Lumbar Flashcards
T/F: women and minorities with LBP exhibit greater pain, disability, but better tx
False, they exhibit greater pain, disability, and POORER tx
Prognosis of aLBP
Generally favorable, HOWEVER.. recurrence rate is high
Those with cLBP typically present with more comorbidities including:
Central sensitization, lumbar muscle alterations, changes in the processing of pain in the brain
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
Does the high intensity zone (HIZ) have something to do with symptomatic LBP
Inconclusive at this point
Most disc herniations/bulges have a spontaneous regression within what time frame?
Typically a year, but up to 40 months
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!!!
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
Which modic type is associated with the presence of LBP?
Type I (mixed evidence)
T/F: modic changes occur naturally with age
True
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)
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!!
What percentage of cLBP has no know anatomical cause
85-95%
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
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)
T/F: Impaired motor control often observed in cLBP can be linked to cortical reorganization
True!!
Is there a true link between cLBP and depression
Yes
Is depression linked with poor PT outcomes?
Yes, It is often associated with poor recovery
What outcome scale can you use for depression assessment in LBP population?
Beck Depression Inventory
What outcome scale can you use for pain catastrophizing assessment in LBP population?
Pain Catastrophizing Scale (PCS)
Any relation between pain catastrophizing and GMV?
Yes, it has been linked to decreased GMV in the DLPFC
Is disability related to pain intensity?
No, psychosocial contributors are MUCH more likely to play a role in disability
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 )
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
