University of Texas, Arlington NURS 5461 NEURO BACK & NECK PAIN

NEURO BACK & NECK PAIN DIAGNOSIS: - A musculoskeletal problem is treated most effectively if the specific cause can be identified - The gold standard for determining the cause of musculoskeletal pain is the physical examination, complemented by a good history - If an adult reports pain in more than one joint, a systemic process may be considered; however, the older adult often have multiple mechanical problems in different sites of the body THE HISTORY - What symptoms accompany the pain? - What brings on the pain? Is it exacerbated when going from lying to sitting, ascending or descending stairs, standing, or walking? - Is the pain worse in the morning, midday, or night? - Does the pain radiate? - Does the pain cause the patient to cease the activity associated with the pain? - Was the pain acute at onset? Or has it worsened over time? THE EXAM - Carefully observe the patient’s mobility - Manually examine joints and muscle groups, focusing on: o Patterns of weakness o Malalignment and swelling of joints (whether the swelling is soft tissue or bony enlargement) o Decreased range of motion (ROM) o Patterns of joint involvement consistent with specific conditions - Order imaging and laboratory tests only after formulating a list of potential diagnoses NECK PAIN - Four general causes: systemic disease, cervical myelopathy, cervical radiculopathy, mechanical neck disease - Systemic disease o Often associated with polymyalgia rheumatica, rheumatoid arthritis, and other inflammatory conditions o Systemic symptoms and signs, other joint complaints, and prolonged morning stiffness are often present o Typical: symmetric loss of ROM of the cervical spine o Lab markers of inflammation, such as C-reactive protein and erythrocyte sedimentation rate, are often increased - Myelopathy produced by cervical stenosis o Does not always cause neck pain o Often characterized by spastic gait disturbance and weakness in the lower extremities with upper motor neuron signs (eg, hyperreflexia, increased muscle tone, positive Babinski signs) o Can also produce lower motor neuron findings in the upper extremities o Bladder symptoms include urgency, frequency, or retention - Cervical radiculopathy o Characterized by pain in the neck and arm, sensory loss, loss of motor function, and reflex changes in the affected nerve-root distribution o Usually due to encroachment of the neuroforamina of the cervical spine; the C7 nerve root is most frequently affected o Suggested by pain that is reproduced by rotating the head or bending it toward the symptomatic side o Most patients improve with symptomatic treatment, and only a relatively small number require surgery - Nonspecific mechanical disease of cervical spine: diagnosis o Cervical disc displacement appears to be a frequent cause of neck pain in older adults o Cervical spine disease can also produce local muscle spasm and tenderness, often mistaken for the “trigger points” of fibromyalgia o Typical: asymmetric loss of ROM of the cervical spine and weakness of the muscles innervated by cervical nerve roots, such as elbow extension and finger abduction in patients with C7, C8, and T1 disease - Nonspecific mechanical disease of cervical spine: treatment o Little hard data on the effectiveness of one therapy versus another o Manual therapy and exercise are more effective than alternative strategies o Surgery should be considered only for significant, persistent, and worsening neurologic signs Assessment of LBP in the Older Adult BACK PAIN: THE EXAM - Evaluate the back, hips, legs, and gait - With patient upright, move the back through the 4 planes of movement of the lumbar spine (flexion to the right, flexion to the left, forward flexion, extension) - Straight leg raise tests can be helpful if positive - The most helpful physical finding in patients with possible back disease is subtle weakness of the L4L5 and L5S1 muscles PHYSICAL EXAM OF OLDER ADULTS W