Musculoskeletal (Spine) Flashcards
What pathophysiological mechanisms underpin non-specific lower back pain and the associated pain response?
- Tension, soreness and/or stiffness of unknown aetiology in the lower back region with joint, disc and connective tissue involvement potentially contributing to symptoms. In those with NSLBP, the pain cannot be attributable to a specific diagnosis. Estimated 85% of patients with isolated LBP are not given a precise pathoanatomical diagnosis to explain their pain (Morris et al. 2020).
- Lower back-related leg pain can be classified as referred (non-specific) pain - back pain that spreads down the leg from structures such as ligament, joint or disc but not involving a spinal nerve root. (Stynes, 2016). Two-thirds of patients with NSLP present with this in secondary care.
PAIN
Pain in NSLBP is predominantly nociceptive, assuming a more sinister pathology has not been missed.
What are the predominant patient-reported dysfunctions for NSLBP?
- Pain in the lumbar spine when moving, especially in the morning.
- Pain provocation when moving after long periods of rest
- Coughing and sneezing also can be painful
- Pain often refers to the upper lower limb
What dysfunctions may be found during an objective assessment for NSLBP?
Pain upon range of motion testing of lumbar spine(AROM)
What modifiable and non-modifiable risk factors influence NSLBP?
Non-modifiable
* Intervertebral damage: Findings from cross-sectional studies on large population samples reported significant association between low back pain and degeneration of the lumbar discs (seen with clinical imaging).
* However, a systematic review with meta-analysis concluded - none of lesions identified by MRI could be established as the cause of LBP - such MRI abnormalities are common in people who are asymptomatic. (4 Balagué et al. 2012)
Modifiable
* Lifestyle factors (Maher et al, 2017): smoking, obesity, and depressive symptoms all increase risk of developing LBP. These risk factors increase odds of LBP by only a modest amount.
* Occupation: A review of lifting at work identified that both weight of the load and no. of lifts increased risk. (Maher et al. 2017). However, eight systematic reviews concluded that it was unlikely that mechanical factors were independently causative of LBP in populations of workers studied. (Balagué et al. 2012)
What is the prognosis for NSLBP and what contributing factors may influence this (with references)?
Acute LBP - typically self-limiting, with a recovery rate of 90% within 6 weeks of the initial episode. 2 to 7% of patients develop chronic LBP and have a high risk of recurrence. (Gianola, et al, 2019).
Prognostic Factors (Costa L da C et al. 2016)
* Taken previous sick leave for LBP
* Have high disability levels or high pain intensity at onset of chronic LBP
* Have lower education
* Perceive themselves as having a high risk of persistent pain.
* Low-back-related leg pain is associated with poor prognosis compared to LBP alone. Leg pain is considered to be an obstacle to recovery and a marker of severity.
* Further the pain radiates down the leg, the greater the likelihood of increased levels of disability and health care use. (Stynes, 2016)
What is the prognosis for Radiculopathy and what contributing factors may influence this (with references)?
Patients with LBP and radiculopathy have poorer outcomes and are more severely affected than those with LPB only (Lancet series 2018)
Most episodes improve substantially within 6 weeks, some pain at 3 months, pain levels low at 12 months. Recurrences common (but evidence around is lacking) - 33% likely to have a recurrence within 1yr of recovering from the previous episode (Lancet 2018 series)
Prognostic Factors (Lancet series 2018)
* Previous episodes (-)
* Pain intensity (-/+)
* Presence of leg pain (-/+).
* High BMI (-)
* Smoking (-)
* Physical activity (-/+)
* Depression (-)
* Catastrophizing (-)
* Fear-avoidance beliefs (-)
* High physical work-loads (-)
* Low education attainment (-)
* Work satisfaction (-/+)
What are the red flags for Cauda Equina Syndrome?
Clinical Physio Flash Cards
- Bilateral radiculopathy
- Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion.
- Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to irreversible urinary retention with overflow urinary incontinence.
- Loss of sensation of rectal fullness
- Perianal, perineal, or genital sensory loss (saddle anaesthesia or paraesthesia).
- Laxity of the anal sphincter.
- Erectile dysfunction.
What are the red flags for Spinal Fracture?
- Major trauma at any age (such as a road traffic collision or fall from a height)
- Mild trauma in people aged over 70 years, prolonged corticosteroid use, history of osteoporosis.
- Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) may be present.
*Contusion or abrasion. - There may be point tenderness over a vertebral body.
What are the red flags for Cancer?
- Age over 50 years or under 18 years.
- Gradual onset of symptoms.
- Severe unremitting pain that remains when the person is supine or at rest, aching night pain that prevents or disturbs sleep, pain aggravated by straining (for example, at stool, or when coughing or sneezing), and thoracic pain.
- Localized spinal tenderness.
- No symptomatic improvement with therapy.
*Unexplained weight loss. - Past history of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasize to the spine.
What are the 5 key treatments for NSLBP (with references)?
- Activity modification/advice to remain active (NICE… 2020; Foster et al, 2018)
- Patient Education (NICE… 2020; Foster et al, 2018).
- Superficial Heat (Foster et al, 2018) - Acute only
- Exercise Therapy (NICE…2020) - Persistent in particular
- CBT (Foster, 2018) - Persistent in particular
What are the key recommendations of the NICE Guidelines for NSLBP & Sciatica (with critical appraisal)?
- Stratify patient care based on case severity assessed by the START BACK risk assessment tool.
- Provide people with advice and information, tailored to their needs and capabilities, to help them self-manage their low back pain with or without sciatica, at all steps of the treatment pathway. Include: information on the nature of low back pain and sciatica and encouragement to continue with normal activities.
- Consider a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches) within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica.
- Take people’s specific needs, preferences and capabilities into account when choosing the type of exercise.
- Promote and facilitate return to work or normal activities of daily living for people with low back pain with or without sciatica.
What were the 4 key findings and 3 recommendations of Cook et al (2018) regarding red flag screening for lower back pain (with critical appraisal)
RF screening for LBP is ineffective because:
1. Red flag symptoms neither rule out nor identify serious pathology.
2. Variability in definitions for red flag symptoms greatly limits research and clinical progress in this area.
3. LBP guidelines do not help
4. Clinicians do not actually screen for red flags; they manage LBP conditions they see
Cook Recommends:
1. Watchful waiting
2. Enhancement of value-based care
3. Linking red flag symptomology not with diagnostic testing but directly with health status
What are the first-line and second-line treatments for ACUTE lower back pain recommended by Foster et al (2018)?
First Line
* Advice to remain active
* Education
Second Line
* Superficial heat
* Spinal Maipulation
* Massage
* Accupunture
What are the first-line and second-line treatments for PERSISTENT lower back pain recommended by Foster et al (2018)?
First Line
* Advice to remain active
* Education
* Exercise Therapy
* CBT
Second Line
* Spinal Maipulation
* Massage
* Accupunture
* Yoga
* Mindfulness based stress reduction
* Interdisiplianry Rehabilition
Outline the objective assessment for L Spine?
Clinical Physio Flashcards
What are the lower limb myotomes?
With Clinical Physio Flash Card
- L2 = Hip flexion
- L3 = Knee Extension
- L4 = Ankle Dorsiflexion
- L5 = Big Toe Extension (BTE)
- S1 = Ankle Plantar Flexion
- S2 = Knee Flexion
Can you accurately visualise the lower limb dermatomes?
Clinical Physio Flashcards
What were the key findings of Lee et al (2008) regarding dermatomes?
- Suggests that most dermatome maps are inaccurate and lack consensus and fail to recognise the significant overlap of nerve root contributions to sensation.
- There is significant variability in dermatomal distribution between individuals
- Their devised “evidence based” schema exemplifies the significant heterogeneity of dermatomes and highlights the potential redundancy fo clinical application.
What were the key findings of Sonoo (2023) regarding dermatomes?
- Highlights the significant discordances in myotome charts presented in most current neuroanatomical textbooks.
- Notes that most charts are based on the flawed and dated research of Herringham & Sharrard.
- Recognises that their own charts are very much heavily reliant on expert opinion and that no chart is perfect, however, notes that they remain useful in clinical practice.
Identify the key L Spine reflexes and their predominant nerve root contribution
Clinical Physio Flashcard
