Lumbar/pelvic Flashcards
What are common side effects of opioid use?
Constipation Nausea Sedation Vomiting Dizziness Itching Dry mouth Discontinue treatment due to side effects
Key consistencies of 3 CPG’s for LBP
Consistencies
- Target acute and chronic lbp
- do not get early imaging
- stay active
- use of NSAIDS
- do not use traction
- surgery if conservative measures fail
- referral pathways
What is the evidence for lumbar traction according to CPG on lbp?
Conflicting evidence
- preliminary evidence that a subgroup of patients with nerve root compression will benefit from intermittent traction
- moderate evidence that clinicians should not use traction for patients with acute or sub acute, non radicular lbp and with chronic lbp
What is the evidence to support flexion exercises for reducing pain with older patients with chronic lbp and radiating pain?
Weak evidence
- weak evidence for flexion exercises combined with manual therapy
What is the level of evidence for patient education in patients with lbp?
Moderate evidence
- do not use patient education that increases perceived threat of lbp(bed rest, pathoanatomical cause)
- should emphasize anatomical structural strength of spine, neuroscience behind pain perception, overall favorable prognosis of lbp,
Use of active coping strategies, early return to activities and importance of increase in activity levels
What is the evidence to support progressive endurance activities?
Strong evidence
- clinicians should consider moderate to high intensity exercise for patients with CLBP
- incorporate progressive low intensity, sub maximal exercises and endurance activities for patients with CLBP
What is the evidence to support centralization and directional preference exercises?
Strong evidence
- clinicians should consider utilizing repeated movements to promote centralization for patients with acute lbp and referred pain into extremities
- clinicians should use repeated exercises in a specific direction determined by treatment response for patients with acute, sub acute, chronic lbp.
What is the evidence for thrust manipulation in lbp?
Strong
- clinicians should consider utilizing thrust manipulation in patients with acute lbp and referred thigh or buttock pain
- can use NTMT for chronic, sub acute and acute lbp
What is the evidence to support trunk coordination, strengthening and endurance exercises for lbp?
Strong
- clinicians should use trunk strengthening, coordination and endurance exercise for patients with sub acute and chronic lbp and post micro diskectomy
What are two validated outcome measures for examination in patient with lbp?
Strong evidence
- clinicians should use Oswestry and Roland Morris Disability Questionnaire.
What is the evidence for considering differential diagnosis with LBP?
Strong evidence
- should refer to appropriate medical practitioner if:
- if suspicious of serious medical pathology
- impairments and activity limitations not consistent with diagnosis/ classification section
- patient symptoms are not resolving with interventions aimed at normalization
What does the research say about risk factors?
Moderate evidence
- current literature does not support a definitive cause for LBP
- risk factors are multifactorial
What is more effective- graded activity or graded exposure for patients with nonspecific LBP?
Graded activity is more effective, although the effect is small for patients with no specific persistent LBP
- can be beneficial for high risk patients identified with STaRT screening tool.
How dips the STarT screening tool scored?
8 Questions
- scores 0 for disagree, 1 for agree
- Total score and Psych score
- Total score <3 low risk
- Psych score <= 3 medium risk
- Psych score >3 high risk
What are signs of infection associated with LBP?
Fever Extreme fatigue Malaise Highly immunocompromised Adenopathy IV drug use
What are signs of cancer associated with LBP?
Age greater than 50 Previous Hx ofCA Unexplained weight loss Inadequate relief with rest Failure to improve with treatment - 4 weeks
What are signs of inflammatory arthritis conditions with LBP?
Symptoms improve with activity Duration greater than 3 months Limitation in movements in all planes Fatigued, weight loss Psoriasis Oral ulcers
What are signs of urinary track disorders associated with lbp?
Urinary frequency/ urgency
Hematuria
Dysuria
Renal
What are reproductive disorders associated with lbp?
Urinalysis infrequency, hesitantsy
Painful ejaculation
Change in menstruation- bleeding, spotting, frequency of period
What are signs of AAA associated with lbp?
Midline lower thoracic abdominal pain Palpable pulsating abdominal mass Throbbing, pulsating pain Positive smoker History of vascular disorders Family history
What are signs of GI disorders associated with LBP.
Nausea Vomiting Abdominal pain Constipation Pain relieved by sitting Fever, chills
Test procedure for AAA
Once pulse is detected, place both index fingers with deep pressure along sides of pulse
- note laterally expansive pulsation
- would warrant prescience if bruit
Two risk factors that have strong LR for AAA.
Current smoker
Use of Statins
What two tests are more likely to R/O AAA?
Abdominal mass <100 cm
No abdominal aortic pulse
What is the best diagnostic test property to RO/RI cauda equina syndrome?
Urinary Retention
+ LR 18, -LR .01
-large to rule in and out
What are symptoms of cauda equina syndrome?
Bilateral leg symptoms
Bowel/ bladder changes
Vague symptoms
Algorithm for Ruling in CA as cause of LBP
Hx of CA
Greater than 50
Failure to improve with treatment
- order ESR, - if negative, than conventional radiographs
- if positive (>50) than advanced diagnostic imaging required
What is the cpr for spinal fractures?
- Female
- > 70
- Trauma
- Prolonged use of Corticosteroids
- 2 or more positive has + LR 15.5 for fracture- + PTP 32
- 3 or more positive + LR 218.3- + PTP 87
What is the prevalence of serious spinal pathology associated with lbp?
Very low
- study 35/1172 patients
What are red flag conditions associated with LBP?
Fracture Cancer Cauda equina Back related infection AAA Spinal malignancy
If needed what is the appropriateness for Imaging with LBP?
LBP - uncomplicated: MRI w/o contrast 2
LBP - concern for fracture : :MRI w/o contrast 8
LBP- ca: MRI w/o contrast 8, with contrast 7
LBP- radiculopathy; surgical cand. : MRI w/o 8
LBP phx surgery: MRI w/ o. Contrast 8.
Cauda equina : MRI without contrast 9
How does early imaging change outcomes in patients with LBP?
Patients who undergo early imaging have longer LOS, increased medical costs, increased opioid dependency,increased rate of surgery and injections as compared to non imaging early PT groups.
What are the three categories of TBC 3.0?
- System modulation
- Movement control
- Functional optimization
What are the clinical findings for a patient placed in the symptom modulation category?
- High disability
- volatile symptom status
- high to moderate pain
What are the clinical findings for a patient in the movement control category.?
- Moderate disability
- Stable symptom status
- moderate to low pain
What are the clinical findings of someone in the functional optimization category?
- Low disability
- controlled symptom status
- low to absent pain
What are treatments that are appropriate for someone in the symptom modulation category?
- directional preference exercises
- manipulation/ mobilization
- active rest
- modalities
- meds