What’s your favorite question to ask of patients?
Here’s the scenario…your patient presents with a diagnosis of low back pain and you can only ask them one question…what would it be? If your goal is to come up with a preliminary hypothesis, what question could you ask that would garner the most information?
So what is your question? Mine would be, “if I asked you to sit, stand, or walk for 30 min, which would bother you the most?” This question gives us so much information. If the patient says that sitting increases their pain, we are thinking they have a disc injury. If they say that standing increases their pain we are thinking they might have an instability. Finally, if they say that walking increases their pain we are thinking they might have stenosis.
Now let us talk about the “whys” behind each answer.
Sitting = Disc
If the patient had a disc injury then sitting would be painful due to the increased inflammatory response from the injury. When we “herniate a disc,” or more accurately suffer from an endplate avulsion lesion, it creates an inflammatory response. When looking at work by Bogduk we see that the resulting inflammatory exudate raises the osmotic pressure within the zone of tissue damage. This inflammatory response is what sensitizes the dura and causes the subsequent peripheral symptoms. When we sit we have an increase in our lumbar flexion posture which also increases the intradiscal pressure. The resultant of the increased osmotic pressure from the injury and the added increase in pressure from sitting is why disc patients do not like to sit.
Standing = Instability
Have you ever heard of the “mommy sway”? A lot of moms sway from side to side to rock their babies to sleep…for those that have a lumbar instability they also rock from side to side because standing still increases their lumbar pain. When you look at the work done by Farfan he shows that when you injury your disc it affects the multifidus of the level that was injured. The muscle is no longer able to perform its job of segmental lumbar stabilization. If the lesion is not properly rehabbed then this becomes chronic and the patient winds up with decreased muscular control of a specific segment. These patients will often sway from side to side to activate the large stabilizers of the lumbar spine to provide the stabilization that the multifidus is not able to do.
Walking = Stenosis
If an initial disc injury is left untreated the natural sequella of events that often occurs is that the disc injury will progress to an instability and eventually stenosis of the segment. Often osteophytes will form and decrease the foramen space. Exiting from the foramen space are vascular and neural structures. If a patient is standing in an upright position the lumbar spine should be in more lumbar lordosis(or extension). This position further compresses the foramen space. This is why they say the longer I am up and walking the worse the pain/paraesthesia gets but if I lean forward (on grocery cart) the pain/paresthesia goes away. This is also why riding a bike does not increase their pain because they are leaning forward in a lumbar flexion position. By leaning forward they are opening up the foramen space and decreasing the compressing force.
If, as a profession, our reimbursement continues to decrease we are going to have to see more patients in shorter periods of time to pay our bills. We need to make sure that we are specific and intentional with what we are asking our patients to keep our assessment moving forward and not stalling out. By asking pointed specific questions we can zero in on the patient’s dysfunction more quickly and move into treatment, which is really what the patient came for.
So that’s my favorite question, what is yours? Do you have one that you like to ask that quickly helps you form a potential hypothesis as to the cause of the patient’s pain/dysfunction?
-Stacy Soaoppman, PT, DSc, COMT, FAAOMPT
Join Stacy for Manip Like A Girl course August 16 in Colorado Springs, CO (males welcome too!)