advpatho unit3 10patho - medical university of south carolinapeople.musc.edu/~decristc/adv...

Adv Patho Unit 3 of 39

File: advpatho_unit3_10patho.pdf C. DeCristofaro, MD

MUSCULOSKELETAL EXAM NOTES: Anatomy lessons online:

Instant Anatomy: http://www.instantanatomy.net/ o Click on the area of the body and then for each area there are muscles, bones,

organs, etc. Lumen Learn’Em:

o http://www.meddean.luc.edu/lumen/meded/grossanatomy/learnem/learnit.htm Lumen Dissector:

o http://www.meddean.luc.edu/lumen/MedEd/GrossAnatomy/dissector/index.html

Why a musculoskeletal system? Axial skeleton & appendicular skeleton is our “framework” for both stability and

mobility Integrity of bones, joints, muscles (& innervation) required for proper function Common pathologies include:

o Injuries o Rheumatologic disorders (joints) o Metabolic problems (calcium/phosphate metabolism, osteoporosis)

Common cause of impairment & disability Functions:

o body movement o protecting vital organs o providing storage space for minerals o producing blood cells for hematopoiesis o resorbing and reforming itself to match the stresses placed on the system (“use

it or lose it”) General anatomy:

o joints held together by ligaments o muscles attached to bones by tendons o cushioned by cartilage

Joint types: o Synarthrosis: no movement permitted o Amphiarthrosis: slightly movable o Diarthrosis: freely movable

Diarthrodial joints: Most are diarthrodial (diathroses) – freely moving articulations enclosed by capsule of

fibrous articular cartilage, with ligaments and cartilage covering ends of opposing bones

Synovial membrane lines the articular cavity and secretes synovial fluid Bursae between bones, tendons & ligaments reduce friction & promote ease of motion Muscle:

o Size & strength influenced by genetics, nutrition, exercise o Must have intact functional innervation

http://www.instantanatomy.net/

http://www.meddean.luc.edu/lumen/meded/grossanatomy/learnem/learnit.htm

http://www.meddean.luc.edu/lumen/MedEd/GrossAnatomy/dissector/index.ht



Some Orthopedic terminology: Apophysis:

o bone growth center that is not a growth plate and has a strong muscle insertion (e.g. greater trochanter of femur).

Cavus: o high longitudinal arch of foot (usually plantar flexed).

Valgus (valgum) angulation of joint/joint: o apex toward the midline o the distal part of the joint pointing laterally. Example: knock-knees.

varum (varus) angulation of bone/joint: o apex away from midline o the distal part of the joint pointing midline. Example: bow-legs.\

dislocation – loss of contact between two bones subluxation – partial loss of contact betweeen two bones (“slippage”) Assessment Diagnostics note: If an abnormality appears to be a possible “anatomic variant”, then order Xrays of the opposite

joint (bilateral joints) such as elbow, shoulder, etc.) – often the abnormality is simply a normal anatomic variant

Use of Goniometer: o Measures range of motion (ROM) o Align fulcrum of goniometer with fulcrum of joint o Align stationary arm of goniomter with limb being measured o Hold goniometer in place as you move thelimb thourgh ROM and measure angle



SPRAIN & STRAIN: there is a difference, although the words are often used interchangeably Anatomy:

o Ligaments connect bone to bone, and tendons connect muscle to bone Traumatic injury to soft tissues, graded according to severity. Sprain: injury to the ligaments around a joint; if the ligament is stretched too far, it tears.

o “first, second, third degree” sprain depending on the degree of tearing and damage (third degree is complete separation from insertion onto bone).

o Degree of sprain determined by clinical exam, and guides treatment (from rest all the way to casting for 6 weeks, like a bone fracture); the older the patient, the longer it will take to heal a sprain, and a severe sprain may require surgery in the older patient

o Defined as first, second, or third degree sprain Grade I (First Degree) Sprain: The ligaments connecting the bones are often over-stretched,

and damaged microscopically, but not actually torn. The ligament damage has occurred without any significant instability developing. Mild tenderness, some swelling.

Grade II (Second Degree) Sprain: injury is more severe and indicates that the ligament has been more significantly damaged, but there is no significant instability. The ligaments are often partially torn. Lots of swelling, may be ecchymosis, usually trouble with the joint (e.g. can’t walk on knee or ankle sprain).

Grade III (Third Degree) Sprain: is the most severe. This indicates that the ligament has been significantly damaged, and that instability has resulted. A grade III injury means that the ligament has been torn. Due to this complete ligament tear, hemorrhage, instability of joint, inability to perform active ROM are seen. Also, usually VERY painful.

Strain, pull or tear: o damage to muscle itself. o Also can be damage of the tendons. o Usually includes bleeding with bruising seen on exam



FRACTURES: fractures are common in pediatrics (10 - 15% of all pediatric injuries) Special consideration in pediatrics: pre-osseous cartilage physis growth plate thicker periosteum produces more callus. More rapid healing at younger age (healing slows with age). Fracture remodeling is ineffective in: displaced intra-articular sites, diaphyseal fracture,

malrotation. In children < 10 y/o, "overgrowth" requires different reduction apposition technique (bayonet

appositon in femoral fractures or the leg heals too long). Fracture repair: a hematoma forms the initial framework procallus (granulation tissue) develops woven bone (callus) and periosteal/endosteal surfaces grow to mimic pre-existing shape &

structure of the damaged area.



Displaced metacarpal Fracture Operative treatment: in kids uses different techniques and hardware hardware is always removed after healing (anatomic alignment more important than rigid

fixation) Classification of fracture: complete: both sides (through cortex on both sides) buckle (torus): compression greenstick (spiral, rotational): may be abuse bowing (bend): deformity is seen, not really fracture, not seen on Xray) open or closed: (not coming through the skin) displaced: fracture site moved so that end-to-end contact is not maintained stress: overuse insufficiency: abnormal bone fractures from normal use

Pediatric fractures: sometimes a long bone fracture is set in "bayonet" style, with overlapping ends. repair is so vigorous in children that the healing (fractured) bone will wind up being longer than

the contralateral side, so the bayonet overlap will allow both sides to remain equal at the end of healing.

Bayonet knife is “fixed” to the rifle when it is time to charge the enemy. It overlaps the rifle barrel. Fracture set similar way.

metaphysis



Epiphyseal fractures (pediatric): peak incidence in males at age 13-14 y/o (girls 11 - 12 y/o) more common in males most common sites are distal radius & then distal tibia. Classification:

o Classification of physeal fractures are the "Salter & Harris" (casually called "Salter") from Class I - V.

o The more poorly aligned (or crushed) the higher the level of Salter, and more likely will need open surgical fixation.

Clinical Management: o Injury to physis is the thing to be concerned about and always requires orthopedic

referral for ongoing management. o Remember the peroneal nerve and foot-drop if too much cast pressure.

Special problems in fractures: Neurovascular injury: distal humerus supracondylar fractures, knee. Compartment syndrome:

o hemorrhage & STS cause compression of blood vessel and/or nerve o may be iatrogenic with cast placement.

Toddler's fracture: distal tibia fracture. o limping, but can't see fracture on Xray; o may need to do a bone scan to verify.

Child abuse: o Greenstick fracture o Shaken baby (shaken child) syndrome:

with metaphyseal "corner" fractures especially of humeral/tibial/femoral shaft. If suspected, needs admission and bone scan to look for old/multiple fractures

and check retina for hemorrhage/detachment.



HEAD & SPINE: Temporomandibular joint lies between the mandile & temporal bone Spine has cervical, thoracic, lumbar, sacral vertebrae (except for sacral) there are fibrocartilaginous discs separating the vertebrae The vertebrae form joints allowing movement in different directions (cervical most

mobile – flexion & extension between skull & C1; rotation between C1 & C2) Sacral vertebrae are fused and form the posterior pelvis (along with the coccyx)



Spinal disc pathologies Nerve Root Compression



RADICULAR PAIN, NERVE ROOTS, & DERMATOME MAPS: Radicular Pain, Radiculopathy, Radiculopathic Pain, and Root Pain are all synonymous “Radicular Pain” more accurately denotes that the pain is coming from the spinal root level An example is “sciatica” which can originate from the L4, L5, or S1 nerve root (all of which

come together to make the sciatic nerve) The nerve roots pass closely by the vertebral discs (in red), and thus a herniated nucleosus

pulposus (HNP) can cause such radicular pain If you look at the DERMATOME chart on the next page, you can see WHERE the L4, L5, S1

pain should “map” – this is where the patient complains of pain Note – up to 40% of middle-aged adults have “hernation” of some degree on MRI scan and

are completely asymptomatic; also, those with disc herniations may NOT map exactly to the dermatome maps as pictured (people are “wired” differently”)

Important: o If there is a sensory complaint (pain, tingling, burning) then usually this can be

managed with conservative therapy (e.g., bedrest, analgesics) o If there is LOSS or REDUCTION in motor or reflexes in that spinal nerve distribution (or atrophy of a muscle) – this is serious! Needs referral and full evaluation for serious nerve impingement at the spinal level (orthopedics, neurology)



Radiculopathies: Part of the evaluation of reflexes, motor and sensory patterns is to find radicular patterns of

motor or sensory deficits Example:

o sciatica – pain from lumbosacral nerve root compression o usually due to lumbar disc prolapse or protrusion (herniated nucleosus pulposus, HNP) o It is important to make sure that pain is not due to nerve root compression (a

radiculopathy) L5/S1 disc prolapse

o Pain along posterior thigh with radiation to heel o Sensory loss in lateral foot o Absent ankle jerk reflex

L4L5 disc prolapse o Pain along posterior or posterolateral thigh with radiation to top of foot o Paresthesia and numbness of top of foot and great toe

L3/L4 disc prolapse o Pain in front of thigh o Wasting of quadriceps o Diminished sensation on front of thigh & medial lower leg o Reduced knee jerk reflex

Bragard Maneuver for lumbar root radiculitis Femoral stretch for lumbar radiculitis



Dermatome – ANTERIOR:



Dermatome – POSTERIOR:



JAW: To see the jaw open and close on its TMJ articulation, go to: (fun) http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/surface/head_neck/tmj.html

Temporomandibular Joint (TMJ) Disorder (Syndrome): if the joint is not working properly, the cartilage (labeled #1 on picture) slides forward and remains stuck in that position. Then the condyle remains “stuck” behind the cartilage and “locks” up. Arthritis may also be present.

CPG on diagnosis: http://www.astmjs.org/final%20guidelines-04-27-2005.pdf AAFP article: http://www.aafp.org/afp/2007/1115/p1477.html

http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/surface/head_neck/tmj.html

http://www.astmjs.org/final%20guid

http://www.aafp.org/afp/2007/1115/



NECK

Good article on radiology of cervical spine trauma (from 1999 but still good): http://www.aafp.org/afp/990115ap/331.html Good article on nonoperative management of cervical radiculopathy (2016): http://www.aafp.org/afp/2016/0501/p746.html

http://www.aafp.org/afp/990115ap/331.html

http://www.aafp.org/afp/2016/0501/p746.html



BACK (POSTERIOR THORAX) – see picture below for anatomic landmarks:



SHOULDER: Glenohumeral joint articulates with humerus & scapula (allows shoulder movement) Acromioclavicular joint is articulation of acromion process and clavicle Sternoclavicular joint is articulation of manubrium (sternum) and clavicle



Shoulder landmarks:



ELBOW: Articulation of humerus, radius, ulna; enclosed in synovial cavity Allows flexion/extension of elbow Flexion: Normal range of motion is 0 to 135 degrees. The muscles that make this motion possible include the brachialis, biceps brachii and

pronator teres. Extension: Muscles are triceps brachii and anconeus Pronation: Muscles are pronator teres and pronator quadratus Supination: “You carry soup when you are supinated” Muscles are biceps and supinator



Anterior cubital fossa landmarks Posterior elbow landmarks



Wrist (radiocarpal joint): Articulation of radius & carpal bones Called a “condyloid joint” (articulates in two planes) Multiple articulations – carpals, metacarpals, proximal/middle/distal phalanges Hand: Carpal bones Metacarpal bones Proximal, middle, distal phalanges



Dorsal Carpal bones Palmar carpal bones Carpal bones key: S = scaphoid, L = lunate, T = triquetrum, P = pisiform, Tm = trapezium, Td = trapezoid, C = capitate, H = hamate (hook) Surface landmarks – bony dorsal Surface landmark – palmaris longis tendon



Wrist & Hand Exam Landmarks: Hypothenar Eminence Pathology such as carpal tunnel may cause atrophy of the thenar eminence



HIP: REMEMBER the hip is NOT the buttock! Articulation of acetabulum and femur Fibrous capsule and three bursae to reduce friction “ball & socket” joint (femur can move on many axes – many directions) Surface landmarks – Anterior Surface landmarks – Lateral



Posterior landmarks hip:



Pediatric maneuvers for DDH (Developmental Dysplasia of the Hip):

Good AAFP article: http://www.aafp.org/afp/2014/1215/p843.html Screening: http://www.aafp.org/afp/2006/0601/p1992.html

You should know the risk factors and how to evaluate as part of newborn exam. You should know the risks of PERFORMING the procedures

See information on the maneuvers next page Gluteal fold irregularity

Barlow & Ortolani





Barlow maneuver: Clinically this is the most important maneuver. This is a provocative test in the newborn infant exam, that attempts to dislocate the unstable hip with pressure (flex & adduct hip of supine infant, push down posteriorly and feel for CFE slipping out of socket). Once pressure is released, hip should spontaneously relocate. Movement in both directions is positive (Barlow's sign) and indicates susceptibility of the hip to actual dislocation. Procedure bend knees, place forefinger/fingers on greater trochanter and thumb in inguinal area, then push laterally/posteriorly with thumb as you adduct (pull to midline). A hip "click" is felt in 1:100 infants, but only 1:800 have true dysplasia

Ortolani maneuver: conversely, this maneuver attempts to reduce

an already dislocated hip, most likely positive at age 1-2 mos since enough time has passed for true dislocation to occur. Flex & abduct hip and try to lift the CFE back into the socket: a "clunk" is felt; this reduction is not possible after 2 months even if the hip is dislocated since now contracture has occurred; undue pressure should not be used causes avascular necrosis of the CFE. Presentation is infant at age 1 - 2 months with hip dislocation, flex and abduct thigh, if reduction is possible it is felt as a "clunk." Note that dislocation cannot be reduced after 2 months of age due to contractures having formed, IATROGENIC COMPLICATION OF FORCED REDUCTION is avascular necrosis of capital femoral epiphysis (CFE) that DESTROYS THE HIP MOST EXPERTS recommend if presentation suspicious of DDH or dislocation at this age, refer urgently to specialist and do not peform the Ortolani.

Allis or Galleazzi Exam: a foreshortened femur, place heels together

with knees flexed & assess where the shortening is.

Ortolani

Barlow

Galleazzi



Trendelenburg Test: Used to assess hip stability. Test: Stand on one leg – this is the “stance” (standing) leg Then, lift the foot on the opposite (contralateral) side by bending at the knee While doing this, the examiner allows the patient to balance slightly by obtaining support with

the index fingers of both outstretched hand Findings: NORMAL: hip is held stable by gluteus medius (abducts the supporting leg) POSITIVE (abnormal): The Trendelenburg sign is positive if the pelvis drops on the side that is lifted (this is the side

opposite to the "stance" standing leg) This tells you that a weakness is present on the side of the "stance" (standing) leg Normally, the body would shift the weight to the stance leg -- but if the stance leg has

weakness, then it can't accept this shift of center of gravity So if lift the right leg, the left leg is the "stance" leg... if pelvis drops on the right side (lifted

side), then the weakness is on the left Reasons to have positive Trendelenburg: subluxation or dislocation of the hip coxa vara (see below) greater trochanter fractures slipped upper femoral epiphysis polio post-operative nerve damage muscle-wasting disease any painful hip disorder which results in gluteal inhibition



KNEE: Articulation of femur, tibia, patella Fibrocartilaginous discs cushion the tibia & femur Collateral ligaments give stabilty to the knee medial & lateral cruciate for anterior & posterior Suprapatellar bursa separates patella, quadriceps tendon, muscle Allows flexion/extension Special maneuvers on knee exam: Ballottement of large knee effusion: Flex the knee slightly, put one hand on supra-patellar pouch and push down (forces

fluid to central part of the joint) Push down on the patella with your other hand (use your thumb) If large effusion, patella fells like it is floating (bounces back up when pushed down) Milking for small knee effusion: Gently stroke up along medial patella, pushing fluid up to top and lateral joint Now push on lateral aspect of joint – you will be pushing the fluid toward the medial

(which bulges out) Lateral and medial meniscus and ligaments (patella has been removed from this picture): Medial Meniscus Lateral meniscus



Surface Landmarks – anterior



Surface landmarks – medial Surface landmarks – lateral Surface landmarks – posterior



Bursae and bursitis: Bursa are fluid-filled pouches between bones & tendons, do NOT communicate with the

joint Swelling, warmth, tenderness are seen with inflammation Movement of the joint does NOT cause discomfort If movement of the joint causes discomfort, it is a joint problem (ligament, meniscus) Pre-patellar bursa – right on top of the patella (injured by direct trauma or people who

spend time on their knees such as carpenters, carpet layers, nuns) Infra-patellar bursa (anserine) – below the knee, also affected by trauma Evaluation of menisci: McMurray’s test, Apley Grind test Subjective:

o Fixed foot and twisted knee can cause the injury o Patient may report feeling or hearing a “pop” o Pain can e precipitated by flexing and standing on the knee; unable to squat or kneel o Patient may feel a “pop” or “clunk” when doing passive ROM of knee

Objective & special test maneuvers: o Effusion may be present (milk down from the top of the knee to see if fluid is present) o Joint line tenderness to palpation may be present o No one single test is confirmatory – use combination of history and multiple tests: o McMurray’s test:

examiner feels a “pop” or “clunk” or “click” on the joint line while flexing and rotating the knee

As originally described by McMurray: patient supine, flex knee completely with heel to buttock; grasp knee with one

hand (palpating with fingers on one side and thumb on the other) grasp ankle with other hand and rotate the knee inwards and outwards to its

fullest extent – if positive, a “pop” or “clunk” or “click” is felt applying valgus or varus stress will help elicit the sign better For MEDIAL meniscus, palpate the medial joint line For LATERAL meniscus, palpate the lateral joint line

o Apley’s test: patient is prone, examiner hyperflexes the knee and rotates o Steinman’s test: patient supine or sitting, bring knee into flexion and rotate

See pictures below



McMurray’s Test/Maneuver

Steinman’s

Apley’s Test/Maneuver



Injury to the cruciate ligaments (the 4 main ligaments in the knee): Medial collateral (MCL), lateral collateral (LCL), anterior cruciate (ACL) and posterior

cruciate (PCL). ACL: injured when the foot is stationary and knee has extreme rotational force (e.g. a cleated

foot caught in the turf while an athlete attempts to rotate towards that side); OR from direct force on the lateral knee while the foot is stationary (blow to the side of the knee).

PCL: less commonly injured then the ACL. Posterior force on the tibia (e.g. the tibia striking against the dashboard in a motor vehicle accident) can lead to disruption.

LCL: Direct force on the medial aspect of the knee while the foot is stationary. MCL: Direct force on the lateral aspect of the knee while the foot is stationary. Tests are stress of the ligaments such as Lachman’s & Anterior Drawer test, Posterior

Drawer test (see below for maneuvers)



Evaluation of cruciate ligaments (ACL, MCL, LCL, PCL): Stress the MCL & LCL: MCL valgus stress test: Slightly flex the knee (~30 degrees) and abduct the ankle while

stabilizing the knee (looking for more than normal movement) LCL varus stress test: Slightly flex the knee (~ 30 degrees) and adduct the ankle while

stabilizing the knee (looking for more than normal movement) ACL – both Lachman’s test and Anterior Drawer test: Lachman’s: Tell patient to relax & slightly flex knee Push down on femur with one hand and pull up on tibia with other hand See if it moves MORE than it should due to ACL being torn Anterior Drawer: Patient has foot planted and knee flexed; pull forward on tibia PCL – Posterior Drawer test: Patient flexes knee, plants foot – you sit on foot! Then, push back on tibia to see if it moves



ANKLE (tibiotalar joint): Articulation of tibia, fibula, talus Allows flexion/extension Additional “pivot” movement due to other joints – subtalar & transverse tarsal Articulations of tarsals, metatarsals, phalanges are condyloid Tarsal Bones Dorsal Tarsal Bones Lateral (right) Tarsal bones medial (right): Tarsal bones key: Ca = calcaneus, T = talus, N = navicular, C = cuboid, Cl = lateral cuneiform, Ci = intermediate cuneiform, Cm = medial cuneiform



FOOT & ANKLE:



DISABILITY DETERMINATION: Disability is not the same thing as impairment Impairment is abnormal functioning or anatomic finding Disability (according to the Social Security Administration) is: “an impairment that results from

anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques” and must be validated by the AMA Guides to the Evaluation of Permanent Impairment (accepted by Courts of Law)

There must have been sufficient time to allow optimal tissue repair and that is unlikely to change, despite further medical or surgical therapy. This is called maximal medical improvement (MMI).

The Americans with Disability Act (ADA) has another definition: o Disability. The term disability means, with respect to an individual (A) a physical or

mental impairment that substantially limits one or more of the major life activities of such individual; (B) a record of such an impairment; or (C) being regarded as having such an impairment.

The other issue is that impairment may cause more disability to different individuals o A construction worker with a 5% impairment due to lumbar radiculopathy is 100%

disabled vocationally o A professor with the same impairment isn’t disabled at all (can still perform activities

related to teaching) Good eMedicine articles on Disability Determination: http://emedicine.medscape.com/article/314195-overview AND http://emedicine.medscape.com/article/314420-overview Common Disability Determination Scoring Instruments: ODI (Owestry Disability Index 2.0) see below Roland-Morris Neck Disability Index

http://emedicine.medscape.com/article/314195-overview

http://emedicine.medscape.com/article/314420-overview



OSWESTRY DISABILITY INDEX 2.0 (ODI)

Section 1: Pain Intensity

I can tolerate the pain I have without having to use pain killers. [0 points]

The pain is bad but I manage without taking pain killers. [1 point]

Pain killers give complete relief from pain . [2 points]

Pain killers give moderate relief from pain. [3 points ]

Pain killers give very little relief from pain. [4 points]

Pain killers have no effect on the pain and I do not use them. [5 points]

Section 6: Standing (Remember, standing is NOT walking.)

I can stand as long as I want without extra pain. [0 points]

I can stand as long as I want but it gives me extra pain. [1 point]

Pain prevents me from standing for more than 1 hour. [2 points]

Pain prevents me from standing for more than 30 minutes. [3 points]

Pain prevents me from standing for more than 10 minutes. [4 points]

Pain prevents me from standing at all. [5 points]

Section 2: Personal Care

I can look after myself normally without causing extra pain. [0 points]

I can look after myself normally but it causes extra pain. [1 point]

It is painful to look after myself and I am slow and careful. [2 points]

I need some help but manage most of my personal care. [3 points]

I need help every day in most aspects of self care. [4 points]

I do not get dressed wash with difficulty and stay in bed. [5 points]

Section 7: Sleeping

Pain does not prevent me from sleeping well. [0 points]

I can sleep well only by using tablets. [1 point]

Even when I take tablets I have less than 6 hours sleep. [2 points]

Even when I take tablets I have less than 4 hours sleep. [3 points]

Even when I take tablets I have less than 2 hours of sleep. [4 points]

Pain prevents me from sleeping at all. [5 points]

Section 3: Lifting

I can lift heavy weights without extra pain. [0 points]

I can lift heavy weights but it gives extra pain. [1 point]

Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned for example on a table. [2 points]

Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned. [3 points]

I can lift only very light weights. [4 points]

I cannot lift or carry anything at all. [5 points]

Section 8: Sex Life (by pain = for fear of causing pain)

My sex life is normal and causes no extra pain. [0 points]

My sex life is normal but causes some extra pain. [1 point]

My sex life is nearly normal but is very painful. [2 points]

My sex life is severely restricted by pain. [3 points]

My sex life is nearly absent because of pain. [4 points]

Pain prevents any sex life at all. [5 points]



Section 4: Walking (bad question)

Pain does not prevent me walking any distance. [0 points]

Pain prevents me walking more than 1 mile. [1 point]

Pain prevents me walking more than 0.5 miles. [2 points]

Pain prevents me walking more than 0.25 miles. [3 points]

I can only walk using a stick or crutches. [4 points]

I am in bed most of the time and have to crawl to the toilet. [5 points]

Section 9: Social Life

My social life is normal and gives me no extra pain. [0 points]

My social life is normal but increases the degree of pain. [1 point]

Pain has no significant effect on my social life apart from limiting energetic interests such as dancing. [2 points]

Pain has restricted my social life and I do not go out as often. [3 points]

Pain has restricted my social life to my home. [4 points]

I have no social life because of pain. [5 points]

Section 5: Sitting ("Favorite chair" includes a recliner.)

I can sit in any chair as long as I like. [0 points]

I can only sit in my favorite chair as long as I like. [1 point]

Pain prevents me sitting more than 1 hour. [2 points]

Pain prevents me from sitting more than 0.5 hours. [3 points]

Pain prevents me from sitting more than 10 minutes. [4 points]

Pain prevents me from sitting at all. [5 points]

Section 10: Traveling

I can travel anywhere without extra pain. [0 points]

I can travel anywhere but it gives me extra pain. [1 point]

Pain is bad but I manage journeys over 2 hours. [2 points]

Pain restricts me to journeys of less than 1 hour. [3 points]

Pain restricts me to short necessary journeys under 30 minutes. [4 points]

Pain prevents me from traveling except to the doctor or hospital. [5 points]

INTERPRETATION: Add up your points for each section and plug it in to the following formula in order to calculate your level of disability: point total / 50 X 100 = % disability (aka: 'point total' divided by '50' multiply by ' 100 = percent disability)

ODI SCORING:

0% to 20%: minimal disability. The patient can cope with most living activities. Usually no treatment is indicated apart from advice on lifting sitting and exercise.

21%-40%: moderate disability. The patient experiences more pain and difficulty with sitting lifting and standing. Travel and social life are more difficult and they may be disabled from work. Personal care, sexual activity and sleeping are not grossly affected and the patient can usually be managed by conservative means.

41%-60%: severe disability. Pain remains the main problem in this group but activities of daily living are affected. These patients require a detailed investigation.

61%-80%: crippled. Back pain impinges on all aspects of the patient's life. Positive intervention is required.

81%-100%: These patients are either bed-bound or exaggerating their symptoms.

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