Low Back Pain Flashcards
What are 5 common causes of low back pain?
fracture, strain, disc herniation, infection, referred pain
90% of all back pain will resolve within ___ weeks; 99% in ___ weeks
6, 12 weeks
What are 3 goals of LBP treatment?
hasten recovery, control pain and facilitate rehabilitation
What are red flags for LBP?
bilateral radicular pain, saddle area anesthesia, urinary incontinence, urinary retention, increased urinary frequency or incontinence, night sweats (cancer)
What are the most serious things that red flags could be?
Acute Cauda Equina syndrome, massive multi-nerve compression, large central disc herniation, hemorrhage into spinal canal, swelling of tumor
How is Cauda Equina Syndrome treated and in what time frame?
Emergency!!! 24 - 48 hours Surgical decompression
What are the risk factors for possible fracture?
major trauma, fall from height, female over age 50 or other risk factors for osteoporosis
What are the risk factors for infection?
HIstory-over age 50 -under age 20 -fever or chills -worse pain supine -recent UTI -IV drug abuse -immune suppression Physical Exam - temperature, spinous process percussive pain
What are the risk factors for tumors?
- over 50, under 20
- unexplained weightloss
- pain worse when supine
- severe nocturnal pain
During the physical exam, what must be ruled out with fever?
infectious etiology of back pain - osteomyelitis, pyelonephritis
During the physical exam, what must be ruled out with weak or rapid pulse or BP?
retroperitoneal hemorrhage
What 6 things should be observed on the back?
congenital skin lesions, rashes, skin infection, bruising, erythema, scars/lacerations/abrasions
During flexion ROM what 3 additional aspects should be recorded?
finger to floor distance, persistence of lordosis and shober test
Describe Shober test.
Mark between PSIS, and then 5 cm down and 10 cm up. When flexed marks should increase to 20 cm.
A positive Trendelenberg test indicates weakness of what muscle?
gluteus medius muscle
Which nerve innervates the gluteus medius muscle?
L5
What is the cause of compromise to L5 nerve?
disc herniation, spinal tumor, intraspinal abscess
How would you test for sciatic nerve?
Straight leg raising
What muscle tightness can be mistaken for sciatic nerve pain?
hamstring muscles
List the two areas of seated percussion and reason.
Flank - Lloyd sign, renal pathology
Spinous process - fracture, tumor, infection (osteomyelitis, abcess)
What three things are tested in a neurologic exam?
muscle strength, reflexes, sensation
Describe reflex grading.
0 - absent 1 - decresed 2 - normal 3 - increased but normal 4 - clonus (spasm)
What is clonus and what does it indicate?
alternating muscle contraction and relaxation in rapid succession; indicates disconnect between UMN and LMN
What nerves are being tested at patellar reflex, Achilles reflex, superficial anal reflex?
L4/S1/S2-S4
What does Babinski sign indicate?
Disconnect between UMN and LMN; multiple sclerosis, amyotrophic lateral sclerosis; cerebrovascular accident or brain tumor
Describe the grades of muscle strength.
0 - flaccid paralysis
1 - palpate muscle contraction but muscle cannot move affected part
2 - can move body part with gravity eliminated
3 - can move body part against gravity
4 - can move body part against gravity with some resistance
5 - full strength an full resistance
Peripheral muscle weakness with LBP indicates ?
presence of neural compression if Grade 3-4 (spinal cord, nerve root, peripheral nerve) Grade 0-2(CNS - CVA, Guillain Barre, MS)
If the iliopsoas was weak which levels could be affected?
L1-L3
If the quadriceps were weak which levels could be affected?
L2-L4
If the hip abductors were weak which levels could be affected?
L2 - L4
If the tibialis anterior was weak which levels could be affected?
L4
If the extensor hallucis longus, extensor digitorum longus/brevis or gluteus medius were weak which levels could be affected?
L5
If the fibularis longus/brevis or gluteus maximus were weak which levels could be affected?
S1
If the gastrocnemius or soleus were weak which levels could be affected?
S1 & S2
What is the most overlooked muscle for the cause of LBP?
quadratus lumborum
List OMT treatments for LBP.
counterstrain for tenderpoints; ME/HVLA restrictions
What is the quality of the pain in somatic dysfunction of LBP?
achy, muscle spasm
LBP may be acute, chronic or both?
both
Where does most back pain problem occur?
Multifidus triangle
Exacerbation of LBP during iliopsoas strength testing often indicates the presence of what type of pain?
discogenic
A patient comes in with flexed contraction of the iliopsoas and a positive Thomas test. What is dx?
psoas syndrome
What are the 5 organic etiologies of psoas syndrome?
appendicitis, sigmoid colon dysfunction, uretal caclculi or dysfunction, prostate CA mets, salpingitis
What are treatment options for psoas syndrome?
Acute: ice
OMT: indirect followed by direct (counterstrain then ME/HVLA)
Chronic: stretching
How would you test iliopsoas muscle (L1-L3)?
pt. seated, have pt lift bent leg and physician pushed down at knee
How would you test quadriceps (L2-L4)?
pt. seated, leg extended; physician pushes down on leg
How would you test hip adductors (L2-L4)?
pt is supine; physician pulls legs out while patient pushes in
How would you test tibialis anterior (L4)?
Have pt. supinate foot (motor), patellar reflex and sensation on medial malleolus
How would you test extensor hallucis longus (L5)?
Extend halluces longus (motor), no reflex, sensation on top of foot
How would you test gluteus medius (L5)?
pt on side and have them lift leg while physician pushes down
How would you test fibularis longus and brevis (S1)?
pronate foot (motor), Achilles tendon reflex, and sensation on outer part of foot
How would you test gluteus maximus (S1)?
pt is pronate with leg bent at knee. Have patient lift thigh while physician presses down
How would you test the gastrocnemius & soleus (S1 & S2)?
Have pt hop
Where would you test sensation for L1-L3?
anterior thigh
Where would you test L4?
medial side of foot
Where would you test L5?
web space between great toe and second toe
Where would you test S1?
lateral side of foot
Where would you test S2-S5?
perianal skin
What are three modalities for sensation testing?
pain (pin prick), light touch (wisp of gauze), vibration (tuning fork)
LBP may be referred pain from abdomen. What three things would you palpate for in the abdomen?
guarding response; masses; abdominal aneurysm (auscultate for bruits)
How would you produce the valsalva test?
Patient is supine. place hand on midabdominal area and increase pressure while patient pushes back. Patient’s face should turn red/purple. Positive test is reproduction of pain.
The valsalva test will exacerbate symptoms in any space occupying ______ in the _____ _____.
lesion, spinal canal
During the Naffziger test the physician compresses which veins?
jugular veins
Describe Soto Hall test.
Patient is supine. Restrain the sternum and flex the neck. Pain is elicited at site of spinal disorder.
What three tests are available to diagnose sacroiliac joint pain?
pelvic rock test, Gaenslen test, Patrick test
What three things can the Patrick test identify?
sacroilitis, hip joint disease, pain reproduction test
How is the Patrick test abbreviated?
FABERE (flexion, abduction, external rotation, extension)
What does the Nachalas test indicate?
pain radiating down the anterior thigh implies femoral nerve entrapment
For how many seconds should a patient be able to hold raised shoulders or legs for normal truncal strength testing?
10 seconds
What degenerative changes happen in spinal stenosis?
hypertrophy of facet joints, Ca2+ deposits in ligamentum flavum/posterior longitudinal ligament and loss of intervertebral disc height
What treatments are available for spinal stenosis?
OMT, PT, NSAIDs, epidural steroid injection, surgical laminectomy
What is the quality of pain in a herniated nucleus propulsus?
numbness, tingling, sharp burning, shooting pain worsens with flexion
What is the quality of pain in spinal stenosis?
achy, shooting pain, paresthesis, worsened by extension
What tests would be used to diagnose herniated nucleus propulsus?
decreased reflexes, sensory deficit, positive straight leg test, MRI (Gold standard)
What OMT technique is generally contraindicated in herniated nucleus propulsus?
HVLA
What type of supportive care can be offered with LBP?
medical management of pain control, therapeutic exercise, OMT
