Lumbar Flashcards
How long do acute instances take to recover for LBP?
6-8 weeks
Does acute LBP have flare ups?
Yes - has flare ups, but quick recovery - pain does not mean failure of tx
What are previously thought risk factors for LBP?
Prolong sitting, lifting, sports - study found no associated factors associated & should not be avoided w/o rationale
Hancock CPR - recovery time: what results in quick recovery?
1) Lower initial pain 2)shorter duration sxs 3)fewer previous episodes - conversely; 1) high deg of disability 2)previous hx of loss of work -> much less likely to recover (overall strength is weak to moderate)
What 3 areas of body do pain modulators affect?
1) spinal cord 2) brain stem 3)higher brain centers
Chronic spinal pain results in firing of what fibers
C-fibers / A-delta fibers; analgesia results in blocking these fibers - sensitization results in lower threshold in these fibers
What area of the brain stem is stimulated for inhibition?
DPag (dorsal periacqueductal grey)
What disease processes affect the heterogeneity of LBP?
1) reduced physical activity 2)inc sitting 3)inc use of computers 4)obesity with chronic inflammation (theoretical)
Should pts be encouraged to initiate early treatment or bed rest?
Early treatment - improves LT outcomes; rapid transition from passive to active treatment
Is a single red flag item predictive of serious disease?
No - need constellation of sxs
What are signs/sxs consistent with metastatic cancer?
1) hx of cancer 2) night pain/pain at rest 3) unexplained weight loss 4) age >50 / <17 5) failure to improve with predicted time frame
What are signs/sxs consistent with infection with disc/vertebrae?
1) immunosuppression 2) prolong fever (100.4) 3)hx of intravenous drug use 4) hx of UTI, cellulitis, pneumonia
What are signs/sxs consistent with AAA?
1) pulsating mass in abdomen 2) hx of atherosclerotic vascular dx 3) throbbing, pulsating back pain at rest 4) age >60 years
What is the CPR by Henscke for vertebral fractures?
1) age > 70 2)female 3) significant trauma 4) prolong use of steroids - 3 or more +LR of 52%
What two MRI findings, according to Hancock systematic review, were meaningful in disc pathology?
1) high intensity zone (associated with annular tear) +LR 1.5 to 5.9 - 2) Modic sign = end plate changes which result in impaired diffusion between subchondral bone/disc - LR 0.21
What positive eval/exam finding is consistent with disc pathology?
Centralization - +LR 2.8
Definition and example yellow flags -
Definition: pt’s personal mistaken beliefs about pain/injury - example = pain catastrophizing, hypervigiliance,
Definition of blue flag
Related to injured worker; describe pt’s perception of work and work conditions that may impair return to work
Definition of black flag
Social & financial issues related to care - ie: unhelpful reimbursement incentive to remain disabled
What are established predictors of chronicity of pain?
1) imaging findings of multi-level DDD 2)strenuous/stressful job 3) leg pain 4) low education background 5) fear avoidance beliefs
Roland Morris Disability Questionnaire - important clinical change?
5 points
Oswestry Disability Index - important clinical change?
10 points
Manual therapy effect on outcomes?
Early use with transition to more active approach - generally thought to have small, moderate effect with potential meaningful
Childs CPR for LBP - 5 factors
1) no sxs distal to knee 2)at least 1 hip > 35 IR 3) FABQ-W <19 4) at least 1 hypomobile L/S segment 5) acute onset <16 days
Define graded exposure:
General hierarchy of feared activities and then gradually progress through these in attempt to reduce activity related anxiety
Define graded activity:
Operant condition to reinforce healthy behavior & progress through different levels of functional activity
What is the research regarding progressive endurance / fitness exercise for LBP?
Aerobic fitness programs reduce inc awareness (hypervigiliance) of neural stimulus // Weight training reduces frequency of acute episodes
According to the LBP CPG: 3 areas for pt education/ counseling:
1) avoid bedrest - stay active 2) cognitive behavioral therapy / graded inc in activity 3) physiology of pain (neuroplasticity, central sensitization - sxs don’t represent serious pathology/disease)
Trigger points, taut bands, in muscles are:
Local areas of congestion, inc concentration of cytokines (hyperalgesia), with sustained muscle contraction & alteration in chemical environment = end plate noise
What theory does trigger point dry needling operate on use?
Gate control effect; activating alpha-delta nerves stimulating dorsal horn interneurons to create opiate like pain reduction
Peripheral manual therapy for LBP results in what changes in the disc?
Diffusion rates of fluid movement in muscles/joints - > changes in disc fluids
What central hormone is found affected with manual therapy?
Cortisol
IVD consists of what 4 layers:
1) nucleus 2) transitional zone 3)inner annulus 4) outer annulus
What are the main features and roles for the IVD?
Support, mobility, maintain stability under loading, permits multi directional & intersegmental motion - maintains vertical distance between vertebrae for tension on ligaments, alignment of facets
Where are nearly ALL the neurovascular structures of the IVD found?
Outer annulus - sensory & nerve fibers as well as blood vessels (depth of 3.5 mm)
What are the two routes of sensory travel for the IVD in lowback pain?
1) segmentally (posterior dorsal root) 2)extra-segmentally thru paravertebral chain sympathetic == vague & diffuse pain
What area of IVD is only area with blood supply and can entertain O2 / nutrient exchange?
Outer annulus - rest of disc relies on osmosis
What is the diurnal variation for the IVD like before and after 35?
< 35- greater water content in AM (after recumbency) loss of 0.9 mm of disc
>35 - decreased ability to perform fluid exchange; DDD
What three tissues are disc pathology associated with?
Nucleus, annulus or subchondral bone/endplate
What force does the annulus abnormally resist with a decreased water content?
Compression - acts as solid restraint vs. flexible interspace
What decade of life is DDD usually present by - and what decade is it universally present by?
Third decade usually
Universally by 7-8th decade
By what decade are the blood vessels gone from the endplate of the IVD?
2nd decade - > Modic sign; changes in endplate intensity on MRI
Define Schmorl Node:
Cartilage protruding into adjacent vertebral body
Where does the annulus typically rupture?
Lower lumbar segments
Where in the IVD annulus do sxs generate due to injury?
Peripheral rim lesions - outer most 3.5 mm
What loss in disc height results in overloading facet joints?
1-3 mm - noticeably reduces foraminal space / loads longitudinal ligaments -> stimulates osetophyte formation (spondylosis)
What is the capacity for healing for the IVD?
Annulus: limited; poorly remodeled scar
Middle/inner: filled granulation tissue - lack of tensile strength
What do the tissue changes of remodeled annulus/middle & inner discs result in for metabolism of the cell?
Decreased diffusion of O2/nutrients - lower O2 = lower pH = higher lactic acid; inactive cells -> cell death
What are the implications for late stage DDD? (disk height, microtrauma, prolong exposure to compressive loads)
1) Microtrauma causes pain next day - delayed onset
2) Avoid lifting first two hours awake
3) Avoid long exposure of compressive load (prolong sitting, lumbar flexion)
What is the biggest predictor of patient satisfaction in clinical interaction?
Therapist interaction with patient - likely results in better clinical outcome
What are signs/sxs for cauda equina?
50-55 y.o., bowel/bladder changes, saddle parestheisa, LE weakness - exacerbated by standing/walking - eased by flexion
Grades for spondylolisthesis:
Grade 1 <25%
Grade 2 25-50%
Grade 3 50-75%
Grade 4 >75%
CPR for return to work with acute LBP: non-recovery at 3 months (negative factors)
1) age > 45 years
2) smoking
3) 2 or more neurologic findings
4) >90 score on psychosocial screen = high distress
Motion in the SIJ: (mm & deg)
1.6 mm - - 4 deg rotation
Laslett special test cluster for SIJ: (5 tests)
1) SIJ compression
2) SIJ distraction
3) thigh thrust
4) sacral thrust
5) gaenslen’s
Van der Wurff special test cluster of SIJ (5 tests)
1) FABERs
2) ASIS distraction
3) thigh thrust
4) ASIS compression
5) gaenslen’s
3 or more tests = Sn 0.85 // Sp 0.79 with +LR 4, -LR 0.19
Where is McBurney’s point?
Line between naval & ASIS; halfway between - positive test = rebound pain
What is the Psoas sign?
Bring the hip passively into extension and adduction which reproduces pain in the abdomen = can be consistent with inflamed appendix
What is the Obturator sign?
Passively flex hip to 90 and IR hip which reproduces pain in the abdomen = cam be consistent with inflamed appendix
