·:{iC0Fp'16 ACOFP 53rd Annual Convention & Scientific Seminars

Back Pain - When to Treat and When to Image Danielle Cooley, DO Rebecca Moore, DO

ACOFP FULL DISCLOSURE FOR CME ACTIVITIES Please check where applicable and sign below. Provide additional pages as necessary. Name of CME Activity: ACOFP 53rd Annual Convention and Scientific Seminars Dates and Location of CME Activity: April 6-9, 2016, The San Juan Puerto Rico Convention Center

Your presentation: Friday, April 8, 2016 New Physicians and Residents Programs: Back Pain - When to Treat and When to Image Name of Faculty/Moderator: __________________________________

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Back Pain: When to Treat and When to Image Danielle Cooley, DO Rebecca Moore, DO

Case #1 A 10 year old girl complains of low back pain for the last 1 week. She describes the pain as a dull, achy pain. The pain is 4/10 and was gradual in onset over the last week. She is a gymnast and works out 4 days a week in the gym. She denies any falls or traumas The pain is worse with extension such as back walkovers and improves with rest or bending forward. The pain does not radiate.

Physical Exam #1 Tenderness to palpation along the paraspinal muscles at L2-4 Decreased left rotation on motion testing of L2-4 Sensation intact of all dermatomes of the bilateral lower extremities 2/4 DTRs in the bilateral lower extremities 5/5 muscle strength in the lower extremities bilaterally

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Structural Exam #1 Right anterior innominate Right psoas spasm L2-4 neutral, rotated right, sidebent left R on L sacral torsion

Treatment #1 Innominate muscle energy Psoas counterstrain

Lumbar spine muscle energy Sacral muscle energy

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Case #2 A 35 year old soccer player complains of mid back pain after her game one week ago. She did note that she jumped up to head the ball and landed on her back when she came down. She describes the pain as a sharp pain that she rates 6/10 on the pain scale. The pain is worse with flexion of the upper body and improves with lying flat on the bed or couch. She denies numbness or tingling or radiation of the pain.

Physical Exam #2 • Muscle strength is 5/5 of the bilateral UE • DTRs 2/4 B/L UE • Normal sensation in all dermatomes

Structural Exam #2 OA Compression Right ribs 5-6 exhalation dysfunction T5 midline tender point T5-9 neutral, sidebend left, rotated right

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Treatment #2 OA release Rib muscle energy Thoracic myofascial release Counterstrain for the T5

Muscle energy of the thoracic spine

Case #3 A 45 year old male complains of low back pain that began 3 days ago after he was doing yardwork. It has progressively gotten worse since it started. Pain is 5/10 at its worse. The pain begins in the L4 area and radiates down his right leg. His starting having difficulty raising his right foot yesterday and now has numbness in his right leg and foot.

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Physical Exam #3 - Right foot drop with ambulation - Muscles strength is 2/5 with dorsiflexion of the right foot, 5/5 of all others of the bilateral lower extremity - Decreased sensation along L4 dermatome with light touch - Tenderness along the paravertebral muscles L45 with palpation

Structural Exam #3 L4-5 flexed, sidebent right, rotated right Right anterior innominate

Right anterior tibia on talus Left on left sacral torsion Left piriformis spasm

Treatment #3 Do Not Treat - order STAT MRI for Acute Nerve Impingement

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Case #4 A 45 year male complains of low back pain that comes and goes for the last year. The pain is sharp and radiates from the right side L4 down to the knee. The pain is worse with flexion and improves with leaning back or lying flat. He rates the pain as a 7/10 on the pain scale. Pt admits to numbness and tingling in the right leg that comes and goes.

Physical Exam #4 Positive right straight leg raise 2/4 DTRs in the bilateral lower extremities

Sensation is intact of all dermatomes of the lower extremities bilaterally Muscle strength is 5/5 in the bilateral lower extremity

Structural Exam #4 L2 flexed, sidebent right, rotated right Right quadratus lumborum tenderpoint

Right posterior innominate Right piriformis spasm L on R sacral torsion

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Treatment #4 Lumbar soft tissue Innominate muscle energy Quadratus lumborum counterstrain

Sacral muscle energy Piriformis muscle energy

Case #5 Back pain with weight loss, fevers, night sweats - A 35 year old male presents to your office complaining of mid to low back pain that has gotten progressively worse over the last 2 months. The pain feels achy and is 7/10 at its worse. There is not radiation of the pain. He does not recall any falls or trauma. Upon further questioning, he does admit to a 20 pound weight loss over the 2 months, recurrent low grade fevers, and night sweats.

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Physical Exam #5 2/4 DTRs in the bilateral lower extremities Sensation is intact of all dermatomes of the lower extremities bilaterally Muscle strength is 5/5 in the bilateral lower

extremity Tenderness to palpation bilaterally at T10-L2

Structural Exam #5 T10-L2 neutral, sidebent right, rotated left Right psoas spasm

Left posterior innominate Right on right sacral torsion

Treatment #5 Do Not Treat - X-ray and/or bone scan to look for cancer

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Case #6 A 60 year old female presents complaining of low back pain after lifting bags of topsoil 1 week ago. She reports that the pain is primarily on the left side close to the spine and it does not travel anywhere. She denies any numbness or tingling in either leg. Patient rates the pain as a 5/10 on the pain scale. She reports that stretching makes the pain better and lifting things makes the pain worse.

Physical Exam #6 2/4 DTRs in the bilateral lower extremities Sensation is intact of all dermatomes of the

lower extremities bilaterally Muscle strength is 5/5 in the bilateral lower extremity

Structural Exam #6 Right anterior innominate Right psoas spasm Left piriformis spasm R on R sacral torsion

L2-5 neutral, rotated left, sidebent right

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Treatment #6 Innominate muscle energy Psoas muscle energy Piriformis counterstrain

Lumbar myofascial release Sacral muscle energy

Case #7 A 50 year old male presents complaining of right side neck pain for 2 days. He states that he woke up with the pain and does not recall any trauma or falls. Pain does not radiate and he denies any numbness or tingling in the arms. He rates the pain as a 6/10 on the pain scale and describes the pain as a sharp pain. He reports that the pain is worse with turning his head to the left and improves with gentle massaging of his neck.

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Physical Exam #7 2/4 DTRs in the bilateral upper extremities Sensation is intact of all dermatomes of the upper extremities bilaterally Muscle strength is 5/5 in the bilateral upper

extremity

Structural Exam #7 OA extended, rotated right, sidebent left C4-5 flexed, rotated right, sidebent right

Right trapezius muscle spasm T2-5 neutral, rotated left, sidebent right

Treatment #7 - OA

release

- Cervical soft tissue - Direct inhibition of the trapezius - ME to the cervical spine -Thoracic spine myofascial release

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Case #8 A 75 year old female presents to your office complaining of acute onset of low back pain that began 1 week ago after she fell down on her kitchen floor. The pain is sharp, non radiating, and 9/10 at its worse. She denies any numbness or tingling in her legs. Pt has a history of moderate to severe COPD and is treated with Ventolin, Spiriva and and daily prednisone

Physical Exam #8 2/4 DTRs in the bilateral lower extremities

Sensation is intact of all dermatomes of the lower extremities bilaterally Muscle strength is 5/5 in the bilateral lower extremity Increased pain with flexion of the lumbar

spine

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Structural Exam #8 Tenderness to palpation of the spinous processes of L2 and L3 L5 extended, rotated right, sidebent right Left quadratus lumborum tender point Left anterior innominate

Treatment #8 Do Not Treat - X-ray for vertebral compression fracture

Case #9 A 17 year old female hit her head on the ground during a volleyball game while diving to save a ball. Afterward, she complains of a headache and neck pain. She does admit to mild dizziness, but denies any blurry vision. There was no loss of consciousness. On exam, she seems a little foggy when answering questions. She is oriented to person, place and time. CN 2 -12 are intact with negative Romberg. Structural exam reveals OA extended, sidebent right, rotated left

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Physical Exam #9 Seems a little foggy with answering questions Oriented to person, place and time CN 2-12 are grossly intact Negative Romberg 2/4 DTRs in the bilateral upper extremities

Sensation is intact of all dermatomes of the upper extremities bilaterally Muscle strength is 5/5 in the bilateral upper extremity

Structural Exam #9 OA extended, rotated right, sidebent left C4 flexed, rotated right, sidebent right

Tenderness to palpation of the paraspinal muscles from C2-6 Right cranial torsion

Treatment #9 - OA release - Cervical FPR - CV4 hold

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Case #10 A 30 year old male presents to you office complaining of progressive low back pain over the last 2 years. He describes the pain as sharp. It is 8/10 at its worse He admits to having morning stiffness which improves with exercise and alternating buttock pain. The back pain awakens him during the second part of the night. On exam, there is tenderness along T8 - L4 with spasms along bilateral paraspinal muscles

Physical Exam #10 2/4 DTRs in the bilateral lower extremities Sensation is intact of all dermatomes of the lower extremities bilaterally

Muscle strength is 5/5 in the bilateral lower extremity

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Structural Exam #10 Tenderness to palpation of the paravertebral muscles along T8-L4 Decreased ROM of the lumbar spine with flexion, extension, rotation in either direction and sidebending in either direction Right posterior innominate Left on right sacral torsion

Treatment #10 Do Not Treat – X-ray for ankylosing spondylitis

References Millicent Channell and David C. Mason. The 5-Minute Osteopathic Manipulative Medicine Consult. Lippincott, 2008 Eileen L. DiGiovanna, Stanley Schiowitz, Dennis J. Dowling, An Osteopathic Approach to Diagnosis and Treatment. 3rd Edition, Lippincott, 2004 Robert Savarese, OMT Review: A Comprehensive Review in Osteopathic Medicine. 3rd Edition. Legis Press, 2003

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