Screening Evaluation of Spinal Pain and Disfunction

Report
Screening Evaluation of Spinal
Pain and Dysfunction
John P. Kafrouni, MD
Rebound Physical Medicine and Rehabilitation,
Orthopedics, and Neurosurgery
Scope of the Problem
 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.
Among Health Care Workers
 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
Scope
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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.
RTW and Absenteeism
 Time Missed from Work
 Return to Work Expected
 6 months
 50%
 1 year
 25%
 2 years
 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
- Intensitymild/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/history
Thought one should marry a freckle
faced girl.
Thought clinicians older than 67
should be kindly euthanized.
Provocations, Alleviation“What is the worst/best thing for
your symptoms”
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ProvocationsSitting
Standing
Walking
Lifting
Transitions
Weight Bearing
Staying Still
With flexion, extension
Valsalva
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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 intraarticular 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…
The Exam
Initial Observation- Seated
 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
Posture- Seated
The Exam
Observation-Sit to Stand
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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
Observation
Posture-Standing
“Take your normal comfortable
posture”
 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
Posture in Standing
Exam-Gait
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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
Trendelenberg Gait
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Initial Range of Motion:
Standing
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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 joint
Confirm 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.
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Posture/scapular orient
Drop arm- posterior view
Supraspinatus testing
O’briens/AC joint
Hawkins
Palpation in Modified
Crass position
 Yergeson’s or Speeds
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Scapular dyskinesia
Painful arc
Cuff
Labrum
Cuff
Cuff- more specific
Bicipital tendinosis/itis
Shoulder Screen
O’Brien’s
Modified Crass position
Palpation while standing
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Spinous processes
Lateral masses
Periscapular
Myofascial
Sacroiliac joint
Trochanters
Have the patient put a finger
on “the spot”
 Can identify step offs with
flexion/extensionspondylolisthesis
 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 testing
Cervical
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C5
C6
C7
C8
T1
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Delt, Biceps
Pronator/Wrist Ex/Infrasp
Triceps/ Ext Ind Prop
Finger flex (3rd)
Interossei/ Small finger
abd
Myotomal testing
Lumbar
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L2
L3
L4
L5
S1
S2,3,4
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Hip Flex
Knee Extension
Ankle dorsi, Ant Tibialis
Great toe extension
Toe Flexion/Heel raising
Sphincter Tone
Reflexes
Cervical/Lumbar
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C5-biceps
C6-pronator
C7-triceps
L3,4-Quads
L5-Hamstrings
S-1-Plantar/Gastroc soleus
 Pathologic reflexesHoffmans/Babinski
 Excessive clonus
 Absence of reflexesJendrassic maneuver
 Great range of normals,
when in doubt check the
upper/lower reflexes
Supine evaluation
Cervical pain
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CervicalPalpate 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 Exam
Lumbar Pain
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Hip Scour
Straight Leg Raise
Sacral sheer
Faber/Modified Patricks
Palpate Ant/Lateral hip
Faking it? SLR, Hoover’s
Knee exam if indicated
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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 Exam
Cervical and Thoracic
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Palpation
Segmental Motion
Scapular mobility
Distant referral of
proximal structures
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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
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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
 Call with questions-1800
REBOUND
Thank you

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