Conflicting Presentation in the Lumbar Spine

In many cases, the patient's subjective history alone should be enough to diagnose the musculoskeletal issue. Whether it's the mechanism of injury, location of pain, and/or pattern of pain, we are often able to formulate our treatment plan from the patient's subjective report. That being said, there are cases where the subjective report doesn't match the typical presentation and is, therefore, insufficient in evaluating the patient. It is for this reason that we must be thorough with our examination.

Recently I had a patient that presented with a subjective history of Lumbar Extension Movement Impairment Syndrome (MIS). However, when I got to the objective examination, all the findings matched with a Lumbar Flexion Movement Impairment Syndrome. Cases like this can be challenging due to the conflicting presentation. This is where implementation of an asterisk sign or a system that utilizes asterisk signs can be useful. 

The two systems I typically use are repeated motions and Sahrmann's Movement Impairment Syndromes. In both methods, first an asterisk sign is measured, followed by the assessment. The asterisk sign is then re-measured. With repeated motions, we want to see an improvement in pain, mobility, strength, reflexes, or other measurement with our asterisk sign after performing sets of 10-20 repetitions. The more repetitions, the more the asterisk sign should improve. With Movement Impairment Syndromes, the painful/abnormal movement pattern is observed, then corrected. If the corrected form eliminates or significantly improves the pain, that increases the likelihood of that direction of preference. Another way of thinking about it is stabilizing the region from excessive movement into a specific direction that it is susceptible to.

In most cases, the subjective report and objective findings match a pattern or presentation. However, what do we do when the pattern doesn't match? What I recommend is to focus on the direction that the objective findings match with. Sometimes the patient doesn't give the most accurate subjective history and the objective examination is reproducible and can show immediate change. That being said, be prepared to re-examine the patient and switch directions following the first couple visits if the patient is not responding (or worsening). Check out the lecture below on how Examination of the Cervical Spine works utilizing Movement Impairment Syndromes!

For more information like this, check out the FREE Mini Course: Management of the Cervical Spine