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

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Presentation on theme: "Screening Evaluation of Spinal Pain and Dysfunction John P. Kafrouni, MD Rebound Physical Medicine and Rehabilitation, Orthopedics, and Neurosurgery."— Presentation transcript:

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

2  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. Scope of the Problem

3  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 Among Health Care Workers

4  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. Scope

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  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 The Exam Initial Observation- Seated

12 Posture- Seated

13  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 The Exam Observation-Sit to Stand

14  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 Observation Posture-Standing “Take your normal comfortable posture”

15 Posture in Standing

16  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 Exam-Gait

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 FlexionRotation

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 Spurling’sStork Test

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  Bicipital tendinosis/itis

23 Shoulder Screen O’Brien’sModified Crass position

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 Sacroiliac jointLevator Scapula

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 Seated SlumpDermatomes

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

30 Myotomal testing Lumbar  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 Reflexes Cervical/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 evaluation Cervical 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 Exam Lumbar 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 Modified Patrick’sHoover’s sign

35

36 Prone Exam Cervical 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 Yeoman’sProne hyperextension

39 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.

40 Sidelying FAIR testOber’s 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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