KNEE PAIN MIGHT ORIGINATE FROM YOUR LOWER BACK

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1 KNEE PAIN MIGHT ORIGINATE FROM YOUR LOWER BACK MOHAMMED BADGHAISH; M. SABBAHI; F. OVAK-BITTAR; A. ABDILAHI. JEDDAH, MINISTERY OF SOCIAL AFFAIRES, KSA; TEXAS WOMAN S UNIVERSITY, SCHOOL OF PHYSICAL THERAPY AND TEXAS ELECTROPHYSIOLOGY SERVICES, HOUSTON, TEXAS, USA. INTRODUCTION 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 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. PURPOSE OF STUDY To identify patients 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 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 The H-reflex Pathway & Measured Parameters Ia afferents to extrafusal muscle fibers (may be one synapse)

2 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 Testing nerve root function/dysfunction could reveal such proposition. HYPOTHESIS: 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. 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 METHODS Participants: 60 patients with knee pain associated with or without LBP were tested. Gender:23 males 37 females. Age range: y.o History of pain: 3 mo.- 20 yrs. Clinical tests: Tenderness regions around the knee. Tenderness 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 H-max) in both lower limbs during: Lying (unloading). Standing (loading). Specific knee test 6+ Tenderness spots. 1. Medial aspect of knee (spot 1 & 2).

3 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. History & Physical. Clinical testing: Testing tenderness spots (How many?) Testing tenderness spots at lumbosacral region. SLR (R & L) Testing cutaneous sensation. Knee extension torque Gait/walking test (subjective) (for limping, asymmetry.etc) Testing pain level (VAS, from 0-10) Electrophysiological testing: REFLEX ASYMMETRY could be the answer (The H/H Ratio) Testing soleus H-reflex from the right and left lower limbs in knee pain patients( n=60) 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. Soleus H-reflexes (R & L) during: 1. Lying (unloading), 2. Neutral stand (Loading) & 3. 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. EXPERMENTAL PROCEDURE DATA AND STATISTICAL ANALYSIS

4 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). RESULT Table 1: Cumulative results of all patients tested. H-Reflex Data- 54/60 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 (H/H Ratio) Posture (OSP): Single axis: 8 patients (4 flexion, 4 Extension) Double axes: 36 patients (RSB+ LR; LSB + RR). RESULT 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 home

5 Mean ± SD H-reflex: Lying: 0.3 mv.(r) 0.3 mv.(l) Standing: 0.8 mv.(r) 1.8 mv. (L) OSP: RSB + LR. Cumulative Results: Limb side with knee pain is correlated. to the limb with smaller H-amplitude ( R=). The severity of knee pain is associated with even smaller H-amplitude. Data continue to be analyzed. DISCUSSIONS Case-study-1: 84 y.o Case-study-2 70 y.o 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. 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. Lying Standing Right Left Right Left 2.6± ± ± ±2.7 The reflex asymmetry with reduced amplitudes on the same side of the symptomatic knee may be due to neural impingement at the spinal level. The increased reflex asymmetry during standing compared to lying, in severe patients condition, may be due to increased impingement during spinal loading on the nerve root during standing. Nerve root decompression with dynamic testing and the resulting reduced knee pain may be due to central spinal mechanism. LBP Descriptive Statistics Injury side Male Female Right Left Bilateral 5 7 DOI 0.5 to >20 yrs 1 to >20 yrs Treatment of the back, using OSP, without any the knee treatment and the resulting alleviation of knee symptomps support the above- mentioned findings.

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