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Screening Evaluation of Spinal Pain and Dysfunction

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

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Screening Evaluation of Spinal Pain and Dysfunction

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  1. Screening Evaluation of Spinal Pain and Dysfunction John P. Kafrouni, MD Rebound Physical Medicine and Rehabilitation, Orthopedics, and Neurosurgery

  2. 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.

  3. 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

  4. Scope 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.

  5. RTW and Absenteeism • Time Missed from Work • 6 months • 1 year • 2 years • Return to Work Expected • 50% • 25% • 0

  6. 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 • Intensity- mild/moderate/severe • 1-10 pain scale tells you more about the patient than the etiology

  7. 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.

  8. Provocations, Alleviation-“What is the worst/best thing for your symptoms” • Provocations- • Sitting • Standing • Walking • Lifting • Transitions • Weight Bearing • Staying Still • With flexion, extension • Valsalva • Alleviation • Sitting • Standing • Walking • At rest • With flexion, extension • Meds- may tell you a bit about the pathology, patient

  9. 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 intra-articular source • Myofascial • Neuropathic

  10. 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…

  11. The ExamInitial 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

  12. Posture- Seated

  13. The ExamObservation-Sit to Stand 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

  14. 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

  15. Posture in Standing

  16. Exam-Gait 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

  17. Trendelenberg Gait

  18. Initial Range of Motion:Standing • 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

  19. Thorasic Range Rotation Flexion

  20. 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

  21. Standing Provocation Stork Test Spurling’s

  22. Shoulder Screen- if no pain with cervical ROM or pure anterior shoulder pain. • Posture/scapular orient • Drop arm- posterior view • Supraspinatus testing • O’briens/AC joint • Hawkins • Palpation in Modified Crass position • Yergeson’s or Speeds • Scapular dyskinesia • Painful arc • Cuff • Labrum • Cuff • Cuff- more specific • Bicipitaltendinosis/itis

  23. Shoulder Screen Modified Crass position O’Brien’s

  24. Palpation while standing • Spinous processes • Lateral masses • Periscapular • Myofascial • Sacroiliac joint • Trochanters • Have the patient put a finger on “the spot” • Can identify step offs with flexion/extension- spondylolisthesis • Local pain • Sclerotomal radiation: • Does it match claimed radiation? • Levator scapula/lateral scapula • Trochanter/IT band/PSIS medial and lateral/paraspinals/lateral sacrum.

  25. Palpation -Standing Levator Scapula Sacroiliac joint

  26. Strength while standing • Heel walking • Toe/heel raising • Anterior tibialis- L4 predominately • S-1, Gastroc/soleus

  27. 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,

  28. Sitting Dermatomes Seated Slump

  29. Myotomal testingCervical • C5 • C6 • C7 • C8 • T1 • Delt, Biceps • Pronator/Wrist Ex/Infrasp • Triceps/ Ext Ind Prop • Finger flex (3rd) • Interossei/ Small finger abd

  30. Myotomal testingLumbar • L2 • L3 • L4 • L5 • S1 • S2,3,4 • Hip Flex • Knee Extension • Ankle dorsi, Ant Tibialis • Great toe extension • Toe Flexion/Heel raising • Sphincter Tone

  31. ReflexesCervical/Lumbar • C5-biceps • C6-pronator • C7-triceps • L3,4-Quads • L5-Hamstrings • S-1-Plantar/Gastroc soleus • Pathologic reflexes- Hoffmans/Babinski • Excessive clonus • Absence of reflexes- Jendrassic maneuver • Great range of normals, when in doubt check the upper/lower reflexes

  32. Supine evaluationCervical pain • Cervical- • Palpate 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.

  33. Supine ExamLumbar Pain • Hip Scour • Straight Leg Raise • Sacral sheer • Faber/Modified Patricks • Palpate Ant/Lateral hip • Faking it? SLR, Hoover’s • Knee exam if indicated • Flexion and Ab/Adduction • Back vs. Radicular pain • S.I. Joint • Hip/S.I. joint • Psoas /Pubic Symphysis

  34. Supine testing-Lumbar Hoover’s sign Modified Patrick’s

  35. Hoover’s sign

  36. Prone ExamCervical and Thoracic • Palpation • Segmental Motion • Scapular mobility • Distant referral of proximal structures • Palpation • Costovertebral junctions • Scapular mobility • Opportunity for Manual Medicine techniques

  37. 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.

  38. Prone-Lumbar Prone hyperextension Yeoman’s

  39. Sidelyingexam • 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.

  40. Sidelying Ober’s test FAIR test

  41. Thoughts • Things that can make patients worse • Anxiety • Depression • Fear • Anger • Terms like Degenerative • Inactivity • Narcotics, NSAIDS • Perceived future disability

  42. 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

  43. Thank you

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