BACK ASSESSMENT & EVALUATIONBy PHILANS COSMOS ANKRAH

OUTLINE

Anatomy

Pathologies

Assessment and evaluation

BRIEF ANATOMY

The spine

Muscles

The spinal cord and nerves

PATHOLOGIES

• Arthritic spine:- spondylosisspondylolisthesisankylosing spondylitis

• Congenital deformities

Causes of back pain 1A. Mechanical - Muscles and

ligaments; Facet joint arthritisProplapsed intervertebral discSpondylolysis / Spinal stenosis

Local tenderness

muscle spasm loss of lumbar lordosispercussion tenderness over

spinous processNO

MOTOR/SENSORY/REFLEXIC LOSS

Causes of back pain

MetabolicOsteoporotic vertebral collapsePaget's diseaseOsteomalacia

Causes of low back pain 4Inflammatory – o Sacroiliitiso Ankylosing Spondylitis,

• Difficult to diagnose if early stages but:• Morning stiffness for > 30 minutes• Pain that alternates from side to side of lumbar spine• Sternocostal pain• Reduced chest expansion

Referred pain

Pleuritic pain Upper UTI / renal calculus Abdominal aortic aneurysm Uterine pathology (fibroids) Irritable bowel (SI pain) Hip pathology

CAUSES

Causes may be anatomical or even psychological Pain may be due to: Sitting for long periods of time Standing for long periods without moving Poor sitting or sleeping posture

The back is prone to a range of problems most of them caused by ; Obesity Lack of regular exercises Bad posture

Red Flags

Weight loss, fever, night sweats

History of malignancy

Acute onset in the elderly

Neurological disturbance Bilateral or alternating symptoms

Sphincter disturbance

Immunosuppression

Infection (current/recent)

Claudication or signs of peripheral ischaemia

Nocturnal pain

Yellow flags

Yellow Flags Factors prolonging back pain Internal factors-Opioid dependency“External controller” patient-type; learned helplessness; factitious disorderMental health- depression or anxietyInterpersonal factors "Sick role“Stressors in relationshipsEnvironmental / societal factors- Disability payments / Litigation /

Malingering

Imaging modalities

• Xrays

• CT Scan

• MRI

OBJECTIVE ASSESSMENT(Musculoskeletal Examination)

1. Observation2. Palpation3. Range of motion4. Neurological exam

• Motor elements• Sensory elements

5. Special tests

The exam should include…

1. OBSERVATION

i. Body type

ii. Postural alignments and asymmetries should be observed from all views

iii. Assess height differences between anatomical landmarks

iv. Look out for signs and symptoms:• pain behaviors–groaning, position changes,

grimacing, etc

• atrophy, swelling, asymmetry, color changes

Postural Malalignments

2. PALPATION

i. Spinous processes

• Spaces between processes - ligamentous or disk related tissue

ii. Transverse processes

iii. Sacrum and sacroiliac joint

iv. Abdominal musculature and spinal musculature

• Assessing for referred pain

Palpation cont.d

v. Have subject perform partial sit-up while palpating PSIS region to determine tone and symmetry

vi. Assess hip musculature and bony landmarks as well

vii. palpate area of pain for temperature, spasm, and pain provocation

viii.point palpation for trigger points/tender points

3. ROM AND FLEXIBILITY

Assess various spinal movements for flexibility: flexion, extension, rotational, lateral bending

Special back flexibility tests• Back-to-wall test• Schober test and modified schober test• Finger to floor distance

Back-to-Wall Test

This test assesses lower back and hip flexibility.

• Stand with your back to a wall so that your heels, buttocks, shoulders, and head

are against the wall.

• Try to press lower back and neck against the wall without bending your knees

or lifting your heels off the floor.

• Have a partner try to place a hand between your back and the wall.

Schober’s Test

4. NEUROLOGICAL ASSESSMENT

Neurologic Exam Determines Presence/Absence and Level of Radiculopathy and Myelopathy

1. Motor elementsmuscle bulk/tone

atrophy/flacciditymuscle strengthcoordinationgait

2. Sensory elements

sensory deficits, eg, touch, position sense, temperature, vibration

allodynia: light touch

hyperalgesia: single or multiple pinpricks

5. SPECIAL TESTS(these may come in handy)

Outline:Upper spine: ***Cervical spine and thoracic spineLower spine: Lumbar, sacral and coccygeal

1. Upper back and arm lift2. Vertebral artery test3. Spurling test.4. Jackson test.5. Compression test.

6. Traction test. 7. Percussion test 8. Tension arm test9. Shoulder abduction test

Upper spine

NB: Cervical movement: Flexion 35-45°; Extension 35-45°; Lateral bending 45°; Rotation 60-80°.

• Upper Back and Arm Lift

This test assesses the strength of upper back muscles

1. Lie facedown.

2. Hold your arms straight out in front of your head.

3. Lift your arms and upper body off the floor.

4. Hold for 10 seconds. Caution: Do not lift your feet off the floor.

• Vertebral Artery Test• Subject is supine

• PT extends, laterally bends, and rotates the c-spine in the same direction

• Dizziness or nystagmus indicates occlusion of the vertebral artery

• Shoulder Abduction Test• Subject places hand on top of

head• A decrease in symptoms may

indicate the presence of nerve root compression, due possibly to a herniated disk

Jackson test TRACTION TEST

Tension arm test Percussion head test

Lower Spine TestsTest Done in Standing Position

1. Forward bending

• Observe movement of PSIS, test posterior spinal ligaments

2. Backward bending

• Anterior ligaments of the spine

• Disk problem

3. Side bending

• Lumbar lesion or sacroiliac dysfunction

4. Standing Trunk Rotation

• Assessment of symmetrical motions w/out pelvic movement

• Single Leg Lift (Prone) This test assesses the strength of your lower back and hip muscles1. Lie face down on the floor. Lift your straight right leg as high as

possible. Hold for a count of 10. Then lower your leg.

2. Repeat using your left leg.

• Straight Leg Raising

• Straight Leg Raise• 0-30 degrees = hip problem or nerve inflammation

• 30-60 degrees= sciatic nerve involvement

• W/ ankle dorsiflexion = nerve root

• 70-90 degrees = sacroiliac joint pathology

• Slump TestMonitor changes in pain as sequential

changes in posture occur

1. Cervical spine flexion

2. Knee extension

3. Ankle dorsiflexion

4. Neck flexion released

5. Both legs extended

Assessment of neural tension

• Bowstring test

Used to determine sciatic nerve involvement

• Leg (on affected side) is lifted until pain is felt

• Knee is flexed to relieve pressure and popliteal fossa is palpated to elicit pain (along sciatic nerve)

• To verify problem w/ nerve root, leg is lowered, ankle is dorsiflexed and neck is flexed.

• Return of pain verifies nerve root pathology

• Knee to Chest

• Bilateral - increases symptoms to lumbar spine

• Single - pain in posterolateral thigh may indicate problem with sacrotuberous ligament

• Pulling knee to opposite shoulder that produces pain in the PSIS region may indicate sacroiliac ligament irritation

• SI Compression and Distraction Tests

Used for pathologies involving SI joint

• Neurological Exam• Sensation Testing• If there is nerve root compression, sensation can be disrupted

• .