KNEE PAIN MIGHT ORIGINATE FROM YOUR LOWER BACK MOHAMED SABBAHI; M. BADGHAISH; F. OVAK-BITTAR; A. ABDILAHI; TEXAS WOMAN’S UNIVERSITY, SCHOOL OF PHYSICAL THERAPY AND TEXAS ELECTROPHYSIOLOGY SERVICES, HOUSTON, TEXAS, USA AND THE MEDICAL PHYSICAL THERAPY CENTER, JEDDAH, KSA. METHODS INTRODUCTION RESULTS 6+ Tenderness spots 1. Medial aspect of knee (spot 1 & 2) 2. lateral aspect of knee (#3) 3. Suprapatellar pouch (#4) 4. Patellar tendon (# 5) (Primary) 5. Popliteal fossa (posterior aspect of knee) (#6). 6. Patellar friction test. 7. Rectus Femoris. 8. Passive knee hyper extension test 9. USUALLY ASSOCIATED WITH CALF MUSCLE CRAMP & TENDERNESS Patient’s clinical tests Tenderness/soreness Pain measurement: Visual Analog Scale (VAS) ROM MMT: Dynamometry Gait ADL Neurologic exam: DTR, Sensory test CASE STUDIES-1 80 y.o female. DOI: > 20 yrs. Bilateral OA with knee pain & deformities (X-Ray & MRI)- No history of LBP Limitation in knee extension and full flexion. Soleus H-Reflex: 0.2 mv. (R, lying), 0.3 mv. (R, standing) 0.1 mv. (L, lying), 0.6 mv. (L, standing OSP: Flexion (forward bend) Results (after 12 sessions of back treatment) Pain significantly decreased, from 8 to 3 (VAS) Improved SLR (bil.) Increased Knee ROM in extension. Improved gait symmetry. Improved ADL. No changes in leg deformity. No significant increase in H-amplitude. CASE STUDY 2 (A-C) 71 yo,F with 9 yrs. history of knee pain (right ) History of LBP for the last several yrs. since she received epidural injection during labor. Pain (6/10), limitation in last degree of extension. Ext. torque: 32 (R), 42 (L) Gait: limping. ADL: Need helper @ home H-reflex: Lying: 0.3 mv.(R) 0.3 mv.(L) Standing: 0.8 mv.(R) 1.8 mv. (L) OSP: RSB + LR Results (12 sessions of back treatment) Pain: 0/10 Extension torque: 40 (R) 50 (L) ROM: WNL Gait: symmetric ADL: Normal/independent. H-reflex: not measured at end. Knee pain, a common pathology affecting all ages. Knee Pain in older population is claimed to be the result of cartilaginous degeneration of the hyaline cartilage. Knee Pain in sports is claimed to be due to injuries of some intra-articular structures. What about adult and mid-age population with Knee pain. NO degenerated cartilage & no intra-articular damage Knee pain associated with or without osteoarthritis is a common pathology in the rehabilitation clinic. Knee pain often diagnosed as idiopathic, referring patient to PT clinic to rehabilitate the knee when the pain might originate from other structure e.g. spine PURPOSE OF STUDY To identify patient with knee pain originating from lumbar spinal disorders (LBP), using soleus H-reflex asymmetry. To test the effect of lumbar spinal treatment on the intensity of knee pain and gait performance THEORY Osteoarthritis of the Knee Prevalence: 3.5% which amount to 7.7 million. Incidence: 240 per 100,000/year Total cost for knee joint replacements: $ 28.5 billion (in 2009) OA of the knee is 1 of 5 leading causes of disability among non-institutionalized adults. PAIN: Is it neural OR cartilage phenomena Cartilage is insensitive to pain. No noxious nerve fibers. Hyaline cartilages are stimulated daily for so many years without pain provocation. But healthy nerve e.g. ulnar or lat. popliteal nerve if touched it will cause pain, numbness or sensory symptoms distal to the stim. Site. Nerve pathology might result in cartilage damage e.g. Charcot-Marie- tooth. The opposite is not true. THEREFORE: Conceptually knee Pain may probably originate from neural pathology- How? Can it come from peripheral nerve damage? Nerve conduction studies are usually normal, in these patients. Nerve root could be the most viable site. Testing nerve root function/dysfunction could reveal such proposition REFLEX ASYMMETRY could be the answer (The H/H Ratio) Testing soleus H-reflex from the right and left lower limbs in knee patients( n=102) showed smaller reflex amplitude on the leg side having the knee pain (e.g. right). Divide H(r)/ H(l) % shows the degree of nerve root impingement toward the right that might cause the KNEE PAIN. H/H ratio completed during unloading (lying) and loading (standing) would reveal the effect of body/spinal loading that may aggravate the pain. Hilton’s Law A nerve innervating muscles that act across a joint must also supply SENSORY fibers to that joint. For example, the femoral nerve (L4) which supplies the quadriceps muscles also sends sensory branches to the knee joint. (The University of Michigan medical school- Gross Anatomy- Introduction to joints). The sciatic nerve (L5 & S1) supplying the hamstrings also send SENSORY branches posteriorly to the knee. The obturator nerve. The H-reflex Pathway & Measured Parameters Ia afferents to @-motoneurones to @-axons to extrafusal muscle fibers (may be one synapse) Parameters: 1) Peak-to-peak amplitudes 2) Latency to deflection Lumbar spinal levels tested by H-Reflex VMO H-reflex ------- L4 Soleus H-reflex ----- S1 Lateral Gastrocnemius H - L5 Although Soleus H may contain Mostly S1, It might have some components from L5 root. EXPERIMENTAL PROCEDURES History & Physical. Clinical testing: Testing tenderness spots (How many?) Testing tenderness spots at lumbosacral region. SLR (R & L) Testing cutaneous sensation. Knee extension torque (sample subjects #) Gait/walking test (subjective) (for limping, asymmetry….etc) Testing pain level (VAS, from 0-10) Electrophysiological testing: Soleus H-reflexes (R & L) during: Lying (unloading) , Neutral stand (Loading) & During dynamic test (please see our presentation in this conference) 5 traces of maximal H-amplitude were averaged for the right & left lower limb during lying & standing postures. Identify the leg with the smallest H-reflex (usually the leg with symptomatic knee pain) Complete the dynamic testing for the soleus H-reflex associated with the knee pain (5 traces in each posture). Identify the Optimum Spinal Posture (OSP), Unwanted spinal Posture (USP). Treat the patient in the OSP (positioning, manipulation & mob. As well as exercises) for 20 min. Measure the intensity of knee pain, Gait performance & SLR pre & post. DISCUSSIONS Some specific knee pain might originate from neural impingement at the lumbosacral region even without LBP. In these patients treatment is recommended for the lower back to decompress the impinged nerve root. Pain might be eliminated without changes in the knee deformity that has been developed over years. RECOMMENDATIONS In patients with knee-pain consider the back as a possible source. Test it!! Knee pain patients with 3-4/6 tenderness points at the knee could be caused by lower back syndrome, even there is no complaints of it (silent back syndrome). H-reflex testing in lying (unloading) and standing (loading) might reveal the source of knee pain from the back. (YOU MIGHT SAVE THE PATIENT A TOTAL KNEE ARTHROPLASTY) DATA AND STATISTICAL ANALYSES REFERENCES This is a descriptive study. Mean + SD for the H-amplitudes during: Lying - Standing - Different trunk postures (Total 8) Gait asymmetry: Yes (mild, moderate, severe), No asymmetry. Intensity of knee pain (pre & post treatment): VAS (0-10) Alrowayeh H., Sabbahi M. H-reflex amplitude asymmetry is an earlier sign of nerve root involvement than latency in patients with S1 radiculopathy. BMC Research Notes 4:102, 1-8, 2011 Alrowayeh H., Sabbahi M. The Proportion of patients with Non- Specific Low Back Pain and Neural Compromise. EMG. Clin. Neurophysiol. 50; 67-73, 2010 Sabbahi M. H-Reflex Changes Under Spinal loading and Unloading of the spine and their relation to the diagnosis of lumbosacral radiculopathy in mechanical back pain.. EMG Clin. Neurophysiol. 112;1952-1954, 2001. Ali A., Sabbahi M. Test – Retest Reliability of the Soleus H-Reflex in Three Different Positions. EMG. Clin. Neurophysiol. 41, 209-214, 2001 Ali A., Sabbahi M. H-Reflex Changes Under Spinal Loading and Unloading Conditions in Normal Subjects. Clin. Neurophysiol. 111: 664-670, 2000 Sabbahi M. Fixing lumbosacral radiculopathy with postural modification: A new method for evaluation and treatment based on electrodiagnostic testing. J. Neurol. Orth. Med. Surg. 17:182-186, 1997. HYPOTHESIS Knee pain of specific clinical signs might originate from the spine. H-reflex asymmetry could identify patients with knee pain due to lumbar spinal disorders even in patients with no Lower back Pain (called silent back syndrome) Spinal treatment might result in alleviation of knee pain. RESULTS Clinical test: Tenderness areas (around the knee): 1) Posteromedial aspect 2) medial capsule 3) Lateral capsule 4) suprapatellar 5) patellar tendon 6) popliteal fossa 7) subpatellar 8) hyperextension of the knee 9) calf 10) Quadricps. H-Reflex Data- 54 Patients In the table: H-amplitude decreased on the ipsilateral side of the painful knee joint (52/52 tested). Reflex asymmetry was either small (12), moderate (13) or severe (27). Optimum Spinal Posture (OSP): Single axis: 8 patients (4 flexion, 4 Extension) Double axes: 36 patients (RSB+ LR; LSB + RR) METHODS Participants: 60 patients with knee pain associated with or without LBP were tested. Gender:23 males 37 females Age range: 32- 80 y.o History of pain: 3 mo.- 20 yrs. Clinical tests: Tenderness regions around the knee. Tenderness areas @ lumbar spine and lower limbs Numbness & tingling areas/dermatomes DTR (ATR, PTR) Gait performance (symmetric/asymmetric), limping ElectrophysiologicalTest: Soleus H-reflex was elicited & recorded (1 msec., 0.2 PPS @ H-max) in both lower limbs during: Lying (unloading) Standing (loading) CONTACT DETAILS Dr. M. Sabbahi: msabbahi@twu.edu Tel. #: (281) 748-9109 (USA) (713) 522- 6004 (USA) (Texas Electrophysiology & Physical Therapy services) Fax: (713) 522- 8785 www.txphysicaltherapy.com