CHIR12007

Clinical Assessment and Diagnosis

Portfolio Exercises Week 4

Exercise 1

A 58 year old woman presented with a gradual onset of low back pain which refers to the top of the buttocks
bilateral. She has had low back stiffness for years which is usually worse in the morning. The intensity of the
discomfort has increased over the past few months. The pain is worse with prolonged standing, lifting, bending and
on long walks. Discomfort is relieved by lying down. An ache can be felt into the right buttock, hip and posterior
thigh but only occasionally. The patient does not experience pain in the night (happen in inflammation, system
disorder,), no bowel or bladder changes are reported. The pain does not increase with coughing or sneezing

List your differentials

- Degenerative disc and spondylosis (worse in the morning and sitting for long periods, lifting bending , relieve
by ling down)
- Central spinal stenosis (worsen in standing (related to extension of lumbar spine))or walking
(neuroclaudication) )
- Radicular pain (worse on standing and walking, presents with LBP or Buttock and leg pain)
- Mechanical disorder (improve on lying down)
- Facet joint dysfunction (improve on lying down)
- Disc problem (relieved by lying down)
- Spondylolisthesis (aggravated by standing or walking)
- Piriformis syndrome (posterior hip or buttock pain that may radiate down the posterior thigh)
- The hip pocket wallet syndrome (causes of sciatica form the buttocks down)
- Inflammatory (gradually onset)

What is the significance of stiffness in the morning?

- Inflammatory disorder
- Degenerative disc and spondylosis
- Early protrusion

Is there anything in the history that suggests this is not mechanical low back pain

- As Mechanical LBP usually

a. unilateral leg pain that does not extend past the knee
b. short duration (days to weeks)
c. onset associated with physical task
d. may be episodic with recurrence over months or weeks
- for this patient, she had bilateral back pain, does not increase with coughing
Does this history warrant x-rays?

- No need for X-ray

Clarify your answer with reasoning.

- Central stenosis
- Piriformis syndrome

Exercise 2

A 62 year old male presents with acute onset low back pain (facet) which began the previous evening and was still
present on waking (spondylolisthesis) with some mild progression of the pain. He is a government worker with
primarily a desk job. He was unable to identify any specific onset or event that caused the pain. No identifiable
position or activity relieves the pain. Although he works a sedentary job, he reports he has recently begun 30
minutes of cardiovascular exercise 7 days a week and weight training 5 days a week as his GP is concerned about his
high blood pressure. His father passed from a heart attack at age 65. Pain is rated on a verbal numeric scale of 6/10,
does not change and feels very deep (mechanical) and boring although every now and then there is a temporary
spike in the pain. On review of systems, vague abdominal pain is mentioned which seems to have increased with this
episode of low back pain.

What areas would you examine in this patient and why

- Exam Lumbosacral joint area and SLR test to find out is hip joint, nerve/disc or SI/lumbar joint problem and
do the supported Adam test to distinguish sacroiliac pain or lumbar pain
- SLR (0-40°: hip joint, 40°-80°: nerve/disc, over 80°: SI/lumbar)

From the history provided, is there evidence of mechanical origin of pain? Please clarify your answer with
reasoning

- With the deep pain which is normal mechanical pain

From the history provided, is there evidence to suggest possible non-mechanical origin of the low back pain?
Please clarify your answers with reasoning

- No identifiable position or activity relieves the pain, normally mechanical pain will relieve by the rest
Exercise 3

Disability
Disuse Recovery
Depression

Avoidance Painful experiences confrontation

catastrophising

Fear of movement No fear

or injury

Exercise 4

What is a Chiropractor’s role in the care of LBP

• To prevent persistent disability the chiropractor should assess the patient’s perceived disability with the
Back Bournemouth Questionnaire and the probability of a return to usual activities, either in the fourth
week if back pain related disability persists, or at the first visit if the patient has a history of long lasting
disability due to back pain.

• When the probability of returning to usual activities is deemed to be low the chiropractor should seek to
identify the barriers preventing the return to usual activities.

• If the patient’s perceived disability improves little or not at all in 4 weeks following assessment of this
perception (BQ), the chiropractor should reassess the barriers preventing the return to usual activities and
revise management.

• The chiropractor should reassure the patient with back pain by providing essential, coherent, accessible and
valid information about his condition and correcting beliefs. The chiropractor should encourage and guide
the patient to continue or to resume usual activities.

• The chiropractor should give priority to treatments with proven efficacy.

• When individual or environmental barriers to return to usual activities are identified after the acute phase of
LBP, the chiropractor should reorient treatment towards minimising those barriers
Exercise 5

There is an article in your week 4 Reading list “Primary care management of non-specific Low Back Pain: Key
message from recent guidelines

Using this source, complete the following statements:

a. Episodes of acute LBP usually have a good prognosis with rapid improvement within _the first 6 weeks___.

b. A diagnostic triage approach is used to:

- identify patients whose LBP arises beyond the lumbar spine (eg, renal, aortic dissection),
- those with neurological deficit (radiculopathy, spinal canal stenosis, cauda equina syndrome),
- those with suspected or confirmed serious spinal pathology (malignancy, infection, fracture),
- and those with inflammatory disease (spondyloarthritis);
- remaining patients are considered to have non-specific LBP.

c. First line care:

Guidelines also reinforce the importance of teaching patients how to self-manage their LBP. Important
messages to convey to the patients are that non-specific LBP ___is benign_____

d. Second line care:

There are now more consistent recommendations in favour of __ manual therapy (such as massage and
spinal manipulation) and psychological therapies (cognitive behavioural therapy is preferred) __as second
line non-pharmacological options, as they can provide small to moderate improvements for pain and
function with mostly low to moderate quality evidence.

Exercise 6

Label each diagram with the correct stage of disc injury:

Extrusion
Protrusion
Disc herniations sequestration
prolapse
(Annular fibers disrupted) (free nuclear
material)
Exercise 7

Briefly list the typical features of lumbar radiculopathy

1. Pain on the contralateral side when the non-painful side is flexed at the thigh with the leg held in extension
(Fajersztajn sign)

2. Loss of sensation on the lateral portion of the foot (Szabo sign)

3. Pain on adduction of the thigh (Bonnet sign)

4. Pain in the buttocks when the great toe is hyperextended (Turyn sign)

5. Pain in the lower back or down the leg when the patient is supine (Linder sign)

6. Pain and dysaesthesia below the buttock area

7. Symptoms radiating below the knee are more likely to indicate a true radiculopathy

8. Symptoms radiating a variable distance down the lateral/posterior leg or foot, especially an isolated part
of the lower leg

9. Dermatomal loss of sensation or feeling or an abnormal sensation in leg or foot

10. Weakness of the lower leg or foot

11. Emergency = loss of bowel or bladder function

12. Pain is increased by activity and may be relieved by rest

13. Leg pain becomes more severe than back pain

• Knowledge of the dermatomes of the lower limb provides a pointer to the involved nerve root
Exercise 8

Neurogenic Claudication Vascular

Cause Spinal canal stenosis Aortoiliac arterial occlusive disease
Age Over 50, long history of backache Over 50
Pain site and radiation Proximal location, Distal location,
Initially lumbar, buttocks and legs Especially buttocks, thighs & calves
Radiates distally Radiates proximally
Type of Pain Weakness, burning, numbing or Cramping aching, squeezing
tingling (not cramping)
Onset Walking (uphill and downhill) Walking a set distance each time,
Distance walked varies especially uphill
Prolonged standing
Relief Lying down, flexing spine, e.g squat Standing still- fast relief
position Slow walking decrease severity
May take 20-30 mins
Associated symptoms Bowel and bladder symptoms Impotence
Rarely paraesthesia or weakness
Peripheral pulses Present Present (usualy)
Reduce or absent in some,
especially after exercise
Lumbar extension Aggravates No Change
Neurologic Saddle distribution No change
Ankle reflex may be reduced after May have abdominal bruits after
exercise exercise