OMM- Low Back Pain

Piriformis tenderness, externally rotated hip, positive SLR

What findings would you expect associated with Piriformis Syndrome?

0

What grade would you give to spondylolysis without spondylolisthesis

Iliopsoas and rectus femoris

What muscles is this stretch targeting?

Piriformis, gemelli, obturator internus, quadratus femoris

What muscles is this stretch targeting?

Anterior innominate

What pelvic diagnosis is being treated in this muscle energy setup?

Inferior innominate shear

What pelvic diagnosis is being treated in this muscle energy setup?

Inflare

What pelvic diagnosis is being treated in this muscle energy setup?

Outflare

What pelvic diagnosis is being treated in this muscle energy setup?

Posterior innominate

What pelvic diagnosis is being treated in this muscle energy setup?

Superior innominate shear

What pelvic diagnosis is being treated in this muscle energy setup?

Sagittal

What plane are the lumbar superior facets?

Inferior pubic shear

What pubic diagnosis is being treated in this muscle energy setup?

Superior pubic shear

What pubic diagnosis is being treated in this muscle energy setup?

Prostate cancer, metastasizes to lumbar spine

What type of common cancer can lead to lower back pain? Why?

Radicular pain

What type of pain is described as "sharp and electric" in a dermatomal distribution?

Myelopathy (spinal stenosis)

What type of pain is describes as a dull, worsening pain radiating into both legs with bilateral numbness that improves when bending over?

L unilateral extension

When diagnosing the sacrum, you note that the right sacral sulcus is deep and the right ILA is posterior/inferior. Seated flexion test is positive on the left. What is the diagnosis?

Sacral base

Where do you contact for ME of a unilateral sacral extension?

ILA

Where do you contact for ME of a unilateral sacral flexion? (Note: Abduct and IR to help pack hip joint)

Grade 3

Which grade of spondylolisthesis describes a 55 percent displacement?

Iliacus

Which tender point is located 1/3 of the distance from the ASIS to midline? (Note: Pressure should be posterolateral)

Psoas

Which tender point is located 2/3 of the distance from the ASIS to the midline? (Note: Pressure should be posterior)

Piriformis

Which tender point is located midpoint between the ILA and the greater trochanter?

R unilateral extension

You are examining the sacrum on a patient with low back pain and find the following: left sacral sulcus deep, right ILA anterior, and a positive spring test. What is your diagnosis?

Spondylolisthesis, spondylolysis

__________ is the anterior "slippage" of a superior vertebra on the one beneath it ________ is a fatigue fracture in the pars interarticularis (commonly @ L5, as seen in image!!)

Dehydration

______________ of the disc causes a decreased ability to handle mechanical load

Grade 2

25-50% slippage of one vertebrae on another (spondylolisthesis) would be considered what grade?

Grade 3

50-75% slippage of one vertebrae on another (spondylolisthesis) would be considered what grade?

Grade 4

75-100% slippage of one vertebrae on another (spondylolisthesis) would be considered what grade?

Grade 1

<25% slippage of one vertebrae on another (spondylolisthesis) would be considered what grade?

L4

A patient is unable to dorsiflex her foot, has diminished sensation to the medial foot, and has absent patellar reflex. Which nerve root is likely involved?

L5

A patient is unable to dorsiflex her great toe, has diminished sensation to the dorsal foot, and has normal reflexes. Which nerve root is likely involved?

S1

A patient is unable to plantarflex her foot, has diminished sensation to the lateral foot, and has absent Achilles reflex. Which nerve root is likely involved?

L4-L5

A patient presents complaining of low back pain. The pain is electric in nature and radiates into the leg. Patellar and Achilles reflexes are 2/4 bilaterally. Patient has weakness with extending his right big toe. Where would you expect to find a disc herniation given his presentation?

L5-S1

A patient presents complaining of low back pain. The pain is electric in nature and radiates into the leg. You note markedly decreased sensation on the left lateral foot. Where would you expect to find a disc herniation given his presentation?

Spondylolisthesis, lateral lumbar x-ray

A patient presents with low back pain that is significantly worsened by extension, slightly worse in flexion. There is lumbar tenderness, lumbar hyperlordosis, and tightness in the hamstrings. What diagnosis do you suspect? What would you order to confirm that diagnosis?

Facet syndrome

A patient presents with low back pain that radiates into the leg. The pain is worse with extension. They were previously diagnosed with "some degenerative issues" in their spine. What diagnosis do you suspect?

Right psoas spasm

A patient presents with low back pain, worse on the right side, that radiates partly down the back of his left leg. Pain is worse when standing after prolonged sitting. On exam, straight leg raise is painful on the left and the patient is slightly hunched over/leaning towards the right. What diagnosis do you suspect?

SI joint conditions

A patient has lower back pain on Patrick testing. What should you be thinking of?

Relative contraindication for HVLA

A patient has low back pain and associated numbness in her left lateral foot. Is OMT contraindicated? If so, which technique(s)?

Cauda Equina Syndrome (Note: Key here is the loss of bladder control, otherwise suspect strain/sprain)

A 45-year-old male presents with acute onset back pain that occurred while he was lifting something at work. He heard a "pop". Since that time he has had pain, weakness in his leg, and loss of bladder control. What is his most likely diagnosis?

Spinal stenosis

A 70-year-old female presents with pain in the legs and buttocks and some difficulty walking. She states the pain gets worse with prolonged walking and improves with rest or leaning forward. She denies bowel or bladder incontinence. She feels "decreased sensation" in both legs with no clear anatomic distribution. What is the most likely diagnosis?

Herniation

A disk __________ is a focal or asymmetric extension of the nucleus pulposus through a tear in the annulus

Bulge

A disk ____________ is a symmetric, circumferential extension of disk material WITHOUT rupture of the annulus

Abdominal aortic aneurysm

A male patient with a 30 year history of smoking and hypercholesterol presents with flank/lower back pain. On exam, you notice a pulsatile abdominal mass. What is likely causing his back pain?

Positive Thomas test on right Type II L1 or L2 dysfunction, SrRr Pelvic shift left Left piriformis dysfunction Sacral torsion Positive Left straight leg raise (piriformis compresses sciatic n.)

A patient has a Right sided Psoas Spasm. List the associated findings you would expect.

Hip conditions

A patient has groin pain on Patrick testing. What should you be thinking of?

Femoroacetabular impingement or hip arthritis

A patient has limited ROM on Patrick testing. What should you be thinking of?

Grade 5

Complete displacement of a vertebrae (spondyloptosis) would be considered what grade?

Degenerative disc disease, lumbar facet arthritis, spondylolisthesis

Degenerative low back pain may be caused by:

Patient prone, doctor on side of dysfunction Flex knee, support distal femur Cephalad hand stabilizes sacrum Lift knee to extend hip Patient pushes knee down

Describe the setup for psoas muscle energy.

Patient supine, doctor on side on tender point Doctor puts foot on table "Frog leg" position, patient ankles crossed Patient lets knees fall outward, doctor flexes Fine tune until -70% reduction (Acronym: F ER Ab)

Describe the treatment set up for Iliacus counterstrain.

Patient prone, doctor on side of tender point Leg hangs off table, rests on doctor's leg Fine tune until -70% reduction (Acronym: F Ab ER)

Describe the treatment set up for Piriformis counter strain. (Note: Remember to always establish pain scale first and DO NOT MOVE YOUR FINGER UNTIL COMPLETED)

Patient supine, doctor on side as tender point Doctor puts foot on table Flex hips/knees with some ER, rest on doctor's leg Pull knees in to create sidebending towards Fine tune until -70% reduction (Acronym: F ST)

Describe the treatment set up for psoas counterstrain.

Lumbar spondylosis (arthritis)

Disk/joint space narrowing, subchondral sclerosis, osteophytes, and degeneration of both the discovertebral joints and facet joints are characteristic of:

Yes

Does low back pain caused by piriformis syndrome or gluteal muscle trigger point radiate?

Ankylosing spondylitis

Dull lower back pain in younger people (<40) that is worse in the morning and improves with activity is likely:

Sclerotomal pain (not sciatica!!)

Dull, nondermatomal pain that radiates down the leg (but usually not past the knee) without any associated numbness is likely:

Disc degeneration

During degeneration of the spine, what occurs first?

Increased facet joint stress

Facet joint degeneration, hypertrophy, and osteophyte formation all come from:

L5

In an L4-L5 herniation, what nerve is likely to be compressed?

S1

In an L5-S1 herniation, what nerve is likely to be compressed?

Backwards, Upwards, Medial (BUM)

In both the cervical and lumbar spine, the superior facets face:

Patient lays on side of axis (left side) Patient rotates torso right (face up) Flex up knees Top leg straightens and hangs off, bottom leg stays on table Doctor sits, pushes down on ankle Patient lifts ankle up

How would you set up ME for R/L sacral torsion?

Patient lays on side of axis (left side) Patient rotates torso left (face down into table) Flex up knees Doctor sits, rests knees on leg Doctor pushes down on ankles Patient lifts ankle up

How would you setup ME for L/L sacral torsion?

Backwards, Upwards, Lateral (BUL)

In the thoracic spine, the superior facets face:

Spondylolisthesis of L4 on L5

Identify the problem seen on this x-ray.

Ankylosing spondylitis

Inflammatory low back pain may be caused by:

Urolithiasis

Low back pain that radiates into the groin with associated nausea, vomiting, CVA tenderness, and hematuria is likely:

Lumbar strain/sprain or somatic dysfunction

Mechanical low back pain may be caused by:

Disc herniation with radiculopathy or spinal stenosis

Neurologic low back pain may be caused by:

Prostate cancer, abdominal aortic aneurysm, urolithiasis

Referred low back pain may be caused by:

Within the disk, facet joint, or lumbar paraspinals

Sclerotomal pain refers to pain arising from:

Disc degeneration

The first step in degeneration of the spine is:

Mechanical, no "medical" reason

The majority of low back pain cases fall under the __________ category and are caused by _________, which is why they are considered lumbar strain/sprains

Severe morning stiffness, pain improves with exercise, alternating buttock pain, age <40

What are the red flag symptoms for spondyloarthritis?

Medial branch of dorsal primary rami

What are the vertebral facets innervated by?

True

True/False: Disk herniations may often be asymptomatic and can repair themselves without additional treatment

False (may be facet, sacroiliac, piriformis syndrome, etc)

True/False: Referred pain is always from a nerve injury

Hip and sacroiliac dysfunction

What does the Patrick Test (aka FABER test) look for?

Radiculopathy from sciatic nerve

What does the Straight Leg Raise test for?

Psoas muscle tightness

What does the Thomas test test for?

1) Type II Lumbar 2) Pubic shear 3) Posterior sacral base 4) Innominate shear 5) Short leg/pelvic tilt 6) Muscular imbalance (includes psoas syndrome)

What 6 somatic dysfunctions are associated with back pain from the "Dirty Half Dozen" or Failed Back Syndrome?

Fracture, dislocation, undiagnosed recent trauma, infection, neurological symptoms, cauda equina, osteoporosis, carcinoma

What are some relative contraindications to OMT?

Significant trauma, prolonged glucocorticoid use, age >50

What are the red flag symptoms for a spinal fracture?

Urinary retention, incontinence, bilateral motor deficit, saddle anesthesia

What are the red flag symptoms for cauda equina syndrome?

PMH of cancer, unexplained weight loss, immunosuppression, injection drug use, nocturnal pain, age >50

What are the red flag symptoms for infection or cancer?