Regis Class Of 2009 Lbp Aop Project

Practice Patterns of Physical Therapist Interns Managing Low Back ►Christopher Beaudoin, SPT Pain Heather Berube, SPT ►Mutya

Castilla, SPT Nathan Edwards, SPT ►Mariah Marsh, SPT Jennifer Williams, SPT ►Research Advisor: Tim Flynn, PT, PhD

Is this important…

Deyo et al 2009

Fritz et al, JOSPT 2007

Spinal manipulation is an effective and lower cost treatment for patients with LBP. 

Brennan et al , Spine, 2006

Ø However, manipulation is underutilized by physical therapists when compared to other common interventions which lack the same level of evidence.

Medical Model of Disease

Signs/symptoms analyzed

Pathology is determined Treatment corrects pathology Signs/symptoms disappear

Implications of the Medical Model Signs and symptoms are directly proportional to the underlying pathology ► Identifying the underlying pathology is critical for guiding treatment ► Signs and symptoms should disappear when pathology is corrected ►

Shortcomings of the Medical Model

15% of LBP can be given a specific pathoanatomical diagnosis ► The remaining - grouped as a homogenous entity (low back sprain/strain, lumbago, mechanical low back pain, etc.) ► Only

Shortcomings of the Medical Model ►

“Treatment of back pain according to the disease model has failed because there is a fundamental flaw to the approach. The disease model views back pain and disability only in terms of spines and physical disease. It does not allow for the complex human responses to pain and disability.” (Waddell, 1998)

Classification “The objectives of a physical therapy diagnosis are focused on classifying movement dysfunction rather than disease and are directed primarily to planning and predicting outcome of treatment.” (Rose, 1989)

Classification Classification systems must specifically direct treatment and improve outcomes. “It is rare to find anyone with a clear idea of what form of physiotherapy is indicated for which type of back pain… The situation takes on the characteristics of a lottery… with treatment left to the whim of the therapist, it is not surprising that the results are often poor.”

Treatment-Based Classification System

“This examination approach leads to a classification that is detailed with regard to the precise type of treatment to be prescribed, and not relegated to nonspecific terminology where any number of conservative strategies can be used for one classification.” (Delitto et al, Phys Ther, 1995)

LBP Treatment Manipula tion No sxs below knee Recent symptoms Hypomobility Low FearAvoidance More hip IR

Manipulation & exercise

Specific Exercise

Stabiliza tion

Traction

 Centralization phenomenon with movement exam

 Prone instability test  Aberrant motions  Hypermobili ty  Younger age

 Neurological Signs  Leg Symptoms  Peripheraliza tion with movement testing  Crossed

Activities to Promote Centralization

Stabilization exercises

Mechanical or Autotraction

Methods

Methods

Did Function & Disability Improve?

P<0.000 1

MCID ~ 6 points

Average Number of Visits = 7

How were patients initially classified? 11.8

22

Graded Mobilization 18.4

Manipulation

9.9 Stabilization Flexion DP Extension DP 52.6

Traction

How often were patients correctly classified?

62%

Did correct classification and the matched treatment improve

p=0.4 4

N =62

N =12

Was there a difference in the group most frequently treated with an unmatched

Discussion ► Patients

experienced a 32% improvement in Oswestry Disability Index

Regis interns were implementing a standardized evidence-based decision making process for patients with LBP 100% of time 



► Data

suggests that patients’ fear of movement may be changed with physical therapy

Grade V (thrust) manipulation is not allowed in Washington Clinical instructor dictated the plan of care A perceived disconnect between CI experience based decision making and current best practice. 

Limitations ► LBP

treatment-based classification systems were developed with patients with acute symptoms from 18-59 yrs ► Non-randomized ► Small number of patients with complete follow up data that were incorrectly classified and/or received unmatched treatment ► Low statistical power

Future Research ► Educational

modules for students and clinical instructors to change clinician behaviors § To improve initial classification for patients with LBP § To improve treatment of patients with LBP

► FABQ

(research in progress)

Conclusion ► Patients’

level of disability improved with physical therapy intervention for low back pain. ► It may be possible to change patients’ fear-avoidance beliefs through physical therapy treatment.

Dr. Tim Flynn

KEEP ON ROCKIN IN THE FREE WORLD

Questions?