EVALUATION

AND

DIAGNOSIS

If you've read this far, you probably have a good idea what kind of back pain you have. And you should know that if you are like most people, you probably will not benefit much from seeing a doctor or other healthcare professional, not in the long run, anyway. Sure, there are some things some healthcare professionals can do to relieve the pain, but your recovery is primarily up to you.

However, there are cases when seeing a professional for back pain is unavoidable. Your situation may be one of these. If you have tried my Four Weeks to A Better Back program, and, after four weeks, you don't feel at least a little better, perhaps you should consider seeing a professional. Should you decide to have your problem diagnosed professionally, it will help both you and the healthcare professional you choose if you know what to expect.

After reading the last chapter, you may have an idea what kind of professional you would like to see. Whomever you decide to consult, you will probably undergo a thorough evaluation and diagnosis process. It is impossible for me to

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describe all the variations on the back pain diagnosis procedure. Each professional may perform slightly different steps in diagnosing back problems, but my experience is that some aspects of the process are unavoidable. This chapter, therefore, will describe the procedure by which a doctor or other professional should diagnose your back problem, by discussing the basics and those parts of the procedure that are the most important. Later in this chapter I will discuss other, more sophisticated diagnostic tests such as x-ray and CT scans. For now, let's look at what you can expect on your first visit to a healthcare professional.

The Case History

Why is it that every time you go to a new healthcare professional they invariably ask you to fill out this long, boring form about yourself? Some forms even ask seemingly unrelated questions about how old your mother is and how many children in your family. Believe it or not, all these questions are important. How one of your parents died, for example, can mean a lot in diagnosing some health problems. Many health problems are geneticthey can be passed on from generation to generation. This also can be a factor when evaluating back pain.

Also on the form should be a place for you to describe your current problem, the reason you are in the office today. You will have an opportunity to discuss this with whomever is performing the examination, of course, but you should still try to be as descriptive here as space permits.

Evaluation and Diagnosis

The important information is where it hurts, when it started hurting (list a certain event, if applicable), what kind of pain you are experiencing, and so on. Being careful and specific on this form will give the examiner an idea what kind of problem you have before they see you. Remember, the healthcare professional is usually very experienced at reviewing these forms, and they will consult them often while discussing your problem with you.

Where Does it Hurt?

Part of a thorough examination is discussing with the patient the nature of the problem. It is during this discussion that the professional will gain the most useful information in diagnosing your problem. Often, it is my patient's answers to my questions about the kind and location of the pain that determines whether I decide to use x-rays or some other technique of exploration. So, as you can see, it is important that you be as specific as possible when discussing your pain with a healthcare professional.

The problem with trying to describe pain, back pain or otherwise, is that often pain seems to move around, and it can seem different from day to dayor even from hour to hour.

"OK. Now tell me where it hurts."

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Sometimes you will experience what feels like a sharp or electric sensation, and other times you will experience a dull ache. Sometimes you may experience two or three different kinds of pain at the same time. The reason for this is the same as the reason you can have a problem in one area of your back and experience pain in another, or even another part of your body: the type and severity of the pain depends on which nerves are affected. If the pain you are feeling is sometimes different, be sure to tell your examiner.

Keeping the above in mind, for our purposes, back pain can be divided into three different types. While, these descriptions are not definitive, they do help immensely in determining the nature of your back problem.

Type 1 back pain is usually caused by a problem in one or more "soft" tissues (skin, ligament or muscles or any tissue other than those in your spinal structure itself). The pain is usually acute and well localized. If you've ever pulled a muscle or sprained a ligament, you are familiar with this kind of pain.

Type 2 pain is a deep, sometimes dull ache that is usually the result of a problem with the spinal structure. I've discussed these structural problems several times. Usually degenerative in nature, they include worn facet joints and problems involving the discs. Fractured vertebrae can also be the cause of this kind of pain. Unlike Type 1 pain, Type 2 pain is not usually localized. Instead it often radiates to the shoulders and hips and thighs.

Type 3 pain is the sensation caused by the irritation of spinal nerves, such as pressure on a nerve from a bulging disc. This pain is usually acute, sharp and electric and can shoot down your arms or legs, or even cause neurologic changes such as a decrease of feeling or loss of strength. This is the kind of pain associated with sciatica.

Evaluation and Diagnosis

The Examination

Depending on how much a patient is suffering, the physical examination can take many forms. If, after reviewing your history and discussing your problem with you, the examiner decides that a complete examination will not cause you too much discomfort, a procedure similar to the one I will describe below probably will be followed. If, however, you are in severe pain, or should the examiner decide that certain parts of the examination could irritate your condition, he or she may skip some of the procedure.

With that in mind, let's move on to the examination. The procedure for determining the source of back pain can be separated into five phases. Each phase provides the healthcare professional with data about your condition. As the examiner moves from phase to phase, more knowledge about the cause of your back pain is gained. As the data gathered is pieced together, a reasonably accurate assessment of your problem comes together into what we doctors call a diagnosisa fancy word for figuring out the problem.

It is from the examination and subsequent diagnosis that a healthcare professional decides what further steps, if any, should be taken. Should you have x-rays, a CAT scan or an MRI, or are bed rest, ice packs and exercise all you need?

The five phases of a physical examination are:

1. Inspection

2. Palpation

3. Motion evaluation

4. Nerve examination

5. Related areas

General Inspection: A healthcare professional can learn a great deal from watching you move around. The first thing I look for is your overall appearance. It doesn't take a trained eye to see that a person is out of shape or has bad posture, nor does it require a professional to tell when somebody is experiencing

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severe back pain. It shows on their face, in the way they move and stand.

During the inspection I first look for the severity of the natural S curve of the spine. In an overweight or pregnant person with poor posture, the S curve is usually exaggeratedan immediate indication of the source of pain.

Viewed from the back, your spine should appear straight. Shoulder and hips should be level. If not, you could have scoliosis, or what some people call curvature of the spine. A good healthcare professional will also measure the length of each of your legs; if one leg is shorter than the other, an imbalance could occur. Also during the inspection phase of an examination, the examiner should look for swelling or other symptoms in the spinal area.

Palpation: When I was a boy I wondered how our family doctor could possibly tell anything about my illnesses by feeling parts of my body. When I tried it all I felt was skin, or, perhaps, pain. Doctors and other healthcare professionals are trained to palpate, or feel, for abnormalities in bones and tissue texture. Tightness or lumps are good signs as to the cause of back pain, as is the way you move when certain tender areas are touched. A thorough palpation of the spine should include examining the spinous processes (the back section of your spinethe part you can feel), and the ligaments between each spinous process, from your skull to your spine. The bones of your pelvis, your hips, thighs and abdominal muscles should also be palpated.

Range of motion evaluation: Dysfunction of any part of your spine can cause pain or restrict motion. A problem with the discs, bones, ligaments, nerves or muscles can cause a change in the way you move. Your spine should be able to move relatively freely in several directions. During an examination a healthcare professional will measure the range of movement of your spine and extremities to help determine the source of your pain.

Evaluation and Diagnosis

The movements of the spine are flexion, extension, lateral bending and rotation. To evaluate flexion the examiner will have you bend over and try to touch the floor with your fingers. To test extension you will bend backwards. Lateral bending is bending from side to side and rotation is twisting your upper body in a circular motion.

Another motion test your healthcare professional should use is the "straight-leg raise" test. For this test you will lay flat on your back. The examiner will then instruct you to keep your legs straight, and will then raise one of them. The level of painless free movement will tell the examiner a lot about your back condition.

Nerve Evaluation: You will remember from the chapter on the anatomy of back pain that healthcare professionals can sometimes determine the source of your back problem by the location of pain in one or both of your extremities. If, for example, you have pain in both your back and the top of your foot, the pain could be caused by pressure on the L5 (fifth lumbar) nerve.

When doing a neurologic examination of the spine, most healthcare professionals will concentrate on the sciatic nerve. The sciatic nerve is a combination of several nerves that exit the spinal column independently and merge into one large nerve. This large nerve then descends to the lower leg through the buttocks and thigh all the way to your foot. When the sciatic nerve is irritated a condition called sciatica exists.

Healthcare professionals diagnose sciatica through palpation. If the sciatic nerve is irritated you should experience tenderness at various places from your lower back to your foot. Another technique used to determine whether sciatica is present is the straight leg raise test.

Related areas: Sometimes problems in other parts of your body can cause back pain. A thorough examination for the cause of your pain should include checking problems in your hips, knees and ankles for arthritis or other conditions that can cause

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back pain. Stomach, intestinal, kidney and other internal problems have also been known to refer pain to the back.

Blood Tests, X-rays, EMG, CT and MRI Scans

Chances are your back pain is not caused by a serious enough condition to warrant one of these more sophisticated diagnostic methods. But then again, your problem could be one of the few cases in which a more thorough evaluation and treatment program is needed. If, after a thorough examination, the healthcare professional thinks it is necessary, they may order one or a couple of the following procedures. If so, there is no cause for alarm; whatever the studies turn up will most likely be treatable.

One instance in which an x-ray or another diagnostic test might be ordered is, as I mentioned earlier, if you are in too much pain to be given a thorough examination. Sometimes it is desirable to let the x-ray machine show us the problem, rather than subjecting you to unnecessary discomfort.

Taking a patient's vital signs can often help a doctor track down a problem

Evaluation and Diagnosis

Before going into a description of each procedure, I'd like to say that there are, of course, many, many other studies available. Those discussed here are the most commonly used today.

Blood Tests: You may be wondering how a blood test can detect bulging discs and fractured vertebrae. Well, blood tests can't detect these kinds of problems. They can however, detect inflammatory arthritis, spondylitis, tumors and kidney infections that could cause back pain. Blood tests are harmless and not too expensive, making them a valuable diagnostic tool.

X-rays: Most often x-rays are the studies a healthcare professional will order to help diagnose your back problem. Usually, a minimum of two x-rays are takenone of the front and one of the side. Depending on what your healthcare professional believes to be your problem, more views could be ordered. X-rays are usually adequate for revealing bone problems such as arthritis, bone spurs, curvature of the spine and fractures. They do not, however, help much in diagnosing problems with soft tissues such as muscles and ligaments.

X-rays were used much more extensively a few years ago, before the dangers of exposing the patient to the radioactivity generated by the procedure were well understood. Nowadays, most doctors and other healthcare professionals try to use x-rays sparingly, and no self-respecting practitioner would prescribe them for a pregnant woman, unless absolutely necessary.

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EMG (electromyography): This study is used to test the reaction of a muscle when it is stimulated by a nerve. If, for example, you have a problem in your foot, the examiner will insert very thin needles along the nerve believed to be causing the problem. The needles are wired to an instrument that can show whether your muscle and nerve reactions are normal.

While we don't want to use them all the time, x-rays can be helpful in locating spinal irregularities.

CT (Computerized Tomography) Scans: a CT, or CAT scan is a very sophisticated form of x-ray. But then, that's not even close to an accurate descriptionit's like saying computers are calculators. What the CT scanner does is take a series of "slices," pictures, at multiple different levels. A computer then combines data from all the different shots to come up with its

Evaluation and Diagnosis

own three-dimensional image of what the x-rayed area looks like.

A CT scan shows not only the bones of your spine, but also the soft tissues, such as discs, the spinal cord, muscles and nerves. This procedure is expensive, but highly effective in diagnosing back conditions. The results are really quite amazing.

MRI (Magnetic Resonance Imaging): This is the very latest in back condition diagnosis. MRI combines the benefits of x-rays and CT scans to provide a picture that shows bone and soft tissue. The results are highly effective in evaluating back pain, but so far the cost of the study prohibits its use for most patients. Many healthcare professionals, including myself, are looking forward to the day when MRI technology is widespread and less costly.

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Acupuncture points.