9/21/2016
LOW BACK PAIN Common and Not so Common Causes ( From an OMT perspective)
OBJECTIVES • Upon the completion of this workshop participants will be able to: • 1. Identify common and uncommon patterns of somatic dysfunction associated with low back pain: a. Lumbar b. Pelvic c. Sacral d. Lower extremity • 2. Treat the above somatic dysfunctions with selected Osteopathic Manipulative techniques: a. Muscle Energy b. Strain/Counterstrain c. Articulatory Technique d. Direct and Indirect Myofascial Release
PRE-TEST QUESTIONS 1. What is the most common cause of low back pain? a) b) c) d) e)
Degenerative disc disorders Scoliosis Spondylosis Nonspecific Malingering
1
9/21/2016
PRE-TEST QUESTIONS 2. Which of the following is/are included in the “Dirty Half Dozen”? a) b) c) d) e)
Sacral restricted nutation Non-neutral lumbar somatic dysfunction Pubic shear Un-level sacral base All of the above
PRE-TEST QUESTIONS 3. Which of the following low back pain “red-flags” would indicate the need for immediate referral or medical intervention? a) Numbness or paresthesia in the perineal region b) c) d) e)
Unexplained upper or lower extremity weakness Abnormal reflexes Gait deficits The patient is a malpractice attorney
DISCLAIMERS AND ACKNOWLEDGEMENTS • This workshop is not intended to present a comprehensive differential diagnosis, work up or treatment plan for Low Back Pain • John Liccardone, DO, MBA and Dave Mason, DO presented Chronic Low Back Pain at the TOMA/TxACOFP meeting in August • I am using some of their slides (with their permission). • Hopefully, I am adding enough new information that this is worth your time!
2
9/21/2016
LOW BACK PAIN HAS MANY CAUSES
THE IMPACT OF LOW BACK PAIN • LBP is common worldwide
• It affects an estimated 632 million persons worldwide
• #1 cause of years lived with disability • Vast majority of LBP, such as that attributed to lumbar strain and sprain, is considered “non-specific” • The costs to society for LBP are staggering –exceeding $100 billion annually in the United States • Medical care for nonspecific low back pain in the United States has been described as “overspecialized, over-invasive, and over-expensive” Vos T. Lancet 2013;380:2163-2196 Katz JN. J Bone Joint Surg Am 2006;88 Suppl 2:21-24 Waddell G. Spine 1996;21:2820-2825
LOW BACK PAIN DEFINITIONS • LBP Definition • Pain, muscle tension, or stiffness • Localized below the costal margin and above the inferior gluteal folds • With or without leg pain (sciatica) •Chronicity • Acute: 50 (>70) (Cat 2) • Worse at night or not relieved by any position (Cat 2) • Recent trauma or surgery in last year (Cat 2) • Don’t forget certain conditions: • Impairment or long standing worker’s comp litigation (Cat 2)
LUMBAR REGION “RED FLAGS”
PHYSICAL FINDINGS
• Neurological deficits not explainable by mononeuropathy (Cat 1) • Upper motor neuron positive tests (Cat 2) • Clonus • Positive Babinski test
• • • • •
Gait deficits (Cat 2) Elevated sed rate (Cat 2) Fever (Cat 2) Abnormal reflexes (Cat 3) Unexplained significant Upper or lower limb weakness (Cat 3)
DERMATOMES OF THE BODY
8
9/21/2016
“TO IMAGE OR NOT IMAGE THAT IS THE QUESTION” • No Imaging if LBP is without “red flags” • Imaging indicted • • • • •
One Cat 1 (immediate referral to orthopedics or neurosurgery) Two to three Cat 2 Progression of symptoms during treatment Failure to respond after four to six weeks of conservative treatment Worker’s comp/ MVC (Cat 2)
• What to order • X-ray if fracture is suspected otherwise limited value • MRI ( CT if MRI contraindicated) if more serious etiology is suspected • No Contrast and Contrast – indicated previous spinal surgery
9
9/21/2016
NOW WHAT YOU HAVE BEEN WAITING FOR: (HOPEFULLY)
The OMT Approach to LBP!
COMMON SOMATIC DYSFUNCTIONS RELATED TO CHRONIC LOW BACK PAIN • Phil Greenman “Dirty Half Dozen” • • • • • •
Non-Neutral Lumbar Somatic Dysfunction Pubic Shear Innominate Shear Restricted Sacral Nutation (aka forward bending- nodding forward) Muscle Imbalance Syndrome (Psoas) Un-level sacral base (LLI)
Greenman, PE Syndromes of the lumbar spine, pelvis and sacrum Phys Med Rehabil Clin N Am 1996: 7-773-85
10
9/21/2016
You begin with anatomy, and you end with anatomy, a knowledge of anatomy is all you want or need
— A.T. Still MD DO Philosophy of Osteopathy
THE EVOLUTION OF BACK PAIN
11
9/21/2016
NON-NEUTRAL LUMBAR SOMATIC DYSFUNCTION
Atlas of Anatomy Vol. 1, 2nd Ed. Schuenke, Michael. Thieme Medical Publishers 2016
NON-NEUTRAL LUMBAR SOMATIC DYSFUNCTION • Prone position-
• Soft tissue thoracic and lumbar spine • Lumbar diagnosis- test one side at a time
• Rotation: Thumbs depress each transverse process • Depress or push on right TP for Left rotation • Depress or push on left TP for right rotation
• Side-bending: Thumb pushes medially to induce • Push left for right side-bend • Push right for left side-bend
Non Neutral= Side-bending and rotation
to the same side usually one segment and tender!
BDCS3
LUMBAR TREATMENT : NON-NEUTRAL LUMBAR PRONE POSITION • Soft Tissue- stretching, kneading • Prone: Indirect to Direct MFR- Still? • One hand using index and thumb- palpate each transverse (costal) Process • Other arm- grab legs • With lumbar contact hand exaggerate the SD ( IF L5 is Rotated right – exaggerate right rotation- depress left TP) • With leg contact hand exaggerate side-bending by angling lower body to the right (for non-neutral L5 is rotated R the it will be right side-bent)
• Wait for a shift then reverse: take lumbar vertebra into left rotation and left side bending • Lumbar depress the right TP • Swing legs left ( lower body) to the left at the same time
12
Slide 36 BDCS3 Practice about 10 min - 5 min to diagnose. treat and switch Browne, Dr. Carol S, 9/1/2016
9/21/2016
LUMBAR MUSCULATURE
LUMBAR TREATMENT: PRONE COUNTERSTRAIN TECHNIQUE Quadratus Lumborum Tender Points
SCS Treatment
QL Treatment position
Side bend trunk and lower body towards the TP Abduct hip, knee at 90 degrees and externally rotate the hip. Fine tune with abduction and rotation
Also, 2 cm above posterior iliac crest and between TP of L1 and Rib 12
BDCS4
LUMBAR TREATMENT: PRONE COUNTERSTRAIN TECHNIQUE
13
Slide 39 BDCS4 Lets stop again- practice finding and treating Posterior Lumbar TP Browne, Dr. Carol S, 9/1/2016
9/21/2016
BDCS5
Lumbar treatment: Supine Counterstrain Technique • Posterior TP at L5 Transverse process – or just lateral • Maintain contact with tender pointflex ipsilateral hip and knee, may need slight SB to same side • When softness or give felt ask patient if pain is reduced ( aim for 70% reduction) • Hold in position about 90 seconds (be sure to relax and breathe yourself!) • Return leg to neutral , retest TP for response
Anterior TPHips flexed Legs supported Trunk rotated knees towards TP • Push feet away – or towards the TP • • • •
PELVIC SOMATIC DYSFUNCTION: SECRETS TO SUCCESS
• Diagnose all first- for coding- ICD-10 • Treatment follows a pattern:
Non-neutrals- lumbar, pelvic, sacral sheers Pubic Somatic dysfunction
Innominate Somatic Dysfunction Sacrum Follow pattern and other dysfunctions lower in the order may improve before treated.
PELVIC SOMATIC DYSFUNCTION: SECRETS TO SUCCESS
• ASIS Compression test • Lateralizing test for Sacroiliac joint.
• Optional to Standing and Seated flexion
• Method: • Patient Supine, “Reset the pelvis” • AP compression to level of SI joint • Restricted motion is positive test
14
Slide 40 BDCS5 practice these two techniques Browne, Dr. Carol S, 9/1/2016
9/21/2016
PELVIC CAUSES
PUBIC / INNOMINATE SHEARS • Pubic Sheer:
BDCS7 BDCS8
PELVIC CAUSES PUBIC / INNOMINATE SHEARS • Respiratory Assist Superior Innominate Shear (Leg Tug): • Patient supine. • Physician at foot end of table grasps ankle of dysfunction side raises 6-10 inches off of table internally rotates hip joint and applies traction force along leg. Patient inhales and exhales deeply five to seven times. • May add on Muscle Energy – ask patient to pull hip up towards shoulder. • May add on gentle Springing- tug leg rhythmically during exhalation. • May Add Tug: On last exhalation the physician tugs on leg simultaneously.
SACRAL RESTRICTIONS: DIAGNOSIS Landmarks
15
Slide 44 BDCS7 PRactice ASIS compression Browne, Dr. Carol S, 9/1/2016
BDCS8 pubic decompression and leg tug, ME, Springing Browne, Dr. Carol S, 9/1/2016
9/21/2016
SACRAL DIAGNOSIS • Deep sulcus and posterior ILA are on the same side= shear ( may be inferior or superior theoretically- Inferior far more common) • Deep sulcus and posterior ILA are on opposite sides= torsion • Shallow sulcus ( posterior) and posterior ILA same side- Margin posterior
Example of a Right sacral shear or Inferior Right Unilateral Sacral Flexion
BDCS9
SACRAL TREATMENT • Springing (LVLA) and ME- good for shears and torsions • Patient prone. Abduct the hip, sit between patient’s legs and place flexed knee on thigh (or position as illustrated)
• INTERNAL ROTATE hip to gap the SI joint. • Heel of hand pushes medially and cephalad on the inferior ILA • Patient takes deep inhalation and holds ( sacral base posterior)
• LVLA springing • Exhalation and Squeeze knees together (also gaps the SI) – muscle energy • Repeat 2-3 times
BDCS2
BDCS11
SACRAL-ILIAC TREATMENT Articulatory Technique:
• • • • • • • •
Pt supine Flex knee and hip of treatment side (e.g. Right) Left hand under pelvis with tips of fingers on the sacral sulcus Lean forward placing patient’s right knee on left shoulder Compress through to fingers Rotate hip clockwise and counter-clockwise Increase range of motion with each rotation
16
Slide 47 BDCS2 Respiration is the main activating force here. LVMA springing and muscle energy augment this treatment Browne, Dr. Carol S, 8/24/2016
BDCS9 Practice- sacral diagnosis Browne, Dr. Carol S, 9/1/2016
Slide 48 BDCS11 try this on each other Browne, Dr. Carol S, 9/1/2016
9/21/2016
MUSCLE IMBALANCE SYNDROME : PSOAS
BUT DON’T FORGET OUR FRIEND: THE PIRIFORMIS
BDCS10
COUNTERSTRAIN TREATMENT: Psoas Counterstrain • Patient supine • Stand on side of tender point • Knees flexed - ankles together on physician’s knee • Flex and side bend pelvis towards side of pain
PSOAS, ILIACUS, AND PIRIFORMIS
Iliacus Counterstrain • Similar to psoas CS • Except knees fall apart
UN-LEVEL SACRAL BASE:
NOT PART OF THE RESEARCH OR PROTOCHOL
• Best determined by postural x-rays • Check sacral base • Treat lower sacral base with heel lift on ipsilateral side • Do not treat femur height discrepancies
17
Slide 50 BDCS10 Practic e counterstrain Psoas/illiacus and Piriformis Browne, Dr. Carol S, 9/1/2016
9/21/2016
HOW TO GET PAID FOR OMT Diagnosis - Somatic ICD-9 / ICD-10 Dysfunction of the: 739.0 739.1 739.2 739.3 739.4 739.5 739.6 739.7 739.8 739.9 /
/ / / / / / / /
M99.00 M99.01 M99.02 M99.03 M99.04 M99.05 M99.06 M99.07
Head (including OA) Neck Thoracic Lumbar Sacral/sacroiliac Pelvis/Hip Lower Extremity Upper Extremity
/ M99.08 Rib M99.09 Abdomen/other
CPT
Body regions treated with OMT
98925 1-2 areas 98926 3-4 areas 98927 5-6 areas 98928 7-8 areas 98929 9-10 areas Include Modifier -25 when billing an E&M CPT code + OMT CPT code. Ex. Established patient moderate MDM with 7 body areas treated = 99214 -25, 98928 Consults: When using CPT codes: 99241-99245, must meet the 3 'R' requirements: 1. Referral (from patients provider) 2. Render (must perform the consult) 3. Report (communication to provider, consult note)
POST-TEST QUESTIONS 1. What is the most common cause of low back pain? a) b) c) d) e)
Degenerative disc disorders Scoliosis Spondylosis Nonspecific Malingering
18
9/21/2016
POST-TEST QUESTIONS 2. Which of the following is/are included in the “Dirty Half Dozen”? a) b) c) d) e)
sacral restricted nutation non-neutral lumbar somatic dysfunction pubic shear un-level sacral base all of the above
POST-TEST QUESTIONS
3. Which of the following low back pain “red-flags” would indicate the need for immediate referral or medical intervention? a) Numbness or paresthesia in the perineal region b) c) d) e)
Unexplained upper or lower extremity weakness Abnormal reflexes Gait deficits The patient is a malpractice attorney
19