tables figures and new Flashcards
how do we define acute low back pain?
less than 3 months of symptoms
how long does it take for acute back to resolve
6-8 weeks
- 50% return to work in 2 weeks
- 83% in 3 months
- 28% report continued symptoms after 1 year
- flare ups are part of the process
what is the difference between etiologic factor and prognostic factors
etiologic - factors present prior to the onset
prognostic - factors present after the onset
what does the STarTBack survey tell you
gives you a relive risk for failure to recover
what is the difference between mechanistic, efficacy, effectiveness and comparative studies
mech - address mechanism of injury
- efficacy - effects of interventions on specific outcomes
- effectiveness - outcomes from clinical trials
- comparative - difference in multiple interventions
Name 4 serious medical conditions that can present as low back pain
- metatstic cancer
- disk of vertebrae infection
- vertebral fracture
- AAA
what are the red flags for metastatic Cancer
- History of LED KTL cancers
- night pain or rest pain
- unexplained weight loss
- age greater than 50 or less than 17
- failure to improve over the predicted time interval following treatment
What percentage of people precent with at least one red flag
“nearly all”, but only 1% had a serious problem
- two or more is a better reference point
what are the low back pain reflags for disc or vertebral infection?
- the patient in immunosuppressed
- a prolonged fever with temp over 100.4
- history of IV drug use
- history of recurrent bladder infections, cellulitis, or pneumonia
what are LRs
likelihood rain
- less than one is negative and suggests a reduced likelihood of the condition being present
- LRs of less than 0.1 and greater than 10 suggest large and conclusive changes
Red flags for undiagnosed vertebral fracture
- prolonged use of crticosteriods
- mild trauma for 50 yo or great
- age greater than 70
- a know history of osteoporosis
- recent major trauma at any age
- bruising over the spine
- female gender
- prolonged use of corticosteriods
red flags for AAA
- pulsating mass in the abdomen
- history of atherosclerotic vascular disease
- a throbbing, pulsing back pain at rest or with recumbency
- age greater than 60
What is Modic sign?
MRI finding believed to represent disruption of the the end plate with subsequent bone marrow edema
- Weighted T2 image
- bright area at the endplate margins
What is a “dark disc”
Decreased T2 weighted signal suggestive of degenerative changes, loss of fluid in the NP
what physical exam test is most suggestive of discogenic back pain
centralization of symptoms
what physical exam test was most suggestive of facet mediated pain?
there is no specific test
what are some yellow flags associated with delayed recovery from back pain and the development of chronic back pain
- emotional distress - high anxiety and depression
- hyper vigilance - excessive pre-occupation with pain
- pain catastrophizing - overestimation of the negative impact of pain
- elevated fear avoidance - inappropriate belief that benign activities are harmful to the spine
- misunderstanding about the nature and likely impact of pain - belief the condition is more serious than it is
- misunderstanding about the strategies for long term success - belief in passive interventions or the need for someone else to fix their back
what are blue flags
- patient perception of work and work conditions
2. job satisfaction and personal conflicts with employer or employees
what is self efficacy?
belief that one can help themselves
what is the CPR for manipulation in low back pain
- no symptoms distal to the knee
- less than 16 days of pain
- at least one hypo mobile segment
- at least one hip with greater than 35 degrees of IR
what effect do aerobic conditioning and anaerobic strengthening have on pain
1- aerobic - appears to have greater influence on central sensitization
2. strengthening decreases frequency of LBP episodes
what impact does manual therapy have on pain
- peripherally it appears to increase tissue water content and possibly change in inflammatory mediators
- dorsal horn inhibition
- central - activation of pain inhibiting pathways in the brains and PAG as well as autonomic responses such as reduced cortisol
what are the parts of the lumbar disc?
- outer annulus - well oriented type 1 bound to the periphery of the vertebral body and outer margin of end plate
- inner annulus- thick type I
- transitional zone - thin fibrous tissue surround the NP
- NP - composed mostly of water and proteoglycans with GAG chains
describe the anatomy of the vertebral end plate
- 0.1-1.6 mm thick
- 2 layers - fibrocartilage layer tightly bound to IVD and hyaline cartilage layer bound loosely to the vertebral body
- does not extend to the margins of the vertebral body
what types of cells are found in discs
- fibrocytes in the annulus
- chondrocytes in the NP
describe the fluid exchange rates of the disc
- dictated by electrochemical behaviors of the proteoglycan’s strong water binding properties
- healthy young disc (less than 35) gain as much as 0.9 mm after long periods of recumbency
- older disc (over the age of 35) don’t show the same disc height changes
what is the mechanical impact of NP height loss on the rest of the disk
Loss of NP means a shift in the weight bearing onto the annulus which it is not designed to do
When does DDD begin to show
Most people by the 3rd decade almost all by the 7th and 8th decades
what are the risk factors of DDD
- genetics
- onset of HNP before 21
- osteoarthritis in the extremities
How does the nutritional capacity of the disc change with time
- reduced end plate permeability
- reduction in PG decreasing NP height
- type II collagen is gradually replaced by type I with strong crossing links
- results in a fibrous disc (AKA dark disk) that has poor nutritional capacity
How doe the end plate change with time
by the second decade you are loosing the blood vessels in disc and permeability is decreasing
How to endplate injuries effect the mechanics of the spine?
- Both the vertebral body and the NP are pressurized containers during weight bearing
- endplate injuries result in loss of pressure balance
what are the different types of annular tears
- peripheral rim lesions - T2 bright areas near the edge of the disc
- circumferential splints between the layers of the annulus
- radial spread outward from the NP
how can the disc healing process result in chronic pain
neovascularization associated with healing can put blood vessels in weight bearing areas resulting in high threshold mechanoreceptors in areas of high threshold loading
what is the spondylosis cascade
- disc end plate or annular injury
- impair diffusion of O2 and nutrients
- low O2 in NP
- anaerobic metabolism
- decreased pH with acid build up
- decreased cellular activity
- cell apotosis with reduction in glycogen stores
- inhibition of PG synthesis
- stiffening of disk
- segmental instability
- further micro-damage with increased proteolytic enzyme activity
- loss of water volume and disc height
- loosing of support connective tissues
- shear motion and facet loading
- foramenal height loss
- osteophyte production with connective tissue motion
describe the relationship between heavy lifting and disc injuries
- Repetitive heavy lifting at work can increased risk of disc injury
- repetitive heavy lifting as an exercise is protective of disc injuries or at the very least does not injure discs
what type of loading is the least tolerated in severe DDD
flexion
what are the benefits of PT in an acute pain problem
- prevention of transition into chronic pain
- help with life style modificaiotn
- reduction in avoidance beliefs
- regular performance of conditioning exercises
what mechanical role to the pedicles play in spine weight bearing
they are the boney bridge between the anterior and posterior weight bearing structures
- as spine degeneration increase the weight bearing through pedicles increases to as much as 50% of the force
describe the role of the vertebral body trabeculae in weight bearing
- they are designed to distribute the load radially and vertically
- the blood filled space supports their function
describe the relationship between the spine and CA
about 10% of all patient with CA develop metastasis in the spine
- the thoracic spine is the most common place
what is the best strategy for prevent bone density issue
develop good bone density pre-puberty
what is the difference between a vertebroplasty and a kyphoplasty
- vertebroplasty - injection of cement into the compressed vertebrae
- kyphoplasty - injection of cement after the vertebrae is structurally restored, less pressure on the bone means less cement leakage
what is the normal load distribution between the disc and the facets in standing
- disc 75-80%
- facet 12-25%
what type of loading pattern typically leads to pars fractures
repeated flexion and extension
describe the difference in force management responsibilities of the disc and facets
disc - axial loading
facet - shear loading
how would you differentiate nerve root irritation/inflammation form nerve root compression
irritation/inflammation
- extremity pain greater than back pain,
- positive neurodynaic,
- centralization of symptoms with movement,
- limb symptoms with pain proximal and paresthesia distal
Nerve compression - neurologic findings
What test is most sensitive for identifying disc irritation?
well straight leg raise
What is the sign of the buttock
collection of 7 test to determine if non MSK is source of low back or glut region pain
- buttock large or swollen
- SLR painful and limited
- limited trunk flexion
- hip flexion with knee flexion limited and painful
- empty end feel of hip flexion
- non capsular pattern of hip ROM loss
- resisted hip movement painful and weak
what movements can isolate the transverse abdominus
- drawn-in - best for coactivation of the multifidi
- abdominal bracing
- posterior pelvic tilt
how do you isolate the rectus abdomenus
lumbar DNF like position and motion while pulling the stomach up during exhalation
