Evaluation of Low Back Pain
What is Back Pain ? 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 ? Several studies have shown that there is no correlation between MRI findings and patients’ low back symptoms. 1. Wittenberg et al., 19982. Smith et al., 1998 3. Savage et al., 1997
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.
Common Sources of LBP Somatic dysfunction Muscle in “spasm” Nerve root In somatic dysfunction, some muscles become overactive (“spasm”)and other muscles become inactive.
Common Sources of LBP Any dysfunction involving the thoracic or lumbarspine, the sacroiliac joint or the hip can createlow back pain.
Common Sources of LBP L2 L3 L4 L5 S1 S2
Common Sources of LBP Disc 1. posteriorly – sinu vertebral nn. 2. laterally – gray rami communicantes a. branches of ventral rami GRC 3. various types of nerve endings up to VPR SVN ½ annulus depth Targets for dorsal primary ramus 1. facet joints DPR 2. interspinous ligaments 3. back muscles
Common Sources of LBP Long dorsal si ligament piriformis sacrospinous ligament sciatic nerve sacrotuberous ligament
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.
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
• 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!
Evaluate for “Red Flags”: May Signal Serious Causes of LBP • Cancer• Infection• Fracture• Sciatica• Cauda Equina syndrome• Ankylosing spondylitis
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
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?
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
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.
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?
• 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
Treatment Approaches Surgery Spine Surgery Outcomes 100 80 ) 60 ate (% 40 Success R 20 0 0 <3 >3 Risk Factors
Mechanisms of Injury • Congenital abnormalities• Poor body mechanics• Back trauma
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
The Key Players
Trunk Musculature Musculature• Superficial – Thoracic group– Abdominal group– Erector Spinae group • Spinalis• Longissimus• Iliocostalis • Deep – Transversospinal group • Multifidus• Rotatores• Intertransversarius
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
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.
Classify patient • Determine cause of problem – Postural • Inflammation of soft tissues – Dysfunctional • Adaptive Shortening• Strain or Sprain – Derangement • Disk• Facet joint• Stress Fracture
Guide to Lumbar Spine Conditions Sprain/Strain Dysfunction/ Derangement Postural ONSET Sudden, simple Gradual Sudden, simple move move PAIN Severe ache, Ache, Sharp, burning, diffuse, spasm intermittent Localized or Radiating MOBILITY Reduced, Reduced b/c of Guarded flexion, movement joint and CT extension increases pain stiffness decreases pain GOALS OF Decrease pain Decrease pain Decrease pain TX Decrease spasmIncrease ROM Centralize disc Restore ROM Posture Prevention Strength/Flex
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”
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.
Sacroiliac Joint Conditions (note this is advanced) • Sacral torsion – Forward or Backward torsion • Ilium torsion, upslip, downslip, outflare, inflare • Piriformis strain/trigger points
Walk through it…What you are thinking.
Unique risk factors for athletes • High impact trauma: – footbal , rugby • End range loading: – gymnastics, diving • Overuse trauma: – impact loading: distance running– rotational loading: golf, basebal– prolonged sitting: travel
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)
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
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
Triad of Assessment • Asymmetry – ASIS, PSIS, iliac crests, mal eoli, 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 rol ”
Kinetic Chain • Why do we need to assess the pelvis, hip and lower extremity?
Foot conditions • Over-pronation • Over-supination – Hip flexion – Hip extension – Anterior pelvic tilt – Hip external rotation – Pelvic rotation/Tilt – Pelvic rotation/tilt
Specific evaluation techniques 1. HISTORY!!!! 7. Sacroiliac tests 2. Alignment and 8. Sitting forward symmetry flexion and hip 3. Lumbar spine active flexion movements 9. Standing forward 4. Neurological Testing flexion and hip 5. Disc Pathology flexion Tests 10.Flexibility testing 6. Extension 11.Feet alignment mechanics – Prone assessment
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
What positions bother you? • Bending• Sitting• Rising from sitting• Standing• Walking• Lying prone• Lying supine
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
Evaluation Techniques • Palpation – This is your chance to “contain” the injury to specific structures. – Also al ows for natural comparison of “normal” landmarks • Muscular Tension – “Tootsie Rol Test” • Ligamentous Tests – Spring Test
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
Tests for Nerve Root Impingement • Valsalva test• Milgram test• Kernigs/Brudzinski’s test• Straight Leg Raise – Affected and Wel• Quadrant test• Slump test
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
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
Lumbar Spine Conditions • Facet Joint Dysfunction – Inflammation, sprain, degeneration– Dislocation or Subluxation (Acute or Chronic) • “stuck open” or “stuck closed” • Usual y localized but may involve several segments • May be associated with nerve root impingement• Often times pain decreases with activity
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
Lumbar Spine Conditions • Herniated Discs – MOI: Overload (Direct or Indirect) or faulty biomechanics (or both) – Protrusion, Prolapse, Extrusion, and Sequestration– Pain usual y 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
Disc and nerve root relationship
Neural Testing • Dermatomes • Myotomes – L1/L2 – Hip flexion– L3/L4 – Knee extension – L4 – Ankle dorsiflexion– L5 – Great toe extension – S1 – Eversion– S2 – Knee flexion
Observation • Posture – Plum line • Motions – Flexion– Extension– Lateral flexion– Rotation
Discogenic Pain • Special Tests: – Lower and Upper quarter screening • Dermatomes and Myotomes – Valsalva test– Milgram test– Wel straight leg raise– Kernig’s/Brudzinski test– Quadrant test
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
Lumbar Spine Conditions • Nerve Root Impingement/Dural Sheath Impingement – Special Tests: • Quadrant test• Femoral nerve stretch test• Kernig’s/Brudzinski test• Slump test
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
Spondylosis • Spondylolysis – general y 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 – “Col ared Scottie dog” deformity
Spondylolisthesis • Bilateral defect in the pars interarticularis which causes forward displacement of vertebra. • “Decapitated Scottie dog” deformity• “Step off deformity”• Adolescents and women
Spondys • Treatment: – REST and ice– Flexion is best. – Reduce extension moments.– Bracing sometimes a solution.
Sacroiliac Conditions • Hip, Ilium, and Sacral problems can stand alone OR • Can be connected to low back symptoms. – Cause or effect?
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
Special Tests for Pelvis and Sacrum • Alignment – Long Sitting Test – Supine and prone – Pen Dot Test – Prone extension • – Sitting forward flexion FABERE and hip flexion – Gaenslen’s – Monitoring PSIS – Compression/Distraction – Monitoring low back – Outflare/Inflare • Standing forward flexion and hip flexion – Monitoring PSIS – Monitoring low back
Pelvis and Sacral Conditions PELVIS SACRUM • Upslip • Flexion – sulcus is deep – ASIS and PSIS higher • Extension – sulcus is • Anterior Rotation shal ow – ASIS lower, PSIS higher • Forward Torsion • Tight hip flexor, weak • Backward Torsion gluteus • Posterior Rotation – ASIS higher, PSIS lower • Tight piriformis/gluteus and weak hip flexor