Low Back Pain Flashcards
Nearly all cases of LBP have what?
aka non-specific LBP- nearly all cases have an unidentified nociceptive source hence the term non-specific LBP
What are some functional questionnaires for LBP?
- Numeric Pain Rating Scale- 2 pts.
- Visual Analog Scale- 1.5 pts
- Oswestry Disability Questionnaire- 6 pts or 12%
- Roland Morris Disability Questionnaire- 2-3 pts
- STarT Back Tool- determines the risk of persistent disabling pain and matches treatments
What is the thoracic prevalence of LBP?
The smallest amount of spine-related pathology
What is the lumbar prevalence of LBP?
The leading cause of:
- Worldwide disability
- Activity limitation and work absence
- 80% will experience LBP in their lifetime
What is the prevalence of LBP in men compared to women and age?
- Biological women > men
- Older (half > 65 yrs. of age21) > younger ages
- Lower educational status: think access
- Higher physical work demands
What are risk factors of LBP?
- Previous LBP
- Co-morbidities (ex: diabetes, asthma, obesity, etc)
- Poor mental health: think coping
- Smoking and low activity levels
- Awkward postures, heavy lifting, and fatigue
- Genetics with age-related disc changes only, otherwise questionable
What structures are involved in LBP?
Variable innervated structures
What might you see on an MRI with LBP?
~ 1/3 of asymptomatic individuals had “abnormal” findings such as:
- IDD
- Age-related disc changes
- Nerve compression
- Facet hypertrophy
- ~ 1/2 of symptomatic individuals had an abnormality
What might you see with both MRI and CT with LBP?
- ~2/3 of asymptomatic 30-80 yr. old individuals had disc changes
- Normal asymptomatic age-related changes MUCH > symptomatic structural changes
- Imaging changes significantly increase with age
Are most scans for LBP helpful or not?
59% of outpatient lumbar scans were inappropriate in 2012
Who should get Imaging with LBP?
- > 50 yrs. of age with a hx of cancer
- Saddle paresthesias
- Bowel and bladder dysfunction
- Specific neurological deficits (spinal n., brain, spinal cord)
- Progressive/disabling symptoms
- No improvement after 6 weeks of conservative Rx
How many LBP cases have an unidentified nociceptive source
Nearly all
What kind of gap is present between evidence and practice?
Substantial
Over utilization of unsupported and ineffective Rx causes what?
- Fear-avoidance behaviors promoted with passive interventions like modalities and even some manual therapies
- Leads to higher costs
- Contributes to greater opioid addiction
- Greater imaging and radiation exposure
- More likely to have invasive procedures, side effects, and missed work
What kind of prevention is available for LBP?
- Inadequate research
- Most promoted preventions lack evidence
- Exercise is largely effective in adults
- For children ergonomic furniture is effective
- For children, exercise has not been evaluated
What percentage of patients that had early PT developed LBP?
2% developed persistent LBP
What happens to work time in pts with LBP that have early PT?
Significant reductions in lost work time
Is early PT supported in studies for LBP?
Yes, Supported by numerous studies
What is the first line Rx for LBP that has moderate to strong evidence behind it?
Education and advice
What kind of “against” education and advice should you give?
- Bed rest
- In-depth explanations
What kind of “for” education and advice should you give?
- Spinal anatomical and structural strength
- Overall favorable prognosis
- Active P! coping mechanisms that ↓ fear/catastrophizing
- Stay active with early resumption of ADLs
- Biopsychosocial contributors and basics of nociplastic pain
- Emphasis on function with back protection techniques
What kind of benefit does dry needling have for LBP?
Weak evidence of short term benefit
What kind of benefits do modalities like heat, US, electrical stimulation, LASER, etc. have for LBP?
- Generally ineffective and not recommended
- Short-term results at best; often no better than placebo
What kind of benefit does soft tissue mobilization/massage have for LBP?
Moderate evidence of short-term benefit
What barriers should we overcome to achieve best practices?
- Increase consultation time and follow-up
- Better incentives to return to work
- Reward quality and NOT volume with reimbursement
- Public service announcements
- Increased provider knowledge of evidence and guidelines for use in clinical reasoning and decision-making
What kind of evidence does Rx in general have for LBP?
- Moderate evidence with acute LBP
- Weaker evidence with chronic LBP due to greater contributing variables
What are the 4 subgroups of Rx for LBP?
- Mechanical Traction
- Directional Preference
- Mobilization/Manipulation
- Stabilization
What kind of LBP benefits from traction?
- Intermittent tx for LBP with LE P!
- Acute and subacute LBP with LE P! that doesn’t centralize
What kind of LBP does not benefit from traction?
- No benefit with static tx
- Should not use with persistent LBP with LE P!
There is moderate evidence against all types of tx when used alone in patients with what?
- Acute, sub-acute, and persistent LBP
- Non-radicular LBP
- Varying symptom patterns
How should mechanical traction be best used?
What is a directional preference?
A position and/or motion that alleviates symptoms
What repreated motions do people with LBP usually make?
- Most commonly extension/hyperextension, may centralize LE symptoms to LB
What is centralization?
Centralization- abolition of distal and/or spinal P! in a distal to proximal direction in response to repetitive motion(s) or sustained position(s)
What can directional prefernces help with?
Can help to choose positions and motions to avoid symptoms and promote exercise and activity
How should directional preference be best used?
What kind of evidence does manipulation have?
- Strong patient preference/belief in short term effectiveness
- Strong evidence for thrust and non-thrust mobilizations for LBP and disability
What LBP group is manipulation most beneficial for?
Manipulation most effective for sub-groups with acute and sub-acute LBP
What kind of predictors helped justify the used of manipulation with LBP?
≥ 4 of 5 predictors improved success from 45 to 95% with a 13.2 LR+ by using lumbar rotation or SI distraction manipulation:
1. NO symptoms distal to knee
2. Symptoms < 16 days
3. Lumbar joint hypomobility
4. Fear Avoidance Behavior Questionnaire at Work < 19
5. ≥ 1 hip with MORE than 35° IR
Added benefit when used with exercise
Mobilizations/ manipulations have strong evidence to improve what?
Strong evidence to improve hip mobility with subacute and persistent LBP
Mobilizations/ manipulations have moderate evidence to improve what?
Moderate to strong evidence to improve LBP and disability with back related LE P!
Mobilizations/ manipulations are short course at most; what does this mean?
