Clinical Pearls
Tell Me Where it Hurts? Part II
22/03/11 21:39
In our last blog posting we looked at the significance of midline lumbar pain as a sensitive and specific predictor of internal disc disruption. But intervertebral disc disease is not the only disorder in which pain distribution can be a useful indicator of its origin. A paper by Clark et al in the journal Rheumatology looked at whether a unique pattern of pain accompanied thoracic osteoporotic compression fractures.
The possibility of osteoporotic compression fracture is usually raised in post-menopausal women suffering from thoracic pain. But is the pain typically felt in the midline, or even over the spine at all?
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The possibility of osteoporotic compression fracture is usually raised in post-menopausal women suffering from thoracic pain. But is the pain typically felt in the midline, or even over the spine at all?
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Tell Me Where it Hurts?
05/03/11 13:45
One of the great challenges of clinical practice is determining the origin of pain. Indeed, the chronic uncertainty that pervades spinal diagnosis has lead to a sort of 'diagnostic paralysis' that affects clinicians of all persuasions. The conventional wisdom seems to be that "Diagnosing spinal pain through physical examination is impossible - so why even try?" This has lead to the development of a number of pragmatic approaches to the question of spinal derangement, including the development of conceptual 'models' to give some sort of theoretical framework, but avoid nailing down a finite diagnosis. For example, physiotherapist Robin McKenzie OBE suggested that the most efficient way to handle the question is to classify back pain patients into 3 broad categories and vary the treatment according to this classification. However, such approaches don't rely upon making a specific tissue diagnosis. Rather, they create a model of what's going on underneath to give some structure to your management.
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Adhesions Revisited
16/12/10 21:24
Spinal pain syndromes, and the functional disorders that underpin these conditions, are clearly complex. And as successful clinicians we need to be able to define the extent and boundaries of the problem - and understand the nature of the variables present. In previous blog entries we have focussed upon some of the functional neurological deficits that seem to lie beneath recurrent spinal pain. These include lack of joint proprioception, inappropriate muscular recruitment and coordination, and even changes to cortical architecture and control. But what about some of the other mechanical or tissue-based aspects of spinal disorders? What else can go wrong 'in there'?
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Facet Joints - What's Really Going On in There?
26/10/10 19:37
When asked the question "Where does spinal pain come from?", most of us would consider the facet joints to be a prime source. Indeed, epidemiology tells us that 31% of chronic lumbar pain and 55% of persistent cervical pain arises from the facet joint 'tissues' (1). But exactly what 'tissues' are we talking about?
If we interrogate the concept of facet joint pain we quickly come to realise that there's no 'one size fits all' diagnosis. And if this is the case, then there's also no 'one size fits all' prognosis, nor treatment. So what does research tell us about the nature of zygapophysial pain? Terms such as 'synovitis' and 'adhesions' are often promoted as an explanation, and they may well be part of the spectrum of facet joint lesions. But how common are these entities, and what causes them?
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If we interrogate the concept of facet joint pain we quickly come to realise that there's no 'one size fits all' diagnosis. And if this is the case, then there's also no 'one size fits all' prognosis, nor treatment. So what does research tell us about the nature of zygapophysial pain? Terms such as 'synovitis' and 'adhesions' are often promoted as an explanation, and they may well be part of the spectrum of facet joint lesions. But how common are these entities, and what causes them?
Read More...
What Are You Adjusting? Hyper or Hypo?
03/06/10 11:22
To most chiropractors quality of spinal motion is a prerequisite for spinal health. We have an intrinsic understanding that a joint must move normally to be normal - or at least to stay that way. As such, our examinations are heavily geared towards assessing and quantifying the relative motion of each segment. We then give it a rating: 'normal', 'hypermobile' or 'hypomobile'.
Most of the time chiropractors tend to focus upon finding areas of limited motion - segments of greater stiffness that would benefit from an adjustment. Indeed, the majority of definitions of joint dysfunction suggest that reduced mobility is a cardinal sign, and that we should try to stay away from any hypermobile segment.
But is this really what's going on? Is it truly the stiffer joints that are the prime source of pain in most of our patients? And is it the stiffer joints that benefit the most from manipulation? Or could it actually be the hypermobile joints that should be the target of, and beneficiaries of, the neurological effects of an adjustment?
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Most of the time chiropractors tend to focus upon finding areas of limited motion - segments of greater stiffness that would benefit from an adjustment. Indeed, the majority of definitions of joint dysfunction suggest that reduced mobility is a cardinal sign, and that we should try to stay away from any hypermobile segment.
But is this really what's going on? Is it truly the stiffer joints that are the prime source of pain in most of our patients? And is it the stiffer joints that benefit the most from manipulation? Or could it actually be the hypermobile joints that should be the target of, and beneficiaries of, the neurological effects of an adjustment?
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Proprioception - The Key to Chiropractic Care
11/05/10 20:10
Since the inception of the chiropractic profession its practitioners have struggled with models of spinal dysfunction. While early notions of structural misalignment have largely given way to ‘functional’ concepts, the average field doctor still questions the exact nature of such lesions. So the question still remains, “What exactly is going on inside the spines and nervous systems of our patients?”
Clearly there are many differing clinical diagnoses that can be made when we attempt to pick a source of pain or a ‘tissue in lesion’. These might include a meniscoid extrapment, a zygapophysial synovitis or one of the various grades of annular tear/disc herniation. However, in such instances we could view any tissue damage as the result of a functional derangement that was already in existence at the time of injury. In other words, many spinal pain syndromes are a symptom of a greater deficit underneath - not simply the unlucky result of an inappropriate movement or accident.
But what ‘deficit’ might precede a spinal injury? And how would we know it was present if our patients are asymptomatic?
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Clearly there are many differing clinical diagnoses that can be made when we attempt to pick a source of pain or a ‘tissue in lesion’. These might include a meniscoid extrapment, a zygapophysial synovitis or one of the various grades of annular tear/disc herniation. However, in such instances we could view any tissue damage as the result of a functional derangement that was already in existence at the time of injury. In other words, many spinal pain syndromes are a symptom of a greater deficit underneath - not simply the unlucky result of an inappropriate movement or accident.
But what ‘deficit’ might precede a spinal injury? And how would we know it was present if our patients are asymptomatic?
Read More...
The Neck - A Sensory Organ for Balance
06/05/10 12:38
When we operate as clinicians in the mechanical realm there is a tendency to view the neck simply as a series of linkages that enable the head to move around on top of the trunk. But it’s really so much more than that. The extraordinary repertoire of movements available to the human neck is only made possible by an exquisite neurology that ensures precise neuromuscular control over the joint segments.
To really appreciate this level of neural control, just focus your attention on your fingers for a moment. Feel how finely you can control their movements and how accurately you can perceive their position. Much of this sensory-motor prowess over your fingers is due to the sheer number of muscle spindles in the musculature - all providing a rich stream of proprioceptive information. And 16 muscle spindles per gram of muscle in the lumbricals certainly sounds like a lot...
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To really appreciate this level of neural control, just focus your attention on your fingers for a moment. Feel how finely you can control their movements and how accurately you can perceive their position. Much of this sensory-motor prowess over your fingers is due to the sheer number of muscle spindles in the musculature - all providing a rich stream of proprioceptive information. And 16 muscle spindles per gram of muscle in the lumbricals certainly sounds like a lot...
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The Vagaries of the Clinical Exam - Who Can You Trust?
29/04/10 21:27
It is unfortunate that the art of clinical diagnosis is exactly that - an art.
While we are fortunate to have the tools of science available to help us, the ultimate assembly of clinical data to construct a diagnosis is as much an art form as it is a science. However, the clinical decisions that we make on a daily basis must be based upon something concrete or we would be paralysed by indecision. So in the end our experience is often called upon to help us decide which of our examination procedures are really trustworthy. The trouble is, sometimes our most cherished practices may not be as reliable as we'd like.
Take, for example, the humble palpatory examination...
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While we are fortunate to have the tools of science available to help us, the ultimate assembly of clinical data to construct a diagnosis is as much an art form as it is a science. However, the clinical decisions that we make on a daily basis must be based upon something concrete or we would be paralysed by indecision. So in the end our experience is often called upon to help us decide which of our examination procedures are really trustworthy. The trouble is, sometimes our most cherished practices may not be as reliable as we'd like.
Take, for example, the humble palpatory examination...
Read More...
Nerve Root Sedimentation Sign in Lumbar Stenosis
27/04/10 21:08
One of the great challenges facing the front-line clinician is to decide whether a radiological finding is actually relevant.
I’m sure that you are all too aware that many ‘abnormalities’ seen on imaging studies are present in an asymptomatic population (for example, 52% of asymptomatic individuals have at least one disc bulge evident on MRI(1)).
So what about lumbar spinal stenosis? When a patient complains of leg pain while walking (claudication), how can we tell whether the stenosis visualised on their MRI scan is relevant and demonstrates the cause of their symptoms? Or should we keep looking for another source of pain? Perhaps their complaint is vascular in origin?
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I’m sure that you are all too aware that many ‘abnormalities’ seen on imaging studies are present in an asymptomatic population (for example, 52% of asymptomatic individuals have at least one disc bulge evident on MRI(1)).
So what about lumbar spinal stenosis? When a patient complains of leg pain while walking (claudication), how can we tell whether the stenosis visualised on their MRI scan is relevant and demonstrates the cause of their symptoms? Or should we keep looking for another source of pain? Perhaps their complaint is vascular in origin?
Read More...