625 lumbar spine exam

Subjective exam

Clear areas above & below central low back pain

• L/S can be source of generalized abdominal pain

• Leg symptoms

• Exact location

• Depth

• Quality (lacinating, ache, N/T)

Establish relationship

Potential pathoanatomical pain generators for LBP

Muscles

Ligaments

Dura mater

Nerve roots

Zygopophyseal joints

SIJ

Annulus fibrosis

Thoracolumbar region

Vertebrae

(Probs won’t determine structure that is primary culprit)

Facet Somatic Referral Patterns

L1/2, L2/3, L4/5 already refer to lumbar spine

L5/S1 referral to gluteal region (68%)

L2/3, L3/4, L4/5, L5/S1 refer to trochanteric region (10-16%)

L3/4, L4/5, L5/S1 referral to lateral thigh, posterior thigh, groin regions (5-30%)

Facet somatic referral symptoms

Deep and achy

Localized to unilateral/bilateral paravertebral area

Common referral areas for facets are

• flank pain

• Buttock pain (rarely below knee)

• Pain overlying iliac crests

• Pain radiating into groin

Pain may be worse in AM

Common aggs: extension, twisting, stretching, lateral bending

SIJ somatic referral patterns

Lower lumbar region (72%)

Lower limb (28%)

Groin (14%)

Foot (12%)

Upper lumbar region (6%)

Abdomen (2%)

SIJ somatic referral prevalence

10-25% in CLBP

Interspinous ligament somatic referral

Injected interspinous ligaments w/ saline

Aching pain in buttock and leg from multiple segmental levels

Implied somatic musculoskeletal structures can refer pain into extremity

Subjective exam: pre/post partum

Pregnancies, deliveries, complications, breast feeding

Type of delivery: vaginal vs C-section

Consideration: pregnancy related back pain- Diastisis Recti Abdominus or pelvic floor dysfunction present

Subjective exam: pelvic girdle pain

Coccydynia (pain/inflammation around coccyx)

Pain w/ intercourse (need to discuss location: pelvis, low back, hips)

Pain w/ voiding

Subjective exam: agg factors

Question preferences for extension or flexion

Sit vs stand tolerance

Transitional movements

Specific activities that provoke symptoms

Subjective exam: ease factors

Positions or movements

Time to settle

Location of symptoms change)

Subjective exam: 24 hr

Sleep:

• difficulty getting comfy bs waking due to pain

• Return to sleep: Change of position, meds, out of bed)

AM symptoms:

• stiffness out of bed? How long?

• Difficulty straightening up or walking upon getting out of bed)

PM symptoms:

• change in symptoms throughout the day?

Subjective exam: history of current symptoms

Obtain specific info regarding when symptoms started

Mechanism of injury?

Course of symptoms since onset?

• worse, better, same?

Spontaneous onset?

• change in activity level

• Work tests or repetitive stresses

Subjective exam: previous history

Episode of symptoms & activity limitations

Was there a mechanism of injury in past?

How did they improve?

• time, meds, PT, Chiropractor, Massage

Did they achieve full recovery?

Are current symptoms similar or different?

Subjective exam: general medical screen: red flags

History of RA

Smoker

Fatigue

Fever/chills/sweats

Nausea/vomiting

Malaise

Mentation/cognition

Subjective exam: signs of infection: red flags

Temp >100 degrees F

BP >160/95

Resting pulse > 100bpm

Resting respiration >25/min

Subjective exam: lumbosacral review

GI

Urinary system

Genital reproductive system

Subjective exam: specific considerations for LBP: red flags

Cancer

Fracture

Infection

• osteomyelitis

• Discitis

Abdominal aortic aneurysm (AAA)

Inflammatory arthritis

• ankylosing spondylitis

Cauda equina syndrome

Differential diagnosis: nonmechanical spinal conditions (1%)

Neoplasia (0.7%)

Infection (0.01%)

Inflammatory arthritis (0.3%)

Pagets disease

Scheuermanns disease

Differential diagnosis: nonmechanical spinal conditions: neoplasia

Multiple myeloma

Mets

Lymphoma/leukemia

Spinal cord tumors

Retroperitoneal tumors

Primary vert. tumors

Differential diagnosis: nonmechanical spinal conditions: infection

Osteomyelitis

Septic diskitis

Paraspinal abscess

Shingles

Differential diagnosis: nonmechanical spinal conditions: inflammatory arthritis

Ankylosing spondylitis

Psoriatic spondylitis

Reiter’s syndrome

IBS

Subjective exam: specific questions/ red flag questions

Discogenic pathology

• pain with cough/sneeze

Cauda equina syndrome

• changes in bowel/bladder function?

• Saddle anesthesia?

• Bilateral weakness, changes in gait/coordination, bilateral changes in sensation?

Differential diagnosis: visceral disease (2%)

Disease of pelvic organs

Renal disease

Aortic aneurysms

Gastrointestinal disease

Differential diagnosis: visceral disease: disease of pelvic organs

Prostatitis

Endometriosis

Chronic PID

Differential diagnosis: visceral disease: renal disease

Nephrolithiasis

Pyelonephritis

Perinephric abscess

Differential diagnosis: visceral disease: GI disease

Pancreatitis

Cholecytitis

Penetrating ulcer

Trauma & immunosuppression history & hypothesis consideration

History of major/minor trauma, fall, MVA, strenuous lifting

• possible fracture, especially in older/osteoporosis patient

Immunosuppresion from transplant, IV drug abuse, or prolonged steroid use

• increased risk of infection

Age & history of cancer history & hypothesis consideration

Age >50

• higher risk of cancer, AAA, fracture, infection

Past/present history of any type of cancer

• increased risk of cancer- causing LBP

• Common metastatic cancers that cause LBP: prostate, breast, kidney, thyroid, lung, lymphoma

Pain not relieved w/rest or wakes at night, not related to movement or position

• increased risk of cancer, infection, AAA

“Constitutional” symptoms, weight loss, & recent infection history & hypothesis consideration

Fevers, chills, night sweats (fever > 100 def F, chills, waking up sweating, temp changes at night)

• increase risk of infection or cancer

Weight loss (unexplained loss of 10+ lbs in 3 months that is unrelated to change in diet or activity)

• may indicate infection or cancer

Recent bacterial infection (UTI, pneumonia, etc)

• increased risk of infection

Saddle anesthesia, bowel/bladder changes, & LE weakness history & hypothesis consideration

Saddle anesthesia (absence of sensation in 2nd-5th sacral nerve roots, personal region)

• cauda equina syndrome (CES)

Bladder dysfunction (urinary retention, changes in frequency of urination, incontinence, dysuria, hematuria)

• CES or infection

Progressive or severe neurological deficit in LE

• may indicate CES

Bowel/bladder questions: incontinence

Stress incontinence:

• leakage w/ cough/sneeze, laugh, exercise stress (running), or valsalva

Bladder incontinence

• question timing to current symptoms

• Is PCP aware?

Bowel incontinence

• question timing of symptoms

• Is PCP aware

• Patient may not be forthcoming until question is asked

Bowel/bladder questions: chronic constipation

Can be indicative of pelvic floor dysfunction

Consider med list

Yellow flags definition

Psychosocial factors that contribute to how a patient manage their beliefs, emotional response, pain behavior, and/or coping strategies related to their condition

Yellow flags: screening for

Fear avoidance beliefs (FABQ)

Anxiety

Depression

Pain catastrophizing and disability

Overall mental health

Prolong med use

FABQ score needed for TBC-manipulation/mobilization

<19

Order of objective exam

Observation

Functional testing

Lumbar AROM

Hip/knee/ankle clearing

Neurological exam

Strength testing/muscle length

Special testing

• slump

• SLR

• PKB

• Compression fracture

Palpation

Accessory testing

• PA: CPA, UPA

Physiological testing

• flexion-extension

• AP translation

• Rotation