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LECTURE HANDOUTS Evidence‐based Examination & Selected Interventions for Patients with Lumbo‐Pelvic Spine & Hip Disorders
www.evidenceinmotion.com
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Management of Hip Osteoarthritis
Timothy W. Flynn, PT, PhD Board Certified in Orthopaedic Physical Therapy
Fellow, American Academy of Orthopaedic Manual Physical Therapists
Hip Osteoarthritis
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Hip Osteoarthritis
• Incidence increases with age, higher in women
• Prevalence of radiographic verified OA (Goldie, 1987)
3% in the ages 55–64 year
5–6% in the ages over 65 years
• Progression to THA (Ingvarsson et al. 1999)
2 to 4 persons per thousand in the 60‐80 age group in Nordic countries
Hip Osteoarthritis What is it?
Diagnosis The act or process of identifying or determining the nature and
cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data.
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Diagnosis
ACR Traditional Criteria: • Hip pain for > 25 of the past 30 days
• And, at least 2 of the following criteria: – Erythrocyte sedimentation
rate <20 mm/1st hr – Osteophytes on x‐ray
examination – Obliteration of the joint
space Erythrocyte sedimentation rate (ESR) are often elevated in rheumatoid arthritis, but they are generally normal in osteoarthritis.
Altman et al. The American College of Rheumatology criteria for the classification of osteoarthritis of the hip. Arthritis Rheum. 1991;34:505-14.
ACR Clinical Criteria
Tests and Measures Sn Sp LR- LR+
Test Cluster 1: • Hip pain and • Hip IR <150 and • Flex <1150
OR - If hip IR >150, then use:
Test Cluster 2: • Painful hip IR and • >50yrs age and • AM hip stiffness <60min
.86
.75
.19
3.4
Altman et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 1991; 34:505‐514.
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Now that we have labeled the disorder how should
we manage it?
Hierarchy of Evidence for Therapeutic Interventions
Higher levels of study design allow you to have increased confidence in the conclusions drawn from the study.
Systematic Reviews & Meta-analyses of RCTs
Multiple RCTs
Randomized Controlled Trial (RCT)
Systematic Reviews & Meta-analyses of Cohort and Case Series/Studies
Observational Cohort or Case Control Studies, Large Case Series
Case Reports, Small Case Series
Biomechanical - Motor Control - Physiologic - Anatomic
Unsystematic Clinical Observations - Testimonials - Historically Perfor
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• Multidisciplinary guideline development group • Established 10 ‘propositions’ with ‘strength of
evidence grades (1A through 4) 1A – Meta‐analysis of RCT; 1B – >1 RCT 2A ‐ > 1 controlled trial without randomization 2B – at least one quasi‐experimental study 3 – descriptive studies 4 – expert reports / opinions
• Evidence exists for manual physical therapy and exercise, but is one more beneficial?
• Determine the effectiveness of manual physical therapy versus exercise in patients with hip OA.
• 109 patients randomly assigned to receive manual physical therapy or exercise for 5 weeks (9 sessions)
• Primary outcome was perceived improvement – Secondary outcomes:
• Pain • Hip function • Walking speed • Range of motion • Quality of life RCT
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38
RCT
44 43
RCT
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• Manual physical therapy – Session started with stretching of shortened muscles – Traction of the hip joint, followed by traction manipulation in
each limited position – All manipulations repeated during each session until optimal
results
• Exercise therapy – Program adjusted to individual symptoms and designed to
improve muscle function, length, joint mobility, pain relief, and walking ability
– Home exercise program RCT
PT for Hip OA – Hoeksma 2004
– Rx: Long axis manipulation + stretching
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RC
T
RC
T
8
Flexion‐Extension ROM
Harris Hip Scale
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Num
ber o
f Pat
ient
s
RCT
30
25
20
15
10
5
0
Manual Therapy Exercise
RCT
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• SUCCESS RATE – 81% Manual physical therapy – 50% Exercise therapy – Odds Ratio 1.9 (CI 1.3‐2.6)
• Manual physical therapy group had significantly better outcomes on pain, stiffness, hip function, and range of motion, with effects persisting 6 months following treatment
• Manual physical therapy provides better outcomes then exercise alone for hip OA
RCT
• No difference observed in the effect of manual therapy on the basis of baseline levels of hip function, pain, and ROM.
• Those patients with severe radiological grading of OA had significantly worse outcome on ROM. However, manual therapy in this group of patients outperformed exercise therapy in terms of pain and hip function.
• Manual therapy should be the treatment of first choice for all patients compared to exercise therapy.
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Case Report‐ Manual Therapy Management of Hip Osteoarthritis
‐Loudon, JMMT, 1999
Describe the physical therapy management and outcomes in a 56 year old female with hip osteoarthritis.
Case
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Case Report‐ Manual Therapy Management of Hip Osteoarthritis
‐Loudon, JMMT, 1999
Baseline 1 Year
Flexion 90 ‐‐‐‐‐‐ 110 Extension 5 ‐‐‐‐‐‐ 7 Adduction 15 ‐‐‐‐‐‐ 20 Abduction 30 ‐‐‐‐‐‐ 40
Case
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Physical Therapy Management of Low Back Disorders
Timothy W. Flynn, PT, PhD Board Certified in Orthopaedic Physical Therapy
Fellow, American Academy of Orthopaedic Manual Physical Therapists
Low Back Pain
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Low Back Pain‐ Quiz
Which of these is predictive of lower back pain?
• Physical Imaging Findings (MRI or Radiographs)
1. Bulging discs without herniation or root contact 2. Bulging discs without herniation but with root contact 3. Herniated / Prolapsed discs 4. Degenerative disk disease 5. Facet arthropathy 6. End plate changes/schmorl’s nodes 7. Foraminal or canal stenosis
• Psychosocial Findings
1. History of depression 2. History of occupational‐related LBP 3. Fearful beliefs about work as reported through a survey
How did you do?
• Physically ‐ Only disk contact with the nerve root has shown to be even a weak predictor of LBP
• Psychosocially – depression, occupational‐ related injury, and fear beliefs were strong predictors of LBP
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Findings on MRI….
• Do not predict who has lower back pain in either the chronic or acute situation (Carraggee et al 2006 and 2005, Borenstien et al 2001, Savage et al 1997)
• Lead to higher rates of surgical intervention (Jarvik et al. 2003)
• Do not predict success or nonsuccess in
rehabilitation or in future disability (Caragee et al 2005, Kleinsteuck et al 2006)
The $$ paid for visits to doctors‘ offices, clinics, surgery, and
prescription medicines for LBP in the U.S.A. in 2005 was
$32 Billion
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A total of 44 million prescriptions were dispensed for back pain in the U.S.A. in the year 2000.
• 16% Traditional NSAIDS (7,040,000) – Significant Life Threatening Side Effects 70K – 211K
• 10% COX‐2 Inhibitors (4,400,000) – Significant Side Effects 70,400 – 211,200
• 18% Muscle Relaxants (7,920,000)
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What did the Physical Therapists actually do?
100 90 80 70 60 50 40 30 20 10
0
Specific
Joint
Soft Tissue
Heat Cold HVT
Exercise Mobilization Techniques Manipulation
Therapist
Patient Factors
Regional
Factors Factors
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What tests matter?
TThhee iimmaaggee ppaarrtt wwiithth rreellaatitioonnsshhiipp IIDD rrIIdd2277
wwaass nnoott ffoouunndd iinn ththee ffiillee..
The image part with relationship ID rId18 was not found in the file.
It depends on what question you are asking…
Diagnosis
Prognosis
Intervention
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Visit 1
Informed Consent Examination
SI Region MANIPULATION
50% Reduction in ODI
Visit 2 NO
YES
Success
Non- NO Success
Examination
SI Region MANIPULATION
50% Reduction
in ODI
YES
Success
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Lumbo Pelvic Region Manipulation
• It is unclear precisely which segment(s) are actually influenced from a mechanical perspective
Results Oswestry Disability Index (ODI)
• 32 (45%) patients improved dramatically and were
classified as Success
• Mean percent change in ODI
– Success group was 73% + 16%
– Non‐Success group, the mean percent change was 15% + 18%
50
40
30
Initial 20 Final
10
0
Success Non-Success
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Examination Items Predicting SUCCESS
• HISTORY
– Duration of symptoms 16 days or less
– Symptoms not distal to the knee
– FABQ work subscale 18 or less
• PHYSICAL EXAM
– At least one hip with internal rotation 350 or more (prone)
– Hypomobility at 1 or more lumbar levels with spring testing
Clinical Prediction Rule
Number of Predictor Variables Present Sensitivity Specificity
Positive Likelihood
Ratio
Probability of Success
5 0.19 1.00 Infinite >95%
4 0.63 0.97 24.4 95%
3 0.94 0.64 2.6 68%
1.00 0.15 1.2 2
1 1.00 0.03 1.0 49% 46%
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Clinical Prediction Rule Developmental Process
• 3‐step process (McGinn, JAMA, 2000) – Derivation – Validation
(Flynn, Spine, 2002)
• Different sample • Different clinicians
– Impact analysis
• Practice patterns/clinician behavior • Outcomes of care • Costs
• Objective: To validate a clinical prediction rule to identify individuals with LBP most likely to benefit from spinal manipulation.
• Study Design: A randomized clinical trial.
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Research Design
Patients with LBP (n=543)
Met Inclusion/Exclusion Criteria (n=157)
Baseline Examination/ Randomization (n=131)
Manipulation Group (n=70)
Exercise Group (n=61)
+CPR (n=23)
‐CPR (n=47)
+CPR (n=24)
‐CPR (n=37)
Lumbo Pelvic Region Manipulation
• It is unclear precisely which segment(s) are actually influenced from a mechanical perspective
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Stabilization Exercises (Visits 3‐5)
In the study by Childs and colleagues, spinal manipulation seemed to offer a “slam dunk” effect if patients met certain criteria. ‐Deyo, Ann Int Med, 2004
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Clinical Prediction Rule Developmental Process
• 3‐step process (McGinn, JAMA, 2000) – Derivation – Validation
(Flynn, Spine, 2002)
(Childs, Ann Int Med, 2004)
• Different sample • Different clinicians
– Impact analysis
• Practice patterns/clinician behavior • Outcomes of care • Costs
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Matched Unmatched Unmatched
Unmatched
Matched
Unmatched
Unmatched
Unmatched
Matched
Will effect size increase if matching takes place?
Clinical Prediction Rule Self -Treatment
Manual Therapy
Spinal Stabilization
Centralization
4 of 5 Manipulation
3 of 4
Stabilization
Methods
Patients with LBP Referred to PT
• Standard baseline examination
- Classification assignment
• Randomized to treatment (2x/wk for 4 weeks)
• Re-assessed after four weeks
Examination
RANDOM ASSIGNMENT
Manual
Therapy Treatment
Stabilization Treatment
Specific
Exercise Treatment
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50
Matched Treatment 40 Un‐Matched Treatment
30
20
10 p=.029 p=.006
0 Baseline 4-week one-year
Clinical Prediction Rule Developmental Process
• 3‐step process (McGinn, JAMA, 2000) – Derivation – Validation
(Flynn, Spine, 2002)
(Childs, Ann Int Med, 2004)
• Different sample • Different clinicians
– Impact analysis (Brennan, Spine, 2006)
• Practice patterns/clinician behavior • Outcomes of care • Costs
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Is it necessary to have an audible pop or crack during the manipulation in order for it to be effective?
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Popping is though to be due to Joint Cavitation
The growth & collapse of gas or vapor bubbles in a liquid
Watson et al. Cineradiography of a cracking joint. The British Journal of Radiology, Vol 63, 145‐147, 1990.
Oswestry Scores
• Limitations‐ Only studied the immediate effects (48 hours).
Flynn et al. Arch Phys Med & Rehabil, 84(7): 1057‐60, 2003.
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Results
• 70 patients (30 women) – Age 33.3 + 11.2 – 65.7% prior history of LBP
• An audible pop occurred 84% of the time in at least one of the treatment sessions. – Session #1‐ 54 Pop 16 No Pop – Session #2‐ 51 Pop 19 No Pop – Either #1 or #2‐ 59 Pop 11 No Pop
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Osw
estr
y %
Results‐ Oswestry
50 45 40 35 30 25 Pop
20 No Pop 15 10
5 0
Bas eline 48 hours 1 week 4 week p > 0.59
Results‐ ROM
120
100
80
60 Pop
No Pop 40
20
0
Bas eline 1 week 4 week p > 0.85
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Does the specific style of manipulative technique affect outcomes in patients with LBP?
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A case series of 12 patients with low back pain (LBP) who satisfy a clinical prediction rule (CPR). The PT targeted the high velocity thrust manipulation to the L4‐L5 segment in all patients.
50 45 40 35 30 25 20 15 10 5 0
Pelvic Technique Alternative Technique Flynn, Childs RCT Cleland Case Series
Initial Final
Does the velocity of the manipulative technique affect outcomes in patients with LBP?
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240 Patients with LBP
R
SMT & Placebo
SMT & Diclofenac
Placebo SMT & Placebo
Placebo SMT & Diclofenac
SMT Group Placebo Group
Results
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Does the Australian Tool Kit no longer include manipulation?
The image part with relationship ID rId5 was not found in the file.
Patient records revealed that most (97%) subjects received low velocity techniques with a small (5%) proportion also receiving high velocity thrust techniques.
Comparison of the Effectiveness of Three Manual Physical Therapy Techniques in a Subgroup of Patients with Low Back Pain Who Satisfy a Clinical Prediction
Rule: A Randomized Clinical Trial
Cleland, Fritz, Kulig, Davenport, Eberhart, Magel, Childs
In Press
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Purpose
• Determine the generalizability of CPR to different thrust and non‐thrust manipulation techniques?
Patient with LBP
4/5 Manipulation Criteria Present?
Provide Informed Consent?
Not Eligible for
No Study
Baseline Evaluation
R
Pelvic Thrust Manipulation
Side-Lying Lumbar Thrust Manipulation
Prone PA Mobilizations
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Visits 1 & 2 (Week 1)
Supine Manipulation
Sidelying Manipulation
Prone Mobilization
Sessions 3‐5 (Weeks 2‐4)
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Agreed to participate and sign informed consent
n=112
Random Assignment
Supine Thrust Technique n=37
Side‐Lying Thrust Technique n=38
Non‐Thrust Technique n=37
1‐Week FU n=36
1‐Week FU n=36
1‐Week FU n=36
1‐Week FU n=33
4‐Week FU n=33
4‐Week FU n=36
6‐Month FU n=33
6‐Month FU n=32
6‐Month FU n=33
Results
• Mean Age: 40.3
• Duration of Symptoms: 45 days
• Pain: 5.2
• Baseline ODI: 36%
• 17 Different PTs
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Num
eric
Pai
n R
atin
g O
swes
try S
core
Oswestry
40 Supine Thrust Manipulation
35 Side-Lying Thrust Manipulation
Non-Thrust Manipulation
30
25
20
15
10
5 * * * 0
Baseline 1-Week 4-Weeks 6-Months
Pain
6
Supine Thrust Manipulation
Side-Lying Thrust Manipulation 5
Non-Thrust Manipulation
4
3
2
1 * 0 *
Baseline 1-Week 4-Weeks 6-Months
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p<.001 p<.01
p<.001
% o
f Pat
ient
s Ac
hiev
ing
a Su
cces
sful
Out
com
e
At Least 50% Reduction in Oswestry Scores
100
90
80
Supine Thrust Manipulation Side-Lying Thrust Manipulation Non-Thrust Mobilization
70
60
50
40
30
20
10
0
1-Week 4-Weeks 6-Months
Side Effects
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The velocity of the therapeutic procedure is important in determining outcomes in acute LBP
Thrust Manipulation
Mobilization
HOLD RELAX
Why the bias against thrust manipulation in
acute LBP?
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Would you manipulate?
• 29 y/o with 10 day history of right LBP ready to return to running?
• Right hip IR 40 degrees
• Hypomobile L4
ANCHORING HEURISTIC
• Anchoring — the tendency to rely too heavily, or "anchor," on a past reference or on one trait or piece of information when making decisions.
• A cognitive bias that occurs when people place too much importance on one aspect of an event, causing an error in accurately predicting the utility of a future outcome.
• ‘leads people to stick with initial impression once they are solidly formed.’
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SUMMARY
CPRs are helpful in decision‐making
• Improve patient outcomes • Help to overcome therapist bias
The velocity of the technique matters
• You cannot generalize the LBP CPR to non‐thrust techniques
The image part with relationship ID rId3 was not found in the file. Audible popping is not necessary
• We should focus on efficient, comfortable, and controlled handling techniques, not the noise.
A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain
Manual Therapy, Nov 2006
John D. Childs, PT, PhD, OCS, FAAOMPT Timothy W. Flynn, PT, PhD, OCS, FAAOMPT Julie M. Fritz, PT, PhD, ATC
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Patients with LBP (n=543)
Met Inclusion/Exclusion Criteria (n=157)
Baseline Examination/Randomization
(n=131)
Ineligible (n=386)
Elected not to participate (n=26)
Manipulation + Exercise Group (n=70)
Exercise Group (n=61)
+CPR (n=23)
‐CPR (n=47)
+CPR (n=24)
‐CPR (n=37)
Patients receiving only exercise were more likely (RR = 8.0; RR = 4.0) to experience a worsening in disability at 1
week and 4 weeks.
Worsening was defined as > 6 point increase in the Oswestry.
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Risk of Not Providing Manipulation
• The NNT with spinal manipulation to prevent one additional patient from experiencing a worsening in disability at the one‐week follow‐up was 9.9 (95% CI: 4.9, 65.3) and this persisted at four weeks.
• No one who was positive on the spinal manipulation clinical prediction rule and received manipulation experienced a worsening in disability, thus the risk estimate and NNT statistic considering only this subgroup was indeterminate.
Risk of Not Manipulating
LBP for > 4 wks at greater risk for chronic disability & work
restrictions 1‐4, account for disproportionate proportion of healthcare dollars & workers comp costs 3.
1. Fritz and George, Phys.Ther. 2002;82:973-83. 2. Frank et al. Spine 1996;21:2918-29. 3. Hashemi et al. J Occup.Environ.Med. 1998;40:1110-9. 4. Hiebert et al. Spine 2003;28:722-8.
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What is the Mechanism?
Biomechanical effects
Neurophysiologic effects
Hypoalgesic effects
SMT Clinical benefits
Does the Pop or Click Really Matter?
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Cracking or Popping
• The audible pop is used by many clinicians as an indication of a successful treatment.1
– “The ultimate criterion for determining the usefulness of any assessment or treatment procedure is its impact on patient outcomes” (Sackett)
• The audible “cracking” sound associated with joint manipulation is thought to be the result of “cavitation” in a synovial joint.
1 Gal, et al. J Manip Physiol Ther. 18: 4-9, 1995.
Cavitation The growth & collapse of gas or vapor bubbles in a liquid
Watson et al. Cineradiography of a cracking joint. The British Journal of Radiology, Vol 63, 145‐147, 1990.
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Flynn et al. Arch Phys Med & Rehabil, 84(7): 1057‐60, 2003.
Results
• Limitations‐ Only studied the immediate effects (48 hours).
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Results
• 70 patients (30 women) – Age 33.3 + 11.2 – 65.7% prior history of LBP
• An audible pop occurred 84% of the time in at least one of the treatment sessions. – Session #1‐ 54 Pop 16 No Pop – Session #2‐ 51 Pop 19 No Pop – Either #1 or #2‐ 59 Pop 11 No Pop
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Osw
estr
y %
Results‐ Oswestry
50 45 40 35 30 25 Pop
20 No Pop 15 10
5 0
Bas eline 48 hours 1 week 4 week p > 0.59
Results‐ ROM
120
100
80
60 Pop
No Pop 40
20
0
Bas eline 1 week 4 week p > 0.85
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Results‐ Pain
7
6
5
4 Pop 3 No Pop
2
1
0 Baseline 4 Days 4 w eek
p > 0.67
Results
• The occurrence of a pop did not improve the odds of achieving a successful outcome (50% or greater reduction in the Oswestry. – Odds Ratio‐ 4 days: 1.1 (95% CI 0.29 ‐ 3.86) – Odds Ratio‐ 4 weeks: 1.7 (95% CI 0.41 ‐ 7.1)
• Statistical Power – Oswestry‐ 78% (8 point change) – Pain‐ 91% (2 point change)
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“closing”/ ”opening”
SI special tests
Centralization phenomenon
Leg pain, neurological
signs
Discussion
• Results validate previous findings that clinicians should not judge the success of a HVT manipulation at either a short‐ or longer‐term follow‐up based on the presence or absence of an audible pop.
– “The belief shared by some patients and operators that if there is no joint noise associated with the manipulative procedure then nothing has happened, is incorrect.”
‐ Isaacs ER & Bookhout MR. Bourdillon’s Spinal Manipulation, 6th Ed., 2002.
Low Back Pain Classifications
Manipulation Specific Exercise Stabilization Traction
•No symptoms below the knee
•Recent symptoms
•Hypomobility
•Low Fear‐Avoidance
•More hip IR
???
??? ???
Manipulation and exercise
Activities to Promote
Centralization
Stabilization exercises
Mechanical/ auto‐ traction
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Predictors of Success with Stabilization
• + Prone instability test
• + Aberrant motions
• Hypermobility
• Younger age
• Greater SLR ROM • FABQ‐PA ≤ 8 (Less Fear Avoidance)
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Stabilization Classification Fritz et al, June 2007
Exercises Stabilization
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“closing”/ ”opening”
SI special tests
Frequent prior episodes, hypermobility
Leg pain, neurological
signs
Spinal Stabilization Exercise Protocol
Low Back Pain Classifications
Manipulation Specific Exercise Stabilization Traction
•No symptoms below the knee
•Recent symptoms
•Hypomobility
•Low Fear‐Avoidance
???
•Prone instability test
•Aberrant motions
•Hypermobility
•Younger age
•Greater SLR ROM
??? •More hip IR •Postpartum
Manipulation and exercise
Activities to Promote
Centralization
Stabilization exercises
Mechanical/ auto‐ traction
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RCT, N=312 pts with LBP Purpose: determine if LBP subgroups respond differently to contrasting
exercise prescriptions Methods: • Standard exam to determine a “directional preference” (DP) • Randomized to:
1. directional exercises “matching” their DP 2. exercises directionally “opposite” 3. “nondirectional” exercises
Outcomes: pain, disability, meds, degree recovery, depression, work loss/interference
Significantly greater improvements occurred in matched subjects compared with both other treatment groups in every outcome (P<0.001), including a threefold decrease in medication use.
RCT
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1/3 unmatched subjects withdrew within 2 weeks because of no improvement or worsening (no matched subject withdrew)
Exercises matching subjects’ DP significantly and rapidly decreased pain and medication use and improved in all other outcomes
Identification of a valid subgroup prior to randomization provided homogeneity, likely contributing to the significant differences • Important implications for LBP management and clinical research
RCT
• 48 subjects with LBP & symptoms distal to buttocks that centralized with extension movement
• Extension oriented treatment vs strengthening program (8 visits + HEP)
• F/U: 1 wk, 4 wks, 6‐mo; OSW & NPRS
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EOTA • Greater
improvements in disability vs trunk strengthening group at 1 wk, 4 wks, 6 mo
• Greater change in pain at 1 wk
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Manual Physical Therapy for LBP in the
Older Adult
Timothy W. Flynn PT, PhD
What is Lumbar Spinal Stenosis?
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What is Lumbar Spinal Stenosis?
A number of degenerative conditions of the aging spine • Lumbar spondylosis • Degenerative disc disease
Associated pathologies • clinical instability • lumbar spinal stenosis
• degenerative spondylolisthesis The Cochrane Collaboration
• “Degenerative Lumbar Spondylosis”
Symptoms associated with degenerative lumbar spondylosis vary in severity and have a relatively low correlation with the severity of anatomical or radiographic changes.
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Clinical Presentation of LSS: Value of the Physical Examination
• Neurological changes • Motion restrictions • Pain with extension • Positive Two-Stage Treadmill Test*
– Earlier sxs and longer recovery time with level TM walking Sp=0.95 +LR = 14.5
– Longer total walk time with inclined TM predictive of LSS Sp = 0.92 +LR = 6.5
*Fritz JM, et al. Preliminary Results of a Two-Stage Treadmill Test. J Spinal Disorders, 1997.
Surgical versus Nonsurgical Management of LSS
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What is Lumbar Segmental Instability? (often used in conjunction with LSS)
I recently met with a surgeon who performs two or three spinal fusions a week. I will call him Dr. Wheeler. (Like some of the doctors I spoke with, he was concerned that candid answers would damage his standing in the medical community and reduce patient referrals.)
"Spinal instability is routinely given as a diagnosis to these patients with chronic lower- back pain. It is a term used to justify an operation. And it's a great diagnosis, because it can't be directly disproved."
When it comes to spinal surgery…geography is destiny!
Rates of surgery for spinal stenosis in Medicare patients (Birkmeyer and Weinstein, 2000)
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Back Surgery Rates in the U.S.
Denver Fort Collins, CO 98th Percentile
http://support.regis.edu/shcp/shcp_forum/Interactions/LumbarSpinalStenosis/
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STUDY DESIGN
Purpose
Compare clinical outcomes for patients treated with two different physical therapy intervention programs.
Subjects referred from their general practitioner to the specialist
Physician/ Specialist Evaluation
Baseline Testing Session
Treating Therapist
Individualized Physical Therapy (Manual Physical Therapy and Unloaded Treadmill Walking)
Traditional Physical Therapy (Flexion Exercises & Level
Treadmill Walking)
6 Week Follow-Up Testing
1 Year Follow-Up Testing
Long Term Follow-Up (phone calls, mailing)
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Enrolled, Baseline Examination (N=60)
R Traditional
Physical Therapy (N = 30)
Individualized
Physical Therapy (N = 30)
1 Drop: Pos. Exclusion (vascular) 1 Drop: Pos. Exclusion (Cancer)
6 Week Assessment: N=29 6 Week Assessment: N=29
2 Drop: 1 MI, 1 CA
1 Year Assessment: N=27 1 Year Assessment: N=29
3 status unknown 3 status unknown, 2 death, 1 refuses f/u
Long Term Follow-Up: N=24 Long Term Follow-Up: N=23
PRIMARY Outcomes
• Perceived Recovery (+ 3 point GRC = Success)
SECONDARY • 15 Point Global Rating of Change (GRC) • Spinal Stenosis Scale (SSS) • Modified Oswestry Disability Index (OSW) • Patient Specific Functional Scale (PSPS) • Other: Surgeries, Injections, Complications
GRC: 7 = “a very great deal better”; 0 = No change; -7 = “a very great deal worse” SSS: Satisfaction (range 1-4) PSFS: 0 = “…unable to do the activity”; 10 = “…able to do the activity like …before my injury.”
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Interventions
All subjects: • In-Clinic Treatment: 2x/wk for 6 wks • Encouragement to walk at home 3x/week
Traditional Physical Therapy
• Level treadmill walking program • Flexion Based Exercises (SKC, DKC) • Sub-therapeutic ultrasound
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9 yrs
5 yrs
p = 0.69 †
39.3 (13.6) 35.8 (13.8) p = 0.40
5.5 (2.1) 5.1 (2.5) p = 0.49
Sex
Individualized Physical Therapy
Unloaded treadmill walking program Manual physical therapy
• Lumbo-Pelvic Region • Thoracic Region • Lower Extremities • Lumbar Stabilization Exercises
Baseline Variables
Variable
Traditional
Individualized
Sig.
Age 70.0 (7.2) 68.9 (8.7) p = 0.60
56 % female 33% female
X2 = 0.06 ‡
Duration LBP (median)
Oswestry
NPRS: LE Pain
† = Mann Whitney U Test; ‡ = Chi Square Test
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O S W
S c o
r es
(% )
Perceived Recovery
*Significant association between treatment group and perceived recovery (P =0.0015). Long term data from mean time of follow-up: 29 months for the FExWG and 27.4 months for the MPTExWG.
Results: Modified OSW
55 50 45
40 35 30 25
20
15 10
5 Baseline 6 Wks 1 Year
Individualized Traditional
6 Wks Individual: 10.5 pts Traditional: 6.5 pts 1 Yr Individual: 7.1 pts Traditional: 5.0 pts
MCID: 4-8 points acute/subacute populations
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PS
F S S
c o re
(0 -1
0 )
Results: Patient Specific Functional Scale
10
9
8
7
6
5
4
3
2 Traditional
1 Individualized
0 Baseline 6 Weeks 1 Year
6 Wks Individual: 2.5 pts Traditional: 1.1 pts 1 Yr Individual: 2.3 pts Traditional: 2.1 pts
PSFS: 0 = “…unable to do the activity”; 10 = “…able to do the activity like before my injury.”
Conclusions The results of our study suggest that patients with LSS can benefit from a course of physical therapy, which includes lumbar flexion exercises and a walking program.
Furthermore, additional gains can be realized with the inclusion of manual physical therapy interventions, exercise, and a progressive body-weight supported treadmill walking program.
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ACKNOWLEDGEMENTS
• Patients • Shane Koppenhaver
• Gail Deyle • Travis Hedman • Jessica Feda • Christopher Flaugh • Terry Gebhardt • Benjamin Hando • Scott Jones • Evan Jones
• Dan Rendeiro • Chad Rodarmer • Christopher Waring • Brian Young • Don Atkins
Funded by: The Orthopaedic Section of the American Physical Therapy Association and the USAF Office of the Surgeon’s General
??
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Regions Treated
Perc
enta
ge
Per
cent
age
100 90 80 70 60 50 40 30 20 10
0
Thoracic Lumbo-Pelvic Hip Knee Ankle/Foot
Interventions Utilized: Spine
100 90 80 70 60 50 40 30 20 10 0
67%
50%
10%
97%
50% 42%
29%
100%
11%
Thoracic/Ribs Lumbar SI/Pelvis
Mobilization Manipulation Stretch MET
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Interventions Utilized: Lower Extremities
Perc
enta
ge
100
90
80
70
60
50
40
30
20
10
62%
96%
21%
75%
50%
25%
50%
63%
0 0 0 0 0
Hip Knee Ankle/Foot Manipulation Mobilization Stretch Muscle Energy
Intervention Program for Individualized Physical Therapy
When it comes to physical therapy…philosophy is destiny!
78
Regions Treated
1
Perc
enta
ge
Per
cent
age
00
90
80
70
60
50
40
30
20
10
0
Thoracic Lumbo-Pelvic Hip Knee Ankle/Foot
Interventions Utilized: Spine
100 90 80 70 60 50 40 30 20 10
0
67%
50%
10% 0.00
97%
50%
42%
29%
0.00
100%
11%
Thoracic/Ribs Lumbar SI/Pelvis
Mobilization Manipulation Stretch MET
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Interventions Utilized: Lower Extremities
Perc
enta
ge
100 90 80
70 60 50 40 30 20 10
0
62%
96%
21%
75%
50%
25%
50%
63%
Hip Knee Ankle/Foot Manipulation Mobilization Stretch Muscle Energy
CASE STUDIES
Case studies allow for a more thorough description of the actual treatment regimens and clinical decision-making used in the management of a particular disorder.
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N = 3 Intervention:
• Impairment specific treatment • 6-10 total visits
Outcomes Instrumentation: • Modified Oswestry Disability Index (OSW) • Modified Spinal Stenosis Questionnaire (SSS)
Modified Oswestry Disability Index Scores
60 60
50
40 34
30
20
10 10 12
48
40
32 16 18
10
Initial 4-6 Weeks 13-32 Weeks 18 Months
6 4 0
Patient #1 Patient #2 Patient #3
MCID = 6 pts
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Modified SSS: Physical Function Scale
4
3.5
3
2.5
2
1.5
1
0.5
0
2.6
1.6
1.2
2.4
1.4 1.5
3.6
1 1
Initial 6-12 Wks 18 Months
Patient #1 Patient #2 Patient #3
MCID = 0.52
Restoring Upright Posture (Overcoming Gravity)
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Anterior Structures
Mobilization Procedures to Increase Hip Extension
83
Hip Mobilization Posterior to Anterior Progression
Hip Mobilization Posterior to Anterior Mobilization in Flexion, Abduction, & External Rotation
84
Mobilization Procedures to Increase Thoracic & Lumbar Extension
Thoracic Spine Extension Manipulation (T3-T10)
85
Lumbar Spine Segmental Mobilization/Manipulation
Lumbar Spine Central PA Mobilization in Neutral