Low Back CPG Flashcards
Factors that increase prevalence of LBP
- women
- age (until 60/65)
- lower educational status
- physically demanding job
Risk Factors for LBP
- Operating Heavy equipment
- HTN (for sciatica)
- Lifestyle (smoking, overweight - for sciatica)
- psychological factors
inconclusive evidence for trunk muscle strength and mobility of lumbar spine
Prognostic Factors for the development of recurrent pain
- hx of previous episode
- excessive spine mobility
- excessive mobility in other joints
- pain of high intensity
- passive coping style
What are the subgroups of TBC?
- mobilization
- specific exercise
- immobilization
- traction
Fritz
ICF diagnosis of : acute low back pain with mobility deficits
- Acute low back, buttock, or thigh pain (duration of 1 month
or less) - Restricted lumbar range of motion and segmental mobility
- Low back and low back–related lower extremity symptoms
reproduced with provocation of the involved lower thorac-
ic, lumbar, or sacroiliac segments
ICF Dx of subacute low back pain with mobility deficits
- Subacute, unilateral, low back, buttock, or thigh pain
- Symptoms reproduced with end-range spinal motions and
provocation of the involved lower thoracic, lumbar, or sac-
roiliac segments - Presence of thoracic, lumbar, pelvic girdle, or hip active,
segmental, or accessory mobility deficits
ICF diagnosis of acute low back pain with movement coordination impairments
- Acute exacerbation of recurring low back pain that is com-
monly associated with referred lower extremity pain - Symptoms produced with initial to mid-range spinal move-
ments and provocation of the involved lumbar segment(s) - Movement coordination impairments of the lumbopelvic
region with low back flexion and extension movements
ICF diagnosis of subacute low back pain with movement coordination impairments
- Subacute exacerbation of recurring low back pain that is
commonly associated with referred lower extremity pain - Symptoms produced with mid-range motions that worsen
with end-range movements or positions and provocation of
the involved lumbar segment(s) - Lumbar segmental hypermobility may be present
- Mobility deficits of the thorax and pelvic/hip regions may
be present - Diminished trunk or pelvic region muscle strength and
endurance - Movement coordination impairments while performing
self-care/home management activities
ICF diagnosis of chronic low back pain with movement coordination impairments
Chronic, recurring low back pain that is commonly associ-
ated with referred lower extremity pain
Low back and/or low back–related lower extremity pain
that worsens with sustained end-range movements or
positions
-
Lumbar hypermobility with segmental motion
assessment
-
Mobility deficits of the thorax and lumbopelvic/hip
regions
-
Diminished trunk or pelvic region muscle strength and
endurance
-
Movement coordination impairments while performing
community/work-related recreational or occupational
activities
ICF diagnosis of acute low back pain with related (referred) lower extremity pain
Low back pain, commonly associated with referred but-
tock, thigh, or leg pain, that worsens with flexion activities
and sitting
*
Low back and lower extremity pain that can be centralized
and diminished with positioning, manual procedures, and/
or repeated movements
*
Lateral trunk shift, reduced lumbar lordosis, limited lum-
bar extension mobility, and clinical findings associated
with the subacute or chronic low back pain with movement
coordination impairments category are commonly present
ICF diagnosis of acute low back pain with radiating pain
Acute low back pain with associated radiating pain in the
involved lower extremity
*
Lower extremity paresthesias, numbness, and weakness
may be reported
*
Symptoms are reproduced or aggravated with initial to
mid-range spinal mobility, lower limb tension/straight leg
raising, and/or slump tests
*
Signs of nerve root involvement (sensory, strength, or reflex
deficits) may be present
ICF diagnosis of subacute low back pain with radiating pain
Subacute, recurring, mid-back and/or low back pain with
associated radiating pain and potential sensory, strength,
or reflex deficits in the involved lower extremity
*
Symptoms are reproduced or aggravated with mid-range
and worsen with end-range lower-limb nerve tension/
straight leg raising and/or slump tests
ICF diagnosis of chronic low back pain with radiating pain
Chronic, recurring, mid-back and/or low back pain with
associated radiating pain and potential sensory, strength,
or reflex deficits in the involved lower extremity
*
Symptoms are reproduced or aggravated with sustained
end-range lower-limb nerve tension/straight leg raise and/
or slump tests
ICF diagnosis of acute or subacute low back pain with related cognitive or affective tendencies
Acute or subacute low back and/or low back–related lower
extremity pain
*
Presence of 1 or more of the following:
-
Two positive responses to Primary Care Evaluation of
Mental Disorders for depressive symptoms
-
High scores on the Fear-Avoidance Beliefs Question-
naire and behavior consistent with an individual who
has excessive anxiety or fear
-
High scores on the Pain Catastrophizing Scale and cogni-
tive processes consistent with individuals with high help-
lessness, rumination, or pessimism about low back pain
ICF diagnosis of chronic low back pain with related generalized pain
Low back and/or low back–related lower extremity pain
with symptom duration of more than 3 months
*
Generalized pain not consistent with other impairment-
based classification criteria presented in these clinical
guidelines
*
Presence of depression, fear-avoidance beliefs, and/or pain
catastrophizing
Diagnostic Prediction Rule for spinal fx
female
age > 70
trauma
prolonged use of corticosteroids (>3 months)
Back related tumor physical findings
age > 50
constant pain not affected by position
hx of cancer ( +LR 23)
failure to improve within 30 days
no relief with bed rest
Cauda Equina history and physical findings
urine retention (+LR 18)
fecal incont
saddle anesthesia
sensory or motor deficits in feet (L4,L5,S1)
Back Related infection
Fever +LR 13,25,41
recent infection
deep constant pain
concurrent immunosuppressant use
spine rigidity
Abdominal aneurysm
back pain
PVD or other cardio risk factors
smoking
family hx
not being white
female
sx not related to mvmt
abdominal girth < 100cm
presence of a bruit in the central epigastric region
palpation of ab aortic pulse
pulse being > 4 cm
Whats the purpose of imaging studies in the low back?
interventional and/or surgical planning or in determining the presence of serious medical conditions.
What is the MCID for the ODI? Is higher or lower better?
10; higher means more disability
MCID of the Roland and Morris?
5 points or 30% ; test is out of 24
CPR for manipulation and what are the 2 most important to have to be successful?
sx less than 16 days **
no sx distal to knee **
lumbar hypomobility
hip Ir > 35
FABQ W < 19
4 or more = 95% success rate/ + LR of 13
CPR for stabilization exercises
age less than 40
positive prone instability
aberrant movements with motion testing
SLR > 91
When should clinicians consider using trunk coordination, strengthening and endurance exercises?
subacute / chronis LBP with movement coordination impairments
s/p microdiscectomy
This treatment should be performed when the patient presents with low back pain with related (referred) lower extremity pain.
Mackenzie Method / centralization & directional preference exercises
Whats the best method of treatment for spinal stenosis or chronic LBP with radiating pain?
Flexion exercises and Walking and lower quarter nerve mobilization
IF you are going to use traction, who should get it and what position?
signs of nerve root compression with peripheralization of sx or a + Crossed SLR test
prone traction
Patient has chronic low back pain without generalized pain, what exercise type are you doing?
mod to high intense exercise
Patient has chronic low back pain with generalized pain, what exercise type are you doing?
progressive, low intensity, submaximal fitness and endurance activities
Red Flags for Cancer
H/o cancer
Night pain or pain at rest
Unexplained weight loss
Age > 50 or < 17
Failure to improve with conservative management
Red Flags for Infections within the Disc or Vertebrae
Immunosuppressed
Prolonged temp over 100.4
H/o IV drug use
Recent UTI, cellulitis, or pneumonia
Red Flags for Vertebral Fracture
Prolonged corticosteroid use
Mild trauma > 50 yo
Age > 70
Osteoporosis
Recent trauma (MVC or fall greater than 5ft)
Bruising over spine following trauma
Red Flags for AAA
Pulsating mass in abdomen
History of atherosclerotic disease
Throbbing, pulsing back pain at rest or with recumbency
Age >60
Treatment for acute LBP w mobility deficits
Manual therapy procedures(thrust and non thrust manipulation) to diminish pain and improve segmental spinal or lumbopelvic motion
Treatment for acute LBP w mobility deficits
Manual therapy procedures(thrust and non thrust manipulation) to diminish pain and improve segmental spinal or lumbopelvic motion
TE to improve or maintain spinal mobility
Patient education that encourages the patient to remain active
Treatment for subacute LBP with mobility deficits
Manual to improve segmental spinal, lumbopelvic and hip mobility
TE to improve and maintain spinal/hip mobility
Focus on preventing reoccuring LBP episodes through the use of 1. TE that address coexisting coordination impairments, strength deficits and endurance deficits 2. education that encouraged the patient to remain active
Treatment for acute LBP with movement coordination impairments
NM re ed to promote dynamic stability to maintain the involved lumbosacral structures in less symptomatic mid range positions
consider the use of temporary external devices to provide support
self care/home management including 1. postures and motions that maintain the involved spinal structures in neutral sx free positions 2. education on staying active
Treatment for subacute LBP with movement coordination impairments
NM reducation
manual and TE to address deficits
self care/home training to keep sx down via mid range positions
initiate work/community reintegration
Treatment for chronic LBP with movement coordination impairments
NM reeducation to provide dynamic stability to maintain the involved structures in less symptomatic, mid range positions during activities
manual and TE to address deficits
pain management strategies while returning to community/work activities
Treatment for Acute LBP with related(referred) LE pain
TE, manual or traction that promote centralization and improve lumbar extension mobility
Patient education in positions that promote centralization
progress to interventions consistent with the subacute or chronic LBP with movement coordination impairments intervention strategies
Treatment for acute LBP with radiating pain
Patient education in positions that reduce strain on nerve roots
traction
manual therapy to mobilize the soft tissue adjacent to the involved nerve roots
nerve mobility exercises in pain free ranges
Subacute LBP with radiating pain
manual to mobilize the soft tissue adjacent to the involved nerve roots
traction
nerve mobility exercises in mid to end ranges
Subacute LBP with radiating pain
manual to mobilize the soft tissue adjacent to the involved nerve roots
traction
nerve mobility exercises in mid to end ranges
Treatment for chronic LBP with radiating pain
manual therapy and TE to address thoracolumbar and lower quarter nerve mobility deficits
patient education pain management strategies
treatment for acute or subacute low back pain with related cognitive or affective tendencies
Patient education and counseling to address specific classifcation exhibited by the patient (depression, fear avoidance, pain castrophizing)
treatment for Chronic low back pain with related generalized pain
Patient education and counseling to address specific classifcation exhibited by the patient (depression, fear avoidance, pain castrophizing)
low intensity prolonged (aerobic) exercise
