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and female, she still only meets 1 of the 4 criteria of the diagnos-
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tic rule for vertebral fracture as proposed by Henschke et al.
212
While a gentle exercise program that the patient can progress
from is more appropriate than bed rest, it is still important to
make sure to rule out any other serious pathology that might
be present.
2.
After 2 weeks of treatment, your patient was not seeing the
results she was expecting and went to get an MRI. e results were positive for degenerative disc disease at multiple
levels with Modic changes (type 1) at L4. You should:
a. Educate the patient that at her age the presence of degen-
erative discs and Modic changes are common and do not
often correlate to symptoms.
b. Refer the patient to a behavior health specialist to manage
her psychosocial comorbidities.
c. Inform the patient that she is unlikely to receive any help
from physical therapy due to the spinal structural changes
associated with her pain.
Refer to an orthopedic surgeon to explore more invasive
d.
options.
e correct answer is a. Educate the patient that at her
age the presence of degenerative discs and Modic changes
are common and do not often correlate to symptoms. For
this patient, due to her age, both degenerative discs and Modic changes are very common and are rarely associated with
symptoms. e presence of these conditions does not indicate
that she is unable to receive benefit from physical therapy. She
should be encouraged by the fact that many people who have
degenerative discs and Modic changes walk around with no
pain and that physical therapy is going to work to get her to that
place. Furthermore, there is no indication from the information
provided that this patient needs higher skilled care to address
any psychosocial comorbidities.
3.
e patient understands about the Modic changes but she
is nervous about the “high intensity zone (HIZ)” that her
physician pointed out. e HIZ is:
a. Where a portion of the disc material is beyond the disc
space and is no longer connected to the remaining disc.
b. A high signal contained within the annulus of a disc, sep-
arated from the nucleus pulposus, on lumbar spine MRI.
c. Where a portion of the disc material has extruded beyond
the circumference of the disc space.
d. A positive indication of vertebral end-plate inflammation.
e correct answer is b. A high signal contained within
the annulus of a disc, separated from the nucleus pulposus,
on lumbar spine MRI. e hypothesized mechanism is that
the HIZ is indicative of a tear in the structurally weak posterior
annulus. However, approximately 1 in 4 individuals without
LBP have a HIZ in their lumbar spine.
After reassuring the patient that the findings on her MRI
4.
are likely to reflect her age and are not indicative of a pathological process, you resume therapy. Up until now the patient has been primarily performing motor control exercises.
However, due to the lack of progress, the patient notes that
this time she wants a different approach. She had a previous
therapist that used a directional-based exercise approach and
she noticed that she received a lot of benefit from those exercises. erefore, you should:
a.
Continue with the motor control exercises as that is what
you feel will work the best for this patient.
Insist to the patient that you know best and continue with
b.
stabilization exercises.
c.
Listen to the patient’s concerns and, taking her previous
experiences into account, switch her exercise program to
one that matches the directional-based exercise approach.
d. Switch to general exercise because all the approaches have
demonstrated equal efficacy.
e correct answer is c. Listen to the patient’s concerns
and, taking her previous experiences into account, switch
her exercise program to one that matches the directionalbased exercise approach. While it is true that all approaches
seem to have equal efficacy in the treatment of LBP, do not forget about the third pillar of evidence: patient values. By listening to the patient, you are also actively engaging in building the
therapeutic alliance that can pay dividends in your treatment.
Case Scenario 3
Your patient is a 49-year-old female with cLBP. On a typical day, her pain is at a 4/10 but about twice a month it will
flare up to a 9/10. She started to have symptoms about 15 years
ago with no clear method of injury. At the time she had an MRI
that was positive for a bulging disc at L4-5. She reports working
in a high-paced sales position where she is under constant pressure to make sales. She has 2 kids, ages 18 and 16, and reports
being too busy to get in any regular exercise. She notes that ever
since having kids her sleep has been interrupted.
Just given the information above, what should be one of your
1.
next steps regarding the patient?
a. Refer the patient back for further physician review due to
the chronicity of the symptoms without any relief and no
clear mechanism of injury.
b. e patient should be given either the FABQ, PCS, or
the OSPRO-YF to determine the extent of the presence
of yellow flags or psychosocial risk factors.
c. e patient has underlying psychosocial factors that neces-
sitate referral to a behavioral health specialist.
d. Continue to treat and evaluate the patient with no more
information.
e correct answer is b. e patient should be given ei-
ther the FABQ, PCS, or the OSPRO-YF to determine the
Academy of Orthopaedic Physical erapy, APTA.
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© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
37
extent of the presence of yellow flags or psychosocial risk
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factors. e patient does not need to be immediately referred
to the physician due to the lack of a clear mechanism of injury.
Remember, most cLBP has no clear mechanism of injury. e
patient so far has only reported experiencing increased stress, so
getting a better understanding of the extent of the psychosocial
risk factors should be a top priority. However, an immediate
referral to a behavioral health specialist is unwarranted because,
just like with red flags, the presence of a single yellow flag is not
always serious.
2.
e patient reports that she is nervous about the bulging disc
in her back. She sits with a rigid posture and does not perform any forward flexion because she has been told by previous health care workers that her disc is like a jelly doughnut
and that any forward bending is going to make her disc “pop
out of place.” You should:
a.
Focus on exercises that only move her into extension to
accommodate her fears.
Educate her that the presence of a bulging disc is very
b.
common and no reason to be afraid; her back is strong
and she should slowly start to exercise and resume regular
activity.
c. Insist she get an updated MRI to assess the progression of
the bulging disc.
d. Instruct her to resist any forward flexion, prolonged sit-
ting, or lifting of heavy objects.
e correct answer is b. Educate her that the presence of
a bulging disc is very common and no reason to be afraid;
her back is strong, and she should slowly start to exercise
and resume regular activity. While accommodating a patient’s
preferences is a good approach, in this scenario the more appropriate response is to educate the patient that the presence of a
bulging disc is a very normal thing. She needs to be assured that
by bending forward she is not going to damage her spine. An
updated MRI will be of little diagnostic value, and continuing
the education of resisting forward flexion, prolonged sitting, or
heavy lifting will only promote her kinesiophobia and impair
her function.
3. e patient states that she has noticed a positive correlation
between her stress levels and her LBP. While the evidence
is not yet conclusive, one treatment option to specifically
address this issue could be:
a. Mindfulness based stress reduction training.
b. Dry needling.
c. Aerobic exercise.
d. Spinal mobilization.
evidence has shown that mobile applications can be effective
for patients, it represents a cheap and easily accessible treatment
option for many. While dry needling, aerobic exercise, and spinal mobilization are all valid treatment options for this patient,
they do not specifically address the increased stress.
4. e patient has been working with you for 4 weeks now and
is ready to be discharged. During her time in therapy, you
have used a combination of transcutaneous electrical nerve
stimulation (TENS), therapeutic exercises, dry needling,
and myofascial release. While she now has a better grasp on
her stress levels, her day is still very demanding and she only
has time to incorporate 1 of your interventions into her daily
life. Which should she choose?
a.
She should continue to see an acupuncturist to receive
needling therapy.
b. She should buy a TENS unit so she can use it at home.
c. She should routinely visit a massage therapist for soft
tissue work.
She should incorporate physical activity into her daily life.
d.
e correct answer is d. She should incorporate physical
activity into her daily life. While all the other options are valid treatment approaches, the patient should prioritize exercise.
Almost all guidelines recommend continued exercise for those
with cLBP.
Case Scenario 4
Your patient is a 72-year-old female who recently slipped
in her kitchen while putting away some dishes. She made it
through the night but was in significant pain even after taking
some acetaminophen. She presents to your clinic with complaints of 8/10 pain that is localized in her mid-lumbar region.
She denies having any lower extremity pain or weakness. Prior
to the fall she was an avid gardener and enjoyed daily walks.
1.
Given this information, what is your first course of action?
a. Screen her for additional red flags as her losing balance
might be indicative of serious pathology.
b. Treat with heat and TENS while in the acute phase, work-
ing your way into gentle therapeutic exercise.
c. Refer her to her physician for radiographs.
Perform spinal manipulation as this is a patient with
d.
acute LBP.
e correct answer is c. Refer her to her physician for
radiographs. is patient is exhibiting 2 out of the 3 red flags
for a vertebral fracture (age >70 years and significant trauma).
Furthermore, given her female sex, the positive likelihood ratio
of having a fracture is 218.3.
e correct answer is a. Mindfulness based stress reduc-
tion training. While the case for MBSR is still growing, there
is emerging evidence that it may be beneficial. Also, because
2. What is the other red flag that would indicate your patient
might have a fracture?
a. Prolonged corticosteroid use.
Academy of Orthopaedic Physical erapy, APTA.
38
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For personal use only. No other uses without permission.
b. A body mass index of less than 20 kg/m2.
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c.
A low Berg-Balance score.
A self-selected walking speed of less than 0.5 m/s.
d.
e correct answer is a. Prolonged corticosteroid use.
While the remaining choices could indicate a greater potential for a fall risk or increased fracture risk in general, only the
prolonged corticosteroid use was found to be correlated with
increased risk for fracture.
3.
e patient plain film radiograph came back positive for a
fracture. e physician put her in a lumbosacral corset for
10 weeks to be followed up with physical therapy. Following
the 10 weeks her pain is at a 6/10 but she is now very weak.
What would be the best course of action?
Advise the patient to take an additional 2 weeks of bed rest
a.
to transition out of having the lumbosacral corset.
b. Focus her remaining visits on passive modalities to reduce
her sensitivity.
c. Focus solely on motor control exercises to compensate for
spinal weakness.
d.
Any combination of motor control exercises, graded exercises, or a walking program to incorporate exercise back
into her treatment regimen.
e correct answer is d. Any combination of motor con-
trol exercises, graded exercises, or a walking program to incorporate exercise back into her treatment regimen. All the
choices are appropriate exercises to get the patient back into
exercising, each with the ability to provide good results. As the
patient is undoubtably weak, motor control exercises can serve
to strengthen her abdominals. Taking the patient’s interests and
hobbies into consideration is also a good strategy when developing an exercise routine. According to the guidelines, the most
important aspect to rehabilitating LBP is to get the patient
performing exercise while encouraging resumption of normal
activities.
After 2 weeks of therapy, your patient has made limited
4.
progress. She reports that she is reluctant to go for a walk
because she is afraid that she might fall again. Furthermore,
she notes that her exercises temporarily increase her pain and
she is afraid that she is making the situation worse by doing
her exercises. What would be your best course of action?
a. Tell her that the best way for her spine to fully heal is
through controlled loading to facilitate bone health.
b.
Educate her on the importance of aerobic exercise for
general well-being.
Discharge her for non-compliance.
c.
d.
Educate your patient about her pain, how the pain she
experiences during exercises does not always mean she is
harming her back, and provide other education centered
around pain neuroscience education (PNE).
e correct answer is d. Educate your patient about her
pain, how the pain she experiences during exercises does not
always mean she is harming her back, and provide other education centered around PNE. is patient is exhibiting some
“yellow flags” relating to fear and anxiety about exercise. While
the evidence is still building, PNE can provide a path for this
patient to reengage in exercise without the fear of further damaging her spine.
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For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
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