CPG LBP--Clinical Prediction

Question 1

Risk Factors

Answer 1

-Genetic factors related to specific disorders
–degenerative disc disease
-Degenerative changes on imaging NOT strongly related to LBP symptoms
-HTN(hypertension) and lifestyle (smoking, obesity) associated with sciatica
-Psychosocial factors play a prognostic role in chronic LBP
(very high fear avoidance schore have a higher % of moving into chronic LBP

Question 2

High rate of false positives findings on imaging

Answer 2

Evidence of HNP in 20-75% of persons with no sciatica
32% os asymptomatic subjects had abnormal findings
47% of subjects with LBP had identified abnotmalities

Question 3

Clinical Course

Answer 3

Prognostic Factoes for Recurrence

• -History of previous episodes
• Excessive spine mobility(with poor control of that area)
• excessive mobility in other joints

Question 4

Prognostic Factors for Chronic Pain

Answer 4

• Symptoms below the knee
• Psycohlogical distress or depression
• Fear of pain, movement or reinjury
• Pain of high intensity
• Passive coping style

Question 5

Differential Diagnosis

Answer 5

Diagnostic prediction rule for spinal fractures

• Female
• > 70 years old
• significant trauma
• prolonged use of corticosteroids

Question 6

Treatment based classification

Answer 6

1. Mobilization (predominantly treating hypomobilization)
2. Specific exercise (people who do not tolerate a certain position very well)
3. Immobilization/Stabilization
   Hypermobile patients
4. traction(irritable pts. do not tolerate a lot of positions very well…access with manual traction before machine)

Question 7

Disc Pts

Answer 7

Better in Extension Do not tolerate Flexion very well

Question 8

Stenosis Pts.

Answer 8

Do not tolerate flexion very well

Question 9

Clinical Prediction Rule

Answer 9

A tool designed to assist the clinical decision making process
Uses evidence to determine which patients are most to benefit from a particular treatment

Question 10

Mobilization/Manipulatioon

Answer 10

CPR
-Duration of symptoms>16 Days
=No symptoms distal to the knee
-Lumbar hypomobility as assessed with PA pressures
-1 hip>35 degrees IR
-FABQ-W (fear avoidance belief questionnaire) score less than 19
-4 out of 5 factors-pt is highly likely to improve
-+LR=24
-2 out of 5 or less is associated with failure to improve
-(-LR .0.09)

Question 11

Treatment Strategies for Mobilization Group

Answer 11

-Manipulation/mobilization of lumbopelvic region
-AROM exercises
(folks that may benefit from controlled motion exercises rather then static stabilization)

Question 12

Stabilization-who to treat

Answer 12

CPR
-Age 91 degrees
3 out of 4 factors-moderate predictive value
-(+=4.0)
–really manifest itself in the saggital plane–with flexion and extension

Question 13

Stabilization-failure to workk

Answer 13

-Factors that predict failure of stabilization to improve LBP
-Negative prone instability tests
-No aberrant movement on lumbar flex/Ext ROM
-Absence of lumbar Hypermobility (PA pressures)
-FABQ>9 physical activity
3 out of 4 factors-highly predictive of failure
-(LR 18.8)

Question 14

Prone Instability Test

Answer 14

Pt: prone with legs hanging off the edge of the table, feet on the floor
Directions: PA force to the lumbar segment elicits symptoms; pt then lifts legs off the floor while PT maintains PA force
Positive test: pain reduction with raised legs

Question 15

Specific Exercise Extension

Answer 15

( People who get the Centralization Phenomenon–pain moves down the leg with flexion activities–prefer to stay in extension–someone who would prefer standing to sitting–classic herniated Disc)

• symtoms distal to the buttock
• symptom centralize with lumbar extension
• symptoms peripheralize with lumbar flexion
• directional preference

Question 16

Specific Exercise Flexion

Answer 16

Older, age>50 YO
Directional preference for flexion (symptoms centralize or abolish with flexion activities–typical stenosis pt. like anything that opens up the interveterbral foramen) (pain will peripheralize here with extension—more pain with standing)
Imaging evidence of lumbar spinal stenosis

Question 17

Flexion Exercise Interventions

Answer 17

-Mobilization or manipulations of the spine and/or lower extremities
-Exercise to address impairments of strength or flexability
-Body weight-supported treadmill
(because they have decreased endurance because decreased tolerance for weight bearing and weight bearing exercises)

Question 18

Specific Exercise

Answer 18

• Lateral Shift (inclined to shift laterally to take the pressure off of the nerve root–correction in WB may peripheralize the pain respond better to correction in prone)
• -frontal plane deviation of shoulders in relation to the pelvis
• -directional preference for lateral translation movements of the pelvis
• Interventions
• -Exercises to correct lateral shift
• -Mechanical or autotraction

Question 19

Traction

Answer 19

• Signs and symptoms of nerve root
• Peripheralization of symptoms with extension movements
• -(+) Well leg raise