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.

EFFECTIVE PAIN MANAGEMENT According to the Agency for Healthcare Research and Quality (AHRQ), a federal agency established in 1989, there are three major barriers to effective pain management: the health-care system health-care professionals clients The health-care system is slow to hold itself accountable for assessing and relieving pain. Many professionals suggest that assessment of pain be included with the measurement of taking vital signs, such as temrerature, pulse, respiration, and blood pressure. Pain assessment would be the fifth vital sign. It is helpful to remember that heart rate and blood pressure may increase with acute pain but not necessarily with chronic pain. The belief is that routinely assessing and relieving pain would prove more cost effective than ignoring the issue. Health professionals are not always educated about the meaning of and assessment of pain management and may be concerned about the use of opioids (narcotics), mainly due to possible addiction. Clients and their fam...
Spine Health. PROCEDURE 6 — EXTENSION IN STANDING The patient stands with the feet well apart and places the hands (fingers pointing backwards) in the small of the back across the belt line. He leans backwards as far as possible, using the hands as a fulcrum, and then returns to neutral standing. The exercise is repeated about ten times. As with extension in lying it is necessary to move to the very maximum to obtain the desired result. Fig. Extension in standing. Effects: Extension in standing produces similar effects on derangement and dysfunction as extension in lying, but it is less effective in the earlier treatment stages of both syndromes. Whenever extension in lying is prevented by circumstances, an extension stress can be given by extension in standing. In derangement, extension in standing is designed to reduce accumulation of nuclear material in the posterior compartment of the intervertebral joint, provided this accumulation is not gross. In the latter case extension in lying will have to be performed first. Th...
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 10 — ROTATION MANIPULATION IN EXTENSION The patient lies prone as for procedure 1. The therapist stands to one side of the patient and, having selected the correct segment, places the hands on either side of the spine as for the technique of rotation mobilisation in extension (procedure 9), which is always applied as a premanipulative testing procedure. The information obtained from the mobilisation is vital and determines on which side and in which direction the manipulation is to be performed. If following testing the manipulation is indicated, the therapist reinforces the one hand with the other on the appropriate transverse process. The manipulation is then performed as in procedure 8. Fig. Rotation manipulation in extension. Effects: The effects of the external force and the reasons for its use are the same as for procedure 9. When the desired result is not obtained with the mobilising technique, manipulation is indicated under certain circumstances. Regarding the direction in which the manipulation is to be...
Spine Health. PROCEDURE 13 — FLEXION IN LYING The patient lies supine with the knees and hips flexed to about forty-five degrees and the feet flat on the couch. He bends the knees up towards the chest, firmly clasps the hands about them and applies overpressure to achieve maximum stress. The knees are then released and the feet placed back on the couch. The sequence is repeated about ten times. The first two or three flexion stresses are applied cautiously, but when the procedure is found to be safe the remaining pressures may become successively stronger, the last two or three being applied to the maximum possible. Fig. Flexion in lying. Effects: Flexion in lying causes a stretching of the posterior wall of the annulus, the posterior longitudinal ligament, the capsules of the facet joints, and other soft tissues. As the movement takes place from below upwards the lower lumbar and lumbo-sacral joints are placed on full stretch at the beginning of the exercise as soon as movement is initiated. Thus, the procedure is very i...