back evaluation
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BACK EVALUATIONBACK EVALUATION
Sara Brown, D.O.Sara Brown, D.O.Assistant ProfessorAssistant Professor
Dept of Family Dept of Family MedicineMedicine
CAQ Sports MedicineCAQ Sports MedicineLoyola University Loyola University Medical CenterMedical Center
RELEVANCERELEVANCE
Low back problems Low back problems affect everyone at affect everyone at some time in their some time in their lifelife
Yearly prevalence of Yearly prevalence of 50% of working 50% of working adultsadults
15-20% seek 15-20% seek medical caremedical care
Fifth most common Fifth most common of PCP visitsof PCP visits
ANATOMYANATOMY SpineSpine
– 5 Lumbar Vertebrae5 Lumbar Vertebrae– SacrumSacrum– Intervertebral discsIntervertebral discs– Spinal cordSpinal cord– Nerve rootsNerve roots
ANATOMYANATOMY MusclesMuscles
– Latissimus DorsiLatissimus Dorsi– Erector SpinaeErector Spinae– Iliocostalis, Iliocostalis,
Longissimus, Longissimus, SemispinalisSemispinalis
– Quadratus LumborumQuadratus Lumborum– IliopsoasIliopsoas
““S’s” of the SpineS’s” of the Spine SpondylolysisSpondylolysis
– Pars interarticularisPars interarticularis– ““Scottie dog”Scottie dog”
SpondylolisthesisSpondylolisthesis– Slippage of one Slippage of one
vertebral body over vertebral body over another another
ScoliosisScoliosis– Curvature of spineCurvature of spine
Spinal StenosisSpinal Stenosis– Narrowing of spinal Narrowing of spinal
canalcanal
HISTORYHISTORY Acute (<6 wks)Acute (<6 wks)
– MVA, Fall, Lifting,TwistingMVA, Fall, Lifting,Twisting
Subacute (6-12 weeks)Subacute (6-12 weeks)– Repetitive motionRepetitive motion– PosturePosture
Chronic (months/years)Chronic (months/years)– Workman’s comp, Workman’s comp,
secondary gainsecondary gain– Myofascial pain vs. organic Myofascial pain vs. organic
etiologiesetiologies– Degenerative joint disease Degenerative joint disease
of the spineof the spine
HISTORYHISTORY
Flexion-BasedFlexion-Based– Lumbar Lumbar
radiculopathyradiculopathy– DiscogenicDiscogenic
Ruptured annulus Ruptured annulus fibrosisfibrosis
HISTORYHISTORY
Extension basedExtension based– Spinal StenosisSpinal Stenosis– SpondylolysisSpondylolysis– SpondylisthesisSpondylisthesis– Facet SyndromeFacet Syndrome
HISTORYHISTORY
Either (Flexion Either (Flexion and/or extension)and/or extension)– Muscular Muscular
(myofascial)(myofascial)– Mechanical LBPMechanical LBP– Sacroiliac (SI) jointSacroiliac (SI) joint– OsteoarthritisOsteoarthritis
AGEAGE
Age <20Age <20– Pars interarticularis Pars interarticularis
stress fxstress fx– SpondylolisthesisSpondylolisthesis– ScoliosisScoliosis– Muscular Muscular – SI jointSI joint
AGEAGE
Age 20-50Age 20-50– Muscle strain Muscle strain
(myofascial)(myofascial)– Mechanical LBP Mechanical LBP
(inflexibility/imbalanc(inflexibility/imbalance)e)
– Herniated discHerniated disc– SacroiliacSacroiliac– Facet syndromeFacet syndrome
AGEAGE
Age >50Age >50– Herniated discHerniated disc– Mechanical LBP Mechanical LBP
(inflexibility/muscle (inflexibility/muscle imbalance)imbalance)
– Spinal StenosisSpinal Stenosis– OsteoarthritisOsteoarthritis– Facet arthropathyFacet arthropathy– Spondylisthesis Spondylisthesis
(degenerative)(degenerative)– Compression Compression
fracturesfractures
RED FLAGSRED FLAGS Age >50 or <20Age >50 or <20 History of cancer, weight loss History of cancer, weight loss
and/or night painand/or night pain - - TumorTumor Bowel/bladder probs or saddle Bowel/bladder probs or saddle
anesthesiaanesthesia– Cauda equina Cauda equina
WeaknessWeakness– Worsening radiculopathyWorsening radiculopathy
Fever/chillsFever/chills– OsteomyelitisOsteomyelitis– PyelonephritisPyelonephritis
Stiffness (Bamboo spine)Stiffness (Bamboo spine)– InflammatoryInflammatory– Ankylosing spondylitisAnkylosing spondylitis
PHYSICAL EXAMPHYSICAL EXAM PosturePosture
– Lumbar lordosisLumbar lordosis– Pelvic HeightPelvic Height– Lumbopelvic rhythmLumbopelvic rhythm
ROMROM– Flexion/ExtensionFlexion/Extension– RotationRotation– SidebendingSidebending– Severe guarding in Severe guarding in
all planes is a red all planes is a red flagflag
PALPATIONPALPATION
Spinous processesSpinous processes
Sacroiliac jointsSacroiliac joints
Paraspinal musclesParaspinal muscles
Piriformis/Gluteus Piriformis/Gluteus mediusmedius
NEUROLOGIC EXAMNEUROLOGIC EXAM GaitGait
– Heel (L5)Heel (L5)– Tip Toe (S1)Tip Toe (S1)
StrengthStrength– Hip flexion (L1)Hip flexion (L1)– Hip abduction (L2)Hip abduction (L2)– Quadriceps (L3)Quadriceps (L3)– Anterior tibialis (L4)Anterior tibialis (L4)– FHL/Abduction hip FHL/Abduction hip
(L5)(L5)– Plantar Plantar
flexion/Eversion (S1)flexion/Eversion (S1)
NEUROLOGIC EXAMNEUROLOGIC EXAM
DTR’sDTR’s– Knee (L4)Knee (L4)– None for L5None for L5– Ankle/Achilles (S1)Ankle/Achilles (S1)
SensationSensation– L4 – medial footL4 – medial foot– L5 – dorsal footL5 – dorsal foot– S1 – lateral footS1 – lateral foot
PROVOCATIVE TESTINGPROVOCATIVE TESTING One leg One leg
hyperextensionhyperextension– SpondylolysisSpondylolysis
Straight leg raise or Straight leg raise or slump testslump test– Supine/seatedSupine/seated– Neural tensionNeural tension– Discogenic/radiculopathyDiscogenic/radiculopathy– Pain below the knee at less Pain below the knee at less
than 70 degrees of flexion than 70 degrees of flexion and aggravated by and aggravated by dorsiflexion most dorsiflexion most suggestivesuggestive
– Crossover pain is a stronger Crossover pain is a stronger indicationindication
PROVOCATIVE TESTINGPROVOCATIVE TESTING
FABER’sFABER’s– Hip or SI JointHip or SI Joint
Gainslen’sGainslen’s– SI JointSI Joint
WADDEL’S SIGNSWADDEL’S SIGNS
Superficial, nonanatomic tendernessSuperficial, nonanatomic tenderness Inconsistent responses – positive Inconsistent responses – positive
straight leg raise, but negative slump straight leg raise, but negative slump testtest
Nondermatomal sensory lossNondermatomal sensory loss Over-reactionOver-reaction No effort No effort
IMAGINGIMAGING
In the absence of red In the absence of red flags, no imaging flags, no imaging necessary initiallynecessary initially
90% resolve 90% resolve spontaneously in 4-6 spontaneously in 4-6 weeksweeks
Imaging studies on Imaging studies on “normal” “normal” asymptomatic people asymptomatic people are commonly are commonly abnormalabnormal
INDICATIONS FOR IMAGINGINDICATIONS FOR IMAGINGPossible Possible causecause
Features Features on H & Pon H & P
ImagingImaging Additional Additional studiesstudies
CancerCancer Wt lossWt loss
Age >50Age >50
>4-6 wks>4-6 wks
H/O H/O cancercancer
XrayXray
MRIMRI
ESRESR
Vertebral Vertebral infectioninfection
FeverFever
IVDAIVDA
Rec. infxnRec. infxn
MRIMRI ESR/CRPESR/CRP
AnkylosinAnkylosing g spondylitispondylitiss
StiffnessStiffness
YoungYoungXrayXray HLA-B27HLA-B27
ESR/CRPESR/CRP
INDICATIONS FOR IMAGINGINDICATIONS FOR IMAGINGPossible Possible causecause
Features Features on H & Pon H & P
ImagingImaging Additional Additional studiesstudies
Cauda Cauda equina equina syndromesyndrome
Urinary retUrinary ret
Fecal Fecal incontincont
Saddle Saddle anesanes
MRIMRI NoneNone
Comp. fxComp. fx osteoporososteoporosisis
Steroid Steroid useuse
Older ageOlder age
XrayXray NoneNone
Severe/Severe/prog neuro prog neuro deficitsdeficits
ProgressivProgressive motor e motor weaknessweakness
MRIMRI Consider Consider EMG/NCVEMG/NCV
INDICATIONS FOR IMAGINGINDICATIONS FOR IMAGINGPossible Possible causecause
Features Features on H & Pon H & P
ImagingImaging Additional Additional studiesstudies
Herniated Herniated discdisc
Sxs >4 Sxs >4 wks back wks back pain + leg pain + leg pain in L4, pain in L4, L5 or S1 L5 or S1 dermatdermat
MRIMRI Consider Consider EMG/NCVEMG/NCV
Spinal Spinal stenosisstenosis
Sxs >4 Sxs >4 wks leg wks leg pain pain relieved relieved by flexionby flexion
MRIMRI Consider Consider EMG/NCVEMG/NCV
MANAGEMENTMANAGEMENT Pain ControlPain Control
TylenolTylenol
NSAIDS NSAIDS
Muscle relaxantsMuscle relaxants
OpiodsOpiods
AntiepilepticsAntiepileptics Therapy based on Therapy based on
diagnoses:diagnoses:– Flexion based painFlexion based pain
centralize pain with centralize pain with extension program extension program (McKenzie)(McKenzie)
– Extension based painExtension based pain William’s flexion William’s flexion
exercisesexercises
MANAGEMENTMANAGEMENT Avoid bed restAvoid bed rest Heat/cold Heat/cold Spinal manipulationSpinal manipulation Massage therapy Massage therapy Proper lifting mechanics Proper lifting mechanics
- Hold close to body at level of navel- Hold close to body at level of navel- No twisting/bending/reaching while lifting- No twisting/bending/reaching while lifting
ErgonomicsErgonomics- Soft support for small of back, arm rests, - Soft support for small of back, arm rests,
etcetc AcupunctureAcupuncture
EVIDENCE FOR ACUTE LBP EVIDENCE FOR ACUTE LBP NONPHARMACOLOGIC NONPHARMACOLOGIC
EFFICACYEFFICACY HeatHeat Spinal manipulationSpinal manipulation
EVIDENCE FOR SUBACUTE LBP EVIDENCE FOR SUBACUTE LBP NONPHARMACOLOGIC NONPHARMACOLOGIC
EFFICACYEFFICACY Intensive interdisciplinary
rehabilitation Exercise therapy Acupuncture Massage therapy Spinal manipulation Yoga Cognitive-behavioral therapy Progressive relaxation
WORK RESTRICTIONSWORK RESTRICTIONS
SevereSevere ModeratModeratee
Mild Mild No sxsNo sxs
Amount Amount of time of time sittingsitting
20 min20 min 30 min30 min 40 min40 min 50 min50 min
Lifting Lifting for menfor men
20 lbs20 lbs 20 lbs20 lbs 60 lbs60 lbs 80 lbs80 lbs
Lifting Lifting for for womenwomen
20 lbs20 lbs 20 lbs20 lbs 35 lbs35 lbs 40 lbs40 lbs
COMMON DIAGNOSESCOMMON DIAGNOSES DiscogenicDiscogenic
– Flexion based painFlexion based pain– Leg pain>back pain if Leg pain>back pain if
radicularradicular
PEPEFlexion painFlexion pain+ SLR, +/-neurologic+ SLR, +/-neurologic
RxRxPT: McKenzie exercisesPT: McKenzie exercisesSteroids/NSAIDs/Steroids/NSAIDs/antiepilepticsantiepilepticsEpidural steroids for leg painEpidural steroids for leg painSurgical decompressionSurgical decompression
MUSCULAR/MECHANICAL LBPMUSCULAR/MECHANICAL LBP
HistoryHistory– Stiffness in all planesStiffness in all planes– +/- h/o trauma+/- h/o trauma
PEPE– Paraspinal muscle spasmParaspinal muscle spasm– InflexibilityInflexibility– Nl provocative testingNl provocative testing
RxRx– PT for core strengthening PT for core strengthening
and teach proper posture and teach proper posture & lifting mechanics& lifting mechanics
– NSAIDs/muscle relaxantsNSAIDs/muscle relaxants
SACROILIAC JOINTSACROILIAC JOINT HistoryHistory
– Twisting/torqueTwisting/torque– +/- trauma+/- trauma– Deep, vague back or Deep, vague back or
pelvic painpelvic pain PEPE
– No pain above L5No pain above L5– Nl ROM, neurologicNl ROM, neurologic– + FABER’s/Gainslen’s+ FABER’s/Gainslen’s
RxRx– NSAID’sNSAID’s– PT: pelvic stabilization PT: pelvic stabilization
and core strengtheningand core strengthening– ManipulationManipulation– SI Joint injectionsSI Joint injections
PARS STRESS FRACTUREPARS STRESS FRACTURE HistoryHistory
Repetitive Repetitive hyperextensionhyperextension
AdolescentsAdolescents PEPE
+ 1-leg hyperextension+ 1-leg hyperextensionNl neurologic, strengthNl neurologic, strength
RxRxLimit extension activityLimit extension activityBracingBracingPT (spinal stabilization)PT (spinal stabilization)
SPINAL STENOSISSPINAL STENOSIS HistoryHistory
– Extension painExtension pain– Pain with walking, relieved Pain with walking, relieved
by rest/flexionby rest/flexion PEPE
– Flexed postureFlexed posture– +/- neurologic exam+/- neurologic exam
RxRx– Steroids/NSAIDs/Steroids/NSAIDs/
antiepilepticsantiepileptics– Flexion based therapyFlexion based therapy– Transforaminal/selective Transforaminal/selective
injections (flouroscopy)injections (flouroscopy)
FACET SYNDROMEFACET SYNDROME HistoryHistory
– Extension based painExtension based pain– No leg painNo leg pain
PEPE– Pain with extensionPain with extension– Nl neuro, strengthNl neuro, strength– Nl provocative testingNl provocative testing
RxRx– NSAIDsNSAIDs– Flexion based therapyFlexion based therapy– Facet injections Facet injections
(flouroscopy)(flouroscopy)
MANIPULATIONMANIPULATION
Pelvic obliquityPelvic obliquity SI joint painSI joint pain Mechanical low Mechanical low
back painback pain Muscular tensionMuscular tension ScoliosisScoliosis Postural painPostural pain
SOFT TISSUESOFT TISSUE
Palpate spinous processesPalpate spinous processes Place thenar and hypothenar Place thenar and hypothenar
eminences of dominant hand just eminences of dominant hand just lateral to spinous processes with lateral to spinous processes with other hand on top used as support other hand on top used as support
Press down first and then gently Press down first and then gently push laterallypush laterally
Repeat this the length of the lumbar Repeat this the length of the lumbar and thoracic spine on both sidesand thoracic spine on both sides
COUNTERSTRAINCOUNTERSTRAIN
Find a tender point in the low backFind a tender point in the low back Keep one finger on the pointKeep one finger on the point Use your other hand to shorten the Use your other hand to shorten the
muscle by elevating the legmuscle by elevating the leg Move the leg into different positions Move the leg into different positions
while monitoring the point to feel while monitoring the point to feel where it is the least tensewhere it is the least tense
Hold for 1-2 minutes and monitor for Hold for 1-2 minutes and monitor for releaserelease
MUSCLE ENERGYMUSCLE ENERGY Place thenar and hypothenar Place thenar and hypothenar
eminences of one hand just superior to eminences of one hand just superior to the ilium on the side that you are the ilium on the side that you are standing on.standing on.
Use your other hand to extend the leg Use your other hand to extend the leg on that side to the natural barrieron that side to the natural barrier
Then have patient push down towards Then have patient push down towards the table for 3 secondsthe table for 3 seconds
Relax for 1 second and extend the leg Relax for 1 second and extend the leg further to the new barrierfurther to the new barrier
Repeat 3 timesRepeat 3 times
THANK YOU!!THANK YOU!!QUESTIONS?QUESTIONS?
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