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Low Back Pain Pearls of Wisdom. Dave Snyder, PT, OCS October 20 th , 2011. Popular Questions…. What can I do to help my patients with back pain get better faster? Is there an exercise sheet I can give out that will get my patients with back pain better? - PowerPoint PPT Presentation
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Dave Snyder, PT, OCSOctober 20th, 2011
Popular Questions…..What can I do to help my patients with back pain get better faster?
Is there an exercise sheet I can give out that will get my patients with back pain better?
What role does physical therapy play in managing low back pain?
Low Back PainUp to 90% of patients with LBP cannot be given a precise pathoanatomical diagnosis Common diagnosis’s include lumbar strain, lumbago, or back painIn the older literature, LBP was viewed as a homogeneous group, leading to no conclusive results of any specific interventionsAlbenhaim, et., al. Spine, 1995, 20:791-795
Low Back PainNonspecific LBP is not a
homogeneous entityCurrent literature suggests the need
to subdivide LBP into smaller sub groups in order to design more precise and effective treatment plans
Kent, Spine, 2004;29:1022-1031
If you send a patient w/ LBP to PT…First we complete a thorough evaluation.With the data collected we attempt to categorize
the patient into one of 6 treatment categories¹Manipulation,StabilizationSpecific Exercise Extension, Flexion, or Lateral
shift Traction
• As the patient proceeds through the rehab process, based on their presentation, the patient may change categories
¹ Dellito, et al. Physical Therapy; 75:470-484
So what does this mean for my practice?In order to offer an intervention during your visit,
you need to take a few moments to identify what your patients actual impairments are
This requires a little extra time to be spent on the subjective and objective portion of your routine exam in order to appropriately classify your patient into a treatment group
If you skip this step, your intervention has a high likelihood of failing and may even hurt the patients condition
First, lets review the basics…CONTINUE TO:Follow normal practice guidelines and procedures to arrive at a medical diagnosisOrder appropriate diagnostics per your standard proceduresOffer pharmacological interventions per your practice guidelinesRefer appropriate patients to Ortho Spine, Physiatry, and Physical Therapy
Before you can offer a movement intervention……Subjective
Try to identify mechanism of injury
Also, try to…Identify a pain generatorIdentify a position of
comfortIdentify aggravating and
easing factors
Other good questions to askHas this happened before? What did you do to feel better?Have you been to therapy before for this
same problem? Did it work? Are you still doing the exercises?
Subjective Continued…Try to categorize patient as Acute vs. Chronic
Interventions and goals of these interventions are different based off of this classification
Acute/Sub Acute LBPDifficulty performing
basic ADLsIncreased levels of self
reported pain and disability
Recent onset with a recallable mechanism of injury
Recent flair up of chronic condition
Chronic LBP
Can perform basic ADL’sHave lower levels of pain and
disabilityHas pain with more
demanding activities
Subjective Continued…Is the patient fearful of movement?Does the patient seem to go out of their way
to avoid pain because of this fear?
If Fear Avoidance is present..
Consider instituting a cognitive behavioral approach to managing the patients care when it is deemed appropriate¹
¹George, Et. Al. Spine 2003; 28: 2551-2560
What does that mean??Establish the need
for exercise to be part of the solution to the patients condition
Establish clear exercise goals that are agreed upon by the patient and the team delivering the care
At this point, what do we know?Mechanism of InjuryPosition of comfortIdentified possible pain
generatorAcute vs. ChronicFear avoidance behavior
identified
Objective Exam:Continue to perform appropriate
objective measures to arrive at your medical diagnosis
In addition, each of the following suggestions will help you to identify impairments that you can offer quick and easy interventions that are highly effective.
Consider your patients posture
Why is posture so important?
What can we learn from posture?
Start with minimal corrections…
Neutral Spine Instruction
Posture with ADLs
Posture with ADL’s continued
Posture with ADL’s continued:log roll supine to sit
Modalities: Ice vs. Heat….Ice when movement
leads to painCool off the fire!
Heat when pain limits movementWarm up the motor!
TARGET THIS INTERVENTION TO THE SUSPECTED PAIN GENERATOR
Should I try to teach the patient specific stretching or strengthening?
Specific Exercise Instruction Requires:Specific impairments measured in
conjunction with faulty movement patterns identified that allows one to make a logical conclusion as to why the patient presents with their particular subjective complaintsShort Hamstrings with posterior pelvic tilt and
long /weak erector spinae muscles leading to excessive compressive forces at L4/L5 disc leading to discogenic pain limiting patients ability to perform ADL’s.
OK…then what should I do?#1 Priority is to diagnose the problem as
accurately as possible with the information you have, within the time frame you have to figure out the problem
Rule out red flags if presentFollow the suggestions outlined in today's talkConsider recommending pain free general
exercise to your patient.Cardiovascular endurance type activityPain free during and after activitySomething that the patient would enjoy to do
regularly
Who needs a PT referral?Mechanical connection to painNever had PT before for this problemHad PT before, it helped, but now the condition
has changed and the patient would benefit from a second look by a PT
Impairments identified that correlate to condition and are potentially correctable with specific exercise or other therapeutic intervention
Patient interested in learning exercises to help improve their condition
What will we do with your referralPrioritize the patients diagnosis and schedule
accordinglyComplete a full evaluation (1 hr) and develop
a unique rehabilitation program to address the impairments found in the evaluation, and set clear goals for the treatment.
Once goals are met, discharge the patient with an independent self management program
QUESTIONS?????