Integrated Low Back Examination

Transcription

1 Integrated Low Back Examination William Thomas, DO, VCOM PPC/OMM Internal Medicine, Pediatrics and Sports Medicine October 2015 Special thanks and appreciation to Mark Rogers, DO

2 Objectives Utilize history and physical exam to create differential diagnosis for musculoskeletal low back pain Identify indications for imaging Identify contraindications to osteopathic manipulative treatment (OMT) Utilize osteopathic structural exam for diagnosis of musculoskeletal low back pain

3 Additional Resources Chila, Chapter 40, pp Casazza, BA. Diagnosis and treatment of acute low back pain. Am Fam Physician; 2012; 85: Kinkade, S. Evaluation and treatment of acute low back pain. Am Fam Physician; 2007; 75: Bates Guide to Physical Examination and History Taking, Chapter 16, Spine

4 Functional Anatomy Remember the low back and pelvis serves as a force transfer link between the torso and lower extremities Remember keys to dx include referred pain patterns, trigger points, spinal reflexes, and Chapman s points

5 Don t forget Red Flags Risk for Fracture Risk for Malignancy Cauda equina symptoms Not improving after several weeks Hx of IV drug abuse BMJ 2013:347:f7095

6 Other conditions that warrant consideration: Imbalance Short Leg Syndrome Dead Butt Syndrome Piriformis Syndrome Psoas Syndrome

7 Orthopedic Exam Facet/Spondy Tests Single-legged hyperextension Standing Kemp s Seated Kemp s Stenosis Tests Pheasant s Lumbar vs Sacrum Yeoman s Test Discogenic Tests Straight Leg Raise/Crossed Braggard s Lasegue s (bent-knee) Discogenic Tests (cont) Bonnet s (piriformis) Hip and Pelvis Tests Thomas (modified) FABERE FADIR FAIR Gluteus firing pattern testing Malingering Tests Hoover Simulated Rotation Axial load

8 Proposed Office Exam Patient Standing Inspection/Postural Exam Functional arch exam Gait Evaluation (shoes off) General ROM Standing Flexion Test Standing Kemp s Hip Drop test Single-Legged Hyperextension Test Simulated Rotation of trunk/pelvis

9 Proposed Office Exam Patient Seated Neurologic testing Sensation DTRs Pulses Seated Kemp s Axial Compression Osteopathic Screen (spine, ribs) Muscle strength testing Thomas (on way to supine position)

10 Proposed Office Exam Patient Supine Osteopathic screen (pelvis, extremity, leg lengths) SLR/crossed SLR Braggard s test (if SLR +) Lasegue s Test Bonnet s Test (if SLR +) FAIR Hoover s Sign Hip Exam ROM FABERE/FADIR

11 Proposed Office Exam Patient Prone Pheasant s Hibb s test Yaoman s test Gluteus firing (dead butt) Palpate Gluteus Piriformis SIJ Osteopathic screen (sacrum, and any other spine not done seated)

12 Inspection Inspect the skeleton and extremities and compare sides for the following: Gait Alignment Contour and symmetry of body parts Gross deformity Tenderness Inspect muscles and compare contralateral sides for the following: Size and symmetry Tone Temperature Swelling

13 Postural Exam

14 ROM Posture Gait Stabilize pelvis when testing Lumbar ROM

15 Palpation Palpate bones, joints, and surrounding muscles for the following: Tissue texture changes Tenderness Swelling Fluctuation(effusion) Crepitus Resistance to pressure

16 Gait Cycle.Osteopathic Phases Right heel strike Right innominate rotates posterior Left rotates anterior Anterior sacrum rotates left Superior sacrum level Spine rotates left Midstance Right leg straight Innominate rotates anteriorly Sacrum rotated right, SB left Lumbar spine rotated left, SB right Rotary at pubic symphysis Brolinson PG. Curr Sports Med Rep 2003; 2:47-56

17 Standing Flexion Test Functional Testing Seated Flexion Test Spring Test

18 - right hip drop + left hip drop Neutral Hip Drop Test Screens for the ability of the lumbar region to sidebend away from the side of the hip drop Physician hands on patient s iliac crests Patient is told to bend one knee without lifting his/her heel off the floor and allowing the hip to drop downward, then bend the other knee The hip that drops the least is the positive side, showing a restriction in lumbar side bending toward the side of the weight bearing leg (opposite the bent knee) Negative (Normal) Smooth curve away from side of hip drop Positive Test (Abnormal) Plane of iliac crest drops <20 Test is named for the bent leg side (+ left hip drop test indicates restricted right lumbar side bending)

19 Lumbar-Posterior Elements Single Legged Hyperextension test Pt standing on one leg & begins with extension of spine Pt then rotates & side bends to the ipsilateral side as the standing leg Reproduction of pain indicates posterolateral spine as region of pain Early symptoms suggest: Possible stenosis Possible lumbar disk Late (or end range) symptoms suggest: Pars Fracture Facet Syndrome

20 Lumbar-Posterior Elements Standing/Seated Kemp s Test Like a Spurling s test for the lumbar region Actively or passively Extend, rotate and side bend spine until symptoms reproduced Early pain suggests disc etiology Later pain suggests facet etiology

21 Straight Leg Raise Test Passively flex hip Lumbar Discogenic (+) if reproduces radicular symptoms Braggard Test If SLR (+) then Lower leg to reduce symptoms Dorsiflex foot (+) if reproduces radicular symptoms Lasegue s Test Flex hip to 90 0 and flex knee Passively extend knee (+) if reproduces radicular symptoms

22 Lumbar Stenosis Pheasant s Test Like Phalen s test for the low back Flex knees & compress lumbars to extend lumbar spine and reduce A-P diameter of canal May need to hold for up to 60 sec (+) if reproduced symptoms

23 Lumbar vs. Sacral Problems Yeoman s Test Pt prone Extend hip (with or without bent knee) while monitoring at L-S joint Reproduction of pain could be L-S, SIJ, or hip Can use progressively less extension & monitor each joint as to when pain starts in order to further localize

24 Lumbar Malingering Simulated Rotation Spine in neutral Rotate pelvis side to side Should not reproduce radicular symptoms (+) test if reproduces radicular symptoms??

25 Lumbar Malingering Axial Compression Press downward on head to add compressive force to spine (+) if reproduces symptoms in back or legs

26 Lumbar Malingering Hoover Place hands on b/l heels Pt actively flex hip with knee extended Should feel downward force through heel on opposite leg (+) if do not feel down force

27 Neurovascular

28 Netter based on Keegan and Garrett 1948

29 Neuro Exam Motor = muscles responsible for foot dorsiflexion DTR = patellar reflex Sensory = medial aspect of leg and foot

30 Neuro Exam Motor = extension of extensor hallucis longus m. against resistance Walk on heels No reflex** Sensory = lateral side of leg and dorsum of foot

31 Neuro Exam Motor = muscles responsible for plantarflexion Walk on your toes DTR = achilles reflex Sensory = lateral malleolus and lateral aspect and plantar foot

32 Pulses Posterior Tibial Artery Dorsalis Pedis Artery

33 Thoracic Spine Ribs Osteopathic Screen (above)

34 Pelvis Leg lengths Extremity Osteopathic Screen (below)

35 Manual Muscle Testing Hip flexion Psoas (L2-4) Hip adduction Adductors (L2-4) Hip abduction Gluteus medius and minimus (L4-5, S1) Hip extension Gluteus maximus (S1) Knee extension Quadriceps (L2-4) Knee flexion Hamstrings (L4-5, S1-2) Ankle dorsiflexion Tibialis anterior (L4-5) Ankle plantarflexion Gastrocnemius and soleus (S1)

36 Specific Hip & Pelvis Exams Thomas Test (modified) Tests for: Iliopsoas tightness Rectus femoris Tensor fascia lata Iliotibial band

37 Piriformis Bonnet s Test For Piriformis Syndrome Mimicker of discogenic pain Straight Leg Raise If +, then Lower leg to relieve symptoms & forcefully IR hip (+) if reproduces symptoms in ipsilateral leg FAIR test Flexion, adduction, internal rotation (+) if reproduces symptoms in ipsilateral leg

38 Specific Hip & Pelvis Exams FABER(E) Flexion, ABduction, ER, Extension Pain reproduced before the SI joint is engaged (groin pain) indicates pain is in the acetabulum / femoral joint Pain after the SI joint is engaged (back pain) indicates SI as source of pain FADIR Flexion, Adduction, Internal Rotation Reproduction of pain symptoms suggests femoral acetabular impingement (FAI)

39 Abnormal Gluteus Firing Test hip extension firing pattern 1) Hamstring 2) Gluteus 3) Contralateral Quadratus Lumborum 4) Ipsilateral Quadratus Lumborum

40 Dead-Butt Syndrome Treatment in the following order: Address any tight anterior hip capsule component Stretch iliopsoas Gluteus muscle retraining Prone position bring toes up on table Straighten knee Tighten gluteus muscles Maintaining gluteus contraction, extend leg Extend toes and hold for 3-5 secs Then slowly return leg to table LAST, relax gluteus muscles After retraining the gluteus, continue to work on Core strength too

41 Figure 1 Dead-Butt Syndrome Diagnosis Treatment

42 Closing Utilize history and physical exam to create differential diagnosis for musculoskeletal low back pain Identify indications for imaging Identify contraindications to osteopathic manipulative treatment (OMT) Utilize osteopathic structural exam for diagnosis of musculoskeletal low back pain