Lumbar Flashcards
Keele STarTBack Screening tool
- combines key items from several previously validated screening questionnaires
- addresses pain location, function, avoidance beliefs, depression, and catastrophizing
- easily adminitered and scored
Red flags
- single red flag may not be predictive of serious disease
- metastatic lesions involving lumbar vertebrae are likely to be the most serious pathology that may present as LBP
Red flags that may increase likelihood of metastatic cancer
1) hx of cancer
2) night pain or pain at rest
3) unexplained weight loss
4) age > 50 or < 17
5) failure to improve over the predicted time interval following treatment
red flags that may suggest presence of an infection within the disk or vertebrae
1) patient is immunosuppressed
2) prolonged fever with a temp over 100.4
3) hx of intravenous drug abuse
4) recent UTI, cellulitis, pneumonia
Red flags suggesting undiagnosed vertebral fracture
1) prolonged use of steroids
2) mild trauma > 50 yrs old
3) age >70 yrs old
4) known hx of osteoporosis
5) recent major trauma at any age
6) bruising over spine following trauma
Red flags that may indicate AAA
1) pulsating mass in the abdomen
2) hx of atherosclerotic vascular disease
3) throbbing, pulsing back pain at rest or with recumbency
4) age > 60yrs
MRI and LBP
- sensitivity to detect subtle fractures, abnormal tissue growth, local and diffuse inflammatory issues, hemorrhage is extremely high
- also good at detecting serious compression of spinal cord
- 99% of patients presenting with acute or chronic LBP DO NOT HAVE THESE ISSUES!
- negative emotional impact with MRIs
Yellow flags
- emotional distress
- hypervigilance
- pain catastrophizing
- elevated fear avoidance beliefs
- low self-efficacy
- misunderstanding about the nature and likely impact of pain
- misunderstanding about the best strategies for long term success
Blue flags
- describe a patient’s perception of work and work conditions that may impair return to work
- ex. low job satisfaction and personal conflicts with employers or fellow workers
Black flags
- social and financial issues
ex. reimbursement incentives to remain disabled
Best questionnaires for LBP
- roland-morris back pain disability questionnaire
- odi
Spinal manipulative therapy
- typically better for acute patients
- significant lower pain and disability compared to those who receive placebo
SMT CPR
1) no symptoms distal to knee
2) less than 16 days
3) FABQ-work subscale less than 19
4) at least 1 hypomobile lumbar segment
5) at least 1 hip with greater than 35* IR
4/5 = + LR of 24
Treatment for subacute and chronic LBP
- motor control exercises are superior to minimal intervention at short and long term follow up
- graded activity and dgraded exposure incorporate cognitive approaches to improve activity tolerance
Graded exposure
-patients with LBP generate a hierarchy of feared activities and then gradually progress through these in an attempt to reduce activity-related anxiety
Graded activity
-uses operant conditioning to reinforce healthy behaviors and progress the patient through different levels of functional activity
Lumbar extension strengthening exercises
-not adequately investigated
Aerobic fitness and chronic LBP
-are helpful to reduce pain and increase function
-help to reduce increased awareness of neural stimulus (central sensitization)
-
Centralization exercises
- likely to reduce pain and increase mobility in patients with acute, subacute and chronic LBP
- likely to lead to better outcomes than passive treatments for patients with acute lbP, but efficacy and effectiveness of mckenzie approach for patients with cLBP was not clear
Patient education for back pain
- valuable to educate regarding maintaining a physically active lifestyle
- educate on the difference between “good pain” (post exertional soreness) and “bad pain”
Modern neuroscience approach
- literature demonstrates that changes in motor control are often coupled with substantial changes in brain structure and function in patients with cLBP
- no data to support yet
Dry needling
- evidence that trigger points are an important pain generator, but the mechanism is under debate
- evidence is inconclusive
Intervertebral disk
- annulus fibrosus
- nucleus pulposus
4 layers;
1) outer most annulus
2) inner portion of the annulus
3) transitional zone
4) vertebral end plate
Outer most annulus
- resistance to tensile loads
- dense, well oriented type 1 collagen
- virtually all the neurovascular structure is here
- loaded under flexion and/or SB
inner portion of annulus
- type I collagen
- lack the organization found in the outer most annulus
Transitional zone
- thin, fibrous tissues that surround and encompass the fourth and deepest layer
- gel like region composed primarily of water
Vertebral end plate
- borders the IVD
- large, flate cartilage covers the central portions of the superior and inferior vertebral bodies creating a semi-permeable barrier between subchondral bone and IVD
- this area is the “weak link” where IVDs are exposed to trauma
Cauda equina
1) urine retention
2) fecal incontinence
3) saddle anesthesia
4) sensory or motor deficits in teh feet (L4-S1 areas)
Thrust and non-thrust manipulation
- is effective for subgroups of patients and as a component of a comprehensive treatment plan
- grade I
- clinicians should consider utilizing thrust manips to reduce pain and disability
- can also be used to improve spine and hip mobility and reduce pain with subacute and chronic
- grade A
Top 2 factors of manip CPR
1) duration less than 16 days
2) symptoms distal to the knee
+ LR of 7.2
Trunk coordination and strengthening
-grade a recommendation for patients with subacute and chronicn LBP
Centralization
-grade A - for acute, subacute and chronic
Nerve mobilization
-grade C
Traction
-grade D - conflicting evidence
Stenosis CPR
- (B) symptoms
- leg pain more than back pain
- pain with walking/standing
- pain relief upon sitting
- age > 48 years
3 tests positive sp=0.88
4 tests positive = 0.98
5 tests positive = 1.0.
sn is poor if > 3 tests positive
