Case
- 38 y.o.
- Episodic LBP for 7 yrs. |
Pain, onset, character
- LB / pelvic region
- 2-3/10 best
- 6-7/10 worst
- Ache & sharp w/ bending |
AF
- Pain during 3rd trimester & postpartum w/ all 4 pregnancies
- Housework & picking up children |
RF
- Rest & periodic chiro
- SMT (spinal manipulation technique) & STW (soft tissue work) techniques |
Extra
- Asthma since childhood - concerned its getting worse (worried there's dampness in house)
- Smokes 20/day for 20 years
- Takes OCP (oral contraceptive pill) |
Psychosocial factors
- Can't read / write well & blames this on getting the MMR vaccine
- Children aren't vaccinated
- Husband passed away last year |
System review
- Non-productive cough in the mornings |
Physical Examination Findings
Observations
- Appears pale + underweight
- Nicotine stains on hands + fingers
- Slightlower crossed posture
- Levoconvex Tx scoliosis |
ROM
- Levoscoliosis (apex T6)
- AROM Lx: flexion & extension - slight limitation at end range w/ discomfort around LS junction
- Small rib hump seen on forward flexion |
Palpations
- QL trigger points
- Glute med, max TTP |
Clinical tests
Kemps:
- Purpose: assess Lx spine facet joint pain
- Findings: L reproduces POC at LS junction; R -ve |
SLR:
- Purpose: identifies impairment in disc anatomy or nerve root irritation
- Findings: 70° bilat. w/ tight hamstrings |
Slump's:
- Purpose: detect altered neurodynamics or neural tissue sensitivity
- Findings: Negative (-ve) |
SI springing:
- Purpose: diagnose joint dysfunction
- Findings: mild LBP R>L |
Faber's:
- Purpose: diagnose hip pathology by attempting reproducing pain
- Findings: mild LBP R>L; no restrictions of hip range |
Thigh thrust:
- Purpose: provocation of SIJ
- Findings: mild LBP R>L |
Gaenslens:
- Purpose: diagnose SIJ lesion, pubic symph. instability, L4 nerve root lesion
- Findings: mild LBP R>L |
Sacral base compression:
- Purpose: diagnose hip pathology
- Findings: mild LBP |
SIJ compression & distraction:
- Purpose: SIJ sprain or dysfunction
- Findings: no pain |
McGills test:
- assess radiographic Lx instability
- Findings: LBP on part 1, decreased pain on part 2 (positive = Lx-pelvic instability) |
Active SLR:
- Purpose: assess Lx-Sx nerve root irritation
- Findings: LBP on part 1, decreased pain on part 2 |
Discussion
Working Dx
- Chronic LBP w/ associated Lx & pelvic functional instability |
Psychosocial
- Pt's circumstances changed dramatically the past year after husband's death
- Now reliant on social support
- Her & her 3 children had to move due to lack of social housing
- Difficulty reading & writing
- On medication for depression & anxiety |
Communication
- Don't talk to pt about tardiness / psychology |
Other
- Chronic pain usually psychosocial
- Scoliosis not related to complaint but may be to some of the findings |
Learning outcomes
Dx of LBP:
- Muscle strain: pain, stiffness, & soreness
- Herniated disc: pain, numbness, & tingling in LB, buttocks, & legs
- OA: pain, stiffness, & loss of mobility
- Spinal stenosis: pain, numbness, & weakness in LB, buttocks, & legs
- Spondylolisthesis: LB pain, numbness, & stiffness, as well as numbness & tingling the legs
- Fibromyalgia: widespread pain, including the LB
- Inflammatory arthritis: inflammation & pain |
Scoliosis:
⏺ Definition:
- Spine curvature - mild or severe
- Can affect all ages
- Most commonly diagnosed in children & adolescents
⏺ Types:
- Idiopathic: most common & cause is unknown
- Congenital: present at birth & caused by abnormal spinal development
- Neuromuscular: caused by neuromuscular disorder (e.g. cerebral palsy or muscular dystrophy)
- Degenerative: caused by degeneration of the spinal discs & joints in the spine (usually seen in adult >65y.)
⏺Symptoms:
- Depend on severity
- Mild: asymptomatic
- Severe: back pain, fatigue, uneven shoulders & hips, & difficulty standing or sitting up straight
⏺ Treatment:
- Depends on severity & age
- Mild: may not require treatment, or manual therapy
- Severe: bracing or surgery |
Management of this pt:
- Pain management: NSAIDs, cognitive behavioural therapy (CBT), acupancture, manual therapy, electrotherapies
⏺ Physical therapy: improve strength, flexibility, stability, core strength, posture, & overall mobility
- Manual therapy: spinal manipulation or mobilisation (relieve pain & improve mobility), soft tissue therapy to relive muscle tension & improve ROM
- Psychosocial interventions: cognitive-behavioural therapy (CBT) to reduce anxiety & depression related to pain
- Bracing: in severe cases provides support to the affected area
- (Surgery only in severe cases) |
Impact of yellow flags present:
- Prolonged recovery
- Increased disability: psychosocial factors can affect their ability to cope w/ pain & perform ADLs
- Increased healthcare utilisation
- Work-related issues: more economic burdens than this pt already has
- Chronic pain: yellow flags are more likely to develop chronic pain (psychosocial factors can contribute to the development of long-term pain conditions) |
Consider other health concerns present in this pt:
- Non-productive cough: likely due to smoking
- Smoking 20 (30?) cigarettes / day for 20 years
- Unvaccinated
- Underweight & pale: iron-deficiency, malnutrition, chronic stress, or depression |
Relationship between depression & LBP:
-Shared biological mechanisms: common biological pathways (e.g. abnormalities in the CNS), that contribute to the development & maintenance of both conditions
- Psychosocial factors: chronic pain can lead to -ve psychosocial consequences (e.g. social isolation, reduced physical activity, & poor quality of life), which can contribute to depression
- Stress: chronic stress is linked to development & exacerbation of both depression & chronic pain
- Behavioural factors: pts w/ chronic pain may adopt maladaptive comping strategies (avoidance), which can lead to a -ve spiral of pain, disability & depression
⏺ LBP & depression interact in complex ways & treatment has combination of pharmacological & psychosocial interventions (CBT) |
Changes needed to make w/ clinical procedures & consent to support this pt:
- Holistic approach
- Pt-centred care
- Informed consent
- Multidisciplinary team
- Screening for depression |
Other tests that should be done:
- Respiratory exam: non-reproductive cough, likely due to smoking
- Wardell sign: how much of the pain is psych. related |
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