WHAT ARE THE BEST THERAPIES ?
BACK PAIN
Low Back Pain Episodes
Low Back Pain Episodes
Acute <3 months
Low Back Pain Episodes
Sub Acute >5 weeks <3 months
Low Back Pain Episodes
Chronic >3 months
LBP affects 70% Adult PopulaKon • Episodes >2 wks have cumulaKve lifeKme prevalence in 14% cases
• Cause Nonspecific in 95%
• Australia : most frequently seen m/s condiKon in General PracKce
NHMRC Evidence Based Management
Advice to Stay AcKve Reduces Sick Leave
NHMRC Evidence Based Management
Massage • No controlled studies in LBP • Might be beneficial + exercises + educaKon • Cochrane 2012 :
NHMRC Evidence Based Management
Lumbar Supports • No controlled studies, insufficient evidence are effecKve
NHMRC Evidence Based Management
Bed Rest • Insufficient Evidence • >2 days increases sick leave • Evidence that prolonged bed rest is harmful
NHMRC Evidence Based Management
Spinal ManipulaKon • ConflicKng evidence v’s placebo first 2-‐4wks
NHMRC Evidence Based Management
Acupuncture • Insufficient evidence v’s injecKon therapy
NHMRC Evidence Based Management
Back Exercises • Similar pain + funcKon outcomes to usual care • Reduces pain + sick leave • Paravert. Muscle ex’s • CoordinaKon/Stability + Strength/Resistance • Complements principle of acKvity
Evidence Based Management
Physical Therapies Structured Exercise Programs + Spinal MobilisaKon effecKve Alongside early acKve movement
Evidence Based Management
ChiropracKc Short term slightly improve pain and disability (Cochrane report) No clinical meaningful difference v’s other intervenKons
NHMRC Evidence Based Management
Homeopathy Curing “like with like” PotenKsing
NHMRC : “Groundless”
NHMRC Evidence Based Management
Review of Scope of Private Health Insurance Rebate !7 Therapies being reviewed Released 1 April 2015
NHMRC Evidence Based Management
Provide InformaKon
NHMRC Evidence Based Management
Provide InformaKon Provide Assurance
NHMRC Evidence Based Management
Provide InformaKon Provide Assurance Advice to Remain AcKve
NHMRC Evidence Based Management
Provide InformaKon Provide Assurance Advice to Remain AcKve Other Pain Management OpKons
NHMRC Evidence Based Management
Acute LBP Management Aims IdenKfy Serious Causes (<5%) Self Management Maximize FuncKon Minimise Disability
REHABILITATION AFTER BACK PAIN EPISODE
• MODIFY ACTIVITIES • CORRECT BIOMECHANICAL ABNORMALITIES • POSTURAL ASSESSMENT OF FUNCTIONAL POSITIONS • LIFTING MECHANICS • CORE STABILITY : LOCAL THEN GLOBAL • ASSESS / STRETCH TIGHTNESS • EDUCATION • HOME EXERCISE REGIME
RehR
REFERRAL PRESCRIPTIONS
Acute Back Pain Local modaliKes for pain/spasm Encourage non-‐aggravaKng movement and exercise Educate / encourage neutral spine Manual therapy techniques Home exercise Back Care advice
RehR
REFERRAL PRESCRIPTIONS
SUB-‐ACUTE BACK PAIN Local modaliKes for pain/spasm/hypo mobility Restore range with manual therapy and exercise Core stability regime and upgrade Review postures/biomechanics Home exercise / Cardio fitness
FUNCTIONAL STABILITY NEED TO UTILISE BOTH MUSCLE FORCES AND PASSIVE STRUCTURES TO DYNAMICALLY STABILISE THE SPINE FUNCTIONALLY ANY DEFICITS ASSESSED NEED TO BE ADDRESSED IN A REHAB. PLAN
CORE STABILITY • MUSCULAR CONTROL TO MAINTAIN FUNCTIONAL STABILITY
• MUSCULAR CORSET
• STABILITY INVOLVES PASSIVE AND ACTIVE STIFFNESS
• INSTABILITY WHEN EITHER COMPONENT DISTURBED
CORE STABILITY
• GLOBAL : DYNAMIC / PHASIC MUSCLES = ACTIVE TRUNK MOVEMENT • RECTUS ABDOMINIS • EXTERNAL OBLIQUES • ILIOCOSTALIS (THORACIC PART) • LATISSIMUS DORSI
• LINK PELVIS TO THORACIC CAGE
CORE STABILITY • LOCAL : POSTURAL / TONIC = INTERSEGMENTAL STABILITY • TRANSVERSUS ABDOMINIS • MULTIFIDIS • PSOAS MAJOR • QUADRATUS LUMBORUM • DIAPHRAGM • ILIOCOSTALIS ( LUMBAR SEGMENT) • INTERNAL OBLIQUE
STABILITY TEACHING/RETRAINING
• EDUCATION : ANATOMY AND FUNCTION • ISOLATE DEEP LAYER T.A • MOTOR RELEARNING • TRAIN STABILISERS IN ISOLATION • ADD FUNCTIONAL MOVEMENTS WITH STABILITY • PAINFREE • NEUTRAL SPINE INITIALLY • FEEDBACK : TACTILE , PBU, ULTRASOUND
STABILISATION EXERCISES
• INITIATE PELVIC FLOOR HELPS ISOLATE T.A. • PALPATE 1CM IN 1CM DOWN A.S.I.S. • FEEL TENSION, NOT BULGE • CONTROLLED BREATHING • SUPINE / 4 POINT KNEEL / STANDING / SITTING • PROGRESS UPGRADED POSITIONS/EXERCISES
CONDITIONING • GENERAL AEROBIC FITNESS • POSTURAL CORRECTION • 20-‐30 MINUTE PERIODS • WEIGHT LOSS • POSITIVE RATHER THAN PURELY CLINICAL SETTING
NORMALISE SETTING : TAI CHI, PILATES, YOGA, GYM CLASSES, SWIM FOCUS ON SELF MANAGEMENT
MULTIMODAL ROLE
• UNDERSTANDING • RELATIONSHIP • EARLY ACTIVITY • EARLY EXERCISE • EARLY MOBILITY • SHIFT ONUS OF RESPONSIBILITY • SELF MANAGEMENT
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