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, no bowel or bladder changes are reported. The pain does not increase
with coughing or sneezing

List your differentials

V – nothing points particularly to vascular but can’t rule out yet

I – no fever, she’s conversant

N – no night pain and no bowel or bladder changes reported

D – she is 58 and has morning stiffness and pain is of the aching kind that is worse with activity,

I – unlikely

C – chronic LBP and no history of a congenital condition

A – no highlighted autoimmune disorder

T – no history of trauma

E – no highlighted endocrine disorder

What is the significance of stiffness in the morning?

Discs have rehydrated and stiffness and pain can result from subsequent increased pressure

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

Mechanical pain generally has a short duration (days to weeks)

Does this history warrant x-rays?

Clarify your answer with reasoning.

Yes, she should have an x-ray. She has a suspected disc herniation. A plain film is not generally
indicated or useful and if doesn’t show the disc material but an MRI should be done to check the
integrity of the disc, effects on spinal canal and nerve root and to evaluate for presence of any
additional pathology.
Exercise 2

A 62 year old male presents with acute onset low back pain which began the previous evening and
was still present on waking 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 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

I would examine his lumbar spine and abdominal region because the patient has presented with pain
in these regions and the lower limb to make sure there is muscle weakness or loss of sensation.

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

It could be a mechanical origin of pain and he has recently become intensive cardiovascular and
weight training.

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

Yes, he has a high blood pressure with constant, deep and boring pain and well as associated vague
abdominal pain

Exercise 3
 Disability

Disuse
Recovery
Depression

Painful experiences
Avoidance Confrontation
Catastrophizing

Fear of
movement/
injury
No fear

Exercise 4

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

 To prevent persistent disability

 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
 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
(spondylarthrosis); 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, most
people have a favourable prognosis with substantial improvement in the first month; it is
unlikely that there is a serious disease present; and imaging is not required and will not
change management.
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 preferable) 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:

Disc protrusion Disc prolapse Disc extrusion Disc sequestration

Exercise 7

Briefly list the typical features of lumbar radiculopathy

1. Most but not all patients with radicular pain have associated LBP
2. Those that don’t present with LBP usually have a history of LBP
3. Typical picture is one of LBP which progresses to leg pain
4. LBP may be due to nerve root compromise (dorsal ramus territory) or due to the other local
factors – often when the nerve root complaint is secondary to disc herniation, a significant
portion of the local LBP arises from the posterior joints
5. If the radicular pain is secondary to IVF encroachment (DJD and DDD especially facet
arthrosis), the leg pain may be relieved on sitting and bringing knees to chest and worse on
standing and walking (patient will also be older)
6. If the radicular pain is secondary to disc herniation the leg pain may be worse on prolonged
sitting
7. Nearly always unilateral
8. Often feels different quality to any local LBP (referred pain from other structures often feels
same as LBP – obviously quite subjective)
 9. Most often involves one nerve root. However, lumbar spine is more common to involve two
roots than in cervical spine
10. The more distal the pain goes, the more severe the neuropathic pain process. Therapeutic
goal is to get the pain to centralise
11. Be more cautious if multiple NR levels involved – may indicate greater canal stenosis (eg.
larger disc pathology or sequestration)
12. Beware BILATERAL radicular features- often a sign of central canal compromise – increased
likelihood of cauda equina compromise, particularly look for saddle anaesthesia, decreased
sphincter tone, rectal or bladder incontinence, constipation urinary stasis, erectile
dysfunction

Exercise 8

Neurogenic Claudication Vascular Claudication

Cause Spinal stenosis or
inflammation or nerves
emanating from the spinal
cord
Age Over 50
Long history of backache
Pain site and radiation Proximal location, initially
lumbar, buttocks and legs
Type of pain Weakness, burning, numbing
or tingling (not cramping)
Relief Lying down
Flexion spine eg. squat
position
May take 20-30mins
Associations Bowel and bladder symptoms
Peripheral pulses Present
Lumbar extension Aggravates
Neurological Saddle distribution
Ankle reflex may be reduced
after exercise
Claudication stems from
circulatory problems
predominantly
Aortoiliac arterial occlusive
disease
Over 50
Distal location, especially
buttocks, thighs and calves
Radiates proximally
Cramping, aching, squeezing
Standing still – fast relief
Slow walking decreases
severity
Impotence
Rarely paraesthesia or
weakness
Present (usually). Reduced or
absent in some, especially
after exercise
No change
No Change
May have abdominal bruits
after exercise