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
What are treatments appropriate for someone classified in the movement control group?
- Sensorimotor exercises
- stabilization exercises
- flexibility exercises
What are treatments appropriate for someone in the functional optimization category?
- Strength and coordination
- work or sports specific task
- aerobic exercises
- general fitness exercises
What are symptoms associated with patients in the symptom modulation category?
- Recent pain( acute Ir recurrent)
- Significant symptoms
- Avoids certain postures
- Hypersensitive
What are symptoms associated with patients in the movement control category?
Low / moderate pain
Pain stable
Arom often full, sometimes with aberrant movements
Exam: impaired flexibility, muscle activation, motor control
What are symptoms of patients in the functional optimization category?
Relatively asymptomatic
Adl’s ok
Well controlled symptoms until systems fatigue
According to the TBC 3.0, what are the local mobility categories for movement control?
Nerve
Joint
Soft tissue
What are the global activity categories in TBC 3.0?
Activation
Acquisition
Assimilation
What should local mobility examination consist of?
Sitting- slump test, thoracic rotation
Standing- observe posture(pelvic asymmetry, LE alignment)
Side lying- Obers test
Supine- leg length, HIP IR/ER, SLR, THomas test
Prone- femoral nerve, PA. Spring test, passive leg ext., hand heel rock
What should a global mobility exam consist of?
Sitting- active knee extension, sit to stand test
Standing- spine ROM, thoracic lumbar dissociation, lumbo pelvic dissociation, step up- down test , squat
Sidelying - clam shell, active hip and, endurance side bridging test
Prone- prone instability test, active hip ext, active hip rotation, bird dog
What is the CPR for those with lbp who will benefit from spinal manipulation ?
- Duration less than 16 days
- No symptoms distal to the knee
- FABQ <19
- at least one hypomobile segment
- greater than or equal to 1 hip with <35 degrees of IR
What are the chances of success for manipulation based on CPR?
- > 3 of five predictors - success 68%. + LR 2.6
->4 of five predictors - success 95% + LR 24
If these two present: - symptoms less than 16 days
-no symptoms distal to the knee
Chance of success 88-91%
If less than 3 of five predictors present chance of 7% success
What is the CPR for success with lumbar stabilization?
- Positive prone instability
- aberrant movements present
- SLR >91 degrees
<40 years old- if 3/4 present + LR 4.0, 65% success
What is the predictor for failure for lumbar stabilization?
FABQ score PA >8 Aberrant movements absent Negative prone instability No hypomobility - greater than two variables present negative LR .18
What is the Mckenzie classification for LBP?
- Postural syndrome: <30 years , no referred pain, no pain with movement, pain with prolonged sitting
- Dysfunction syndrome: < 30 years, pain at end range, restricted ROM
- Derangement syndrome: 20-55 yo, sudden onset, parasthesia, Pain t/o rom.
What is the treatment for postural syndrome by McKenzie?
Postural correction exercises, lumbar roll, arom and prom exercises
What is the treatment for dysfunction syndrome by McKenzie?
Mobilizations/ manipulations, postural education
What is the treatment for derangement syndrome?
Repeated ext in prone, lateral deviation, postural education.
What is the cpr for SIJ pain cluster?
- Distraction, compression, FABER, Thigh thrust, Gaenslan
- if 3/ 5 positive then +PTP 59%
- if less than 3 positive - LR .12, PTP 4%
When would you use an extension oriented approach?
Symptoms distal to buttock
Peripheralization with L/S flexion and centralization with extension
Directional preference for extension
EOTA trunk strengthening in these patients
What is mcnabbs classification of disc herniation?
Disc protrusion
- localized annular bulge(lateral)
- diffuse annular bulge (posterior and bilateral)
Herniations
-Prolapsed- nucleus migrates through inner rings
- Extruded - nucleus has broken through the outermost layer
- Sequestered- nucleus has broken from the disc, and is in the spinal canal
What factors favor EOTA?
- Strong preference for sitting or walking
- Centralization with motion testing
- Peripheralization in direction opposite of centralization
What factors are against the use of SMT for patients with lbp?
- Symptoms distal to the knee
- Peripheralization with motion testing
What is the difference between centralization and directional preference?
Centralization is the change in symptom location to a more proximal location
Directional preference is the reduction in pain intensity from repeated motion testing
Directional preference will not necessarily coincide with centralization
Who might benefit from FOTA?
Patients with:
- symptoms to buttocks or distal, often bilateral
- improvement with flexion oriented activities
- worsening symptoms with extension( walking, prone, standing extension)
What are common impairments associated with lumbar stenosis?
- Diminished AROM
- Poor ambulation tolerance
- Decreased strength and sensation on one or both LE’s
- Weakness of hip musculature- glutes, hip abductors
What outcome measure has the best MCID for patients with lumbar spinal stenosis?
Oswestry
- MCID of 5
What are symptoms of neurogenic claudication?
Compressed nerves in lower spine
Causes pain or cramping in the legs
Typically bilateral at buttocks and thighs
Walking with flexed posture relieves symptoms
Worse with walking downhill
Prosthesias and Weakness in LE’s
What are signs of intermittent claudication?
Main symptoms of PVD
Tight, aching or squeezing pain in the foot, calf, thigh
Pain occurs with the same amount of
exercise and relieved with rest
Worse walking uphill, better with static standing
What test is the best to use for clinical assessment of intermittent claudication?
Treadmill test
How would you treat intermittent claudication?
Exercise and patient education
- stop smoking
- compliance with medications
Describe treadmill walking exercise guidelines by AHA for intermittent claudication
- supervised treadmill walking that illicit symptoms within 3-5 minutes intensity of 1 on the claudication scale
Walking until pain is moderate, followed by rest until symptoms resolve - repeat cycle of exercise and rest x 35 minutes
-increased program by 5 min per session
3-5 sessions x 12 weeks
How do you score the Ankle Brachial Index?
ABI
- 3 x BP at rest ankle, arm
- 5min treadmill walking
- repeat 3x bp measures
ABI= mean 3 systolic LE/ mean systolic UE
What does results of ABI indicate?
Normal resting ABI 1-1.1
- resting ABI <1 abnormal
- less than . 95 significant narrowing of one or more blood vessels in legs
- less than . 8 = intermittent claudication
- .25 or below, severe limb - threatening PAD
Exercises for lumbar stabilization
Transverse Abdominus
- Abdominal Bracing x 30 with 8 sec hold
- progress with heel slide>leg lifts>standing>standing row >walking
Erector spinae/ multifidus
- Quadraped arm lifts with bracing>leg lifts>alternate
QL
- side support with knees flexed>extended
Obliques abdominals
- same as QL
As per lasletts CPR for SIJ, what happens to the post test probability of SIJ pain?
In the absence of centralization with McKenzie repeated motion testing and at least 3 positive tests, +LR 7 and + PTP 77%
What are the symptoms of PGP in pregnant women?
- Pain over PSIS
- Pain gluteal region
- groin pain
- posterior thigh pain
What outcome measure can be used for PGP?
Pelvic girdle questionnaire
What are risk factors for poor prognosis in pregnant and post partum pop with PGP?
- Minimal/ no weight loss after delivery
- LBP prior to pregnancy
- several + special tests
- long term PGP
- onset of pain early during pregnancy
- prolonged labor
- difficulty with ASLR
- compete PGP= bilateral SIJ, Pubic symphysis
What is the level of evidence for treating lbp in pregnancy?
- Moderate evidence for exercise and patient education.
- limited evidence for manual therapy
When should you recommend imaging?
Only if there is progression of neurological deficits.
Where is the dermatome of L2?
- Anterior thigh
Reflex - suprapatellar
Where is the dermatome for L3?
-Anterior lower thigh
Reflex
- suprapatellar
Where is the dermatome for L4?
- Medial calf, foot
- Lateral thigh
Reflex - Patellar
Where is the dermatome for L5?
-Lateral calf, dorsal aspect of foot
- reflex
None
What is the dermatome for S1?
-Lateral foot
Reflex
- Achilles
Where is the dermatome for S2-4?
Anus
Describe the prone instability test
Patient lies prone with legs over the edge of the table, feet on the floor. Examiner applies posterior to anterior pressure over spinal segments and pain is noted. Patient lifts legs off the floor and again PA pressure is applied.
- if pain improves in the second position it is considered positive
- if pain persists in the second position then it is negative
- useful as part of a cluster of tests, not as a stand alone test
Describe judgement of the presence of aberrant movements.
Aberrant movements:
- painful arc with flexion
- Pain with return from flexion
- gowers sign
- instability catch
- reversal of lumbopelvic rhythm
Describe the SLR test
Patient lies supine and examiner raises leg by flexing hip with leg extended
- positive if it reproduces LE radiating/ radicular Pain
- range up too 45 degrees
Describe the slump test
Patient is asked to sit in a slumped position at the edge of the table- cervical flexion, knee extension, and ankle DF are sequentially added to the onset of LE symptoms
- relief of symptoms when cervical component is extended or nerve tension is relieved from 1 or more lower limb components
Describe trunk extensor test.
Patient positioned in prone:
- instructed to extend and raise chest off the table to approx. 30 degrees
- test is timed
- 31 sec. for male , 33 for female is normal
- less than that - correlates to lbp
Describe trunk flexor test
patient is supine:
- examiner elevates legs until scarum rises off the table
- patient is asked to maintain lb contact on the table while lowering the legs
- examiner measures when lb loses contact with the table
- anterior pelvic tilt for hip flexion >50 degrees males, 60 degrees females more likely to develop lbp
Describe lateral abdominal strength test
Patient is sidelying:
- hips at neutral, knees flexed to 90, resting upper body on elbow
- patient lifts pelvis off the table without rolling forward or back
- position held and timed
Describe test for TA
Patient lies prone on inflated cuff to 70 mmhg
- patient is asked to draw in abdominals for 10 seconds without inducing pelvic movement
- maximal decrease in pressure is recorded
- decrease in pressure of 4 mmhg is normal
- failure to decrease cuff by 2 mmhg is associated with lbp
Describe hip abductor test
Patient lies sidelying with both legs fully extended
- patient instructed to raise leg towards the ceiling while keeping limb in line with body.
- patient are graded on quality of movement
- correlates to lbp in standing
Describe hip extensor test
Patient lies supine with knees bent to 90 degrees
- patient instructed to raise pelvis off the table to a point where shoulders hips and knees are in a straight line
- position is held and timed
- mean duration for patients with lbp 76.7 sec compared to 172.9 seconds for those without lbp
