Spine- Thoracolumbar III- LBP Flashcards
Why is it non-specific LBP?
Nearly all cases have an unidentified source
What are some functional questionnaires for LBP with minimally clinically important effect?
- Numeric Pain Rating Scale
- Visual Analog Scale
- Oswestry Disability Questionnaire
- Roland Morris Disability Questionnaire
What functional questionnaire determined the risk of persistent disabling back pain and matches treatments?
*STarT Back Tool
How many points must a patient progress on functional questionnaires for the difference to be meaningful?
2 points
What is lumbar pain the leading cause of?
- worldwide disability
- activity limitation and work absence
What percentage of people will experience LBP in their lifetime?
80%
Where is there the smallest amount of spine related pathologies?
Thoracic
Do women or men experience more back pain?
Women
Do older or younger people experience more LBP?
Older (half > 65 years of age)
What other factors can lead to LBP?
- lower educational status (think access to healthcare, earlier addressing of issues)
- higher physical work demands
What are some risk factors for LBP?
- 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
What can genetics ONLY impact?
Age related disc changes, BUT can modify genes with epigenetic
What is the functional ROM necessary for sit to stand?
35 - 42 degrees of flexion
What is the functional ROM necessary for picking up objects from the floor?
60 degrees of flexion
What is the percentage of individual that showed abnormal findings with an MRI?
~1/3 (33%) had abnormal findings
- IDD
- Age related disc changes
- Nerve compression
- facet hypertrophy
What percentage of symptomatic individuals had an abnormality with imaging?
~1/2
What percentage of asymptomatic 30-80 year old individuals had disc changes with a CT and MRI?
~2/3
What was shown much more than symptomatic structural changes on the CT and MRI?
Normal asymptomatic age related changes
What percent of outpatient lumbar scans were inappropriate in 2012?
59%
Who should get imaging with LBP?
- > 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
What does imaging NOT do?
- improve outcomes
Is routine imaging recommended in the guidelines?
NO
How many LBP cases have an unidentified nociceptive source?
Nearly all
What is there between evidence and practice?
A substantial gap
What do patients over utilize?
Unsupported and ineffective rx
What can promote fear avoidance behaviors?
Passive interventions like modalities and even some manual therapies
What does the overutilization of ineffective rx lead to?
- higher costs
- greater opioid addiction
- greater imaging and radiation exposure
- more likely to have invasive procedures, side effects, and missed work
What PT rx has been shown to be largely effective in adults?
EXERCISE
What do we know about research on preventing LBP?
Inadequate, most lack evidence
What do we know about PT rx for children with LBP?
- ergonomic furniture effective
- exercise not evaluated
What difference can early PT make in those with LBP?
- only 2% developed persistent LBP
- significant reductions in lost work time
- supported by numerous studies
- can prevent unnecessary imaging
What is the FIRST LINE rx with moderate to strong evidence?
Education and advice
What should we advise and educate a LBP patient AGAINST?
- bed rest
- in depth explanations (freaks people out)
What should we advise and educate patients with LBP FOR?
- 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
What do we know about dry needling for LBP?
weak evidence of short term benefit
What do we know about modalities for LBP? (heat, US, e-stim, LASER, etc)
generally ineffective and NOT recommended
- short term results at best; often no better than placebo
What do we know about soft tissue mobilization/massage for LBP?
Moderate evidence of short term benefit
What can we do to overcome barriers to BEST practice?
- 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
What are the LBP rx classifications?
- moderate evidence with acute LBP
- weaker evidence with chronic LBP (due to greater contributing variables)
What are the 4 subgroups of LBP rx?
- Mechanical traction
- Directional Preference
- Mobilization/Manipulation
- Stabilization
When is there no benefit with mechanical traction?
- static tx
When should we use mechanical traction?
- intermittent tx for LBP with LE pain
What type of back pain benefits from mechanical traction?
- acute and subacute LBP with LE pain that doesn’t centralize
- had preliminary support
When is there MORE support for mechanical traction with acute LBP that doesn’t centralize?
- 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
What type of back pain should we NOT use mechanical traction for?
Persistent LBP with LE pain
When is there moderate evidence AGAINST all types of mechanical traction?
When used alone in patients with…
* acute, subacute, and persistent LBP
* Non-radicular LBP
* Varying symptom patterns
How should mechanical traction be best used?
With radicular pain that is acute and does not centralize
What is directional preference?
- a position and/or motion that alleviates symptoms
What is the MOST common directional preference?
Extension/hyperextension that may centralize LE symptoms to LB
What is centralization?
Abolition of distal and/or spinal pain in a distal to proximal direction in response to repetitive motions or sustained positions
When should directional preference be used?
- preference for sitting or walking
- centralization with motion testing
-peripheralization in direction opposite centralization
What is positive about mobilization/manipulation for LBP?
- Strong patient preference/belief in short term effectiveness
- strong evidence for thrust and non-thrust mobilizations for LBP and disability
What is manipulation MOST effective for?
Sub-groups with acute and sub-acute LBP
What are some predictors to improve success of mobilizations for LBP?
- 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
What should we use WITH mobilization/manipulation?
MET, added benefit when used with exercise
What does mobilization/manipulation have strong evidence to do?
Improve hip mobility with subacute and persistent LBP
What does mobilization/manipulation have moderate to strong evidence to do?
Improve LBP and disability with back related LE pain
What does mobilization/manipulation being SHORT course at MOST mean?
- used to get people back to exercising and back to ADLs
Which has a greater effect on LBP? Mobilization or manipulation?
manipulation effect larger than mobilization
Is a long term effect of mobilization/manipulation well established?
NO
What type of LBP is stabilization good for?
Acute LBP, sub-acute and persistent LBP
Is Stabilization safe to do early?
Safe and effective to do early
What is typically unnecessary for stabilization for acute LBP?
Supervision typically unnecessary unless NOT progression or risk factors for persistent LBP exist
What should stabilization be the first line RX for?
Sub-acute and persistent LBP
What are the most effective treatements for function for sub-acute and persistent LBP? (in order)
- Motor activation/ coordination and stabilization
- Aquatic therapy, pilates, and yoga
What other benefits are there for stabilization for sub-acute and persistent LBP?
-strong support
- mental health benefits with resistance and aerobic training
- What should be graded with stabilization>
Graded activity and individualized - i.e. MET
What does stabilization promote?
Motor control such as local muscle activation
What type of LBP/function is stabilization effective for?
Non-specific LBP and function in isolation or with other therex
What can stabilization with therex do long term?
- 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
What can stabilization improve regarding the trunk?
- Improved trunk control and created Earlier muscle activation
What can provide added benefit to stabilization?
Trunk balance exercises
What has strong evidence with persistent LBP for any intensity of aerobic activity?
Progressive endurance exercise
With stabilization, can tele-rehab home programs be as effective as in person exercise?
YES
What evidence is there for LE neural mobilizations?
Moderate evidence of short-term benefit with chronic LBP with LE pain
What is William’s flexion exercises / protocol from 1937? (theory, goal, and exercises)
Theory: deforming the spine by forcing ourselves to stand
Goal: reduce lordosis
Exercises: involved posterior pelvic tilting and trunk and hip flexion
What evidence is there for William’s flexion exercises/protocol?
WEAK evidence
What do we need to know about stretching with LBP?
- no difference in pain and function vs. no intervention at all with persistent LBP
What is the first line rx for persistent LBP?
cognitive therapy
What is cognitive behavioral therapy for LBP?
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
What are some unhelpful lifestyle behaviors one can have with LBP?
- activity and social avoidance
- mental/emotional stress : directly related to symptoms/persistance
- sleep dysfunction
- SAD
What is cognitive functional therapy?
Like behavior therapy plus addressing QUALITY of movement
What can cognitive functional therapy provide for LBP?
Large and sustained improvements with persistent LBP at least that half the cost of usual care
What are the three components of cognitive functional therapy?
- making sense of pain from a biopsychosocial perspective
- graded return to activity
- ADLs
- MET
- Pain control and confidence to move - lifestyle behavior changes
What is cognitive functional therapy LESS effective than?
Combining manual therapy and stabilization exercises
What should we expect within one month for LBP patients?
RAPID improvements
When should most LBP patients improve substantially?
6 weeks
What percentage of the typical patients report persistent LBP on out after therapy?
- 66% report pain at 3 and 12 months
What are the chances of recurrence with LBP?
- 24-65%
33% of LBP patients have reoccurrence within ______ ______
1 year
What had moderate evidence to prevent reoccurrence of LBP?
Post-DC HEP
What increases the risk for disability with LBP?
- depression, anxiety, catastrophizing, and lack of self efficacy
- higher pain intensity and multiple painful areas
What behaviors are more influential than the pain itself with LBP?
Fear avoidance behaviors
What contributes to persistent LBP?
low income and low education
When are medications ONLY recommended with LBP?
With an inadequate response to exercise and cognitive behavioral therapy
What should we know about medication use with LBP?
- many with insufficient and uncertain influence and are NOT recommended
- Any utilization should be limited and very selective with the lowest effective dose
What invasive procedures are NOT recommended for non-specific LBP?
Epidural and facet joint injections
When are epidural injections recommended?
- 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
