Lumbar Spine

Question 1

What are the 4 Primary LBP Classification Systems

Answer 1

1) Mechanical (McKenzie)
2) Movement (Sahrmann)
3) Mechanism (O’Sullivan)
4) Treatment (Delitto)

Question 2

Mechanical Dx & Therapy classification model

Answer 2

McKenize

Question 3

Movement System impairment syndromes

Answer 3

Sahrmann

Question 4

Mechanism-based classification system

Answer 4

O’Sullivan

Question 5

Treatment-based classification system

Answer 5

Delitto

Question 6

Which of the 4 primary LBP classification systems has the best evidence supporting it?

Answer 6

Movement System Impairement and McKenzie

Question 7

What are the 3 McKenzie classifications?

Answer 7

1) Postural syndrome
2) Dysfunction syndrome
3) Derangement syndrome

Question 8

Sxs of Postural Syndrome:

Answer 8

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

Question 9

Interventions for postural syndrome:

Answer 9

• Postural training
• Lumbar roll
• Active & Passive extension exercises

Question 10

Sxs of dysfunction syndrome:

Answer 10

1) Age >30yrs (unless trauma)
2) Sedentary occupation (often)
3) Localized pain at end-range movements
4) Restricted ROM c soft tissue shortening

Question 11

Interventions for dysfunction syndrome:

Answer 11

• postural training
• flexion/ext and/or lateral deviation stretching & corrections
• mobilization and/or manipulation

Question 12

Sxs of derangement syndrome:

Answer 12

1) Age 20-55 (typically)
2) Sudden onset
3) Radicular symptoms
4) Pain often “constant” & increased with certain movements
5) Possible postural deformity

Question 13

Interventions for derangement syndrome:

Answer 13

• reduce derangement
• postural training
• repeated extension exercises (prone/stand)
• lumbar roll
• mobilization/manipulation
• intermittent pain: flexion ex’s followed by extension

Question 14

Is graded activity or graded exposure better for persistent low back pain?

Answer 14

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.

Question 15

Characteristics of graded activity?

Answer 15

• 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

Question 16

How to score to STarT?

Answer 16

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

Question 17

Musculoskeletal abdominal pain questionnaire is used for?

Answer 17

Determining if abdominal pain is musculoskeletal in origin or something else like abdominal aortic aneurysm etc.

Question 18

Sxs of cauda equina syndrome?

Answer 18

• bilateral leg symptoms
• saddle anesthesia
• bowel/bladder changes
• may be vague or intermittent symptoms
• red flag - medical emergency

Question 19

Most reliable symptom to rule in/out cauda equina?

Answer 19

Urinary retention

Question 20

Most reliable symptom to rule in/out back related infection?

Answer 20

Fever

Question 21

Most reliable symptom to rule in spinal compression fx?

Answer 21

hx of major trauma (ex: MVA, fall from a height or direct blow to the spine)

Question 22

Most reliable factors to rule out abdominal aneurysm ( >4cm)

Answer 22

• abdominal girth < 100 cm (.14 -LR)

- palpation of abdominal aortic pulse (.22 -LR)

Question 23

Best factor to rule in cancer as cause of low back pain?

Answer 23

Previous hx of cancer (14.7 +LR)

Question 24

Best factor to rule out cancer as cause of low back pain

Answer 24

Relief with bed rest

Question 25

What factors to identify patients likely to present with a vertebral compression fracture?

Hanschke CPR in development

Answer 25

Henschke, et al.:

1. Female sex
2. Age > 70 years old
3. Significant trauma (major in young patients, minor in elderly patients)
4. Prolonged use of corticosteroids

*If they meet 2+ criteria order films

Question 26

What are the signs and symptoms indicative of lumbar spinal stenosis?

Answer 26

1. Bilateral symptoms
2. Leg pain > back pain
3. Pain during walking/standing
4. Pain relief upon sitting
5. > 48 years old

Question 27

When to order advanced imaging in pts c low back pain?

Answer 27

-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

Question 28

When to use Roland-Morris Disability Questionnaire vs Oswestry Disability Index?

Answer 28

Roland-Morris is more sensitive to change in patients with less pain and disability.

Question 29

What was Orebro musculoskeletal pain screening questionnaire originally used for? And was does it test for?

Answer 29

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

Question 30

Which manual therapy interventions should you use for subacute and chronic low back and back-related lower extremity pain?

Answer 30

Thrust and non-thrust manipulative

*Improves spine and hip mobility and reduces pain and disability. Level A evidence

Question 31

Which manual therapy interventions should you use for acute low back and back-related lower extremity (buttock or thigh) pain?

Answer 31

Thrust manipulative procedures.

*Reduces pain and disability

Question 32

What exercise prescription for pts c chronic low back pain without generalized pain?

Answer 32

moderate to high intensity exercise

Level A evidence

Question 33

What exercise prescription for pts c chronic low back pain and generalized pain?

Answer 33

progressive, low intensity, sub maximal fitness and endurance activities

Level A evidence

Question 34

Lower quarter nerve mobilization procedures should be used with which pts?

Answer 34

Pts c subacute and chronic low back pain and radiating pain.

Level C evidence

Question 35

Which pts would benefit from lumbar Stabilization program? (still in development)

Answer 35

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

Question 36

Which exercises best recruit the TrA and IO?

Answer 36

Horizontal Side Support

Abdominal crunch

Question 37

Which exercises best recruit the TrA?

Answer 37

DIM

Qped alt UE/LE

Question 38

Which exercises have the ‘best’ activation of core muscles?

Answer 38

Roll-out & Pike

*activated upper/lower rectus abdomens, IO, EO & lats. minimized activity of paraspinals and rectus femoris.

Question 39

Clinical improvement following spinal manipulative tx is associated with what affect on lumbar multifidus?

Answer 39

Increased thickening of lumbar multifidus during submax task.

Question 40

What are the 3 steps of CPR development?

Answer 40

1) initial
2) Validation
3) Utility/Impact

Question 41

What factors are used to identify patients with low back pain who likely will improve with spinal manipulation?

Answer 41

1. Duration of symptoms < 16 days
2. At least one hip with > 35° of internal rotation
3. (+) Lumbar spring test (hypomobile + pain)
4. No symptoms distal to the knee
5. FABQ-W score < 19

• cavitation is not required for success
• thrust is more effective than non-thrust but both statistically significant