Workshop Balatonfüred

02 December 2016

Differential Diagnosis for leg symptoms with

nerve root involvement.

Handout.

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Dear participant,

Welcome to the workshop presented by the Hungarian McKenzie Institute.

The goal of the workshop is to work together on four case studies from patients

who have leg symptoms with nerve root involvement. To think and discuss

about the diagnosis and treatment options.

There are some guidelines for the workshop, which are explained in the

introduction of the workshop on Friday.

Thank you in advance for your participation and cooperation.

Jan Kuiper.

Content:

Pictures of the movements used in the examination

How to use the examination form

Case studies with questions

Evaluation form

Movements used in the examination

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Flexion in Standing:

FIS

Extension in Standing:

EIS

Flexion in Lying:

FIL

Extension in Lying:

EIL

Sidegliding in Standing:

SGIS

To the left on picture.

Extension in prone Lying

Static test

Description of the contents in the history and the clinical examination used in this examination form

Name: Age: Profession: Leisure: Functional limitations:

Relevant Symptoms: Here you find the symptoms the patient has now

Duration: This describes the duration of this episode of back/leg pain

Behaviour of symptoms: Is the status of the condition worsening,

improving or unchanging on the moment? Are the relevant symptoms constant

or intermittent?

What makes it worse? Can the patient give information if certain postures,

movements or loading strategies can produce or increase the symptoms.

What makes it better? Can the patient give information if certain postures,

movements or loading strategies can stop or reduce the symptoms.

Previous History and Therapy: Description of the possible episodes of

back/leg pain the patient had in the past, and if they resolved completely.

Description of therapy in the past for this and past episodes, and their effect.

General health and contraindications: Special questions on general

health, imaging, medication use, neurological deficits, night pain, unexplained

weight loss and previous trauma and surgery.

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Here we learn to know details about the

person we are interviewing.

We learn about the impact this episode of

back pain has on the patient´s life.

In the „body chart“ you find the localization

of the pain this whole episode of back/leg

pain.

Areas with other symptoms are circled.

Clinical Examination

Inspection: Evaluation of the patient´s

posture, possible acute deformities, and other relevant issues.

Neurological Examination: Results of strength, sensibility, reflexes, dural

stretch (SLR, PNB) tests.

Movement loss: Testing the flexibility of the lumbar spine in different

directions.

Repeated movement testing: Effect of repeated movement testing on:

• the symptom intensity

• the symptom localization

• mechanical behaviour of the lumbar spine

Static tests: When necessary testing the effect of static end range positions

on the symptoms

Conclusion: Provisional classification/diagnosis of the patients problem

Proposed Management: Possibilities:

• Mechanical treatment

• Other treatment

• Referral of patient to specialist

Goal of treatment/management

Repeated movements:

With repeated movement we mean that the patient does the movement more than

one time after each other, in the given direction.

The movements are end range movements, meaning that the patient moves as far as

he/she can. A normal set of repetitions would be 10 movements, depending on the

reaction of the symptoms with the repetitions.

The reason to repeat a certain movement is that it gives more information about the

state of the tissue. For example shortened scarred tissue reacts with end range pain

every time the tissue is loaded, not remaining worse after the movement is stopped.

Static tests:

Static tests are used to detect the influence of time and loading on the symptoms in a

certain position.

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History István

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Name: István Age: 45 Profession: Farmer Leisure: No sports Functional limitations: Not able to work, since 2 weeks

VAS: Leg pain 7

Relevant Symptoms: As drawn in the body chart Duration: back pain 4 weeks, leg pain 3 weeks Behaviour of symptoms: The leg symptoms are severe, and constant, they are worsening since 2 weeks.

What makes it worse? Every position or loading increases the leg pain after a few minutes, very limited walking capacities.

What makes it better? Only lying down decreases the symptoms for a short time. Medication helps.

Previous History and Therapy: Patient had around 5 episodes of back pain in the past 10 years, this is the first episode with leg symptoms.

General health and contraindications: The patient enjoys a good general health, except for his leg symptoms he feels well. The patient complains about walking problems, not being able to lift his foot actively, and sometimes stumbles over his right foot. Bladder behavior is normal. Medication: Analgetics, they give short time relief. Imaging: not done yet The patient has night pain, which prevents him from sleeping. There is no previous surgery, relevant trauma, unexplained weight loss.

„Numb“

Clinical Examination István

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Inspection: The patient is not able to sit with weight on his right buttock, in standing there is a shift to the left, which the patient cannot correct. With walking the patient shows a drop foot.

Neurological Examination: There is loss of sensibility in the big toe, the resistance test to foot dorsal flexion shows a major power loss, and reflexes are normal, SLR positive with 20 degrees angle.

Movement loss: Not done

Repeated movement testing: Not done

Static tests: Not done

Questions:

1. From the history: what is the most important information you get?

2. Can you detect a strategy from the better worse section to help the

patient?

3. What are the most important tests you think of after taking the

history, and why?

4. Why was the clinical examination stopped?

5. What is your conclusion today?

6. Which management do you propose?

History Béla

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Name: Béla Age: 45 Profession: Administrator, sitting 8 hours every day Leisure: Playing tennis, gardening Functional limitations: Not playing tennis because of leg pain, limited gardening, avoids bending forward

VAS: leg pain 4

Relevant Symptoms: Leg pain below the buttock, “numbness”, no back pain anymore. Duration: Episode duration: 6 months, Leg pain, numbness: 4/12 Behaviour of symptoms: Unchanging since 2/12, Intermittent leg pain, Constant “numbness”

What makes it worse? Bending forward produces leg pain, Driving car produces leg pain. Numbness not influenced by posture or movement. Walking with big steps produces leg pain.

What makes it better? If not Driving, Bending there is no leg pain.

Previous History and Therapy: Back pain episodes since 5 years, this episode is the first episode with leg pain. In this episode there was constant severe leg pain for two months.

General health and contraindications: Good general health. No neurological symptoms, except the “numbness” No medication on the moment. MRI: shows disc herniation No previous surgery, relevant trauma, night pain, unexplained weight loss.

„Numb“

Clinical Examination Béla

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Inspection: Patient has a poor sitting posture, no symptoms in sitting. Posture correction does not produce leg pain. Good standing posture.

Neurological Examination: Some loss of sensibility in the big toe, right foot, reflexes, muscle power normal. SLR: major loss, produces leg pain

Movement loss: Major loss of FIS, produces leg pain. EIS: minimal loss, no pain, SGIS no movement loss

Repeated movement testing: Repeated FIS: Produces leg pain at end range, the pain doesn´t remain after the repetition, and there are no mechanical changes. Neither of the other movements produce leg pain.

Static tests: Not tested.

Questions:

1. From the history, do you see any psychosocial issues that may play a role in the

pathology?

2. Which factors in the history indicate a mechanical cause of the relevant symptoms?

3. From the better worse section; what is the relevant information you get?

4. Would you - after taking the history - prepare for a normal or a very careful

mechanical examination? Give the reasons why.

5. What information from the clinical examination helps you the most to come to a

conclusion?

6. What is your conclusion after the clinical examination?

7. What is the management you propose?

History Árpád

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Name: Árpád Age: 68 Profession: Retired Leisure: Walking, Gardening Functional limitations: Walking distance is restricted, only 1 km. without pain.

VAS: 3-7

Relevant Symptoms: Bilateral leg pain poorly localized, including some back pain, and pareasthesia in a non-dermatomal area Duration: 1 year Behaviour of symptoms: The symptoms are intermittent, and are slowly getting worse over the last year.

What makes it worse? Limited walking distance because of leg symptoms, standing can produce the pain. Lying prone produces the pain

What makes it better? Bending, sitting stop the symptoms

Previous History and Therapy: Back pain episodes since 20 years, this time slow onset, slowly increasing symptoms.

General health and contraindications: The patient reports a good general health; there are no indications for motoric neurological deficit. Medication: Antiinflammatory pills, they have no effect Imaging: not done yet No previous surgery, relevant trauma, night pain, or unexplained weight loss.

„Numb“

Clinical Examination Árpád

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Inspection: Patient has a poor sitting posture, and shows a reduced lordosis in standing, no acute deformity. Posture correction in sitting has no effect.

Neurological Examination: No neurological changes detected. SLR normal.

Movement loss: No loss in FIS. Major Loss in EIS, no pain produced. Minimal loss in SGIS in both directions, no pain.

Repeated movement testing: There is no production of pain with any repeated movement, and there are no mechanical changes.

Static tests: Lying prone in extension produces the familiar leg symptoms after 5 minutes.

Questions:

1. From the history: do you think the symptoms have a mechanical

origin?

2. Do you see a pattern in the better worse section? Explain which

pattern.

3. Do you recognize psychosocial factors in the history we may need to

consider with the management of the patient´s problem?

4. Would you prepare for a normal clinical examination, or be very

careful with loading the patient´s back?

5. What are the most significant features you see in the clinical

examination?

6. What is your conclusion today?

7. What is your management proposal?

History László

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Name: László Age: 45 Profession: Truck driver, sitting most of the day Leisure: Running Functional limitations: Off work since one week, no running, because of this episode VAS: leg pain 7

Relevant Symptoms: Leg pain below the buttock, and “numbness”, mild back pain Duration: Back pain since 1 month, leg pain, numbness since 1 week Behaviour of symptoms: There is a constant leg pain, the numbness is intermittent, since the leg pain started, the back pain decreased. The patient tells he is worsening.

What makes it worse? Almost every movement or activity increases the pain, lying is the best, but does not stop the leg pain, the patient wakes up during the night, but can fall asleep again.

What makes it better? Changing position and lying can somewhat decrease the pain.

Previous History and Therapy: This is the first episode of back and leg pain.

General health and contraindications: The patient has a good general health, can walk normally without power loss. Medication: anti-inflammatory pills, they help Imaging: not done yet. No previous surgery, relevant trauma, night pain, or unexplained weight loss.

„Numb“

Clinical Examination László

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Inspection: Patient has a bad sitting posture; in standing no acute deformities are detected. Correcting the sitting posture increases the leg pain

Neurological Examination: Sensibility: some loss in the right big toe, Muscle strength normal, reflexes normal. SLR: positive at 60 degree angle.

Movement loss: Major loss of FIS and EIS, with increasing leg pain.

Repeated movement testing: Repeated movement testing stopped after a few repetitions because of increasing leg pain. Static tests: No position found that decreases the leg pain.

Questions:

1. From the history: which factors indicate a mechanical cause for the

symptoms?

2. Which factors indicate other than a mechanical cause?

3. Would you - after taking the history - prepare for a normal or a

very careful mechanical examination? Give the reasons why.

4. What are the most significant findings in the clinical examination?

5. What is your conclusion after the clinical examination?

6. What is the management you propose?

Evaluation form Workshop Balatonfüred 02.12.2016

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Please fill in the form at the end of the workshop.

Rating: 5: I completely agree, 4: I agree, 3: Neutral, 2: I disagree, 1: I completely disagree

Please circle the appropriate number.

My proposals to improve workshops like this:

What helped me the most in this workshop to learn:

Thank you very much for your effort to fill in this form.

Jan Kuiper

The workshop was presented in a clear way. 5 4 3 2 1

The workshop was helpful for my clinical reasoning with leg pain. 5 4 3 2 1

The handout was helpful during the workshop. 5 4 3 2 1

The group work was useful to discuss the case study 5 4 3 2 1

I would visit more events like this if possible 5 4 3 2 1