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

Mechanical Dysfunction in LBP

Degenerative: DDD/ spondylosis/ facet arthrosis

What is the significance of stiffness in the morning?

Morning stiffness is the usually associated with pain (back pain)

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

no

Does this history warrant x-rays?

Not bases on history alone

Might be considering if justified with age, chronic progression

Clarify your answer with reasoning.

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

Lower Back and hips

Abdomen

Thoracic cage

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

Yes, he had been working out for 7 days so he would experience muscle and joint pain, however
there was no specific onset or cause identifiable, nor any position or activity that relieved the pain,
so his pain remained a 6/10

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, as mentioned above, there was no identifiable cause to the pain

No relieve with rest or change in position, and increase abdominal pain with increase in LBP

Exercise 3
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.

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 ___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; 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
therapies_________ and __ _psychological therapies_______ 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 herniations Free Nuclear
(Annular fibers disrupted) Material

A. Protrusion B. Prolapse C. Extrusion D. Sequestration

Exercise 7

Briefly list the typical features of lumbar radiculopathy


Most but not all patients with radicular pain have associated LBP.
 Those who do not present with associated LBP usually have a history of LBP in the past
 The typical picture is one of LBP which progresses to leg pain; LBP is then often much less
noticeable than the leg pain – PERIPHERALISATION (same phenomenon is seen in the c-
spine)
 The 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
 If the radicular pain is secondary to IVF encroachment (DJD & DDD especially facet
arthrosis), the leg pain may be relieved on sitting and bringing knees to chest and worse on
standing around and walking (patient will also be older).
 If the radicular pain is secondary to disc herniation the leg pain may be worse on prolonged
sitting
 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

Clinical features of neurogenic and vascular claudication

Neurogenic claudication Vascular claudication
Cause Spinal canal stenosis Aortoiliac arterial occlusive disease

Age Over 50 Over 50

Long history of backache

Pain site and Proximal location, initially
radiation lumbar, buttocks and legs
Radiates distally
Type of pain Weakness, burning,
numbing or tingling (not
cramping)
Distal location, especially buttocks,
thighs and calves
Radiates proximally
Cramping, aching, squeezing

Onset Walking (uphill and Walking a set distance each time,

downhill). Distance walked especially uphill
varies. Prolonged standing

Relief Lying down Standing still – fast relief

Flexing spine, e.g. Slow walking decreases severity
squat position
May take 20-30 minutes

Associations Bowel and bladder Impotence

symptoms Rarely, paraesthesia or weakness

Peripheral Present Present (usually). Reduced or

pulses absent in some, especially after
exercise

Lumbar Aggravates No change

extension

Neurological Saddle distribution No change

Ankle reflex may be May have abdominal bruits after
reduced after exercise exercise