4(a) Clinical reasoning in treatment of specific disorders of lumbar spine

Question 1

How is back pain conceptualised?

Answer 1

Biopsychosocial model - From the biological perspective, difficult to make a difinitve pathoanatomical diagnosis

Question 2

What are most people with back pain diagnosed as?

Answer 2

Non-specific LBP

Question 3

When would non-provocative technique for back pain be used?

Answer 3

Mod/severe pain or cases with central sensitisation or altered central pain processing

Question 4

What are some specific conditions that would guide treatment of back pain?

Answer 4

Radiculopathy
Acute LBP
Clinical instability
Chronic LBP

Question 5

What are the main causes of nerve root/spinal nerve injury?

Answer 5

Compression
Repetitive mechanical irritation (friction)
Chemical irritation
Anoxia

Question 6

What must be present for a diagnosis or radiculopathy?

Answer 6

change in:
sensation
motor
DTR

Question 7

What should be ensured when examining someone with acute nerve root pain?

Answer 7

Patient is in a comfotable position - First question should be ‘what position makes you more comfortable?’

Question 8

How would somebody with acute nerve root pain present?

Answer 8

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

Question 9

What is the behaviour of acute nerve root pain?

Answer 9

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

Question 10

What is the symptomatology of chronic nerve root problems?

Answer 10

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

Question 11

What is the behaviour of chronic nerve root pain?

Answer 11

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

Question 12

What is the history of chronic back pain?

Answer 12

Often not a full recovery from acute bout
Gradiual onset ; check for injury
Usually long standing, often > 6 months

Question 13

What should be taken into account when performing p/e of acute nerve root pain?

Answer 13

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

Question 14

What is the cause of deformity in acute nerve root pain?

Answer 14

Often protective deformity, correction will oftem reproduce the patient’s pain

Question 15

What is the first thing to consider with an acute nerve root patient?

Answer 15

Anything you do must RELIEVE not cause pain.

Perform active movements to seek position of ease.
Explain presentation using spine.

Question 16

What is the examination for acute nerve root pain?

Answer 16

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

Question 17

What is the physical examination of chronic nerve root?

Answer 17

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

Question 18

What are things to remember when treating acute nerve root pain?

Answer 18

Be confident and assuring to the patient

The condition often takes time to settle, depends on the nature of pathology (disc extrusion&raquo_space; disc protrusion)

Question 19

What are initial treatments for acute nerve root pain?

Answer 19

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

Question 20

What is contraindicated in acute nerve root pain

Answer 20

high velocity manipulastion

Question 21

What are subsequent treatments for acute nerve root pain?

Answer 21

• 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

Question 22

When should patient with acute nerve root pain be referred on?

Answer 22

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

Question 23

What is the treatment for less severe or chronic nerve root pain?

Answer 23

Manual therapy - combined techniques of articular and neural tissues
Very gentle neurodynamic mobilisation techniques
full program of therapeutic exercise
Self help and ergonomic advice

Question 24

How to diagnose neural system mechanosensitivity

Answer 24

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

Question 25

What are physical signs of mechanosensitivity

Answer 25

Nerve trunk hyperalgesia - nerves tender to palpation

tender points: areas of superficial tenderness related to the nerve involved

Specific signs of local dysfunction e.g. local joint dysfunction

Question 26

What are the treatment guidelines for nerve root pain?

Answer 26

Always treat nervous tissue with respect and gentle, non-provocative treatment approaches

First approach is always to treat the neural tissue disorder by treating the interface, that is the neighbouring joint or muscle through which the nerve passes

Gentle, direct mobilisation of the neural tissues may be indicated.