Week 2: Tue 1.19.16 LBP Classification, screening, PRO's PART 1 of 2

Question 1

What is the medical diagnositc model in relationship to back pain?

Answer 1

The medical diagnostic model has traditionally tried to classify persons with the LBP based on a pathoanatomical source.

A pathoanotomical source is something that can be seen in the anatomy to have a pathology (like seeing stenosis on a radiograph).

Question 2

What is a big problem with classifying persons with LBP based on pathoanatomical source?

Answer 2

The problem with this is that in more than 85% of pts with LBP, a precise anatomical tissue cannot be reliably identified as the cause or pain generator. However, it can be related in some cases such as cancer, compression fracture, spinal infection, ankylosing spondylitis, spinal stenosis, an cauda equina syndrome.

Labeling most pts with LBP by using specific anatomical diagnoses has not been validated in rigorous studies or shown to improve outcomes.

**It is more effective to use LBP subgrouping classifications shown to improve outcomes.

Question 3

Name the main reason for using a classification approach for treating LBP.

Answer 3

The limited medical (pathoanatomical -facet sprain, muscle strain, degenerative disc, herniated disc) model has led to the diagnostic category of nonspecific LBP, but not all persons will benefit from a single intervention. This model offers no model for informed decision making related to interventions, results in less than optimal outcomes, increased costs and variations in PT practice patterns.

Now it is recognized that classifying persons with nonspecific LBP into subgroups with similar characteristics and matching those subgroups to the best management strategies results in improved PT outcomes when compared to an alternative approach. (pg 114)

Question 4

What are the 10 LBP classifications?

Answer 4

1. Mobilization and Manipulation plus Exercise (also depicted as LBP mobility deficits)
2. Stabilization Exercise classification (also depicted as LBP with movement coordination impairments)
3. Direction-Specific exercise (DSE) classification also depicted as LBP with lower extremity referred pain)
4. Mechanical Traction classification for LBP with lower extremity-related pain
5. Impairment-based classification for symptomatic lumber spinal stenosis
6. Impairment-based classification for LBP with altered neurodynamics
7. Subclassification of low back-related leg pain (LBRLP) based on predominating pain mechanisim (ie, central sensitization, peripheral nerve sensitization, denervation, and musculoskeletal referred pain)
8. Chronic LBP (CLBP) or chronic, disabling lumbopelvic pain related to minor control impairments (MCIs) based on a biopsychosocial apporach
9. Pelvic girdle pain (PGP) classification based on a biopsychosocial and neurophysiological pain mechanism classification
10. Pregnancy-related PGP classification

Question 5

What is an alternate name for the Mobilization and Manipulation plus Exercise LBP classification subgroup

Answer 5

(also depicted as LBP mobility deficits)

Question 6

What is an alternate way to depict the Stabilization Exercise LBP subgroup classification?

Answer 6

(also depicted as LBP with movement coordination impairments)

Question 7

What is an alternative way to depict the Direction-Specific exercise (DSE) classification subgroup?

Answer 7

also depicted as LBP with lower extremity referred pain

Question 8

Subclassification of low back-related leg pain (LBRLP) based on predominating pain mechanisms:

• What are some predominating pain mechanisim examples? (4)

Answer 8

1. central sensitization,
2. peripheral nerve sensitization,
3. denervation, and
4. musculoskeletal referred pain

Question 9

Mobility deficits - Mobilization, Manipulation subclassification:

• List key exam findings (6)

Answer 9

1. No s/s distal to the knees
2. recent onset (<16 days)
3. LFABQ work scale <19
4. Hypomobility (AROM limited, End -range pain increased but no worse with repeated movement, passive accessory intervertebral movement +)
5. hip IR >35° (at least one hip measured prone)
6. regional deficits (mobility, muscle performance / length, activity limitations)

Question 10

Mobility deficits - Mobilization, Manipulation subclassification:

• List key interventions (6)

Answer 10

1. lumbopelvic mobilizations or manipulations
2. muscle energy technique (MET)
3. AROM: anterior/posterior pelvic tilt (supine or quadruped, 10 reps, 3/4 times daily)
4. AROM and stabilization exercises
5. A/P ROM to augment mobilization manipulation
6. address regional and functional deficits

Question 11

Movement Coordination Impairments - stabilization exercise subclassification:

• List keyexam findings (9+1)

Answer 11

1. younger (<40)
2. 3 or more prior episodes
3. ↑frequency of episodes
4. generally > flexibility
5. aberrant movement: instability catch or thigh climbing, painful arc mid-range during F/E
6. SLR ROM >91°
7. central (PA) passive accessory intervertebral movement hypermobility
8. no centralization or peripheralization
9. • prone instability test
10. For Postpartum pt:
    
    • +P4 test, active SLR, Trendelenburg, pain with palpation of long dorsal sacroiliac ligament or pubic symphysis
    • strength, endurance coordination trunk deficits
    • hip mobility deficits

Question 12

Movement Coordination Impairments - stabilization exercise subclassification:

• List key exam findings for postpartum pt (3 categories)

Answer 12

1. +P4 test, active SLR, Trendelenburg, pain with palpation of long dorsal sacroiliac ligament or pubic symphysis
2. strength, endurance coordination trunk deficits
3. hip mobility deficits

Question 13

What is the P4 test?

Answer 13

Posterior pelvic pain provocation test (aka Thigh Thrust aka Posterior Shear)

I think we learned it as Thigh Thrust Test?

From http://www.physio-pedia.com/Posterior_pelvic_pain_provocation_test_%28aka_Thigh_Thrust_aka_Posterior_Shear%29

The posterior pelvic pain provocation test is a pain provocation test used to determine the presence of sacroiliac dysfunction. It is used (often in pregnant women) to distinguish between pelvic girdle pain and low back pain.[1] [2] [3]

The test is also known as:

• PPPP test
• P4 test
• Thigh thrust test
• Posterior shear test
• POSH test

Technique

With the patient supine, the hip is flexed to 90° (with bended knee) to stretch the posterior structures. By applying axial pressure along the length of the femur, the femur is used as a lever to push the ilium posteriorly. One hand is placed beneath the sacrum to fixate its position while the other hand is used to apply a downward force to the femur. Broadhurst and Bond suggest to add hip adduction towards the midline while Laslett & Williams advise to avoid excessive adduction due to discomfort for the patient. [4][5][6][7]

The test is positive for pelvic girdle pain if the axial pressure provokes pain over the sacroiliac joint that is familiar to the patient.

Question 14

Movement Coordination Impairments - stabilization exercise subclassification:

• List interventions (3)

Answer 14

1. promote isolated contraction and cocontraction (endurance) of deep trunk muscles
2. generalized strengthening of the superficial trunk muscles
3. manual therapy and exercise for thoracic/hip mobility, motor control and strength deficits

Question 15

How many subgroups are there in the DSE subclassification?

What are they?

Answer 15

1. Extension subgroup
2. Flexion subgroup
3. Lateral shift subgroup

Question 16

Direction specific exercise (DSE) - LBP with lower extremity referred pain subclassification: EXTENSION SUBGROUP

• List key findings (5)

Answer 16

1. symptoms distal to knee
2. centralize with E
3. peripheralize with F
4. s/s of nerve root compression may be present
5. +SLR may be present

Question 17

Direction specific exercise (DSE) - LBP with lower extremity referred pain subclassification: EXTENSION SUBGROUP

• List interventions (4)

Answer 17

1. E exercises
2. mobilization to promote E
3. temporarily avoid F activities
4. address neurodynamic and other deficits as needed

Question 18

Direction specific exercise (DSE) - LBP with lower extremity referred pain subclassification: FLEXION SUBGROUP

• List Key Findings (7)

Answer 18

1. directional preference for F
2. nerve mobility deficits possible
3. older >65
4. imaging evidence of LSS (lateral spinal stenosis)
5. s/s distal to knee
6. s/s of nerve root compression may be present
7. +SLR may (or may not) be present

Question 19

Direction specific exercise (DSE) - LBP with lower extremity referred pain subclassification: FLEXION SUBGROUP

• List Interventions (6)

Answer 19

1. flexion exercises
2. mobilization to promote flexion
3. imaging evidence of central spinal stenosis (CSS)
4. unweighted ambulation
5. temporarily avoid extension
6. address neurodynamic and other deficits as needed

Question 20

Direction specific exercise (DSE) - LBP with lower extremity referred pain subclassification: LATERAL SHIFT SUBGROUP

• List Key Findings (10)

Answer 20

1. unilateral or asymmetrical symptoms
2. sudden or recent postural change
3. flexion and extension activities aggravate
4. sidelying may be an easing position
5. S/S of nerve root compression may be present
6. visible shift or frontal plane deviation
7. decreased lumbar lordosis
8. asymmetrical lateral flexion AROM
9. PAIVM may be hypomobile and/or provacative
10. S/S centralize with shift correction

Question 21

Direction specific exercise (DSE) - LBP with lower extremity referred pain subclassification: LATERAL SHIFT SUBGROUP

• List Interventions (4)

Answer 21

1. lateral shift correction
2. manual or self-correction in standing
3. non-weightbearing shift correction exercises: repeated extension in lying with hips off center
4. address neurodynamic and other deficits as needed

Question 22

Traction subclassification:

• List Key Findings (3)

Answer 22

1. radiating LE s/s (below the buttock pain and/or paresthesia)
2. s/s of nerve root compression
3. inability to centralize symptoms (pg 248 / Fritz artcle)

Question 23

Traction subclassification:

• List Interventions (6)

Answer 23

1. parameters are variable ??????????? (traction machine variables probably)
2. extension oriented treatment approach ?????????????????? (dosn’t make sense)
3. mechanical traction, 3 dimensional, prone static for 12 min at 40-60% body weight
4. mechanical traction static, supine with knees and hips at 90° on stool, 5-60Kg, 10-20 min
5. optimal dosage parameters for mechanical traction are unknown
6. manual traction

Question 24

Symptomatic Lumbar Spinal Stenosis (LSS), Impairment based classification subclassification (Selected manual therapy and exercise techniques):

• List potential impairments based on examination (6)

Answer 24

1. Lumbar A ROM mobility deficits
2. Decreased walking tolerance
3. Hip ROM mobility deficits - priority to extension
4. Decreased hip muscle performance - priority to hip extenision and abduction
5. Decreased muscle performance - priority to poor abdominal activation
6. Altered neurodynamics

Question 25

Symptomatic Lumbar Spinal Stenosis (LSS), Impairment based classification subclassification (Selected manual therapy and exercise techniques): * if the impairment is **Lumbar active ROM mobility deficits** * Explain general instructions if any * List potential interventions (5)

Answer 25

No general instructions Potential interventions 1. side-lying rotational mobilization or manip in neutral 2. Central or unilateral PA passive accessory intervertebral movement (CPA, UPA) 3. T-Spine as needed 4. single and double knee to chest 5. home rotational exercise to augment manual therapy

Question 26

Symptomatic Lumbar Spinal Stenosis (LSS), Impairment based classification subclassification (Selected manual therapy and exercise techniques): * if the impairment is **↓ walking tolerance** * Explain general instructions if any * List potential interventions (3-6)

Answer 26

No general instructions Potential interventions 1. body weight supported treadmill, walking, cycling, aquatics, mall walking 2. body weight supported treadmill: * use minimum (20-40% BW) needed to eliminatebuttock/thigh/leg s/s, or 50% BW if unable to eliminate S/S * self-selected, regular comfortable pace, not to exceed 7 on perceived exertion scale * to tolerance, max 45 min, each visit ↑ by 10% BW 3. Daily walking: distance and pace that doesn't aggravate symptoms using similar parameters

Question 27

Symptomatic Lumbar Spinal Stenosis (LSS), Impairment based classification subclassification (Selected manual therapy and exercise techniques): * if the impairment is **hip ROM mobility deficits- priority to extension** * List potential interventions (7)

Answer 27

Potential Interventions 1. daily muscle lengthening: 3 X 30 sec bouts 2. supine inferior glide to hip in F 3. supine iliacus/psoas lengthening 4. Prone PA glide 5. prone rectus femoris lengthening 6. knee/ankle/foot as needed 7. home exercise to augment manual therapy

Question 28

Symptomatic Lumbar Spinal Stenosis (LSS), Impairment based classification subclassification (Selected manual therapy and exercise techniques): * if the impairment is **decreased hip muscle performance - priority to hip E and ABD** * General instructions if any * List potential interventions (5)

Answer 28

General instructions * Dosage: individualized ot pt needs Potential Interventions 1. clamshell, bridging, side-lying ABD 2. Bilateral squat, sit-to-stand, step up 3. leg press 4. home exercise 5. aquatic therapy

Question 29

Symptomatic Lumbar Spinal Stenosis (LSS), Impairment based classification subclassification (Selected manual therapy and exercise techniques): * if the impairment is **decreased trunk muscle performance - priority to poor abdominal activation** * General instructions if any * List potential interventions (2-7)

Answer 29

No general instructions Potential Interventions 1. stabilization exercise 2. ADIM (abdominal brace, sit/stand), heel slides, wall slides, bridging, quadruped (single leg lifts), side bridge \*\*ADIM = abdominal drawing in manuver

Question 30

Symptomatic Lumbar Spinal Stenosis (LSS), Impairment based classification subclassification (Selected manual therapy and exercise techniques): * if the impairment is **altered neurodynamics** * General instructions if any * List potential interventions (1) \*\*\*This might be the same as the Impairment based-based classification for LBP with altered neurodynamics

Answer 30

no general instructions Potential interventions * neurodynamic mobilization

Question 31

Low back-related leg pain (LBRLP) based on predominating pain mechanism subcategory * CENTRAL SENSITIZATION * Classification * Mechanisms (3) * Effect (1) * Symptoms (5) * Signs (2)

Answer 31

* Classification * neuropathic * mechanisms: 1. sensitization of wide dynamic range neurons 2. disinhibition 3. forebrain-mediated central sensitization * effect: 1. enhanced processing of peripheral input * symptoms 1. distal pain 2. hyperaesthesia 3. hyperalgesia 4. paraesthesia 5. allodynia * signs : 1. LANSS score P12 (Leeds Assessment of Neuropathic Symptoms and Signs) 2. may have features of the diagnostic group’s denervation and peripheral sensitization

Question 32

Low back-related leg pain (LBRLP) based on predominating pain mechanism subcategory * DENERVATION * Classification * Mechanisms (2) * Effect (2) * Symptoms (4) * Signs (5)

Answer 32

* classification * neuropathic * mechanisms: 1. Wallerian degeneration 2. demyelination * effect: 1. conduction block 2. diafferentation * symptoms 1. segmentally distributed distal pain 2. hypoesthesia 3. weakness 4. palsy * signs : 1. LANSS score \<12 (Leeds Assessment of Neuropathic Symptoms and Signs) 2. diminished light touch and pinprick 3. diminished or absent reflexes 4. muscle weakness 5. minimal features of peripheral sensitization

Question 33

What does LANSS stand for?

Answer 33

Leeds Assessment of Neuropathic Symptoms and Signs

Question 34

Low back-related leg pain (LBRLP) based on predominating pain mechanism subcategory * PERIPHERAL NERVE SENSITIZATION * Classification * Mechanisms (2) * Effect (1) * Symptoms (2) * Signs (3)

Answer 34

* Classification * neuropathic or nociceptive * mechanisms: 1. inflammation 2. increases Na channel and mechanosensitive channel expression and conductance * effect: 1. enhanced nerve trunk mechanosensitivity * symptoms 1. pain anywhere in the leg 2. pain associated with movements that elongate the nerve trunk * signs : 1. LANSS score \<12 (Leeds Assessment of Neuropathic Symptoms and Signs) 2. nerve is sensitive to elongation and pressue 3. reduced active movements corresponding to nerve mechanosensitivity

Question 35

Low back-related leg pain (LBRLP) based on predominating pain mechanism subcategory * MUSCULOSKELETAL * Classification * Mechanisms (1) * Effect (1) * Symptoms (3) * Signs (2)

Answer 35

* Classification * nociceptive * mechanisms: 1. convergence * effect: 1. mental projection of pain to the limb * symptoms 1. referred leg pain 2. pain tend to be worse proximally 3. normal neurological function * signs : 1. LANSS score \<12 (Leeds Assessment of Neuropathic Symptoms and Signs 2. none of the signs shown left (as in signs of other LB-

Question 36

Chronic LBP or chronic, disabling lumbopelvic pain related to motor control impairments based on a biopsychosocial approach: * What are the altered motor respnsses in the three subgroups of a CLBP classification?

Answer 36

1. Adaptive/protective altered motor response to an underlying disorder * Inflammatory disorders * centrally mediated pain * sympathetically maintained pain * neurogenic pain * neuropathic pain 2. Altered motor response and centrally mediated pain _secondary_ to dominant psychosocial factors 3. Mal-adaptive motor control patterns that drive the pain disorder * movement impairments * control impairments * (may result in excess or loss of spinal stability)

Question 37

Chronic LBP or chronic, disabling lumbopelvic pain related to motor control impairments based on a biopsychosocial approach: * What are 5 examples of underlying disorders that can cause an Adaptive/protective altered motor response

Answer 37

Adaptive/protective altered motor response to an underlying disorder 1. Inflammatory disorders 2. centrally mediated pain 3. sympathetically maintained pain 4. neurogenic pain 5. neuropathic pain

Question 38

Chronic LBP or chronic, disabling lumbopelvic pain related to motor control impairments based on a biopsychosocial approach: * What are 7 different approaches to treat various CLBP as described in Figure 4-2?

Answer 38

1. **Mangement** (advice, medical, surgical - as appropriate) 2. **Management** (cognitive/motor learning, medical) 3. **Multi-diciplinary managment** (psychological [CBT], medical, functional rehabilitation) 4. **Medical management/Functional Rehabilitation** 5. **Motor learning within cognitive framework** (enhance force closure)/**Functional restoration** 6. **Motor learning within cognitive framewor**k (reduce force closure/relaxation)/**Functional restoration** 7. **Motor learning within cognitive framework** (enhance control)/**Functional restoration** \*\*CBT = Cogintive Behavioral Therapy I can't figure out how to put the info in this chart into flash cards. Most likely because I don't yet really understand the chart.

Question 39

Does low back pain typically follow a predictable course toward resolution without treatment?

Answer 39

NO, LBP is not a self-limiting condition with predictable recovery or outcomes during each phase (pg. 115). There is a length of time that symptoms persist (acute, sub, chronic)

Question 40

What is the time period commonly accepted as Acute, Subacute, and Chronic for nonspecific, mechanical LBP? How does this compare to the Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society?

Answer 40

* Acute LBP- up to 4 weeks * Subacute LBP- from 2 to 6 months * Chronic LBP- starting at 3 to 6 months Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society define: * Acute LBP- less than 4 weeks * Subacute LBP- between 4 weeks and 3 months * Chronic LBP- greater than 3 months

Question 41

List the most common clinical features and risk factors that would help a clinician screen for (rule in or rule out): cancer: AKA: Cancer Clinical Findings (9) When used alone, which three of these findings raises the posttest probability of cancer to a clinical significant level?

Answer 41

1. Previous hx of non-skin cancer\* 2. Failure of conservative management in past month 3. Age ≥ 50 years 4. Unexplained weight loss \>4.5 kg 6 months 5. ESR ≥ 50 mm/h\* 6. Presence of anemia 7. Hematocrit \<30%\* 8. WBC count \> 12,000 9. Clinical judgement \*When used alone, raises the posttest probability of cancer to a clinical significant level.

Question 42

List the most common clinical features and risk factors that would help a clinician screen for (rule in or rule out): Spinal Fx AKA: Spinal Fx Clinical Findings (7)

Answer 42

1. Age \>50 years 2. Female 3. Major trauma 4. Pain & tenderness 5. Distracting painful injury 6. Trauma with neurological signs 7. Structural deformity or neurological deficit Note: Corticosteroid use and altered consciousness did not alter the probability of fx. \*\*\*It was weird that in the text (pg 120) it says that “long-term corticosteroid therapy has a specificity of 0.995 and, thus, a compression fx is considered likely until proven otherwise.” - We should ask maybe.