Diagnosis of OLBP - clinical reasoning framework Flashcards
1
Q
central pain mechanism - neurobiological processes underpinning
A
- neuromodulatory issue
- maladaptive psychology
- social issues
2
Q
triage - fracture risk
A
trauma sudden sharp, deep pain usually high severity multidirectional provocation highly painful on palpation OP risk BMI low age > 50, more so if >70 non traumatic fracture before metabolic disease long term steroid use acute spinal deformity
3
Q
Infection risk
A
open wound post surgery or had invasive operation indwelling catheter/indwelling device used red, swollen, hot locally immunosuppressed IV drug use fever night sweats rigors unwell feeling UTI or other recent infection
4
Q
Cancer risk
A
constant unremitting pain non mechanical insidious onset no relief with rest unexplained weight loss associated symptoms i.e. coughing blood up night pain family hx of cancer pt hx of cancer age > 50 with first episode of LBP risky activities i.e. smoking generally feeling unwell treatment unsuccessful failure to ease pain
5
Q
Neurological risk
A
bilateral distribution bladder dysfunction bowel dysfunction glove & sock anaesthesia saddle aneasthesia S2 distribution S2 toe flexion test +ve unsteadiness clumsiness hyperreflexia spasticity widespread signs (over a few levels) severe weakness (even if only 1 level) progressive signs (even if only 1 level) dermatomal rash diabetic
6
Q
Inflammatory risk
A
slow insiduous onset persistant episodic pain morning worst time morning stiffness lasts >1/2 hour wakes 2nd half of night eases with activity worse with rest multi jnt involvement hot/red/swollen jnts family hx past hx eye redness psoarisis dry eyes/mouth stomach problems related to jnt pain enthesopathies (tendon pain) alternating SIJ pain NSAIDS help +++ hot bath/shower helps +++ dactylitis ( swollen finger ) persistent limitation all directions hip/shoulder/neck stiffness in AM fatigue/fever/malaise
7
Q
Non spinal pathology
A
Renal
gynaecological
other organ
psychiatric
Vascular i.e. AAA: - PVD/CAD
- HTN
- >60
- smoker
- pulsatile mass
- abdominal pain
- syncope (drop in HR/BP giving fainting)
- Bruit (blood gushing sound)
8
Q
Peripherally dominant signs
A
well defined area anatomical pattern makes sense mechanical behaviour appropriate level of irritability turns off and on clear stimulus response pattern progression in keeping with physiology standard history predictable and consistent response to physical loading loading response makes biomechanical sense reasonably stable
9
Q
Centrally dominant signs
A
widespread pain not within usual anatomical boundaries extensive spreading of pain pain shifts around sustained high levels of pain spontaneous pain non noxious triggers non standard clinical course other sensitivites (noise, smell, chemical etc) distorted stimulus response relationship non restorative sleep extreme fatigue concentration problems unpredicatable and varied response to treatment widespread hyperalgesia widespread allodynia pain affected by emotions illness, anxiety and depression related to pain negative perceptions and expectations unhelpful behaviour (withdrawal, excessive rest) contradictions in behaviour inconsistencies in behaviour extreme behaviours waddells symptoms
10
Q
Waddells symptoms
A
coccyx pain whole leg pain whole leg numbness whole leg giving way never free from pain intolerance/reaction to many treatments hospital admission with NSLBP
11
Q
Peripheral neurogenic pain - nerve trunk pain
A
deep, aching pain pulling pain dragging heaviness along line of nerve tension point of pain linking of pains form line of enrve mild non-dermatomal paraesthesia
12
Q
Peripheral neurogenic pain - dysaesthetic pain
A
sharp/shooting/stabbing/lancinating burning/gripping paroxysmal pain pain felt in sensory distribution of pain paraesthesia anaesthesia weakness hyperalgesia allodynia latent pain after pain feel awful, wearing autonomic changes peripheral tenderness
13
Q
Peripheral somatic pain
A
back pain usually main problem
deep, aching pain
back pain can be well localised
back pain can be sharp or catching
referred pain qualities: deep, aching dull but may become severe static in location expand slowly if stimulus increases aware of centre but hard to localise boundaries less often below knee spreads slowly non tender in referred area after pain uncommon
14
Q
Mobility dysfunction
A
older age less episodic less variation in symptom intensity slower to resolve when aggravated not increasing in frequency less intense less likely to be immobilised or stuck associated with stiffness morning pain pain with position change relief with stretching less when warmed up
15
Q
loading dysfunction
A
less episodic slower development mid range pain pain with static loading may be more fearful and anxious relief when distracted relief with relaxation describe tightness describe tiredness muscular distribution to some pains burning LBP (ischaemic) quality maladaptive stability beliefs worse with stability training rigid and cautious to move anticipate pain breath holding
