The Biering-Sørensen Test

- 40 years old and still going strong...

What it is and how to use it .... A 🧵 Based on our recent double publication on trunk strength and endurance testing I wanted to give a synopsis of the most common and most studied trunk endurance test- The Biering-Sørensen Test (BST).

This is why we need to understand anatomy 👇

6️⃣ Stages of spinal degeneration in 1️⃣ MRI.

A 🧵... This lady presented with worsening low back pain with radiation of pain into both legs with walking (neurogenic claudication)

Her MRI shows signs of a typical cascade of spinal degeneration at a single level (L4/5) as follows....

Lumbar Foraminal Stenosis

Pathology, Diagnosis & Management

A 🧵... Foraminal stenosis is defined as an entrapment-type radicular presentation due to stenosis of the nerve root canal in the intervertebral foramen

It can be determined on MRI as per image below.
Note the nerve root between the white arrow.
See the nerve roots above and below - the white ring around the black dot denotes perineural fat.
In general the less white (fat), the greater the stenosis and degree of nerve root compression

ajronline.org/doi/10.2214/AJ…

How does Exercise reduce pain?

A 🧵..... There are 3 physiological processes thought to be involved in "Exercise-Induced-Analgesia"

1️⃣ Endocannabinoid and Opioid Mechanisms
2️⃣ Release of anti-inflammatory cytokines
3️⃣ Reduced Stress-induced hyperalgesia

The evolution of 'Core Stability'...

And why we need to Evolve beyond it...

A 🧵.... A concept of lumbar spine mechanical stability was developed by Anders Bergmark (1989) - a Swedish Professor of solid mechanics.
His theory (see image) was that the system (the spine) was stable if the spring (muscles & Ligaments) was stiff enough.

Chiari Malformations 

An important differential diagnosis for neck pain and headaches - one not to miss ❗

A 🧵.... Chiari malformations are a group of deformities involving the posterior fossa where portions of the hindbrain (cerebellum, pons & medulla oblongata) protrude through the foramen magnum into the spinal canal.

Neurological Red Flags for Low Back Pain‼️

A 🧵.... There is good awareness of the signs and symptoms of certain serious pathologies in back pain such as malignancy, Cauda Equina, fracture, Inflammatory/Rheumatology and infection.

Here's an excellent paper that covers these👇

jospt.org/doi/10.2519/jo…

Trunk Muscle Strength for Low Back Pain 💪

Clinical Relevance & How To Test it 👇

A 🧵.... 'Strength' gets used (incorrectly) in many different contexts - especially in clinically communication.
This is the definition of what strength and endurance are 👇

Do people with low back pain move differently?

YES.

Here's a 🧵on 4 different flexion movement patterns and how to apply them clinically. This study was carried out by Rob Laird where they took 140 people with no LBP and 126 people with significant LBP.
They assessed lumbopelvic motion and EMG during forward bending (flexion) and found 4 distinct subgroups of movement.

Does Posture matter in Low Back Pain?

YES.

Here's a 🧵why ... 4 different spinal postures have been identified in research 

From this image they are
* Swayback (A)
* Flatback (B)
* Hyperlordotic (C)
* Neutral (D)

pubmed.ncbi.nlm.nih.gov/21641850/

Neuropathic Pain

Definition, Mechanisms & Clinical Presentations 🧵 Neuropathic pain is “Pain caused by a lesion or disease of the somatosensory nervous system”.

Central (e.g. spinal cord injury, stroke, or multiple sclerosis) and peripheral (e.g. radicular) neuropathic pain types exist.
For this 🧵 we will only be discussing the peripheral types as they are most applicable to MSK conditions.

Nociplastic Pain

Definition, Mechanisms & Clinical Presentations 🧵 Nociplastic pain is “pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain”.

Nociceptive Pain

Definition, Mechanisms & Clinical Presentations 🧵 Nociceptive pain is pain arising from the activation of nociceptors in response to actual or threatened damage.

In the periphery thermal, mechanical & chemical stimuli of sufficient intensity can lead to action potentials in these nociceptors (C fibres and A delta fibres)

Do Psychological interventions for back pain actually reduce pain?
And if so, how?

A 🧵..

This studys intervention (PRT) helped patient's reconceptualize their pain as a brain-generated "false
alarm" over 8 sessions. 
👉 more effective than usual care & placebo at 12 months. How does this pain reduction occur?

This may be 1️⃣ mechanism

⬇️ brain activity in the anterior midcingulate(aMCC), anterior prefrontal and left anterior insula regions were all found on fMRI vs placebo & usual care in response to experimentally induced pain (evoked pain).

1⃣ Disc Degeneration (DD)
2⃣Degenerative Disc Disease (DDD)
3⃣Discogenic Pain

Definitions, pathophysiology, diagnosis and some thoughts

A 🧵.... Disc degeneration (DD) occurs from the first decade of life.

For this reason I think we should use the term disc degeneration not degenerative disc disease as it is part of normal ageing.

There is no definition as to when it becomes a "disease" so lets not make it nocebic.

Anatomy of the lumbar, thoracic and cervical paraspinal regions

(A) Lumbar

iA, intercostal artery
Iv, intercostal vein
M, multifidus
L, longissimus
SC sympathetic chain
LS, levator scapulae
SN, spinal nerve; 
P, psoas;
QL, quadratus lumborum;
TLF, thoracolumbar fascia; Schematic of Lumbar Spine paraspinal anatomy

Deep Gluteal Syndrome is

'The presence of pain in the buttock caused from non-discogenic and extrapelvic entrapment of the sciatic nerve' 

A 🧵... The Deep Gluteal space (with Gluteus Maximus reflected)
1.Sciatic N. 
2. Piriformis 
3.Sacrotub Ligament
4. Hamstring origin 
5. Gemelli-obturator internus complex
6. Quadratrus femoris  
7.  Lesser trochanter 
8. Greater trochanter

The psoas gets implicated as being a spinal "stabiliser"....but its not. 

Here's an analysis of psoas function and its clinical relevance in the rehabilitation of back pain.
🧵.... Psoas muscle fibre content shows that it is 40% type I and 60% type II.
Type II % increases and type I % decreases as you travel from cranial to caudad. 

This indicates a "dynamic" role at the hip and a "postural" role at the lumbar spine.
ncbi.nlm.nih.gov/pmc/articles/P…

The 3️⃣ different types of lumbar spinal stenosis and how they are recognised on imaging

A 🧵... 1️⃣ Central (Spinal) Canal stenosis:
AP Diameter < 12-15mm
OR
Transverse diamater < 15mm
OR
Lee Grading System 
Grade 0 - Normal
Grade 1 - Mild
Grade 2- Moderate
Grade 3 - Severe

2 weeks after the publication of the RESTORE CFT trial in the Lancet, and following all the social media responses.....
These are the 10 reasons why I think it is the most influential Physiotherapy-led back pain study EVER...

thelancet.com/journals/lance… 1. Individualised treatment works - The study shows very clearly that understanding and addressing individual BPS factors can lead to sustained long term improvements, directly challenging outdated homogenous approaches to LBP.