Low Back Pain Presentation Imp

Conservative Therapy for Back Pain – The Family Doctor and the Physiotherapist Facilitators: Dr. Ranald Donaldson, BSc, MSc, MD Dr. Peter Huijbregts, PT, MSc, MHSc, DPT

Adult Case: Back Pain Tom is a 45 year old who presents complaining of back pain to his family doctor, Dr Grey. He moved some heavy boxes four weeks prior, and since has had a low grade, but bothersome “muscle spasm” of the low mid back with some radiation to the right buttock. He has had similar symptoms previously, but they have never persisted this long.

Adult Case: Back Pain Our patient Tom is a manager in the electronics department at a big retail store. He is married and has two young teenaged daughters. He last saw his family doctor two years prior at his wife’s urging. At that time his diabetes screen had been borderline, and he had been counselled about dietary management. He had not succeeded in making any significant lifestyle changes. He skips breakfast, takes lunch at the food court, drinks three cans of coke over the day, and usually prepares himself a large pasta dish for dinner. His exercise consists of participation in his weekly old-timers hockey game, which runs through the fall and winter. Over the last two years he has in fact gained 2 kg, such that he is now weights 120 kg.

Let us first get a misconception out of the way…

LBP Myths “80-90% of people with LBP get better in about 6 weeks irrespective of administration or type of treatment" Waddell G. A new clinical model for the treatment of lowback pain. Spine 1987;12:632-643.

PRIMARY CARE PHYSICIAN STUDY Follow up within 1-2 weeks - 2% reported no pain or disability At 3-months follow up – 21% reported no pain or disability At 12-months – only 25% of those interviewed reported no complaints So 75% of those interviewed still had continuing LBP and disability at 1 year Croft PR, et al. Outcome of low back pain in general practice: a prospective study. BMJ 1998;316:13561359)

SYSTEMATIC REVIEW

62% of patients (range 42-75%) still experience LBP at 12 months 16% (range 3-40%) of patients still sick-listed at 6 months Recurrence of LBP in 60% (range 4478%) Recurrent sick-listing 33% (range 2637%) Hestbaek L, et al. Low back pain: what is the longterm course? Eur Spine J 2003;12:149-165

LBP is not a self-limiting problem but a problem characterized by exacerbations and remissions, which becomes chronic in about 10% of the population Hestbaek L, The Natural Course of Low Back Pain and Early Identification of High-Risk Populations. PhD Thesis. Odense, Denmark: University of Southern Denmark, 2003.

The 10% of patients with LBP who go on to have chronic LBP and disability are responsible for 80% of the costs associated with this condition Murphy PL, Courtney TK. Low back pain disability: Relative costs by antecedent and industry group. Am J Ind Med 2000;37:558-571.

Role of the physician  Differential

diagnosis  Medical-surgical management  Referral to other providers for comanagement

Role of the physical therapist Medical

screening based on systems approach and appropriate referral for medical-surgical (co) management Evaluation

and management of patients with mechanical LBP Potential

role in the co-management of patients with LBP due to trauma, metabolic, infectious, inflammatory, and neoplastic disease

Types of Low Back Pain   



Simple or mechanical back pain Back pain with neurological involvement Back pain with suspected serious spinal pathology: Red Flags But also: Back pain with indicators of poor prognosis or Yellow Flags

Patho-anatomical diagnosis  



Traditional medical, structure-based model Assumes a direct correlation between underlying pathology and signs and symptoms Note: Unable to provide up to 85% of patients with low-back pain a specific diagnosis: Simple or mechanical low back pain

Mechanical Low Back Pain with or without Neurological Involvement        

Zygapophyseal joint pain syndrome Diskogenic pain Lumbar radiculopathy Spinal stenosis Sacroiliac joint syndrome Lumbar instability Muscle/ligamentous sprain or strain Myofascial pain syndrome

Zygapophyseal Joint Pain Syndrome





Restricted motion lumbar spine with low back or buttock pain Pattern of motion loss indicating opening or closing restriction zygapophyseal joint: Decreased extension, sidebending, and rotation

Diskogenic Pain 



Report of centralization or peripheralization of symptoms during repetitive movements or during prolonged periods in certain positions Difficulty with curve reversal: Rising after sitting or straightening up in morning out of bed

Lumbar radiculopathy 



Lower extremity pain or paraesthesiae greater than low back pain Radicular deficit noted: Decreased strength or sensation

Spinal Stenosis 

Pain in lower extremities that is exacerbated by an extension posture (standing and walking) and relieved by a flexion posture (sitting, semi-Fowler, sidelying, leaning on shopping cart)

Sacroiliac Joint Syndrome  

 

Predominant unilateral pain just inferior to PSIS Also pain low back, posterolateral buttock, posterior thigh to knee, and groin Worse with load transfer through affected side 13% (95% CI: 9-26%) of patients with persistent low back pain have the origin of pain confirmed as the SIJ

Lumbar Instability 



Recurrent locking, catching, giving way of the low back during active motion Difficulty with sustained postures

Muscle and Ligament Sprain or Strain 



Pain aggravated with stretch of ligaments or muscles Pain increased with muscular contraction

Myofascial Pain Syndrome    

Myofascial trigger points Central sensitization Peripheral neuropathy Chronic pain states

History     

Inventory of current complaint Screening for yellow and red flags History of current complaint Medical history Social history

Inventory of Current Complaint         

Location of pain Intermittent, constant, episodic Aggravating and easing factors Effect of coughing, sneezing, and straining Range of motion impairments (also locking and crepitus) Sensory abnormalities Motor deficits Inflammatory symptoms: redness, swelling, increased temperature Cauda equina syndrome

Zygapophyseal Joint Pain Syndrome

Lumbar Radiculopathy

Myofascial Pain Syndrome

Myofascial Pain Syndrome

Myofascial Pain Syndrome

Visceral Referral: Angiotomes

Visceral Referral: Organs

Mechanical versus Non-Mechanical

    

Constant versus intermittent Episodic Aggravating and easing factors Coughing, sneezing, and straining Inflammatory symptoms

Lumbar Spinal Stenosis        

Do you have no pain when sitting +LR = 6.6; -LR = 0.58 Are you symptoms improved while seated +LR = 3.3; - LR = 0.58 Age > 65 +LR = 2.5; - LR = 0.33 Do you have severe lower extremity pain +LR = 2.0; - LR = 0.52

Lumbar Spinal Stenosis      

Are you able to walk better when holding onto a shopping cart +LR = 1.9; - LR = 0.55 Do you have pain below the knees +LR = 1.5; -LR = 0.70 Do you have pain below the buttock? +LR = 1.3; - LR = 0.35

Katz JN, et al. Degenerative lumbar spinal stenosis: Diagnostic value of history and physical examination. Arthritis Rheum 1995;38:12361241.

Screening for Yellow and Red Flags  



Non-mechanical low back pain General health: Night pain, unexplained weight loss, etc. Indicators of poor prognosis

Cauda Equina Syndrome 

   

Urinary retention: sensitivity 90%, specificity 95% Fecal incontinence Saddle area anesthesia: sensitivity 75% Sexual dysfunction Unilateral or bilateral sciatica, sensory, or motor deficits: > 80% sensitivity

Deyo R, et al. What can the history and physical examination tell us about low back pain? JAMA 1992;268:760-765.

Back Pain and Pathology Visceral disease: Retroperitoneal and pelvic region or the gastrointestinal system Vascular disease: Abdominal aortic aneurysm Hematological disease: Hemoglobinopathies and myelofibrosis Trauma: Fracture, fatigue fracture, insufficiency fracture

Metabolic and endocrine disease: Osteoporosis, osteomalacia, Paget disease, and diabetes (diabetic radiculopathy) Infectious disease: Diskitis and osteomyelitis Inflammatory disease: Spondylarthropathies Neoplastic disease: Osteoid osteoma, multiple myeloma, metastases Huijbregts PA. HSC 11.2.4. Lumbopelvic region: Aging, disease, examination, diagnosis, and treatment. In: Wadsworth C. HSC 11.2. Current Concepts of Orthopaedic Physical Therapy. LaCrosse, WI: Orthopaedic Section APTA, 2001.

Yellow Flags: Depression Random population-based survey Multivariate

analysis excluded confounding variables. Independent

relationship between depressive symptoms and onset of neck or back pain episode. Comparing

lowest quartile of depression scores to highest quartile. Adjusted

3.97

risk ratio most depressed

Carroll LJ, et al. Depression as a risk factor for onset of an episode of troublesome neck and low back pain. Pain 2004;107:134-139.

Depression Screening 





During the past month have you often been bothered by feeling down, depressed, or hopeless? During the last month have you often been bothered by little interest or pleasure in doing things? Sensitivity 97%; specificity 67%

Arroll B, et al. Screening for depression in primary care with verbally asked questions: A cross sectional study. BMJ 2003;327:144-1146.

Yellow Flags: Fear Avoidance Prospective interventional case series design 36

patients with chronic LBP.

Fear

avoidance beliefs questionnaire – physical activity subscale. Comparing

<20.

FABQ-PA >29 to FABQ-PA

Increased

probability of negative outcome in high-score group: Likelihood ratio 3.78 Al-Obaidi SM, et al. The relationship of anticipated pain and fear avoidance beliefs to outcome in patients with chronic low back pain who are receiving workers’ compensation. Spine 2005;30:1051-1057.

Prospective cohort study on risk factors in chronic workrelated LBP  Multiple regression analysis - 854 patients  Severe leg pain (7-10 pain rating): odds ratio (OR) 1.92  Body mass index >30: OR 1.68  Oswestry Disability Index (ODI) score 21-40: OR 3.1  ODI score 41-59: OR 3.98  ODI score >60: OR 3.43  General Health Questionnaire (GHQ-28) score >6: OR 1.87  Unavailability of light duties: OR 1.66  Lifting >75% of the day: OR 1.98 Fransen M, el al. Risk factors associated with the transition from acute to chronic occupational back pain. Spine 2002;27:92-98.

Prospective cohort study to determine clinical prediction rule for return-to-work status at 2 years for 1,007 patients with LBP         

>50% successful return-to-work (RTW) by 12 weeks. Seven relevant questions to predict RTW. “Do you think you will be back to your normal work in 3 months?” “Does your pain radiate into your arms or legs?” “Have you ever had back surgery?” “On a scale of 0-10, how do you rate your pain?” “Lately because of your back pain, do you change position often?” “Lately because of your back pain, are you more irritable?” “Does your back pain affect your sleep?”

Dionne CE, et al. A clinical return-to-work rule for patients with back pain. CMAJ 2005;172:1559-1567.

Common-sense summary 



Include a screen for depression and the Oswestry Disability Index and Fear Avoidance Beliefs Questionnaire in your initial evaluation of a patient with LBP Implement appropriate intervention if risk factors for chronic LBP are present

History of Current Complaint   



Timeline Mechanism of injury Management of complaint and effect of various management strategies Diagnostic tests done…

Medical History    

Previous medical history Family history Medication use Imaging and lab test findings

Social History   

Occupation Leisure time activities Environment/social role

Open versus Closed Questions? 



Anything else I forgot to ask that might be relevant or related to your current complaint? Limit open question but give the patient a chance to have his or her say…

Physical Examination   



Observation Active range of motion testing Neuroconductive testing including straightleg raise Special tests

Active Range of Motion Testing 





Cardinal plane motions: Flexion, extension, rotation, sidebending Combined motions: Flexion and extension with ipsilateral sidebending/rotation Repeated motion testing: McKenzie or Mechanical Diagnosis and Therapy

Neuroconductive Examination: Patellar DTR 





Sensitivity of 12% and a specificity of 65% in the diagnosis of L4 nerve root compression Sensitivity and specificity were 100% and 65%, respectively, for L3 nerve root compression Sensitivity and specificity were 14% and 65% for L5 nerve root compression

Knuttson B. Comparative value of electromyographic, myelographic, and clinical-neurological examinations in diagnosis of lumbar root compression syndrome. Acta Orthop Scand 1961;(Suppl 49):19-49.

Neuroconductive Examination: Achilles DTR 



Sensitivity of 87% and specificity of 89% in the diagnosis of L5-S1 disk herniation Sensitivity of 12% and specificity of 89% for the diagnosis of L4-L5 disk herniation.

Kerr RSC, Cadoux-Hudson TA, Adams CBT. The value of accurate clinical assessment in the surgical management of the lumbar disc protrusion. J Neurol Neurosurg Psychiatry 1988;51:169-173.

Neuroconductive Examination: Myotomal Strength (Kerr et al, 1988) 





Hip extension weakness for the diagnosis of L4L5 and L5-S1 disc protrusion: sensitivity was 12% and 9% and specificity 96 and 89%, respectively. Ankle dorsiflexion weakness had a sensitivity of 33%, 66%, and 49% for L3-L4, L4-L5, and L5-S1 disc protrusion, respectively; specificity values were 89% for all levels Ankle plantar-flexion weakness had 0%, 0%, and 28% sensitivity for the diagnosis of L3-L4, L4-L5, and L5-S1 disc protrusion, respectively; specificity values were 100% for all levels

Neurodynamic Examination: Dermatomal Light Touch L4 (L3-L4 disc herniation) L5 (L3-L4 disc herniation) S1 (L3-L4 disc herniation) L4 (L4-L5 disc herniation) L5 (L4-L5 disc herniation) S1 (L4-L5 disc herniation) L4 (L5-S1 disc herniation) L5 (L5-S1 disc herniation) S1 (L5-S1 disc herniation)

Sensitivity 0.50 0.50 0.0 0.59 0.50 0.23 0.16 0.42 0.74

Specificity 0.875 1.0 0.875 0.875 1.0 0.875 0.875 1.0 0.875

+ LR 4 NA 0 4.7 NA 1.8 1.3 NA 5.9

-LR 0.6 NA 0 0.5 NA 0.9 0.96 NA 0.3

Straight Leg Raise 

  



Positive test for presence of disk herniation: reproduction of back or leg pain at less than 40 degrees Sensitivity 91%; specificity 26% Crossed straight leg raise Positive if reproduction of pain in involved leg Sensitivity 29%; specificity 88%

Additional Tests  

Prone knee bend test Slump test

Special Tests   

Hip passive range of motion Sacroiliac tests Segmental tests: accessory motion, physiological motion, stability

Hip Osteoarthritis Test cluster 1   

Hip pain Hip IR rotation ROM < 15 degrees Hip flexion ROM < 115 degrees

Hip Osteoarthritis Test cluster 2 (if hip IR ROM > 15 degrees)   

Painful hip with IR >50 years of age Morning stiffness <60 minutes

Hip Osteoarthritis 



All 3 components of either test cluster present: + LR = 3.4 If all three are not met: - LR = 0.19

Altman R, et al. The American College of Rheumatology Criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 1991;34:505514.

Sacroiliac Joint Tests     

Compression Distraction Torsion (Gaenslen) Thigh thrust Sacral thrust

Sacroiliac Joint Tests  



Three or more positive pain provocation SIJ tests have sensitivity of 91% and specificity 78%, respectively. Specificity of three or more positive tests increases to 87% in patients whose symptoms cannot be made to move towards the spinal midline, i.e., centralize. In chronic back pain populations, patients who have three or more positive provocation SIJ tests and whose symptoms cannot be made to centralize have a probability of having SIJ pain of 77%, and in pregnant populations with back pain, a probability of 89%.

Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Manual Manipulative Ther 2008;16:142-152.

Active Straight Leg Raise Test  



Test of load transfer Supine 5-10 degree active straight leg raise Near-perfect association with radiological instability sacroiliac joint

Mens JMA, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ. The active straight leg raise test and mobility of the pelvic joints. Eur Spine J 1999;8:468-473.

Segmental tests  





Motion and provocation tests Accessory motion tests: prone posteriorto-anterior pressure Physiological motion tests: Flexion, extension, sidebending, rotation Stability: Translational mobility

Accessory Motion Tests

Physiological Motion Tests

Segmental Motion Tests      

Combination of accessory and physiological manual tests Compared to lumbar spinal block Prospective study component Segmental dysfunction based on both mobility and pain findings Sensitivity 95% Specificity 100%

1Phillips DR, Twomey LT. A comparison of manual diagnosis with a diagnosis established by a uni-level lumbar spinal block procedure. Man Ther 1996;2:82-87.

Palpation     



Diagnosis myofascial trigger points Essential criteria include: Taut band palpable (where muscle is accessible) Exquisite spot tenderness of a nodule in a taut band Patient recognition of current pain complaint by pressure on the tender nodule (identifies an active trigger point) Painful limit to full stretch range of motion

Palpation    



Confirmatory observations are: Visual or tactile identification of a local twitch response Imaging of an local twitch response induced by needle penetration of tender nodule Pain or altered sensation (in the distribution expected from a trigger point in that muscle) on compression of tender nodule Electromyographic demonstration of spontaneous electrical activity characteristic of active loci in the tender nodule of a taut band

Simons DG, Travell JG, Simons LS. Travell and Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Vol. 1. Baltimore, MD: Williams & Wilkins, 1999.

Imaging and Lab Tests   



Imaging not required when red flags are absent High number of false positives of CT and MRI Imaging needs to be interpreted in light of findings of clinical examination Lab tests?

Management    



Medical management Surgical management Other specialist referral Physiotherapy: Evaluation and diagnosis, education, exercise, manual therapy and massage, modalities, acupuncture and dry needling, orthotics/bracing/taping, ergonomic advice and adaptations Other

LBP Myths “Randomized controlled trials, studies into diagnostic accuracy, systemic reviews, and meta-analysis with provide the answer to all our diagnostic and management dilemmas!”

Anybody for exercise? 

Systematic review on the use of exercise therapy for acute and chronic LBP:  No indication that specific exercises are effective for treatment of acute LBP.  Conflicting evidence on the effectiveness of exercise therapy compared with inactive treatments for chronic LBP.  Exercise therapy was more effective than usual care by the general practitioner and just as effective as conventional PT for chronic LBP. Van Tulder M, et al. Exercise Therapy for Low Back Pain: A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000;25:2784-2796

Systematic review on the use of exercise therapy for acute and chronic LBP:  Reviewed

only articles that used a diagnostic classification method with implications for treatment  Only 5/82 studies met inclusion criteria  Exercise better than pragmatic control interventions in 4/5 studies Cook C, et al. Physical therapy exercise intervention based on classification using the patient response method: A systematic review of the literature. J Manual Manipulative Ther 2005;13:152-162.

Meta-analysis on exercise for non-specific LBP Slightly

effective at improving pain and function in chronic LBP Graded

activity decreases sick-leave in subacute LBP As

effective as no treatment in acute

LBP Hayden JA, et al. Meta-analysis: Exercise therapy for non-specific low back pain. Ann Intern Med 2005;142:765-775.

Advice to stay active? Systematic review on advice to stay active as a single treatment: Little beneficial effects for patients with LBP.  Little or no effect for patients with sciatica.  Better than advice to have bed rest. 

Hagen KB, et al. The Cochrane Review of advice to stay active as a single treatment for low back pain and sciatica. Spine 2002;27:1736-1741.

Manipulation? Meta-analysis manipulation versus other therapies: No evidence that manipulation is superior to other standard treatments for patients with acute and chronic LBP. Assendelft WJJ, et al. Spinal manipulative therapy for low back pain. Ann Intern Med 2003;138:871-881.

Systematic review of spinal mobilization and manipulation for LBP and neck pain: Moderate

evidence favoring manipulation over mobilization for acute LBP. Moderate

evidence that manipulation and mobilization are more effective than general practitioner care and placebo for chronic LBP. Manipulation

and mobilization is a viable treatment option for patients with LBP. Bronfort G, et al. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: A systematic review and best evidence synthesis. Spine 2004;4:335-356.

Common-sense summary Inconclusive, inconsistent, and even contradictory summary statements from systematic reviews and meta-analysis are not much help for the clinician…

Systematic reviews and metaanalysis of controlled clinical trials using heterogenous populations or people with LBP based on timedelineated or structure-based classification systems will not provide information useful for management of LBP

However, pragmatic trials with homogenous populations based on a treatment-based classification system are much more likely to produce clinically relevant information!

Clinical Implication Classify patients using a TREATMENT-BASED diagnostic classification model and treat accordingly for optimal outcome

University of Pittsburgh Diagnostic Classification System 

 





Attempts to provide subclassification of the heterogenous group of patients with non-specific LBP into 4 homogenous subgroups based on physical therapy treatment response. Initially based on expert consensus. Four different treatment-based diagnostic categories: stabilization, manipulation, specific exercise, and traction. Established interrater reliability classification decisions: Kappa=0.60. Interrater reliability irrespective of therapist level of experience.

Fritz JM, et al. An examination of the reliability of a classification classification algorithm for subgrouping patients with low back pain. Spine 2006;31:772006;31:77-82.

STABILIZATION CATEGORY:       

Average SLR PROM >91°. Positive prone instability test. Positive aberrant movements: painful arc, catch, climbing thighs. Hypermobility with prone spring testing. Increasing LBP episode frequency. Three or more prior episodes. Age <40 years.

TREATMENT: Trunk strengthening and stabilization exercises.

STABILIZATION CATEGORY: 

Variables associated with failure of a stabilization approach were (Hicks et al, 2005):



Negative prone instability test Absence of aberrant motions Absence of hypermobility on lumbar spring testing Fear Avoidance Beliefs Questionnaire Physical Activity (FABQ-PA) subscale score of < 9

  



Two or more of these variables present carried a negative LR of 0.18 (95% CI: 0.08-0.38)

MANIPULATION CATEGORY: Recent

onset of symptoms, i.e. <16 days.

Hypomobility No

on prone spring testing.

symptoms distal of the knee.

Low

FABQ score (<19)

TREATMENT: Manual therapy and end or range motion exercises.

SPECIFIC EXERCISE CATEGORY:

  

Preference for sitting (flexion category) or walking (extension category). Centralization of symptoms with repeated movement testing. Peripheralization of symptoms with repeated movement testing in opposite direction.

TREATMENT: Repeated end of range exercises.

TRACTION CATEGORY: Radicular

symptoms.

Symptoms

did not improve with any movement

Symptoms

worsened with most movement tests.

tests.

TREATMENT: Traction and repeated end of range exercises. Fritz JM, et al. An examination of the reliability of a classification algorithm for subgrouping patients with low back pain. Spine 2006;31:77-82.

Five-factor clinical prediction rule manipulation and LBP: 

    

Positive response defined as a >50% improvement in ODI score in one to two treatments. Duration of current episode <16 days. No symptoms distal to the knee. FABQ work subscale score <19. Prone hypomobility testing indicates one or more hypomobile segments. One or both hips have >35° of internal rotation in prone position.

Patients

with 4 of 5 criteria clinical prediction rule met and who received manipulation has an odds ratio for successful outcome of 60.8. Childs JD, et al. 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;141:920-928.

Two-factor clinical prediction rule manipulation and LBP:   

Duration of current symptoms <16 days. No symptoms distal to the knee. Positive likelihood ratio for 50% decrease in ODI if positive on the two-factor rule and treated with manipulation: 7.2.

Fritz JM, et al. Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following brief spinal manipulation intervention. BMC Family Practice 2005;6:29.

Four-factor clinical prediction rule stabilization and LBP: Positive

response defined as a >50% improvement in ODI score after twice a week treatment for 8 weeks. Age

>40 years.

Average

SLR >91°.

Aberrant

movement present.

Positive

prone instability test.

If

3 of 4 criteria clinical prediction rule were met the positive likelihood ratio for success with stabilization was 4.0. Hicks JM, et al. 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;86:1753-1762.

Common-Sense Summary 



A treatment-based classification for patients with non-specific LBP has the potential of producing an optimal diagnosis-intervention combination. Preliminary research indicates the ability to reliably and with prognostic validity classify patients with non-specific LBP

How about cost?  

Manipulation clinical prediction rule validation study At the 6-month follow-up patients, who had received manipulation had significantly lower health care utilization, medication use, and time off work due to LBP than those receiving exercise only Childs JD, et al. 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;141:920-928.

UK

BEAM trial comparing physician management to manipulation or manipulation and exercise for nonspecific LBP Economic

analysis

Manipulation

or manipulation combined with exercise was most the cost-effective approach to the management of patients with LBP UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomized trial: Cost effectiveness of physical treatments for back pain in primary care. BMJ 2004;329:1381.

 



Patients with occupational LBP that fit the twofactor clinical prediction rule Receiving thrust and non-thrust techniques resulted in greater reductions in disability and pain than not receiving these interventions However, physical therapy treatment cost, number of therapy sessions, and duration of stay in therapy were significantly smaller in the thrust as compared to the non-thrust group Fritz JM, Brennan GP, Leaman H. Does the evidence for spinal manipulation translate into better outcomes in routine clinical care for patients with occupational low back pain? A case-control study. Spine J 2006;6:289-295.

Common-Sense Summary A

treatment-based classification for patients with non-specific LBP has the potential of producing an optimal diagnosis-intervention combination

Preliminary

research indicates the ability to reliably and with prognostic validity classify patients with non-specific LBP

 Treatment-based classification and intervention seem to provide for superior outcome with regard to pain, function, and health care cost

Mechanism-Based versus Treatment-Based 



The mechanism-based classification system is based on the premise that impairments identified during examination are the cause of musculoskeletal pain and dysfunction In the treatment-based system, a cluster of signs and symptoms from the patient history and physical examination is used to classify patients into subgroups with specific implications for management

Adult Case: Back Pain With ibuprofen and physiotherapy there is no significant improvement. In fact, at four weeks the pain is suddenly ten fold worse and shooting down the right leg. It is always present. He cannot walk or sit comfortably, his sleep is disturbed. He calls in sick to work. He is essentially immobile, and certainly not performing the physiotherapy exercises. He tries T3’s, and quickly is taking more than is recommended. Soon he obtains a prescription from hydromorphone from Dr Grey.

Can fear-avoidance beliefs be altered and how does this affect LBP and disability?

Cognitive-behavioral

programs.

Outpatient

pain management (psychologist and physical therapist) successfully affected pain beliefs, selfefficacy, and psychological distress. Decreased

fear-avoidance beliefs and perceptions of control over pain explained 71% of the variance of reductions in disability. Sowden, Sowden, et al. Can four psychosocial risk factors for chronic pain and disability (Yellow Flags) be modified by a pain management programme: programme: A pilot study. Physiother 2006;92:432006;92:43-49. Woby SR, et al. Are changes in fear avoidance beliefs, catastrophing, catastrophing, and appraisals of control, predictive of changes in chronic low back pain and disability. disability. Eur J Pain 2004;8:2012004;8:201-210.

TAKE-HOME MESSAGE 



Differential diagnosis by the physician and medical screening by the physical therapist is aimed at identifying those patients with non-mechanical LBP that require medical-surgical management Screening for risk factors and appropriate intervention may decrease the transition from acute to chronic LBP and disability

TAKE-HOME MESSAGE 



Diagnosis of mechanical LBP aims to classify the patient into a treatment-based diagnostic category with clear implications for management Mechanism-based treatment is used when guidance based on treatment-based research is lacking

TAKE-HOME MESSAGE 

  

Remember the three pillars of evidencebased medicine 1. Best available evidence 2. Clinician expertise 3. Patient preference