Download Chronic Low Back Pain: Differential Diagnosis

Assessment and Treatment
of Low Back Pain
Steven Stanos, DO
Medical Director
Center for Pain Management
Rehabilitation Institute of Chicago
Asst. Professor, Dept. PM&R
Northwestern University Medical School
Feinberg School Of Medicine
Goals
• Individualized yet
comprehensive
• Efficient
• Comfortable for patient
• Comfortable for clinician
• Build rapport
• Educate and prepare patient
for treatment
• Monitor for inconsistencies
Physical Exam Overview
– Pain behavior
– Gait
– Motor strength
– Muscle stretch reflexes
– Dural tension testing
– Sacral iliac joint testing
– Myofascial assessment
– Kinetic Chain considerations
Anatomy of LumboSacral Spine
Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.
Annulus Fibrosis
Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.
Lumbar Facets:
zygapophysial joints “z-joint”
Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.
Degenerative Cascade
Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.
Definitions
• Somatome: field of somatic and
autonomic innervation based on
embryologic segmental origin of somatic
tissues
three basic elements:
1. Dermatome: cutaneous structures
2. Myotome: skeletal musculature
3. Sclerotome: bones, joints, and ligaments
8
Inman VT, Saunders J. J Nerv Ment Dis 1944;99:660-67.
Spinal “stability”
Neural
Control Unit
Spinal Column
Spinal Muscles
Vertebral Position
Muscle
Spinal Loads
Activation Patterns
Spinal Motions
Panjabi MM. J Electromyography Kinesiology 2003:12:371-9
“Core” muscle groups
– Abdominals (Front)
– Paraspinals and gluteals (Back)
– Diaphragm (Roof)
– Pelvic floor and hip muscles (Bottom)
Richardson C, et al .Therapeutic exercise for spinal stabilization and low back pain. Edinburgh
(Scotland): Churchill Livigstone1999.
Abdominals
Local muscles
(Slow twitch)
• Transversus
abdominus
• Multifidi
• Internal oblique
ERECTOR SPINAE
• Pelvic
floor
Global Muscles
(Fast-twitch)
• Erector spinae
• External oblique
• Rectus abdominus
Panjabi MM. J Electromyography Kinesiology 2003:12:371-9
MULTIFIDI
the “15 minute rotisserie special”
Pain Behaviors
•
•
•
•
•
•
•
Grimace
Groan
Guarding
Overreaction
Inconsistencies
Give-way weakness
Shaking
•
•
•
•
•
Equipment
Cane
Ice-packs,
Heating pads
Braces: collars
Gait
•
•
•
•
•
•
Balance
Base of support
Arm swing/ trunk and shoulder rotation
Cadence
Leg: cicumduction, stance time, position
Pain behavior
Static Stance Assessment
L4-L5
PSIS
(J. Rittenberg. Photos from practice & personal files used with permission)
Differential
Diagnosis
Flexion Based
Muscular
Ligamentous
Compression
Fracture
Discogenic
Extension
Based
Stenosis
Facet
Spondylosis
Central Disc
Transitional
Spondylolisthesis
Sacroiliac
Facet
Facet Arthropathy
• Zygapophyseal (z-joint)
• Poor correlation with
history and exam1
• Commonly pain with
extension & rotation
• Referral patterns2
1.
Schwarzer AC, et al. Spine 1994;19:1132-7.
2. Slipman, C. Arch PM&R 81:334-338, 2000.
Myofascial Assessment
Myofascial Trigger Points
Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2.
Williams & Wilkins, Baltimore, 1992.
“Muscle pain is not skin
pain”
Jay Shah, MD
Myofascial Trigger Points
(MTrPs)
Active – cause a clinical pain complaint
or other abnormal sensory symptoms
Latent – show all the other
characteristics of active MTrPs, except
that they’re pain free
Muscle Pain
• Aching and cramping
• Difficult to localize and refers to other deep
somatic tissues (fascia, muscle, joints)
• Muscle nociceptive activity is processed
differently in the CNS
• Inhibited more strongly by descending
pain-modulating pathways than cutaneous
pain
Symptoms
• Local & referred pain
• Pain with iso
contraction
• Stiffness, limited
ROM
• Muscle weakness
• Paresthesia &
numbness
• Propriocpetive
disturbance
• Autonomic
dysfunction
Physical Findings
• Local Tenderness
• Single or multiple
muscles
• Palpable nodules
• Firm or Taut Bands
• “twitch response”
(LTR)
• Jump sign
• Muscle shortening
• Limited joint motion
• Muscle Weakness
Motor Strength Testing
• 5 = Normal, full ROM vs. gravity,
max resistance
• 4 = Good, full ROM vs. gravity,
moderate resistance
• 3 = Fair, full ROM vs. gravity,
no resistance
• 2 = Poor, full ROM,
gravity eliminated
• 1 = Trace
• 0 = No activity
Core Stabilization Testing
Muscle Stretch Reflexes
Lower Limb
– Patella (L2, L3,L4)
– Medial hamstring
(L5,S1)
– Achilles (S1, S2)
Muscle Stretch Reflexes
4 + = hyperactive with clonus
3 + = more brisk
2 + = normal response
1 + = decreased with
facilitation
0 = no response
Radiculopathy
Sitting
• Standing
• Walking
• Bending
• Valsalva
or cough
•
Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed.
Churchill Livingstone, 1999.
Dural Tension Signs
• Straight Leg Raise
(SLR)
• Slump Seated
• Femoral Nerve Stretch
(J. Rittenberg. Photos from practice & personal files used with permission)
Straight Leg Raise:
Epidural Space
• Contents:
– Loose areolar connective
tissue
– Semiliquid fat
– Lymphatics
– Arteries
– Extensive plexus of veins
– Spinal nerve roots
• Segmented and
discontinuous
Transforaminal Approach
Injection Techniques
S1 Transforaminal Epidural
Nelemans PJ, et al. Spine 2001;26:501-15.
Dr. Stanos’ personal files.
Caudal Approach
Axial Low Back Pain
•
•
•
•
Degenerative disc disease (DDD)
Internal disc derangement (IDD)
Facet dysfunction
Myofascial dysfunction
© 2005 Rehabilitatio Institute of Chicago
Dorsal Rami
Anatomy
Sacroiliac Joint and Pelvis
Integral Components of SIJ motion
• Form closure: joint surfaces congruently
fit together
• Force closure: muscles & ligaments
provide force to withstand load
• Motor control: timing & sequencing of
muscle activation & release
• Emotion & awareness: emotions can
influence motor control
Vleeming A, et al. Spine 1990;15:133-5
Sacroiliac Joint Pain Referral
Zones
Buttocks
Thigh
Lower leg
Foot / ankle
Groin
Abdomen
Dreyfuss D, J Am Acad Ortho Surg 2004, 12.
94%
48%
28%
13%
14%
2%
SIJ Assessment
(J.Rittenberg. Photos from practice & personal files used with permission)
Sacroiliac Joint Provocative Tests:
• SIJ border
tenderness
• Patrick’s test
• Gaenslen’s test
• Prone hip
extension
• Compression
testing
Fortin J, et al, Spine 1994;19:1475-82.
Sacroiliac Joint Injections
Bogduk N, MJA 2004;19:79-83.
Lumbar Spinal Stenosis: Posture
Akuthota, V. Pathogenesis of lumbar spinal
stenosis pain. Phys Med Rehab Clin N Am 14:17-28, 2003.
With permission.
J. Rittenberg. Used with permission.
Neurovascular Claudication
•
•
•
•
Onset with walking
“Heavy” sensation
Variability
Attempt to increase
flexion
• Stooped posture
BI-Level Central
Porter RW. Spine 1996;21:2046-52.
Lumbar Spinal Stenosis:
Simian Stance
•
•
•
•
•
Posterior pelvic tile
Hips, knees flexed
Hands face backwards
Hip and psoas tight
Gluteus and
piriformis inhibited
• Gait: lumbar flexion
Weak and
Inhibited
Muscles
Geraci, M. Rehabilitation of the hip and pelvis. In: Kibler WB. Functional Rehab Sports
Musculoskeletal Med; Aspen Publishers,1998. With permission.
Finding Balance
Underactive
Stabiliser
Overactive
Synergist
Shortened
Antagonist
Glut Medius
TFL, QL, Piriformis Thigh adductors
Glut Maximus
Iliocast, Hamstring Iliopsoas, Rec Fem
Lower Trapezius
Levator Scapulae
Upper trapezius
Pectoralis Major
Geraci, M. Rehabilitation of the hip and pelvis. In: Kibler WB. Functional Rehab Sports
Musculoskeletal Med; Aspen Publishers,1998. With permission.
trapezius and cercival spine
Cervical & Scapular Dysfunction
(Janda 2002)
APS: LBP Guidelines
• Categorize the condition
– Nonspecific low back pain?
– Back pain associated with neurologic deficits,
radiculopathy or spinal stenosis?
– Back pain associated with an alternate
cause?
• Identify patients who require urgent
surgical evaluation
Chou R, et al. Ann Intern Med. 2007;147:478-491.
Acute Low Back Pain
‘Red Flags’
•
•
•
•
Cauda equina syndrome?
Cancer?
Infection?
Fracture?
– Confirmation of red flag conditions may require
• Lab testing [complete blood count (CBC)/erythrocyte
sedimentation rate (ESR)/C-reactive protein (CRP)/
urinalysis (UA) and PSA when appropriate]
• Medical imaging [lumbosacral (LS) radiographs/computed
tomography (CT)/magnetic resonance imaging (MRI)]
• Test results may indicate need for emergent surgical referral
Chou R, et al. Ann Intern Med. 2007;147:478-491.
Chou R, et al. Lancet. 2009;373:463-472.
Pharmacologic Interventions
Acute Low Back Pain
Drug
Net benefit
Level of
evidence
Acetaminophen
Small to moderate
Fair
NSAIDs
Moderate
Good
Skeletal muscle
relaxants
Moderate (for acute LBP only)
Good
Chou R, et al. Ann Intern Med. 2007;147:504-514.
Guideline Highlights
Guideline Highlights
1. Conduct a focused history and physical
examination
–
Assess severity of baseline pain and
functional deficits
2. Evaluation of psychosocial risk factors is
essential to predict the risk for chronic, disabling
low back pain
3. Limit use of diagnostic imaging and testing
–
Except in patients with signs of severe or
progressive underlying disease or those with
neurologic deficits
Chou R, et al. Ann Intern Med. 2007;147:478-491.
Recommendation 6
ACP/APS Guidelines 2007
• Clinicians should consider the use of medications with
proven benefits in conjunction with back care information
and self-care. Clinicians should assess the severity of
baseline pain and functional deficits, potential benefits,
risks, and relative lack of long-term efficacy and safety data
before initiating therapy. For most patients, first-line
medication options are acetaminophen or NSAIDs.
(Strong recommendation, moderate-quality evidence)
Chou R, et al. Ann Intern Med. 2007;147:504-514.
Pharmacologic Interventions
Drug
Net benefit
Level of evidence
Acetaminophen
Small to moderate
Fair
NSAIDs
Moderate
Good
Skeletal muscle
relaxants
Moderate (for acute LBP only)
Good
Tricyclic
antidepressants
Small to moderate (for chronic
LBP only)
Good
Opioids and tramadol Moderate
Fair
Benzodiazepines
Moderate
Fair
Small (for gabapentin in patients
Fair for gabapentin to
poor for topiramate
Antiepileptic
medications
Systemic steroids
with radiculopathy only)
Unable to estimate topiramate
No benefit
Chou R, et al. J Pain. 2009;10:113-130.
Good
Summary
• Comprehensive, but focused
• Efficient
• Exam should be easy on you and the
patient
• Great opportunity to initiate a therapeutic
relationship and dialogue
• Use a “good” exam to improve outcomes
and identify deficits or impairments
Thanks