1a - Red and Yellow Flags Flashcards
what are the 3 categories of med screening
appropriate for PT
yellow - appropriate w consult
red - not appropriate
what are clinical yellow flags (per this class definition)
pain associated psych distress that adversely influence outcomes for MSK pain
what type of factors are clinical red flags (per this class definition)
biomedical factors
what cases is the classification of neck pain into 4 groups especially helpful
if imaging isn’t showing a particular path
- can base treatment off of their clinical presentation instead
what are the steps per the CPGs when a pt comes in w neck pain
- med screening - appropriate for PT?
- classify neck pain into 4 groups
- determine condition stage (acute/subacute/chronic)
- intervention
what are the 4 groups that neck pain can be classified as
- neck pain w mobility deficits
- neck pain w HAs
- neck pain w movement coordination impairments (ie WAD)
- neck pain w radiating pain (ie radicular)
what are the 4 groups that neck pain can be classified as
- neck pain w mobility deficits
- neck pain w HAs
- neck pain w movement coordination impairments (ie WAD)
- neck pain w radiating pain (ie radicular)
how will acute neck pain present
highly irritable
- pain at rest or w initial to mid-range spinal movements (ie before tissue resistance)
time component to pain
- pain won’t stop after stopping activity
- will take good amt of time to recover
how will subacute neck pain present
mod irritability
- pain w mid-range motions that worsens w end-range spinal movements (ie w tissue resistance)
how will chronic neck pain present
low degree of irritability
- pain worsens w sustained end-range spinal movements or positions (ie overpressure into tissue resistance)
urgent vs emergent referral
urgent - not emergency/911, but needs follow up
- ex: neck pain w gait disturbance/LOB
emergent - 911
- ex: chest pain w exertion, cardiac issue, stroke - concern for cervical/arterial dissection, VBI
what is the OSPRO-ROS
Optimal Screening for Prediction of Referral and Outcome - Review of Systems
- identify red flags w high accuracy
what are 8 cervical red flags
- neoplastic conditions
- cervical fx
- upper cervical ligamentous injury/instability
- systemic inflammatory disease
- infection
- cardiac
- cervical vascular path
- cervical myelopathy*
pt comes in complaining of severe neck pain or HA unlike any other, what is likely the path
arterial
pt comes in not feeling well, fever, chills - what is likely the path
infection
pt has pain on exertion, what is likely the path? what should you do?
cardiac
check VS
pt isn’t improving in PT for over a month now, what do you do
reason for a referral
- could be a medical issue that needs to be treated
what are 2 systemic inflammatory diseases and why are these red flags in the neck
ankylosing spondylosis, RA
could make condition worse, more sensitive
** more ligamentous laxity in upper cervical spine - esp transverse lig***
- more cautious in upper c-spine, esp AA region
what is myelopathy
dz/neurologic deficit related to spinal cord
what is degenerative cervical myelopathy
aka compressive cervical myelopathy; cervical spondylitic myelopathy
- compression of SC caused by narrowing of spinal canal from degenerative changes, disc herniation, or osteophyte formation
what is radiculopathy
any dz of spinal nerve roots and spinal nerves
- pain and/or neuro deficit in a specific nerve root distribution resulting in motor loss, sensory changes, and sometimes depression of reflexes
what are 3 etiologies of cervical myelopathy
acquired
traumatic
spinal cord tumor
how are cervical myelopathy typically acquired
cervical spinal stenosis -degenerative dz superimposed on congenitally narrow canal
what are 6 traumatic etiologies of cervical myelopathy
spinal shock
hematomyelia
spinal epidural hematoma
barotrauma
electrical injuries
compression by bone fx
- could be minor trauma after setting of spinal stenosis
where are spinal canal tumors responsible for cervical myelopathy typically located
usually extradural (55%), followed by 40% intradural extramedullary (ie meningiomas, neurofibromas)
intramedullary spinal cord tumors are relatively uncommon (5%)
how is degenerative cervical myelopathy dx
thru neurological exam
MRI
what are the Nurick Classification grades for degenerative cervical myelopathy
grade 1: mild
- UMN signs w normal gait
- can be treated conservatively
- yellow flag - close monitoring
grade 2-5: mod to severe
- UMN signs, worsening gait disturbances
- poor prog
- generally treated surgically (surgical decompression)
how does pure myelopathy present in degenerative cervical myelopathy? how common is this?
UMN signs below level of the lesion
50% of the time
how does a combination of myelopathy and radiculopathy present in degenerative cervical myelopathy? how common is this?
LMN signs at level of lesion, UMN signs below level of lesion
49% of the time
what is a risk factor for developing myelopathy after a disc herniation
congenitally narrow spinal canal
what might be the first presentation of degenerative cervical myelopathy
sensory disturbance in hand
- could be presenting as carpal tunnel
if a sensory disturbance in hand is present for awhile in degenerative cervical myelopathy, how can this progress
result in loss of dexterity of hands
- ie opening soda, doing buttons on shirt
what is a more severe presentation of degenerative cervical myelopathy
sphincter disturbance
what are the 5 most common s/sx associated w degenerative cervical myelopathy
- hyper-reflexia
- babinski reflex
- spasticity
- sphincter disturbance
- sensory disturbance in hands beginning in finger tips, progressing proximally
what are the s/sx of degenerative cervical myelopathy (14- but think of main groups/clusters)
- neck pain, radicular arm pain
- HAs, dizziness
- wide based or unsteady gait
- hyper-reflexia, spasticity, clonus
- presence of pathologic reflexes: babinski, hoffmans, rhomberg
- sensory disturbance in hands distal -> prox, intrinsic ms wasting of hands, loss of dexterity of hands
- non specific weakness of extremities
- sphincter disturbance
how do sx of degenerative cervical myelopathy present
often unilateral or absent in UE
bilateral in LE
how does degenerative cervical myelopathy present over time
progressive hx w stable neurological function b/w exacerbations
what are the 5 clustered findings for dx of cervical spinal myelopathy (CSM)
- age >45yo
- (+) hoffman’s sign
- (+) inverted supinator sign
- (+) babinski test
- (+) gait abnormality
treatment guidelines for degenerative cervical myelopathy (DCM)
MILD: surgery or supervised structured rehab
MOD/SEVERE: surgery
nonop: watch for neuro deterioration
- surgery recommended if neuro deterioration or pt fails to improve
what are 4 rehab strategies for DCM
manual therapy
exercise - cervical stabilization
balance training
core stability
what manual therapy is utilized in DCM
thoracic mobs/manip
cervical traction
what are 3 self-report questionnaires utilized w yellow flag screening
- Fear-Avoidance Belief Questionnaire (FABQ)
- Pain Catastrophizing Scale
- OSPRO-YF
what subscales make up the FABQ
- physical activity (FABQPA)
- work (FABQW)
what pt is the FABQ appropriate to utilize in
people who are afraid of moving, scared it will make the pain worse
how are the results of the FABQ interpretted
higher score = higher level of fear avoidance
what is the cut-off score for the FABQ? why is there a cut-off scores? what other outcome tool can validate that cut off
cut-off score = 48
presence of prolonged disability in pts w neck pain is partially related to fear-avoidance beliefs
NDI is best predictor of those at risk for prolonged neck disability
what are 3 signs that a pt is catastrophizing their pain
- ruminate about pain
- magnify their pain
- feel helpless to manage their pain
what is a clinically significant score Pain Catastrophizing Scale and what does this mean
30
represents clinically relevant level of catastrophizing
how are the results from the Pain Catastrophizing Scale interpreted
high score = worse
what is the OSPRO-YF
concise yellow flag assessment tool that allows for accurate estimates of 11 individual psych questionnaire scores
what are the 3 main categories of pt psych status does the OSPRO-YF assess
- neg mood
- fear avoidance
- pos affect/coping
what pt is the OSPRO-YF especially helpful in
if not sure what the problem is
how are the results of the OSPRO-YF interpreted
higher score = higher level of yellow flag
what are the main strategies of PIPT (2)
pt ed
- movement is important
- pain might be okay
do better in group setting
- w other pts, in gym
- better for motivation
what pts are appropriate for PIPT vs PIPT w referral
PIPT
- mod impact of yellow flags
- no sx of mental illness
PIPT w referral
- mod-high impact of YFs
- sx of mental illness
