Lumbar Flashcards by Katie Young

T/F: women and minorities with LBP exhibit greater pain, disability, but better tx

False, they exhibit greater pain, disability, and POORER tx

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Prognosis of aLBP

Generally favorable, HOWEVER.. recurrence rate is high

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Those with cLBP typically present with more comorbidities including:

Central sensitization, lumbar muscle alterations, changes in the processing of pain in the brain

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T/F: vertebral end-plates play a role in getting nutrition to the IVD?

True, the end plate has a semi-permeable barrier that allows diffusion of some nutrients to the avascular IVD

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Does the high intensity zone (HIZ) have something to do with symptomatic LBP

Inconclusive at this point

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Most disc herniations/bulges have a spontaneous regression within what time frame?

Typically a year, but up to 40 months

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T/F: The worse a disc herniation/bulge looks on imaging = the less likely the chance of spontaneous resolution

False, actually the worse it is on imaging, the more likely the resolution!!!

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Modic changes and types

Modic changes describe changes in the endplate and bone marrow

Type I: inflammatory reaction in bone marrow

Type II: fatty infiltration to bone marrow

Type III: sclerotic changes to bone marrow

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Which modic type is associated with the presence of LBP?

Type I (mixed evidence)

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T/F: modic changes occur naturally with age

True

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T/F: Gray matter volume (GMV) thickness plays a role in LBP

True

GMV was reduced in dorsal lateral prefrontal cortex (DLPFC), temporal lobes, insula, and somatosensory cortex (S1 - mixed results)

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Does tx have any effect on the GMV thickness?

Yes, it’s found that cortical thickness can increase for those who responded positively to tx!!

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What percentage of cLBP has no know anatomical cause

85-95%

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3 possible non-structural changes that contribute to cLBP

1) People with LBP move differently

2) People with LBP process nociception differently

3) Somatotopic organization differes in individuals with cLBP

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Cortical smudging

Loss of discrete organization in the motor cortex in individuals w/ LBP (aka the place that is responsible for TA activation is now reassigned with something else)

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T/F: Impaired motor control often observed in cLBP can be linked to cortical reorganization

True!!

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Is there a true link between cLBP and depression

Yes

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Is depression linked with poor PT outcomes?

Yes, It is often associated with poor recovery

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What outcome scale can you use for depression assessment in LBP population?

Beck Depression Inventory

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What outcome scale can you use for pain catastrophizing assessment in LBP population?

Pain Catastrophizing Scale (PCS)

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Any relation between pain catastrophizing and GMV?

Yes, it has been linked to decreased GMV in the DLPFC

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Is disability related to pain intensity?

No, psychosocial contributors are MUCH more likely to play a role in disability

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Is there a way to predict if aLBP can turn into cLBP

Not really, a functional MRI can look at the motivation-valuation circuitry but is not practical to the clinic due to price

aka No way to tell, can use clinical judgement and some outcome measures to help (SBT or OMPQ )

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Which 2 outcome measures can possibly help screen for risks of poor prognosis or cLBP?

Which is more superior tool?

SBT: STarT Back Screening Tool

OMPQ: Orebro Musculoskeletal Pain Questionnaire

SBT is BETTER!

NOTE: SBT in combo with MDQ (mod oswestry) can adequately predict those who will respond WELL to tx

What is considered the mainstay of PT management in LBP?

Exercise in combo with education

What outcomes questionnaires can be used to screen for red and yellow flags in LBP pathology?

OSPRO-ROS and OSPRO-YF

Is neurological screening useful in LBP patients?

Yes, however use an abundance of caution when trying to make diagnostic conclusions about exact nature and location of pathology

Is posture important when treating someone with LBP?

Not necessarily... Helping pt's find a posture that is that is more relaxed and comfortable IN COMBO with education on how their posture is safe = symptom relief

Those with LBP tend to display greater (upper/lower) lumbar excursion during the first 20-50° of motion while limiting the amount of concurrent hip flexion during fwd bending

Upper NOTE: increase in early lumbar motion correlated with self-reporting of functional limitations

What aspect of a physical exam of LBP is the most related to reproduction of the comparable sign (CS)?

ROM assessment Best is an assessment that looks at both quality and pain reproducibility

Treatment-based classification (TBC): 3 rehabilitation approaches

1) Symptom modulation 2) Movement control 3) Functional optimization

Efficacy of the TBC approach

Concerning.. recent studies show that those who receive matched tx care did no better vs those who received unmatched care

Surgery vs non-surgical management of LBP (i.e. lumbar stenosis)

Same outcome

Are graded activity and graded exposure approach helpful for tx of LBP?

Yes, they have been proven to reduce pain and disability vs minimal tx HOWEVER: graded activity/exposure is no better vs generalized exercise

Graded activity and graded exposure VS generalized exercise

Same in effectiveness

Motor control exercises VS generalized exercise

Same in effectiveness at restoring proper movement patterns

Motor control exercises VS placebo

Motor control is BETTER vs placebo

MDT (i.e. directional preference) vs placebo

MDT was superior to placebo NOTE: same as generalized exercise though

Walking vs non-pharmacological interventions

Same, goal 150 mins a week Helpful if pt's can't tolerate PT

T/F: motor control, stabilization, graded exposure/activity, and MDT are all equal vs generalized exercise

True

Dosing of exercise for cLBP

Unknown A study found that increasing the frequency per week was the most likely cause of pain relief for pt's w/ cLBP

Is spinal manipulation and mobilization helpful in treating LBP? Is any superior to the other?

Yes, especially in aLBP and also occasionally cLBP Manip > mobs (as it relates to reducing disability)

Clinical prediction rule for who would respond best to spinal manip (4/5 = +LR 24.38)

1) No symptoms past knee 2) Pain duration <16 days 3) Score <19 FABQ 4) At least 1 hypomobile segment 5) 1 or both hips at least IR >35°

Can spinal manipulative therapy (SMT) be used as a stand alone tx?

Unlikely that SMT in isolation will provide optimal benefit so use in CONJUNCTION with other therapies (i.e. exercise)

Is dry needling indicated in tx of LBP?

Dry needling vs sham was effective in reducing pain and disability NOTE: Low quality studies

Dry needling vs acupuncture in tx for LBP

Dry needling better in short-term, however same results long-term

Can dry needling be used as stand alone tx?

No, best used in conjunction with other therapies

Is using a bio-medical educational model indicated in tx of cLBP?

No, it may increase fears, anxiety, and stress. Education going more towards reassuring the pt's that they have a good prognosis and return to typical activities

Is using pain neuroscience education (PNE) indicated in tx of cLBP?

Yes!! Compared to traditional education, PNE demonstrates significant improvements with reduction in healthcare utilization, disability, pain beliefs, pain catastrophizing, and both SLR and fwd bending

Can PNE be used as a stand alone tx in cLBP?

No, best in combo with exercise and other physical interventions

Is using pain neuroscience education (PNE) indicated in tx of aLBP?

No, it is no better vs placebo in treating ACUTE LBP. However, primary-care basic advice and reassurance seems to be adequate.

Does patient rapport play a role in outcomes for cLBP?

Yes, the therapeutic alliance has been shown to be a strong predictor of outcomes for cLBP

3 Primary components of a "Therapeutic Alliance"

1) agreement on goals 2) agreement on tx 3) affective bond

Mindfulness Based Stress Reduction (MBSR)

Technique to treat the "psychosocial" aspect of care, 8 wk program Unknown to tx LBP

Mindfulness Based Stress Reduction (MBSR) vs CBT

Same outcome, both able to relieve pain to a similar extent

Has an app for MBSR been shown to help?

Yes, good results

Classic red flags for diagnosing spinal fracture (4*)

1) Prolonged use of corticosteroids 2) Significant trauma 3) Age >70 y/o 4) Female (variable factor) NOTE: only first 3 variables have research behind it 2+ factors are positive = +LR >10