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PHTY2220 > L12/13: Hypothesis Generation Clinical Reasoning in the Subjective Examination of the Lumbar Spine and Pelvis > Flashcards

L12/13: Hypothesis Generation Clinical Reasoning in the Subjective Examination of the Lumbar Spine and Pelvis Flashcards

1
Q

Why do we use hypothesis generation instead of diagnosis?

A
  • May change over time
  • Can never be very sure

A ‘diagnosis’ is dynamic and evolving — an iterative process that accounts for multiple, changing perspectives.

With significant uncertainty and inability to accurately ‘diagnose’, the term ‘hypothesis generation’ is used to reflect our expectations of both ourselves and patients and facilitate a shift in culture

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2
Q

Should we be worried about Red Flags?

A

NO But we should be vigilant….. Very easy to pick up- just need to be cautious

Physiotherapists are autonomous, first contact practitioners Therefore we need to be able to identify those patients who need urgent medical review and act accordingly.

MSK vs non-MSK pain

  • Need to know how to identify
  • What are you going to do after identified
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3
Q

What is the most common and main red flag?

A

Lumbar fracture

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4
Q

What are 5 factors that are most helpful for identifying spinal fractures?

A
  1. age greater than 50 years (positive likelihood ratio negative likelihood ratio
  2. female gender
  3. history of major trauma
  4. pain and tenderness
  5. a co-occurring, distracting/painful injury
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5
Q

What are the 5 diagnostic prediction rules/risk factors for identifying spinal fractures?

A
  1. being female
  2. older than 70 years
  3. significant trauma
    • Does not mean MVA or from height, can be elderly falling==> sudden onset, high load
  4. prolonged use of corticosteroids
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6
Q

Mid to lower_____ is more commonly fractured in the younger adults

A

thoracic

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7
Q

What are 5 red flags in back pain?

A
  1. Lumbar fracture
  2. Tumour
  3. Spinal cord compression
  4. Infection
  5. Abdominal Aneurysm
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8
Q

What do you do if you spot a lumbar fracture which is a red flag?

A

Refer for imaging X ray or MRI

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9
Q

What are 6 features of a tumour (red flag)?

A
  1. Constant Pain
  2. Age over 50
  3. History of Cancer
  4. Failure of improvement within 30 days
    • Not in mechanical in nature –> sudden get BP
  5. Unexplained weight loss
  6. No relief with rest
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10
Q

Where is a tumour (red flag) most common in the back?

A

Thoracolumbar spine

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11
Q

What are 6 features of a spinal cord compression(red flag)?

A
  1. Leg weakness
  2. Limb numbness
  3. Ataxia
  4. Urinary retention
  5. Hyper-reflexia
  6. Clonus
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12
Q

What do you do if you spot a tumour which is a red flag?

A

Immediate medical referral and or refer for MRI

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13
Q

What do you do if you spot a spinal cord compression which is a red flag?

A

Immediate medical referral and or refer for MRI (CT and blood test)

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14
Q

What do you say to the patient if you spot a possible red flag?

A

You symptoms are a bit usual and don’t seem to be MSK related. I am just going to take the side of caution and would like to refer you to your GP to get some tests done.

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15
Q

What are 4 features of an infection (red flag)?

A
  1. Recent infection
  2. Concurrent immunosuppressive disorder
  3. Deep constant pain worsens with weight bearing
  4. Fever and swelling
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16
Q

What do you do if you spot an infection which is a red flag?

A

Immediate medical referral

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17
Q

What are 8 features of an abdominal aneurysm (red flag)?

A
  1. Presence of peripheral vascular disease or coronary artery disease
  2. Male, Age over 50, smoker, hypertension
  3. Family history
  4. Non-caucasian
  5. Abdominal girth > 100cm
  6. Palpable pulsatile abdominal mass (35-40% of cases)
  7. Unchanging ache, possible night pain
  8. Dissection – ripping/tearing sensation, pain ++ medical emergency
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18
Q

What do you do if you spot an abdominal aneursym which is a red flag?

A

Immediate medical referral to A&E

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19
Q

Which 2 red flags need Immediate medical referral to A&E?

A
  1. Abdominal aneurysm
  2. Cauda equina
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20
Q

What are yellow flags?

A
  • Prognostic risk factors
  • Hypothesis generation with a biopsychosocial approach INCLUDES identifying the presence of risk factors
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21
Q

What is the relationship between red flags, specific and non-specific LBP?

A
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22
Q

What are 6 attitudes and beliefs about back pain that are yellow flags?

A
  1. Belief that pain is harmful or disabling
  2. Belief that all pain must be abolished
  3. Expectation of increased or ‘permanent’ pain
  4. Catastrophising, thinking the worst
  5. Belief that pain is uncontrollable
  6. Passive attitude to rehabilitation “ I want you to fix my back”
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23
Q

What can you do about yellow flags in terms of the lower back?

A

Recognise this and do what we can to change beliefs

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24
Q

What are 6 yellow flags for LBP?

A
  1. Attitudes and beliefs about back pain
  2. Compensation issues
  3. Iatrogenic issues
  4. Emotion
  5. Family
  6. Work
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25
Q

What are 4 compensation issues about back pain that are yellow flags?

A

Less likely to have good outcomes

  1. Delay in accessing support
  2. History of claim(s)
  3. History of extended time off work
  4. Health professional sanctioning disability
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26
Q

What are 6 iatrogenic issues about back pain that are yellow flags?

A
  1. Risks where physios give negative and unhelpful words
  2. Experience of conflicting explanations for back pain “Yeah you work really made it worst, you shouldn’t have done that”
  3. Diagnostic language
  4. Indepth patho-anatomical or biomechanical explanations for LBP
  5. Dramatisation of back pain by health professional Make sure you reassure patient = don’t exaggerates
  6. Expectation of a ‘techno-fix’
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27
Q

What are 5 emotions about back pain that are yellow flags?

A
  1. Fear of increased pain
  2. Depression (especially long-term low mood)
  3. Anxiety
  4. Heightened awareness of body sensations
  5. Feeling unable to maintain sense of control
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28
Q

What are 4 family issues about back pain that are yellow flags?

A
  1. Over-protective
  2. Solicitous behaviour
  3. Extent to which family members support any attempt to return to work
  4. Lack of support person to talk to about problems
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29
Q

What are 8 work issues about back pain that are yellow flags?

A
  1. History of manual work
  2. Work history
  3. Belief that work is harmful
  4. Unsupportive or unhappy environment
  5. Shift work or working ‘unsociable hours’
  6. Minimal availability of selected duties
  7. Negative experience of workplace management
  8. Absence of interest from employer
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30
Q

If work is unsupportive, what is the reason? What can you do about this?

A
  • Why is he unhelpful or overly protective?
    • Usually mis-informed
  • Physio and patient can inform boss of specifics
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31
Q

if the patient says: “I don’t want to tell my boss –> they will be worried..etc”. What can you as a physio do?

A
  • Advocate for supportive work
  • Encourage to tell employer esp. need to monitor duties
  • Physio can offer to send an email to work Lets see how you are going and we can reassess
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32
Q

What are 7 suggested questions that go in addition to the risk identification tools to assess yellow flags?

A
  1. Have you had time off work in the past with back pain?
  2. Do you think that you will return to work? When?
  3. Do you have any particular concerns about returning to work?
  4. What do you understand is the cause of your back pain?
  5. Do you have any concerns about your recovery or injury?
  6. How is your employer responding to your back pain? Your co-workers? Your family?
  7. How are you coping with your back pain?
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33
Q

What are the 3 risk identification tools for assessing yellow flags?

A
  1. Orebro
  2. Start back screening tool
  3. FABQ
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34
Q

What are 5 things that persistent disability from LBP is associated with when understanding risk factors?

A
  1. Depression
  2. Psychological distress
  3. Passive coping strategies
  4. Fear avoidance beliefs
  5. NOT pain
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35
Q

What is the connect between the 5 things that are associated with persistent disability (risk factors)?

A

None are MSK, biological problems

They are all psychosocial problems

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36
Q

What are 6 major predictors of lomg term disability from LBP, which have the greatest influence on the outcome of low back pain conditions, irrespective of the severity of symptoms or any underlying physical pathology?

A
  1. Attitudes and beliefs (about recovery and cause of pain)
  2. negative affect
  3. expectation of passive recovery
  4. low self-efficacy
  5. catastrophizing
  6. fear avoidance beliefs and behaviours
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37
Q

In LBP, _____ management is far better for good outcomes than _____ management

A

Active; passive

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38
Q

What is the relationship between imaging and persistent, long term pain?

A

Imaging increases risk of someone developing persistent pain

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39
Q

What are 3 approaches to diagnoses based on? What does this have an impact on?

A
  1. imaging findings
  2. physical examination
  3. manual examination

Correlate poorly with a patients symptoms, their onward path of symptoms, or their treatment responsiveness

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40
Q

What are the 5 4 types of specific low back pain?

A
  1. Symptomatic spondylolysis or spondylolisthesis
  2. Spinal Stenosis
  3. Cauda Equina
  4. Lumbar radiculopathy
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41
Q

What is ratio specific and non-specific low back pain?

A

Specific: 10%

Non-specific: 90%

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42
Q

What is lumbar radiculopathy?

A

Compromise of the nerve root with resultant pain, weakness, and/or sensory impairment

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43
Q

What are 3 things that could cause lumbar radiculopathy?

A
  1. direct trauma
  2. mechanical compromise
  3. chemical irritation
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44
Q

In about 90% of the cases of specific low back pain the cause is herniated disc with _____ compromise, but lumbar stenosis and (less often) tumour or infection are also possible causes

A

nerve root

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45
Q

How common is lumbar radiculopathy as a specific LBP?

A

The most common neuropathic pain syndrome in patients with LBP

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46
Q

Symptoms in lumbar radiculopathy are limited to a “_________” distribution

A

neuroanatomically plausible

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47
Q

What are 5 things that people with neuropathic LBP (eg. lumbar radiculopathy) experience higher levels of when compared to non specific LBP?

A
  1. Pain
  2. Disability
  3. Anxiety
  4. Depression
  5. Reduced quality of life
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48
Q

Usually there is a ____ (Longer/shorter) prognosis with specific LBP (radiculopathy) compared to non-specific LBP

A

Longer

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49
Q

What 3 history and physical examination findings are consistent with the diagnosis of lumbar disc herniation with radiculopathy?

A
  1. Manual muscle testing
  2. Sensory testing
  3. Supine straight leg raise
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50
Q

Is spinal stenosis common or rare?

A
  • Very rare
  • More common in elderly
  • Complain fatigue
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51
Q

What is spinal stenosis?

A

Degenerative condition with diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes.

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52
Q

While symptoms can vary, what are 5 common symptoms of spinal stenosis?

A
  1. Gluteal and/or lower extremity pain and/or fatigue (may occur with or without back pain)
  2. Symptoms on upright exercise such as walking
  3. Relief with forward flexion, sitting and/or recumbency (Sit, Lie down)
  4. May get NR pain specifically if one NR irritated – may present like radiculopathy
  5. Patient often has stiffness (Lack of mobility) too – likely due to associated degenerative joint disease
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53
Q

Why does someone with spinal stenosis have normal neurological (even they are compromised and the spinal cord)?

A

Usually when you see the diminished space is enough to cause pain but not enough to cause neurological symptoms

Space is not diminished as much in supine compared to when standing

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54
Q

Patients whose pain is not made worse with walking have a ____ (high/low) likelihood of stenosis

A

low

55
Q

_____ is suggested as the most appropriate method to confirm spinal stenosis

A

MRI

56
Q

When is imaging advised and when is it not (more detrimental)?

A

Specific LBP: advised and helpful to confirm

Non-specific LBP: more detrimental than helpful- won’t change management

57
Q

What is the Modified Extension Test (Lumbar Quadrant) used for?

A

Used for lumbar stenosis to help confirm diagnosis

58
Q

What are you looking for in the Modified Extension Test (Lumbar Quadrant) to confirm a positive lumbar stenosis?

A
  • Hand up on oppose shoulder
  • Extension and rotation towards the same side
  • Looking for replication of the patient’s symptoms
59
Q

What are 6 assessments in the physical exam for lumbar spinal stenosis?

A
  1. Functional impairments in walking distances, standing time
  2. Measure – function and quality of life measures
  3. Observation – possible flexion posture in lumbar spine
  4. Pain or significant reduction in Lumbar extension
  5. Neurological may be unremarkable – unless also has NR compression
  6. Check adjacent areas – Thoracic spine may be stiff and lack extension, hips may lack extension & rotation, ankles may lack dorsiflexion If they walk, how will they compensate?
    • have to go into lumbar extension
    • Can be a management strategy –> improve flexibility
60
Q

What is the prognosis in lumbar spinal stenosis?

A

One third to ½ of those with mild to moderate condition have a favourable prognosis

61
Q

What does a favourable prognosis mean?

A
  • Doesn’t mean full recovery
  • Means that wont get worst and will get a little bit better
62
Q

In those with a mild to moderate condition of lumbar spinal stenosis, rapid or catastrophic neurologic decline is _____ (common/rare).

A

rare

63
Q

Can spondylolysis or spondylolisthesis be asymptomatic?

A

Yes

64
Q

What is spondylosis?

A

A stress fractire of pars inter articularis

65
Q

Where is the most common segement to have spondylolysis?

A

L5

66
Q

What are 4 features that spondylolysis is classified as?

A
  1. Isthmic (stress fracture from sport or repetitive loading)
  2. Dysplasic (congenital)
  3. Degenerative
    • Seen in elderly –> slowly breaks down
  4. Traumatic
67
Q

The majority of spondylolysis are _____. What does that mean?

A

isthmic

Due to repetitive loading

68
Q

_____ is relatively common in gymnasts, cricket fast bowlers especially with sudden increases in loading – especially into extension/quadrant position

A

spondylolysis

69
Q

_____ occurs in about 50% of cases. This is more common in individuals with bilateral spondylolysis and females

A

Spondylolisthesis

70
Q

What are 4 clear symptoms of spondylolysis?

A
  1. Aggravated by extension, standing or pars “stress” activities (quadrant), especially with increased training.
  2. Pain subsides with rest
  3. Pain may be localised with referred pain
  4. Clearly aggravated with activity
71
Q

What are 4 ways to diagnosis spondylolysis?

A
  1. Symptom history
  2. Physical exam – pain on extension, especially quadrant
  3. Oblique view XRAY
  4. Bone Scan is gold standard or MRI
72
Q

What is symptomatic spondylolisthesis?

A

Spondylolisthesis refers to the anterior positioning of one vertebra over another (or the L5 over sacrum).

73
Q

What are 5 features of symptomatic spondylolisthesis?

A
  1. Isthmic: the most common form, considered a consequence of spondylolysis (stress fracture), many asymptomatic, especially in adolescents.
  2. Degenerative
  3. Traumatic (rare)
  4. Pathologic
  5. Dysplastic: (rare): congenital, resulting from malformation of the pars.
74
Q

Is symptomatic spondylolisthesis stable or unstable

A

Very stable spine just the position is different

75
Q

What are 2 groups that symptomatic spondylolisthesis is commonly seen?

A
  • Weight lifters –> Can give mechanical advantage due to the positioning
  • Athletes
76
Q

What are the 5 grades based on the degree of translation in spondylolisthesis?

A
  1. Grade I: 0-25%.
  2. Grade II: 26-50%.
  3. Grade III: 51-75%.
  4. Grade IV: 76-100%.
  5. Grade V (spondyloptosis): >100%.
77
Q

What is the classification in degree of translation of spondylolisthesis based on?

A

based on the ratio of the overhanging part of the superior vertical body to the anterio-posterior length of the inferior vertebral body

78
Q

What are the 3 symptoms of spondylolisthesis?

A
  1. Similar symptom profile to spondylolysis – worse with activity – may complain of tightness and stiffness
  2. May be aggravated by flexion activities
  3. Aggravated by extension but may still be aggravated by flexion
79
Q

What is the management for spondylolisthesis?

A

similar to nonspecific/mechanical LBP – identifying impairments conservation

80
Q

What are 4 circumstances where further investigation and non-conservative management is required?

A
  1. Severe pain that does not get better with treatment
  2. Weakness of muscles in one or both limbs •
  3. Bowel/bladder symptoms
  4. Neurological compromised
81
Q

Normally, spinal deformities are most often _____ (symptomatic/asymptomatic)

A

asymptomatic

82
Q

There ____ (is/is no) significant association with pain in adolescent idiopathic scoliosis

A

is no

83
Q

Is Scheuermann disease associated with pain or not?

A

Yes

Wedge shaping of thoracic spine –> kyphosis

84
Q

What are 3 non- specific back conditions where there is non significant association between LBP?

A
  1. Spondylolysis
  2. Isthmic Spondylolisthesis
  3. Degenerative Spondylolisthesis

Only diagnosis if it is causing symptoms Otherwise they are not likely

85
Q

What are 9 structures (tissues) in the back that could be capable of generating nociceptive input?

A
  1. Muscles, trigger points
  2. Thoracolumbar Fascia
  3. Interspinous Ligaments
  4. Sacroiliac Joints
  5. Zygapophyseal Joints
  6. Intervertebral Discs
  7. Local nerves
  8. Vertebrae
  9. Nerve Roots and Dura Mater (mechanical or chemical irritation)
86
Q

While there are 9 sources of pain, there is huge inter-individual variation in sensitivity to this input. What does this mean then?

A

Impossible to tell the difference between the structures

87
Q

____ changes and ____are as common in people with no back pain as they are in people with back pain.

A

Degenerative; Disc bulges

There is no relationship between the findings on MRI and the likelihood of getting LBP, the severity of symptoms or the prognosis

Problems with imaging and non-specific LBP = that’s why we don’t do imaging

88
Q

Imaging is STRONGLY _____ (encouraged/discouraged) in current LBP guidelines unless symptoms suggest serious ____ pathology, or _____ symptoms that are worsening or not improving after ____ weeks of conservative management.

A

discouraged; spinal; neurological: 4-6

89
Q

Imaging is STRONGLY _____ (encouraged/discouraged) in current LBP guidelines unless symptoms suggest serious ____ pathology, or _____ symptoms that are worsening or not improving after ____ weeks of conservative management.

A

discouraged; spinal; neurological: 4-6

90
Q

What are the 2 guidelines for imaging in people with non-specific LBP?

A
  1. imaging is only indicated for severe progressive neurological deficits or when red flags are suspected, and
  2. routine imaging does not result in clinical benefit and may lead to harm
91
Q

What are 3 outcomes of radiological imaging for LBP patients?

A
  1. Poorer health outcomes
  2. Poor perceived prognosis
  3. More likely to have surgery
92
Q

Why are there negative effects of radiological imaging on LBP patients?

A

the risk of labelling patients with an anatomical diagnosis that is unrelated to their symptoms leading to changes in behaviour and onward path of treatment.

Due to interpretation of the imaging

Changes treatment negatively –> More likely to have injection and surgery in their back

93
Q

Most MRI findings, including disc bulges, annular tears or Schmorl’s nodes are unrelated to ____

A

LBP

94
Q

Imaging findings of lumbar ____ are poorly related to functional status or the presence of pain

A

osteoarthritis

95
Q

Up to half of all older people without LBP show evidence of lumbar ____joint osteoarthritis on CT assessment

A

facet

96
Q

80% of participants without symptoms or pain could be diagnosed with one mild _______ or ______ in the lumbar spine, and 38% of participants had two or more of these degenerative changes

A

disc protrusion; disc herniation

97
Q

What are the only 3 findings that correlated with LBP?

A
  1. Modic type 1 changes (of the end-plate) Change where the disc attaches to the end plate
  2. Extensive zygapophyseal oedematous change (severe facet OA)
  3. Spinal Stenosis
98
Q

What is a good source for people who have done MRI to try and change their views?

A

Helpful for people who have done MRI –> good for patient to understand that it is normal and are age-related changes

99
Q

______ was the only clinical feature found to increase the likelihood of the disc as the source of pain

A

Centralisation

100
Q

____ tests in combination are informative in identifying the source of non specific LBP.

A

SIJ

101
Q

No tests for ____ joint pain are informative in identifying the source of non specific LBP.

A

facet

102
Q

Tests do exist that change the probability of the ____ or ____ (but not the ____ joint) as the source of low back pain – but only for some patients

A

disc; SIJ; facet

103
Q

What are 9 features that have been considered by clinicians to be associated with discogenic pain based on hypothetical mechanisms? (opinion only- not based on research)?

A
  1. Patient has a directional preference to movement
  2. Symptoms being aggravated by prolonged sitting (>60 minutes)
  3. Symptoms being aggravated by lifting
  4. Symptoms being aggravated by forward bending
  5. Symptoms being aggravated by sit to stand
  6. Symptoms being aggravated by cough/sneeze
  7. History of working in a job with heavy manual handling
  8. The mechanism of injury being associated with flexion/rotation and/or compression loading
  9. Symptoms much worse the next morning or day after injury
104
Q

Referral patterns of disc, facet and SIJ using definitive diagnostic ____.

A

injections

105
Q

____ correlated with referral patterns such as hip, thigh and pelvic pain.

A

Age

106
Q

____ did not have correlation with referral patterns are unable to discriminate between disc, facet and SIJ pain.

A

Structure

107
Q

What are 4 limitations of Discogenic vs SIJ vs Z Joint (Pathoanatomical diagnoses)?

A
  1. Limited validity and reliability of symptoms and tests.
  2. Many patients do not fit into categories
  3. Deciding on a category does not inform best treatment
  4. Risk of giving patient a ‘label’ and providing explanations to the patient that are patho-anatomical which goes against evidence based practice and best management guidelines
108
Q

Making a ____ based on the specific tissues in non-specific LBP is no longer widely accepted

A

diagnosis

109
Q

The pursuit of a _____diagnosis should be implemented only when a specific diagnosis is needed (ie surgery, interventional injections, neurotomies etc).

A

pathoanatomical

110
Q

A patho-anatomical diagnosis is often not pursued because there are no ____ available that could establish a diagnosis, and in any case a pathoanatomical diagnosis would not change ______.

A

tests; management (Won’t change outcome)

111
Q

What are 4 reasons why we do not need to find a specific tissue lesions (as well as it being not possible)?

A
  1. Will not affect patient satisfaction (as long as a good explanation is made)
  2. Will not affect the long term prognosis
  3. Will not influence management of the patient
  4. Has a risk of negatively affecting outcomes
112
Q

What are 4 examples of terminology that should be used for ‘diagnosis’ in non-specific LBP?

A
  1. L4/5 mechanical LBP with (or without) somatic referral
  2. L4/5 non-specific LBP with (or without) somatic referral
  3. L4/5 discogenic LBP
  4. L4/5 flexion impairment

“mechanical”, “nociceptive” or “non-specific”

113
Q

What matters most when diagnosing?

A

what is conveyed or explained to others:

  • NOT in-depth patho-anatomical or biomechanical explanations to describe pain to the patient
  • Using accepted and understood terms when communicating with other health professionals
114
Q

While we cannot be very specific with what tissues are affected, we can still find the ______ of symptoms and explain injury and pain effectively to the patient with non-specific LBP.

A

segmental level

115
Q

What are 2 benefits of not using in-depth patho-anatomical explanations for a person’s pain?

A
  1. We are less likely to create iatrogenic issues (fear avoidance, reliance on passive treatments etc)
  2. We are more likely to treat the patient based on their individual factors using a patient-centred approach when we are not focussed on tissues
116
Q

What are 4 things we can still do, whilst we don’t diagnose the patho-anatomical condition?

A
  1. We can still find the segmental level of symptoms
  2. We can still explain injury and pain effectively to the patient with non-specific LBP
  3. We can still consider subgroups – factors that the patient presents with that indicate their likely response to treatment approaches Finding or not finding a specific tissue doesn’t change our management of the patient
117
Q

What are 2 circumstances where clinicians should consider using further subgrouping classifications?

A
  1. the patient’s clinical findings are suggestive of serious medical or psychological pathology
  2. the patient’s symptoms are not resolving with interventions aimed at normalization of the patient’s impairments.
118
Q

When diverse perspectives occur in clinical practice, this results in different management approaches. What are 2 benefits?

A
  1. Can be helpful to reduce heterogeneity
  2. May give us information about how to approach management
119
Q

We should not solely use one classification system for LBP, but incorporate the multiple _____ of LBP (including pain mechanisms) into clinical reasoning, in order to better _____ and ___ those with LBP

A

dimensions; assess; treat

120
Q

What are treatment groups based on symptoms like?

A

Developed by providing specific treatments to patients and then looking retrospectively at their symptoms and assessment findings which suggested they had better outcomes

121
Q

What are 3 advantages of treatment groups based on symptoms?

A
  1. Allows the clinician to ‘choose’ a treatment that matches the patient.
  2. Relatively simple to use
  3. Some evidence to support better patient outcomes when they are classified
122
Q

What are 5 disadvantages of treatment groups based on symptoms?

A
  1. Does not consider psychosocial factors
  2. Limited evidence to support management
  3. Not patient-centred
  4. Not every patient fits into a category
  5. Includes treatments that are not supported by evidence or guidelines (ie traction)
123
Q

What are treatment groups based on response to treatment like? What are the 3 subgroups?

A
  1. Manipulation
  2. Motor control training
  3. Direction Specific Exercise
124
Q

What is manipulation as a treatment groups based on response?

A

Patients meet the following criteria; recent onset of symptoms, symptoms localized to the back only, hypo-mobility in the lumbar spine on PAIVMs, low FABQ scores.

125
Q

What is motor control retraining as a treatment groups based on response?

A

Younger in age, aberrant motions on ROM, recurrent episodes, persistent pain. Findings in subjective assessment Lumbar stability questionnaire (>9/15)

126
Q

What is Direction Specific Exercise (McKenzie approach) as a treatment groups based on response?

A

Patients who have a directional preference to movement, the presence of centralization and peripheralization with repeated lumbar spine movements.

127
Q

Contemporary hypothesis generation/diagnosis of LBP must consider the presence and extent of ____ mediated symptoms

A

centrally Central sensitisation affects everyone

128
Q

_____ does not restricted to any one type of pain or injury and does not require an injury to occur

A

Central sensitisation

“Cells that fire together, wire together.”

129
Q

The ____ nervous system can learn a dysfunctional pattern of communication between the dorsal horn, spinal cord, and brain, leading to the _____ of pain receptors and signalling

A

central; oversensitization

130
Q

What does specific and non-specific LBP without versus with central sensitisation look like?

A
131
Q

What are 4 characteristics of specific and non specific LBP without central sensitisation?

A
  1. Clear proportionate response to aggravating and easing factors
  2. Clear and plausible anatomical location
  3. Movement Sensitivity
  4. Lower scores on SBST (low or moderate risk)
132
Q

What are 4 characteristics of specific and non specific LBP with central sensitisation?

A
  1. Exaggerated or inconsistent or unpredictable response to mechanical stress
  2. No clear and plausible anatomical location
  3. Hypersensitivity to other factors (cold, pressure etc)
  4. Higher scores on SBST (mod to high risk)
133
Q

What are the 7 roles that physios do in hypothesis generation?

A
  1. We can identify SPECIFIC causes of LBP (Spondylolysis, Symptomatic Spondylolisthesis, Radiculopathy, Spinal Stenosis, Cauda Equina)
  2. We can identify the segmental level in mechanical LBP (or SIJ)
  3. We can help identify risk factors of developing persistent pain or poor recovery
  4. We can try and identify centrally mediated symptoms
  5. We can identify the factors associated with symptoms (aggravating and easing factors, work stress, prolonged postures, activities) including directional preference to movement
  6. We can identify joint and/or muscle impairments and/or motor control impairments that may be contributing to the symptoms
  7. We can provide effective education about their condition without using potentially harmful in-depth patho-anatomical explanations

PHTY2220 (31 decks)

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