CPG LBP--Clinical Prediction Flashcards
Risk Factors
-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
High rate of false positives findings on imaging
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
Clinical Course
Prognostic Factoes for Recurrence
- -History of previous episodes
- Excessive spine mobility(with poor control of that area)
- excessive mobility in other joints
Prognostic Factors for Chronic Pain
- Symptoms below the knee
- Psycohlogical distress or depression
- Fear of pain, movement or reinjury
- Pain of high intensity
- Passive coping style
Differential Diagnosis
Diagnostic prediction rule for spinal fractures
- Female
- > 70 years old
- significant trauma
- prolonged use of corticosteroids
Treatment based classification
- Mobilization (predominantly treating hypomobilization)
- Specific exercise (people who do not tolerate a certain position very well)
- Immobilization/Stabilization
Hypermobile patients - traction(irritable pts. do not tolerate a lot of positions very well…access with manual traction before machine)
Disc Pts
Better in Extension Do not tolerate Flexion very well
Stenosis Pts.
Do not tolerate flexion very well
Clinical Prediction Rule
A tool designed to assist the clinical decision making process
Uses evidence to determine which patients are most to benefit from a particular treatment
Mobilization/Manipulatioon
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)
Treatment Strategies for Mobilization Group
-Manipulation/mobilization of lumbopelvic region
-AROM exercises
(folks that may benefit from controlled motion exercises rather then static stabilization)
Stabilization-who to treat
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
Stabilization-failure to workk
-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)
Prone Instability Test
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
Specific Exercise Extension
( 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
Specific Exercise Flexion
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
Flexion Exercise Interventions
-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)
Specific Exercise
- 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
Traction
- Signs and symptoms of nerve root
- Peripheralization of symptoms with extension movements
- -(+) Well leg raise
