Lumbar

Question 1

Keele STarTBack Screening tool

Answer 1

• combines key items from several previously validated screening questionnaires
• addresses pain location, function, avoidance beliefs, depression, and catastrophizing
• easily adminitered and scored

Question 2

Red flags

Answer 2

• single red flag may not be predictive of serious disease

- metastatic lesions involving lumbar vertebrae are likely to be the most serious pathology that may present as LBP

Question 3

Red flags that may increase likelihood of metastatic cancer

Answer 3

1) hx of cancer
2) night pain or pain at rest
3) unexplained weight loss
4) age > 50 or < 17
5) failure to improve over the predicted time interval following treatment

Question 4

red flags that may suggest presence of an infection within the disk or vertebrae

Answer 4

1) patient is immunosuppressed
2) prolonged fever with a temp over 100.4
3) hx of intravenous drug abuse
4) recent UTI, cellulitis, pneumonia

Question 5

Red flags suggesting undiagnosed vertebral fracture

Answer 5

1) prolonged use of steroids
2) mild trauma > 50 yrs old
3) age >70 yrs old
4) known hx of osteoporosis
5) recent major trauma at any age
6) bruising over spine following trauma

Question 6

Red flags that may indicate AAA

Answer 6

1) pulsating mass in the abdomen
2) hx of atherosclerotic vascular disease
3) throbbing, pulsing back pain at rest or with recumbency
4) age > 60yrs

Question 7

MRI and LBP

Answer 7

• sensitivity to detect subtle fractures, abnormal tissue growth, local and diffuse inflammatory issues, hemorrhage is extremely high
• also good at detecting serious compression of spinal cord
• 99% of patients presenting with acute or chronic LBP DO NOT HAVE THESE ISSUES!
• negative emotional impact with MRIs

Question 8

Yellow flags

Answer 8

• emotional distress
• hypervigilance
• pain catastrophizing
• elevated fear avoidance beliefs
• low self-efficacy
• misunderstanding about the nature and likely impact of pain
• misunderstanding about the best strategies for long term success

Question 9

Blue flags

Answer 9

• describe a patient’s perception of work and work conditions that may impair return to work
• ex. low job satisfaction and personal conflicts with employers or fellow workers

Question 10

Black flags

Answer 10

• social and financial issues

ex. reimbursement incentives to remain disabled

Question 11

Best questionnaires for LBP

Answer 11

• roland-morris back pain disability questionnaire

- odi

Question 12

Spinal manipulative therapy

Answer 12

• typically better for acute patients

- significant lower pain and disability compared to those who receive placebo

Question 13

SMT CPR

Answer 13

1) no symptoms distal to knee
2) less than 16 days
3) FABQ-work subscale less than 19
4) at least 1 hypomobile lumbar segment
5) at least 1 hip with greater than 35* IR

4/5 = + LR of 24

Question 14

Treatment for subacute and chronic LBP

Answer 14

• motor control exercises are superior to minimal intervention at short and long term follow up
• graded activity and dgraded exposure incorporate cognitive approaches to improve activity tolerance

Question 15

Graded exposure

Answer 15

-patients with LBP generate a hierarchy of feared activities and then gradually progress through these in an attempt to reduce activity-related anxiety

Question 16

Graded activity

Answer 16

-uses operant conditioning to reinforce healthy behaviors and progress the patient through different levels of functional activity

Question 17

Lumbar extension strengthening exercises

Answer 17

-not adequately investigated

Question 18

Aerobic fitness and chronic LBP

Answer 18

-are helpful to reduce pain and increase function
-help to reduce increased awareness of neural stimulus (central sensitization)
-

Question 19

Centralization exercises

Answer 19

• likely to reduce pain and increase mobility in patients with acute, subacute and chronic LBP
• likely to lead to better outcomes than passive treatments for patients with acute lbP, but efficacy and effectiveness of mckenzie approach for patients with cLBP was not clear

Question 20

Patient education for back pain

Answer 20

• valuable to educate regarding maintaining a physically active lifestyle
• educate on the difference between “good pain” (post exertional soreness) and “bad pain”

Question 21

Modern neuroscience approach

Answer 21

• literature demonstrates that changes in motor control are often coupled with substantial changes in brain structure and function in patients with cLBP
• no data to support yet

Question 22

Dry needling

Answer 22

• evidence that trigger points are an important pain generator, but the mechanism is under debate
• evidence is inconclusive

Question 23

Intervertebral disk

Answer 23

• annulus fibrosus
• nucleus pulposus

4 layers;

1) outer most annulus
2) inner portion of the annulus
3) transitional zone
4) vertebral end plate

Question 24

Outer most annulus

Answer 24

• resistance to tensile loads
• dense, well oriented type 1 collagen
• virtually all the neurovascular structure is here
• loaded under flexion and/or SB

Question 25

inner portion of annulus

Answer 25

- type I collagen | - lack the organization found in the outer most annulus

Question 26

Transitional zone

Answer 26

- thin, fibrous tissues that surround and encompass the fourth and deepest layer - gel like region composed primarily of water

Question 27

Vertebral end plate

Answer 27

- borders the IVD - large, flate cartilage covers the central portions of the superior and inferior vertebral bodies creating a semi-permeable barrier between subchondral bone and IVD - this area is the "weak link" where IVDs are exposed to trauma

Question 28

Cauda equina

Answer 28

1) urine retention 2) fecal incontinence 3) saddle anesthesia 4) sensory or motor deficits in teh feet (L4-S1 areas)

Question 29

Thrust and non-thrust manipulation

Answer 29

- is effective for subgroups of patients and as a component of a comprehensive treatment plan - grade I - clinicians should consider utilizing thrust manips to reduce pain and disability - can also be used to improve spine and hip mobility and reduce pain with subacute and chronic - grade A

Question 30

Top 2 factors of manip CPR

Answer 30

1) duration less than 16 days 2) symptoms distal to the knee + LR of 7.2

Question 31

Trunk coordination and strengthening

Answer 31

-grade a recommendation for patients with subacute and chronicn LBP

Question 32

Centralization

Answer 32

-grade A - for acute, subacute and chronic

Question 33

Nerve mobilization

Answer 33

-grade C

Question 34

Traction

Answer 34

-grade D - conflicting evidence

Question 35

Stenosis CPR

Answer 35

1. (B) symptoms 2. leg pain more than back pain 3. pain with walking/standing 4. pain relief upon sitting 5. age > 48 years 3 tests positive sp=0.88 4 tests positive = 0.98 5 tests positive = 1.0. sn is poor if > 3 tests positive