UTTERANCE DURING SUBJECTIVE INTERPRETATION

7. So your symptoms are a low back pain which is a deep ache that is around the centre o f your low back pain and that doesn't extend any further than your low back

Diagnostic Cues:

<localised LBP> <Deep ache>

UTTERANCES USING TRAINING AID (after subjective) INTERPRETATION

9. Your symptoms are a 6 OK just looking at length of time taken for symptoms to settle is about 10 minutes and length of time taken for symptoms to aggravate is about 20 minutes so therefore the irritability score is 10 divided by 20 no sorry gives a score of about 5 # » how severe are the symptoms « they're quite severe because they're on sitting and they take about 10 minutes to go away but they only occur on sitting which is negating evidence = irritability similar « irritability score is 2 which suggests that they're not very irritable « this is confirmed by the fact that it is only sitting which brings it on but negated by the fact that any change in position just eases it

Hypotttetis 1.1 ^

IF <decreases (in 10') & increases quickly (in20')on sitting, irritability score is 2 and severity score is 6>THEN

{condfOon is not very irritable but quite severe} BUT

eased by any change o f position A N D only aggravated on sitting

KS [symptom variation] [lifestyle]

^S YM PTO M - PATTERN

10. possible cause of the condition then = it sounds like it could be due to the discs because of the prolonged pressure in one position sitting no probably not due to discs because it doesn't get worse when you sit when you stand up «

Hypothesis 2.1 ^

IF <increased on sitting but not in standing>THEN

{unlikely to be discogenic}

KS [disc pattem] & ,, ^SYMPTOM

11. it's associated with a postural position which suggests it could be musculo-skeletal and it could be joints because this is a prolonged position with the joints in one position and they don't like it ligaments are being stressed when you're sitting down

Hypothesis 3.1

IF <assoc/afBd wiüj sitbng>THEN {could be

arthrogenic} BECAUSE the joints do not like being held in one position & this is stressing the ligaments

KS Doint pattem] PATTERN

UTTERANCES USING TRAINING AID (after objective) INTERPRETATION

21. Does the patient have any neurogenic signs « altered neurological tests no he didn't there were no problems anywhere and there was no referred pain anywhere and there were no signs and it had no latency either

Diagnostic Cues:

<no referred pain> <no neurological signs> <no latency>

22. does the patient have any arthogenic signs yes his symptoms were reproduced on active and passive joint movement and there was was there pain or stiffness on accessory palpation of the joints yes there was and was there hypermobility or hypomobility at adjacent joints no not that I've specified

Diagnostic Cu es:

<pain reproduced on active/passive/accessory movements

<no obvious hypo/hypermobility>

23. does the patient have myogenic signs for example more passive than active range of movement no that wasn't tested for = are the symptoms produced on static testing we did get pain on static testing yes we did actually no we didn't # tightness in one set of structures opposite structures lengthened and weak we got tightness and reduced flexibility at L3 on skin rolling does the patient have fasciogenic signs are the symptoms produced on stretching a specific ligament possibly because there's pain on L 3 L4 sorry L4 & L5 and is there an abnormal tissue feel yes there is at L3 so it's possible fasciogenic signs

Diagnostic Cues:

<tissues feel tight and abnormal over L3>

24. subjective markers are the pain which is a deep ache and the objective markers are « the pain on flexion and the pain on extension and the slight stiffness on side flexion to the left and to the right and rotation to the left and right and objectively also there seemed to be hinging at L3 and movements seemed to be localised to the lumbar spine no diagnosis as yet and no treatment plan as yet

Diagnostic Cues:

<deep ache>

<pain on flexion / extension>. <stiffness on side flexion / rotation> <hinging at L3>

25. OK the test results reproducing problem « well we got pain specifically especially at L4 and L5 there was a lot o f pain there both on PAs and unilateral to the right and to the left and

Diagnostic Cues:

<pain at L4/5>

26. there seems to be adhesions around L3 which suggests that possibly there has been an inflammatory process going on as adhesions have formed

HypottWftis 3.2

IF <possible arthrogenic problem a s ^ ia te d with static posture & L3 findings>THEN {adhesions are corwequence of inflammatory process}

27. we didn’t actually reproduce ttie pain but we reproduced pains in specific positions like with the PAs and the unilaterals and there have been postural changes which goes back to the objective markers especially the increased lumbar lordosis and the anterior tilt of the pelvis

Diagnostic Cues:

<increased lordosis with anterior pelvic tilt>

28. OK if we go down to the cause of the condition = arthogenically evidence for structure = possibly the disc which joint oh right L4/5 although all the lumbar or L3/4 L4/5 is very painful but all around that area of L3/4 L4/5 L5/S1 there's reduced flexion on physiological movements there's pain and tenderness there also seems to be adhesions overlying L3

which suggests that there's some inflammation and pathological changes in that area

Hypothesis 3.3 ^

IF <adhesions (at L3) associated with static postures, decreased passive movement and pain & tenderness f (L3,4,5)> THEN {these levels are affected} BECAUSE there has been inflammation in that area # KS [general pathology] [joint pattem] : PiCTURE

29. myogenically there's weak abdominals which could cause a muscle imbalance around the lumbar spine and she's got an a slightly anteriorly tilted pelvis with muscle and ligament changes in the lumbar spine to compensate for that she's also overweight which puts an extra pressure onto the spine joints and ligament and structures =

Hypothesis 4.1 .

IF <muscle weakness (abdominals)>JHEH {myogenic dysfunction could be due to muscle imbalance} BECAUSE postural problemi^ and overweight have ^ caused structural changes in soft tissues of lumbar spine KS [muscle pattem] [muscle dysfur«ctlon|[fa^al pattem] [posture]# * p a t t e r n

30. the patient does have a lot of fasciogenic signs we've got reproduced signs when we palpated when we stretched the structures around doing PAs and unilaterals and there's also an abnormal tissue feel so that's evidence in favour of that =

Hypothesis 3.4 ^

IF <signs produced on pa^ation & stretohing tissues which fee! abnormal, arthrogenic (L3,4,5) problem> THEN {there is associated fasciogenic dysfunction} KS [fasoal pattem] " f " * " PATTERN

31. neurogenically there doesn't seem to be any evidence for a neurogenic = origin but there does seem to be evidence against in the fact that there's no referred pain and it's a dull ache rather than a sharp shooting pain.

Hypothesis 5.1

IF <no referred pain and it is dull ache> THEN {not

neurogenic} ,

Chapter 8: Testing the Model Page 148

Figure 8.3: Final Model for 83^/2

M eth od olo gical K n ow ledg e

A re a o f s y m p to m s , b e h a v io u r o f s y m p to m s , d a ily p a tte rn , history, d a ily a ctivitie s, o b s e rv a tio n , ra n g e o f m o ve m e n t, m u scle te stin g , n e u ro lo g ic a l te s tin g , te n s io n te s ts , p a lp a tio n .

O bject L e v e l K S s

S ym p to m va ria tio n , life style , p o s tu re , d is c p a tte rn , jo in t p a tte rn , m u s c le p a tte rn , n e u ra l p a tte rn , fa s c ia l p a tte rn , g e n e ra l p a th o lo g y , m u s c le d y s fu n c tio n , (jo in t d y s fu n c tio n ).

C o ntro l know ledge

S u b je c tiv e te s tin g a n d a n a to m y a t e n d o f s u b je c tiv e P a th o lo g y , o b je c tiv e te s tin g a n d a n a to m y a t e n d o f o b je c tiv e

BLA CK B OA RD