Lower Back Pain: Non-Surgical Management

Question 1

goal of the first visit when someone presents with non-specific lower back pain

Answer 1

using the start back tool, rule out red flags and reassure patient. Then, stay active and use appropriate analgesics.

Question 2

list some red flags of lower back pain.

Answer 2

CAUDA EQUINA SYNDROME IS A VERY EMERGENT CONDITION– IF YOU DO NOT CATCH IT YOU WILL PARALYZE THE PATIENT.

If they’re using IV drugs, there is an increased risk of infection of spine. Widespread neurological signs or acute onset backspin late in life needs to examined ASAP/

Question 3

T/F degenerative changes are normal age-reltaed changes

Answer 3

true.”Degenerative Disease” is so broad– the patient thinks their back is crumbling. Degernerative joint disease is a disturbing label and the patient associates this label as a poor prognosis.
DEGENERATIVE CHANGES ARE NORMAL AGE-RELATED CHANGES.

Question 5

what is the one predictive factor of lower back pain that is not found on imaging

Answer 5

depression.

Question 6

What is the choosing wisely guidelines in terms of ordering an MRI scan for LBP

Answer 6

DO NOT order imaging with lowe back pain REGARDLESS OF THE DURATION of symptoms unless there are red flags or the doctor is planning eveidenced based therapetuic intervention.

there is an extremely high false positive rate in mechanical axial pain, and it does not improve patient care. leads to other investigations/treatment and increases detrimetnal outcomes/

Question 7

T/F if a person has been struggling with lower back pain for more than 10 months without resolution, it is reasonable to order an imaging test.

Answer 7

Don’t routinely image patients with low back pain regardless of the duration of symptoms unless…redflas

Question 8

which redflags should you expedite a spinal MRI

Answer 8

Question 9

when the patient comes back after 1-2 weeks for visit #2, what do you do now?

Answer 9

rule our red and yellow flags again.

refer to the STarT back Tool

Pain diagrams– has the pain changed in any way? Is it starting to radiate?

Barriers to alleviating lower back pain? are there supports in place?

Identify the pain generator– it is vital you determine the actual generator rather than leaving it as non-specific low back pain. having this non specific label causes increased rates of lost work and absenteeism and reduced productivity. results in diagnosis of chronic pain syndrome. .

Question 10

outline some Yellow Flags

Answer 10

Question 11

outline the startback tools coring system

Answer 11

if you score four or more, you at at high risk for chronic pain. you need help with a multidicplinary team. by doing scoring early (by the first or second visit) you can determine the needs of the patient.

Question 13

note: myofasical pain and sciatica of the glute minimus. can radiate, often has a trigger point.

Question 14

myofacial pain is a myalgic condition characterized by local and refferred. pain that originates in a ___ ____ ___

Answer 14

myofascial trigger point. may be the primary cause of pain in 20-85% of pts complaining of musculoskeletal pain.

Question 15

molecular appearance of normal vs strained muscle

Answer 15

In normal muscle, sarcomeres are aligned. In strained muscles, the sarcomeres overlap resulting in lack of oxygen, strain, release of inflammatory mediators.

Question 16

criteria for MAJOR myofasical pain:

1. exquisite spot tenderness in ___ ___ with firm pressure applied for 5 seconds
2. expected distribution of ___ ___ from a myofascial trigger point.
3. regional pain complaint
4. restricted ROM when measurable, but not complete loss of ROM.

Answer 16

(Blanch thumb nail and put pressure for 5 seconds on the point. Do not just rub the area when palpating lol. If the pain is referred, there will be pain in other areas in addition to the spot directly underneath your point of palpation.)

1. exquisite spot tenderness in TAUGHT BAND with firm pressure applied for 5 seconds
2. expected distribution of REFERRED PAIN from a myofascial trigger point.
3. regional pain complaint
4. restricted ROM when measurable, but not complete loss of ROM.

Question 17

criteria for MINOR myofascial pain.

1. reproduction of symptoms
2. ___ ___ ____ by transvers snapping palpation at tender spot or needle insertion
3. pain alleviated by stretching muscle/injecting trigger point.

Answer 17

1. reproduction of symptoms
2. LOCAL TWITCH RESPONSE by transvers snapping palpation at tender spot or needle insertion
3. pain alleviated by stretching muscle/injecting trigger point.

if you have 5 major and 1/3 minor criteria you can likely diagnosis of myofasiacla pain.

Question 18

5 common muscles that perpetuate myofascial pain

Answer 18

glute max, glute medius, glute minimus, piriformis, quadratus lumborom

Question 19

Answer 19

Question 20

a person has trigger point pain and difficulty standing up after being seated. what muscle might be having myofascial pain?

Answer 20

gluteus minimus

Question 21

a person has trigger point pain just underneath the iliac crest and has difficulty standing on 1 leg unsupported. what muscle is affected and causing myofascial pain/

Answer 21

gluteus medius

Question 22

a person has trigger point pain and has difficulty sitting and walking uphill. which muscle is contributing to the myofascial pain?

Answer 22

glute maximus

Question 23

a person has trigger point pain around the lower rib cage and iliac crest. what muscle has myofascial pain?

Answer 23

quadratus lumobroum. it couldve been around the glute med/minimus, but the rib cage is the origin point for the QL.

Question 24

in general, combining ___ ___ with other treamtnets may be superior.

Answer 24

dry needling.

Question 25

a person has trigger pint pain on anterior thigh and groin. what muscle is triggering myofasical pain?

Answer 25

The psoas muscle joints with the iliac to form the iliopsoas muscle/tendon down into the groin region. Can get pain in the groin, anterior thigh and into the back region.

the iliopsoas.

Question 26

self management modalities for myofascial pain.

Answer 26

breathing, posture, stretching and strengthening to manage trigger points. foam rollers help a lot. same with shepherds hook or the stick.

Alot of MF pain can be helped just by
the patient facilitating their own care and movement.

Question 27

what’re the 3 joints of the pelvis

Answer 27

1. right sacroiliac joint
2. left sacroiliac joint
3. sym pubis.

Question 28

what kind of joint is the SI joint and what is it innervated by?

Answer 28

-Diarthrodial joint, antr 1/3 true synovial joint

• Posterior ilium side is fibrocartilage
• Remainder is supported by ligamentous structures
• Innervated by dorsal rami L4-S2

Question 29

role of the sacroiliac joint

Answer 29

The effective transfer
of load between the
trunk and the lower
extremities during
both static and
dynamic activities

Question 30

typical flexibility sacroiliac joint

Answer 30

FLEXIBILITY Angular 1° - 4° Avg 2 °
Linear translation < 1.6 mm avg < 0.5 mm
 Walking  Shock absorption during weight
bearing

Question 31

intra andextra articular causes of SI joint pain

Answer 31

Question 32

what test is done that has 100% sensitivity for SI joint pain?

Answer 32

Question 33

in order to diagnose pelvic girdle pain (SI joint disfunction, or other joint), what 3 tests need to be positive?

Answer 33

1. Fortin’s Finger test
2. ASLR- active straight leg raise. ASLR test is measured by effort not pain.
3. Pain provocation tests.

16-30% of patients with LBP have PGP. that’s the second most common reason to LBP compared to myofascial pain.

Question 34

biomechanical treatments for pelvic girdle pain that can help with load transfer.

Answer 34

1. passive intervensions like a SI blet or cane.
2. active exercise like core stability.

Question 35

what type of physical treatment can you give for someone with SI joint pain/PGP.

Answer 35

SI joint block might help in diagnosis of SI joint dysfunction. Local anesthetic resulting in joint block then pain relief can solidify your diagnosis.

Injected with combo of local anesthetic and corticosteroid– if pain goes down by 2 points after getting block in SI joint it’s probably the SI joints that’s causing pain.

Question 36

the lumbar facets are innervated by ___ branches of the __ ___ ramie. They are named for onee segment less than the name of the joint. therefore, the L4-l5 facet joint is innervated by the L3-L4 medial branches.

Answer 36

 Medial branches of
lumbar dorsal rami

Question 37

note

Question 38

T/F lumbar facet syndrome can cause pain to radiate down the legs

Answer 38

FALSE. faced mediated pain is AXIAL. it does not radiate down the leg by itself. Facet syndrome contributes to 15-45% of LBP cases.

Question 39

treatment progression for lumbar facet syndrome (most common source of mechanical lower back pain)

Answer 39

1. selective lumbar facet joint blocks
2. medial branch blocks
3. radiofrequency ablation.

Question 40

indications to get a facet block for your lumbar facet syndrome

Answer 40

1. at least 3 monghts of persistent nonradicular axial pain

2, non responding to conservative managemnt and physio

3. functionally disabled.

Question 41

Medial branch nerve blocks is the second most intense procedure for managing lumbar facet syndrome. What percentage decrease in pain must MBB elicit in pain to consider ablation?

Answer 41

need at least 50% reduction in pain to consider radiofrequency ablation.

Question 42

process of lumbar radiofrequency ablation

Answer 42

steroid at each level, and RF probes inserted and heated continuously at 80 degrees for 90 seconds. pulsed at 42 degrees for 2 minutes.

Question 43

T/F RFA or blocks can help with discogenic pain like they do for lumbar facet syndrome

Answer 43

false. Evidence supports RFA for Lumbar Facet and SI Joint mediated pain and NOT for discogenic pain.

Question 44

we sit too much. how can we prevent slipped discs?

Answer 44

WE NEED TO DYNAMICALLY SIT.

Question 45

note: you look for potential pain generators when ruling out yellow flags.

Answer 45

Persistent LBP may have identifiable etiologies
with specific treatment modalities
 Myofascial pain
 Lumbar facet syndrome
 SI joint dysfunction
 Interventional procedures may assist with rehabilitation programs in persistent LBP