Evidence Based Treatment of the Lumbar Spine - AHN · Evidence Based Treatment of the Lumbar Spine Objectives Discuss incidence, prevalence and economic impact of low back pain Discuss

04/04/2016

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Matthew Caster PT, DPT, OCS

Allegheny Chesapeake Physical Therapy

Evidence Based Treatment of the

Lumbar Spine

Objectives

Discuss incidence, prevalence and economic impact of low

back pain

Discuss current guidelines and classification systems

Present current updated Treatment Based Classification

System (TBC)

Case examples

LBP defined

Pain, stiffness or muscle tension below the costal margin and

above the inferior gluteal folds

Can be with or without leg pain

Chronicity

Acute < 6 weeks

Sub-acute 6 to 12 weeks

Chronic > 12 weeks

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LBP

Common disorder that is a burden to individuals and society

Lifetime prevalence approximately 84%

60 to 80% of Americans will suffer an episode of LBP

resulting in loss of work

Economic Impact

USA: annual cost over $50 billion

Low Back Pain

Non-Mechanical

Prevalence 3%

Mechanical

Prevalence 97%

Pathologies

Red Flag / Non-mechanical (prevalence 1%)

Neoplasia

Infection

Inflammatory arthritis

Paget and Scheumerman disease

Jarvik and Deyo. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Annals of Internal Medicine

2002; 137: 586-597.

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Pathologies

Red Flag / Visceral (prevalence 2%)

Aortic aneurysm

Pelvic

Renal

GI


2002; 137: 586-597.

Pathologies

Mechanical LBP (prevalence 97%)

Strain

DDD / facet

Herniated disc

Stenosis

FX

Spondy

Congenital

Instability


2002; 137: 586-597.

Approximately 85% of patients are unable to be given a

specific structurally based (patho-anatomic) diagnosis

“Non-specific low back pain”

How can we effectively treat this large group?

Deyo RA, Phillips WR. Low back pain: a primary care challenge. Spine (Phila Pa 1976) 1996;21:2826-32.

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Guidelines vs Classification Systems

Guidelines

Summary of available evidence

Developed from a clinical perspective

Classification Systems

Match treatments to patient sub-groups using a clinically driven

decision making process

American College of Physicians &

American Pain Society Acute LBP

Spinal Manipulation

Chronic / sub-acute LBP Interdisciplinary rehabilitation Exercise therapy Acupuncture Massage therapy Spinal manipulation Yoga Cognitive behavioral therapy

o Chou et al. Diagnosis and Treatment of Low Back Pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147(7):478-491.

European Spine Journal 2011

Intervention Effectiveness

Exercise Therapy

“Back School”

TENS

Heat / Cold

Low-level Laser Therapy

Patient Education

Traction

Massage

Behavioral Treatments

Lumbar Support

Multidisciplinary Treatment

Middlekoop et al. A systematic review on the effectiveness of physical and rehabilitation

interventions for chronic-non specific low back pain. Eur Spine J 2011 20: 19-39

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Intervention Effectiveness

Exercise Therapy

“Back School”

TENS

Heat / Cold

Low-level Laser Therapy

Patient Education

Traction

Massage

Behavioral Treatments

Lumbar Support

Multidisciplinary Treatment

Middlekoop et al. A systematic review on the effectiveness of physical and rehabilitation

interventions for chronic-non specific low back pain. Eur Spine J 2011 20: 19-39


Summary of recommendations for the treatment of low back

pain

Acute or Sub acute

Re-assure patients

Advise to stay active

Prescribe meds if necessary (time contingent)

Discourage bed rest

Do not advise a supervised exercise program

Koes et al. Eur Spine J. 2010 Dec; 19 (12): 2074-94.

European Spine Journal

Summary of recommendations for the treatment of low back

pain

Chronic low back pain

Discourage use of modalities

Short term use of meds / manipulation

Supervised exercise

Cognitive behavioral therapy

Multidisciplinary treatment

Koes et al. Eur Spine J. 2010 Dec; 19 (12): 2074-94.

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Treatment results?

Despite much research there is little consensus on the most

effective treatments for individuals with non-specific low

back pain.

Guidelines summarize research

Heterogeneous sample sizes + wide inclusion criteria

= diluted treatment effect

Classification Systems

Mechanical Diagnosis and Treatment (MDT)

Treatment Based Classification (TBC)

Pathoanatomic Based Classification (PBC)

Movement System Impairment Syndromes (MSI)

O’sullivan Classification System


Developed in 1995

3 “levels”

1. Referral?

2. Staged based on acuity if symptoms

3. Classified into “syndromes”

History and examination drive the decision making process

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Updated in 2007

Clinical trials showed improved patient outcomes

Clinical prediction rules were further developed

FABQ (fear avoidance)

4 classification groups emerged


Group into one of four categories based on patient response

to examination:

Specific Exercise

Mobilization

Immobilization (stabilization)

Traction

Specific Exercise

Prescribe exercises that “centralize”, reduce symptoms or

address the primary condition

Centralization: pain arising from the spine and felt laterally or

distally into an extremity is reduced and moves to a more

central position during certain movements

Creates a “directional preference”

Similar to McKenzie approach

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Specific Exercise

Inclusion criteria:

Centralization with two or more movements in the same

direction

Or

Centralize with movement in one direction and perpheralize

with an opposite movement

Study: 84% of patients who performed appropriate directional preference

ex had significant decrease in pain and disability in 2 weeks

Long et al. Specific directional exercises for patients with low back pain: a case series. Physiother Can. 2008:60(4):307-

317.

Centralization

Mobilization

Inclusion criteria:

Duration of symptoms less than 16 days

No symptoms distal to the knee

Low FABQ (less than 19)

Hip internal rotation > 35°

Hypomobility with spring testing

Must meet 3

≥ 4 = 50% reduction in ODI score over 2 treatments Childs et al. A clinical prediction rule to indentify patients with low back pain most likely to benefit from spinal

manipulation: a validation study. Ann Intern Med. 2004 141(12):920-928

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Manipulation / mobilization

Stabilization

Inclusion criteria:

Average SLR > 90°

Positive prone instability test

Positive abberant movements

Age < 40

≥ 3 = 80% probability of improvement Fritz et al Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop

Sports Phys Ther. 2007;37:290-302.

Stabilization

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Traction

Inclusion criteria:

Signs and symptoms of nerve root compression

+SLR, reflex / sensory / muscular weakness

Pain or numbness distal to the buttock in previous 24 hours

Peripheralization / symptoms with extension

+XSLR

Must meet all criteria (short term benefit compared to no

traction group) Fritz et al. Is there a subgroup of patients with low back pain likely to benefit from mechanical traction: results of a

randomized clinical trial and subgrouping analysis. Spine (Phila Pa 1976). 2007; 32:E793-E800.

Traction

Limitations of 2007 TBC model

25% of test subjects met criteria for more than one subgroup

Most common overlap: Mobilization & specific exercise

Another 25% did not meet any subgroup

Stanton et al. Evaluation of a treatment based classification algorithm for low back pain: a cross sectional study. Phys Ther.

2011;91:496-509.

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TBC 2015 Update

Initial “first contact” triage (various health care providers)

3 Managements tracks

Rehab professional triage process

3 Approaches

Assess risk at both levels (1st provider & rehab professional)

Co-morbidities

Fear avoidance

Alrwaily et al. Treatment based classification system for low back pain: revision and update. Phys Ther 2016. DOI

http://dx.doi.org/10.2522/ptj.20150345

Triage by “first contact” health care

provider

Medical management

Red-flag

Screen co-morbidities

Self-care management

Unlikely to develop disabling LBP during current episode

Provide advice / guidance

Rehabilitation management

Majority of patients with LBP

Triage by rehabilitation provider Placed into one of 3 rehabilitation “approaches”

Symptom modulation

Movement control

Functional optimization

Relies on assessment of pain, disability and perception of clinical status (risk)

STarT Back Tool

Orebro Musculoskeletal Pain Questionnaire

FABQ

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Symptom Modulation Approach

Clinical Findings

Disability: high

Symptom status: volatile

Pain: high to moderate

Treatments

Directional preference exercise

Manipulation / mobilization

Traction

Active rest

Symptom Modulation Approach

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Movement Control Approach

Clinical Findings

Disability: moderate

Symptom status: stable

Pain: moderate to low

Treatments

Sensorimotor exercises

Stabilization exercises

Flexibility exercises

Movement Control Approach

Functional Optimization Approach

Clinical Findings

Disability: low

Symptom status: controlled

Pain: low to absent

Treatments

Strength and conditioning exercises

Work / sport specific tasks

Aerobic exercises

General fitness activity

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Functional Optimization Approach

Case 1

55 y/o housekeeping employee at SNF

Injured left low back moving hospital bed

Symptom duration: 2 weeks

Pain: 4/10 intermittent bending / lifting

Work status: light duty

Medication: Naprosyn, Flexeril

Wishes to resume resistance exercise

PMH: HBP, TTDM

Case 1


Exam:

FABQ 10

FOTO score 55

Lumbar AROM WNL: pain with extension overpressure (L lumbar)

Limited P-A mobility left L4 – L5 segments

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Case 1


Decision making using updated TBC

Symptoms: stable

Pain: moderate to low

Disability: moderate

Movement control approach

Sensitized neurologic structure? No

Joint mobility impairment? Yes

Treatment: manipulation

3 visits: 1/10 pain, FOTO score 72

Case 2

27 y/o graduate student / barrista

Belted driver in MVA 3 weeks ago

Pain 8/10 central low back and right leg

Symptoms: sleep, walk, stand

Meds: hydrocodone

Unable to return to school / work due to symptoms

Case 2


Exam

FABQ 60

ODI 74

Pain and limited AROM: flexion and extension

+ right SLR

Symptoms centralize with extension

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Case 2


Decision making using updated TBC

Symptoms: volatile

Pain: high

Disability: high

Symptom modulation approach

Symptom centralization? Yes, extension

Treatment: prescribe extension exercises

6 visits: ODI 34, return to work / school

Stay tuned!

More research to be published on TBC

Thank you!

Documents

Evidence Based Treatment of the Lumbar Spine - AHN · Evidence Based Treatment of the Lumbar Spine Objectives Discuss incidence, prevalence and economic impact of low back pain Discuss