LBP inservice
Transcript of LBP inservice
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Clinical Prediction Criteria for
Management of LBP
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Purpose
Next to a cold, LBP is most common reason
individuals visit the doctor
Estimated $100-$200 billion in health careexpenditures and lost wages annually in the
U.S.
Importance of matching pts with interventions
they will most likely benefit from
Improve decision making and outcomes
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Current Evidence
A clinical prediction rule for classifying patients withlow back pain who demonstrate short-termimprovement with spinal manipulation. Flynn T,
Fritz J, Whitman J, et al. Spine. 2002; 27(24):2835-43
Clinical prediction for success of interventions for
managing low back pain. Herbert J, KoppenhaverS, Fritz J, Parent E. Clin Sports Medicine 2008; 27:163-179
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A clinical prediction rule for classifying patients
with low back pain who demonstrate short-
term improvement with spinal manipulation.
Flynn T, Fritz J, Whitman J, et al. Spine. 2002;
27(24): 2835-43
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Background
Several RCTs shown manipulation to be more
effective than placebo or other interventions.
Found to be beneficial for a subgroup of ptswith more acute sym or more limited SLR
ROM
Other studies have not shown any benefits
Problems? No attempt to id pts most likely to
benefit
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Design: Prospective cohort.
Level of Evidence: Level 2
Objective: Develop a clinical prediction rule for
identifying patients with low back pain who
improve with spinal manipulation
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Methods
71 Pts age 18-60 referred to PT w/ a chiefcomplaint of pain and/or numbness in the lumbarspine, buttock, and or lower extremity
Pain diagram and rating (0-10) Modified Oswestry Disability Questionnaire
(OSW)-assessed disability related to LBP
Fear Avoidance Belief Questionnaire (FABQ)-assess pts beliefs about the influence of activityon LBP.
2 subscales: general physical activity and work
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Inclusion/Exclusion Criteria
Baseline Oswestry disability score of at least30%
Exclusion
current pregnancy
signs consistent with nerve root compression (+straight leg raise at
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Underwent standard exam and history (i.e.M.O.I., nature of sym, prior episodes etc.)
Side to be manipulated was determined by theside + with standing flexion test, if side of
tenderness during sacral sulcus palpation, if not,side reported tby pt to be more symptomatic
Response to treatment served as a referencestandard, all pts were treated with the same
protocol for 2 sessions Success was determined using percent change in
disability scores over 3 sessions
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Pt passively side-bent away from therapist. Therapist passively rotated pt
and delivered a quick posterior and inferior thrust through ASIS.
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Cavitation
NOYES
Proceed to other
components:
1.) Instruction in
supine pelvic tilt ROM,10 reps 3-4x daily.
2.) Instruction to
maintain usual activity
level within limits of
pain
1st Session
Reposition and
attempt again
Cavitation?
YES
NOAttempt opposite
side
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2nd Session 2-4 days later
OSW questionnaire- improvement of >50% from intial= success,
participation ended
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Results
75 entered 71 completed
29 females (41%)
59 (83%) had prior history of LBP
Mean age 37.6 +/- 10.6 yrs 32 (45%) were classified as treatment successes, 39
nonsuccesses
20 successful after 1 session
Mean OSW improvement in success group was 73.2+/- 15.8%
Nonsuccess group was 14.6 +/- 18.2%
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Results
Out of 11 potential prediction variables, five
were retained in the final model:
Duration of symptoms 35O internal rotation
Hypomobility with lumbar spring testing
FABQ work subscale score
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Results
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Results
The best predictor of success withmanipulation was the duration of sym
Supports the hypothesis that pts with moreacute sym respond better to manipulation.
The presence of 4/5 variables increased thelikelihood of success with manipulation from45% to 95%
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Why is this important?
Being able to accurately predict which pts will
have a positive response before hand would
be beneficial for effective and efficient clinical
decision making
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Clinical prediction for success of interventions
for managing low back pain. Herbert J,
Koppenhaver S, Fritz J, Parent E. Clin Sports
Medicine 2008; 27: 163-179
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D
esign- Systematic Review
Level of evidence- Level 1
Objective- Review evidence for variousinterventions commonly used in the treatment ofLBP.
-Identify clusters of findings from the history andclinical examination that predict a more favorableoutcome with a specific treatment approach.
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Treatment Approaches
Specific Exercise
Flexion
Extension
Stabilization
Manipulation
Traction
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Evidence is inconclusive
Ones that show some benefits, the
magnitude of observed effects is often small One therapy can look as appealing as the next
leading to less effective and efficient
treatment
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Specific Exercise
First emphasized by McKenzie
Emphasizes treatment using repeated orsustained end-range movements of the
lumbar spine in a specific direction to affect
the intensity and location of a pts pain.
Flexion, extension, or lateral translation
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Exam findings identifying pts in this subgroup: Presence of sym in the LE
Signs of nerve root compression (+ SLR, diminishedreflex, sensation, or strength)
Principle finding is the presence of centralization or adirectional preference during examination
*the absence of centralization has been associated withdelayed recovery and the development of chronic LBPand disablility. (Werneke et al. Spine 2001)*
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Studies that have applied this treatment to pts
fitting this subgrouping have reported
evidence favoring this approach over other
exercise interventions
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Stabilization Exercises
Lack of trunk control may compromise
function or stability of the lower extremities
Stabilization exercise programs are typicallydesigned to address the deficits in strength,
endurance, and function of the trunk muscles
identified in LBP
Thought to decrease pain and disability by
improving control of spinal segments
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Previous studies
Been shown to improve trunk muscle function inindividuals with LBP
Improvements may represent important
outcomes of rehab programs but physiologicchanges may not correspond to patient-centeredimprovements in pain and disability.
Rackwitz and colleagues concluded thatstabilization exercises for LBP is more effective
than treatment by a gen practitioner but notmore effective than other physiotherapyinterventions.
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But..
Conflicting evidence supports the considerationthat there may be a subgroup of pts with LBPwho are most likely to benefit from thisapproach.
Four variables most predictive of success definedas 50% reduction in disability as measured by theOSW. Younger than age 40
Avg SLR >91o
Aberrant movement present
Positive prone-instability test
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Spinal manipulation
See previous slides
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Traction
Subject of debate and controversery
Traditional signs of sciatica or nerve root
compression indication for treatment These symptoms not enough. . . 2 more
factors
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Traction
1. Peripheralization with extension movement
2. A positive crossed (contralateral) straight-leg
raise test3. Symptoms below buttock
4. Signs of nerve root compression
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Summary
Identification of predictive factors in pts with
LBP should allow the pt to be matched with
the most appropriate intervention to
maximize the likelihood of a favorable clinical
outcome
More information and research is needed