Screening Evaluation of Spinal Pain and

DysfunctionJohn P. Kafrouni, MD

Rebound Physical Medicine and Rehabilitation, Orthopedics, and Neurosurgery

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

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

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

RTW and Absenteeism

Time Missed from Work

6 months

1 year

2 years

Return to Work Expected

50%

25%

0

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

William Osler, MD Father of Modern Clinical Training Techniques, bedside exam/historyThought one should marry a freckle faced girl.Thought clinicians older than 67 should be kindly euthanized.

Click icon to add picture

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

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

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…

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 ExamInitial Observation- Seated

Posture- Seated

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 ExamObservation-Sit to Stand

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”

Posture in Standing

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

Trendelenberg Gait

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

Thorasic Range

Flexion Rotation

Standing- provocation (just after/during ROM)

Spurlings test Lhermitte’s test Stork test

Cervical radiculopathy

Cervical myelopathy Sacroiliac joint/Facet

jointConfirm ipsilateral or contralateral pain and axial vs. appendicular pain- which may implicate a lateral lumbar disc

Standing Provocation

Spurling’s Stork Test

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

Shoulder Screen

O’Brien’s Modified Crass position

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.

Palpation -Standing

Sacroiliac joint Levator Scapula

Strength while standing

Heel walking

Toe/heel raising

Anterior tibialis- L4 predominately

S-1, Gastroc/soleus

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,

Sitting

Seated Slump Dermatomes

Myotomal testingCervical

C5 C6 C7 C8 T1

Delt, Biceps Pronator/Wrist

Ex/Infrasp Triceps/ Ext Ind Prop Finger flex (3rd) Interossei/ Small

finger abd

Myotomal testingLumbar

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

ReflexesCervical/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

Supine evaluationCervical 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.

Supine ExamLumbar 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

Supine testing-Lumbar

Modified Patrick’s Hoover’s sign

Hoover’s sign

Prone ExamCervical and Thoracic

Palpation Segmental Motion Scapular mobility Distant referral of

proximal structures

Palpation Costovertebral

junctions Scapular mobility Opportunity for

Manual Medicine techniques

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.

Prone-Lumbar

Yeoman’s Prone hyperextension

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.

Sidelying

FAIR test Ober’s test

Thoughts

Things that can make patients worse

Anxiety Depression Fear Anger Terms like Degenerative Inactivity Narcotics, NSAIDS Perceived future

disability

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

Thank you