Lumbar Spine and Pelvis

Question 1

True or False: Most low back pain episodes are short lived (2-3 months) and patients return to PLoF quickly.

Answer 1

True, 50% of patients with acute low back pain had returned to work within 2 weeks and 83% had returned in 3 months and only 28% of patients report symptoms after one year

Question 2

True or False: Patients with acute low back pain are at increased risk of recurrent episodes

Answer 2

True, LBP recurrences are likely and these flare-ups are normal and do not necessarily represent a failure of treatment

Question 3

True or False: We should provide patients education on the pathoanatomical origin of their LBP

Answer 3

False, LBP is extremely hard to pin point exact anatomical causes and educating patients on a pathoanatomical origin may actually harm their recovery

If a patient asks how therapy would work even if we do not know the cause of the pain educate them that spinal tissues work together, are like to be injured together, and are likely to be stimulated together during intervention

Question 4

What red flags should be screened for that may increase the likelihood of metastatic cancer that may be referring into LBP?

Answer 4

-Hx of cancer
-night pain or pain at rest
-unexplained weight loss
-age over 50 or age under 17
-failure to improve over the predicted time interval following treatment

Question 5

What red flags should be screened for that may increase the likelihood of an infection within the disk or vertebrae?

Answer 5

-patient is immuno-surpressed
-prolonged fever with temp over 100.4F
-Hx of intravenous drug use
-Hx of a recent UTI, pneumonia, or cellulitis
-spinal rigidity
-deeper constant pain that increases with weight bearing

Question 6

What red flags should be screened for that may increase the likelihood of a lumbar vertebral fracture?

Answer 6

-prolonged use of corticosteroids
-mild trauma in pts over 50 years of age
-age over 70
-known Hx of osteoporosis
-bruising over the spine following trauma

Question 7

What red flags should be screened for that may increase the likelihood of abdominal aortic aneurysm?

Answer 7

-pulsating mass in abdomen
-Hx of atherosclerotic vascular disease
-throbbing pulsating back pain at rest or with recumbency
-age over 60 years

Question 8

We know imaging is not a good resource for determining pain source, however there are two MRI findings that may actually help with diagnosis

What findings from an MRI may help determine the intervertebral disc as a pain source?

Answer 8

High intensity zone in the annular region of the IVD may indicate an annular tear and be associated with discogenic pain

“Modic Sign” or a high T2-signal in or near a vertebral end plate which impairs nutrient uptake in the disc and can cause discogenic pain

Question 9

What are blue flags?

Answer 9

work related issues including attitude towards work, beliefs that their work may be harming them, etc.

Question 10

What are black flags?

Answer 10

a broad topic that can include social and economic stressors, such as reimbursement advantages of staying disabled

Question 11

What is the CPR for lumbar manipulation?

Answer 11

-No symptoms distal to the knee
-Pain onset less than 16 days ago
-FAB-Q work scale score of less than 19
-At least one hypomobile lumbar segment
-At least one hip with greater than 35deg of IR

Question 12

Should physical therapists attempt to address psychosocial factors correlated to pain such as depression, fear, poor expectations of personal recovery, or other comorbidities?

Answer 12

Yes, these factors are often more important than physical comorbidities as it relates to prognosis

Question 13

What prognostic factors could lead a patient into having chronic symptoms of LBP?

Answer 13

-presence of symptoms below the knee
-psychological distress/depression
-fear of pain, movement, and re-injury (low expectation of recovery)
-high intensity pain
-passive coping style

Question 14

What red flags would indicate a patient may have Cauda Equina syndrome?

Answer 14

-bowel/bladder changes
-saddle paresthesia
-sensory or motor deficits in L5-S1 area

Question 15

What is the clinical prediction rule for patients who may benefit from stabilization exercise?

Answer 15

-younger than 40
-post-partum or SLR over 91deg
-instability catch or aberrant movement with flexion/extension
-positive prone instability test

Question 16

What is the prone instability test?

How is it performed?

What is considered positive?

Answer 16

A test for the likelihood of a patient with low back pain responding to a stabilization exercise program

The patient lies prone with the body on the examining table and legs over the edge and feet resting on the floor. While the patient rests in this position with the trunk muscles relaxed, the examiner applies posterior to anterior pressure to an individual spinous process of the lumbar spine. Any provocation of pain is reported. Then the patient lifts the legs off the floor (the patient may hold table to maintain position) and posterior to anterior compression is applied again to the lumbar spine while the trunk musculature is contracted.

The test is considered positive if pain is present in the resting position but subsides in the second position, suggesting lumbo-pelvic instability. The muscle activation is capable of stabilizing the spinal segment.

Question 17

What are the signs a patient may be appropriate for lumbar traction?

Answer 17

-symptoms of nerve root compression such as pain and sensory issues in dermatomal patterns, positive cross SLR test, or diminished DTR
-peripheralization of symptoms with flexion or extension

Question 18

According to the treatment based classification 3.0 which treats symptoms as more of a spectrum rather than in boxes, which category is for higher irritability patients?

Moderate irritability?

Low Irritability?

Answer 18

High-Symptom Modulation
Moderate-Movement Control
Low-functional optimization

Question 19

How do patients in the symptom modulation category usually present?

Answer 19

-high disability (oswestry over 40%)
-high pain levels (7/10 or higher)

Question 20

How do patients in the movement control category present?

Answer 20

Moderate disability (ODI between 21-40%)

moderate pain (3-6/10)

Question 21

How do patients in the functional optimization category present?

Answer 21

ODI under 20% and low pain levels under 2/10

Question 22

According to the Low Back Pain CPG, what level of evidence is given for Manual therapy and what specific manual therapy do they mention to use?

Answer 22

A level evidence for the use of thrust manipulation for those with acute LBP and thrust or non-thrust manual therapy for reducing pain in sub-acute or chronic LBP

Question 23

According to the Low Back Pain CPG, what level of evidence is given for trunk coordination, strengthening, and endurance exercises?

Answer 23

A level evidence supporting the use of trunk coordination, strengthening, and endurance exercise to reduce pain and disability for sub-acute and chronic LBP as well as for pts after microdiscectomy

Question 24

According to the Low Back Pain CPG, what level of evidence is given for centralization and directional preference exercises and procedures (McKenzie Protocol)?

Answer 24

A level evidence supporting the use of repeated movements and exercises to promote centralization and reduce symptoms of acute LBP with referred lower extremity pain

Can also use repeated movements and exercise to reduce symptoms in pts with sub-acute and chronic LBP with mobility deficits

Question 25

According to the Low Back Pain CPG, what level of evidence is given for flexion exercises for older patients with chronic LBP with radiating pain?

Answer 25

C level evidence supporting the use of flexion exercises combined with other interventions such as manual and nerve mobilization

Question 26

According to the Low Back Pain CPG, what level of evidence is given for lower quarter nerve mobilization procedures?

Answer 26

C level evidence supporting their use to reduce pain and disability in pts with subacute and chronic LBP with radiating pain

Question 27

According to the Low Back Pain CPG, what level of evidence is given for Traction?

Answer 27

D level conflicting evidence, mostly DO NOT use traction with chronic LBP

Question 28

According to the Low Back Pain CPG, what level of evidence is given for patient education and counseling?

Answer 28

B level evidence suggesting therapist DOES NOT educate patient on pathoanatomic cause of pain or suggest bed rest

Education SHOULD be about:
-How strong the spine is
-pain neuroscience
-favorable prognosis of LBP
-active coping mechanisms for fear avoidance and catastrophizing
-early resumption of normal activity, despite pain
-importance of improvement in activity levels not just pain

Question 29

According to the Low Back Pain CPG, what level of evidence is given for progressive endurance exercise and fitness activities?

Answer 29

A level evidence supporting therapist to use moderate to high intensity exercise for patients with chronic LBP without generalized pain and incorporating progressive, low intensity, submaximal fitness and endurance activities into the pain management and health promotion strategies for patients with chronic low back pain with generalized pain

Question 30

What types of cancer are most related to cancer related low back pain?

Answer 30

Prostate, breast, kidney, thyroid, lung, and lymphatic cancers are all metastatic cancers that increase the risk of cancer-related low back pain.

A mnemonic to remember these is PB KTLL, or “Peanut Butter Kettle.”