Evidence Based Treatment of Low Back Pain

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Evidence Based Treatment of Low Back Pain

• Dr. Joe Strunce, PT, DSc
• Dr. Alicia Souvignier, PT, DPT

COF Tucson, AZ 10 June 2008
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Course Objectives

• Understand current evidence for a classification
  system to treat Low Back Pain
• Demonstrate the ability to use a classification
  system to treat patients with LBP

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Low Back PAIN!
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Diagnoses for LBP
(Saal, JS 2002)

• No specific pathoanatomical diagnosis in 85 of
  patients
• Poor association between symptoms and imaging

• Nonspecific labels
• Sprain, strain, degenerative joints or discs

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Look at the Evidence

• Historically, we have many RCTs
• Compared treatments versus nothing
• Sometimes we didnt do better
• Compared multiple treatments
• What happens if they all work equally
• LBP has a large population prevalence
• Patient diversity demonstrated need to look at
  subgroups of patients

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What do PTs have to offer

• Mobilization or manipulation
• Immobilization or stabilization
• Specific exercises
• Extension oriented
• Flexion oriented
• Traction

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Research?
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Who Responds to Manipulation

• Several studies show manipulation is more
  effective than placebo
• Technique used to address spinal hypomobility or
  restriction
• Patients have demonstrated short-term pain relief

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Baseline Exam
(Flynn, TW 2002)

• Demographic information
• Self-report measures
• Historical questions
• Physical exam
• ROM, strength, special tests

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Treatment
(Flynn, TW 2002)

• 71 subjects- collect baseline variables
• Self reports
• Range of motion- lumbar and hip
• SI joint special tests gt25
• All patients receive same intervention
• Identify responders gt 50 reduction in disability

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Results
(Flynn, TW 2002)
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Clinical Prediction Rule
(Flynn, TW 2002)

• Symptom duration lt 16 days
• Symptom location not below the knee
• FABQ work subscale lt 18 points
• Hip medial rotation gt 35 at least 1 hip
• Lumbar hypomobility

• 3 of 5 tests are positive 68 success

• 4 of 5 tests 95 success

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Now What?
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Validation of Rule
(Childs, JD 2004)

• RCT between manipulation and exercise
• 131 patients randomly assigned into treatment
  groups
• 1-week, 4-week, 6-month follow-ups
• 4 groups created

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Group Comparisons
(Childs, JD 2004)
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Results
(Childs, JD 2004)
P lt 0.001
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Classification of Treatments

• Mobilization
• Stabilization
• Specific exercises
• Extension oriented
• Flexion oriented
• Traction

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Who Responds to Stabilization

• Lumbar segmental instability- decreased stiffness
  or hypermobility within the spine
• Diagnosis has been flexion and extension
  radiographs
• High rate of false positives
• Historical variables of instability or catch
• Research has shown that specific exercises can
  decrease symptoms

(Richardson 1995)
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Baseline Exam
(Hicks, GE 2005)

• Demographic information
• Self-report measures
• Historical questions
• Physical exam
• ROM, strength, special tests

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Treatment
(Hicks, GE 2005)

• 54 subjects received PT BIW for 8 weeks
• Required to perform exercises daily
• Muscles targeted
• Rectus abdominus
• Transversus abdominus
• Erector spinae multifidus
• Internal oblique
• Quadratus lumborum

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Stabilization Exercises

• Crunching- Rectus abdominus
• Abdominal bracing- transversus abdominus -
• Quadruped- erector spinae and multifidus
• Side support- internal oblique and quadratus
  lumborum

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Results
(Hicks, GE 2005)
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Clinical Prediction Rule
(Hicks, GE 2005)

• Age lt 40 years
• Average SLR gt 91
• Aberrant movement present
• Positive prone instability test

• 2 of 4 tests are positive 94 success
• 3 of 4 tests 97 success

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Classification of Treatments

• Manipulation
• Stabilization
• Specific exercises
• Extension oriented
• Flexion oriented
• Traction

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Extension Oriented Exercises
(Browder, DA 2007)

• RCT versus clinical prediction rule
• Extension oriented exercises
• Stabilization exercises
• Inclusion criteria
• LBP and symptoms distal to buttocks
• Centralization w/ any extension movement
• Single or repeated movement
• Standing or prone position

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Extension Oriented Exercises
(Browder, DA 2007)

• 300 eligible patients
• 63 pts (21) met inclusion criteria
• Pts treated 2 X 2 weeks 1 X 2 weeks 6 visits
  for 4 weeks
• Baseline, 1-, 4-wk, and 6-mo follow-ups
• Functional outcome- Oswestry
• Pain scale- NPRS

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Treatment Groups
(Browder, DA 2007)

• Stabilization exercises
• Abdominal bracing, quadruped, and side support
• Extension oriented exercises
• Sustained and repeated extension in prone and
  standing
• Posterior-to-anterior lumbar mobilizations
• Manual therapy model
• Therapist determined level and intensity
• Education on activities and decrease sitting

(Hicks, GE 2005)
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Extension versus Stabilization
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Results
(Browder, DA 2007)

• Statistically significant decrease in disability-
  Oswestry
• No significant difference in pain
• If patient meets inclusion criteria-
• LBP and symptoms distal to buttocks
• Centralization w/ any extension movement
• Treatment uses manual therapy model

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Classification of Treatments

• Manipulation
• Stabilization
• Specific exercises
• Extension oriented
• Flexion oriented
• Traction

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Now What?
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Validating Subgroups
(Brennan, GP 2006)

• Manipulation
• Symptoms lt 16 days
• No symptoms distal to the knee
• Stabilization exercises
• Age lt 40 years ? Ave. SLR lt 91
• aberrant movements ? prone instab. test
• Directional exercises
• Centralization of symptoms with extension

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Validating Subgroups
(Brennan, GP 2006)

• Randomized Clinical Trial
• 3 treatment options
• Manipulation, stabilization, extension exercises
• 1/3 chance of correct treatment
• 2 groups
• Patients who are matched to correct treatment
• Patients NOT matched to correct treatment

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Comparison
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Validating Subgroups
(Brennan, GP 2006)

• Inclusion criteria
• LBP lt 90 days
• With or w/out symptoms distal to buttock
• Exclusion criteria
• Visible lateral shift
• Inability to reproduce symptoms w/ ROM or
  palpation
• Signs of nerve root compression
• SLR and reflex or strength deficits

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Treatments

• Manipulation
• Manipulation or mobilization and pelvic ROM
• Stabilization
• Abdominal bracing, quadruped, and side support
• Directional exercises
• Extension or flexion based on symptoms

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Treatments

• Randomized treatment for up to 4-weeks
• Therapist prescribe treatment according to
  correct subgroup
• Stage 2 exercises change in Oswestry
• Aerobic, stabilization and flexibility
• Baseline, 4-week and 1-year follow-ups

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Validating Subgroups
(Brennan, GP 2006)

• 123 eligible patients enrolled
• 40 randomized into manipulation
• 46 randomized into stabilization
• 37 randomized into specific exercise
• 50 patients matched to correct treatment
• 73 were not matched
• Agreement of classification 83

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Results
(Brennan, GP 2006)
P 0.03
P 0.006
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Classification of Treatments

• Mobilization
• Stabilization
• Specific exercises
• Extension oriented
• Flexion oriented

• Traction

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Traction
(Fritz, JM 2007)

• RCT and subgroup analysis
• Extension exercises traction versus extension
  exercises
• Subgroup analysis of patients that improved with
  the addition of traction
• Inclusion criteria
• LBP and symptoms distal to buttocks
• Signs of nerve root compression
• SLR, reflex, sensory, or motor deficit

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Subjects
(Fritz, JM 2007)

• 64 patients
• Traction group 4 x 1-2 wks 1 x 3-6 wks w/ max 12
  visits in 6 wks
• Exercise only 2 x 1-3 wks 1 x 4-6 wks w/ max 9
  visits in 6 wks
• Baseline, 2 and 6 week f/u
• Oswestry, pain scale, FABQ, and GRC

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Treatment Groups
(Fritz, JM 2007)

• Extension oriented exercises
• Sustained and repeated extension in prone and
  standing
• Posterior-to-anterior lumbar mobilizations
• Education on activities and decrease sitting
• Traction for 2 wks extension exercises
• Prone position to maximize centralization
• 10 min static traction 40-60 of BW 1 min ramp
  up/down 12 min traction
• Prone gt 2 min repeated press-ups

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Results
(Fritz, JM 2007)

• No significant difference between groups for
  Oswestry, pain, or GRC
• Traction group had significantly more visits 8
  vs 4
• Baseline analysis found interaction effect
• Peripheralized w/ extension movement
• Positive crossed SLR
• 84 success w/ traction and 45 w/ ex

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Classification of Treatments

• Mobilization
• Stabilization
• Specific exercises
• Extension oriented
• Flexion oriented
• Traction

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Classification of Treatments

• Manipulation or Mobilization

• Subjective-
• Symptoms lt 16 days
• Symptoms not below the knee
• Not afraid to work
• Objective-
• Lumbar hypomobility
• Hip medial rotation gt 35 at least 1 hip

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Classification of Treatments

• Stabilization

• Subjective-
• Age lt 40 years
• Objective-
• Average SLR gt 90
• Aberrant movement present
• Positive prone instability test

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Classification of Treatments

• Extension oriented exercises

• Subjective-
• Symptoms distal to buttocks
• Objective-
• Centralization w/ any extension movement

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Classification of Treatments

• Traction

• Subjective-
• Symptoms distal to buttocks
• Objective-
• Peripheralize w/ any extension movement
• crossed SLR

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Patient Scenarios
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Patient 1- Subjective

• 45 yo female
• LBP only x 3 years. 2/10 - 6/10
• This episode for past month
• Occupation hotel housekeeping
• Agg Lifting wet towels/sheets from washer to
  dryer, mopping, making beds
• Ease no position of comfort, OK sit for about 15
  min.
• 24hr Wakes 2x / night, repositions

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Patient 1 Objective

• AROM Flex lim 50 Gowers, ext full with end
  range pain, SB WNL.
• PROM B hip and knee full, end range hip flex B
  reproduce LBP
• Palpation PAs to lumbar spine. pain at L4 and
  L5 with hypermobility at L3
• -SLR, 0-95

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Classification?

• Stabilization

• Why?
• Aberrant Movement
• Segmental hypermobility
• SLR gt 90

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Patient 2 Subjective

• 35 yo male
• LBP with L leg radiation to heel x 2 wks
• MOI Lifting chains off truck
• Agg Driving, sitting, walking gt 10
• Ease constant position change

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Patient 2 Objective

• Gait decrease pelvic rotation
• AROM Lumbar flex lim 50, Ext 25, L SB lim 75
• MMT B LE WNL, except Hip flex painful
• Peripheralization of LE symptoms with lumbar
  extensions
• SLR B 30 degrees

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Classification

• Traction

• Why?
• Contralateral SLR
• Peripheralizes with extension

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Patient 3 Subjective

• 25 yo male, construction
• R sided LBP without radiation x 1 week
• MOI Lifting drywall
• Agg Walking, lifting at work
• Ease Sitting, lying

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Patient 3- Objective

• AROM flex lim 25, Ext WNL, L SB limited and
  painful, B rotation painful
• PROM B hips WNL, full flex agg back pain
• Palpation muscle guarding and pain with PAs to
  L2-L5, decreased motion L4,L5

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Classification?

• Manipulation

• Why?
• Symptoms duration lt 16 days
• Continues to work
• Segmental hypomobility
• No distal symptoms

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Thats the Evidence
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Lumbo-pelvic Manipulation?

• Lets try it

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Lumbo-pelvic Manipulation (Classic)

• Translate pelvis toward you to maximally
  side-bend the lower extremities and trunk
• Thread your arm through the patients arms
  (interlocked hands behind their neck). Rest your
  fingertips on the patients sternum or the table
• Contact the patients ASIS on opposite side with
  your palm
• Rotate the trunk toward you (maintaining
  side-bend)
• When ASIS rises from the table, perform a
  smooth, quick thrust in a posterior direction

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Lumbo-pelvic Manipulation(Alternate)

• Translate pelvis toward you to maximally
  side-bend the lower extremities and trunk
• Without losing the side-bend, lift rotate the
  trunk so the patient is rotated on shoulder
• Contact the patients ASIS on opposite side with
  your palm
• Grasp the scapula and rotate the trunk toward you
  (maintaining side-bend)
• When ASIS rises from the table, perform a
  smooth, quick thrust in a posterior direction

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QUESTIONS?