Screening Evaluation of Spinal
Pain and Dysfunction
John P. Kafrouni, MD
Rebound Physical Medicine and Rehabilitation,
Orthopedics, and Neurosurgery
Scope of the Problem
 Low back pain/cervical pain lasting a whole day in the
last 3 months – 26, 14 percent US adults. Deyo 2002
 Thorasic Prevalence ranges in studies varies greatly
due to study design ( 0.4 to 72%). Similar values for
Lumbar/Cervical (11-84%). Briggs 2010
 UNC study showed a marked rise (> double) in chronic
LBP between 1992 and 2006. Possibly due to
increased awareness, rising rates of depression and
obesity.
Among Health Care Workers
 District Health Care Workers in Nottingham, 1992
 ½ of all respondents (n= 1363) had back pain in last
year, ½ of those under age of 25
 ½ of these had functionally significant pain interfering
with sport, ADLs or sleep
 Nurses 60 %
 Ambulance Workers highest rates
 25% had time off in last 5 years secondary to back pain
Scope
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LBP second to URI for absenteeism in work force
Cost inclusive
5,000,000 disabled due to LBP
25,000,000 Americans lose 1 or more days a year
Yearly prevalence continues to grow at a rate greater
than the U.S. population.
RTW and Absenteeism
 Time Missed from Work
 Return to Work Expected
 6 months
 50%
 1 year
 25%
 2 years
 0
History is 90% - Osler (1893 or so)
 Temporal:
- Onset abrupt, subacute,
indolent
- With or without apparent
trauma
- Improving, stable,
worsening
- Intermittent, AAT
- Improves/worsens with
activity
- A.M worst?
 Quality:
- Sharp, dull, burning,
aching, nerve-like
- Intensitymild/moderate/severe
- 1-10 pain scale tells you
more about the patient
than the etiology
William Osler, MD
Father of Modern Clinical Training
Techniques, bedside exam/history
Thought one should marry a freckle
faced girl.
Thought clinicians older than 67
should be kindly euthanized.
Provocations, Alleviation“What is the worst/best thing for
your symptoms”
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ProvocationsSitting
Standing
Walking
Lifting
Transitions
Weight Bearing
Staying Still
With flexion, extension
Valsalva
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Alleviation
Sitting
Standing
Walking
At rest
With flexion, extension
Meds- may tell you a bit
about the pathology,
patient
Categories
 Flexion
 Extension
 Transitional
 Radiation patterns are
very important and
underscore that often
more than one thing is
going on at once.
 Axial
 Radicular- true
 Sclerotomal- non
radicular extremity pain
 Referable to peri- or intraarticular source
 Myofascial
 Neuropathic
Red Flags
 Gait ataxia
 Sphincter dysfxn, saddle
anaesthesia, ur. Retention
 Night pain/ weight loss
 Fever/chills
 Associated
cognitive/speech/CN
changes
 Myelopathy
 Myelopathy, cauda/conus
injury
 Neoplastic
 Infection
 Upper Motor neuron
Signs: consider CVA, MS,
etc…
The Exam
Initial Observation- Seated
 Seated
 Symmetry – off loading hemipelvis- think SI joint, Hip,
Ischial/trochanteric bursitis
 Can’t sit – Think Disc
 Turns torso to face you without cervical
bending/rotation- think radiculopathy, cervical facet
 Can’t sit still- may have implications for sedentary
work restrictions
Posture- Seated
The Exam
Observation-Sit to Stand
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Symmetry
Avoidance of specific plane
Proximal muscle weakness
Pain avoidance
Malingering, out of proportion splinting relative to
history, or simple observation of apparent distress
 Fear/ Anger/ Slug-like behavior
Observation
Posture-Standing
“Take your normal comfortable
posture”
 Asymmetry
 Body Parts relative to the Line of Gravity-head
forward, lumbar curve, kyphosis. This gives
tremendous info in myofascial pain
 Habitus
 Watch for the tendency to want to sit down, which
may give an indication of general habits
Posture in Standing
Exam-Gait
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Prefers which plane?
Flexion- think Spinal stenosis
Antalgia
Trendelenberg- weakness/pain inhibition of hip abductors.
Foot drop – circumduction, hip hiking, flop/slap on heel
strike.
 Wide based or steppage- peripheral neuropathy
 Spastic- myelopathy
Trendelenberg Gait
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Initial Range of Motion:
Standing
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Flexion
Extension
Lateral bending
Rotation
Thoracic rotation/flexion
 Avoidance of planes
 Ipsilateral or contralateral
pain- joint vs. myofascial
 General range of motion –
check cervical to compare
with lumbar and vice-versa
 Ask specifically if back/neck
and/or arm/leg pain
 range- assess
hamstring/lumbar muscle
length
Thorasic Range
Flexion
Rotation
Standing- provocation (just
after/during ROM)
 Spurlings test
 Lhermitte’s test
 Stork test
 Cervical radiculopathy
 Cervical myelopathy
 Sacroiliac joint/Facet joint
Confirm ipsilateral or
contralateral pain and axial
vs. appendicular pain- which
may implicate a lateral
lumbar disc
Standing Provocation
Spurling’s
Stork Test
Shoulder Screen- if no pain with
cervical ROM or pure anterior
shoulder pain.
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Posture/scapular orient
Drop arm- posterior view
Supraspinatus testing
O’briens/AC joint
Hawkins
Palpation in Modified
Crass position
 Yergeson’s or Speeds
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Scapular dyskinesia
Painful arc
Cuff
Labrum
Cuff
Cuff- more specific
Bicipital tendinosis/itis
Shoulder Screen
O’Brien’s
Modified Crass position
Palpation while standing
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Spinous processes
Lateral masses
Periscapular
Myofascial
Sacroiliac joint
Trochanters
Have the patient put a finger
on “the spot”
 Can identify step offs with
flexion/extensionspondylolisthesis
 Local pain
 Sclerotomal radiation:
- Does it match claimed
radiation?
- Levator scapula/lateral
scapula
- Trochanter/IT band/PSIS
medial and
lateral/paraspinals/lateral
sacrum.
Palpation -Standing
Sacroiliac joint
Levator Scapula
Strength while standing
 Heel walking
 Toe/heel raising
 Anterior tibialis- L4
predominately
 S-1, Gastroc/soleus
Sitting
 Upper/Lower extremity
strength/Sensation
 Muscle stretch reflexes
 Pulses
 Sit Slump- sensitize with
ankle dorsiflexion
 Hip IR/ER
 Knee exam if indicated
 See myotomes/MSR
 Dermatomes
Dural stretch- clarify axial or
true radicular, myofascial,
Sitting
Seated Slump
Dermatomes
Myotomal testing
Cervical
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C5
C6
C7
C8
T1
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Delt, Biceps
Pronator/Wrist Ex/Infrasp
Triceps/ Ext Ind Prop
Finger flex (3rd)
Interossei/ Small finger
abd
Myotomal testing
Lumbar
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L2
L3
L4
L5
S1
S2,3,4
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Hip Flex
Knee Extension
Ankle dorsi, Ant Tibialis
Great toe extension
Toe Flexion/Heel raising
Sphincter Tone
Reflexes
Cervical/Lumbar
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C5-biceps
C6-pronator
C7-triceps
L3,4-Quads
L5-Hamstrings
S-1-Plantar/Gastroc soleus
 Pathologic reflexesHoffmans/Babinski
 Excessive clonus
 Absence of reflexesJendrassic maneuver
 Great range of normals,
when in doubt check the
upper/lower reflexes
Supine evaluation
Cervical pain
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CervicalPalpate lateral masses
Greater occipital nerves
Muscle tension eval
Gentle traction
Sclerotomal referral
Repeat flexion/rotation
Opportunity for muscle
energy techniques
 Opportunity to palpate
cervical structures with
less muscle tension and
guarding
 Traction may increase
facet pain, decrease
discogenic/radicular pain,
increase or decrease
muscle pain.
Supine Exam
Lumbar Pain
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Hip Scour
Straight Leg Raise
Sacral sheer
Faber/Modified Patricks
Palpate Ant/Lateral hip
Faking it? SLR, Hoover’s
Knee exam if indicated
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Flexion and Ab/Adduction
Back vs. Radicular pain
S.I. Joint
Hip/S.I. joint
Psoas /Pubic Symphysis
Supine testing-Lumbar
Modified Patrick’s
Hoover’s sign
Hoover’s sign
Prone Exam
Cervical and Thoracic
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Palpation
Segmental Motion
Scapular mobility
Distant referral of
proximal structures
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Palpation
Costovertebral junctions
Scapular mobility
Opportunity for Manual
Medicine techniques
Prone Exam
Lumbar/Pelvis
 Palpation
-L4 is top of iliac crest
 Femoral stretch/Yeomans
 Hyper extension“up dog”
 Identify Spinous
processes, Articular pillars
 Iliac Crest, PSIS, Lateral
sacrum, GreatrTrochanter
 L2,3,4 radiculitis/SI joint
 Sensitizes pain of articular
pillars, may decrease disc
pain.
Prone-Lumbar
Yeoman’s
Prone hyperextension
Sidelying
exam
 Gaenslens test
 Ober’s test
 FAIR test
 Palpation of
peritrochanteric
structures/ sidelying
abduction
 Sacroiliac joint
 Iliotibial band
 Piriformis test-much
talked about, seldom
seen.
 Assessment of lateral hip
syndrome.
Sidelying
FAIR test
Ober’s test
Thoughts
 Things that can make
patients worse
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Anxiety
Depression
Fear
Anger
Terms like Degenerative
Inactivity
Narcotics, NSAIDS
Perceived future disability
Thoughts
 Treat the patient not the
scan
 Don’t panic, call a physiatrist
 A bulging/herniated disc
does not a surgery make,
but progressive weakness,
bladder/bowel changes,
myelopathy, intractable pain
requiring hospitalization do
 Thank you very much for
your attention and
participation
 Call with questions-1800
REBOUND
Thank you