WK6 - Low Back Pain Flashcards
List a few characteristics of adolescents with back pain.
Half of adolescent athletes report LBP
Most common: isthmic spondylolysis (stressie)
- EXT based
- stress fracture (potential complications)
What are the different types of Spondylo conditions?
Spondylitis (axial or peripheral subclass) - inflammation causing arthritis
Spondylolysis - wear and tear causing disc adn joint degeneration = stress fracture of pars interarticularis of Lx vertebrae (unilateral)
Spondylolithesis (bilateral pars fracture) = both sides of pars interarticularis are cracked (breaking one side most likely causes the other to break)
What is ankylosing spondylitis (AS)?
Inflammatory disease that over time can cause some bones of spine (vertebrae) to fuse.
- usually not diagnosed until 40s
- can refer to other structures like Achilles tendinopathy, planta fasciitis
What is enteropathic arthritis?
- bacterial infection, sets of immune response and get arthritis response to it
What is reactive arthritis?
- infections like chlamydia or salmonella
What are the different types of spondylitis?
- ankylosing spondylitis
- enteropathic arthritis
- psoriatic arthritis
- reactive arthritis
- undifferentiated spondyloarthritis
- juvenile spondyloarthritis
What does the term ‘sandwich bone’ mean in spondylolysis?
- compact bone separated by cancellous “filling”
- cortices bear bending load (tension and compression)
- cancellous keeps cortices from buckling and bears shear stress
Consider the stress vs strain curve (Hooke’s Law)
Define the elastic-Continuum Damage Mechanics.
The material is still structurally integrated but absorbs energy by developing diffuse microcracking damage at the expense of stiffness and residual strength
What are the effects of discontinuum between spinous process and vertebral bodies in spondylolisthesis?
- potential for shifting (-listhesis) and ‘slippage’
- both sides broken = unlikely to heal –> slippage (grade 1-2)
- unlikely for athlete to have any more shifting by the time they finish growth spurt
- regular x-rays
What do the grades of spondylolithesis depend on?
depend on diameters of shift
Grade1-Grade 4
- shift determined by how much vertebral body moves
Grade1 ~1/4, more worrying from Grade 2 onwards.
What does it mean when the first primary diagnosis is spondylolisthesis?
- unlikely it will ever heal
- may get fibrosis tissue/scar tissue
- can cause pain
- different from minor crack (spondylolysis) which occurs before spondylolisthesis
What are the longer term complications of spondylolisthesis?
e.g. L4 moving on L5, L4 nerve root going to be caught/impinged
disc between L4 and 5 not sitting properly
A spondylolisthesis at L4/5 will cause central and lateral recess stenosis, thus affecting L5 nerve roots (in lateral recess) and sacral nerve roots (in thecal sac)
What are the characteristics of degenerative spondylolisthesis?
e.g. in old people, esp. women >60y
- typically Lx spine
- potential for spinal stenosis (due to tightening of canal) and nerve root compression)
- may cause leg pain when walking uphill (EXT) and fine in downhill (FLEX) –> spinal claudication
define Spinal claudification.
may cause leg pain when walking uphill (EXT) and fine in downhill (FLEX)
What is isthmic spondylolisthesis?
- spinal disorder where 1 vertebra slides forward over vertebra below
- L5-S1 levels
- usually common among younger age group
What are the risk factors for LBP?
Facet orientation
- natural predisposition and orientation
- differential orientation from 1 side to another
- facet joint trophism –> asymmetry between sagittal angle of L and R facet joints (higher chance of disc degeneration)
What is pelvic incidence?
tilt of pelvis
- can lead to arthritis
- ANT tilt, swayback (need to improve balance, posture, abdominal wall strength)
- pubic symphysis relative to ASIS
- EOS scan (ADLs not reflected in posture used in scan
Implications of sagittal –> coronal pelvic tilt.
- more lower Lx spine pathology
- more tilt could alter the way forces are distributed causing more pars interarticularis stress fractures
What are pelvic tilt techniques?
different technique = different Lx loading
Fast bowling e.g.
- bowling with more EXT front knee, faster ball release speed and increase shoulder counter-ROT related to increased Lx-pelvic loading
- peak transverse plane ROT moments and ANT POS shear forces
List some considerations of the different in rate of growth and maturation between athletes.
- not all athletes will tolerate the same volume of training
- strength and conditioning important
What is the typical presentation of LBP // sponylolysis?
- insidious (gradual and subtle), but can be acute onset of EXT-based pain
- pain with impact (EXT activities e.g. running)
- pain improves with rest
- different types of pain (dull/sharp)
- pain can refer to butt, thigh but not likely to have radicular signs
One-legged hyperEXT test not useful in detecting active spondylolysis and shouldn’t be relied on to exclude diagnosis. True or False?
TRUE
-lack of pain on EXT doesn’t mean there is no stress fracture
- pain presents differently in different athletes
In those with radiologically confirmed stress fracture, only 7/10 get pain in this position, means will miss every 3/10 using this test.
What are the pros and cons of using MRI for diagnosis of LBP?
MRI can be useful depending on what type of scan is done
-Stimulate CT scans without the high dosage of radiation
-3D T1 VIBE inverted/Pars protocol MRI
*100% accurate in diagnosing complete pars fractures
*Good diagnostic ability in detection and characterization of incomplete pars stress fractures
*Avoid unnecessary exposure to radiation
What are the pros and cons of using x-rays for diagnosis of LBP?
- May not detect
-If detecting a complete fracture means its already past the middle point (spondylolysis) and gone straight to spondylolisthesis, missing the point for diagnosis of LBP from stressie
What is the Rx of LBP?
Early diagnosis to prevent LBP sequelae
-90% athletes recover from 3 months rest
-RTP after 3 months but must be a graded return
-Athletes who rest for 3 months are 16x more likely to have excellent results
-Effectiveness of bracing over isolated rest? Does it do anything for healing?
*Would need to be professionally custom made
*Bracing may not do much for overall recovery if they are further down the track
*Hard to do studies on this because it’s unlikely to get many athletes with exact same condition
What to consider with LBP in adolescent athletes?
- may have worse prognosis regarding function compared to non-athletes
- 65% have continued pain/recurrence of symptoms within 6months (management, another injury, predisposed?)
- 1 in 8 with spondylolysis had to stop/reduce sport participation at long-term follow-up (may not have biomechanical/anatomical suitability to sport)
