Lumbar

Question 1

Questionnaires good for self-report with LBP (2)

Answer 1

1. Oswestry

2. Roland-Morris

Question 2

Clinical progression of LBP (3 + time periods)

Answer 2

1. Acute (<1 month)
2. Subacure (1-2 months)
3. Chronic/recurrent (>3 months)

Question 3

On/off switches at what three levels of the NS?

Answer 3

1. Spinal cord
2. Brain stem
3. Higher brain centers

Question 4

Gate control theory - “switch off”

at the spinal cord

Answer 4

non-nociceptive A-beta fibers recruit inhibitory neurons in the substantia gelatinosa of the posterior spinal cord
- chemically block ascending A-delta fibers and c-fibers

Question 5

Four types of neurons in ascending pathways -

1. names of fibers
2. information carried
3. Myelination?
4. speed

Answer 5

1. A-alpha, proprioception, myelinated
2. A-beta, touch, myelinated
3. A-delta, pain (mechanical and thermal), myelinated
4. C-fibers, pain (mech, therm, chem), NON-myelinated

Question 6

Spinal cord “switch on” with gate control theory

- theory of chronic spine pain

Answer 6

repetitious c-fiber firing thought to be enhanced by rapidly expressed genes => further increases sensitivity/sensitization of nociceptors = decreases threshold to stimulation and results in a wider receptor field

Question 7

Brain stem “switch off”

Answer 7

stimulation of periaqueductal gray matter (PAG m.) by descending pathways from HIGHER centers
- PAG is opiodergic (descends to and affects the dorsal horn)

Question 8

higher brain centers

• interaction with pain (conscious
• spinothalmic tr.

Answer 8

• Modulates neural activity and/or conscious perception of pain
• Numerous cortical regions of spinothalmic tr. produce the multidimensional pain exp.

Question 9

Chemicals/agents released by higher brain centers for pain management

Answer 9

Dopamine
Serotonin
Endogenous opiates
Cannabinoids

Question 10

Chemical responses from higher brain centers in presence of placebo, direct interventions, or both?

Answer 10

Clinical research has shown that both placebo and direct interventions may cause the release of multiple substances into the CNS in an opiodergic fashion

Question 11

Subgroup for Targeted Treatment (STartT) Back Screening Tool
- use?

Answer 11

Promising tool to address homogeneity

• avoiding the one-size-fits/rx-all concept
• used to identify pts with LBP at risk for long term functional limitations

Question 12

Poor prognosticators for individuals with CLBP (2)

Answer 12

1. high pain

2. high disability

Question 13

T or F: single red flag is predictive for serious dz

- if false, why?

Answer 13

False - many people have single red flags show up, but these should be used in clusters to lead the therapist to concerns for serious pathology - the higher the number of red flags, the greater the concern

Question 14

T or F: nearly all pts will show one red flag w/o notable serious dz
- if false, why?

Answer 14

True

Question 15

Two major serious dx to screen for in the outpatient setting

Answer 15

1. Metastatic CA

2. Undiagnosed fractures

Question 16

Key clinical features of metastatic lesions (2)

Answer 16

1. hx of CA

2. overall clinician judgement

Question 17

red flags of metastatic lesions (4)

Answer 17

1. previous hx of CA
2. insidious onset of symptoms
3. older age at onset (>50 y/o)
4. failure to recover/improve

Question 18

red flags of undiagnosed vertebral fractures (CPR developed by Henschke and colleagues)

Answer 18

1. > 70 y/o
2. significant trauma/injury
3. prolonged use of corticosteroids
4. female gender

Question 19

T or F: MRIs are good for identification of serious pathology
- if false, why?

Answer 19

True

Question 20

T or F: MRIs are good for identifying painful stimulus agents in LBP of non-serious pathology
- if false, why?

Answer 20

False - good at finding abnormalities, but these abnormalities may not be the cause of the pt’s pain
- may lead to pt stress over patho label

Question 21

T or F: MRIs may lead to lower levels of false positives regarding low back pain stimuli

Answer 21

False - MRIs can see a lot, but clinical research has shown that this may lead to more pathoanatomical “labels” which is not directly tied to a pt’s LBP

Question 22

T2 weight vs T1 weighted MRIs

- visual difference between CSF

Answer 22

https://case.edu/med/neurology/NR/MRI%20Basics.htm
T1 - CSF is dark
T2 - CSF is light

Question 23

Dark disk in T2

• what is it (historically)?
• possible negative impacts of pts emotionally

Answer 23

Thought to signs of DDD, but is usually benign and asymptomatic
- pt may hear “I have a deteriorating spine” and send them down a dark emotional path

Question 24

What is Modic’s sign?

• IVD and vertebral body involvement
• what MRI image type is it seen (T1 or T2?)

Answer 24

• Suspected disruption of the end-plate with subsequent bone marrow edema (sus nutrient waste)
• IVD and vertebral body - possible contributors to pain stimulus
• T2 weighted MRI image

Question 25

What is a high intensity zone (HIZ)? - where, what, though to be? - what MRI image type is it seen (T1 or T2?)

Answer 25

- area of high (bright) signal along the annular region of the IVD - though to be an annular tear, possible comp. of discogenic pain - T2 weighted MRI image

Question 26

What is a yellow flag?

Answer 26

Patient's personal mistaken beliefs about pain and injury (table 3, pg 13)

Question 27

Can yellow flags cause/change physiologic processes?

Answer 27

Yes

Question 28

What can the Pain Catastrophizing Scale possibly be an independent predictor of?

Answer 28

Predictor of disability

Question 29

Why should fear avoidance beliefs be examined over the duration of treatment instead of just at beginning of treatment?

Answer 29

Pt may not realize they have a fearful avoidance of some tasks until faced with the activity/functional task.

Question 30

Is elevated fear avoidance a good predictor of chronicity in isolation?

Answer 30

No per current clinical findings

Question 31

What questionnaire(s) may be used to determine Fear Avoidance?

Answer 31

Fear Avoidance Belief Questionnaire (FABQ) along with variants - FABQ - Work (FABQ-W) - FABQ - Physical Activity (FABQ-PA)

Question 32

SMT shown to be best for acute or chronic case? | - Does it help both

Answer 32

Best for acute, but have seen benefits in both populations

Question 33

What is a Blue Flag? | - two examples of Blue Flags

Answer 33

Blue flag is a primarily related to work related injuries 1. Low job satisfaction 2. Negative personal interactions/conflicts with employers and/or fellow coworkers.

Question 34

What is a Black Flag?

Answer 34

Wider context of issues compared to yellow and blue flags. - may be unhelpful or possible perverse nature of systems - example: reimbursement to remain disabled

Question 35

CPR for using lumbar manipulation (dev. by Flynn et al)

Answer 35

1. No symptoms distal to knee 2. Less than 16 days since onset/current episode duration 3. FABQ score: <19 4. Hip IR ROM: at least one hip >35 deg of IR * *some debate on generalizability - unable to be reproduced b Hancock et al.

Question 36

What is graded exposure with fear avoidance in pt's with LBP?

Answer 36

asks pts with LBP to generate a hierarchy of feared activities and gradually progress through these to attempt to reduce activity-related anxiety.

Question 37

Graded activity

Answer 37

operant condition (behavior gets expected consequence) to reinforce health behaviors and progress pt through different levels of functional activity

Question 38

Treatment approach to motor control exercises described by Costa et al. (2)

Answer 38

1. Train coordinated activity of trunk muscles (TA and multifidus activation, decreased superficial muscles activation) 2. implement precision of the desired coordination (train skills in static tasks, progress to dynamic task and functional positions with these skills)

Question 39

Exercise treatment plans for pts with chronic LBP with central sensitization - what types

Answer 39

low to moderate intensity aerobic exercise with slow progressing

Question 40

Pt education from PTs regarding LBP (3)

Answer 40

1. stay active, avoid bed rest, understand diff of good vs. bad pain 2. PT perform behavioral education with cognitive behavioral theory, graded activity increase 3. Educate pts on physiology of pain- neuroplasticity, central sensitization (esp. good for pts w/ CLBP)

Question 41

Novel interventions gaining popularity for LBP rx (2)

Answer 41

1. Modern neuroscience approach | 2. Dry needling.

Question 42

clinical instability questionnaire | - best exercise regimens for >9 or <9 (score)

Answer 42

1. for scores =/> 9 (high): better with motor control exercises 2. for scores <9 (low): graded activity approach better

Question 43

T or F: lumbar DD is strongly linked to genetic factors

Answer 43

True | - 4-5x more likely to have a FMH of bulging lumbar disks if diagnosed with a protruding lumbar disc <21 y/o

Question 44

Loss of hydration in the nucleus of the IVD results in impaired diffusion of what? (4)

Answer 44

nutrients oxygen water metabolites

Question 45

Hydrostatic properties of the IVD are reliant on what IVD structure?

Answer 45

Annulus of the IVD

Question 46

Loss of annular support is likely to lead to.... (3)

Answer 46

1. accelerated degeneration 2. loss of internal stability 3. reactive bone formation (osteoblastosis)

Question 47

Present literature supported systems for identifying DD and strategies to treat the specific pain-provoking tissues noninvasively.

Answer 47

Currently are none. Wah-wah.

Question 48

Three sub-groups of PT management per the "Revised" TBC system (not the treatments)

Answer 48

1. Symptom modification 2. Motor coordination 3. Functional optimization

Question 49

Ankylosing spondylitis most commonly seen in what three regions/joints?

Answer 49

1. Lumbar region 2. SI joint 3. Shoulder