How to reach a useful diagnosis and how to define a treatment strategy for lumbar problems by using the Cyriax Assessment Form.
Introduction
It is not easy to reach a valid and useful diagnosis with patients who suffer from low back pain.
Many different examination procedures are available, often leading to a therapeutic confusion. Unfortunately some of the procedures which are used nowadays don't have any diagnostic validity and some are even so extensive (very high number of tests) that it becomes difficult to execute the procedure in daily practice.
Therapists along the world seem to speak many different diagnostic languages. If a patient with low back pain consults on the same day, hypothetically, 10 different therapists, then most likely he is going to be confronted with perhaps 7 different conclusions. Not only the patient is confused and mislead but of course this also has major effects on the treatment outcome. It is obvious that different diagnostic procedures are at least very questionnable.
Which questions are asked during the history taking and which are the therapeutic consequences of the answers on those questions ? Which elements in the inspection are relevant and which can be neglected ? How did the functional examination look like ? Those questions deserve an answer.
It is obvious we need a, more or less, useful, understandable, uniform and valid diagostic procedure.
The advantages are obvious : this would improve not only the diagnostic efficiency but automatically also the therapeutic effect, not to mention the financial benefit for the health care system.
We not only have to question the diagnostic procedures but also ourselves as therapists.
It is important that we think about what we do, how we do it and what the reason is for doing it : it is imperative that the tests we carry out are as reliable as possible, so that we really test what we think or hope we are testing. Unfortunately some procedures have more a "wishful thinking" character (e.g. SI-mobility tests).
There might be a clear contrast between on the one hand what the therapist "feels" with his "thinking fingers" and, on the other hand, the objective elements obtained from some parts of the clinical examination.
(E.g. : the contrast between "feeling" that the SI-joint is locked and the clinical evidence there are clear dural symptoms and signs, thus excluding symptomatic SI-involvement).
So, we should focus on information which can be trusted upon and which really helps us to define the nature of the problem. It is quite possible we won't reach a "specific" diagnosis, but, this is in many cases of low back pain, merely a wish instead of a fact. Furthermore, specificity is, in a majority of cases, even not necessary for what is concerned the treatment procedure. Sometimes however it is possible to be more specific (e.g. a disc protrusion with pressure on the S1-nerve root, causing motor deficit : this must be the L5-disc).
The Cyriax Assessment Form enables us to speak a more uniform, objective and controllable language that optimizes the diagnostic and, consequently, the therapeutic strategy. Of course this cannot be seen as the only possibility, because, in certain situations, links can be and should be made : specifically the link between the Cyriax and McKenzie approach is interesting. Good knowledge of both approaches is therefore necessary.
This assessment form also incorporates the links to many different differential diagnostic options and gives an overview of very important red flags (extra-articular pathologies). It is easy and quickly useable in daily practice. The information we gather is spread over 8 different sections, each covering a different aspect. Allthough a lot of information can be found on this form, an exercised therapist needs about 15-20 minutes to go through this entire protocol. Considering the importance of the obtained information, I consider these 20 minutes as "the investment of the first treatment". It is this investment which consequently influences our future therapeutic strategy.
Besides that, it also allows us to share detailed information between different practioners treating the same patient.
This article gives you a summarized overview of this diagnostic procedure.
As an example, a lumbar case study is described. Accessorry, some other general information per section is added too.
Section 1 : general information
This section merely covers the general administrative information.
Section 2 : general and specific history
This section consists out of two parts :
a) The more specific history :
We have to keep in mind that open questions offer more possibilities to get a real idea of the patient's problems. Let's listen to his story but make sure we don't put words in his mouth ; we try not to be suggestive. We gather information concerning the onset (when and how did it start) and the localisation of the pain, taking into account the evolution in the time (does the pain centralize or peripheralize ?). How can the symptoms be provoked or abolished ? What is the general evolution ? We also note the presence of pins and needles, subjective limitation of movement or the subjective feeling of weakness. Note that this weakness could be the result of severe pain, and not necessary because of a real motor deficit. The data of the history should be in relation to the data obtained from the functional examination. A "small" story should go together with a "small" clinical image and vice versa.
b) General information :
an overview of the professional and leisure activities is useful from the prophylactic point of view : we also have to determine if certain self treatment elements are favourable. Is the patient off work since he has his problem ? What about his bed : too hard, too soft, good ? Is there incontinence since the beginning of the complaints : this is an important alarm sign, implicating the involvement of the S4-root. In that case the patient should be referred immediately for further examination.
Is it the first time the patient has this kind of problem ? Did the patient receive previous treatments ? Which kind of treatment ? Perhaps the patient states that he received, some time ago, manipulation without any success : this does not automatically mean that, today, some kind of manipulative intervention would not be indicated. Before applying any technique, we have to interpret in detail the total image ; all puzzle pieces have to fit ! We also have to take into account all specific indications and contra-indications of active treatment.
Information obtained from medical imaging can be interesting, but, is not always reliable. Medical imaging is mostly interesting for differential diagnostic purposes. The problem of modern medicine however is, that on many occasions people rely completely on those data and have forgotten about the value of history and functional examination.
The questions about general health and unexpected loss of weight both point into the direction of other non-mechanical serious pathology (e.g. metastases).
For what is concerned medication we are specifically interested in the use of anticoagulant medication and the long term use of corticosteroids, because those are real contra-indications for manipulative treatment.
Section 3 : inspection
Inspection can be relevant or irrelevant. It is interesting to observe how the patient is sitting during the history-taking, how the patient performs a curve-reversal movement, how he undresses and dresses (note how he incorporates ADL-instructions). This information should be in relation with what we hear and what we see, later on, in the functional examination.
Once the patient is undressed, standing in front of the examiner, we specifically look for some kind of deviation : a flexion or a lateral deviation (remark : a small lateral deviation with clear rotational component is considered as being irrelevant).
The presence of a lateral deviation indicates that the lesion is already more expressive and that treatment is going to take some more time.
A flexion deviation coming from the hip joints cannot be related with internal derangement pathology and is considered as an alarm sign.
In some severe cases of sciatica the patient is not able to have an equal weightbearing on both feet : one knee is slightly flexed and he cannot put his heel on the ground ; mostly this goes together with a heterolateral lateral deviation of the patient.
An angular kyphosis could be the result of severe local arthrosis or a fracture.
A shelf is indicative for spondylolisthesis, but, if spondylolisthesis is really responsible for the actual complaints, then, we also should hear the specific history : pain on walking and standing, which disappears fast in sitting and lying. Clearly this is a totally different story as the one of an internal derangement (discodural or discoradicular conflict).
Section 4 : basic functional examination
In this basic functional examination we look for :
* bony signs
* articular signs
* dural signs
* root signs (motor and sensory conduction)
We interpret pain (when and where does it appear), range of motion, end-feel of certain movements and weakness.
It is important to check the presence of pain at rest and to note where this pain is felt, because this is going to be our reference. On performing tests it is necessary to interpret the influence of the test on the patient's symptoms. If pain is worsened or produced, don't automatically assume that it happened at the same spot as where he felt his pain at rest. It is quite possible that the patient experiences lumbar pain at rest and produces leg pain on performing an extension movement : this has clear diagnostic and therapeutic consequences (it is an unfavourable sign for manipulative treatment : most likely manipulation is not going to succeed).
If a patient has pain and/or limitation of movement during flexion, and an accessory neck flexion is worsening or abolishing an e.g. unilateral gluteal pain, then, this is a clear diagnostic dural sign, excluding the facet and the SI-joints as possible pain sources.
The SI-distraction test, which is a pain provocation test, can only be considerd positive if it produces or worsens unilateral pain. The SI-joint cannot cause central lumbar pain.
A negative straight leg raise does not necessary rule out the presence of an internal derangement. A SLR can be interpreted in at least 6 different ways (limited or not, painful arc, motor deficit,...). The SLR is not only a test for the L4-L5-S1-S2 nerve roots, but also stretches the dura mater.
Positive tests are going to be our therapeutic guides which help us to interpret results obtained by certain strategies. After each treatment maneouvre (manipulation, exercise, traction,...) we check the influence of what we did, on the positive tests and interpret if there is an amelioration/change.
It is imperative to perform the P hip flexion immediately after the SLR, in order to detect a "sign of the buttock" (= the passive hip flexion is more limited than the SLR) which is one the important alarm signs, indicating local gluteal pathology.
A positive Babinski jerk is, of course, an absolute contra-indication for active treatment because of spinal cord compression.
Section 5 : accessory examination
The accessory examination is only called for in cases of trauma, in order to help exclude the suspicion of a fracture, a muscle lesion or psychogenic involvement.
Section 6 : palpation
Palpation is probably the most overrated and unreliable diagnostic procedure for what is concerned lumbar problems, specifically for trying to determine the level at fault.
We only perform an extension pressure on the spinous processes in order to interpret pain and end-feel. Normally pain is provoked in the low lumbar region. If the patient has clear pain in the upper lumbar region (L1-L2), then, this could be an alarm sign too. This high lumbar zone has been called the "forbidden area", because other pathology than internal derangement is more frequent.
We already palpated (section 4) for sensory deficit : this is done bilaterally in the most distal part of the dermatomes.
Section 7 : diagnosis - differential diagnosis
What did we hear, what did we see ? How do we have to filter this information ?
Did we see something mechanical or non-mechanical ?
If it is mechanical, in which direction do we have to think ? Is there a need for active treatment.
This interpretation is the result of thorough knowledge of the orthopaedic medicine Cyriax.
In the case of non-mechanical disorders, take into account the presence of important alarm signs.
Sacroiliac-appendix
When the history pointed into this direction, then further examination can be useful. Probably the SI-joint is one of the most overrated diagnostic culprits and this is largely the result of the use of non-optimal tests and the absence of to the point history-taking.
Those tests are non-specific pain provocation tests. Mobility tests have been proven to be utmost unreliable.
Section 8 : treatment strategy
In the treatment strategy we decide what we are going to do and how. We have a clear expectation pattern and know how the patient should react and within which time frame (this partly depends on the specific kind of internal derangement).
Immediately after applying one treatment procedure/maneouvre we check the positive tests from our functional examination and assess whether there is an improvement or not. Improvement means : less pain, less number of movements painful, more mobility, the appearance of a painful arc or centralization of symptoms.
The patient can be dismissed when he is symptomfree, regained his function and incorporated the self-treatment and profylactic advice in a good manner.
We have to note,however, that patient compliance is a big challenge.
Conclusion
A logical and practical strategy is called for. There is no need for "artificial hyper-complication" of certain procedures. The comprehension of basic diagnostic procedures linked to an honest treatment strategy (which not always involves therapist's hands) can optimize the therapist and patient satisfaction.
The Cyriax Assessment Form gives you a possibility to incorporate these goals into your daily practice .
It is nice to fly high in the sky above the clouds, where the sun is always shining...
But, flying without knowing how to run, makes the landing very painful.
Steven De Coninck. |
Back ... |
|
|
|
 |
|
|
|
|
Invest in Efficient Knowledge |
|
|
|
Contact : Steven De Coninck, MSc PT |
|
|
|
Lepelemstraat 4 |
|
|
|
B 8421 De Haan, Belgium |
|
|
|
E-mail: info@etgom.be |
|
|
|
Tel.: ++32 475 730 911 |
|
|
|
GSM: www.cyriaxlatinoamerica.com |
|
|
|
Fax: www.cyriax.com.pl |
|
|
|
|
|
 |
|
|
|
|
|
© European Teaching Group of Orthopaedic Medicine 2013 |
|
|
|
www.om-cyriax.com |
|
|
|
|
|
|
|
|
