Clinical Reasoning in Low Back Pain - case presentation
by Martin Krause
Clinical reasoning is the process by which the Musculoskeletal Physiotherapist assesses the client's dysfunction. Titled Australasian Musculoskeletal Physiotherapists are trained in the superior clinical reasoning skills required for independent self-directed reasoning. The cognitive and meta-cognitive skills required for clinical reasoning may lead to expertise if applied clinically for at least 10 years. This process not only allows the clinician to recognize their limitations, moreover it empowers the clinician to know how to plug any gaps in their knowledge by either researching a particular topic and/or attending post-graduate training courses (self directed learning). These skills are founded under the umbrella of life long learning (the 3 L's).
The following is an illustration of the process of clinical reasoning using the Maitland approach. Other examples of using clinical reasoning are found in the 'mind maps' section of this site, as well as the 'neurophysiology of treatment of low back pain using mechanical traction' and the presentation on viewing the 'muscles as an organ of the immune system'.
I: Body Chart
Relationships : - # Pain A alone;
#Pain A with i# Pain B
- # Pain B + # Pain D , and C
- can have # Pain D and E without # Pain A
- can have P+N / numbness without # Pain B
From the body chart what is your 'working hypothesis'?
Do you think there is more than one structure involved? Why?
Are there symptoms suggesting referred somatic or radicular pain? What are they?
II : Past History
nil history of Pain A prior to 6/12 ago
past history of Pain B over past 5 years
- onset after lifting a heavy load (~body weight) in a bent over position
- initial injury took 2-3 weeks to subside
- gradually worsening
increased frequency of Pain B (~ 2-3 times per year)
increased intensity of Pain B
takes longer to get better again ( ~ 4-6 weeks vs a few days)
takes less effort/strain for pain B to come on again
quality of pain B has changed from a 'dull ache' to a 'deep ache & throbbing'
past history of Pain C similiar to Pain B
- onset 5 years ago during the incidence of Pain B
- also gradually worsening , however the recurrences are not as frequent as Pain B
Pain D started at a similar time to pain A but is more frequent (almost constant tightness)
Pain E started some 2 years ago - insidious onset / little changed
history of recurrent sprained ankle on left.
unsure of onset of Pins and Needles / Numbness
previous physiotherapy treatment consisted of electrotherapy and massage and some exercises that helped
What information does the past history reveal w.r.t
- the relationships of the pain?
- your 'working hypothesis'?III : Current History
Pain A commenced 6/12 ago
- insidious onset that gradually worsened over the past few months
- started in the bottom of the heel and became greater in area and intensity.
- mostly constant pain since 2 months
- had been working a lot in the cold open air at the time of onset
- 3 week rest from running made little change
- 12 treatments from a Physiotherapist consisted of massage, ice and a stretching regime - has helped a little but did not last. Recommenced back exercises as Pain B had also been getting worse. Exercises consisted of 'modified' pushups and bring knee to chest whilst lying on back
What information does the current history reveal to help your 'working hypothesis'?
- central pain generating mechanisms? (neurophysiology)
-peripheral pain generating mechanisms? (neurophysiology and anatomical)
History of abuse, overuse, misuse?
Aggravating factors
- standing on a ladder for 30 minutes -> Pain A 3/10; Pain B 3/10
- can continue standing on ladder (risk of Pain C and D)
- standing and moving on ladder for 60 minutes -> Pain A 5/10; Pain B 2/10
- running 10km, the first few km?s are quite painful (~3/10) then it settles down to ~1/10, unless on uneven ground.
Easing factors
- After standing on the ladder for 60 minutes must stop activity, whereby Pain A decreases after approx. 30 minutes to 2-3/10. Pain B remains at 2-3/10.
- Stretching the 'Hamstring muscles' relieves Pain E somewhat.
- Extension exercises help Pain B, little effect on Pain A during day but good a.m.
- Brief (~ 5 minutes) icing of the heel helps Pain A when severe
- NSAIDS help Pain A a little with morning pain and stiffness
- Repeated or heavy (~10kg overhead) lifting may cause pain B
V : 24 hour behaviour
Morning
- the morning after running 10 km, when getting out of bed-> Pain A 7/10 ; stiff in region of pain B. Occasional Pain E.
- takes Pain A some 30 - 45 minutes to loosen up using a hot shower and stretches.
Evening
- both Pain A and Pain B can be worse if having spent a lot of the day climbing ladders;
- frequently Pain D is worse at the end of the day, as are the pins & needles
- running on even ground in the evening helps Pain B and Pain A after a period of time
Note
- pain A constant dull ache but better than during the day
- pain B wakes him occasionally. Unsure whether he wakes due to movement or due to positioning. Takes some 10-15 minutes to sleep again. Prefers to sleep on right side with the left knee up towards chest
- occasional calf cramps at night
- no pins and needles at night
What is the "irritability"? why?
What is the "Severity" ? Why?
What is the "Stage" of the disorder ? Why?
What is the "stability" of the disorder? Why?
Is there evidence for inflammation?
- neurogenic?
- non neurogenic?
- adverse neural tension?
How will you measure technique and treatment success?
Special Questions
Weight loss OK; Steroids OK; Corda Equina OK; Cord OK; Xrays NAD; Operations OK; Other jnts; OK Diabeties OKVI: Physical Examination
Achilles : very tender to palpation, some rubifaction, some swelling, medial and lateral calf tightness
- : heel raise -> pain A 2/10, dev.inv.
Ankle : lateral instability
- : small big toe
Detailed information regarding the neuromodulation of pain as it relates to musculoskeletal physiotherapy
more clinical reasoning for the cervical spine-upper quadrantUpdated : 14 November 2012
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