Peripheral Neurogenic LBP Flashcards
Central Canal Problem
affects nerve roots in the lumbar spine - mostly degenerative degenerative central canal stenosis spondylosthesis - slow onset - typically affects older people
Lateral Canal Problem
posterolateral canal herniation affects the lateral canal acute onset more irritable affected younger people can be degenerative - older, slow, less severe
What movements increase the size of the IVF?
traction
flexion
contralateral side flexion
rotation - differs from person to person
- may open with contralateral or ispilateral rotation
Methods of up-regulating sensitivity
chemical from adjacent pathology
acute disc herniation
changes in circulatory perfusion
Increasing Sensitivity - Chemicals from Adjacent Pathology
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
Increasing Sensitivity - Acute Disc Herniation
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
Increasing Sensitivity - Circulatory Perfusion
occurs via disc herniation and abnormal IVF mechanics
means reduced perfusion to the nerve
nerve becomes fibrotic
causes circulatory stasis, ischaemia and acidosis
Sensitivity States
Mechanosensitivity - nerve is sensitive to pinching and stretching
Ischemosensitivity - sensitivity to perfusion changes
Adrenosensitivity - sensitive to stress and worry
Features of Lateral Canal Pain
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
Radicular Pain Only
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
Radiculopathy and Radicular Pain
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
Dysaesthetic Pain
sharp, stabbing, lancinating strange and unpleasant sensitive in leg latent/after pain feel awful/wearing paraesthesia anaesthesia weakness
Nerve Trunk Pain
deep aching pain dragging feeling pulling pain heaviness pins and needles occasionally
Pain Behaviour
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
Physical Examination
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
Local Contributing Factors
chemical environment
IVF not opening enough or closing too much
Remote Contributing Factors
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
Management - Psychological Function
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
Management - General Function
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
Management - Tissue Sensitivity
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
Management - Local Function Movement
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
Management - Local Function Muscle Performance
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
Management - Remote Function
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
