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Slide 1 - Evaluation of Low Back Pain
Slide 2 - Introduction
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Slide 5 - Most disc herniations occur at L5-S1 At least 30% of the healthy symptomless population have clinically significant disc protrusions (Stadnik et al., 1998). What is Back Pain ?
Slide 6 - What is Back Pain ? Several studies have shown that there is no correlation between MRI findings and patients’ low back symptoms. 1. Wittenberg et al., 1998 2. Smith et al., 1998 3. Savage et al., 1997
Slide 7 - What is Back Pain ? There are many more joints in the back than discs. There are many more muscles than joints. The most common cause of low back pain is when one or more muscles “forget” to relax. We call this a somatic dysfunction.
Slide 8 - Common Sources of LBP Somatic dysfunction Muscle in “spasm” Nerve root In somatic dysfunction, some muscles become overactive (“spasm”) and other muscles become inactive.
Slide 9 - Common Sources of LBP Any dysfunction involving the thoracic or lumbar spine, the sacroiliac joint or the hip can create low back pain.
Slide 10 - Common Sources of LBP
Slide 11 - Common Sources of LBP Disc 1. posteriorly - sinu vertebral nn. 2. laterally - gray rami communicantes a. branches of ventral rami 3. various types of nerve endings up to ½ annulus depth Targets for dorsal primary ramus 1. facet joints 2. interspinous ligaments 3. back muscles VPR DPR GRC SVN
Slide 12 - Long dorsal si ligament sacrotuberous ligament sacrospinous ligament Common Sources of LBP
Slide 13 - Role of the sacroiliac joint The coxal bones consist of a thin shell of cortical bone (1-2 mm) over trabecular bone. Muscles play an important role in helping the pelvis resist stress. When muscles can’t work due to pain, the risk of injury increases.
Slide 14 - Back Facts
Slide 15 - Introduction COMMON, 2ND only to URTI Tx is symptomatic HISTORY is critical to ruling out serious issues. Conduct a Physical Exam to confirm and assess functional status
Slide 16 - What Causes Acute Low Back Pain Muscle strain? DJD or OA? Disc disease? Who cares? Initially they are all treated same for the most part. Most all get better with conservative treatment. Beware of the serious causes!
Slide 17 - Evaluate for “Red Flags”: May Signal Serious Causes of LBP Cancer Infection Fracture Sciatica Cauda Equina syndrome Ankylosing spondylitis
Slide 18 - Sciatica The sciatic nerve is the longest nerve in your body. It runs from your spinal cord to your buttock and hip area and down the back of each leg. The term "sciatica" refers to pain that radiates along the path of this nerve — from your back down your buttock and leg. Source: Mayoclinic.com
Slide 19 - Cauda Equina Syndrome: Caused by massive midline disc herniation or mass compressing cord or cauda equina. Rare (<.04% of LBP patients). Needs emergent surgical referral. Symptoms: bilateral lower extremity weakness, numbness, or progressive neurological deficit. Ask about: Recent urinary retention (most common) or incontinence? Fecal incontinence?
Slide 20 - Ankylosing spondylitis Ankylosing spondylitis is one of many forms of inflammatory arthritis, the most common of which is rheumatoid arthritis. Ankylosing spondylitis primarily causes inflammation of the joints between the vertebrae of your spine and the joints between your spine and pelvis (sacroiliac joints). Source: Mayoclinic.com
Slide 21 - Evaluation of the Patient With LBP Start with a detailed history – your best diagnostic tool. Get an idea of the severity. Look for the “red flags” of serious causes. Use the physical exam to confirm what you suspect based on history. Keep in mind: Most of the time you won’t have a definitive diagnosis. Imaging rarely changes initial treatment. Most patients get better with conservative TX.
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Slide 23 - What Was the Mechanism of Injury or Overuse? Was there an acute trauma or injury? Sudden severe pain with bending. Motor vehicle accident or fall. Was there a recent history of excessive lifting or bending?
Slide 24 - About 85-90% of LBP sufferers will get better in 3 days to 6 weeks Most back problems are not surgical cases Of the remaining 10-15%, most will never get completely well
Slide 25 - Success Rate (%) Risk Factors Spine Surgery Outcomes Treatment ApproachesSurgery
Slide 26 - Causes/Exacerbating Factors
Slide 27 - Mechanisms of Injury Congenital abnormalities Poor body mechanics Back trauma
Slide 28 - Pathology of Low Back Pain Causes: Herniated disks, facet pathology, spinal stenosis, stress fractures (spondys), compression fractures, ligamentous sprains, adaptive shortening, and muscle strain Do spinal abnormalities always cause low back pain? MRIs on 98 people with no back pain Dr. Maureen Jensen, Hoag Memorial Hospital, Newport Beach, CA. (1995) Nearly 2/3 had spinal abnormalities including bulging or protruding discs
Slide 29 - Intervertebral Discs
Slide 30 - The Key Players
Slide 31 - Trunk Musculature Musculature Superficial Thoracic group Abdominal group Erector Spinae group Spinalis Longissimus Iliocostalis Deep Transversospinal group Multifidus Rotatores Intertransversarius
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Slide 33 - Nerves Spinal Nerves and Plexi 31 spinal nerves 4 Plexi Cervical Brachial Lumbar (T12-L5) Femoral, Obturator Sacral (L4-S5) Sciatic Tibial and Common Peroneal
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Slide 35 - Neural Testing Dermatomes -correspond to an area of skin that is innervated by the cutaneous neurons of a single spinal nerve or cranial nerve. Myotomes -correspond to groups of muscles innervated by a specific nerve root.
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Slide 37 - Classification
Slide 38 - Classify patient Determine cause of problem Postural Inflammation of soft tissues Dysfunctional Adaptive Shortening Strain or Sprain Derangement Disk Facet joint Stress Fracture
Slide 39 - Guide to Lumbar Spine Conditions
Slide 40 - Lumbar Spine Conditions Low Back Muscle Strain Acute (Overextension) and Chronic (Faulty posture) Facet Joint Dysfunction Dislocation or Subluxation (Acute or Chronic) Low Back fracture Compression, Stress, or Spinous and Transverse Processes Herniated Disc Protrusion, Prolapse, Extrusion, and Sequestration Local and Radiating Pain Classic term “Sciatica”
Slide 41 - Lumbar Spine Conditions Spondylolysis Unilateral defect in the pars interarticularis Spondylolisthesis Bilateral defect in the pars interarticularis which causes forward displacement of vertebra. Spina Bifida Occulta Congenital condition – spinal cord is exposed = delays in development.
Slide 42 - Sacroiliac Joint Conditions(note this is advanced) Sacral torsion Forward or Backward torsion Ilium torsion, upslip, downslip, outflare, inflare Piriformis strain/trigger points
Slide 43 - Walk through it…What you are thinking.
Slide 44 - Unique risk factors for athletes High impact trauma: football, rugby End range loading: gymnastics, diving Overuse trauma: impact loading: distance running rotational loading: golf, baseball prolonged sitting: travel
Slide 45 - Evaluation Techniques HOPS/HIPS History, Observation/Inspection, Palpation, Special Tests Your first priority! Establish the integrity of the spinal cord and nerve roots History and several specific tests provide information (Dermatomes, Myotomes, Reflexes)
Slide 46 - Assessing the Low Back On-Field Assessment Primary Survey ABCs Level of consciousness/Movement Neurological system intact? Secondary Survey Pain, Dermatomes, Myotomes ROM – only if no motor or sensory decrements Further assessment on sidelines
Slide 47 - Assessing the Low Back Off-Field Assessment HISTORY!!!! Observation and Palpation The Triad of Assessment Asymmetry, ROM alteration, Tissue texture Special Tests Begin to be selective in you choices. Classify tests as to their main findings Use results of key tests to determine further testing
Slide 48 - Triad of Assessment Asymmetry ASIS, PSIS, iliac crests, malleoli, feet Range of motion alterations Standing and seated flexion tests Single leg stance test (Stork) Springing of facet and sacroiliac joints Guarding of certain positions Tissue texture abnormalities Muscles – “tootsie roll”
Slide 49 - Kinetic Chain Why do we need to assess the pelvis, hip and lower extremity?
Slide 50 - Foot conditions Over-pronation Hip flexion Anterior pelvic tilt Pelvic rotation/Tilt Over-supination Hip extension Hip external rotation Pelvic rotation/tilt
Slide 51 - Specific evaluation techniques HISTORY!!!! Alignment and symmetry Lumbar spine active movements Neurological Testing Disc Pathology Tests Extension mechanics Prone assessment Sacroiliac tests Sitting forward flexion and hip flexion Standing forward flexion and hip flexion Flexibility testing Feet alignment
Slide 52 - History Location of pain Onset of pain Acute, chronic, or insidious Mechanism of Injury (MOI) Consistency of the pain Constant vs. Intermittent pain Bowel and Bladder signs Changes in activity, surface, or equipment
Slide 53 - What positions bother you? Bending Sitting Rising from sitting Standing Walking Lying prone Lying supine
Slide 54 - Evaluation Techniques Observation/Inspection Posture! Range of motion AROM PROM RROM Observe their mechanics as they enter the room, get on table, remove shirts or shoes
Slide 55 - Evaluation Techniques Palpation This is your chance to “contain” the injury to specific structures. Also allows for natural comparison of “normal” landmarks Muscular Tension “Tootsie Roll Test” Ligamentous Tests Spring Test
Slide 56 - Special Tests Are they malingering? Hoover’s Test Determine whether injury is associated with intervertebral disc, nerve root, dural sheath, or bony deformity. Positive tests for disc, nerve, or bony deformity ALWAYS warrant a referral to a physician
Slide 57 - Tests for Nerve Root Impingement Valsalva test Milgram test Kernigs/Brudzinski’s test Straight Leg Raise – Affected and Well Quadrant test Slump test
Slide 58 - Lumbar Spine Conditions Low Back Muscle Strain Very common and self-limiting Acute (Overextension) and Chronic (Faulty posture) Pain increases with passive and active flexion and resisted extension Key Evaluative techniques: History and Palpation Rule out neural involvement Test PROM, AROM, and RROM
Slide 59 - Lumbar Spine Conditions Low Back fracture Compression or Stress Body, Spinous Process, and Transverse Processes Localized or diffuse pain Treatment doesn’t relieve symptoms X-ray and MRI are definitive diagnoses
Slide 60 - Lumbar Spine Conditions Facet Joint Dysfunction Inflammation, sprain, degeneration Dislocation or Subluxation (Acute or Chronic) “stuck open” or “stuck closed” Usually localized but may involve several segments May be associated with nerve root impingement Often times pain decreases with activity
Slide 61 - Facet Joint Dysfunction AROM Flexion = “opening” and Extension = “closing” Lumbar facet joints “open” on right side with left lateral flexion and left rotation Lumbar facet joints “close” on right side with right lateral flexion and right rotation Prone assessment – elbows to hands Spring test Quadrant test
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Slide 63 - Lumbar Spine Conditions Herniated Discs MOI: Overload (Direct or Indirect) or faulty biomechanics (or both) Protrusion, Prolapse, Extrusion, and Sequestration Pain usually aggravated by activity Prolonged body position often increases symptoms Patient may choose a position that relieves pain Local and Radiating Pain Reflexes and Sensory/Motor screening is essential Definitive diagnosis comes from MRI
Slide 64 - Disc and nerve root relationship
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Slide 66 - Neural Testing Dermatomes Myotomes L1/L2 – Hip flexion L3/L4 – Knee extension L4 – Ankle dorsiflexion L5 – Great toe extension S1 – Eversion S2 – Knee flexion
Slide 67 - Observation Posture Plum line Motions Flexion Extension Lateral flexion Rotation
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Slide 69 - Back Malalignments
Slide 70 - Discogenic Pain Special Tests: Lower and Upper quarter screening Dermatomes and Myotomes Valsalva test Milgram test Well straight leg raise Kernig’s/Brudzinski test Quadrant test
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Slide 72 - Lumbar Spine Conditions Sciatica General term for inflammation of sciatic nerve Sciatica is a result and NOT an injury in and of itself Need to find what has caused the irritation Disc, Muscle, Spondylopathy Special tests: Straight leg raise Tension sign (Bowstrings) Slump Test
Slide 73 - Lumbar Spine Conditions Nerve Root Impingement/Dural Sheath Impingement Special Tests: Quadrant test Femoral nerve stretch test Kernig’s/Brudzinski test Slump test
Slide 74 - Lumbar Spine Conditions Spondylopathies Mechanisms – Hyperextension Onset – Insidious Muscular imbalances Pain usually localized (may radiate) Increased during and after activity Single leg stork stand Unilateral – Pain with opposite leg MRI or X-ray are definitive diagnoses
Slide 75 - Spondylosis Spondylolysis generally mean changes in the vertebral joint characterized by increasing degeneration of the intervertebral disc with subsequent changes in the bones and soft tissues. Unilateral or bilateral stable defect in the pars interarticularis “Collared Scottie dog” deformity
Slide 76 - Spondylolisthesis Bilateral defect in the pars interarticularis which causes forward displacement of vertebra. “Decapitated Scottie dog” deformity “Step off deformity” Adolescents and women
Slide 77 - Spondys Treatment: REST and ice Flexion is best. Reduce extension moments. Bracing sometimes a solution.
Slide 78 - Sacroiliac Conditions Hip, Ilium, and Sacral problems can stand alone OR Can be connected to low back symptoms. Cause or effect? Cause? or Effect?
Slide 79 - CAUSE or EFFECT? Pelvis or Sacral alignment Hamstring Tightness Straight Leg Raise 90/90 test Hip Flexor tightness Thomas Test Trigger points Piriformis tightness IR of hip is limited Trigger points
Slide 80 - Special Tests for Pelvis and Sacrum Alignment Supine and prone Prone extension Sitting forward flexion and hip flexion Monitoring PSIS Monitoring low back Standing forward flexion and hip flexion Monitoring PSIS Monitoring low back Long Sitting Test Pen Dot Test FABERE Gaenslen’s Compression/Distraction Outflare/Inflare
Slide 81 - Pelvis and Sacral Conditions PELVIS Upslip ASIS and PSIS higher Anterior Rotation ASIS lower, PSIS higher Tight hip flexor, weak gluteus Posterior Rotation ASIS higher, PSIS lower Tight piriformis/gluteus and weak hip flexor SACRUM Flexion – sulcus is deep Extension – sulcus is shallow Forward Torsion Backward Torsion