World of Education/World of Education.iso/world_b/bkache56.zip/PART2.EXE/EXAM.TXT

Text File | 1992-12-04 | 20KB | 330 lines

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                      BACK PAIN EXAMINATION AND DIAGNOSIS
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       A visit to the doctor's office is an event filled with anxiety.
       The fact that the visit is in connection with your back pain
       makes it even more troublesome. Could it be cancer? Is a disc
       ruptured? Could I have meningitis or tuberculosis of the spine?
       What will happen to my job and work schedule if I have to go
       into the hospital?

       The good news, however, is that the diagnosis and treatment of
       back pain has been significantly advanced in recent years by a
       variety of new imaging methods and diagnostic tools which can
       determine the source of your back pain quickly and reliably.
       Unlike an obscure tropical disease, back pain today is usually
       diagnosed quickly and accurately. But the first step is always
       an examination by a physician.

       Although the format of an office exam varies depending on the
       doctor, the content remains roughly similar with some parts of
       the following "ideal" exam omitted by the clinician and other
       parts added or enhanced. The state of medical technology and the
       pattern of arriving at a logical medical diagnosis varies from
       patient to patient so do not be concerned about the exact
       sequence of events which are outlined below.

       Typically the physician will consider the following methods to
       arrive at a diagnosis of your specific back pain 1) a physical
       exam to determine normal back movement and limits 2) circulatory
       exam 3) neurological exam 4) X rays 5) exam of reproductive
       system if warranted 6) advanced imaging methods and diagnostic
       tests if warranted.

       The first step prior to the examination is for you to assemble
       prior patient records, X rays and lab tests which have been done
       to assess your back pain. Perhaps your family physician has
       previously ordered chest and back X rays and done a limited
       orthopedic examination and then referred you to a specialist.
       Maybe members of your family have a history of ruptured discs or
       back injuries. The more information and background you can
       assemble before the examination, the more quickly and accurately
       the physician can arrive at a diagnosis.

       Also take the time to jot down the history and description of
       the back pain. Did it begin on the job? Is it a chronic problem?
       How long has the pain been with you? Does it worsen when you
       stand, exercise, bend or lie down? Do weather or temperature
       changes affect the pain? Does warmth or cold relieve the pain?

       Do you drive long distances or sit at a desk all day? What types
       of exercise and sports do you engage in? Is your exercise
       regular or weekend in frequency? What medications do you take?
       Use words like sharp, dull, burning or stabbing to describe the
       pain. Do you smoke or drink alcohol? How would you describe your
       family and home life? How would you describe your current level
       of stress and emotional state? Is the backache or pain getting
       better or worse?

       Did you have meningitis as a child? Any other childhood
       diseases? Are the pains localized in your back, legs, neck or
       combinations of the above? Do the pains shoot into your legs and
       what movement or position causes the pain to move into your
       legs? Have you visited a chiropractor, physical therapist,
       acupuncture specialist?

       Have you had previous back operations? What home remedies have
       you tried? Do you have any infectious diseases such as
       tuberculosis? What is your job and how do you move your back
       during the day as you perform that job?

       Take a moment to assemble the answers to these questions before
       the office visit. Surprisingly the answers to these questions
       may lead the physician to immediately consider the exact range
       of tests which will confirm the source of the pain.

       After these preliminaries, the physical examination takes place.

       Normally the patient wears only a gown and may be asked to
       perform various movements either partially or fully unclothed so
       that the physician can note the movements and relative positions
       of your legs, back, neck and torso. Many physicians ask the
       patient to initially perform various movements and changes in
       posture without touching the patient. After this initial phase a
       "hands on" exam at the examination table usually follows.

       As you stand quietly before the physician he or she may begin by
       looking for clues. Is the posture and lordosis (curve of the
       lower back) within normal limits? Is the spine straight or
       curved? Are there any bends laterally to the side (a diagnostic
       hint of scoliosis?) Do the legs seem of nearly identical length?
       Are the shoulders stooped or straight? Any malformation of
       muscles?

       Next, usually without touching the patient, the physician
       requests a series of motions or activities to be undertaken. You
       may be asked to walk normally forwards and backwards. In
       addition you may be asked to walk on your tiptoes and then again
       on the heels. Do you have fallen arches/flat feet? Can you hop
       on one leg then the other? Can you twist and bend forwards,
       backwards and side to side? Can you bend and touch your toes
       without pain? You may be asked to maintain the position(s) in
       certain cases. The physician may ask you to comment on the
       presence or absence of pain during some of these simple
       exercises and movements. Information is now flowing to the
       physician and he is beginning to eliminate a some possible
       causes and consider others.

       Muscle spasm, vertebral disc status and nerve compression or
       irritation can be inferred from results of these simple tests.
       For example, a ruptured disc may cause pain when bending from
       side to side. Compounding the problem can be an overlap of
       symptoms among patients having both arthritis and disc ruptures.

       The next stop is usually to sit on examination table for a brief
       test of reflexes - tapping knees and ankles with a rubber
       hammer. This can reveal quite a bit about nerve compression and
       health in some back injuries.

       Next you may be asked to lie down on your back on the exam table
       for leg, calf, thigh and buttock comparative measurements. The
       reason for this is that damaged muscles which are infrequently
       used due to pain can atrophy, shrink or lose tone when a single
       muscle is compared to its "twin companion" muscle on the other
       side of the body.

       Some physicians may follow these tests with nerve checks by
       lightly touching or probing the skin of the leg, foot or calf
       with a pin or pointed object. The reason for this is that nerve
       roots which pass through the lumbar region of the lower back
       serve these extremities and if the nerve has been pinched or
       damaged in the vicinity of the spine, loss of sensation may be
       apparent in areas of the body served by those nerves.

       An adjunct to these nerve tests are related tests of muscle
       strength and tone. For example, the physician may ask you to
       lift, extend or pull a leg, foot or toe in a specific direction
       while he attempts to keep it in position. Conversely he may try
       to move a toe, leg or foot while he asks you to resist. This
       will tell the doctor about the condition of a nerve which passes
       through the lower back and the muscle tone of the extremity in
       question. Frequently the knees, ankles, and hips are tested for
       any sign of nerve damage by extension and retraction with
       resistance offered by the hand of the doctor.

       Routine blood circulation tests are also performed by checking
       skin color in the legs, back and buttocks. Pulse is checked in
       these regions. Blockage of blood flow in the leg may give rise
       to back and upper leg pain especially in the elderly.

       Still lying on your back, the doctor will probably instruct you
       to keep your knee straight as he slowly lifts your leg and foot
       from the table. A high angle of leg elevation in this position
       indicates healthy hamstrings and, if little pain is present,
       little likelihood of sciatic nerve pressure and ruptured disc
       injury as the cause of back pain.

       Conversely, tight hamstrings and pain in the lower back and
       buttocks are usually consistent with the possibility of disc
       injury. By the way, tight hamstrings are associated with back
       problems in general which speaks to the positive effect of an
       exercise program in preventing backaches.

       The doctor may next bring one or both knees and thighs close to
       your chest. For most people this should not be painful, but some
       types of back injuries can cause additional pain in this
       position and the doctor will note this. Hip joints are usually
       rotated in and out and extended to assess any painful positions
       and potential nerve or hip damage. Older patients are more prone
       to hip injuries and fractures - sometimes both back and hip
       injuries are found together in these patients.

       You will usually be asked to lie on your stomach while still on
       the exam table as the doctor directly feels along the length of
       your spine, kidneys and rib cage. He may press or tap and note
       both sound and sensation along the length of the spine. The
       kidneys will be probed and examined. Kidney pain is often
       confused with spinal pain in many patients.

       The pelvis will be felt and examined for pain. Ligaments, facets
       of the vertebrae and muscles along the spine are usually
       palpated (probed) by hand for tenderness or sign of injury. The
       doctor may ask you to tense or clench your buttocks. In some
       cases of nerve damage or pain, one of the two buttock muscles
       may be smaller or softer then the other during this maneuver and
       the difference between the two will be noted. Disc ruptures and
       nerve damage are sometimes suspected by loss of muscle tone
       localized on one side of the body - a valuable clue to a medical
       professional.

       A gynecologic exam may be requested for women, and this is
       usually performed by the woman's gynecologist rather than the
       orthopedic specialist or internist. For men a prostate exam done
       manually with the gloved physician's hand and/or also by newer
       ultrasound methods may be requested. Infections, tumors and
       other abnormalities of the reproductive organs sometimes are
       manifested in lower back pain.

       Laboratory blood tests are not normally done for the majority of
       back pain patients since muscle, bone and disc problems are
       usually the source of most back pains. However arthritis,
       infections and some tumors can be detected with blood tests. If
       a physician suspects one of these conditions, a blood chemistry
       profile group, blood count and ESR sedimentation test may be
       ordered.

       A blood count simply measures the number and concentration of
       white and red blood cells. If white cells are increased the
       patient may have an infection. If red cells are decreased, the
       patient may be suffering from anemia. The blood chemistry
       profile checks uric acid, phosphorous and calcium levels.
       Results of this test can reveal significant data about overall
       metabolism, possibility of gout as the cause of back pain and
       other indicators. The ESR sedimentation test reveals the general
       state of the body's immune system and the presence of
       unidentified infections. In addition, other blood tests can
       reveal the presence of certain forms of arthritis which can
       affect the spine.

       Most back pain patient will undergo a routine X ray of the
       spine. These standard X rays are normally used to reveal shape
       and curvature of the spine, compression of intervertebral discs,
       suggestions of arthritis, spondylosis and congenital
       abnormalities such as spina bifida. By themselves, X rays are
       not useful for conclusive diagnosis of soft tissue damage such
       as disc rupture. Similarly, the narrowing of space between two
       vertebrae may suggest the collapse of a disc, but the X ray does
       not produce an image of the soft tissue disc itself.

       A more specialized type of X ray image, the MRI (magnetic
       resonance image) also known as NMR (nuclear magnetic resonance)
       may be ordered to provide high resolution images of soft tissue
       structures such as the discs and spinal cord. NMR does not
       involve X ray radiation, but instead relys on high level
       magnetic and radio frequency pulses to produce a soft tissue
       cross section image of the area of study. This test is
       relatively expensive and only available at larger hospitals or
       special imaging centers. A computer processes the pulses of
       energy from the magnetic field and radio frequency beams as they
       pass through the patient to produce remarkably clear images of
       soft tissue.

       Another test which may be ordered is a CT (computerized
       tomography) also known as CAT scan which likewise produces
       images of a cross-sectional area of the body. Unlike NMR it uses
       X ray beams and is useful for imaging ruptured discs, vertebrae
       and the spinal canal. However it is limited in resolution and
       because of its X ray imaging method produces better images of
       bone and solid tissue than the NMR imaging method which is
       superior for soft tissue. In comparison to NMR imaging, CAT is
       less expensive but does require the patient to receive a small
       amount of X ray irradiation.

       A bone scan is another diagnostic test which may be considered
       for some patients. During this test a small amount of slightly
       radioactive dye is injected into the blood stream. Several hours
       after the injection, the patient is placed on a table or bed
       above which a radioactivity detector or sensor is slowly moved
       to detect accumulations of the radioactive material. Normal bone
       cells pick up or collect measurable amounts of this special
       radioactive material. Bone cells which are abnormal or dead may
       pick up little of the material. Finally, bone cells which are
       diseased, healing from fracture or hyperactive from tumor growth
       pick up extra amounts of the radioactive material. This "map" of
       concentrations of the radioactive material can thus reveal
       unusual bone cell activity or lack of it and thus assist in
       diagnosis. Arthritis of the spine, tumors and old fractures can
       thus be revealed by this diagnostic method.

       A myelogram is another test which may be suggested for some back
       pain patients. An injection of X ray dye is made into the spinal
       canal. This is normally done in the hospital on an X ray table
       or bed. After the dye has entered the spinal canal, X rays are
       taken. In most cases the patient will be tilted or rotated to
       allow the dye to flow upwards or downwards in the spinal canal.
       Additional X rays are taken after movement of the dye to a new
       area within the spinal canal. It should be noted that NMR or MRI
       imaging produce nearly the same or better detail than this
       method and for that reason the myelogram is gradually becoming
       less popular than the non-invasive NMR imaging exam. However in
       difficult diagnosis, the myelogram still has unique diagnostic
       value.

       A variation of the myelogram takes advantage of the fact that
       since the dye is designed for X ray detection, some physicians
       order a CAT scan following the myelogram to enhance the CAT
       image. The myelogram dye in the spinal canal is eventually
       absorbed by the body and excreted in the urine within a few
       days. Excellent images of the spinal canal are obtained by this
       method and are quite useful to a physician in diagnosing some
       types of back pain.

       A diskogram is an imaging method which examines a specific
       intervertebral disc. An X ray dye is inserted by needle directly
       into a disc which is suspected as damaged or ruptured. If a
       rupture has taken place, the X ray image of the dye will tend to
       flow out of the central core of the disc towards the area of
       disc rupture and thus reveal the presence or absence of disc
       injury. The test is obviously done under the control of a
       radiologist and placement of the needle is precisely located
       within a single disc.

       The EMG test does not involve X rays or imaging methods but is
       instead a test of nerve condition. Electrically conductive wires
       are inserted directly into a specific muscle and measurements
       are made of electrical activity. Damaged, spastic or injured
       muscles provide unique "signatures" of activity which are shown
       as tracings on graph paper. Thus the health of a specific muscle
       can be examined reliably.

       A nerve conduction test also uses electrical sensors to measure
       muscle activity, but in this case attempts to determine the
       speed at which a nerve impulse travels down a nerve path to or
       through a muscle. The time is takes for the impulse to travel
       can be graphed and nerve and muscle health or damage can be
       deduced from this data.

       This tutorial is merely a starting point! For further
       information on back care and back pain, be sure to register this
       software ($25.00) which brings by prompt postal delivery a
       printed, illustrated guide to back pain written by a physician
       plus two software disks. From the main menu select "Print
       Registration Form." Or from the DOS prompt type the command
       ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO
       Box 1506, Mercer Island, WA 98040. If you cannot print the order
       form, send $25.00 to the above address and a short letter
       requesting these materials. End of chapter.