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

· Mechanical LBP – dysfunction

· Degenerative – Disc Degeneration, Spondylosis, facet arthrosis

What is the significance of stiffness in the morning?

· Suggests that its relieved ones pressure is taken of the issue – suggests
· Is there anything in the history that suggests this is not mechanical low back pain

Does this history warrant x-rays?

· No

Clarify your answer with reasoning.

· Not based on history given alone

· Might be considered if justified with age or chronic 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.
What areas would you examine in this patient and why

Lumbar spine – area of pain

Pelvis - area of pain
Abdomen – complained of pain in this area

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

No there isn’t really as there is no specific activity or moment that triggered it. There also isn’t any
obvious positions or activities that relieve it. However mechanical origin should not be completely
crossed out

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, he has a history of high blood pressure. There isn’t a specific onset and there seems to be no
way to relieve it. (points towards a possible vascular problem)

Exercise 3

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

The purpose of treatment is to speed recovery and restore function, as well as alleviate pain and
distress.
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 with LBP that arises from beyond the lumber spine (renal etc)
- Identify those with neurological deficits (spinal stenosis, cauda equina or radiculopathy)
- Identify patients with suspected and or confirmed serious spinal pathology (cancers,
infection, fractures
- Those with inflammatory disorders (spondylarthritis)
- All other patients would be 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
- Its benign
- Most cases have favourable prognosis with substantial improvement in the first month
- It’s unlikely to have serious disease present
- Imagining is not required and will not change the 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:

Exercise 7

Briefly list the typical features of lumbar radiculopathy

· Patients classically presents with LBP or buttock and leg pain.

· Distribution depends on level of involvement.
· In radiculopathy, leg pain typically exceeds back pain
· May have history of flexion/rotation at onset
· More severe radiculopathy pain may radiate as far as the calf and foot
· Pain is sharp and severe in nature
· Associated symptoms – lower limb numbness, pins and needles, weakness
· Aggravating factors – trunk flexion, coughing, sneezing, sitting
· Relieving factors – supine with supported hip/knee flexion
· Commonly history of chronic or repetitive LBP
· Usually unilateral
· Usually involves one nerve root but can have two
· The more distal the pain goes, the more severe the neuropathic pain process. Therapeutic
goal is to get the pain to CENTRALISE

Exercise 8

Neurogenic Claudication Vascular Claudication

Cause Spinal canal stenosis Aortoiliac arterial occlusive disease
Age Over 50, usually long history of LBP Over 50
Pain site and Proximal location, initially lumber, Distal location, especially buttocks,
radiation buttocks and legs, radiates distal thigh and calf, radiates proximally
Type of pain Weakness, burning, numbness, Cramping, aching and squeezing
tingling
Onset Walking (uphill and downhill), distance Walking a set distance, especially
varies, prolonged standing uphill
Relief Lying down, forward flexion, may take Standing still – fast relief, walking
20-30 minutes slowly decreases the severity
Associated Possible bowl/bladder Impotence, rarely paraesthesis or
symptoms weakness
Peripheral Present Usually present or may be reduced
pulses peripherally
Lumber Aggravates No change
extension
Neurologic Saddle (?), ankle flexed may be No change (?), abdominal pulsing or
decreased after exercise bruit?, same for iliac or femoral