Transcript Chronic Pelvic Pain

Mechanical Leg Dominant Pain (PEP)
Case 4: Derrick
www.pspbc.ca
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Objectives
When working with CPP, you will be able to:
 Identify abnormal neurological signs and
symptoms
 List 3 assessment tools that may be useful
 Assessing for Neuropathic Pain
 Address patient expectations for return to work and
activity
 Prescribing exercise and rehabilitation
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Mechanical Leg Dominant Pain
 Derrick is a 42 year old man who has been
experiencing low back and left leg pain for 6
months.
 His leg pain (7/10) is worse than his back pain
(4/10). It was constant for the first 4 months and
currently he complains of intermittent but
frequent pain. It will occur a few times a day for
20-30 minutes. It is improving overall.
 He occasionally gets tingling down his left leg
over the lateral calf and lateral foot. This can
last for 5-45 minutes.
 His morning stiffness in his back lasts for about
30 minutes.

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What are your Key Questions?
 How do you determine if
this is mechanical back
pain ?
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History
He occasionally gets tingling down his left leg over the
lateral calf and lateral foot. This can last for 5-45 minutes
Is this Radicular Pain?
Is this Referred Pain ?
Is this Neuropathic Pain?
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Leg Dominant Pain
Radicular Pain
Referred Pain
 In acute stage, this pain is
constant but in resolving
stage can become
intermittent
 Intermittent
 Always has a positive
neurological component
 SLR
 Normal Neurological
 Positional in nature
 Can have associated
tingling, usually myofascial
related
 Myotomal Weakness
 Decreased DTR
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Physical Exam
 What physical examination techniques would you use?
We found:
Flexion aggravated low back pain
Difficult to find any comfortable position
 Positive SLR at 80 deg. 4/10, previously 8/10 at 30 deg
 Normal left Achilles reflex
 Normal myotomal strength of Left toe extension
 No hypersensitivity in left leg
 Prone Extension relieved symptoms
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Physical Examination
 Use the Prone Extension
movement to determine
pattern
 Prone Extension Positive
relieves symptoms in leg
for Pattern 4 - PEP
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We asked
What aggravates ?
Sitting, Bending
What eases ?
Walking
What can you not do now ?
What has helped you in the
past?
Can’t drive for more than
20 minutes, Can’t lift box
from floor
Swimming
Physiotherapy
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Key Clinical Information
 What are the key criteria for MRI investigation?
 Lack of treatment response
 Evolving Neurological tests
 Leg Dominant Pain Syndrome
Derrick
- Positive response to Swimming and Physio
- Nerve root irritation is improving
What would you do ?
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Activity Recommendations
What would you ask to determine optimal activity
management strategy ?
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Work Recommendations
 Derrick works at an Electronics Store as a
manager and has been off for 2 months due to
Leg dominant pain
 He occasionally has to assist with unloading large
deliveries which involves bending and lifting
 He has some administrative duties that requires
computer work
 He walks the floor and assists customers and
trouble shoots complaints
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Facilitating Work Discussions
 How do you determine restrictions?
 How do you start the conversation of modified
activities/ hours ?
 How do your progress the worker’s reintegration of
duties ?
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Clinical Impression
 Pattern 4 –Leg Dominant Pain PEP
 Leg dominant and flexion continually increases pain
 Positive Straight Leg Raise
 He is frustrated about slow pace of progress and
inability to work
 His leg pain causes the clinician concern but he is
improving so follow up is needed but not
investigations
 He Is concerned about going back to work before
pain is fully resolved.
 He is keen on trying some activity management
and exercise
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Summary
When working with Mechanical Leg Dominant Pain, it is
important to:
1. Identify Neurological symptoms and signs
2. Do a full neurological examination
3. Evaluate treatment response.
4. Consider MRI only if no response to appropriate
therapy and escalating leg dominant pain.
5. Encourage activity
6. Re-integrate to work duties
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References
 Alberta TOP (Towards Optimizing Practice) Low
Back Pain Guideline
http://www.topalbertadoctors.org/cpgs/885801
 Worksafe BC September 2011 Article in BCMJ
on Guidelines
 BC Pain Tool Box
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