Low Back Pain

Question 1

Nearly all cases of LBP have what?

Answer 1

aka non-specific LBP- nearly all cases have an unidentified nociceptive source hence the term non-specific LBP

Question 2

What are some functional questionnaires for LBP?

Answer 2

• Numeric Pain Rating Scale- 2 pts.
• Visual Analog Scale- 1.5 pts
• Oswestry Disability Questionnaire- 6 pts or 12%
• Roland Morris Disability Questionnaire- 2-3 pts
• STarT Back Tool- determines the risk of persistent disabling pain and matches treatments

Question 3

What is the thoracic prevalence of LBP?

Answer 3

The smallest amount of spine-related pathology

Question 4

What is the lumbar prevalence of LBP?

Answer 4

The leading cause of:
- Worldwide disability
- Activity limitation and work absence
- 80% will experience LBP in their lifetime

Question 5

What is the prevalence of LBP in men compared to women and age?

Answer 5

• Biological women > men
• Older (half > 65 yrs. of age21) > younger ages
• Lower educational status: think access
• Higher physical work demands

Question 6

What are risk factors of LBP?

Answer 6

• Previous LBP
• Co-morbidities (ex: diabetes, asthma, obesity, etc)
• Poor mental health: think coping
• Smoking and low activity levels
• Awkward postures, heavy lifting, and fatigue
• Genetics with age-related disc changes only, otherwise questionable

Question 7

What structures are involved in LBP?

Answer 7

Variable innervated structures

Question 8

What might you see on an MRI with LBP?

Answer 8

~ 1/3 of asymptomatic individuals had “abnormal” findings such as:
- IDD
- Age-related disc changes
- Nerve compression
- Facet hypertrophy
- ~ 1/2 of symptomatic individuals had an abnormality

Question 9

What might you see with both MRI and CT with LBP?

Answer 9

• ~2/3 of asymptomatic 30-80 yr. old individuals had disc changes
• Normal asymptomatic age-related changes MUCH > symptomatic structural changes
• Imaging changes significantly increase with age

Question 10

Are most scans for LBP helpful or not?

Answer 10

59% of outpatient lumbar scans were inappropriate in 2012

Question 11

Who should get Imaging with LBP?

Answer 11

• > 50 yrs. of age with a hx of cancer
• Saddle paresthesias
• Bowel and bladder dysfunction
• Specific neurological deficits (spinal n., brain, spinal cord)
• Progressive/disabling symptoms
• No improvement after 6 weeks of conservative Rx

Question 12

How many LBP cases have an unidentified nociceptive source

Answer 12

Nearly all

Question 13

What kind of gap is present between evidence and practice?

Answer 13

Substantial

Question 14

Over utilization of unsupported and ineffective Rx causes what?

Answer 14

• Fear-avoidance behaviors promoted with passive interventions like modalities and even some manual therapies
• Leads to higher costs
• Contributes to greater opioid addiction
• Greater imaging and radiation exposure
• More likely to have invasive procedures, side effects, and missed work

Question 15

What kind of prevention is available for LBP?

Answer 15

• Inadequate research
• Most promoted preventions lack evidence
• Exercise is largely effective in adults
• For children ergonomic furniture is effective
• For children, exercise has not been evaluated

Question 16

What percentage of patients that had early PT developed LBP?

Answer 16

2% developed persistent LBP

Question 17

What happens to work time in pts with LBP that have early PT?

Answer 17

Significant reductions in lost work time

Question 18

Is early PT supported in studies for LBP?

Answer 18

Yes, Supported by numerous studies

Question 19

What is the first line Rx for LBP that has moderate to strong evidence behind it?

Answer 19

Education and advice

Question 20

What kind of “against” education and advice should you give?

Answer 20

• Bed rest
• In-depth explanations

Question 21

What kind of “for” education and advice should you give?

Answer 21

• Spinal anatomical and structural strength
• Overall favorable prognosis
• Active P! coping mechanisms that ↓ fear/catastrophizing
• Stay active with early resumption of ADLs
• Biopsychosocial contributors and basics of nociplastic pain
• Emphasis on function with back protection techniques

Question 22

What kind of benefit does dry needling have for LBP?

Answer 22

Weak evidence of short term benefit

Question 23

What kind of benefits do modalities like heat, US, electrical stimulation, LASER, etc. have for LBP?

Answer 23

• Generally ineffective and not recommended
• Short-term results at best; often no better than placebo

Question 24

What kind of benefit does soft tissue mobilization/massage have for LBP?

Answer 24

Moderate evidence of short-term benefit

Question 25

What barriers should we overcome to achieve best practices?

Answer 25

- Increase consultation time and follow-up - Better incentives to return to work - Reward quality and NOT volume with reimbursement - Public service announcements - Increased provider knowledge of evidence and guidelines for use in clinical reasoning and decision-making

Question 26

What kind of evidence does Rx in general have for LBP?

Answer 26

- Moderate evidence with acute LBP - Weaker evidence with chronic LBP due to greater contributing variables

Question 27

What are the 4 subgroups of Rx for LBP?

Answer 27

- Mechanical Traction - Directional Preference - Mobilization/Manipulation - Stabilization

Question 28

What kind of LBP benefits from traction?

Answer 28

- Intermittent tx for LBP with LE P! - Acute and subacute LBP with LE P! that doesn’t centralize

Question 29

What kind of LBP does not benefit from traction?

Answer 29

- No benefit with static tx - Should not use with persistent LBP with LE P!

Question 30

There is moderate evidence against all types of tx when used alone in patients with what?

Answer 30

- Acute, sub-acute, and persistent LBP - Non-radicular LBP - Varying symptom patterns

Question 31

How should mechanical traction be best used?

Question 32

What is a directional preference?

Answer 32

A position and/or motion that alleviates symptoms

Question 33

What repreated motions do people with LBP usually make?

Answer 33

- Most commonly extension/hyperextension, may centralize LE symptoms to LB

Question 34

What is centralization?

Answer 34

Centralization- abolition of distal and/or spinal P! in a distal to proximal direction in response to repetitive motion(s) or sustained position(s)

Question 35

What can directional prefernces help with?

Answer 35

Can help to choose positions and motions to avoid symptoms and promote exercise and activity

Question 36

How should directional preference be best used?

Question 37

What kind of evidence does manipulation have?

Answer 37

- Strong patient preference/belief in short term effectiveness - Strong evidence for thrust and non-thrust mobilizations for LBP and disability

Question 38

What LBP group is manipulation most beneficial for?

Answer 38

Manipulation most effective for sub-groups with acute and sub-acute LBP

Question 39

What kind of predictors helped justify the used of manipulation with LBP?

Answer 39

≥ 4 of 5 predictors improved success from 45 to 95% with a 13.2 LR+ by using lumbar rotation or SI distraction manipulation: 1. NO symptoms distal to knee 2. Symptoms < 16 days 3. Lumbar joint hypomobility 4. Fear Avoidance Behavior Questionnaire at Work < 19 5. ≥ 1 hip with MORE than 35° IR Added benefit when used with exercise

Question 40

Mobilizations/ manipulations have strong evidence to improve what?

Answer 40

Strong evidence to improve hip mobility with subacute and persistent LBP

Question 41

Mobilizations/ manipulations have moderate evidence to improve what?

Answer 41

Moderate to strong evidence to improve LBP and disability with back related LE P!

Question 42

Mobilizations/ manipulations are short course at most; what does this mean?