Presentation on advances in the physical therapy diagnosis, prognosis, and management of patients with low back pain

8/14/2019 Presentation on advances in the physical therapy diagnosis, prognosis, and management of patients with low back pain

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ADVANCES IN DIAGNOSIS, PROGNOSIS,ADVANCES IN DIAGNOSIS, PROGNOSIS,

AND MANAGEMENT OFAND MANAGEMENT OF

LOW BACK PAINLOW BACK PAIN

Presented byPresented by

Peter Huijbregts, PTPeter Huijbregts, PT

Physiotherapy Orthopaedic ForumPhysiotherapy Orthopaedic ForumTuesday, May 8Tuesday, May 8th,th, 20072007

Victoria General HospitalVictoria General Hospital


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About your Presenter:About your Presenter:

B.Sc. Physiotherapy, 1990B.Sc. Physiotherapy, 1990

M.Sc. Manual Therapy, 1994M.Sc. Manual Therapy, 1994

M.H.Sc. Physical Therapy, 1997M.H.Sc. Physical Therapy, 1997 Doctor of Physical Therapy, 2001Doctor of Physical Therapy, 2001

Fellow in AAOMPT and CAMTFellow in AAOMPT and CAMT

BoardBoard--certified in Orthopaedic PTcertified in Orthopaedic PT


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Current Positions:Current Positions:

Consultant,Consultant, ShelbourneShelbourne Physiotherapy ClinicPhysiotherapy Clinic

Assistant Professor, USAHSAssistant Professor, USAHS EditorEditor--inin--Chief, JMMTChief, JMMT

Consulting Editor, Jones & BartlettConsulting Editor, Jones & Bartlett

Educational Consultant, Dynamic PhysicalEducational Consultant, Dynamic PhysicalTherapyTherapy


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About this presentation:About this presentation:

Presentation for general practitioners on statePresentation for general practitioners on state--

ofof--thethe--art physical therapy diagnosis, prognosis,art physical therapy diagnosis, prognosis,and managementand management

US physiciansUS physicians

Parallel to Canadian situation?Parallel to Canadian situation?


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A patient complains ofA patient complains of

low back painlow back pain

So now what do we do?So now what do we do?


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Topics:Topics:

EpidemiologyEpidemiology

LBP MythsLBP Myths

LBP FactsLBP Facts

Clinical ImplicationsClinical Implications

Other ResearchOther Research


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1.1. EpidemiologyEpidemiology


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Lifetime prevalence: 80% of all people willLifetime prevalence: 80% of all people will

experience LBP at some point in their livesexperience LBP at some point in their lives(Source: Waddell G. A new clinical model for the treatment of(Source: Waddell G. A new clinical model for the treatment of

lowlow--back pain.back pain. SpineSpine 1987;12:6321987;12:632--643)643)


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Back symptoms are the mostBack symptoms are the mostfrequently cited reason for consultingfrequently cited reason for consulting

orthopaedic andorthopaedic and neuroneuro--surgeons andsurgeons and

represent the second most commonrepresent the second most common

reason to visit a physicianreason to visit a physician

(Source: Taylor VM, et al. Low back pain hospitalization.(Source: Taylor VM, et al. Low back pain hospitalization. SpineSpine

1994;19:12071994;19:1207--1213)1213)


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Point prevalence for LBP in NorthPoint prevalence for LBP in North

American adults is estimated atAmerican adults is estimated at

5.6%: 10 million of 178 million US5.6%: 10 million of 178 million US

adults experience LBP at any givenadults experience LBP at any given

dayday

(Source:(Source: LoneyLoneyPL, Stratford PW. The Prevalence of low backPL, Stratford PW. The Prevalence of low backpain in adults: A methodological review of the literature.pain in adults: A methodological review of the literature. PhysPhys

TherTher1999;79:3841999;79:384--396)396)


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OneOne--year prevalence of LBP in Northyear prevalence of LBP in NorthAmerican adults: 32+/American adults: 32+/--23%: Up to 97.923%: Up to 97.9

million of 178 million US adults experiencemillion of 178 million US adults experience

LBP in the course of a yearLBP in the course of a year

(Source:(Source: LoneyLoneyPL, Stratford PW. The prevalence of low back painPL, Stratford PW. The prevalence of low back pain

in adults: A methodological review of the literature.in adults: A methodological review of the literature. PhysPhys TherTher

1999;79:3841999;79:384--396)396)


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What is the yearly cost toWhat is the yearly cost tosociety of LBP?society of LBP?

Greater than 10 billionGreater than 10 billion

pounds in the UKpounds in the UK

Greater than 170Greater than 170

billion dollars in the USbillion dollars in the US

(Source: Bishop A, Foster NE. Do(Source: Bishop A, Foster NE. Do

physical therapists in the Unitedphysical therapists in the UnitedKingdom recognize psychosocialKingdom recognize psychosocial

factors in patients with acute low backfactors in patients with acute low back

pain?pain? SpineSpine 2005;30:13162005;30:1316--1322)1322)


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CommonCommon--sense summary:sense summary: LBP is a big health care and societal problem. However, dontLBP is a big health care and societal problem. However, dont

we all know the following statements to be true?we all know the following statements to be true?

Most people get better no matter what we do.Most people get better no matter what we do.

The situation is definitely improving.The situation is definitely improving.

The health care community knows how to dealThe health care community knows how to deal

with the problem.with the problem.

EvidenceEvidence--based practice will provide thebased practice will provide the

definitive answer.definitive answer.


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The question is:

Are these commonly heardstatements fact or fiction?


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2. Low Back Pain Myths2. Low Back Pain Myths


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LBP Myth #1LBP Myth #1

8080--90% of people with LBP get90% of people with LBP getbetter in about 6 weeks irrespective ofbetter in about 6 weeks irrespective of

administration or type of treatment"administration or type of treatment"

(Source: Waddell G. A new clinical model for the treatment of lo(Source: Waddell G. A new clinical model for the treatment of loww--

back pain.back pain. SpineSpine 1987;12:6321987;12:632--643).643).


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PRIMARY CARE PHYSICIAN STUDY:PRIMARY CARE PHYSICIAN STUDY:

Follow up within 1Follow up within 1--2 weeks2 weeks -- 2%2%reported no pain or disability.reported no pain or disability.

At 3At 3--months follow upmonths follow up 21% reported21% reportedno pain or disability.no pain or disability.

At 12At 12--monthsmonths only 25% of thoseonly 25% of thoseinterviewed reported no complaints.interviewed reported no complaints.

SoSo 75%75% of those interviewed still hadof those interviewed still hadcontinuing LBP and disability at 1 yearcontinuing LBP and disability at 1 year..

(Source: Croft PR, et al. Outcome of low back(Source: Croft PR, et al. Outcome of low backpain in general practice: a prospective study.pain in general practice: a prospective study. BMJBMJ1998;316:13561998;316:1356--1359)1359)


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SYSTEMATIC REVIEW:SYSTEMATIC REVIEW:

62% of patients (range 4262% of patients (range 42--75%) still75%) stillexperience LBP at 12 months.experience LBP at 12 months.

16% (range 316% (range 3--40%) of patients still sick40%) of patients still sick--listed at 6 months.listed at 6 months.

Recurrence of LBP in 60% (range 44Recurrence of LBP in 60% (range 44--78%)78%)

Recurrent sickRecurrent sick--listing 33% (range 26listing 33% (range 26--37%)37%)

(Source:(Source: HestbaekHestbaekL, et al. Low back pain: what isL, et al. Low back pain: what isthe longthe long--term course?term course? EurEur Spine JSpine J 2003;12:1492003;12:149--165.)165.)


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CommonCommon--sense summary:sense summary:

The natural history of LBP is not asThe natural history of LBP is not as

benign as we might think!benign as we might think!


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There is no LBP epidemic: The situation isThere is no LBP epidemic: The situation isimprovingimproving


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National Hospital Discharge SurveyNational Hospital Discharge Survey

data (1979data (1979--1990):1990):Increase in low back surgery fromIncrease in low back surgery from147,500 to 279,000.147,500 to 279,000.

Increase from 102 to 158 low backIncrease from 102 to 158 low back

surgeries per 100,000 adults (adjustedsurgeries per 100,000 adults (adjustedfor population growth)for population growth)

NonNon--fusion surgery increased byfusion surgery increased by47%.47%.

Surgeries involving fusion increasedSurgeries involving fusion increasedwith 100%.with 100%.

(Source: Taylor VM, et al. Low back pain(Source: Taylor VM, et al. Low back painhospitalization.hospitalization. SpineSpine 1994;19:12071994;19:1207--1213.)1213.)


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Estimated yearly cost to societyEstimated yearly cost to societyfor LBP in the US:for LBP in the US:

1994: greater than 50 billion1994: greater than 50 billiondollars.dollars.

2005: greater than 170 billion2005: greater than 170 billiondollars.dollars.

(Sources: Taylor VM, et al. Low back pain(Sources: Taylor VM, et al. Low back painhospitalization.hospitalization. SpineSpine 1994;19:12071994;19:1207--1213.1213.

Bishop A, Foster NE. Do physical therapistsBishop A, Foster NE. Do physical therapistsin the United Kingdom recognizein the United Kingdom recognizepsychosocial factors in patients with acutepsychosocial factors in patients with acutelow back pain.low back pain. SpineSpine 2005;30:13162005;30:1316--1322.)1322.)


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It does not look like that peskyIt does not look like that pesky and veryand very

costlycostly LBP problem is being solved!LBP problem is being solved!


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The health care community knows how toThe health care community knows how tofix the LBP problem.fix the LBP problem.


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Annual LBPAnnual LBP surgerysurgery rates in the US (1988rates in the US (1988--1990):1990):

113 per 100,000 in the Western US.113 per 100,000 in the Western US.

131 per 100,000 in the Northeastern US.131 per 100,000 in the Northeastern US.

157 per 100,000 in the Midwest.157 per 100,000 in the Midwest.171 per 100,000 in the South171 per 100,000 in the South

Yet, reported LBP prevalence in these 4 areas wasYet, reported LBP prevalence in these 4 areas wasnearly identical.nearly identical.

Conclusion: The indications used for surgicalConclusion: The indications used for surgicalmanagement of LBP are far from uniform!management of LBP are far from uniform!

(Source: Taylor VM, et al. Low back pain(Source: Taylor VM, et al. Low back painhospitalization.hospitalization. SpineSpine 1994;19:12071994;19:1207--1213.)1213.)


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But the situation must have improvedBut the situation must have improvedsince then?since then?

22 Orthopedic and 8 Neurosurgeons of varying22 Orthopedic and 8 Neurosurgeons of varyingregions and backgrounds were asked about surgicalregions and backgrounds were asked about surgicalindication, approach, and use of fusion andindication, approach, and use of fusion and

instrumentation for 5 simulated cases.instrumentation for 5 simulated cases. Significant variation between surgeons on allSignificant variation between surgeons on all

variables in 4 of 5 cases presented.variables in 4 of 5 cases presented.

Conclusion: It does not look like the situation hasConclusion: It does not look like the situation hasbecome any better?become any better?

(Source: Irwin ZN, et al. Variation in surgical decision making(Source: Irwin ZN, et al. Variation in surgical decision makingfor degenerative spinal disorders. Part I: Lumbar spine.for degenerative spinal disorders. Part I: Lumbar spine. SpineSpine2005;30:22082005;30:2208--2213.)2213.)


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Telephone survey nationallyTelephone survey nationallyrepresentative sample of 5,490representative sample of 5,490primary care doctors:primary care doctors:

Clinical vignette: 35 y/o man withClinical vignette: 35 y/o man with

foot drop.foot drop.

Decision to recommend MRI wasDecision to recommend MRI wasbased on whether the physician livedbased on whether the physician livedin a highin a high-- or lowor low--spending region ofspending region ofthe country.the country.

(Source:(Source: SirovichSirovich BE, et al. Variations in theBE, et al. Variations in thetendency or primary care physicians totendency or primary care physicians tointervene.intervene. Arch Intern MedArch Intern Med2005;165:22522005;165:2252--2256.)2256.)


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Practice variation based on geographicalPractice variation based on geographical

region does not seem to indicate researchregion does not seem to indicate research--

based consensus on management?based consensus on management?


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Randomized controlled trials, studies intoRandomized controlled trials, studies into

diagnostic accuracy, systemic reviews, and metadiagnostic accuracy, systemic reviews, and meta--

analysis with provide the answer to all ouranalysis with provide the answer to all our

diagnostic and management dilemmas!diagnostic and management dilemmas!


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Anybody forAnybody for

exercise?exercise?

Advice to stayAdvice to stayactive?active?

Manipulation?Manipulation?


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Anybody for exercise?Anybody for exercise? Systematic review on the use of exercise therapySystematic review on the use of exercise therapy

for acute and chronic LBP:for acute and chronic LBP:

No indication that specific exercises are effective forNo indication that specific exercises are effective fortreatment oftreatment ofaacute LBP.cute LBP.

Conflicting evidence on the effectiveness of exerciseConflicting evidence on the effectiveness of exercisetherapy compared with inactive treatments fortherapy compared with inactive treatments forchronic LBP.chronic LBP.

Exercise therapy was more effective than usual careExercise therapy was more effective than usual careby the general practitioner and just as effective asby the general practitioner and just as effective as

conventional PT for chronic LBP.conventional PT for chronic LBP.

(Source: Van Tulder M, et al. Exercise Therapy for Low Back Pain(Source: Van Tulder M, et al. Exercise Therapy for Low Back Pain: A: A ssystematicystematic rrevieweviewwwithinithinthethe fframeworkramework of the Cochrane Collaboration Back Review Group.of the Cochrane Collaboration Back Review Group. SpineSpine2000;25:27842000;25:2784--2796)2796)


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Systematic review on the use ofSystematic review on the use ofexercise therapy for acute andexercise therapy for acute andchronic LBP:chronic LBP:

Reviewed only articles that used a diagnosticReviewed only articles that used a diagnosticclassification method with implications forclassification method with implications fortreatment.treatment.

Only 5/82 studies met inclusion criteria.Only 5/82 studies met inclusion criteria.

Exercise better than pragmatic controlExercise better than pragmatic controlinterventions in 4/5 studies.interventions in 4/5 studies.

(Source: Cook C, et al. Physical therapy exercise intervention b(Source: Cook C, et al. Physical therapy exercise intervention b ased onased onclassification using the patient response method: A systematic rclassification using the patient response method: A systematic r eview ofeview ofthe literature.the literature. J Manual ManipulativeJ Manual ManipulativeTherTher 2005;13:1522005;13:152--162.)162.)


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MetaMeta--analysis on exercise for nonanalysis on exercise for non--specific LBP:specific LBP:

Slightly effective at improving pain andSlightly effective at improving pain andfunction in chronic LBP.function in chronic LBP.

Graded activity decreases sickGraded activity decreases sick--leave inleave insubacutesubacute LBP.LBP.

As effective as no treatment in acute LBP.As effective as no treatment in acute LBP.

(Source: Hayden JA, et al. Meta(Source: Hayden JA, et al. Meta--analysis: Exerciseanalysis: Exercise

therapy for nontherapy for non--specific low back pain.specific low back pain. Ann InternAnn InternMedMed 2005;142:7652005;142:765--775.)775.)


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Advice to stay active?Advice to stay active?

Systematic review on advice to stay active asSystematic review on advice to stay active as

a single treatment:a single treatment:

Little beneficial effects for patients with LBP.Little beneficial effects for patients with LBP.

Little or no effect for patients with sciatica.Little or no effect for patients with sciatica.

Better than advice to have bed rest.Better than advice to have bed rest.

(Source: Hagen KB, et al. The Cochrane Review of(Source: Hagen KB, et al. The Cochrane Review of

advice to stay active as a single treatment for lowadvice to stay active as a single treatment for lowback pain and sciatica.back pain and sciatica. SpineSpine 2002;27:17362002;27:1736--1741.)1741.)


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Manipulation?Manipulation?

MetaMeta--analysis manipulation versusanalysis manipulation versusother therapies:other therapies:

No evidence that manipulation isNo evidence that manipulation issuperior to other standard treatments forsuperior to other standard treatments forpatients with acute and chronic LBP.patients with acute and chronic LBP.

(Source:(Source: AssendelftAssendelft WJJ, et al. SpinalWJJ, et al. Spinalmanipulative therapy for low back pain.manipulative therapy for low back pain. AnnAnnIntern MedIntern Med 2003;138:8712003;138:871--881.)881.)


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Systematic review of spinal mobilizationSystematic review of spinal mobilization

and manipulation for LBP and neck pain:and manipulation for LBP and neck pain:Moderate evidence favoring manipulationModerate evidence favoring manipulationover mobilization for acute LBP.over mobilization for acute LBP.

Moderate evidence that manipulation andModerate evidence that manipulation andmobilization are more effective thanmobilization are more effective thangeneral practitioner care and placebo forgeneral practitioner care and placebo forchronic LBP.chronic LBP.

Manipulation and mobilization is a viableManipulation and mobilization is a viabletreatment option for patients with LBP.treatment option for patients with LBP.(Source:(Source: BronfortBronfort G, et al. Efficacy of spinal manipulation andG, et al. Efficacy of spinal manipulation andmobilization for low back pain and neck pain: A systematic reviemobilization for low back pain and neck pain: A systematic reviewwand best evidence synthesis.and best evidence synthesis. SpineSpine2004;4:3352004;4:335--356.)356.)


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Inconclusive, inconsistent, and evenInconclusive, inconsistent, and even

contradictory summary statementscontradictory summary statements

from systematic reviews and metafrom systematic reviews and meta--analysis are not much help for theanalysis are not much help for the

clinicianclinician


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3. LBP Facts3. LBP Facts


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LBP Fact #1:LBP Fact #1:

LBP is not a selfLBP is not a self--limiting problemlimiting problem

but a problem characterized bybut a problem characterized by

exacerbations and remissions, whichexacerbations and remissions, which

becomes chronic in about 10% of thebecomes chronic in about 10% of the

population.population.

(Source:(Source: HestbaekHestbaekL,L, The Natural Course of Low Back Pain and Early Identification ofThe Natural Course of Low Back Pain and Early Identification ofHighHigh--

Risk Populations.Risk Populations. PhD Thesis.PhD Thesis. OdenseOdense, Denmark: University of Southern, Denmark: University of Southern

Denmark, 2003.)Denmark, 2003.)


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The 10% of patients with LBPThe 10% of patients with LBPwho go on to have chronic LBPwho go on to have chronic LBPand disability are responsible forand disability are responsible for

80% of the costs associated with80% of the costs associated withthis condition.this condition.(Source: Murphy PL, Courtney TK. Low back pain disability:(Source: Murphy PL, Courtney TK. Low back pain disability:Relative costs by antecedent and industry group.Relative costs by antecedent and industry group. Am JAm JIndInd MedMed2000;37:5582000;37:558--571.)571.)


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Treatment costs for LBPTreatment costs for LBPare rising by at least 7% perare rising by at least 7% per

year.year.(Source: Bishop A, Foster NE. Do physical therapists(Source: Bishop A, Foster NE. Do physical therapistsin the United Kingdom recognize psychosocial factorsin the United Kingdom recognize psychosocial factorsin patients with acute low back pain.in patients with acute low back pain. SpineSpine2005;30:13162005;30:1316--1322.)1322.)


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Our current approach toOur current approach to

evaluation and managementevaluation and management

based on a mainlybased on a mainlypathophysiologic and authoritypathophysiologic and authority--

based rationale is not working tobased rationale is not working to

solve the LBP problemsolve the LBP problem


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Systematic reviews and metaSystematic reviews and meta--analysis ofanalysis of

controlledcontrolled clinical trials usingclinical trials using

heterogenousheterogenous populations or peoplepopulations or people

with LBP based onwith LBP based on timetime--delineated ordelineated or

structurestructure--basedbased classification systemsclassification systems

will not provide information useful forwill not provide information useful for

management of LBP.management of LBP.


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However, pragmatic trials withhomogenous populations based on a

treatment-based classification systemare much more likely to produce clinicallyrelevant information!


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4. Clinical Implications4. Clinical Implications


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Clinical Implication #1Clinical Implication #1

First determine if the patient belongs in yourFirst determine if the patient belongs in youroffice!office!

LBP can be a symptoms of:LBP can be a symptoms of:

Visceral disease:Visceral disease: Retroperitoneal and pelvicRetroperitoneal and pelvic

region or the gastrointestinal system.region or the gastrointestinal system.Vascular disease:Vascular disease: Abdominal aorticAbdominal aortic

aneurysm.aneurysm.

HaematologicalHaematological disease:disease:Haemoglobinopathies andHaemoglobinopathies and myelofimyelofibrbrosisosis..

Trauma:Trauma: FractuFracturre, fatigue fracture,e, fatigue fracture,insufficiency fracture.insufficiency fracture.


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Metabolic and endocrine disease:Metabolic and endocrine disease:

Osteoporosis,Osteoporosis, osteomalaciaosteomalacia,, PagetsPagets disease,disease,and diabetes (diabetic radiculopathy).and diabetes (diabetic radiculopathy).

Infectious disease:Infectious disease: DiskitisDiskitis andandosteomyelitisosteomyelitis..

Inflammatory disease:Inflammatory disease:SpondylarthropathiesSpondylarthropathies..

Neoplastic disease:Neoplastic disease: Osteoid osteomaOsteoid osteoma,,multiplemultiple myelomamyeloma, metastases., metastases.

(Source: Huijbregts PA. HSC 11.2.4. Lumbopelvic region:(Source: Huijbregts PA. HSC 11.2.4. Lumbopelvic region:Aging, disease, examination, diagnosis, and treatment. In:Aging, disease, examination, diagnosis, and treatment. In:Wadsworth C. HSC 11.2.Wadsworth C. HSC 11.2. Current Concepts of Orthopaedic PhysicalCurrent Concepts of Orthopaedic PhysicalTherapy.Therapy. LaCrosseLaCrosse, WI: Orthopaedic Section APTA, 2001.), WI: Orthopaedic Section APTA, 2001.)


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Role of the physician:Role of the physician:

Differential diagnosis.Differential diagnosis.

MedicalMedical--surgical management.surgical management.Referral to other providers for coReferral to other providers for co--

management.management.


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Role of the physicalRole of the physical

therapist:therapist:Medical screeningMedical screening based on systemsbased on systemsapproach and appropriate referral forapproach and appropriate referral formedicalmedical--surgical (co) management.surgical (co) management.

Evaluation and management ofEvaluation and management ofpatients withpatients with mechanical LBPmechanical LBP..

Potential role in thePotential role in the coco--managementmanagementof patients with LBP due to trauma,of patients with LBP due to trauma,metabolic, infectious, inflammatory,metabolic, infectious, inflammatory,andand neoplasticneoplastic disease.disease.


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Make sure you are the appropriateMake sure you are the appropriate

person to see this particular patientperson to see this particular patient

with LBP.with LBP.


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Clinical Implication #2Clinical Implication #2

Determine the presence of riskDetermine the presence of riskfactors for chronic LBP andfactors for chronic LBP anddisability.disability.


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Random populationRandom population--based survey:based survey:

Multivariate analysis excludedMultivariate analysis excludedconfounding variables.confounding variables.

Independent relationship betweenIndependent relationship betweendepressive symptoms and onset of neck ordepressive symptoms and onset of neck orback pain episode.back pain episode.

Comparing lowest quartile of depressionComparing lowest quartile of depression

scores to highest quartile.scores to highest quartile.Adjusted risk ratio most depressed 3.97Adjusted risk ratio most depressed 3.97(Source: Carroll LJ, et al. Depression as a risk factor for onse(Source: Carroll LJ, et al. Depression as a risk factor for onset of an episodet of an episodeof troublesome neck and low back pain.of troublesome neck and low back pain. PainPain 2004;107:1342004;107:134--139.)139.)


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Prospective interventional case series design:Prospective interventional case series design:

36 patients with chronic LBP.36 patients with chronic LBP.

Fear avoidance beliefs questionnaireFear avoidance beliefs questionnaire physical activity subscale.physical activity subscale.

Comparing FABQComparing FABQ--PA >29 to FABQPA >29 to FABQ--PAPA


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Prospective cohort study on risk factors in chronic workProspective cohort study on risk factors in chronic work--related LBP:related LBP:

Multiple regression analysisMultiple regression analysis -- 854 patients.854 patients. Severe leg pain (7Severe leg pain (7--10 pain rating): odds ratio (OR) 1.92.10 pain rating): odds ratio (OR) 1.92.

Body mass index >30: OR 1.68.Body mass index >30: OR 1.68.

Oswestry Disability Index (ODI) score 21Oswestry Disability Index (ODI) score 21--40: OR 3.1.40: OR 3.1.

ODI score 41ODI score 41--59: OR 3.98.59: OR 3.98.

ODI score >60: OR 3.43.ODI score >60: OR 3.43.

General Health Questionnaire (GHQGeneral Health Questionnaire (GHQ--28) score >6: OR28) score >6: OR1.87.1.87.

Unavailability of light duties: OR 1.66.Unavailability of light duties: OR 1.66.

Lifting >75% of the day: OR 1.98.Lifting >75% of the day: OR 1.98.(Source:(Source: FransenFransen M, el al. Risk factors associated with the transitionM, el al. Risk factors associated with the transition

from acute to chronic occupational back pain.from acute to chronic occupational back pain. SpineSpine 2002;27:922002;27:92--98.)98.)


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Prospective cohort study to determine clinical predictionProspective cohort study to determine clinical prediction

rule for returnrule for return--toto--work status at 2 years for 1,007 patientswork status at 2 years for 1,007 patients

with LBP:with LBP:

>50% successful return>50% successful return--toto--work (RTW) by 12 weeks.work (RTW) by 12 weeks.

Seven relevant questions to predict RTW.Seven relevant questions to predict RTW.

Do you think you will be back to your normal work in 3 months?Do you think you will be back to your normal work in 3 months?

Does your pain radiate into your arms or legs?Does your pain radiate into your arms or legs?

Have you ever had back surgery?Have you ever had back surgery?

On a scale of 0On a scale of 0--10, how do you rate your pain?10, how do you rate your pain?

Lately because of your back pain, do you change position often?Lately because of your back pain, do you change position often?

Lately because of your back pain, are you more irritable?Lately because of your back pain, are you more irritable?

Does your back pain affect your sleep?Does your back pain affect your sleep?

(Source: Dionne CE, et al. A clinical return(Source: Dionne CE, et al. A clinical return--toto--work rule for patientswork rule for patientswith back pain.with back pain. CMAJCMAJ 2005;172:15592005;172:1559--1567.)1567.)


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Can fearCan fear--avoidance beliefs beavoidance beliefs be

altered and how does this affectaltered and how does this affectLBP and disability?LBP and disability?


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CognitiveCognitive--behavioral programs.behavioral programs.Outpatient pain management (psychologistOutpatient pain management (psychologist

and physical therapist) successfully affected painand physical therapist) successfully affected pain

beliefs, selfbeliefs, self--efficacy, and psychological distress.efficacy, and psychological distress.

Decreased fearDecreased fear--avoidance beliefs andavoidance beliefs and

perceptions of control over pain explained 71%perceptions of control over pain explained 71%

of the variance of reductions in disability.of the variance of reductions in disability.(Sources:(Sources: SowdenSowden, et al. Can four psychosocial risk factors for chronic pain and, et al. Can four psychosocial risk factors for chronic pain and

disability (Yellow Flags) be modified by a pain managementdisability (Yellow Flags) be modified by a pain management programmeprogramme: A pilot: A pilotstudy.study. PhysiotherPhysiother2006;92:432006;92:43--49.49. WobyWobySR, et al. Are changes in fear avoidance beliefs,SR, et al. Are changes in fear avoidance beliefs,

catastrophingcatastrophing, and appraisals of control, predictive of changes in chronic lo, and appraisals of control, predictive of changes in chronic low backw back

pain and disability.pain and disability. EurEurJ PainJ Pain2004;8:2012004;8:201--210)210)


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Include a screen for depression and theInclude a screen for depression and the

Oswestry Disability Index and Fear AvoidanceOswestry Disability Index and Fear Avoidance

Beliefs Questionnaire in your initial evaluationBeliefs Questionnaire in your initial evaluation

of a patient with LBP.of a patient with LBP.

Implement appropriate intervention if riskImplement appropriate intervention if risk

factors for chronic LBP are present.factors for chronic LBP are present.


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Clinical Implication #3:Clinical Implication #3:

Classify patients using aClassify patients using a

TREATMENTTREATMENT--BASEDBASED diagnosticdiagnostic

classification model and treatclassification model and treataccordingly for optimal outcome.accordingly for optimal outcome.


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Attempts to provide subclassification of the heterogenousAttempts to provide subclassification of the heterogenousgroup of patients with nongroup of patients with non--spspeecificcific LBP into 4LBP into 4homogenous subgroups based on physical therapyhomogenous subgroups based on physical therapytreatment response.treatment response.

Initially based on expert consensus.Initially based on expert consensus. Four different treatmentFour different treatment--based diagnostic categories:based diagnostic categories:

stabilization, manipulation, specific exercise, and traction.stabilization, manipulation, specific exercise, and traction.

Established interrater reliability classification decisions:Established interrater reliability classification decisions:Kappa=0.60.Kappa=0.60.

Interrater reliability irrespective of therapist level ofInterrater reliability irrespective of therapist level ofexperience.experience.

(Source: Fritz JM, et al. An examination of the reliability of a(Source: Fritz JM, et al. An examination of the reliability of a classification algorithm forclassification algorithm forsubgrouping patients with low back pain.subgrouping patients with low back pain. SpineSpine2006;31:772006;31:77--82.)82.)

University of Pittsburgh diagnosticUniversity of Pittsburgh diagnostic

classification system:classification system:


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STABILIZATION CATEGORY:STABILIZATION CATEGORY:

Average SLR PROM >91.Average SLR PROM >91.

Positive prone instability test.Positive prone instability test.

Positive aberrant movements: painful arc, catch,Positive aberrant movements: painful arc, catch,

climbing thighs.climbing thighs. Hypermobility with prone spring testing.Hypermobility with prone spring testing.

Increasing LBP episode frequency.Increasing LBP episode frequency.

Three or more prior episodes.Three or more prior episodes.

Age


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MANIPULATION CATEGORY:MANIPULATION CATEGORY:

Recent onset of symptoms, i.e.


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SPECIFIC EXERCISE CATEGORY:SPECIFIC EXERCISE CATEGORY:

Preference for sitting (flexion category) or walkingPreference for sitting (flexion category) or walking(extension category).(extension category).

Centralization of symptoms with repeated movementCentralization of symptoms with repeated movementtesting.testing.

Peripheralization of symptoms with repeatedPeripheralization of symptoms with repeatedmovement testing in opposite direction.movement testing in opposite direction.

TREATMENT: Repeated end of range exercises.TREATMENT: Repeated end of range exercises.


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TRACTION CATEGORY:TRACTION CATEGORY:

Radicular symptoms.Radicular symptoms.

Symptoms did not improve with any movement tests.Symptoms did not improve with any movement tests.

Symptoms worsened with most movement tests.Symptoms worsened with most movement tests.

TREATMENT: Traction and repeated end of rangeTREATMENT: Traction and repeated end of rangeexercises.exercises.

(Source: Source: Fritz JM, et al. An examination of the reliabil(Source: Source: Fritz JM, et al. An examination of the reliabil ity of a classificationity of a classificationalgorithm foralgorithm for subgroupingsubgroupingpatients with low back pain.patients with low back pain. SpineSpine 2006;31:772006;31:77--82.)82.)


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FiveFive--factor clinical prediction rulefactor clinical prediction rulemanipulation and LBP:manipulation and LBP:

Positive response defined as a >50% improvement inPositive response defined as a >50% improvement inODI score in one to two treatments.ODI score in one to two treatments.

Duration of current episode


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Patients with 4 of 5 criteria clinicalPatients with 4 of 5 criteria clinicalprediction rule met andprediction rule met and whowho receivedreceivedmanipulation has an odds ratio formanipulation has an odds ratio for

successful outcome of 60.8.successful outcome of 60.8.(Source: Childs JD, et al. A clinical prediction rule to(Source: Childs JD, et al. A clinical prediction rule toidentify patients with low back pain most likely toidentify patients with low back pain most likely tobenefit from spinal manipulation. A validation study.benefit from spinal manipulation. A validation study.

Ann Intern MedAnn Intern Med2004;141:9202004;141:920--928.)928.)


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TwoTwo--factor clinical prediction rulefactor clinical prediction rulemanipulation and LBP:manipulation and LBP:

Duration of current symptoms


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If 3 of 4 criteria clinical predictionIf 3 of 4 criteria clinical predictionrule were met the positive likelihoodrule were met the positive likelihoodratio for success with stabilizationratio for success with stabilization

was 4.0.was 4.0.

(Source: Hicks JM, et al. Preliminary development of a clinical(Source: Hicks JM, et al. Preliminary development of a clinical predictionpredictionrule for determining which patients with low back pain will resprule for determining which patients with low back pain will respond to aond to astabilization exercise program.stabilization exercise program. Arch Phys MedArch Phys MedRehabilRehabil 2005;86:17532005;86:1753--1762.)1762.)


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A treatmentA treatment--based classification for patientsbased classification for patients

with nonwith non--specific LBP has the potential ofspecific LBP has the potential of

producing an optimal diagnosisproducing an optimal diagnosis--interventionintervention

combination.combination.

Preliminary research indicates the ability toPreliminary research indicates the ability to

reliably and with prognostic validity classifyreliably and with prognostic validity classify

patients with nonpatients with non--specific LBP.specific LBP.


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204 patients with chronic LBP (> 3 months); ODI 16%204 patients with chronic LBP (> 3 months); ODI 16%

All patients were provided with examination, education, andAll patients were provided with examination, education, andinstruction by physicianinstruction by physician

Random assignment to only physician consultation orRandom assignment to only physician consultation or

consultation in combination with 4 sessions of manipulation andconsultation in combination with 4 sessions of manipulation andstabilization exercisesstabilization exercises

At 5 and 12 months, significant betweenAt 5 and 12 months, significant between--group differences ingroup differences infavour of manipulation/stabilization group for patient report offavour of manipulation/stabilization group for patient report ofpain and disabilitypain and disability

(Source:(Source: NiemistoNiemisto L, et al. A randomized trial of combined manipulation, stabilizL, et al. A randomized trial of combined manipulation, stabilizing exercises,ing exercises,and physician consultation compared to physician consultation aland physician consultation compared to physician consultation alone for chronic low back pain.one for chronic low back pain.SpineSpine2003;28:21852003;28:2185--2191).2191).

Additional evidence for the use ofAdditional evidence for the use of

stabilization exercises:stabilization exercises:


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Significant betweenSignificant between--group difference in favour ofgroup difference in favour of

surgery group on decrease in ODI score (betweensurgery group on decrease in ODI score (between--group difference 4.1 points)group difference 4.1 points)

No significant betweenNo significant between--group differences on anygroup differences on anyother outcome measures, including shuttle walkingother outcome measures, including shuttle walkingtest, SFtest, SF--36 general health status questionnaire, return36 general health status questionnaire, return--

toto--work status, or psychological assessmentwork status, or psychological assessment19 intra19 intra--operative complications and 11 reoperative complications and 11 re--surgeriessurgeries

No complications in the rehabilitation programNo complications in the rehabilitation program

(Source:(Source: FairbankFairbankJ, et al.J, et al. RandomisedRandomised controlled trial to compare surgical stabilization of thecontrolled trial to compare surgical stabilization of thelumbar spine with an intensive rehabilitation programme for patilumbar spine with an intensive rehabilitation programme for pati ents with chronic low backents with chronic low backpain: The MRC spine stabilisation trial.pain: The MRC spine stabilisation trial. BMJBMJ2005;330:12332005;330:1233--1241).1241).


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How about cost?How about cost?

Manipulation clinical prediction rule validationManipulation clinical prediction rule validationstudystudy

At the 6At the 6--month followmonth follow--up patients, who hadup patients, who hadreceived manipulation had significantly lowerreceived manipulation had significantly lowerhealth care utilization, medication use, and timehealth care utilization, medication use, and timeoff work due to LBP than those receivingoff work due to LBP than those receivingexercise onlyexercise only(Source: Childs JD, et al. A clinical prediction rule to identif(Source: Childs JD, et al. A clinical prediction rule to identify patientsy patientswith low back pain most likely to benefit from spinal manipulatiwith low back pain most likely to benefit from spinal manipulation: Aon: Avalidation study.validation study. Ann Intern MedAnn Intern Med2004;141:9202004;141:920--928).928).


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UK BEAM trial comparing physicianUK BEAM trial comparing physicianmanagement to manipulation ormanagement to manipulation ormanipulation and exercise for nonmanipulation and exercise for non--specificspecificLBPLBP

Economic analysisEconomic analysis

Manipulation or manipulation combinedManipulation or manipulation combinedwith exercise was most the costwith exercise was most the cost--effectiveeffectiveapproach to the management of patientsapproach to the management of patientswith LBPwith LBP

(UK BEAM Trial Team. United Kingdom back pain exercise(UK BEAM Trial Team. United Kingdom back pain exerciseand manipulation (UK BEAM) randomized trial: Costand manipulation (UK BEAM) randomized trial: Costeffectiveness of physical treatments for back pain in primaryeffectiveness of physical treatments for back pain in primarycare.care. BMJBMJ 2004;329:1381).2004;329:1381).


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Patients with occupational LBP that fit the twoPatients with occupational LBP that fit the two--factor clinical prediction rulefactor clinical prediction rule

Receiving thrust and nonReceiving thrust and non--thrust techniquesthrust techniquesresulted in greater reductions in disability andresulted in greater reductions in disability andpain than not receiving these interventionspain than not receiving these interventions

However, physical therapy treatment cost,However, physical therapy treatment cost,

number of therapy sessions, and duration of staynumber of therapy sessions, and duration of stayin therapy were significantly smaller in the thrustin therapy were significantly smaller in the thrustas compared to the nonas compared to the non--thrust groupthrust group

(Source: Fritz JM, Brennan GP,(Source: Fritz JM, Brennan GP, LeamanLeaman H. Does the evidence for spinal manipulationH. Does the evidence for spinal manipulationtranslate into better outcomes in routine clinical care for patitranslate into better outcomes in routine clinical care for patients with occupationalents with occupationallow back pain? A caselow back pain? A case--control study.control study. Spine JSpine J 2006;6:2892006;6:289--295).295).


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CostCost--effectiveness analysis of the studyeffectiveness analysis of the study

comparing surgical stabilization to intensivecomparing surgical stabilization to intensiverehabilitationrehabilitation

Mean total cost surgery group patientMean total cost surgery group patient7,8307,830

Mean total cost rehabilitation group patientMean total cost rehabilitation group patient4,5264,526

Significant betweenSignificant between--group differencegroup difference

3,304 (95% CI: 2,3173,304 (95% CI: 2,317

--4,291)4,291)

(Source: Rivero(Source: Rivero--Arias O, et al.Arias O, et al. Surgical stabilization of the lumbar spine compared with aSurgical stabilization of the lumbar spine compared with aprogramme of intensive rehabilitation programme for the managemeprogramme of intensive rehabilitation programme for the management of patients withnt of patients withchronic low back pain: Cost utility analysis based on achronic low back pain: Cost utility analysis based on a randomisedrandomised controlled trial.controlled trial. BMJBMJ2005;330:12392005;330:1239--1241).1241).


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CommonCommon--sense summarysense summary

A treatmentA treatment--based classification forbased classification for

patients with nonpatients with non--specific LBP has thespecific LBP has thepotential of producing an optimalpotential of producing an optimal

diagnosisdiagnosis--intervention combinationintervention combination


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Preliminary research indicates thePreliminary research indicates the

ability to reliably and with prognosticability to reliably and with prognostic

validity classify patients with nonvalidity classify patients with non--

specific LBPspecific LBP


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TreatmentTreatment--based classification andbased classification andintervention seem to provideintervention seem to provide

forfor superior outcome with regard tosuperior outcome with regard to

pain, function, and health care costpain, function, and health care cost


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5.5. Other Research:Other Research:So, research into LBP can provide clinically relevant informatioSo, research into LBP can provide clinically relevant information. Is theren. Is there

any other such research being done?any other such research being done?


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TAKETAKE--HOME MESSAGEHOME MESSAGE

Differential diagnosis by the physician and medicalDifferential diagnosis by the physician and medicalscreening by the physical therapist is aimed atscreening by the physical therapist is aimed atidentifying those patients withidentifying those patients with nonnon--mechanical LBPmechanical LBPthat require medicalthat require medical--surgical managementsurgical management

Screening for risk factorsScreening for risk factors and appropriateand appropriateintervention may decrease the transition from acuteintervention may decrease the transition from acuteto chronic LBP and disabilityto chronic LBP and disability

Diagnosis ofDiagnosis ofmechanical LBPmechanical LBP aims to classify theaims to classify the

patient into a treatmentpatient into a treatment--based diagnostic categorybased diagnostic categorywith clear implications for managementwith clear implications for management

Documents

Presentation on advances in the physical therapy diagnosis, prognosis, and management of patients with low back pain