Puducherry

December 2010

MANAGING SPINAL PAIN
One Day Workshop

Richard Bartley Physiotherapist Wales, UK

AN EVIDENCE-BASED APPROACH
With full reference list
Courses • Maitland’s Mobilsations and Manipulation, Sheffield 1985 - 1986. • Electrotherapy and Massage for Remedial Gymnasts. Bath 1986. • McKenzie Parts A B C. London 1989. • Medical Acupuncture. Rotherham 1991. • Management Skills for PTs. London 1992. • Nags and Snags. London 1994. • Muscle Imbalance. Cardiff 1996. • Advanced Medical Acupuncture. Surrey 2005. • Electrotherapy Update. Northampton 2006. • Plus numerous one day clinical courses. Extra-Curricular Activities • Lecturer in sports medicine. Middlesex Polytechnic 1985 - 1986. • Lecturer in anatomy. Oxford Chiropractic College 1996 - 1999. • Editor of Management of Low Back Pain in Primary Care, published in 2001. Education • Diploma in Remedial Gymnastics, University Hospital of Wales, Wales 1980 • Masters degree in Research Methodology, University of London 1998

This handout has been written and published by Richard Bartley in 2004 and updated in 2010.

[1]

INTRODUCTION

We have an obligation to our patients to provide them with the most up to date treatments, i.e. treatments based on clinical research. Unfortunately, up until the 1990’s, very little research on Controlled trials are the only way of avoiding confounding variables spinal pain took place. (which can lead to completely As a result, physiotherapists and false conclusions). However, doctors have treated patients with these are not always easy to empirical treatments, of which few u n d e r t a k e a n d r e q u i r e have any supporting evidence to considerable funding and time. show that they are effective. A good example of this is lumbar Case studies and audits (or observational studies) cannot and cervical traction. provide irrefutable proof that a However, the last twenty years treatment works. However, they has seen good progress in terms may reveal whether the ‘total’ of research. Here are some things therapy input is creating any discernible change in outcome(s). we now know: A smoker is four times more likely to suffer back pain than a nonsmoker. Bed rest prolongs back pain Patients who go off sick from work take longer to get better than those that return to work early. Providing patients with convenient ‘labels’, such as slipped discs and arthritis can cause patients to ‘catastrophise’. X-rays have little value in diagnosising spinal pain and over exposure may be dangerous. Exercise therapy and cognitive behavioural therapy are effective at treating chronic pain associated with biopsychosocial influences (i.e. Yellow Flags). We are still not sure whether the following treatments are effective for back pain:

Does this mean that we should not use these modalities? Perhaps. However, absence of proof is not proof of absence. We simply do not know enough yet about their efficacy.

This is important as sensitivity to the different sub-groups of spinal disorders (e.g. sciatica) may vary considerably and care should be taken to assess the appropriateness of each measurement tool. It is important to recognise that there is not always a proportional relationship between impairment and disability. For instance, we know that it is possible to be severely disabled whilst having a relatively minor impairment, and vice versa.

• Manipulation • TENS • Acupuncture • Trigger Point Therapy • Massage • Traction • Ultrasound • Pulsed SWD

This can have the disadvantage of allowing perceptual elements affect the overall score. Patients who are in considerable pain may still be able to work and may score ‘low’, even in the presence of Patients can be asked to complete serious impairment such as a questionnaires before therapy and severe root compression. some time after they have completed their treatment. By C o n v e r s e l y a p a t i e n t w i t h comparing results, the results may psychological problems may score provide an insight into the value of ‘high’ in the absence of any ‘total’ physiotherapy, albeit the s i g n i f i c a n t p a t h o l o g y o r level of placebo or the benefit of impairment. The potential for individual treatment components patients to score high or low with a will remain unknown. predetermined level of impairment may reflect cultural differences A number of indices have been and attitudes to illness. developed to assess the level of disability in patients with spinal Even allowing for these inherent disorders. weaknesses, the use of outcome measurement questionnaires are There are generally two types: still the best tools we possess to generic and disease-specific. a s s e s s t h e e ff i c a c y o f o u r Generic questionnaires (e.g. the treatments. Sickness Impact Profile) include questions to cover impairment, As an example, the picture on the functional status, perceptions and next page shows the Roland social opportunities, and are Morris Questionnaire (RMQ). The designed to get an ‘overview’ of RMQ is a self-administered back the patient’s general quality of life. pain disability measure in which greater levels of disability are Disease-specific questionnaires reflected by higher numbers on a (e.g. the RMQ) target specific 24-point scale. diagnostic groups and are more specific to the area of the body Simply count the scores for a which is affected. result between 0 and 24. Scores under 4 and over 20 may not T h e l a t t e r u s u a l l y s a c r i f i c e show significant change over time. comprehensiveness for better Patients scoring 20+ are likely to responsiveness (i.e. the ability to be psychosocial pain patients. record minor, but essential, clinical Changes of four points or more, changes) and are therefore more pre- and post-treatment, are sensitive. significant.

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Work Ask them to describe their job (manual or sedentary). Do they like their job? What previous jobs did they have? If they are still at work, do their current symptoms affect their ability to do their job well? Are they currently off sick from their work, and if so, how long? If they are on sick leave, do they plan to return to work soon? If they are on sick leave and they have a sedentary job, ask them why they are not at work If they are on sick leave, but wish to return to work, could they negotiate with their employer for them to go on light duties? Hobbies/Interests The RMQ has been shown to yield reliable measurements, which are valid for inferring the level of disability, and to be sensitive to change over time for groups of patients with low back pain. Other pain and disability indices exist for low back pain and neck pain. Get the patient to talk about their interests. Nearly every patient has something they enjoy, whether it is reading, playing sport or looking after animals. Find out if their current symptoms prevent them from participating in their hobbies. First observe your patient as he/ Talking about their interests also she enters your clinical area. How allows the clinician to get to know do they walk, what expression do a little more about their patient. they have on their face (are they u p b e a t o r d o t h e y l o o k It is often worthwhile to take a little depressed)? Observe how they time to ask a few questions about take off their coat or jacket and their hobbies. This may not always appear to have any clinical benefit how they sit down. or relevance directly, but it helps These first impressions provide to engender a good working the clinician with valuable r e l a t i o n s h i p b e t w e e n t h e information, which can then be physiotherapist and the patient. matched with the patient’s history The patient will nearly always be a n d e x a m i n a t i o n f i n d i n g s pleased that you have taken an (although sometimes they do not interest in his/her life. match at all!). Social Circumstances Once you have noted the patient’s personal details (name, age, It is important to establish the occupation), ask them to tell you a p a t i e n t ’s f a m i l y a n d s o c i a l circumstances. little about themselves. You may decide later in the interview to ask the patient if you would both prefer to use each other’s first names. However, this is not usually appropriate for senior citizens. Is their spouse well?

ASSESSMENT OF THE PATIENT
Always welcome your patient with a firm handshake or a local cultural gesture that acknowledges that you are delighted to meet your patient. This will set the agenda for your professional relationship with the patient. Always introduce yourself by your full name, not your first name (e.g. “I am Mr Bartley”). Equally, you should not address your patient by his/her first name.

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Do they live alone? If the patient is elderly, can he/she manage the stairs at home or bathe? For those with difficulties, a visit by an occupational therapist or district nurse may be appropriate. Current Symptoms Some patients, particularly those with a long history of chronic spinal pain, present with a mental script of what they wish to tell you. This often provides the clinicians with 90% superfluous information and 10% helpful information. These patients their script chronological physiotherapist confused. don’t always get in the right order, so the can easily get

If life is too short for this approach, you may have to diplomatically steer the patient to describing their current symptoms first. With chronic pain patients this can be very difficult as they will usually be anxious to get back to their prepared mental script. It takes a very experienced physiotherapist to keep the patient on track! Before you question the patient about their symptoms, ask them to draw their pain on a pre-prepared body chart. This will provide a clinical record of the patient’s pain and other symptoms. However, it can also provide a useful insight into the patient’s mindset.

to standing, turning in bed, prolonged sitting, walking, looking down or turning the head)? If walking worsens the pain, how far can the patient walk before they have to rest (important for patients with neurogenic claudication) What eases the pain? If the patient has night pain, is it worse being in one position, or worse when turning over?

What painkillers/NSAIDS is the patient taking and do they help (usually the patient says they don’t help until they stop taking them Patients with simple back pain or and they realise that in fact they nerve root pain usually draw small were helping)? circles or a thin straight line to describe the pain. Patients with These questions aim to elicit the abnormal illness behaviour will progression of the patient’s often draw an elaborate work of mechanical pain, i.e. is it getting art, with numerous areas of pain, worse, better or in status quo? complete with written descriptions. These are of course general Questions you should ask about guidelines. For example, a few the patient’s current episode: patients with lumbar nerve root pain, secondary to a disc hernia, When did the current episode may be worse in standing rather begin? than sitting. How did the pain come on The golden rule of spinal pain (trauma, gradual onset, several diagnosis is that there are no days after a fall)? golden rules. The physiotherapist attempts to work with symptom How have the symptoms behaved patterns, but he/she must always since the onset? expect the atypical presentation. Have the symptoms changed in location, duration and intensity since the onset? Where exactly is the pain today?

When is the pain at its worst; One approach to this is just to morning, mid-day, evening or at listen. It may take an eternity for night? the patient to deliver their life Is the patient’s back/neck stiffer history. in the morning on rising from But if you listen carefully, the bed, or in the evening? patient will actually provide much of the information required. The Does the patient have days ability to sift out what is relevant completely free of pain? and irrelevant is what determines What worsens the pain (e.g. an adequate history profile. standing, transferring from sitting

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EXAMINATION OF THE PATIENT
It is better to have the patient undress down to their underwear, although female patients might prefer to not undress if they are being assessed by a male physiotherapist. In such circumstances, they could wear light trousers that can be pulled down a little and a t-shirt that can be pulled up and tucked under the bra strap. Female patients of certain religious backgrounds have the right to be examined by a female physiotherapist. When you examine a patient, you are seeing a snapshot of their back problem. You may examine the patient in the morning when Is it taking the patient longer to they are at their best or perhaps at their worst. recover between episodes? You may examine them on a relatively ‘good’ day or a ‘bad’ day. Repeat examination at each appointment allows the physiotherapist to obtain an overall picture of the patient. The first rule of examination is to see how the patient moves and undresses (e.g. how easy or difficult it is for them to take off their socks).

Previous Symptoms This need not be too detailed.

Has the patient had back/neck If the patient has had continuous pain in the past. If so, has it been pain for many years, when did intermittent or continuous? their symptoms first come on and how? Is there a history of early trauma? Are there associated conditions, If the back/neck pain has occurred such as clinical depression? a number of times in the past, is there a pattern emerging? What treatments have they had in the past? For example, are the episodes Are they currently taking drugs becoming more frequent and/or s u c h a s G a b a p e n t i n o r intense? Amitriptyline?

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This will allow the physiotherapist to assess the severity of their symptoms, or in some cases match the patient’s personal account of their symptoms with what the physiotherapist actually witnesses. The patient should be visually assessed in standing (with their legs slightly apart). The physiotherapist should look for deformity, local redness and/or swelling. Small discrepancies in leg length are not clinically significant. However, a 3 cm+ leg length discrepancy may be relevant, and this may require a heel or sole raise on the shoe of the shortened leg.

A slight feeling of tightness in one direction, which bears no relation to the patient’s normal pain, is probably not significant (it may just be the effect of stretching a shortened muscle).

For patients with low grade pain (e.g. they only get back pain whilst playing tennis), it may be necessary for the physiotherapist to perform passive movements in standing, i.e. take the patient’s trunk to the limit of each direction It is advisable to ask the patient to and apply overpressure, to see perform each movement twice, as w h e t h e r a n y m o v e m e n t s they often go a little further on the reproduce the patient’s pain. second attempt. Patients may display a deformity Worsening pain on extension, during an active movement, which combined with relatively good is not present when the patient is flexion, might suggest pain in the standing upright. This is often posterior elements of a lumbar associated with a unilateral nerve segment. root lesion. Very occasionally, the deformity is due to a subluxed facet joint. A normal straight leg raise should enable differentiation.

Multidirectional stiffness with pain on repeated flexion, might suggest an anterior compartment problem. McKenzie advocates would recommend repeated testing of Any deformity present could be in these movements. the sagittal plane (hyper-lordosis or kyphosis) or in the coronal plane (scoliosis). A severe kyphosis could be due to late stage ankylosing spondylitis or one or more osteoporotic fractures. A scoliosis could be long-standing or a result of recent onset unilateral muscle spasm. The patient’s history should help in differentiating between the two types. Long term idiopathic scoliosis, or advanced degenerative scoliosis, should be assessed by a spinal surgeon. Lumbar Assessment Testing active range of movement is achieved by asking the patient to flex forward with their knees straight in standing, extend with their hands on the hips and sideflex to each side keeping the trunk straight (i.e. not leaning forward). It is a good idea to have the patient perform extension with the anterior thighs against a raised plinth to prevent hip extension. The movements should be recorded, for range and whether each movement reproduces the patient’s pain.

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With the patient in the prone lying position, have the patient’s feet over the bottom end of the examination plinth. Test each ankle reflex. Then test the femoral reflex (knee). Finally, with the patient still prone, firmly tap each vertebra with the tips of your fingers to test for exquisite sensitivity (patients with Ca spine or infection will report severe pain on this test). The patient should then be Whilst the patient is still in supine, examined lying supine on an test their knee reflexes by gently examination couch. tapping each ligamentum patella with the knees slightly flexed. Leg length can measured by flexing both knees and lining up Then test sensation by stroking the heels so that they are level. the thighs, shins, outer calves and inner and outer feet, using a Eyeballing the knees from the side cotton pad. Compare each area or from the bottom end of the stroked on both legs. Very few plinth will allow the physiotherapist patients have total numbness. to clearly see a significant leg length discrepancy. B y t e s t i n g t h i s w a y, t h e physiotherapist is looking for a With the patient’s legs flat (if they loss of fine sensation (total can tolerate this), first test each numbness should raise suspicion straight leg raise (SLR). Take care of a non mechanical cause). when doing this as patients with nerve root pain can find this To test for an L3 root lesion, procedure very uncomfortable. position the patient in prone lying Compare both leg measurements. and passively flex the knee of the painful leg. This should reproduce The straight leg raise test is their leg pain (again NOT their performed with the patient supine. back pain). The affected leg is passively raised. When performing the passive knee bend test, many patients will A positive test should demonstrate complain of tightness in their two clinical signs: (i) the leg will quadriceps. Do not confuse this not raise more than 45 degrees with a postive nerve tension sign. due to pain, (ii) the pain is You should then test the strength reproduced in the leg, NOT the of the hamstrings and record all back. your findings. Passively raising the opposite ‘good’ leg is a worthwhile test. If it reproduces pain in the ‘bad’ leg, this is considered a positive crossover sign and is highly indicative of a disc hernia. Be aware that patients on opiatebased medication may achieve a higher SLR than if they were not on any medication at all. This may provide a false-negative result. Finally, test the power of the quadriceps, dorsiflexors and extensor hallucis flexors in both legs and record all your findings (see more pictures in Appendix). Still with the patient supine, and after asking the patient’s permission, palpate the abdomen and note any masses or a distended bladder. Report unusual findings to a medic. If the patient has severe leg pain (i.e. worse than their back pain) do expect to reproduce a positive straight leg raise or passive knee bend. However, many patients with nerve root pain will have normal motor, sensory and reflex findings. If neurological signs are present, compare these with the pain referral pattern described by the patient (e.g. in their pain chart) for consistency. L3 – Pain and/or numbness anterior thigh, diminished or absent knee reflex, quads weakness, positive passive knee bend test. L4 – Pain and/or numbness across anterior knee and into medial shin, diminished or absent knee reflex (rare), weak ankle dorsiflexors, positive straight leg raise test. L5 – Pain and/or numbness down side of leg, normal reflexes, weak extensor hallucis longus, positive straight leg raise test. S1 – Pain and/or numbness back of leg, diminished or absent ankle reflex, weak hamstrings, positive straight leg raise test. Remember that 93% of patients with back pain do not have nerve root pain. Many may have vague aches in their buttocks or thighs, but these do not follow normal nerve root referral patterns.

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To test for sacroiliac dysfunction, place the patient supine with their legs straight. Place the right ankle on top of the left knee and see if the patient can slowly lower the right knee. Repeat with the opposite leg.

The physiotherapist blocks L3 and asks the patient to retract their upper pelvis. This is tested for strength. The other side is then repeated.

Ask the patient to perform the following neck movements: flexion, extension, side flexion and rotation. Once any limitations of movement are noted, including which movements worsen the patient’s symptoms, have the patient lie supine with the head towards the end of the plinth. The clinician should then gently retest these movements passively, asking the patient to raise an arm if a movement hurts. With facet pain, often the patient will present with limitation of rotation in one direction and limitation of opposite side flexion. Palpation will often reveal a tender unilateral facet joint, although pain in the upper cervical spine will often be elicited on gentle palpation of the spinous process of C2. The brachial nerves should be tested for sensation, reflexes and muscle power. C5 mainly forms the axillary nerve to innervate the deltoid muscle. and C6 mainly forms the musculocutaneous nerve to innervate biceps.

Often a unilateral weakness is detected. The weak multifidus Record if the patient had difficulty muscle is on the LOWER side of lowering one of his/her legs. If so, the midline of the spine (i.e. this is a fairly reliable sign that the closest to the plinth). patient has an SI dysfunction on the same side as the leg that was For the oblique muscles, the difficult to lower. patient should lie supine with the knees bent and held together. The For patients with low grade back patient then attempts to rotate the pain, that only occurs when knees to the left, with the playing sport or being very active physiotherapist applying gentle at work, it is worth testing the resistance. length of the ilio-tibial band, hip flexors and hamstrings on the The knees are then taken to the affected side. right and a comparison made. Often one side is weak, but Shortening of any one, or more, of sometimes both sides may be these muscle groups can lead to found to be weak. increased strain on the lower lumbar spine. Stretching exercises Thoracic Spine are recommended. Check for any deformity, kyphosis Finally, the multifidus and oblique and/or scoliosis. Observe the skin, muscles should be tested for looking for redness. weakness. The patient lies on his/ her side with the knees and hips Ask the patient to perform active bent to 90 degrees. The shoulders flexion, extension, side flexion and should be in line. rotation in standing and sitting. Look for any movement deficit and which movement brings on the patient’s pain.

Accurate diagnosis of thoracic C7 mainly forms the radial nerve pain is very difficult. Disc hernias to innervate triceps. C8 mainly can occur, but are very rare. forms the median nerve to innervate flexor digitorum The most common problem is a superficialis and profundus. T1 costo-vertebral subluxation, which mainly forms the ulnar nerve to can cause severe pain, often innervate the intrinsic muscles of associated with pain on deep the hand. inspiration. This is discussed in more detail later. These muscle groups should be individually tested for strength. Cervical Spine Sensation for the C5 nerve can be First look for deformity. How does tested by stroking the outer upper the patient hold his or her head? arm, along the thumb for C6 and Is the head rotated to one side? along the little finger for C7. If it is, this may suggest spasm of the sternocleidomastoid muscle (SCOM). This muscle will usually shorten and spasm if a cervical facet is injured in some way. Tapping the biceps tendon with a reflex hammer tests the C6 reflex and tapping the triceps tendon tests the C7 reflex.

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DIAGNOSTIC TRIAGE
Numerous attempts have been made in the past to classify spinal pain. Few succeeded due to a lack of consensus between clinicians and researchers. However, due to the rise in low back pain disability, the Royal College of General Practitioners in London in 1999 published new guidelines based on a simple system of diagnostic triage, whereby patients with low back pain are divided into one of three types:

13. Renal disease 14. Osteomyelitis 15. Severe psychiatric illness 16. Drug abuse 17. HIV 18. TB 19. Gram-negative infection 20. Post-partum sacro-iliac staphylococcus infection 21. Discitis in young patients 22. Pelvic abscess 23 Arnold-Chiari malformation 24 Myelopathy (esp. C spine)

or has to pace up and down in their house, might suggest that there is some serious underlying pathology (e.g. metastases).

- mechanical pain - nerve root pain - suspected serious pathology
The guidelines recommended that clinicians triage all spine patients, in order to segregate those that needed urgent medical attention, from those that could be managed with simple advice, reassurance and physiotherapy. These guidelines can be applied to all cases of spinal pain. Let us examine each of these in reverse order.

Suspected Serious Pathology
It is not the responsibility of the physiotherapist to diagnose and manage serious spinal pathology. However the physiotherapist should be aware of nonmechanical causes, however rare they may be. These include: 1. Cauda equina syndrome 2. Severe osteoporosis 3. Progressive idiopathic scoliosis 4. Worsening Grade 2+ spondylolisthesis 5. Ankylosing Spondylitis 6. Paget’s Disease 7. Haematological cancers 8. Primary tumours 9. Metatastic disease 10. Pelvic sarcomas 11. Aortic aneurysms

Be aware of elderly patients who have fallen in case they have an osteoporotic fracture. Osteoporotic fractures in the anterior bodies of the vertebra cause kyphotic deformity, but do not usually present as a medical emergency. Fractures in the posterior elements may cause spinal cord Serious spinal pathology is often damage. labeled “Red Flags’. These are not as easy to detect as one might Patients who take longer than 30 expect. minutes to loosen up in the morning may have ankylosing Clearly, some patients present spondylitis. with florid signs, such as a history of rapid weight loss, profuse night The investigation of choice for sweats, tremor and significant spinal pain is taking a history. malaise. More information can be gleaned by just listening to the patient than However, many ‘Red Flags’ ordering tests. initially present with what appear to be normal signs of mechanical Blood tests have a low yield for p a i n . C l i n i c i a n s n o r m a l l y detecting serious pathology, as do distinguish these patients from x-rays. other patients with spinal pain by observing them over time and A lumbo-sacral x-ray exposes the noting any significant worsening of patient to one hundred times the their symptoms. amount of radiation than a chest x-ray. However, chronic pain patients worsen over time too. The vigilant With the exception of serious clinician should therefore be trauma, plain x-rays provide very scrupulous in his/her history little useful information (for taking, because at some stage the example, early tumours are not ‘Red Flag’ patient will inevitably easily detected on plain x- ray). begin to show some, or all, of the constitutional changes described Disc space narrowing, as seen on above. plain radiographs, are just as common in the asymptomatic Night pain is population as they are in spinal n o t a g o o d pain patients. indicator of s u s p e c t e d Magnetic resonance imaging has s e r i o u s become an important tool in the p a t h o l o g y . diagnosis of spinal pain. However M o s t s p i n a l surgical management based p a t i e n t s purely on MRI findings is e x p e r i e n c e inappropriate unless they are night pain. matched to clinical findings and much controversy remains over However the the validity of MRI findings in p a t i e n t t h a t relation to clinical conditions such has to sit out as spinal pain, brachialgia and of bed in a sciatica. chair at night,

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Numerous papers have highlighted the incidence of abnormal lumbar spine morphological findings in asymptomatic volunteers. These are termed ‘false positives’.

Does the patient’s back feel rigid? Is the patient off his/her food?

Nerve Root Pain

5% of all spinal patients have some form of nerve root Does the patient feel abnormally compression. The most common tired? cause is a nerve root compressed by a lumbar or cervical disc Boden et al in 1990, performed Does the patient feel generally hernia. MRIs on 67 individuals who had unwell? never had low back or radicular Disc hernias can be contained (i.e. pain. Of those under 60 years of Does the patient have a history of the annulus simply bulges against age, 20% had a disc hernia whilst cancer, TB or HIV? an exiting nerve root) or nonthe figure was higher at 36% in contained (the annulus tears, the over 60 year olds. Does the patient have loin pain allowing the nucleus pulposus to with urinary changes (i.e. renal e x t r u d e f r o m t h e d i s c , Jensen et al in 1994, carried out a problem)? compressing a nerve root). similar study on 98 asymptomatic people and found that 64% had T h e s e a r e q u e s t i o n s a Nerve root pain can treated abnormal discs at all levels, 52% physiotherapist needs to ask to s u c c e s s f u l l y w i t h r e s t a n d had a minor disc hernia at each ensure that any treatment they analgesia. 90% of all cases level and 27% had a significant provide is not contraindicated: resolve within 9 to 12 weeks of disc hernia. onset. Is the patient undergoing They concluded that the presence treatment for cancer or a current However, the pain can be severe of disc hernias may not be infection? and it is not unusual for patients to clinically relevant. require opiate-based medication Does the patient have sensory as well as NSAIDS. The presence of clinical findings in loss, due to another illness, such symptomatic patients requires as multiple sclerosis? Whether a disc hernia is contained careful scrutiny to ensure that they or non-contained does not alter are valid and sensitive to the Has the patient recently been on a the outcome. The contained clinical features and degree of course of blood thinning agents hernias are sometimes responsive d i s a b i l i t y p r e s e n t e d t o t h e (e.g. Warfarin) or long-term to McKenzie techniques. However, clinician. corticosteroids? no one can manipulate a noncontained disc hernia ‘back into In other words, the MRI findings Does the patient have a history of place’. must correspond to the clinical r h e u m a t o i d a r t h r i t i s ( s o m e symptoms and signs and level of patients confuse RA with OA and Once the nucleus pulposus has disability reported if they are to may say yes when they do not exited the disc, it cannot be have any role in the clinical have it)? manipulated back into place (this decision making process. was would be akin to squeezing Has the patient undergone a the toothpaste back into its tube). Questions to ask to exclude recent course of radiotherapy? Most hernias dissolve with time. In potential serious pathology: fact many remain in situ many Is the patient currently receiving months after the symptoms of Is the pain unremitting, despite treatment by a different therapist? nerve root pain have resolved. medication (particularly if it is in the thoracic spine)? Affirmative answers will clearly This is because nerve root pain is determine the type of treatment l a r g e l y c h e m i c a l i n n a t u r e . Is the pain so severe at night that that the physiotherapist will Mechanical compression of a the patient has to frequently get provide. Do not forget that simple nerve root should only cause out of bed? advice on self-care and posture is sensory and/or motor changes still physiotherapy. (and in most patients only the Has the patient lost weight former). recently without dieting? If in doubt about any patient, always discuss your concerns It is the inflammatory reaction to Does the patient sweat profusely with the family doctor or your the mechanical compression that at night (enough to soak the supervising medical specialist. leads to pain extending down the sheets)? It is not your responsibility to length of the nerve root. manage serious pathology. Does the patient have a tremor?

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In the lumbar spine 98% of all disc hernias affect the L4, L5 or S1 roots (making up the sacral plexus). Only 2% of disc hernias affect the L2 or L3 nerve roots. In the cervical spine the most common levels of disc herniation are C5/6 and C6/7.

clear sign of an L5 root lesion. A weak calf or hamstring, with a numb heel and an absent ankle reflex, is always indicative of an S1 root lesion.

have undergone discectomy compared with those that haven’t. However, at five years, the discectomy patients are slightly worse. Most patients with nerve root pain do NOT do well with physiotherapy, but do require deep spinal muscle retraining once the leg pain has resolved in order to prevent a relapse. Avoid traction. Patients who have bilateral leg pain, saddle anaesthesia, an inability to empty their bladder, combined with a loss of anal tone, may have cauda equina syndrome. This is an EMERGENCY that requires prompt referral to a medic. Although this is a rare condition, you miss it at your peril. Differential diagnosis includes rare cases of nerve root pain due to osteophytosis (a bony spur too close to a nerve root) or a tumour pressing on one or more nerve roots. The latter is rare, but the former is common in people over 60 years of age. Nerve root pain in older patients, and particularly those with diabetes, is often worse than that experienced in younger patients. This is because the vascular supply to the nerve root is usually very poor. However, the recovery rates for patients with nerve root pain caused by osteophytosis is again 9 to 12 weeks. Clinicians should be alert to signs of myelopathy caused by a large cervical disc hernia (particularly if the spinal canal is already narrow congentally or due to degenerative changes) or fracture following trauma.

L4 root lesions cause pain extending across the knee and into the medial side of the shin and are usually, but not always, accompanied by a diminished Nearly all patients with nerve root knee reflex. pain will report a few days of back o r n e c k a c h e , w h i c h t h e n Pain that only extends to the knee dramatically converts into leg or may still be an L4 root lesion. It arm pain after a simple twist, may simply not be severe enough c o u g h o r s t r a i n . O n c e t h i s to extend further down the leg. conversion occurs, the back or However, the straight leg raise test neck pain either lessens or will differentiate it from an L3 resolves altogether. lesion. The straight leg raise test (SLR) is the most sensitive test for nerve root pain. A tiny number of patients have wide spinal canals and this can result in a false negative result but this is not common. The test is discussed in more detail later. Although not all patients with nerve root pain have motor weakness, those that rapidly develop a drop foot require urgent attention. However in general, patients with nerve root pain do not require surgery, unless their pain cannot be adequately managed with medication. In the cervical spine, the arm pain is worse when the arm hangs loose (some patient place their hand in their pockets for a little relief). C6 lesion result in pain extending to the thumb and maybe associated with a loss of power in the biceps and thumb extensor muscles and an absent biceps reflex.

In the lumbar spine, most patients have worsening leg pain on prolonged sitting, but a few may be worse on weight bearing. The latter have claudicating nerve root pain and although this is more common in older patients, this pattern can be seen in younger patients too.

C7 lesion result in pain on the outer two fingers, with a loss of Patients reporting neck pain and The leg pain always follows a power in the triceps muscle and bilateral weakness/sensory loss in dermatomal pattern (see diagram an absent triceps reflex. all four limbs requires urgent above). A weak extensor hallucis medical attention. A positive longus combined with altered Surgical follow-up rates at one Lerhmitte’s sign would confirm sensation on the outside of the year show no difference in this. foot and a normal ankle reflex is a outcome between patients who

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Piriformis Syndrome and Myalgia This usually occurs when the Parasthetica can mimic nerve root patient is standing and walking pain in the lower limb. (when the diameter of the spinal canal naturally narrows). The With the first, the piriformis muscle nerve roots become ischemic becomes over active and painful. leading to increased pain the This can refer pain into the leg. It further the patient stands or walks. is best treated with massage, ultrasound, trigger point therapy Flexion gives rapid relief and and stretching exercises. many patients with this condition find it helpful to lean on a trolley Myalgia Parasthetica is caused by as they walk (e.g. a supermarket e n t r a p m e n t o f t h e l a t e r a l trolley). cutaneous nerve as it passes through the inguinal ligament in S u c h p a t i e n t s n e e d t o b e the left or right iliac fossa of the differentiated from patients with abdomen. vascular claudication. One way to do this is check the pedal pulses This causes an oval patch of (not very reliable). numbness, and sometimes burning, on the outside of the Another method is to place both thigh. It can be treated with type of patients on a treadmill and ultrasound to an area 1 cm medial record how far they can walk. Both to the ASIS (palpate to get the will stop at some point due to pain. exact tender point). If you then place both patients on There is another important group a b i c y c l e , t h e p a t i e n t w i t h of patient with nerve root pain that neurogenic claudication will cycle often get overlooked. These are for a much longer period than the patients with spinal stenosis, i.e. patient with vascular claudication narrowing of the central spinal (because they are in flexion). canal or any one of the exiting foramen that the nerve roots pass through as they leave the spine. This narrowing can be symptomless, but in many cases it can cause neurogenic claudication (sometimes described as spinal claudication). Stenosis is usually degenerative, i.e. thickening of the ligamentum flavum, combined with facet joint hypertrophy and a bulging lumbar disc. However, it can also be hereditary, particularly in shorter Not all patients with neurogenic people. claudication have progressive symptoms. Those that do, and A combination of hereditary and who are a low anaesthetic risk, do degenerative factors can lead reasonably well with surgical some relatively young patients decompression (80% success (i.e. in their fifties and sixties) to rate). become quite disabled. Neurogenic claudication is where one or more nerve roots are squeezed due to the lack of space within a narrow spinal canal or exit foramen.

The few older patients with severe stenosis, who are an anaesthetic risk, can be provided with a fourwheel rollator, complete with seat. This aid enables them to leave their house. As their symptoms worsen they can stop, apply the brakes, and sit down for a period of time. Such devices can have a profoundly beneficial effect on patients with this condition. Questions to ask if you suspect the patient has nerve root pain: Where is the pain in the leg (does it follow a clear dermatomal pattern)? Is the leg pain getting worse, better or ISQ? Which is worse, the leg pain or the back pain (if it is the back pain, then the patient is unlikely to have nerve root pain)? Does coughing make the pain worse (generally more common in disc hernias)? Does the patient experience pins and needles or numbness? Is the pain worse in sitting or standing? Does the patient feel that their foot flops when he/she walks (and is this getting worse)? Questions to ask if you suspect the patient has cauda equina syndrome: Does the patient have bilateral leg pain? Can the patient empty his/her bladder and does he/she have normal bladder flow? Does the patient experience saddle anaesthesia?

Patients who can walk more than half a kilometer, probably fall Is the patient experiencing outside the surgical range and weakness in their legs (e.g. do therefore require physiotherapy their feet feel like cotton wool or flexion exercises. do they feel as their legs are going to give way)?

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Can the patient feel the difference Sometimes the patient finds even between flatus and passing a the most simple movements bring stool? on their pain and they have difficulty transferring from sitting/ Any positive answer to the cauda lying to standing and turning in equina questions (or progressive bed at night. foot drop) should prompt the patient to seek medical help as Many textbooks claim that acute soon as possible. back pain is worse with activity and better with rest. This is not In the absence of these particular always true. clinical signs, the patient is best treated by observation over time, The important markers are that with advice on positioning and their pain is positional and that pacing. there are clear exacerbating and relieving factors (e.g. cancer pain It may be helpful to liaise with the is unremitting and not related to patient’s family doctor to ensure change of position). that the patient has adequate analgesia (nerve root pain by its 60% of patient with acute back n a t u r e , m a y r e q u i r e o p i a t e pain improve by 80% within two compound medication). weeks of onset. A further 30% will be virtually pain free within twelve Deep muscle retraining will be weeks. 10% will go on to develop required once the leg pain has chronic low back pain. resolved. This latter group include complex pain patients, so-called ‘Yellow Mechanical Pain Flags”, and these will be Part One: Lumbar discussed later. This is the most common type of spinal pain. It used to be called lumbago, a term used by AngloIndian railway workers during the 19th century. Simple back pain is usually characterised by a sudden or gradual onset of pain in the L2 to S4 region.

thighs and even sometimes below the knees. However, referred pain is more vague than nerve root pain and is certainly not as severe. The preferred medication for simple back pain is paracetamol, NSAIDs and muscle relaxants if muscle spasm is present. There is no clinical justification for patients to take opiate-combination drugs. Patients should be encouraged to maintain normal daily activities and remain at work if possible. There is NO justification for more than 48 hours bed rest. Physiotherapists should also provide reassurance, that although the patient’s pain may feel severe, they are not going to end up in a wheelchair!

It is not possible to accurately diagnose the cause of mechanical low back pain. Clinical tests for precise diagnosis of disc hernias, unless there is significant nerve root pain, lack sensitivity (false negatives) and specificity (false Referred pain into one or both positives). legs is common. However, if the patient reports that their back pain This can often frustrate the patient is worse than their leg pain, it is and it is very tempting for the unlikely that they are experiencing physiotherapist to provide the nerve root pain (trapped nerve). patient with a ‘label’ or diagnosis. Nearly all patients expect a Numerous soft-tissue structures in diagnosis and no clinician wants the lumbar spine can cause to look vague or stupid in front of referred pain into the buttocks, their patient.

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Some patients are difficult to assess in the early stages. They may have considerable difficulty get undressed and getting on and off an examination plinth is near impossible. Unless the patient is reporting significant motor loss in the lower limbs, it is probably wise to treat them with proprioceptive strapping for the first few days (see picture below). However, using labels such as slipped disc, crumbling spine and arthritis frighten patients and can lead them to treat their spines as though they were made of glass.

Acute Facet Joint Syndrome

This is by far the most common presentation of mechanical low back pain. The pain usually comes on suddenly, especially after a This can cause some patients to twisting ‘flexion’ action and is ‘catastrophise’, leading to chronic nearly always accompanied by There are then reinforced with back pain, which is discussed in lumbar muscle spasm. shorter longitudinal strips at T5, more detail later. T10 and S2. The patient must An acute facet sprain may be due keep still whilst the taping is Most commonly used indicators, to a capsular or meniscal injury applied. The tape should be leg length discrepancy, ‘flat a n d m a y i n v o l v e a s l i g h t placed taut on the skin, especially backs’, one hip higher than the subluxation of the joint and in the hollow of the lower back. other, a twisted pelvis, being synovitis (swelling). overweight or degenerative The patient is then able to extend changes on an x-ray, have little Acute facet pain usually subsides and side flex reasonably well, but diagnostic value. within 21 to 28 days. Patients his/her flexion will be restricted. usually present with unilateral Numerous studies have found spine immobility and respond well The taping maintains the lumbar similar findings in patients without to manipulation and flexion spine in the neutral position, i.e. in back pain. exercises (after the spasm is a lordosis, which is the best treated with muscle relaxants or position for de-loading the lower For example, Jensen in 1997 support strapping). lumbar segments. The tape can found that 27% of patients with no be kept on for five days. history of low back pain, had at Attacks often reoccur. Usually least one significant lumbar disc t h e r e a r e l o n g p e r i o d s o f hernia on MR imaging. remission between attacks, but the attacks may slowly become However, there are two factors more frequent and take longer to that are significant. Firstly, settle down. smokers are four times more likely to suffer back pain than non- Repetitive acute facet syndrome is smokers. difficult to manage and the evidence for surgical fixation is Secondly, muscle inhibition in all weak. Patients respond better to deep and superficial lumbar and muscle strengthening exercise trunk muscles can lead to soft- regimes, although some patients tissue instability increasing the risk are never completely symptom of future episodes. free. Although it is wise to avoid exact diagnoses with low back pain patients, there are five typical syndromes that clinicians frequently come across. Aiming for a reduction in episodes and faster healing times is the the most realistic outcome of any rehabilitation regime.

This involves having the patient stand as erect as possible, preferably with a slight lordosis. Two long strips of zinc oxide tape are applied to the back from T4 to S4 in an ‘X’ formation.

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Some physiotherapists teach their patients lumbar extension exercises whilst the tape is in place. However, this is not recommended, as the trauma may be in the posterior elements, which will be exacerbated by excessive extension.

Taping is preferable to a lumbar corset. The patient cannot see the taping and therefore it feels less like a ‘psychological crutch’. It still allows some active movements and it is unlikely to lead to muscle wasting. However, a repeat examination should be done to confirm that the The drawback with taping, is that patient has unilateral stiffness some patients are sensitive to the only. tape and may be only able to tolerate it for 48 hours. If the physiotherapist is not trained at using short-lever manipulation As the muscle spasm eases the techniques (in Maitland’s terms, physiotherapist can teach simple this would be called a grade V), flexion in sitting. The patient sits he/she may choose to mobilise upright in a firm chair, with one leg the patient using the same crossed over the other leg, in the positioning for a manipulation. The way that a man would cross his Maitland method of mobilisation is leg rather than a woman. the most common form of passive movements. The patient places his hands (with fingers interwoven together) under When full range of movement has the crossed knee and gently pulls been restored and the patient’s the knee towards his/her chin. pain has lessened, it would be This should be repeated slowly at now appropriate to teach the first for ten repetitions. patient how to retrain their multifidus msucles. At this point, the patient changes over legs and repeats the process Research studies has shown that with the opposite leg. It is often at these muscles often weaken after this point that the more painful injury or pregnancy and do not side of the spine is revealed as automatically regain their full tone the patient will report that one of over time. the two legs is harder to pull up. It is important to retrain these This exercise helps to stretch muscles using simple exercises, shortened muscles in the spine perhaps taught one at a time (to and buttock, and also helps to gap maintain patient compliance). the facet joints and facilitate gentle gliding within an injured joint. Multifidus is particularly important to retrain following a back sprain. The patient should perform the It is segmentally innervated, which exercise on both legs with equal means it has only one nerve repetitions of ten pulls each leg supply. performed up to three times a day. An injury on one side of a lumbar This exercise is unlikely to cause segment (anterior or posterior severe pain, so if a patient returns compartment) can inhibit the at their next visit stating that the nerve supply to a single multifidus e x e r c i s e h a s c a u s e d t h e m muscle. extreme pain, the physiotherapist

should be suspicious that he/she An underperforming multifidus and may be a Yellow Flag patient. maybe associated with hyperactive extra-segmental Manipulation is not recommended muscles, such as extensor spinae on the patient’s first appointment. and quadratus lumborum. These However, if they return for the latter muscles try to compensate second appointment a few days for the weakened deep intrinsic later and the exercise has helped muscles. a little, then the physiotherapist m a y c o n s i d e r p e r f o r m i n g This over performance by the manipulation, as long as there are superficial muscles, which is part no contraindications (long-term of the body’s protective adaptive s t e r o i d u s e , e x p o s u r e t o process, is usually excessive and radiotherapy, RA etc.). far too late. Over time, the patient can suffer repeat episodes of acute muscle spasm, a consequence of the deep stabilising muscles not doing their job and the superficial extrinsic muscles trying clumsily to provide back-up protection. This inevitably leads to chronic pain in the superficial muscles, that may eventually become fibrosed and inflamed, the perfect environment for nuturing hypersensitive nerve endings. A weakened single multifidus muscle is often found on the painful side of the spine. This muscle provides extra stability for the facet joints and the lumbar discs. In other words, it provides stability to both the anterior and posterior elements of each lumbar segment. To retrain multifidus, the patient lies on his/her side with pillows supporting the head and the knees and hips positioned at 90 degrees. The patient then pulls his/her upper pelvis backwards, whilst keeping the upper trunk and shoulders still. The contraction is held for five seconds and repeated slowly ten times. If one side feels weaker than the other, the patient should perform the exercise on the weak side only (i.e. x10 reps – 3x daily). However, if there is bilateral weakness, then the patient will need to perform this exercise on both sides (i.e. x10 reps – 3x daily on each side).

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If the patient is making good progress, this exercise can be made more difficult by getting the patient to position himself or herself against a flat wall or piece of furniture.

The aim of the class to recondition the entire patient’s muscular system that may have deconditioned after a long period of back pain. These classes are normally held in physio gymnasiums, although some The patient places an extra pillow hospitals run aqua-fitness classes behind their upper pelvis and then in the hydrotherapy pool. pushes the pelvis against the pillow, thus working against Patients usually enjoy attending resistance. the classes (those that don’t, turn up once and are never seen If the physiotherapist has noted again!). shortening of the major muscle The classes provide peer support groups of the hip and thigh, it may to patients (i.e. “so I am not the be wise to teach the patient only person with this type of back exercises to lengthen these pain”). muscles. The class is usually run once or The final stage of treatment for twice weekly by a physiotherapist these patients is to invite them to for four to eight weeks, depending enroll on a Back Fitness Class on the frequency of the classes. (BFC). This is a 45-minute exercise session, where patients Patients with high blood pressure, perform up to 15 exercises, each d i a b e t e s o r o t h e r c a r d i o performed for one minute. pulmonary conditions may require

consent from their family doctor before enrolling on the class. There is good evidence to support the use of these exercise classes. In fact the evidence for them is far more robust that it is for individual taught exercises or manipulation techniques in patients with acute and sub-acute low back pain.

Chronic Facet Joint Syndrome
Many patients experience chronic facet pain (N.B. little correlation exists between symptoms and morphological changes on plain xray). Patients with chronic facet pain usually experience pain on prolonged standing, walking, turning in bed at night, often have early morning stiffness and a have constant need to keep changing their position. Again, examination usually reveals unilateral stiffness (as opposed to multi-directional stiffness) and the patient does not like extending his/ her spine. Although these patients frequently feel depressed, they continue to work, keep up their housework and socialise. In other words, they try to lead a normal life as possible and display relatively low levels of disability even though their pain may cause them considerable discomfort. They exhibit normal illness behaviour. They usually respond very well to passive therapy and gentle exercises. TENS is highly recommended. These patients should undergo the same exercise regime as described for patients with acute pain, although patients over 50 years of age may not be suitable for the advanced exercises or the BFC. Because these patients are in constant pain, and have been for some time before they reach the physiotherapy department, they

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tend to cope better with exercises This is a difficult syndrome to treat once their chronic pain is brought and some observers believe there under better control. are no physiotherapy techniques more effective than natural The family doctor can help by healing. prescribing 20mg of Amitriptyline at night, possibly combined with a McKenzie advocates will always low dose anti-inflammatory. try and claim dramatic successes. However, patients with discogenic The Amitriptyline may help by syndrome with accompanying modulating hyper-sensitivity in the nerve root pain, should not dorsal horn of the spinal canal, undergo McKenzie treatment, thereby de-sensitising that part of u n l e s s t h e s y m p t o m s a r e the neural network. resolving quickly and the McKenzie techniques do not bring A TENS machine can be bought on ANY leg pain. by the patient for permanent treatment in the future. The patient There is currently much debate as must be taught how to use the to whether the McKenzie rationale TENS machine in order to ensure is sound. It is based partly on the an effective outcome. idea that performing repetitive extension can reduce a disc Once the patient’s pain is under hernia. This is far from proven. better control, the early stage However, the method clearly exercises taught for acute facet works for some patients. pain can be introduced. These patients do particularly well with I f p a s s i v e t r e a t m e n t i s flexion in sitting. unsuccessful, the physiotherapist may invite the patient to begin Discogenic Syndrome muscle retraining. This should first be done on an individual basis, T h e s e p a t i e n t s h a v e m u l t i - often by trial and error (i.e. seeing directional stiffness. They are which movement direction the significantly worse towards the patient prefers). Once the patient’s end of the day. The pain originates pain is under much better control from the anterior compartment of and that there is NO longer multia lumbar segment. directional stiffness, they can then progress to the Back Fitness This does not mean that they have Class. a disc hernia. For instance, it could be a symptomatic annular Sacroiliac Syndrome tear. The sacroiliac joint sprain is a The healing time for discogenic much over-used diagnosis, but l e s i o n s c a n l a s t m o n t h s . they one can occur post-partum Sometimes patients recover and can be occasionally seen in d e s p i t e p h y s i o t h e r a p y, n o t athletes and in squash and because of it! badminton players who play on hard floor surfaces. However, postural and lifting advice is very important for these It usually involves pain in the area patients. of one SI joint, with or without pubic symphasis pain. These patients do NOT do well with manipulation, even if they T h e p a i n f u l j o i n t m a y b e have no leg pain. Many clinicians h y p e r m o b i l e d u e t o a s t i ff would choose extension exercises contralateral SI joint. Patients with for this type of patient instead (e.g. an SIJ problem have pain at the McKenzie) although the evidence midpoint of rising from sitting to for such an approach is weak. standing.

Deep muscle retraining as described earlier is important to give support to the ilio-lumbar and sacro-iliac ligaments. This may include pelvic floor exercises for those with post-partum sacroiliac and/or symphasis pubic pain. A failure to relieve the symptoms might require the patient to undergo further investigations, for conditions such as staphylococcus infection or sacroiliitis secondary to Reiter ’s Syndrome or ankylosing spondylitis. Biopsychosocial Syndrome These patients have chronic pain with no particular clinical pattern and their reported symptoms do not fit in with normal expected clinical presentations. They do not maintain activities of daily living, they go on long term sick leave from work and they rely heavily on family and friends (they often have a colluding spouse). They exhibit exaggerated illness behaviour, often shopping around different doctors and therapists trying to obtain the elusive ‘diagnosis’. Their failure to find a diagnosis becomes an impediment to their recovery. These patients are labelled ‘Yellow Flags’. Nearly all seek some form of compensation. This can be financial (litigation or social benefit payments) or emotional (attention from family members and friends). They are four times more likely to suffer depression than the general population. Clinically, they present with total body pain, multiple tender areas across their spine, neck pain, headaches, vague aches and pains in their legs and laboured movements. Attempts to perform the SLR tests fail, as they will usually cry out with pain as the leg reaches 20 degrees off the examination plinth.

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Yet if you ask them to sit up with their legs extended they always perform this without difficulty (one of Waddell’s non-organic signs see references). Passive one-to-one therapy does NOT work. The patient may report some early improvement but they always deteriorate again.

always complain that a mobilisation technique or a massage has made them worse.

Individual therapy reinforces the notion that they must have “something seriously wrong with them”, a concept that other A multi-disciplinary team of p a t i e n t s d o n o t a n a e s t h e t i s t s , c l i n i c a l entertain. psychologists, physiotherapists and occupational therapists is These patients can be required to manage these non- detected at their first copers. appointment through careful history taking, Adjuvant medications, such as clinical examination Gabapentin and Amitriptyline may and by asking them to also help as part of a rehabilitation complete a back pain programme. questionnaire, preferably combined Cognitive behavioural therapy can with a psychometric play a very important role by t e s t ( e . g . m o d i f i e d r a i s i n g t h e t o l e r a n c e a n d Zung). acceptance of pain amongst chronic pain patients and by Patients who score high teaching them to pace their on both questionnaires may be activities. considered for referral to a pain clinic. Pacing involves asking patients to keep an activity diary. Patients are When a pain clinic is not available, encouraged to maintain the same palliative treatment (e.g. TENS levels of activities on both good and general advice) may be given and bad days. instead. These activities are slowly increased over time. This is to prevent patients ‘over doing it’ on their ‘good’ days, and then taking to their beds for five days because they have made their pain worse. Liaising closely with employers can sometimes lead to a few patients returning to work. However, this is not an easy task. Many employers do not want to take on patients with a history of back pain.

Occasionally the pain may follow the ribs around the chest wall, or pass directly thought the chest, sometimes making the patient think they are having a heart attack (however the pain is not worse on physical exertion).

Attempts to treat these patients on a one to one basis, outside the support system of a pain clinic, is a recipe for disaster. Some patients may report some early However, most cases of thoracic improvement, but this rarely lasts. pain have no clear diagnosis and most often result in a deep Very few of these patients can ‘toothache’ type pain which is tolerate exercises and will nearly often worse with slouching.

Pain in the thoracic spine which is significantly worse at night (i.e. the Mechanical Pain patient has to get out of bed and Part Two: Thoracic sleep in a chair) should always make one highly suspicious of Thoracic pain can be acute with serious underlying pathology. pain on deep inspiration. This is nearly always due a costo- Benign thoracic pain can be treated with a combination of vertebral subluxation. mobilisations, exercises and A single cost-vertebral joint may postural advice. be tender on deep palpation and trunk mobility will have reduced A useful exercise is for the patient to sit upright, with his/her hands rotation to one side. tucked behind the neck (so the This can be treated with gentle elbows are close to each other). rotational mobilisation away from The patient than ‘writes’ the letters the pain (i.e. rotations to the good of the alphabet by moving their elbows in the air. side initially).

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Mechanical Pain Part Three: Cervical
Acute Torticiollis

Acute torticollis is most often caused by a cervical facet sprain, causing the ipsi-lateral muscles to go into spasm. This pulls the head to one side. Referred pain to the upper arm may occur. This can be posterio-anterior mobilisation of the spinous The healing time is usually 5 - 10 processes or 30 degree angled d a y s a n d m u s c l e r e l a x a n t s mobilisation of the vertebral combined with anti-inflammatories bodies. can help considerably. Sensible use of a collar can aid recovery. These techniques should be perfomed gently and must result in It is not wise to perform some pain reduction and mobilisations when the neck increased mobility. If they do not, muscles are in spasm. then discontinue them.

Instead teach postural advice and Chronic CVS allow the spasm to ease before performing any passive stretches. Chronic cervical spondylosis (CVS) is common in older A simple exercise to teach is have patients. A combination of disc the patient lie prone with his or her d e g e n e r a t i o n , o s t e o p h y t e forehead resting on the back of formation and long term muscle the hands. shortening can lead to intermittent episodes of neck pain and The patient then gently rotates to stiffness. the head AWAY from the pain and repeats this on a regular basis. As Referred pain to the upper arm the pain subsides the patient can and trapezius areas is very gently introduce rotation to the c o m m o n a n d s h o u l d b e painful side. differentiated from nerve root pain, which travels to the hand. Passive rotation of the head by the clinician (with the patient lying It is not unusual for patients to supine) should be done gently develop secondary shoulder following the above regime, but problems, such as a rotator cuff avoid manipulating the neck as l e s i o n s o r s u b - a c r o m i o n this can in some cases causes impingement syndrome. Often the vertebro-basilar artery damage. clinician will need to treat both the neck and the shoulder. Before gently rotating the head therapeutically, the clinician Treatment should consist of home should check of verterbro-basilar exercises, postural advice and the insufficiency. use of hot packs. Mobilisations can be performed following the This is done by gently rotating the same criteria and precautions as head to each side whilst the head for acute torticollis. is in slight extension. Whiplash The clinician should observe and changes in pupil size or if Whiplash injuries are more nystagmus occurs. The patient common in countries where road may also verbally report being traffic litigation is high. In other dizzy. words, it is a cultural condition, which makes it difficult to treat. Do NOT proceed with any gentle passive rotation techniques if any O f t e n n o s i n g l e l e s i o n i s adverse effect is noted on testing. diagnosable and patients often become emotional and highly The clinician however may choose dependent on others. to perform some gentle accessory movements with the patient lying prone (i.e. carefully noting what the patient can tolerate).

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Patients are often reluctant to perform exercises or follow the advice of the physiotherapist as recovery may reduce or obviate their claim. Whiplash is thus best managed with simple advice and exercises and patients should be encouraged to self manage their condition as much as possible. Discogenic Pain Disc hernias at C5/6 and C6/7 are not uncommon, especially in younger patients. Recovery is usually very slow and patients will usually experience severe arm pain that may be worse than any pain they feel in the neck. Reflexes, sensation and motor power may be impaired in the affected limb and patients will have considerable difficulty sleeping at night. Support taping to the shoulder may relieve the pain by limiting the traction effect of the arm hanging by the patient’s side. Gentle rotation exercises away from the pain may be initiated, but should be stopped immediately if this worsens the arm pain (not the neck pain). Differential diagnosis should include thoracic outlet syndrome. Often reassurance and simple postural advice is all that the clinicians can offer. It is unwise to attempt to manipulate the neck and traction is unlikely to have any significant long term benefit.

REFERENCES
ACC 1997 New Zealand acute low back pain guide. Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee, Wellington, NZ

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