Clinical Skills 4 Flashcards
Nociceptive pain
most common
potentially harmful stimuli detected by nociceptors
usually acute
Neuropathic pain
injured neural structures
acute or chronic
increased risk of chronicity
Nociplastic pain
arises from altered nociception despite no actual or threatened tissue damage
What is acute pain?
- presence and duration relate directly to tissue damage
- predominately nociceptive
- generally less than 3-6 months
- normal physiological response to noxious stimulus
- activation of tissue nociceptors
- modified by fear, anxiety and previous experience
Symptoms of acute pain
localised pain, often sharp, proportionate to injury
What is chronic pain?
- lasts beyond the normal healing time after injury or illness
- predominately nociplastic
- results from neuroplastic changes to pain pathways (peripheral & central sensitisation, descending facilitation & disinhibition)
- influenced by social cognitive & affective factors
Symptoms of chronic pain
widespread or diffuse pain, hyperalgesia/allodynia, temperature sensitivity
Neuropathic pain
- consequence of a lesion or disease affecting the somatosensory system
- central or peripheral, such as radicular pain from an injured nerve
- chronic neuropathic pain may involve central sensitisation
Symptoms of Neuropathic pain
burning, shooting, pricking pain
sensory &/motor deficits
What is referred somatic pain?
- produced by a noxious stimulation of nerve endings within spinal structures
- proposed mechanism of referral is convergence of nociceptive afferents on second-oder neurons in the spinal cord
What is radicular pain?
- evoked by ectopic discharges emanating from a dorsal root or its ganglion
- disc herniation is the most common cause
- Inflammation of the affected nerve
- pain is lancinating, shocking, electric in a narrow band-like distribution down the leg
Common lumbar spine conditions
Nonspecific low back pain
degenerative joint disease
intervertebral disc disease
spondylolysis & spondylolisthesis
congenital anomalies
inflammatory arthritides
visceral referral
Uncommon lumbar spine conditions
Malignancy
Infection
Pagets disease
Diffuse idiopathic skeletal hyperostosis
Non-specific low back pain (NSLBP)
- pathoanatomical cause of pain cannot be determined
- most cases (90%) of uncomplicated LBP
- can be acute or chronic
Degenerative joint disease
- synonymous with Osteoarthritis
- chronic degenerative condition of lumbar spine that affects vertebral bodies & intervertebral discs, facet joints and contents of spinal canal
- part of aging (>90% of those >50 y/o)
- severity has little relationship to degree of LBP
Typical presentation of Degenerative joint disease
older age group
gradual onset/chronic condition
aching pain
spinal tenderness
stiffness
aggravated by overuse
stiffness after periods of inactivity
pain reduced by paracetamol
Risk factors for Degenerative joint disease
heavy, physical work
excess weight
previous low back injury
early onset can be familial
Diagnosis for Degenerative joint disease
History
Physical examination
X-ray
What is lateral canal stenosis?
narrowing of the intervertebral foramen
Causes of Lateral canal stenosis
DJD
disc protrusion or prolapse
Conditions of lateral canal stenosis
- can be asymptomatic
- usually unilateral
- nerve root &/ spinal nerve impact (radicular pain/radiculopathy)
What is central canal stenosis?
Narrowing of the spinal canal
Causes of Central canal stenosis
DJD
Disc protrusion or prolapse
congenital
spondylolisthesis
Conditions of central canal stenosis
can be asymptomatic
may impact spinal cord/cauda equina (neurogenic claudication, cauda equina syndrome)
What is Neurogenic claudication?
pain, paraesthesia, cramping, heavy legs on walking
What symptoms are with cauda equina syndrome?
LBP, Lower limb pain/weakness, perineal parestesthesia, bowel/bladder disturbance
WHat are the causes of Cauda equina syndrome?
- rare but serious neurological condition
- caused by compression of the cauda equina
- most often due to IVD prolapse
- requires urgent medical/surgical referral
Symptoms of CES
back pain and/or unilateral/bilateral leg symptoms
reduced perineal sensation
altered bladder function
loss of anal tone
loss of sexual function
What is an intervertebral disc disease?
Degenerative
prolapse & herniation
internal disc disruption
What is degenerative disc disease?
similarities to DJD
normal part of aging
- discs become less hydrated and thinner with age, lose capacity for shock absoption and become susceptible to tears
often asymptomatic
Diagnosis for Degenerative disc disease
MRI
but findings do not correlate well with symptoms
clinical presentation is more relevant
Symptom presentation of Degenerative disc disease
- disruption of innervated annulus causes diffuse mechanical LBP
- bulging/prolapse can cause inflammation or compression resulting in lateral or central canal stenosis inflammation or compression
Typical presentation for Degenerative disc disease
- severe, acute LBP
antalgic posture
paraspinal muscle spasm/guarding
radiating pain in a lower limb
lower limb paraesthesia
agg: by flexion and bearing down (sneezing, toilet)
rel: rest (lying down)
Internal disc disruption symptoms
- constant deep aching pain, aggravated by any movement that stresses disc
- cannot be diagnosed clinically
What is Spondylolysis?
- defect or stress fracture in pars interarticularis of vertebral arch
- results from repetitive mechanical load/stress
- typically presents in young athletic population
- bilateral/unilateral
- most often asymptomatic
- if symptoms: focal LBP with buttock pain, agg by extension/rotation, hyperlordosis, relieved by rest
What is Spondylolisthesis?
- slippage of one vertebra on the next causing pain and/or radicular symptoms
- congenital or acquired
- often caused by spondylolysis
- most commonly anterolisthesis
- most frequently L5/S1
- slippage graded 0-4
- most grade 1-2 are stable and asymptomatic
- if severe, can produce canal stenosis
Presentation of Spondylolisthesis
- intermittent, localised LBP
- Agg by flexion/extension
- pain on palpation
- step-off sign
- relieved lying supine
- Hamstring tension/discomfort
- less commonly: ssx of lateral canal stenosis
- rarely: ssx of central canal stenosis
- diagnosed via xray
What are congenital anomalies?
Congenital anomalies comprise a wide range of abnormalities of body structure or function that are present at birth and are of prenatal origin
What is Spina bifida occulta?
- asymptomatic non-union of the posterior vertebral elements
- may observe hairy patch, dimple in back, fatty deposits, port wine mark
What is Facet tropism?
Asymmetry in the sagittal orientation of the facet joints
- may be associated with instability and degeneration
What is a transitional vertebrae?
Lumbarisation - S1 is not fully fused with the sacrum
Sacralisation - L5 takes on characteristics of and is fully or partially fused with sacrum
Where is Inflammatory arthritides more commonly present?
extremities
What is Ankylosing spondylitis?
Inflammation of joints
inflammatory changes cause pain, stiffness and loss of ROM
2:1 male:female
symptom onset 20-40 y/o
can cause progressive fusion of spinal joints
can be associated with uveitis, inflammatory bowel disease, weight loss
Typical presentation of Ankylosing spondylitis
- low back/buttock/SI pain is often the first symptom
- insidious onset
- spinal stiffness
- morning stiffness
- chronic in nature
- relieved by activity
- aggravated by rest
Diagnosis of Ankylosing spondylitis
Clinical presentation, Blood tests, Xray
What is visceral referral pain?
- conditions of the visceral organs can present as low back pain
- visceral conditions can cause LBP via inflammation, distension, ischaemia or neurological referral
Abdominal aortic aneurysm - rare but serious cause of LBP
Which organs commonly refer pain to the low back?
reproductive organs, bladder, ureter, large & small bowel, appendix, kidney
What is Osteomyelitis?
bone infection
insidious onset pain and stiffness
fever, chills, loss of appetite, night sweats
risk factors: previous infection, immunocompromise, pelvic surgery
What is Malignancy?
> 50 y/o
history of malignancy
diffuse back pain, worse at night, unrelieved by rest or treatment
fatigue, weight loss
most commonly secondary metastasis
What is Paget’s disease?
metabolic disease causing abnormal bone formation
affecting 2-4% of adults over 55 years of age
often asymptomatic
presents as constant, deep, aching, bone pain, worse at night
agg by rest and relieved by activity
often an incidental finding
What is diffuse idiopathic skeletal hyperostosis?
calcification of soft tissue attaching to spine
often asymptomatic and discovered incidentally
more common in males and older adults >60
pain and progressive stiffness
impacts of hyperostosis on other organs
What is a red flag?
signs and symptoms which indicate the possibility of serious pathology requiring urgent investigation
Red flags for the investigation of acute low back pain
- age of onset <20 or >55
- recent history of violent trauma
- constant progressive, non mechanical pain
- thoracic pain
- past medical history of malignant tumour
- prolonged use of corticosteroids
- drug abuse, immunosuppresion, HIV
- systemically unwell
- unexplained weight loss
- widespread neurological symptoms
- structural deformity
- fever
What are the red flags that must be screened for?
night pain, pain at rest
radiating pain, paraesthesia, weakness
alterations to bowel & bladder function
Which ligaments are palpable in the posterior hip/lower back region?
Supraspinous ligament
Interspinous ligament
Ilio-lumbar ligament
sacroiliac ligament
sacrococcygeal ligament
AROM of Lower back
Flexion - 55-70º
extension - 35-45º
LSB/RSB - 20-30º
Rotation L/R - 5-10º
Diagnostic palpation with low back pain
bony - Lumbar SP’s & TP’s
Ligaments - Supraspinous, interspinous & iliolumbar ligament
muscles - erector spinae & multifidus, QL, Lats
Diagnostic palpation with sacral pain
bony - PSIS, SIJ, sacral SP’s
Ligaments - posterior SI, long dorsal SI
Muscles - Gluteus medius, piriformis
Joint play - Lumbar spine
PA springing
Joint play - Pelvis & Sacrum
ASIS springing
Nutation
Counternutation
Which neurodynamic tests are used for the lumbar spine and lower limb?
Straight Leg raise
Slump test
Prone Knee bend
What is the Slump test testing for?
mechanosensitivity of lumbosacral nerves and/or neural connective tissues
Orthopaedic tests for SIJ
Thigh thrust test
SIJ distraction test
SIJ compression test
Sacral thrust test
Active SLR
Articulation - Sidelying
flexion, extension, sidebending, rotation
Articulation - prone
extension, side bending, rotation, PA lumbar springing, sacral nutation and counternutation
Lower Limb reflexes
Knee - L3/4
Ankle - S1
Babinski response
Clonus
Motor strength testing lower limb
L 1/2 - hipflexion
L3/4 - knee extension
L4/5 - knee flexion/ankle dorsiflexion
L5 - big toe extension
S1/2 - ankle plantar flexion
