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Flashcards in Lumbar CPG Deck (23):
1

RISK FACTORS

Current literature does not support a definitive cause for initial episodes of low back pain.

Risk factors are multifactorial, population specific, and only weakly associated with the development of low back pain.

(Recommendation based on moderate evidence.)

2

CLINICAL COURSE LBP

The clinical course of low back pain can be described as acute, subacute, recurrent, or chronic.

Given the high prevalence of recurrent and chronic low back pain and the associated costs, clinicians should place high priority on interventions that prevent

(1) recurrences

(2) the transition to chronic low back pain.

(Recommendation based on theoretical/foundational evidence.)

3

DIAGNOSIS/CLASSIFICATION

Low back pain, without symptoms or signs of serious medical or psychological conditions, associated with clinical findings of

(1) mobility impairment in the thoracic, lumbar, or sacroiliac regions

(2) referred or radiating pain into a lower extremity

(3) generalized pain

4

DIFFERENTIAL DIAGNOSIS LBP

DDX of serious medical conditions or psychosocial factors and initiate referral to the appropriate medical practitioner when

(1) patient’s clinical findings are suggestive of serious medical or psychological pathology

(2) reported activity limitations or impairments of body function and structure are NOT consistent with those presented in diagnosis/classification section of CPG

(3) patient’s symptoms NOT resolving with interventions aimed at normalization of impairments of body function.

(Recommendation based on strong evidence.)

5

LBP EXAMINATION – OUTCOME MEASURES

ODI (MCID 10/100 points or 30% baseline)

Roland-Morris (MCID 5/24 points or 30% baseline)

Useful to ID baseline status relative to pain, function, and disability AND for monitoring a change in a patient’s status throughout the course of treatment.

(Recommendation based on strong evidence.)

6

LBP EXAMINATION – ACTIVITY LIMITATION AND PARTICIPATION RESTRICTION MEASURES:

Clinicians should routinely assess activity limitation and participation restriction through validated performance-based measures.

Changes in the patient’s level of activity limitation and participation restriction should be monitored with these same measures over the course of treatment.

(Recommendation based on expert opinion.)

7

LBP INTERVENTIONS – MANUAL THERAPY

Consider thrust manipulative procedures for patients with:

1. mobility deficits and acute low back and back-related buttock or thigh pain to reduce pain and disability

2. subacute / chronic low back & back-related lower extremity pain to improve spine and hip mobility and reduce pain and disability .

(Recommendation based on strong evidence.)

8

INTERVENTIONS – TRUNK COORDINATION, STRENGTHENING, AND ENDURANCE EXERCISES

Use trunk coordination, strengthening, and endurance exercises to reduce low back pain and disability in patients

1. subacute / chronic LBP with movement coordination impairments

2. post lumbar microdiscectomy.

(Recommendation based on strong evidence.)

9

INTERVENTIONS – CENTRALIZATION AND DIRECTIONAL PREFERENCE EXERCISES AND PROCEDURES:

Patients with

1. Acute low back pain with related (referred) lower extremity pain:

  •  repeated movements, exercises, or procedures to promote centralization to reduce symptoms

2. Acute, subacute, or chronic low back pain with mobility deficits:

  • repeated exercises in a specific direction determined by treatment response to improve mobility and reduce symptoms

(Recommendation based on strong evidence.)

10

INTERVENTIONS – FLEXION EXERCISES

Older patients with chronic low back pain with radiating pain

Flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking.

for reducing pain and disability in

(Recommendation based on weak evidence.)

11

LBP INTERVENTIONS – LOWER-QUARTER NERVE MOBILIZATION PROCEDURES

Patients with subacute and chronic low back pain and radiating pain.

Use lower-quarter nerve mobilization procedures to reduce pain and disability

(Recommendation based on weak evidence.)

12

LBP INTERVENTIONS – TRACTION:

Conflicting evidence

efficacy of intermittent lumbar traction for patients with low back pain.

Preliminary evidence

subgroup (nerve root compression with peripheralization of symptoms OR a positive crossed straight leg raise) will benefit from intermittent lumbar traction in the prone position.

moderate evidence

Do not utilize intermittent or static lumbar traction for reducing symptoms in patients with acute or subacute, nonradicular low back pain or patients with chronic low back pain.

(Recommendations based on conflicting evidence.)

13

LBP INTERVENTIONS – PATIENT EDUCATION AND COUNSELING ... DO NOT  

Directly/indirectly increase perceived threat or fear associated with LBP...

(1) DO NOT promote extended bed-rest

(2) DO NOT provide in-depth, pathoanatomical explanations for the specific cause of the patient’s low back pain.

14

LBP INTERVENTIONS - PATIENT EDUCATION AND COUNSELING DO

DO emphasize

(1) understanding of the anatomical/structural strength inherent in the human spine

(2) neuroscience that explains pain perception

(3) overall favorable prognosis of low back pain

(4) the use of active pain coping strategies that decrease fear and catastrophizing

(5) early resumption of normal or vocational activities, even when still experiencing pain

(6) the importance of improvement in activity levels, not just pain relief

(Recommendation based on moderate evidence.)

15

INTERVENTIONS – PROGRESSIVE ENDURANCE EXERCISE AND FITNESS ACTIVITIES

Chronic LBP without generalized pain:

(1) moderate- to high-intensity exercise

 Chronic LBP with generalized pain:

(2) progressive, low-intensity, submaximal fitness and endurance activities into the pain management and health promotion strategies

(Recommendation based on strong evidence.)

16

Hancock 2009

Rate of recovery predicted with acute LBP?

• Predictors

1. Baseline pain ≤ 7/10

2. Dura>on of current episode ≤5 days

3. Number of previous episodes ≤1

• All 3 Predictors Present:

– 60% recovery at 1 wk

– 95% recovery at 12 wks

INCLUSION

• LBP w/ or w/o LE pain

• Pain <6 wks dura>on

• Moderate pain & disability

(adap>ng items 7, 8 on SF-36)

17

Spinal Fracture CPR

  1. Female
  2. Age < 70
  3. Trauma (major in young, minor in elderly)
  4. Corticosteroid

1 positive  = Sn .88, Sp .50 +LR 1.8

2 positive = Sn .63, Sp .96, +LR 15.5

3 positive = Sn .38, Sp 1.00 +LR 218

 

18

Serious spinal conditions risk factors

(cancer)

Cancer (Deyo et al)

  • >50yo (Sn 0.77, Sp 0.71, +LR 2.7, -LR 0.32)
  • history of cancer (Sn 0.31, Sp 0.98, +LR 15.5)
  • unexplained weight loss (Sn 0.31, Sp 0.94, +LR 2.5)
  • failure of conservative therapy (Sn 0.31, Sp 0.90, +LR 2.6)

Any patient with hx of ca & new onset of back pain ==> MRI

Any of the other three get radiographs & ESR

19

Serious spinal conditions risk factors

(infection)

Infection

  • Fever
  • intravenous drug use
  • recent infection

==> MRI/ESR+CRP

20

Serious spinal conditions risk factors (AAA)

AAA

  • PVD, CAD (or associated risk factors)
  • hx of smoking history
  • family AAA hx
  • >5cm aortic pulse
  •  >70yo

21

Serious spinal conditions risk factors 

(compression fx)

Compression fracture

General: history of osteoporosis, use of corticosteroids, older age

Henschke et al 2008

  • >50 years (+LR 2.2, -LR 0.34
  • female gender (+LR 2.3, -LR 0.67)
  • major trauma (+LR 12.8, -LR 0.37)
  • pain and tenderness (+LR 6.7, -LR 0.44)
  • distracting painful injury (+LR 1.7, - LR 0.78)

3/4 --> 52%

22

Serious spinal conditions risk factors 

(AS)

Ankylosing spondylitis

  • Morning stiffness,
  • mprovement with exercise
  • alternating buttock pain
  • awakening due to back pain during the second part of the night
  • younger age

==> x-ray, ESR, CRP HBLA-27

23

Serious spinal conditions risk factors 

(severe neurological deficits)

Severe neurological deficits

Progressive motor weakness ==> MRI

Cauda equina syndrome ==>MRI

Urinary retention, motor deficits at multiple levels, fecal inontinence, saddle anesthesia ==>MRI