CPR For Diagnosis of Low Back Pain and SI Joint Dysfunction


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Clinical questions: What clinical prediction rules can be used to make diagnosis of LBP more accurate?


Low Back Pain - Pain in the lower back relating to problems with the lumbar spine, discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, or the skin covering the lumbar area[1].

Common Sources
-Majority of cases are linked to a general condition or mechanical nature[2]
  • Muscle strain/sprain
  • Stenosis
  • Degenerative disc disease
  • Sacroiliac joint dysfunction
  • Skeletal irregularities


Low Back Pain Prevelance
  • 80% of the population experiences low back pain in their lifetime
  • 20% of cases progress to chronic stage
  • 3rd most burdensome condition in the US in terms of mortality/poor health (2010)
  • 30%-40% of workforce reports some back pain at any given time
  • Most common cause of work-related disability[3,4]



Low Back Pain Cost

Overall a $200 billion/year problem[5,6]
  • Costs >$50 billion/year in lost work productivity.


Typical Medical Diagnostic Costs

  • MD office visit $200
  • Low back X-Ray $200-$300
  • MRI $800-$1,300
  • Low back CT $1,000-$1500
  • Over the counter pain medication $15/month
  • Prescription pain medication $100/month

Diagnosing Generalized LBP [7]

  • Frenquently misdiagnosed
  • Traditionally diagnosed on expert opinion
  • Need for CPRs to help sub-type LBP diagnosis

Lumbar Spinal Stenosis (LSS) [8]

Narrowing of the spinal canal and intervertebral foramen
The most common cause is Osteoarthritis
  • Most common in people over the age of 60
  • More than 200,000 people per year [9]
  • Interferes with function and ADLs


Common Symptoms of LSS [7]
  • Low back pain
  • Numbness or tingling in the lower extremities
  • Weakness in the lower extremities


CPR for LSS
  • Systematic review in the JOSPT reported a CPR for LSS that has been validated
  • Consists of 10 variables
  • Derived from a study published in the European Spine Journal

Derivation [10]
  • Study used multivariate linear regression to determine what factors were useful for predicting presence of LSS
  • Factors were compared to a panel of experts that was used as the gold standard [10]
  • Primary symptoms of the 469 participants in the study were pain or leg numbness [10]
  • Sensitivity of .92 and specificity of .72[10]
  • Results based on a point scale


Overview of LSS diagnostic CPR

Variable
Score
Age (years)

<60
0
60-70
1
>70
2
Diabetes

Present
0
Absent
1
Intermittent claudication

Present
3
Absent
0
Exacerbation of symptoms when standing

Present
2
Absent
0
Symptoms improve with trunk flexion

Present
3
Absent
0
Symptoms induced with trunk flexion

Present
-1
Absent
0
Symptoms are induced with trunk extension

Present
1
Absent
0
Peripheral artery circulation

Dorsalis pedis artery has diminished pulse or ABI <0.9
0
Dorsalis pedis artery easily be palpated or ABI >0.9
3
Achilles tendon reflex

Normal
0
Absent or low
1
Straight leg raise test

Positive
-2
Negative
0




Variables

  • Age
<60 = 0
60-70 = 1
>70 = 2

  • Comorbidity of Diabetes
-Present = 0
-Absent = 1

  • Intermittent Claudication
-Present = 3
-Absent = 0

  • Exacerbation of symptoms when standing
-Present = 2
-Absent = 0

  • Symptoms improve with trunk flexion
-Present = 3
-Absent = 0

  • Symptoms induced with trunk flexion
-Present = -1
-Absent = 0

  • Symptoms induced with trunk extension
-Present = 1
-Absent = 0

  • Peripheral artery circulation
-Dorsalis pedis pulse diminished or ABI <0.9 = 0
-Dorsalis pedis pulse easily palpated or ABI >0.9 = 3

  • Achilles tendon reflex
-Normal = 0
-Absent or low = 1

  • Straight leg raise test (specificity of .74 for lumbar disc herniation) [11]
-Positive = -2
-Negative = 0

https://youtu.be/LdAD9GNv8FI?t=50s [12]



Score Cutoff
  • Score >7 indicates possible lumbar stenosis [10]
  • Not a definitive tool, but can be very helpful


Inflammatory Back Pain

ankylosing spondylitis spine picture.jpg
http://kids.britannica.com/comptons/art-166962/Ankylosing-spondylitis-is-an-arthritic-condition-that-can-fuse-bones

  • Inflammatory back pain isn't a condition, it's a group of symptoms[13]
    • Inflammation of the vertebrae, facet joints, or tendon and ligament attachment sites
  • Associated with conditions known as spondylo-arthritides
  • Ankylosing spondylitis (Also known as Axial Spondyloarthritis)- Most common spondylo-arthritide in IBP. Inflammation of the vertebrae, that can cause severe pain and functional limitation. In some advanced cases, the inflammation of bones can lead to fusion of the spine and cause a forward stooped posture[13]
      • SI Joint is most commonly involved (sacroiliitis)
      • Can affect other joints of the body, and rarely, the heart and lungs
      • Genetic link: marker known as HLA-B27, found in 95% of caucasians with ankylosing spondylitis[13]
      • Prevalence: 0.4%-1.4%, depending on the population. The cause of chronic low back pain in 4%-5% of patients[14]
ankylosing spondylitis 2.jpg
http://www.indeedcare.com/physiotherapy-for-ankylosing-spondylitis/

Why need a Clinical Prediction Rule?[7]

  • Inflammatory back pain may take several years to show up radiographically.
  • Early identification is crucial to successful management of the disorder
  • CPR's can't definitely diagnose IBP, but can indicate whether further testing needs to be done, and how to manage the treatment.

Clinical Prediction Rules for Inflammatory Back Pain

Berlin Criteria[15]

Objective:

Differentiate between inflammatory back pain and mechanical low back pain by identifying individual features of each disorder.

Methods:

  • 213 patients recruited, with the patients required to be less than or equal to 50 years old.
  • Each patient had already been diagnosed prior to the study. This allowed the researchers to use a questionnaire to identify common symptoms in AS
  • Unblinded trained examiner provided face to face interviews to give the questionnaires.
  • Each patient answered various questions about their symptoms, as well as had a measurement taken of their low back flexion ROM.

What They Found:

From the questionnaire, these 4 variables were identified as the most independent combination of predictors of Inflammatory Back Pain from Mechanical Low Back Pain.
Berlin Criteria .png
[7]
If two or more variables are present in the patient, the sensitivity is 0.73 and the specificity is 0.81[7]

Validation Studies:[7]

1. Sleper et al: 20 patients, sensitivity:0.84, Specificity: 0.63
2. Sleper et al: 648 patients, sensitivity: 0.70, specificity: 0.81
3. Chan et al: 25 patients, sensitivity: 0.92, specificity: 0.67

Berlin Criteria 3.png
[7]

"IBP According To Experts" Criteria[16]

Objective:

Inflammatory Back Pain is an important symptom of Axial Spondyloarthritis, and a newer criteria is discussed

Methods:
  • 20 patients who had back pain and possibly had AS, were observed by 13 different rheumatologists who are considered experts in AS
  • Each expert interviewed the patients and judged whether they had IBP based on parameters typical for the disorder
  • The expert's judgment was used as a dependent variable in a logistical regression to determine the best individual parameters for IBP diagnosis

What They Found:[7]
From the experts judgment, the best predictors for IBP were 5 different items
Experts on IBP 2.png
If 4 or more of the above variables are positive in the patient, then the sensitivity is 0.77, and the specificity is 0.92.

Validation Study[7]

1. Sieper et al: 648 patients, sensitivity: 0.80, specificity: 0.72


LBP resulting from Sacroiliac Joint



Sacroiliac Joint (2)

SI.jpg
http://www.spinehealth.com/images/sacroiliac-joint-pain.jpg


Where the sacrum and ilium articulate to support the weight of the upper body when upright and shift the load to the lower extremities with ambulation.
Pain can be caused by overuse, trauma, ligament instability, secondary to other conditions/pregnancy, or uneven biomechanics with ambulation; and is a result of the SI joint becoming inflamed. It is described as dull or sharp pain that can radiate to the butt, thighs, groin, or upper back.
The vague description and patterns of symptoms often lead to misdiagnosis. It is commonly misdiagnosed as a LBP cause by Lumbar Discs/Zygapophyseal Joints/Nerve Roots/ and others.17,18

With LBP being such a frequent phenomenon there is a need for a Clinical Prediction Test for differential diagnosis. Examination of the Lumbar Spine and Pelvis have not been proven successful and there has not been a definitive composite of symptoms or clinical signs adopted. Contrast enhanced intra-articular anesthetic injections have been the test to show diagnostic value with a sensitivity of 98% and a low false positive rate. (science ss) The International Association for the Study of pain has proposed criteria for Spinal Pain stemming from the Sacroiliac Joint as: Pain in the sacroiliac joint region with or without referred pain to lower limb girdle or lower limb and must fulfill all the following criteria: 1. Pain in S.I. Joint regio. 2. Selective clinical stress tests of the S.I. Joint reproduces patient's pain. 3. Injection of local anesthetic to symptomatic joint completely relieves the patient of pain. (IASP)18,19

How can we accurately and confidently identify the S.I. Joint as the cause of a patient’s LBP?

The Problem

Stress Testing of S.I. Joint can reproduce symptoms of S.I. origin BUT stress testing cannot load that specific structure without involving others. When familiar pain is provoked there cannot be certainty it is the S.I. Joint.

The Solution

Composite of multiple different stress tests. Isolating structures with each test can rule out structures and narrow down the structure of origin.

Present Study

This was a validation and expansion study from one they conducted in 2003 which

“identified a composite of three provocation SIJ tests in the absence of centralization during repeated movement testing has clinically useful sensitivity, specificity and positive likelihood ratio (93%, 89% and 6.97%, respectively)20

Key Search Words
  • Sacroiliac joint;
  • Low back pain;
  • Physical examination;
  • Diagnosis;
  • Validity;
  • Sensitivity;
  • Specificity

Inclusion Criteria
  • Patients with buttock pain, with or without lumbar or lower extremity symptoms.
  • Patients were scheduled for the clinical evaluation
  • Each patient had undergone imaging studies
  • Had variety of unsuccessful therapeutic interventions.
  • They were referred for diagnostic evaluation and procedures by a variety of medical and allied health practitioners and a few were self-referred.

Exclusion Criteria
  • o Patients were excluded from the study if they were unwilling to participate,
  • o had only midline or symmetrical pain above the level of L5,
  • o had clear signs of nerve root compression (complete motor or sensory deficit), or
  • o were referred for specific procedures excluding SIJ injection.
  • o Those deemed too frail to tolerate a full physical examination, were also excluded.

Operational Definitions20,21
  • The familiar symptom: Pain or other symptoms (such as aching, burning, paraesthesiae or numbness) identified on a pain drawing. Patient verified and distinguished form other symptoms during examination. It can be manipulated and abolished during testing.
    • Positive provocation SIJ test: A provocation SIJ test that produces or increases familiar symptoms.
    • Positive SIJ injection: Injection that provokes familiar pain and local anesthetic injected reduced it. Positive injections were given a confirmatory block injection.


Overview

Sixty-two patients agreed to participate. Forty-eight patients satisfied all inclusion criteria. There were no significant differences between positive and negative responders to diagnostic injection with regards to age, gender, working status, Dallas and Roland questionnaire results or pain intensity prior to examination. Injection and examination were done in the same day blinded from one another and results were recorded on separate data collection forms. Therapists were blinded to previous results of imaging and injections. 6 provocation test were selected and have shown acceptable inter-examiner reliability. Individually the test are not very strong but with 3+ positive tests there was a sensitivity of 93.8%, specificity of 78.1%, and AUC of 0.842 for S.I. Joint being the cause of LBP. Distraction test has the single highest predictive value and thigh thrust, compression, and sacral thrust improved diagnostic ability. These should be performed first and two positive results are satisfactory for diagnosis and not further testing is needed, AUC of (0.819, s.e. 0.054) sensitivity of 0.88 and specificity of 0.78. This is to avoid subjecting patients to extra tests and discomfort. All patients with S.I. Joint being identified by injection as the cause had at least one positive test therefore if all are negative S.I. Joint can be ruled out. Injection and tests had no adverse effects reported aside from short term local discomfort and soreness.20

Examination & Tests
ü Patient History
ü VAS Pain Scale
ü Disability Questionnaires (Dallas & Roland)
ü McKenzie Examination
ü Hip Joint Assessment
üThe sacroiliac pain provocation tests:**

  1. I. Sacral Distraction (Most Specific)Sacral Distraction.jpg
  2. II. Thigh Thrust (Most Sensitive)Thigh Thrust.jpg
  3. III. Gaenslen's test Gaenslen's test.jpg
  4. IV. SIJ Compression SI Compression.jpg
  5. V. sacral thrust Sacral Thrust.jpg
  6. VI. fluoroscopically guided contrast enhanced SIJ arthrography injection


SI Joint CPR.jpg

Limitations and Future Research

Patients in the study were more chronic and disabled than the average patient with this condition. Further trials should be conducted to confirm its generalization to the general population.
Tests were performed in sequence without a specified rest period which could cause interactions and confounding effects of each test individually.
Severe pain with all body movements and tests is more likely from a different source and S.I. Joint should not be diagnosed as the underlying cause.
Diagnostic Injections are the only clinical test that can be compared against for validity but false positives/false negatives are possible. In this study a second injection was done to confirm the diagnosis and found a false positive rate of zero.(surgical science)20,21

References
1 Ullrich, P. F., Dr. (n.d.). Lower Back Pain. Retrieved April 22, 2016, from http://www.spine-health.com/conditions/lower-back-pain
2 Lower Back Pain Health Center. (n.d.). Retrieved April 22, 2016, from http://www.spine-health.com/conditions/lower-back-pain
3 National Institute of Neurological Disorders and Stroke. (2014, December). Low Back Pain Fact Sheet. Retrieved April 21, 2016, from http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm
4 Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the US workforce. JAMA. 2003 Nov 12;290(18):2443-54.
5 Spine (Phila Pa 1976). 2006 Dec 15;31(26):3052-60, Back pain exacerbations and lost productive time costs in United States workers, Ricci JA, Stewart WF, Chee E, Leotta C, Foley K, Hochberg MC.
6. The American Academy Of Pain Medicine. (n.d.). Retrieved April 26, 2016, from http://www.painmed.org/patientcenter/cost-of-pain-to-businesses/
7.Haskins R, Osmotherly PG, Rivett DA. Diagnostic Clinical Prediction Rules for Specific Subtypes of Low Back Pain: A Systematic Review. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 2015;45(2):61–76. doi:10.2519/jospt.2015.5723.
8. Lumbar Spinal Stenosis-OrthoInfo - AAOS. Lumbar Spinal Stenosis-OrthoInfo - AAOS. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=a00329. Accessed April 24, 2016.
9. Lurie, J, Tomkins-Lane, C. Management of lumbar spinal stenosis. Bmj. 2016. doi:10.1136/bmj.h6234.
10. Konno, S, Hayashino, Y, Fukuhara, S, et al. Development of a clinical diagnosis support tool to identify patients with lumbar spinal stenosis. European Spine Journal Eur Spine J. 2007;16(11):1951–1957. doi:10.1007/s00586-007-0402-2.
11. Capra, F, Vanti, C, Donati, R, Tombetti, S, O'reilly, C, Pillastrini, P. Validity of the Straight-Leg Raise Test for Patients With Sciatic Pain With or Without Lumbar Pain Using Magnetic Resonance Imaging Results as a Reference Standard. Journal of Manipulative and Physiological Therapeutics. 2011;34(4):231–238. doi:10.1016/j.jmpt.2011.04.010.
12. Straight Leg Raise / Lasègue's Test (NEW VERSION)⎟Lumbar Radiculopathy [video]. Youtube https://youtu.be/LdAD9GNv8FI?t=50s. Published February 8, 2016. Accessed April 24,2016.
13. Ankylosing Spondylitis. (n.d.). Spondylitis Association of America. Retrieved from https://www.spondylitis.org/Learn-About-Spondyloarthritis/Ankylosing-Spondylitis. April 23, 2016.
14.Bunyard, Matthew. Ankylosing Spondylitis. Cleveland Clinic: Center For Continuing Education. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/rheumatology/ankylosing-spondylitis/. Published August 2010. Accessed April 23, 2016.
15. Rudwaleit, M., Metter, A., Listing, J., Sieper, J., & Braun, J. Inflammatory back pain in ankylosing spondylitis: A reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis & Rheumatism. 2006; 54(2), 569–578. http://doi.org/10.1002/art.21619
16. Lindström, U., Bremander, A., Haglund, E., Bergman, S., Petersson, I. F., & Jacobsson, L. T. H. Back pain and health status in patients with clinically diagnosed ankylosing spondylitis, psoriatic arthritis and other spondyloarthritis: a cross-sectional population-based study. BMC Musculoskeletal Disorders. 2009;17(1), 106. http://doi.org/10.1186/s12891-016-0960-8
17. Sacroiliitis. Overview; Mayo Clinic. 2015. Available at: http://www.mayoclinic.org/diseases-conditions/sacroiliitis/home/ovc-20166357. Accessed April 25, 2016.
18. Mitchell B, Macphail T, Vivian D, Verrills P, Barnard A. Diagnostic Sacroiliac Joint Injections: Is a Control Block Necessary? Surgical Science SS 2015;06(07):273–281. doi:10.4236/ss.2015.67041.
19. Merskey H, Bogduk N, eds. CLASSIFICATION OF CHRONIC PAIN DESCRIPTIONS OF CHRONIC PAIN SYNDROMES AND DEFINITIONS OF PAIN TERMS . International Association for the Study of Pain 2002.
20. Laslett M, Aprill CN, Mcdonald B, Young SB. Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests. Manual Therapy 2005;10(3):207–218. doi:10.1016/j.math.2005.01.003.
21. Laslett M, Young SB, Aprill CN, Mcdonald B. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy 2003;49(2):89–97. doi:10.1016/s0004-9514(14)60125-2.