EBPR Week 2 - Lumbar Spine Conditions

What is the definition of Pain?

unpleasant sensory and emotion experience associated with actual or potential tissue damage

What is the differenc ebetween Neuropathic, Nociceptive, and nociplastic pain?

Neuropathic - caused by lesion or disease of the somatosensory NS, nociceptive - pain that arises from actual damage to non-neural tissue and is due to the activation of nociceptors, nociplastic - persistent pain from altered nociception despite no evidence of actual tissue tamage

What differentiates the a-delta from c-fibers?

A = myelin, fast, high sharp pain (20% of nociception), C = slow, dull throbbing pain (80% nociception)

How does the withdrawal reflex work

stimulus → afferent → integrating → efferent → effector

What is Gate Control Theory of Pain

A-delt and c-fibers = pain afferent, A beta = inhibit pain before afferents arrive

What is sensitization?

Decreased pain threshold

How does hyperalgesia and allodynia arise due to sensitization

Hyperaglesia = Higher magnitude and duration of pain stimulus (injury site) Allodynia = lower pain threshold → increased pain for usually non-painful stimuli

What is the Endogenous Opioid Theory?

Inhibition of GABA —> lower pain afferent and higher a-beta & pain inhibition (natural painkillers)

VAS

Visual analog scale, outcome measure, no pain to worst pain on a line

NPRS

numeric pain rating scale, outcome measure, 0-10 with 10 being worst pain

RMDQ

roland-morris LBP and disability questionnaire, 24-item self-report, how lbp affects functional, yes/no, higher score = higher disability

ODI

Oswestry disability index, outcome measure for LBP, 10-item self-report, best for severe disability, 0-5 scale, greater score = greater disability

ODI disability categories

0-10 = minimal, 11-20 = moderate, 21-30 = severe, 31-40 = crippled, 41-50 = bed-bound

lordosis vs kyphosis

exaggerate lumbar curve (inwards) vs exaggerated throacic curve (outwards)

flat back

decrease kyphotic curve

humpback

hyperkyphosis

round back

thoracic sways back and posterior pelvic tilt

ROM of lower back

flexion = 40-60, extension = 20-35, side flexion = 15-20, rotation = 3-18

Charting active ROM & Pain symbols

Most provocative combined movement

Rotation and extension

Grading of 4 patterns of nervous or contractile lesions

strong and pain free = none, strong and painful = gr 1-2, weak and painful = severe, weak and pain free = gr3 or nerve

SLR

Special test for neural compression from disc herniation, positive = pain or tight in back or posterior leg

SLR individual nerves

TED (tibial = eversion and DF), PIP (peroneal = inversion and PF), SID (sural = inversion and DF)

Slump test

Special test for neural compression from disc herniation, pt sits with arms behind back and slumps and head to chest, positive = pain or tight in post leg when knee extended and relieved when lift head back up

Prone knee bend test

Special test for neural compression at L2-L3, pt prone passive knee flex, positive = pain or tightness in anterior thigh or lower back or buttock

Passive lumbar extension test

Special test for lumbar instability, pt prone and passively lift both legs, positive = pain/heavy low back when lifted

Pone instability test

Special test for lumbar instability, pt prone off edge of bed then pushing each lumbar vertebrae, if pain then ask to lift leg and check for pain, positive = pain in resting position only

Prevalence of LBP conditions

Non-specific mechanical LBP = most common, non-mechanical LBP = rare

Mechanical LBP presentation

Cyclical pain - gets worse throughout day, start pain, pain increase or decrease w/movement, pain is relieved with change of position

Non-mechanical LBP presentation

Unclear pain pattern - at rest or at night, red flags and other flags

LBP red flags

N - cauda equina, I - spina infection, F - spinal fracture, T - spinal malignancy

Cauda equina syndrome

Compression of multiple lumbar nerve roots, *changes in bladder/bowel function

Types of disc herniation from least severe to worst

bulge, protrusion, extrusion, sequestration

Disc herniation presentation

Severe LBP, radiating into buttock and leg, mechanical pain, pain exacerbated by coughing or sneezing

What is the bio-medical model

Classification of LBP, finding anatomical defect causing the pain, MRI = gold standard

Limitations of the bio-medical model

Excessive reliance on diagnostic testing and being overly cautious

When are x-rays and CT scans plausible?

Red flags

What is the McKenzie Classification?

Classification of LBP, mechanical diagnosis & treatment (MDT), categorization based on pain patterns during sustained and repeated spinal movements

Three primary categories of Mckenzie Classification

Postural syndrome = appears after prolonged static loading (sitting hurts after a while, best case)

Dysfunction syndrome = adaptive shortening, resulting in loss of mobility, causing pain (pain at end of ROM)

Derangement syndrome = pain arises due to a displacement in the intervertebral segments (pain during or after movement, or rest, worst case)

What is the CORE Back Tool

Helps recognize common mechanical back pain syndromes and screen for other conditions

What is the Treatment-Based Classification System for LBP

Two levels of triage, first level = first-contact health provider, rules out serious pathologies to determine if pt requires medical (severe), rehabilitation (moderate), or self-management (mild) (family doctors/physician), second level = rehabilitation management, conduct symptom modulation, movement control, & functional optimization (PT/OT)

What are the 3 rehabilitation management approaches and the clinical findings and treatments for each

Symptom modulation (severe): high disability, volatile symptoms, high to moderate pain; traction/manipulation, movement control: moderate findings; sensorimotor/stabilization/flexibility, functional optimization: low findings; strength and conditioning, specific tasks (sport/work)

What is SINSS?

Clinical reasoning tool to help understand symptoms, Severity, Irritability, Nature, Stage, Stability

Explain each term of SINSS

Severity - NPRS (0-10), impact on ADLs, night pain Y/N

Irritability - ratio of aggravating to easing 2:1 & no sleep interrupt (mild) 1:1 & sleep interrput <30 mins (moderate) 1:2 & sleep interrupt >30 mins(severe)

Nature - describing patient characteristics and their pain (poor, old lady, lets pain continue)

Stage - acute, sub-acute, chronic

Stability - Improving, not improving, worsening, or up and down

What are the best and worst interventions for the management of acute LBP?

Grade A = strong evidence and best

A - manual therapy (join mobilization), active education (biopsychosocial contributors to pain and self-management strategies like remaining active)

B - MT (massage/STR), passive education (providing links of articles to patients), classification systems (TBC), exercise (LBP)

C - classification systems (Mckenzie), exercise (LBP with leg pain)