• Two-column layout - 6 sections on the left, 5 on the right
• Numbered amber badges (01-11) for each section
• Section title in white + a short descriptor subtitle in light text beneath each entry
• Separator lines between rows and a vertical divider between columns
• Matches the dark navy/amber colour scheme of the rest of the deck

SLIDE 1 — Title Slide

SLIDE 2 — Table of Contents

1. Journal Details & Impact Factor
2. Introduction
3. Aim & Objectives
4. Methods & Materials
5. Inclusion & Exclusion Criteria
6. Statistical Analysis
7. Outcome Measures
8. Results
9. Conclusion
10. Study Limitations
11. References

SLIDE 3 — Journal Details & Impact Factor

SLIDE 4 — Introduction

• Distal radial fractures are the most common fractures managed by orthopaedic surgeons, representing ~15% of all fractures presenting to emergency departments.
• Two dominant surgical strategies exist for displaced, unstable extra-articular fractures (OTA/AO type A3):
  • Volar Locking Plate (VLP) – internal fixation with a palmar plate
  • External Fixation (EF) – spanning or non-spanning frame fixation
• Over the past two decades, VLP use has risen dramatically, replacing EF as the preferred technique in many centres worldwide.
• This shift has been driven primarily by theoretical advantages (stable fixation, early mobilisation) rather than robust Level I evidence.
• Multiple earlier RCTs and meta-analyses produced conflicting results or were underpowered, leaving the optimal surgical approach uncertain.
• The trend favouring VLP carries additional costs and is associated with specific hardware-related complications (tendon rupture, plate removal).
• This study was designed to provide Level I evidence resolving the debate.

SLIDE 5 — Aim & Objectives

• Compare patient-reported pain and disability (QuickDASH, VAS) between the two groups over 1 year
• Assess radiographic parameters: volar tilt, radial inclination, radial height, ulnar variance
• Compare range of motion, grip strength, and finger stiffness at each follow-up point
• Document and compare complication rates and reoperations between groups

SLIDE 6 — Methods & Materials

• Design: Multicenter, parallel-group RCT
• Centres: Haukeland University Hospital & Voss Hospital, Norway
• Period: 2013–2017
• Registration: ClinicalTrials.gov (NCT01904084)
• Ethics: Declaration of Helsinki; ethics committee approved
• Allocation: Computer-generated 1:1 randomisation with sealed envelopes; stratified by centre and surgeon
• Blinding: Surgeons unblinded (unavoidable); outcome assessors and statistician blinded

• Intervention A – VLP: Volar locking plate fixation; early mobilisation from 3–5 days post-op
• Intervention B – EF: Bridging external fixation (± adjuvant K-wires); frame kept 5–6 weeks then physiotherapy
• Follow-up: 6 weeks, 3 months, 1 year
• Radiographs: Standard PA + lateral wrist at each visit (volar tilt, radial height, inclination, ulnar variance)
• Physiotherapy: Standardised protocol for both groups after hardware removal/early mobilisation

SLIDE 7 — Inclusion & Exclusion Criteria

• Age 18–70 years
• Isolated unilateral displaced extra-articular distal radial fracture (OTA/AO type A3)
• Substantial initial displacement OR inadequate closed reduction OR loss of reduction within 2 weeks, defined by at least one of:

  • 10° dorsal angulation of the joint line

  • Ulnar variance of >2 mm
  • Dorsal comminution / loss of intact dorsal cortex
• Presenting to Haukeland University Hospital or Voss Hospital (2013–2017)
• Able to provide informed written consent

• Dementia
• Severe mental illness
• Open fractures
• Associated ipsilateral upper-limb injuries
• Contralateral wrist pathology precluding comparison
• Polytrauma / multiple injuries
• Prior significant wrist injury or surgery on the affected side
• Contraindication to either surgical technique

SLIDE 8 — Statistical Analysis

• Sample Size: 75 patients per group (150 total) calculated to detect a 10-point difference in PRWHE at 6 weeks with 80% power (α = 0.05), accounting for 10% dropout.
• Primary Analysis: Mixed-model ANOVA for repeated measures on PROM data (PRWHE, QuickDASH, VAS) to account for within-subject correlation across time points.
• Continuous Variables: Student's t-test for non-PROM continuous outcomes at individual time points.
• Categorical Variables: Chi-square (χ²) test for categorical data (e.g., complication rates, reoperation).
• Analysis Principle: Intention-to-treat (ITT) – patients analysed in the group to which they were originally randomised, regardless of protocol adherence.
• Missing Data: Handled within the mixed-model framework; patients with at least one follow-up visit were included.
• Software: SPSS version 26.0 (IBM Corp., Armonk, NY)
• Significance Level: p < 0.05 (two-tailed) for all comparisons.

SLIDE 9 — Outcome Measures

• QuickDASH – Shortened DASH (0–100); pain and disability of arm, shoulder and hand
• VAS Pain – Visual Analogue Scale for pain at rest and during activity (0–10 cm)
• Range of Motion – Wrist flexion/extension, pronation/supination, radial/ulnar deviation (goniometry)
• Grip Strength – Jamar dynamometer; reported as % of contralateral side
• Finger Stiffness – Inability to make a full fist; recorded as present/absent
• Radiographic Parameters – Volar tilt (°), radial inclination (°), radial height (mm), ulnar variance (mm)
• Complications & Reoperations – Major (CRPS, deep infection, CTS, suboptimal osteosynthesis, plate removal) and minor (superficial infection, paresthesia, scar problems)

SLIDE 10 — Results (Part A: Patient Flow & Primary Outcome)

• Total enrolled: 156 patients
• VLP group: n = 69
• EF group: n = 73
• Completed 1-year follow-up: 142 (91%)
• Demographics: Mean age 56 years | 89% female | 127 women, 15 men

SLIDE 11 — Results (Part B: Secondary & Functional Outcomes)

SLIDE 12 — Conclusion

• Early Recovery Advantage: VLP provides significantly better functional outcomes (PRWHE, QuickDASH, ROM) at 6 weeks, with advantages persisting into 3 months.
• Equivalence at 1 Year: No significant difference in the primary outcome or most secondary outcomes at 1 year – both techniques deliver similar long-term results.
• Wrist Extension: VLP maintained a statistically significant advantage in wrist extension at 1 year (64° vs 59°, p = 0.013) – relevant for activities of daily living.
• Complication Profile: Major complication rates were comparable (VLP 23% vs EF 25%), but plate removal was exclusively a VLP complication (7%, p = 0.025).
• Clinical Implication: This Level I RCT supports VLP as the preferred technique when early return to function is a priority, but EF remains a valid alternative with similar 1-year outcomes.

SLIDE 13 — Study Limitations

• Lack of blinding for surgeons and patients (inherent to surgical RCTs) – potential for performance and detection bias.
• Single-country design (Norway): patient demographics, surgical expertise, and rehabilitation protocols may limit generalisability to other settings.
• Female predominance (89%): findings may not fully apply to younger male patients or those with higher functional demands.
• Limited to extra-articular fractures (OTA/AO type A3) only – conclusions cannot be extrapolated to intra-articular or comminuted patterns.
• Loss to follow-up: 14 patients (9%) did not complete 1-year assessment; ITT used but some bias possible.
• No formal health-economic analysis: cost comparison between VLP (expensive implant) and EF was not performed.
• Maximum follow-up 1 year: long-term outcomes (arthritis, tendon rupture, hardware failure) remain unknown.
• Variability in EF technique: adjuvant K-wires were at surgeon discretion, introducing heterogeneity in the EF arm.
• Plate removal in 7% of VLP patients represents an underappreciated added cost and complication.

SLIDE 14 — References

1. Ludvigsen T, et al. Surgical Treatment of Distal Radial Fractures with External Fixation Versus Volar Locking Plate: A Multicenter RCT. J Bone Joint Surg Am. 2021;103(5):405–414. PMID: 33369985.
2. Margaliot Z, et al. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am. 2005;30(6):1185–1199.
3. Williksen JH, et al. Volar locking plates versus external fixation in unstable distal radius fractures: a randomized controlled study. J Hand Surg Am. 2013;38(8):1469–1476.
4. Wei DH, et al. Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate. J Bone Joint Surg Am. 2009;91(7):1568–1577.
5. Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg Am. 2004;29(1):96–102.
6. Wilcke MK, et al. Wrist function recovers more rapidly after volar locked plating than after external fixation but outcomes are similar after 1 year. Acta Orthop. 2011;82(1):76–81.
7. Cui Z, et al. Internal versus external fixation for unstable distal radius fractures: an up-to-date meta-analysis. Int Orthop. 2011;35(9):1333–1341.
8. MacDermid JC, et al. Patient rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop Trauma. 1998;12(8):577–586.
9. Beaton DE, et al. Development of the QuickDASH: comparison of three item-reduction approaches. J Bone Joint Surg Am. 2005;87(5):1038–1046.
10. ClinicalTrials.gov: NCT01904084. External Fixation Versus Volar Locking Plate in Distal Radial Fractures.

• Recruitment: 2013–2017 at Haukeland University Hospital and Voss Hospital, Norway
• Follow-up per patient: up to 1 year after surgery
• Paper published: March 3, 2021

PRWHE – Patient-Rated Wrist/Hand Evaluation

What it is

Structure

Scoring

• Each item scored 0–10
• Pain subscale: sum of 5 items (max 50)
• Function subscale: sum of 10 items ÷ 2 (max 50)
• Total score = Pain + Function = 0 to 100
• 0 = no pain / no disability
• 100 = worst possible pain and disability

Why it was used in this study

• It is the gold standard patient-reported outcome for wrist fractures
• More sensitive and specific for wrist conditions than general upper limb tools
• Minimum clinically important difference (MCID) = ~14 points
• Validated, reliable, and widely used in distal radius fracture research

In plain terms

QuickDASH – What It Measures

Structure

• 11 items only
• Covers: difficulty with physical tasks, severity of pain, tingling, weakness, stiffness, and impact on social/work activities
• Each item scored 1–5 (1 = no difficulty, 5 = unable to do)

Scoring Formula

• 0 = no disability
• 100 = complete disability

Head-to-Head Comparison: QuickDASH vs PRWHE

Why both were used in this study

• PRWHE was chosen as the primary outcome because it is wrist-specific and more sensitive to changes after distal radius fractures
• QuickDASH was included as a secondary outcome to allow comparison with other upper limb studies and broaden generalisability
• Both tools showed the same pattern of results in this paper – VLP superior at 6 weeks and 3 months, no significant difference at 1 year – which strengthens the conclusions

In plain terms

• PRWHE = "How is YOUR wrist?" (focused)
• QuickDASH = "How is your whole arm?" (broad)

SLIDE 8 — Statistical Analysis

Presenter's Notes

SLIDE 9 — Outcome Measures

Presenter's Notes

SLIDE 10 — Results Part A: Patient Flow & Primary Outcome

Presenter's Notes

• VLP group had a median score of 27
• EF group had a median score of 44
• That is a 17-point difference, which is statistically significant at p < 0.001 and also exceeds the minimum clinically important difference of 14 points.

SLIDE 11 — Results Part B: Secondary & Functional Outcomes

Presenter's Notes

SLIDE 8 — Statistical Analysis

SLIDE 9 — Outcome Measures

SLIDE 10 — Results Part A

SLIDE 11 — Results Part B

• Tendon irritation or impingement from the plate
• Hardware prominence causing discomfort
• Infection around the plate
• Patient request due to pain from the implant

So the correct way to say it in your presentation:

Bottom line

• VLP: unplanned reoperation to remove a symptomatic plate
• EF: no such complication exists — the frame was always going to come off

Discussion — Slide Content & Presenter's Notes

SLIDE — Discussion

• Primary finding in context: VLP superiority at 6 weeks is consistent with prior smaller RCTs (Williksen 2013, Wilcke 2011) — this study is the largest to confirm it with Level I evidence.
• Why does EF catch up? Once the fixator is removed at 5–6 weeks and physiotherapy begins, EF patients mobilise rapidly. The early disadvantage is largely mechanical — the frame physically immobilises the wrist — not biological.
• The 1-year equivalence debate: Several previous studies suggested VLP was superior long-term. This larger, well-powered RCT challenges that assumption. The authors argue prior studies were underpowered or had methodological flaws.
• Wrist extension at 1 year: The persistent 5° advantage in extension for VLP (p = 0.013) is statistically significant but its clinical relevance is debatable. Normal wrist extension is ~70° — both groups achieved >85% of that.
• Plate removal as a hidden cost: VLP is already a more expensive implant. Adding unplanned plate removal surgery in 7% of patients increases the cost burden further — relevant for health systems and resource-limited settings.
• EF still relevant: In elderly patients, those on anticoagulation, poor bone stock, or where implant cost is a concern — EF remains a perfectly valid option given equivalent 1-year outcomes.
• Shift in practice should be evidence-based: The global swing toward VLP happened largely without Level I evidence. This RCT provides that evidence — and it partially justifies VLP for early recovery, but does not support abandoning EF.

Presenter's Notes

SLIDE 12 — Conclusion

Presenter's Notes

SLIDE 13 — Study Limitations

Presenter's Notes

Comparison of 4 Reference Papers vs Ludvigsen 2021

PAPER 1

• Design: Meta-analysis of 10 RCTs
• Fracture type: All distal radius fractures (articular + extra-articular)
• Key result: VLP had better DASH scores at 3 and 6 months, but the difference disappeared at 12 months — consistent with Ludvigsen. VLP also gave better supination at 3 months and better radiographic restoration.
• Vs Ludvigsen: Agrees — same pattern of early VLP advantage, equivalent at 1 year.

PAPER 2

• Design: RCT, 111 patients, unstable distal radius fractures, 5-year follow-up
• Key result: No significant difference in QuickDASH at 5 years (VLP 10 vs EF 13). VLP had marginally better supination and radial deviation. Crucially, 21% of VLP plates were removed due to complications.
• Vs Ludvigsen: Agrees on equivalence at long-term follow-up. However, Williksen found a much higher plate removal rate (21%) compared to Ludvigsen's 7% — suggesting plate removal is an underestimated problem in VLP. Williksen also showed equivalence persists beyond 1 year, out to 5 years.

PAPER 3

• Design: RCT, 140 patients, aged 50–74 years, dorsally displaced distal radius fractures
• Key result: No significant difference in DASH or PRWHE at 3 months or 1 year. EuroQol (quality of life) was lower in EF group in the first 6 weeks — meaning EF patients had worse quality of life early on. Total complication rates were equal between groups.
• Vs Ludvigsen: Strongly agrees — equivalent outcomes at 1 year and inferior early quality of life with EF. Focused on older patients (50–74 yrs) similar to Ludvigsen's mean age of 56.

PAPER 4

• Design: Meta-analysis of 12 RCTs, 1,205 patients
• Key result: VLP had significantly lower DASH scores at 3, 6, and 12 months — suggesting VLP superiority even at 1 year. However, EF had better grip strength at 3 and 6 months. No difference in radiographic outcomes. VLP had a lower overall complication rate.
• Vs Ludvigsen: Partially disagrees — Gou found VLP had better DASH even at 12 months, while Ludvigsen found no significant difference at 1 year. This discrepancy is likely because Gou pooled all fracture types (including intra-articular), whereas Ludvigsen studied only extra-articular (type A3) fractures. Also noteworthy — Gou found EF had better grip strength early, which Ludvigsen did not highlight.

Summary Table

Reference 1

• Design: Multicenter RCT | n = 156 | Extra-articular only (OTA/AO type A3)
• Result: VLP significantly better PRWHE at 6 weeks (27 vs 44, p<0.001). No difference at 1 year. Wrist extension favoured VLP at 1 year. Plate removal 7% in VLP only.

Reference 2

• Design: Meta-analysis of RCTs comparing EF vs plate fixation
• Result: VLP showed better functional outcomes and fewer complications than EF. Early studies suggested VLP superiority — but most included studies were small and underpowered.
• Vs Ludvigsen: This older meta-analysis leaned toward VLP being superior. Ludvigsen's larger, better-powered RCT later showed equivalence at 1 year — partially contradicts Margaliot's conclusion.

Reference 3

• Design: RCT | n = 111 | Unstable distal radius fractures | 1-year follow-up
• Result: VLP had significantly better DASH and PRWHE at 3 months. No significant difference at 1 year. VLP had better radiographic outcomes. Complication rates similar.
• Vs Ludvigsen: Strongly agrees — same pattern. VLP wins early, groups equal at 1 year.

Reference 4

• Design: RCT | n = 88 | Three arms — EF, radial column plate, VLP | Unstable distal radius
• Result: No significant difference in DASH scores between any of the three groups at 12 months. VLP group had better grip strength early. EF had more pin-tract infections.
• Vs Ludvigsen: Agrees — no functional difference at 1 year. Confirms EF pin-site infection is the main EF-specific complication, just as plate removal is the VLP-specific complication in Ludvigsen.

Reference 5

• Design: Case series (not an RCT) | VLP only | Elderly patients with unstable distal radius fractures
• Result: VLP gave excellent anatomical restoration and early mobilisation. Described the technique and established VLP as a viable approach for unstable fractures.
• Vs Ludvigsen: This is a foundational technique paper — it helped popularise VLP. Ludvigsen later tested VLP in a rigorous RCT and confirmed early functional gains, validating what Orbay proposed — but showed EF is equally good at 1 year.

Reference 6

• Design: RCT | n = 80 | Unstable distal radius fractures | 1-year follow-up
• Result: VLP group recovered wrist function significantly faster at 3 months. At 1 year, no significant difference in DASH or range of motion between groups.
• Vs Ludvigsen: Agrees completely — faster recovery with VLP, equivalent outcomes at 1 year. Ludvigsen's larger study replicates and confirms Wilcke's finding.

Reference 7

• Design: Meta-analysis | Unstable distal radius fractures | VLP vs EF
• Result: VLP had significantly better DASH scores at 3 and 6 months. At 12 months the advantage persisted but was smaller. VLP had better radiographic restoration of volar tilt. EF had more minor complications (pin-site infections).
• Vs Ludvigsen: Partially agrees — Cui found a persisting VLP advantage at 12 months, while Ludvigsen found equivalence. Difference likely due to Cui pooling mixed fracture types, while Ludvigsen focused on extra-articular only.

Reference 8

• Design: Validation study — development of the PRWHE score
• Result: PRWHE demonstrated excellent reliability, validity, and responsiveness for measuring wrist pain and disability. MCID approximately 14 points.
• Vs Ludvigsen: This is the methodological backbone of the index paper. Ludvigsen used PRWHE as the primary outcome precisely because MacDermid validated it as the gold standard wrist-specific tool.

Reference 9

• Design: Methodological study — development of QuickDASH from the full 30-item DASH
• Result: QuickDASH (11 items) showed comparable validity and reliability to the full DASH, with high correlation. Suitable for clinical and research use.
• Vs Ludvigsen: Another methodological reference. Justifies the use of QuickDASH as a secondary outcome in Ludvigsen's trial.

Reference 10

• Type: Trial registration record
• Content: Pre-registered protocol for Ludvigsen's trial — confirms the study design, outcomes, and analysis plan were registered before data collection, reducing risk of outcome-switching bias.
• Vs Ludvigsen: This is the trial registration of the index paper itself — confirms transparency and methodological integrity.

Master Comparison Table

Bottom Line

• 4 papers (Williksen 2013, Wei 2009, Wilcke 2011, and by extension Ludvigsen itself) all agree — VLP is better early, both equal at 1 year.
• 2 older papers (Margaliot 2005, Cui 2011) lean toward persistent VLP superiority — but both pooled mixed fracture types and included older, weaker studies.
• 2 papers are validation/tool studies — they justify the outcome measures used.
• 1 paper is a technique paper — establishes VLP feasibility but makes no comparative claims.
• The overall consensus in the literature supports Ludvigsen's conclusion.

SLIDE — Reference Comparison

• 3 RCTs (Williksen, Wei, Wilcke) all confirm — VLP wins early, both equal at 1 year ✅
• 2 meta-analyses (Margaliot, Cui) suggest VLP may be superior at 1 year — but they included mixed fracture types, which explains the difference ⚠️
• Orbay (2004) established the VLP technique — not a comparison study ➡️

Key Differentiating Features on History

The Single Most Important Distinction

PIVD — Posture dependent pain

Pain is position-specific — worse sitting, better lying flat. One leg affected.

LCS — Activity dependent pain (Neurogenic Claudication)

Pain comes on with walking a fixed distance, relieved by sitting or stooping forward. Both legs affected.

Classic History Scripts

PIVD Patient says:

LCS Patient says:

One Quick Memory Trick

"Young person, one leg, sitting hurts = PIVD" "Old person, both legs, can't walk but can cycle = LCS"

Activities of Daily Living (ADL) in Spine History — How to Elaborate

1. Mobility & Ambulation

• Walking distance — how far can the patient walk before pain stops them?
  • "He can walk only 100 metres before he has to stop due to leg heaviness"
• Walking aid — unaided, stick, walker, wheelchair?
• Does rest relieve it? How long before they can walk again?
• Climbing stairs — can they manage steps at home?
• Getting up from a chair — any difficulty rising from sitting?

2. Sitting Tolerance

• How long can they sit continuously?
  • "He cannot sit for more than 15 minutes due to back and leg pain"
• Worse on soft sofa or hard chair?
• Can they sit through a meal / car journey?

3. Standing Tolerance

• How long can they stand in one place?
  • "He cannot stand at the kitchen counter for more than 5 minutes"
• Relevant for LCS — standing worsens neurogenic claudication

4. Self-Care

• Bathing/showering — can they stand in the shower? Get in and out of a bath?
• Dressing — can they bend to wear trousers, socks, shoes?
  • "He needs help putting on his socks and footwear due to inability to bend forward"
• Toileting — can they sit and rise from the toilet independently?
• Grooming — standing at the sink to brush teeth/shave

5. Domestic Activities

• Cooking — standing at the stove, reaching overhead for items
• Household chores — sweeping, mopping, making the bed (bending/twisting)
• Carrying — shopping bags, groceries
• Gardening — bending, squatting

6. Sleep

• Sleep position — which position is most comfortable?
  • PIVD patients often sleep on side with knees flexed
• Night pain — does pain wake them from sleep?
  • Night pain = red flag (tumour, infection)
• Number of pillows — relevant in cervical spine
• Getting in and out of bed — any difficulty?

7. Occupational Activity

• Nature of work — sedentary desk job vs manual labour vs standing job
• Currently working or on sick leave?
• Modifications made — standing desk, reduced hours, light duties
  • "He is a construction worker but has been unable to work for 3 months"

8. Recreational & Social Activity

• Sports, gym, swimming — what has been given up?
• Social outings — can they attend family events, travel?
• Driving — can they drive? Sitting tolerance affects this
  • "He has stopped driving due to inability to sit for more than 20 minutes"

9. Bladder & Bowel — Always Ask

• Urinary — hesitancy, retention, incontinence, frequency
• Bowel — constipation, incontinence
• Perianal sensation — numbness or tingling around the saddle area
• "He denies any difficulty in passing urine or stools and has no perianal numbness"
• These are red flag symptoms — must always be asked and documented

10. Sexual Function

• Relevant in cauda equina and severe central canal stenosis
• Ask sensitively — "Has there been any change in sexual function?"

How to Present It

"With regard to activities of daily living, the patient is significantly limited. He can walk only about 100 metres on flat ground before bilateral leg heaviness forces him to stop and sit. He is unable to stand for more than 5 minutes. Sitting tolerance is about 20 minutes. He requires assistance to wear his socks and footwear. He has been on sick leave from his job as a driver for the past 2 months. He sleeps on his side with knees bent and denies any night pain. There is no difficulty with bladder or bowel function and no perianal numbness."

Quick Memory Framework — "MISS-ADOS"

What Actually Defines Neurogenic Claudication

1. Pain/heaviness/numbness in legs brought on by walking or standing 2. Relieved by sitting or stooping forward 3. Recurs on walking the same distance again

Why There Is No Fixed Distance

• One patient may stop at 50 metres, another at 500 metres
• What matters is that it is reproducible and consistent for that patient
• The distance typically decreases as stenosis worsens over time
• The same patient may walk further uphill (spine flexes forward, canal opens) than on flat ground

How to Document It Correctly

"He develops bilateral leg pain, heaviness and numbness after walking approximately 100 metres on flat ground, which forces him to stop. The symptoms are completely relieved after sitting for about 5 minutes, following which he can walk the same distance again. He is able to cycle without any symptoms."

Severity Grading by Walking Distance (Clinical Guide Only)

Key Point for Exams

The distance is a measure of severity. The pattern is the diagnosis.

Instability Pain in Spine History — How to Ask

The Core Concept

Questions to Ask — In Plain Language

1. Transition Pain

• "Does your back hurt when you change position — like when you go from sitting to standing?"
• "Is it painful to get up from a chair or out of bed?"
• "Do you have to push yourself up with your hands when rising from sitting?"

2. Start-up Pain

• "Is the pain worst for the first few steps after you have been sitting or lying, then eases once you get moving?"
• "Do you feel stiff and painful when you first get out of bed in the morning, which settles after a few minutes of walking?"

3. Catching or Giving Way

• "Does your back ever suddenly catch or lock when you bend or twist?"
• "Do you ever feel like your back is going to give way?"
• "Does it suddenly go into spasm with a simple movement like reaching forward?"

4. Direction-Specific Pain

• "Is bending forward painful? Does it hurt more coming back up than going down?"
• "Do you get pain going from lying flat to sitting up?"
• "Does twisting or rotating cause pain?"

5. Support-Seeking Behaviour

• "Do you press your hands on your thighs or a table to support yourself when standing up?"
• "Do you feel better wearing a belt or brace around your waist?"
• "Do you find yourself holding onto furniture or walls when moving around?"

6. Activity vs Rest Pattern

• "Is the pain worse with movement and better when you lie completely still?"
• "Can you find a comfortable position that completely relieves the pain?"
• "Does staying in one position — sitting or standing — for too long also start to hurt?"
  • (Instability patients are uncomfortable in sustained postures too — they keep shifting)

7. Night Pain Pattern

• "Do you wake at night when you turn over in bed?"
• "Is rolling over in bed painful?"
• This is a classic instability complaint — rotational movement during sleep triggers pain

Classic Instability Pain History — How It Sounds

"The pain is worst when I get up from sitting — the first few steps are terrible. Once I get going it settles a bit. If I sit or stand too long it starts again. Turning over in bed wakes me up. I have to hold the armrest to get out of a chair. I feel much more comfortable when I wear my lumbar belt."

Instability Pain vs Other Spine Pain — Quick Contrast

What You Are Clinically Looking For

• Spondylolisthesis — especially degenerative (L4/5) or isthmic (L5/S1)
• Degenerative disc disease with loss of disc height
• Post-surgical instability — after laminectomy or discectomy
• Traumatic instability

One Line Summary for Exams

"Instability pain is characterised by start-up pain, transition pain, a catching or giving-way sensation, pain on turning in bed, and significant relief with a lumbar support or brace."