PRESENTED BY:PAULA P. GODES, PT, DPT

DEWITT PHYSICAL THERAPYDECEMBER, 2009

Treating Back PainA Physical Therapy

Approach

OUTLINE

Prevalence and CostACP GuidelinesRuling out Red FlagsClassification SystemsInterventions Core StabilityStability Exercise ProgressionOutcome MeasuresOur ApproachImproving EfficacyReferences

PREVALENCE and COST

90% of Americans will experience back pain in their life Most common cause of pain and disability Second only to respiratory problems for visits to PCM Most acute cases are self-limiting: 4-6 weeks 85% of patients who experience pain cannot be attributed to a specific disease or

spinal abnormality Strong association with pain and psychosocial risk factors

60% of LBP suffers experience functional limitation or disability as a result of their pain Pain and disability expenditures: 100 – 200 billion in health care costs and

lost wages annually LBP and economic cost unchanged in past decade, despite medical advances Leading cause of disability in persons younger than 45 and 3rd leading cause

of disability in persons > 45 years of age

ACP Guidelines for the Dx and Tx of LBP

PCM exam to classify in one of three categories: Nonspecific pain Pain associated with radiculopathy or spinal stenosis Pain from another specific spinal cause

Routine imaging not recommended for patients with nonspecific pain

Dx imaging performed in patients with severe or progressive neurologic deficits or serious underlying condition

S/S of radiculopathy or spinal stenosis: MRI (preferred) or CT if candidate for injection or surgery

Patients provided with evidence-based information on expected tx course, advised to remain active, provided info about self-care options.

NSAIDS recommended as first-line medication options If not improving w/ self-care: recommend nonpharmacologic

therapies

American Family Physician, Vol 77, Number 11, June 2008

ACP Guidelines for the Dx and Tx of LBP

Intervention type

Acute pain (duration < 4 weeks)

Subacute or chronic pain (duration > 4 weeks)

Self-careAdvice to remain active Yes YesApplication of superficial heat

Yes No

Books, handouts Yes YesPharmacologic therapyAcetaminophen Yes YesAntidepressants (TCAs) No YesBenzodiazepines Yes YesNSAIDs Yes YesSkeletal muscle relaxants

Yes No

Tramadol (Ultram), opioids

Yes Yes

Nonpharmacologic therapyAcupuncture No YesCognitive behavior therapy

No Yes

Exercise therapy No YesMassage No YesProgressive relaxation No YesSpinal manipulation Yes YesYoga No YesIntensive interdisciplinary rehabilitation

No Yes

TABLE 2

Intervetions for the Management of Low Back Pain

Management of Low Back Pain in Adults

                                                    

The Role of Exercise in the Prevention and Management of Acute Low Back Pain

There is no proven benefit to prolonged bed rest (> 4 days) in acute LBP without radiculopathy

Aerobic fitness may be mildly protective against low back injury and pain

Aerobic exercises should be incorporated into the spine rehab program as early as possible

Findings of reduced strength, endurance and flexibility are common in patients who have LBP. These findings may be consequences of acute deconditioning and a potential causative factor for dysfunction in the future

There is a mild relationship between trunk muscle strength and LBP There is a mild relationship between decreased flexibility in the

direction of repeated spinal motion and LBP The causes of LBP are multifactorial, even when a pain generator is

identified

Dugan, 2006

Red Flags of Back Pain

Gradual onset Age <20 or > 50 years Thoracic back pain Pain > 6 weeks History of trauma Fever/chills/night sweats Unintentional weight loss Pain worse with recumbency Pain worse at night Unrelenting pain despite

analgesics History of malignancy History of immunosuppression Recent procedure known to

cause bacteremia History of intravenous drug use

FeverHypotensionExtreme hypertensionPale, ashen appearancePulsatile abdominal

massPulse amplitude

differentialsSpinous process

tendernessFocal neurologic signsAcute urinary retention

HISTORY PHYSICAL EXAM

Winters et al, 2006

Classification Systems

Bernard and Kirkaldy-Willis Developer: Orthopedic surgery Status Index 23 categories based on pathophysiology

and disease Delitto and Colleagues

Developer: Physical Therapy Clinical guideline index Three levels of classification

McKenzie Developer: Physical Therapy Clinical guideline index 13 categories

Postural Syndrome 4 dysfunction syndromes 7 derangement syndromes

Quebec Task Force Developer: Medical and nonmedical

disciplines Mixed Index 11 categories with 2 axes

The development of classification systems for low back pain stemmed from the realization that pathoanotomical causes are often unclear

The lack of cause makes it difficult to treat patients within a medical model where all disease must be explained in terms of derangement of underlying physical mechanisms

The classification systems presented today represent a paradigm shift away from the medical model

Classification: A process of organizing clinical data into named categories for the purpose of making decisions regarding treatment

Classification schemes are designed to reliably group patients into treatment-directing categories Which tx work on which subgroups? Clinical Prediction Rules (CPR) “predict”

which treatment is most likely to benefit the patient

Riddle, 1998

LBP Classification SystemBrennan et. al, 2006

LBP Classification System

Outcomes are better for patients treated matched in the classification category

The study was conducted to ensure that improved outcomes were secondary to treatment within the classification scheme and not due to superior treatment

As patient met preset criteria, the therapists progressed both matched and unmatched patients into more advanced care

Brennan et. al, 2006

Interventions

Self care - positioningMedication/NSAIDSSTMModalitiesGeneral exerciseMobilization **Stabilizing exercises **StretchingInjectionsSurgery ** CPR developed

Intervention: Modalities

Includes heat, ice, ultrasound, electrical stimulationMay be effective for short term, acute interventionLimited use in outpatient settingWeak correlation for long-term resultsPromotes passive, rather than active interventionTENS for chronic pain may be tried – if effective,

recommend PCM orders to reduce use of medicationTraction – limited use – may be effective for radicular

symptoms that do not localize w/ movement

Intervention: CPR for Mobilization

4 of 5 positive for Rule

Childs et al, 2004

Intervention: CPR for Stability Exercises

A CPR for stabilization was developed Predictors of success: + PIT, avg SLR > 90 deg, age

<40, aberrant motions – re: “Gower’s” sign upon return from FF

Numerous physical exam variables were conducted then treatment stabilization exercise was given

After completion of the program the authors evaluated which pretreatment variables precluded dramatic success with the stabilization protocols

73% of the 54 subjects with LBP responded favorably to lumbar stab program (27% failed to respond)

Hicks et al, 2003

Stability Exercises Outcomes

MODIFIED OSWESTRY

Hicks et al, 2003

MUSCLES FUNCTION

Major core muscles: Transversus abdominus Multifidus Pelvic floor muscles Internal and external

obliques Rectus abdominus Erector spinae Diaphragm

Minor core muscles: Latissimus dorsi Gluteus maximus Trapezius

Contraction of the TA and other muscles reduces the vertical pressure on the intervertebral discs by as much as 40%.

The transversus abdominis and the segmental stabilizers (multifidi) of the spine are designed to work in tandem

The “core” stabilize the thorax and the pelvis during dynamic movement

Control of whole-body equilibrium

What is Core Stability?

Transversus Abdominus

Major muscle of the functional core of the human bodyCreates rigid cylinder

Enhances stiffness of the lumbar-spine and lateral tension through attachment to transverse processes to assist rotational motion

Creates pressurized visceral cavity anterior to the spine Creates forces against apex of lumbar-lordosis Prevents spinal extension Counteracts pull of psoas (flutter kicks, sit-ups)

Fibers run horizontally and attach via thoraco-lumbar fascia to transverse processes

Enhances stabilization of spine

Lumbar Multifidus

Vertebra-to-vertebraSegmental innervationProvides segmental stiffness, support and

control, intervertebral compressionControl of anterior rotation and translationStrongest influence on lumbar segmental

stability-as compared to erector spinae (Wilke et al – 1995)

Type I fibers – ENDURANCE (increased pain w/ prolonged sitting, standing)

Training the Transverse Abdominus

Pelvic Tilt: contraction of TA“belly button to spine”Biofeedback using ultrasound, inflation cuff maintaining 40 PSI

Using Ultrasound for Biofeedback

Progression

Phase I Isolate transverse abdominus/multifidus Avoid substitutions – assess via BP cuff/US

Phase II Integrate local muscles into extremity antigravity

movement (prone swimmer, dying bug)Phase III

Develop global muscle activation with closed chain weight bearing activity (lunges, push-ups, plank, bridge)

Progression cont.

Progress from stable to unstableLarge simple movements to smaller, more

complexOne plane of movement to multiple/combinedShort lever arm to longerNo weights to weightsSlow speed to fastRelate to functional tasks, sports, gym

Low Back Stretches

Knee to chest Double knee to chest

Lumbar rotation Lumbar rotation – leg extension – contralateral arm elevation

Stretches cont.

Supine Hamstring – knee extended90 deg – normal length

Periformis stretch – pressing outward on crossed knee

Hip Flexor stretch – front kneeat 90 degrees

Deeper stretch – elevate arm on same side of extended leg

ROM/Localizing/Strengthening

Prone on elbows Prone Press-upsPain free only

Multifidus engagement – activate TAExtend leg 2-3 inches off surface

Swimmers (Multifidus) – activate TAExtend opposite arm/leg

Strengthening - TA

Plank – activate TA – elevate on forearms - toes

3-point Plank – raise one foot

2-point plank – elevate opposite arm/leg

Side plank – obliques, greatest activation of TA

Side plank – Elevate leg

Star Plank – extend top leg/arm

Bridge – activation of TAPelvis level

Bridge – unstable surface (Bosu)

Bridge with SL extension Switch legs without lowering trunk or pelvis

Increase difficulty with Bosu Response to perturbations

Want a challenge? Bridge on Bosu, single leg extension with hip abduction against resistance band

Progressing difficulty – Plank on Bosu, Dead Bug on foam roller, double leg lift/lower on foam roller, Tband “sword” on foam roller

STABILITY BALLPelvic Rocks – activation of TASide to sideAnterior – PosteriorSeated marching

Crunches on ball – pelvis level

Bridge on ball

Front resting plank on ball

Plank on ball with arm extension

Outcome Measures

Oswestry Disability Index “Gold Standard” of low back functional outcome tools 25 years of clinical use

Scoring The ODI score (index) is calculated as:

0% to 20%: minimal disability: The patient can cope with most living activities.

Usually no treatment is indicated apart from advice on lifting sitting and exercise. 21%-40%: moderate disability: The patient experiences more pain and difficulty with

sitting lifting and standing. Travel and social life are more difficult and they may be disabled from work. Personal care and sleeping are not grossly affected and the patient can usually be managed by conservative means.

41%-60%: severe disability: Pain remains the main problem in this group but activities of daily living are affected. These patients require a detailed investigation.

61%-80%: crippled: Back pain impinges on all aspects of the patient's life. Positive intervention is required.

81%-100%: These patients are either bed-bound or exaggerating their symptoms

Fairbank, 2000

Our Approach

Referral received – Initial evaluation with Physical Therapist Initial Oswestry exam Subjective: Hx of pain, extent of limitation, current activity level,

agg/ease of symptoms, past occurrences or interventions, medications, r/o red flags

Objective: ROM, GMMT, Neuro screen, special tests – classify to tx subgroup

Instruction: Stretches, basic Phase I core stability Intervention: Mobilization if appropriate Return to clinic for advanced exercises – in clinic for limited

treatments/ mobes Follow-up in 4-6 weeks – re-assess Oswestry May consider additional clinic sessions or aquatic therapy to assist

w/ progression of exercises and strength building Consideration of advanced imaging and additional referral if not

progressing after 3 mos.

Improving Efficacy

Introduction of a Back Class – focus on general exercise, posture, ergonomic education

Clinic treatments: Designed to promote independence and compliance – “lifestyle” change

Promote an understanding of multifactoral issues contributing to back pain: stress, inactivity, muscular imbalance and tightness, weakness Goal is for patient to understand and manage through a

variety of self-care options and exercise techniques Goal is not for physical therapy to “fix” the pain

Understand there is a cognitive and behavioral contribution to back pain, as well as secondary gains that may prevent optimal outcomes

References

Childs JD, Fritz JM, Flynn TW, et al. Validation of a clinical prediction rule to identify patients with low back pain likely to benefit from spinal manipulation. Ann Intern Med 2004;141:920–8

Cleland, J, Fritz, J, Whitman, J, Childs, J, Palmer, J. (2006) The use of a lumbar spine manipulation technique by physical therapists in patients who satisfy a clinical prediction rule: A case series. Journal of Orthopaedic and Sports Physical Therapy 36(4): 209- 214.

Dugan, S (2006) The Role of Exercise in the Prevention and Management of Acute Low Back Pain. Clin Occup Environ Med 5(3) 615-632

Davidson M & Keating J (2001) A comparison of five low back disability questionnaires: reliability and responsiveness. Physical Therapy. 82:8-24.

Fairbank JC. (2000)The Oswestry Disability Index. Spine 25(22):2940-2952 Feuerstein, M, Harrington, C, Lopez, M, Haufler, A. (2006) How do job stress and ergonomic

factors impact clinic visits in acute low back pain? A prospective study. JOEM 48(6): 607 – 614.

Fritz, J, Delitto, A, Erhard, R (2003) Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain. Spine (28)13: 1363-1372.

Hammill, R, Beazell, J, Hart, J. (2008) Neuromuscular consequences of low back pain and core dysfunction. Clin Sports Med 27 (2008) 449-462.

Hebert, J, Koppenhaver, S, Fritz, J, Parent, E (2008) Clinical prediction for success of interventions for managing low back pain. Clin Sports Med 27: 463-479.

References Cont.

Hicks GE, Fritz JM, Delitto A, et al. (2003) The reliability of clinical examination measures used for patients with suspected lumbar segmental instability. Arch Phys Med Rehabil 84:1858–64.

Hides, J, Jull, G, Richardson, C. (2001) Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine 26(11): 243 – 248.

Horsley, L (2008) ACP Guidelines for the diagnosis and treatment of low back pain. American Family Physician. 77(11): 1607-1610.

Last, A, Hulbert, K (2008) Chronic low back pain: Evaluation and management. American Family Physician 79(12): 1067-1074.

Long, A, Donelson, R (2004) Does it Matter Which Exercise? Spine 29(23): 2593-2602 Riddle, D (1998) Classification and low back pain: A review of the literature and critical

analysis of selected systems. Physical Therapy 78(7): 708-737. Shelerud, R. (2006) Epidemiology of Occupational Low Back Pain. Clin Occup Environ

Med 5(3): 501-528. Wasiak, R, Kim, J, Pransky, G. (2007) The association between timing and duration of

chiropractic care in work-related low back pain and work-disability outcomes. JOEM 49(10): 1124-1134.

Winters, M, Kluetz, P, Zilberstein, J (2006) Back pain emergencies. Med Clin N Am 90: 505-523.