L-spine/LE Medical Screening Flashcards
1
Q
what are red flags?
A
- patient who is inappropriate for independent management by MSK provider
- require medical management and present with S/Sx of serious pathology
- may have evidence of serious comorbidities including RA/central sensitization
2
Q
what are broad clinical concerns?
A
- fever, chills, sweats
- unexplained weight loss
- fatigue/malaise
- unexplained nausea/vomiting (sometimes unremitting)
- night pain
- inability to increase or decrease pain/Sx
3
Q
pathologic fractures S/Sx
A
- older individuals
- female
- prolonged corticosteroid use
- mild trauma/sudden pain without reason
- history of osteoporosis
- Sign of Buttock if sacral insufficiency fracture present
red flag
4
Q
what 4 components are part of diagnositc rule to screen for vertebral fractures?
A
- female
- age >70
- significant trauma (major in young, minor in elderly)
- prolonged corticosteroid use
5
Q
sacral stress fracture S/Sx
A
- athletic female
- increased level of vigorous/repetitive athletic activity
- pain involves buttocks
- pain reproduced with athletic activities (e.g. running)
- dietary insufficiency
- menstrual irregularities
- previous stress fractures
- non-responsiveness to previous treatment
6
Q
what is Sign of Buttock?
A
- cluster of discomfort
- combination of findings that indicates serious pathology of gluteal/sacroiliac/low back region
7
Q
what are 5 parts of Sign of Buttock?
A
- limited trunk flexion noted during standing exam
- supine straight leg raise limited/painful (but not radicular pain)
- hip flexion with knee flexion limited/painful (limitation > than that of SLR)
- hip rotation is painful/limited but in non-capsular pattern
- empty end feel on hip flexion
8
Q
spondylolysthesis/spondylolysis S/Sx
A
- young individual
- repetitive hyperextension injury
- seen commonly in wrestlers/American football linemen
- sudden severe bilateral sciatica occurred during athletic activity
- pain with extension (prone with passive bilateral hip extension)
- no urinary bowel incontinence
9
Q
spinal compression fracture S/Sx
A
- history of major trauma (such as vehicular accident, fall from height, direct blow to spine)
- history of minor trauma for osteoporotic/elderly individuals (such as falls/heavy lifts)
- age > 75
- prolonged use of corticosteroids
10
Q
what factors would increase index of suspicion for spinal compression fracture?
A
- increased pain with WB (supine is position of comfort)
- point tenderness over site of fracture (tap over SP)
11
Q
what factors would decrease index of suspicion for spinal compression fracture?
A
- age ≤ 50
- Sx not aggravated with weight loading or thoracolumbar flexion movements
- clinical findings are consistent with one/more of ICF-based LBP subgroups
12
Q
abdominal aortic aneurysm (AAA) S/Sx
A
- pain at rest/night
- pulsating abdominal mass that is found with inspection/palpation of abdomen
- patient typically complains of throbbing type pain
- family history of cardiovascular disease
- risk increases with family history of AAA
- Sx cannot be provoked with mechanical examination of lower back
- back/abdominal/groin pain
- presence of peripheral vascular disease or coronary artery disease and associated risk factors (age > 50, smoker, HTN, DM)
13
Q
what factors would increase index of suspicion for AAA?
A
- symptoms not related to movement stresses associated with somatic LBP
- abdominal girth < 100cm (40in)
14
Q
vascular claudication S/Sx
A
- older individual
- family history of cardiovascular disease
- pain in calf with activity, relieved with rest
- one foot colder than other
- symptoms cannot be provoked with mechanical examination of lower back
- positive inclined treadmill test (pain with flat AND inclined treadmill)
key symptom → bolded
15
Q
neurogenic claudication S/Sx
A
- compression of nerves
- Sx with walking but Sx disappear if patient is walking with shopping cart
- for treadmill test → Sx on flat treadmill, but if inclined to 25° patient will be forced to bend trunk to walk and Sx should disappear
16
Q
kidney stones S/Sx
A
- sudden sharp pain of intermittent nature (reaches testicles or labium)
- same pain with fever
- renal infection
- Sx cannot be provoked with mechanical examination of lower back
17
Q
genitourinary issues S/Sx
A
- lumbosacral pain
- night pain
- Sx cannot be provoked with mechanical examination of lower back
18
Q
gastrointestinal issues S/Sx
A
- pain occurs after eating in upper lumbar area (L1-2)
- pain can be relieved by further intake of food
- Sx cannot be provoked with mechanical exam of low back
- typically Sx are chronic and progressive
- associated with abdominal pain
19
Q
ankylosing spondylitis S/Sx
A
- middle-aged individual
- pain on/off, regardless of exertion
- progressive loss of ROM
- alternating pain in sacroiliac joints with walking
- later sign → gross bilateral limitation of side bending
- pain goes in vertical direction (not laterally or to LE)
- stiffness in morning eases with movement
- no paresthesia
- 25% of people have inflammation of eye that worsens with exposure to bright light
rheumatic disease
20
Q
what are 3 differential diagnoses of LBP with potential neurologic involvement?
A
- radiculopathy from acute disc herniation
- spinal stenosis
- cauda equina syndrome
21
Q
cauda equina S/Sx
A
- neurologic emergency
- treatment within first 48 hours is correlated with better outcomes
- commonly caused by atraumatic midline posterior disc herniation at L3-S1 levels
- bilateral severe pain/weakness in LE
- saddle pain/paresthesia
- urinary/bowel incontinence (S4 nerve root not affected) → urinary RETENTION is Sx of reference
key symptoms → bolded
22
Q
what factors would increase index of suspicion for cauda equina syndrome?
A
- saddle anesthesia
- sensory/motor deficits in feet (L4, L5, S1 areas)
23
Q
what factors would decrease index of suspicion for cauda equina syndrome?
A
- LE sensation is normal/improving
- LE muscle performance is normal/improving
- normal reflexes
24
Q
cancer (spinal tumor) S/Sx
A
- previous history of cancer
- patient age > 50 with new onset of low back pain
- unexplained weight loss
- night pain
- worsening pain
- no response to conservative management
- Sign of Buttock
- constant pain not affected by position/activity, worse at night
- no relief with bed-rest
key symptoms → bolded
25
what are the cancers that frequently cause LBP?
"lead kettle" (PB KTLL)
* prostate
* breast
* kidney
* thyroid
* lung
* lymphoma
26
what factors would increase index of suspicion for back related tumor?
* constant pain not affected by movement, but worse with WB
* pain not responsibe to therapy (failure to improve within 30 days)
27
what factors would decrease index of suspicion for back related tumor?
* clinical findings consistent with one or more of ICF-based LBP subgroups
* Sx resolving with subgroup matched interventions
28
infection S/Sx
* **fever**
* recent bacterial infection
* recent lumbar spine symptoms
* **immunocompromised** status
* night pain
* worsening pain
* no response to conservative management
* **IV drug user/abuser**
| key symptoms → bolded
29
what factors would increase index of suspicion for back related infection?
* fever, malaise, swelling
* spine rigidity; accessory mobility may be limited
* elevated body temperature (increasing suspicion of tuberculosis osteomyelitis, pyogenic osteomyelitis, spinal epidural abscess)
30
what factors would decrease index of suspicion for back related infection?
* body temperature is normal
* clinical findings are consistent with one or more of ICF-based LBP subgroups
31
central sensitization S/Sx
* not traditional "red flag," but patients require medical management
* patients typically classified as chronic with past history of episodes of back pain and inability to heal ("doctor shoppers")
* widespread pain
* pain does not follow anatomical pattern (patients will sometimes color entire pain diagram)
* high psychological distress
* pain disproportionate to provocation and easing tests
* hypersensitivity to light touch
32
what are yellow flags?
MSK disorder that can be treated but there is underlying medical/psychological issue that may need co-management/outright referral
33
what are 7 physical comorbidities associated with LBP?
* arthritic conditions (RA, OA)
* endocrine conditions (thyroid)
* cardiovascular conditions (HTN, HLD, angina, atherosclerosis)
* gastrointestinal conditions (constipation)
* metabolic conditions (diabetes)
* neuropathies (MSK conditions, irreducible disk lesion, congenital spine pathologies)
* pulmonary conditions (asthma, coughing, COPD)
34
what are 2 tools for assessment of physical comorbidities associated with LBP?
* Cumulative Illness Rating Scale (14 body system assessment)
* Functional Comorbidity Index (binary 18 item scale, correlates with SF-36)
35
what are the questions used in a 2 item depression screen?
* over the past 2 weeks, have you felt down, depressed, or hopeless?
* over the past 2 weeks, have you felt little interest or pleasure in doing things?
| one (+) answer → 96% sensitivity, 57% specificity
36
what are psychosocial factors?
within context of LBP, psychosocial factors describe characteristic of patients that pose risks of poor treatment outcomes
37
what are the costs of ignoring/inappropriately managing psychosocial factors?
* unnecessary patient suffering
* restricted participation in valued activities
* loss of productivity at work
* waste of valuable health care resources
38
why is it important to assess psychosocial factors?
* risk of presence of high psychosocial factors
* function determines treatment outcome to be poor (pain/return to work both unreliable)
39
what are 6 psychological factors we should assess?
* catastrophizing
* unhelpful beliefs
* depression
* anxiety
* passive coping strategies
* fear of movement
| these are potentially modifiable
40
what are 5 social factors we should assess?
* perception about workplace
* job dissatisfaction
* inability to modify work
* worker injury compensation
* legislations precluding patient from return to work
| might not be able to modify
41
what is the summary of psychological process for pain?
42
what does the FABQ assess?
fear of movement
43
what does the Tampa Scale of Kinesiophobia assess?
measures fear of LBP
44
what does the PCS (Pain Catastrophizing Scale) assess?
extent of catastrophic cognitions (pain catastrophizing)
45
why aren't the FABQ and pain scales enough?
* they don't classify risk
* OREBRO → good predictor of future absenteeism due to sickness/function, but not of pain (may promote use of appropriate interventions for patients with psychological risk factors)
* STarT Back → predict progression to chronic status (not an outcome measure)
46
what is the OSPRO?
multidimensional yellow flag assessment tool
47
what is the core philosophy of current PT practice?
address impairments based on biomedical concepts
48
what is the primary goal of current PT practice?
reduce symptoms
49
what is the core philosophy of psychologically informed practice?
incorporate patient attitudes, beliefs, and emotional responses into patient management based on biopsychosocial models
50
what is the primary goal of psychologically informed practice?
secondary prevention of disability (prevent the progression from acute → chronic)
51
what is the core philosophy of current psych practice?
identify/treat mental illness
52
what is the primary goal of current psych practice?
minimize impact of psych disorder on well-being/function
