4(a) Clinical reasoning in treatment of specific disorders of lumbar spine Flashcards
How is back pain conceptualised?
Biopsychosocial model - From the biological perspective, difficult to make a difinitve pathoanatomical diagnosis
What are most people with back pain diagnosed as?
Non-specific LBP
When would non-provocative technique for back pain be used?
Mod/severe pain or cases with central sensitisation or altered central pain processing
What are some specific conditions that would guide treatment of back pain?
Radiculopathy
Acute LBP
Clinical instability
Chronic LBP
What are the main causes of nerve root/spinal nerve injury?
Compression
Repetitive mechanical irritation (friction)
Chemical irritation
Anoxia
What must be present for a diagnosis or radiculopathy?
change in:
sensation
motor
DTR
What should be ensured when examining someone with acute nerve root pain?
Patient is in a comfotable position - First question should be ‘what position makes you more comfortable?’
How would somebody with acute nerve root pain present?
Pain, radicular and somatic (local and referred) , distal pain often worse
Acute, non remitting pain, severe
Neuro signs: numbness, P&N, weakness
Associated features : ANS (sweating, legs feel cold/heavy)
Often very anxious/ been up all night. Look very sick, pale
What is the behaviour of acute nerve root pain?
Aggravates: movement that reduces the size of canal OR increases tension on NR
Eases: Difficulty finding a position of ease
Irritability: usually irritable (easy to provoke, severe, long time to ease)
PM: pain often worse, difficulty sleeping, often walk around at night.
AM: no difference
What is the symptomatology of chronic nerve root problems?
Pain sharp, in limb, superficial, often well defined, dermatomal +/- somatic referral pain, patchy pain
Neurological signs, numbness, P&N, weakness
Usually less irritable, “old,cold” disorder
Neural mechanosensitivity
What is the behaviour of chronic nerve root pain?
Persistent and limits normal function
Still often difficulty gaining a positiong og ease
Sleep disturbance is not a major feature
Often not a lot of functional restriction
What is the history of chronic back pain?
Often not a full recovery from acute bout
Gradiual onset ; check for injury
Usually long standing, often > 6 months
What should be taken into account when performing p/e of acute nerve root pain?
Very gentle examination (depends on severity)
Limit examination to that necessary to achieve a diagnosis (often clear from the p/i)
May be restricted due to pain
Further examination is performed as the patient progresses
What is the cause of deformity in acute nerve root pain?
Often protective deformity, correction will oftem reproduce the patient’s pain
What is the first thing to consider with an acute nerve root patient?
Anything you do must RELIEVE not cause pain.
Perform active movements to seek position of ease.
Explain presentation using spine.
What is the examination for acute nerve root pain?
Neurological (mandatory)
Also mechanosensitivity of neural system (care and sensitivity) SLR often restricted to <30
Manual examination to confirm segmental level
Examine deep muscle system, a gentle isometric assessment will be non-provocative of pain
What is the physical examination of chronic nerve root?
correct deformity
examination of all systems, articular, muscle and neural systems (examination is not neccessarily restricted)
Active movements, may be more subtle restrictions, often still reproduction of distal pain.
neural minore changes
manual examination
full examination of muscle syste
What are things to remember when treating acute nerve root pain?
Be confident and assuring to the patient
The condition often takes time to settle, depends on the nature of pathology (disc extrusion»_space; disc protrusion)
What are initial treatments for acute nerve root pain?
Severe > treat in position of ease (should not compromise size of IVF)
- traction
- indirect neurodynamic techniques
- medication
- home care and self help. RIB may be appropriate for a few days
- Explaination of variability of symptoms
What is contraindicated in acute nerve root pain
high velocity manipulastion
What are subsequent treatments for acute nerve root pain?
- add in manual therapy (rotations to open intervertebral canal, other techniques)
- care that canal is not compromised
- address muscle system
- self help and ergonomic advice
- slow to respond
When should patient with acute nerve root pain be referred on?
If condition deteriorates (i.e. signs in the neurological exam increasing) or if there is no improvement after 2 to 3 weeks > surgical consultation
Consult with GP for specialist referral
What is the treatment for less severe or chronic nerve root pain?
Manual therapy - combined techniques of articular and neural tissues
Very gentle neurodynamic mobilisation techniques
full program of therapeutic exercise
Self help and ergonomic advice
How to diagnose neural system mechanosensitivity
Posture: out of tension posture
Active movements: impairment to movement reinforced with additional manoeuvres (eg add passive neck flexion)
Passive movement impairment: comparable and relevant to active movements including eg SLR
