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clinical practice guidelines > lumbar > Flashcards

lumbar Flashcards

1
Q

what percentage of individual can be given a patho-anatomic diagnosis with back pain

A

20%

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2
Q

What is the general consensus regarding risk factors for developing low back pain

A

No definitive cause has been identified. Risk factors are multifactorial, population specific and only weakly associated with development of low back pain

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3
Q

what is the consensus regarding the clinical course of low back pain

A

It can be described as acute, subacute, recurrent or chronic
- due to the high prevalence of recurrent and chronic back pain interventions should focus on preventing recurrences and helping people transition into chronic stage

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4
Q

What are the recommended general diagnosis or PT classification of low back pain

A
  1. mobility impairments of the spine and SIJ
  2. referred or radiating pain into the lower extremity
  3. generalized pain
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5
Q

What differential diagnosis recommendations are made for outside referrals

A
  1. clinical findings suggestive of serious medial or psychological pathology
  2. functional limitations and impairments are not consistent with MSK back pain
  3. symptoms are not resolving with treatment
    * strong evidence for recommendation
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6
Q

what self reported questionnaires are recommended for back pain

A
  1. Roland Morris

2. Oswestry

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7
Q

What is the general recommendation regarding Thrust manipulations

A
  1. strong recommendation for patients with back pain and falling into the mobility deficit classification
  2. Thrust and non-Thrust are recommended for improving spine and hip mobility
  3. reducing pain and disability for subacute and chronic low back pain and back related leg pain
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8
Q

What are the general recommendations regarding trunk coordination, strengthening and endurance exercise with low back pain

A
  1. use them to reduce pain and disability in patients with subacute and chronic back pain with movement coordination impairments AND POST LUMBAR MICRODISCECTOMY
    * strong evidence
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9
Q

what are the general recommendations regarding centralization and directional preference exercises

A
  1. repeated motions exercises and procedures to promote centralization
  2. recommended for all stages acute to chronic in patient with mobility deficits
    * strong evidence
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10
Q

what are the general recommendations regarding flexion based exercises

A
  1. helpful in reducing pain and disability in older patients radiating pain
  2. recommended for subacute and chronic stages
    * week evidence
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11
Q

what are the general recommendations regarding nerve mobilization exercises

A
  1. helpful with radiating pain
  2. subacute and chronic stages
    * week evidence
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12
Q

What are the general recommendations regarding traction for low back pain

A
  1. intermittent type traction
  2. prone when presenting with subacute nerve root with peripheralization or positive cross SLR
    * emerging evidence
  3. DON’T do traction with acute/subacute nonradicular or chronic back pain
    * moderate evidence
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13
Q

What type of education interventions are discouraged

A

Anything that directly or indirectly promotes perceived threat or fear associated behaviors including (1) extended bed rest (2) in-depth pathoanatomic explanations of low back pain
*moderate evidence

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14
Q

What types of educational interventions are encouraged

A
  1. Understanding the pathoanatomic “strength” of the spine
  2. neuroscience of pain perception
  3. favorable prognosis for spine pain
  4. use of active pain coping strategies that decrease fear and catastrophizing
  5. early resumption of activity even when they are still in pain
  6. Recognition of improvements in function not just pain
    * moderate evidence
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15
Q

what is the general recommendation for pregressive endurance exercise and fitness training in indvidual with back pain

A
  • strong level of evidence for
    (1) Moderate to high intensity exercise for patients with chronic low back pain without generalized pain
    (2) incorporating progressive, low intensity, submaximal fitness and endurance activities into the pain management and promotion strategies for patients with chronic low back pain with generalized pain
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16
Q

Describe the prevalence of low back pain

A
  1. one year incidence of first ever back pain is between 6.3 and 15.3%
  2. episodes of low back pain are from 1.5-36%
  3. Reoccurrence of low back pain is 24-33%
  4. Women higher than men
  5. severity progresses with age until 60-65 years
  6. lower socioeconomic status is associated with increased prevalence, longer episodes and worse outcome
  7. jobs with higher physical demands have greater prevalence of back pain (material handling jobs 39% and sedentary jobs 18.3%)
  8. Working and non working prevalence is about the same
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17
Q

what are the two major categories of risk factors for developing low back pain

A
  1. individual factors

2. activity related factors

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18
Q

What are the individual risk factors for developing low back pain

A
  1. some relation to genetic, body build and early environment influences
  2. cardiovascular hypertension and lifestyle (weight and smoking) are risk for “sciatica”
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19
Q

how do psychosocial factors influence risk for developing low back pain

A
  1. They play a larger prognostic role that physical factors
  2. kineisophobia has a strong link to the development of chronic back pain
  3. distress and depression have a strong influence over the early stages of recovery
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20
Q

What variable suggest a more favorable outcome in individuals with back pain

A
  1. lower pain levels
  2. higher job satisfaction
  3. active coping style
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21
Q

what variables appear to low impact on recovery from low back pain, yet may influence prevalence of low back pain

A
  1. history of low back pain
  2. job satisfaction
  3. educational levels, marital status, number of dependents, smoking, working more than 8 hour shifts, occupation, size of company
  4. complex back problems recover as well as simple back problems
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22
Q

describe the risk factors for developing low back pain in adolescence

A

very similar to adults

  • psychosocial variable are strong predictors of chronicity
  • sporting activities such as rowing and weight lifting have higher risk for developing low back pain
  • girls as much as 3:1
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23
Q

What is the over conclusion on risk factors for low back pain

A

GRADE B - Current evidence does not support definitive causes for initial low back pain
- risk factors are multifactorial, population specific and only weakly associated with development of low back pain

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24
Q

Describe the role of imaging in identifying a pathoanatomic cause of low back pain

A

poor association between anatomy and pathology

  1. 20-76% of individuals without symptoms have anatomic impairment
  2. 32% of asymptomatic individuals compared 47% of symptomatic individuals have “abnormal” MRI findings
  3. Boos followed asymptomatic patients for 5 years and found a stronger association between job characteristics and pyschological aspects with development of back pain than radiological findings
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25
Q

what are the different temporal stages of back pain

A

acute - less than one month
subacute - 2-3 months
chronic - greater than 3 months
* challenge with these descriptions is that low back pain is episodic in nature with episodes occurring in as much as 65% of individuals and as often as every 2 months in t

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26
Q

what factors are predictive of developing recurrent or chronic low back pain

A
  1. history of previous back pain
  2. excessive spine mobility
  3. excessive joint mobility in other joints
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27
Q

what prognostic factors put someone at risk for developing chronic pain

A
  1. presence of symptoms below the knee
  2. psycological distress or depression
  3. fear of pain, movement and reinjury or low expectations of recovery
  4. high pain intensity
  5. passive coping style
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28
Q

what is the first step in evaluating low back pain

A

Rule out medical red flags and nerve root compression

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29
Q

What does the evidence suggest about treatment classifications for low back pain

A

strong support for classifying patients into subgroups

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30
Q

what are the CPG recommended treatment classification of low back pain

A
  1. low back pain with mobility deficits
  2. low back pain with movement coordination impairments
  3. low back pain with related lower extremity pain
  4. low back pain with radiating pain
  5. low back pain with related generalized pain (psychosocial impacts)
    * * all are rated with a level of acuity and irritability (relationship of movement and pain)
31
Q

Describe the relationship of ROM impairment and symptoms in the classficiation of low back pain

A
  1. beginning ROM and segmental mobility impairment - fits the acute low back pain with mobility class
  2. mid to end range pain with passive and active motion - subacute classes of mobility, coordination or radiating pain
  3. sustained end range - chronic classes of coordination or radiating pain
32
Q

what clinical findings would you expect with acute mobility deficit classification

A
  • acute low back, buttock or thigh pain of less than one month
  • restricted lumbar ROM and segmental mobility
  • low back and low back related LE symptoms produced with provocation testing of the T, L and SI regions
33
Q

. what clinical findings would you expect with subacute mobility deficit classification

A
  • subacute symptoms that do not go past the knee
  • symptom production at end ranges of motions
  • spine and hip mobility deficits
34
Q

what ICD code is associated with each classification

A
  1. lumbosacral segmatal/somatic dysfunction - mobility deficit
  2. spinal instabilities - movement coordination
  3. flat back syndrome or lumbago due to displace of IVD - back pain with related LE pain
  4. lumbago with sciatica - radiating pain
  5. Low back pain/low back strain/lumbago - pain with related cognitive deficit or generalized pain
35
Q

describe acute and subacute clinical finding expectations for movement coordination classification

A 
acute
- commonly associaete with referred pain
- begin got mid range pain
- movement coordination impairments 
subacute
- mid to end range motion impairments
- segmental hypermobility
- decreased trunk strength or endurance
- movement coordination impairments with routine activities
36
Q

what clinical findings would you expect for LBP with related LE pain

A
  • referred pain down to the knee that increases with flexion based motion
  • symptoms can be centralized with motion, manual interventions or repeated movement
  • lateral trunk shift, reduced lumbar lordosis, limited lumbar extension mobility
37
Q

what clinical findings would you expect with LBP with radiating pain

A

acute
- LBP with LE parethesia, numbness or weakness
- begging to mid ROM impairments and positive neurodynamic testing
- signs of nerve root involvement - neuro testing
subacute
- mid to end range motion
- mid to end range neurdynamic testing
chronic
- chronic or recurring symptoms
- sustained end range neurdynanic testing

38
Q

what clinical findings would you expect with LBP related to cognitive or affective tendencies

A
  • back pain
  • presence of Primary care for depressive symptoms, high FABQ, High pain catastophizing Scale or cognitive process consistent with helplessness, rumination or pessimism regarding back pain
39
Q

What is the first goal of the PT evaluation

A

Determine if the person is appropriate for physical therapy

40
Q

What are some common red flags for evaluation of back pain

A
  1. tumor
  2. cauda equina syndrom
  3. back related infection
  4. spinal compression fractures
  5. abdominal aneurysm
  6. failure to improve with treatment after 30 days
  7. spinal fractures
41
Q

what clinical findings would you expect with low back pain associated with a tumor

A
  1. constant pain not affected by position or activity, worse with weight bearing, worse at night
  2. over 50
  3. History of cancer
  4. failure to improve with conservative care
  5. unexplained weight loss
  6. no relief with bed rest
42
Q

what clinical findings would you expect with cauda equina syndrome

A
  1. urine retention
  2. fecal incontinence
  3. saddle anesthesia
  4. sensory or motor deficits in the feet
43
Q

What clinical findings would you expect with back related infections

A
  1. recent infections or IV drug use
  2. concurrent immunosuppressive drugs
  3. deep constant pain that increases with weight bearing
  4. fever, malasie, swelling
  5. spine rigidity
44
Q

what clinical findings would you expect with spinal fractures

A
  1. age greater than 70
  2. female
  3. history of major trauma
  4. prolonged corticosteriod use
45
Q

what guidelines are suggested to help guide referrals other health care practitioners

A

consider referral when:

  1. clinical findings are suggestive of serious medical or psychological pathology
  2. clinical findings are not consistent with clinical classification
  3. symptoms are not resolving with interventions
46
Q

what are the American College of Physicians’ recommendations on diagnostic imaging with low back pain

A
  1. recommended for severe progressive neurological deficits

2. routine imaging does not result in clinical benefit and may lead to harm

47
Q

what types of muscular changes have been observed in individuals with chronic low back pain

A
  1. multifidi atrophy
  2. fatty infiltration
  3. altered multifidi firing patterns
48
Q

what is the minimally important change in Oswestry and Roland Morris DQ score

A
  • OS - 10 of 100 or 30%

- RM - 5 of 24 or 30%

49
Q

what does the Gouttebarge systematic review conclude regarding FCE

A

more information is needed and Isernhagen system had good reliability and predictive validity

50
Q

describe the measurement properties for segmental mobility testing

A
  1. low reliability for ordinal scales
  2. good reliability for classifying as hypo or hyper
  3. good validity with radiographic correlation of instability and response to treatment
51
Q

describe the measurement properties of pain provocation with segmental mobility testing

A

spring test over facets and SPs

- Kappa values are moderate to good for pain provocation (0.25 to 0.55)

52
Q

what are the clinical findings associated with lumbar aberrant movement and the measurement properties

A
  1. painful arc of motion
  2. “catch” or deviation form the sagittal plane of motion
  3. Gower sign
  4. reversal of lumbopelivc rythm - a sudden bend in the knees as they return from the upright position
    * moderate to good reliability (kappa of 0.6)
53
Q

What is the CPG recommendation for testing trunk flexors

A
  1. passive elevation of the extended legs in supine until the sacrum rises
  2. keeping the back in contact with the bed measure how low they can lower their legs before their back comes up
  3. less than 50 deg male and 60 deg females is associated with back pain
54
Q

what is the CPG recommendation for testing TA

A

prone pressure transducer

  • 70 mmHg under stomach then such in the TA to determine how much pressure then can decreased
  • 4mmHg reduction is normal 2mmHg associated with back pain
55
Q

CPG recommendation for trunk extension strength

A

Prone shoulder raise time with hands behind back

- males unable to hold longer than 31” (female 33”) are more likely to have back pain

56
Q

what are the norms for hold a bridge position for assessing hip extension endurance

A
  • 172 seconds healthy

- 79 with low back pain

57
Q

Describe the process recommended by the CPG for hip motion

A
  • rotation - prone
  • extension - Thomas test starting from flexed position and lowering one leg down
  • flexion - supine and flex up until the contralateral leg starts to rise
58
Q

How would you score a FABQ

A
  • 0 to 42 work scale with higher scores indicated greater fear
    greater than 29 poor return to work expectation and self reported debiliaty at 6 months
    greater than 22 poor return to function for general population without the work related questions
59
Q

how would you score pain catastrophizing scale

A

0-52 points higher score more catastrophy

  • rumination items 8-11
  • magnification items 6,7,13
  • helplessness itmes 1-5, 12
60
Q

what is the Orebro MSK pain screening questionnaire

A

The Örebro Musculoskeletal Pain Questionnaire (ÖMPQ) is a ‘yellow flag’ screening tool that predicts long-term disability and failure to return to work when completed four to 12 weeks following a soft tissue injury. A cut-off score of 105 has been found to predict those who will recover (with 95 per cent accuracy), those who will have no further sick leave in the next six months (with 81 per cent accuracy), and those who will have long-term sick leave (with 67 per cent accuracy)1

61
Q

what is the STarT back screening tool

A

AKA Keele STarT

  • The Keele STarT Back Screening Tool (SBST) (9-item version) is a brief validated tool, designed to screen primary care patients with low back pain for prognostic indicators that are relevant to initial decision making
  • The distress subscale score is used to identify the high-risk subgroup. To score this subscale add the last 5 items; fear, anxiety, catastrophising, depression and bothersomeness (bothersomeness responses are positive for ‘very much’ or ‘extremely’ bothersome back pain). Subscale scores range from 0 to 5 with patients scoring 4 or 5 being classified into the high-risk subgroup [1].
  • The overall score is used to separate the low risk patients from the medium-risk subgroups. Scores range from 0-9 and are produced by adding all positive items; patients who achieve a score of 0-3 are classified into the low-risk subgroup and those with scores of 4-9 into the medium-risk subgroup
62
Q

What is the CPG consensus on manipulation for low back pain

A

consider using manipulation with patient demonstrating mobility deficits, acute LBP and back related buttock or thigh pain

63
Q

what variables are predictive of success with manipulation

A 
PRIMARY
- symptoms less than 16 days
- no symptoms distal to knee
SECONDARY
- lumbar hypomobility
- FABQ less than 19
- at least one hip with greater than 35 degrees of IR
64
Q

what findings would suggest a patient could benefit from a stabilization program

A
  • age less than 40
  • positive prone instability
  • presence of aberrant movements with motion testing
  • SLR greater than 91
65
Q

How does motor control exericse for LBP compare to walking program for subactue back pain

A

36 month follow up motor control group did better with improvement in preseved debility and health parameters.

66
Q

what is the CPG general consecuse regarding exercise and LBP

A

Grade A- exercise works in subacute and chronic back pain

67
Q

when are repeated motion with centralization and directional preference exercises recommended

A

GRADE A evidence - to reduce symptoms in patients with acute low back pain with related/referred lower extremity pain

68
Q

Describe the evidence for neurodynamic treatment

A

GRADE C - suggestion for patients with subacute or chronic low back pain and radiating pain

69
Q

what treatment modality was described as positively impacting central sensitization

A

GRADE A - progressive endurance activity and fitness activity

70
Q

what are the treatment recommendations for ACUTE LBP with mobility deficits

A
  1. manual therapy procedures
  2. exercise
  3. patient education
71
Q

what are the treatment recommendations for subacute LBP with mobility deficits

A
  1. manual therapy
  2. ther ex
  3. prevention of recurring by addressing coexisting impairments and encouraging long term activity
72
Q

what are the treatment recommendations for acute low back movement coordination

A
  1. NMR
  2. temporary external support
  3. self care and home management strategies including good posture and promoting activity
73
Q

what are the treatment recommendations for subacute LBP with coordination impairment

A
  • NMR and stability exercise in pain free ranges
  • manual therapy
  • ther ex for trunk and pelvic strength
  • self care strategies

clinical practice guidelines (10 decks)

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