Lbp assessement
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Assessment of low back pain patients
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Lbp assessement
- 1. LOW BACK PAIN ASSESSMENT DR. VARUN SINGLA MD (PGI Chandigarh) PDCC-Pain Management (SGPGI Lucknow) Fellow FPCI (Mumbai) Member, Indian Society for Study of Pain Peer Reviewer, Cochrane PaPaS, UK
- 2. OVERVIEW Epidemiology Anatomy Etiology Classification Approach History Examination Diagnostics
- 3. EPIDEMIOLOGY Among top 10 diseases and injuries that account for highest number of DALYs . Lifetime prevalence - 60-70% Leading cause of activity limitation and work absence with significant social and economic impact. Global number of individuals with LBA is likely to increase in future
- 4. ANATOMY LBA : Pain in posterior aspect of body from lower margin of 12th ribs to lower gluteal folds ± referred pain to one or both lower limbs that lasts for atleast one day
- 6. NON-SPINAL Pancreatitis Gall bladder disease Abdominal aortic aneuysm Appendicitis Kidney disease Bladder infection Pelvic infection Testicular torsion Ovarian cancer/ cyst Prostate cancer Fibromyalgia
- 8. CLASSIFICATION Acute (< 6 weeks) Sub- acute (6 weeks – 12 weeks) Chronic (> 12 weeks) DIVISION (DURATION OF SYMPTOMS) • 0-8 weeks • 8 wks- 6 mth • >6 mth Spitzer, W.O an dLeblanc , F.E, 198
- 9. ASSESSMENT HISTORY PAIN DESCRIPTION PSYCHOLOGY PHYSICAL EXAMINATION DIAGNOSTIC STUDIES PAIN QUESTIONNAIRES
- 10. CATEGORIZATION Non- specific low back pain Back pain with radiculopathy or spinal stenosis Back pain with other spinal cause
- 11. APPROACH Rule out serious pathology “red flags” Confirm that pain is : In lower back Mechanical Not inflammatory Rule out specific causes
- 13. RED FLAGS CAUDA EQUINA SYNDROME: SPINAL FRACTURE CANCER/ INFECTION
- 14. HISTORY Search should be directed to answer two questions: “Where is the disease causing the pain—in the brain, spinal cord, plexus, muscle, tendon, or bone?” and “What is the nature of the disease?” “One physician willing to sit and actually listen to patients can be of more practical benefit than 100 magnets (of any Tesla strength).”
- 15. HOW TO GO ABOUT IT!! Build rapport A routine social history Establish chief complaint. Why is the patient here? Use pain litany. Where is the pain? What is its nature? Do not jump to conclusions Determine impact of pain on patient's life Explore past medical and family history Drug history
- 16. PAIN LITANY 1. Mode of onset 2. Location 3. Chronicity 4. Tempo (duration and frequency) 5. Character and severity 6. Associated factors: Premonitory symptoms and aura, Precipitating factors, Environmental factors (occupation), Family history, Age at onset, Pregnancy and menstruation, Gender, Past medical and surgical history, Socioeconomic considerations, Psychiatric history, Medications and drug and alcohol use
- 17. MODE OF ONSET Sudden or insiduous Distinguishes sick from well patients
- 18. LOCATION SPECIFIC POINT VS ACROSS BACK SUPERFICIAL VS DEEP INVOLVE ANY OTHER REGION (LOWER EXTREMITY) SITE OF MAXIMUM PAIN
- 19. CHRONICITY first or worst syndrome - accentuated pain presentation, deserve serious concern, view with medical urgency Equating chronicity with benign disease is dangerous. Identify ominous changes in a long-standing, stable pain syndrome
- 20. DURATION AND FREQUENCY Gives an idea about nature of disease. Severity of disease Make Differential diagnosis
- 21. QUALITY AND SEVERITY Dull aching Sharp / shooting Burning Tearing / pop • Intermittent • Constant
- 22. AGGRAVATING/ RELIEVING FACTORS What makes better What makes worse BEWARE Nothing makes pain better
- 23. ASSOCIATED Numbness Tingling Burning sensation Weakness Falls incontinence
- 24. MEDICATION HISTORY Duration, frequency and amount Red flag drugs : morphine, codeine, fentanyl, cocaine, hydromorphone, methadone, barbiturates, BZDs, Other important drugs : Oral contraceptives, Anticoagulants (heparin, warfarin, clopidogrel), Antiplatelet agents (aspirin, ticlopidine), Antianginals (nitrates)
- 25. PSYCHOLOGY Patient’s expectations – cure? Physician pursuing it!!! Psychosocial issues often contribute to, and may be the main cause of disability too. Need to address psychological aspect.
- 26. PSYCHOSOCIAL FACTORS – PREDICTORS OF POOR OUTCOME Depression, anxiety Job dissatisfaction, stress (time of work) Stress – marital/other Secondary gain Maladaptive thinking and coping styles Multiple somatic complaints
- 27. EXAMINATION Inspection Palpation Range of motion Neurologic tests Provocative tests
- 28. INSPECTION/ GENERAL SURVEY Skin and Subcutaneous tissue - lumbar lipoma, an abnormal hair patch, or a port wine stain, cafe au lait spots and nodular skin swellings
- 29. POSTERIOR ASPECT SYMMETRY SCOLIOSIS SPONDYLOLISTHE NORMAL HYPERLORDOSIS FLAT BACK
- 30. GAIT Sciatica - walk with the hip more extended and the knee more flexed Antalgic gait - putting as little weight as possible on the affected side and then quickly transferring the weight to the unaffected side. Heel walking – ankle dorsiflexors strength. L4 innervated tibialis anterior, L3-L4 disc herniation. Toe walking – S1 innervated gastrosoleus muscle, L5-S1 disc herniation
- 31. RANGE OF MOTION Flexion : angle between the final position of the trunk and a vertical plane (80° to 90°) OR distance from the patient's fingertips to the floor (10 cm). Extension : angle between trunk and vertical line; 20° to 30° Lateral bending :angle between imaginary line of vertebra prominens and sacrum; 20 -30° Rotation : angle between new plane of rotated shoulders and coronal plane; 30° to 40°
- 32. PALPATION Spinous process Tuffier’s line : L4-L5 interspace Step off : spondylolisthesis, vertebral compression fracture Paraspinal muscle spasm : lateral bending Muscular tenderness, trigger points, tender nodules Facet joint tenderness, transverse process fracture
- 33. MUSCLE TESTING Flexion : rectus abdominis Extension : erector spinae
- 36. L1 and L2 – iliopsoas muscle (hip flexor) L3 – quadriceps L4 – tibialis anterior (heel walk) L5 – EHL, gluteus medius S1 – gastrosoleus (plantar flexor), evertor of ankle (peroneus longus and brevis), extensor of hip (gluteus maximus) S2, S3, S4 – bladder, rectum (external anal
- 38. REFLEXES Patellar tendon reflex (L4) Tibialis posterior and medial hamstring reflex (L5) Achilles tendon reflex (S1)
- 40. SENSORY Pain and temperature : spinothalamic tract Light touch, position sense, vibration : posterior column
- 41. NERVE ROOT TENSION TESTS SLR Cross leg SLR Lasegue’s test Slump test Bowstring sign
- 42. SLR, CROSSED SLR AND LASEGUE TEST stretches the L5 and SI nerve roots 2 mm to 6 mm hamstring tightness SLR - extremely sensitive (0.9) but less specific (0.26) Crossed SLR - less sensitive (.29) but more specific (.88) Lasegue test – Sensitivity (0.7).
- 44. BOWSTRING SIGN AND SLUMP TEST Bowstring sign – sensitivity (0.69)
- 45. FEMORAL NERVE STRETCH TEST L2, L3, or L4 nerve root compression VALSALVA MANOUVRE •Increases intrathecal pressure – thus pain due to pressure on spinal cord or its nerve roots
- 46. SINGLE LEG HYPEREXTENSION TEST Specific test for spondylosis.
- 47. WADDELL SIGNS FOR NON-ORGANIC PAIN Superficial non-anatomic tenderness Pain from maneuvers that should not ellicit pain Distraction maneuvers that should ellicit pain BUT don’t Disturbances not consistent with known patterns of pain Over-reacting during the exam Not definitive to rule out organic disease
- 48. SACROILIAC JOINT TESTS Yeomen test Patrick’s test(FABER) Gaenslen’s test Sacroiliac shear test Distraction test Thigh thrust test
- 49. CLINICAL TESTS FOR SACROILIAC JOINT DYSFUNCTION Faber Patrik Test Yeoman’s Test
- 50. Gaenslen’s Test Sacro-iliac shear test
- 51. DISTRACTION TEST THIGH THRUST TEST
- 52. DIAGNOSTIC STUDIES X – RAY MRI CT SCAN BONE SCAN DISCOGRAM MYELOGRAM EMG SSEP
- 53. X- RAY
- 55. MRI Sensitive for soft tissue sturctures (nerves, disc) $$$$
- 57. CT SCAN Assess bony spine Faster and cheaper than MRI Reconstruction images or with other modalities
- 58. DISCOGRAM Injection of contrast material into disc space Concordant vs discordant pain Assess discogenic pain
- 59. MYELOGRAM Series of plain X –rays with contrast agent into thecal sac promoting better defintion of these structures
- 60. OTHER INVESTIGATIONS ESR , CRP – infection, cancer, rheumatologic disese RF, Anti – CCP – rheumatoid arthritis HLA-B27 – ankylosing spondylitis
- 61. THANK YOU
- 62. CLINICAL FEATURES OF LUMBAR FACET SYNDROME
- 63. PAIN REFERRAL IN FACET
Hinweis der Redaktion
- What are we dealing with Global burden of disease study 2010 Out of 291 diseases LBA ranked at 6th in health burden Future – as population ages
- Global burden of disease study 2010
- Spitzer, W.O an dLeblanc , F.E, 1987 Most people recover from an acute episode within 8 weeks NASS (north american spine society, 2000) guidelines define “initila phase of care” = 8 weeks Symptomatic after 6 months = poor prognosis for significant improvement
- Based on history and examination
- remains vigilant for signals of an urgent situation. Pain of uncertain origin should always be regarded as a potential emergency. Rule out hip pathology Aggravated or relieved by certain movemnets or postures Inflammatory – after waking / second half of night - morning stiffness >30 minutes - relieved by activity - lab test / inflammatory markers
- Saddle anaesthesia Bladder/ bowel involvement Motor weakness Sudden onset severe central pain (relieved by lying down) H/O trauma : major / minor spinal deformity >50 yr or <20 yr H/O cancer Constitutional symptoms Pain when supine, causing sleep disturbance, thoracic Major truma - RTA or FFH Minor trauma – strenous lifting in osteoporotic patient
- introduce self occupation, place of employment, marital status, and number of children Assess patient's mood, anxiety level, and capability of giving a history on his or her own. Is it pain?, prescription renewal, morbid fear of cancer. Open ended questions allow the patient to tell his or her own story ask about other doctors whom the patient has seen and their treatments. psychological fears, family issues (marriage), compensation, and work record. current pain should be placed in context with other major medical events: previous surgery, hospitalizations, cancer
- Pain litany - formulaic exploration of the patient’s pain history office should be both professional and comfortable patients have a private place where they undress and are examined .
- distinguishing sick from well patients. For example, the sudden, explosive presentation of a subarachnoid hemorrhage secondary to a ruptured intracranial aneurysm, manifested by severe headache, neck pain, and a sense of impending doom, contrasts sharply with the chronic diffuse headache and vague neck tightness of tension-type cephalalgia
- The pain in trigeminal neuralgia is Usually limited to one or more branches of cranial nerve (CN) V and does not spread beyond the distribution of the nerve.4 The V2 and V3 divisions of this nerve are much more frequently involved than is V1 (Fig. 5.1). The pain is rarely bilateral except in certain cases of multiple sclerosis, brainstem neoplasms and skull base tumors, and infections. burning, prickling dysesthesias of meralgia paresthetica. The unilateral involvement of the lateral femoral cutaneous nerve produces painful dysesthesias in the anterior thigh, more Commonly in men, who notice the disturbance when they put a hand in a trouser pocket.
- “How long have you had this pain?” try to date the pain in relation to other medical events, such as trauma, surgery, and other illnesses. back pain that has been present for 30 years and is not associated with any progression is strong evidence of a self-limited pain syndrome severe low back pain of sudden onset or pain that suddenly changes in character must be assigned to the category of “sick until proved otherwise.” Identify ominous changes in a long-standing, stable pain syndrome (e.g., when a patient with chronic low back pain suddenly becomes incontinent). n Recognize new symptoms superimposed on chronic complaints
- trigeminal neuralgia (tic douloureux) is described as brief electric shocks or stabbing pain. Onset and termination of attacks are abrupt, and affected patients are usually pain free between episodes. Attacks last only a few seconds. It is not unusual for a series of attacks to occur in rapid succession over several hours. In contrast, the pain of temporal (giant cell) arteritis is usually described as a dull, persistent, gnawing pain that is exacerbated by chewing.3
- The patient with acute lumbar disk herniation often writhes before the physician and is essentially unable to sit in a chair. The body language and facial expressions Vascular headaches tend to be throbbing and pulsatile, and the pain intensity is often described as severe.3 Cluster headaches may have a deeper, boring, burning, wrenching quality. Trigeminal neuralgia is typically described as paroxysmal, jabbing, or shocklike, in contrast to non-neuralgic pain such as experienced in temporomandibular joint (TMJ) dysfunction, which is often described as a unilateral, dull, aching pain
- Standing, walking, sitting, froward flexion, extension, weight bearing, lying down
- Until drug dependency issues are addressed, effective inroads into the management of chronic pain will be thwarted. anticoagulants (warfarin, heparin) or antiplatelet agents (aspirin, clopidogrel [Plavix], and ticlopidine Inadvertent overdosing of an older, confused patient can cause intracerebral bleeding (headache) or back and radicular pain (secondary to retroperitoneal hemorrhage
- LBA is recurrent in 33-70% of patients. Expectations fail to reflect it (von korf , spine 1996. haestback, european spine journal 2003)
- Treat these and if refractory to treatment anticipate poor outcome
- Skin and Subcutaneous Tissue : lumbal lipoma, an abnormal hair patch, or a port wine stain may be associated with spina bifida or even myelomeningocele. cafe au lait spots and nodular skin swellings may indicate neurofibromatosis, a condition that may cause secondary deformity of the spine.
- Longitudinal furrow in midline. Spinous processes run in this and prominent in flexion. Paraspinous muscles – superficial column – erector spinae or sacrospinalis muscle – Multifidus, longissimus, iliocostalis Paraspinous muscle spasm – prominence on one side (due to any painful lesion of lumbar spine or paraspinal muscle strain) A, spinous processes; B, erector spinae; C, iliac crests; D, posterior facet joints; E, transverse processes. Symmetry – space between upper limb and trunk (detect a subtle coronal deformity of the spine ) Pelvic obliquity – imaginary line between PSIS or iliac crest parallel to floor. (scoliosis, anamolous vertebra, leg length discrepancy, list) Spondylolisthesis or vertebral compression fracture : Step-Off Deformity. body of involved vertebra slide forward . M/C L5-S1 normal lumbar lordosis (60%) should exactly complement the thoracic kyphosis and cervical lordosis, so that the base of the occiput rests directly above the sacrum Hyperlordosis -swayback – buttocks prominent lumbar flatback syndrome - Compression fractures that result in anterior wedging of the lumbar vertebral bodies, Advanced degeneration of the lumbar intervertebral disks, Decreased lumbar lordosis is often a temporary, reversible deformity related to pain and associated muscle spasm spondylolysis, reflexive decrease in lumbar lordosis. Ankylosing spondylitis more rigid decrease Gibbus - sharp, angular kyphotic deformity, protruding spinous process, tuberculosis of the spine, localized collapse of anterior portion of vertebral column
- Spinal stenosis, spndylolisthesis – pain increase in extension , relieved with flexion Discogenic , vertebral body source – increase with flexion, axial loading Pain in extension – LCS, SOL, ds of posterior element of vertebrae (spondylosis, facet arthropathy) Herniated disc - avoid lateral bending towards side of impingement. Paraspinal muscle spasm – muscles on side of bend do not relax unusually. Lumbar discogenic pain is often restricted to the axial spine and is associated with intolerance of the sitting position and pain provoked by coughing, sneezing, and Valsalva maneuvers
- Localized tenderness at a particular level - sprains or disruptions of posterior ligaments of the spine, fractures and tumors of the posterior elements The amount of slippage usually must be at least 50% of the diameter of the lumbar vertebral bodies before the step-off can be detected by physical examination. Trigger points may also indicate the presence of fibromyalgia facet joint arthritis or a painful facet joint syndrome. localized unilateral tenderness deep to the paraspinous muscles following trauma should suggest the possibility of a transverse process fracture
- crunch or sit-up. Extension : pain associated with disorders of the posterior elements of the lumbar spine, such as spondylolysis or facet joint arthritis, or of spinal stenosis may be exacerbated by this test.
- gluteus medius - hip abduction
- Grades 1 to 3 are relatively objective and less prone to interobserver variation.
- Monosynaptic arc. The afferent limb is provided by sensory fibers, which innervate muscle spindles. These fibers project centrally toward the spinal cord and synapse with alpha motor neurons in the ventral horn. The alpha motor neurons comprise the efferent limb of the reflex arc. patellar tendon L4 , some L3 Reinforcement - by jendrassik manouvre (interlock fingers) and jaw clenching Tibialis Posterior examiner holds the patient's foot in a small amount of eversion and dorsiflexion and strikes the posterior tibial tendon just below the medial malleolus plantar flexion inversion response Medial Hamstring strikes the thumb, which is pressing on the semitendinosus tendon Achilles' Tendon dorsiflexes the foot to place the Achilles tendon under tension, and then strikes the Achilles about 3 cm above the calcaneus unilateral decrease herniated L5-S1 disk impinging the ipsilateral S1 nerve root. Bilateral hyperreflexia – upper motor neuron lesion undue briskness of the Achilles or the patellar tendon reflexes - upper motor neuron lesion, carry out provocative tests for ankle clonus and the Babinski sign
- Performing the straight-leg raising test on the side opposite that of the sciatica but it puts little tension on the more proximal nerve roots suggests a lesion of either the L5 or the S1 nerve root. tightness in the posterior thigh rather than sciatica, associated with a wide variety of conditions, including spondylolysis. for confirming the presence of a compressed or irritated lumbar nerve root
- SLUMP TEST back straight, looking straight ahead (Fig. 9-28A). The patient is then encouraged to slump, allowing the thoracic and lumbar spines to collapse into flexion while still looking straight ahead (Fig. 9-28B). The next step is to fully flex the cervical spine (Fig. 9-28C). The patient is then instructed to extend one knee, thus performing a straight-leg raise (Fig. 9-28D). The patient then dorsiflexes the foot on the same side, thus duplicating the Lasegue test
- prone on the examination table with the knee flexed to at least 90°. The patient's hip is then extended passively by lifting the thigh off the examination table When one of the nerve roots that contribute to the femoral nerve is compressed, this maneuver reproduces the patient's radicular pain in the anterior thigh.
- stand in the straddle position with one lower limb extended behind the other. The patient is then instructed to lean back as far as possible procedure is then repeated with the position of the lower limbs reversed unilateral spondylolysis, hyperextension tends to exacerbate the patient's pain and the pain tends to be more severe when the lower limb on the affected side is extended posteriorly
- Weakness involving multiple muscle groups in a nonmyotomal distribution with “give-way” effort Sensory loss in a segmental pattern (e.g., glove-stocking rather than a dermatomal distribution) observed in a patient in whom polyneuropathy is not an appropriate Diagnosis Limitations Widespread superficial tenderness is commonly found in patients with fibromyalgia, and tenderness on deep palpation is part of myofascial pain syndrome Sensory loss in a glove-stocking distribution is present with peripheral polyneuropathy. Recent data - Waddell’s signs cannot accurately distinguish between organic and nonorganic causes of pain
- review of prior imaging Studies in light of a newly derived specific historical or physical finding can be particularly helpful
- To assess the structure of spine and alignment of vertebra
- Spondylolisthesis Grade 1: 1% to 25% slippage. B, Grade 2: 26% to 50% slippage. C, Grade 3: 51% to 75% slippage. D, Grade 4: 76% to 100% slippage.
- Visulalise spinal cord and nerves in relation to surrounding spine structures (bone, joint, disc, etc)