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111 Cards in this Set

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Describe Loeser's Conceptual Pain Model.
Nociception --> Pain --> Suffering --> Pain behaviour
Viscer-somatic referred pain often has what associated symptoms?
Tenderness and muscle contraction (e.g. in appendicitis) and hyperaesthesia (e.g. in biliary colic)
Somato-somatic referred pain (also known as spondylogenic referred pain) generally are referred from what structures?
Somatic structures such as joints, ligaments, muscles, fascia and the disc.
What is referred pain?
Pain referred to any somatic structure innervated by the same spinal level as the original injury - due to the convergence of connections in the spinal cord and brain.
Somatic referred pain is usually affected by what?
Movement or posture.
Does somatic referred pain have neurological signs?
No, although vague sensory symptoms may occur.
L5/S1 disc injury can give what signs and symptoms?
- Lower back pain.
- Buttock +/- posterior thigh +/- calf pain
- Tender/trigger points in the glutei.
- Hyperaesthesia in the posterior thigh/calf.
What sort of structures will give more localised pain?
Superficially structures, such as superficially located tendon sheaths, ligaments, fascia, and periosteum.
What sort of structures will give more diffuse and referred pain?
Deep somatic structures such as deep ligaments, muscles and joints.
Area and distance of referred pain is proportional to...
The strength of stimulus at the site of injury.
What are the usual origins (structures) of spondylogenic referred pain?
Ligaments, muscles, apophyseal joints, intervertebral discs, dura mater
What are the usual origins (structures) of radicular pain?
Nerve roots, dorsal root ganglia.
What are the usual causes of spondylogenic referred pain?
Inflammation, mechanical compression, mechanical strain.
What are the usual causes of radicular pain?
Mechanical compression, ischaemia and chemical irritation (PLA2).
What are the clinical features of spondylogenic referred pain?
- Deep, dull aching.
- Reduced by rest.
- No localising features.
- No dermatomal reference.
- No neurological signs.
What are the clinical features of radicular pain?
- Sharp, burning pain.
- Dermatomal reference.
- Paresthesia.
- Anesthesia.
- Neurological signs.
What is the lifetime prevalence of lower back pain?
60-90%
What is the annual incidence of lower back pain in adults?
5%
What is the peak age for lower back pain?
42.
What are the mechanical causes of lower back pain?
Spondylogenic, radicular.
What are the non-mechanical causes of lower back pain?
Infective, inflammatory, malignant.
What are the non-spinal causes of lower back pain?
Viscerogenic, Psychogenic
What are the mechanical causes of lower back pain?
Spondylogenic, radicular.
What are the non-mechanical causes of lower back pain?
Infective, inflammatory, malignant.
What are the non-spinal causes of lower back pain?
Viscerogenic, Psychogenic
What are the spondylogenic structures?
Ligaments, muscles, facet joints, intervertebral discs, and dura mata.
A history of the following indicates what cause?
- Pain aggravated by change of position, prolonged sitting, getting up, ending and lifting.
- Triggering event.
Mechanical.
A history of the following indicates what cause?
- History of malignancy.
- Unexplained weight loss.
- Visit to the doctor in the last month and not improving.
Malignancy.
A history of the following indicates what cause?
- Pain > 3 months and morning stiffness > 1/2 hour and <35 years old.
Inflammation.
A history of the following indicates what cause?
- IV drug use or recent discogram or fever.
Infection.
A history of the following indicates what cause?
- Significant trauma.
Fracture.
A history of the following indicates what cause?
- Sharp pain following nerve pathways.
- Leg pain extending to below the knee.
- Dermatomal paresthesia.
- Localised weakness.
Radiculopathy.
A history of leg pain on walking relieved by rest or lumbar flexion indicates what possible cause?
Spinal stenosis or vascular disease.
A history of associated urinary, gynaecological or GIT symptoms indicates what possible cause?
Viscerogenic pain or referred somato-visceral relationship.
A history of bilateral leg pain and sphincter disturbance indicates what possible cause?
Cauda equina compression.
A history of pain worse on standing and walking, but relieved by sitting indicates what possible cause?
Spondylolisthesis.
What is the normal angle for lumbar extension?
20-30 degrees.
What is the normal angle for lumbar flexion?
80-90 degrees.
What is the normal angle for lateral flexion?
30 degrees.
What is the general order for palpation of the back?
Palpation aims to identify the level and side of maximum tenderness and stiffness, as well as to correlate it with other signs and symptoms. The order is:
- Light touch first to gauge increased muscle tone and skin hypersensitivity.
- Central palpation over spines and interspinous ligaments.
- Over facet joints.
- Sacroiliac joints.
- Muscles, especially the gluteus medius/minimus (L5) and piriformis (S1), for tender/trigger points.
What are the neural tension signs?
- Stretch nerves and dura and back of discs.
- Positive if reproduces leg pain.
- Straight leg raising (care with interpretation if > 45 degrees).
- Slump test (6 steps, more sensitive and less specific).
- Femoral nerve stretch (for anterior thigh or leg pain).
Left sided L5/S1 intervertebral dysfunction would give:
- Lower back pain centrally and to the left.
- Buttock +/- posterior thigh pain.
- Tender points and tightness in the muscles over the left L5/S1 +/- left buttock muscles.
Damage to the thoracolumbar junction commonly results in referred pain at the:
Lateral iliac crests.
Damage to the mid-lumbar spine commonly results in referred pain at the:
Lower lumbar region and anterior thigh.
Damage at the low lumbar spine commonly results in referred pain at the:
Superior/lateral buttocks and posterior thigh/calf.
Damage at the sacroiliac joints commonly results in referred pain at the:
Inferior/medial buttocks and psterior thigh/calf.
X-rays should be ordered at the first GP's visit if:
- Significant trauma.
- History of cancer.
- Unexplained weight loss.
- Fever.
- Drug or alcohol abuse.
- Corticosteroid use.
- Neuromotor deficit.
An x-ray should be ordered after 4-8 weeks if:
- Age over 50 years.
- Failure to improve.
- Compensation factors.
- Suspected ankylosing spondylitis.
A CT scan could assist with diagnosing:
- Radicular pain.
- Malignancy.
- Infection.
ESR/CRP could assist with diagnosing:
- Malignancy.
- Infection.
- Inflammatory arthritis.
What treatment modalities have strong evidence for treating lower back pain?
- Multimodal/multidisciplinary approach with reassurance, activation, exercises and manipulation +/- steroid injections.
- Reassurance and home rehabilitation.
- Multidisciplinary programme with cognitive behavioural therapy and intensive exercises.
- Facet joint denervation for chronic pain.
- Discectomy for radicular pain.
What treatment modalities for lower back pain have limited evidence?
- Spinal function for chronic pain (patient selection crucial).
- Manipulation for acute and chronic pain.
- Muscle stabilising exercises for spondylisthesis.
- Prolotherapy ('ligament strengthening') injections for chronic pain.
- Steroid/LA injections of facet joints give short term relief in chronic pain.
- Tender point injection.
- Analgesics.
- NSAIDs.
- TCAs for chronic pain.
What treatment modalities for lower back pain have no clear evidence?
- Acupuncture is equal to no treatment, sham acupuncture, trigger point injections or transcutaneous nerve stimulation.
- Bed rest.
- Muscle relaxants.
- Magnet therapy.
- Back school.
Management of a patient's "I HURT"?
- Explain cause in convincing fashion.
- Express optimism about recovery.
- Discuss need (or lack thereof) for x-rays.
Management of a patient's "I CAN'T MOVE"?
- Explain cycle of pain, inactivity and stiffness.
- Simple stretching exercises.
- Encourage normal activities. Set activity goals.
Management of a patient's "I CAN'T WORK"?
- Check beliefs and address concerns.
- Explain danger of sick leave.
- Facilitate return to work.
Management of a patient's "I'm scared"?
- Explore anxieties and discuss them.
- Suggest strategies for coping.
- Suggest measures for acute exacerbations of pain, e.g. stretching, heat, massage and analgesics.
Yellow flags of back pain.
- Attitudes and beliefs about back pain.
- Behaviours - avoidance, medication abuse.
- Compensation issues.
- Diagnosis and treatment - especially conflicting advice, etc.
- Family.
- Work.
Management of chronic low back pain.
- Assessment very similar to acute pain.
- Address psychological, social and occupational factors not already addressed by previous therapists.
- Beware persistence with monotherapies.
- Consider an intensive multidisciplinary approach if available.
- Consider precision diagnosis of treatable causes with MRI, discogram and facet joint blocks.
What are the differences with thoracic spinal pain from lower back pain
- Costovertebral joints.
- Disc problems rare.
- More crush fractures.
- More metastatic disease.
- Differentiating spinal from visceral.
There is a relationship with twisting and breathing below T4.
True or false?
True.
Arm pain or paresthesia indicates a lesion above or below what spinal level?
Above T4.
There is a relationship with neck movements above T4. True or false?
True.
Lesions in the upper thoracic spine (T1-T4) is often referred to:
Pain in the scapulae, axillae, and upper limb.
Lesions in the mid-thoracic spine (T5-T8) is often referred to:
Pain in the infrascapular region, lateral chest wall, and lower chest wall anteriorly.
A lesion in the lower thoracic spine (T9-T12) is often referred to:
Lower chest wall posteriorly and laterally; abdomen; groin; upper lumbar region
Inspection of kyphoscoliosis is particularly important for what population?
Teenage females.
Rotation movement testing is important for problems below or at what spinal level?
T5.
Neck movement testing is important for problems at or above what spinal level?
T4.
T3 and T7 levels can be located via what landmarks.
The top and the bottom of the scapula respectively.
Why should you turn your palpating thumb laterally when palpating the spine?
To cover both the facet and costotransverse joints.
What is the annual incidence of neck pain?
35%.
What is the lifetime incidence of neck pain?
50-70%.
What is the point prevalence of neck pain?
13-17%.
What are the red flag conditions and locations in neck pain?
Anterior Neck:
- Pharynx.
- Oesophagus.
- Thyroid.
- Lymph nodes.
- Carotid arteries.

Head:
- Meningitis.
- Intracranial haemorrhage.

Viscera:
- Heart.
- Diaphragm.
- Stomach.
What are the muscoloskeletal causes of neck pain (common and uncommon)?
COMMON:
- Intervertebral dysfunction.

UNCOMMON:
- Musculoligamentous strain with whiplash.
- Radicular pain.
- Rheumatoid arthritis.
Cervicogenic pain is almost always located:
Posteriorly and/or laterally. Isolated anterior pain is rare.
Upper cervical spine (C0-C3) dysfunction often results in referred pain at:
The head!
Mid cervical spine (C3-C5) dysfunction often results in referred pain at:
Upper trapezius; scapula; deltoid and the upper limb. Pain occasionally occurs in the upper chest wall.
Lower cervical spine (C6-C7) dysfunction often results in referred pain at:
Scapula; interscapular region; upper limb.
What are the risk factors for neck pain?
- Female gender.
- Lower educational level.
- Occupations: Clerical, industry, agriculture.
- Physical and mental stress at work.
- Previous injury.
- Working with machines.
What differences occur in neck examination that differentiate it from other areas of the back?
Palpation:
- Landmarks at C2 to C7 spines.
- Tender/trigger points common in trapezius and rotator cuff muscles.
- Can be done prone or supine.

Other:
- Brachial plexus tension test if arm pain and numbness/weakness.
- Shoulder examination if shoulder pain.
- Cranial nerve examination for headache.
What is the evidence for mobilisation/manipulation in neck pain?
- Some short term benefit for neck pain and headache.
- Similar to TENS or soft collar with analgesics.
- Mobilisation similar to salicylate and better than massage and traction.
- No different to physio or GP care in chronic pain.
Is there any good evidence for the efficacy of simple analgesics and NSAIDs in neck pain?
No good evidence.
Is there any good evidence for the efficacy of diazepam and phenobarbital in neck pain?
No evidence.
Is there any good evidence for the efficacy of electromagnetic therapy in neck pain?
More 'moderately better' patients.
What is the pathophysiological mechanism behind whiplash?
Sudden, unexpected impact with neck structures unprotected by muscles - most commonly flexion-extension with reflex whipping action of the anterior muscles.
- Macro and microtrauma to discs, joints, and soft tissues usually missed by investigations.
- The lower back may also become affected with more severe trauma.
What are the common clinical presentation of whiplash?
- Headache and shoulder pain.
- Pain and tenderness is more diffuse and also anteriorly as well as posteriorly.
- Upper neck extension typically most affected.
- Delayed onset, but risk of chronicity higher than for 'usual' neck pain.
Whiplash has a greater morbidity in which populations?
Females and the elderly.
What is the treatment options for whiplash?
Treatments of lesser efficacy in the first 8-12 weeks:
- Rest and analgesia.
- Combination of TENS, US, and electromagnetic therapy.
- Soft Collars.

Treatments of greater efficacy in the first 8-12 weeks:
- Tailored physiotherapy.
- Electromagnetic therapy alone.
- Home exercises.
- Ice followed by mobilisation/heat/exercise/analgesia.

Treatment of lesser efficacy at 6 months:
- Home exercises

Treatment of greater efficacy at 6 months:
- No good evidence for anything.
What is the cause of somatic referred pain?
Due to spread of pain from deep spinal tissues.
Somatic referred pain - Describe the back and leg pain characteristics.
Back pain worse than leg pain, which may be bilateral.
Radicular pain - Describe the back and leg pain characteristics.
Unilateral leg pain worse than back pain.
Where does somatic referred pain usually radiate to?
Pain concentrates proximally in buttock and thigh but may spread below the knee.
Where does radicular pain usually radiate to?
Pain concentrates distally, running into the lower limb, usually extending below the knee.
What is the quality of somatic referred pain?
Deep, dull aching, expanding pressure-like quality.
What is the quality of radicular pain?
Sharp, shooting, electric quality, often both deep and
superficial.
What is the distribution of somatic referred pain?
Vague location, varies over time, ill defined distribution.
What is the distribution of radicular pain?
Pain runs along defined narrow band in dermatome distribution.
Is there any altered sensation with somatic referred pain?
Poorly defined paraesthesia may be present.
Is there any altered sensation with radicular pain?
Numbness and paraesthesia in dermatomal distribution.
Are there any neurological signs with somatic referred pain?
Normal reflexes and power.
Are there any neurological signs with radicular pain?
Reflexes may be reduced or absent. Motor weakness may be present
What are the red flag signs for back pain?
- Sudden onset of unremitting pain without any precipitating
factor.
- Pain unrelieved by rest.
- Pain at night.
What are the poor prognostic factors regarding return to work from a back injury?
- Personal history of back pain.
- Long distance travelled to work.
- Low job satisfaction.
- Perceived work stress.
- Conflict with an employer or supervisor.
What is oxycontin?
Oral short acting opioid.
Why shouldn't diazepam be used for back pain?
- Significant incidence of side effects.
- Effectiveness is lost after 1 week.
At each visit on follow-up, what do you need to do?
• Check for red flags or neurological signs.
• Assess need for nvestigation or referral.
• Check adherence to medications and exercise
advice – reinforce.
• Review medication, and
• Assess and address fears:
– explain/educate/inform
– reassure/encourage
– activate
– check return to work progress.
If there is poor response to initial therapy for musculoskeletal pain, what options do you have?
- Manipulation.
- Mobilisation.
- Autotraction.
- Cortisone injections.
When should you review a patient for back pain?
4 weeks.
If after 4 weeks, patient shows little improvement, what do you need to do?
- Reassess for red flags.
- Check adherence and understanding.
- Reconsider psychosocial factors.