Peripheral Neurogenic LBP

Question 1

Central Canal Problem

Answer 1

affects nerve roots in the lumbar spine 
- mostly degenerative 
degenerative central canal stenosis 
spondylosthesis 
- slow onset
- typically affects older people

Question 2

Lateral Canal Problem

Answer 2

posterolateral canal herniation 
affects the lateral canal 
acute onset
more irritable 
affected younger people
can be degenerative - older, slow, less severe

Question 3

What movements increase the size of the IVF?

Answer 3

traction
flexion
contralateral side flexion
rotation - differs from person to person
- may open with contralateral or ispilateral rotation

Question 4

Methods of up-regulating sensitivity

Answer 4

chemical from adjacent pathology
acute disc herniation
changes in circulatory perfusion

Question 5

Increasing Sensitivity - Chemicals from Adjacent Pathology

Answer 5

inflammation from adjacent tissue injury
results in sensitising and pain causing chemicals
may result in an auto-immune response
sensitisation of nervi nervorum
- demyelination and neuronal degradation
- loss of conduction
- formation of AIGs
invasion and activation of inflammatory cells
nerve becomes fibrotic - slides less
more irritable

Question 6

Increasing Sensitivity - Acute Disc Herniation

Answer 6

typically caused by loading under flexion with compression
side flexion then strains one side of the posterior wall
more likely to occur in younger, non-degenerative discs
more likely to occur with annular tears - herniation occurs through the radial fissures

Question 7

Increasing Sensitivity - Circulatory Perfusion

Answer 7

occurs via disc herniation and abnormal IVF mechanics
means reduced perfusion to the nerve
nerve becomes fibrotic
causes circulatory stasis, ischaemia and acidosis

Question 8

Sensitivity States

Answer 8

Mechanosensitivity - nerve is sensitive to pinching and stretching
Ischemosensitivity - sensitivity to perfusion changes
Adrenosensitivity - sensitive to stress and worry

Question 9

Features of Lateral Canal Pain

Answer 9

unilateral leg pain
worsen than back pain
back pain is occasionally absent
pain in sensory distribution of the nerve roots
pain along the line of the peripheral nerve
may have clumping of symptoms along the nerve path

Question 10

Radicular Pain Only

Answer 10

from mechanical stimulation 
from ischemia 
from adrenostimulation 
mainly nerve trunk pain 
mainly stretch sensitive 
minimal associated symptoms 
negative neural integrity tests 
peripheral tenderness 
less adrenosensitive

Question 11

Radiculopathy and Radicular Pain

Answer 11

from nerve compression 
from nerve degradation 
from ischemia 
pathology is very important 
dysaesthetic or nerve trunk pain 
stretch and compression sensitive 
associated symptoms 
positive neural integrity 
peripheral tenderness
more adrenosensitive

Question 12

Dysaesthetic Pain

Answer 12

sharp, stabbing, lancinating 
strange and unpleasant 
sensitive in leg 
latent/after pain 
feel awful/wearing 
paraesthesia 
anaesthesia 
weakness

Question 13

Nerve Trunk Pain

Answer 13

deep aching pain 
dragging feeling 
pulling pain 
heaviness
pins and needles occasionally

Question 14

Pain Behaviour

Answer 14

can be constant
some mechanical pattern but can vary
aggravated by IVF closing positions - radiculopathy
aggravated by nerve lengthening - both
relief with IVF opening - radiculopathy
relief with nerve unloading - both
onset/relief with sustained positions - both

Question 15

Physical Examination

Answer 15

antalgic positions unload the nerve or open IVF
aggravated by IVF closing positions - radiculopathy
aggravated by nerve lengthening - both
positive NDT and palpation
may lack mobility into IVF opening
may have good mobility into IVF closing but be poorly controlled
remote function drives hole closing

Question 16

Local Contributing Factors

Answer 16

chemical environment

IVF not opening enough or closing too much

Question 17

Remote Contributing Factors

Answer 17

poor flexibility into hole closing directions causes lumbar spine compensation

• reduced thoracic extension
• reduced hip extension
• reduced thoracic SF
• reduced hip rotation

poor independent muscle function into same directions

ALL drives hole closing

Question 18

Management - Psychological Function

Answer 18

explain problem

• low chance of serious illness
• has favourable outcomes
• use non threatening and reversible language
• focus on functional factors
• biopsychosocial view
• pain = protection

Treatment Plan

• explicitly active
• encourage self management
• discourage excessive protection
• importance of moving and loading
• encourage helpful behaviours and active coping

Question 19

Management - General Function

Answer 19

advice on load management. specific to their pathology
discourage excessive sedentary behaviour
progressive general exercise program
technique modification
manual handlign advice
sleep hygeine
involve other HCP where appropriate

Question 20

Management - Tissue Sensitivity

Answer 20

drugs may be helpful - not much evidence which are best
injections - short term effects
surgery - effective for 10% of people, but still not better than simple good rehab

Question 21

Management - Local Function Movement

Answer 21

Promote IVF opening

• without loading the nerve or disc adversely
• initially avoid flexion and side flexion
• early stages use traction and rotation
• use sustained movement
• home exercise program

Nerve Movement - some evidence for nerve mobilisation once neural integrity normalised

Question 22

Management - Local Function Muscle Performance

Answer 22

want to control neural compressive load and reduced IVF closing 
FIND IT 
- independent movement in IVF opening 
- early stages use side glide, then progress to flexion 
CONTROL IT 
- improve control under IVF closing load 
- unilateral extension
- ipsilateral SF
- rotation 
LOAD IT 
- extension 
- side flexion 
- not necessary for everyone

Question 23

Management - Remote Function

Answer 23

Want to take IVF closing away from the lumbar spine
Promote Movement above and below lumbar spine into IVF closing directions
- at thoracic spine promote extensions and ipsilateral side flexion
- at the hip promote extension
- promote rotation
- if leg pain is caused by ipsilateral lumbar rotation, want to promote medial rotation
- if leg pain is caused by contralateral lumbar rotation, wnat to promote lateral rotation

Improve capacity of muscles to work independently into these directions

Improve remote neurodynamics