If it's progressive, if it's poly root, so if it involves multiple segments, so not just the foot drop, but possibly you've got weak knee extension as well, or if it's profound. So again, coming back to that foot drop analogy, that would certainly make me more concerned and I would certainly want to have more of a specialist opinion.
SPEAKER_01:Spine-related leg pain can bring with it a minefield of terminology and differentials. In today's episode, we chat with Charlie Clements about spine-related leg pain and the other terms that are often used for these presentations commonly seen in practice. Charlie works as a specialist physiotherapist within primary care currently in a first contact role. He completed his degree in sports conditioning, rehabilitation and massage at Cardiff Metropolitan University before then completing his degree in physiotherapy at the University of West of England. Charlie is well known as the thread physio on social media and is passionate about sharing knowledge to help fellow therapists. Charlie has done a masterclass with the Physio Network work on spine-related leg pain where you can dive a lot deeper into this area than we were able to do in today's episode. If you're keen to find out more, please click the link in the show notes below to watch Charlie's Masterclass for free with our seven-day trial. Enjoy today's episode. I'm James Armstrong and this is Physio Explained. Charlie, it is brilliant to have you on the podcast today. Thank you very much for joining me.
SPEAKER_02:Thanks, James. Yeah, lovely to meet you. And thanks so much for having me on. Brilliant.
SPEAKER_01:So really exciting. You've recently done a masterclass for the Physio Network on spine related leg pain. And we're looking at root causes all the way through to treatment strategies in that wonderful masterclass. And today we're going to dive into this term we're using here, spine related to leg pain. So should we dive straight into that, Charlie? What do we mean by spine related leg pain?
SPEAKER_02:Previously, it was always sort of termed sciatica, and it's a little bit of a contentious topic nowadays. I personally quite like still using it amongst patients just because it's pretty user-friendly and everybody sort of gets that terminology. But I guess for us as clinicians and those who get involved in research, they've given it now this sort of umbrella term that's considered low back-related leg pain or spine-related leg pain. So that kind of encompasses an array of pain presentations, and that's a essentially meant to illustrate how it's quite a heterogeneous pain presentation so you have things that come under that somatic referred pain which is usually pain that comes from things like the soft tissue the disc or possibly even the joints themselves and that can often cause more of like a dull achy diffuse pain typically tends to be more proximal so around the sort of lumbar pelvic region and that can often be brought on through mechanical movements and postures really so That's where the back is usually worse than the leg pain. That then differs to the second subtype, which is radicular pain. So this is where we get more of our sort of what we know as our classic sciatica. So irritation to one of the spinal nerve roots or their ganglion, and that essentially really irritates it and causes it to let off lots of different signals. So ectopic firing of that nerve root. And that usually has our sort of really distinguishable pain characteristics. So we get raging leg pain that's much much worse than the back and usually distal to the knee, so often in the calf or maybe the foot. And that often has a bit more of a spontaneous pain profile. So you'll just get random severe pain attacks with those types of things. So that's considered like a gain in function. And then the third subtype is looking more at like a painful radiculopathy. So a radiculopathy we know is a loss of function. So that's where we get either slowing or a complete conduction block between the peripheral nervous system and then more centrally. And that tends to result in some form of neurological deficit. So we might see sensory disturbances, so numbness, and more rarely we might then see things like motor disturbances, so a loss of reflex It's quite interesting, isn't it, with
SPEAKER_01:the way... terminology evolves and how we use it and some of the ways we use it and what's accepted. And as you say, sciatica actually is quite a useful term for patients sometimes, isn't it?
SPEAKER_02:Yeah, I think we can sort of all count a lot of times where probably patients have come in and say they've had sciatica and then it turns out to be something completely different. And also saying that I've had countless referrals where other clinicians have thought people have had sciatica and then it turns out to be something completely different as well. So I guess really that was kind of the aim of me doing the masterclass was to try and get people a bit more clued up and savvy with recognising some of the differentials.
SPEAKER_01:And that's something that in the masterclass you go into a lot of detail around is some of these other differentials. What about some of the other things that we might see in clinic that might be give a painful response into the legs. And I'm thinking more sort of down this vascular and other types of maybe peripheral neuropathies as well.
SPEAKER_02:Yeah, definitely. So I work currently in the NHS as a first contact physio. So a lot of what I see needs to certainly consider like those other pain presentations, like you say. So I sort of call them like medical masqueraders. Obviously, I don't tend to treat them, but it's important within my role that we can recognise them and then refer on. So the masterclass looks at things like vascular pathologies, so deep vein thrombosis, and also peripheral arterial disease. So how we can spot those and differentiate Yeah, definitely. Going back to the sciatica and this, the
SPEAKER_01:leg pain tends to be greater than the back pain. Am I right in that? side of things?
SPEAKER_02:Yeah so clinically we don't have any sort of true gold standard is what we would call it to diagnostic criteria but instead I guess it's considering clusters so clusters of features whether that's what the patient reports whether that's what you see physically that can just increase our suspicion of it really so I typically tend to use a paper that came out in 2018 by sort of Steins et al that looked at people who presented to primary care with low back-related, spine-related leg pain. They found that there were five key features that increased our suspicion of it. So one of them was a subjective report of sensory change, often sort of a sensory loss. We then also had, as you said, leg pain that's worse than the back. And usually the third feature was that the pain was distal to the knee. The fourth feature was looking at some form of neurological deficit, so whether that's a sensory loss, areflexia, or possibly myotomal weakness. And I guess if we consider those three in themselves, if we've got things like myotomal weakness, that's probably going to weigh heavier in our suspicion compared to something like sensory loss. Or it certainly would to me, that would increase my suspicion of some form of spinal nerve root or peripheral nerve problem. And then the fifth one is looking at a positive neurodynamic, so some form of neural tension test. So that would be our straight leg raise or maybe something like a slump test. That was scored out of 10. So they were all given sort of different weightings. I can't remember the exact values for each. But if you got five or more out of 10, it meant that you were around 80%. possibly a little bit more likely to have a diagnosis of sciatica. So over 80% confident that that would be some form of lumbar radicular pain.
SPEAKER_00:Want to take your physio skills to the next level? Look no further than our Masterclass video lectures from world-leading experts. With over 100 hours of video content and a new class added every month, Masterclass is the fastest way to build your clinical skills, provide better patient care, and tick off your CPD or CEUs. Click the link in the show notes to try PhysioNetwork's masterclasses for free today.
SPEAKER_01:If we've got a patient in front of us and we're starting to see really good use of a cluster there to give us a good index of suspicion that we're dealing with something that is more like a sciatic presentation or that ridiculous pain presentation, When might we be looking to potentially have any onward referrals and things like that, looking at when might they not be for us as physiotherapists in a rehabilitation setting?
SPEAKER_02:Yeah, really good question. I think they're tricky conditions to manage. I wouldn't say I'm an expert by any means, but it's an area of interest and I still struggle because of the presentation that comes with that. A simpler way of thinking of it, I guess, is again, looking at derivatives of it. And one that I quite like is using something like the three Ps, which I sort of picked up from a spinal specialist, Adam Dobson, that looks at myotoma weakness. So if it's progressive, if it's poly root, so if it involves multiple segments, so not just the foot drop, but possibly you've got weak knee extension as well, or if it's profound. So again, coming back to that foot drop analogy. That would certainly make me more concerned and I would certainly want to have more of a specialist opinion. So whether that's spinal specialist or whether that's orthopedic, neurosurgical, I would certainly not sit on the fence. I would be wanting to refer them on to have a look at that. It goes without saying, obviously, red flags. So if we're suspicious of something like a malignancy, an infection, a fracture that's burst into the canal or cauda equina, they certainly need to be seen same day emergency referral, but that's a completely different topic to talk about. And the final one would be the pain as well. So I wouldn't really sit on the fence for pain if it's profound. So if it's really, really severe, excruciating pain, you know, they can't do anything. Or if, again, if that's getting progressive so if it's progressively worsening and having a profound effect on just life in general we've trialled certain medications and it's not had any effect we've trialled maybe a couple of exercises I would be referring them on again in my role I can refer for imaging but I would probably get a more specialist opinion because we may need to go down the line of nerve root blocks or yeah possibly even surgery
SPEAKER_01:That's really good so the three P's can you remind us of those three P's again Charlie just so we've got those as a good takeaway today
SPEAKER_02:Yeah so profound polyroutes or progressives.
SPEAKER_01:And that can look at a myotoma or weakness and it can look at a sensory and it can also be regarded pain as well. So those three key things. That's fantastic. If we were to go any deeper into this, we'd be here all day and this is a short form podcast. So for those who've listened to this and want to get a deeper dive into some of this spinal related leg pain which is a big area and an area I think is really important for clinicians out there because we are going to see it and most likely we're going to see massive variations in the presentations and the things we might end up seeing and not wanting to hold on to for too long. So the masterclass you've done, that's going to be available and those listening will be able to click in the show notes and get a seven day free trial to masterclasses so that would be fantastic and really useful. Charlie, tell us how can we find you what's the best platform at the moment to check you out
SPEAKER_02:I'd say probably Instagram now that Mr Musk has taken over formerly known as Twitter so you can find me as the thread physio on Instagram or just look up my name or the same on Twitter yeah I share quite a little bit of CPD so yeah hopefully you'll find it useful
SPEAKER_01:your threads are certainly on ex Twitter have been really useful to me and I'm looking forward to them carrying on onto Instagram onto whatever platform you feel is most beneficial because I've certainly gained a lot from them and I'm sure the listeners will and from the masterclass so thank you so much Charlie, thank you very much for your time today. We look forward to the masterclass. I'm sure everyone's going to gain an awful lot from it. So thank you very much.
SPEAKER_02:Thank you. Pleasure.