Lumbar Assessment:
Traditional vs. Contemporary Methods
Scott D. Coon, DC, PCP-C, PSCP
Adjunct Assistant Professor
New York Chiropractic College
Overview
Patient is diagnosed with lumbar segmental
dysfunction (739.3) complicated by lumbar
osteoarthritis (721.3) with symptoms associated
with lumbar stenosis (721.42).
• Patient is diagnosed with lumbar segmental
dysfunction (M99.13) complicated by lumbar
osteoarthritis (M47.816) with symptoms
associated with lumbar stenosis (M48.06).
• Under ICD-9 system about 14,000 codes are
available, under the new ICD-10 system over
60,000 codes are available.
Dr. K.S.J. Murkowski
WHO Develops the ICD-10-CM
• Dr. K.S.J. Murkowski represented all
chiropractors (ICA/ACA) to the World Health
Organization on ICD-10.
• There were in excess of 500 codes suggested
for vertebral subluxation complex (VSC and its
eight physical and eight chemical components.
• This was a 5 year process with 2 of those years
just having the ACA/ICA agree on the
definition of VSC.
http://www.icd10data.com/ICD10CM/
Codes/M00-M99
Recommended Texts
Recommended Texts
Recommended Texts
Shift in our Understanding of LBP
Pathoanatomical Model
(Suffering can only be explained by tissue
injury/pathology)
Pathophysiological Model
(Suffering results from complex processes of
dysfunction)
Shift in our Approach to LBP
Biomedical Model
(The tissues involved are responsible for the pain)
Biopsychosocial Model
(Other systems prevent the inhibitions of pain and
contribute to the magnification of pain)
NYCC’s Post-Graduate Seminar Series, “PRIMARY
SPINE CARE PRACTITIONERS PROGRAM”
Module 1 - 12 Hours
Module 2 - 12 Hours
Module 3 - 12 Hours
Recommended Texts
The “CRISP” protocols as developed
by Donald Murphy, DC, provides a
blueprint for a new type of health
care professional. The primary
spine practitioner (PSP). There are 3
diagnostic questions to ask:
#1) Is the patient’s complaint life
threatening or of visceral origin?
#2) Where is the pain coming from?
#3) What has happened to this
person to cause the pain experience
to develop and persist?
#1. Is the patient’s complaint life
threatening or of visceral origin?
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Cancer
Benign Tumor
Infection
Fracture
Dissected or Ruptured AAA
GI Disease
GU Disease
Cauda Equina Syndrome
#2. Where is the pain coming from?
• Disc Derangement (Most Common)
• Joint Dysfunction
– Facet Joints
– Sacroiliac Joints
• Radiculopathy
• Myofascial Pain
– Trigger Points
– Sprain / Strain
Assessing Disc Derangement
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Antalgic?
Pain worse in the morning?
Due to imbibition of fluid
and increases in
Pain increases during flexion?
intradiscal pressure.
Pain increases with sitting?
Pain increases with standing and stays with you
for several minutes but gradually gets better?
• Confirm disc derangement with End Range
Loading (ERL) Exam.
Disc Derangement – ERL Exam
• Loading in the “Direction of Detriment”
causes further displacement of the intradiscal
material during the arc of motion and at the
end of range, thus causing peripheralization of
symptoms.
• Loading in the “Direction of Benefit” is
movement in the direction obstructed by the
displacement of nuclear material.
Assessing Joint Dysfunction
• Lumbar Facet Joints
– Extension-Rotation Test
• Sacroiliac Joints
– Five SI Provocation Tests
Lumbar Extension-Rotation Test
• Patient starts in a neutral standing position
with hands on their PSIS.
• Patient extends backward at the waist and
asked if pain is present.
• The patient then extends backward with right
or left torso rotation.
• If pain is provoked with the addition of the
rotation then the test is positive.
Five SI Provocation Tests
“Cluster of Laslett Tests”
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Distraction Test
Thigh Thrust Test
Gaenslen’s Test
Compression Test
Sacral Thrust Test
3 out of 5 tests must be positive
in order to consider the SI joint as
being the primary pain generator.
Clinical Pearl: Disc vs. SI
• Disc Derangement
– When going from sitting to standing the patient
will be very slow to complete the process of
standing up straight due to the obstruction of disc
material.
• Sacroiliac Joint
– Painful going from sitting to standing position but
the difficulty getting to a full upright position will
not be present.
Assessing Radiculopathy
• Younger patient more often have disc
herniation as the cause of radiculopathy while
older patients with radiculopathy is caused by
stenosis.
• The extremity pain is of neural origin and
involves the nerve roots although piriformis
syndrome can present very similar.
• Radiculopathy is assessed with “nerve root
tension tests”.
Nerve Root Tension Tests
• Straight Leg Raise
• Slump Test
• Femoral Nerve Stretch Test
• With all these tests, an increase in pain with
tension of the neural structures and a
decrease in pain with lessening of the tension
indicates a neural structure cause of the pain.
Assessing Myofascial Pain
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Lumbar Erector Spinae
Lumbosacral Multifidis
Quadratus Lumborum
Glutues Medius
Piriformis
#3. What has happened to this person
to cause the pain experience to
develop and persist?
• Somatic Factors
• Psychological Factors
Somatic Factors
• Dynamic Instability
• Passive Instability
• Nociceptive System Sensitization
Psychological Factors
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Fear
Catastrophizing
Passive Coping
Poor Self- Efficacy
Depression
Perceived Injustice
Hypervigilance for Symptoms
Cognitive Fusion
Anxiety
Keele STarT Back Screening
Keele STarT Recommendations
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1. Build rapport, validate and normalize the patient’s experiences.
2. Conduct a comprehensive biopsychosocial assessment (physical examination, exploration
of the impact that pain is having on the patient’s physical and psychosocial functioning,
identification of the patient’s beliefs and expectations regarding LBP and its management and
structured identification of potential obstacles to recovery).
3. Address gaps in patients knowledge, correct possible misunderstandings and provide a
credible explanation for their pain (e.g. cause, mechanisms, prognosis, role of investigations
and treatments),
4. Create opportunities for patient’s to respond differently to difficult internal experiences
(thoughts, feelings and bodily sensations) and to maintain or alter activity in keeping with
their goals.
5. Provide guidance on a variety of pain rehabilitation techniques including pacing and graded
activity.
6. Provide support in returning to usual activities, sleep and work.
7. Specifically focus on the psychological prognostic indicators (catastrophizing, low mood,
anxiety and pain related fear) with the adoption of simple cognitive behavioral techniques.
8. Encourage patients to put skills into practice between sessions, review and reinforce
progress and problem solve difficulties.
9. Emphasize the role of active self-management of ongoing or future episodes.
Keele STarT Groups
CBT – Cognitive Behavioral Therapy
Patient-Specific Functional Scale
Shift in our Understanding of LBP
Pathoanatomical Model
(Suffering can only be explained by tissue
injury/pathology)
Pathophysiological Model
(Suffering results from complex processes of
dysfunction)
Shift in our Approach to LBP
Biomedical Model
(The tissues involved are responsible for the pain)
Biopsychosocial Model
(Other systems prevent the inhibitions of pain and
contribute to the magnification of pain)
Dr. Coon Contact Information
NYCC Adjunct Faculty Office
2360 State Rte. 89
Seneca Falls, NY 13148
scoon@nycc.edu
drscottcoon.com
(585) 425-9820