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MSK II - Exam 1 > Spine- Thoracolumbar III- LBP > Flashcards

Spine- Thoracolumbar III- LBP Flashcards

1
Q

Why is it non-specific LBP?

A

Nearly all cases have an unidentified source

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2
Q

What are some functional questionnaires for LBP with minimally clinically important effect?

A
  • Numeric Pain Rating Scale
  • Visual Analog Scale
  • Oswestry Disability Questionnaire
  • Roland Morris Disability Questionnaire
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3
Q

What functional questionnaire determined the risk of persistent disabling back pain and matches treatments?

A

*STarT Back Tool

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4
Q

How many points must a patient progress on functional questionnaires for the difference to be meaningful?

A

2 points

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5
Q

What is lumbar pain the leading cause of?

A
  • worldwide disability
  • activity limitation and work absence
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6
Q

What percentage of people will experience LBP in their lifetime?

A

80%

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7
Q

Where is there the smallest amount of spine related pathologies?

A

Thoracic

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8
Q

Do women or men experience more back pain?

A

Women

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9
Q

Do older or younger people experience more LBP?

A

Older (half > 65 years of age)

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10
Q

What other factors can lead to LBP?

A
  • lower educational status (think access to healthcare, earlier addressing of issues)
  • higher physical work demands
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11
Q

What are some risk factors for LBP?

A
  • previous LBP
  • Comorbidities such as diabetes, asthma, obesity, etc.
  • poor mental health (think coping)
  • smoking and low activity levels
  • Awkward postures, heavy lifting and fatigue
  • Genetics
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12
Q

What can genetics ONLY impact?

A

Age related disc changes, BUT can modify genes with epigenetic

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13
Q

What is the functional ROM necessary for sit to stand?

A

35 - 42 degrees of flexion

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14
Q

What is the functional ROM necessary for picking up objects from the floor?

A

60 degrees of flexion

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15
Q

What is the percentage of individual that showed abnormal findings with an MRI?

A

~1/3 (33%) had abnormal findings
- IDD
- Age related disc changes
- Nerve compression
- facet hypertrophy

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16
Q

What percentage of symptomatic individuals had an abnormality with imaging?

A

~1/2

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17
Q

What percentage of asymptomatic 30-80 year old individuals had disc changes with a CT and MRI?

A

~2/3

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18
Q

What was shown much more than symptomatic structural changes on the CT and MRI?

A

Normal asymptomatic age related changes

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19
Q

What percent of outpatient lumbar scans were inappropriate in 2012?

A

59%

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20
Q

Who should get imaging with LBP?

A
  • > 50 years of age with a hx of cancer
  • saddle paresthesias
  • bowel and bladder dysfunction
  • specific neurological deficits ( spinal nerve, brain, spinal cord)
  • progressive/disabling symptoms
  • NO improvement after 6 weeks of conservative rx
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21
Q

What does imaging NOT do?

A
  • improve outcomes
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22
Q

Is routine imaging recommended in the guidelines?

A

NO

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23
Q

How many LBP cases have an unidentified nociceptive source?

A

Nearly all

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24
Q

What is there between evidence and practice?

A

A substantial gap

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25
Q

What do patients over utilize?

A

Unsupported and ineffective rx

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26
Q

What can promote fear avoidance behaviors?

A

Passive interventions like modalities and even some manual therapies

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27
Q

What does the overutilization of ineffective rx lead to?

A
  • higher costs
  • greater opioid addiction
  • greater imaging and radiation exposure
  • more likely to have invasive procedures, side effects, and missed work
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28
Q

What PT rx has been shown to be largely effective in adults?

A

EXERCISE

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29
Q

What do we know about research on preventing LBP?

A

Inadequate, most lack evidence

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30
Q

What do we know about PT rx for children with LBP?

A
  • ergonomic furniture effective
  • exercise not evaluated
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31
Q

What difference can early PT make in those with LBP?

A
  • only 2% developed persistent LBP
  • significant reductions in lost work time
  • supported by numerous studies
  • can prevent unnecessary imaging
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32
Q

What is the FIRST LINE rx with moderate to strong evidence?

A

Education and advice

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33
Q

What should we advise and educate a LBP patient AGAINST?

A
  • bed rest
  • in depth explanations (freaks people out)
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34
Q

What should we advise and educate patients with LBP FOR?

A
  • spinal anatomical and structural strength
  • overall favorable prognosis
  • active pain coping mechanisms that decrease fear/catastrophizing
  • stay active with early resumption of ADLs
  • Biopsychosocial contributors and basics of nociplastic pain
  • emphasis on function with back protection techniques
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35
Q

What do we know about dry needling for LBP?

A

weak evidence of short term benefit

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36
Q

What do we know about modalities for LBP? (heat, US, e-stim, LASER, etc)

A

generally ineffective and NOT recommended
- short term results at best; often no better than placebo

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37
Q

What do we know about soft tissue mobilization/massage for LBP?

A

Moderate evidence of short term benefit

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38
Q

What can we do to overcome barriers to BEST practice?

A
  • increase consultation time and follow up
  • better incentives to return to work
  • reward quality and not volume with reimbursement
  • PSAs
  • increased provider knowledge of evidence and guidelines for use in clinical reasoning and decision making
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39
Q

What are the LBP rx classifications?

A
  • moderate evidence with acute LBP
  • weaker evidence with chronic LBP (due to greater contributing variables)
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40
Q

What are the 4 subgroups of LBP rx?

A
  • Mechanical traction
  • Directional Preference
  • Mobilization/Manipulation
  • Stabilization
41
Q

When is there no benefit with mechanical traction?

A
  • static tx
42
Q

When should we use mechanical traction?

A
  • intermittent tx for LBP with LE pain
43
Q

What type of back pain benefits from mechanical traction?

A
  • acute and subacute LBP with LE pain that doesn’t centralize
  • had preliminary support
44
Q

When is there MORE support for mechanical traction with acute LBP that doesn’t centralize?

A
  • PRONE
  • 18-60 years of age
  • paresthesias in last 24hrs distal to knee
  • Oswestry questionnaire score > 30
  • positive spinal nerve compression, crossed SLR, and/or centralization
45
Q

What type of back pain should we NOT use mechanical traction for?

A

Persistent LBP with LE pain

46
Q

When is there moderate evidence AGAINST all types of mechanical traction?

A

When used alone in patients with…
* acute, subacute, and persistent LBP
* Non-radicular LBP
* Varying symptom patterns

47
Q

How should mechanical traction be best used?

A

With radicular pain that is acute and does not centralize

48
Q

What is directional preference?

A
  • a position and/or motion that alleviates symptoms
49
Q

What is the MOST common directional preference?

A

Extension/hyperextension that may centralize LE symptoms to LB

50
Q

What is centralization?

A

Abolition of distal and/or spinal pain in a distal to proximal direction in response to repetitive motions or sustained positions

51
Q

When should directional preference be used?

A
  • preference for sitting or walking
  • centralization with motion testing
    -peripheralization in direction opposite centralization
52
Q

What is positive about mobilization/manipulation for LBP?

A
  • Strong patient preference/belief in short term effectiveness
  • strong evidence for thrust and non-thrust mobilizations for LBP and disability
53
Q

What is manipulation MOST effective for?

A

Sub-groups with acute and sub-acute LBP

54
Q

What are some predictors to improve success of mobilizations for LBP?

A
  • No symptoms distal to knee
  • symptoms for >16 days
  • lumbar joint hypomobility
  • fear avoidance behavior questionnaire at work <19
  • ≥ hip with MORE than 35 degrees of internal rotation
55
Q

What should we use WITH mobilization/manipulation?

A

MET, added benefit when used with exercise

56
Q

What does mobilization/manipulation have strong evidence to do?

A

Improve hip mobility with subacute and persistent LBP

57
Q

What does mobilization/manipulation have moderate to strong evidence to do?

A

Improve LBP and disability with back related LE pain

58
Q

What does mobilization/manipulation being SHORT course at MOST mean?

A
  • used to get people back to exercising and back to ADLs
59
Q

Which has a greater effect on LBP? Mobilization or manipulation?

A

manipulation effect larger than mobilization

60
Q

Is a long term effect of mobilization/manipulation well established?

A

NO

61
Q

What type of LBP is stabilization good for?

A

Acute LBP, sub-acute and persistent LBP

62
Q

Is Stabilization safe to do early?

A

Safe and effective to do early

63
Q

What is typically unnecessary for stabilization for acute LBP?

A

Supervision typically unnecessary unless NOT progression or risk factors for persistent LBP exist

64
Q

What should stabilization be the first line RX for?

A

Sub-acute and persistent LBP

65
Q

What are the most effective treatements for function for sub-acute and persistent LBP? (in order)

A
  1. Motor activation/ coordination and stabilization
  2. Aquatic therapy, pilates, and yoga
66
Q

What other benefits are there for stabilization for sub-acute and persistent LBP?

A

-strong support
- mental health benefits with resistance and aerobic training

67
Q
  • What should be graded with stabilization>
A

Graded activity and individualized - i.e. MET

68
Q

What does stabilization promote?

A

Motor control such as local muscle activation

69
Q

What type of LBP/function is stabilization effective for?

A

Non-specific LBP and function in isolation or with other therex

70
Q

What can stabilization with therex do long term?

A
  • prevented reoccurances at 3 years after 4 weeks of training
  • maintained pain and functional gains at 2 and a half years after 10 weekly training sessions in instability patients
71
Q

What can stabilization improve regarding the trunk?

A
  • Improved trunk control and created Earlier muscle activation
72
Q

What can provide added benefit to stabilization?

A

Trunk balance exercises

73
Q

What has strong evidence with persistent LBP for any intensity of aerobic activity?

A

Progressive endurance exercise

74
Q

With stabilization, can tele-rehab home programs be as effective as in person exercise?

A

YES

75
Q

What evidence is there for LE neural mobilizations?

A

Moderate evidence of short-term benefit with chronic LBP with LE pain

76
Q

What is William’s flexion exercises / protocol from 1937? (theory, goal, and exercises)

A

Theory: deforming the spine by forcing ourselves to stand
Goal: reduce lordosis
Exercises: involved posterior pelvic tilting and trunk and hip flexion

77
Q

What evidence is there for William’s flexion exercises/protocol?

A

WEAK evidence

78
Q

What do we need to know about stretching with LBP?

A
  • no difference in pain and function vs. no intervention at all with persistent LBP
79
Q

What is the first line rx for persistent LBP?

A

cognitive therapy

80
Q

What is cognitive behavioral therapy for LBP?

A

Helping patients understand and manage all biopsychosocial elements contributing to their symptoms such as:
- nociplastic pain
- inaccurate belief on tissue damage
- unhelpful lifestyle behaviors
- medications
= possible referral to other health professionals

81
Q

What are some unhelpful lifestyle behaviors one can have with LBP?

A
  • activity and social avoidance
  • mental/emotional stress : directly related to symptoms/persistance
  • sleep dysfunction
  • SAD
82
Q

What is cognitive functional therapy?

A

Like behavior therapy plus addressing QUALITY of movement

83
Q

What can cognitive functional therapy provide for LBP?

A

Large and sustained improvements with persistent LBP at least that half the cost of usual care

84
Q

What are the three components of cognitive functional therapy?

A
  1. making sense of pain from a biopsychosocial perspective
  2. graded return to activity
    - ADLs
    - MET
    - Pain control and confidence to move
  3. lifestyle behavior changes
85
Q

What is cognitive functional therapy LESS effective than?

A

Combining manual therapy and stabilization exercises

86
Q

What should we expect within one month for LBP patients?

A

RAPID improvements

87
Q

When should most LBP patients improve substantially?

A

6 weeks

88
Q

What percentage of the typical patients report persistent LBP on out after therapy?

A
  • 66% report pain at 3 and 12 months
89
Q

What are the chances of recurrence with LBP?

A
  • 24-65%
90
Q

33% of LBP patients have reoccurrence within ______ ______

A

1 year

91
Q

What had moderate evidence to prevent reoccurrence of LBP?

A

Post-DC HEP

92
Q

What increases the risk for disability with LBP?

A
  • depression, anxiety, catastrophizing, and lack of self efficacy
  • higher pain intensity and multiple painful areas
93
Q

What behaviors are more influential than the pain itself with LBP?

A

Fear avoidance behaviors

94
Q

What contributes to persistent LBP?

A

low income and low education

95
Q

When are medications ONLY recommended with LBP?

A

With an inadequate response to exercise and cognitive behavioral therapy

96
Q

What should we know about medication use with LBP?

A
  • many with insufficient and uncertain influence and are NOT recommended
  • Any utilization should be limited and very selective with the lowest effective dose
97
Q

What invasive procedures are NOT recommended for non-specific LBP?

A

Epidural and facet joint injections

98
Q

When are epidural injections recommended?

A
  • for radicular pain
  • if no benefit by 4 weeks

BUT
- don’t reduce risk of surgery, create rare but serious side effects, guided with camera better than not guided

MSK II - Exam 1 (7 decks)

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