Wednesday, January 23, 2013

Spinal Pelvic Ring and Complex Pain, TLABC Medical Legal Conference, Mexico, 2013

These are my rough notes on a fascinating topic.  Dean specifically encouraged us all to consider the mechanics and malallignment in the 10 to 15% of cases where they are not getting better.  There was alot of detailed anatomy and explanation with the underlying cause of the 'referral' of pain, 'trigger points' and why 'chroniciity' occurs.  The slides were excellent and the presentation is best 'seen' but this hopefully gives an idea of the breadth and depth of information presented on this topic which as great relevance in the court scenarios.  

Jan 23, 2013
Dr B Armstrong MD PHD (Complex Chronic Pain) and  Dean Kotopski BScPT RMT

Dr. John B. Armstrong, graduate of McGill where he received an MD and a PhD in neuroscience, completed post graduate training in clinical neurology at McGill's Montreal Neurological Institute and at University of Toronto for Sick Children where he was Staff Neurologist and subsequently Staff Neurologist at Montreal Children's Hospital, was medical director at Pfizer, working in clinical pharmacology development, and subsequently medical device development.....then for last 18 years he has worked in diagnosis and management of complex chronic pain - founded Fraser Valley Recovery Management Program

Spinal Pelvic Ring 
Injury to the Pelvis
Spinal Pelvic Ring

upslips and malrotations

Importance to balance 
Involved in all walking movement

Mechanism of injury to SPR
Intervertebral discs


Soft Tissue Pain and Stiffness
-Upper and mid back
-low bak
-lower limb

Clinical signs
Pain diagram
Asymmetrical stance
Asymmetrical gait
"The Squirm" - constantly butt shifting

#2 Palpation
Iliac crest, psis and asis
sacrum, coccyx and symphysis pubis
Greater trochanter because pyriformis muscle inserts
Buttocks - glutes, priformis and It

#3 Percussion
Lumbar spine

#4Special Clinical Tests
Static - patrick (FABER) , Gaensen
Dynamic - Gillet - demonstrates abn of mobility and allignment

Injection and imaging

Injection of LA and CS under fluroscopic gudiance - there are a number of pain generators in the area, so this is not the gold standard because it can miss

Ultrasound - not yet reliable

-may show but requires a lot of attention to technique so it may be missed if it is sent to a general lab. 
Best done standing and routinely these scans are done lying down 
Positional Scanner - Campbell River - only one in Canada - can be scanned in upright posture 

Clinical Diagnosis Associated Disorders
malalligned pelvis

-piriformis syndrome
refers down lateral part of the leg
-sometimes the lack of response to disc surgery is that the piriformis trigger point is causing the pain -- sciatic nerve passes under the muscle or in 15% through the muscle so is a pinch point - pain shows on straight leg raising because it's not necessarily a nerve root problem but a nerve stretching problem  - difference in peripheral and central nerve entrapment
-leg length discrepancy - true versus apparent - this is apparent
-Patello-Femoral Pain Syndrome 
-Excessie ankle pronation
-shin splints - localized treatment with a malallignment results in symptomatic treatment but pain returns
Trendelenburg Gait -
Increased L4,5 and L5,Si Facet compression and muscle tension 
-classic case - right sided low back pain - been to massage therapist, dx malallignment - shortening of same-sided iliopsoas muscle 

thorough history and exam
postural/alignment scan of the spine and pelvis as well as the ankle joints
must be primarily directed at source of misallignment

First phase
-ims and injections
if you can't loosen muscle you can't go onto next phase
second phase
-capsular stretching
third phase
-Conditioning phase
-isometrics, isokinetrics, isotonics

Conclusions 1
 SPRD exists
Diagnosed clinically
Caregivers often lack experience in dx

Axial and para axial myofascial symptons and sings unimproved for more than 3 months
Axial asymmetry (e.g. scoliosis) - lie them down and see if it disapperas
Lumbar Disc Disease and or radiculopathy
"The squirm"

#3 SPRD is treatable
Sprd is curable
SPRD neglect is devastating for client
SPRD unrecognised affects credibility of client.

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