Management of Low Back Pain in Physical Therapy

1
Management of Low Back Pain in Physical Therapy

• CPT Jason Silvernail, MPT, OCS, CSCS
• Physical Therapy Service
• October 2005

2
Agenda

• Introduction and Background
• Acute Pain Manipulation and the CPR
• Manipulation Discussion
• Chronic Pain Prognosis is Key
• Who should see a Physical Therapist?
• Treatments offered in PT
• Conclusion/Discussion

3
Quick Back Facts

• Up to 60 of the caseload in outpatient rehab
  settings
• Frequently the primary complaint of individuals
  seeking medical care
• Extremely common problem in Primary Care settings
• Costs associated with LBP treatment are enormous
• Chronic LBP and disability a much larger problem
  than acute back pain

4
Acute Back Pain Management

• Whats our operational definition of acute?
• Onset of pain within the last 2 wks or so
• OR
• Acute exacerbation of a chronic condition

This time period will be important later
5
Acute Back Pain Management

• How do we treat these cases?
• DOD/VA LBP CPG provides guidance
• Appropriate analgesic medication
• Profile/Duty restriction
• Advice to keep active
• Minimize imaging studies

6
What Else Can We Do?

• Does it matter if we do anything else?
• Arent analgesic medications and advice to stay
  active enough?

7
Dont most acute LBP cases get better quickly
anyway?

• There is some evidence to indicate that many do
  NOT get better, but simply stop seeking medical
  care temporarily, and in fact may be at
  considerable risk for developing chronic
  disability
• Subsequent bouts of pain may be of increasing
  frequency and intensity
• Outcomes of LBP in general practice A
  prospective study. Croft P, MacFarlane G,
  Papageorgiou A, et al.
• British Medical Journal 199831613569.

8
How do we most effectively treat back pain in
its acute setting so as to decrease the
likelihood of chronicity?
9
Spinal Manipulation Clinical Prediction Rule

• Is there a simple thing we can do for LBP
  patients that might significantly reduce their
  pain?
• There is a way to determine if the acute back
  pain patient in front of you will benefit from
  manipulation therapy
• A clinical prediction rule for classifying
  patients with low back pain who demonstrate
  short-term improvement with spinal manipulation.
  Spine. 2002 Dec 1527(24)2835-43.
• A clinical prediction rule to identify patients
  with low back pain most likely to benefit from
  spinal manipulation a validation study. Ann
  Intern Med. 2004 Dec 21141(12)920-8.

10
Spinal Manipulation Clinical Prediction Rule

• Conducted by a team of military and civilian
  Physical Therapists
• Works just like the Ottawa ankle/knee rules or
  the Wells criteria for DVT
• There is a subgroup of people for whom we can
  predict excellent results with a simple spinal
  manipulative procedure which almost anyone can
  learn

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Clinical Prediction Rule Criteria

• No pain distal to the knee
• Radiculopathy unlikely
• FABQ-W score lower
• low fear avoidance beliefs about work
• Lumbar Hypomobility to segmental exam
• Time of onset 16 days or less
• Hip internal rotation ROM greater than 35

12
Success Rates

• 4 or 5 out of 5 Criteria 95
• 3 out of 5 Criteria 68
• 2 out of 5 Criteria 49
• 1 out of 5 Criteria 46
• Success considered a 50 reduction in their
  self-report disability score

13
Everyone ready to start checking those 5 criteria
on every new LBP patient you see??
Dont worry, you dont have to
14
Simplified CPR for Primary Care!

• No symptoms distal to knee
• Onset of pain less than 16 days
• Pragmatic application of a clinical prediction
  rule in primary care to identify patients with
  low back pain with a good prognosis following a
  brief spinal manipulation intervention.
• BMC Fam Pract. 2005 Jul 146(1)29.

15
What does the manipulation look like??
16
Manipulation Key Points pg1

• This manipulation is a simple psychomotor skill
• No mystical powers or advanced training required
• Offering manipulation to a group of patients with
  LBP will quickly ease symptoms and may reduce the
  chance for chronicity

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Manipulation Key Points pg2

• Manipulation is available with many different
  providers in clinics throughout the DHCN
• Training is available from providers here in the
  DHCN for interested physicians
• For patients who dont meet the criteria for
  manipulation, the LBP CPG gives good management
  advice

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Manipulation Key Points pg3

• Manipulation can be safely used for short periods
  to enhance patient outcome
• No evidence exists for the use of prolonged
  courses of manipulation without other
  interventions

19
What about chronic back pain?What should be the
main focus of our treatment for this
population?Who should I send to Physical
Therapy?
20
How should we handle Chronic Low Back Pain?

• Again, the DOD/VA LBP CPG provides guidance
• Medication
• Education
• Consult other providers (PT, Ortho, Pain Clinic,
  PMR, etc)

21
Whats the Name of the Game?Chronicity
Prevention!

• There are some great studies recently that help
  clarify who will most likely become chronic, and
  therefore are people we should devote EARLY time
  and resources toward.

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So How Do We Prevent an Acute Case from Becoming
Chronic?
Good question!
23
Prognostic Factors for Chronicity and Poor Outcome

• Job Factors
• Low job satisfaction
• Perceived high job stress
• Prolonged sitting or driving gt4 hrs per day
• Whole body vibration
• Presence of a disability compensation system

• Personal Factors
• Smoking
• Poor social support
• Lower socioeconomic status
• Fear-Avoidance Beliefs or Psychologic factors
• Pain extending below the knee

The exact factors vary somewhat between studies,
but these are the most frequent culprits!
24
Managing Chronic Low Back Pain Referral

• For those with chronic pain, the picture is more
  complex
• Consider the chronicity factors when making
  referrals
• When in doubt, refer!

25
Managing Chronic Low Back Pain Patient Education
and Imaging

• Make diagnostic imaging decisions carefully be
  especially careful before ordering an MRI
• Make sure to downplay the significance of
  age-appropriate degenerative changes
• Remember that pathology and symptoms are rarely
  linked in the chronic population

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Managing Chronic Low Back Pain Physical Therapy

• Not every LBP patient needs to see a Physical
  Therapist, but many who could benefit from
  therapy do not end up seeing one
• There is ample evidence to help guide the choice
  of nonsurgical treatment in Physical Therapy
• PTs have a wide variety of treatment approaches
  backed by evidence to use in the chronic
  population

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What kinds of treatments are available in
Physical Therapy?

• Manipulation and manual therapy approaches
• Lumbar stabilization training
• General cardiovascular training and core
  strengthening
• Pain education and coping skills
• Ergonomics and biomechanics instruction
• Pain relief modalities (hot/cold/EStim, etc)

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I dont want to dump low back patients on you
guys

• Dont worry about referring a patient who you
  think could benefit from our skills
• Its not a favor for us to take care of patients,
  its what were here for!
• Please call or email if youve any concerns or
  questions about referrals or individual patients

29
Questions?
PT in action! LTC Joe Moore
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REFERENCES pg1

• PROGNOSIS/ PSYCH FACTORS
• Psychosocial differences as predictors for
  recovery from chronic low back pain following
  manipulation, stabilizing exercises and physician
  consultation or physician consultation alone. J
  Rehabil Med. 2005 May37(3)152-8.
• Epidemiology and natural history of low back
  pain. Eura Medicophys. 2004 Mar40(1)9-13.
• What questions are appropriate for predicting the
  risk of chronic disease in patients suffering
  from acute low back pain? Orthop Ihre Grenzgeb.
  2005 May-Jun143(3)299-301.
• Should treatment of (sub)acute low back pain be
  aimed at psychosocial prognostic factors? Cluster
  randomised clinical trial in general practice.
  BMJ. 2005 Jul 9331(7508)84.
• The effects of cognitive-behavioral and physical
  therapy preventive interventions on pain-related
  sick leave a randomized controlled trial. Clin
  J Pain. 2005 Mar-Apr21(2)109-19.
• How to identify patients with a poor prognosis in
  daily clinical practice. Best Pract Res Clin
  Rheumatol. 2005 Aug19(4)577-91
• Occupational factors associated with low back
  pain in urban taxi drivers. Occup Med (Lond).
  2005 Sep 1
• Early disability risk factors for low back pain
  assessed at outpatient occupational health
  clinics. Spine. 2005 Mar 130(5)572-80

31
REFERENCES pg2

• SURGICAL / MANIPULATION / REHAB OUTCOMES 1
• Randomised controlled trial to compare surgical
  stabilisation of the lumbar spine with an
  intensive rehabilitation programme for patients
  with chronic low back pain the MRC spine
  stabilisation trial. BMJ. 2005 May
  28330(7502)1233
• Surgical stabilisation of the spine compared with
  a programme of intensive rehabilitation for the
  management of patients with chronic low back
  pain cost utility analysis based on a randomised
  controlled trial. BMJ. 2005 May 28330(7502)1239
• Lumbar stabilization core concepts and current
  literature, Part 1. Am J Phys Med Rehabil. 2005
  Jun84(6)473-80
• Increasing days at work using function-centered
  rehabilitation in nonacute nonspecific low back
  pain a randomized controlled trial. Arch Phys
  Med Rehabil. 2005 May86(5)857-64
• Systematic review strategies for using exercise
  therapy to improve outcomes in chronic low back
  pain. Ann Intern Med. 2005 May 3142(9)776-85
• United Kingdom back pain exercise and
  manipulation (UK BEAM) randomised trial
  effectiveness of physical treatments for back
  pain in primary care. BMJ. 2004 Dec
  11329(7479)1377
• United Kingdom back pain exercise and
  manipulation (UK BEAM) randomised trial cost
  effectiveness of physical treatments for back
  pain in primary care. BMJ. 2004 Dec
  11329(7479)1381

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REFERENCES pg3

• SURGICAL / MANIPULATION / REHAB OUTCOMES 2
• A clinical prediction rule for classifying
  patients with low back pain who demonstrate
  short-term improvement with spinal manipulation.
  Spine. 2002 Dec 1527(24)2835-43.
• A clinical prediction rule to identify patients
  with low back pain most likely to benefit from
  spinal manipulation a validation study. Ann
  Intern Med. 2004 Dec 21141(12)920-8.
• Pragmatic application of a clinical prediction
  rule in primary care to identify patients with
  low back pain with a good prognosis following a
  brief spinal manipulation intervention. BMC Fam
  Pract. 2005 Jul 146(1)29.
• Does it matter which exercise? A randomized
  control trial of exercise for low back pain.
  Spine. 2004 Dec 129(23)2593-602
• Sacroiliac joint dysfunction evidence-based
  diagnosis. Orthopedic Division Review May/Jun
  2004. www.orthodiv.org
• 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
  Sep86(9)1753-62