back evaluation

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




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




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


Spinal Spinal stenosisstenosis

Sxs >4 Sxs >4 wks leg wks leg pain pain relieved relieved by flexionby flexion


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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