lumbar

Question 1

what percentage of individual can be given a patho-anatomic diagnosis with back pain

Answer 1

20%

Question 2

What is the general consensus regarding risk factors for developing low back pain

Answer 2

No definitive cause has been identified. Risk factors are multifactorial, population specific and only weakly associated with development of low back pain

Question 3

what is the consensus regarding the clinical course of low back pain

Answer 3

It can be described as acute, subacute, recurrent or chronic
- due to the high prevalence of recurrent and chronic back pain interventions should focus on preventing recurrences and helping people transition into chronic stage

Question 4

What are the recommended general diagnosis or PT classification of low back pain

Answer 4

1. mobility impairments of the spine and SIJ
2. referred or radiating pain into the lower extremity
3. generalized pain

Question 5

What differential diagnosis recommendations are made for outside referrals

Answer 5

1. clinical findings suggestive of serious medial or psychological pathology
2. functional limitations and impairments are not consistent with MSK back pain
3. symptoms are not resolving with treatment
   * strong evidence for recommendation

Question 6

what self reported questionnaires are recommended for back pain

Answer 6

1. Roland Morris

2. Oswestry

Question 7

What is the general recommendation regarding Thrust manipulations

Answer 7

1. strong recommendation for patients with back pain and falling into the mobility deficit classification
2. Thrust and non-Thrust are recommended for improving spine and hip mobility
3. reducing pain and disability for subacute and chronic low back pain and back related leg pain

Question 8

What are the general recommendations regarding trunk coordination, strengthening and endurance exercise with low back pain

Answer 8

1. use them to reduce pain and disability in patients with subacute and chronic back pain with movement coordination impairments AND POST LUMBAR MICRODISCECTOMY
   * strong evidence

Question 9

what are the general recommendations regarding centralization and directional preference exercises

Answer 9

1. repeated motions exercises and procedures to promote centralization
2. recommended for all stages acute to chronic in patient with mobility deficits
   * strong evidence

Question 10

what are the general recommendations regarding flexion based exercises

Answer 10

1. helpful in reducing pain and disability in older patients radiating pain
2. recommended for subacute and chronic stages
   * week evidence

Question 11

what are the general recommendations regarding nerve mobilization exercises

Answer 11

1. helpful with radiating pain
2. subacute and chronic stages
   * week evidence

Question 12

What are the general recommendations regarding traction for low back pain

Answer 12

1. intermittent type traction
2. prone when presenting with subacute nerve root with peripheralization or positive cross SLR
   * emerging evidence
3. DON’T do traction with acute/subacute nonradicular or chronic back pain
   * moderate evidence

Question 13

What type of education interventions are discouraged

Answer 13

Anything that directly or indirectly promotes perceived threat or fear associated behaviors including (1) extended bed rest (2) in-depth pathoanatomic explanations of low back pain
*moderate evidence

Question 14

What types of educational interventions are encouraged

Answer 14

1. Understanding the pathoanatomic “strength” of the spine
2. neuroscience of pain perception
3. favorable prognosis for spine pain
4. use of active pain coping strategies that decrease fear and catastrophizing
5. early resumption of activity even when they are still in pain
6. Recognition of improvements in function not just pain
   * moderate evidence

Question 15

what is the general recommendation for pregressive endurance exercise and fitness training in indvidual with back pain

Answer 15

• strong level of evidence for
  (1) Moderate to high intensity exercise for patients with chronic low back pain without generalized pain
  (2) incorporating progressive, low intensity, submaximal fitness and endurance activities into the pain management and promotion strategies for patients with chronic low back pain with generalized pain

Question 16

Describe the prevalence of low back pain

Answer 16

1. one year incidence of first ever back pain is between 6.3 and 15.3%
2. episodes of low back pain are from 1.5-36%
3. Reoccurrence of low back pain is 24-33%
4. Women higher than men
5. severity progresses with age until 60-65 years
6. lower socioeconomic status is associated with increased prevalence, longer episodes and worse outcome
7. jobs with higher physical demands have greater prevalence of back pain (material handling jobs 39% and sedentary jobs 18.3%)
8. Working and non working prevalence is about the same

Question 17

what are the two major categories of risk factors for developing low back pain

Answer 17

1. individual factors

2. activity related factors

Question 18

What are the individual risk factors for developing low back pain

Answer 18

1. some relation to genetic, body build and early environment influences
2. cardiovascular hypertension and lifestyle (weight and smoking) are risk for “sciatica”

Question 19

how do psychosocial factors influence risk for developing low back pain

Answer 19

1. They play a larger prognostic role that physical factors
2. kineisophobia has a strong link to the development of chronic back pain
3. distress and depression have a strong influence over the early stages of recovery

Question 20

What variable suggest a more favorable outcome in individuals with back pain

Answer 20

1. lower pain levels
2. higher job satisfaction
3. active coping style

Question 21

what variables appear to low impact on recovery from low back pain, yet may influence prevalence of low back pain

Answer 21

1. history of low back pain
2. job satisfaction
3. educational levels, marital status, number of dependents, smoking, working more than 8 hour shifts, occupation, size of company
4. complex back problems recover as well as simple back problems

Question 22

describe the risk factors for developing low back pain in adolescence

Answer 22

very similar to adults

• psychosocial variable are strong predictors of chronicity
• sporting activities such as rowing and weight lifting have higher risk for developing low back pain
• girls as much as 3:1

Question 23

What is the over conclusion on risk factors for low back pain

Answer 23

GRADE B - Current evidence does not support definitive causes for initial low back pain
- risk factors are multifactorial, population specific and only weakly associated with development of low back pain

Question 24

Describe the role of imaging in identifying a pathoanatomic cause of low back pain

Answer 24

poor association between anatomy and pathology

2. 20-76% of individuals without symptoms have anatomic impairment
3. 32% of asymptomatic individuals compared 47% of symptomatic individuals have “abnormal” MRI findings
4. Boos followed asymptomatic patients for 5 years and found a stronger association between job characteristics and pyschological aspects with development of back pain than radiological findings

Question 25

what are the different temporal stages of back pain

Answer 25

acute - less than one month subacute - 2-3 months chronic - greater than 3 months * challenge with these descriptions is that low back pain is episodic in nature with episodes occurring in as much as 65% of individuals and as often as every 2 months in t

Question 26

what factors are predictive of developing recurrent or chronic low back pain

Answer 26

1. history of previous back pain 2. excessive spine mobility 3. excessive joint mobility in other joints

Question 27

what prognostic factors put someone at risk for developing chronic pain

Answer 27

1. presence of symptoms below the knee 2. psycological distress or depression 3. fear of pain, movement and reinjury or low expectations of recovery 4. high pain intensity 5. passive coping style

Question 28

what is the first step in evaluating low back pain

Answer 28

Rule out medical red flags and nerve root compression

Question 29

What does the evidence suggest about treatment classifications for low back pain

Answer 29

strong support for classifying patients into subgroups

Question 30

what are the CPG recommended treatment classification of low back pain

Answer 30

1. low back pain with mobility deficits 2. low back pain with movement coordination impairments 3. low back pain with related lower extremity pain 4. low back pain with radiating pain 5. low back pain with related generalized pain (psychosocial impacts) * * all are rated with a level of acuity and irritability (relationship of movement and pain)

Question 31

Describe the relationship of ROM impairment and symptoms in the classficiation of low back pain

Answer 31

1. beginning ROM and segmental mobility impairment - fits the acute low back pain with mobility class 2. mid to end range pain with passive and active motion - subacute classes of mobility, coordination or radiating pain 3. sustained end range - chronic classes of coordination or radiating pain

Question 32

what clinical findings would you expect with acute mobility deficit classification

Answer 32

- acute low back, buttock or thigh pain of less than one month - restricted lumbar ROM and segmental mobility - low back and low back related LE symptoms produced with provocation testing of the T, L and SI regions

Question 33

. what clinical findings would you expect with subacute mobility deficit classification

Answer 33

- subacute symptoms that do not go past the knee - symptom production at end ranges of motions - spine and hip mobility deficits

Question 34

what ICD code is associated with each classification

Answer 34

1. lumbosacral segmatal/somatic dysfunction - mobility deficit 2. spinal instabilities - movement coordination 3. flat back syndrome or lumbago due to displace of IVD - back pain with related LE pain 4. lumbago with sciatica - radiating pain 5. Low back pain/low back strain/lumbago - pain with related cognitive deficit or generalized pain

Question 35

describe acute and subacute clinical finding expectations for movement coordination classification

Answer 35

``` acute - commonly associaete with referred pain - begin got mid range pain - movement coordination impairments subacute - mid to end range motion impairments - segmental hypermobility - decreased trunk strength or endurance - movement coordination impairments with routine activities ```

Question 36

what clinical findings would you expect for LBP with related LE pain

Answer 36

- referred pain down to the knee that increases with flexion based motion - symptoms can be centralized with motion, manual interventions or repeated movement - lateral trunk shift, reduced lumbar lordosis, limited lumbar extension mobility

Question 37

what clinical findings would you expect with LBP with radiating pain

Answer 37

acute - LBP with LE parethesia, numbness or weakness - begging to mid ROM impairments and positive neurodynamic testing - signs of nerve root involvement - neuro testing subacute - mid to end range motion - mid to end range neurdynamic testing chronic - chronic or recurring symptoms - sustained end range neurdynanic testing

Question 38

what clinical findings would you expect with LBP related to cognitive or affective tendencies

Answer 38

- back pain - presence of Primary care for depressive symptoms, high FABQ, High pain catastophizing Scale or cognitive process consistent with helplessness, rumination or pessimism regarding back pain

Question 39

What is the first goal of the PT evaluation

Answer 39

Determine if the person is appropriate for physical therapy

Question 40

What are some common red flags for evaluation of back pain

Answer 40

1. tumor 2. cauda equina syndrom 3. back related infection 4. spinal compression fractures 5. abdominal aneurysm 6. failure to improve with treatment after 30 days 7. spinal fractures

Question 41

what clinical findings would you expect with low back pain associated with a tumor

Answer 41

1. constant pain not affected by position or activity, worse with weight bearing, worse at night 2. over 50 3. History of cancer 4. failure to improve with conservative care 5. unexplained weight loss 6. no relief with bed rest

Question 42

what clinical findings would you expect with cauda equina syndrome

Answer 42

1. urine retention 2. fecal incontinence 3. saddle anesthesia 4. sensory or motor deficits in the feet

Question 43

What clinical findings would you expect with back related infections

Answer 43

1. recent infections or IV drug use 2. concurrent immunosuppressive drugs 3. deep constant pain that increases with weight bearing 4. fever, malasie, swelling 5. spine rigidity

Question 44

what clinical findings would you expect with spinal fractures

Answer 44

1. age greater than 70 2. female 3. history of major trauma 4. prolonged corticosteriod use

Question 45

what guidelines are suggested to help guide referrals other health care practitioners

Answer 45

consider referral when: 1. clinical findings are suggestive of serious medical or psychological pathology 2. clinical findings are not consistent with clinical classification 3. symptoms are not resolving with interventions

Question 46

what are the American College of Physicians' recommendations on diagnostic imaging with low back pain

Answer 46

1. recommended for severe progressive neurological deficits | 2. routine imaging does not result in clinical benefit and may lead to harm

Question 47

what types of muscular changes have been observed in individuals with chronic low back pain

Answer 47

1. multifidi atrophy 2. fatty infiltration 3. altered multifidi firing patterns

Question 48

what is the minimally important change in Oswestry and Roland Morris DQ score

Answer 48

- OS - 10 of 100 or 30% | - RM - 5 of 24 or 30%

Question 49

what does the Gouttebarge systematic review conclude regarding FCE

Answer 49

more information is needed and Isernhagen system had good reliability and predictive validity

Question 50

describe the measurement properties for segmental mobility testing

Answer 50

1. low reliability for ordinal scales 2. good reliability for classifying as hypo or hyper 3. good validity with radiographic correlation of instability and response to treatment

Question 51

describe the measurement properties of pain provocation with segmental mobility testing

Answer 51

spring test over facets and SPs | - Kappa values are moderate to good for pain provocation (0.25 to 0.55)

Question 52

what are the clinical findings associated with lumbar aberrant movement and the measurement properties

Answer 52

1. painful arc of motion 2. "catch" or deviation form the sagittal plane of motion 3. Gower sign 4. reversal of lumbopelivc rythm - a sudden bend in the knees as they return from the upright position * moderate to good reliability (kappa of 0.6)

Question 53

What is the CPG recommendation for testing trunk flexors

Answer 53

1. passive elevation of the extended legs in supine until the sacrum rises 2. keeping the back in contact with the bed measure how low they can lower their legs before their back comes up 3. less than 50 deg male and 60 deg females is associated with back pain

Question 54

what is the CPG recommendation for testing TA

Answer 54

prone pressure transducer - 70 mmHg under stomach then such in the TA to determine how much pressure then can decreased - 4mmHg reduction is normal 2mmHg associated with back pain

Question 55

CPG recommendation for trunk extension strength

Answer 55

Prone shoulder raise time with hands behind back | - males unable to hold longer than 31" (female 33") are more likely to have back pain

Question 56

what are the norms for hold a bridge position for assessing hip extension endurance

Answer 56

- 172 seconds healthy | - 79 with low back pain

Question 57

Describe the process recommended by the CPG for hip motion

Answer 57

- rotation - prone - extension - Thomas test starting from flexed position and lowering one leg down - flexion - supine and flex up until the contralateral leg starts to rise

Question 58

How would you score a FABQ

Answer 58

- 0 to 42 work scale with higher scores indicated greater fear greater than 29 poor return to work expectation and self reported debiliaty at 6 months greater than 22 poor return to function for general population without the work related questions

Question 59

how would you score pain catastrophizing scale

Answer 59

0-52 points higher score more catastrophy - rumination items 8-11 - magnification items 6,7,13 - helplessness itmes 1-5, 12

Question 60

what is the Orebro MSK pain screening questionnaire

Answer 60

The Örebro Musculoskeletal Pain Questionnaire (ÖMPQ) is a ‘yellow flag’ screening tool that predicts long-term disability and failure to return to work when completed four to 12 weeks following a soft tissue injury. A cut-off score of 105 has been found to predict those who will recover (with 95 per cent accuracy), those who will have no further sick leave in the next six months (with 81 per cent accuracy), and those who will have long-term sick leave (with 67 per cent accuracy)1

Question 61

what is the STarT back screening tool

Answer 61

AKA Keele STarT - The Keele STarT Back Screening Tool (SBST) (9-item version) is a brief validated tool, designed to screen primary care patients with low back pain for prognostic indicators that are relevant to initial decision making - The distress subscale score is used to identify the high-risk subgroup. To score this subscale add the last 5 items; fear, anxiety, catastrophising, depression and bothersomeness (bothersomeness responses are positive for 'very much' or 'extremely' bothersome back pain). Subscale scores range from 0 to 5 with patients scoring 4 or 5 being classified into the high-risk subgroup [1]. - The overall score is used to separate the low risk patients from the medium-risk subgroups. Scores range from 0-9 and are produced by adding all positive items; patients who achieve a score of 0-3 are classified into the low-risk subgroup and those with scores of 4-9 into the medium-risk subgroup

Question 62

What is the CPG consensus on manipulation for low back pain

Answer 62

consider using manipulation with patient demonstrating mobility deficits, acute LBP and back related buttock or thigh pain

Question 63

what variables are predictive of success with manipulation

Answer 63

``` PRIMARY - symptoms less than 16 days - no symptoms distal to knee SECONDARY - lumbar hypomobility - FABQ less than 19 - at least one hip with greater than 35 degrees of IR ```

Question 64

what findings would suggest a patient could benefit from a stabilization program

Answer 64

- age less than 40 - positive prone instability - presence of aberrant movements with motion testing - SLR greater than 91

Question 65

How does motor control exericse for LBP compare to walking program for subactue back pain

Answer 65

36 month follow up motor control group did better with improvement in preseved debility and health parameters.

Question 66

what is the CPG general consecuse regarding exercise and LBP

Answer 66

Grade A- exercise works in subacute and chronic back pain

Question 67

when are repeated motion with centralization and directional preference exercises recommended

Answer 67

GRADE A evidence - to reduce symptoms in patients with acute low back pain with related/referred lower extremity pain

Question 68

Describe the evidence for neurodynamic treatment

Answer 68

GRADE C - suggestion for patients with subacute or chronic low back pain and radiating pain

Question 69

what treatment modality was described as positively impacting central sensitization

Answer 69

GRADE A - progressive endurance activity and fitness activity

Question 70

what are the treatment recommendations for ACUTE LBP with mobility deficits

Answer 70

1. manual therapy procedures 2. exercise 3. patient education

Question 71

what are the treatment recommendations for subacute LBP with mobility deficits

Answer 71

1. manual therapy 2. ther ex 3. prevention of recurring by addressing coexisting impairments and encouraging long term activity

Question 72

what are the treatment recommendations for acute low back movement coordination

Answer 72

1. NMR 2. temporary external support 3. self care and home management strategies including good posture and promoting activity

Question 73

what are the treatment recommendations for subacute LBP with coordination impairment

Answer 73

- NMR and stability exercise in pain free ranges - manual therapy - ther ex for trunk and pelvic strength - self care strategies