Back Pain: When to Treat and When to Image · 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

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

Back Pain - When to Treat and When to Image

Danielle Cooley, DORebecca Moore, DO

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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

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Back Pain: When to Treat and

When to ImageDanielle 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 L4-

5 with palpation

Structural Exam #3

L4-5 flexed, sidebent right, rotated right


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


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


Quadratus lumborum counterstrain


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





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





extremity

Structural Exam #6


Right psoas spasm

Left piriformis spasm

R on R sacral torsion

L2-5 neutral, rotated left, sidebent right

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Treatment #6


Psoas muscle energy

Piriformis counterstrain

Lumbar myofascial release


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


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





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





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

Documents

Back Pain: When to Treat and When to Image · 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