Low Back Pain

1
Low Back Pain

• Examination Motivation Rehabilitation

2
Kennedy F. 1946 The mind of the injured worker
its effects on disability periods. Compensation
medicine volume 119-21
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Is compensation involved?

• Miller H. 1961
• Accident Neurosis British Medical Journal vol 1
  919-925
• Cure by verdict

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The Effects of Compensation on Recovery from Low
Back Pain Greenough CG et al 1989 Spine 14
pages 947-955 five years after settlement- still
a massive difference
5
Waddell G 2004 The Back Pain Revolution, second
edition. Churchill Livingstone, New York

• although he acknowledges that compensation
  patients respond less well to PMP and
  rehabilitation
• methodological flaws in many studies
• samples small
• patients highly selected with poor diagnostic
  criteria
• poor follow-up
• failure to allow for other factors such as job
  demands
• differences are small

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Occupational Perspectives Section 5 pages 331-2
in Main CJ et al 2008 Pain ManagementElsevier,
Edinburgh
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Main C.J. Pain Management

• video evidence questionable because
• offers only samples
• samples may not be representative
• usually unable to replicate the actual physical
  demands of work
• does not capture the after effects of exertion

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Spine movements

• Forward Flexion

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Spine Movements

• Forward Flexion Standing
• Vs
• Forward Flexion Sitting

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Spine Movements

• Side Flexion

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Spine Movements

• Side Flexion Standing
• Vs
• Side Flexion Sitting

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Straight Leg Raise Test
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Straight Leg Raise Test

• How gross a restriction is allowed?
• Bilateral should be less ltd than unilateral
• Bilateral vs sitting with knees extended

14
Neurological

• Calf Muscle Power

15
Neurological

• Calf muscles tested lying
• Vs
• Standing

16
Neurological

• Quadriceps Power

17
Neurological

• Quads tested lying
• Vs
• Standing

18
Neurological

• Psoas Power

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Neurological

• Psoas tested lying
• Vs
• Sitting

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Neurological

• Tibialis Anterior Power

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Neurological

• Tibialis Anterior Lying
• Vs
• Tibialis anterior Standing (by heel-walking)
• Vs
• Tibialis Anterior Sitting (one at a time then
  both together)

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Neurological

• Peronei Power

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Neurological

• Peronei tested each side separately
• Vs
• Both together

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Hip Movement Test

• Bilateral Passive Hip Flexion

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Hip Movement Test

• Bilateral passive hip flexion tested face up
• Vs
• Face down

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Inconsistancies found

• So what?

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Inconsistancies FoundWe can accept all the
loose ends and inexplicable featuresWe dont
organize the next round of expensive and
counter-productive investigations/third opinions
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What do we tell the patient?

• You are completely mad and I will arrange for you
  to be admitted sraight away to a psychiatric
  hospital

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What do we tell the patient?

• Your back is sound.
• Your pain receptors are over-reacting reporting
  damage and danger incorrectly

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The way forward

• Between us we can switch these pain receptors
  off.
• But you may have to do the hard work