Epidemiology lumbar instability

Epidemiology lumbar instability

Lumbar instability Clinical spinal instability is controversial and not well understood. White and Panjabi defined clinical instability of the spine as the loss of the spine’s ability to maintain its patterns of displacement under physiologic loads so there is no initial or additional neurologic deficit, no major deformity, and no incapacitating pain.1
Incidence The amounts recorded in the general practice are between 30 and 35 episodes per 1000 patients per year. For physiotherapists, low-back pain is a common referral diagnosis, 27% ​​of the patients who come to physiotherapists have low back pain.5
Pain location Low back, pelvis and thoracic spine. Referred pain patterns are possible.
Symptoms – “Gower’s sign”,

– Flattenedlumbar spine,

– Disrupted lumbar-pelvic rhythm or flexion pattern,

– Extension pattern,

– Lateral shift pattern,

– Multidirectionallypattern,

– Hypertonia erector spinae,

– Position and movement deviations, hitches including antalgic movement behavior, – Reduced qualitative posture while standing and sitting,

– Impaired coordination and strength endurance global and segmental musculatuur4

History of injury MacNab considers the occurrence of traction spurs (tiny osteophyte formation on the edges of the vertebral body) as a sign of instability (Radiological)3
Range of motion A reduced range of motion in full flexion and lateral bending, but not in axial twist, was found when elderly were compared to younger subjects.6 In addition, males had more mobility in flexion-extension, while females were more mobile in lateral flexion.7
3 Systems The spinal stabilizing system of the spine was conceptualized by Panjabi to consist of three subsystems:2

– The passive system includes the vertebrae, intervertebral disci, the facet joints and ligaments;
– The active system consists of the muscles and tendons that surrouned and work on the spine;
– The neural system consists of the nerves and the central nervous system, which drive and monitor the active system by providing and maintaining dynamic stability. 2

Literature
  1. A.A. White, M.M. Panjabi (Eds.), Clinical biomechanics of the spine, 2nd ed, Philadelphia, PA, 1990.
  2. M.M.T. Panjabi, The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement, J Spinal Disord 5 (1992) 389390.
  3. MacNab I. Backache. Williams & Wilkins, Baltimore, 1983:119.
  4. Nachemson, 1985; Panjabi, 1992; Hodges et al., 1996; Hides et al., 1996; O’Sullivan, 2000; van Dieen et al, 2003
  5. Bekkering G. E., et al., KNGF- richtlijn bij Lage- rugpijn, supplement bij het Nederlands Tijdschrift voor Fysiotherapie, nummer 1, jaargang 115, maart 2005.
  6. McGill SM, Yingling VR, Peach JP. Three-dimensional kinematics and trunk muscle myoelectric activity in the elderly spine-A database compared to young people. Clin Biomech (Bristol, Avon) 1999;6:389–95.
  7. Biering-Sorensen F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine 1984;9:106-19.

 

 Physical Examination

Purpose Test Outcome
Show segmental lumbar instability1,2,3,4,9

 

Stabilisor5

Posterior-anterior (PA)6,7

Passive physiological intervertebral movements (PPIVMs) extension8

Passive physiological intervertebral movements (PPIVMs) flexion8

Prone instability test7

The inability to hold local stabilizers for 10x10sec under 20mm Hg to 30 mm Hg pressure5

 

Literature
  1. Fritz JM, Erhard RE, Hagen BF. Segmental instability of the lumbar spine. Physical Therapy 1998; 78(8): 889-895
  2. Jull GA, Richardson CA, Toppenberg R, Commerford M, Bui B. Towards a measurement of active muscle control for lumbar stabilisation. Australian Journal of Physiotherapy 1993; 39(3): 187-193
  3. Richardson CA, Jull GA, Hides JA, Hodges PW. Therapeutic exercise for spinal segmental stabilisation in low back pain, scientific basis and clinical approach. Churchill Livingstone Edinburgh, 1999: 11-19
  1. Richardson CA, Jull GA. Muscle control pain control. What exercises would you prescribe? Manuel Therapy 1995; 1:2-10
  2. CLINICAL ASSESSMENT OF THE DEEP CERVICAL FLEXOR MUSCLES: THE CRANIOCERVICAL FLEXION TEST,    Gwendolen A. Jull, PT, PhD,a Shaun P. O’Leary, PT, PhD,b and Deborah L. Falla, PT, PhDc Jull G, Barrett C, Magee R, Ho P. Further characterisation of muscle dysfunction in cervical headache. Cephalalgia 1999;19: 179-85.
  3. Philips DR, Towmey LT. A comparison of manual diagnosis with a diagnosis established by a uni-level lumbar spinal Block procedure. Man Ther. 1996;1(2);82-87
  4. Fritz JM, Piva S, Childs J. Accuracy of the clinical examination to predict radiographic instability of the lumbar spine. Eur Spine J. 2005;14(8):743-50
  5. Abbott JH, McCane B, Herbison P, Moginie G, Chapple C, Hogarty T. Lumbar segmental instability: a criterion-related validity study of manual therapy assessment. BMC Musculoskelet Disord. 2005;6:56
  6. Aad van der el. Manuele diagnostiek, wervelkolom; zevende druk 2005: 434

 

Evidence Based Practice

Lumbar instability tests
Test Study Methodological data
Posterior-anterior (PA)
(utility score 2)
  Philips & Twomey (nonverbal response combined to identify the painful segment)(13)

 

– sensitivity 50%
– specificity 78%
– LR+ 2.24
– LR- 0.64
  Fritz, Piva, & Childs (lack of hypomobility to diagnose radiographic instability) (14)

 

– sensitivity 46%
– specificity 81%
– LR+ 2.42
– LR- 0.66

– kappa .48

  Fritz, Piva & Childs (presence of pain to diagnose radiographic instablility) (15) – sensitivity 43%
– specificity 81%
– LR+ 2.26
– LR- 0.70
– kappa .57
Passive physiological intervertebral movements (PPIVMs) extension
(utility score 2)
  Abott et al. (  Extension rotational PPIVMs) (16)

 

– sensitivity 22%
– specificity 97%
– LR+ 7.3
– LR- 0.80
  Abott et al. (Extension transitional PPIVMSs) (17) – sensitivity 16%
– specificity 98%
– LR+ 8
– LR- 0.85
Passive physiological intervertebral movements (PPIVMs) flexion
(utility score 2)
  Abott et al. (flexion rotational PPIVMs) (18)

 

– sensitivity 5%
– specificity 99%
– LR+ 5
– LR- 0.96

 

  Abott et al. (flexion transitional PPIVMs) (19) – sensitivity 5%
– specificity 99%
– LR+ 10
– LR- 0.95
Prone instability test
(utility score 3)
Fritz, Piva & Childs (20) – sensitivity 61%
– specificity 57%
– LR+ 1.41
– LR- 0.69
– kappa .69
Literature (13)  Philips DR, Twomey LT. A comparison of maual diagnosis with a diagnosis established by a uni-level lumbar spinal Block procedure. Man Ther. 1996;1(2);82-87

(14) Fritz JM, Piva S, Childs J. Accuracy of the clinical examination to predict radiographic instability of the lumbar spine. Eur Spine J. 2005;14(8):743-50

(15) Fritz JM, Piva S, Childs J. Accuracy of the clinical examination to predict radiographic instability of the lumbar spine. Eur Spine J. 2005;14(8):743-50

(16) Abbott JH, McCane B, Herbison P, Moginie G, Chapple C, Hogarty T. Lumbar segmental instability: a criterion-related validity study of manual therapy assessment. BMC Musculoskelet Disord. 2005;6:56

(17) Abbott JH, McCane B, Herbison P, Moginie G, Chapple C, Hogarty T. Lumbar segmental instability: a criterion-related validity study of manual therapy assessment. BMC Musculoskelet Disord. 2005;6:56

(18) Abbott JH, McCane B, Herbison P, Moginie G, Chapple C, Hogarty T. Lumbar segmental instability: a criterion-related validity study of manual therapy assessment. BMC Musculoskelet Disord. 2005;6:56

(19) Abbott JH, McCane B, Herbison P, Moginie G, Chapple C, Hogarty T. Lumbar segmental instability: a criterion-related validity study of manual therapy assessment. BMC Musculoskelet Disord. 2005;6:56

(20) Fritz JM, Piva S, Childs J. Accuracy of the clinical examination to predict radiographic instability of the lumbar spine. Eur Spine J. 2005;14(8):743-50

 

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