Transcript Evaluating and Treating Back Pain April 30th, 2012

Evaluation and Treatment of
Low Back Pain: Utilization of
Evidence Based Practice
April 17th, 2015
SCOTT TAUFERNER MPT, LAT
[email protected]
Objectives

Participants will be able to explain treatment based
classifications and how they assist in the decision
making for patients with low back pain.

Participants will be able to identify and utilize
evidence based clinical decision making/prediction
rules in treatment of patients with low back pain.

Participants will be able to select intervention
strategies supported by research evidence for
treatment of patients with low back pain.
Clinical Questions

Do patients with low back pain treated with
spinal manipulative therapy and/or
mobilization demonstrate improved pain and
disability?

Do patients with low back pain show
improved benefit when physical therapy
utilizes a treatment based classification
approach?
Evaluation

Goal of visit 1 is to:

Improve motion/pain

1-3 exercises that will facilitate decreased pain,
increased/normal motion, and help me hone in on
a solid assessment.

Never give an exercise that could do more harm
than good

Don’t give an exercise just to keep them busy
Evaluation
Identify/implicate a region/motion that correlates
with pain via reproduction of patients
pain/symptoms or reduction in symptoms
Identify an Asterisk sign
If you can’t identify a cause in the lumbar spine look
to rule out the hip or thoracic spine – Is the pain
generator non-musculoskeletal
PMH and General Health questioning
Rule out Red Flags
Low Back Pain

In most cases of acute LBP, an objective cause
cannot be found11

Every patient is unique, treatments always vary
even though EBP has developed CPR’s.

Most often treatment is a combination of manual
therapy and exercise 3
Making your diagnosis

As the evaluation progresses you will be lead by
your findings to a region or focus of dysfunction or
impairments that may or may not be associated
with the pain

When a dysfunction/impairment is found, “treat” it
if possible, then reassess asterisk sign

Assess – Treat – Reassess – move on and repeat
Assessment:
Anatomical Based

Any innervated structure in the lumbar spine can
cause symptoms of low back and referred pain into
the extremity or extremities.

Potential structures include:

muscles

ligaments

dura mater and nerve roots, zygapophyseal joints

annulus fibrosis

thoracolumbar fascia

vertebrae
Clinicians should not utilize patient education and
counseling strategies that either directly or indirectly
increase the perceived threat or fear associated
with low back pain, such as education and
counseling strategies that:
(1)
promote extended bed-rest
(2)
provide in-depth, pathoanatomical explanations for
the specific cause of the patient’s low back pain. 3
Clinical Question:
Do patients with low back pain show
improved benefit when physical therapy
utilizes a treatment based classification
approach?
The best available evidence supports a
classification approach that deemphasizes the importance of identifying
specific anatomical lesions after red flag
screening is completed3
Assessment:
Treatment Based Classification

Stabilization

Mobilization

Specific Exercise

Traction

Recent studies indicated that classifications
are unclear for approximately 34% of people
with LBP13 and 25% meet more than 1
classification12
Stabilization

Clinical Prediction Rule – the one “everyone”
uses5,7,8,9

Positive Predictors:
 Aberrant
 Prone
 SLR
motion (sagittal plane),
instability
>91°,
 age
<40 years old

If 3 of 4 criteria met probability of improvement is 80%

Modified Clinical Prediction (mCPR)1
Stabilization


Negative Predictors: Shook out in the stats

Negative prone instability test

Absence of aberrant movements during sagittal plane
lumbar ROM

Absence of lumbar hypermobility(assessed with PA
pressure)

Score of 9 or higher on the FABQ physical activity
subscale
The presence of at least 3 of these findings was
highly predictive of failure (positive LR, 18.8),
indicating that if a patient was presumed to have a
25% probability of failing, the presence of at least 3
of these factors would increase the probability of
failure to 86%7
Motor control exercises

Treatment Progression
 Train
core neutral
 TrA/Multifidi
(hook lying, prone,
quadruped) add arms, legs
 Swiss
ball - sitting, supine, prone
 Standing
sagittal/frontal plane with
ADIM/TrA activation
 Standing
Diagonal/PNF, Rotation
 Movement/travelling
challenge
Motor Control Exercise

Motor control exercises for nonspecific low back
pain, when used in isolation or with additional
interventions, are effective at decreasing pain
and disability related to nonspecific low back
pain3
Clinical Question

Do patients with low back pain treated
with spinal manipulative therapy and/or
mobilization demonstrate improved pain
and disability?
Manipulation

Classification by examining predictors of
improvement defined as a 50% or greater
reduction in self-reported disability occurring over
2 treatment sessions in 71 patients with
nonradicular LBP

Clinical Prediction Rule






No symptoms distal to knee
Duration of symptoms <16 d
Lumbar hypomobility
Fear-Avoidance Beliefs Questionnaire for Work<19
Hip internal rotation range of motion >35
Improvement 97% when at least 4 factors were
present and decrease to 9% when 2 or fewer
factors were present7
Manipulation

Most common techniques in current research are
the general lumbopelvic technique and a side
lying rotational technique3


The 2 groups receiving thrust manipulation fared
significantly better than a group receiving nonthrust
mobilization at 1 week, 4 weeks, and 6 months -
Spinal Manipulative Therapy appears to be
effective for pain reduction in the short,
intermediate, and long terms11
Manipulation/Mobilization

The immediate changes in pain intensity and
pressure pain threshold after a single high-velocity
manipulation do not differ by region-specific
versus non–region-specific manipulation
techniques in patients with chronic low back
pain4
Manipulation/Mobilization

Thrust manipulative and non-thrust mobilization
procedures can also be used to improve spine
and hip mobility and reduce pain and disability in
patients with sub acute and chronic low back
and back-related lower extremity pain3

Clinicians should consider utilizing thrust
manipulative procedures to reduce pain and
disability in patients with mobility deficits and
acute low back and back-related buttock or
thigh pain3
Muscle Energy Techniques

Muscle energy techniques appear to be effective
in combination with exercise in reducing disability
scores over a 4-week period compared with
exercise only15

There is a lack of high-quality research regarding
the efficacy and effectiveness of MET, as well as
the therapeutic mechanisms, but emerging
evidence supports the clinical usefulness of this
technique16
Muscle Energy Techniques
Specific Exercise

Matched to patients impairments/directional
preference



Centralization of symptoms is the goal
Repeated motions x 1 x 10 x 10 x 10

Disc - correct lateral shift first, then extension (prone
lying (pillows if needed), POE, POE with over
pressure, standing Extension, POE with rotation)

Stenosis – SKTC, DKTC, seated flexion hands down
legs, reaching forward, standing flexion
As symptoms resolve add controlled motion

Supine , standing, moving
Traction

Traction

Symptoms peripheralize with extension

a positive crossed (ie, contralateral) straight-leg
raise test.

Signs of nerve root compression

50-60% Body Weight – prone or supine, Intermittent
or static
When to refer

Clinicians should consider diagnostic classifications
associated with serious medical conditions or
psychosocial factors and initiate referral to the appropriate medical practitioner when:

(1) the patient’s clinical findings are suggestive of
serious medical or psychological pathology

(2) the reported activity limitations or impairments of
body function and structure are not consistent with
those presented in the diagnosis/classification section
of these guidelines

(3) the patient’s symptoms are not resolving with
interventions aimed at normalization of the patient’s
impairments of body function. 3
My 2 Cents

Must assess before treatment of any kind and
continue to reassess through the treatment -- golfer

Motion should not be initiated by the spine – core
strength – initiate through the hips, stable spine

Use your manual skills to facilitate normal joint
mechanics any time possible

Exercise should never hurt – exercise to promote
good motor patterns as well as strength


Patients/people are great at moving around pain and
despite pain - don’t encourage/facilitate abnormal
movement patterns
Get your patients up and moving!!!!
Resources
1.
Alon Rabin, DPT, PhD1, Anat Shashua, BPT, MS2, Koby Pizem, BPT3, Ruthy Dickstein, PT, DSc4, Gali Dar, PT, PhD4.
A Clinical Prediction Rule to Identify Patients With Low Back Pain Who Are Likely to Experience Short-Term
Success Following Lumbar Stabilization Exercises: A Randomized Controlled Validation Study. J Orthop Sports
Phys Ther. 2014 Jan: 44(1):6-18
2.
Beattie, Paul F PT, PhD, OCS, FAPTA. The lumbar Spine: Physical therapy patient management utilizing current
evidence. Current Concepts of Orthopedic Physical Therpy, 3rd Edition 2011.
3.
Delitto A1, George SZ, Van Dillen LR, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ. Low Back Pain:
J Orthop Sports Phys Ther. 2012 Apr;42(4):A1-57
4.
de Oliveira RF1, Liebano RE, Costa Lda C, Rissato LL, Costa LO. Immediate effects of region-specific and nonregion-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled
trial. Phys Ther. 2013 Jun;93(6):748-56
5.
Flynn T1, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A clinical prediction
rule for classifying patients with low back pain who demonstrate short-term improvement with spinal
manipulation. Spine (Phila Pa 1976). 2002 Dec 15;27(24):2835-43.
6.
Fritz, Cleland and Childs. Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to
Physical Therapy. Journal of orthopaedic and sports physical therapy June 2007 Vol 37 (6) p 290-302.
7.
Fritz JM1, Lindsay W, Matheson JW, Brennan GP, Hunter SJ, Moffit SD, Swalberg A, Rodriquez B. Is there a
subgroup of patients with low back pain likely to benefit from mechanical traction? Results of a randomized
clinical trial and subgrouping analysis. Spine (Phila Pa 1976). 2007 Dec 15;32(26):E793-800
8.
Hebert J, Koppenhaver S, Fritz J, Parent E. Clinical prediction for success of interventions for managing low back
pain. Clin Sports Med. 2008 Jul;27(3):463-79
Resources
9.
10.
Hicks GE1, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for
determining which patients with low back pain will respond to a stabilization exercise program.
Arch Phys Med Rehabil. 2005 Sep; 86(9):1753-62.
Robert A Laird1,5*, Jayce Gilbert2, Peter Kent3,4 and Jennifer L Keating1 . Comparing lumbopelvic kinematics in people with and without back pain: a systematic review and meta-analysis.
BMC Musculoskeletal Disorders 2014, 15:229
11.
Simon Dagenais, DC, PhDa,b et al. NASS Contemporary Concepts in Spine Care: Spinal
manipulation therapy for acute low back pain. The Spine Journal 10 (2010) 918–940
12.
Stanton, Tasha R, Julie M. Fritz, et al. Evalaution of a Treatment –Based Claissifcation algorithm for
low back pain: a cross-sectional study. PHYS THER. 2011; 91:496-509.
13.
Stanton, Tasha et al. What Characterizes People Who Have an Unclear Classification Using a
Treatment-Based Classification Algorithm for Low Back Pain? A Cross-Sectional Study. PHYS THER.
2013; 93:345-355.
14.
Leonardo O.P. Costa et al. Motor Control Exercise for Chronic Low Back Pain: A Randomized
Placebo-Controlled Trial PHYS THER. 2009; 89:1275-1286
15.
Day Joseph M and Nitz Arthur J. The Effect of Muscle Energy Techniques on Disability and Pain
Scores in Individuals With Low Back Pain Journal of Sport Rehabilitation, 2012, 194-198
16.
Gary Fryer. Muscle energy technique: An evidence-informed approach. International Journal of
Osteopathic Medicine 14 (2011) 3e9
17.
Cook Chad E., et al. Effectiveness of Physical Therapy administered spinal manipulation
for
the treatment of low back pain: A systematic review of the literature. The International Journal of
Sports Physical Therapy Vol 7, Number 6 December 2012 P 647-662.