Week 2: Thu 1.21.16 Lumbar Subjective Flashcards
In what age groups is LBP most likely to occur?
20-50
What are the most consistently reported occupational factors associated with the development of LBP? (4)
- heavy and frequent lifting
- high exposure to whole body vibrations such as driving
- prolonged or frequent bending or twisting
- postural stresses (ie. high load, awkward postures)
What is the U-shaped curve between physical (and probably occupational) activity and LBP?
- U-shaped curve- too little or too much activity equally increases risk of LBP.
- Physical activity not associated w/ CLBP by type, intensity, duration. But extremes of total activity pattern are associated w/ CLBP.
- Example: One extreme being a very sedentary lifestyle versus the opposite, a physically strenuous lifestyle.
LBP: which body areas and common symptoms should be cleared during the subjective exam? (3)
- Lower thoracic spine and lumbosacral spine (unilaterally and centrally)
- Bilateral buttocks and both lower extremities (circumferentially)
- Abdominal and groin (anteriorly)”
Accepted MCID for the NPRS
2 points
How should the PT proceed with the subjective exam if the patient reports a gradual or insidious onset of pain?
If onset is gradual or insidious, clinician must ask about predisposing factors: unusual activity, repetitive activities, changes in work, training, recent illness, or stress.
What can gradual onset of pain mean?
“Gradual” may mean over one day or over weeks or months. Spinal loads with cumulative or repetitive stress and biomechanical creep leading may subject some tissues to fatigue damage.
Why is insideous onset a concern?
A truly insidious onset merits concern about the underlying cause of the condition and raises the suspicion of a non musculoskeletal problem.
What pattern of progression, stability or response to previous treatment suggests a red flag?
Symptoms unchanged, worsened, or improved then get worse again despite appropriate PT interventions are considered a red flag
What is the analytic value of agg and ease of standing/walking? (3, sorta 5)
- lumbar extension
- lower extremity loading and balance
- hip stability and mobility
What is the analytic value of agg and ease of relaxed sitting? (2)
- mostly lumbar flexion
- adequate hip mobility
What is the analytic value of agg and ease of bending? (1)
produces more flexion of the lumbar spine than squatting
What is the analytic value of agg and ease of lying?
depends on many factors, but also upon position- supine, prone, or side lying
4 positions/movements that may have analytic value when reviewing agg/ease factors for LBP
- standing/walking
- relaxed sitting
- bending
- lying supine/prone/sidelying
Two important reasons for inquiring about sleep?
- Night pain can a red flag
- If pain is most intense at night and the patient is unsure of what wakes him or her, gets up and walk around, and has difficulty returning to sleep, consider possibility of an active inflammatory component or more serious pathology
- Pain at night is typical of mechanical problem- pt. reports inability to lie on the involved side or waking w/ symptoms that are simply relieved by a change of position and return to sleep.
- determine the frequency, provocative position, and symptoms produced.
What info would guide a PT to determine that pt. report of muscle stiffness is Non-musculoskeletal?
symptoms that remain unchanged in am.
Caveat: could also be a minor mechanical problem
What info would guide a PT to determine that pt. report of muscle stiffness is Degenerative Mechanical?
can be better or worse in am. any stiffness typical resolves within 30-60 min.
What info would guide a PT to determine that pt. report of muscle stiffness is inflammatory disease?
Systemic inflammatory disorders such as Ankylosing Spondylitis are usually better with rest but present the greatest stiffness first thing in am, usually longer than 60 min
How does a patient’s perception of general health status impact prognosis? What about expectations/goals? (4)
- poor self assessment = poor prognosis.
- Can be predictive of future mortality, functional limitations, and development of chronic conditions.
- more likely to have back problems along w/ a variety of other medical problems
- poor general health due to comorbidities are likely to progress slowly w/ rehab and are at risk for delay in the normal healing process
Why is it important to screen patients with LBP for cardiovascular disease? (2)
- Over 50% of patients examined by orthopedic PT have cardiovascular disease (CVD)
- Ultimately, screening is recommended to help identify medical precautions and any contraindications to physical activity and exercise
Is there a standard for how to screen LBP patients for cardiovascular disease?
NO
ASCM developed guidelines for risk factors and how that should correspond with intensity for exercise. No standard currently exists in PT lit right now for screening CVD
6 common drugs likely to be taken by LBP patients
Most Common
- NSAIDs
- Skeletal Muscle Relaxants
- Opioids
Less Common
- Corticosteroids
- Antidepressants
- Statin-related drugs (?- from the book)
What are the most common side effects of NSAIDs taken for LBP? (5)
- back and/or shoulder pain due to retroperitoneal bleeding
- GI symptoms
- kidney problems
- liver problems
- MI
What are the most common side effects of muscle relaxants taken for LBP? (1)
sedation
What are the most common side effects of opioids taken for LBP? (5)
- nausea
- constipation
- dry mouth
- dizziness
- addiction
What are the most common side effects of statin-related medications taken by LBP patients? (1)
musculoskeletal pain
What are the most common side effects of corticosteroids taken by LBP patients? (4)
- AVN femoral head
- osteoporosis
- immunosuppression
- steroid-induced myopathy
What are the most common side effect of anti-depressants taken by LBP patients?
movement disorders
What is the appropriate general recommendation for the use of imaging in acute LBP? In LBP lasting more than 6 weeks?
- Acute LBP (6 weeks or less), imaging is not recommended
- Greater than 6 weeks, clinical judgement is used for imaging. Must balance out role and relative impact of imaging for LBP
Describe several problems associated with the overuse of imaging
- need to consider impact of exposure to radiation for some imaging, cost, negative impact of labeling patient with irrelevant diagnosis based on imaging
- many degenerative or pathological changes are asymptomatic or treatment did not change based on imaging results, imaging may not pinpoint the actual cause of LBP
What assessment tool can be used to plan the objective exam based off of the subjective exam?
SINSS
- Severity of disorder
- Irritability of symptoms
- Nature of complaint
- Stage of Pathology
- Stability of symptoms
What factors should be explored during the subjective exam with LBP patients? (9)
- erganomics
- conditioning
- depression
- job requirements
- body awareness
- sensory motor integrity
- trauma
- previous episodes
- other medical problems
How does the presence of leg pain affect prognosis?
- Associated with poorer outcomes and increased chance of developing chronic symptoms.
- However, centralization of leg symptoms is linked to good outcomes.
- Failure to centralize symptoms is a strong predictor of chronicity
