CHIR12007

Clinical Assessment and Diagnosis

Por:olio 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
buIocks bilateral. She has had low back sLffness 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, liQing, bending and on long walks. Discomfort is relieved by lying down. An ache
can be felt into the right buIock, hip and posterior thigh but only occasionally. The paLent 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 differenLals

A: Non-specific (mechanical) back pain, lumbar arthropothies or DDD, etc.

What is the significance of sLffness in the morning?

A: indicaLve of osteoarthriLs (most common), other degeneraLve condiLons/disorders.

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

A: While she has no visceral signs or symptoms and no red flag symptoms, she does show
characterisLcs other than mechanical LBP. Some of her signs and symptoms fall under the
inflammatory LBP category (e.g. her morning sLffness, and ease in condiLon with rest/lying down).

Does this history warrant x-rays?

Clarify your answer with reasoning.

A: She is a 58 yow, with no red flags and no acute characterisLcs of LBP (it was gradual onset). No
imaging would be necessary straight away. However, due to her age, monitoring her progress with
her treatment is necessary. Imaging should be considered should no improvement in treatment
occur.

Exercise 2

A 62 year old male presents with acute onset low back pain which began the previous evening and
was sLll present on waking with some mild progression of the pain. He is a government worker with
primarily a desk job. He was unable to idenLfy any specific onset or event that caused the pain. No
idenLfiable posiLon or acLvity 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 aIack 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 menLoned which seems to have increased with this episode of low back
pain.

What areas would you examine in this paLent and why

A: Considering no movement changes his pain, there is very liIle that further physical examinaLon
could do. His visceral signs and symptoms lead to a red flag, so I’d be quesLoning any physical
examinaLon at this point.

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

A: All of his symptoms lead to vascular and visceral issues. He has no change in pain with movement
or acLvity, and can (presumably) perform 30minutes of cardio 7 days per week with no issues or
change in state.

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

A: Yes. Again, all evidence points to vascular issues. For example, his family history of MI and his
history of high blood pressure. The type of pain described and its nature (being acute) points to a
possible abdominal aorLc rupture or aneurism. This is a red flag and he should be sent straight to
hospital.

Exercise 3

Disability
Disease Recovery
Depression

Painful experiences Confrontation

Avoidance
Catastrophising

Fear of movement
or injury No fear

Exercise 4

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

1. To prevent persistent disability with the use of index’s/quesLonnaires.

2. To determine the rate at which the paLent can return to normal ADL’s and work, and idenLfying
the barriers prevenLng the return tot these acLviLes.
3. ConLnuously revising barriers prevenLng the return to acLviLes every 4/12 when there is no
improvement.

4. PosiLve and factual encouragement and communicaLon with their paLent presenLng with LBP.
5. Give priority to treatments with proven efficiency

6. Minimising the idenLfies barriers for the future to avoid or prevent a relapse of LBP/another onset
of LBP/episodic nature.

Exercise 5

There is an arLcle 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 6
weeks.

b. A diagnosLc triage approach is used to differenLate between non-specific (mechanical),

neurological involvement and serious pathology (red flags).

c. First line care:

Guidelines also reinforce the importance of teaching paLents how to self-manage their LBP.
Important messages to convey to the paLents are that non-specific LBP is benign.
d. Second line care:
There are now more consistent recommendaLons in favour of manual therapy (such as
massage and spinal manipulaLon) and psychological therapies (cogniLve behavioural
therapy is preferred) as second line non-pharmacological opLons, as they can provide small
to moderate improvements for pain and funcLon with mostly low to moderate quality
evidence.

Exercise 6

Label each diagram with the correct stage of disc injury:

Protrusion Extrusion
Prolapse Sequestration
Exercise 7

Briefly list the typical features of lumbar radiculopathy

A:

• Nearly always unilateral.

• Often feels different quality to any local LBP (referred pain from other structures often feels same
as LBP – obviously quite subjective).
• Most often involves one nerve root. However, lumbar spine is more common to involve two roots
than in cervical spine.
• The more distal the pain goes, the more severe the neuropathic pain process. Therapeutic goal is
to get the pain to CENTRALISE.
• Be more cautious if multiple NR levels involved – may indicate greater canal stenosis (eg. larger
disc pathology or sequestration).
• 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

A:

Cause: spinal canal stenosis (neurogenic claudicaLon). AorLc arterial occlusive disease (vascular
claudicaLon).

Age: Over 50 and long history of backache (neurogenic claudicaLon). Over 50 (vascular claudicaLon)

Pain site and radiaLon: Proximal locaLon, iniLally Lumbar, buIocks and legs, radiates distally
(neurogenic claudicaLon). Distal locaLon especially buIocks, thighs and calves, radiates proximally
(vascular claudicaLon).

Type of pain: Weakness, burning, numbing or Lngling (neurogenic claudicaLon). Cramping, aching
and squeezing (vascular claudicaLon).

Onset: Walking up or down hill, distance walks and prolonged standing (neurogenic claudicaLon).
Walking a set distance each Lme, especially uphill (vascular claudicaLon).

Relief: Lying down or flexion of spine for longer than 20minutes (neurogenic claudicaLon). Standing
sLll gives fast relief and slow walking (vascular claudicaLon).

Associated symptoms: Bowel and bladder symptoms (neurogenic claudicaLon). Impotence and at
Lmes, though rarely, weakness and/or paraesthesia (vascular claudicaLon).

Peripheral pulses: Present (neurogenic claudicaLon). Present usually, reduced or absent in some
especially aQer exercise (vascular claudicaLon).
Lumbar extension: Aggravates (neurogenic claudicaLon). No change/not present (vascular
claudicaLon).
Neurologic: Saddle distribuLon and ankle reflex may be reduced aQer exercise (neurogenic
claudicaLon). No change (vascular claudicaLon).