jacquelinezak.files.wordpress.com · Web viewAs the presenting physical impairments and radiating pain may be difficult to differentiate between diagnoses, recent research has expressed

MSE Case AnalysisLow Back Pain

Jacqueline ZakDPT 772 PT Management Complex Condition III

Cleveland State UniversityDoctor of Physical Therapy Program

April 10, 2017

Background and Purpose:

Although clinical practice guidelines for neck and low back pain work to assist healthcare providers in clinical decision making, the spine presents a challenge to the clinician in predicting an accurate prognosis and reaching the correct diagnosis. As the presenting physical impairments and radiating pain may be difficult to differentiate between diagnoses, recent research has expressed the importance of considering psychosocial factors that add to the complexity of the diagnosis and prognosis of spine related conditions.1 Psychosocial factors including fear avoidance, catastrophizing, perceptions about risk of persistence, depression, self-efficacy, expectations, beliefs about the future and illness perceptions regarding the patient’s problem are considered important prognostic factors.1,2 These factors are especially important to keep in mind when a patient is experiencing pain and associates the pain with movement, turning into fear avoidance.1 Inadequate history taking, physical examination, neurological examination and psychosocial screening leads to poor outcomes and a greater chance of misdiagnosis or mismanagement.2 As a clinician, it is crucial to be mindful of psychosocial factors that may be impacting the patient coupled with adequate knowledge of the musculoskeletal system and referral patterns in order to determine the need for a timely appropriate referral.2,3

The clinician’s clinical decision making should be clearly expressed not only to the healthcare team involved in the patient’s care, but also to the patient himself. When clinical guidelines are implemented successfully, research has shown that a clinical team is more likely to deliver healthcare services efficiently and effectively.4 Focusing on the individualized patient’s needs is an essential aspect when using clinical practice guidelines to reduce the occurrence of misinterpretation.3 Collaboration among healthcare providers and with the patient is a crucial component in producing a positive outcome. Collaboration in the form of written and oral communication is key to an interdisciplinary team who work towards a common goal.5 The purpose of this case report is to demonstrate the diagnostic process in low back pain including the physical aspect as well as the psychosocial aspect.

Case Description:

A 61 year old male presents with intermittent, low back pain he noticed from landscaping in 2014 that lasted for about two to three weeks. The patient states the pain has been recently worsening the past few months, especially while spending prolonged time sitting at work, prolonged standing, reaching forward and repetitive lifting. The pain is better when the patient stretches, exercises and lying on his stomach. Patient is independent with all activities of daily living. Patient has a history of left hip osteoarthritis experiencing hip pain involving groin, buttock and greater trochanter area and broke his wrist in 2007. Patient is not experiencing radiating pain, tingling or numbness in either lower extremity. Patient rates the current pain as 2/10 and states the pain can increase to 3-4/10 when reaching, sitting for prolonged periods of time and extended amount of time exercising. Patient states he is very active and he chose not to play slow pitch softball this year with his friends due to his low back pain and noticeable decreased mobility in his left hip. The patient sleeps on a firm mattress on his right side and states the low back pain and the hip pain are recently causing disturbed sleep and pain when changing positions in bed. Patient experiences morning stiffness, difficulty walking and sometimes has joint pain in his left hip. Patient is a full-time accountant and part-time landscaper

PAGE \* MERGEFORMAT 17

during the summer. He lives alone in a two-story home, with three steps with a railing to access the home and eleven steps with a railing to the bedroom and full bathroom on the second floor. The patient has 12 steps with a railing to the basement where the laundry room is. Patient states he has support of family members and friends that live close by if needed.

Patient is 6 feet tall and weighs 176 lbs. with a BMI of 23.9. The cardiovascular/pulmonary system is not impaired. The patient presents with a heart rate of 74 beats per minute, respiratory rate of 15 breaths per minute, blood pressure of 118/78 and does not show signs of edema. The patient’s integumentary system is not impaired. The patient’s skin is smooth, intact and light in complexion with no signs or presence of scar formation. The patient demonstrates limited range of motion of his lumbar spine and left hip, while overall gross strength is not impaired. Patient presents with rounded shoulders, forward head and decreased lumbar lordosis in sitting and more noticeably in standing. Balance, locomotion, transfers and transitions are not impaired, however the patient’s gait is impaired due to pain. The patient’s motor function, communication, affect and cognition are not impaired. The patient does not present with any learning barriers and will benefit from disease process education and safety education. Patient prefers pictures and demonstrations, followed by return demonstration.

Patient states his goals for therapy include: ability to sleep throughout the night and decrease his low back pain to 0/10. Additionally, patient would like to decrease his discomfort he experiences when sitting for prolonged periods of time at work and increase his flexibility. Patient would like to return to play slow pitch softball with his friends next year.

Clinical Impression #1

Based on the case history, the primary problem this patient is experiencing is intermittent low back pain, decreased mobility and left hip pain. This low back pain increases with prolonged sitting, prolonged standing, reaching forward and repetitive lifting motions. The patient experiences difficulty walking due to the low back pain and left hip osteoarthritis. The potential differential diagnoses based on the case history include: mobility deficit of the lumbar spine, movement coordination impairment of the lumbar spine, left hip pain, or a postural impairment.

Additional information that was not provided in the initial patient interview or history that was requested from the patient include: time frame of imaging and diagnosis of hip osteoarthritis, reason for imaging, assistive devices available, time spent in different positions at work, type of living arrangements, home set up, available support at home, prior level of function and specific patient goals. The time frame as well as the reason for imaging is important to know as a clinician in order to understand other factors that may be contributing to the patient’s low back pain. Additionally, it is important to know when the patient was diagnosed as well as a time frame of symptoms experienced associated with the left hip osteoarthritis in relation to the onset of low back pain. With severe hip osteoarthritis, the patient may be compensating or avoiding movements that cause pain to his hip, in turn affecting his low back or pain in his back may be affecting his hip. The time spent sitting at work is important information to know in order to educate the patient in proper positioning when sitting and differing positions during the day, as in implementing a five minute walk around his office every few hours. Information regarding available assistive devices allows the clinician to know if equipment needs and patient education


are necessary. Living arrangements and the patient’s environment is important to know in order for the patient to function optimally and safely within their surroundings. Available support at home helps the clinician in determining the discharge plan, overall wellness of the patient if psychosocial factors are involved and the overall outcome for the patient. Prior level of function and specific patient goals are critical for a clinician to be aware of and understand, in order to individualize a plan of care. These factors explained above will help predict the prognosis for the patient as well as the diagnosis.

The plan for the examination is to assess posture, complete a neurological screen, mobility testing, repeated movement testing, trunk endurance tests, special tests and completion of outcome measures. A posture assessment clarifies observations or the presence of a lateral shift. A neurological screen helps to rule out any lower extremity paresthesia, tingling or numbness that may correlate to a patient that has an impaired nervous system.6 A mobility deficit can be ruled in or ruled out when completing mobility testing that includes: PA testing and goniometric measurements. Repeated movement testing can help rule in or rule out diagnoses depending on where in the range pain is felt or in what direction, toward deformation of structures or opposite deformation.6 Trunk endurance tests are helpful in ruling in or ruling out movement coordination impairments.7 Special tests like the straight leg raise and slump test can help rule out symptoms of radiating pain involving the sciatic nerve, whereas the quadrant test and one leg standing lumbar extension test help to assess the lumbar spine facet joints if the pain is local or determine if a nerve root is involved if the patient experiences radiating pain.6 The outcome measures include: Functional Movement test (lift 10lbs. ground to plinth), Timed Up and Go (TUG), Oswestry Disability Index (ODI), Fear Avoidance Belief Questionnaire (FABQ), McGill Pain Questionnaire and VAS. These measures assess how the specific patient problem is affecting the patient’s ability to manage in everyday life, mobility, risk of falling, disability level, cognitive and affective aspect in relation to low back pain and pain level respectively.6 These outcome measures help to objectively measure patient improvement throughout therapy interventions.

Examination:

Table 1: Examination FindingsExamination findings:Procedure: Results: Reliability and Validity: Rationale for procedure:Posture assessment: Sitting Standing

Sitting: rounded shoulders, slight forward head and decreased lumbar lordosisStanding: slight rounded shoulders and decreased lumbar lordosis

Forward head posture:Inter-rater reliability8: 0.02Gross body posture9 (observation): kappa = 0.79

Posture was assessed to see if the patient demonstrates normal curvature of the spine, shoulders and head and ability to maintain the pelvis in a neutral position.

Neuroscreen: Dermatomes Myotomes

Dermatomes L1-S1: WNLMyotomes L1-S1: WNLPatellar tendon: 2/4

Not available. These screening procedures would have to be consistent and reproducible for

A neuroscreen is completed to determine if nerve roots are affected


Reflexes Achilles tendon: 2/4 clinician’s to obtain data. and if the patient shows signs of an impaired nervous system.

Mobility testing:

PA testing of the lumbar spine

Goniometric measurements of the lumbar spine

Goniometric measurements of the hips

PA glides of thoracic and lumbar spine: decreased mobility of L3-L5

Lumbar spine goniometric measurements:Lumbar flexion: 32°Lumbar extension: 15°R lateral flexion: 15°L lateral flexion: 15°Inclinometer: Lumbar flexion 26°; Lumbar extension 8°

Hip goniometric measurements:R hip flexion: 112°; L hip flexion: 92°R hip extension: 14°; L hip extension: 12°R hip internal rotation: 21°; L hip internal rotation: 8°R hip external rotation: 18°; L hip external rotation: 15°R hip adduction:18°; L hip adduction:15°R hip abduction: 30°; L hip abduction: 24°

PA testing of lumbar spine10:Intertester reliability for identifying least mobile segment was good (agreement= 82.8%, kappa= .71, 95% confidence interval= .48 to .94)Intertester reliability for identifying most mobile segment was poor (kappa= .29, 95% confidence interval= -.13 to .71) with good agreement (79.3%)Validity of PA assessments of least and most mobile segments was poor (kappa= .04, 95% confidence interval= -.16-.24, agreement= 24.1%)Goniometry7:Lumbar spine: reliability with radiographic measures; r= 0.93 overall, r= 0.95 flexion, r= 0.85 extension; interrater reliability: r= 0.88 flexion and r= 0.42 extensionHip: intrarater reliability IR and ER 0.96 to 0.99 (excellent), hip flexion 0.94 (excellent), hip extension 0.70 to 0.89 (moderate to excellent)Inclinometer11:Total lumbar range of motion: r= 0.97Lumbar flexion: r= 0.98Lumbar extension: r= 0.75

Mobility of the lumbar spine and hip are assessed to determine any range of motion impairments or segmental mobility is contributing to the patient’s impairments.

Manual muscle testing (MMT):

R and L hip flexion, hip extension, hip ER, hip abduction and hip adduction: 5/5R hip IR: 5/5 ; L hip IR: 4/5 d/t pain

Interrater reliability: 41-51% (grade of MMT); 87-93% (grade of +/-)12

Intrarater reliability: 54-65% (grade of MMT); 96-98% (grade of +/-)12

Predictive validity: ASIA LE subscale 66% FIM lower cord scores; quadraplegia MMT 0.95 (strong)12

Manual muscle testing is assessed to determine if muscle weakness is present.


Repeated movement testing:

Lumbar flexion: pain with end-range, decreased with more repetitionsLumbar extension: slight pain with end-rangeProne press up: no symptoms, “stretch”

Reliability13:Lumbar patients: k= 0.89Centralization: k= 0.7290

Direction preference: k= 0.9290

Repeated movement testing is used to assess pain and symptoms throughout the range or after repetitions. Symptoms may peripheralize or centralize.

Trunk muscle power and endurance tests:

Trunk flexors: smooth, controlledTrunk extensors: > 30 seconds, WNLLateral abdominals: > 30 seconds, WNLTransverse abdominals: 9 mmHg drop, WNLHip abductors: R smooth, controlled; L guarded, uncontrolledHip extensors: > 180 seconds, WNL

Reliability7:ICC= 0.89-0.90 (good)Lateral abdominal reliability: 0.97 (excellent)Hip extension reliability: 0.84 (good)

Endurance tests are used to assess the patient’s ability to maintain a certain position with an isometric hold or the ability to control the motion. Impairments can lead to movement incoordination problems.

Special tests:

Straight leg raise Slump test Quadrant test One leg standing

lumbar extension

SLR: -Slump test: -Quadrant test: + (local pain, no radiating pain)One leg standing lumbar extension: R: + (discomfort) L: + (d/t left hip pain)

SLR:Reliability7:kappa= 0.68Sensitivity14: 0.87 and specificity14: 0.94; Sensitivity6: 40-97% and Specificity6: 10-57%; reliability6: kappa= 0.32-0.86Slump test15:reliability kappa= 0.83 to 0.89; sensitivity 0.84 and specificity 0.83Quadrant test: Sensitivity, specificity and reliability are not established6

One leg standing lumbar extension16:Sensitivity: 0.96, specificity: 0.88

The Straight leg raise helps assess neural mobility and the sciatic nerve and its branches, due to the sensitivity and specificity it tends to rule out a patient with neurological signs.

The Slump test helps to rule out neurological involvement as well as radiating pain and joint mobility.7

The Quadrant test is used to assess intervertebral foramen pathology and the patient may experience local pain or radicular symptoms.6

The one leg standing lumbar extension test assesses for a stress fracture or facet joint pathology.13

Outcome measures: Functional Movement

test (lift 10lbs. from ground to plinth)

Functional movement test (lift 10 lbs.): able with good body mechanics, no painTUG: 6.7 seconds

*refer to table under “Outcome”

*refer to table under “Outcome”


Timed Up and Go (TUG) Oswestry Disability

Index (ODI) Fear Avoidance Belief

Questionnaire (FABQ) McGill Pain

Questionnaire (with VAS)

ODI: 4/50FABQ-PA: 14/24; FABQ-WORK: 18/42McGill Pain Questionnaire: S: 5/33A: 1/12 ; VAS: 2/10

Examination procedures included assessing posture, with the patient sitting and standing. To assess posture, the clinician observed the patient’s head in relation to the shoulders and neutral spine as well as the patient’s shoulders and curvature of the spine, specifically the lordosis in the lumbar spine. Next, myotomes and dermatomes were assessed. With the patient’s eyes closed, the clinician assessed the dermatomes L1-S1 by touching the trochanter for L1, anterior thigh for L2, knee for L3, big toe for L4, lateral plantar foot for L5 and posterior leg for S1/S2.13 To assess myotomes the patient keeps their eyes open and the clinician applies resistance to the hip flexors to assess L2 and L3, anterior tibialis for L4, extensor hallucis for L5 and plantarflexors for S1.13 Next, with the patient seated on treatment table, clinician uses a reflex hammer to assess the patellar tendon reflex and Achilles tendon by bringing the foot into slight dorsiflexion.13 For mobility testing, the patient is prone on the treatment table and is asked to expose the area of the lumbar spine being assessed. The clinician uses the pisiform to apply an anteriorly directed force on the lower thoracic and lumbar spinous processes keeping elbows extended to assess mobility as normal, hypermobile or hypomobile.7

For goniometric measures of the lumbar spine, clinician places the axis of the goniometer at the midaxillary line at the level of the lowest rib, moving arm along the midaxillary line and stationary arm vertical to the floor to measure lumbar flexion and extension.17 The clinician instructs the patient to bend forward and bend backwards. For lumbar lateral flexion, the axis of the goniometer is placed at the spinous process of S1, moving arm towards the spinous process of C7 and the stationary arm vertical to the floor as the clinician instructs the patient to slide hand along side of thigh as far as possible.17 For goniometric measurements of the hip, the axis is placed at the greater trochanter, moving arm on midline of the femur and stationary arm on midline of trunk for hip flexion and extension.17 For hip abduction and adduction, the axis of the goniometer is placed on the ASIS on the ipsilateral side, moving arm on the midline of the femur and stationary arm towards the contralateral ASIS.17 For hip internal and external rotation, the patient is seated on the treatment table and the axis of the goniometer is placed at the mid-point of the patella, moving arm on the shaft of the tibia and stationary arm perpendicular to the floor.17

In order to assess repeated movements, the clinician has the patient stand and flex forward five times and extend backwards five times and assesses symptoms. For trunk muscle power and endurance tests, the clinician is assessing symptoms, recording the time or looking at the patient’s quality of movement. For trunk flexors, the patient is supine and the clinician brings both of the patient’s legs up to when the sacrum appears to rise off the table and instructs the patient to lower their legs while maintaining contact of the back with the treatment table.7 The clinician will observe for the low back elevating off the table if the patient is in an anterior pelvic


tilt. To assess trunk extensors, the patient is prone with their hands by their side and the clinician instructs them to lift their chest off to table and hold the position.7 For lateral abdominals, the patient is side lying with knees flexed and elbow resting on table.7 The clinician instructs the patient to lift off the table and maintain the position. For transversus abdominis, the patient is prone on the treatment table and the clinician places pressure biofeedback unit that is inflated to 70 mmHg under transversus abdominis.7 Then, the clinician asks the patient to draw in their stomach for 10 seconds and records the drop in pressure. For hip abductors, the clinician observes for quality of movement as the patient is side lying with legs extended and raises the top leg.7 Hip extensors are assessed by the patient performing a bridge and maintaining the position.7 Manual muscle testing is performed by the clinician as the clinician resists the direction of motion of the patient and grades muscle performance.12 Further into the examination, the clinician performs special tests. With the straight leg raise, the patient extends both legs on the table and the clinician elevates on leg at a time until symptoms are produced, then decreases the hip flexion angle and dorsiflexes the foot and reassess for symptoms.6 In order to complete the slump test, the patient is seated and instructed to slouch then the clinician extends one leg at a time and dorsiflexes the ipsilateral foot and can have patient extend neck to assess for symptoms.13 For the quadrant test, the patient is standing and moves into extension and ipsilateral side bend with the clinician standing behind the patient and assessing for symptoms.6 The patient is standing on one leg for the one leg standing lumbar extension test and extending backwards as the clinician also assesses for symptoms.13

In regards to the above examination data, it is apparent that the patient demonstrates forward head, rounded shoulders and decreased lumbar lordosis, which are factors influencing the low back pain. Additionally, the patient presents with decreased lumbar segmental mobility, reduced lumbar range of motion and decreased left hip range of motion, specifically internal rotation, due to left hip osteoarthritis. The patient’s strength is not impaired, however the left hip internal rotators are limited due to left hip pain during examination. During repeated movement testing, the patient experienced symptoms at end-range spinal motions, especially during lumbar flexion, and did not experience symptoms when completing a prone press up. Trunk endurance tests did not show impairments, whereas the hip abduction endurance test on the left side was uncontrolled and painful. From the special tests, it is apparent that the patient experiences symptoms when the facet joints are stressed and intervertebral foramen are narrowed.13

Clinical Impression #2

The concordant signs of this patient are low back pain and lateral left hip pain involving groin, buttock and greater trochanter regions. The initial impressions are still consistent in this case.

Based on the JOSPT guidelines and the examination findings, the diagnosis most likely is subacute low back pain with mobility deficits, including lumbosacral segmental/somatic dysfunction, with a good prognosis due to the motivation and active lifestyle the patient demonstrates.7 The patient presents with unilateral hip and thigh pain as well as low back pain and back stiffness.7 Symptoms for the patient were produced with end-range spinal motions and were apparent during the provocation tests that include: the Quadrant test an One leg standing lumbar extension test. Additionally, the patient demonstrates restricted lumbar range of motion and segmental mobility coupled with restricted hip range of motion.7 A possible competing


diagnosis would be subacute low back pain with movement coordination impairments including spinal instabilities, due to the worsened pain at end-range of motion, low back pain reproduced with provocation tests and mobility deficits of the lumbopelvic and hip regions.7 In regards to pathologies present related to the spine, the patient may be at risk for spondylosis considering the patient is over 40 years old and , presents with forward head and occurs in men more than women.13 Additionally, the patient presents with hip osteoarthritis and may have arthritis in the lumbar region of the spine or degenerative disc disease. These pathologies can cause the decreased joint play that was assessed by performing segmental mobility during the examination.13

The plan of action for this patient entails an intervention plan and a referral for a consultation with an orthopedic surgeon due to the left hip osteoarthritis. Although some researchers suggest a total hip replacement for a patient with severe osteoarthritis to improve low back pain, others suggest that a total hip replacement can cause low back pain.18,19 Taking this into consideration, it is important as a clinician to refer this patient to an orthopedic surgeon to be evaluated and undergo more recent imaging, since the patient’s imaging results are from one year ago. However, the patient, whether undergoing a total hip replacement in the future or not, can still participate in physical therapy. The intervention plan includes: manual therapy to improve lumbar and hip mobility, therapeutic exercises to improve lumbar and hip range of motion and patient education regarding positioning and pain management strategies while returning to activities like slow pitch softball.7Additionally, exercises that address coordination impairments will be beneficial as well as stabilization exercises. If no action is taken to address the impairments the patient is presenting with and interventions including manual therapy, stabilization exercises, therapeutic exercises and patient education are neglected, the patient will present with greater mobility deficits and likely experience more pain. The patient will present with greater limitations in lumbar range of motion and a greater stress on the anterior structures due to the increased flexed posture, rounded shoulders, forward head and decreased lumbar lordosis13 With greater impairments and range of motion limitations, the patient’s activities of daily living will become more impaired and may lead to the patient feeling depressed and anxious.

Proceeding with treatment, the overarching goal for intervention is to decrease low back pain to 0/10 and increase mobility of his low back and left hip. Additionally, patient will return to playing slow pitch softball with his friends with no pain by next year. Patient will decrease score of FABQ-PA, FABQ-WORK, McGill Pain Questionnaire and VAS.

For follow up evaluation of outcomes, the clinician will reassess lumbar mobility, including PA segmental mobility and goniometric measures as well as hip goniometric measures every two weeks. These mobility tests are crucial to reassess to determine adequate intervention methods to increase range of motion. Additionally, posture will be reassessed to encourage normal curvatures of the spine and reduce greater amounts of stress on the vertebra. Additionally, the outcome measures that include the ODI, FABQ-PA and FABQ-WORK, McGill Pain Questionnaire and VAS will be assessed every two weeks. Additional tests I would implement include the Harris Hip Rating Scale and the Oxford Hip Score to further determine the level of impairment particularly in the patient’s hip. The Harris Hip Rating Scale involves a pain, function absence of deformity and range of motion section.6 The Oxford Hip Score has twelve


multiple choice questions and relates to the severity of hip arthritis.6 These tests will help further differentiate between the low back impairment and the hip impairment.

Intervention

The interventions that will be implemented in regards to physical therapy involve manual therapy to improve lumbar and hip mobility, therapeutic exercises to improve lumbar and hip range of motion and patient education regarding positioning and pain management strategies to be able to return to prior activities like slow pitch softball. Additionally, with the referral for a consultation with an orthopedic surgeon, the patient may benefit from a total hip replacement due to the severe osteoarthritis in his left hip.18,19 However, the patient will still benefit from physical therapy services before a total hip replacement if a replacement is needed.

Table 2: Intervention

Physical Therapy InterventionsPrimary Problem: Acute Phase (moderate to minimum

protection) Interventions→ Progressions (minimum to no protection)

Rationale for Intervention:

Low back pain and hip pain Neutral spine Active spinal control in supine, prone,

quadruped, sitting, standing Dynamic maintenance of pain-free

position with activities (mid-range) Patient education encouraging patient

to return to or pursue an active lifestyle

Progress to: Neutral spine in functional activities, patient education encouraging return to active lifestyle

To promote kinesthetic awareness and implement proprioception training of safe movement and postures to decrease low back pain.

Decreased lumbar segmental mobility, lumbar range of motion and left hip range of motion

Gentle spinal movement into painful range

Stretch LE muscles; stabilize spine in position of bias (hip flexors, extensor, abductors)

Manual therapy to improve segmental lumbar (PA glides) and hip mobility (inferior, posterior, lateral glides if no inflammation in severe case of OA)6

Progress: Moving into painful ranges to stretch as indicated

To increase mobility and flexibility of the lumbar spine and left hip by stretching and manipulating restricting tissues.


https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi_5qm9xObSAhUI4oMKHRKSAEgQjRwIBw&url=https://www.youtube.com/watch?v%3DmCZ19YXQru4&psig=AFQjCNFgNSgUTFsQNCXUbBVxpjtRyI2wNw&ust=1490149035482849

Decreased lumbar segmental mobility and decreased endurance of hip abductors

Stabilization exercises with extremity loading- active control of spine position (abdominals: opposite LE on mat bent leg fall out, opposite LE on mat, opposite LE at 90° hip flexion with UE; trunk extensors: extend one LE and slide on mat, extend one LE and lift 6-8 inches off mat, flex one UE and extend contralateral LE)

Emphasize muscle endurance Perturbation training Low intensity dynamic spinal exercises

Progress: Stabilization with transitional motions and functional activities; emphasize strength (abdominals: opposite LE at 90° hip flexion no UE, bilateral LE movement; trunk extensors: extend one LE, extend both LE and lift head arms and LE), dynamic trunk strengthening, trunk and extremity strengthening exercises in patterns that reinforce activity goals (slow pitch softball)

Stabilization training will help activate deep muscles for increased stability while also increasing muscle endurance and strength.

Decreased cardiopulmonary endurance due to limited activity participation (ex. Slow pitch softball)

Low to moderate intensity with moderate to minimal protection: cycling, walking on treadmill

Use activities that emphasize extension and flexion

Progress to: Walking further distances and for a longer period of time

Increasing cardiopulmonary endurance will promote level of activity anticipated in returning to play slow pitch softball.

Decreased participation level in sport activities and decreased amount of time in sitting positions at work.

Stable spine body mechanics with self-care/home management

Strengthen LE while stabilizing spine (hip extensors and hip flexors with theraband)

Stable spine body mechanics Environmental and ergonomic

adaptations (at work- decrease sitting time)

Practice prevention of recurring low back pain episodes

Initiate community/work reintegration training in pain management strategies while returning to community/work activities

Progress to: Community/work reintegration

Increase participation in functional activities including: proper body mechanics, skill in home, in the community, work, recreational activities and slow pitch softball with his friends.


training in pain management strategies while returning to community/work activities, high-intensity functional activities, endurance and strengthening activities that replicate return to desired activities and practice Prevention

Outcome

To help determine patient improvement after intervention strategies are implemented, outcome measures are crucial to include, understand and interpret appropriately. The outcome measures include: the Functional Movement test, Timed Up and Go (TUG), Oswestry Disability Index (ODI), Fear Avoidance Belief Questionnaire (FABQ) and McGill Pain Questionnaire including the Visual Analog Scale (VAS). Additionally, mobility testing, muscle testing, repeated movement testing and trunk muscle and endurance testing can be implemented to measure improvement of range of motion, muscle strength and muscle endurance.

The Functional Movement test assesses the ability of the patient to lift ten pounds from the ground to the plinth with proper body mechanics. The TUG is used to assess mobility, an individual’s walking ability and the risk of falling in older adults.21 The ODI is used to assess limitations a patient is experiencing in their daily life including: pain, intensity, personal care, lifting, walking, standing, sleeping, sex life or homemaking life, social life and travel.6 The FABQ assesses the patient’s fear avoidance behaviors in relation to their pain experienced during physical activity and work.6 The McGill Pain Questionnaire describes the patient’s pain and allows the clinician to assess the influence of intervention on the patient’s pain level.6

Table 3: Outcome measures

Outcome measure: Reliability: Validity: Minimal clinical important difference (MCID) and MCD:

Functional Movement Test (10lb. lift from ground to plinth)

Not available. The 10 lb. lift would be reliable and valid for this case since the patient is either able to complete the task or not, and the clinician observes for proper body mechanics or compensations while assessing for symptoms.



Timed Up and Go (TUG) Test-retest reliability21

Excellent (ICC= 0.75 osteoarthritis)ICC= 0.97 (community dwelling older adults)Interrater reliability21

Excellent (ICC= 0.87

Criterion validity22

Excellent between TUG and radiological stages (r= 0.628)Excellent between TUB and Berg (r= -0.81), gait speed (r= -0.61), Barthel Index of ADL (r= -0.78)

MCID: not establishedMDC24

2.9 secs (chronic stroke)4.09 secs (Alzheimer’s Disease)


osteoarthritis)ICC= 0.99(community dwelling older adults)

Construct validity23

Excellent between TUG and STR (r= 0.88) ; TUG and VAS (r= 0.58)

Oswestry Disability Index (ODI)

Test-retest reliability25

Excellent (ICC= 0.94 (0.89-0.97); 95% CI)


Poor correlation between baseline and change scores (r= 0.11)Construct validity25

Excellent correlation with Pelvic Girdle Questionnaire (PGQ) r=0.71Adequate correlation with FABQ (r= 0.33)

MDC25

11.1 points

Fear Avoidance Belief Questionnaire (FABQ)

Test-retest reliability26

FABQ-PA: r=0.64 (excellent- chronic LBP)FABQ-W: r= 0.80 (excellent- chronic LBP)Interrater reliability26

ICC=0.94


FABQ-W to pain disability 0.57 (adequate)FABQ-PA to pain disability 0.40 (adequate)FABQ-PA to trunk ext/flex torque (TEF): 0.28 (poor)Construct validity26

FABQ-PA adequate correlation with FABQ-W (r=0.41), ODI (r= 0.49), numeric pain rating scale (r= 0.37)FABQ-W adequate correlations with numeric pain rating scale (r= 0.37), ODI (r= 0.34)

MCID26

13 pointsMDC26

6.1 for FABQ-PA; FABQ-W: 13 points; FABQ-PA: 8 points

McGill Pain Questionnaire Test-retest reliability27

Excellent (r= 0.96)Interrater/intrarater reliability27

not established

Content validity28

low back pain (71.9% variance)

MCID and MDC not established27

*Refer to Appendix A for explanation of outcome measures, refer to Table 1 for reliability and validity of mobility testing, muscle testing, repeated movement testing and trunk muscle and endurance testing.

The outcome measures mentioned above will be reassessed for this patient every two weeks in throughout the patient’s plan of care. Goniometric measures and the McGill Pain Questionnaire are crucial outcome measures that will specifically indicate to the clinician if the interventions are effective for this specific patient. Increased mobility and decreased pain in both the lumbar spine and hip are crucial goals in this patient’s plan of care in order to return to play slow pitch softball.

Since the patient is not being followed over an entire episode of care, one cannot compare the outcome measures following physical therapy intervention to the outcome measures that were


collected at baseline. The goals of this patient’s plan of care would be to increase lumbar and hip range of motion. Additionally, to decrease the pain experienced in the low back region and hip in order for the patient to be able to return to play slow pitch softball with his friends by next year. Also, to decrease the FABQ-PA, FABQ-WORK scores and specifically the McGill Pain Questionnaire score that would be indicative of an effective treatment plan.

Discussion

Since hip and spine problems commonly co-exist, the diagnostic and prognostic dilemma of undergoing physical therapy or having the patient consult with an orthopedic surgeon regarding severe hip osteoarthritis and a possible total hip replacement was resolved. Prior to the possibility of having a hip replacement, the patient will still be able to greatly benefit from physical therapy due to his mobility deficit. Researchers stress the importance of identifying if the low back pain is caused by a spinal impairment or if the low back pain is secondary to the hip osteoarthritis.18 Although this can be very challenging for a clinician along with accounting for psychosocial factors mentioned above, researchers have identified that the pattern of pain in the lower back and pain associated with hip osteoarthritis present differently. Patients with hip osteoarthritis typically present with ipsilateral groin pain and buttock pain, whereas patients with a spinal disorder typically experience pain in their anterior thigh, shin and calf which is typically relieved when the patient is sitting.18,19 With this in mind, it is important for a clinician to account for the factors that could possibly play a role in an individual’s low back pain, helping to guide the clinician further in their decision making process from a treatment and prognostic perspective.

This case is unique when compared to other relevant reports in the literature due to the controversial research of low back pain with hip osteoarthritis and with a total hip replacement. While research on conservative treatment of patients with both hip osteoarthritis and low back pain is limited, some studies have suggested exercise and manual therapy are effective.29 Exercise and manual therapy help to decrease pain and increase range of motion, while hip exercises implemented long term can improve the severity of hip osteoarthritis.29,30 As a clinician, it is important to encompass the patient as a whole and incorporate examination of the hip along with the examination of the lumbar spine when the patient is experiencing low back pain. Incorporation of clinical guidelines assist clinicians in their decision making process, however the clinician should consider psychosocial factors since it is critical for a proper diagnosis of low back pain in order for a successful outcome.


References

1. Foster N & Delitto A. Embedding Psychosocial Perspectives Within Clinical Management of Low Back Pain: Integration of Psychosocially Informed Management Principles Into Physical Therapist Practice- Challenges and Opportunities. Journal of Physical Therapy, 2011; 91(5): 790-803.

2. Monie AP, Fazey PJ & Singer KP. Low Back Pain Misdiagnosis or Missed Diagnosis: Core Principles. Manual Therapy, 2016; 22: 68-71.

3. Woolf S, Grol R, Hutchinson A, Eccles M & Grimshaw J. Potential Benefits, Limitations, and Harms of Clinical Guidelines. The British Medical Journal, 1999; 318(7182): 527-530.

4. Underwood M, O’Meara S & Harvey E. The Acceptability to Primary Care Staff of o Multidisciplinary Training Package on Acute Back Pain Guidelines. Family Practice, 2002; 19(5); 511-515.

5. Higgs J, Jones M, Loftus S & Christensen N. Clinical Reasoning in the Health Professions. 3rd edition, 2008.

6. Wise, CH. Orthopaedic Manual Physical Therapy: From Art to Evidence. Philadelphia: FA Davis, 2015.

7. Delitto A, George SZ, et al. Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 2012; 42(4): A1-A57.

8. Silva A, Punt D & Johnson M. Reliability and Validity of Head Posture Assessment by Observation and a Four-Category Scale. Manual Therapy, 2010; 15(5): 490-495.

9. Looze MP, Toussaint HM, Ensink J, Mangnus C, & Van Der Beek AJ. The Validity of Visual Observation to Assess Posture in a Laboratory-Simulated, Manual Material Handling Task. Ergonomics, 2007; 37(8): 1335-1343

10. Landel R, Kulig K, Fredericson M, Li B & Powers C. Intertester Reliability and Validity of Motion Assessment During Lumbar Spine Accessory Motion Testing. Journal of Physical Therapy, 2008; 88(1): 43-49.

11. Saur P, Ensink FB, Frese K, Seeger D & Hildebrandt J. Lumbar Range of Motion: Reliability and Validity of in Inclinometer Technique in the Clinical Measurement of Trunk Flexibility. Spine, 1996; 21(11): 1332-1338.

12. Berryman-Reese N. Muscle and Sensory Testing, 3rd Ed. St. Louis: Elsevier Saunders, 2012.


13. Magee 6th edition. Physical Rehabilitation: Assessment & Treatment. 4th Edition. Philadelphia: FA Davis, 2014.

14. Mens JM, Vleeming A, Snijders CJ, Koes BW & Stam HJ. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine, 2001; 26(10):1167-1171.

15. Majlesi J, Togay H, Unalan H & Toprak S. The Sensitivity and Specificity of the Slump and Straight Leg Raise Tests in Patients With Lumbar Disc Herniation. Journal of Clinical Rheumatology, 2008.

16. Laslett M et al. Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests. Manual Therapy, 2005; 10:207–218.

17. Berryman-Reese N & Brandy B. Joint Range of Motion and Muscle Length Testing, 2nd Ed. St. Louis: Elsevier Saunders, 2012.

18. Wang W, Sun M, Xu Z, Qui Y & Weng W. The Low Back Pain in Patients With Hip Osteoarthritis: Current Knowledge on the Diagnosis, Mechanism and Treatment Outcome. Annals of Joint, 2016; 1(9): 1-5.

19. Chimenti PC et al. Factors Associated With Early Improvement in Low Back Pain After Total Hip Arthroplasty: A Multi-Center Prospective Cohort Analyses. The Journal of Arthroplasty, 2016; 31: 176-179.

20. Kisner C & Colby LA. Therapeutic Exercise: Foundations and Techniques.6th Edition. Philadelphia: FA Davis, 2013.

21. Kennedy DM et al. Assessing Stability and Change of Four Performance Measures: A Longitudinal Study Evaluating Outcome Following Total Hip and Knee Arthroplasty. Musculoskeletal Disorders, 2005; 6(3): 1-12.

22. Podsiadlo D & Richardson, S. The Timed "Up & Go": A Test of Basic Functional Mobility for Frail Elderly Persons. Journal of American Geriatrics Society, 1991; 39(2): 142-148.

23. Lin MR et al. (2004). Psychometric Comparisons of the Timed Up and Go, One-leg Stand, Functional Reach, and Tinetti Balance Measures in Community-Dwelling Older People. Journal of the American Geriatrics Society, 2004; 52(8): 1343-1348.

24. Flansbjer UB et al. Reliability of Gait Performance Tests in Men and Women with Hemiparesis After Stroke. Journal of Rehabilitation Medicine, 2005; 37(2): 75-82.

25. Grotle M et al. Reliability and Construct Validity of Self-Report Questionnaires for Patients with Pelvic Girdle Pain. Physical Therapy Journal, 2012; 92(1): 111-123.


26. George S et al. Fear-Avoidance Beliefs as Measured By The Fear-Avoidance Beliefs Questionnaire: Change in Fear-Avoidance Beliefs Questionnaire is Predictive of Change in Self-Report of Disability and Pain Intensity for Patients with Acute Low Back Pain. The Clinical Journal of Pain, 2016; 22(2), 197-203.

27. Ferraz MB et al. Reliability of Pain Scales in the Assessment of Literate and Illiterate Patients with Rheumatoid Arthritis. Journal of Rheumatology, 1990; 17(8): 1022-1024.

28. Byrne M et al. Cross Validation of the Factor Structure of the McGill Pain Questionnaire. Pain, 1982; 13(2): 193-201.

29. Hoeksma HL et al. Comparison of Manual Therapy and Exercise Therapy in Osteoarthritis of the Hip: A Randomized Clinical Trial. Arthritis Rheumatology, 2004; 15(5): 722. (32)

30. Burns SA, Mintkenn PE & Austin GP. Clinical Decision Making in a Patient With Secondary Hip-Spine Syndrome. Physiotherapy Theory Practice Journal, 2011; 27(5): 384. (34)


Appendix A: Outcome Measures

Functional Movement Test:The patient is instructed to lift 10lbs. from the ground to the plinth. While the patient performs this task the clinician assesses the patient’s body mechanics and symptoms. Also, the clinician documents whether the patient was able to complete the task or not.

Timed Up and Go (TUG): The patient sits with their back up against the back of the chair and when the clinician instructs them to start, the patient walks three meters at a comfortable speed and walks back to the chair. The clinician will mark where the patient has to walk to and will time the patient. If the patient uses an assistive device during one of the trials, the patient must use the same device if the TUG is completed again. The time of the patient is then compared to normative data within their age range. This outcome measure assesses the risk of falling in older adults, balance and mobility.21

Oswestry Disability Index (ODI):This is a self-reported questionnaire that is used to assess limitations a patient is experiencing in their daily life including: pain, intensity, personal care, lifting, walking, standing, sleeping, sex life or homemaking life, social life and travel. Each of these 10 sections is scored from 0 signifying no pain or limitations to 5 signifying severe limitations. The ODI is scored by adding up the 10 sections and taking the number and dividing it by 50 to determine the level of disability with a lower score indicating minimal disability.6

Fear Avoidance Belief Questionnaire (FABQ): This is a self-reported questionnaire consisting of 16 questions; the first 5 questions pertain to physical activity while the remaining 11 pertain to work. The clinician scores the assessment by combining the items 2, 3, 4 and 5 for the physical activity subscale which is out of 24 and the work subscale by combining items 6, 7, 9,10,11,12 and 15, which is out of 42. Each item is scaled from 0 to 6 and a higher score is indicative of greater fear avoidance behaviors.6

McGill Pain Questionnaire: This is a self-reported questionnaire that monitors a patient’s pain level and effectiveness of treatment. The short form consists of item 1 to 11 that represents the sensory dimension and items 12 to 15 represent the affective dimension. The patient either marks none, mild, moderate or severe for each of the items. The clinician adds the score with 0 indicating none, 1 indicating mild, 2 indicating moderate and 3 indicating severe. Then, the clinician adds the items mentioned above and the sensory domain is out of 33 points and the affective domain is scored out of 12 points. The VAS score is also assessed by the patient rating their pain level on a scale from 0 indicating no pain a 10 indicating the worst pain possible.6


Documents

jacquelinezak.files.wordpress.com · Web viewAs the presenting physical impairments and radiating pain may be difficult to differentiate between diagnoses, recent research has expressed