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    Clinical Prediction Criteria for

    Management of LBP

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    Purpose

    Next to a cold, LBP is most common reason

    individuals visit the doctor

    Estimated $100-$200 billion in health careexpenditures and lost wages annually in the

    U.S.

    Importance of matching pts with interventions

    they will most likely benefit from

    Improve decision making and outcomes

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    Current Evidence

    A clinical prediction rule for classifying patients withlow back pain who demonstrate short-termimprovement with spinal manipulation. Flynn T,

    Fritz J, Whitman J, et al. Spine. 2002; 27(24):2835-43

    Clinical prediction for success of interventions for

    managing low back pain. Herbert J, KoppenhaverS, Fritz J, Parent E. Clin Sports Medicine 2008; 27:163-179

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    A clinical prediction rule for classifying patients

    with low back pain who demonstrate short-

    term improvement with spinal manipulation.

    Flynn T, Fritz J, Whitman J, et al. Spine. 2002;

    27(24): 2835-43

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    Background

    Several RCTs shown manipulation to be more

    effective than placebo or other interventions.

    Found to be beneficial for a subgroup of ptswith more acute sym or more limited SLR

    ROM

    Other studies have not shown any benefits

    Problems? No attempt to id pts most likely to

    benefit

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    Design: Prospective cohort.

    Level of Evidence: Level 2

    Objective: Develop a clinical prediction rule for

    identifying patients with low back pain who

    improve with spinal manipulation

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    Methods

    71 Pts age 18-60 referred to PT w/ a chiefcomplaint of pain and/or numbness in the lumbarspine, buttock, and or lower extremity

    Pain diagram and rating (0-10) Modified Oswestry Disability Questionnaire

    (OSW)-assessed disability related to LBP

    Fear Avoidance Belief Questionnaire (FABQ)-assess pts beliefs about the influence of activityon LBP.

    2 subscales: general physical activity and work

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    Inclusion/Exclusion Criteria

    Baseline Oswestry disability score of at least30%

    Exclusion

    current pregnancy

    signs consistent with nerve root compression (+straight leg raise at

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    Underwent standard exam and history (i.e.M.O.I., nature of sym, prior episodes etc.)

    Side to be manipulated was determined by theside + with standing flexion test, if side of

    tenderness during sacral sulcus palpation, if not,side reported tby pt to be more symptomatic

    Response to treatment served as a referencestandard, all pts were treated with the same

    protocol for 2 sessions Success was determined using percent change in

    disability scores over 3 sessions

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    Pt passively side-bent away from therapist. Therapist passively rotated pt

    and delivered a quick posterior and inferior thrust through ASIS.

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    Cavitation

    NOYES

    Proceed to other

    components:

    1.) Instruction in

    supine pelvic tilt ROM,10 reps 3-4x daily.

    2.) Instruction to

    maintain usual activity

    level within limits of

    pain

    1st Session

    Reposition and

    attempt again

    Cavitation?

    YES

    NOAttempt opposite

    side

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    2nd Session 2-4 days later

    OSW questionnaire- improvement of >50% from intial= success,

    participation ended

    -

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    Results

    75 entered 71 completed

    29 females (41%)

    59 (83%) had prior history of LBP

    Mean age 37.6 +/- 10.6 yrs 32 (45%) were classified as treatment successes, 39

    nonsuccesses

    20 successful after 1 session

    Mean OSW improvement in success group was 73.2+/- 15.8%

    Nonsuccess group was 14.6 +/- 18.2%

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    Results

    Out of 11 potential prediction variables, five

    were retained in the final model:

    Duration of symptoms 35O internal rotation

    Hypomobility with lumbar spring testing

    FABQ work subscale score

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    Results

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    Results

    The best predictor of success withmanipulation was the duration of sym

    Supports the hypothesis that pts with moreacute sym respond better to manipulation.

    The presence of 4/5 variables increased thelikelihood of success with manipulation from45% to 95%

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    Why is this important?

    Being able to accurately predict which pts will

    have a positive response before hand would

    be beneficial for effective and efficient clinical

    decision making

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    Clinical prediction for success of interventions

    for managing low back pain. Herbert J,

    Koppenhaver S, Fritz J, Parent E. Clin Sports

    Medicine 2008; 27: 163-179

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    D

    esign- Systematic Review

    Level of evidence- Level 1

    Objective- Review evidence for variousinterventions commonly used in the treatment ofLBP.

    -Identify clusters of findings from the history andclinical examination that predict a more favorableoutcome with a specific treatment approach.

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    Treatment Approaches

    Specific Exercise

    Flexion

    Extension

    Stabilization

    Manipulation

    Traction

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    Evidence is inconclusive

    Ones that show some benefits, the

    magnitude of observed effects is often small One therapy can look as appealing as the next

    leading to less effective and efficient

    treatment

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    Specific Exercise

    First emphasized by McKenzie

    Emphasizes treatment using repeated orsustained end-range movements of the

    lumbar spine in a specific direction to affect

    the intensity and location of a pts pain.

    Flexion, extension, or lateral translation

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    Exam findings identifying pts in this subgroup: Presence of sym in the LE

    Signs of nerve root compression (+ SLR, diminishedreflex, sensation, or strength)

    Principle finding is the presence of centralization or adirectional preference during examination

    *the absence of centralization has been associated withdelayed recovery and the development of chronic LBPand disablility. (Werneke et al. Spine 2001)*

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    Studies that have applied this treatment to pts

    fitting this subgrouping have reported

    evidence favoring this approach over other

    exercise interventions

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    Stabilization Exercises

    Lack of trunk control may compromise

    function or stability of the lower extremities

    Stabilization exercise programs are typicallydesigned to address the deficits in strength,

    endurance, and function of the trunk muscles

    identified in LBP

    Thought to decrease pain and disability by

    improving control of spinal segments

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    Previous studies

    Been shown to improve trunk muscle function inindividuals with LBP

    Improvements may represent important

    outcomes of rehab programs but physiologicchanges may not correspond to patient-centeredimprovements in pain and disability.

    Rackwitz and colleagues concluded thatstabilization exercises for LBP is more effective

    than treatment by a gen practitioner but notmore effective than other physiotherapyinterventions.

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    But..

    Conflicting evidence supports the considerationthat there may be a subgroup of pts with LBPwho are most likely to benefit from thisapproach.

    Four variables most predictive of success definedas 50% reduction in disability as measured by theOSW. Younger than age 40

    Avg SLR >91o

    Aberrant movement present

    Positive prone-instability test

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    Spinal manipulation

    See previous slides

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    Traction

    Subject of debate and controversery

    Traditional signs of sciatica or nerve root

    compression indication for treatment These symptoms not enough. . . 2 more

    factors

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    Traction

    1. Peripheralization with extension movement

    2. A positive crossed (contralateral) straight-leg

    raise test3. Symptoms below buttock

    4. Signs of nerve root compression

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    Summary

    Identification of predictive factors in pts with

    LBP should allow the pt to be matched with

    the most appropriate intervention to

    maximize the likelihood of a favorable clinical

    outcome

    More information and research is needed