Transcript A Treatment-Based Classification Approach to Low Back Pain

A Treatment-Based
Classification Approach to
Low Back Pain
Monte Wong PT, DPT, ATC, CSCS
Senior Physical Therapist
TRIA Orthopaedic Center
Minneapolis, MN
Evidence Based Practice
A
Treatment-Based Classification
Approach to Low Back Syndrome:
Identifying Patients for Conservative
Treatment
 Delitto et. al, 1995
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Low Back Pain
 Management
of low back disorders are
difficult
 Inability to identify a causative agent
 Difficulty getting a specific diagnosis
 “illness in search of a disease”
 Limitation to pathology based model
becomes apparent if you do not have a
specific diagnosis
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Low Back Pain
Agency for Health Care Policy and Research
(1994)
 Developed clinical practice guidelines
 Recommendations
 Aspirin/NSAIDS, trial of manipulation
 Assure and educate about back problems
 Encourage low stress aerobic exercise
 Avoid irritating activities
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Low Back Pain
AHCPR (1994)
 Options for patients
 Physical agents or modalities (home use)
 Shoe insoles
 Muscle conditioning exercises after a few
weeks
 Epidural steroid injections in the
presence of radiculopathy
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Low Back Pain
AHCPR (1994)
 Recommendations against
 Physical agents provided a healthcare
provider
 TENS
 Lumbar corsets and support belts
 Traction
 Bed rest (> 4 days)
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Low Back Pain
 United
Kingdom (2000)
 “on the evidence available at present,
it is doubtful that specific back
exercises produce significant
improvement in acute low back pain,
or that it is possible to select which
patient’s will respond to which
exercises”
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Low Back Pain
Delitto et al, 1995
 There is a need for classification
 Current systems of grouping patients are
inadequate (mostly based on pathology)
 The use of clearly described classification
systems may enhance the effectiveness of
treatment
 Without
classification, the choice of treatments
takes on an appearance of a lottery
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Low Back Pain
Purpose
 Classification approach specifically directs
conservative management of low back pain
 Will result in a management strategy that is
detailed with regards to the precise type of
treatment
 Precise type of treatment is prescribed and not
relegated to nonspecific terminology where any
number of conservative strategies can be used
for one classification
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Low Back Pain
3 levels of classification
 First Level- appropriate of
conservative treatment by the
clinician
 Second Level- Staging of the Patient
 Third Level- assigning patient to
specific treatment classification
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First Level Classification
 First
level of decision is determining
the patient’s care:
 Can be managed by a clinician solely
 Can be managed by a clinician in
consultation with another specialist
 Cannot be managed by a clinician and
requires referral to another specialist
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First Level Classification
2
things to ponder:
Is there a serious pathology that
might be referring pain to the low
back? (Red Flags)
Is there a psychosocial influence
on the symptom behavior (Yellow
Flags)
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First Level Classification

Red Flags
 Fracture
 Trauma
(major/minor)
 Severe muscle spasm on physical examination
 Radiological examination
 Infection/Osteomyelitis
 Fever
 Chills
 Unexplained
weight loss
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First Level Classification
 Red
flags Continued
 Cauda Equina Syndrome
Saddle
anesthesia
Recent onset of bladder dysfunction
Severe or progressive neurological
deficit in the lower extremity
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First Level Classification
 Red
flags Continued
Ankylosing
Spondylitis
 Morning
stiffness
 Improvement with activity
 Onset before 40
 Pain not relieved in supine
 Local SI joint tenderness
 Paraspinal muscle spasm
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First Level Classification
 Red
Flags Continued
 Cancer
Age
> 50 years or < 20
Previous history of cancer
Unexplained weight loss
No relief with complete bed rest
Pain that worsens when supine
Severe night time pain
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First Level Classification

Yellow Flags
 Factors that increase the risk of developing, or
perpetuating long-term disability and work loss
associated with low back pain (Kendall et al, 1997)
 Factors known to consistently predict poor outcomes:
 Fear-Avoidance Beliefs and Behaviors
 Expectation that passive treatments will help more
than active treatments
 Tendency to low mood and withdrawal from social
interaction
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First Level Classification
 Measurement
Tools for Yellow Flags
 Fear Avoidance Belief Questionnaire
 Modified Oswestry Questionnaire
 Numeric Pain Rating Scale
 Pain Body Diagram
 Waddell’s Nonorganic Signs and
Symptoms
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FABQ
The following statements are about how
your physical activity affects or would
affect your back pain
 1. My pain was caused by physical activity
 2. Physical activity makes my pain worse
 3. Physical activity might harm my back
 4. I should not do physical activities which
(might) make my pain worse
 5. I cannot do physical activities which
(might) make my pain worse
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FABQ
The following statements are about how your normal work affects or would
affect your back pain
6. My pain was caused by my work or by an accident at work
7. My work aggravated my pain
8. I have a claim for compensation for my pain
9. My work is too heavy for me
10. My work makes or would make my pain worse
11. My work might harm my back
12. I should not do my normal work with my present pain
13. I cannot do my normal work with my present pain
14. I cannot do my normal work until my pain is treated
15. I do not think that I will be back to my normal work within 3 months
16. I do not think that I will ever be able to go back to work
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First Level Classification

FABQ
 16 item questionnaire developed by Waddell et
al in 1993
 2 subscales
 Work (items 6-7, 9-12, 15)- 42 points
possible
 Physical activity (items 2-5)- 24 points
possible
 >30 for the FABQ-W; >15 for the FABQPA
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Oswestry Pain Questionnaire

Pain Intensity
I can tolerate the pain I have without having to use
pain medication.
 The pain is bad, but I can manage without having to
take pain medication.
 Pain medication provides me with complete relief
from pain.
 Pain medication provides me with moderate relief
from pain.
 Pain medication provides me with little relief from
pain.
 Pain medication has no effect on my pain.

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Oswestry Continued

Personal Care (e.g., Washing, Dressing)
 I can take care of myself normally without causing increased
pain.
 I can take care of myself normally, but it increases my pain.
 It is painful to take care of myself, and I am slow and careful.
 I need help, but I am able to manage most of my personal
care.
 I need help every day in most aspects of my care.
 I do not get dressed, I wash with difficulty, and I stay in bed.
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Oswestry Continued

Lifting
I can lift heavy weights without increased pain.
 I can lift heavy weights, but it causes increased pain.
 Pain prevents me from lifting heavy weights off the
floor, but I can manage if the weights are
conveniently positioned (e.g., on a table).
 Pain prevents me from lifting heavy weights, but I
can manage light to medium weights if they are
conveniently positioned.
 I can lift only very light weights.
 I cannot lift or carry anything at all.

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Oswestry Continued

Walking
 Pain does not prevent me from walking any distance.
 Pain prevents me from walking more than 1 mile. (1
mile = 1.6 km).
 Pain prevents me from walking more than 1/2 mile.
 Pain prevents me from walking more than 1/4 mile.
 I can walk only with crutches or a cane.
 I am in bed most of the time and have to crawl to the
toilet.
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Oswestry Continued

Sitting
 I can sit in any chair as long as I like.
 I can only sit in my favorite chair as long as I like.
 Pain prevents me from sitting for more than 1 hour.
 Pain prevents me from sitting for more than 1/2
hour.
 Pain prevents me from sitting for more than 10
minutes.
 Pain prevents me from sitting at all.
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Oswestry Continued

Standing
 I can stand as long as I want without increased pain.
 I can stand as long as I want, but it increases my pain.
 Pain prevents me from standing for more than 1 hour.
 Pain prevents me from standing for more than 1/2 hour.
 Pain prevents me from standing for more than 10 minutes.
 Pain prevents me from standing at all.
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Oswestry Continued

Sleeping
 Pain does not prevent me from sleeping well.
 I can sleep well only by using pain medication.
 Even when I take medication, I sleep less than 6
hours.
 Even when I take medication, I sleep less than 4
hours.
 Even when I take medication, I sleep less than 2
hours.
 Pain prevents me from sleeping at all.
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Oswestry Continued

Social Life
My social life is normal and does not increase my
pain.
 My social life is normal, but it increases my level
of pain.
 Pain prevents me from participating in more
energetic activities (e.g., sports, dancing).
 Pain prevents me form going out very often.
 Pain has restricted my social life to my home.
 I have hardly any social life because of my pain.

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Oswestry Continued

Traveling
I can travel anywhere without increased pain.
 I can travel anywhere, but it increases my pain.
 My pain restricts my travel over 2 hours.
 My pain restricts my travel over 1 hour.
 My pain restricts my travel to short necessary
journeys under 1/2 hour.
 My pain prevents all travel except for visits to the
physician / therapist or hospital.

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Oswestry Continued
Employment / Homemaking
 My normal homemaking / job activities do not cause pain.
 My normal homemaking / job activities increase my pain, but
I can still perform all that is required of me.
 I can perform most of my homemaking / job duties, but pain
prevents me from performing more physically stressful
activities (e.g., lifting, vacuuming).
 Pain prevents me from doing anything but light duties.
 Pain prevents me from doing even light duties.
 Pain prevents me from performing any job or homemaking
chores.
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Oswestry Pain Questionnaire
 Scoring
 Scale:
012345
 Add Scores / 50 x 100%
 Total x 2 (if all 10 questions are
answered)
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Numeric Pain Rating Scale
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Pain Body Diagram
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Pain Body Diagram
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First Level Classification
 Waddell’s
Nonorganic Signs and
Symptoms
 Proposed characteristics
Able
to separate physical and
nonorganic elements of examination
Able to identify abnormal illness
behavior
Predictive of treatment outcome
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First Level Classification

Waddell’s Nonorganic Signs (5 possible)
Regional disturbance of sensory changes or weakness
that is divergent from accepted neuroanatomy
 Superficial/Nonanatomic Tenderness
 Simulation

Axial loading
 Rotation


Distraction


Straight leg raise
Overreaction
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Rotation
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Axial Loading (done in standing)
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Distraction- SLR
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Distraction-SLR
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First Level Classification

Waddell’s Nonorganic Symptoms (7 possible)
Do you get pain in your tailbone?
 Do you have numbness in your entire leg?
 Do you have pain in your entire leg?
 Does your whole leg ever give way?
 Have you had any time during this episode when you
have had very little back pain?
 Have you had to go to the emergency room because
of your back pain?
 Has all treatment for your back made you worse?
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
First Level Classification
 Now
that you have some info….what
do you do???
1.Red Flags: Refer to Physician
2.Yellow Flags: Consult and treat
3.No red flags/yellow flags: proceed to
stage 2
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First Level Classification



Clinician only
 Stage 1 inflammatory
 Stage 1 mechanical
 Stage 2
 Stage 3
Consultation
 Inflammatory process (medical)
 Psychological
Referral
 Medical
 Psychological

Surgical
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Second Level Classification
 Easy
to classify movement disorders into stages
based on acuteness of the injury
 Studies have shown the usefulness of assigning
patients related to acute, sub-acute and chronic
 Most classifications of acuteness of injury are
based on the number of days since the injury
 Cutoffs for categorizations in this manner are
arbitrarily set and now always useful in directing
conservative care
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Second Level Classification
 Rather
than days since injury, define
acuteness as more related to the
severity of symptoms
 Data from testing in first level
classification will be related to
staging criteria (ie) Oswestry
questionnaire
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Second Level Classification

Stage 1
Characterized as the inability to perform the basic
mechanical functions of standing, walking or sitting
 If people can’t perform these functions, we cannot
expect them to perform a more complex and stressful
activity
 Unable to stand > 15 minutes
 Unable to sit > 30 minutes
 Unable to walk > ¼ mile
 Oswestry within 40%-60%

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Second Level Classification
 Stage
1
 Proposal of therapeutic intervention
Pain
modulation
Specific exercises, lateral shift regimens,
manipulation, traction, occasional
immobilization regimens
Adjunctive pharmacological treatments
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Second Level Classification

Stage 2
 Exceeds the requirements for stage 1 (sitting,
standing, walking) but unable to perform basic
functional ADL’s
 Oswestry score between 20-40%
 Able to sit, stand and walk with little difficulty
 Improve on weakness, flexibility that falls outside the
ideal range, poor aerobic capacity, faulty body
mechanics and posture
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Second Level Classification

Stage 3
 About to return to activity
 Tolerates ADL’s and even activities involving high
physical demand
 Oswestry score < 20%
 Usually asymptomatic but deconditioned from
inactivity
 Need to tolerate high demands of activity for
prolonged periods of time without exacerbation of
symptoms
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Third Level Classification


Identification of subgroup to which the patient belongs (Stage
1 patients)
4 classifications:
 Stabilization
 Manipulation/Mobilization
 Specific Exercise
 Extension
 Flexion
 Lateral shift
 Traction
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Third Level Classification

Examination:
 History taking
 Observation of posture in standing and sitting
 Assessment of symmetry of pelvic landmarks in
sitting and standing
 Examination of trunk movements (forward,
backward, side bend, pelvic translocation)
 Neurological testing for patients who exhibit
symptoms of nerve root involvement (symptoms
below the knee)
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Third Level Classification

Stabilization Classification
 Key examination findings
 Frequent prior episodes of low back pain
 Increasing frequency of episodes of low back pain
 Instability catch or painful arcs during ROM
 Hypermobility of the lumbar spine
 Positive Prone Segmental Instability test
 Treatments
 Trunk strengthening stabilization exercises
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Prone instability Test
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Gower’s Sign
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Bridging Exercise
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Core Stability Exercise
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Prone Plank
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Side Plank
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Third Level Classification


Manipulation/Mobilization
 No symptoms distal to the knee
 Recent onset of symptoms (<16 days)
 Low levels of fear avoidance beliefs
 Hypomobility of the lumbar spine
 Increased hip internal rotation (>35 degrees) or discrepancy
in hip IR ROM between right and leg hip
Treatments
 Manipulation or mobilization techniques to the SI joint or
lumbar region
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 Range of Motion exercises
SI joint Manipulation
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Muscle Energy Techniques
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Third Level Classification

Specific Exercise Classification
 Extension Pattern
 Symptoms distal to the knee
 Signs and symptoms of nerve root compression
 Symptoms centralize with lumbar extension
 Symptoms peripheralize with lumbar flexion
 Treatment
 Extension exercises
 Mobilization to promote extension
 Avoid flexion activities
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Cat/Camel
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Prone Press Up
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Standing Back Extension
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
Third Level Classification
Specific Exercises Classification
 Flexion Pattern
 Older age (>55 years old)
 Symptoms distal to the knee
 Signs and symptoms of nerve root compression
 Symptoms peripheralize with lumbar extension
 Symptoms centralize with lumbar flexion
 Treatment
 Flexion exercises
 Mobilization to promote flexion
 De-weighted ambulation
 Avoid extension activities
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Cat/Camel
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Hand Heel Rocks
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Double Knee to Chest
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De-weighted exercises
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Third Level Classification

Specific Exercise Classification
 Lateral shift pattern
 Visible frontal plane deviation of the shoulders
relative to the pelvis
 Asymmetrical side bending active ROM
 Painful and restricted extension active ROM
 Treatment
 Pelvic translocation exercises
 autotraction
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Lateral Shift
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Lateral Shift Correction
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Third Level Classification

Traction Classification
 Signs and symptoms of nerve root compression
 No movements centralization symptoms
 Treatment
 Mechanical traction
 Autotraction
 Goal is for patient to remain status quo with movement, at
which time mobilization techniques may be used, or
improve with movement at which time patient will move
into a self-treatment category
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Mechanical Traction
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Traction with activity
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Conclusion

What does this mean for Athletic Trainers???
Effectiveness of the classification approach especially
in patients with acute low back pain
 Treatment selection is more directed rather than
taking a lottery, and that treatment is specific
 Classification systems may improve the power of
clinical research as previous research has not
identified patients who actually need the treatment

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Questions?
[email protected]
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Thank You
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