Title: Oh my aching back
1Oh my aching back
- Application of diagnostic imaging studies to
Physical Therapy in the acute care setting
By Nicole M. Boyko, MSPT
2Objectives
- To use a case study format to
- Identify what imaging studies may be useful in
the work-up of intractable back pain in the acute
care setting - Relate the results of imaging studies to the
formulation of a PT diagnosis and plan of care
3Overview Mr. Fs aching back
- History and Physical Examination
- PT/OT Examination
- Results of Imaging Studies
- Rationale for Use of Imaging Studies
- Implications to PT plan of care
- Patient Outcomes
4History and Physical Examination
- 60 y/o African-American male presents to Hospital
X on 1/24/05 with c/o intractable back pain and
is admitted to med/surg floor - PMH none
- PSH s/p hernia repair
- No bowel or bladder complaints
5History Physical Exam Cont
- History of Present Illness
- 1/19 presented to Hospital Y with same
complaints received injection in ER and was
D/Cd home with appt for ortho follow-up - 1/21Had ortho consult and was scheduled for MRI
as outpatient - 1/22 to ER at Hospital Y where he received L-S
X-Ray and was D/Cd home on Skelaxin and Percocet
with min relief. - 1/24 MRI as outpatient at Hospital Y. Results
unavailable but pt reports two herniated disks.
6History Physical Exam Cont
- Admitting MDs plan of care
- Pharmaceuticals for relief of pain/inflammation
- Dilaudid 42-4 mg IV q 6hr
- Toradol 3 mg IV q 8 hr prn
- Prednisone 40 mg po x 1
- Flexeril 10 mg po tid
- PT/OT consults ordered
- Ortho consult ordered
- X-Ray and MRI reports requested from Hospital Y
7PT/OT Initial Examination 1/25
- X-Ray MRI results not yet available at time
of initial exam - Subjective I cant move. My son has to lift
me. - Prior level of function Lives with wife, son and
mother in 1 level home. (I) with ADLS and amb, no
A.D. up until 1 wk ago. Was given standard
walker at hospital Y but states he is unable to
use it. Relies on his son to help him mobilize.
8PT/OT Initial Exam Cont
- Pain 10/10 (L) low back/buttock
- Exacerbated by sup?sit txfrs, sitting with wt
bearing on (L) pelvis, standing with wt bearing
on (L) pelvis - Relieved by min relief with sidelying on (L)
side in semi-fetal position, min relief from pain
meds - Palpation/observation tenderness and puffiness
(L) low back/pelvis - Sensation ? lt touch (L) L2
9PT/OT Initial Exam Cont
- ROM grossly WFLs but painful to LEs
- Strength limited by pain with resistance
- L4, L5, S1 5/5 (B)
- L1-2, L3 grossly 3/5
- Special Tests SLR (-) (R), () 40º (L)
- ADLs
- UE ADLs mod (I)
- LE ADLs max (A) due to pain
- Toileting/bathing max (A) due to pain
10PT/OT Initial Exam Cont
- Functional Mobility
- Rolling mod (I) with rails to (L) unable to
roll to (R) due to pain - Scooting mod (I)
- Sup ? Sit mod (I) with rails. Min verbal cues
for logrolling technique. - Sit ? Stand/Gait Pt unable to achieve due to
severe (L) LBP with attempt despite max (A)
provided by PT/OT
11PT/OT Initial Intervention
- Patient instructed in positioning for comfort
sidelying with pillow between knees or supine
with pillow under knees - Patient instructed in proper log rolling
technique - Patient instructed in the following therapeutic
exercises single knee to chest (L), piriformis
stretch (L), gentle abdominal setting
12Initial Assessment by Therapy
- Pt is a 60 y/o male with 1 wk history of
intractable back pain causing him to be unable to
sit up or walk without significant assistance
from his son. Pt did well today with logrolling
to sit but was unable to stand or walk due to
significant pain. Suspicious for HNP, perhaps L2
or L3, but MRI results are unavailable at this
time. Recommend PT and OT to follow to maximize
mobility/ADLs for safe D/C to home where pt will
be further worked up by neurosurgeon.
13Initial Therapy Goals
- PT Goals x 3-4 days
- (I) HEP
- (I) sup ?sit via logrolling
- (I) sit ?stand
- (I) amb gt 50 ft with least restrictive assistive
device
- OT Goals x 3-4 days
- Pt will be mod (I) for all ADLs with appropriate
adaptive equipment - Equipment needs 3 in 1 commode, reacher, sock
aide
14Radiology Results
- X-Rays AP and lat views of the L-spine
demonstrate mild osteophyte production at several
levels with mild narrowing of the L5-S1 disc
space. No acute fx/dislocation is seen.
Example of claw osteophyte (white arrows)
Example of traction osteophyte (white arrow)
15Radiology Results Cont
Lateral View Normal
16Radiology Results Cont
AP View Normal
17Radiology Results Cont
Degenerative changes to the lumbar spine (lateral
view)
18Radiology Results
- MRI Results
- Technique sagittal and axial T1- and T2 weighted
images and sagittal STIR images - Findings DDD L3-4, L4-5, L5-S1
- Diffuse disc bulge L3-4 moderately narrowing the
central spinal canal and resulting in (B) neural
foramina narrowing with (L) L3 nerve root
impingement - Disc bulge L4-5 which mildly narrows the central
canal and results in (B) neural foramina
narrowing without nerve root impingement - Diffuse disc bulge L5-S1 with (B) neural foramina
narrowing and possible (L) sided nerve root
impingement
19Radiology Results Cont
Normal
HNP L5-S1
20Radiology Results Cont
Axial View of a normal L4 disc
Axial view of a 4mm L5 HNP
21To Image or Not To Image?
- Lifetime prevalence of LBP 80
- Often relieved by analgesics and activity
modification with no further workup needed - In 80 of cases of LBP, imaging does NOT affect
the treatment - Can lead to unnecessary additional testing due to
the discovery of incidental benign lesions or
degenerative processes - Ex In one study, MRI scans revealed herniated
discs in approximately 25 percent of asymptomatic
persons less than 50 years of age and in 33
percent of those more than 50 years of age.
22American College of Radiologys Criteria to Justify Further Evaluation with Imaging for Low Back Pain
Recently significant trauma Unexplained weight loss Unexplained fever Immunosuppression History of cancer IV drug use Prolonged use of corticosteroids Age gt70 Duration gt 3 months
23Additional Clinical Indications for Advanced Imaging in LBP
Radiating pain Symptoms of nerve root compression/cauda equina syndrome (B) LE weakness Urinary retention Saddle anesthesia
24Rationale For Use of Imaging Studies for Mr. F
- Incapacitating LBP gt 1wk
- Unrelieved by analgesics/activity modification
- () SLR indicating space occupying lesion
- Signs of possible nerve root compression
- Motor weakness
- Sensory changes
25Choice of Imaging Modality
- X-Rays Screening tool to detect abnormalities of
bone - i.e abnormalities of the spine, fx/dislocation,
ankylosing spondylitis, RA, OA, tumors,
osteoporosis, Pagets disease - Discs not visualized on X-Ray but DDD is
suspected whenever there is IV disc space
narrowing - Most cost effect modality for spinal imaging
- MRI used to delineate abnormalities
- Superior visualization of soft tissue and bone
marrow - Sagittal view best to delineate herniation of
nucleus pulposus through annulus fibrosis - Transverse images best to define compression of
thecal sac and nerve root - Costs approximately 2x as much as CT imaging
26Choice of Imaging Modality
- Myelography requires injection of radio-opaque
dye in subarachnoid space via lumbar puncture - Offers good visualization of nerve roots
- Excellent for diagnosing diseases of spinal cord
and canal - HNP seen as a defect in the normal filling of the
dye - Formerly gold standard for spinal cord
radiography - Falling out of favor as it is more invasive and
less accurate than MRI or CT - CT Scan best modality for looking at bone
- Delineates anatomy and pathology better than
myelography - Used to diagnose occult spinal fx, determine the
extent of fx and localize vertebral fx fragments,
especially those displaced into spinal canal - Can determine presence of intervertebral disc
disease
27Narrowing in on Mr. F
- Signs and symptoms pointing to suspected nerve
root compression - Standard AP and lat radiographs inexpensive
screening tool to rule out tumor/fx fragment as
sources of compression - X-Rays also revealed presence of osteophytes and
disc space narrowing - MRI best option for visualizing soft tissue
(nerve roots, IV discs) leading to our ultimate
dx of multiple level HNP and nerve root
impingement
28Implications to PT Plan of Care
- MRI results coupled with neurosurgery consult
identified patient as potential surgical
candidate - Discussion with pt and surgeon revealed
willingness to explore conservative PT while
surgical work-up in progress - PT focus on
- Restoring functional mobility
- Relief of nerve root compression through
stretching, positional distraction and manual
techniques - Instruction in self-management of pain and HEP
29Patient Outcomes
- Patient D/Cd from Hospital X on 1/27 with
- Neurosurgery follow-up appt
- Recommendation for outpatient PT pending outcome
of neurosurgery appt - Patient lost to follow-up as he normally receives
care at Hospital Y, which is closer to his home - Patients neurosurgeon operates out of both
Hospital X and Hospital Y. - Pt has not yet appeared on OR list for Hospital X
to date.
30Questions?
31References(for facts and figures)
- Erkonen WE, Smith WL, eds. Radiology 101 The
Basics and Fundamentals of Imaging.
Philadelphia, PA Lippincott-Raven, 1998. - Gillard DM. How To Read Your MRI or CT. 2002.
http www.chirogeek.com/003_CT-Axial_Tutorial.htm.
5 April 2005. - Jensen MC, Brant-Zawadski MN, Obuchowski N, Modic
MT, Malkasian D, Ross JS. Magnetic resonance
imaging of the lumbar spine in people without
back pain. New England Journal of Medicine, 1994,
33169-73. - Kraus G. Radiology of low back pain. 2005.
http//www.lowbackpain.com/radiology.htm. 5
April 2005. - Miller JC. When is Imaging Helpful for Patients
with Back Pain? MGH Radiology Rounds serial
online January 2004 Volume 2, Issue 1. - Palmer, W. Spine Imaging Modality Approach
Spectrum of Cases. MGH Dept of Radiology.
Prepared as PowerPoint presentation for this
course) - Pfirrmann, CW, Resnick, D. Schmorl Nodes of the
Thoracic and Lumbar Spine Radiographic-
Pathologic Study of Prevalence, Characterization
and Correlation with Degenerative changes of
1,650 Spinal Levels in 100 Cadavers. Radiology.
2001, 219 368-374. - Richardson, ML. Radiographic Anatomy of the
Skeleton- Lumbar Spine. 1997. http//www.rad.washi
ngton.edu/RadAnat/Lspine.html. 5 April 2005.