Physical examination of the patient with back pain

Physical examination of the patient with back pain Mitchell K Freedman DO Clinical Associate Professor at Sidney Kimmel Medical College of Thomas Jefferson University Hospital

Goals of Lecture Discuss the utilization of physical examination in the diagnosis of lower back pain Case presentation This will NOT be a comprehensive review of lower back examination options

Case Presentation: History 30 year old female with 10 months of back pain which came after bending at work Exacerbated at work 2 months ago. 10/10 sharp left lower back pain which radiates down the back of the left leg to the ankle Points at left lower back as the center of the pain Diffuse weakness and tingling in left leg Worse with driving and walking

Case presentation: History Patient is in bed for the majority of the day Not working. Limited ability to sit or walk. Poor sleep No relief with therapy No relief with nonsteroidal medication, gabapentin and tramadol

Physical examination: Positives Uncomfortable at rest. Tenderness to light palpation in left lumbar area Lumbar flexion and extension limited with pain Straight leg raise on left at 10 degrees causes pain in back and posterior left leg to calf Internal rotation of the left hip causes back pain

Physical Examination Strength is 4/5 in left leg Sensation is variably decreased to pin prick throughout the left leg Reflexes are intact Gait is antalgic but stable

Physical examination Provocative sacroiliac tests result in nonspecific pain at and above the iliac crest and left leg

MRI lumbar spine

Impression: Nonspecific back pain Treatment Nortriptyline at night Physical therapy Tens Counseled patient on importance of staying out of bed and function EMG/NCV ordered: normal Sacroiliac injection ordered

Gold standard of diagnosis Diagnostic injections Zygapophyseal joint Sacroiliac joint Discography Schwarzer et al, 1995

Physical examination of Sacroiliac Joint Motion tests Palpation Fortin finger test Provocative tests Solomon et al in Malanga, Nadler, 2006

Sacroiliac joint: Motion tests Standing flexion test 42-44 % interexaminer reliability Vincent- Smith et al, 1999 Potter et al, 1985 13 % false positive in patients with back pain of other proven etiology Dreyfuss et al, 1994

Sacroiliac joint: Physical examination Palpation Palpation of posterior superior iliac spine, sacral sulcus, and sacral inferior lateral angle by 10 medical student Inter-examiner reliablity:.04-.08 Intra-examiner reliability:.21-.33» O Haire et al 2000 Palpation of iliac crest and PSIS 35% reliable Potter et al, 1985

Fortin finger test 16 subjects from 54 consecutive patients had positive test Provocative sacroiliac injections validated finding Subset of 10 patients had negative evaluation for zygapophaseal joint and discogenic pain No confirmative studies for sensitivity, specificity, or reliability Fortin JD, Falco FJ, 1997

Physical Examination of Sacroiliac Joint Provocative tests Compression test (sacral midline thrust) Gapping test (distraction) Patrick (fabere) test Gaenslen s test Shear test (midline sacral thrust) Solomon et al in Malanga, Nadler, 2006

Compression test (Midline Sacral thrust) Inter-examiner reliability 70-90% Kappa coeff:.26-.73 Sensitivity 0-19% Specificity 90-100%

Gapping test (Distraction) Inter-examiner reliability 88-94% Kappa coeff.36-.69 Sensitivity 11-21% Specificity 90-100%

Patrick test (Fabere) Inter-examiner reliability 85-95 % Kappa coeff:.38-.62 Sensitivity 57-77 % Specificity 16-100 %

Gaenslen s Test Inter-examiner reliability 82% Kappa coeff:.61 Sensitivity 68% Specificity 35%

Shear test (Midline sacral thrust) Inter-examiner reliability 80% Kappa coeff:.30 Sensitivity 51-80% Specificity 20-100%

Confounding anatomic issues Translated motion Lumbar spine Hip Disc, facet joint, sacroiliac joint Lumbar and sacral vertebrae Bursa, labrum, joint Pelvis

Examination of Sacroiliac Joint: provocative tests Provocative sacroiliac joint tests do not predict sacroiliac pain Slipman et al, 1998 Maigne et al, 1996 Dreyfus et al, 1996

Combination of provocative tests in sacroiliac pain 3 or greater are positive: : 91% sensitive, 78% specificity Thigh thrust most sensitive Distraction most specific Gaenslen s test did not improve diagnosis SI joint not involved if all 5 tests are not painful Less effective if pain centralizes Laslett et al, 2005

Nonorganic physical signs Waddell et al, 1980 Tenderness Superficial, nonanatomic Simulation Axial loading, rotation Distraction Straight leg raise Regional Weakness, sensory Overreaction

Waddell s signs Signs of illness behavior May correlate with neurotic triad of MMPI Hypochondiasis, depression, hysteria 80% reproducible 3/5 tests significant Does not rule out underlying pathology Does not prove malingering

Physical findings and the Zygapophysial Joint Revel et al, 1998 5/ 7 clinical characteristics predict patients who may respond to facet anesthesia Age over 65 Pain well relieved by recumbent posititon Absence of pain with Coughing Forward flexion Arising from flexion Hyperextension Extension and rotation

Clinical characteristics do not predict Z-joint pain Laslett et al, 2004 Did not reproduce Revel s findings No clinical findings that predict relief with Z-joint anesthesia Schwarzer et al, 1994 Dreyfuss et al, 1995

Negative predictors of response to Z - joint anesthesia In patients with 90-95 % response to single block ¼ clinical prediction rules are negative Age over 50 Pain is best with walking Pain is best with sitting Negative extension rotation test Presence of centralization MSPQ score >13(consistent with somatization disorder) increases chance of positive block Laslett, 2006

Centralization of back pain Centralization of pain Progressive retreat of referred pain towards the midline of the back in response to standardized movement testing Peripheralization of pain Progressive movement of the pain further from the midline of the back towards the periphery or worsening of peripheral symptoms Inter-examiner reliability is acceptable when carried out by trained personel Kilpikoski et al, 2002 Laslett et al, 2005

Centralization of pain Donnelson, 1997 Mckenzie technique compared to discograms 50 % of patients centralized 74 % had positive discogram of which 91% had intact annulus 25% peripheralized 69% positive discogram 25 % with distal pain that did not respond 12.5% positive discogram P<.001 that Mckenzie can distinguish painful discs

Centralization of pain and distress and disability Laslett et al, 2005 Effect of disability and distress on centralization as predictor of provocational discography Overall sensitivity: 40%, specificity: 94% Severe disability Sensitivity: 46%, specificity: 80% Moderate to no disability Sensitivity: 37%, specificity: 100% No distress Sensitivity: 35%, specificity: 100%

Case Patient received 2 sacroiliac injections with 40% relief on each occasion Physical therapy Nortriptylene, ibuprofen cyclobenzaprine with no impact Back to full duty Pain in buttock 6/10 No findings on exam

Diagnosis: Nonspecific back pain SI joint injection equivocal SI joint examination points against this diagnosis Probable illness behavior with underlying pain generator which is unknown

Do not jump to conclusions! Not all physical findings are reliable Physical findings can be influenced by nonphysical factors False positives can be seen with history, physical, diagnostic studies and diagnostic injections Look at the whole picture