LOW BACK PAIN Common and Not so Common Causes ( From an OMT perspective)

9/21/2016 LOW BACK PAIN Common and Not so Common Causes ( From an OMT perspective) OBJECTIVES • Upon the completion of this workshop participants wi...
Author: Kellie Briggs
3 downloads 2 Views 6MB Size
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