Inflammatory Disorders E.G. (Ankylosing Spondylitis) Spondylolisthesis Radiculopathies Arthroses

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
 Inflammatory disorders e.g. (ankylosing spondylitis)

 Spondylolisthesis
 Radiculopathies
 Arthroses
Tutorial answers
 Mechanical LBP-dysfunction
 Degenerative: DDD/ spondylosis/ facet arthrosis
What is the significance of stiffness in the morning?
 Due to the disk rehydrating and subsequently increasing the pressure

 Could also mean she has an inflammatory disorder
Tutorial answers
 Morning stiffness is usually associated with biomechanical pain (back pain)
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
Tutorial answers
 No
Does this history warrant x-rays?
 No
Tutorial answers
 Not based on this history alone
 Might be considered if justified with age, chronicity, progression
Clarify your answer with reasoning.
 Chronic LBP with no red flags, first line is conservative therapy without imaging
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
 Going off the family history I would check the cardiovascular system due to the sudden increase in
physical exercise. The main factors that could be exacerbating the pain could be vasculature in nature
such as inflammation or vascular claudication
 V - positive Abdominal Aortic Aneurysm pain pattern or vascular claudication

 I - positive inflammatory signs
 N -Nil
 D- possibly spondylosis
 I- yes
 C- NIL
 A- NIL
 T- NIL
 E- hyperparathyroidism unlikely
Tutorial answers
 Low back (and hips)
 Abdomen
From the history provided, is there evidence of mechanical origin of pain? Please clarify your answer with
reasoning
 Possibly anaerobic respiration build up of lactic acid
Tutorial answers
 Yes – muscles and joints from exercise (why the sudden occurrence though?)
BUT
 Specific onset or cause not identifiable
 No position or activity relieves the pain
 Pain does not change
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, possibly vascular claudication

 Localised inflammation
Tutorial Answers
 See above
 Can’t identify the cause
 No relief with rest
 Not relieved by change in position
 Abdominal pain that has also increased with LBP
Exercise 3
Disability
Disuse Recovery
Depression
Avoidance Painful Experiences

Catastrophising Confrontation
Fear of movement
or injury No Fear
Exercise 4
What is a Chiropractor’s role in the care of LBP
 Speed recovery and restore function

 Pain relief
 Utilise treatments with known efficacy and prioritise those with evidenced based outcomes
 Education, advice, work modification
 Reassurance
 Prevent persistent disability
- Identify activities that may be a barrier to returning to normal activities
 Further investigation or referred for further investigation and evaluation if indicated
- Red flags
- Failure to respond
- Appropriate clinical reasons
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 (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); 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- Protrusion
2. Stage 2- Prolapse
3. Stage 3- Extrusion
4. Stage 4- Sequestration
Exercise 7
Briefly list the typical features of lumbar radiculopathy
 Pain on the contralateral side when the non-painful side is flexed at the thigh with the leg held in
extension
 Loss of sensation on the lateral portion of the foot
 Pain on adduction of the thigh
 Pain in the buttocks when the great toe is hyperextended
 Pain in the lower back or down the leg when the patient is supine
 Pain and dysaesthesia below the buttock area
 Symptoms radiating below the knee are more likely to indicate a true radiculopathy
 Symptoms radiating a variable distance down the lateral/posterior leg or foot, especially an
isolated part of the lower leg
 Dermatomal loss of sensation or feeling or an abnormal sensation in leg or foot
 Weakness of the lower leg or foot
 Emergency = loss of bowel or bladder function
 Pain is increased by activity and may be relieved by rest
 Leg pain becomes more severe than back pain
Exercise 8

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CHIR12007

Clinical Assessment and Diagnosis

 Inflammatory disorders e.g. (ankylosing spondylitis)

What is the significance of stiffness in the morning?

 Due to the disk rehydrating and subsequently increasing the pressure

Does this history warrant x-rays?

Clarify your answer with reasoning.

What areas would you examine in this patient and why

 V - positive Abdominal Aortic Aneurysm pain pattern or vascular claudication

 Possibly anaerobic respiration build up of lactic acid

 Yes, possibly vascular claudication

Avoidance Painful Experiences

 Speed recovery and restore function

- The first six weeks

b. A diagnostic triage approach is used to

c. First line care:

d. Second line care:

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