Thứ sáu, 27 Tháng 6 2014 17:07

Examination of the Knee

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Inspection

Inspection is only possible with adequate exposure. Begin by placing the patient in shorts or tying the gown up above the knee. The patient's gait should be observed first. Pay attention to the positioning of the knee on both the medial/lateral plane (valgus vs. varus) and the anterior/posterior plane (extension lag vs. knee recurvatum). Also, observe the joint above and below. Be sure to note any restrictions in the hip or ankle motion. Look at the foot for evidence of pes cavus (high arch) or pes planus (flat footed). The patient should then sit or lie on a table.

It is important to next look at the joint for any gross evidence of effusion or discoloration. Any changes can be evaluated further as the examination proceeds. Next, the examiner should assess for any muscle atrophy or fasciculations. If there is atrophy, the thigh or calf circumference should be measured and compared with the unaffected side. Finally, check the skin for any evidence of scarring from previous surgery of trauma.

Palpation

Palpation of the knee should be done systematically. Begin either medially or laterally, and work across the knee. Address the skin, soft tissue, and bony aspects of the joint. Begin the examination by laterally palpating the overlying skin, which should move freely over the soft tissue and bones. The lateral collateral ligament can be palpated next. Palpate along the length of the ligament from the lateral femoral condyle to the insertion on the fibula. Have the patient cross the leg (FABER—Flexion of the knee to 90 degrees, ABduction and External Rotation of the hip) to better palpate the ligament. Moving more proximally, the biceps femoris tendon can be palpated as it comes down to its insertion on the fibular head.

Bony palpation should include the lateral tibial plateau, fibular head, and the lateral femoral condyle. All should be felt for tenderness or palpable osteophytes. In addition, the anterior portion of the lateral meniscus lies on the lateral tibial plateau and may be tender after an injury. This should be checked with the knee in 90 degrees of flexion. Moving across, the anterior portion of the knee should be palpated. Palpate over the prepatellar bursa (above the patella) and the superficial infrapatellar bursa (overlying the infrapatellar ligament). Next in the region is the patella. All four poles of the patella should be palpated, in addition to the undersurface of the medial and lateral aspects. Palpation of the medial and lateral facets of the patella can be performed with the patient lying supine and the knee completely relaxed. Tenderness or hypersensitivity is indicative of patellofemoral pathology. Furthermore, one should palpate the lateral retinacula for the presence of a synovial plica (Fig. 2-11). Proximally, the quadriceps muscle should be palpated for any discomfort of defects. Distally, the infrapatellar tendon should be palpated to its insertion on the tibia at the tibial tubercle.

FIGURE 2-11. Palpation of the lateral retinacula of the knee for synovial plica.

The medial portion of the knee is addressed in a similar fashion. Palpate the skin, and palpate in the region of the pes anserine bursa (medial to the tibial tubercle and just above the insertion of the tendons of the sartorius, gracilis, and semitendinosus). Next, palpate the medial collateral ligament from its origin on the medial femoral condyle to the medial tibia. Moving proximally, the tendons of the sartorius, gracilis, and semitendinosus should be followed from their insertion to the muscle tendon junction.

Bony palpation medially should include the medial femoral condyle and the medial tibial plateau. As with the lateral tibial plateau, the medial meniscus can be palpated. This is made possible by internally rotating the tibia with the knee at 90 degrees and palpating between the tibial plateau and femoral condyle. Palpate for joint line tenderness medially and for any palpable osteophytes.

Before turning the patient, the joint should be checked for an effusion. With the patient in the supine position, with the leg in full extension, place the examiner's thumb on the medial side below the patella. Compress the suprapatellar pouch and lateral knee to accumulate fluid on the lateral side. Compression medially should give a sense of fullness laterally. In addition, the patellar ballottement test can be performed. Using both hands, the proximal hand starts 10 cm above the patella with the thumb lateral and fingers medial. The distal hand starts 5 cm below with the same orientation. While compressing the tissues, the hands are slowly brought toward each other. When they are just above and below the patella, the index finger from the distal hand taps the patella. Without an effusion, the patella will be in the femoral condyles and there will be no findings. With an effusion, the patella will "tap" onto the femur and the examiner will feel the sensation.

The last region to be inspected is the posterior aspect of the knee. This is done best with the patient in the prone position. Palpate for the boundaries of the popliteal fossa, which include medially the semitendinosus and semimembranosus muscles. Laterally palpate for the biceps femoris muscle and inferiorly the two heads of the gastrocnemius. Within the region of the popliteal artery are the popliteal vein and posterior tibial nerve. Palpate for any popliteal cysts, which is best done with the knee in extension.

Range of Motion

Range of motion of the knee should be approximately 135 degrees of flexion and 0 degrees of extension. Both internal and external rotation should be approximately at 10 degrees. Loss of range of motion can be of traumatic or degenerative causes. It is important to check both active range of motion and passive range of motion. A patient with quadriceps weakness may be unable to achieve full active extension but with the examiner's assistance has full range of motion.

The testing can be performed with the patient seated on the edge of the examination table to start. Check the active and passive extensions (this can be incorporated into the manual muscle testing). Watch the patella during extension for its position in the trochlear groove. Active flexion can also be tested in this position, but passive flexion is better tested with the patient in the supine position. Loss of terminal flexion and extension can also be attributed to a joint effusion.

Neurological

The neurologic examination should consist of manual muscle testing, sensation, and reflexes. The manual muscle testing is performed to test quadriceps strength by extending the knee. Hamstring testing should be performed with the patient flexing the knee while sitting. Another useful test is a step down test. Watch the patient step down from a foot stool in the room to assess his or her control descending and the amount of increase in the Q angle. Table 2-10 lists what should be included in manual muscle testing (24).

Reflexes can be addressed next. Table 2-11 lists what should be included in reflex testing (24).

Finally, sensation can be tested for both pinprick (lateral spinothalamic tract) and light touch (dorsal columns). Table 2-12 lists what should be included in sensation testing (24).

Ligament Stability

Stability of the ligaments should be tested with the patient relaxed and in a supine position. Beginning with the collateral ligaments, the examiner should firmly grasp the distal leg and provide a valgus (laterally applied) force to the knee. This will test the medial collateral ligament. The test should be completed with the knee in 20 to 30 degrees of flexion and also with the knee in full extension to test medial capsular integrity (Fig. 2-12). Remember to apply three points of pressure, one being distal lateral leg, the next lateral knee, and finally distal medial knee to maintain control of the leg. If possible, palpate around the knee, and palpate the ligament for a defect during the application of a valgus force.

FIGURE 2-12. Evaluation of the stability of the collateral ligaments of the knee.

In a similar fashion, apply a varus (medially applied) force to the knee to check the lateral collateral ligament. Again, it is helpful to place a finger on the ligament during the maneuver. It is also important to apply three points of pressure. As with the medial side, check in full extension and in 20 to 30 degrees of flexion.

The anterior and posterior cruciate ligaments should be examined next. The Lachman's maneuver is the most sensitive test for injury to the anterior cruciate ligament (ACL). The test is performed by firmly grasping the distal lateral thigh with the outside hand in a supine patient. The knee is then placed in slight flexion, approximately 30%. Next, the proximal medial leg is grasped by the examiner's inside hand and slightly laterally rotated. A quick upward force is then applied to the tibia by the inside hand while the thigh remains stabilized by the outside hand. The examiner is feeling for a sharp end point of the ACL. This examination maneuver is difficult and must be practiced many times before it can be done correctly (Fig. 2-13), but this is the most accurate method of judging the integrity of the ACL (25).

FIGURE 2-13. Evaluation of the stability of the ACL of the knee.

With the patient in a supine position and the hip flexed at 45 degrees while the knee is in 90 degrees of flexion, the examiner can test both the posterior and the anterior cruciate ligaments. The foot is stabilized when the examiner sits on the patient's foot. To test the ACL, the examiner grasps around the proximal tibia and places the thumbs on the medial and lateral tibial plateaus. The tibia is then pulled anteriorly with respect to the femur. The amount of anterior movement should be minimal and equal to the opposite side. The movement is compared with the opposite knee.

Testing of the posterior cruciate ligament is completed just after the ACL. With the patient supine, the hip is flexed to 45 degrees and the knee flexed to 90 degrees. The foot is immobilized by the examiner sitting on the foot. The examiner then gives a posteriorly directed force to the tibia with the thumbs on the tibiofemoral junction. As with the anterior drawer test, the laxity is compared with the opposite side. Another indication of a posterior cruciate tear is hyperextension of the knee joint. This can be observed with the patient supine and the hip and knee flexed at 90 degrees. The examiner elevates the leg by lifting the heel with all muscles relaxed. Again, both sides should be tested for comparison.

The posterolateral complex of the knee includes the posterolateral capsule, the popliteus muscle, and the lateral collateral ligament. When one or more of these structures are injured, particularly in the setting of a posterior cruciate ligament deficiency, the knee becomes susceptible to rotatory instability. Posterolateral complex laxity can be demonstrated by examining the tibial external rotation with the knee flexed at 90 degrees and comparing it with the contralateral side.

Medial and Lateral Menisci

The medial and lateral menisci may account for the second most commonly injured structures in the knee, second only to the patellofemoral joint (PFJ) as a source of knee pain in the younger patient groups. Rotatory motion, particularly when combined with compression, is felt to be the common biomechanical factor leading to injury. An aging and degenerative meniscus is probably more susceptible to this type of trauma. Commonly, injury to the meniscus will result in an effusion, making the detection of an effusion an important clinical test when looking for meniscal injury. Joint line tenderness is sensitive for meniscal injury but not specific. The posterior horns are loaded during flexion so that simultaneous knee flexion and rotation will be sensitive for pain secondary to a posterior horn meniscal tear. Pain associated with the internal tibial rotation tends to be more indicative of injury of the lateral meniscus, whereas external rotation may be more suggestive of the medial meniscus.

A test for meniscal injury would be the McMurray's test (26). McMurray's test is performed with the patient supine.

The knee is brought into full flexion, and the tibia is internally rotated and then extended to 90 degrees while being held internally rotated. An audible pop, click, or locking is considered a positive McMurray's test and felt to be specific for posterior horn bucket handle lateral meniscal tear. Externally rotating the tibia and performing the same motion will detect injury to the posterior horn of the lateral meniscus (Fig. 2-14).

FIGURE 2-14. Evaluation for meniscal injury or McMurray's test of the lateral meniscus for the knee.

Biomechanics of the Knee

The knee appears to function primarily as a hinge joint, but with closer observation, its biomechanics are more complex. Rotatory motion also occurs and, although very limited, may play an important role for many of the acute traumatic and chronic overuse injuries. The primary static stabilizers include the anterior cruciate and posterior cruciate ligaments, the posterolateral complex, the remaining capsular structures, and, to a lesser extent, the medial and lateral menisci. The role of the dynamic stabilizers of the knee in controlling rotatory motion has not been well studied. However, it does appear that the medial hamstrings, lateral hamstrings, and popliteus muscles play a role here in dynamic rotary stabilization. Although knee muscle kinesiology has been extensively studied, the great majority of work has been looking at the biomechanics of the PFJ (27-33). This is not surprising, considering that patellofemoral syndrome is the most common knee disorder causing pain and limiting function.

There is no other musculoskeletal disorder in which the kinetic chain plays a greater role or requires a more thorough analysis than with patellofemoral-related pain. It is widely believed that the relative position of the patella in the PFJ, how it sits at rest, and how it travels during dynamic activities can contribute to patellofemoral syndrome and be a risk factor for patellofemoral subluxation/dislocation (26,34). The quadriceps muscles are the primary knee extensors, with a small contribution coming from some fibers of the adductor magnus (35). Three muscles of the PFJ—the vastus lateralis (VL), the vastus medialis, and the vastus intermedius—cross only the knee joint and are relatively fixed in their line of pull. Tightness in the lateral or medial retinacular structures can somewhat alter this. The hip joint is the primary rotator of the lower limb, and the degree of rotation may play an important role in patella tracking disorders. The fourth quadriceps muscle, the rectus femoris, is a two-joint muscle that crosses the hip in addition to the knee joint. It originates from the anterior superior iliac spine (ASIS), and calculating the Q angle reflects its line of pull. The Q angle is measured by extending a line from the ASIS to the midpoint of the patella. One measures the angle created by the intersection of the second line that connects the midpoint of the patella to the tibial tubercle. The normal Q angle is 10 to 14 degrees, and any significant deviation from this may lead to improper patella tracking and subsequent PFJ pain. External rotation of the hip decreases the Q angle, whereas internal rotation increases it. During normal gait mechanics, ankle pronation occurs simultaneously with hip internal rotation; conversely, supination occurs with hip external rotation. Therefore, hyperpronation can increase the Q angle, whereas hypersupination can decrease it.

EMG has been used to study knee muscle function, primarily looking at the balance and relationship among the VL, vastus medius (VM), and vastus medialis oblique (VMO), and to better understand patellofemoral maltracking syndromes (27,36-39). Sczepanski et al. (38) compared VMO and VL EMG activity during concentric and eccentric isokinetic exercises in asymptomatic individuals and found a greater VMO/ VL ratio only during concentric contractions at 120 degrees per second. Reynolds et al. (37) studied asymptomatic women and found no difference in the VMO/VL relationship through full range of motion. In a study that looked at the effect of Q angles, Boucher et al. (27) found no significant differences in VMO/VL EMG ratio between asymptomatic volunteers and patients with patellofemoral maltracking syndromes. They did find a decrease in the VML/VL ratio in a subset of patellofemoral syndrome (PFS) patients with Q angles greater than 22 degrees at 15 degrees of knee extension. Voight and Wieder (39) compared the reflex response times of the VMO and VL EMG following a tendon tap. There was an increase in the VL response times in patellofemoral maltracking syndrome patients. These studies are far from conclusive, and the debate about the relationship between the VMO and the VL as contributing factors for patellofemoral disorders continues, while conventional clinical management remains based on these principles.

Kinesiological work has also been done to better understand muscle mechanics as it pertains to patients who have torn their ACLs and to help determine the most effective methods of managing these patients both nonsurgically and postoperatively. The ACL restrains anteromedial rotation of the tibia. An EMG study by Limbard et al. (40) on ACLdeficient patients found an increase in biceps femoris activity with a simultaneous decrease in quadriceps activity during swing-to-stance transition at normal walking speeds. At this point in gait, the hamstring may have been firing to prevent anteromedial tibial rotation. The hamstrings were less active in these patients from midstance to terminal stance. Branch et al. (41) found an increase in EMG activity of the lateral hamstrings in ACL-deficient patients during swing phase and an increase in medial hamstring and a decrease in quadriceps activity during stance phase. Tibone et al. (42) had reported similar findings. Solomonow et al. (43) stressed that an intact ACL led to excitement of the hamstrings and inhibition of the quadriceps. Baratta et al. (44) studied coactivation patterns. Hypertrophy of the quadriceps impaired hamstring coactivation, and strengthening of the hamstrings reduced this. Lutz et al. (45) demonstrated a greater ability to perform cocontractions of the hamstrings and quadriceps during closed kinetic chain exercises, thus conferring more stability to the knee. Weresh et al. (46) studied the popliteus muscle and found no difference in activation between ACL-deficient patients and controls.

Based on these EMG studies, one can now look for some of the muscle imbalances and other anatomic factors for patellofemoral maltracking syndromes such as hyperpronation or excessive hip internal rotation during the physical examination. Once these findings have been identified, they can then be more specifically addressed with physical therapy or some other form of a structured exercise program.

REFERENCES

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ năm, 26 Tháng 6 2014 17:05

Examination of the Lumbar Spine

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Inspection

The examination of the low back, like the other areas of the body, should begin as the patient enters the office and examination room. Watch how the patient moves while walking and how he or she moves changing positions. The patient's posture should be noted. The patient should be in a gown that opens in the back for full exposure. Look at the muscle bulk and symmetry of the low back. Also look at the skin for scarring or discoloration. Inspect the lumbar spine from behind and the side to assess for lordosis. Often, patients with stenosis may have hypolordosis because of spinal stenosis. Young athletes might have hyperlordosis because of an imbalance of paraspinal to abdominal strength.

Palpation

The next step involves palpation of the muscles of the back, spinous processes, and important landmarks of the pelvis. From the back, the paraspinal muscles and the interspinous ligaments can be palpated. Palpate for the spinous processes, and in an older patient, these should be percussed to help in the diagnosis of a compression fracture. Finally, palpate for the bilateral posterior superior iliac spines (PSIS) to determine pelvis alignment. The examiner should place her thumbs on the bilateral PSIS and index fingers on the iliac crests. The height of the pelvis can be checked for alignment by comparing the two sides. Look for symmetry of bulk.

Range of Motion

Range of motion should be tested both actively and actively assisted if possible. Both are important in the evaluation of the low back. Range of motion should be checked in flexion, extension, rotation, and side bending. If there is posterior pain to one side, the examination should include extension to both the left and the right to stress the zygapophyseal joints and to narrow the foramen in a patient with foraminal stenosis or a foraminal disc protrusion.

It is important to watch the spine during motion. In forward flexion, ask the patient to touch his or her toes and watch to see whether the motion comes from the spine or hips. Watch for reversal of the lumbar lordosis by inspecting the prominence of the spinous processes. In extension, look for the motion in the lumbar spine versus the hip and knees in many patients. While assessing range, ask the patient whether the discomfort is greater in flexion or extension. Be aware of conditions that can lead to spinal inflexibility like ankylosing spondylitis or diffuse idiopathic spinal hyperostosis (DISH).

Rotation and side bending can be evaluated next. The patient should be able to rotate his or her shoulders perpendicular to the pelvis. It is often helpful to stabilize the pelvis while the patient is rotating. Have the patient side bend next, and compare it to the opposite side. With each maneuver, the examiner can follow the active motion with active assisted motion to see to what degree the active motion is limited.

Examination of the hip joint and the muscles crossing it is an important part of the lumbar spine examination because of the intimate association with the pelvis and lumbar spine. Limited hip rotation may lead to increased rotatory forces in the spine. A tight rectus femoris may tilt the pelvis anteriorly, increasing the lumbar lordosis, whereas hamstring tightness may tilt it posteriorly and decrease it.

Maybe no other joint in the young person has seen more change in approach over the past few years than the hip. In evaluating the spine, the examiner should have an idea of any suspected loss of range of motion. In the older patient, the loss of range of motion, particularly internal rotation, needs to be documented, and the practitioner needs to determine how much that pain contributes to the patient's symptoms. In a younger patient, the loss of range of motion can be early osteoarthritis, but in the absence of joint space loss on plain film radiographs, it could be a soft tissue injury or a bony anatomy change. Studies have shown that labral tears can be seen in young patients with complaints of groin pain approximately 20% of the time (21). These lesions have a high association with bony abnormalities (22) and could be precursors for osteoarthritis (23).

The examination of the hip should consist of at least three elements. The first standing on one leg or walking to look for dynamic weakness in the form of a lurch to the opposite side or compensation to the same side due to weakness. This can be checked in the side lying position statically. Next, the patient should be supine and simple range of motion should be checked at 90 degrees of hip and knee flexion. Finally, the hip should be checked in flexion at 90 degrees, adduction, and internal rotation for the presence of groin pain. Table 2-6 shows normal range of motion of the hip.

Neurological

The examination of the low back always includes a full neurologic examination of the lower limbs. Radiculopathies can be very subtle, and as with the cervical spine examination, manual muscle testing, sensory examination, and reflexes all must be addressed to find these subtle changes. The order to proceed is examiner dependent. Similar to the cervical spine examination, manual muscle testing should also be confirmed with additional muscles when subtleties exist because the muscles of the lower limbs have two or more levels of innervation. However, unlike the upper limbs, the lower limb muscles can generate greater force. The examiner needs to provide enough resistance to detect subtle muscle weakness. In addition, heel and toe walking can be added to the gait examination to test the tibialis anterior and gastrocnemiussoleus muscles. Table 2-7 lists what should be included in manual muscle testing (19).

Reflexes can be addressed next. Table 2-8 lists what should be included in reflex testing (19).

Finally, sensation can be tested for both pinprick (lateral spinothalamic tract) and light touch (dorsal columns). Table 2-9 lists what should be included in sensation testing (19).

Additional Tests

Examination of the low back should include special tests that are specific for certain pathologies. Every back examination should include a straight leg raise if there is concern about radiculopathy. The straight leg raise, also known as the Lasegue's test, can be performed with the patient seated or in the supine position. With the patient supine, raise the affected lower limb with the knee in full extension. Starting at 30 degrees of leg elevation, patients with nerve root irritation will begin to have discomfort. Stretch on the nerve will be maximal at 65 degrees, and pelvic rotation will begin. A positive test is pain down the limb to the knee in the arc of 35 to 65 degrees. For more subtle cases, ankle dorsiflexion can be added to maximize the nerve stretch.

REFERENCES

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ tư, 25 Tháng 6 2014 17:03

Examination of the Shoulder

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Inspection

Inspection of the shoulder requires that the shoulder be exposed and the patient appropriately draped. The shoulder "joint" actually consists of four different joints: sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic. Three of the joints are true joints, while the scapulothoracic joint is not a true articulating joint lined with cartilage. It is important to visualize each of the joints. Begin by inspecting the normal bony prominences and muscle bulk. The most obvious changes can be seen in the acromioclavicular joint. Comparison to the other shoulder is essential.

Palpation

Palpation can be done either from in front of the patient or from behind the patient. Begin by palpating from the sternoclavicular joint along the clavicle to the acromioclavicular joint. Palpate the coracoid process and the coracoclavicular ligament. Move laterally, and palpate the tendon of the long head of the biceps. Continue palpation medially to the lesser tuberosity and laterally to the greater tuberosity. Next, palpate the scapula along the acromion and medially along the spine of the scapula. Find the superior and inferior angles of the scapula.

The muscles should also be palpated for tender points and evaluation of their bulk. The supraspinatus, infraspinatus, and teres minor can be palpated by bringing the upper limb into extension at the shoulder and palpating anteriorly (3).

Range of Motion

The motion of the joints should be observed. Watch the different joints and their symmetry of motion. This should be done from in front of and behind the patient.

The shoulder has the greatest range of motion of any joint. Subtle changes must be assessed and asymmetries noted during the physical examination. Active and passive motions should be assessed. To begin, check the patient's active range of motion. There are six directions of motion: abduction, adduction, extension, flexion, internal rotation, and external rotation. Active abduction should allow the patient to touch the dorsal surface of his hands with the arms straight above the head. Adduction will allow the patient to bring her arm into the plane of the torso. Each of these can be tested in conjunction with the testing for internal and external rotations or alone. Functional internal rotation can be demonstrated by having the patient touch his midback (Fig. 2-2). Record the level that the thumb touches, and repeat on the opposite side. Have the patient reach over the head and touch the upper back to test external rotation. As with internal rotation, record both sides. Finally, have the patient bring the straight upper limb forward to test flexion and backward to test extension.

FIGURE 2-2. Internal rotation determination during shoulder range of motion evaluation.

The shoulder should then be checked for passive range of motion. The importance of checking the passive range can be seen in a patient with adhesive capsulitis. Although there may appear to be both internal and external rotations, the motion often comes from the scapular thoracic joint. By isolating the glenohumeral motion, both can be assessed, and there is increased reliability in the assessment of the glenohumeral motion (8).

FIGURE 2-3. Stabilization of the scapula during shoulder range of motion evaluation.

Passive internal and external rotations can be tested by bringing the shoulder into 90 degrees of abduction while holding the elbow to 90 degrees of flexion. Stabilizing the scapula with one hand to truly evaluate glenohumeral motion, internally and externally rotate the shoulder (Fig. 2-3). For some examiners, placing the patient in the supine position with a posteriorly directed force on the coracoid process might be easier and has been found to be reliable (9). Note the motion, compare it to the other side, and repeat with the scapula free to see the scapulothoracic motion. Table 2-4 shows the normal range of motion.

Neurological

Motor testing of the shoulder should follow the examination of the range of motion. Each motion should be tested for strength. The major muscles used to move the shoulder are the deltoid, pectoralis major, latissimus dorsi, biceps, and triceps. In addition, there are smaller stabilizing muscles, including the rotator cuff muscles. Additionally, the scapular position and control are coordinated by the trapezius, levator scapulae, rhomboids, and serratus anterior. Test the major movers with one hand stabilizing the shoulder and the other providing resistance.

After testing the larger movers of the shoulder, it is important that the smaller stabilizers are addressed, as these are often involved in the pathology of the shoulder. The supraspinatus is tested with the upper limb abducted 90 degrees, internally rotated with the thumb down and in the plane of the scapula. Apply steady pressure while asking the patient to abduct the limb (Fig. 2-4). Next, the external rotators can be assessed. Have the patient adduct the limb and flex the elbow at 90 degrees. The examiner stabilizes the elbow against the torso with one hand and places the other hand on the distal forearm. The patient then rotates the forearm away from the body against resistance.

FIGURE 2-4. Supraspinatus strength determination during shoulder evaluation.

Finally, the subscapularis should be assessed.This is the most difficult to check for subtle changes. The classically described maneuver is the "lift-off test." This is done by the patient placing the dorsum of his hand on his back while the elbow is flexed at 90 degrees. The examiner then holds the hand off the back and instructs the patient to hold his hand in that position once the hand is released. If the patient is able to maintain the hand position, the subscapularis is intact. If the hand falls to the back, there is some deficiency in the muscle (Fig. 2-5).

FIGURE 2-5. Subscapularis strength determination during shoulder evaluation.

Sensory testing of the shoulder should be done in conjunction with the neck. Of importance for the shoulder, the dermatome for the axillary nerve should be tested. This is a silver dollar-sized area over the deltoid on the lateral upper arm. This is especially important after dislocations, as the axillary nerve can be injured.

Additional Tests

Impingement Tests

There are many tests for impingement of the rotator cuff muscles. We will address two of the more common tests. The first is the Hawkins' maneuver (10). With the arm abducted to 90 degrees, elbow flexed at 90 degrees, and the humerus in the plane of the scapula, the examiner stabilizes the scapula and internally rotates the shoulder (Fig. 2-6). Pain with this maneuver is caused by impingement of the greater tuberosity on the coracoacromial ligament.

FIGURE 2-6. Hawkins' maneuver to evaluate shoulder rotator cuff impingement.

The Neer's impingement sign is performed by stabilizing the scapula and slowly forward flexing the shoulder (11; Fig. 2-7). The elbow should be straight during the maneuver. The limb can be tested both internally rotated and neutral during testing.

FIGURE 2-7. Neer's impingement sign to evaluate shoulder rotator cuff impingement.

Labral Tests

Another test of importance to the shoulder exam is the active compression test. The test is used to assess for anterior labral tears and acromioclavicular injuries. With the patient standing, the examiner stands on the affected side. The shoulder is brought into 90 degrees of abduction, 10 to 15 degrees of adduction, and internal rotation of the upper limb. The patient then resists a downward force by the examiner. At this point, the patient should either feel pain at the top of the shoulder (A-C joint pathology) or inside the shoulder (anterior labrum). The limb is then brought into full external rotation and the symptoms should be alleviated. Sensitivity and specificity are both excellent for the test (12).

Stability Tests

Shoulder instability can be diagnosed with a variety of maneuvers and most likely more accurately using the results of two or more tests. The examiner can begin with the apprehension test. The patient is placed in a supine position with the upper limb to be examined next to the edge of the table. The shoulder is then abducted to 90 degrees, and the elbow is flexed. The examiner then externally rotates the shoulder (Fig. 2-8). A patient with a positive "apprehension sign" has discomfort and a feeling of apprehension in the shoulder as it is externally rotated past 90 degrees that is relieved when the examiner stabilizes the shoulder with a posteriorly directed force to the shoulder with his free hand. The second part of the examination is named the "relocation sign" (Fig. 2-9). Both parts of the examination check for anterior instability of the shoulder, although the relocation test adds specificity to the diagnosis.

FIGURE 2-8. Apprehension sign to evaluate anterior instability of the shoulder.

FIGURE 2-9. Relocation sign to evaluate anterior instability of the shoulder.

The next tests are the anterior and posterior drawer signs (13). With the patient in the same supine position, the examiner stabilizes the forearm and the humerus. Next, the examiner places her free hand on the glenohumeral joint. With the distal portion of the joint stabilized, the humerus is directed anteriorly and posteriorly (Fig. 2-10). The amount that the humeral head moves beyond the rim of the glenoid fossa is graded in Table 2-5. Similarly, this can be applied to the posterior movement.

FIGURE 2-10. Anterior and posterior drawer signs to evaluate posterior instability of the shoulder.

The final piece of instability is the inferior drawer or "sulcus sign." With the patient seated or standing, the examiner pulls down the upper limb. The examiner's free hand is stabilizing the scapula. A positive "sulcus sign" is when an indentation in the skin is noticed between the acromion and the humeral head (14).

Sports Biomechanics

Identifying the biomechanical flaws in a thrower that contribute to the development of bicipital tendonitis or a superior labrum anterior posterior (SLAP) lesion, or the flaws in a runner that lead to patellofemoral pain, requires an understanding muscle kinesiology and joint biomechanics. This helps determine not only the factors that may have been causative but also those that may increase the risk of an injury, and if so identified, allow prevention. This can be especially valuable during preparticipation examinations (15). The focus of sports medicine continues to be treatment rather than prevention. One reason for this is the limited scientific data that clearly demonstrate the effectiveness of prevention programs based on preinjury evaluations. Intuitively we believe that restrictions in motion or certain strength deficits may predispose an athlete to an injury, and if we address them, we can lower the risk. But do we have the research to back this up?

Much of our understanding of muscle kinesiology comes from work done in labs using electromyography (EMG) to look at muscle firing patterns. One must be extremely cautious interpreting these studies. Although very general muscle firing patterns can be determined, some important technical factors are often overlooked. The relative activity of one muscle cannot be compared with another for several reasons. One is that the amplitude of a muscle's EMG signal varies widely based on whether a muscle is contracting concentrically or eccentrically. During certain sports activities, there will usually be muscles undergoing both (usually agonists and antagonists) types of contractions simultaneously, and it may not always be readily evident which is doing which. For example, during the acceleration phase of throwing, the shoulder flexes forward, but the exact point at which the shoulder internally rotates is important in determining which of the rotator cuff muscles are contracting concentrically and which are contracting eccentrically. To be certain, one must also perform a video kinematic analysis.

Several other factors play an important role in comparing the EMG signal of different muscles. The amplitude of the EMG signal will vary based on the location of the electrode (in relation to the muscle's motor point), the type of electrode (surface vs. intramuscular), and the degree of muscle fatigue. Furthermore, because one compares the EMG activity to activity during maximal voluntary contraction (MVC) of the same muscle, activity determined during MVC must be reliable and statistically reproducible. This issue is frequently not fully and adequately addressed.

Nevertheless, the information collected on muscle kinesiology has allowed us to better understand basic muscle mechanics. Understanding the major technical limitations will help prevent us from drawing erroneous conclusions.

Biomechanics of the Overhead Athlete

The biomechanics of the overhead athlete have been extensively studied. The motion of throwing a baseball and serving a tennis ball overhead has similarly been broken into five phases: windup, early cocking, late cocking, acceleration, and follow-through. The stage of late cocking, during which the shoulder is abducted and externally rotated, may potentially be dangerous to the glenohumeral joint, where inherent instability may lead to anterior translation and load the labrum or capsule anteriorly. Symptoms of posterior impingement can also be elicited when there is excessive anterior/posterior translation compressing redundant scar tissue in the region of the posterior capsule. Kinesiological studies have demonstrated that all four muscles of the cuff are most active from the late cocking to acceleration phase (16-18). This is not surprising because the cuff is felt to be a dynamic stabilizer of the glenohumeral joint, and the position in late cocking puts the glenohumeral joint in a potentially unstable position. Studies have also demonstrated that the triceps begins to fire in late cocking and then in acceleration (16,17). This is probably to prevent hyperflexion of the elbow during late cocking and may also serve as a prestretch to create a plyometric type of contraction of the triceps during acceleration to propel the forearm, wrist, and hand along with either the racquet or the baseball. The biceps then fires during the deceleration phase to allow elbow extension to occur in a controlled fashion. If this occurs too rapidly because of inadequate biceps control, overload can occur to the biceps muscle or biceps tendon or lead to avulsion, in which the biceps tendon anchors itself along the superior labrum. Injury to the labrum at this level has been identified as a SLAP lesion (19). The muscle kinesiological data collected have supported the theoretical basis for the mechanisms of injury to these various structures. This information can then be used on physical examination so that the clinician can reproduce symptoms in the phase where injury occurs. One then combines some basic physical examination findings based on observation and palpation with functional tests, such as the apprehension sign or testing the biceps during an eccentric load. Not only can an anatomic diagnosis be made of the injured structure, but a functional diagnosis can be made as well. One must also be careful to not confuse strength with motor skill. Adequate strength on manual muscle testing does not guarantee proper muscle function. Poorly developed muscle skill, proprioception, the proper agonist/antagonist balance during contractions, and the lack of proper timing of muscle firing can all contribute to an overuse injury. Any of these should be considered at least a potentially contributing factor.

To further shed light on a more complete biomechanical picture, the kinetic chain must also be considered. This requires a sound understanding of the role each component of the chain plays during a skilled athletic maneuver. Any pathology at any point in the chain can alter the athlete's mechanics and lead to overload elsewhere. This may sound somewhat vague and generalized, but it is part of the functional approach practitioners working with athletes should consider. Throwers who have lost trunk/spine flexion/extension or pelvic/hip rotation may lose power from the loss of torque normally created during late cocking into acceleration phase or may have difficulty slowing down elbow extension during deceleration phase (20). Other components of the kinetic chain essential to minimizing trauma to the shoulder and arm are adequate neck rotation and eccentric strength of quadriceps. Compensation for restrictions in motion and relative weakness may lead to greater demands on power generated by the rotator cuff. This can create greater torque in the glenohumeral joint or require a greater and excessive eccentric contraction of the biceps. Eccentric overload of the biceps may injure the bicipital tendon of the labrum at its point of origin creating a SLAP lesion (19).

REFERENCES

Source: Physical Medicine and Rehabilitation - Principles and Practice

Inspection

Inspection of the neck begins upon meeting the patient. Look to see if the patient moves the shoulders when he or she turns the neck, a sign of decreased range of motion, or if he or she winces with certain motions. Take note of the patient's relaxed posture as changes to improve poor posture can be easily addressed in therapy. As the examination proceeds, the clinician should make sure that the neck is properly exposed for evaluation. Look at the muscle bulk and symmetry of the neck, upper back, and shoulders. Also look at the skin for scarring or discoloration. You will be surprised at the details left out by patients. It is not uncommon to learn about a patient's previous surgery during the exam.

Palpation

The next step involves palpation of the neck and upper thoracic region. Begin in a systematic fashion, either starting from the front or back. From the back, the paraspinal muscles and the nuchal ligament can be palpated. Working down, the upper and middle trapezius muscles should also be palpated for tender or trigger points (2). Palpate for the spinous process of the seventh cervical vertebrae, which should be larger than the superior segments in a neutral position of the cervical spine.

Place the patient in the supine position with the patient's head near the end of the table. Sit with your stool directly behind the patient's head, and continue palpation. Rotate the patient's neck 45 degrees, palpate each zygapophyseal joint, and note whether the patient feels discomfort at a joint that is greater than the opposite corresponding zygapophyseal joint. From this position, the anterior muscles, most notably the sternocleidomastoid and more laterally the scalenes, can be palpated. Palpate the sternocleidomastoid muscle from its origin at the sternoclavicular joint to the insertion on the mastoid process. Rotate the neck from side to side to make the muscle more prominent if it is initially difficult to find. Look for symmetry and bulk.

Range of Motion

Range of motion should be tested both actively and passively. Both are important in the evaluation of the neck. Guarding due to pain, muscle tightness, and muscle imbalances can reduce range of motion to one side during active testing, but the motion may often be full when tested passively. Osteophytes and zygapophyseal joint arthritis can also lead to fixed restrictions. This would be confirmed when the same loss of range of motion found actively is also demonstrated passively.

Range of motion should be checked in flexion, extension, rotation, and lateral or side bending. Motion is not divided equally between the vertebrae. Approximately 50% of flexion and extension come from the atlanto-occipital joint. At the atlantoaxial joint, approximately 50% of the rotation takes place (3).

Guidelines for normal motion are as follows: Normal flexion allows the patient to touch his chin to his chest, and extension allows the patient to look up at the ceiling. In normal rotation, the patient should be able to bring her chin over the acromion. Side bending done toward the ipsilateral shoulder should be approximately 45 degrees. Always begin with active range of motion, particularly in the injured patient. The patient may guard, and this will reduce the range. Forcing motion may make the patient uncomfortable and can injure a patient with zygapophyseal joint dysfunction (4).

Neurological

Included in any examination of the neck is a full neurologic examination of the upper limbs. Radiculopathies can be very subtle, and all components of the examination, manual muscle testing, sensory examination, and reflexes must be addressed to find these subtle changes. The order to proceed is examiner dependent. Manual muscle testing should also be confirmed with additional muscles when subtleties exist, as the muscles of the upper limb have two or more levels of innervation. Table 2-1 shows what should be included in manual muscle testing.

Reflexes can be addressed next. Table 2-2 shows what should be included in reflex testing.

Finally, sensation can be tested for both pinprick (lateral spinothalamic tract) and light touch (dorsal columns). If there is a concern about carpal tunnel or double crush, two-point discrimination may be more sensitive (5). Table 2-3 shows what should be included in sensation testing.

Examination of the neck should also include a compression test or Spurling's maneuver (6) (Fig. 2-1). The test assesses the mechanical neuroforaminal narrowing of the C4-5, C5-6, and C6-7 with ipsilateral oblique extension (7). The objective of the test is to compress an irritated nerve with the following motion: The neck is brought into slight extension and side bending followed by an axial compression. A positive result reproduces pain along a dermatome below the shoulder. Finally, as with the joints, it is always important to examine the adjacent joints. In the case of the cervical spine, a full examination of the shoulder should be performed to rule out underlying or contributing shoulder pathology.

FIGURE 2-1. Compression test or Spurling's maneuver.

REFERENCES

Source: Physical Medicine and Rehabilitation - Principles and Practice

The rehabilitation evaluation of chronic disease often shows lost function. Through the functional history, the physician characterizes the disabilities that have resulted from disease and identifies remaining capabilities. The functional history is considered part of the history of the present illness by some physicians and a separate segment of the patient interview by others. The examiner must know not only the functional status associated with the present illness but also the level of function at one or more times before the present illness; therefore, we prefer to consider it separately. 

Although the specific organization of the activities of daily living varies somewhat, the following elements of personal independence remain constant: communication, eating, grooming, bathing, toileting, dressing, bed activities, transfers, and mobility. 

When obtaining the functional history, the physician may record in a descriptive paragraph the patient's level of independence in each activity. However, functional stability is best communicated, followed over time, and made accessible for study when the physician uses a standard functional assessment scale. 

Communication

A major component of rehabilitation is education; thus, communication is critical. The interviewer must assess the patient's communication options. In the clinical situation, this aspect of the evaluation blurs the distinction between history and physical examination. It is difficult to interact with the patient in a meaningful way without coincidentally examining his or her ability to communicate; significant speech and language deficiencies become obvious. However, for purposes of discussion, certain facets of the assessment relate more specifically to the history and will be discussed here. Additional facets are presented below in the section on the physical examination. 

Speech pathology has provided clinicians with numerous classification systems for speech and language disorders. From a functional view, the elements of communication hinge on four abilities  (2): 

  1. Listening 
  2. Reading 
  3. Speaking 
  4. Writing 

By assessing these factors, the examiner can determine a patient's communication abilities. Representative questions include the following: 

  1. Do you have difficulty hearing? 
  2. Do you use a hearing aid? 
  3. Do you have difficulty reading? 
  4. Do you need glasses to read? 
  5. Do others find it hard to understand what you say? 
  6. Do you have problems putting your thoughts into words? 
  7. Do you have difficulty finding words? 
  8. Can you write? 
  9. Can you type? 
  10. Do you use any communication aids? 

Eating

The abilities to present solid food and liquids to the mouth, to chew, and to swallow are basic skills taken for granted by able-bodied people. However, in individuals with neurologic, orthopedic, or oncologic disorders, these tasks can be formidable. Dysfunctional eating can be associated with far-reaching consequences, such as malnutrition, aspiration pneumonitis, and depression. As in the assessment of other skills for activities of daily living, inquiries about eating function should be specific and methodical. 

Representative questions include the following: 

  1. Can you eat without help? 
  2. Do you have difficulty opening containers or pouring liquids? 
  3. Can you cut meat? 
  4. Do you have difficulty handling a fork, knife, or spoon? 
  5. Do you have problems bringing food or beverages to your mouth? 
  6. Do you have problems chewing? 
  7. Do you have difficulty swallowing solids or liquids? 
  8. Do you ever choke? 
  9. Do you regurgitate food or liquids through your nose? 

Patients with nasogastric or gastrostomy tubes should be asked who helps them prepare and administer their feedings. The type, quantity, and schedule of feedings should be recorded. 

Grooming 

Grooming may not be considered as important as feeding. However, the inability to make oneself attractive and presentable can have injurious effects on body image and self-esteem, social sphere, and vocational options. Consequently, grooming skills should be of real concern to the rehabilitation team. 

Representative questions include the following: 

  1. Can you brush your teeth without help? 
  2. Can you remove and replace your dentures without help? 
  3. Do you have problems fixing or combing your hair? 
  4. Can you apply your makeup independently? 
  5. Do you have problems shaving? 
  6. Can you apply deodorant without assistance? 

Bathing 

The ability to maintain cleanliness also has far-reaching psychosocial implications. In addition, deficits in cleaning can result in skin maceration and ulceration, skin and systemic infections, and the spread of disease to others. Information about independence in bathing should be sought. 

Representative questions include the following: 

  1. Can you take a tub bath or shower without assistance? 
  2. Do you feel safe in the tub or shower? 
  3. Do you use a bath bench or shower chair? 
  4. Can you accomplish a sponge bath without help? 
  5. Are there parts of your body you cannot reach? 

For patients with sensory deficits, bathing is also a convenient time for skin inspection, and inquiry about the patient's inspection habits should be made. For patients using a wheelchair, architectural barriers to bathroom entry should be determined. 

Toileting

To the cognitively intact person, incontinence of stool or urine can be the most psychologically devastating deficit of personal independence. Ineffective bowel or bladder control has an adverse impact on self-esteem, body image, and sexuality, and it often impairs or prevents employment and social relationships. Dignity may even prohibit the person from venturing from the house for fear of an accident. Soiling of skin and clothing often results in ulceration, infection, and urologic complications. The rehabilitation physician should vigorously pursue questioning about toileting dependency with sensitivity. 

Representative questions include the following: 

  1. Can you use the toilet without assistance? 
  2. Do you need help with clothing before or after using the toilet? 
  3. Do you need help with cleaning after a bowel movement? 

For patients with indwelling urinary catheters, the usual management of the catheter and leg bag should be examined. If bladder emptying is accomplished by intermittent catheterization, the examiner should learn who performs the catheterization and should have a clear understanding of the technique. For patients who have had ostomies for urine or feces, the examiner should determine who cares for the ostomy and should ask the patient to describe the technique. 

Feminine hygiene is generally performed while on or near the toilet, so at this point in the interview, it may be convenient to inquire about problems with the use of sanitary napkins or tampons. 

Dressing

We dress to go out into the world: to be employed in the workplace, to dine in restaurants, to be entertained in public places, and to visit friends. Even at home, convention dictates that we dress to entertain anyone except close friends and family. We dress for protection, warmth, self-esteem, and pleasure. Dependency in dressing obviously results in a severe limitation to personal independence and should be investigated thoroughly during the rehabilitation interview. 

Representative questions include the following: 

  1. Do you dress daily? 
  2. What articles of clothing do you regularly wear? 
  3. Do you require assistance putting on or taking off your underwear, shirt, slacks, skirt, dress, coat, stockings, panty hose, shoes, tie, or coat? 
  4. Do you need help with buttons, zippers, hooks, snaps, or shoelaces? 
  5. Do you use clothing modifications? 

Bed Activities

The most basic stage of functional mobility is independence in bed activities. The importance of this functional level should not be underestimated. Persons who cannot turn from side to side to redistribute pressure and periodically expose skin to the air are at high risk of developing pressure sores over bony prominences and skin maceration from heat and occlusion. For the person who cannot stand upright to dress, bridging (lifting the hips off the bed in the supine position) will allow the donning of underwear and slacks. Independence is likewise enhanced by an ability to move between a recumbent position and a sitting position. Sitting balance is required to accomplish many other activities of daily living, including transfers. 

Representative questions include the following: 

  1. Can you turn onto your front, back, and sides without assistance? 
  2. Can you lift your hips off the bed when supine? 
  3. Do you need help to sit or lie down? 
  4. Do you have difficulty maintaining a seated position? 
  5. Can you operate the bed controls on an electric hospital bed? 

Transfers

The second stage of functional mobility is independence in transfers. Skills to move between a wheelchair and the bed, toilet, bath bench, shower chair, standard seating, or car seat often serve as precursors to independence in other areas. Although a male patient can use a urinal to void without transferring, a female patient cannot be independent in bladder care without the ability to transfer to the toilet and will probably require an indwelling catheter. Travel by airplane or train is difficult without the ability to transfer from the wheelchair to other seating. Bathing or showering is not independent without the ability to move to the bath bench or shower chair. The inability to transfer to a car seat precludes the use of a motor vehicle with standard seating. Also included in this category is the ability to move from a seated position to a standing position. Low seats without arm supports present a much greater problem than straight-backed chairs with arm supports. 

Representative questions include the following: 

  1. Can you move to and from the bed, toilet, bath bench, shower chair, standard seating, or car seat and the wheelchair without assistance? 
  2. Can you get out of bed without difficulty? 
  3. Do you require assistance to rise to a standing position from low or high seats? 
  4. Can you get on and off the toilet without help? 

Mobility 

Wheelchair Mobility 

Although wheelchair independence is more likely than walking to be inhibited by architectural barriers, it provides excellent mobility for the nonwalking person. With today's manual wheelchairs of lightweight materials and efficient engineering, the energy expenditure of wheeling on flat ground is only slightly greater than that of walking. With the addition of a motorized drive, battery power, and controls for speed and direction, a wheelchair can be propelled even by a person without the upper extremity strength necessary to propel a manual wheelchair and, thus, can help maintain independence in mobility. 

Quantification of manual wheelchair skills can be accomplished several ways. Patients may report in feet, yards, meters, or city blocks the distance they are able to traverse before resting. Alternatively, the number of minutes they can continuously propel the chair can be specified, or the environment in which they are able to use the chair can be described (e.g., within a single room, around the house, or throughout the community). 

Representative questions include the following: 

  1. Do you propel a wheelchair? 
  2. Do you need help to lock the wheelchair brakes before transfers? 
  3. Do you require assistance to cross high-pile carpets, rough ground, or inclines? 
  4. How far or how many minutes can you wheel before you must rest? 
  5. Can you move independently about your living room, bedroom, and kitchen? 
  6. Do you go out to stores, to restaurants, and to friends' homes? 

With any of these functional levels of wheelchair mobility, patients should be asked what keeps them from going farther and whether help is needed to lift the wheelchair into an automobile. 

Ambulation 

The final level of mobility is ambulation. In the narrow sense of the word, ambulation is walking, and we have used this definition to simplify the following discussion. However, within the sphere of rehabilitation, ambulation may be any useful means of movement from one place to another. In the view of many rehabilitation professionals, the person with a bilateral above-knee amputation ambulates with a manual wheelchair, the patient with C-4 tetraplegia ambulates with a motorized wheelchair, and the survivor of polio in an underdeveloped country might ambulate by crawling. To some, driving a motor vehicle also is a form of ambulation. Ambulation ability can be quantified the same way wheelchair mobility is quantified. Persons may report the distance they are able to walk, the duration between necessary rest periods, or the scope of the environment within which they walk. 

Representative questions include the following: 

  1. Do you walk unaided? 
  2. Do you use a cane, crutches, or a walker to walk? 
  3. How far or how many minutes can you walk before you must rest? 
  4. What stops you from going farther? 
  5. Do you feel unsteady, or do you fall? 
  6. Can you go upstairs and downstairs unassisted? 
  7. Do you go out to stores, to restaurants, and to friends' homes? 
  8. Can you use public transportation (e.g., bus, subway) without assistance? 

Operation of a Motor Vehicle 

In the perception of many patients, full independence in mobility is not attained without the ability to operate a motor vehicle independently. Although driving skills are by no means necessary for urban dwellers with readily available public transportation, they may be essential to persons living in a suburban or rural environment. Driving skills should always be assessed in patients of driving age. 

Representative questions include the following: 

  1. Do you have a valid driver's license? 
  2. Do you own a car? 
  3. Do you drive your car to stores, to restaurants, and to friends' homes? 
  4. Do you drive in heavy traffic or over long distances? 
  5. Do you use hand controls or other automobile modifications? 
  6. Have you been involved in any motor vehicle accidents or received any citations for improper operation of a motor vehicle since your illness or injury? 

REFERENCES

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Ordinarily, the patient history is obtained in an interview of the patient by the physician. If communication disorders and cognitive deficits are encountered during the rehabilitation evaluation, additional collaborative information must be obtained from significant others accompanying the patient. The spouse and family members are valuable resources. The physician also may find it necessary to interview other caregivers, such as paid attendants, public health nurses, and home health agency aides. 

The major components of the history are the chief report of symptoms, history of the present illness, functional history, past medical history, review of systems, patient profile, and family history. 

Chief Report of Symptoms 

The goal in assessing the chief report of symptoms is to document the patient's primary concern in his or her own words. The report often is an impairment in the form of a symptom that implies a certain disease or group of diseases. The report of “chest pain when I walk up a flight of stairs” suggests cardiac disease, and a report that “ my hands ache and go numb when I drive” hints at carpal tunnel syndrome. 

Of equal importance is recognition that a chief report of lost function also may be the first implication of a disability or handicap. The homemaker's report that “my balance has been getting worse and I've fallen several times” may be related to disease involving the vestibular system and to disability created by unsafe ambulation. Similarly, the farmer's declaration that “I can no longer climb up onto my tractor” not only suggests a neuromuscular or orthopedic disease but also conveys to the physician that the disorder has resulted in a handicap by virtue of the patient's inability to accomplish vocational expectations. 

History of the Present Illness 

The history of the present illness is obtained when the patient tells the story of the medical predicament. All physicians at some time during their medical education have no doubt been admonished to “listen to your patients, for they will tell you their diagnosis” Few maxims are so true. When necessary, patients should be asked to define the specific words they use. It is often surprising to find out what “numbness” or “weakness” really means. Specific questions relating to a particular symptom may also help focus the interview. Using these techniques, the physician gently guides the patient to follow a chronological sequence and to describe fully the symptoms and their consequences.  

Above all, the patient should be allowed to tell the story. More than one symptom may be elicited during the interview, and the physician should document each problem in an orderly fashion (Table 1-2) (1). 

TABLE 1-2. Analysis of Symptoms
1. Date of onset  

2. Character and severity  

3. Location and extension  

4. Time relationships  

5. Associated symptoms  

6. Aggravating and alleviating factors  

7. Previous treatment and effects  

8. Progress, noting remissions and exacerbations  

A complete list of current medications should be obtained. Polypharmacy is encountered commonly in people with chronic disease, at times with striking adverse effects. Side effects of medications can further impede cognition, psychological state, vascular reflexes, balance, bowel and bladder control, muscle tone, and coordination already impaired by the present illness or injury. 

The history of the present illness should include a record of handedness, which is important in many areas of rehabilitation. 

REFERENCES

Source: Physical Medicine and Rehabilitation - Principles and Practice

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As with other branches of medicine, the cornerstone of rehabilitation medicine is a meticulous and germane patient evaluation. Therapeutic intervention must be based on proper patient assessment. The disability cannot be isolated from preexisting and concurrent medical problems. Although the rehabilitation evaluation encompasses all elements of the general medical history and physical examination, its scope is more comprehensive; thus, the rehabilitation evaluation provides a broader perspective. 

Evaluation of Function 

Medical diagnosis concentrates on the historical clues and physical findings that lead the examiner to the correct identification of disease. After the medical diagnosis is established, the rehabilitation physician must then ascertain the functional consequences of disease that constitute the rehabilitation diagnosis. An adept functional assessment requires the examiner to have a clear understanding of the distinctions among disease, impairment, disability, and handicap. 

If the disease cannot be challenged directly through medical or surgical means, measures are used to minimize the impairment. For example, a weak muscle can be strengthened or a hearing impairment can be minimized by an electronic aid. With chronic disorders, disease and impairment are not reducible; hence, intervention must address the disability and the handicap. The identification of intact functional capabilities is essential to successful rehabilitation. When intact capabilities can be augmented and adapted to new uses, functional independence can be enhanced. 

Case 1 

AW had gained much enjoyment and self-esteem as a competitive runner before his spinal cord injury. During and after inpatient rehabilitation, he vigorously pursued a cardiovascular and upper extremity conditioning program. After obtaining an ultra-lightweight sport wheelchair, he resumed competitive athletics as a wheelchair racer, winning several regional races. 

Comment: AW's intact capabilities included normal arm strength, a competitive spirit, and self-discipline. Through augmentation and adaptation, he regained enjoyment and self-esteem in his athletic endeavors. 

Despite their best efforts, physicians are occasionally unable to ascertain the specific disease responsible for a patient's constellation of historical, physical, and laboratory findings. Medical management must then be symptomatic. Although highly desirable, diagnosis is not a necessary prerequisite to the identification and subsequent management of functional loss. To determine expectations of future disease activity based on past activity, the rehabilitation physician should attempt to characterize historically the temporal nature of the disease process. 

CASE 2 

FZ, a 62-year-old woman, presented with difficulty climbing stairs. Questioning revealed that she and her husband had been in the habit of taking a 30-minute evening walk for many years, but 2 years earlier, fatigue began to limit her to no more than a few blocks. During the previous year, she had had difficulty rising from low seating, and 6 months previously, she reluctantly quit taking walks. During the preceding few weeks, she had found that climbing stairs was a burden, and she had started taking showers because she needed assistance getting out of the bathtub. 

FZ reported no sensory deficits. Physical examination showed hypotonic muscle stretch reflexes and predominantly proximal muscle weakness. Electrodiagnostic studies and muscle biopsy demonstrated a noninflammatory myopathy; however, further extensive evaluation failed to determine a cause. FZ was provided with a bath bench, a toilet seat riser, a lightweight folding wheelchair for long-distance mobility, and a cane for short distances. She was instructed in safe ambulation with the cane, operation of the wheelchair, energy conservation techniques, and the proper placement of bathroom safety bars. Safe automobile operation was documented, and she was provided with a handicapped parking sticker. The philosophy of rehabilitation medicine concerning her potentially progressive muscle weakness was discussed with her, and she was given supportive counseling. 

When FZ returned for a follow-up examination 1 month later, muscle testing showed only slight progression of her weakness, and her functional capabilities had not changed. Another follow-up examination was scheduled for 6 weeks later. 

Comment: Although a specific diagnosis was not established, rehabilitation intervention specific to FZ's functional losses was accomplished. Such extrapolation is not always accurate; however, serial evaluations performed at regular follow-up intervals allow the rehabilitation physician to identify and minimize future functional loss. 

Comprehensiveness of Evaluation

Unlike some medical specialties, rehabilitation medicine is not limited to a single organ system. Attention to the whole person is a rehabilitation absolute. The goal of the rehabilitation physician is to restore handicapped people to the fullest possible physical, mental, social, and economic independence; this requires analysis of a diverse aggregate of information. Consequently, the person must be evaluated in relation not only to the disease but also to the way the disease affects and is affected by the person's family and social environment, vocational responsibilities and economic state, avocational interests, hopes, and dreams. 

CASE 3 AND 4 

CC, a 63-year-old piano tuner, had a left cerebral infarction manifested only as minimal dysfunction of the dominant right hand. Despite demonstrating discrete digit function in the involved hand on physical examination, he was psychologically devastated to find that he could no longer accomplish the fine but elegant motor patterns necessary to continue in his profession. 

BD, a 63-year-old corporate attorney, had a left cerebral infarction resulting in severe spastic weakness of his nondominant upper extremity. He did some paperwork every day during his inpatient rehabilitation and returned to full-time employment shortly after completing treatment. 

Comment: For each person, the degree of impairment has little or no relationship to the severity of resultant disabilities and handicaps. 

Interdisciplinary Nature of Evaluation

Although most of this chapter addresses the patient history and physical examination as they relate to the rehabilitation evaluation, these are only part of the comprehensive rehabilitation assessment. This statement is not meant to deprecate the usefulness of these traditional tools of the physician. Both are of critical importance and serve as the basis for further evaluation; yet, by their nature, they also are limited. Speech and language disorders can inhibit communication. Subjective interpretation of the facts by the patient and the family can cloud the objective assessment of function. Performance is not assessed optimally by interview. 

For example, inquiring about ambulation skills during the interview may identify a potential problem, but such skills can be assessed objectively and reliably only by having the physician and physical therapist observe the patient during ambulation in various situations. Likewise, the occupational therapist must assess the performance of activities of daily living, and the rehabilitation nurse must assess the safety and judgment of the patient while in the ward. The speech therapist furnishes a measured assessment of language function and, through special communication skills, may obtain information from the patient that was missed during the interview. The rehabilitation psychologist provides a quantified and standardized assessment of cognitive and perceptual function and a skilled assessment of the patient's current psychological state. Through interaction with the patient's family and employer, the social worker can provide useful information that is otherwise unavailable regarding the patient's social support system and economic resources. The concept of the rehabilitation team applies not only to evaluation of the patient but also to ongoing management of the rehabilitation process. 

Setting and Purpose 

Because of the expanding scope of rehabilitation medicine, the evaluation setting can be diverse. A necessary corollary to the setting is the purpose of the evaluation. Both the setting and the purpose will affect the format and extent of the evaluation. Traditionally, the inpatient rehabilitation unit has been the optimal setting for a comprehensive evaluation by the entire rehabilitation team. However, in these days of increasing medical costs and intervention by the government and other third-party payers, creativity must be used to accomplish comprehensive rehabilitation evaluations in the clinic and elsewhere in the community (Table 1-1). 

REFERENCES

Source: Physical Medicine and Rehabilitation - Principles and Practice

Although still controversial, discography (diagnostic intervertebral disc injection) is both an imaging study and a provocative physiologic study for determining whether an intervertebral disc is in fact a pain generator in a given patient (Table 68-7). Inserting a spinal needle into the center of the intervertebral disc and injecting contrast dye provides both physiologic information on whether a degenerative disc is painful and on anatomic features of the intervertebral disc. There is currently no other method to establish reliably whether a disc is a patient’s pain generator.

Clinical Presentation of Discogenic Pain

Patients with lumbar discogenic pain typically have low back pain but can also have pain referred to the buttock, hip, groin, thigh, or distal lower limb. (175). Discogenic pain is typically worse with lumbar flexion and unsupported sitting, as intradiscal pressures have been found to be higher in these positions (176). Physical examination should reveal a normal neurologic examination if the discogenic pathology does not affect the nerve roots.

Radiographic Correlation

MRI and CT of the lumbar spine can be useful initial assessment tools because they are noninvasive tests that allow for visualization of multiple discs. Although they have high sensitivity (Figs. 68-18 and 68-19) for detecting anatomic disc abnormalities, surgically proven internal disc disruption has been reported in cases of normal-appearing MRIs (177). MRI carries a high rate of false-positive findings, as shown in studies of asymptomatic patients (178). In addition, they cannot provide the physiologic information about whether an abnormal- appearing disc is actually a pain generator. Although highintensity signal zones (HIZ) in the posterior annulus on MRI have been linked to discogenic pain (Fig. 68-19), the HIZ can also occur in asymptomatic patients (179–182). With no pathognomonic features of discogenic pain and a high falsepositive rate of anatomic findings on noninvasive diagnostic tests, the diagnosis of symptomatic lumbar disc diseases requires a physiologic study for better clinical correlation of a patient’s pain with CT or MRI abnormalities. Provocation discography is a physiologic test for discogenic pain.

Anatomy and Pathophysiology of Discogenic Pain

The intervertebral disc is a well-innervated structure with A-delta and C-pain fibers (183) containing nociceptive substances such as substance P, calcitonin gene-related product, VIPs in the annulus fibrosis (184–186). Nerve growth factor has been found in both the annulus fibrosis and nucleus pulposus, which may increase pain sensitization (187). In healthy intervertebral discs, only the outer one third of the annulus fibrosis is innervated. Study of intraoperative samples from degenerative intervertebral discs of patients with chronic back pain demonstrated evidence of inward growth of nerve fibers along the radial fissures into the inner annulus (185,186). The presence of the neural structures and nociceptive fibers is believed to be the anatomic basis of chronic low back pain due to degenerative disc diseases. Discogenic pain may occur in internal disc disruption, which is a condition characterized by a degraded nucleus pulposus with radial fissures extending into the peripheral annulus fibrosis (Fig. 68-19) (188,189). The outer margin of the annulus is intact. The nucleus pulposus, reaching the innervated outer annulus through the annular fissures, invokes an intensive local inflammatory process. These inflammatory substances irritate and sensitize the nociceptive fibers in the outer annulus. The threshold for nociceptive mechanical stimulation is lowered in these chemically sensitized nociceptors. Chronic discogenic pain may result from mechanical stimulation of sensitized nociceptors with normal lumbar disc loading. In fact, intraoperative mechanical stimulation of the posterior annulus in the presumed painful segment induced low back pain in one study (190). Degenerative disc disease is believed to account for some 40% of patients with chronic low back pain of unclear origin (191).

FIGURE 68-18. Lateral plain film nucleography demonstrating a posterior annular fissure in the L4-5 and L-S1 discs, respectively, through which contrast leaked into the ventral epidural space. Compare this image with that in Figure 68-23. The nucleography of the L3-4 discs was normal. The patient had concordant back pain at the L4-5 and L5-1 discs but no pain at the L3-4 discs.

FIGURE 68-19. T2-weighted sagittal images of lumbar spine. MRI demonstrating degenerative disc disease, especially at L5-S1.

Indications

Indications for discography appear in the “Position Statement on Discography” from 1988 and 1996 by the Executive

Committee of the North American Spine Society (192):

  • Patients with unremitting spinal pain of greater than 4 months and unresponsive to all appropriate methods of conservative therapy
  • Patients in whom other investigations have failed to explain the source of pain
  • Chronic back pain patients who are contemplating intradiscal or surgical procedures such as spinal fusion

Technique

Discography is generally performed in a radiologic suite or an operating room. The patient is placed in either a prone or oblique side-lying position. A pillow is placed under the patient’s abdomen to reverse lumbar lordosis. The lumbosacral area is prepared and draped in a sterile fashion. The patient’s vital signs should be monitored and oxygen saturation recorded with a pulse oximeter. A peripheral intravenous line should be established for light conscious sedation.

An AP fluoroscopic view is then used to identify the appropriate disc level. The fluoroscope is tilted in either a cephalad or caudad direction to best visualize the target disc space on radiograph. The C-arm is then rotated ipsilaterally to place the superior articular process of the subjacent vertebral body in a position that bisects the vertebral body above. An appropriate size spinal needle, typically a 25-gauge, 3.5-in. spinal needle is used to infiltrate the skin and subcutaneous tissue down to the superior articular process with 1% lidocaine. Caution should be exercised not to inject local anesthetic overzealously in the superior articular process area in order to avoid potential spread to the epidural or nerve root areas, thus compromising the patient’s ability to perceive pain during the subsequent provocative discography. To reduce the chance of discitis, a two-needle technique with 18- or 20-gauge, 3.5-in. introducers and 22- or 25-gauge, 6-in. inner needles, is recommended.

The introducer needle is inserted and directed to the outer edge of the superior articular process in the AP view and just to the anterior border of the superior articular process in the lateral view. The inner needle is then inserted through the introducer and slowly advanced to the center of the nucleus pulposus using alternating AP and lateral views. If the patient complains of radicular pain or paresthesias in a nerve root distribution during needle advancement, the needle should be withdrawn and redirected. If a pressure-controlled system is used for the injection, the needle is connected to an injection system with a manometer that is filled with nonionic and water-soluble contrast. The injectionist then injects contrast slowly, monitoring the pressure reading and the patient’s reports of pain simultaneously. The opening pressure is the pressure reading at the first appearance of dye in the disc on fluoroscopy. The endpoint of the injection occurs when the patient reports concordant pain (defined as reproduction of pain in the same location and intensity), or when 2 mL of total volume is injected into the disc or the pressure reading reaches 90 lb per square inch (psi). To help minimize the chance of discitis, 5 to 10 mg of cefazolin can be injected into each disc before needle removal. One level above and below the disc with concordant pain should be also studied so as to serve as a control (Figs. 68-20 to 68-22).

Information obtained from discography includes the volume of contrast injected, the patient’s pain response (no pain, dissimilar or discordant pain, similar pain, and exact pain provocation or concordant pain), degree of resistance to injection, morphology of the nucleogram, and postdiscogram CT morphology of the disc (193).

FIGURE 68-20. Sagittal T2-weighted lumbar spine MRI demonstrating degenerative disc disease at L5-S1 and possible degenerative disc disease at L4-5 and L3-4.

FIGURE 68-21. Lateral view of lumbar discograms reveals a posterior annular fissure at L4-5 and L5-S1 discs. The discography reproduced the patient’s clinical symptoms (concordant) at L4-5 and L5-S1 discs but no pain at L3-4 discs.

FIGURE 68-22. AP view of lumbar discograms demonstrated left side posterior annular fissures.

Postinjection CT scanning provides an axial view of the injected discs (Fig. 68-23). Patterns of radial and concentric annular fissures are more clearly defined in this plane. Postdiscography CT scanning should be performed within 2 hours of the discogram to prevent diffusion of dye out of the nucleus. The Dallas Discogram Description, in addition to recording the pain and contrast volume injected, describes morphologic degrees of annular degeneration and disruption (194). Annular degeneration and disruption are graded by the percentage of the contrast injected that fills the annulus and annular fissures toward the outer annulus as revealed by the contrast (Table 68-8) (195). A study by Derby et al. found that there was a significant correlation between the extent of annular disruption on CT and the rate of symptomatic disc on discography, with significant differences between grade 3 and 5 versus grade 0 and 2 (196).

FIGURE 68-23. Lumbar postdiscography CT image demonstrating the track of contrast that leaked through a radial fissure into a circumferential outer annular fissure.

A positive discogram requires a concordant pain response, an abnormal nucleogram, and a normal control level. In contrast, multilevel painful discs without a normal control disc on injection are unexplainable and cannot be regarded as positive.

Validity of Discography

In a prospective and controlled study in 1990, by applying modern manometry and postdiscography CT technology, refined needle placement techniques, less irritating contrast dye, stressing concordant pain, or discordant pain in addition to disc morphology (195), Walsh concluded that using stringent criteria, the false-positive rate of lumbar discography in asymptomatic individuals is 0% and the true-positive rate in symptomatic patients is 89% (189). However, Walsh’s study is limited by its small sample size (i.e., only ten controls and seven patients).

In a retrospective study, Derby et al. reported that a patient with a chemically sensitive disc, defined as one having a concordant pain response provoked with intradisc pressure of less than 15 psi as measured by a manometer, has a better outcome with interbody fusion versus intertransverse fusion surgery (197). This better surgical outcome presumably resulted from the removal of the mechanical load or stimulation to the chemically sensitive disc through removal of the painful intervertebral discs and stabilization with interbody fusion (197). Nevertheless, these investigators pointed out that discography should never stand alone as a diagnostic tool and sole factor for a clinical decision. The presence of a chemically sensitive disc does not rule out other coexisting sources of pain, nor does it exclude patients with excessive pain magnification. Discography should be used in conjunction with other diagnostic tests, such as MRI and CT scans, as well as the patient’s history, physical examination findings, response to a comprehensive therapeutic program, and psychometric profile information. Therefore, careful candidate selection is the key to maximizing clinically valuable data from discography. A recent study by Carragee et al. in 2000, although controversial, revealed a high false-positive rate with lumbar discography in a mixed population of 26 asymptomatic patients (182). A significant positive pain response and pain-related behavior with discography were found in 10% of the pain-free group and in 83% of the somatization disorder group. Discs with annular disruption were more likely to be painful on injection. The study concluded that if strict criteria are applied, the rate of false-positive discography may be low in subjects with normal psychometric profiles. Schwarzer et al. in 1995 (183) reported that a discogram is likely to provide highly specific information on the painful lumbar disc when the following characteristics are present: (a) unremitting low back pain persisting after 6 months of conservative care; (b) no prominent psychological dysfunction; (c) injection of all degenerated discs and one normal disc by MRI; or (d) combination of the results of appropriately and carefully performed provocative and imaging tests.

Complications of Discography

Potential complications of discography include discitis (0.05% to 4%), nerve root injury, subarachnoid puncture, chemical meningitis, bleeding, and allergic reaction (192). Use of sterile technique, a two-needle technique, as well as intradiscal antibiotics, can reduce the risk for infection (198).

Summary

In addition to providing imaging of disc morphology, discography is the only provocative physiologic test that can provide information on whether a degenerative disc is the source of pain. In appropriately selected patients, discography is a safe, reproducible, objective diagnostic tool when testing includes volume, pressure, fluoroscopic abnormalities, and pain provocation. Discography results help guide surgical management of chronic back pain. A negative discogram or a multilevel positive discogram without a painless control level can help to exclude a patient as a surgical candidate. Conversely, a singleor double-level positive discogram, along with other clinical data, can help to guide operative planning with respect to fusion or other surgical procedures. This potentially optimizes surgical outcomes. Whether diagnostic discography will actually change surgical outcome depends on many factors, such as a patient’s psychosocial factors, job situation, and the surgical technique employed. The true value of diagnostic discography will likely remain controversial until a prospective, randomized, double-blind, and controlled clinical trial on the outcomes of surgery based on discography is carried out.

Refferences

Source:  Physical Medicine and Rehabilitation - Principles and Practice

Coccyx pain (coccydynia) apparently occurs far less commonly than lumbosacral pain. Coccydynia can be a severe and persistent pain, causing significant suffering, frustration, and functional limitations (199). These patients often have a history of coccyx trauma (e.g., from a fall or childbirth) resulting in contusions, fractures, dislocations, or other injuries. However, other cases are idiopathic. Typical symptoms include focal tailbone pain, particularly worse with sitting and sometimes immediately worse upon going from sit-to-stand (199). Careful screening should seek to exclude malignancies of the spine (e.g., chordoma) and intrapelvic structures (e.g., rectum) (199,200). Useful diagnostic studies may include x-rays, MRI, CT scans, and colonoscopy (199). Dynamic radiographs comparing coccygeal alignment and angulation while sitting (weight bearing on the coccyx) versus standing may reveal dynamic instability (dislocations) not visualized via non—weight-bearing studies (201,202).

Injections for coccyx pain may include focal corticosteroids placed at the posterior coccyx or into a sacrococcygeal or coccygeal joint, ideally performed under fluoroscopic guidance to maximize injection accuracy and minimize the risk for inadvertent puncture of the rectum or other nearby structures. Diagnostic nerve blocks can include local anesthetic blockade of the somatic posterior coccygeal nerve fibers as well as the sympathetic nerve fibers (ganglion Impar) anterior to the coccyx (203–207). For both diagnostic and therapeutic injections, it is frequently helpful to simultaneously block both the anterior (sympathetic) and posterior (somatic) nerves. This combination can more completely shut off all afferent inputs from the coccyx, with resultant relief implying that the coccyx is the source of pain. Also, effective local anesthetic blockade can provide therapeutic benefit, sometimes including complete and permanent relief (208). The mechanism is perhaps via disrupting hyperactive and/or hypersensitive afferent reflex arcs or sympathetically maintained pain. The various technical approaches to the ganglion Impar include injecting a spinal needle from inferior to the coccyx (above the anus), or passing the needle through the sacrococcygeal joint or through the intracoccygeal joints (203–207). Fluoroscopic guidance is crucial for safe and effective performance of sympathetic nerve blocks at the ganglion Impar, especially given the close proximity to the bacteria-laden rectum. Nerve ablation in the coccyx region may be beneficial for selected patients with coccydynia (207). Most patients with tailbone pain will obtain adequate relief via nonsurgical treatments such as injections, thus often avoiding the need for surgery and its potential complications (209).

Refferences

Source:  Physical Medicine and Rehabilitation - Principles and Practice

The sacroiliac (SI) joint can be a significant source of low back pain (141–143). Etiologies of SI pain include spondylo arthropathy, crystal arthropathy, septic arthritis, trauma, and pregnancy diasthesis (144). In addition, SI joint dysfunction (pain from a biomechanical disorder without a demonstrable lesion) has been proposed as a possible etiology of SI pain (145). Among patients with chronic low back pain, a study using a single block technique of the SI joint with a local anesthetic, estimated the prevalence of SI joint pain as between 13% and 30% (141). A study on 54 patients with unilateral low back pain suspected from the SI joint, using a dual local anesthetic block technique, demonstrated an 18.5% prevalence of SI joint-based pain (142).

Anatomy and Pathophysiology

The SI joint is a true diarthrodial joint and is innervated by nerves from the L4 through S2 levels (146). Studies on human and animal SI joint capsules demonstrated the presence of mechanoreceptors and nociceptors (147,148). The SI joint has a close anatomic relationship to the lumbosacral plexus and the L5 and S2 nerve roots. Therefore, SI joint pathology such as inflammation or chronic synovial irritation from joint dysfunction can not only serve as a pain generator, but also can potentially involve the nearby neural tissues and induce pain. Injection of the joint with contrast material in healthy volunteers produced pain that extended approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine in a linear strip (146). Patients with pain diagrams similar to the SI joint pain mapping were confirmed as having SI pain with SI joint provocation injection (149).

Diagnosis of the SI Joint Pain

The value of clinical data from history and physical examination in the diagnosis of SI joint pain remains controversial (141–143,150,151). Although SI joint pain frequently manifests as pain in the sacral sulcus areas, SI joint pain can refer to the buttock, lower lumbar region, groin, and lower limb (152). However, none of these symptoms, signs or various provocative tests are pathognomonic for SI joint pain. Other sources of low back pain, such as lower lumbar Z-joint arthropathy or degenerative disc disease, can present similarly. By using fluoroscopically guided SI joint blocks to confirm cases of SI joint pain (Fig. 68-17), several authors have shown that clinical medical history and pain provocation tests are not reliable in the diagnosis of SI joint pain (141–143,150,151).

FIGURE 68-17. AP view of right SI joint arthrogram demonstrating contrast in the posterior (medial) and anterior (lateral) joint space. This 23-year-old man complained of persistent right-sided low back pain after a front-impact motor vehicle collision. He was forcefully pressing his right foot on the brake during the collision, with resultant right SI pain. Injecting the right SI joint with 1 mL of 2% lidocaine relieved 90% of his low back pain, lasting several hours. SI joint injections can have both diagnostic and therapeutic benefits.

In a clinical trial involving 84 patients with possible low back pain from the SI joint, Dreyfuss et al. studied clinical history and the 12 physical examination tests deemed most reliable by a panel of experts for isolating SI joint pain (143). Fluoroscopically guided intra-articular SI joint injections of local anesthetic and corticosteroid were performed to confirm the diagnosis. The criterion for a positive result was the achievement of at least 90% pain relief postinjection. The study demonstrated that neither the history nor the physical examination data was of significant value in diagnosing SI joint pain (141). Maigne et al. investigated 54 patients with clinical features of chronic low back pain compatible with the origin in the SI joint with the following features: unilateral buttock pain, tenderness over the SI joint, normal lumbar CT scan, failure of previous epidural, or facet injections (142). They applied seven “SI pain provocation tests” before and after the dual block of SI joint. To be considered diagnostic, patients had to report 100% pain relief after block with 1% lidocaine and at least 75% pain relief after block with 0.25% marcaine. There was an 18.5% rate of positive responders to this dual block. The result demonstrated that none of the SI joint pain provocation tests were able to isolate SI joint pain (142). Slipman et al. performed a diagnostic fluoroscopically guided SI joint injection in 50 consecutive patients with low back pain presumed to be from SI joint (162). A reduction of the VAS rating by at least 80% was considered a positive response to SI joint block. The authors concluded that the various SI joint provocative maneuvers were not useful in diagnosing SI joint pain (162). A diagnostic imaging study done with bone scan was found to have low sensitivity and high specificity for diagnosing the SI joint syndrome (149). This study excluded patients with SI joint pain from inflammation, such as in a seronegative spondyloarthropathy. However, another study using single photon emission CT (SPECT) was performed in 54 patients with symptoms of low back pain of at least 3 months duration, the presence of higher erythrocyte sedimentation rate, and higher C-reactive protein levels who had not received anti-inflammatory drugs. The results demonstrated high sensitivity (97%) and specificity (90%) in diagnosing inflammatory disease within SI joints (153).

Indications

Although exact guidelines for administering an SI joint injection are unclear, one set of guidelines is as follows: a diagnostic SI joint injection is indicated in patients with pain over the sacral sulcus who have failed to respond to 4 to 6 weeks of directed physical therapy and oral nonsteroidal anti-inflammatory agents (154,155).

Technique

The patient is placed in a prone position. The skin over the sacral area is prepped and draped in a sterile manner. By rotating the C-arm fluoroscope slightly contralaterally, but occasionally ipsilaterally, intermittent fluoroscopy is used to identify the medial joint line when it just separates from the lateral joint line of the SI joint. Some adjustment of the C-arm in the caudal or cephalad plane may then be used to best isolate and visualize the lower portion of the SI joint. The targeted area is the small lucent area just below the joint line. The skin entry site is selected slightly lower than the targeted area, and is infiltrated with a small amount of 1% lidocaine. A 22- or 25-gauge 2.5 to 3.5-in. spinal needle is inserted and directed down to contact the ilium. The needle is then withdrawn 2 to 3 mL and redirected toward the inferior-medial aspect of the joint into the lucent area (156). Typically, the needle tip will bend if it enters the SI joint, and a tactile sense of a sliding into the joint will be appreciated (157). Applying a slight curve at the tip of the needle prior to use may help assist this process (156). A small amount of contrast is then injected to outline the SI joint. If the needle fails to plunge and no contrast flow is seen on fluoroscopy, one technique advocates that the needle be slowly extracted a millimeter at a time, while continuing to maintain pressure on the plunger until there is a loss of resistance (157). Once an SI joint arthrogram without a vascular uptake pattern is demonstrated, anesthetic with or without steroid is injected (depending upon if the injection intent is for therapeutic or diagnostic use, respectively). One milliliter of 2% lidocaine or 0.5% bupivacaine mixed with 40 mg/mL of triamcinolone acetonide, or other equivalent corticosteroid, is injected into the SI joint (158–161). A total of no more than 2.0 mL of volume is generally injected due to the limited volume of the SI joint (160).

Efficacy

Diagnostic Injection of SI Joints

Because the gold standard for proof of SI joint pain is unclear, the sensitivity and specificity of diagnostic SI joint injections has not been clearly established.

Maigne et al. (142) have suggested that the SI joint block has diagnostic value only for pain from intra-articular sources, not for SI joint pain from extra-articular sources such as the periosteum, interosseous ligaments, erector spinae muscles, or fascial elements, all of which contain nociceptors and hence are possible pain generators (147,148). Therefore, an SI joint block procedure that involves injection of an agent into the extra-articular components rather than the joint cavity may show better correspondence to the clinical features. Future studies should address whether the combination of pericapsular and intra-articular SI joint injection with corticosteroid can improve outcomes.

Therapeutic Injection of the SI Joint

The efficacy of SI joint corticosteroid injections has been reported in prospective and retrospective studies of patients with spondyloarthropathy (163,164). In a retrospective study, Slipman et al. reported a significant benefit from SI joint steroid injection in patients with SI joint syndrome (165). Thirty-one patients with chronic SI joint syndrome received an average of 2.1 fluoroscopic-guided SI joint corticosteroid injections. The average follow-up was 94.4 weeks. Of the 29 patients who completed the study, there was a significant improvement in the Oswestry disability score, VAS, and work status (165). Although these retrospective results are encouraging, there are currently no prospective studies on the efficacy of fluoroscopically guided therapeutic SI joint corticosteroid injections.

Radiofrequency Ablation of the SI Joint

Radiofrequency ablation (RF-A) has recently been proposed as a potential long lasting treatment for SI joint pain, and has been gaining more popularity along with other nonsurgical spinal procedures. RF-A involves de-innervation of the SI joint nerves believed to be responsible for generating pain (166,167). It is indicated as a treatment for those patients who have failed more conservative measures, yet only received transient benefit from diagnostic and/or therapeutic injections of the SI joint (168). The true effectiveness of RF-A of the SI joint is unclear, as of yet (169). In contrast to RF-A in treating lumbar spine facet-mediated pain, which directly targets the medial branches of the dorsal rami, which innervate the facet joints (170), the SI joint has complex innervations (171). Therefore, no consistent procedural technique has been described in the literature. Multiple studies have, in fact, been done using various techniques for RF-A of the SI joint, which are summarized in Table 68-6. The table shows that there are variations among the techniques used in regard to structures, nerves, and patterns of ablation to the SI joint.

The table underscores the fact that there is no standard pattern of ablation and not enough available prospective data to determine which rami or branches should be ablated, or if a pattern technique (i.e., “leap frog” vs. “strip lesion”) is more efficacious. The studies do not show uniformity and additional studies to determine if RF-A is useful for treating chronic SI joint pain are warranted.

Refferences

Source:  Physical Medicine and Rehabilitation - Principles and Practice
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