Contents
1.0 Introduction
2.0 General Points on Questioning
3.0 What do our Patients come to see us
for?
4.0 Red Flags
5.0 The Present Condition (PC)
5.1 Type of Pain
5.2 Depth of Pain
5.3 Behaviour of Symptoms
5.4 24 Hour Pattern
5.5 Special Questions
5.6 Behaviour of Pain & Pain Mechanisms
6.0 History of Present Condition (HPC)
7.0 Yellow Flags
8.0 Previous Medical History (PMH)
9.0 Drug History (DH)
10. Social History (SH)
11. SIN Factor
12. Planning the Objective Examination
13. The Objective Examination
14. Observation
15. ROM (active/passive/resisted)
15.1 End feel
15.2 Capsular Patterns
16. Neurological Examination
17. Neurodynamic Examination
18. Muscle Length/Strength/Endurance
19. Palpation
20. Specific Testing
21. The Impression
22. Initial Treatment Plan
23. Bibliography
App 1 – Masqueraders
App2 – Theoretical Aggravating & Easing
Factors
App3 – Lower Limb Dermatomes
sourece 2.hud.ac.uk
Saturday, 16 July 2011
Low Back Pain
The aims of back pain assessment are:1
source patient.co.uk
Typical symptoms include:
Acute (meaning quick onset) lower back pain that does not follow an obvious trauma, or movement associated with the onset of pain, can be a symptom of an enlargement of the aorta (large artery) in the abdomen, called an abdominal aortic aneurysm. This condition becomes a serious medical emergency if the blood vessel ruptures or internal bleeding occurs.
The primary symptoms of an abdominal aortic aneurysm are unremitting sharp and crushing pain in the low back and abdomen, so severe that it can prevent someone from being able to stand up straight, leaving them literally doubled over in pain.
Most infections can be treated successfully with antibiotics if brought to the attention of a physician.
- To recognise serious pathology.
- To relieve pain.
- To improve function.
- To recognise and assess level of disability.
- To identify barriers to recovery.
- To prevent recurrence or persistence of symptoms.
Red flags from history
Red flags for possible serious spinal pathology from the history are:1- Recent violent trauma (such as vehicle accident or fall from a height)
- Minor trauma, or even just strenuous lifting, in people with osteoporosis
- Age at onset less than 20 or over 50 years (new back pain)
- History of:
- Cancer
- Drug abuse
- HIV
- Immunosuppression
- Prolonged use of corticosteroids
- Constitutional symptoms, e.g. fever, chills, unexplained weight loss
- Recent bacterial infection, e.g. urinary tract infection
- Pain that is:
- Worse when supine
- Severe at night time
- Thoracic
- Constant and progressive
- Non-mechanical without relief from bed rest or postural modification
- Unchanged despite treatment for 2-4 weeks
- Accompanied by severe morning stiffness (rheumatoid arthritis and ankylosing spondylitis)
- Severe and leaves patients unable to walk or self-care
- Accompanied by saddle anaesthesia or recent onset of difficulty with bladder or bowels
source patient.co.uk
When Back Pain May Be a Medical Emergency
Patients who experience any of the following symptoms should seek medical attention as quickly as possible:
- Progressive leg weakness and/or loss of bowel or bladder control
- Unexplained weight loss accompanied by pain and neurological impairment
- Acute, severe stomach pain along with low back pain such that the patient can not stand straight
- Fever with increased pain which does not respond to common fever reducers
Progressive Leg Weakness, Loss of Bladder or Bowel Control
Patients who experience sudden bladder and/or bowel incontinence (dysfunction that causes retention of urine, inability to hold urine in, or loss of rectal control), or feel progressive weakness or numbness in the hips and legs should seek immediate medical attention. These symptoms are indicative of cauda equina syndrome, which is usually caused by a compressed nerve in the lower spine.Typical symptoms include:
- Severe or progressive weakness, numbness or altered sensation in the lower extremities - the legs and/or feet
- Loss of sensation or altered sensation in the “saddle” area (the area where a body is positioned on a saddle: inner thighs/between the legs, buttocks, back of legs, sacral region)
- Difficulty walking without stumbling because of pain or numbness or weakness in one or both legs
Unexplained Weight Loss, Loss of Appetite, Pain and Neurological Problems
Adult patients who have weighed the same for months and for no apparent reason lose weight rapidly (e.g. more than 5 pounds a week for a couple of weeks) or lose their appetite for even favorite foods should consult with their doctor. Rapid, unexplained weight loss can indicate a serious medical condition, such as cancer. For example, a spinal tumor that is lodged in or around the spine would typically result in the following symptoms:- Pain in the neck or back, followed by neurological problems (such as weakness or numbness of the arms or legs or a change in normal bowel or bladder habits)
- Back pain that does not diminish with rest, and pain that may be worse at night - even waking the patient during sleep - than during the day
- Any of the above symptoms along with loss of appetite, unplanned weight loss, nausea, vomiting, or fever, chills or shakes
Severe, Continuous Abdominal and Lower Back Pain
Low back pain from a spine condition generally is localized in the back or extremities affected by nerves aligned with spine segments. Rarely does low back pain migrate to the abdomen. However, abdominal disorders can often extend to the low back and be experienced as acute back pain in the lower back.Acute (meaning quick onset) lower back pain that does not follow an obvious trauma, or movement associated with the onset of pain, can be a symptom of an enlargement of the aorta (large artery) in the abdomen, called an abdominal aortic aneurysm. This condition becomes a serious medical emergency if the blood vessel ruptures or internal bleeding occurs.
The primary symptoms of an abdominal aortic aneurysm are unremitting sharp and crushing pain in the low back and abdomen, so severe that it can prevent someone from being able to stand up straight, leaving them literally doubled over in pain.
Unresponsive Fever Followed by Increased Pain
Fever (defined as a sustained temperature of more than 101° in adults) can indicate an infection. In the spine an infection can arise gradually if the immune system has been weakened, or it can occur following surgery. Although relatively rare, spinal infections can give rise to an epidural abscess (a pus-filled cavity in the epidural space) that can press on the nerve structures in the cervical spine (neck) or thoracic spine (upper back). This can impair gross motor skills, and result in paraplegia or quadriplegia.Most infections can be treated successfully with antibiotics if brought to the attention of a physician.
- Post-surgical or wound infections occur in about 1% of patients, and more frequently in diabetics or people in poor health. An infection may develop 1 to 2 weeks after the procedure, even as pain from the surgery is abating. The most common infection is a wound infection, which results in a fever of greater than 101 degrees, increased redness and pain around the incision, and a change in drainage from the wound, such as clear discharge becoming yellow and thick and the wound not closing.
- A vertebral body infection (called vertebral osteomyelitis, or bone infection) spreads to the spine by veins carrying bacteria generated in other parts of the body. This kind of infection could arise after a urologic procedure such as a colonoscopy or a cystoscopy, a diagnostic test using a thin telescope to inspect the bladder, often prescribed when there is blood in the urine or before prostate surgery. Other conditions that make a vertebral body infection more likely are intravenous drug abuse, or long-term use of epidural steroids (e.g. to treat rheumatoid arthritis), because both of these activities increase the chances that bacteria will be introduced to the body.
| Causes of Low Back Pain | ||||||||||||||||||||||||||
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| Red Flags for Acute Low Back Pain |
| History Cancer Unexplained weight loss Immunosuppression Prolonged use of steroids Intravenous drug use Urinary tract infection Pain that is increased or unrelieved by rest Fever Significant trauma related to age (e.g., fall from a height or motor vehicle accident in a young patient, minor fall or heavy lifting in a potentially osteoporotic or older patient or a person with possible osteoporosis) Bladder or bowel incontinence Urinary retention (with overflow incontinence) Physical examination Saddle anesthesia Loss of anal sphincter tone Major motor weakness in lower extremities Fever Vertebral tenderness Limited spinal range of motion Neurologic findings persisting beyond one month |
| source aafp |
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