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For the Primary Care clinician

Low Back Pain: Focused Exam. For the Primary Care clinician. Low Back Pain. Common complaint in primary care, yet: Often difficult complaint to address when dealing with a complicated patient Providers may be unsure of exam

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For the Primary Care clinician

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  1. Low Back Pain: Focused Exam For the Primary Care clinician

  2. Low Back Pain • Common complaint in primary care, yet: • Often difficult complaint to address when dealing with a complicated patient • Providers may be unsure of exam • Seen as chronic problem that does not improve, and may be concerned about medication- or disability-seeking patients

  3. Today’s talk • Focus on practical information to help the practitioner know: • what questions to ask, • what exam to perform, • what studies to order.

  4. Today’s talk • Anatomy review • Pain generators of the back • Exam to rule out emergent issues • Exam for radiculopathy • Exam to discover cause of patient’s pain • Appropriate ordering of studies

  5. Anatomy review • 7 Cervical vertebrae • 12 Thoracic vertebrae • 5 Lumbar vertebrae • Sacrum (5 fused) • Coccyx (4 fused) • Focus today on lumbar/sacral spine

  6. Anatomy review • Vertebra • Intervertebral discs • Facet joints • Spinal nerve • Epidural space

  7. Anatomy review

  8. Pain generators • Disc rupture • Nerve impingement • Joints-facets or SI • Myofascial

  9. Emergent causes of back pain • Cancer • Ask: 1) history of cancer; 2) pain which wakes patient from sleep, 3) weight loss, 4) new onset of pain in an elderly patient, • Cauda equina • Ask: 1) bowel or bladder problems such as retention, incontinence, decreased sensation; 2) saddle numbness. • Infection • Ask: 1) fevers, 2) history of epidurals or IVDU

  10. Examination for Radicular pain • Mostly caused by intervertebral disc problems such as herniation, degenerative disc disease, or narrowing from degenerative joint disease. • Looking for a pattern of neurologic deficits: for example, that L5 strength, reflexes and sensation are all affected.

  11. Examination for Radicular pain • Neurologic exam: • Strength • Reflexes • Sensation • Provocative tests: • Straight leg raise (SLR), contralateral SLR, Slump test

  12. Strength testing • Explain to patient that you are testing her strength and would like her to push as hard as possible; difference between true weakness and pain-inhibited weakness. • In general, you should not be able to “break” the person’s strength; if you can, there may be weakness. Test against strength of non-affected side, if possible.

  13. Neuro Exam-Strength • Hip Flexor Strength Testing • L1,2,3

  14. Neuro Exam-Strength • Knee Extension • L2-4 • Buttock should rise from table

  15. Neuro Exam-Strength • Dorsiflexion • L4,5

  16. Neuro Exam-Strength • Extensor Hallucis Longus (EHL) • Big toe dorsiflexion • L5

  17. Neuro Exam • Plantar Flexion • One-legged x 3 = 5/5 strength • S1

  18. Neuro Exam-reflexes • Patella Reflex • L4

  19. Neuro Exam-reflexes • Medial Hamstring Reflex • L5

  20. Neuro Exam-reflexes • Achilles Reflex • S1

  21. Neuro Exam-Sensation • Pinprick Sensation Testing • L2

  22. Neuro Exam-Sensation • Pinprick Sensation Testing • L3

  23. Neuro Exam-Sensation • Pinprick Sensation Testing • L4

  24. Neuro Exam-Sensation • Pinprick Sensation Testing • L5

  25. Neuro Exam-Sensation • Pinprick Sensation Testing • S1

  26. Neuro Exam-Sensation • Pinprick Sensation Testing • S2

  27. Provocative testing • SLR • cSLR • 30-70 degrees

  28. Radicular Pain • If your neurologic exam shows concern for acute neurologic changes in a nerve root pattern, consider MRI and referral to orthopedic surgeons. • If you are unclear about the cause of neurologic changes, such as radiculopathy versus diabetic neuropathy, consider referral for EMG.

  29. Disc disease • May see disc space narrowing on plain films. • May see disc extrusion, bulges on MRI

  30. Degenerative joint disease • Facet joints, or sacroiliac joint may be affected • You may see facet degeneration, spurring, and/or osteophyte formation on radiographic studies.

  31. Combined Extension & Rotation • Reproduction of Pain

  32. Myofascial pain • May see muscle spasm, tense, tight muscles. • Patient may get relief from NSAIDs, acetaminophen, topical preparations, stretching, trigger point injection. • May be a component of pain, no matter the root cause of pain.

  33. Exam

  34. Alignment • Weight Bearing Joints • If unable to determine free standing – try having patient stand against a wall

  35. Offset • Rotation • hand position • shoulder position

  36. Weight Balance

  37. Exam • Shoulder Height • symmetric

  38. Exam • Iliac Crest Height • symmetric

  39. Adam’s Forward Bending Test • Scoliosis • Fingertip to Floor • ROM • Reproduction of Pain

  40. Extension • ROM • Reproduction of Pain

  41. Waddell test • Tests of malingering • Each test counts as +1 if +, 0 if - • Superficial skin tenderness to light pinch over wide area of lumbar spine • Deep tenderness over wide area, often extending to thoracic spine, sacrum, and/or pelvis. • Low back pain on axial loading of spine in standing • SLR test positive supine, but not when seated with knee extended to test babinski reflex. • Abnormal or inconsistent neurological (motor and/or sensory) patterns. • Overreaction. • If 3+ points or more, investigate for non-organic cause. Waddell, GJ et al. Nonorganic physical signs in low back pain. Spine. 5:117-25, 1980.

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