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  2. 2. OUTLINE Anatomy Pathologies Assessment and evaluation
  3. 3. BRIEF ANATOMY The spine Muscles The spinal cord and nerves
  4. 4. PATHOLOGIES • Arthritic spine:- spondylosis spondylolisthesis ankylosing spondylitis • Congenital deformities
  5. 5. Causes of back pain 1 A. Mechanical - Muscles and ligaments; Facet joint arthritis Proplapsed intervertebral disc Spondylolysis / Spinal stenosis  Local tenderness  muscle spasm  loss of lumbar lordosis  percussion tenderness over spinous process  NO MOTOR/SENSORY/REFLEXIC LOSS
  6. 6. Causes of back pain  Metabolic Osteoporotic vertebral collapse Paget's disease Osteomalacia
  7. 7. Causes of low back pain 4 Inflammatory – o Sacroiliitis o Ankylosing Spondylitis, • Difficult to diagnose if early stages but: • Morning stiffness for > 30 minutes • Pain that alternates from side to side of lumbar spine • Sternocostal pain • Reduced chest expansion
  8. 8. Referred pain  Pleuritic pain  Upper UTI / renal calculus  Abdominal aortic aneurysm  Uterine pathology (fibroids)  Irritable bowel (SI pain)  Hip pathology
  9. 9. CAUSES  Causes may be anatomical or even psychological  Pain may be due to:  Sitting for long periods of time  Standing for long periods without moving  Poor sitting or sleeping posture  The back is prone to a range of problems most of them caused by ;  Obesity  Lack of regular exercises  Bad posture
  10. 10. Red Flags Weight loss, fever, night sweats History of malignancy Acute onset in the elderly Neurological disturbance Bilateral or alternating symptoms Sphincter disturbance Immunosuppression Infection (current/recent) Claudication or signs of peripheral ischaemia Nocturnal pain
  11. 11. Yellow flags
  12. 12. Yellow Flags Factors prolonging back pain Internal factors-Opioid dependency “External controller” patient-type; learned helplessness; factitious disorder Mental health- depression or anxiety Interpersonal factors "Sick role“ Stressors in relationships Environmental / societal factors- Disability payments / Litigation / Malingering
  13. 13. Imaging modalities • Xrays • CT Scan • MRI
  14. 14. OBJECTIVE ASSESSMENT (Musculoskeletal Examination)
  15. 15. 1. Observation 2. Palpation 3. Range of motion 4. Neurological exam • Motor elements • Sensory elements 5. Special tests The exam should include…
  16. 16. 1. OBSERVATION i. Body type ii. Postural alignments and asymmetries should be observed from all views iii. Assess height differences between anatomical landmarks iv. Look out for signs and symptoms: • pain behaviors–groaning, position changes, grimacing, etc • atrophy, swelling, asymmetry, color changes
  17. 17. Postural Malalignments
  18. 18. 2. PALPATION i. Spinous processes • Spaces between processes - ligamentous or disk related tissue ii. Transverse processes iii. Sacrum and sacroiliac joint iv. Abdominal musculature and spinal musculature • Assessing for referred pain
  19. 19. Palpation cont.d v. Have subject perform partial sit-up while palpating PSIS region to determine tone and symmetry vi. Assess hip musculature and bony landmarks as well vii. palpate area of pain for temperature, spasm, and pain provocation viii. point palpation for trigger points/tender points
  20. 20. 3. ROM AND FLEXIBILITY Assess various spinal movements for flexibility: flexion, extension, rotational, lateral bending Special back flexibility tests • Back-to-wall test • Schober test and modified schober test • Finger to floor distance
  21. 21.  Back-to-Wall Test This test assesses lower back and hip flexibility. • Stand with your back to a wall so that your heels, buttocks, shoulders, and head are against the wall. • Try to press lower back and neck against the wall without bending your knees or lifting your heels off the floor. • Have a partner try to place a hand between your back and the wall.
  22. 22.  Schober’s Test
  23. 23. 4. NEUROLOGICAL ASSESSMENT Neurologic Exam Determines Presence/Absence and Level of Radiculopathy and Myelopathy 1. Motor elements muscle bulk/tone  atrophy/flaccidity muscle strength coordination gait
  24. 24. 2. Sensory elements sensory deficits, eg, touch, position sense, temperature, vibration allodynia: light touch hyperalgesia: single or multiple pinpricks
  25. 25. 5. SPECIAL TESTS (these may come in handy) Outline: Upper spine: ***Cervical spine and thoracic spine Lower spine: Lumbar, sacral and coccygeal
  26. 26. 1. Upper back and arm lift 2. Vertebral artery test 3. Spurling test. 4. Jackson test. 5. Compression test. 6. Traction test. 7. Percussion test 8. Tension arm test 9. Shoulder abduction test Upper spine NB: Cervical movement: Flexion 35-45°; Extension 35-45°; Lateral bending 45°; Rotation 60-80°.
  27. 27. • Upper Back and Arm Lift This test assesses the strength of upper back muscles 1. Lie facedown. 2. Hold your arms straight out in front of your head. 3. Lift your arms and upper body off the floor. 4. Hold for 10 seconds. Caution: Do not lift your feet off the floor.
  28. 28. • Vertebral Artery Test • Subject is supine • PT extends, laterally bends, and rotates the c-spine in the same direction • Dizziness or nystagmus indicates occlusion of the vertebral artery
  29. 29. • Shoulder Abduction Test • Subject places hand on top of head • A decrease in symptoms may indicate the presence of nerve root compression, due possibly to a herniated disk
  30. 30. Jackson test  TRACTION TEST
  31. 31. Tension arm test Percussion head test
  32. 32. Lower Spine Tests Test Done in Standing Position 1. Forward bending • Observe movement of PSIS, test posterior spinal ligaments 2. Backward bending • Anterior ligaments of the spine • Disk problem
  33. 33. 3. Side bending • Lumbar lesion or sacroiliac dysfunction 4. Standing Trunk Rotation • Assessment of symmetrical motions w/out pelvic movement
  34. 34. • Single Leg Lift (Prone)  This test assesses the strength of your lower back and hip muscles 1. Lie face down on the floor. Lift your straight right leg as high as possible. Hold for a count of 10. Then lower your leg. 2. Repeat using your left leg.
  35. 35. • Straight Leg Raising
  36. 36. • Straight Leg Raise • 0-30 degrees = hip problem or nerve inflammation • 30-60 degrees= sciatic nerve involvement • W/ ankle dorsiflexion = nerve root • 70-90 degrees = sacroiliac joint pathology
  37. 37. • Slump Test Monitor changes in pain as sequential changes in posture occur 1. Cervical spine flexion 2. Knee extension 3. Ankle dorsiflexion 4. Neck flexion released 5. Both legs extended Assessment of neural tension
  38. 38. • Bowstring test Used to determine sciatic nerve involvement • Leg (on affected side) is lifted until pain is felt • Knee is flexed to relieve pressure and popliteal fossa is palpated to elicit pain (along sciatic nerve) • To verify problem w/ nerve root, leg is lowered, ankle is dorsiflexed and neck is flexed. • Return of pain verifies nerve root pathology
  39. 39. • Knee to Chest • Bilateral - increases symptoms to lumbar spine • Single - pain in posterolateral thigh may indicate problem with sacrotuberous ligament • Pulling knee to opposite shoulder that produces pain in the PSIS region may indicate sacroiliac ligament irritation
  40. 40. • SI Compression and Distraction Tests Used for pathologies involving SI joint
  41. 41. • Neurological Exam • Sensation Testing • If there is nerve root compression, sensation can be disrupted
  42. 42. • .