Back Pain. Diagnosis

THE THERAPIST’S RESPONSIBILITY

The therapist is part of the team involved in the treatment and rehabilitation of patients suffering low back pain. In some countries manipulative therapists are primary contact practitioners. Consequently, their diagnostic skills have greatly improved, enabling them to define which mechanical conditions can be helped by mechanical therapy and to separate these conditions from the nonmechanical lesions which have no place in the therapy clinic.

However, differential diagnosis is really not within the scope of manipulative therapy. It is my view that differential diagnosing by medical practitioners is necessary to exclude serious and unsuitable pathologies from being referred for mechanical therapy. In making diagnoses the manipulative therapist should confine himself to musculo-skeletal mechanical lesions. Specialised in this field, he is usually able to make far more accurate diagnoses than most medical practitioners. As the manipulative therapy profession gains international respect, we may soon see the day that this specialisation becomes generally accepted.

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DIAGNOSTIC DIFFICULTIES

In the low back mechanical diagnosis is extremely difficult. As yet, no means have been devised which enable us to selectively stress individual structures and identify the source of many pains. As Nachemson states, there is only one condition which allows a fairly confident diagnosis to be made:

“the patient with sciatica caused by sequestration from the disc which impinges on a nerve root. Such patients, though, represent only a small proportion of those who have low back pain problems, and constitute at most only a few percent.”

This means that perhaps as many as ninety percent of patients cannot be diagnosed in a very specific manner. Various authorities have stated that in many instances it is impossible to define the exact pathological basis for low back pain and, consequently, to achieve a precise diagnosis. Nachemson has said:

“No one in the world knows the real cause of back pain and I am no exception.”

When authorities such as these clearly state that the problems surrounding specific diagnosis of low back pain are insurmountable, it seems that the time has come to alter the rules of the game. Instead of aiming for a specific diagnosis based on a particular pathology, we must apply an alternative system of assessment. This can be used until further development of our knowledge and diagnostic procedures enables us to become more specific.

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In order to analyse mechanical low back pain and categorise the symptoms a new approach is necessary. I believe we have a means of overcoming the present diagnostic impasse. If mechanical pain is caused by mechanical deformation of soft tissues containing nociceptive receptors, we must confine our diagnosis within this framework.

THE THREE SYNDROMES

All spinal pain of mechanical origin can be classified in one of the following syndromes:

The postural syndrome:

This is caused by mechanical deformation of soft tissues as a result of postural stresses. Maintenance of certain postures or positions which place some soft tissues under prolonged stress, will eventually be productive of pain. Thus, the postural syndrome is characterised by intermittent pain brought on by particular postures or positions, and usually some time must pass before the pain becomes apparent. The pain ceases only with a change of position or after postural correction.

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The dysfunction syndrome:

This is caused by mechanical deformation of soft tissues affected by adaptive shortening. Adaptive shortening may occur for a variety of reasons which will be discussed later. It leads to a loss of movement in certain directions and causes pain to be produced before normal full range of movement is achieved. Thus, the dysfunction syndrome is characterised by intermittent pain and a partial loss of movement. The pain is brought on as soon as shortened structures are stressed by end positioning or end movement and ceases almost immediately when the stress is released.

The derangement syndrome:

This is caused by mechanical deformation of soft tissues as a result of internal derangement. Alteration of the position of the fluid nucleus within the disc, and possibly the surrounding annulus, causes a disturbance in the normal resting position of the two vertebrae enclosing the disc involved. Various forms and degrees of internal derangement are possible, and each presents a somewhat different set of signs and symptoms. These will be discussed later. Thus, the derangement syndrome is usually characterised by constant pain, but intermittent pain may occur depending on the size and location of the derangement. There is a partial loss of movement, some movements being full range and others partially or completely blocked. This causes the deformities in kyphosis and scoliosis so typical of the syndrome in the acute stage.

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The three syndromes presented are totally different from each other, and each syndrome must be treated as an entity on its own, requiring special procedures which are often unsuitable for the other syndromes. In order to identify which syndrome is present in a particular patient a history must be established and an examination must be performed.

Back pain. The Cause of Pain THE NOCICEPTIVE RECEPTOR SYSTEM Most tissues in the body possess a system of nerve endings which, being particularly sensitive to tissue dysfunction, may be referred to as nociceptive receptors. The free nerve endings of the nociceptive system provide the means by which we are made aware of pain. Wyke describes the distribution of the nociceptive receptor system in the lumbar area: it is found in the skin and subcutaneous tissue; throughout the fibrous capsule of all the synovial apophyseal joints and sacro-iliac joints; in the longitudinal ligaments, the fiaval and interspinous ligaments and sacro-iliac ligaments; in the periosteum covering the vertebral bodies and arches, and in the fascia, aponeuroses and tendons attached thereto; and also in the spinal dura mater, including the dural sleeves surrounding the nerve roots. The nociceptive innervation of the spinal ligaments varies from one ligament to another. The system is found to be most dense in the posterior longitudinal l...
Spine Health. PROCEDURE 15 — FLEXION IN STEP STANDING In this procedure the patient stands on one leg while the other leg rests with the foot on a stool so that hip and knee are about ninety degrees flexed. Keeping the weight bearing leg straight the patient draws himself into a flexed position, firmly approximating the shoulder and the already raised knee (both being on the same side). If possible the shoulder should be moved even lower than the knee. The patient may apply further pressure by pulling on the ankle of the raised foot. The pressure is then released and the patient returns to the upright position. The sequence is repeated about six to ten times. It is important that the patient returns to neutral standing and restores the lordosis in between each movement. Fig. Flexion in step standing. Effects: This procedure causes an asymmetrical flexion stress on the affected segments. It is applied when there is a deviation in flexion, which may occur in dysfunction as well as derangement. Both in dysfunction and derangement th...
Spine Health. PROCEDURE 5 — SUSTAINED EXTENSION To apply a sustained extension stress to the lumbar spine an adjustable couch, one end of which may be raised, is a necessary piece of equipment. The patient lies prone with his head at the adjustable end of the couch which is gradually raised, about one to two inches at the time over a five to ten minute period. Once the maximum possible degree of extension is reached, the position may be held for two to ten minutes, according to the patient’s tolerance. When lowering the patient the adjustable end of the couch should slowly be returned to the horizontal over a period of two to three minutes. This must not be done rapidly, for acute low back pain may result. Fig. Sustained extension. Effects: The procedure is predominantly used in the treatment of derangement. The effect is similar to that of the third procedure, but a time factor is added with the graduated increase and the sustained nature of the extension. In certain circumstances a sustained extension stress is preferable...
Spine Health. PROCEDURE 11 — SUSTAINED ROTATION/MOBILISATION IN FLEXION The patient lies supine on the couch, and the therapist stands on the side to which the legs are to be drawn, facing the head end of the couch. The patient’s far shoulder is held firmly on the couch by the therapist’s near hand, providing fixation and stabilisation. With the other hand the therapist flexes the patient’s hips and knees to a rightangle and carries them towards himself, causing the lumbar spine to rotate. With the patient’s ankles resting on the therapist’s thigh the knees are allowed to sink as far as possible and the legs are permitted to rest in that extreme position. The lumbar spine is now hanging on its ligaments in a position which combines side bending and rotation. By pushing the knees further towards the floor the therapist applies overpressure to take up the remaining slack in the lumbar spine. Depending on the purpose for which the procedure is used, the position of extreme rotation is maintained for a shorter or longer period. Fig. Sustained rotation/mob...
Recovering From Acute Low Back Pain. General Instructions You have recovered from the acute episode because of your ability to master the exercises which relieved your pain. These exercises must be repeated whenever situations arise which have previously caused pain. You must perform the corrective movements before the onset of pain. This is essential. If you carry out the following instruction, you can resume your normal activities without the fear of recurrence. SITTING When sitting for prolonged periods the maintenance of the lordosis is essential. It does not matter if you maintain this with your own muscles or with the help of a supportive roll, placed in the small of your back. In addition to sitting correctly with a lumbar support, you should interrupt prolonged sitting at regular intervals. On extended car journeys you should get out of the car every hour or two, stand upright, bend backwards five or six times, and walk around for a few minutes. BENDING FORWARDS When engaged in activities which require prolonged fo...