Lumbar exam in patients with Chronic Pain

3,255 views
2,702 views

Published on

Published in: Health & Medicine
2 Comments
11 Likes
Statistics
Notes
No Downloads
Views
Total views
3,255
On SlideShare
0
From Embeds
0
Number of Embeds
6
Actions
Shares
0
Downloads
0
Comments
2
Likes
11
Embeds 0
No embeds

No notes for slide

Lumbar exam in patients with Chronic Pain

  1. 1. Low back pain exam in chronic pain Julio A. Martinez-Silvestrini, MD Outpatient Medical Director Baystate Physical Medicine and Rehabilitation Assistant Clinical Professor Tufts University School of Medicine
  2. 2. Disclosures <ul><li>None </li></ul>
  3. 3. Objectives <ul><li>Discuss the differential diagnosis of low back pain, with focus in patients with chronic pain </li></ul><ul><li>Brief description of history and potential pitfalls on the evaluation of patient with chronic pain </li></ul><ul><li>Apply physical examination concepts to determine pain generators </li></ul><ul><li>Define common pathologies for spinal and non-spinal musculoskeletal low back pain </li></ul>
  4. 4. Low Back Pain <ul><li>Pain, muscle tension or stiffness localized below the costal margin and above the inferior gluteal folds </li></ul><ul><ul><li>Van der Heijden, 1991 </li></ul></ul>
  5. 5. Low Back Pain <ul><li>70-90% of people in developed countries will have at least one episode of low back pain </li></ul><ul><ul><li>90% will improve in 4-6 weeks </li></ul></ul><ul><li>Chronic low back pain </li></ul><ul><ul><li>12 weeks or more </li></ul></ul>
  6. 6. Case <ul><li>60 years old male with low back pain for 30+ years </li></ul><ul><li>Pain worsen in the last 4 years </li></ul><ul><li>Seen by Neurosurgery: no new disc herniations </li></ul><ul><li>Had lumbar epidurals 6 months ago: some relief </li></ul><ul><li>Constant pressure 7-10/10, improved with sitting, no change with hydrocodone/acetaminophen. </li></ul>
  7. 7. Case <ul><li>Physical exam: </li></ul><ul><ul><li>Tender paraspinal muscles </li></ul></ul><ul><ul><li>Pain aggravated with flexion and extension </li></ul></ul><ul><ul><li>Positive straight leg raise on right lower extremity </li></ul></ul><ul><li>MRI </li></ul><ul><ul><li>Laminectomies L4-S1 </li></ul></ul><ul><ul><li>Enhancing scar tissue possibly encasing right S1 nerve root </li></ul></ul><ul><li>Plan: Lumbar epidural steroid injection </li></ul>
  8. 8. History <ul><li>When? </li></ul><ul><ul><li>The pain started </li></ul></ul><ul><li>Where? </li></ul><ul><ul><li>Pain location(s) </li></ul></ul><ul><li>How? </li></ul><ul><ul><li>Pain quality </li></ul></ul><ul><ul><ul><li>Acute on chronic </li></ul></ul></ul><ul><ul><ul><li>New pain generator </li></ul></ul></ul><ul><li>What? </li></ul><ul><ul><li>Makes the pain worse/better </li></ul></ul><ul><ul><li>Treatment successes/failures (surgeries) </li></ul></ul><ul><ul><ul><li>Brand name medication requests </li></ul></ul></ul>
  9. 9. History: “ Red Flags ” <ul><li>Bowel incontinence, urinary retention and/or saddle anesthesia </li></ul><ul><li>Bilateral radicular pain </li></ul><ul><li>Night pain that awakens the patient </li></ul><ul><li>Age: Below 18 or older than 50 </li></ul><ul><li>Progressive motor deficits </li></ul><ul><li>Unexplained weight loss </li></ul><ul><li>Failure of improvement with bed rest </li></ul><ul><li>Associated febrile illnesses </li></ul><ul><li>Use of intravenous drugs </li></ul>Chou R. Ann Int Med, Feb 2011.
  10. 10. Pitfalls <ul><li>Prejudice </li></ul><ul><ul><li>Personal or external </li></ul></ul><ul><ul><ul><li>Nursing, secretarial and other medical assistant staff </li></ul></ul></ul><ul><li>Physical Therapy (PT) “failed” </li></ul><ul><ul><li>High pain levels upon referral to PT </li></ul></ul><ul><ul><li>Medications, injections and other complementary medical tools to relieve pain PRIOR to PT referral </li></ul></ul>
  11. 11. Pitfalls <ul><li>Limited Physical Exam </li></ul><ul><ul><li>“ Move around the pain” </li></ul></ul><ul><ul><li>Control pain, then complete physical exam </li></ul></ul><ul><li>Multiple pain generators </li></ul><ul><ul><li>Pain may “change” after treatment </li></ul></ul><ul><ul><ul><li>Radicular pain changes to facet syndrome presentation after lumbar epidural steroid injection </li></ul></ul></ul><ul><ul><ul><li>Concomitant radicular and facet pain sources </li></ul></ul></ul>
  12. 12. Physical Examination
  13. 14. Inspection
  14. 15. Inspection <ul><li>Look for leg length inequality </li></ul><ul><ul><li>ASIS and PSIS height </li></ul></ul><ul><li>Lumbar lordosis </li></ul><ul><ul><li>Increased </li></ul></ul><ul><ul><ul><li>Abdominal weakness </li></ul></ul></ul><ul><ul><li>Loss of lordosis reversal with forward flexion </li></ul></ul><ul><ul><ul><li>Increased muscle tension </li></ul></ul></ul>
  15. 16. Palpation <ul><li>Should include pelvic girdle muscles and Sacroiliac (SI) joints </li></ul><ul><li>Paraspinal muscles and spinous processes </li></ul><ul><ul><li>Step-off deformity (Spondylolisthesis) </li></ul></ul><ul><ul><li>“ Poor Man Discogram” </li></ul></ul>
  16. 17. Palpation <ul><li>TART </li></ul><ul><ul><li>T enderness </li></ul></ul><ul><ul><ul><li>Poor reproducibility and low specificity (Deyo, 1992) </li></ul></ul></ul><ul><ul><li>A symmetry </li></ul></ul><ul><ul><li>R ange of motion </li></ul></ul><ul><ul><li>T exture </li></ul></ul>
  17. 18. Range of Motion <ul><li>Flexion </li></ul><ul><ul><li>Lumbopelvic rhythm (Cailliet, 1988) </li></ul></ul><ul><ul><ul><li>First 45° of flexion are attributed to reversal of lumbar lordosis </li></ul></ul></ul><ul><ul><ul><li>Pelvic rotation completes the motion </li></ul></ul></ul><ul><ul><li>Reproduces anterior column pain and muscular pain </li></ul></ul><ul><ul><ul><li>Disc </li></ul></ul></ul><ul><ul><ul><li>Vertebral body </li></ul></ul></ul><ul><li>Extension </li></ul><ul><ul><li>Reproduces facet and spinal stenosis pain </li></ul></ul>
  18. 19. Anterior Posterior
  19. 22. Neurologic exam <ul><li>Strength </li></ul><ul><ul><li>Calf-raises are useful for S1 radiculopathies </li></ul></ul><ul><li>Sensation </li></ul><ul><li>Muscle stretch reflexes (DTR ’ s) </li></ul>
  20. 23. Provocative maneuvers <ul><li>Straight leg raising (SLR) </li></ul><ul><ul><li>Symptoms at less 30°: Non-physiologic response </li></ul></ul><ul><ul><li>Symptoms at more than 70°: May suggest SI dysfunction </li></ul></ul><ul><ul><li>90% sensitivity </li></ul></ul>
  21. 24. Slump Test <ul><li>Step 1: Slump forward </li></ul><ul><li>Step 2: Neck flexion </li></ul><ul><li>Step 3: Leg extension </li></ul><ul><li>Step 4: Passive dorsiflexion of the ankle </li></ul>
  22. 25. Spinal Stenosis
  23. 26. Waddell ’ s signs <ul><li>DO ReST </li></ul><ul><ul><li>D istraction </li></ul></ul><ul><ul><li>O verreaction </li></ul></ul><ul><ul><li>Re gional disturbance </li></ul></ul><ul><ul><li>S imulated tests </li></ul></ul><ul><ul><li>T enderness (superficial) </li></ul></ul><ul><ul><ul><li>Differentiate from Allodynia </li></ul></ul></ul><ul><li>3/5: Consider non-organic component </li></ul>
  24. 27. Common Diagnoses
  25. 28. Mechanical low back pain <ul><li>Also known as non-specific low back pain </li></ul><ul><li>Pain generators include </li></ul><ul><ul><li>Facet joints </li></ul></ul><ul><ul><li>Interspinous ligaments </li></ul></ul><ul><ul><li>Paraspinal muscles </li></ul></ul><ul><ul><li>Annulus fibrosus </li></ul></ul>
  26. 29. Mechanical LBP <ul><li>History of stiffness, lasting less than 1 hour </li></ul><ul><ul><li>If stiffness last >1 hr; consider a possible spondyloarthropathy or other rheumatologic disorders </li></ul></ul><ul><li>Tenderness to palpation </li></ul><ul><li>Limited range of motion </li></ul><ul><ul><li>Flexion </li></ul></ul><ul><ul><li>Flexion AND extension </li></ul></ul><ul><li>Normal neurologic exam </li></ul>
  27. 30. Radicular pain <ul><li>“ Sciatica ” </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><ul><li>Burning </li></ul></ul></ul><ul><ul><ul><li>Shooting </li></ul></ul></ul><ul><ul><li>Numbness </li></ul></ul><ul><li>Radiculopathy </li></ul><ul><ul><li>Weakness in the corresponding myotome </li></ul></ul><ul><li>SI joint </li></ul><ul><ul><li>Tender SI region </li></ul></ul><ul><ul><li>Faber test </li></ul></ul><ul><li>Piriformis syndrome </li></ul><ul><ul><li>Piriformis stretch </li></ul></ul>
  28. 31. Sacroiliac joint pain <ul><li>Common low back pain generator </li></ul><ul><li>Potential causes include </li></ul><ul><ul><li>Sacroillitis </li></ul></ul><ul><ul><li>Sacroiliac ligament sprain </li></ul></ul><ul><ul><li>Myofascial pain </li></ul></ul>
  29. 34. Sacroiliac joint pain <ul><li>Patrick’s test </li></ul><ul><ul><li>FABER </li></ul></ul><ul><ul><ul><li>F lexion </li></ul></ul></ul><ul><ul><ul><li>Ab duction </li></ul></ul></ul><ul><ul><ul><li>E xternal R otation </li></ul></ul></ul><ul><ul><li>Anterior hip pain: Hip pathology </li></ul></ul><ul><ul><li>Posterior pain: SI dysfunction </li></ul></ul>
  30. 35. Sacroillitis <ul><li>Not to be confused with SIJ pain </li></ul><ul><ul><li>Ankylosing Spondylitis </li></ul></ul><ul><ul><li>Reactive arthritis </li></ul></ul><ul><ul><ul><li>Reiter ’ s syndrome </li></ul></ul></ul><ul><ul><li>Psoriatric arthritis </li></ul></ul><ul><ul><li>Inflammatory bowel disease </li></ul></ul>
  31. 36. SI Joint dysfunction
  32. 37. SI Joint dysfunction
  33. 38. SI Joint dysfunction
  34. 39. Piriformis syndrome <ul><li>Tender middle buttock </li></ul><ul><li>May be associated to leg pain </li></ul><ul><li>Thick, fat wallet in the back pocket </li></ul><ul><li>Rarely, neurogenic compression </li></ul>
  35. 40. Piriformis syndrome
  36. 41. Piriformis stretch
  37. 42. Greater trochanteric bursitis <ul><li>CC: Hip pain </li></ul><ul><li>Pain when sleeping on the affected side </li></ul><ul><li>Tender at lateral hip (not hip joint or groin pain) </li></ul><ul><li>Patrick’s test: Lateral hip pain </li></ul>
  38. 43. Hip Osteoarthritis <ul><li>Hx: “ Deep ” hip/groin pain </li></ul><ul><li>PE: Weak gluteus medius </li></ul><ul><ul><li>Trendelenburg Sign </li></ul></ul><ul><ul><li>Reverse Trendelenburg (gait) </li></ul></ul><ul><ul><ul><li>Trunk Lurch </li></ul></ul></ul>
  39. 44. Workshop <ul><li>Inspection </li></ul><ul><ul><li>ASIS </li></ul></ul><ul><ul><li>PSIS </li></ul></ul><ul><li>Palpation </li></ul><ul><ul><li>Paraspinal processes </li></ul></ul><ul><ul><li>Muscles </li></ul></ul><ul><ul><li>SIJ </li></ul></ul><ul><li>ROM </li></ul><ul><ul><li>Extension </li></ul></ul><ul><ul><li>Flexion </li></ul></ul><ul><li>Neurologic exam </li></ul><ul><ul><li>Strength </li></ul></ul><ul><ul><li>Sensation </li></ul></ul><ul><ul><li>MSR’s </li></ul></ul><ul><li>Special tests </li></ul><ul><ul><li>SLR </li></ul></ul><ul><ul><li>Patrick’s </li></ul></ul><ul><ul><li>Piriformis stretch </li></ul></ul><ul><ul><li>Simulated tests </li></ul></ul>
  40. 45. Case <ul><li>Patient seen and history revealed his injection was done passing through the surgical scar </li></ul><ul><li>Caudal Epidural steroid injection </li></ul><ul><li>1 month follow up: </li></ul><ul><ul><li>Pain 0-1/10 </li></ul></ul><ul><ul><li>Straight leg raise (-) </li></ul></ul><ul><ul><li>Referred to PT, patient waived due to insurance. </li></ul></ul><ul><ul><li>Educated in home exercise program </li></ul></ul><ul><li>4 months follow-up </li></ul>
  41. 48. Contact information <ul><li>Twitter: JulioMartinezMD </li></ul><ul><li>E-mail: julio.martinez@baystatehealth.org </li></ul>
  42. 49. Thanks!

×