Lumbar

Question 1

How long do acute instances take to recover for LBP?

Answer 1

6-8 weeks

Question 2

Does acute LBP have flare ups?

Answer 2

Yes - has flare ups, but quick recovery - pain does not mean failure of tx

Question 3

What are previously thought risk factors for LBP?

Answer 3

Prolong sitting, lifting, sports - study found no associated factors associated & should not be avoided w/o rationale

Question 4

Hancock CPR - recovery time: what results in quick recovery?

Answer 4

1) Lower initial pain 2)shorter duration sxs 3)fewer previous episodes - conversely; 1) high deg of disability 2)previous hx of loss of work -> much less likely to recover (overall strength is weak to moderate)

Question 5

What 3 areas of body do pain modulators affect?

Answer 5

1) spinal cord 2) brain stem 3)higher brain centers

Question 6

Chronic spinal pain results in firing of what fibers

Answer 6

C-fibers / A-delta fibers; analgesia results in blocking these fibers - sensitization results in lower threshold in these fibers

Question 7

What area of the brain stem is stimulated for inhibition?

Answer 7

DPag (dorsal periacqueductal grey)

Question 8

What disease processes affect the heterogeneity of LBP?

Answer 8

1) reduced physical activity 2)inc sitting 3)inc use of computers 4)obesity with chronic inflammation (theoretical)

Question 9

Should pts be encouraged to initiate early treatment or bed rest?

Answer 9

Early treatment - improves LT outcomes; rapid transition from passive to active treatment

Question 10

Is a single red flag item predictive of serious disease?

Answer 10

No - need constellation of sxs

Question 11

What are signs/sxs consistent with metastatic cancer?

Answer 11

1) hx of cancer 2) night pain/pain at rest 3) unexplained weight loss 4) age >50 / <17 5) failure to improve with predicted time frame

Question 12

What are signs/sxs consistent with infection with disc/vertebrae?

Answer 12

1) immunosuppression 2) prolong fever (100.4) 3)hx of intravenous drug use 4) hx of UTI, cellulitis, pneumonia

Question 13

What are signs/sxs consistent with AAA?

Answer 13

1) pulsating mass in abdomen 2) hx of atherosclerotic vascular dx 3) throbbing, pulsating back pain at rest 4) age >60 years

Question 14

What is the CPR by Henscke for vertebral fractures?

Answer 14

1) age > 70 2)female 3) significant trauma 4) prolong use of steroids - 3 or more +LR of 52%

Question 15

What two MRI findings, according to Hancock systematic review, were meaningful in disc pathology?

Answer 15

1) high intensity zone (associated with annular tear) +LR 1.5 to 5.9 - 2) Modic sign = end plate changes which result in impaired diffusion between subchondral bone/disc - LR 0.21

Question 16

What positive eval/exam finding is consistent with disc pathology?

Answer 16

Centralization - +LR 2.8

Question 17

Definition and example yellow flags -

Answer 17

Definition: pt’s personal mistaken beliefs about pain/injury - example = pain catastrophizing, hypervigiliance,

Question 18

Definition of blue flag

Answer 18

Related to injured worker; describe pt’s perception of work and work conditions that may impair return to work

Question 19

Definition of black flag

Answer 19

Social & financial issues related to care - ie: unhelpful reimbursement incentive to remain disabled

Question 20

What are established predictors of chronicity of pain?

Answer 20

1) imaging findings of multi-level DDD 2)strenuous/stressful job 3) leg pain 4) low education background 5) fear avoidance beliefs

Question 21

Roland Morris Disability Questionnaire - important clinical change?

Answer 21

5 points

Question 22

Oswestry Disability Index - important clinical change?

Answer 22

10 points

Question 23

Manual therapy effect on outcomes?

Answer 23

Early use with transition to more active approach - generally thought to have small, moderate effect with potential meaningful

Question 24

Childs CPR for LBP - 5 factors

Answer 24

1) no sxs distal to knee 2)at least 1 hip > 35 IR 3) FABQ-W <19 4) at least 1 hypomobile L/S segment 5) acute onset <16 days

Question 25

Define graded exposure:

Answer 25

General hierarchy of feared activities and then gradually progress through these in attempt to reduce activity related anxiety

Question 26

Define graded activity:

Answer 26

Operant condition to reinforce healthy behavior & progress through different levels of functional activity

Question 27

What is the research regarding progressive endurance / fitness exercise for LBP?

Answer 27

Aerobic fitness programs reduce inc awareness (hypervigiliance) of neural stimulus // Weight training reduces frequency of acute episodes

Question 28

According to the LBP CPG: 3 areas for pt education/ counseling:

Answer 28

1) avoid bedrest - stay active 2) cognitive behavioral therapy / graded inc in activity 3) physiology of pain (neuroplasticity, central sensitization - sxs don't represent serious pathology/disease)

Question 29

Trigger points, taut bands, in muscles are:

Answer 29

Local areas of congestion, inc concentration of cytokines (hyperalgesia), with sustained muscle contraction & alteration in chemical environment = end plate noise

Question 30

What theory does trigger point dry needling operate on use?

Answer 30

Gate control effect; activating alpha-delta nerves stimulating dorsal horn interneurons to create opiate like pain reduction

Question 31

Peripheral manual therapy for LBP results in what changes in the disc?

Answer 31

Diffusion rates of fluid movement in muscles/joints - > changes in disc fluids

Question 32

What central hormone is found affected with manual therapy?

Answer 32

Cortisol

Question 33

IVD consists of what 4 layers:

Answer 33

1) nucleus 2) transitional zone 3)inner annulus 4) outer annulus

Question 34

What are the main features and roles for the IVD?

Answer 34

Support, mobility, maintain stability under loading, permits multi directional & intersegmental motion - maintains vertical distance between vertebrae for tension on ligaments, alignment of facets

Question 35

Where are nearly ALL the neurovascular structures of the IVD found?

Answer 35

Outer annulus - sensory & nerve fibers as well as blood vessels (depth of 3.5 mm)

Question 36

What are the two routes of sensory travel for the IVD in lowback pain?

Answer 36

1) segmentally (posterior dorsal root) 2)extra-segmentally thru paravertebral chain *sympathetic* == vague & diffuse pain

Question 37

What area of IVD is only area with blood supply and can entertain O2 / nutrient exchange?

Answer 37

Outer annulus - rest of disc relies on osmosis

Question 38

What is the diurnal variation for the IVD like before and after 35?

Answer 38

< 35- greater water content in AM (after recumbency) loss of 0.9 mm of disc >35 - decreased ability to perform fluid exchange; DDD

Question 39

What three tissues are disc pathology associated with?

Answer 39

Nucleus, annulus or subchondral bone/endplate

Question 40

What force does the annulus abnormally resist with a decreased water content?

Answer 40

Compression - acts as solid restraint vs. flexible interspace

Question 41

What decade of life is DDD usually present by - and what decade is it universally present by?

Answer 41

Third decade usually Universally by 7-8th decade

Question 42

By what decade are the blood vessels gone from the endplate of the IVD?

Answer 42

2nd decade - > Modic sign; changes in endplate intensity on MRI

Question 43

Define Schmorl Node:

Answer 43

Cartilage protruding into adjacent vertebral body

Question 44

Where does the annulus typically rupture?

Answer 44

Lower lumbar segments

Question 45

Where in the IVD annulus do sxs generate due to injury?

Answer 45

Peripheral rim lesions - outer most 3.5 mm

Question 46

What loss in disc height results in overloading facet joints?

Answer 46

1-3 mm - noticeably reduces foraminal space / loads longitudinal ligaments -> stimulates osetophyte formation (spondylosis)

Question 47

What is the capacity for healing for the IVD?

Answer 47

Annulus: limited; poorly remodeled scar | Middle/inner: filled granulation tissue - lack of tensile strength

Question 48

What do the tissue changes of remodeled annulus/middle & inner discs result in for metabolism of the cell?

Answer 48

Decreased diffusion of O2/nutrients - lower O2 = lower pH = higher lactic acid; inactive cells -> cell death

Question 49

What are the implications for late stage DDD? (disk height, microtrauma, prolong exposure to compressive loads)

Answer 49

1) Microtrauma causes pain next day - delayed onset 2) Avoid lifting first two hours awake 3) Avoid long exposure of compressive load (prolong sitting, lumbar flexion)

Question 50

What is the biggest predictor of patient satisfaction in clinical interaction?

Answer 50

Therapist interaction with patient - likely results in better clinical outcome

Question 51

What are signs/sxs for cauda equina?

Answer 51

50-55 y.o., bowel/bladder changes, saddle parestheisa, LE weakness - exacerbated by standing/walking - eased by flexion

Question 52

Grades for spondylolisthesis:

Answer 52

Grade 1 <25% Grade 2 25-50% Grade 3 50-75% Grade 4 >75%

Question 53

CPR for return to work with acute LBP: non-recovery at 3 months (negative factors)

Answer 53

1) age > 45 years 2) smoking 3) 2 or more neurologic findings 4) >90 score on psychosocial screen = high distress

Question 54

Motion in the SIJ: (mm & deg)

Answer 54

1.6 mm - - 4 deg rotation

Question 55

Laslett special test cluster for SIJ: (5 tests)

Answer 55

1) SIJ compression 2) SIJ distraction 3) thigh thrust 4) sacral thrust 5) gaenslen's

Question 56

Van der Wurff special test cluster of SIJ (5 tests)

Answer 56

1) FABERs 2) ASIS distraction 3) thigh thrust 4) ASIS compression 5) gaenslen's 3 or more tests = Sn 0.85 // Sp 0.79 with +LR 4, -LR 0.19

Question 57

Where is McBurney's point?

Answer 57

Line between naval & ASIS; halfway between - positive test = rebound pain

Question 58

What is the Psoas sign?

Answer 58

Bring the hip passively into extension and adduction which reproduces pain in the abdomen = can be consistent with inflamed appendix

Question 59

What is the Obturator sign?

Answer 59

Passively flex hip to 90 and IR hip which reproduces pain in the abdomen = cam be consistent with inflamed appendix