Lumbar Spine Flashcards
What are the 4 Primary LBP Classification Systems
1) Mechanical (McKenzie)
2) Movement (Sahrmann)
3) Mechanism (O’Sullivan)
4) Treatment (Delitto)
Mechanical Dx & Therapy classification model
McKenize
Movement System impairment syndromes
Sahrmann
Mechanism-based classification system
O’Sullivan
Treatment-based classification system
Delitto
Which of the 4 primary LBP classification systems has the best evidence supporting it?
Movement System Impairement and McKenzie
What are the 3 McKenzie classifications?
1) Postural syndrome
2) Dysfunction syndrome
3) Derangement syndrome
Sxs of Postural Syndrome:
1) age <30 yrs (unless trauma)
2) sedentary occupation
3) Midline pain (no referral)
4) Paine with prolonged positioning
5) No pain caused by movement
6) Possible hypomobility
Interventions for postural syndrome:
- Postural training
- Lumbar roll
- Active & Passive extension exercises
Sxs of dysfunction syndrome:
1) Age >30yrs (unless trauma)
2) Sedentary occupation (often)
3) Localized pain at end-range movements
4) Restricted ROM c soft tissue shortening
Interventions for dysfunction syndrome:
- postural training
- flexion/ext and/or lateral deviation stretching & corrections
- mobilization and/or manipulation
Sxs of derangement syndrome:
1) Age 20-55 (typically)
2) Sudden onset
3) Radicular symptoms
4) Pain often “constant” & increased with certain movements
5) Possible postural deformity
Interventions for derangement syndrome:
- reduce derangement
- postural training
- repeated extension exercises (prone/stand)
- lumbar roll
- mobilization/manipulation
- intermittent pain: flexion ex’s followed by extension
Is graded activity or graded exposure better for persistent low back pain?
Graded activity is an effective tx for low back pain. However there is no evidence that either is superior to traditional exercise program for persistent low back pain.
Characteristics of graded activity?
- operant conditioning principles to reinforce healthy behaviors.
- focus is functional activities and progresses in a time cotangent manner regardless of pain to achieve functional goals and increased activity
- principles of quotas, pacing and self-reinforcement are key
How to score to STarT?
Total score < 3 = low risk
Total score > 3 -> go to psych score
If psych score is 3 or less = medium risk
If psych score is > 3 = high risk
Musculoskeletal abdominal pain questionnaire is used for?
Determining if abdominal pain is musculoskeletal in origin or something else like abdominal aortic aneurysm etc.
Sxs of cauda equina syndrome?
- bilateral leg symptoms
- saddle anesthesia
- bowel/bladder changes
- may be vague or intermittent symptoms
- red flag - medical emergency
Most reliable symptom to rule in/out cauda equina?
Urinary retention
Most reliable symptom to rule in/out back related infection?
Fever
Most reliable symptom to rule in spinal compression fx?
hx of major trauma (ex: MVA, fall from a height or direct blow to the spine)
Most reliable factors to rule out abdominal aneurysm ( >4cm)
- abdominal girth < 100 cm (.14 -LR)
- palpation of abdominal aortic pulse (.22 -LR)
Best factor to rule in cancer as cause of low back pain?
Previous hx of cancer (14.7 +LR)
Best factor to rule out cancer as cause of low back pain
Relief with bed rest
What factors to identify patients likely to present with a vertebral compression fracture?
Hanschke CPR in development
Henschke, et al.:
- Female sex
- Age > 70 years old
- Significant trauma (major in young patients, minor in elderly patients)
- Prolonged use of corticosteroids
*If they meet 2+ criteria order films
What are the signs and symptoms indicative of lumbar spinal stenosis?
- Bilateral symptoms
- Leg pain > back pain
- Pain during walking/standing
- Pain relief upon sitting
- > 48 years old
When to order advanced imaging in pts c low back pain?
-Hx of ca & 1 more (>50yrs, weight loss or failure to improve with conservative tx)
Then see if ESR >50 mm/h
If both factors present order advanced diagnostic imaging or biopsy, if ESR <50 order conventional radiographs
When to use Roland-Morris Disability Questionnaire vs Oswestry Disability Index?
Roland-Morris is more sensitive to change in patients with less pain and disability.
What was Orebro musculoskeletal pain screening questionnaire originally used for? And was does it test for?
Developed to assist primary care practitioners in identifying psychosocial “yellow flags” and its at risk for future work disability due to pain.
Measurement of limitation in activities and participation. Measurement of impairment of body function. Disability, catastrophizing, fear, comorbid pain and time off work reference standards.
*Demonstrates concurrent validity in comparison to the STarT
Which manual therapy interventions should you use for subacute and chronic low back and back-related lower extremity pain?
Thrust and non-thrust manipulative
*Improves spine and hip mobility and reduces pain and disability. Level A evidence
Which manual therapy interventions should you use for acute low back and back-related lower extremity (buttock or thigh) pain?
Thrust manipulative procedures.
*Reduces pain and disability
What exercise prescription for pts c chronic low back pain without generalized pain?
moderate to high intensity exercise
Level A evidence
What exercise prescription for pts c chronic low back pain and generalized pain?
progressive, low intensity, sub maximal fitness and endurance activities
Level A evidence
Lower quarter nerve mobilization procedures should be used with which pts?
Pts c subacute and chronic low back pain and radiating pain.
Level C evidence
Which pts would benefit from lumbar Stabilization program? (still in development)
1) (+) prone instability test**
2) (+) aberrant mvmnts **
3) SLR >91
4) Age <40
- **a modified CPR containing only these 2 factors demonstrates better predicted validity of those that would benefit from SSE.
- not a validated CPR but reliability is excellent
Which exercises best recruit the TrA and IO?
Horizontal Side Support
Abdominal crunch
Which exercises best recruit the TrA?
DIM
Qped alt UE/LE
Which exercises have the ‘best’ activation of core muscles?
Roll-out & Pike
*activated upper/lower rectus abdomens, IO, EO & lats. minimized activity of paraspinals and rectus femoris.
Clinical improvement following spinal manipulative tx is associated with what affect on lumbar multifidus?
Increased thickening of lumbar multifidus during submax task.
What are the 3 steps of CPR development?
1) initial
2) Validation
3) Utility/Impact
What factors are used to identify patients with low back pain who likely will improve with spinal manipulation?
- Duration of symptoms < 16 days
- At least one hip with > 35° of internal rotation
- (+) Lumbar spring test (hypomobile + pain)
- No symptoms distal to the knee
- FABQ-W score < 19
- cavitation is not required for success
- thrust is more effective than non-thrust but both statistically significant
