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Average 3.1 of 33 Ratings
A 35-year-old female presents for evaluation of new onset lumbar spine pain. Which of the following physical exam findings is indicative of an organic cause of low back pain symptoms?
Positive straight-leg raise with patient distraction
Pain with axial loading of the spine
Diffuse tenderness with palpation of the paraspinal lumbar musculature
Lower extremity numbness in a non-dermatomal pattern
Pain with simulated rotation of the lumbar spine
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Non-organic signs of low back pain (ie. Waddell Signs) include superficial and non-anatomic tenderness, pain with axial compression or simulated rotation of the lumbar spine, negative straight-leg raise with patient distraction, regional disturbances which do not follow a logical dermatomal pattern, and overreaction to physical examination.
Waddell et al described and standardized these non-organic signs of low-back pain in 350 North American and British patients. They divided them into 5 categories (tenderness tests, simulation tests, distraction tests, regional disturbances, and overreaction), and found that when three or more categories were positive, the finding was considered clinically significant. This was also correlated with high scores for depression, hysteria and hypochondriasis on the Minnesota Multiphasic Personality Inventory (MMPI).
Waddell G, McCulloch JA, Kummel E, Venner RM.
Spine (Phila Pa 1976). 1980 Mar-Apr;5(2):117-25. PMID: 6446157 (Link to Abstract)
Waddell, SPINE 1980
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Average 3.0 of 20 Ratings
A 29-year-old male reports a 2-day history of atraumatic low back pain. He denies constitutional symptoms. He denies any bowel or bladder difficulties and physical examination reveals full motor strength and sensation. No pathologic reflexes are detected. All of the following are appropriate at the initial visit EXCEPT?
Limited oral analgesia
Radiographs of lumbar spine
Schedule outpatient follow-up visit within 4 weeks
Early range of motion exercises
A previously healthy patient with an acute onset of nontraumatic lower back pain does not need diagnostic imaging before proceeding with therapeutic treatment. This patient had no "red flags" during the history (recent trauma or constitutional symptoms), and physical examination was normal without focal neurologic deficits. The appropriate treatment for acute onset lower back pain is solely symptomatic treatment. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful and symptoms are prolonged.
Miller et al found the use of radiographs can lead to better patient satisfaction but not better outcomes.
Chou et al peformed a metanalysis that also concluded that lumbar imaging without indication of serious underlying condition does not improve clinical outcomes.
Miller P, Kendrick D, Bentley E, Fielding K.
Spine (Phila Pa 1976). 2002 Oct 15;27(20):2291-7. PMID: 12394910 (Link to Abstract)
Miller, SPINE 2002
Chou R, Fu R, Carrino JA, Deyo RA
Lancet. 2009 Feb;373(9662):463-72. PMID: 19200918 (Link to Abstract)
Average 2.0 of 37 Ratings
A 32-year-old manual laborer has work-related chronic musculoskeletal back pain for several years. Which of the following is the strongest negative predictor for a successful clinical outcome with non-operative treatment?
High Visual Analog Scale (VAS) scores prior to treatment
Type of occupation
In patients with chronic disabling work-related musculoskeletal disorders, high pre-rehabilitation ratings of pain intensity, as measured by high Visual Analog Scale (VAS) scores, is a negative predictor for a successful outcomes.
McGeary et al evaluated the ability of pain intensity ratings in 3,106 patients with chronic disabling occupational musculoskeletal disorders to predict the rehabilitation outcomes and identify patients at risk for poor outcomes. High pain intensity prior to rehabilitation was linearly associated with declining rates of program completion and higher rates of self-reported depression and disability after rehabilitation. The authors did not find any correlation between poor clinical outcomes and race, smoking, gender, or type of occupation.
Proctor et al "found that about 25% of patients with a chronic disabling work-related musculoskeletal disorder pursue new health-care services after completing a course of treatment, and this subgroup accounts for a significant proportion of lost worker productivity, unremitting disability payments, and excess health-care consumption."
McGeary DD, Mayer TG, Gatchel RJ
J Bone Joint Surg Am. 2006 Feb;88(2):317-25. PMID: 16452743 (Link to Abstract)
McGeary, JBJS 2006
Proctor TJ, Mayer TG, Gatchel RJ, McGeary DD.
J Bone Joint Surg Am. 2004 Jan;86-A(1):62-9. PMID: 14711947 (Link to Abstract)
Proctor, JBJS 2004
Average 1.0 of 71 Ratings
HPI - Condition started back in 2005 with lower back pain which was treated conservatively and slightly improved. In 2009 the patient had progressive left hip pain. In 2012 pt was diagnosed to have stress fracture of left femoral neck and had percutaneous fixation of the neck. The patient had slight improvment of symptoms for a short period of time. Now the patient continues ot have bilateral hip pain and low back pain. Current radiographs show an incomplete fracture of the right femoral neck and L5 pars defect. Lab studies have been normal.
What do you think is the most likely cause of the patients current symptoms?