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- 38 y.o.
- Episodic LBP for 7 yrs. |
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Pain, onset, character
- LB / pelvic region - 2-3/10 best - 6-7/10 worst - Ache & sharp w/ bending |
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AF
- Pain during 3rd trimester & postpartum w/ all 4 pregnancies - Housework & picking up children |
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RF
- Rest & periodic chiro - SMT (spinal manipulation technique) & STW (soft tissue work) techniques |
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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) |
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Psychosocial factors
- Can't read / write well & blames this on getting the MMR vaccine - Children aren't vaccinated - Husband passed away last year |
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System review
- Non-productive cough in the mornings |
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Observations
- Appears pale + underweight - Nicotine stains on hands + fingers - Slightlower crossed posture - Levoconvex Tx scoliosis |
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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 |
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Palpations
- QL trigger points - Glute med, max TTP |
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Kemps:
- Purpose: assess Lx spine facet joint pain - Findings: L reproduces POC at LS junction; R -ve |
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SLR:
- Purpose: identifies impairment in disc anatomy or nerve root irritation - Findings: 70° bilat. w/ tight hamstrings |
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Slump's:
- Purpose: detect altered neurodynamics or neural tissue sensitivity - Findings: Negative (-ve) |
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SI springing:
- Purpose: diagnose joint dysfunction - Findings: mild LBP R>L |
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Faber's:
- Purpose: diagnose hip pathology by attempting reproducing pain - Findings: mild LBP R>L; no restrictions of hip range |
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Thigh thrust:
- Purpose: provocation of SIJ - Findings: mild LBP R>L |
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Gaenslens:
- Purpose: diagnose SIJ lesion, pubic symph. instability, L4 nerve root lesion - Findings: mild LBP R>L |
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Sacral base compression:
- Purpose: diagnose hip pathology - Findings: mild LBP |
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SIJ compression & distraction:
- Purpose: SIJ sprain or dysfunction - Findings: no pain |
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McGills test:
- assess radiographic Lx instability - Findings: LBP on part 1, decreased pain on part 2 (positive = Lx-pelvic instability) |
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Active SLR:
- Purpose: assess Lx-Sx nerve root irritation - Findings: LBP on part 1, decreased pain on part 2 |
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Working Dx
- Chronic LBP w/ associated Lx & pelvic functional instability |
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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 |
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Communication
- Don't talk to pt about tardiness / psychology |
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Other
- Chronic pain usually psychosocial - Scoliosis not related to complaint but may be to some of the findings |
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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 |
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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 |
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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) |
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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) |
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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 |
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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) |
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Changes needed to make w/ clinical procedures & consent to support this pt:
- Holistic approach - Pt-centred care - Informed consent - Multidisciplinary team - Screening for depression |
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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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