The physical assessment helps the physician reliably document the back pain or neuropathy, which is challenging as several signs and symptoms may overlap. Repeat physical examinations are often necessary to construct the pathway to the offending lesion.
Examine the primary site of the discomfort and extend the evaluation to the shoulder, ribs, and pelvis to determine if there is a referred source. Shoulder pain may be referred from a subdiaphragmatic source; knee and hip pain may be referred from a lumbar spine lesion. The source of pain can be created by muscle or tendon insertions from the shoulders, ribs, or pelvis to the back and cause limitation in motion.
The neck evaluation will embody the head, including cranial nerves, and a fundoscopic evaluation, which will help assess for suspected intracranial pathology and lesions at the skull base that extend to the neck.
The spine is evaluated from the front, sides, and back. The curves of the spine are also assessed. Look for flattening of the lumbar curve. Assess for muscle spasms and decreased spinal mobility, which may be associated with ankylosing spondylitis. An accentuated lumbar lordosis can be associated with a protuberant abdomen. The accentuated thoracic kyphosis can be associated with compression fractures of the spine. Collapsed vertebrae can cause a protuberant spinous process such as that found in a gibbus deformity. Collapsed vertebrae have also been associated with osteoporosis and infections (such as tuberculosis, metastatic diseases, and multiple myeloma).
Look for differences in height of the shoulders and for tilt of the neck. If scoliosis is suspected create an imaginary line down the center of the spine and observe for curvature. Examine the iliac crest height to exclude pelvic tilt associated with leg length discrepancy.
Palpate the spine from behind. The patient may be in a sitting or standing position. Identify any prominent spinous processes. Palpate for tenderness on the spinous process. Inspect and palpate the paravertebral muscles for tenderness and spasm. Spasm of the paravertebral muscles causes the muscles to appear prominent, feel tight, and be tender on palpation. Palpate the sacroiliac joint. Feel and observe for fine muscle fasciculations and any areas of warmth.
The upper and lower back examinations include both sensory and motor pathway evaluations, which are beneficial for patients with a distorted posture or restricted limb movement.
Observe the patient rising from a sitting position without the use of arm support, if possible, without the use of arm support. Ask the patient to step up onto a platform or step. Alternatively, the patient may stand on his toes or roll back on his heels while lifting his toes. If there is proximal muscle weakness involving the pelvic girdle and legs the patient will have difficulty performing these activities.
Back pain and neuropathy can affect movement and attitude of the gait. Observe the gait pattern and inquire into the use of an ambulatory aid, for example, a cane, corset, wheelchair, or walker. Observe the gait from several projections. With aging, the normal step becomes short (even shuffling), with diminished speed and balance. The legs may be flexed at the hip and knees.
A gait disturbance can be characterized by several patterns, including antalgic, drop foot, and foot drag. Antalgic gait displays a shortened stance or bend in the affected limb, which may be due to pain at the hip, knee, or foot. Drop foot is due to weakness of the dorsiflexor muscles affecting the ankle and foot. The weakness causes the patient during the stepping to lift the knee higher than the unaffected leg and the foot appears to be slapping onto the floor. Drop foot can affect one or both sides of the body and is usually related to a lower motor neuron process. Foot drag can indicate a nerve injury and may not be muscular in origin. Upper or lower motor neuron lesions can be suspected.
A rectal examination and assessment of urinary function are useful for suspected plexopathy and spinal cord lesions.
Patients should be evaluated for tremors or involuntary movement in the digits of the hands and feet. Also determine if there is a sense of loss of balance by having the patient stand with closed eyes and feet together. A positive Rhomberg's sign is discovered by loss of balance and has been associated with posterior fossa or cerebellar symptoms.
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Deal With Your Pain, Lead A Wonderful Life An Live Like A 'Normal' Person. Before I really start telling you anything about me or finding out anything about you, I want you to know that I sympathize with you. Not only is it one of the most painful experiences to have backpain. Not only is it the number one excuse for employees not coming into work. But perhaps just as significantly, it is something that I suffered from for years.