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

List your differentials

Lumbar Arthrosis with possible piriformis syndrome & Stenosis

What is the significance of stiffness in the morning?

Intervertebral Discs rehydrating over night during sleep which applies pressure upon waking and
initial movements as the increased pressure on soft tissues structures which are used to limited
range are at stretch and need to be warmed up to decrease hypersensitivity.

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

Not at this stage.

Does this history warrant x-rays?

Clarify your answer with reasoning.

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.
What areas would you examine in this patient and why

Abdomen to rule out any red flags such as an early Aortic Aneurism

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

Possible, non-identifiable mechanical pain from a career of sitting and increased cardiovascular and
strength training.

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, BP that the GP is keeping an eye on. 1 st degree familial history on paternal side of heart attack.

Exercise 3

Exercise 4

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

Identify patients perceived disability, identify barriers to returning to usual activities, provide
information, priority of treatment with proven efficacy, reorient treatments to barriers of return to
normal activities.

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 ___6
weeks________.
b. A diagnostic triage approach is used to __identify patients whose LBP arises from beyond
the Lumbar Spine, those neurological deficit, those suspected or confirmed with serious
spinal pathology and those with inflammatory disease.___________________.
c. First line care:
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 _provide
reasurrence of benign nature, explain imaging is not required, encourage to stay active and
avoid bed rest, avoid language which creates fear of pain.______ _____
d. Second line care:
There are now more consistent recommendations in favour of __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

Mostly involve L5/S1

Vast majority are spondylosis or disc herniation

Nerve root lesions above these levels can be mechanical but more often will be non-mechanical =
higher clinical suspicion
S2-S4 not common, but mostly will be degenerative in nature

Exercise 8

Clinical features of neurogenic and vascular claudication

Neurogenic claudication Vascular claudication
Cause Spinal canal stenosis Aortoiliac arterial occlusive disease

Age Over 50 Over 50

Long history of backache

Pain site and Proximal location, initially
radiation lumbar, buttocks and legs
Radiates distally
Type of pain Weakness, burning,
numbing or tingling (not
cramping)
Distal location, especially buttocks,
thighs and calves
Radiates proximally
Cramping, aching, squeezing

Onset Walking (uphill and Walking a set distance each time,

downhill). Distance walked especially uphill
varies. Prolonged standing

Relief Lying down Standing still – fast relief

Flexing spine, e.g. Slow walking decreases severity
squat position
May take 20-30 minutes

Associations Bowel and bladder Impotence

symptoms Rarely, paraesthesia or weakness

Peripheral Present Present (usually). Reduced or

pulses absent in some, especially after
exercise

Lumbar Aggravates No change

extension

Neurological Saddle distribution No change

Ankle reflex may be May have abdominal bruits after
reduced after exercise exercise