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76 Cards in this Set

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5 categories of low back pain
UNCOMPLICATED LOW BACK PAIN - nonradiating with no structural damage or defect
UNCOMPLICATED SCIATICA- radiating back pain that does not extend below knee
MAJOR NEUROLOGIC DYSFUNCTION - loss of motor function or continence
MAJOR MECHANICAL PROBLEM - spinal fracture or instability
INFECTION/NEOPLASM
Potential anatomic pain generators
- Myofascial tissues
- Facet (zygapophyseal joints)
- Discs
- Nerves
- Ligaments
- Bony structures
_ % recover by 6 weeks
_ % recover by 12 weeks from lower back pain
60-70
80-90
Nonorganic low back pain can be divided into categories
- Psychosomatic spinal pain (tension syndrome-fibrositis, or muscle tension generated physiologically by anxiety)
-Psychogenic spinal pain (somatization of anxiety into neck or back pain with no physiologic changes as in conversion reaction)
- Psychogenic modification of organic spinal pain ( an emotional reaction that modifies appreciation of organic pain)
- Situational spinal pain (litigation reaction, consious overconcern or exaggeration)
Metabolic disorders can contribute to neuropathy, fracture, muscle tension or associated depression/anxiety - what are they
Electrolyte disorders, diabetes, thyroid, renal and liver disease
Goal of diagnosis in people with lower back pain is _
Define anatomic pain generators as soon as possible recognizing that this is not always possible
Important historical factors in evaluation of patients with low back pain
Mechanism of onset
Location of symptoms
Duration of pain
Character of pain
Neurologic
Constitutional
Behavioral
Medical illness
Prior surgery/back pain
Lifestyle/trauma
Legal/disability issues
Pharmacologic
Systems review
Red flags
Symptoms or physical findings suggestive of potentially serious cause for pain that requires immediate evaluation. Examples include history of progressive physical deficit, fever, pain at rest or at morning awakening without relief, distal numbness or weakness or loss of bowel or bladder control with saddle anesthesia
High impact trauma is risk factor for _
Serious fractures and misalignements
Weight loss, fatigue, insomnia and night pain can indicate _
Malignancy with metastases to bones or chronic infection such as osteomyelitis
Spinal ostemyelitis can present with _
Back pain, fever, night sweats
In young people with lower back pain what should you consider
Ankylosing spondylitis, spondylosis and spondylolisthesis
Yellow flags
Denote adverse prognostic indications
Examples - depressive symptoms, work related injuries still in ligation, signs and symptoms not consistent with pain severity, and behaviors incogruent with underlying anatomic and physiologic principles
Yellow flags signal potential need for more complex and intensive treatment and/or earlier specialist referral. Emotional stress can be contributing to pain or its perception. When yellow flags are present physicians should be concerned with deviations from normal course of illness
Signs of drug addiction or diversion in patients seeking pain medications
- History of known substance abuse
- Visits to multiple physicians
- Requests for specific medications
- Lost prescriptions
- Multiple failed therapies
- Inconsistent responses to dosage changes or patient resistance to switching to approximately equipotent opioid
Palpation of lower back can reveal _
Crepitus suggestive of fracture (often with severe point tenderness over bone), instability, myositis, myofascial trigger points or visceral organ tenderness
Pain on upper body flexion or rotation indicates what
Facet arthropathy or other structural problesm
Rectal exam with assesment of lower back pain can help find what
Prostatitis, sacral pathology or colon cancer
Waddell signs for nonorganic pain
Indicate nonorganic pathogenesis of back pain
- Include superficial nonanatomic tenderness
- Pain from simulation maneuvers that should not elicit pain
- Distraction maneuvers that should elicit pain but do not
- Regional disturbances not consistent with known patterns of pain
- Over reaction during examination
Greater number of signs present indicate greater likelihood that nonorganic cause of back pain is present, but do not definitively rule out organic cause
Why do you want to minimize unnecessary imaging studies
Diagnosis can be confused by high incidence of radiographic abnormalities in asymptomatic persons
Majority of asymptomatic abnormalities on MRI
Bulges and protrusions but not extrusions
Imaging studies should be ordered in patients with _
Progressive neurologic deficits, failure to improve, history of trauma and those at elevated risk for malignancy and infections
What is the best initial test for multiple myeloma given that many patients will have normal bone scan
Serum or urine protein electrophoresis
Which signs would be indicative of infection as cause of lower back pain
Fever, elevated ESR and CRP, leukocytosis
What is the most sensitive and specific test for identifying spinal infection
MRI
What should be initial drug therapy in patients with low back pain
Acetaminophen, NSAID or COX 2 inhibitor. Muscle relaxants can be used if muscle spasm present (SEDATIVE!), short-acting opioids for moderate to severe pain. Long acting opioids when other treatment modalities have been inadequate (if not responsive to opioid - discontinue it)
Adjuvant tricyclic antidepressants and anticonvulsants in patients with underlying depression or neuropathic component to pain
Epidural corticosteroid injections for radiculopathy
Physical modalities for treatment of lower back pain
- Stretching, ice, heat
- Massage
- Bed rest should be avoided except possibly first 24 hours, patients should be encouraged to return to work and their usual activities as soon as possible
Potentially beneficial therapies - exercise rehabilitation programs, electrical muscle stimulation, work hardening programs and acupuncture
Interventional pain management of lower back pain
- Diagnostic facet and nerve blocks
- Therapeutic rhizotomies and nerve ablations
- Selective joint injections
- Epidural injections
- Intradiscal distraction therapy and spinal endoscopy
- Epidural steroids have been shown effective for pain with a significant inflammatory component including nerve irritation or impingement
Confounding factor in evaluation and management of lower back pain
"Yellow flags"
- Belief that back pain is harmful or potentially severely disabling
- Fear-avoidance behavior and reduced activity levels
- Tendency to depressed mood and withdrawal from social interaction
- Expectation of passive treatment rather then belief that active participation will help
- Other factors that may interfere with recovery - anxiety, depression, unresolved occupational issues, prior disability claims)
AFFECTIVE DISORDERS ARE VERY COMMON CONFOUNDING FACTORS IN PATIENTS WITH CHRONIC PAIN
- Pseudoaddiction - patient behvior pattern often caused by undertreatment of pain, patient initially seems to be drug seeking but normal behavior returns with appropriate pain management
Most appropriate diagnostic approach to lower back pain
Look for specific biomechanical causes and identify potential anatomic pain generators when possible
Pain that is inconsistent with known patterns of disease represents _ and requires _
Yellow flag
Re-evaluation
Tendons connect _ to _
Muscle to bone
How do tendons contribute to joint movement
Allow transmission of forces generated by muscle to bone
Healthy tendons are _
White in color and have fibroelastic structure
Cells of tendons
90-95% - tenoblasts (immature, spindle shaped, high metabolic activity) and tenocytes (mature, elongated, low metabolic activity)
5-10% - chondrocytes, synovial cells of tendon sheath, vascular cells (capillary endothelial cells and smooth muscle cells of arterioles)
Oxygen consumption of tendon is _ then muscle
Lower (7.5 times)
What is essential for tendon to carry loads and maintain tension for long periods reducing risk for ischemia or necrosis
Low metabolic rate and anaerobic capacity
Tendon is 30% _ and 70% _
30% dry mass - collagen type I + elastin
70% water
Ground substance of ECM surrounding collagen and tenocytes composed of _
- PROTEOGLYCANS - strongly hydrophilic, enable rapid diffusion of water soluble molecules and migration of cells
- ADHESIVE GLYCOPROTEINS - fibronectin and thrombospondin - repair and regeneration
- TENASCIN C - abundant in tendon body, functions as elastic protein, expression regulated by mechanical strain and is upregulated in tendinopathy, plays role in collagen fiber allignment and orientation
Fine loose connective tissue sheath containing vascular, lymphatic and nerve supply to tendon, covers whole tendon
EPITENON
Thin reticular network of CT investing each tendon fiber
ENDOTENON
Superficially epitenon is surrounded by _
PARATENON
Synovial tendon sheaths are found in which areas
-Areas subjected to increased mechanical stress - tendons of feet and hands where efficient lubrication is required
Weakest point of tendon muscle unit
Myotendinous junction
Osteotendoinous junctions is composed of 4 zones - name them - explain
Dense tendon zone
Fibrocartilage
Mineralized fibrocartilage
Bone
Specialized structure prebents collagen or fiber bending, fraying, shear or failure
Tendons receive their blood supply from 3 major sources - ?
Intrinsic systems at myotendinous junctions and osteotendinous junctions and extrinsic system through paratenon or synovial sheath
Blood supply from osteotendinous junction is _
Sparse and is limited to insertion zone of tendon
Tendon vascularity is compromised at _
Junctional zones and sites of torsion, friction or compression
Tendon innervation originates from _
Cutaneous, muscular and peritendinous nerve trunks
Most nerve fibers enter body of tendon - T/F
FALSE - most nerve fibers do not actually enter main body of tendon but terminate as nerve endings on surface
Nerve endings of myelinated fibers function as _
Mechanoreceptors - GOLGI TENDON ORGANS - most numerous at insertions of tendons to muscle - detect changes in pressure or tension
Unmyelinated nerve endings serve as _
NOCICEPTORS - sense and transmit pain
Biomechanics of tendon
Transmit force from muscle to bone and act as buffer by absorbing external forces to limit muscle damage, exhibit high mechanical strength, good flexibility and optimal level of elasticity
If strain remains less then 4% tendon behaves _
In elastic fashion and returns to original length when unloaded
Microscopic faliure of tendon occurs at _
Macroscopic failure occurs at _
Strain exceeding 4%

8-10% of strain
Tendons are at highest risk for rupture if _
tension is applied quickly and obliquely and the highest forces are seen during eccentric muscle contraction
_ mechanism has been reported in up to 90% of sports related Achilles tendon ruptures
Acceleration- decceleration
Most common histological finding in spontaneous tendon rupture
Degenerative tendinopathy
_ play causative role in 2/3 of Achilles tendon disorders
Intrinsic factors such as allignment and biomechanical faults
_ has been linked with increased prevalence of Achilles tendinopathy
Hyperponation of foot
Main pathological stimulus for degeneration of Achilles tendon
Excessive loading of tendons during vigorous physical trainng
Tendons response to repetitive overload by _
Inflammation of sheath, degeneration of body or both
Repair mechanism in tendon is carried by _
Tenocytes - maintain balance between ECM production and degradation
What is the main theory of tendinopathy
Ischemia - occurs when tendon is under max tensile load. On relaxation reperfusion occurs, generating oxygen free radicals, can cause tendon damage resulting in tendinopathy (increased peroxiredoxin - enzyme that protects from oxidative stress). Hypoxia alone result in degradation
Cytokines can be mediators of tendinopathy - T/F
TRUE - prolonged mechanical stimuli induce production of cytokines and inflammatory prostaglandins which may be mediators of tendinopathy
Which drugs induce IL1 mediated MMP3 release and is associated with tendon rupture
Ciprofloxacin
Fluoroquinolones inhibit tenocyte metabolism reducing cell proliferation and collagen and matrix synthesis - induction of tendinopathy
MMP's
Proteolytic enzymes - ability to degrade components of ECM and to facilitate tissue remodeling
What induces release of MMP's
Cytokines
Tendinopathy vs tendinitis/tendinosis
Tendinopathy - generic descriptor of clinical conditions in and around tendons arising from overuse - tendinitis, tendinosis used only after histopathological examination
Histological examination of tendinopathy shows _
Disordered, haphazard healing with absense of inflammatory cells, poor healing response, noninflammatory intratendinous collagen degradation, fiber disorientation and thinning, hypercellularity, scattered vascular ingrowth and increased interfibrillar glycosaminoglycans
_ degeneration often found in _
Achilles tendon
Tendinosis is _
Failure of cell matrix to adapt to variety of stresses as result of imbalance between matrix synthesis and degeneration
- Tendon thickening - diffuse, fusiform or nodular
- Grey-brown and amorphous appearance
- Clinically silent, only manifestation - rupture
What can trigger acute inflammatory response in tendon weakening it and predisposing it to rupture
Collagen degradation and tenocyte necrosis
What generates pain in tendinopathy
Chemical irritants and neurotransmitters (high concentration of glutamate, substance P)
Tendon healing occurs in three overlapping phases - what are they
- Initial inflammatory phase - erythrocytes and inflammatory cells (neutrophils) enter site of injury, in first 24 hours monocytes and macrophages predominate and phagocytosis of necrotic materials occurs, vasoactive and chemotactic factors are released, angiogenesis initiated, stimulation of tenocyte prolideration and recruitment of more inflammatory cells, tenocytes gradually migrate to wound and type III collagen is synthesized
- Proliferative phase - synthesis of type III collagen peaks, starts after few days and lasts for few weeks, high water and GAG content
- Remodeling phase- after 6 weeks, decreased cellularity and decreased collagen and GAG - can be divided into consolidation and maturation phase. Consolidation phase begins at 6 weeks and continues up to 10 weeks - repair tissue changes from cellular to fibrous, tenocyte metabolism high and tenocytes and collagen fibers become aligned in direction of stress, high proportion of collagen I synthesis. Maturation stage - after 10 weeks - gradual change of fibrous tissue to scar like tissue over the course of 1 year
Mechanisms of tendon healing
Intrinsically by proliferation of epitenon and endotenon tenocytes
Extrinsically - by invasion of cells from surrounding sheath and synovium
Which healing is better
Intrinsic - better biomechanics and less complications (extrinsic - scar tissue forms adhesions and prevents gliding)