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

- Degenerative disc or spondylosis

What is the significance of stiffness in the morning?

- The disc has rehydrated during the night so there is subsequent increased pressure

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

- The onset of mechanical back pain is generally associated with a physical task
- Mechanical back pain is usually characterised by pain that is worse on movement and
coughing

Does this history warrant x-rays?

Clarify your answer with reasoning.

- No. Patients with persistent low back pain and signs or symptoms of radiculopathy or spinal
stenosis shoulder undergo MRI or CT only if positive results would potentially lead to surgery
or epidural steroid injection for suspected radiculopathy.

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

 - Would examine his lower back region and abdominal region

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

- Yes there is evidence of mechanical low back pain

- Sedentary job and a recent change in fitness routine could cause mechanical lower back pain
e.g. sprain, strain
- Boring pain is a characteristic of muscles, fascia, periosteum, ligaments, joints, vessels, dura

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, possible infection

- Pain is continuous, day and night
- Abdominal pain which is worse now with the LBP
- Pain was not precipitated by anything
-

Exercise 3

Exercise 4

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

- Spinal manipulation therapy

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
six weeks.
b. A diagnostic triage approach is used to identify patients whose LBP arises beyond the lumbar
spine, those with neurological deficit, those with suspected or confirmed serious spinal
pathology, and those with inflammatory disease; remaining patients are considered to have
non-specific LBP.
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 is benign; most
people have 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 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:

1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4

Exercise 7

Briefly list the typical features of lumbar radiculopathy

- Nearly always unilateral

- Often feels different quality to any local LBP (referred pain from other structures often feels
same as LBP)
- Most often involves one nerve root. However, lumbar spine is more common to involve two
roots than in cervical spine
 - The more distal the pain goes, the more severe the neuropathic pain process. Therapeutic
goal is to get the pain to centralise
- Be more cautious if multiple NR levels involved – may indicate greater canal stenosis (e.g.
larger disc pathology or sequestration)
- Beware bilateral radicular features – often a sign of central canal compromise – increased
likelihood of cauda equina compromise, particularly look for saddle anaesthesia, decreased
sphincter tone, rectal or bladder incontinence, constipation, urinary stasis, erectile
dysfunction

Exercise 8