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

Lumbar arthrosis or LBP non specific

Mechanical LBP – dysfunctional

Degenerative: DDD spondylosis/facet arthrosis

What is the significance of stiffness in the morning?

Morning stiffness is usually associated with degenerative pain (back pain)

Is there anything in the history that suggests this is not mechanical low back pain

NO

Does this history warrant x-rays? No

Clarify your answer with reasoning.

Based on history alone not required if chronic progression that it is getting worse might require
them.

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

Heart: take blood pressure because of family history of heart attack and

Abdominal: abdominal pain which worsens with the back pain

Lumbar/pelvis: Low back pain

From the history provided, is there evidence of mechanical origin of pain? Please clarify your answer
with reasoning

Yes, potentially from the high activity load although muscle and joint

But specific onset or cause not identifiable and pain doesn’t change/ or is relieved

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

Non specific LBP, nothing to relieve it and history of Vascular disease

Abdominal aching back pain and spiking

Possible aneurysm than mechanical pain

Exercise 3

Disability disuse
depression Recovery

Painful/catastroph Confrontation
Avoidance
ic experience

Fear of
movement or No fear
injury

Exercise 4

What is a Chiropractor’s role in the care of LBP

To find/refer for possible Red Flags, help manage and treat as well as reducing pain and improving
patient quality of life. Fear avoidance and reassurance.

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 6
weeks.
b. A diagnostic triage approach is used to Identify patients whose LBP arise be beyond the
lumbar spine (eg renal, aortic dissection)
- Those with neurological deficit (radiculopathy, spinal anal stenosis, cauda equina
syndrome)
- Those with suspected or confirmed serious spinal pathology (malignancy, infection,
fractures)
- And those with inflammatory disease (spondylarthritis)
- Remaining 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
d. Second line care:
There are now more consistent recommendations in favour of manual therapy (massage and
spinal manipulation) and psychological therapies (cognitive behavioural therapy is preferred)
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. Disc protrusion
2. Disc Prolapse
3. Disc Extrusion
4. Sequestration
Exercise 7

Briefly list the typical features of lumbar radiculopathy

Exercise 8

Spinal canal stenosis Aortoiliac arterial occlusion disease

Over 50 usually long history LBP Over 50

st
Proximal location, 1 lumbar buttocks and legs Distal location, buttocks, thighs and
radiation is distal calf, radiates proximally

Weakness, burning, numbness and tingling Cramping, aching and squeezing

Walking (uphill and downhill) Walking a set distance, especially

Lying down, forward flexion (20-30 minutes)
Possible bowel/bladder
uphill
Standing sill – fast relief; waling
slowly decreases the severity
Impotence rarely paraesthesia or
weakness

Present Normally present or nay be reduced

peripherally
Aggravates No change
Saddle ankle reflex nay be decreased after No change abdominal pulsing Sane
exercise for ilia or femoral artery