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MANAGING SPINAL PAIN Puducherry December 2010

AN EVIDENCE-BASED APPROACHWith full reference list

Courses• Maitland’s Mobilsations and Manipulation,

Sheffield 1985 - 1986.

• Electrotherapy and Massage for Remedial

Gymnasts. Bath 1986.

• McKenzie Parts A B C. London 1989.

• Medical Acupuncture. Rotherham 1991.

• Management Skills for PTs. London 1992.

• Nags and Snags. London 1994.

• Muscle Imbalance. Cardiff 1996.

• Advanced Medical Acupuncture. Surrey 2005.

• Electrotherapy Update. Northampton 2006.

• Plus numerous one day clinical courses.

Education• Diploma in Remedial Gymnastics, University

Hospital of Wales, Wales 1980

• Masters degree in Research Methodology,

University of London 1998

Extra-Curricular Activities• Lecturer in sports medicine. Middlesex

Polytechnic 1985 - 1986.

• Lecturer in anatomy. Oxford Chiropractic College

1996 - 1999.

• Editor of Management of Low Back Pain in Primary Care, published in 2001.

This handout has been written and published by Richard Bartley in 2004 and updated in 2010.

Richard Bartley

Physiotherapist

Wales, UK

One Day Workshop

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INTRODUCTION

We have an obligation to our patients to provide them with the most up to date treatments, i.e. treatments based on clinical research. Unfortunately, up until the 1990’s, very little research on spinal pain took place.

As a result, physiotherapists and doctors have treated patients with empirical treatments, of which few have any supporting evidence to show that they are effective. A good example of this is lumbar and cervical traction.

However, the last twenty years has seen good progress in terms of research. Here are some things we now know:

A smoker is four times more likely to suffer back pain than a non-smoker.

Bed rest prolongs back pain

Patients who go off sick from work take longer to get better than those that return to work early.

Providing patients with convenient ‘labels’, such as slipped discs and arthritis can cause patients to ‘catastrophise’.

X- rays have l i t t le va lue in diagnosising spinal pain and over exposure may be dangerous.

Exercise therapy and cognitive behavioural therapy are effective at treating chronic pain associated with biopsychosocial influences (i.e. Yellow Flags).

We are still not sure whether the following treatments are effective for back pain:

•Manipulation•TENS•Acupuncture •Trigger Point Therapy •Massage•Traction•Ultrasound •Pulsed SWD

Does this mean that we should not use these modalities? Perhaps. However, absence of proof is not proof of absence. We simply do not know enough yet about their efficacy.

Controlled trials are the only way of avoiding confounding variables (which can lead to completely false conclusions). However, these are not always easy to u n d e r t a k e a n d r e q u i r e considerable funding and time.

Case studies and audits (or observational studies) cannot provide irrefutable proof that a treatment works. However, they may reveal whether the ‘total’ therapy input is creating any discernible change in outcome(s).

Patients can be asked to complete questionnaires before therapy and some t ime af ter they have completed their treatment. By comparing results, the results may provide an insight into the value of ‘total’ physiotherapy, albeit the level of placebo or the benefit of individual treatment components will remain unknown.

A number of indices have been developed to assess the level of disability in patients with spinal disorders.

There are generally two types: generic and disease-specific. Generic questionnaires (e.g. the Sickness Impact Profile) include questions to cover impairment, functional status, perceptions and social opportunities, and are designed to get an ‘overview’ of the patient’s general quality of life.

Disease-specific questionnaires (e.g. the RMQ) target specific diagnostic groups and are more specific to the area of the body which is affected.

The lat ter usual ly sacr i f ice comprehensiveness for better responsiveness (i.e. the ability to record minor, but essential, clinical changes) and are therefore more sensitive.

This is important as sensitivity to the different sub-groups of spinal disorders (e.g. sciatica) may vary considerably and care should be t a k e n t o a s s e s s t h e a p p r o p r i a t e n e s s o f e a c h measurement tool.

It is important to recognise that there is not always a proportional relationship between impairment and disability. For instance, we know that it is possible to be severely disabled whilst having a relatively minor impairment, and vice versa.

This can have the disadvantage of allowing perceptual elements affect the overall score. Patients who are in considerable pain may still be able to work and may score ‘low’, even in the presence of serious impairment such as a severe root compression.

Conve rse l y a pa t i en t w i t h psychological problems may score ‘high’ in the absence of any s i g n i f i c a n t p a t h o l o g y o r impairment. The potential for patients to score high or low with a predetermined level of impairment may reflect cultural differences and attitudes to illness.

Even allowing for these inherent weaknesses, the use of outcome measurement questionnaires are still the best tools we possess to assess the eff icacy of our treatments.

As an example, the picture on the next page shows the Roland Morris Questionnaire (RMQ). The RMQ is a self-administered back pain disability measure in which greater levels of disability are reflected by higher numbers on a 24-point scale.

Simply count the scores for a result between 0 and 24. Scores under 4 and over 20 may not show significant change over time. Patients scoring 20+ are likely to be psychosocial pain patients. Changes of four points or more, pre- and post-treatment, are significant.

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The RMQ has been shown to yield reliable measurements, which are valid for inferring the level of disability, and to be sensitive to change over time for groups of patients with low back pain.

Other pain and disability indices exist for low back pain and neck pain.

ASSESSMENT OF THE PATIENT

Always welcome your patient with a firm handshake or a local c u l t u r a l g e s t u r e t h a t acknowledges that you are delighted to meet your patient. This will set the agenda for your professional relationship with the patient.

Always introduce yourself by your full name, not your first name (e.g. “I am Mr Bartley”). Equally, you should not address your patient by his/her first name.

You may decide later in the interview to ask the patient if you would both prefer to use each other’s first names. However, this is not usually appropriate for senior citizens.

First observe your patient as he/she enters your clinical area. How do they walk, what expression do they have on their face (are they u p b e a t o r d o t h e y l o o k depressed)? Observe how they take off their coat or jacket and how they sit down.

These first impressions provide the c l in ic ian w i th va luab le information, which can then be matched with the patient’s history a n d e x a m i n a t i o n f i n d i n g s (although sometimes they do not match at all!).

Once you have noted the patient’s personal details (name, age, occupation), ask them to tell you a little about themselves.

Work

Ask them to describe their job (manual or sedentary).

Do they like their job?

What previous jobs did they have?

If they are still at work, do their current symptoms affect their ability to do their job well?

Are they currently off sick from their work, and if so, how long?

If they are on sick leave, do they plan to return to work soon?

If they are on sick leave and they have a sedentary job, ask them why they are not at work

If they are on sick leave, but wish to return to work, could they negotiate with their employer for them to go on light duties?

Hobbies/Interests

Get the patient to talk about their interests. Nearly every patient has something they enjoy, whether it is reading, playing sport or looking after animals. Find out if their current symptoms prevent them from participating in their hobbies. Talking about their interests also allows the clinician to get to know a little more about their patient.

It is often worthwhile to take a little time to ask a few questions about their hobbies. This may not always appear to have any clinical benefit or relevance directly, but it helps to engender a good working r e l a t i o n s h i p b e t w e e n t h e physiotherapist and the patient. The patient will nearly always be pleased that you have taken an interest in his/her life.

Social Circumstances

It is important to establish the pat ient ’s fami ly and soc ia l circumstances.

Is their spouse well?

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Do they live alone?

If the patient is elderly, can he/she manage the stairs at home or bathe?

For those with difficulties, a visit by an occupational therapist or district nurse may be appropriate.

Current Symptoms

Some patients, particularly those with a long history of chronic spinal pain, present with a mental script of what they wish to tell you. This often provides the clinicians with 90% superfluous information and 10% helpful information.

These patients don’t always get t h e i r s c r i p t i n t h e r i g h t chronological order, so the physiotherapist can easily get confused.

One approach to this is just to listen. It may take an eternity for the patient to deliver their life history.

But if you listen carefully, the patient will actually provide much of the information required. The ability to sift out what is relevant and irrelevant is what determines an adequate history profile.

If life is too short for this approach, you may have to diplomatically steer the patient to describing their current symptoms first. With chronic pain patients this can be very difficult as they will usually be anxious to get back to their prepared mental script. It takes a very experienced physiotherapist to keep the patient on track!

Before you question the patient about their symptoms, ask them to draw their pain on a pre-prepared body chart. This will provide a clinical record of the patient’s pain and other symptoms. However, it can also provide a useful insight into the patient’s mindset.

Patients with simple back pain or nerve root pain usually draw small circles or a thin straight line to describe the pain. Patients with abnormal illness behaviour will often draw an elaborate work of art, with numerous areas of pain, complete with written descriptions.

Questions you should ask about the patient’s current episode:

When did the current episode begin?

How did the pain come on (trauma, gradual onset, several days after a fall)?

How have the symptoms behaved since the onset?

Have the symptoms changed in location, duration and intensity since the onset?

Where exactly is the pain today? When is the pain at its worst; morning, mid-day, evening or at night?

Is the patient’s back/neck stiffer in the morning on rising from bed, or in the evening?

Does the patient have days completely free of pain?

What worsens the pain (e.g. standing, transferring from sitting

to standing, turning in bed, prolonged sitting, walking, looking down or turning the head)?

If walking worsens the pain, how far can the patient walk before they have to rest (important for p a t i e n t s w i t h n e u r o g e n i c claudication)

What eases the pain?

If the patient has night pain, is it worse being in one position, or worse when turning over?

What painkillers/NSAIDS is the patient taking and do they help (usually the patient says they don’t help until they stop taking them and they realise that in fact they were helping)?

These questions aim to elicit the progression of the patient’s mechanical pain, i.e. is it getting worse, better or in status quo?

These are of course general guidelines. For example, a few patients with lumbar nerve root pain, secondary to a disc hernia, may be worse in standing rather than sitting.

The golden rule of spinal pain diagnosis is that there are no golden rules. The physiotherapist attempts to work with symptom patterns, but he/she must always expect the atypical presentation.

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Previous Symptoms

This need not be too detailed.

Has the patient had back/neck pain in the past. If so, has it been intermittent or continuous?

Is there a history of early trauma?

If the back/neck pain has occurred a number of times in the past, is there a pattern emerging?

For example, are the episodes becoming more frequent and/or intense?

Is it taking the patient longer to recover between episodes?

If the patient has had continuous pain for many years, when did their symptoms first come on and how?

Are there associated conditions, such as clinical depression?

What treatments have they had in the past?Are they currently taking drugs s u c h a s G a b a p e n t i n o r Amitriptyline?

EXAMINATION OF THE PATIENT

It is better to have the patient undress down to their underwear, although female patients might prefer to not undress if they are being assessed by a male physiotherapist.

In such circumstances, they could wear light trousers that can be pulled down a little and a t-shirt that can be pulled up and tucked under the bra strap. Female patients of certain rel igious backgrounds have the right to be e x a m i n e d b y a f e m a l e physiotherapist.

When you examine a patient, you are seeing a snapshot of their back problem. You may examine the patient in the morning when they are at their best or perhaps at their worst.

You may examine them on a relatively ‘good’ day or a ‘bad’ day. Repeat examination at each a p p o i n t m e n t a l l o w s t h e physiotherapist to obtain an overall picture of the patient.

The first rule of examination is to see how the patient moves and undresses (e.g. how easy or difficult it is for them to take off their socks).

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This will allow the physiotherapist to assess the severity of their symptoms, or in some cases match the patient’s personal account of their symptoms with what the physiotherapist actually witnesses.

The patient should be visually assessed in standing (with their l e g s s l i g h t l y a p a r t ) . T h e physiotherapist should look for deformity, local redness and/or swelling.

Small discrepancies in leg length are not clinically significant. However, a 3 cm+ leg length discrepancy may be relevant, and this may require a heel or sole raise on the shoe of the shortened leg.

Any deformity present could be in the sagittal plane (hyper-lordosis or kyphosis) or in the coronal p lane (scol ios is) . A severe kyphosis could be due to late stage ankylosing spondylitis or o n e o r m o r e o s t e o p o r o t i c fractures.

A scoliosis could be long-standing or a result of recent onset unilateral muscle spasm. The patient’s history should help in differentiating between the two types. Long term idiopathic s c o l i o s i s , o r a d v a n c e d degenerative scoliosis, should be assessed by a spinal surgeon.

Lumbar Assessment

Testing active range of movement is achieved by asking the patient to flex forward with their knees straight in standing, extend with their hands on the hips and side-flex to each side keeping the trunk straight (i.e. not leaning forward).

It is a good idea to have the patient perform extension with the anterior thighs against a raised plinth to prevent hip extension.

The movements shou ld be recorded, for range and whether each movement reproduces the patient’s pain.

A slight feeling of tightness in one direction, which bears no relation to the patient’s normal pain, is probably not significant (it may just be the effect of stretching a shortened muscle).

It is advisable to ask the patient to perform each movement twice, as they often go a little further on the second attempt.

Worsening pain on extension, combined with relatively good flexion, might suggest pain in the posterior elements of a lumbar segment.

Multidirectional stiffness with pain on repeated flexion, might suggest an anterior compartment problem. McKenzie advocates would recommend repeated testing of these movements.

For patients with low grade pain (e.g. they only get back pain whilst p lay ing tenn is ) , i t may be necessary for the physiotherapist to perform passive movements in standing, i.e. take the patient’s trunk to the limit of each direction and apply overpressure, to see w h e t h e r a n y m o v e m e n t s reproduce the patient’s pain.

Patients may display a deformity during an active movement, which is not present when the patient is standing upright. This is often associated with a unilateral nerve root lesion.

Very occasionally, the deformity is due to a subluxed facet joint. A normal straight leg raise should enable differentiation.

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The patient should then be examined lying supine on an examination couch.

Leg length can measured by flexing both knees and lining up the heels so that they are level.

Eyeballing the knees from the side or from the bottom end of the plinth will allow the physiotherapist to clearly see a significant leg length discrepancy.

With the patient’s legs flat (if they can tolerate this), first test each straight leg raise (SLR). Take care when doing this as patients with nerve root pain can find this procedure very uncomfortable. Compare both leg measurements.

The straight leg raise test is performed with the patient supine. The affected leg is passively raised.

A positive test should demonstrate two clinical signs: (i) the leg will not raise more than 45 degrees due to pain, (ii) the pain is reproduced in the leg, NOT the back.

Passively raising the opposite ‘good’ leg is a worthwhile test. If it reproduces pain in the ‘bad’ leg, this is considered a positive crossover sign and is highly indicative of a disc hernia.

Be aware that patients on opiate-based medication may achieve a higher SLR than if they were not on any medication at all. This may provide a false-negative result.

Whilst the patient is still in supine, test their knee reflexes by gently tapping each ligamentum patella with the knees slightly flexed.

Then test sensation by stroking the thighs, shins, outer calves and inner and outer feet, using a cotton pad. Compare each area stroked on both legs. Very few patients have total numbness.

B y t e s t i n g t h i s w a y, t h e physiotherapist is looking for a loss of fine sensation (total numbness should raise suspicion of a non mechanical cause).

To test for an L3 root lesion, position the patient in prone lying and passively flex the knee of the painful leg. This should reproduce their leg pain (again NOT their back pain).

When performing the passive knee bend test, many patients will complain of tightness in their quadriceps. Do not confuse this with a postive nerve tension sign. You should then test the strength of the hamstrings and record all your findings.

Finally, test the power of the quadriceps, dorsiflexors and extensor hallucis flexors in both legs and record all your findings (see more pictures in Appendix).

Still with the patient supine, and a f t e r a s k i n g t h e p a t i e n t ’ s permission, palpate the abdomen and note any masses or a distended bladder. Report unusual findings to a medic.

With the patient in the prone lying position, have the patient’s feet over the bottom end of the examination plinth.

Test each ankle reflex. Then test the femoral reflex (knee).

Finally, with the patient still prone, firmly tap each vertebra with the tips of your fingers to test for exquisite sensitivity (patients with Ca spine or infection will report severe pain on this test).

If the patient has severe leg pain (i.e. worse than their back pain) do expect to reproduce a positive straight leg raise or passive knee bend.

However, many patients with nerve root pain will have normal motor, sensory and reflex findings. If neurological signs are present, compare these with the pain referral pattern described by the patient (e.g. in their pain chart) for consistency.

L3 – Pain and/or numbness anterior thigh, diminished or absen t knee re f lex , quads weakness, positive passive knee bend test.

L4 – Pain and/or numbness across anterior knee and into medial shin, diminished or absent knee reflex (rare), weak ankle dorsiflexors, positive straight leg raise test.

L5 – Pain and/or numbness down side of leg, normal reflexes, weak extensor hallucis longus, positive straight leg raise test.

S1 – Pain and/or numbness back of leg, diminished or absent ankle reflex, weak hamstrings, positive straight leg raise test.

Remember that 93% of patients with back pain do not have nerve root pain. Many may have vague aches in their buttocks or thighs, but these do not follow normal nerve root referral patterns.

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To test for sacroiliac dysfunction, place the patient supine with their legs straight. Place the right ankle on top of the left knee and see if the patient can slowly lower the right knee. Repeat with the opposite leg.

Record if the patient had difficulty lowering one of his/her legs. If so, this is a fairly reliable sign that the patient has an SI dysfunction on the same side as the leg that was difficult to lower.

For patients with low grade back pain, that only occurs when playing sport or being very active at work, it is worth testing the length of the ilio-tibial band, hip flexors and hamstrings on the affected side.

Shortening of any one, or more, of these muscle groups can lead to increased strain on the lower lumbar spine. Stretching exercises are recommended.

Finally, the multifidus and oblique muscles should be tested for weakness. The patient lies on his/her side with the knees and hips bent to 90 degrees. The shoulders should be in line.

The physiotherapist blocks L3 and asks the patient to retract their upper pelvis. This is tested for strength. The other side is then repeated.

Often a unilateral weakness is detected. The weak multifidus muscle is on the LOWER side of the midline of the spine (i.e. closest to the plinth).

For the oblique muscles, the patient should lie supine with the knees bent and held together. The patient then attempts to rotate the knees to the lef t , wi th the physiotherapist applying gentle resistance.

The knees are then taken to the right and a comparison made. Often one side is weak, but sometimes both sides may be found to be weak.

Thoracic Spine

Check for any deformity, kyphosis and/or scoliosis. Observe the skin, looking for redness.

Ask the patient to perform active flexion, extension, side flexion and rotation in standing and sitting. Look for any movement deficit and which movement brings on the patient’s pain.

Accurate diagnosis of thoracic pain is very difficult. Disc hernias can occur, but are very rare.

The most common problem is a costo-vertebral subluxation, which can cause severe pain, often associated with pain on deep inspiration. This is discussed in more detail later.

Cervical Spine

First look for deformity. How does the patient hold his or her head? Is the head rotated to one side?

If it is, this may suggest spasm of the sternocleidomastoid muscle (SCOM). This muscle will usually shorten and spasm if a cervical facet is injured in some way.

Ask the patient to perform the fo l lowing neck movements : flexion, extension, side flexion and rotation.

Once any limitations of movement are noted, inc lud ing which movements worsen the patient’s symptoms, have the patient lie supine with the head towards the end of the plinth.

The clinician should then gently retest these movements passively, asking the patient to raise an arm if a movement hurts.

With facet pain, often the patient will present with limitation of rotation in one direction and limitation of opposite side flexion.

Palpation will often reveal a tender unilateral facet joint, although pain in the upper cervical spine will of ten be el ic i ted on gent le palpation of the spinous process of C2.

The brachial nerves should be tested for sensation, reflexes and muscle power.

C5 mainly forms the axillary nerve to innervate the deltoid muscle. a n d C 6 m a i n l y f o r m s t h e musculocutaneous nerve to innervate biceps.

C7 mainly forms the radial nerve to innervate triceps. C8 mainly forms the median nerve to i n n e r v a t e f l e x o r d i g i t o r u m superficialis and profundus. T1 mainly forms the ulnar nerve to innervate the intrinsic muscles of the hand.

These muscle groups should be individually tested for strength.

Sensation for the C5 nerve can be tested by stroking the outer upper arm, along the thumb for C6 and along the little finger for C7.

Tapping the biceps tendon with a reflex hammer tests the C6 reflex and tapping the triceps tendon tests the C7 reflex.

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DIAGNOSTIC TRIAGE

Numerous attempts have been made in the past to classify spinal pain. Few succeeded due to a lack of consensus between clinicians and researchers.

However, due to the rise in low back pain disability, the Royal College of General Practitioners in London in 1999 published new guidelines based on a simple system of diagnostic triage, whereby patients with low back pain are divided into one of three types:

- mechanical pain- nerve root pain- suspected serious pathology

The guidelines recommended that clinicians triage all spine patients, in order to segregate those that needed urgent medical attention, from those that could be managed with simple advice, reassurance and physiotherapy.

These guidelines can be applied to all cases of spinal pain. Let us examine each of these in reverse order.

S u s p e c t e d S e r i o u s Pathology

It is not the responsibility of the physiotherapist to diagnose and manage serious spinal pathology. However the physiotherapist s h o u l d b e a w a r e o f n o n -mechanical causes, however rare they may be.

These include:

1. Cauda equina syndrome 2. Severe osteoporosis3. Progressive idiopathic scoliosis 4. Worsening Grade 2+ spondylolisthesis5. Ankylosing Spondylitis6. Paget’s Disease7. Haematological cancers8. Primary tumours9. Metatastic disease10. Pelvic sarcomas11. Aortic aneurysms

13. Renal disease14. Osteomyelitis15. Severe psychiatric illness16. Drug abuse17. HIV18. TB19. Gram-negative infection20. Post-partum sacro-iliac staphylococcus infection21. Discitis in young patients22. Pelvic abscess23 Arnold-Chiari malformation24 Myelopathy (esp. C spine)

Serious spinal pathology is often labeled “Red Flags’. These are not as easy to detect as one might expect.

Clearly, some patients present with florid signs, such as a history of rapid weight loss, profuse night sweats, tremor and significant malaise.

However, many ‘Red Flags’ initially present with what appear to be normal signs of mechanical p a i n . C l i n i c i a n s n o r m a l l y distinguish these patients from other patients with spinal pain by observing them over time and noting any significant worsening of their symptoms.

However, chronic pain patients worsen over time too. The vigilant clinician should therefore be scrupulous in his/her history taking, because at some stage the ‘Red Flag’ patient will inevitably begin to show some, or all, of the constitutional changes described

above.

Night pain is n o t a g o o d i nd i ca to r o f s u s p e c t e d s e r i o u s p a t h o l o g y . Mos t sp ina l p a t i e n t s e x p e r i e n c e night pain.

However the pa t i en t t ha t has to sit out of bed in a chair at night,

or has to pace up and down in their house, might suggest that there is some serious underlying pathology (e.g. metastases).

Be aware of elderly patients who have fallen in case they have an osteoporotic fracture. Osteoporotic fractures in the anterior bodies of the vertebra cause kyphotic deformity, but do not usually present as a medical emergency. F rac tu res i n t he pos te r i o r elements may cause spinal cord damage.

Patients who take longer than 30 minutes to loosen up in the morning may have ankylosing spondylitis.

The investigation of choice for spinal pain is taking a history. More information can be gleaned by just listening to the patient than ordering tests.

Blood tests have a low yield for detecting serious pathology, as do x-rays.

A lumbo-sacral x-ray exposes the patient to one hundred times the amount of radiation than a chest x-ray.

With the exception of serious trauma, plain x-rays provide very l i t t le useful information (for example, early tumours are not easily detected on plain x- ray).

Disc space narrowing, as seen on plain radiographs, are just as common in the asymptomatic population as they are in spinal pain patients.

Magnetic resonance imaging has become an important tool in the diagnosis of spinal pain. However surgical management based pu re l y on MRI f i nd ings i s inappropriate unless they are matched to clinical findings and much controversy remains over the validity of MRI findings in relation to clinical conditions such as spinal pain, brachialgia and sciatica.

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N u m e r o u s p a p e r s h a v e highlighted the incidence of a b n o r m a l l u m b a r s p i n e m o r p h o l o g i c a l f i n d i n g s i n asymptomatic volunteers. These are termed ‘false positives’.

Boden et al in 1990, performed MRIs on 67 individuals who had never had low back or radicular pain. Of those under 60 years of age, 20% had a disc hernia whilst the figure was higher at 36% in the over 60 year olds.

Jensen et al in 1994, carried out a similar study on 98 asymptomatic people and found that 64% had abnormal discs at all levels, 52% had a minor disc hernia at each level and 27% had a significant disc hernia.

They concluded that the presence of disc hernias may not be clinically relevant.

The presence of clinical findings in symptomatic patients requires careful scrutiny to ensure that they are valid and sensitive to the clinical features and degree of d isab i l i t y p resented to the clinician.

In other words, the MRI findings must correspond to the clinical symptoms and signs and level of disability reported if they are to have any role in the clinical decision making process.

Questions to ask to exclude potential serious pathology:

Is the pain unremitting, despite medication (particularly if it is in the thoracic spine)?

Is the pain so severe at night that the patient has to frequently get out of bed?

Has the patient lost weight recently without dieting?

Does the patient sweat profusely at night (enough to soak the sheets)?

Does the patient have a tremor?

Does the patient’s back feel rigid?

Is the patient off his/her food?

Does the patient feel abnormally tired?

Does the patient feel generally unwell?

Does the patient have a history of cancer, TB or HIV?

Does the patient have loin pain with urinary changes (i.e. renal problem)?

T h e s e a r e q u e s t i o n s a physiotherapist needs to ask to ensure that any treatment they provide is not contraindicated:

I s t h e p a t i e n t u n d e r g o i n g treatment for cancer or a current infection?

Does the patient have sensory loss, due to another illness, such as multiple sclerosis?

Has the patient recently been on a course of blood thinning agents (e.g. Warfarin) or long-term corticosteroids?

Does the patient have a history of rheumato id a r th r i t i s ( some patients confuse RA with OA and may say yes when they do not have it)?

Has the patient undergone a recent course of radiotherapy?

Is the patient currently receiving treatment by a different therapist?

Affirmative answers will clearly determine the type of treatment that the physiotherapist wil l provide. Do not forget that simple advice on self-care and posture is still physiotherapy.

If in doubt about any patient, always discuss your concerns with the family doctor or your supervising medical specialist. It is not your responsibility to manage serious pathology.

Nerve Root Pain

5% of all spinal patients have s o m e f o r m o f n e r v e r o o t compression. The most common cause is a nerve root compressed by a lumbar or cervical disc hernia.

Disc hernias can be contained (i.e. the annulus simply bulges against an exiting nerve root) or non-contained (the annulus tears, allowing the nucleus pulposus to e x t r u d e f r o m t h e d i s c , compressing a nerve root).

Nerve root pain can treated success fu l l y w i th res t and analgesia. 90% of all cases resolve within 9 to 12 weeks of onset.

However, the pain can be severe and it is not unusual for patients to require opiate-based medication as well as NSAIDS.

Whether a disc hernia is contained or non-contained does not alter the outcome. The contained hernias are sometimes responsive to McKenzie techniques. However, no one can manipulate a non-contained disc hernia ‘back into place’.

Once the nucleus pulposus has exited the disc, it cannot be manipulated back into place (this was would be akin to squeezing the toothpaste back into its tube). Most hernias dissolve with time. In fact many remain in situ many months after the symptoms of nerve root pain have resolved.

This is because nerve root pain is largely chemical in nature. Mechanical compression of a nerve root should only cause sensory and/or motor changes (and in most patients only the former).

It is the inflammatory reaction to the mechanical compression that leads to pain extending down the length of the nerve root.

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In the lumbar spine 98% of all disc hernias affect the L4, L5 or S1 roots (making up the sacral plexus).

Only 2% of disc hernias affect the L2 or L3 nerve roots. In the cervical spine the most common levels of disc herniation are C5/6 and C6/7.

Nearly all patients with nerve root pain will report a few days of back o r neck ache , wh i ch t hen dramatically converts into leg or arm pain after a simple twist, cough or st ra in. Once th is conversion occurs, the back or neck pain either lessens or resolves altogether.

In the lumbar spine, most patients have worsening leg pain on prolonged sitting, but a few may be worse on weight bearing. The latter have claudicating nerve root pain and although this is more common in older patients, this pattern can be seen in younger patients too.

The leg pain always follows a dermatomal pattern (see diagram above). A weak extensor hallucis longus combined with altered sensation on the outside of the foot and a normal ankle reflex is a

clear sign of an L5 root lesion. A weak calf or hamstring, with a numb heel and an absent ankle reflex, is always indicative of an S1 root lesion.

L4 root lesions cause pain extending across the knee and into the medial side of the shin and are usually, but not always, accompanied by a diminished knee reflex.

Pain that only extends to the knee may still be an L4 root lesion. It may simply not be severe enough to extend further down the leg. However, the straight leg raise test will differentiate it from an L3 lesion.

The straight leg raise test (SLR) is the most sensitive test for nerve root pain. A tiny number of patients have wide spinal canals and this can result in a false negative result but this is not common. The test is discussed in more detail later.

Although not all patients with nerve root pain have motor weakness, those that rapidly develop a drop foot require urgent attention. However in general, patients with nerve root pain do not require surgery, unless their pa in cannot be adequate ly managed with medication.

In the cervical spine, the arm pain is worse when the arm hangs loose (some patient place their hand in their pockets for a little relief).

C6 lesion result in pain extending t o t h e t h u m b a n d m a y b e associated with a loss of power in the biceps and thumb extensor muscles and an absent biceps reflex.

C7 lesion result in pain on the outer two fingers, with a loss of power in the triceps muscle and an absent triceps reflex.

Surgical follow-up rates at one year show no difference in outcome between patients who

have undergone discectomy compared with those that haven’t. However, at f ive years, the discectomy patients are slightly worse.

Most patients with nerve root pain d o N O T d o w e l l w i t h physiotherapy, but do require deep spinal muscle retraining once the leg pain has resolved in order to prevent a relapse. Avoid traction.

Patients who have bilateral leg pain, saddle anaesthesia, an inability to empty their bladder, combined with a loss of anal tone, m a y h a v e c a u d a e q u i n a syndrome.

This is an EMERGENCY that requires prompt referral to a medic. Although this is a rare condition, you miss it at your peril.

Differential diagnosis includes rare cases of nerve root pain due to osteophytosis (a bony spur too close to a nerve root) or a tumour pressing on one or more nerve roots. The latter is rare, but the former is common in people over 60 years of age.

Nerve root pain in older patients, and par t icu lar ly those wi th diabetes, is often worse than that experienced in younger patients. This is because the vascular supply to the nerve root is usually very poor. However, the recovery rates for patients with nerve root pain caused by osteophytosis is again 9 to 12 weeks.

Clinicians should be alert to signs of myelopathy caused by a large cervical disc hernia (particularly if the spinal canal is already narrow congentally or due to degenerative changes) or fracture following trauma.

Patients reporting neck pain and bilateral weakness/sensory loss in all four limbs requires urgent medical attention. A positive Lerhmitte’s sign would confirm this.

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Piriformis Syndrome and Myalgia Parasthetica can mimic nerve root pain in the lower limb.

With the first, the piriformis muscle becomes over active and painful. This can refer pain into the leg. It is best treated with massage, ultrasound, trigger point therapy and stretching exercises.

Myalgia Parasthetica is caused by e n t r a p m e n t o f t h e l a t e r a l cutaneous nerve as it passes through the inguinal ligament in the left or right iliac fossa of the abdomen.

This causes an oval patch of numbness , and somet imes burning, on the outside of the thigh. It can be treated with ultrasound to an area 1 cm medial to the ASIS (palpate to get the exact tender point).

There is another important group of patient with nerve root pain that often get overlooked. These are patients with spinal stenosis, i.e. narrowing of the central spinal canal or any one of the exiting foramen that the nerve roots pass through as they leave the spine.

T h i s n a r r o w i n g c a n b e symptomless, but in many cases it can cause neurogenic claudication (sometimes described as spinal claudication).

Stenosis is usually degenerative, i.e. thickening of the ligamentum flavum, combined with facet joint hypertrophy and a bulging lumbar disc. However, it can also be hereditary, particularly in shorter people.

A combination of hereditary and degenerative factors can lead some relatively young patients (i.e. in their fifties and sixties) to become quite disabled.

Neurogenic claudication is where one or more nerve roots are squeezed due to the lack of space within a narrow spinal canal or exit foramen.

This usually occurs when the patient is standing and walking (when the diameter of the spinal canal naturally narrows). The nerve roots become ischemic leading to increased pain the further the patient stands or walks.

Flexion gives rapid relief and many patients with this condition find it helpful to lean on a trolley as they walk (e.g. a supermarket trolley).

Such pa t i en t s need t o be differentiated from patients with vascular claudication. One way to do this is check the pedal pulses (not very reliable).

Another method is to place both type of patients on a treadmill and record how far they can walk. Both will stop at some point due to pain.

If you then place both patients on a b icyc le, the pat ient wi th neurogenic claudication will cycle for a much longer period than the patient with vascular claudication (because they are in flexion).

Not all patients with neurogenic claudication have progressive symptoms. Those that do, and who are a low anaesthetic risk, do reasonably well with surgical decompression (80% success rate).

Patients who can walk more than half a kilometer, probably fall outside the surgical range and therefore require physiotherapy flexion exercises.

The few older patients with severe stenosis, who are an anaesthetic risk, can be provided with a four- wheel rollator, complete with seat.

This aid enables them to leave their house. As their symptoms worsen they can stop, apply the brakes, and sit down for a period of time. Such devices can have a profoundly beneficial effect on patients with this condition.

Questions to ask if you suspect the patient has nerve root pain:

Where is the pain in the leg (does it follow a clear dermatomal pattern)?

Is the leg pain getting worse, better or ISQ?

Which is worse, the leg pain or the back pain (if it is the back pain, then the patient is unlikely to have nerve root pain)?

Does coughing make the pain worse (generally more common in disc hernias)?

Does the patient experience pins and needles or numbness?

Is the pain worse in sitting or standing?

Does the patient feel that their foot flops when he/she walks (and is this getting worse)?

Questions to ask if you suspect the patient has cauda equina syndrome:

Does the patient have bilateral leg pain?

Can the patient empty his/her bladder and does he/she have normal bladder flow?

Does the patient experience saddle anaesthesia?

Is the pat ient exper iencing weakness in their legs (e.g. do their feet feel like cotton wool or do they feel as their legs are going to give way)?

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Can the patient feel the difference between flatus and passing a stool?

Any positive answer to the cauda equina questions (or progressive foot drop) should prompt the patient to seek medical help as soon as possible.

In the absence of these particular clinical signs, the patient is best treated by observation over time, with advice on positioning and pacing.

It may be helpful to liaise with the patient’s family doctor to ensure that the patient has adequate analgesia (nerve root pain by its nature, may requi re opiate compound medication).

Deep muscle retraining will be required once the leg pain has resolved.

Mechanical PainPart One: Lumbar

This is the most common type of spinal pain. It used to be called lumbago, a term used by Anglo-Indian railway workers during the 19th century.

Simple back pain is usually characterised by a sudden or gradual onset of pain in the L2 to S4 region.

Sometimes the patient finds even the most simple movements bring on their pain and they have difficulty transferring from sitting/lying to standing and turning in bed at night.

Many textbooks claim that acute back pain is worse with activity and better with rest. This is not always true.

The important markers are that their pain is positional and that there are clear exacerbating and relieving factors (e.g. cancer pain is unremitting and not related to change of position).

60% of patient with acute back pain improve by 80% within two weeks of onset. A further 30% will be virtually pain free within twelve weeks. 10% will go on to develop chronic low back pain.

This latter group include complex pain patients, so-called ‘Yellow F l a g s ” , a n d t h e s e w i l l b e discussed later.

Referred pain into one or both legs is common. However, if the patient reports that their back pain is worse than their leg pain, it is unlikely that they are experiencing nerve root pain (trapped nerve).

Numerous soft-tissue structures in the lumbar spine can cause referred pain into the buttocks,

thighs and even sometimes below the knees. However, referred pain is more vague than nerve root pain and is certainly not as severe.

The preferred medication for simple back pain is paracetamol, NSAIDs and muscle relaxants if muscle spasm is present. There is no clinical justification for patients to take opiate-combination drugs.Patients should be encouraged to maintain normal daily activities and remain at work if possible.

There is NO justification for more t h a n 4 8 h o u r s b e d r e s t . Physiotherapists should also p r o v i d e r e a s s u r a n c e , t h a t although the patient’s pain may feel severe, they are not going to end up in a wheelchair!

It is not possible to accurately diagnose the cause of mechanical low back pain. Clinical tests for precise diagnosis of disc hernias, unless there is significant nerve root pain, lack sensitivity (false negatives) and specificity (false positives).

This can often frustrate the patient and it is very tempting for the physiotherapist to provide the patient with a ‘label’ or diagnosis. Nearly all patients expect a diagnosis and no clinician wants to look vague or stupid in front of their patient.

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However, using labels such as slipped disc, crumbling spine and arthritis frighten patients and can lead them to treat their spines as though they were made of glass.

This can cause some patients to ‘catastrophise’, leading to chronic back pain, which is discussed in more detail later.

Most commonly used indicators, leg length discrepancy, ‘f lat backs’, one hip higher than the other, a twisted pelvis, being overweight or degenerat ive changes on an x-ray, have little diagnostic value.

Numerous studies have found similar findings in patients without back pain.

For example, Jensen in 1997 found that 27% of patients with no history of low back pain, had at least one significant lumbar disc hernia on MR imaging.

However, there are two factors that are signif icant. First ly, smokers are four times more likely to suffer back pain than non-smokers.

Secondly, muscle inhibition in all deep and superficial lumbar and trunk muscles can lead to soft-tissue instability increasing the risk of future episodes.

Although it is wise to avoid exact diagnoses with low back pain patients, there are five typical s y n d r o m e s t h a t c l i n i c i a n s frequently come across.

Acute Facet Joint Syndrome

This is by far the most common presentation of mechanical low back pain. The pain usually comes on suddenly, especially after a twisting ‘flexion’ action and is nearly always accompanied by lumbar muscle spasm.

An acute facet sprain may be due to a capsular or meniscal injury a n d m a y i n v o l v e a s l i g h t subluxation of the joint and synovitis (swelling).

Acute facet pain usually subsides within 21 to 28 days. Patients usually present with unilateral spine immobility and respond well to manipulat ion and f lexion exercises (after the spasm is treated with muscle relaxants or support strapping).

Attacks often reoccur. Usually t h e r e a r e l o n g p e r i o d s o f remission between attacks, but the attacks may slowly become more frequent and take longer to settle down.

Repetitive acute facet syndrome is diff icult to manage and the evidence for surgical fixation is weak. Patients respond better to muscle strengthening exercise regimes, although some patients are never completely symptom free.

Aiming for a reduction in episodes and faster healing times is the the most realistic outcome of any rehabilitation regime.

Some patients are difficult to assess in the early stages. They may have considerable difficulty get undressed and getting on and off an examination plinth is near impossible.

Unless the patient is reporting significant motor loss in the lower limbs, it is probably wise to treat them with proprioceptive strapping for the first few days (see picture below).

This involves having the patient stand as erect as possible, preferably with a slight lordosis. Two long strips of zinc oxide tape are applied to the back from T4 to S4 in an ‘X’ formation.

There are then reinforced with shorter longitudinal strips at T5, T10 and S2. The patient must keep still whilst the taping is applied. The tape should be placed taut on the skin, especially in the hollow of the lower back.

The patient is then able to extend and side flex reasonably well, but his/her flexion will be restricted.

The taping maintains the lumbar spine in the neutral position, i.e. in a lordosis, which is the best position for de-loading the lower lumbar segments. The tape can be kept on for five days.

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Some physiotherapists teach their p a t i e n t s l u m b a r e x t e n s i o n exercises whilst the tape is in place. However, this is not recommended, as the trauma may be in the posterior elements, which will be exacerbated by excessive extension.

Taping is preferable to a lumbar corset. The patient cannot see the taping and therefore it feels less like a ‘psychological crutch’. It still allows some active movements and it is unlikely to lead to muscle wasting.

The drawback with taping, is that some patients are sensitive to the tape and may be only able to tolerate it for 48 hours.

As the muscle spasm eases the physiotherapist can teach simple flexion in sitting. The patient sits upright in a firm chair, with one leg crossed over the other leg, in the way that a man would cross his leg rather than a woman.

The patient places his hands (with fingers interwoven together) under the crossed knee and gently pulls the knee towards his/her chin. This should be repeated slowly at first for ten repetitions.

At this point, the patient changes over legs and repeats the process with the opposite leg. It is often at this point that the more painful side of the spine is revealed as the patient will report that one of the two legs is harder to pull up.

This exercise helps to stretch shortened muscles in the spine and buttock, and also helps to gap the facet joints and facilitate gentle gliding within an injured joint.

The patient should perform the exercise on both legs with equal repetitions of ten pulls each leg performed up to three times a day.

This exercise is unlikely to cause severe pain, so if a patient returns at their next visit stating that the exerc ise has caused them extreme pain, the physiotherapist

should be suspicious that he/she may be a Yellow Flag patient.

Manipulation is not recommended on the patient’s first appointment. However, if they return for the second appointment a few days later and the exercise has helped a little, then the physiotherapist m a y c o n s i d e r p e r f o r m i n g manipulation, as long as there are no contraindications (long-term s t e r o i d u s e , e x p o s u r e t o radiotherapy, RA etc.).

However, a repeat examination should be done to confirm that the patient has unilateral stiffness only.

If the physiotherapist is not trained at using short-lever manipulation techniques (in Maitland’s terms, this would be called a grade V), he/she may choose to mobilise the patient using the same positioning for a manipulation. The Maitland method of mobilisation is the most common form of passive movements.

When full range of movement has been restored and the patient’s pain has lessened, it would be now appropriate to teach the patient how to retrain their multifidus msucles.

Research studies has shown that these muscles often weaken after injury or pregnancy and do not automatically regain their full tone over time.

It is important to retrain these muscles using simple exercises, perhaps taught one at a time (to maintain patient compliance).

Multifidus is particularly important to retrain following a back sprain. It is segmentally innervated, which means it has only one nerve supply.

An injury on one side of a lumbar segment (anterior or posterior compartment) can inhibit the nerve supply to a single multifidus muscle.

An underperforming multifidus and m a y b e a s s o c i a t e d w i t h hyperact ive extra-segmental muscles, such as extensor spinae and quadratus lumborum. These latter muscles try to compensate for the weakened deep intrinsic muscles.

This over performance by the superficial muscles, which is part of the body’s protective adaptive process, is usually excessive and far too late.

Over time, the patient can suffer repeat episodes of acute muscle spasm, a consequence of the deep stabilising muscles not doing their job and the superficial extrinsic muscles trying clumsily to provide back-up protection.

This inevitably leads to chronic pain in the superficial muscles, that may eventually become fibrosed and inflamed, the perfect e n v i r o n m e n t f o r n u t u r i n g hypersensitive nerve endings.

A weakened single multifidus muscle is often found on the painful side of the spine. This muscle provides extra stability for the facet joints and the lumbar discs. In other words, it provides stability to both the anterior and posterior elements of each lumbar segment.

To retrain multifidus, the patient lies on his/her side with pillows supporting the head and the knees and hips positioned at 90 degrees. The patient then pulls his/her upper pelvis backwards, whilst keeping the upper trunk and shoulders still. The contraction is held for five seconds and repeated slowly ten times.

If one side feels weaker than the other, the patient should perform the exercise on the weak side only (i.e. x10 reps – 3x daily). However, if there is bilateral weakness, then the patient will need to perform this exercise on both sides (i.e. x10 reps – 3x daily on each side).

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If the patient is making good progress, this exercise can be made more difficult by getting the patient to position himself or herself against a flat wall or piece of furniture.

The patient places an extra pillow behind their upper pelvis and then pushes the pelvis against the pil low, thus working against resistance.

If the physiotherapist has noted shortening of the major muscle groups of the hip and thigh, it may be wise to teach the patient exercises to lengthen these muscles.

The final stage of treatment for these patients is to invite them to enroll on a Back Fitness Class (BFC). This is a 45-minute exercise session, where patients perform up to 15 exercises, each performed for one minute.

The aim of the class to recondition the entire patient’s muscular s y s t e m t h a t m a y h a v e deconditioned after a long period of back pain. These classes are n o r m a l l y h e l d i n p h y s i o gymnasiums, although some hospitals run aqua-fitness classes in the hydrotherapy pool.

Patients usually enjoy attending the classes (those that don’t, turn up once and are never seen again!). The classes provide peer support to patients (i.e. “so I am not the only person with this type of back pain”).

The class is usually run once or twice weekly by a physiotherapist for four to eight weeks, depending on the frequency of the classes.

Patients with high blood pressure, d i a b e t e s o r o t h e r c a r d i o -pulmonary conditions may require

consent from their family doctor before enrolling on the class.

There is good evidence to support the use of these exercise classes. In fact the evidence for them is far more robust that it is for individual taught exercises or manipulation techniques in patients with acute and sub-acute low back pain.

Chronic Facet Joint Syndrome

Many patients experience chronic facet pain (N.B. little correlation exists between symptoms and morphological changes on plain x-ray).

Patients with chronic facet pain usual ly exper ience pain on prolonged standing, walking, turning in bed at night, often have early morning stiffness and a have constant need to keep changing their position.

Again , examinat ion usual ly reveals unilateral stiffness (as opposed to mult i-directional stiffness) and the patient does not like extending his/ her spine.

Although these patients frequently feel depressed, they continue to work, keep up their housework and socialise. In other words, they try to lead a normal life as possible and display relatively low levels of disability even though their pain may cause them considerable discomfort.

They exhibi t normal i l lness behaviour. They usually respond very well to passive therapy and gentle exercises. TENS is highly recommended.

These patients should undergo the same exercise regime as described for patients with acute pain, although patients over 50 years of age may not be suitable for the advanced exercises or the BFC.

Because these patients are in constant pain, and have been for some time before they reach the physiotherapy department, they

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tend to cope better with exercises once their chronic pain is brought under better control.

The family doctor can help by prescribing 20mg of Amitriptyline at night, possibly combined with a low dose anti-inflammatory.

The Amitriptyline may help by modulating hyper-sensitivity in the dorsal horn of the spinal canal, thereby de-sensitising that part of the neural network.

A TENS machine can be bought by the patient for permanent treatment in the future. The patient must be taught how to use the TENS machine in order to ensure an effective outcome.

Once the patient’s pain is under better control, the early stage exercises taught for acute facet pain can be introduced. These patients do particularly well with flexion in sitting.

Discogenic Syndrome

These pat ients have mul t i -directional stiffness. They are significantly worse towards the end of the day. The pain originates from the anterior compartment of a lumbar segment.

This does not mean that they have a disc hernia. For instance, it could be a symptomatic annular tear.

The healing time for discogenic l e s i o n s c a n l a s t m o n t h s . Sometimes patients recover desp i te phys io therapy, no t because of it!

However, postural and lifting advice is very important for these patients.

These patients do NOT do well with manipulation, even if they have no leg pain. Many clinicians would choose extension exercises for this type of patient instead (e.g. McKenzie) although the evidence for such an approach is weak.

This is a difficult syndrome to treat and some observers believe there are no physiotherapy techniques more effect ive than natural healing.

McKenzie advocates will always try and claim dramatic successes. However, patients with discogenic syndrome with accompanying nerve root pain, should not undergo McKenzie treatment, u n l e s s t h e s y m p t o m s a r e r e s o l v i n g q u i c k l y a n d t h e McKenzie techniques do not bring on ANY leg pain.

There is currently much debate as to whether the McKenzie rationale is sound. It is based partly on the idea that performing repetitive extension can reduce a disc hernia. This is far from proven. However, the method clearly works for some patients.

I f p a s s i v e t r e a t m e n t i s unsuccessful, the physiotherapist may invite the patient to begin muscle retraining. This should first be done on an individual basis, often by trial and error (i.e. seeing which movement direction the patient prefers). Once the patient’s pain is under much better control and that there is NO longer multi-directional stiffness, they can then progress to the Back Fitness Class.

Sacroiliac Syndrome

The sacroiliac joint sprain is a much over-used diagnosis, but they one can occur post-partum and can be occasionally seen in athletes and in squash and badminton players who play on hard floor surfaces.

It usually involves pain in the area of one SI joint, with or without pubic symphasis pain.

T h e p a i n f u l j o i n t m a y b e hypermobi le due to a s t i f f contralateral SI joint. Patients with an SIJ problem have pain at the midpoint of rising from sitting to standing.

Deep musc le re t ra in ing as described earlier is important to give support to the ilio-lumbar and sacro-iliac ligaments. This may include pelvic floor exercises for those with post-partum sacroiliac and/or symphasis pubic pain.

A failure to relieve the symptoms might require the patient to undergo further investigations, for conditions such as staphylococcus infection or sacroiliitis secondary t o R e i t e r ’ s S y n d r o m e o r ankylosing spondylitis.

Biopsychosocial Syndrome

These patients have chronic pain with no particular clinical pattern and their reported symptoms do not fit in with normal expected clinical presentations.

They do not maintain activities of daily living, they go on long term sick leave from work and they rely heavily on family and friends (they often have a colluding spouse).

They exhibit exaggerated illness behaviour, often shopping around different doctors and therapists trying to obtain the elusive ‘diagnosis’. Their failure to find a d i a g n o s i s b e c o m e s a n impediment to their recovery.

These patients are labelled ‘Yellow Flags’. Nearly all seek some form of compensation. This can be financial (litigation or social benefit payments) or emotional (attention from family members and friends). They are four times more likely to suffer depression than the general population.

Clinically, they present with total body pain, multiple tender areas across their spine, neck pain, headaches, vague aches and pains in their legs and laboured movements.

Attempts to perform the SLR tests fail, as they will usually cry out with pain as the leg reaches 20 degrees off the examination plinth.

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Yet if you ask them to sit up with their legs extended they always perform this without difficulty (one of Waddell’s non-organic signs - see references).

Passive one-to-one therapy does NOT work. The patient may report some early improvement but they always deteriorate again.

A mult i-discipl inary team of a n a e s t h e t i s t s , c l i n i c a l psychologists, physiotherapists and occupational therapists is required to manage these non-copers.

Adjuvant medications, such as Gabapentin and Amitriptyline may also help as part of a rehabilitation programme.

Cognitive behavioural therapy can play a very important role by r a i s i n g t h e t o l e r a n c e a n d acceptance of pain amongst chronic pain patients and by teaching them to pace their activities.

Pacing involves asking patients to keep an activity diary. Patients are encouraged to maintain the same levels of activities on both good and bad days.

These act iv i t ies are s lowly increased over time. This is to prevent patients ‘over doing it’ on their ‘good’ days, and then taking to their beds for five days because they have made their pain worse.

Liaising closely with employers can sometimes lead to a few pat ients re turn ing to work. However, this is not an easy task. Many employers do not want to take on patients with a history of back pain.

Attempts to treat these patients on a one to one basis, outside the support system of a pain clinic, is a recipe for disaster. Some patients may report some early improvement, but this rarely lasts.

Very few of these patients can tolerate exercises and will nearly

always complain that a mobilisation technique or a massage has made them worse.

I n d i v i d u a l t h e r a p y reinforces the notion that they must have “something seriously wrong with them”, a concept that o ther p a t i e n t s d o n o t entertain.

These patients can be detected at their first appointment through careful history taking, clinical examination and by asking them to complete a back pain q u e s t i o n n a i r e , preferably combined with a psychometric test (e.g. modi f ied Zung).

Patients who score high on both questionnaires may be considered for referral to a pain clinic.

When a pain clinic is not available, palliative treatment (e.g. TENS and general advice) may be given instead.

Mechanical PainPart Two: Thoracic

Thoracic pain can be acute with pain on deep inspiration. This is nearly always due a costo-vertebral subluxation.

A single cost-vertebral joint may be tender on deep palpation and trunk mobility will have reduced rotation to one side.

This can be treated with gentle rotational mobilisation away from the pain (i.e. rotations to the good side initially).

However, most cases of thoracic pain have no clear diagnosis and most often result in a deep ‘toothache’ type pain which is often worse with slouching.

Occasionally the pain may follow the ribs around the chest wall, or pass directly thought the chest, sometimes making the patient think they are having a heart attack (however the pain is not worse on physical exertion).

Pain in the thoracic spine which is significantly worse at night (i.e. the patient has to get out of bed and sleep in a chair) should always make one highly suspicious of serious underlying pathology.

Benign thoracic pain can be treated with a combination of mobilisations, exercises and postural advice.

A useful exercise is for the patient to sit upright, with his/her hands tucked behind the neck (so the elbows are close to each other). The patient than ‘writes’ the letters of the alphabet by moving their elbows in the air.

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Mechanical PainPart Three: Cervical

Acute Torticiollis

Acute torticollis is most often caused by a cervical facet sprain, causing the ipsi-lateral muscles to go into spasm. This pulls the head to one side. Referred pain to the upper arm may occur.

The healing time is usually 5 - 10 days and muscle re laxants combined with anti-inflammatories can help considerably. Sensible use of a collar can aid recovery.

I t i s n o t w i s e t o p e r f o r m mobilisations when the neck muscles are in spasm.

Instead teach postural advice and allow the spasm to ease before performing any passive stretches.

A simple exercise to teach is have the patient lie prone with his or her forehead resting on the back of the hands.

The patient then gently rotates to the head AWAY from the pain and repeats this on a regular basis. As the pain subsides the patient can gently introduce rotation to the painful side.

Passive rotation of the head by the clinician (with the patient lying supine) should be done gently following the above regime, but avoid manipulating the neck as this can in some cases causes vertebro-basilar artery damage.

Before gently rotating the head therapeutically, the cl inician should check of verterbro-basilar insufficiency.

This is done by gently rotating the head to each side whilst the head is in slight extension.

The clinician should observe and changes in pupil size or i f nystagmus occurs. The patient may also verbally report being dizzy.

Do NOT proceed with any gentle passive rotation techniques if any adverse effect is noted on testing.

The clinician however may choose to perform some gentle accessory movements with the patient lying prone (i.e. carefully noting what the patient can tolerate).

This can be posterio-anterior mobi l isat ion of the spinous processes or 30 degree angled mobilisation of the vertebral bodies.

These techniques should be perfomed gently and must result in s o m e p a i n r e d u c t i o n a n d increased mobility. If they do not, then discontinue them.

Chronic CVS

Chronic cervical spondylosis (CVS) is common in o lder patients. A combination of disc d e g e n e r a t i o n , o s t e o p h y t e formation and long term muscle shortening can lead to intermittent episodes of neck pain and stiffness.

Referred pain to the upper arm and trapezius areas is very c o m m o n a n d s h o u l d b e differentiated from nerve root pain, which travels to the hand.

It is not unusual for patients to develop secondary shoulder problems, such as a rotator cuff l e s i o n s o r s u b - a c r o m i o n impingement syndrome. Often the clinician will need to treat both the neck and the shoulder.

Treatment should consist of home exercises, postural advice and the use of hot packs. Mobilisations can be performed following the same criteria and precautions as for acute torticollis.

Whiplash

Whiplash in jur ies are more common in countries where road traffic litigation is high. In other words, it is a cultural condition, which makes it difficult to treat.

O f t e n n o s i n g l e l e s i o n i s diagnosable and patients often become emotional and highly dependent on others.

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Patients are often reluctant to perform exercises or follow the advice of the physiotherapist as recovery may reduce or obviate their claim.

Whiplash is thus best managed with simple advice and exercises a n d p a t i e n t s s h o u l d b e encouraged to self manage their condition as much as possible.

Discogenic Pain

Disc hernias at C5/6 and C6/7 are not uncommon, especially in younger patients.

Recovery is usually very slow and patients will usually experience severe arm pain that may be worse than any pain they feel in the neck.

Reflexes, sensation and motor power may be impaired in the affected limb and patients will have considerable di ff icul ty sleeping at night.

Support taping to the shoulder may relieve the pain by limiting the traction effect of the arm hanging by the patient’s side.

Gentle rotation exercises away from the pain may be initiated, but should be stopped immediately if this worsens the arm pain (not the neck pain).

Differential diagnosis should include thoracic outlet syndrome.

Often reassurance and simple postural advice is all that the clinicians can offer. It is unwise to attempt to manipulate the neck and traction is unlikely to have any significant long term benefit.

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