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

Question 1

What does TBC stand for?

Answer 1

TBC = Treatment-Based Classification

Question 2

What does TBC consist of (how many subgroups, and what are they?)

Answer 2

TBC Consists of 4 subgroups - with 1 super-subgroup (pg 217)

1. Manipulation (mobs)
2. Stabilization
3. DSE (flexion, extension, and lateral shift groups)
   
   • Stenosis (Impairment-Based Classification for symptomatic Lumbar Spinal Stenosis is included under flexion preference, but also listed as one of the 10 LBP classifications)
4. Traction

(these are the main categories we learned last year)

Question 3

What are LBP classifications that are not under TCB?

Answer 3

1. Neurodynamic Diagnostic Classification
2. Mechanism-Related Classification of LBRLP
3. Chronic LBP Classification
4. Pelvic Girdle Pain (PGP)
   
   • Pregnancy related PGP (listed as one of the 10 LBP classifications)

Question 4

Nest the 10 LBP classifications/subgroups Dr. M wanted us to learn

Answer 4

LBP Classifications

• Treatment-Based Classifications
  
  • Manipulation (mobs)
  • Stabilization
  • DSE (flexion, extension, and lateral shift groups)
    
    • Stenosis (flexion preference)
  • Traction
• Neurodynamic Diagnostic Classification
• Mechanism-Related Classification of LBRLP
• Chronic LBP Classification
• Pelvic Girdle Pain (PGP)
  
  • Pregnancy related PGP

Question 5

list the most common clinical features and risk factors that would help a clinician screen for (rule in or rule out): Cauda Equina Syndrome (5)

Answer 5

1. Urinary retention
2. Unilat or bilat sciatica
3. Unilat or bilat sensory & motor deficits
4. Sensory deficit: buttock, posterior-superior thigh, & perianal region
5. Positive SLR

Question 6

List the most common clinical features and risk factors that would help a clinician screen for (rule in or rule out): Vascular Claudication (3 + a note)

Answer 6

1. Presence of cool skin
2. Presence of at least 1 bruit (iliac, femoral, popliteal)
3. Any palpable abnormality

Note: combo of findings didn’t increase the likelihood of PAD. When all findings are normal, the likelihood of PAD is lower

Question 7

list the most common clinical features and risk factors that would help a clinician screen for (rule in or rule out): Ankylosing Spondylitis (4)

Answer 7

1. Morning stiffness >30 min duration (Dr Mincer said > 30-60 min!!)
2. Improvement in back pain w/exercise but not rest
3. Nocturnal awakening (2nd half of the night only)
4. Alternating buttock pain

• Note: if 2 of 4 present- SN=.70, SP=.81, +LR=3.7*
• If 3 of 4 present +LR 12.4*

Question 8

What does CES stand for?

Answer 8

Cauda Equina Syndrome

Question 9

What is the definition of AAA?

Answer 9

defined as an infrarenal aortic artery whose diameter exceeds 3.0cm)

Question 10

T/F: The presentation of AAA is very consistent and typical.

Answer 10

• False: Presentation Highly Variable

Question 11

Where are two patterns of pain that someone might report if they have AAA?

Answer 11

• May have pain in the following patterns
  
  • lower thoracic or lumbar and abdominal pain
  • hip, groin, and buttock pain

Question 12

AAA: What are some ways a pt may describe their pain/symptoms?

Answer 12

Potential descriptors

• Constant, deep boring pain
• Throbbing or pulsating

Question 13

AAA: What is another clue besides pattern of pain, risk factors, and pain/symptom descriptors that could alert you to potential AAA?

Answer 13

• Absence of aggravating factors related to movement

Question 14

AAA: 10 Risk Factors (3 major, 7 additional)

Answer 14

• AAA: 3 Major Risk Factors
  
  • Male
  • Hx of smoking (100 cigarettes in a person’s lifetime)
  • Age 65 or older
• AAA: 7 Additional Risk factors
  
  1. Family history
  2. CHD
  3. Claudication
  4. HTN
  5. Hypercholesterolemia (dyslipidemia)
  6. Cerebrovascular disease
  7. Increased Height

Question 15

• AAA: 3 Factors associated with decreased risk

Answer 15

• Female
• Diabetes Mellitus
• African American

Question 16

List the most common clinical features and risk factors that would help a clinician screen for (rule in or rule out): Infection (8)

Answer 16

Risk Factors

1. Intravenous drug use
2. Urinary tract infection,
3. Indwelling urinary catheter
4. Skin infection
5. Fever has high specificity (98%), but not necessarily sensitivity (cannot rule out)
6. Recent bilateral infection
7. Pneumonia
8. Immunocompromised states

Question 17

What are three things that could clue you in to the risk factor for infection of immunocompromised state for someone with LBP?

Answer 17

• Corticosteroid therapy
• Organ transplant
• Diabetes.

Question 18

Kidney/urinary disorders: 7 Symptoms that raise suspension for Urological condition:

Answer 18

1. Unilateral flank, lower abdominal pain above the pubic bone
2. LBP with or without radiation to the groin
3. Difficulty initiating urination
4. Painful urination
5. Or blood in the urine
6. History of urinary tract infections/past episodes of similar symptoms
7. Bilateral swelling of LEs (suggestive of kidney failure, but may also be related to other diseases such as heart failure or liver disease)

Question 19

Define, recognize and differentiate signs of radiculopathy and symptomatic spinal stenosis.(everything)

Answer 19

Radiculopathy (S&C pg. 128): refers to the S&S associated w/nerve root pathology including paresthesia, hypoesthesia, anesthesia, motor loss, and pain.

• Lateral canal stenosis and herniated disc are the 2 most common causes of radiculopathy.
• More than 90% of clinically important lumbar disc herniations occur at the 2 lowest levels (L4-5 and L5-S1) and involve the L5 or S1 nerve roots.
• Thus, common physical exam findings are weakness of the ankle and great toe DF, and sensory loss along the dorsum of the foot (L5); or weakness of the ankle PF, diminished ankle reflex, and sensory loss along the lateral aspect of the foot (S1).
• Involvement of the higher lumbar nerve roots is associated w/about 2% of disc herniations.
  
  1. S&S often involve pain and/or numbness in the anterior thigh more prominently than the lower leg, quads, and/or psoas weakness and absent patellar tendon reflex
• Sensory impairment is considered abnormal when either vibration or pinprick is diminished. If all 3 clinical findings of reflexes, weakness, and sensation are impaired, the sensitivity is decreased and specificity is increased.
• If all 3 findings and the SLR are abnormal, the likelihood of radiculopathy increases.

Spinal Stenosis (S&C pg. 130): a narrowing of the spinal canal or lateral recess, is usually a result of degenerative (most common), developmental, or congenital disorders.

• A narrow canal in radiographic imaging is not a definitive diagnosis
• Lumbar spinal stenosis (LSS) is defined by symptoms and clinical findings combined w/radiographic evidence.
• Lateral recess or foraminal stenosis generally results in spinal nerve or nerve root compression
• In central canal stenosis, the cauda equina is compressed unless the stenosis occurs at the upper lumbar (L1-2) vertebral levels. Since the spinal cord ends at L1-2, narrowing the spinal canal in this location may result in myelopathy and the S&S of an UMN disorder.
• Reported symptoms are variable, but patients classically complain of neurogenic claudication with or without LBP.

Question 20

What is Radiculopathy?

Answer 20

refers to the S&S associated w/nerve root pathology including paresthesia, hypoesthesia, anesthesia, motor loss, and pain. (must be a peripheral nerve)

Question 21

What are the two most common causes of radiculopathy?

Answer 21

• Lateral canal stenosis and herniated disc are the 2 most common causes of radiculopathy.

Question 22

At what level(s) do more than 90% of clinically important lumbar disc herniations occur?

Which nerve root(s) do they affect?

Answer 22

• More than 90% of clinically important lumbar disc herniations occur at the 2 lowest levels (L4-5 and L5-S1) and involve the L5 or S1 nerve roots.

Question 23

What are the most common physical exam findings for most clinically important lumbar disc herniations? (5)

Answer 23

common physical exam findings are

• weakness of the ankle and great toe DF, and
• sensory loss along the dorsum of the foot (L5);

or

• weakness of the ankle PF,
• diminished ankle reflex, and
• sensory loss along the lateral aspect of the foot (S1).

Question 24

What percentage of disc herniations are associated with involvement of higher lumbar nerve roots?

Answer 24

2%

Question 25

What are the s/s of herniated disc that involves the higher lumbar nerve roots? (3)

Answer 25

S/S often involve

• pain and/or numbness in the anterior thigh more prominently than the lower leg,
• quads, and/or psoas weakness and
• absent patellar tendon reflex

Question 26

When is sensory impairment considered abnormal?

Answer 26

Sensory impairment is considered abnormal when either vibration or pinprick is diminished.

***If all 3 clinical findings of reflexes, weakness, and sensation are impaired, the sensitivity is decreased and specificity is increased.

What happens to the liklihood of raduculopathy if all three clinical findings of reflexes, weakness, and sensation and SLR are abnormal?

It increases

Question 27

What is Spinal Stenosis?

Answer 27

a narrowing of the spinal canal or lateral recess, is usually a result of degenerative (most common), developmental, or congenital disorders.

Question 28

True/False: A narrow canal in radiographic imaging is a definitive diagnosis of spinal stenosis

Answer 28

False. A narrow canal in radiographic imaging is not a definitive diagnosis. Lumbar spinal stenosis (LSS) is defined by symptoms and clinical findings combined w/radiographic evidence.

Question 29

Spinal Stenosis: What does lateral recess or foraminal stenosis generally result in?

Answer 29

Spinal nerve or nerve root compression.

Question 30

Spinal Stenosis: What is compressed in central canal stenosis?

Answer 30

In central canal stenosis, the cauda equina is compressed unless the stenosis occurs at the upper lumbar (L1-2) vertebral levels. Since the spinal cord ends at L1-2, narrowing the spinal canal in this location may result in myelopathy and the S&S of an UMN disorder.

Question 31

What are some symptoms of Spinal Stenosis?

Answer 31

Reported symptoms are variable, but patients classically complain of neurogenic claudication with or without LBP.

Question 32

What two yellow-flag like things is it important to screen for in a pt with LBP?

Answer 32

Depression and Fear Avoidance

Question 33

Why is it important to screen for depression in the patient with LBP? (1 main, + three details)

Answer 33

1. Depression is a poor prognostic indicator and may suggest that the episode of LBP is likely to be prolonged.
2. Yellow flags raise the index of suspicion for the potential to develop a chronic problem that may require appropriate cognitive and behavior management strategies. In some instances,
3. Depression is a predictor of developing LBP and also a response to the experience of LBP. In the acute phase of back pain, anxiety and worry are natural reactions, but the lack of an exact cause and inadequate pain relief may result in helplessness, anger, and depression. An underlying depression often impairs the ability to cope with pain, potentially leading to an increased perception or experience of pain.
4. Depression is known to adversely impact rehab outcomes and contribute to work-related disability.

Question 34

Why is it important to screen for fear avoidance in the pt with LBP?

Answer 34

High pain intensity is a threatening experience that often results in escape and avoidance, but fear of pain is often more disabling than pain itself.

Question 35

What does FAMEPP stand for and what is it?

Answer 35

Fear-Avoidance Model of Exaggerated Pain Perception (FAMEPP):

• fear of pain and resultant fear-avoidance beliefs and behaviors (Table 2-7) are theorized to be important factors in determining whether a person with acute nonspecific LBP recovers in the short term or transitions to CLBP.
• In the FAMEPP model, a person’s fear-avoidance response to acute nonspecific LBP rests somewhere along a continuum of confrontation to avoidance.

Question 36

What is a “Confronter”?

Answer 36

Confronters: are patients w/low levels of fear-avoidance who are associated with a normal recovery process and gradual return to prior functional levels.

Question 37

What is an “Avoider”?

Answer 37

Avoiders: have a higher level of fear-avoidance usually associated with a maladaptive response to LBP and the potential to develop chronic pain and disability.

Question 38

What does ODI stand for?

Answer 38

Oswestry LBP Disability Index

Question 39

What does RMDQ stand for?

Answer 39

Roland-Morris Disability Questionnaire

Question 40

What does PSFS stand for?

Answer 40

Patient-Specific Functional and Pain Scale

Question 41

What does GRC stand for?

Answer 41

Global rate of Change Scales

Question 42

ODI: Use, Advantages, and Disadvantages

Answer 42

Low score is better

Use:

• Self-administered, reliable, and valid questionnaire that takes about 6 minutes to complete and score. Contains 10 sections related to ADL and pain designed to describe the patient on the day of the visit.

Advantages:

• Similar to the RMDQ, the ODI has good test-retest reliability and can be given on the initial visit and then re-evaluated at 2 or 4 weeks or at discharge.

Disadvantages:

• Not patient-specific (it is condition or region-specific fixed-item questionnaire)
• (S&C pg. 134)*

Question 43

RMDQ: Use, Advantages, and Disadvantages

Answer 43

Low score is better (I think)

Use:

• 24 “yes” or “no” items that focus on a limited range of physical functions, but no psychosocial items related to LBP

Advantages:

• Reliability and validity are well established for patients with LBP
• The RMDQ has good reliability when used at initial eval and up to 6 weeks after intervention with a recommended MCID cutoff of 5.2

Disadvantages:

• Limited range of physical functions
• No psychosocial items related to LBP
• Not patient-specific (it is condition or region-specific fixed-item questionnaire)

(S&C pg. 134)

Question 44

PSFS: Use, Advantages, Disadvantages

Answer 44

Higher score is better

Use:

• The PSFS allows the patient to identify up to 5 important activities that they are having difficulty with or unable to perform and rate the difficulty level of each activity on an 11-point scale.

Advantages:

• Patient-specific
• Administered in 4 minutes
• Reliability and validity have been established for patients w/LBP
• Some research in patients w/LBP suggests that scales such as the PSFS are more responsive to clinical change than questionnaires with predefined terms.

Disadvantages:

• none listed
• (S&C pg. 136)*

Question 45

GRC scale: Use, Advantages, Disadvantages

Answer 45

Higher score is better

Use:

• Commonly used self-perceived outcome measure. The scale consists of one question that quantifies a patient’s improvement or deterioration over a period of time and, along with other outcomes, assists in establishing the effect of an intervention in clinical practice or research.
• The person’s ability to recall and quantify overall status at a previous date and time is required for proper use

Advantages:

• Simple to score and administer and allows the patient to decide what aspects of pain, disability, or function are most important when deciding about his/her health status.
• Sufficient evidence exists to support the use of a balanced 7-or-11 point numerical scale.
• If rehab occurs over several months, GRC serial measures are preferred due to the potential effect on validity of an increasing length of recall time.

Disadvantages:

• The patient must be able to recall information from a previous date
• Design and title of GRC scales vary widely
• MCID varies in some studies due to arbitrary cutoff scores.

(S&C pg. 137-138)