screening evaluation of spinal pain and dysfunction john p. kafrouni, md rebound physical medicine...
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Screening Evaluation of Spinal Pain and
DysfunctionJohn P. Kafrouni, MD
Rebound Physical Medicine and Rehabilitation, Orthopedics, and Neurosurgery
Low back pain/cervical pain lasting a whole day in the last 3 months – 26, 14 percent US adults. Deyo 2002
Thorasic Prevalence ranges in studies varies greatly due to study design ( 0.4 to 72%). Similar values for Lumbar/Cervical (11-84%). Briggs 2010
UNC study showed a marked rise (> double) in chronic LBP between 1992 and 2006. Possibly due to increased awareness, rising rates of depression and obesity.
Scope of the Problem
District Health Care Workers in Nottingham, 1992
½ of all respondents (n= 1363) had back pain in last year, ½ of those under age of 25
½ of these had functionally significant pain interfering with sport, ADLs or sleep
Nurses 60 % Ambulance Workers highest rates 25% had time off in last 5 years secondary
to back pain
Among Health Care Workers
LBP second to URI for absenteeism in work force
Cost inclusive 5,000,000 disabled due to LBP 25,000,000 Americans lose 1 or more days a
year Yearly prevalence continues to grow at a rate
greater than the U.S. population.
Scope
RTW and Absenteeism
Time Missed from Work
6 months
1 year
2 years
Return to Work Expected
50%
25%
0
History is 90% - Osler (1893 or so)
Temporal:- Onset abrupt, subacute,
indolent- With or without apparent
trauma- Improving, stable,
worsening- Intermittent, AAT - Improves/worsens with
activity- A.M worst?
Quality:- Sharp, dull, burning,
aching, nerve-like- Intensity-
mild/moderate/severe
- 1-10 pain scale tells you more about the patient than the etiology
William Osler, MD
Father of Modern Clinical Training Techniques, bedside exam/historyThought one should marry a freckle faced girl.Thought clinicians older than 67 should be kindly euthanized.
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Provocations, Alleviation-“What is the worst/best thing for your
symptoms”
Provocations- - Sitting- Standing- Walking- Lifting- Transitions- Weight Bearing- Staying Still- With flexion, extension- Valsalva
Alleviation- Sitting- Standing- Walking- At rest- With flexion, extension- Meds- may tell you a
bit about the pathology, patient
Categories
Flexion Extension Transitional
Radiation patterns are very important and underscore that often more than one thing is going on at once.
Axial Radicular- true Sclerotomal- non
radicular extremity pain
Referable to peri- or intra-articular source
Myofascial Neuropathic
Red Flags
Gait ataxia Sphincter dysfxn,
saddle anaesthesia, ur. Retention
Night pain/ weight loss Fever/chills Associated
cognitive/speech/CN changes
Myelopathy Myelopathy,
cauda/conus injury Neoplastic Infection Upper Motor neuron
Signs: consider CVA, MS, etc…
Seated Symmetry – off loading hemipelvis- think SI
joint, Hip, Ischial/trochanteric bursitis Can’t sit – Think Disc Turns torso to face you without cervical
bending/rotation- think radiculopathy, cervical facet
Can’t sit still- may have implications for sedentary work restrictions
The ExamInitial Observation- Seated
Posture- Seated
Symmetry Avoidance of specific plane Proximal muscle weakness Pain avoidance Malingering, out of proportion splinting
relative to history, or simple observation of apparent distress
Fear/ Anger/ Slug-like behavior
The ExamObservation-Sit to Stand
Asymmetry Body Parts relative to the Line of Gravity-
head forward, lumbar curve, kyphosis. This gives tremendous info in myofascial pain
Habitus Watch for the tendency to want to sit down,
which may give an indication of general habits
Observation Posture-Standing
“Take your normal comfortable posture”
Posture in Standing
Prefers which plane? Flexion- think Spinal stenosis Antalgia Trendelenberg- weakness/pain inhibition of hip
abductors. Foot drop – circumduction, hip hiking, flop/slap
on heel strike. Wide based or steppage- peripheral neuropathy Spastic- myelopathy
Exam-Gait
Trendelenberg Gait
Initial Range of Motion:Standing
Flexion Extension Lateral bending Rotation Thoracic
rotation/flexion
Avoidance of planes Ipsilateral or contralateral
pain- joint vs. myofascial General range of motion –
check cervical to compare with lumbar and vice-versa
Ask specifically if back/neck and/or arm/leg pain
range- assess hamstring/lumbar muscle length
Thorasic Range
Flexion Rotation
Standing- provocation (just after/during ROM)
Spurlings test Lhermitte’s test Stork test
Cervical radiculopathy
Cervical myelopathy Sacroiliac joint/Facet
jointConfirm ipsilateral or contralateral pain and axial vs. appendicular pain- which may implicate a lateral lumbar disc
Standing Provocation
Spurling’s Stork Test
Shoulder Screen- if no pain with cervical ROM or pure anterior shoulder pain.
Posture/scapular orient Drop arm- posterior
view Supraspinatus testing O’briens/AC joint Hawkins Palpation in Modified
Crass position Yergeson’s or Speeds
Scapular dyskinesia Painful arc Cuff Labrum Cuff Cuff- more specific Bicipital
tendinosis/itis
Shoulder Screen
O’Brien’s Modified Crass position
Palpation while standing
Spinous processes Lateral masses Periscapular Myofascial Sacroiliac joint Trochanters Have the patient put a
finger on “the spot” Can identify step offs with
flexion/extension- spondylolisthesis
Local pain Sclerotomal radiation:- Does it match claimed
radiation?- Levator scapula/lateral
scapula - Trochanter/IT band/PSIS
medial and lateral/paraspinals/lateral sacrum.
Palpation -Standing
Sacroiliac joint Levator Scapula
Strength while standing
Heel walking
Toe/heel raising
Anterior tibialis- L4 predominately
S-1, Gastroc/soleus
Sitting
Upper/Lower extremity strength/Sensation
Muscle stretch reflexes
Pulses Sit Slump- sensitize
with ankle dorsiflexion
Hip IR/ER Knee exam if
indicated
See myotomes/MSR Dermatomes
Dural stretch- clarify axial or true radicular, myofascial,
Sitting
Seated Slump Dermatomes
Myotomal testingCervical
C5 C6 C7 C8 T1
Delt, Biceps Pronator/Wrist
Ex/Infrasp Triceps/ Ext Ind Prop Finger flex (3rd) Interossei/ Small
finger abd
Myotomal testingLumbar
L2 L3 L4 L5 S1 S2,3,4
Hip Flex Knee Extension Ankle dorsi, Ant
Tibialis Great toe extension Toe Flexion/Heel
raising Sphincter Tone
ReflexesCervical/Lumbar
C5-biceps C6-pronator C7-triceps L3,4-Quads L5-Hamstrings S-1-Plantar/Gastroc
soleus
Pathologic reflexes- Hoffmans/Babinski
Excessive clonus Absence of reflexes-
Jendrassic maneuver Great range of
normals, when in doubt check the upper/lower reflexes
Supine evaluationCervical pain
Cervical- Palpate lateral masses Greater occipital nerves Muscle tension eval Gentle traction Sclerotomal referral Repeat flexion/rotation Opportunity for muscle
energy techniques
Opportunity to palpate cervical structures with less muscle tension and guarding
Traction may increase facet pain, decrease discogenic/radicular pain, increase or decrease muscle pain.
Supine ExamLumbar Pain
Hip Scour Straight Leg Raise Sacral sheer Faber/Modified
Patricks Palpate Ant/Lateral
hip Faking it? SLR,
Hoover’s Knee exam if
indicated
Flexion and Ab/Adduction
Back vs. Radicular pain
S.I. Joint Hip/S.I. joint Psoas /Pubic
Symphysis
Supine testing-Lumbar
Modified Patrick’s Hoover’s sign
Hoover’s sign
Prone ExamCervical and Thoracic
Palpation Segmental Motion Scapular mobility Distant referral of
proximal structures
Palpation Costovertebral
junctions Scapular mobility Opportunity for
Manual Medicine techniques
Prone Exam Lumbar/Pelvis
Palpation-L4 is top of iliac crest
Femoral stretch/Yeomans
Hyper extension“up dog”
Identify Spinous processes, Articular pillars
Iliac Crest, PSIS, Lateral sacrum, GreatrTrochanter
L2,3,4 radiculitis/SI joint
Sensitizes pain of articular pillars, may decrease disc pain.
Prone-Lumbar
Yeoman’s Prone hyperextension
Sidelying exam
Gaenslens test Ober’s test FAIR test
Palpation of peritrochanteric structures/ sidelying abduction
Sacroiliac joint Iliotibial band Piriformis test-much
talked about, seldom seen.
Assessment of lateral hip syndrome.
Sidelying
FAIR test Ober’s test
Thoughts
Things that can make patients worse
Anxiety Depression Fear Anger Terms like Degenerative Inactivity Narcotics, NSAIDS Perceived future
disability
Thoughts
Treat the patient not the scan
Don’t panic, call a physiatrist
A bulging/herniated disc does not a surgery make, but progressive weakness, bladder/bowel changes, myelopathy, intractable pain requiring hospitalization do
Thank you very much for your attention and participation
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