1 Chronic Low Back Pain with Lumbar Hyperlordosis: A Case StudyBy Drew Haverly

2 Body Chart and DemographicsVAS Scale: Current: 1 Best: 1 Worst: 10 26 years old Female Mod. Oswestry: 14/50 (28% Impaired)

3 Initial Hypotheses Spondylolysis SpondylolisthesisLumbar Herniated Disc Lumbar Facet Syndrome

4 Subjective Exam Chronic LBP (ache) for 10+ years since lumbar flexion injury in P.E. class lifting heavy object 2 recent flare-ups with 10/10 sharp p! in low back radiating to LLE to knee: 6/30/17: Standing and cooking 7/3/17: Standing up after prolonged sitting in meeting at work Symptoms lasted several minutes before relieved with self-massage and rest Aggravating factors: Standing/walking 1+ hour; sitting for 2-3 hrs Relieving factors: Changing positions; cooling cream

5 Relevant Past Medical HistoryDiagnosed with Osteopenia (related to PCOS) X-rays: Lumbarization of S1 No Pars Fx

6 Local or Referred Structures

7 Primary Hypotheses Post-SubjectiveFacet Syndrome Differential Diagnoses: Herniated disc Spondylolisthesis SI Joint

8 Physical Exam “Asterisks”Observation: Standing: Excessive lumbar lordosis Gait: BIL Trendelenberg with excessive lumbar lordosis/decreased hip EXT in terminal stance Lumbar EXT>L Rot/L SB: p! in low back and limited ROM (75%) (+) R>L Post Quadrant Test for p! in low back ROM: BIL Hip EXT: -30 degrees with knee in 90 degrees Flex Leg length: L>R Apparent positional faultR innominate anteriorly rotated L ABD MMT: 3+ Lateral Step Down Test: L=4; R=2 SL Squat: L: Dynamic Valgus and Trendelenberg. R: Lat trunk lean LPM: 3/5 R AP and L PA: Poor initiation and endurance SLR: L>R p! in low back at degrees Slump: (+) L only

9 Severity/Irritability & Stage/StabilityModerate Severity Ache in low back for 10+ years, but recent more severe episodes with sharp and radiating pain. Moderate Irritability Constant ache for 10+ years with increased symptomatic pain induced through simple lumbar movements Stage Acute on Chronic Stability Fluctuating (due to recent flare-ups)

10 Recognizable Pattern Post-Objective ExamFacet Syndrome with Lower Quarter Cross Syndrome Clues Extension and Asymmetrical Sensitivity 2. Weak gluteal muscle strength 3. Weak abdominal muscles/core activation 4. Tight hip flexors

11 Initial Evaluation HEPS/L ABD SLRs – 3x10 Quadruped Alt UE/LE Lifts (Bird-Dogs) – 3x5 each side Psoas half-kneel stretch – 3x30” Standing Quadriceps stretch – 3x30” Based on this patient’s presentation and examination findings, is there anything else that you all would have looked at or dug deeper on?

12 Clarification Needed (+) SLR and Slump SI Joint assessmentRF vs Iliopsoas Tightness Determine where the neural tension plays into the big picture? Is it due to adhesion from the initial disc/flexion injury? Difference in leg length: NEED to look at SIJ

13 My Gap In Knowledge The association or relevance between lumbar hyperlordosis and LBP

14 Clinical Question In a 26 year old female patient with chronic LBP and lumbar hyperlordosis, would focusing exercises on decreasing the lumbar lordotic angle, when compared to conservative treatment of lumbar stabilization exercises alone, reduce the number of visits and pain level with functional activities?

15 Effects of William Training on Lumbosacral Muscles: MEffects of William Training on Lumbosacral Muscles: M. Javid, et al 2015 Journal of Back and Musculoskeletal Rehabilitation Randomized Controlled Trial Purpose: Evaluate the effects of 8 weeks of William’s training on flexibility of lumbosacral muscles and lumbar angles in females with hyperlordosis. Methods: 40 female high school students with hyperlordosis with LBP randomly divided into an exercise (William’s Training) or control group, and received training for 3 sessions/week for 8 weeks Post-8 weeks: Improvement was assessed via lumbar lordosis measurement, HS flexibility, Hip flexor muscle strength, lumbar muscle flexibility, abdominal strength, and pain. **Discusses the evidence of the association between lumbar hyperlordosis and increased prevalence of LBP** Discusses how the increase in lordotic angle proportionally increases the shearing strain in the anterior direction and shifts COG anteriorly Muscles can provide segmental stabilization by controlling motion in the neutral zone, and the neutral zone can be regained by effective muscle control. 40 high school females selected from high schools in Dehdasht, Iran who had increased lumbar lordosis (used flexible ruler: Youdas method=index of lordosis=4(arctan2H/L).) HS flex: Active knee EXT test (90-90 knee ext w/inclinometer 1 in below fibular head) Abdominal ms: Kendall and McCreary: Angle at which subject could no longer maintain post pelvic tilt with knee EXT from hip 90 deg flex Lumbar extensor flexibility: Modified Schober: 10 cm sup to psis and 5 cm inf to psis…flexed FW and measure distance Hip flexor tightness: Thomas test Pain: VAS

16 William’s Training ProtocolPosterior Pelvic Tilt (5-10” hold) Single Knee to chest (5-10” hold) Double knee to chest (5-10” hold) Partial sit-up with posterior pelvic tilt Hamstring Stretch in long-sit Hip Flexor stretch Squats Baseline for all exercises were 1x10, and all progressed to 3x20. Control group: “Corrective Training” was not described Dr. Williams (orthopedic surgeon in 1937) designed this exercise protocol specifically for men under 50 and women under 40 with lumbar hyperlordosis. Purpose of exs to reduce pain and ensure stability of lower trunk by toning ab muscles, buttocks and hamstrings, with the extension of hip flexors and sacrospinal muscles. Single and Double knee to chest: Stretch the LOW BACK muscles, glutes, and HS…..Also hip flexor of stationary leg Why HS stretch? Was referred to in passing in the study, but not talked about. Just mentioned a past study looking at increasing HS flexibility through isokinetic training as effective in improving HS performance. ***He later talks about the exercises “toning” the HS, so by stretching the HS, their belief is they will perform better and provide more stability to the trunk.*** Stretching of a musculotendinous unit may also affect neuromuscular transmission . Says “HS muscle stretching exercises seem to be commonly used and applied.” Refers to this article, but conclusions from it=CONCLUSION AND DISCUSSION: The results of this study suggest that there is no relationship between hamstring muscle length and lumbopelvic posture. There was some indication, however, that stretching the hamstring muscles may affect motion during forward bending. Hip flexor stretch: Lizard pose Control group: mentions commonly prescribed therapeutic exercise

17 Values of P<0.05 significantExercise group: Sig differences: Lumbar angle, Abdominal strength, lumbar Extensor muscles flexibility; HS flexibility; Pain

18 Experimental Group Main causes of back deformities: weak abdominal and gluteal muscles, and tight hip flexors and erector spinae muscles

19 A Randomized, Controlled Trial of Manual Therapy and Specific Adjuvant Exercise for Chronic Low Back Pain: Geisser, et al. 2005 Clinical Journal of Pain Purpose: Examine the effectiveness of manual therapy with specific adjuvant exercise for treating CLBP. Methods: 100 subjects aged with primary c/o CLBP were randomly assigned to 1 of 4 treatment groups: Manual therapy with specific adjuvant exercise program (SE); Manual therapy with non-specific exercises; Sham manual therapy with SE; Sham manual therapy with non-specific exercises. Outcomes: Pain (VAS and MPQ), Disability (QBPDS and MPI), Satisfaction with Treatment Questionnaire QBPDS: Quebec Back Pain Disability Scale – ADL’s MPI: Multidimensional Pain Inventory – how p! interferes w/life

20 Study Interventions Manual Therapy (MT) Sham Manual TherapyPrimarily METs specific to patient impairments Sham Manual Therapy Patients placed in controlled position that would potentially correct dysfunction, but METs were not performed Specific Adjuvant Exercise Program (SE) Designed to help improve specific musculoskeletal dysfunctions observed during evaluation Non-specific Exercises (NE) Did not target specific M-S dysfunctions SE: Self-corrections for innominate dysfunction; Stretches (ie supine hip flexor, supine HS, kneeling QL stretch (Childs pose and to the R and L); TFL stretch); Strengthening (ie lower abdominal progression, prone hip EXT, S/L hip ABD/ER, Glut med strengthening with hip diagonals) NE: AEROBIC EXERCISES 3x/wk (No direction); Quad stretch, double/single knee to chest stretch, sitting and prone on elbows HS stretches. Instructed to do stretches and/or self-corrections 2x/day

21 Pain Results A combo of MT-SE had significant effect on p! using both p! scales. Sham MT and NE had worst as one would expect. SE had slightly better than MT Change scores: subtracting pre-tx scores from post-tx scores. NEG change denotes IMPROVEMENT on a particular measure. POS score = decline over tx. Residual change scores: (z-scores) – control for regression to the mean effects - mean of 0 and SD of 1

22 Disability Results MT-SE SMT-SE MT-NE SMT-NE*No significant changes in disability with exception of sham MT-SE displaying a significant increase in disability. --Did cite another article from 2003 that shows significant improvements at 1 year follow-up in both pain and disability in both Manual and Exercise groups, with more significant changes in the manual group COMBO of MT and SE had greatest efficacy for treating CLBP; not either alone. *Pain reduction with CLBP doesn’t necessarily lead to change in function. MT-SE reported greatest satisfaction Sham MT-SE reported least amt of satisfaction Discussion: Can’t account for all of the psychosocial aspects that relate to back pain

23 Electromyographic Analysis of Core, Trunk, Hip, and Thigh Muscles During 9 Rehabilitation Exercises: Ekstrom, et al. 2007 Journal of Orthopaedics and Sports Physical Therapy Purpose: Identify exercises that could be used for strength development and the exercises that would be more appropriate for endurance/stabilization training. Methods: Surface EMG analysis on 30 subjects while performing 9 different exercises. Focused on RA, EO, Abdominis, Longissimus Thoracis, Multifidus, Gluteus Maximus, Gluteus Medius, Vastus Medialis, and Hamstring muscles

24

25 Gluteus Medius and Maximus

26 Lumbar and Core Stabilizers

27 My Patient Impairments Functional Limitations GoalsLimited and painful lumbar EXT, L ROT, L SB Pain with prolonged walking (1 hour) Patient will increase hip EXT ROM from -30 deg to 0 deg in order to improve gait mechanics. Increased lumbar lordosis/Anterior pelvic tilt Pain with prolonged standing (1 hour) Patient will be able to perform 10 SL squats on each leg without trunk sway or dynamic valgus. Decreased Hip EXT ROM Pain with prolonged sitting (2-3 hours) Patient will be able to walk for at least 1 hour w/o c/o pain. Weak gluteal strength L>R Patient will be able to attend Barre class 3x/wk w/o c/o p! during or after class. Decreased core activation

28 Visit 1 Daily comments: Pt experienced pain for 2 days post I.E., but was then able to do exercises 2x/day. Had difficulty understanding how to maintain proper back position during exercises. Assessed SIJ: (-) All special tests Palpation: Tender and wincing at central and R transverse processes of L4 and L5 Assessed Hip EXT in S/L: RF and Iliopsoas equally limited R>L Manual Therapy Stretches Exercises Supine MET for R Anterior Innominate Half-kneel Iliopsoas stretch - 3x30” S/L ABD SLR – 3x10 S/L Hip EXT Contract-Relax Standing quadriceps stretch – 3x30” Pressure Biofeedback: Neutral spine with ALT UE, marches, ALT LE EXT S/L Hip EXT Agonist-Reversal S/L Hip EXT Reciprocal Inhibition Supine MET: Resisted R hip EXT and Left hip FLEX

29 Visit 2 Daily Comments: Pt feels better this past week than she did the week before last treatment. Home exercises still challenging, but going well. Pre-tx Re-assessment: (+) for p! in low back and 75% ROM with lumbar EXT; (-) for L SB and L rot; (+) for R lower quadrant test. (+) L SLR test with p! in low back between degrees of flexion Post-tx Re-assessment (-) Lumbar EXT and R lower quadrant test (100% w/o c/o p!) Manual Therapy Exercises Supine MET for R Anterior Innominate Sciatic nerve gliding in L SLR with PF/DF Supine Hip EXT Contract-Relax (Thomas Test pos.) Pressure Biofeedback: Neutral spine with LE marches and ALT LE EXT at 90-90 S/L Hip EXT Agonist-Reversal S/L Hip EXT Reciprocal Inhibition Planks: Prone, L, and R

30 Visit 3 Daily comments: Pt reported she had a good week. No c/o p! except 1 night having 2/10 ache in low back that went away with Ibuprofen. Dealt with landlord issues all week, so wasn’t able to consistently perform HEP. Did post pelvic tilt exs every other day and planks 2x which she found very challenging. Pre-tx assessment: Pt had “awareness” of sensitivity in low back with Lumbar EXT, L SB, R lower quadrant test, but not p!. (-) SLR, Slump Post-tx re-assessment: No p! with any lumbar movements. Manual Therapy Exercises Supine MET for R Anterior Innominate Pressure Biofeedback: supine hook-lying LE marches, Alt LE Ext Alt LE EXT S/L Hip EXT Contract-Relax Planks: Prone, L, and R S/L Hip EXT Agonist-Reversal Staggered stance shoulder flex with ab bracing: Level 1 tubing S/L Hip EXT Reciprocal Inhibition

31 Future Recognition of Facet Syndrome and Lower Quarter Cross SyndromeSubjective Objective P! with prolonged standing/walking Asymmetrical loss of motion with ipsilateral lumbar SB/Rot loss and EXT sensitivity Localized p! in low back Increased lumbar lordosis No numbness or tingling Weak gluteal muscle and abdominal/core strength No radiating p! below knee Lack of hip EXT ROM

32 Prognosis and ExpectationsProgression: Increased repetitions and hold times with strengthening exercises (ie planks) Standing exercises with abdominal bracing More functional training while maintaining neutral spine (emphasizing gluteal and abdominal strength) Prognosis: Good Favorable Factors: Young; Active; Healthy BW; Positive response to initial treatment Unfavorable Factors: Chronic pain for 10+ years; Osteopenia

33 Reflection Make sure to differentiate between RF and Iliopsoas tightness If SIJ is a potential differential diagnoses, perform the cluster of special tests that can accurately rule it in or out. Utilize palpation in evaluation Palpation can be very helpful in terms of locating regions of pain or discomfort, assessing mobility of the joints and the integrity of soft tissue. Continually assess and re-assess to determine efficacy of treatments Focusing on improving impairments of Lower Cross Syndrome can improve mechanical deformities and decrease pain in patients with low back pain.

34 References Javid, Marziyeh, Rouholah Fatemi, and Ebrahim Najafabadi. "Effects of William Training on Lumbosacral Muscles Function, Lumbar Curve, and Pain." Journal of Back and Musculoskeletal Rehabilitation 28 (2015): Geisser, Michael E., Ph.D, Elizabeth A. Wiggert, PT, Andrew J. Haig, MD, and Miles O. Colwell, MD. "A Randomized, Controlled Trial of Manual Therapy and Specific Adjuvant Exercise for Chronic Low Back Pain." Clinical Journal of Pain 21.6 (2005):   Ekstrom, Richard A., PT, Robert A. Donatelli, Ph.D, and Kenji C. Carp, PT. "Electromyographic Analysis of Core Trunk, Hip, and Thigh Muscles During 9 Rehabilitation Exercises." Journal of Orthopaedic and Sports Physical Therapy  (2007): Cairnes, Mindy C., Karen Harrison, and Chris Wright. "Pressure Biofeedback: A useful tool in the quantification of abdominal muscular dysfunction?" Physiotherapy 86.3 (2000):   Ferreira, Manuela, Paulo Ferreira, and Jane Latimer. "Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial." Pain 131 (2007): Aure, Olav, PT, Jens Nilsen, PT, and Ottar Vasseljen, PhD. "Manual therapy and exercise therapy in patients with chronic low back pain." SPINE 28.6 (2003):