Clinical Diagnosis of Lumbar Discogenic Pain
Physio Scholar Webinar September 1 2014
Dr Mark Laslett, FNZCP, PhD, Dip.MT, Dip.MDT
Registered Physiotherapy Specialist (Musculoskeletal)
Email: mark.laslett@xtra.co.nz
Terminology
•
Nociception – afferent input to the CNS from peripheral nociceptors (mediated by small
diameter unmyelinated C fibres)
•
Pain: The unpleasant psycho-emotional awareness of nociception. Rarely is this experience
generated de novo from the CNS
•
Pain initiated and sustained from the substance of the lumbar intervertebral disc is
DISCOGENIC
•
Pain initiated and sustained from the substance of the nerve root and adjacent dura mater is
NEUROGENIC
•
Somatic referred pain originates from chemical, mechanical or thermal stimulation of
terminal ending of type C nerve endings
•
•
Characterized by diffuse, deep and aching quality distant from the nociceptive
source
Radicular pain is the referred pain experience from irritation or compression of the dura,
nerve root or dorsal root ganglion i.e. direct stimulation of axons rather than terminal nerve
endings
•
characterized by sharp, twinging or electric shock description in a narrow band
•
Radiculopathy is clinical evidence of nerve root compression i.e. motor or sensory deficit,
NOT pain or paraesthesia
•
Paraesthesiae (pins and needles) are not equivalent to anaesthetic sensations. Probably a
CNS phenomenon and may accompany radicular pain and radiculopathy
•
MDT: abbreviation for Mechanical Diagnosis and Therapy, a term coined by Robin McKenzie
to describe his assessment and treatment system. It’s singular most different aspect from
other systems lies in the assessment using repeated end range physiological movements and
sustained postures to determine the presence or absence of ‘directional preference’ and the
centralisation phenomenon
•
Directional preference. A term first used by Donelson R et al 1991 but implicit in McKenzie’s
previous writings. It describes a specific pattern of pain response to MDT assessment of
repeated movements in that symptoms are reduced and/or centralised by repeated
movements in one direction, AND increased or peripheralised by repeated movements in
another (usually opposite) direction. This phenomenon must be repeatable and reversible.
•
Centralisation Phenomenon. A term first described and defined explicitly by McKenzie but
implicit in writing by Dr James Cyriax. See work by Werneke M et al for full definitions, but
the essence of the concept is that the patient reports a progressive retreat of referred pain
towards the spinal midline over a short period of time (minutes to days), in response to
repeated movements and posture instruction towards a specific direction. If the effect is
maintained, prognosis is excellent. The phenomenon is highly specific to discogenic pain as
revealed by provocation discography (Laslett M et al 2005)
•
Acute deformities. Lateral shift and acute lumbar scoliosis are synonymous and describe a
lateral displacement of the trunk with respect to the pelvis. Thus a left lateral shift is a
displacement of the trunk to the left of the pelvis. Acute lumbar kyphosis is a flattening or
reversal of the normal lumbar lordosis. The lateral shift and kyphosis are commonly seen
together. Acute fixed lordosis is a normal or accentuated lumbar lordosis than cannot be
flattened or reversed by normal movement. These three acute deformities are quite distinct
from the normal asymmetries commonly seen, and quite different from idiopathic scoliosis
which are consequences of asymmetries of the vertebrae themselves. A more full
explanation of the lateral shift and its management may be found in my paper13. The
characteristic that most easily distinguishes these acute, acquired deformities that
movements that an attempt to correct the deformity by a patient’s own movement or a
movement imposed by the examiner, are obstructed and provoke the patient’s typical pain.
An idiopathic deformity on the other hand is not painfully obstructed even though range of
motion may be asymmetrical or limited from usual expectation.
1-12;14-19
References
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13. Laslett M. Manual correction of an acute lumbar lateral shift: maintenence of correction and
rehabilitation: A case report with video. Journal of Manual & Manipulative Therapy 17(2),
78-85. 2009.
14. Laslett M, Aprill CN, McDonald B et al. Diagnosis of sacroiliac joint pain: validity of individual
provocation tests and composites of tests. Manual Therapy 10(3), 207-218. 2005.
15. Laslett M, McDonald B, Aprill CN et al. Clinical predictors of screening lumbar zygapophysial
joint blocks: Development of clinical prediction rules. The Spine Journal 6(4), 370-379. 2006.
16. Laslett M, McDonald B, Tropp H et al. Agreement between diagnoses reached by clinical
examination and available reference standards: a prospective study of 216 patients with
lumbopelvic pain. BMC Musculoskelet Disord. 6(1), 28. 2005.
17. Laslett M, Oberg B, Aprill CN et al. Centralization as a predictor of provocation discography
results in chronic low back pain, and the influence of disability and distress on diagnostic
power. The Spine Journal 5, 370-380. 2005.
18. Laslett M, Oberg B, Aprill CN et al. A study of clinical predictors of lumbar discogenic pain as
determined by provocation discography. Eur Spine J 15(10), 1473-1484. 2006.
19. Laslett M, Young SB, Aprill CN et al. Diagnosing painful sacroiliac joints: a validity study of a
McKenzie evaluation and sacroiliac joint provocation tests. Aust J Physiother 49, 89-97.
2003.