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.

GATE CONTROL THEORY OF PAIN What occurs at the cellular level when pain is experienced? The gate control theory of pain, by P. D. Wall and Ronald Melzack, offers a useful model of the physiological process of pain. Gate control is recognized as a major pain theory. According to the gate control theory, pain is a balance between information traveling into the spinal cord through large nerve fibers and information traveling into the spinal cord through small nerve fibers. Without any stimulation, both the large and small nerve fibers are quiet, and the substantia gelatinosa (SG) blocks the signal to the transmission cell (T cell) connected to the brain. The “gate is closed,” and there is no pain. With pain stimulation, small nerve fibers are active. They activate the T-cell neurons but block the SG neuron, making it impossible for the SG to block the T-cell transmission to the brain. The result is that the “gate is open”; therefore, there is pain. In other words, pain is experienced whenever the substances that ...
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 3 — EXTENSION IN LYING The patient, already lying prone, places the hands (palms down) near the shoulders as for the traditional press-up exercise. He now presses the top half of his body up by straightening the arms, while the bottom half, from the pelvis down is allowed to sag with gravity. The top half of the body is then lowered and the exercise is repeated about ten times. The first two or three movements should be carried out with some caution, but once these are found to be safe the remaining extension stresses may become successively stronger until the last movement is made to the maximum possible extension range. If the first series of exercises appears beneficial, then a second series may be indicated. More vigour can be applied and a better effect will be obtained if the last two or three extension stresses are sustained for a few seconds. It is essential to obtain the maximum elevation by the tenth excursion and once obtained the lumbar spine should be permitted to relax into the most extreme ...
Spine Health. PROCEDURE 14 — FLEXION IN STANDING The simple toe touching exercise in standing does not need much elaboration. The patient, standing with the feet about thirty centimeters apart, bends forward sliding the hands down the front of the legs in order to have some support and to measure the degree of flexion achieved. On reaching the maximum flexion allowed by pain or range, the patient returns to the upright position. The sequence is repeated about ten times, should be performed rhythmically, and initially with caution and without vigour. It is important to ensure that in between each movement the patient returns to neutral standing. Fig. Flexion in standing. Effects: Flexion in standing differs from flexion in lying in various ways. Naturally, the gravitational and compressive forces act differently in both situations. In flexion in standing the movement takes place from above downwards, and the lower lumbar and lumbo-sacral joints are placed on full stretch only at the end of the movement. In addition, the lumbo...
Spine Health. PROCEDURE 16 — CORRECTION OF LATERAL SHIFT This procedure has two parts: first the deformity in scoliosis is corrected; then, if present, the deformity in kyphosis is reduced and full extension is restored. The patient, standing with the feet about thirty centimeters apart, is asked to clearly define the areas where pain is being felt at present. The therapist stands on the side to which the patient is deviating and places the patient’s near elbow at a right angle by his side. The elbow will be used to increase the lateral pressure against the patient’s rib cage. The therapist’s arms encircle the patient’s trunk, clasping the hands about the rim of the pelvis. Now the therapist presses his shoulder against the patient’s elbow, pushing the patient’s rib cage, thoracic and upper lumbar spine away while at the same time drawing the patient’s pelvis towards himself. In this manner the deformity in scoliosis is reduced and, if possible slightly overcorrected. Initially, there will be significant resistance to the procedure, wh...