Lumbar Flashcards
Questionnaires good for self-report with LBP (2)
- Oswestry
2. Roland-Morris
Clinical progression of LBP (3 + time periods)
- Acute (<1 month)
- Subacure (1-2 months)
- Chronic/recurrent (>3 months)
On/off switches at what three levels of the NS?
- Spinal cord
- Brain stem
- Higher brain centers
Gate control theory - “switch off”
at the spinal cord
non-nociceptive A-beta fibers recruit inhibitory neurons in the substantia gelatinosa of the posterior spinal cord
- chemically block ascending A-delta fibers and c-fibers
Four types of neurons in ascending pathways -
- names of fibers
- information carried
- Myelination?
- speed
- A-alpha, proprioception, myelinated
- A-beta, touch, myelinated
- A-delta, pain (mechanical and thermal), myelinated
- C-fibers, pain (mech, therm, chem), NON-myelinated
Spinal cord “switch on” with gate control theory
- theory of chronic spine pain
repetitious c-fiber firing thought to be enhanced by rapidly expressed genes => further increases sensitivity/sensitization of nociceptors = decreases threshold to stimulation and results in a wider receptor field
Brain stem “switch off”
stimulation of periaqueductal gray matter (PAG m.) by descending pathways from HIGHER centers
- PAG is opiodergic (descends to and affects the dorsal horn)
higher brain centers
- interaction with pain (conscious
- spinothalmic tr.
- Modulates neural activity and/or conscious perception of pain
- Numerous cortical regions of spinothalmic tr. produce the multidimensional pain exp.
Chemicals/agents released by higher brain centers for pain management
Dopamine
Serotonin
Endogenous opiates
Cannabinoids
Chemical responses from higher brain centers in presence of placebo, direct interventions, or both?
Clinical research has shown that both placebo and direct interventions may cause the release of multiple substances into the CNS in an opiodergic fashion
Subgroup for Targeted Treatment (STartT) Back Screening Tool
- use?
Promising tool to address homogeneity
- avoiding the one-size-fits/rx-all concept
- used to identify pts with LBP at risk for long term functional limitations
Poor prognosticators for individuals with CLBP (2)
- high pain
2. high disability
T or F: single red flag is predictive for serious dz
- if false, why?
False - many people have single red flags show up, but these should be used in clusters to lead the therapist to concerns for serious pathology - the higher the number of red flags, the greater the concern
T or F: nearly all pts will show one red flag w/o notable serious dz
- if false, why?
True
Two major serious dx to screen for in the outpatient setting
- Metastatic CA
2. Undiagnosed fractures
Key clinical features of metastatic lesions (2)
- hx of CA
2. overall clinician judgement
red flags of metastatic lesions (4)
- previous hx of CA
- insidious onset of symptoms
- older age at onset (>50 y/o)
- failure to recover/improve
red flags of undiagnosed vertebral fractures (CPR developed by Henschke and colleagues)
- > 70 y/o
- significant trauma/injury
- prolonged use of corticosteroids
- female gender
T or F: MRIs are good for identification of serious pathology
- if false, why?
True
T or F: MRIs are good for identifying painful stimulus agents in LBP of non-serious pathology
- if false, why?
False - good at finding abnormalities, but these abnormalities may not be the cause of the pt’s pain
- may lead to pt stress over patho label
T or F: MRIs may lead to lower levels of false positives regarding low back pain stimuli
False - MRIs can see a lot, but clinical research has shown that this may lead to more pathoanatomical “labels” which is not directly tied to a pt’s LBP
T2 weight vs T1 weighted MRIs
- visual difference between CSF
https://case.edu/med/neurology/NR/MRI%20Basics.htm
T1 - CSF is dark
T2 - CSF is light
Dark disk in T2
- what is it (historically)?
- possible negative impacts of pts emotionally
Thought to signs of DDD, but is usually benign and asymptomatic
- pt may hear “I have a deteriorating spine” and send them down a dark emotional path
What is Modic’s sign?
- IVD and vertebral body involvement
- what MRI image type is it seen (T1 or T2?)
- Suspected disruption of the end-plate with subsequent bone marrow edema (sus nutrient waste)
- IVD and vertebral body - possible contributors to pain stimulus
- T2 weighted MRI image
What is a high intensity zone (HIZ)?
- where, what, though to be?
- what MRI image type is it seen (T1 or T2?)
- area of high (bright) signal along the annular region of the IVD
- though to be an annular tear, possible comp. of discogenic pain
- T2 weighted MRI image
What is a yellow flag?
Patient’s personal mistaken beliefs about pain and injury (table 3, pg 13)
Can yellow flags cause/change physiologic processes?
Yes
What can the Pain Catastrophizing Scale possibly be an independent predictor of?
Predictor of disability
Why should fear avoidance beliefs be examined over the duration of treatment instead of just at beginning of treatment?
Pt may not realize they have a fearful avoidance of some tasks until faced with the activity/functional task.
Is elevated fear avoidance a good predictor of chronicity in isolation?
No per current clinical findings
What questionnaire(s) may be used to determine Fear Avoidance?
Fear Avoidance Belief Questionnaire (FABQ) along with variants
- FABQ - Work (FABQ-W)
- FABQ - Physical Activity (FABQ-PA)
SMT shown to be best for acute or chronic case?
- Does it help both
Best for acute, but have seen benefits in both populations
What is a Blue Flag?
- two examples of Blue Flags
Blue flag is a primarily related to work related injuries
- Low job satisfaction
- Negative personal interactions/conflicts with employers and/or fellow coworkers.
What is a Black Flag?
Wider context of issues compared to yellow and blue flags.
- may be unhelpful or possible perverse nature of systems
- example: reimbursement to remain disabled
CPR for using lumbar manipulation (dev. by Flynn et al)
- No symptoms distal to knee
- Less than 16 days since onset/current episode duration
- FABQ score: <19
- Hip IR ROM: at least one hip >35 deg of IR
* *some debate on generalizability - unable to be reproduced b Hancock et al.
What is graded exposure with fear avoidance in pt’s with LBP?
asks pts with LBP to generate a hierarchy of feared activities and gradually progress through these to attempt to reduce activity-related anxiety.
Graded activity
operant condition (behavior gets expected consequence) to reinforce health behaviors and progress pt through different levels of functional activity
Treatment approach to motor control exercises described by Costa et al. (2)
- Train coordinated activity of trunk muscles (TA and multifidus activation, decreased superficial muscles activation)
- implement precision of the desired coordination (train skills in static tasks, progress to dynamic task and functional positions with these skills)
Exercise treatment plans for pts with chronic LBP with central sensitization
- what types
low to moderate intensity aerobic exercise with slow progressing
Pt education from PTs regarding LBP (3)
- stay active, avoid bed rest, understand diff of good vs. bad pain
- PT perform behavioral education with cognitive behavioral theory, graded activity increase
- Educate pts on physiology of pain- neuroplasticity, central sensitization (esp. good for pts w/ CLBP)
Novel interventions gaining popularity for LBP rx (2)
- Modern neuroscience approach
2. Dry needling.
clinical instability questionnaire
- best exercise regimens for >9 or <9 (score)
- for scores =/> 9 (high): better with motor control exercises
- for scores <9 (low): graded activity approach better
T or F: lumbar DD is strongly linked to genetic factors
True
- 4-5x more likely to have a FMH of bulging lumbar disks if diagnosed with a protruding lumbar disc <21 y/o
Loss of hydration in the nucleus of the IVD results in impaired diffusion of what? (4)
nutrients
oxygen
water
metabolites
Hydrostatic properties of the IVD are reliant on what IVD structure?
Annulus of the IVD
Loss of annular support is likely to lead to…. (3)
- accelerated degeneration
- loss of internal stability
- reactive bone formation (osteoblastosis)
Present literature supported systems for identifying DD and strategies to treat the specific pain-provoking tissues noninvasively.
Currently are none. Wah-wah.
Three sub-groups of PT management per the “Revised” TBC system (not the treatments)
- Symptom modification
- Motor coordination
- Functional optimization
Ankylosing spondylitis most commonly seen in what three regions/joints?
- Lumbar region
- SI joint
- Shoulder
