Low Back Pain (and More)

Question 1

What key questions should clinicians consider during the treatment planning and implementation process?

Answer 1

Clinicians should consider:
* Do I need imaging?
* How long do I need to rest?
* How much pain is appropriate for self-care, massage therapy, and day-to-day activities?
* Will this exercise cause more damage to the area?

Question 2

What are Clinical Practice Guidelines (CPG)?

Answer 2

Clinical Practice Guidelines (CPG) are recommendations for clinicians about the care of patients with specific conditions. They are based on the best available research evidence and practice experience.

Question 3

Why are Clinical Practice Guidelines important in low back pain management?

Answer 3

They provide evidence-based recommendations that help clinicians make informed decisions about patient care, ensuring effective and appropriate treatment for low back pain.

Question 4

Why are red flags important in managing low back pain?

Answer 4

Red flags help identify rare but potentially serious conditions. Clinicians cannot always assume that red flags have been ruled out, so they must be aware of them and refer the patient to an MD or ER when necessary.

Question 5

What are the referral timelines for patients presenting with red flags?

Answer 5

• Emergency: Referral within hours.
• Urgent: Referral within 24-48 hours.
• Soon: Referral within weeks.

Question 6

What are some red flags for emergency referral in acute low back pain?

Answer 6

Features of cauda equina syndrome, including: Sudden or progressive loss of bladder/bowel control. Saddle anesthesia.

Question 7

What are some red flags for urgent referral in acute low back pain?

Answer 7

• Severe worsening pain, especially at night or when lying down.
• Significant trauma.
• Weight loss, history of cancer, or fever.

Question 8

What are some red flags for soon referral in acute low back pain?

Answer 8

• First episode of severe back pain in a patient over 50, especially over 65.
• Widespread neurological signs.

Question 9

What do yellow flags indicate in the context of pain recovery?

Answer 9

Yellow flags indicate psychosocial barriers to recovery, which can hinder the healing process and prolong pain-related issues.

Question 10

What are some yellow flags related to beliefs about pain and activity?

Answer 10

The belief that pain and activity are harmful is a yellow flag.

Question 11

What are examples of yellow flags related to behavior during pain?

Answer 11

Sickness behaviors, such as extended rest, are yellow flags.

Question 12

What are some yellow flags related to mood and social behavior?

Answer 12

• Low or negative mood.
• Social withdrawal.

Question 13

What are some yellow flags related to treatment expectations?

Answer 13

Treatment expectations that do not align with best practice are considered yellow flags.

Question 14

What are some yellow flags related to work issues?

Answer 14

• Problems at work and poor job satisfaction.
• Heavy work or unsociable hours, such as shift work.

Question 15

What are some yellow flags related to family and support?

Answer 15

• An overprotective family.
• Lack of support from family or social circles.

Question 16

What are some yellow flags related to compensation and claims?

Answer 16

• Problems with claim and compensation processes.
• A history of back pain, time off work, or other claims.

Question 17

What can a patient’s history help an RMT identify within the CPG scope of practice?

Answer 17

A patient’s history can help identify:
* Back or leg dominant pain
* Intermittent or consistent pain
* Associated aggravating movements
* Non-mechanical vs mechanical pain
* Red flags and yellow flags

Question 18

What does identifying patterns in a patient’s history help define?

Answer 18

It helps define mechanical back pain. If no pattern is identified, altered processing, such as nociplastic pain, may be considered.

Question 19

How does a physical examination support the findings from a patient’s history?

Answer 19

The physical examination can refute or support the back pain pattern identified in the patient’s history.

Question 20

What neurological signs are associated with referred leg pain and radicular pain?

Answer 20

• Referred leg pain: Normal neurological exam.
• Radicular pain: Positive straight leg raise (SLR) with reproduction of leg pain and possible abnormal neurological signs.

Question 21

How should range of motion be interpreted during a physical examination?

Answer 21

Interpretation of range of motion should include the pain response to flexion and extension movements.

Question 22

What are some initial management goals for RMTs working with patients experiencing pain?

Answer 22

Goals may include:
* Reducing pain
* Increasing activity

Question 23

What is the recommendation regarding movement for pain management?

Answer 23

Frequent movement in small doses is recommended.

Question 24

What does self-management involve for patients?

Answer 24

Self-management involves patient-driven goals, such as:
* Motivating behavior change (e.g., exercise, medication compliance, activity modification).

Question 25

How should recovery positions or exercises be tailored for patients?

Answer 25

Recovery positions and exercises should be customized to the individual patient.

Question 26

When might a patient require a referral, and what types of referrals might be needed?

Answer 26

Referrals may be required based on the RMT’s findings, including to:
* Rehabilitation
* Surgery
* Specialists
* Imaging or laboratory tests

Question 27

What is the goal of “Choose Wisely Canada” in healthcare?

Answer 27

“Choose Wisely Canada” aims to reduce unnecessary tests and treatments in healthcare.

Question 28

Why are imaging tests often unnecessary at the start of back pain?

Answer 28

Imaging tests don’t help people recover faster and can lead to additional procedures that complicate recovery. Most people feel better within a month, regardless of imaging.

Question 29

What did studies find about the outcomes of people with back pain who had imaging tests early?

Answer 29

Studies found that people who had imaging tests early did not recover faster and sometimes did worse than those who used simpler treatments like applying heat, staying active, or using OTC pain relievers.

Question 30

What was discovered about patients who had an MRI within the first month of back pain?

Answer 30

Patients who had an MRI in the first month were eight times more likely to have surgery but did not recover faster than those who didn’t.

Question 31

Why is a lumbar spine disc bulge a common incidental finding in imaging?

Answer 31

Disc bulges are common, even in people without symptoms, and can often resolve on their own without medical intervention. Imaging might not change management but can cause unnecessary worry and treatment.

Question 32

What are SLAP lesions, and why can they lead to over-treatment?

Answer 32

SLAP lesions are incidental findings in imaging, often seen in patients with non-specific chronic shoulder pain. They can cause unnecessary anxiety and lead to over-treatment.

Question 33

What is important to educate patients about regarding SLAP lesions?

Answer 33

Patients should be educated that SLAP lesions are common and often asymptomatic in the general population, and the focus should be on reducing aggravating activities and improving movement, function, and pain management.

Question 34

When do imaging tests make sense for patients?

Answer 34

Imaging tests are recommended if there are signs of severe or worsening nerve damage, serious underlying conditions like cancer or spinal infection, or if any of the previously discussed red flags are present.

Question 35

What is the first important question to ask your patient in the Musculoskeletal Clinical Translation Framework?

Answer 35

The first question is about their perspective—to understand their view of their condition and its impact.

Question 36

What is the second important question to ask your patient according to the Musculoskeletal Clinical Translation Framework?

Answer 36

The second question focuses on their day-to-day—how the condition affects their daily activities and quality of life.

Question 37

What is the third important question to ask your patient in the Musculoskeletal Clinical Translation Framework?

Answer 37

The third question is about their expectations from you—what they hope to achieve through treatment or care.

Question 38

What is nociceptive pain?

Answer 38

Nociceptive pain arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors. It occurs with a normally functioning somatosensory nervous system.

Question 39

What are the clinical characteristics and management of nociceptive pain?

Answer 39

Nociceptive pain is typically short-lasting and stimulus-response coupled. Management involves early movement, staying active, and using simple analgesics.

Question 40

What is nociceptive (inflammatory) pain, and when does it occur?

Answer 40

Inflammatory pain, a subtype of nociceptive pain, is associated with acute tissue damage, infection, or inflammatory conditions like rheumatoid arthritis.

Question 41

What are the management strategies for inflammatory nociceptive pain?

Answer 41

Managing pain to increase activity without flares is key. This type of pain responds to simple analgesics, but conditions like rheumatoid arthritis may require DMARDs (Disease-Modifying Anti-Rheumatic Drugs).

Question 42

Define neuropathic pain and provide examples.

Answer 42

Neuropathic pain is caused by a lesion or disease of the peripheral somatosensory nervous system. Examples include shingles, radiculopathy, neuroma, phantom limb pain, and diabetic neuropathy.

Question 43

How is neuropathic pain typically managed?

Answer 43

Neuropathic pain management involves specific pharmacologic treatments like antidepressants, membrane stabilizers, opioids, NMDA antagonists, and topical treatments.

Question 44

What is nociplastic pain?

Answer 44

Nociplastic pain arises from altered nociception without clear evidence of actual or threatened tissue damage or somatosensory system disease. Conditions include fibromyalgia, IBS, interstitial cystitis, and tension headaches.

Question 45

How should nociplastic pain be managed?

Answer 45

Nociplastic pain is managed through interdisciplinary approaches, education on comorbidities, careful activity pacing, and addressing lifestyle factors. Simple analgesics are often ineffective.

Question 46

What is mixed pain, and what are examples?

Answer 46

Mixed pain involves a combination of pain types, such as nociceptive and neuropathic pain (e.g., low back pain with radiculopathy) or neuropathic pain with functional pain (e.g., sciatica with IBS or dysmenorrhea).

Question 47

How is mixed pain managed?

Answer 47

Mixed pain management targets contributing factors like education, sensorimotor training, functional restoration, and addressing lifestyle factors. Pharmacologic management must account for all involved pain types.

Question 48

When is pain considered good in a clinical setting?

Answer 48

Pain is considered good when the tissue is challenged enough to elicit change, but not so much that it triggers a neurological protective output.

Question 49

What common worry do patients with chronic pain often have, and how can it be alleviated?

Answer 49

Patients often worry about the fear of the unknown, such as whether self-care or massage therapy will cause more damage. Educating them helps reduce this worry.

Question 50

Why is it important to explain to patients that some tests may elicit their pain during assessment?

Answer 50

Explaining that provoking some pain is necessary to narrow down the clinical impression reassures patients and helps them understand the purpose of the assessment.

Question 51

What does LOFDSAQ stand for?

Answer 51

LOFDSAQ stands for the elements to assess during a clinical evaluation: Location, Onset, Frequency, Duration, Severity, Aggravating factors, and Quality of pain.

Question 52

What pain score should techniques during treatment generally not exceed?

Answer 52

Techniques during treatment should not exceed a subjective score of 7/10.

Question 53

What indicates a successful trigger point compression during treatment?

Answer 53

A successful trigger point compression is indicated by a decrease in pain after 30-60 seconds. If the pain stays the same or worsens, the area should be reassessed or a different technique tried.

Question 54

What is the importance of reassessing range of motion (ROM) after working on a muscle?

Answer 54

Reassessing ROM helps to determine if the pain has improved after treatment, indicating progress.

Question 55

When and why should pain post-treatment be reassessed?

Answer 55

Pain should be reassessed 24-48 hours after treatment to gauge how much the area hurts post-session and whether the treatment was effective.

Question 56

What is the general rule for the subjective pain score during self-care exercises?

Answer 56

The general rule is to ensure self-care exercises do not exceed a subjective pain score of 4/10.

Question 57

What should be monitored to track progress in self-care exercises?

Answer 57

Progress is monitored by consistently testing the same parameters with less pain. If pain decreases, it’s time to increase the weight or rep range to keep self-care challenging.

Question 58

What question should be asked post-self-care to assess soreness?

Answer 58

Ask the patient how sore they were after self-care to evaluate whether the exercises were appropriately challenging but not overly painful.

Question 59

Why do patients seem to suffer from tendon pain for years?

Answer 59

Tendon pain is multifactorial and can take up to 3 months or more of consistent loading to resolve. Many patients do not stay with rehab long enough to see improvement, and feelings of anxiety and inadequacy can hinder the process.

Question 60

What role does patient education play in managing tendon pain?

Answer 60

Patient education is vital for managing tendon pain. It helps patients understand the need for consistent rehab, the timeline for recovery, and addresses concerns like anxiety and feelings of inadequacy about slow progress.

Question 61

How long can tendon pain take to resolve with consistent loading?

Answer 61

Tendon pain can take up to 3 months or more to resolve with consistent loading and rehab.

Question 62

How should rest be managed for load-bearing tendons, such as the patellar or Achilles?

Answer 62

Load-bearing tendons may need a few days of rest to allow pain or inflammation to subside. However, rest can be difficult for patients with busy lives or jobs requiring long periods of ambulation.

Question 63

Why might tendon pain take longer to resolve for certain professions, like computer workers with tennis/golfer’s elbow?

Answer 63

Tendon pain may take longer to resolve for certain professions because their job activities (e.g., repetitive movements) can continuously strain the affected tendons, making it difficult to fully rest and recover.

Question 64

When does pain associated with self-care for tendon injuries typically manifest?

Answer 64

Pain from self-care exercises for tendon injuries may take up to 24 hours to manifest, making it important for patients to monitor for delayed pain responses to ensure they didn’t do too much too soon.