Tx Based Classification of Low Back

Diagnoses that refer to the low back

aneurysm, Vascular Claudication, Kidney Stone, Gastrointestinal Pathology

sxs of an aneurysm

Pain at rest or night

Pulsating abdominal mass found w/ inspection/palpation of abdomen

Family hx of CVD

Sxs cannot be provoked w/ mechanical exam of low back

Red Flag Diagnoses that refer from the low back

Pathologic Fracture, cancer, Acute Spondylolisthesis, Sacral Stress Fracture, infections, cauda equina, ankylosing spondylitis

Acute Spondylolisthesis typically seen in young individuals (get imaging) signs/sxs include

Repetitive hyperextension injury

Sudden severe bilateral sciatica occurred during athletic activity

Pain w/ extension (prone w/ passive bilateral hip extension)

No urinary bowel incontinence

Pathologic Fracture of low back typically found at L1-L2 in older female individuals & sxs/subjective include

Prolonged corticosteroid use

Mild trauma or sudden pain w/o reason

History of osteoporosis

Sign of buttock if sacral insufficiency fracture present

Cancer red flag sxs for low back pain include

PMH of cancer, pt over 50 w/ new onset of LBP

Unexplained weight loss

Night pain, Worsening pain

No response to conservative management

Sign of buttock

Sacral Stress Fracture typically seen in athletic females w/ signs/sxs including

Increased level of vigorous/repetitive athletic activity

Pain involves buttock & reproduced w/ athletic activities (e.g. running)

Dietary insufficiency, Menstrual irregularities

Previous stress fractures

Non-responsiveness to previous tx

Ankylosing Spondylitis signs include middle aged individual w/ pain on & off irrespective of

exertion, Progressive loss of ROM

Alternating pain in SI joints w/ walking

Later sign: gross bilateral limitation of sidebending

Pain goes in vertical direction – not laterally or to LE

Stiffness in morning eases w/ movement

No paresthesia

Gastrointestinal Pathology signs

Pain in upper lumbar area (L1-2) occurs after eating

Pain can be relieved by further intake of food

Sxs cannot be provoked w/ mechanical exam of low back

Vascular Claudication signs/sxs

Older individual

Family hx of CVD

Pain in calf w/ activity relieved w/ rest

One foot is colder than other

Sxs cannot be provoked w/ mechanical exam

kidney stone signs

Sudden sharp pain of intermittent nature; It reaches testicles or labium

Same pain w/ fever = renal infection

Symptoms cannot be provoked w/ mechanical exam of low back

Biomedical Model in back pain: Only ~15% of LBP can be given a

specific pathoanatomical diagnosis (rest get nsLBP or lumbago)

Biomedical Model in back pain- Pathoanatomic findings are often present in asymptomatic people

64% of asymptomatic individuals have abnormal discs

20% have intersegmental motion exceeding threshold

Mild scoliosis, disc degeneration, spondylosis are AS common on symptomatic as

asymptomatic radiographs (Radiologist can pick out symptomatic individuals by their imaging ~50% of time)

what is term for when healthcare professionals try to over treat diagnosis rather than treat pt sxs?

medicalization

(the Challenges of LBP) Psychological Variables & Social Determinants of Health are strongest predictors of

long-term outcomes, Non-Specific LBP is a heterogeneous population that is often studied homogeneously, Clinicians generally agree that LBP is heterogeneous but disagree on how to classify patients w/ LBP

triage by the first contact healthcare provider

medical: red flags? medical referral

Rehabilitation Management: Psychosocial risk stratification, Appropriate for PT

self care: Low psychosocial risk, High self efficacy

Variables Influencing Recovery from Acute LBP include

Self perceived general health (including physical & psychosocial dimensions)

pt’s expectations of recovery

Care providers perception of risk of persistence at baseline

Fear Avoidance Beliefs Questionnaire (FAB-Q) for physical activity

< 14 points low risk,

> 16 points high risk

Fear Avoidance Beliefs Questionnaire (FAB-Q) for work

<21 points for low risk

>24 points for high risk

STarT Back Screening Tool: 9 item multidimensional Screening Measure Score 0-9 w/

a 0-5 Psychosocial Sub-scale

STarT Back Screening Tool score categorizing

High Risk: >3 on Psychosocial Sub-Scale

Medium Risk: overall SBT score >=4 & psychosocial scores <4

Low Risk: <4 Overall Score

STarT Back Screening Tool - high risks are more likely to experience

pain catastrophizing, Fear, pain, & depression

STarT Back Screening Tool - high risk scores have a poorer prognosis w/

physical medicine alone (PT & Medicine) Consider referral to psych consultations

STarT Back Screen Tool - 61% of medium to high risk individuals changed their SBT Risk Category to

low risk after receiving physical therapy care

STarT Back Screen Tool - Differences in SBT scores at 0 & 5 weeks were greater predictors of

6 month outcomes than initial SBT scores

STarT Back Screen Tool - If SBT score remains a high risk after 5 weeks of PT then

referral for further psychological consult may be warranted

STarT Back Low/Medium risk - goals:

Restore function

Minimize disability

Self management

Encourage activity

Rehabilitation Triage and Management - treatments for high disability

directional preference exercises

manipulation/mobilizations

traction

active rest

is the pt irritable and inflammed? yes

address the inflammation by active rest

does the pt peripheralize w/ extension & flexion or have positive crossed SLR test? yes

prescribe traction

does the pt centralize w/ flexion or extension? yes

prescribe specific exercises that centralize the symptoms

does the pt stop to centralize and have no sxs distal to knee? yes

prescribe manipulation

is there a sensitized neurological structure? yes

address the sensitized neurological structure

is there a joint mobility or muscle flexibility impairment? yes

prescribe flexibility exercises or jt mobs

is there a motor control impairment? yes

prescribe motor control exercises

is there a muscles endurance impairment? yes

prescribe endurance exercises