Sat 1420-lower-back-exam- -park

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Sat 1420-lower-back-exam- -park

  1. 1. 23/05/2014 1 Lower Back Physical Exam: What you Need to Know June 8, 2014 2014 BCCFP Spring Family Medicine Conference Teri Fisher BSc, BEd, MSc, MD, Dip Sport Med Assistant Clinical Professor Family, Sport & Exercise Medicine University of British Columbia Presenter Disclosure • Relationships with commercial interests: – None • Disclosure of commercial support: – None • Potential for conflicts of interest: – None
  2. 2. 23/05/2014 2 Objectives • Review the approach to lower back conditions • Review lower back physical examination Overview – Lower Back Pain • Affects up to 85% of population • Est annual cost $40 Billion (US) • Most common disability <45 yo • Often NOT possible to make PRECISE anatomical/pathological diagnosis • Pain generators: – Disc (nucleus pulposus, anulus fibrosus), facet joints, ligaments, muscles, nerves, synovium
  3. 3. 23/05/2014 3 Causes – Lower Back Pain • Common: – Degenerative disc, facet joint, stress fracture (spondylolysis), SI joint, paravertebral muscle • Less common: – Spondylolisthesis, spinal stenosis, disc prolapse, vertebral fracture, fibromyalgia, rheum/GI/GU/Gyne pain • Not to be missed – Malignancy (primary, metastatic), osteoid osteoma, multiple myeloma, severe OP Case 1 – The Grad Student • 28 year old female grad student with lower back pain • Started while writing her thesis
  4. 4. 23/05/2014 4 Lower Back Pain History • Mechanism of onset – Trauma? Gradual? • Position – Anatomical location • Quality – Sharp? Dull? Burning? • Radiation – Distally? Dermatome? • Severity – 0-10 (10 = worst pain imaginable) • Timing – Onset? Trauma? Constant? Intermittent? • Aggravating – Activity? Rest? • Alleviating – Rest? • Neuro symptoms – Numbness? Weakness? Bowel/bladder Dysfunction? • Inflammatory signs – Morning Stiffness? Fever? Iritis? IBD? Other joint involvement? Weight loss? Malaise? Night pain? History • Started 2 weeks ago • Lower back pain, right side • Aching quality • No radiation • Severity ranges from 3-6/10 (depending on activities) • Worse while studying/typing • Improved with stretching • No weakness, no paresthesia • No bowel/bladder dysfunction • No morning stiffness • No systemic symptoms
  5. 5. 23/05/2014 5 Surface/Bony Anatomy Anatomy - Muscles
  6. 6. 23/05/2014 6 Physical Exam • Inspection: – Gait, foot type, knee alignment (varus, valgus), bruising, erythema, scars, atrophy, skin changes, scoliosis • Palpation: – Spinous processes, Paraspinal muscles, posterior iliac crests, Facet joints, SI joints • Range of Motion: – Active • Functional Tests: – Toe walk, heel walk • Special Tests: – Trendelenberg, SLR, Bowstring, Lasegue’s Tripod, Slump, Facet load, Faber’s, Leg lengths • Neuro Screen: – Sensation, motor function, reflexes Dermatomes
  7. 7. 23/05/2014 7 Dermatomes/Myotomes/Reflexes Level Sensory Area Myotome Refle x L2 Mid-anterior thigh Hip flexion (iliopsoas) L3 Medial knee Knee extension (quadriceps) Knee L4 Medial ankle Dorsiflexion (Tibialis anterior) Knee L5 1st toe webspace Toe extension (EHL) S1 Lateral ankle Platarflexion (gastroc, soleus) Ankle Back Physical Exam • Demonstration
  8. 8. 23/05/2014 8 Physical Exam • No scoliosis • Tender L3-L5, R paraspinal • N back ROM • N sensation • N Strength (5/5) • SLR neg • Fabers neg • Reflex 2+, symmetrical Case 1 - Investigations Required? NO! • Indications: – Suspected traumatic fracture, stress fracture, spondylolisthesis, cancer – Pain not responding to treatment
  9. 9. 23/05/2014 9 Back Strain – Treatment • Reduce pain and inflammation – Rest, NSAIDs, Electrotherapeutic modalities (i.e. Ultrasound), taping • Address contributing factors – Poor posture when sitting or standing – Poor lifting technique – Working in stooped positions – Bed with poor support • Restore full-range pain-free movement • Achieve optimal flexibility and strength • Maintain fitness • Physiotherapy Case 2 – The Construction Worker • 48 year-old construction worker • Sudden Back pain
  10. 10. 23/05/2014 10 History • Started yesterday when lifting concrete block • Lower Back • Central spine • Sharp quality • Shooting pain to R foot • Severity ranges from 7/10 • Worse when sitting, bending, coughing, sneezing • Improved when lying down/standing • “pins and needles”, numbness in foot • N bowel/bladder function • No systemic symptoms Physical Exam • In obvious discomfort • Protective scoliosis • Tender L5-S1, midline • Decreased back flexion ROM • Decreased sensation R dorsal foot, 1st toe • Strength 4/5 Toe extension • SLR +, Bowstring +, Lesague’s +, Slump +, Tripod + • Fabers neg • Reflex 2+, symmetrical
  11. 11. 23/05/2014 11 Case 2- Investigations • X-ray • MRI Acute Disk Prolapse • Nucleus pulposus extruded through defect in anulus fibrosus into canal • Often occurs in disks previously injured • Usually age 20-50 • L5-S1 > L4>L5
  12. 12. 23/05/2014 12 Acute Disk Prolapse - Management • Rest in position of maximum comfort (lie down; avoid sitting) • Analgesia – NSAIDs • Physiotherapy • Transforaminal epidural cortisone injection • Surgical Referral (persistent symptoms, cauda equina) Case 3 – The Gymnast • 18 year-old gymnast • Chronic back pain
  13. 13. 23/05/2014 13 History • Chronic back pain x 1 month • Right-sided low back pain • Worse with back extension • Sharp quality • Severity 4-7/10 • No numbness • Normal bowel/bladder function • No weakness Physical Exam • Excessive lordotic posture • Tender near L L4 facet • Decreased/painful back extension • Painful facet load • Normal sensation • Normal reflexes • SLR negative • No systemic signs
  14. 14. 23/05/2014 14 Case 3- Investigations • X-ray – often unremarkable • SPECT scan • CT scan Spondylolysis (pars interarticularis stress fracture) • Management – Rest from sport – Restrict responsible athletic activity – Hamstring/gluteal muscle stretching – Abdominal/back muscle strengthening when pain-free – Identify and correct causes
  15. 15. 23/05/2014 15 Spondylolisthesis (pars interarticularis stress fracture) • Slipping of part or all of 1 vertebrae • Often associated with bilateral pars defects • Usually develop in childhood - ages 9-14 • Usually L5 slips forward on S1 (Grades I-IV) • Imaging: Lateral x-ray Spondylolisthesis - Treatment • Grade I/II – Rest from aggravating activities – Core/back strengthening, hamstring stretching – Physiotherapy – Antilordotic bracing • Grade III/IV – Symptomatic treatment as above – Avoid high speed/contact sports – If progression, consider spinal fusion
  16. 16. 23/05/2014 16 References and Images Brukner, Peter and Karim Khan. Clinical Sports Medicine. 3rd Ed. 2007. http://hscweb3.hsc.usf.edu/blog/2012/05/31/1979/ http://modernhealthandfitness.com/how-do-i-treat-sciatica-pain/ http://www.lumbarspinalstenosis.com/lumbar-radiculopathy-symptoms- causes-treatments-low-back-leg-pain.html http://www.ochsner.org/services/orthopedics/ http://www.studyblue.com/notes/note/n/chapter-22- musculoskeletal/deck/1329298 http://www.eastvicparkphysiotherapy.com.au/Blog%20Images/lower- back-pain.jpg http://www.unisa.edu.au/Media-Centre/Releases/Study-aims-to-ease- the-burden-of-lower-back-pain/#.U3Kd2jmhA5Q http://www.sciatica-clinic.com/wp-content/uploads/2013/03/SCIATICA- FROM-HERNIATED-DISC.jpg http://alexsimotasmd.com/conditions/spondylolisthesis Questions? • teri.fisher@ubc.ca

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