Low Back CPG

Question 1

Factors that increase prevalence of LBP

Answer 1

• women
• age (until 60/65)
• lower educational status
• physically demanding job

Question 2

Risk Factors for LBP

Answer 2

• Operating Heavy equipment
• HTN (for sciatica)
• Lifestyle (smoking, overweight - for sciatica)
• psychological factors

inconclusive evidence for trunk muscle strength and mobility of lumbar spine

Question 3

Prognostic Factors for the development of recurrent pain

Answer 3

1. hx of previous episode
2. excessive spine mobility
3. excessive mobility in other joints
4. pain of high intensity
5. passive coping style

Question 4

What are the subgroups of TBC?

Answer 4

1. mobilization
2. specific exercise
3. immobilization
4. traction

Fritz

Question 5

ICF diagnosis of : acute low back pain with mobility deficits

Answer 5

• 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

Question 6

ICF Dx of subacute low back pain with mobility deficits

Answer 6

• 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

Question 7

ICF diagnosis of acute low back pain with movement coordination impairments

Answer 7

• 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

Question 8

ICF diagnosis of subacute low back pain with movement coordination impairments

Answer 8

• 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

Question 9

ICF diagnosis of chronic low back pain with movement coordination impairments

Answer 9

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

Question 10

ICF diagnosis of acute low back pain with related (referred) lower extremity pain

Answer 10

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

Question 11

ICF diagnosis of acute low back pain with radiating pain

Answer 11

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

Question 12

ICF diagnosis of subacute low back pain with radiating pain

Answer 12

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

Question 13

ICF diagnosis of chronic low back pain with radiating pain

Answer 13

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

Question 14

ICF diagnosis of acute or subacute low back pain with related cognitive or affective tendencies

Answer 14

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

Question 15

ICF diagnosis of chronic low back pain with related generalized pain

Answer 15

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

Question 16

Diagnostic Prediction Rule for spinal fx

Answer 16

female
age > 70
trauma
prolonged use of corticosteroids (>3 months)

Question 17

Back related tumor physical findings

Answer 17

age > 50
constant pain not affected by position
hx of cancer ( +LR 23)
failure to improve within 30 days
no relief with bed rest

Question 18

Cauda Equina history and physical findings

Answer 18

urine retention (+LR 18)
fecal incont
saddle anesthesia
sensory or motor deficits in feet (L4,L5,S1)

Question 19

Back Related infection

Answer 19

Fever +LR 13,25,41
recent infection
deep constant pain
concurrent immunosuppressant use
spine rigidity

Question 20

Abdominal aneurysm

Answer 20

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

Question 21

Whats the purpose of imaging studies in the low back?

Answer 21

interventional and/or surgical planning or in determining the presence of serious medical conditions.

Question 22

What is the MCID for the ODI? Is higher or lower better?

Answer 22

10; higher means more disability

Question 23

MCID of the Roland and Morris?

Answer 23

5 points or 30% ; test is out of 24

Question 24

CPR for manipulation and what are the 2 most important to have to be successful?

Answer 24

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

Question 25

CPR for stabilization exercises

Answer 25

age less than 40 positive prone instability aberrant movements with motion testing SLR > 91

Question 26

When should clinicians consider using trunk coordination, strengthening and endurance exercises?

Answer 26

subacute / chronis LBP with movement coordination impairments s/p microdiscectomy

Question 27

This treatment should be performed when the patient presents with low back pain with related (referred) lower extremity pain.

Answer 27

Mackenzie Method / centralization & directional preference exercises

Question 28

Whats the best method of treatment for spinal stenosis or chronic LBP with radiating pain?

Answer 28

Flexion exercises and Walking and lower quarter nerve mobilization

Question 29

IF you are going to use traction, who should get it and what position?

Answer 29

signs of nerve root compression with peripheralization of sx or a + Crossed SLR test prone traction

Question 30

Patient has chronic low back pain without generalized pain, what exercise type are you doing?

Answer 30

mod to high intense exercise

Question 31

Patient has chronic low back pain with generalized pain, what exercise type are you doing?

Answer 31

progressive, low intensity, submaximal fitness and endurance activities

Question 32

Red Flags for Cancer

Answer 32

H/o cancer Night pain or pain at rest Unexplained weight loss Age > 50 or < 17 Failure to improve with conservative management

Question 33

Red Flags for Infections within the Disc or Vertebrae

Answer 33

Immunosuppressed Prolonged temp over 100.4 H/o IV drug use Recent UTI, cellulitis, or pneumonia

Question 34

Red Flags for Vertebral Fracture

Answer 34

Prolonged corticosteroid use Mild trauma > 50 yo Age > 70 Osteoporosis Recent trauma (MVC or fall greater than 5ft) Bruising over spine following trauma

Question 35

Red Flags for AAA

Answer 35

Pulsating mass in abdomen History of atherosclerotic disease Throbbing, pulsing back pain at rest or with recumbency Age >60

Question 36

Treatment for acute LBP w mobility deficits

Answer 36

Manual therapy procedures(thrust and non thrust manipulation) to diminish pain and improve segmental spinal or lumbopelvic motion

Question 37

Treatment for acute LBP w mobility deficits

Answer 37

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

Question 38

Treatment for subacute LBP with mobility deficits

Answer 38

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

Question 39

Treatment for acute LBP with movement coordination impairments

Answer 39

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

Question 40

Treatment for subacute LBP with movement coordination impairments

Answer 40

NM reducation manual and TE to address deficits self care/home training to keep sx down via mid range positions initiate work/community reintegration

Question 41

Treatment for chronic LBP with movement coordination impairments

Answer 41

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

Question 42

Treatment for Acute LBP with related(referred) LE pain

Answer 42

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

Question 43

Treatment for acute LBP with radiating pain

Answer 43

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

Question 44

Subacute LBP with radiating pain

Answer 44

manual to mobilize the soft tissue adjacent to the involved nerve roots traction nerve mobility exercises in mid to end ranges

Question 44

Subacute LBP with radiating pain

Answer 44

manual to mobilize the soft tissue adjacent to the involved nerve roots traction nerve mobility exercises in mid to end ranges

Question 45

Treatment for chronic LBP with radiating pain

Answer 45

manual therapy and TE to address thoracolumbar and lower quarter nerve mobility deficits patient education pain management strategies

Question 46

treatment for acute or subacute low back pain with related cognitive or affective tendencies

Answer 46

Patient education and counseling to address specific classifcation exhibited by the patient (depression, fear avoidance, pain castrophizing)

Question 47

treatment for Chronic low back pain with related generalized pain

Answer 47

Patient education and counseling to address specific classifcation exhibited by the patient (depression, fear avoidance, pain castrophizing) low intensity prolonged (aerobic) exercise