont always find it so great. I have also taken Ola Grimsbys courses, LPI, Back education and training, the Kaltenborn-Evjenth system and spine stabilization.
I'm either going through a funk or it just seems that I haven't been all that excited about any of them lately.
I appreciate all your expertise and could use your refreshing clinical experience.
Tom Fletcher,PT
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Re: Whats your lumbar evaluation method - April 6, 2005 9:39:00 PM
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Alex Brenner PT MPT OCS
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Tom,
I really really look at pelvic assymetry and make ALL my clinical decisions based on this. Just joking, I am having a flash back from a thread a few months ago.
Seriously though, I think I base my physical exam kind of on where the patient takes me with the patient history and the severity of the symptoms. When I perform a physical exam I really like to put my hands on the patient which is why I don't like Mckenzie too much.
When assessing lumbar range of motion I really like to get in there with my hands and evaluate what happens with different motions. I used to do a lot of special tests but have gotten away from this. My special tests mainly try to assess if there may be a neural component to the spine pain. I also of course look at the CPR and adminster the modified Oswestry and FABQ. Lastly I really take a close look at the hip to see if there are any contributing factors here. There usually are. This includes some special tests here but mainly looking at passive accessory motion and response to mobilization.
Tom, it seems you are really in to courses. If you want a good evidence based lumbar spine exam and intervention (utilizing the most current evidence in the literature, not anecdotal evidence) then I would suggest going to the the evidence in motion website and attending one of their courses. I would bet it would be one the best courses that you attend all year.
http://www.evidenceinmotion.com/
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Whats your lumbar evaluation method - April 7, 2005 3:12:00 AM
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tf8560
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From: miami
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Alex, thanks for the info. After being in the field for 18 years I have gone to many courses just because of the time I've been around. I usually attend 2 or 3 a year and not too many of them give much new insight. most are just a refreshing break from the clinic and a chance to pick the instructors brains. I think more gets learned while talking during lunch or dinner (or over a beer or two).
PS My brother was an Army PT Ft Sam Houston/ Ft Bragg now in private practice in the Seattle area.
I look forward to more interesting conversations and insights.
Tom Fletcher,PT
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Re: Whats your lumbar evaluation method - April 7, 2005 3:34:00 AM
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JLS_PT_OCS
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I think I practice a lot like Alex (even though we were not trained together) but I like to think this is because we both incorporate evidence so much into what we do.
My exam is much more....streamlined than it once was.
For acute people, it's quite a short note.
I think there was an example of a classification approach I saw, and I kind of generally stick to that, I'll try to look it up and get back to you.
Other than that, anyone who doesn't move smoothly gets manual therapy - manipulation or mobs/METs.
I use pain complaints and ROM restrictions to guide this. I don't do motion palpation or look for ERSs or any of that foolishness. If they hurt when flexing, they get general lumbosacral stuff or "opening" manips. If they hurt in other motions they get appropriate techniques. Home ex program is motion to reinforce the therapy I've done in their direction they are limited, encouragement to stay active, and a strength or muscle activation exercise appropriate to the situation. No more than 3 exercises at any one time. Anyone I mob or manip comes back inside of a week for brief recheck, and I have some pm appts that are real short for just that purpose.
That's just a start...
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Whats your lumbar evaluation method - April 7, 2005 6:25:00 AM
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Shill
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From: Madison WI USA
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Tom,
If your current state of LBP management is not satisfying you at the moment, take a look here
[URL=http://www.americanbackpaincenter.com]www.americanbackpaincenter.com[/URL] I have no affiliation with these folks, other than having been to the cervical and lumbar courses they provide, with plans on going to the migrane course as well. This approach was created by a man who used to teach the McKenzie problem solving course, and recognized some of the shortcomings of the McKenzie approach, focusing in greater detail on more relevant information. Alex and Jason will be glad to know that manipulation is used in this approach, if needed.
This is the approach I use, and quite often, the results are astounding.
Also, the gentleman who teaches this, does work as a spine consultant, and will come to your facility for consultative and mentoring purposes, if desired. This is all explained on the website.
Good luck,
Steve Hill PT
Madison WI
_____________________________
Steve Hill PT
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Re: Whats your lumbar evaluation method - February 19, 2006 2:27:00 PM
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juju
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Tom, I went through the same problems you did. 35 years experience, took all the spine course, settled on McKenzie, but became disillusioned.
I met Angelo DiMaggio 1985, when he was a faculty member of the McKenzie Institute. He helped me a great deal with private consultations (beyond McKenzie).
He established the American Back Pain Center and now teaches Strategic Orthopedics. It sums up what he learned from teaching courses and consulting.
His courses do not force any specific technique on you (like Paris for wxample), but concentrate on documentatio. Let the patient dictate direction of treatment.
Read his comment section.
Heidi
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Re: Whats your lumbar evaluation method - February 19, 2006 3:41:00 PM
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truthseeker
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I try to figure out what is the source of their pain, look for imbalances in the sagittal (amount of lordosis), frontal (leg length discrepancies) and transverse planes. If they are extended and prefer sitting, I look for things that might provoke facets, such as too little iliopsoas or rectus fem flexibility, or gluteal tightness (transverse plane).
If their pain is more in sitting, I look more at hamstring flixibility, lifting technique, and/or, traction.
I find that when you move someone toward "neutral" many of their symptoms go away on their own. I agree with Jason that fewer exercises are better for compliance. It is often not the injured body part's fault that it is injured. Usually, as Alex said, it is another body part failing to do what it does well e.g. if the hip fails to move then the spine will be expected to do so and the shapes of the bones and the size and orientation of the muscles are not suited for motion, rather, they are suited for stabilization.
if they are lordotic, I move them toward flexion, if they are flat backed, I move them toward lordosis, if they are lopsided (LLD) I try to level them and teach them to level themselves. If none of the above are true, then I look at movement techniques, abdominal weakness (or more commonly muscle stupidity - they are strong but don't fire when they are needed).
I also agree with Jason that when evaluating the acute patients, it is a rare moment when I am able to get a reliable assessment. They are often too guarded so its IFC, ice, and manual traction or facet gapping mobilizations.
I have found that the Richard Jackson courses have been evidence based and very practically applicable the very next clinic day. Also, Gary Gray courses (Chain Reaction) are very insightful, logical, and philosophical. There is evidence there as well in the basic sciences but much of the treatment and assessment is evidence based by inference rather than by someone studying the specific responses of a tri-planar iliopsoas stretch when compared to a single plane stretch.
food for thought
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Re: Whats your lumbar evaluation method - February 20, 2006 3:15:00 AM
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PTupdate.com
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I usually put the patient into either a neurological category, or a mechanical category
Those in the neurological category, specifically blatant HNP patients, get a program (at least initially) geared towards protection, centralization, and positioning, with pain relief of course.
Those in the other category are typical mechanical, non-specific LBP (and some that are specific). These are the ones that I just stand back and view the entire spine and whatever influences it, and correct all those variables that are not satisfactory.
The programs I use are a bleshing of many different schools of thought, including Paris, McKenzie, and Mulligan. My personal preference is the severe stenotic elderly patient...the one that often has to use a cane due to leg pain or is brought in using a wheelchair. I have so much luck with these and usually get them back to full function. I'd say next in line are the HNP patients, and I think most experienced PT's have a good idea early on as to whether they are going to get out of that hellhole early during the treatment program
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Whats your lumbar evaluation method - February 20, 2006 6:07:00 AM
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SJBird55
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Do share, Duff... put a patient case up of an elderly patient with severe stenosis.
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Re: Whats your lumbar evaluation method - February 22, 2006 6:37:00 PM
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Geert Jeuring
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From: Möhnesee, Germany
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I use the diagnostic triage (Waddell) with a few things added to it. If the patient has an unspecific Backpain or leg pain (referred) I evaluate if they are provocated by flexion, extension, show signs of instability or if its more of an postural problem (long maintained postures that cause the backpain). I do not try to evaluate which structure causes the unspecific backpain because I`ve found that exercise has a very low intertester reliability and isn´t really very usefull.
Greetings
Geert
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Re: Whats your lumbar evaluation method - February 26, 2006 9:23:00 AM
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mcap56
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Hey Tom:
I think we have all reached that point in our management of spinal patients. It helps to keep reading, taking courses and thinking things through. (A scehdule heavy on knees and shoulders as well as vacations can help also :) .
I agree with a lot of what has been said but what really helped me was a step back. The reality is that we may not ultimately have as much control as we think we do with a spine patient. When the chronic patient comes to see us, there are very complex changes in their pain physiology and there are psychosocial/behavioral factors that can far outweigh anything that we do in physical therapy. As PTs we are looking for a very mechanical answer to what is a multdimensional problem. What you say to the patient can be more important than anything physical that you do.
For my advice, I would start by reading Waddell's back pain revolution from cover to cover. Then, move into some of the courses mentioned and tweak your approach as needed.
For my students we use a mechanical evaluation system that has elements of the McKenzie system but there is a lot more included. Treatment also includes a variety of approaches with a heavy emphasis on stabilization but including repeated motions and manual techniques. Our eval also includes several questions designed to detect psychosocial "yellow flags" that may interfere with rehab.
It should be noted that McKenzie system is rigid for purposes of teaching and research. But, if you watched the diplomates treat patients, I am sure you would see them take a much larger view of the patient and employ a variety of measures. I think true the value of any system or approach is that you learn more about the spine in general.
Good luck!!
Marc
[URL=http://www.thebackpage.net]www.thebackpage.net[/URL]
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Re: Whats your lumbar evaluation method - February 26, 2006 10:27:00 AM
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nari
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Marc
Well stated!
A mechanical approach which defines only a focus on peripheral tissues doesn't work all that well for complex pain; education and dialogue can be very useful.
A multi-faceted approach with several other health professionals has been shown to be more effective, although marginally so.
Do you find stabilisation techniques useful? There is a lot of controversy now about the benefits of "core stability"..it appears no-one quite knows whether it is beneficial long term or not. Or do you mean a different stabilisation technique?
Nari
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Re: Whats your lumbar evaluation method - February 26, 2006 6:29:00 PM
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mcap56
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Hi....
Thanks!! I am referring to the stabilization protocol based on the work of Richardson and company. From the two long term follow up studies on those technqiues, there would appear to be a clear, long term benefit.
I also encourage reactivation and aerobic exercise.
Marc
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Re: Whats your lumbar evaluation method - February 26, 2006 7:17:00 PM
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nari
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Thanks Marc.
I was aware of the two follow-up studies, and they look pretty good; but there is some dissidence over the role of multifidi in the process. Shall do a bit of hunting to find where I read that - it was a while ago.
I agree that TA activation works as an assistance to pain relief but have not clinically found it at all helpful for chronic complex pain patients.
Too many other fingers in the pie for that group, I think.
Nari
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Re: Whats your lumbar evaluation method - February 27, 2006 12:45:00 PM
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mcap56
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I have found the routine to very useful. I have a three phase program that I take the patients through. It is certainly no panacea and I explain that it is one small part of the big picture.
The multifidi are the primary stabilizers of the spine. I think Richardson et al verified that they co-contract with the TA. We also palpate the multifidi during the exercises.
Haven't been in clinic a lot recently. Would love to get back in a bit. But, this program was an important part of my intervention strategy for most patients.
Best
Marc
[URL=http://www.thebackpage.net]www.thebackpage.net[/URL]
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Re: Whats your lumbar evaluation method - February 27, 2006 4:19:00 PM
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nari
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From: Australia
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Marc
I cannot find the article..yet..but the study showed that multifidi operate independently of the large spinal muscles and therefore the link between them was tenuous. Will find it one day...
Can you seriously palpate multifidi and know what you are palpating? I understood that palpation was an unreliable indicator at that depth.
Hope to be more specific when I locate this study.
Nari
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Re: Whats your lumbar evaluation method - February 27, 2006 4:45:00 PM
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mcap56
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You are correct that they are difficult to palpate. Very subtle and of course, I have no way of knowing whether I am actually feeling it. Haven't they used U/S to verify the contractions though????
Marc
[URL=http://www.thebackpage.net]www.thebackpage.net[/URL]
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Re: Whats your lumbar evaluation method - February 27, 2006 8:58:00 PM
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Randy Dixon
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The research I've been reading pretty much shows that you can look for a few things-directional preference, hypo-hypermobility. Hypermobility responds to stabilization, hypo-responds to manipulation. Chronic LBP has a large psychological and neurological component to it so it is actually a separate category.
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Re: Whats your lumbar evaluation method - March 4, 2006 8:11:00 AM
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Omar Ha-Redeye
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Multifidus can theoretically be palpated with activation around L4-L5.
The only long term prognostic factor for chronic back pain in systematic reviews is psychosocial issues.
This means that PTs will have to deal with stress management and counselling beyond simply manual techniques.
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Re: Whats your lumbar evaluation method - March 14, 2006 4:08:00 PM
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rodgere
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Angelo, rules
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