CHIR12007

Clinical Assessment and Diagnosis

Portfolio Exercises Week 4

Exercise 1

A 58 year old woman presented with a gradual onset of low back pain which refers to the top of the
buttocks bilateral. She has had low back stiffness for years which is usually worse in the morning. The
intensity of the discomfort has increased over the past few months. The pain is worse with
prolonged standing, lifting, bending and on long walks. Discomfort is relieved by lying down. An ache
can be felt into the right buttock, hip and posterior thigh but only occasionally. The patient does not
experience pain in the night, no bowel or bladder changes are reported. The pain does not increase
with coughing or sneezing

- Chronic low back pain

- Radiculopathy  usually would go below the knee if it is a true radiculopathy
- No bowel or bladder changes  rules out a few red flags
- Advanced degenerative stages  spinal stenosis  trouble walking long distances

List your differentials

- Mechanical low back pain – dysfunction

- Degenerative disc disease
- Spondylosis
- Facet arthrosis

What is the significance of stiffness in the morning?

- Osteoarthritis
- Usually associated with degenerative back pain

Is there anything in the history that suggests this is not mechanical low back pain

- No

Does this history warrant x-rays?

- Not based on history alone

- Maybe because she is old and it is chronic with progression

Exercise 2**

A 62 year old male presents with acute onset low back pain which began the previous evening and
was still present on waking with some mild progression of the pain. He is a government worker with
primarily a desk job. He was unable to identify any specific onset or event that caused the pain. No
identifiable position or activity relieves the pain. Although he works a sedentary job, he reports he
has recently begun 30 minutes of cardiovascular exercise 7 days a week and weight training 5 days a
week as his GP is concerned about his high blood pressure. His father passed from a heart attack at
age 65. Pain is rated on a verbal numeric scale of 6/10, does not change and feels very deep and
boring although every now and then there is a temporary spike in the pain. On review of systems,
vague abdominal pain is mentioned which seems to have increased with this episode of low back
pain.

- Moderate pain

What areas would you examine in this patient and why

- Abdominal area  abdominal pain that coincides with back pain

- Lower back

From the history provided, is there evidence of mechanical origin of pain? Please clarify your answer
with reasoning

- Yes
- Mechanical: maybe muscle and joint from lots of exercise but it’s weird that it would start
so randomly but no position that relieves it

From the history provided, is there evidence to suggest possible non-mechanical origin of the low
back pain? Please clarify your answers with reasoning

- Yes
- Abdominal aortic aneurism  cardiovascular disease, age
- No cause, nothing relieves pain, high blood pressure  important
- Father passed from vascular issues  hereditary

Exercise 3

Disability
Disease
depression Recovery

Avoidance Painful experiences

Confrontation
castrophising

Fear of movment or No fear

injury
Exercise 4

What is a Chiropractor’s role in the care of LBP

- Decrease pain, inflammation and muscle spasm

- Promote tissue healing
- Increase pain-free ROM

Exercise 5

There is an article in your week 4 Reading list “Primary care management of non-specific Low Back
Pain: Key message from recent guidelines

Using this source, complete the following statements:

a. Episodes of acute LBP usually have a good prognosis with rapid improvement within the first
6 weeks
b. A diagnostic triage approach is used to identify patients whose LBP arises beyond the lumbar
spine (eg, renal, aortic dissection), those with neurological deficit (radiculopathy, spinal
canal stenosis, cauda equina syndrome), those with suspected or confirmed serious spinal
pathology (malignancy, infection, fracture), and those with inflammatory disease
(spondyloarthritis)

First line care:

c. Guidelines also reinforce the importance of teaching patients how to self-manage their LBP.
Important messages to convey to the patients are that non-specific LBP hat non‐specific LBP
is benign; most people have a favourable prognosis with substantial improvement in the first
month; it is unlikely that there is a serious disease present; and imaging is not required and
will not change management.

d. Second line care:

There are now more consistent recommendations in favour manual therapy and
psychological therapies as second line non-pharmacological options, as they can provide
small to moderate improvements for pain and function with mostly low to moderate quality
evidence.

Exercise 6

Label each diagram with the correct stage of disc injury:

Protrusion prolapse extrusion sequestration

Exercise 7

Briefly list the typical features of lumbar radiculopathy

- Most patients have associated LBP

- Those who do not present with LBP have a history of LBP
- Typical picture: LBP which progresses to leg pain  peripheralisation
- LBP may be due to nerve root compremise or due to other local factors
- If radicular pain is secondary to IVF encroachment the leg pain may be relieved on sitting
and bringing knees to chest and worse on standing around and walking
- If radicular pain is secondary to disc herniation the leg pain may be worse on prolonged
sitting
- Nearly always unilateral
- Often feels different quality to any local LBP
- Most often involves one nerve root
- The more distal the pain goes, the more severe the neuropathic pain process
- Be more cautious if numerous nerve root levels involved  may indicate greater canal
stenosis
- Beware bilateral radicular features – often a sign of central canal compromise  increases
likelihood of cauda equina compromise.

Exercise 8

Spinal canal stenosis Aortoiliac arterial occlusive

disease
Over 50 Over 50
Proximal location, Distal location, buttocks,
buttocks, lumbar and legs thighs, calves, radiate
radiates distally proximally
Weakness, burning, Cramping, aching,
numbing or tingling squeezing
Walking, prolonged Walking a set distance each
standing time
Lying down Standing still, slow walking
Bowel and bladder impotence
symptoms
present Present usually. Reduced or
absent in some especially
after exercise
aggravates No change
Saddle distribution, ankle No change
reflex may be reduced
after exercise