Category: CONTRACTILE DYSFUNCTION

 

 

  1. Lumbar spinal stenois (LSS)…defined by any narrowing of the spinal canal and/or nerve root canals…In patients with severe LSS, a space reduction of 67% has been found in the spinal canal.”

 

Spinal stenosis is the narrowing of the holes of the spine. The spine has 3 holes in it in the lumbar region. Each hole carries a nerve. It could either be the nerve of the spinal cord down the middle, and larger, hole. It could be the nerve roots out of the holes on the side of the spine. Each hole needs to be big enough so that it doesn’t irritate the nerve that it allows to pass through the hole. Picture a water pipe. If you put too much stuff in the pipe it will clog up. Sometimes there are tissues that can make their way into the holes of the spine to clog the holes. When the hole is clogged, the nerves don’t have as much room to do their job (transmitting signals to and from the brain). Now take that same pipe and come back and look at it over decades. There will be sludge and stuff built up around the pipe. This is essentially creating a smaller diameter on the inside of the pipe. This smaller diameter due to sludge is also creating a smaller hole. This could happen in the spine with severe arthritis or degenerative disc issues in which the hole gets smaller. A visual is much better so maybe this will help. image for spinal stenosis

 

  1. “…estimated the incidence of LSS in Denmark to 272 per one million inhabitants per year”

 

In other words, it is not very common in Denmark.

 

  1. “…it is important to discriminate between LSS and disc generated pain since these conditions have different prognoses and the range of evidence based treatments are different, as well.”

 

The treatment between the two issues, discogenic back pain and stenotic back pain, is very different. A thorough evaluation can start to correlate symptoms with either discogenic pain or non-discogenic pain. Many patients believe that an MRI will be the answer to why they have pain, but unfortunately this isn’t so.

 

  1. “a valid and reliable clinical assessment protocol for identifying LSS would be valuable in terms of choosing relevant treatment and informing the patient about the prognosis as early as possible.”

 

This article was written in 2009. The medical profession has existed for eons. There is still not a valid way to assess a patient in order to determine spinal stenosis. There are biologically plausible ways, meaning that when I assess you, I can make an educated guess from some of the findings in the history and physical, but it is not a valid (proven) way of coming to a conclusion.

 

  1. “The high sensitivity and specificity of MRI suggests this is a good test for ruling in and out the disease.”

 

The MRI does a great job of telling us what is abnormal, but it doesn’t do a great job of telling us if the abnormal finding is causing symptoms. As seen in the link above, there are abnormal findings in a population without symptoms. We have to take the imaging findings and see if they make sense after performing a physical exam.

 

  1. “…history will provide strong clues to the presence of spinal stenosis…more than 65 years of age…prolonged history of low back pain and intermittent radiating symptoms having developed gradually…limited walking capacity…Movements or positions involving flexion e.g. sitting or stooping, will often abolish symptoms…total loss of lumbar extension range is usually found, while flexion most often is well preserved.”

 

The typical patient with lumbar spinal stenosis will notice that the ability to walk has gradually reduced over time and there is a need to sit due to back or leg pain. Sitting will typically turn down or off the symptoms rapidly. This patient will have limited motion into extension (think of looking over your head to see the stars or bending backwards while standing).

 

  1. “…stenosis from zygapophyseal joint hypertrophy, ligament thickening or other degenerative changes, it cannot be expected that physical exercise or manual treatment will create a lasting change in the degree of space reduction in the spinal canal or intervertebral foramina”

 

In the presence of physical changes to the bones, ligaments or loss of disc height, there is nothing that a PT can do to change these back to the way that they were previously. These have been described as wrinkles on the inside. If we look at your face we can start to see how much age you have based on the wrinkles in the face. This is also done on the inside in that some “degenerative” changes are normal. Wrinkles are normal; they are not symptoms of anything sinister. The same can be said for physical changes on the inside. They don’t have to be pain generators. It takes a physical exam to determine how your symptoms respond and whether or not this matches the images on an MRI or X-ray. Even then, we can’t say that movement won’t help, only that we won’t change the physical “inside wrinkles”.

 

  1. “The main purpose of this pilot study is to evaluate the validity and intertester reliability of an algorithm of physical examination tests, in relation to identifying symptomatic lumbar spinal stenosis.”

 

This is good. A pilot study is like a pilot for a t.v. show. This is done to see if additional episodes should be done. This study will conclude if additional studies on this topic should be done.   What it hopes to find is a reliable (consistent) way of determining validity (actually seeing what the test hopes to see) in testing for lumbar spinal stenosis. A test that is both reliable and valid should be able to test for spinal stenosis regardless of who is performing the test and who is measuring the test.

 

  1. “Two patients were classified as “LSS” and five patients “Not LSS”, meaning a 29% prevalence of “LSS” Intertester agreement for overall diagnostic conclusion was 100%”

 

There are so few patients that this study will likely not yield any results that are actionable. The interesting thing is that the examiners agreed 100% of the time. This is not common in the medical field to have 100% agreement on near anything.

 

  1. “…the algorithm in its present form can not be used as a screening test to rule out LSS, although it may be able to diagnose the condition.”

 

There were so few people in the study that it is hard for any clinician to put it to use in the clinic. It may be able to diagnose the condition in that it demonstrated a specificity of 1.0, which is really good.

 

 

Excerpts taken from:

 

Lengsoe L, Lyhne S, Melbye M. An algorithm for clinical identification of spinal stenosis-a pilot study of validity and intertester reliability. International J of MDT. 2009;4(2):21-28.

 

Can’t find the abstract to the study, but it is listed under the author’s CV http://pure.au.dk/portal/en/persons/martin-melbye(ed4ee688-2d9e-4c17-b0b1-44a5b4b59ada)/publications/an-algorithm-for-clinical-identification-of-spinal-stenosis–a-pilot-study-of-validity-and-intertester-reliability(6d714ee0-d910-11de-9e3b-000ea68e967b).html

 

 

 

 

Outline to back pain presentation

žCentralization

žCentralization, although first described by McKenzie14, has been replicated in multiple research studies15,16,17.

žCentralization is the movement of symptoms from an area distal to the spine to a more proximal segment14,18.

žPeripherilization is the movement of symptoms, originating from the spine, from a more proximal and central location to a more distal location14.

žThe centralization phenomenon, when produced in patients, correlates with good outcome9,10,18,19.

žPatients presenting as non-centralizers are six times more likely to require surgical intervention19.

žCentralization is shown to highly correlate with a discogenic lesion20.

žOTHER CONSIDERATIONS

  • Spinal Stenosis= reduction of the surface area of the spinal canal or foramen

–No clinical feature or diagnostic test can confirm that stenosis is the cause of symptoms

–A literature review determined that “all studies favored decompressive surgery for improvement of pain, function and quality of life, as well as in terms of patient satisfaction” compared to conservative care24

  • The advantage of surgery was noted within 3-6 months and remained constant for up to 4 years.
  • Surgery is more cost-effective for this group of patients
  • Appropriate for patients that have not improved with 12 weeks of conservative care.

žEPIDURAL STEROID INJECTIONS

žThere are multiple systematic reviews demonstrating that ESI’s can be effective in the short term and long term for managing back pain for both discogenic pain and stenotic pain21,22

žFollowing an ESI, about 45% of patients then demonstrate centralization and report 90% satisfaction of results after 1 year23

žAny questions?

žreference

1.Garzillo MJD, Garzillo TAF. Review of the Literature: Does Obesity Cause Low Back Pain? JMPT 1994;17(9):601-604.

2.Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with the current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378:1560-1571.

3.Walker BF, Williamson OD. Mechanical or inflammatory low back pain. What are the potential signs and symptoms? Manual Therapy 2009;14:314-320.

4.Fritz JM, Cleland JA, Speckman M, et al. Physical Therapy for Acute Low Back Pain: Associations with Subsequent Healthcare Costs. Spine 2008;33(16):1800-1805.

5.Shin G, Mirka G. An in vivo assessment of the low back response to prolonged flexion: Interplay between active and passive tissues. Clin Biomech 2007;22:965-971.

6.Kelsey JL, Githens PB, White AA, et al. An Epidemiologic Study of Lifting and Twisting on the Job and Risk for Acute Prolapsed Lumbar Intervertebral disc. J Orthop Research 1984;2:61-66.

7.Pople IK, Griffith HB. Prediction of an Extruded Fragment in Lumbar Disc Patients from Clinical Presentations. Spine 1994;19(2):156-158.

8.Natural history of lumbar disc hernia with radicular leg pain: Spontaneous MRI changes of the herniated mass and correlation with clinical outcome. J orthopedic surg 2001;9(1):1-7.

9.Long A, Donelson R, Fung T. Does it Matter Which Exercise? A Randomized Control Trial of Exercise for Low Back Pain. Spine 2004. 29(23):2593-2602.

10.Long A, May S, Fung T. Specific Directional Exercises for Patients with Low Back Pain: A Case Series. Physiotherapy Canada 2008;60:307-317.

ž

  1. Kovacs FM, Urrutia G, Alarcon JD. Surgery Versus Conservative Treatment for Symptomatic Lumbar Spinal Stenosis: A Systematic Review of Randomized Controlled Trials. Spine 2011;36(20):1334-1351.
  2. Urquhart DM, Bell R, Cicuttini FM, et al. Low back pain and disability in community-based women: prevalence and associated factors. Menopause 2009;16(1):24-29.
  3. Konstantinou K, Dunn K. Sciatica: Review of Epidemiological Studies and Prevalence Estimates. Spine 2008;33(22):2464-2472.
  4. McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis and Therapy. 2nd ed. Waikanae, New Zealand: Spinal Publication Ltd;2003.

15.Delitto A, Cibulka MT, Erhard RE, et al. Evidence for an extension-mobilization category in acute low back syndrome: A prescriptive validation pilot study. Phys Ther 1993;73:216-228.

16.Donelson R, Silva G, Murphy K. The centralizaiotn phenomenon: Its usefulness in evaluationg and treating referred pain. Spine 1990;15:211-215.

17.Donelson R, Grant W, Kamps C, Medcalf R. Pain response to sagittal end-range spinal motion: A multi-centered, prospective randomized trial. Spine 1991;16:S206-212.

  1. Werneke MW, Hart DL, Cutrone G, et al. Association Between Directional Preference and Centralization in Patients with Low Back Pain. JOSPT 2011;41(1): 22-31.
  2. Skytte L, May S, Peterson P. Centralization: its prognostic value in patients with referred symptoms and sciatica. Spine 2005;30(11):293-299
  3. Laslett M, Oberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal 2005;5:370-380.

ž

  1. Manchikanti L, Kaye AD, Manchikanti K, et al. Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesth Pain Med. 2015;5(1):e23139.
  2. ManchikantiL, Buenaventura RM, Manchikanti K, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15(3):E199-245.
  3. van Helvoirt H, Apeldoorn AT, Ostelo RW, et al. Transforaminal Epidural Steroid Injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. Pain Med. 2014;15(7):1100-1108.

ž

Rehab post TKA

Piva SR, Gil AB, Almeida GJM, et al. A Balance Exercise Program Appears to Improve Function for Patients With Total Knee Arthroplasty: A Randomized Clinical Trial. Phys Ther. 2010;90:880-894.

Intro: 37% of TKA’s still have functional limitations p one year. Diminished walking speed, difficulty ascending/descending stairs, inability to return to sport are chief functional complaints. During TKA surgery several tendons, capsule, and remaining ligaments are retightened to restore the joint spaces deteriorated by the arthritis. Some of the knee ligaments are removed or released, which may affect mechanoreceptors/balance.

PURPOSE:

  1. To determine the feasibility of applying a balance exercise program in patients with TKA
  2. To investigate whether an F (functional) T (training) program supplemented with a balance exercise program (FT+B) could improve function compared to FT program alone
  3. To test the method and calculate a sample size for a future RCT with a larger sample size

METHOD: Double-blind pilot RCT (very strong evidence)

Inclusion: TKA in the previous 2-6 months (meaning not eligible for study if the TKA was before 2 months previous)

Exclusion: 2 or more falls in the previous year. Unable to ambulate 100 feet with an AD or rest period, acute illness or cardiac issues, uncontrolled HTN, severe visual impairment, LE amputation, progressive neurological disorder or pregnant (interesting exclusion criteria).

All went through a quadriceps muscle-sparing incision (cuts through the fascia of the patella instead of the quadriceps) this may be a factor in reducing rehab stay.

See the appendix for the protocol (6 weeks).

Testing measures:

  1. Self-selected gait speed (interesting, but probably not feasible for our clinic)
  2. Timed chair rise test (5 repetitions): easily added to our testing.
  3. single leg stance time: easily added in
  4. LEFS
  5. WOMAC

RESULTS:

  1. Adherence for both groups is 100% and the HEP adherence was similar (filled out logs)
  2. walking speed continued to improve over the course of 6 months for the FT+B group and was 25% better than the FT only group.
  3. The interesting fact is that improvement continued up to 6 months, when previous literature describes 3 months and done.
  4. Single leg stance: FT+B improved (as expected due to SAID), but the FT group either maintained or worsened on speed and balance.

DISCUSSION: FT+B demonstrates clinically important differences in walking speed, SLS, stiffness and pain, without adverse events. Subjects in the FT+B could balance on average 4 seconds longer than baseline. This may be important for weight bearing during the stance phase of walking. Performance-based measures should be used in place of subjective measures.

TAKE HOME: Patients will benefit from the addition of balance exercises post-surgically. It may be prudent to discuss with the surgeons of increasing the length of stay in therapy and decreasing the number of visits per week, as progress continues to occur past the 3 months initially surmised. Each patient should be tested with one or more of the following:

  1. SLS
  2. Chair rise test
  3. Gait speed: important indicator of function/independence/death
  4. Balance test (excluding Tinetti due to possible ceiling affect when the patient no longer needs an AD).

If you need therapy after a total knee replacement, you can contact me at the following location.
Dr. Vince Gutierrez, PT, cert. MDT

Functional Therapy and Rehabilitation (Now part of the Goodlife family)

903 N Infantry Dr.

suite 500

Joliet, IL

60435

815-483-2440