Lumbar 1 Flashcards
Sympt worsening since onset
- Gentle approach/unstable condition
- Carefully monitor symptom response
- Educational approach, espec. 1:st 24-48h
- Sustained pos. may be of more use than repeated movements.
- May indicate serious pathology.
(2:14 p.383)
Onset - what to have in mind when asking about.
- Mostly no apparent reason, says patient
- Usually flexed activities around onset
- Red flags
- Obvious incident: osteoporosis (older female) and spondylolisthesis (adolecents at sports injury)
Sympt at onset - if changed location
Always indicate derangement
Constant or intermittent
- Constant means 100% of their waking day!
- Constant: inflammatory disease, recent trauma (infl responce) or MECHANICAL DEFORMATION (derangement)
- Never in Postural Syndr. or Dysfunction
Constant pain is more difficult to treat than intermittent. Why?
Patient is usually unable to identify a directional or postural preference.
Pain that may spread, not change location…?
Inflammatory, as it worsens
What makes the pain worse/better?
Sitting, driving and bending causes
Flexion. Posterior derangement
Standing and walking usually causes
Extension.
Theory of pain in rising from sitting position
Usually posterior derangement. Deformity of prolonged sittning prevents immediate CURV REVERSAL or else the act of LEANING FORWARD in order to stand may cause momentary increase in pain. (2:14, p387)
Myelopati
Ryggmärgspåverkan. Disk, osteofyter. Gång, smärta, fumlighet i armar.
Nociceptor activates by three mechanisms
Thermal, Mechanical, Chemical
Management of acute phase of Trauma, subgroup OTHERS: Injury & Inflammation
Hours to days
Protect from further damage.
Prevent excessive inflammatory exudate.
Reduce swelling.
Mid-range movements. Isometric contractions.
Management of trauma: Sub acute phase: Repair & Healing
Days to weeks
Gentle tension & loading without lasting pain.
(Prod. NW.)
Progressive return to normal loads & tension.
Management of Trauma: Remodelling
Weeks to months
Prevent contractures. Full range movements.
Normal loading & tension to increase strength
& flexibility.
Indications for MDT
Nerve root problems
Mechanical back pain
- Mostly aged 20-55 years at onset
- Lumbosacral region, buttocks and thighs
- “Mechanical” in nature, that is the pain varies with physical activity and over
time
- Patient is generally well
Contraindications for MDT
Serious spinal pathology
Cauda equina, cancer, cord signs, infections, fractures, widespread neurological deficit
The literature suggests the incidence of these is < 2%
Describe the clinical characteristics of the Derangement Syndrome
Derangement Syndrome is a clinical presentation associated with a mechanical
OBSTRUCTION of an affected joint. DIRECTIONAL PREFERENCE is an essential feature and
CENTRALISATION is an important phenomenon observed in the spine.
Features of Derangement
Inconsistency and change is a characteristic of Derangement. Its clinical presentation is variable;
DERANGEMENT; Pattern in the history: Location? Symptom: behavior? when? Onset? SPT and Mech-Presentation are influenced by...? Movements and postures...? Sustained postures and activities can...? Back pain history?
Location of pain may be local, referred or radicular or a combination
Symptoms may move from side to side, proximally and distally
Symptoms may be constant or intermittent
Therefore they are variable during the day and over time
Pain may arise gradually or suddenly, often with an insidious onset
Onset may be accompanied by sudden disability
Symptomatic and mechanical presentations are influenced by postural loading
strategies during activities of daily living
Movements and postures cause symptoms to increase/decrease, centralise/
peripheralise, produce/abolish
Sustained postures and activities can rapidly and progressively worsen or
improve the severity and spread of pain
May have history of previous episodes
DERANGEMENT: Pattern in the examination:
- Mechanical presentaiton:
- May include:
- May desplay:
- Can cause lasting changes…?
- Cause symptom so produce/abolish?
- Cause increased/decrease in?
Mechanical presentation always includes diminished range or obstruction of
movement
May include temporary deformity, e.g. kyphosis, lordosis, lateral shift
May display deviation of normal movement pathways.
Loading strategies can cause lasting changes
Repeated movements cause symptoms to produce/abolish,
increase/decrease, and pain to centralise/peripheralise
Repeated movements cause increase/decrease in range of movement
Characteristics of Centralisation
Only occurs in Derangement Syndrome
Occurs in response to loading strategies (repeated movements or postures)
Is usually a rapid and always a lasting change in pain location
Can be reliably assessed
Characteristics of Peripheralisation
The lasting production of distal symptoms
Occurs in response to loading strategies (repeated movements or postures)
Directional Preference describe…?
Directional Preference describes the clinical phenomenon where a specific
direction of repeated movement and / or sustained position results in a clinically
relevant improvement in either symptoms and / or mechanics though not
always the Centralisation of the symptoms. It is an essential feature of the
Derangement Syndrome.
When to restore funktion?
After 2:nd visit usually. In more difficult cases after 10-12 days.
What to do if create a new derangement in opposite direction?
?
Criteria to establish the clinical relevance of a lateral shift
Upper body is visibly and unmistakably shifted to one side
Onset of shift occurred with back pain
Patient is unable to correct shift voluntarily
OR, if patient is able to correct shift they cannot maintain correction
Correction affects intensity of symptoms
Correction causes either centralisation or worsening of peripheral symptoms
THE DYSFUNCTION SYNDROME
Pain is caused by?
Pain is caused by mechanical deformation of
structurally impaired soft tissues.
This abnormal tissue may be the product of
previous trauma, or inflammatory or degenerative processes. These events cause
contraction, scarring, adherence, adaptive shortening, or imperfect repair.
THE DYSFUNCTION SYNDROME
Felt when?
Pain is felt when the abnormal tissue is loaded.
Articular or contractile structures can be
affected – the former is most common in the spine.
When affecting articular structures, it is characterised by a painful restriction of end range
movement.
THE DYSFUNCTION SYNDROME
Pattern in the history (5):
History of trauma, derangement, or years of poor posture or degenerative
changes
Present for at least 8-12 weeks
Pain is Always local except in the case of an Adherent Nerve Root (ANR)
Pain is ALWAYS Intermittent and produced only when loading structurally
impaired tissue
Symptoms cease when loading is ended, and the pain never lasts
THE DYSFUNCTION SYNDROME
Pattern in the examination (3):
Consistent direction and amount of movement produces pain
Restricted movement(s) in one or more planes
Appropriate repeated movement will produce symptoms, which do not remain
worse
THE POSTURAL SYNDROME
Pain cause?
Caused by mechanical deformation of soft
tissues or vascular insufficiency arising from prolonged positional or postural
stresses affecting the articular structures or the contractile muscles, their tendons
or the periosteal insertions. No pathological changes occur in this syndrome.
THE POSTURAL SYNDROME
Pattern in the history?
Usually young
Sedentary lifestyle
Time is an essential causative factor
Symptoms always local and intermittent
But may have simultaneous cervical, thoracic, and lumbar pain
Brought on only by prolonged static loading of normal tissues
No pain with movement or activity
Most common provocative posture is slumped sitting
THE POSTURAL SYNDROME
In examination?
Poor posture – forward head posture, increased thoracic kyphosis, reduced
lumbar lordosis
Posture correction abolishes
No loss of movement
Repeated movements have no effect
Pain produced / abolished on static tests
OTHER
Chronic Pain Syndrome Inflammatory Mechanically Inconclusive Mechanically Unresponsive Radiculopathy Post Surgery SIJ Spinal stenosis Structurally Compromised Traum
McKenzie Classification – Spinal OTHER
Serious pathology (list is not exhaustive)
Category Clinical findings (Red Flags)
Clinical Examples
Cancer Age >55, history of cancer, unexplained weight loss, progressive, not relieved by rest
=May be primary site or metastases
Cauda equina syndrome/cord compression
Bladder / bowel dysfunction, saddle anaesthesia, global or motorweakness in legs. Clumsiness in legs
Spinal fracture History of severe trauma, older age, prolonged steroid use OR young, active with sport related back pain. =Compression fracture, stress fracture of the pars
Spinal related infection Fever, malaise, constant pain, all movements worsen
=Epidural abscess, discitis, transverse myelitis
Vascular Vascular disease, smoking history, family history, age over 65, male>female. History of trauma, dizziness, diplopia, dysarthria and multiple other nonmechanical symptoms =Abdominal aortic aneurism,
cervical artery dysfunction
