Movement System Dysfunction and the role of the Lumbar Spine Flashcards
Low Back Pain Today:Prevalence
LBP is the leading cause of disability worldwide
Global Burden of Disease (Lancet 2017): point prevalence = 7.8% = 577 million people at any one time
Costly: US $134 billion, more than 154 other conditions studied (annual increase of 6.7% between 1996-2016)
Once you have had LBP the chances of it recurring are ___
24-65%
Chronic LBP is increasing: reported range of ___ in people over age 18, up to ___ in older populations
3.9-20.3%
25.4%
Low Back Pain Today=
Rx for LBP and related spine disorders now represents the most expensive medical problem (more than heart disease and cancer combined)
Non-communicable diseases worldwide get very little attentions despite being more burdensome, MSK disorders are rarely mentioned
The lower a person’s SES, the worse their health status
Low Back Pain Today:Etiology
Difficult to determine the pathoanatomical cause of LBP.
Any innervated structure in the low back can cause pain and refer pain to the lower extremities.
False positive findings on imaging studies are common.
Pain can occur in the absence of findings on imaging and imaging can show abnormal findings in the pain free population.
Etiology of Mechanical LBP
Almost 50% of patients did not have any structural changes on dynamic radiograph
100 LBP patients
> 51 structural changed -> 25 hypermobility
> 49 NO structural changes -> 37 hypermobility
Imaging of L spine in 60 asymptomatic volunteers: ages 20-59
Disc protrusion: 62-67%
Extrusion: 18%
Sequestration: 0%
Early ZAJ arthrosis: 13-18%
Nerve root deviations: 3-7%
imaging study results:
Less than 5-10% of all LBP is d/t a specific underlying spinal pathology
Remaining 90-95% no serious cause, should be managed conservatively
imaging diagnosis and outcomes:
Dx triage based on clinical hx and exam can help distinguish between NSLBP from more serious LBP
Imaging may do more harm than good (worse outcomes, higher costs, prolonged recovery)
Sound education and reassurance can help patients concerned about whether their LBP is serious
Low Back Pain:Clinical Course
Acute: less than 1 month
Sub-acute: 2-3 months
Chronic: greater than 3 months since onset of LBP
Recurring: episodes of LBP that recur between periods of time where the pt has no pain
Clinical pearl – patients can become sensitized early =
doesn’t always take 3 months
Low Back Pain:Prognosis
LBP is common and most of the time resolves
> Emphasize this with your patients with first time LBP
Worse prognosis with reoccurring pain, excessive spine mobility, general excessive joint mobility, sx below the knee, high intensity pain, depression, and fear of pain & movement.
Clinicians should prioritize interventions to reduce reoccurring LBP and reduce the transition from subacute to chronic
Prognosis: Psychosocial factors
Larger prognostic role than physical factors!
Fear, distress and depression play important roles in LBP in the EARLY stages so clinicians should focus on these factors
Patients’ expectation of recovery is a predictor of return to work
Pts with higher expectations had less sickness absence
Coping style (active coping associated with better outcomes)
___ of acute LBP in primary care transitions to chronic
26%
Nonconcordant processes of care:
Prescription opioids, diagnostic imaging, subspecialty referral (ortho, neuro, pain specialists)
After controlling for patient characteristics (obesity, smoking, etc)
Recommend DPT’s to be recognized as primary care providers for spinal care – initial or early point of contact
Prevalence of Nonspecific Low Back Pain (NSLBP)
It is evident that NSLBP is not an acute disease that is cured with time but is more of a recurrent problem that ends as a chronic disease/disability
Early Intervention =
Timing of PT for LBP
> Early 48 hrs to 2-4 weeks
>Late – more than 30 days
Early PT resulted in decreased health services utilization, decreased long-term opioid use
Promote movement and return to activity/participation
Recognizing appropriate referral and interprofessional practice
HSU – overall cost, imaging, medications, spinal injections, surgery, physician office visits
> Costs doubled for late PT
Differential diagnosis
Primary goal of diagnosis: match patient’s clinical presentation with most efficacious treatment approach
Screen for red flags
Yellow flags
> Psychosocial risk factors for persistent pain
> Social determinants of health
Diagnostic value of red flag screening
Fracture, malignancy, infection, cauda equina
Lack of high quality evidence supporting diagnostic accuracy of red flags
Combination of multiple red flags showed higher diagnostic accuracy
- advanced age
- neurological signs
- hx of malignancy
Diagnostic value of red flag screening - levels of concern:
low = no concerning features - decision: begin trial of therapy - revise management of clinical features change unexpectedly
few concerning features - decision: begin a trial of therapy with watchful waiting - monitor progress closely and revise if unexpected changes
some concerning features - decision: URGENT referral - don’t begin a trial - further investigation
high = some concerning features - decision: EMERGENCY referral -
consider further investigation:
timing of this depends on the specific pathology
may be urgent or same day/emergency
refer to condition-specific sections for details
if investigations are negative, consider further referral or restart treatment
Movement System =
Strong biopsychosocial component
Education is important = Explanation given to a patient was pivotal in generation of a good Rx outcome
PT’s need to be aware that their pain beliefs may influence patient management
Reassure the patient: the disc will heal
Avoid end-range positions (temporarily) to prevent stress on healing tissues
Utilize postures and activities to enhance ebb and flow of disc hydration
If herniated material reaches vascular supply at posterior vertebral body, it will be absorbed; takes about 10 months
LBP and social determinants of health
SDH = The social conditions in which people are born, grow, live, work and age
Inequities in power, money and resources are responsible for disparities in health outcomes within and between countries
Education status, SES, and occupational factors are consistently associated with adverse outcomes
Consider the “cause of the cause” of poor health outcomes
“Health service and promotion initiatives can be adopted through models that are developed to consider, evaluate, and enhance health equity.”
Architecture suitable for increased load =
Lordosis d/t wedge shape of disc
Lateral foramen lies at disc level
Cartilaginous endplate plays a role in disc nutrition and can be involved with disc lesions
Endplate can absorb hydrostatic pressure dissipated by disc under loading
Schmorl’s node – prolapse through endplate
IVD ___ ratio vertebral body to disc height
3:1
IVD : nucleus and annulus
Nucleus
> 85% H2O
> Proteoglycans
> Collagen type II
Annulus
> 60% H2O
> Proteoglycans
> Collagen type I
Outer Annulus =
Poly-segmental innervation (sinuvertebral nerve)
Diffuse pain
Inner Annulus =
Mono-segmental innervation
Local Pain (IDD)
Annulus and nucleus maintain a symbiotic relationship when responding to compressive load
Disc nutrition via diffusion at the end plate
Pumping enhances anaerobic metabolism, which enhances healing
Pumping = Dehydration and rehydration
considerations specific to the lumbar disc =
mechanical
chemical
nutritional
psychological
social
genetic
At every spinal level, dorsal & ventral roots come together to form a spinal nerve =
Spinal nerve divides into dorsal and ventral rami
Ventral rami
Dorsal rami
Sinuvertebral nerve provides local innervation of spinal segment with sympathetic and sensory fibers
Free nerve endings contain: substance P, calcitonin gene-related peptide (CGRP), nitric oxide
Ventral rami =
primarily form the plexus (lumbar, lumbosacral, brachial, cervical): motor and sensory
Dorsal rami has 3 branches:
cutaneous, articular, motor
Segmental somatic innervation =
Sinuvertebral nerve innervates the dura, PLL, dorsal aspect of the disc, medial aspect of the facet joint
Facet joint capsule innervated by the medial branch of the dorsal ramus
> Mechanoreceptor endings
> Nociceptive endings
- Substance P sensitive
Non-specific LBP = what age?
12-35 y.o.
Acute disc disorder = what age?
25-45 y.o.
Posterolateral protrusion/prolapse = what age?
18-45 y.o.
