Clinical Patterns For Lower Spine And Pelvis

Question 1

What is the definition of non specific lower back pain

Answer 1

Discomfort / pain in the lower part of the spine that is not specific to an underlying medical condition or identifiable structural problem
Lacks clear MOI
Common musculoskeletal complaint

Question 2

What are the risk factors with non specific lower back pain

Answer 2

Increases with age
Weak fitness levels
Occupancy eg heavy lifting or prolonged sitting
Smoking - reduces blood flow to spine
Obesity
Psychological factors
Posture
Genetics

Question 3

What are common symptoms of lower back pain in subjective assessment

Answer 3

Specific identifiable origin
Dull ache that’s localised or radiates into buttocks / thigh
Tender and muscle spasms
Bending, lifting, twisting is AGGS
Rest eases it
24hr pattern - prolonged inactivity causes pain
Irritability varies from mild to severe

Question 4

What are the clinical signs and reliable measures for non specific lower back pain

Answer 4

Pain on palpation
Limited ROM in flexion and Rotation
Patient shows gaurding behaviours such as protecting back by limiting movements
Altered gait

Question 5

What are management options for non specific lower back pain and what is the evidence level for these management options

Answer 5

Education - encouraging to stay active and provide info on NSLBP = strong evidence
Exercise therapy - promoting regular PA and structured exercise programmes including aerobic strength and flexibility = SE
Manual therapy - spinal manipulation or massage = moderate evidence
Pharmalogical therapy = recommend paracetamol = ME
Psychological therapy - CBT for individuals with persistent LBP = ME
Workplace interventions has limited evidence

Question 6

Define spinal stenosis

Answer 6

Narrowing of the spinal canal which is the passage through which nerves travel as they exit the spinal cord
The narrowing can compress and impinge on the spinal cord or nerves

Question 7

Population / risk factors for spinal stenosis

Answer 7

Age - older adults, due to degenerative changes in spine like osteoarthritis, disc herbiation
Previous spinal trauma
Genetics
Congenital factors - born with structural abnormalities
Occupations - with repetitive spinal movement, heavy lifting or prolonged sitting periods
Obesity and lack of PA
Having other spinal conditions such as scoliosis, spondylosisthesis

Question 8

What are the common symptoms of spinal stenosis

Answer 8

Localised pain in affected area which are intermittent or constant
Nerve compression symptoms such as radiating pain, numbness or tingling, weakness in muscles
Neurogenic claudication = leg pain with walking, improves with sitting or bending forward and relief with rest

Question 9

Clinical signs and reliable measures for spinal stenosis

Answer 9

neurological assesmmmet assess muscle strength, sensation and reflexes which helps identify signs of nerve compression and involvement
Gait assessment - observe patients gait may show neurogenic claudification
Use MRI or CT scans to show spinal canal

Question 10

What investigations can be used for spinal stenosis

Answer 10

Epidural steroid injections - if symptoms improve it can help confirm the diagnosis
Electomyography
MRI OR CT IMAGES

Question 11

What are atypical presentations for spinal stenosis

Answer 11

Hip pain
Bilateral symptoms
Absence of neurogenic claudification
Upper extremity symptoms like cervical spinal stenosis
Non specific symptoms or asymptomatic

Question 12

Management options for spinal stenosis with level of evidence

Answer 12

Physical therapy = stretching, strengthening and improving posture have moderate level of evidence
Activity modification = avoid exacerbating symptoms has limited evidence
Weight loss has limited evidence
NSAIDS - for pain reflows and reduce inflammation has moderate evidence
Injections - epidural steroid injection has moderate evidence
Surgical interventions, decompressive surgery has moderate to high evidence and spinal fusion has moderate

Question 13

What is the definition for spondylolysis

Answer 13

Fracture of the pars interartixularis of the lumbar spine described as a stress fracture which occurs due to hereditary disposition
Most common at L5 and can be bilateral
More common in males

Question 14

What is the definition of spondlylolthesis

Answer 14

Forward displacement of the vertebral body on it’s lower neighbour, classified in the degree of slippage
Most common in L4/5 and L5/S1

Question 15

What are the population and risk factors for spondylolysis.

Answer 15

Most common overuse sporting injury of the lower back, occurring contralaterally
Can occur in children and adolescents

Question 16

What are population and risk factors for spondylolythesis

Answer 16

Occurs secondary to bilateral spondylolysis in adolescent males
Secondary to OA in people over 50
Not common in under 50s
More prevalent in black women or people with exaggerated lumbar lordosis

Question 17

What are common symptoms for spondylolysis
And spondylolithesis

Answer 17

Lower back pain that is specific to affected area and varies in intensities
Radiating pain in some cases can be sharp and shooting
Stiffness may be experienced in flexibility
Muscle spasms, numbness or tingling
Changes in posture and gait
Weakness

Spondy*thesis - can cause sciatica symptoms

Question 18

What are clinical signs and reliable measures for spondylolysis

Answer 18

Palpation on area has localised tenderness
Limited ROM
Muscle strengths and relflexes
Functional movement tests like prone instability tests or stoke test

Question 19

What investigations can be used for spondylolysis

Answer 19

X ray idenitfies scotty dog appearance
MRI or CT
Diagnostic nerve blocks

Question 20

What are atypical presentations for spondylolysis

Answer 20

Mild symptoms
Hip or buttock primary pain
Pain with specific movements not typically associated
Unilateral symptoms less common
Neurological symptoms like compressions of nerves

Question 21

Management options for spondylolysis

Answer 21

Activity modification has limited evidence
Bracing to stabilise lumbar spine has limited evidence
Physical therapy to help improve spinal stability and reduce symptoms has moderate evidence
NSAIDS has limited evidence
Epidural steroid injection as short term reliefs has limited evidence
Surgical fusion has moderate evidence for sponsylolithesis conditions
Gradual return to sport
Manual therapy for spondylolithesis is limited evidence
Decompression and fusion for a surgical intervention on spondylolithesis has moderate to high evidence

Question 22

What is osteoporosis

Answer 22

Weakening of bones leading to an increased risk of fractures
An imbalance between bone formation and bone resorption resulting in decreased bone density and strength
Commonly occur in hip
‘Silent disease’

Question 23

Common populations and Risk factors for osteoporosis

Answer 23

Aging as bone density decreases with age
Women are at higher risk, especially after menopause
Family history
Low body weight
Hormonal factors
Certain medications - long term uses
Lifestyle - lack of PA, smoking, low calcium diet

Question 24

What are common symptoms of osteoporosis

Answer 24

Typically has no symptoms until a fracture occurs
Bone fracture - particularly in weight baring bones like hip, spine and wrist
Back pain - dull, achy or sharp and may worsen with movement
Loss of height - due to compression fractures in spine lead to hunched posture
Decreased bone density - assessed in BMD testing

Question 25

What are clinical signs and reliable measures / investigations of osteoporosis

Answer 25

Bone mineral density testing
Fracture risk assessment tools
History and physical examination
Height measurement overtime
Asses risk factors
Blood tests
X-rays

Question 26

Atypical presentations for osteoporosis

Answer 26

Nom fracture related symptoms like generalised weakness, fatigue or mobility loss
Localised pain like away from common areas
Fractures in aytpical areas, or non-traumatic areas

Question 27

Management options for osteoporosis and their level of evidence

Answer 27

calcium and vitamin D intake = moderate
Weight-bearing exercise to help improve bone density and reduce risk of falls = moderate
Stop smoking = moderate
Limit alcohol = limited
Bisphosphonates and other pharmacological interventions = high

Fall prevention strategies like exercise programmes in older adults = moderate
Hip fracture surgery = high

Question 28

What is Cauda equina syndrome

Answer 28

Rare neurological condition occurring due to compression or damage of Cauda equina - a bundle of nerve roots at lower end of spinal cord
Caused by herniated disc, spinal tumour, spinal stenosis, trauma, infection or inflammation

Question 29

What are the common symptoms of Cauda equina syndrome

Answer 29

Severe lower back pain - intense and localised
Bilateral leg weakness or paralysis
Saddle anaesthesia
Bowel and bladder dysfunction
Sexual dysfunction

Question 30

What are the common populations and risk factors with Cauda equina

Answer 30

Degenerative spinal conditions
Herniated discs in lumbar spine more common in labourers or athletes involved in repeated twisting lifting bending etc
Past trauma
Spinal tumours or infections in spinal canal
Older adults over 50
Pregnancy and obesity

Question 31

What are common clinical signs and reliable measures for Cauda equina syndrome

Answer 31

Red flags
Drop in blood pressure when standing
Neurological examination
Imaging like MRI

Question 32

Atypical presentations of Cauda equina syndrome

Answer 32

Unilateral symptoms
Gradual onset
Pain dominant presentation - less neurological deficits
Painless presentation
Isolated bladder and bowel

Question 33

Management options for Cauda equina and levels of evidence

Answer 33

Urgent surgical decompression = high quality
Steroid therapy = limited
Pain management like NSAIDs, muscle relaxants - this is essential but lacks limited evidence for specific pain management
Post op rehab = widely recommended but limited evidence
Regular follow ups

Question 34

What is definition for pelvic girdle pain

Answer 34

Specific form of lower back pain that occurs separately or in conjunction with LBP
Related to non-optimal stability of pelvic girdle joints, increased or decreased motion of sacro-illiac joint

Question 35

What populations and risk factors are related to pelvic girdle pain

Answer 35

Repeated micro-trauma as a result of sporting incidences
Major trauma - ligament strain around joint
Secondary to hormonal changes e.g associated with pregnancy

Question 36

What are common symptoms of pelvic girdle pain

Answer 36

Unilateral S/I pain
Pubic symphysis pain
Pain radiating from buttock, post medial thigh, abdomen and groin
Aggs - unilateral weight bearing, prolonged standing and sitting
Eases - rest,

Question 37

What are clinical signs and reliable measures for pelvic girdle dysfunction

Answer 37

SIJ - posterior shear test
Gaenslens test
Patrick FABERS test
Modified Trendelenburg and palpation of symphysis
Active SLR
MRI useful for early detection of AS and tumours

Question 38

What are atypical presentations for pelivic girdle pain

Answer 38

Referred pain
Scaitica-like symptoms - pain tingling or numbness
Perineal pain -
SIJ dysfunction
Psychological or emotional impact

Question 39

Management options and their levels of evidence for pelvic girdle dysfunction

Answer 39

Physical therapy during pregnancy
Recommend individual treatment programme including stabilising exercises
Aqua therapy
Possible use of acupuncture
Infra-articular SIJ injections
Avoid surgical fusion

Question 40

What is a description for ankylosing spondylitis

Answer 40

Chronic inflammatory condition Autoimmune spondyloarthropathy
Common gene of HLA-B27
Inflammation in spine which cause stiffness and loss of motion
Can cause spinal changes like bamboo spine
Peripheral structures can be affected
Can cause spinal ossification = calcium deposits and spine can fuse togther

Question 41

Common populations and risk factors for ankylosing spondylitis

Answer 41

Age of onset in early adulthood 17-45
More common in males
Strong genetic component B27
Gene can be more common in some ethnic groups like Caucasians
Environmental factors - infections, smoking etc
Autoimmune conditions

Question 42

Common symptoms for ankylosing spondylitis

Answer 42

Inflammatory back pain usually in lower back - dull diffuse
Worse in morning or periods of inactivity
Stiffness - often in morning
Sacroiliitis - inflammation of sacroiliac joints
Enthesitis - inflammation at sites where tendons and ligaments attach to bone
Fatigue
Restricted chest expansion
Peripheral joints affected
Extra-articular manifestations
Neck pain and stiffness

Question 43

What clinical signs and reliable measures can be used for ankylosing spondylitis

Answer 43

For Lx spine use schober test and SF, measure change of length in spine when touching toes
For Tx spine measure chest expansion
For Cx spine use Tagus to wall test
ROM - intermallelor distance - lye on backs and bring legs as wide as possible

Question 44

What investigations can be used for ankylosing spondylitis

Answer 44

Blood tests for HLA b27 gene
X-ray and mri
BASMI - bath AS metrology index
BASFI - functional index
BASDI - disease activity index

Question 45

What management can be used for ankylosing spondylitis

Answer 45

NSAIDs or corticosteroids if NSAIDS don’t work
Biological medications

Therapy management looks to decrease pain, increase mobility and functional capacity
Psychosocial status improved
Education to increase adherence
Independent personalised program