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5002 Case 6 Cheat Sheet by

Chronic LBP with associated Lx & pelvic functional instability


- 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
- Pain during 3rd trimester & postpartum w/ all 4 pregnancies
- Housework & picking up children
- Rest & periodic chiro
- SMT (spinal manipu­lation technique) & STW (soft tissue work) techniques
- 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

- Appears pale + underweight
- Nicotine stains on hands + fingers
- Slight­lower crossed posture
- Levoconvex Tx scoliosis
- Levosc­oliosis (apex T6)
- AROM Lx: flexion & extension - slight limitation at end range w/ discomfort around LS junction
- Small rib hump seen on forward flexion
- QL trigger points
- Glute med, max TTP

Clinical tests

- Purpose: assess Lx spine facet joint pain
- Findings: L reproduces POC at LS junction; R -ve
- Purpose: identifies impairment in disc anatomy or nerve root irritation
- Findings: 70° bilat. w/ tight hamstrings
- Purpose: detect altered neurod­ynamics or neural tissue sensitivity
- Findings: Negative (-ve)
SI springing:
- Purpose: diagnose joint dysfunction
- Findings: mild LBP R>L
- 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
- 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


Working Dx
- Chronic LBP w/ associated Lx & pelvic functional instab­ility
- 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
- Don't talk to pt about tardiness / psychology
- 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
- Spine curvature - mild or severe
- Can affect all ages
- Most commonly diagnosed in children & adolescents
- 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.)
- Depend on severity
- Mild: asymptomatic
- Severe: back pain, fatigue, uneven shoulders & hips, & difficulty standing or sitting up straight
- 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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