Worksheet 1

Question 1

1. IASP defines lumbar pain as pain experienced in this area.

Answer 1

Pain perceived as arising from anywhere within a region bounded superiorly by an imaginary transverse line through the tip of the last thoracic spinous process, inferiorly by an imaginary transverse line through the tip of the first sacral spinous process, and laterally by vertical lines tangential to the lateral borders of the lumbar erectores spinae. Pain located over the posterior region of the trunk but lateral to the erectores spinae is best described as loin pain to distinguish it from lumbar spinal pain. If required, lumbar spinal pain can be divided into upper lumbar spinal pain and lower lumbar spinal pain by subdividing the above region into equal halves by an imaginary transverse line

Question 2

2. IASP defines sacral pain as pain experienced in this area:

Answer 2

Pain perceived as arising from anywhere within a region bounded superiorly by an imaginary transverse line through the tip of the first sacral spinous process, inferiorly by an imaginary transverse line through the posterior sacrococcygeal joints, and laterally by imaginary lines passing through the posterior superior and posterior inferior iliac spines.

Question 3

3. What is the difference between somatic and visceral pain?

Answer 3

Somatic pain results from noxious stimulation of one of the MSK components of the body. This term stands in contrast to visceral pain in which the noxious stimulus happens to an organ of the body and in contrast to neurogenic pain in which the nociceptive information arises as a result of irritation or damage not to nerve endings but to the axons or cell body of a peripheral nerve.

Question 4

Somatic pain results from

Answer 4

noxious stimulation of one of the MSK components of the body. Neurophysiologicaly it arises as a result of the stimulation of nerve endings in a bone, ligament or muscle..

Question 5

visceral pain .

Answer 5

noxious stimulus happens to an organ of the body

Question 6

neurogenic pain

Answer 6

nociceptive information arises as a result of irritation or damage not to nerve endings but to the axons or cell body of a peripheral nerve

Question 7

4. definition of “referred pain”

Answer 7

pain perceived in a region innervated by nerve other than those that innervate the actual source of pain. It may be perceived in areas relativly remote from the source of the pain but often the distinction is blurred when the regions of local and referred pain are contiguous and the two pains appear to be confluent.

Question 8

The anatomical basis for spinal referred pain appears to be convergence. Explain…

Answer 8

Afferent fibers from the vertebral column synapse in the spinal cord with second-order neurons that happen also to receive afferents from other nerves. In the absence of any further localizing information, the brain is unable to determine whether the information it receives from the second order neuron was initiated by the vertebral afferent or the other convergent fibers, and so attributes its origin to both.

Question 9

5. your understanding of “referred pain” from the study/treatment of trigger points in manual skills?

Answer 9

Trigger points are most likely to occur in the muscle at the site of stress or muscles involved with faulty posture (due to increased metabolic demands and decreased circulation)
Referred Pain is dull achy pain that arises in a trigger point but is felt at a distant, often entirely remote area. Trigger point referral pain is specific, reproducible and predictable although it does not always follow the researched patterns. Pain of TrP’s does not follow neurological patterns or visceral patterns of pain. Often, myofascial referral pain remains within the same dermatome, myotome or sclerotome as the muscle with the TrP but does not cover the entire segment

Question 10

6. Bogduk writes that “the physiological basis for referred pain is convergence” Please explain this, using the “buttock pain” referral information as an example

Answer 10

physiological basis for refered painis convergence is refering to the convergence of the neurons that relay to and from the different peripheral nerve sites but converge into common neurons to relay info to the higher centers within the spinal cord and thalamus. Because of this integration the brain is unable to determine which of the sensory receptors in what area of the periphery has been affected. The buttock example shows the LBP associated (radiating) into the gluteal area shares similar segmental nerve supply (L4,L5, S1) as the lumbosacral region. The back is innervated by the dorsal rami of these nerves whereas the deep tissue of the buttock are innervated by the ventral rami ( the superior/ inferior gluteal nerves).

Question 11

7. What is radiculopathy?

Answer 11

A neurological condition in which conduction is blocked in the axons of the spinal nerve or its roots. Conduction block in sensory axons result in numbness while conduction block in motor axons result in weakness. This can be caused by compression or ischemia of the affected axons.

Question 12

8. Is radiculopathy a source of pain?

Answer 12

No it is a state of neurological loss.

Question 13

9. What sensory experience does radiculopathy create?

Answer 13

Conduction block in sensory axons result in numbness while conduction block in motor axons result in weakness. This can be caused by compression or ischemia of the affected axons.

Question 14

10. What is radicular pain?

Answer 14

Radicular pain is pain that arises as a result of irritation of a spinal nerve or its roots. Radicular pain is distinguished from nociception by the axons being stimulated along their course; their peripheral terminals are not the site of stimulation. Ectopic activation may occur as a result of mechanical deformation of a dorsal root ganglion, mechanical stimulation of previously damaged nerve roots, inflammation of a dorsal root ganglion, and possibly by ischemic damage to dorsal root ganglia.

Question 15

Radicular pain is distinguished from nociception by

Answer 15

the axons being stimulated along their course; their peripheral terminals are not the site of stimulation.

Question 16

Ectopic activation may occur as a result of

Answer 16

mechanical deformation of a dorsal root ganglion, mechanical stimulation of previously damaged nerve roots, inflammation of a dorsal root ganglion, and possibly by ischemic damage to dorsal root ganglia.

Question 17

11.Please describe symptoms that occur with “nerve root compression” in clinical studies.

Answer 17

Neurophysiological experiments have shown that nerve root compression does not evoke nocireceptive activity. The nerve at best briefly evokes a discharge at the time of compression stimulus but thereafter becomes silent.
Only when dorsal root ganglia are compressed a sustained activity is evoked but this activity occurs not only in the nocireceptive axons but also in beta fibers (carry info related to touch).

Question 18

once believed radicular pain was due to nerve root compression. .

Answer 18

UNTRUE

Question 19

12. What is the difference between radicular pain and somatic referred pain?

Answer 19

Radicular pain is distinct from somatic referred pain as it is shooting and band like as opposed to being in a constant position but poorly localized and diffuse, with an aching quality.

Question 20

Radicular pain

Answer 20

is shooting and band like

Question 21

somatic referred pain

Answer 21

poorly localized and diffuse, with an aching quality.

Question 22

13. Who is Nikolai Bogduk?

Answer 22

one of the leading authorities IN THE WORLD on pain. pursued the problem of spinal pain and headache across several disciplines
devised anaesthetic techniques whereby nerves that might be mediating a patient’s pain might be blocked, as a diagnostic test. devised surgical procedures whereby spinal pain and headache could be stopped.

Question 23

14. What kind of pain has been produced experimentally by stimulating nerve roots? Describe it:

Answer 23

Shooting pain in a band like distribution.

Question 24

15. describe your understanding of “SCIATICA”.

Answer 24

Sciatica should only present with shooting band like pain. Pain presenting as constant , deep ache in the lower limb arises from irritation or damage to an axon or cell body of a peripheral nerve.

Question 25

16. What is the most common cause of radicular pain?

Answer 25

Disc herniation is single most common cause of radicular pain due to INFLAMATION.

Question 26

18. What happens when disc material penetrates into the epidural space, which may account for pain? (ref. p. 186, Bogduk)

Answer 26

Herniated disc material attracts macrophages, fibroblasts, and lymphocytes and a variety of inflamitory chemicals are produced by these cells or the disc material itself. There is evidence that the disc material evokes a chemical inflammation. The resulting edema causes nerve root conduction block and the features of radiculopathy. Ectopic impulses generated in the dorsal root ganglia are responsible for the radicular pain and are probably produced by the ischemia.

Question 27

19. Where does one experience radicular pain?

Answer 27

Radicular pain is felt in the lower limb, not in the back.

Question 28

20. Are vertebral body fractures painful? Explain.

Answer 28

Vertebral bodies of the lumbar vertebrae are innervated. Nerve fibers derived from the plexuses of the ALL and PLL supply the periostium of the bones and penetrate deep into the vertebral bodies where they provide a possible substrate for bone pain. It is therefore believed the vertebral periostium is pain sensitive.

Question 29

21. What is the most common disease affecting the lumbar spine?

Answer 29

Osteoporosis

Question 30

22. evident from a bone scan?

Answer 30

Bone scans are most useful before the fracture has actually occurred, when the scan detects the stress reaction in the pars articularis. Once the fracture has actually occurred the scan may or may not be positive, and tends to be negative in patients with chronic pain.

Question 31

Can fractures of the pars interarticularis be a likely cause of chronic back pain?

Answer 31

will be filled with fibrous scar tissue riddled with free nerve endings
and nerve fibers containing calcitonin, gene- related peptide, vasoactive intestinal peptide and peptide Y. Nominally, therefore, it could be a source of pain.

Question 32

23. summarise Bogduk’s theory of muscle sprain to the musculature of the low back.

Answer 32

The concept of muscle strain stems from everyday experience and sports medicine where it is commonplace for muscles to become painful after sever or sustained exertion. It is therefor easy to postulate that analogous injuries might befall the back muscles when they are forcibly stretched against contraction. The resulting lesion would presumably evoke an inflamitory repair response, which is easily accepted as a source of pain. More diffuse muscle pain following exertion theoretically explicable on the basis of ischemia.

Question 33

Does Bogduk consider sprain a likely source of chronic low back pain? Explain.

Answer 33

No. He goes on to say that such mechanisms probably underlie some cases of exertional back pain , but this pain should be self limiting.

Question 34

24. Many massage therapists are in the habit of using language like “it’s probably a muscle spasm” or “we need to improve the muscle balance” around a structure of the body (e.g. core). Bogduk shares challenging theories on these ideas, on page 189, based on laboratory evidence. Do you agree with his conclusions? Explain your reasoning.

Answer 34

Yes I do agree. Until evidence using something more conclusive, for example PET scans, is investigated the language we us should be toned down. There is a lot of information available on line these days and our clients are much more aware. Giving “simple” blanket diagnoses that may be contradictory to what a medical adviser may report only serves to make the profession look uneducated. We are not diagnostic or imaging specialists and should stay within our scope , while referring out to the other professions for actual diagnoses. We can use less conclusive language such as increasing blood flow and trying to to redirect the nervous systems in our explanations to “ our understanding according to what has been taught”, when it comes to managing pain.

Question 35

25. The thoracolumbar fascia could be responsible for a type of “compartment syndrome”pain in the low back. How likely is this, given the conclusions presented in this paper? Explain your reasoning.

Answer 35

Again the study quoted seems to lack true empirical evidence and does not produce actual values for the magnitude of the pressures caused within the “compartments”. In theory this all sounds great and would be a nice variable to use as an “ educated guess”. I cannot say how “likely this is” as I am no where near the level of education it would require to do the scientific inquiry to even have a say in the likelyhood. We should not be presenting guess work or inconclusive evidence to a client in pain as it will not help build trust or reliability in our profession should the theory be disproved.