LBP Flashcards
Back pain accounts for at least_______ of all presenting
problems in general practice in Australia and 6.5%
in Britain.
5%
The most common cause of back pain is a _______ but people
suffering from this type of back pain usually do not
seek medical treatment as most of these soft tissue
problems resolve rapidly
minor
strain to muscles and/or ligaments,
The main cause of back pain presenting to the
doctor is dysfunction of the intervertebral joints
of the spine due to injury, also referred to as
__________
mechanical back pain (at least 70%).
The second most common cause of back pain is
________(synonymous with osteoarthritis and
degenerative back disease). It accounts for about
10% of cases of low back pain
spondylosis
L5 and S1 nerve root lesions represent most of the
cases of_________presenting in general practice.
sciatica
what is the cause of disruption of the intervertebral disc in the cause of
back pain
minor intervertebral
derangement (MID).
The MID always involves _________ in the mobile segment, thus
initiating nociceptive activity in the posterior primary
dermatome and myotome.
one of the two
apophyseal joints
In theory, any structure with a nociceptive nerve
supply may be a source of pain. Such structures
include the______
ligaments, fascia and muscles of the
lumbosacral spine, intervertebral joints, facet joints,
dura mater and sacroiliac joints.`
This term has been introduced to identify psychosocial
and occupational factors that may increase the risk of
chronicity in people presenting with acute back pain
Yellow flag pointers
What are the Yellow flag pointers for LBP
- abnormal illness behaviour
- compensation issues
- unsatisfactory restoration of activities
- failure to return to work
- unsatisfactory response to treatment
- treatment refused
- atypical physical signs
Pain characteristics
• \_\_\_\_\_\_\_\_\_ = inflammation (e.g. sacroiliitis) •\_\_\_\_\_\_\_\_\_\_\_= referred pain (e.g. dysmenorrhoea) •\_\_\_\_\_\_\_\_\_ = local pain (e.g. muscular strain)
aching throbbing pain
deep aching diffuse pain
superficial steady diffuse pain
Pain characteristics
•_______ = bone disease (e.g. neoplasia,
Paget disease)
•________ = radicular pain (e.g. sciatica)
boring deep pain
intense sharp or stabbing (superimposed on a
dull ache)
Continuous pain, present day and night, is
suggestive of _____ or ______
neoplasia or infection
Pain on waking also suggests _______
inflammation or depressive illness
Pain provoked by activity and relieved by rest suggests
_________ while pain worse at rest and
relieved by moderate activity is typical of ____
mechanical dysfunction
inflammation.
Pain aggravated by standing or walking that is
relieved by sitting is suggestive of_______
Pain aggravated by sitting (usually) and improved
with standing indicates a _______
spondylolisthesis.
discogenic problem
Pain of the calf that travels proximally with walking
indicates _______; pain in the buttock
that descends with walking indicates _____
vascular claudication
neurogenic claudication
A useful screening test for a disc lesion and dural
tethering is the______
slump test
active movements in PE
Forward flexion
extension
lateral extension
Landmarks
• The tops of the iliac crest lie at the level of the
______interspace (or the L4 spinous process).
• The PSISs lie opposite ____
L3–4
S2.
If lateral deviation (scoliosis) is present it
is usually _______
away from the painful side.
What test?
The
patient lies supine with both knees extended and the
ankle dorsiflexed. The affected leg is raised slowly,
keeping the knee extended
SLR
What is the SLR if there is sciatica
If sciatica with dural
irritation is present, 20 ° to 60 ° of elevation causes
reproduction of pain.
The ________ is an excellent provocation test for
lumbosacral pain and is more sensitive than the SLR
test. It is a screening test for a disc lesion and dural
tethering
slump test
When to do slump test?
It should be performed on patients who
have low back pain with pain extending into the leg,
and especially for posterior thigh pain.
Positive slump test?
A positive result is reproduction of the patient’s
pain, and may appear at an early stage of the test
(when it is ceased).
Significance of the slump test
• If positive, it suggests ______.
• If negative, it may indicate lack of serious disc
pathology.
• If positive, one should approach ____
disc disruption
manual therapy
with caution
The neurological examination consists of:
1 quick tests: _____
2 dural stretch tests: _____
3 specific nerve root tests (L4, L5, S1): ____
walking on heels (L5), walking on toes (S1)
slump test, straight leg raising
sensation, power, reflexes
What nerve roots?
• femoral stretch test (prone, flex knee, extend hip) • motor—extension of knee • sensation—anterior thigh • reflex—knee jerk (L3, L4)
L3
What nerve roots?
- motor—resisted inversion foot
- sensation—inner border of foot to great toe
- reflex—knee
L4
What nerve roots?
• motor: walking on heels, resisted extension
great toe
• sensation—middle three toes (dorsum)
• reflex—nil
L5
What nerve roots?
- motor: walking on toes, resisted eversion foot
- sensation—little toe, most of sole
- reflex—ankle jerk (S1, S2)
S1
Investigations for back pain can be classified into three broad groups: 1 2 3
front-line screening tests;
specific disease investigations;
and procedural and
preprocedural tests
Continuous pain (day and night) = _____
neoplasia, especially malignancy or infection
The other three metastases are from
thyroid,
kidney/adrenal and melanoma
Pain with standing/walking (relief with sitting)
=______
spondylolisthesis
In a young person with inflammation think of
_____
ankylosing spondylitis
Stiffness at rest, pain with or after activity, relief
with rest =______
osteoarthritis
Pain provoked by activity, relief with
rest = _______
mechanical dysfunction
T or F
The rule of thumb for the lumbar nerve root
lesions is L3 from L2–3 disc, L4 from L3–4, L5
from L4–5 and S1 from L5–S1.
T
A ___________ from anticoagulation
therapy can give intense nerve root symptoms
and signs
retroperitoneal bleed f
Back pain in children
Tumours causing back pain include ____ and ____
the benign
osteoid osteoma and the malignant osteogenic
sarcoma
______ is a very small tumour
with a radiolucent nucleus that is sharply demarcated
from the surrounding area of sclerotic bone. Although
more common in the long bones of the leg, it can
occur in the spine
Osteoid osteoma
Spondylolisthesis can occur in older children, usually due to a 1 2 3
slip of L5 or S1, because the articular
facets are congenitally absent or because of a stress
fracture in the pars interarticularis
_______ is still the most
common cause of back pain in the elderly
Traumatic spinal dysfunction
The two nerve roots that account for most of
these problems are L5 and S1 and the commonest
disc lesion is _____closely followed by L5–S1.
L4–5,
The pain is caused by
extreme stretching of the interspinous ligaments
or of the nerve roots. The onset of back pain in
many of these patients is due to concurrent disc
degeneration rather than a mechanical problem
Spondylolisthesis
What should be avoided Spondylolisthesis?
hyperextension.
_______ also known as degenerative
osteoarthritis or osteoarthrosis, is a common
problem of wear and tear that may follow vertebral
dysfunction, especially after severe disc disruption
and degeneration
Lumbar spondylosis,
Lumbar spondylosis Cx
leading to subluxation of the facet joints
spinal canal stenosis
The ______ are a group
of disorders characterised by involvement of the
sacroiliac joints with an ascending spondylitis and
extraspinal manifestations, such as oligoarthritis and
enthesopathies
seronegative spondyloarthropathies
Tests for non-organic back pain
(the ‘migratory pointing’ test
Magnuson method
How to do Magnuson method
1 Request the patient to point to the painful sites
2. Palpate these areas of tenderness on two
occasions separated by an interval of several
minutes, and compare the sites
Tests for non-organic back pain
What test?
- Ask the patient to kneel on a low stool, lean over
and try to touch the floor.
2 The person with non-organic back pain will
usually refuse on the grounds that it would
cause great pain or that he or she might
overbalance in the attempt
Burn’s ‘kneeling on a stool’ test
This may be effective for relatively isolated points
using 5–8 mL of local anaesthetic. Studies indicate that
it is likely to be more beneficial for chronic back pain
Trigger point injection
This enzyme has been advocated for the treatment
of acute nuclear herniation that is still intact
Chymopapain
Corticosteroid injection under radio-image intensification
is widely used in some clinics. The procedure
is delicate and expertise is required
Facet joint injection
Physical therapy
______ are the best form of physical therapy
Active exercises
Physical therapy
_____ at the end range is a safe,
effective method
Passive spinal stretching
Physical therapy
________
is a gentle, repetitive, rhythmic movement within the
range of movement of the joint
Spinal mobilisation
_______ is a high velocity thrust
at the end range of the joint. It is generally more
effective and produces a faster response but requires
accurate diagnosis and greater skill
Spinal manipulation
