Lumbar spine (APTA) Flashcards
1
Q
T or F;
Low back pain is the most common cause of disability and lost work time among working-age adults in industrialized countries.
A
- T
2
Q
Chronic LBP prevalence in the US may be as high as ____%
A
- 30%
3
Q
World-wide prevalence for LBP on a given day is estimated at ___%; during a one-month range ____%
A
- 11.9%
- 23.2%
4
Q
What’s the difference between acute and chronic low back pain?
A
- acute has symptom duration of < 3 months; chronic > 3 months
- acute can expect recovery in 6-8 weeks without extensive treatment
- chronic has a much lower likelihood of recovery and may require more complex treatment strategies
5
Q
What is the expected % of people with acute low back pain that will return to work within 2 weeks? 3 months?
A
- 2 weeks: 50%
- 3 months: 83%
6
Q
What % of people with acute low back pain will still report symptoms 12 months after onset?
A
- ~28%
7
Q
What is the implication of the relatively common nature of flare-ups of low back pain?
A
- it’s fairly normal for low-back symptoms to flare-up, and these instances do not necessarily represent a failure of treatment
8
Q
What portion of chronic LBP patients did Costa et al find to have essentially fully recovered at 12 months?
A
- more than 1/3rd. Implication is that chronic LBP may not have as poor a prognosis as people typically think.
9
Q
T or F;
For pts with persistent and debilitating LBP, there are no interventions that have been shown to provide widespread effectiveness.
A
- T
10
Q
T or F;
Work-related spinal loading, prolonged sitting, and sports activities are associated with duration of recovery from LBP.
A
- F;
- implication is that these things are not likely to be harmful and shouldn’t necessarily be limited without a clear rationale
11
Q
What characteristics are associated with the CPR that predicts quicker recovery time?
A
- those with lower than average initial pain, shorter duration of symptoms, and fewer previous episodes of LBP are likely to recover more quickly than those that do not have these characteristics
12
Q
In most pts, we cannot accurately determine the specific tissues that are causing LBP. Why? Why is this not necessarily a problem?
A
- Most tissues are work together, thus they’re likely to be injured together, not in an isolated manner.
- Also, they’re likely to be stimulated together during intervention
13
Q
T or F;
Common medications used to manage LBP (opioids, gabapentin) can both facilitate and inhibit pain transmission; i.e., at some times w/ some patients, pain meds may actually make pain worse.
A
- T
14
Q
What 3 regions are thought to be associated with switching pain “on” or “off”?
A
- spinal cord
- brain stem
- higher brain centers
15
Q
What mechanisms switch pain relatively “on” or “off” in the spinal cord?
A
- off: gate control mechanism
- on: spinal sensitization. Dorsal horn neurons may increase their excitability, lowering the threshold for firing, as well as widening their receptor field
16
Q
What mechanisms can modulate pain from the brainstem?
A
- diffuse inhibition of pain can occur following stimulation of periaquaductal gray matter, which is endogenous opiate pathway
- changes in these regions can modulate the experience of pain
17
Q
What outcome measure can be used to get a sense of prognostics for low back pain?
A
- Keele STarTBack Tool
- Can help stratify patients into low, moderate, or high risk for failure to recover
18
Q
What are some of the consistent themes for LBP CPGs?
A
- early treatment initiation
- discouraging bed rest
- early recognition of psychologic and work-related factors
- supervised exercises and cognitive behavioral therapy for chronic LBP
19
Q
What are 2 of the most important conditions that may be associated with red flags in LBP?
A
- metastatic lesions
- undiagnosed fractures
20
Q
What are primary red flags associated with metastatic cancer when screening LBP? (5)
A
- hx of cancer
- night pain or pain at rest
- unexplained weight loss
- age > 50 or < 17
- failure to improve over the predicted time interval following treatment
21
Q
What are primary red flags associated with infection in the disk (diskitis) or vertebrae (osteomyelitis)? (4)
A
- pt is immunosuppressed
- prolonged fever w/ temp over 100.4*
- hx of intravenous drug use
- hx of recent UTI, cellulitis, or pneumonia
22
Q
What are primary red flags associated with undiagnosed vertebral fx? (6)
A
- prolonged corticosteroid use
- mild trauma > 50 yo
- age > 70 yo
- a known hx of osteoporosis
- recent major trauma
- bruising over the spine following trauma
23
Q
What is the incidence rate for spinal malignancy in pts seeking care for LBP?
A
- between 1.0 to 3.5%; although other studies have it lower (0-0.66%)
24
Q
What is a CPR for undiagnosed fx? (4)
A
- age > 70 yo
- female gender
- significant trauma
- prolonged use of corticosteroids
- want at least 3 of 4
25
T or F;
Initial medical screening by physical therapists does not increase the likelihood of missing a serious, undiagnosed condition
- T
26
What single clinical exam finding can be useful for ruling in discogenic low back pain?
- centralization of symptoms with movement
| - no other exam findings are predictive in isolation
27
What 2 MRI findings may be associated with discogenic pain?
- a high intensity zone (signal) in the annular layer of the disc
- end plate changes
28
MRI is not considered to be indicated without at least one of which two factors?
- presence of a red flag
| - worsening neurological symptoms
29
What are yellow flags in the context of LBP?
- yellow flags describe a personal mistaken beliefs about pain and injury
30
T or F;
Cognitive processes in response to pain can influence the perception of pain.
- T
31
What outcome measure is an independent predictor of disability, and a stronger predictor of disability than pain intensity?
- Pain catastrophizing scale
32
What two outcome measures are appropriate for predicting chronic symptoms?
- Fear Avoidance Beliefs Questionnaire
| - Tampa Scale for Kinesiophobia
33
T or F;
Most pts who demonstrate yellow flags with LBP will benefit from mental health referrals.
- F;
- It's pretty normal for most people with LBP to have some level of negative emotional response, inappropriate beliefs, etc. They will likely benefit from patient-specific advice from PT
34
What are blue flags in the context of LBP?
- related to injured workers. Include:
- perception of work
- perception of work conditions that may impair return- to-work
- low job satisfaction
- personal conflicts with employers or co-workers
35
What are black flags in the context of LBP?
- relate to social/financial issues
| - e.g., financial reincentives to remain on disability
36
What are the 2 most recommended self-report outcome measures for outcome following physical therapy?
- Roland Morris Disability questionnaire
| - Oswestry Disability Index
37
What is the MCID for the Roland-Morris and Oswestry?
- RM: 5 points
| - Oswestry: 10 pts
38
Is spinal manipulation/mobilization appropriate for treatment of LBP?
- yes.
- Has at least a short term effect on pain and mobility.
- more likely to be appropriate for acute LBP vs chronic, but still can be effective with chronic
39
Is spinal mobilization/manipulation likely to be effective for LBP in isolation?
- not really
| - should be a first-line treatment; more likely helpful early on during intervention
40
What is the CPR for use of spinal manipulation with acute low back pain?
- no symptoms distal to the knee
- less than 16 days of symptoms
- <19 on FABQ work subscale
- at least 1 hypomobile segment in lumbar spine
- at least 1 hip with IR >35*
41
Is there an effect of motor control exercises on LBP?
- yes; it's appropriate to do, but has a generally small effect size in isolation
42
What is "graded exposure" and how does it related to LBP treatment?
- graded exposure incorporates a cognitive element to treatment, essentially asking the pt to produce a hierarchy of feared activities, with gradual progress through these activities
43
What is "graded activity"?
- graded activity uses operant conditioning to reinforce healthy behaviors and progress the pt through different levels of functional activity
44
Are graded exposure/graded activity better than other exercise based approaches to intervention?
- not really per the literature so far
45
What tool can be used to identify pts who may be more likely to benefit from a motor control or graded activity approach to intervention?
- the clinical instability questionnaire
- those with high scores (>/= 9) are likely to do better with motor control
- those with low scores (< 9) are likely to do better with graded activity
46
Is lumbar extension strengthening an appropriate approach for LBP management?
- it's appropriate (i.e., better than no treatment), but there's not currently enough research to show whether it's better than other exercise approaches
47
Is progressive endurance/fitness exercise appropriate for LBP management?
- yes. Is shown to improve pain and function in those w/ LBP
48
Are there differences in efficacy with aerobic exercise vs strength/weight training exercise for LBP?
- kind of
- aerobic fitness seems to have an effect on central sensitization in chronic LBP
- weight-training has been shown to reduce the frequency of acute episodes of LBP
49
T or F;
Regularly low intensity exercise should be a common pathway for pts with low back pain.
- F
| - well...it's probably fine, but high intensity exercise actually has more support
50
Approaches based on directional preference have effects in what areas? With which types of patients?
- likely to reduce pain and improve mobility
| - acute, subacute, and chronic LBP
51
What is the support for the McKenzie approach?
- likely to lead to better outcomes than passive treatments with acute LBP
- efficacy and effectiveness is unclear with chronic LBP
- likely to reduce health care use, but no appreciable improvements when added to standard initial treatment (Tylenol, reassurance, advice)
52
T or F;
Education has not been found to have a significant effect for LBP treatment.
- F. at least currently
| - considered to be a significant portion of appropriate care for LBP
53
What 5 components should be part of pt education for LBP?
- Benefits of staying active and avoiding bedrest
- Modifying activity to avoid overloading of potentially impaired structures
- Understanding the difference between "good" and "bad" pain
- should include cognitive behavioral theory and graded exposure/activity
- physiology of pain, including neuroplasticity and central sensitization
54
T or F;
There do not seem to be substantive differences between various types of exercise or manual therapy for LBP
- T
55
What is a physiologic rationale for trigger points as pain generators?
- trigger points can be thought of as local areas of sustained muscle contractions associated with fluid congestion and cytokine buildup, provoking pain
56
T or F;
Dry needling is shown to be an effective treatment for LBP.
- eh...F mostly. Evidence is still inconclusive. It's likely to be better than nothing, like most all other approaches.
57
The theoretical peripheral effects of manual therapy are though to reduce _________
- muscle spasm in the low back
58
What physiologic mechanism is thought to create the positive effects from manual therapy for low back pain?
- changes in the rates of diffusion of fluids
59
What support is there for diffusion of fluids as a mechanism for mediating low back pain?
- one study showed an immediate increase in diffusion of water into intervertebral discs in pts who had decreases in pain following mobilization, prone press-ups, or manipulation
- pts who had no change in pain, also had no change in diffusion
60
What is the classic model of intervetebral disc anatomy?
- outer annulus fibrosis
| - inner nucleus proposus
61
Current thought of the anatomy of the intervertebral discs has what for layers?
- outer most annulus
- inner portion of annulus
- transition zone of annulus
- nucleus proposus
62
Describe the outer most annular layer of the IVD.
- provides substantial resistance to tensile loads
- dense, well-oriented Type I collagen fibers
- contains virtually all of the neurovascular structures in normal, non-diseased IVDs
63
How deep do sensory nerve fibers go in the IVD?
- usually within the outer most annular layer, to a depth of ~ 3.5 mm
64
The regions of the disc that are most innervated are most likely to be loaded with which movements/postures?
- end range flexion
| - side-bending
65
What aspect of the anatomy of sensory nerves in the IVDs may contribute to the vague, diffuse nature of LBP?
- has two routes to the spinal cord
- first is segmentally through the adjacent posterior (dorsal) root
- second is extrasegmentally through the paravertebral sympathetic chain
66
Describe the second layer of the IVD.
- like the first layer, dense Type I collagen fibers, but doesn't have the parallel alignment
- begins to decrease in density as it gets to the third layer
67
Describe the third layer of the IVD.
- thin, fibrous tissue layer that surrounds the nucleus propulsus
68
Describe the 4th layer of the IVD.
- mainly water
| - held in suspension by hydrophillic glycosaminoglycan that is bonded to proteoglycan molecules
69
Describe the vertebral end plates.
- large, flat cartilage
- 0.1 - 1.6 mm thick
- covers the superior and inferior vertebral bodies
- creates semi-permeable barrier between subchondral bone of vertebrae and IVD
70
What is the tissue makeup of the vertebral end plates?
- IVD side is fibrocartilage that is strongly bonded to the nuclear and annular regions
- vertebral side is hyaline cartilage that is weakly bonded to the subchondral bone
71
What is thought to be the "weak link" when IVDs are exposed to trauma?
- the vertebral side of the end plate which is weakly bonded to subchondral bone
- may be an important mechanism in the development of DD
72
Can the IVD repair itself?
- kind of. The outer layer of the annulus does secrete Type I collagen, while the nucleus secretes Type II collagen.
73
Describe considerations for IVD nutrient health.
- only the outermost layer has vascularization, so fluid diffusion is the means for the rest of the disc to stay healthy.
- rate of diffusion may be influenced by loading and unloading through the spine, as well as the health of the tissue at the vertebral end plates
- for people with disc degeneration and those over the age of 35 with normal discs, they do not see diurnal changes in disc height changes
74
What is a good running definition for disc degeneration?
- an aberrant, cell-mediated response to progressive structural failure
75
When are signs of disc degeneration often present for most people?
- third decade of life
| - almost universal by seventh and eighth decade
76
Disc degeneration accounts for what % of adult spinal surgeries?
- 90%
77
T or F;
Smoking and a history of heavy lifting are predictive of disc degeneration.
- F
| - competitive weight lifters have a lower degree of degeneration in the absence of trauma
78
What are the strongest predictors of the development of disc degeneration?
- genetic factors that influence water content and the shape of spinal structures, as well as synthesis and breakdown of tissues in the IVD
79
What association lends further support to genetic mediators as primary risk factors for the development of DD?
- DD has the highest prevalence in those who have OA in the extremities
80
Describe the hypothesized age-related changes to disc health.
- over time, end-plate permeability decreases, impacting IVD metabolism
- IVD hydration decreases
- thin, Type II collagen in the nucleus is replaced with thicker Type I collagen, which further disrupts fluid diffusion
81
The vertebral end plates are thought to be most vulnerable with what type of loading?
- compressive loading; axial
82
Are there differences between symptomatic degenerative discs, and those with age-related changes?
- there may be; one study showed some small differences in diffusion capacity
83
What may be a sign on imaging that a degenerative disc may be painful?
- Modic sign
84
What type of lesion in the disc is associated with:
- trauma
- repetitive compressive stress
- disc degeneration
- trauma: peripheral rim lesions
- repetitive compressive stress: circumferential tears
- DD: radial fissures
85
T or F;
Annular tears can heal.
- T...but very limited capacity. Peripheral tears have a much better chance at healing.
86
What are some factors that can make healing from annular tears difficult?
- poor blood supply
- the healing process replaces structure suboptimally; really doesn't create good tissue alignment
- the inflammatory process may create neovascularization and nerve growth where there wasn't sensation before.
87
Anatomically, why may two people with the same disc injury have significantly different pain responses?
- neovascularization with new peripheral nerve fibers in one patient with the inflammatory response, compared to another that doesn' thave the same response.
88
Can end plate or annular injury create destabilization in the region?
- Sort of. With the changes following the injury, the nutrient exchange is damaged, with suboptimal structural repair, reducing capacity for load transduction, and segmental instability.
It's a bit of a self-perpetuating process/spiral
89
What are some regional consequences of disc degeneration?
- decreased disc height of 1-3 mm can result in significant increases in facet loading.
- repeated micromotion can increase loading on ligaments and the outermost annulus, resulting in disk-osteophyte formation, aka spondylosis
90
T or F;
The changes in disc structure with DD directly cause pain.
- eh, F-ish
- more likely the changes in disc structure with DD may lower the pain thresholds in outer annulus, subchondral bone, or adjacent tissues
91
T or F;
Current literature does not provide a valid system by which to use findings of DD to identify pts with DD, or provide appropriate strategies to treat these pts noninvasively.
- T
92
What adjustments to exercise intervention should be made for pts with early/mild DD?
- none really needed. Graded weight training is appropriate
93
T or F;
Repeated occupational exposure to lifting is not related to DD.
- T
| - It is related to the development of low back pain though...
94
What numbers are associated with occupational lifting and development of low back pain?
- lifting 25kg or > 25x or more per day is associated with a 4% increase in LBP incidence annually.
95
What are some considerations for exercise intervention with pts with later stage/moderate-severe DD?
- will likely need to be more conservative with loading progressions
- likely better to avoid intense/vigorous loading near end ranges of trunk motion, as the IVD is unlikely to be sufficient to resist loading as effectively
96
Is a person with more advanced DD likely to feel pain immediately during exercise, or afterwards?
- could feel it more afterwards.
- may be able to tolerate more vigorous loading during activity, with microtrauma and edema taking a little bit of time to develop and start to create pain.
97
What is a paradox associated with lumbar stabilization exercise and DD?
- TA and multifidus contraction may increase a pt's tolerance for IVD loading, but with the increased loading, more microtrauma may actually occur
98
T or F;
Pts w/ DD should avoid end-range flexion for at least 2 hours in the morning.
- T-ish
- Those that did that had significantly less pain/disability than those that did early-morning lumbar flexion exercises
- may related to increased hydrostatic pressure in discs in the morning (diurnal changes)
99
What are the concerns for prolonged sitting for disc health w/ DD?
- prolonged or excessive compression, especially in lumbar flexion, can lead to decreased activity and/or death of cells in the IVD
100
T or F;
Use of injectable biomaterials is unlikely to be effective for IVD degeneration.
- F-ish
| - shows promise for early/mild damage, but unlikely helpful for severely degenerated IVDs
101
What are the 3 pillars of PT intervention for LBP?
- manual
- exercise
- education
102
T or F;
Most people will recover from an acute episode of LBP whether they receive care or not.
- T
103
What has been found to amplify a placebo effect?
- strong therapeutic alliance. Pts put on estim got much better results with increased interaction with the therapist compared to minimal.
104
A sign on MRI of early stage disc degeneration is: _______
- reduced signal intensity in the nuclear area of the disc; i.e., "dark disk"
