For the Primary Care clinician Low Back Pain: Focused Exam For the Primary Care clinician

Low Back Pain Common complaint in primary care, yet: Often difficult complaint to address when dealing with a complicated patient Providers may be unsure of exam Seen as chronic problem that does not improve, and may be concerned about medication- or disability-seeking patients

Today’s talk Focus on practical information to help the practitioner know: what questions to ask, what exam to perform, what studies to order.

Today’s talk Anatomy review Pain generators of the back Exam to rule out emergent issues Exam for radiculopathy Exam to discover cause of patient’s pain Appropriate ordering of studies

Anatomy review 7 Cervical vertebrae 12 Thoracic vertebrae 5 Lumbar vertebrae Sacrum (5 fused) Coccyx (4 fused) Focus today on lumbar/sacral spine

Anatomy review Vertebra Intervertebral discs Facet joints Spinal nerve Epidural space

Anatomy review

Pain generators Disc rupture Nerve impingement Joints-facets or SI Myofascial

Emergent causes of back pain Cancer Ask: 1) history of cancer; 2) pain which wakes patient from sleep, 3) weight loss, 4) new onset of pain in an elderly patient, Cauda equina Ask: 1) bowel or bladder problems such as retention, incontinence, decreased sensation; 2) saddle numbness. Infection Ask: 1) fevers, 2) history of epidurals or IVDU

Examination for Radicular pain Mostly caused by intervertebral disc problems such as herniation, degenerative disc disease, or narrowing from degenerative joint disease. Looking for a pattern of neurologic deficits: for example, that L5 strength, reflexes and sensation are all affected.

Examination for Radicular pain Neurologic exam: Strength Reflexes Sensation Provocative tests: Straight leg raise (SLR), contralateral SLR, Slump test

Strength testing Explain to patient that you are testing her strength and would like her to push as hard as possible; difference between true weakness and pain-inhibited weakness. In general, you should not be able to “break” the person’s strength; if you can, there may be weakness. Test against strength of non-affected side, if possible.

Neuro Exam-Strength Hip Flexor Strength Testing L1,2,3

Neuro Exam-Strength Knee Extension L2-4 Buttock should rise from table

Neuro Exam-Strength Dorsiflexion L4,5

Neuro Exam-Strength Extensor Hallucis Longus (EHL) Big toe dorsiflexion L5

Neuro Exam Plantar Flexion One-legged x 3 = 5/5 strength S1

Neuro Exam-reflexes Patella Reflex L4

Neuro Exam-reflexes Medial Hamstring Reflex L5

Neuro Exam-reflexes Achilles Reflex S1

Neuro Exam-Sensation Pinprick Sensation Testing L2

Neuro Exam-Sensation Pinprick Sensation Testing L3

Neuro Exam-Sensation Pinprick Sensation Testing L4

Neuro Exam-Sensation Pinprick Sensation Testing L5

Neuro Exam-Sensation Pinprick Sensation Testing S1

Neuro Exam-Sensation Pinprick Sensation Testing S2

Provocative testing SLR cSLR 30-70 degrees

Radicular Pain If your neurologic exam shows concern for acute neurologic changes in a nerve root pattern, consider MRI and referral to orthopedic surgeons. If you are unclear about the cause of neurologic changes, such as radiculopathy versus diabetic neuropathy, consider referral for EMG.

Disc disease May see disc space narrowing on plain films. May see disc extrusion, bulges on MRI

Degenerative joint disease Facet joints, or sacroiliac joint may be affected You may see facet degeneration, spurring, and/or osteophyte formation on radiographic studies.

Combined Extension & Rotation Reproduction of Pain

Myofascial pain May see muscle spasm, tense, tight muscles. Patient may get relief from NSAIDs, acetaminophen, topical preparations, stretching, trigger point injection. May be a component of pain, no matter the root cause of pain.

Exam

Alignment Weight Bearing Joints If unable to determine free standing – try having patient stand against a wall

Offset Rotation hand position shoulder position

Weight Balance

Exam Shoulder Height symmetric

Exam Iliac Crest Height symmetric

Adam’s Forward Bending Test Scoliosis Fingertip to Floor ROM Reproduction of Pain

Extension ROM Reproduction of Pain

Waddell test Tests of malingering Each test counts as +1 if +, 0 if - Superficial skin tenderness to light pinch over wide area of lumbar spine Deep tenderness over wide area, often extending to thoracic spine, sacrum, and/or pelvis. Low back pain on axial loading of spine in standing SLR test positive supine, but not when seated with knee extended to test babinski reflex. Abnormal or inconsistent neurological (motor and/or sensory) patterns. Overreaction. If 3+ points or more, investigate for non-organic cause. Waddell, GJ et al. Nonorganic physical signs in low back pain. Spine. 5:117-25, 1980.