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Evaluation and Treatment of Low Back Pain: Utilization of Evidence Based Practice April 17th, 2015


Clinical Questions. Do patients with low back pain treated with spinal manipulative therapy and/or mobilization demonstrate improved pain and disability? – PowerPoint PPT presentation

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Title: Evaluation and Treatment of Low Back Pain: Utilization of Evidence Based Practice April 17th, 2015

Evaluation and Treatment of Low Back Pain
Utilization of Evidence Based Practice April
17th, 2015
  • Scott Tauferner MPT, LAT
  • stauferner_at_uwhealth.org

  • Participants will be able to explain treatment
    based classifications and how they assist in the
    decision making for patients with low back pain.
  • Participants will be able to identify and utilize
    evidence based clinical decision
    making/prediction rules in treatment of patients
    with low back pain.
  • Participants will be able to select intervention
    strategies supported by research evidence for
    treatment of patients with low back pain.

Clinical Questions
  • Do patients with low back pain treated with
    spinal manipulative therapy and/or mobilization
    demonstrate improved pain and disability?
  • Do patients with low back pain show improved
    benefit when physical therapy utilizes a
    treatment based classification approach?

  • Goal of visit 1 is to
  • Improve motion/pain
  • 1-3 exercises that will facilitate decreased
    pain, increased/normal motion, and help me hone
    in on a solid assessment.
  • Never give an exercise that could do more harm
    than good
  • Dont give an exercise just to keep them busy

  • Identify/implicate a region/motion that
    correlates with pain via reproduction of patients
    pain/symptoms or reduction in symptoms
  • Identify an Asterisk sign
  • If you cant identify a cause in the lumbar spine
    look to rule out the hip or thoracic spine Is
    the pain generator non-musculoskeletal
  • PMH and General Health questioning
  • Rule out Red Flags

Low Back Pain
  • In most cases of acute LBP, an objective cause
    cannot be found11
  • Every patient is unique, treatments always vary
    even though EBP has developed CPRs.
  • Most often treatment is a combination of manual
    therapy and exercise 3

Making your diagnosis
  • As the evaluation progresses you will be lead by
    your findings to a region or focus of dysfunction
    or impairments that may or may not be associated
    with the pain
  • When a dysfunction/impairment is found, treat
    it if possible, then reassess asterisk sign
  • Assess Treat Reassess move on and repeat


Assessment Anatomical Based
  • Any innervated structure in the lumbar spine can
    cause symptoms of low back and referred pain into
    the extremity or extremities.
  • Potential structures include
  • muscles
  • ligaments
  • dura mater and nerve roots, zygapophyseal joints
  • annulus fibrosis
  • thoracolumbar fascia
  • vertebrae

  • Clinicians should not utilize patient education
    and counseling strategies that either directly or
    indirectly increase the perceived threat or fear
    associated with low back pain, such as education
    and counseling strategies that
  • promote extended bed-rest
  • provide in-depth, pathoanatomical explanations
    for the specific cause of the patients low back
    pain. 3

Clinical Question
  • Do patients with low back pain show improved
    benefit when physical therapy utilizes a
    treatment based classification approach?

  • The best available evidence supports a
    classification approach that de-emphasizes the
    importance of identifying specific anatomical
    lesions after red flag screening is completed3

Assessment Treatment Based Classification
  • Stabilization
  • Mobilization
  • Specific Exercise
  • Traction
  • Recent studies indicated that classifications are
    unclear for approximately 34 of people with
    LBP13 and 25 meet more than 1 classification12

  • Clinical Prediction Rule the one everyone
  • Positive Predictors
  • Aberrant motion (sagittal plane),
  • Prone instability
  • SLR gt91,
  • age lt40 years old
  • If 3 of 4 criteria met probability of improvement
    is 80
  • Modified Clinical Prediction (mCPR)1

  • Negative Predictors Shook out in the stats
  • Negative prone instability test
  • Absence of aberrant movements during sagittal
    plane lumbar ROM
  • Absence of lumbar hypermobility(assessed with PA
  • Score of 9 or higher on the FABQ physical
    activity subscale
  • The presence of at least 3 of these findings was
    highly predictive of failure (positive LR, 18.8),
    indicating that if a patient was presumed to have
    a 25 probability of failing, the presence of at
    least 3 of these factors would increase the
    probability of failure to 867

Motor control exercises
  • Treatment Progression
  • Train core neutral
  • TrA/Multifidi (hook lying, prone, quadruped) add
    arms, legs
  • Swiss ball - sitting, supine, prone
  • Standing sagittal/frontal plane with ADIM/TrA
  • Standing Diagonal/PNF, Rotation
  • Movement/travelling challenge

Motor Control Exercise
  • Motor control exercises for nonspecific low back
    pain, when used in isolation or with additional
    interventions, are effective at decreasing pain
    and disability related to nonspecific low back

Clinical Question
  • Do patients with low back pain treated with
    spinal manipulative therapy and/or mobilization
    demonstrate improved pain and disability?

  • Classification by examining predictors of
    improvement defined as a 50 or greater reduction
    in self-reported disability occurring over 2
    treatment sessions in 71 patients with
    nonradicular LBP
  • Clinical Prediction Rule
  • No symptoms distal to knee
  • Duration of symptoms lt16 d
  • Lumbar hypomobility
  • Fear-Avoidance Beliefs Questionnaire for Worklt19
  • Hip internal rotation range of motion gt35
  • Improvement 97 when at least 4 factors were
    present and decrease to 9 when 2 or fewer
    factors were present7

  • Most common techniques in current research are
    the general lumbopelvic technique and a side
    lying rotational technique3
  • The 2 groups receiving thrust manipulation fared
    significantly better than a group receiving
    nonthrust mobilization at 1 week, 4 weeks, and 6
    months -
  • Spinal Manipulative Therapy appears to be
    effective for pain reduction in the short,
    intermediate, and long terms11

  • The immediate changes in pain intensity and
    pressure pain threshold after a single
    high-velocity manipulation do not differ by
    region-specific versus nonregion-specific
    manipulation techniques in patients with chronic
    low back pain4

  • Thrust manipulative and non-thrust mobilization
    procedures can also be used to improve spine and
    hip mobility and reduce pain and disability in
    patients with sub acute and chronic low back and
    back-related lower extremity pain3
  • Clinicians should consider utilizing thrust
    manipulative procedures to reduce pain and
    disability in patients with mobility deficits and
    acute low back and back-related buttock or thigh

Muscle Energy Techniques
  • Muscle energy techniques appear to be effective
    in combination with exercise in reducing
    disability scores over a 4-week period compared
    with exercise only15
  • There is a lack of high-quality research
    regarding the efficacy and effectiveness of MET,
    as well as the therapeutic mechanisms, but
    emerging evidence supports the clinical
    usefulness of this technique16

Muscle Energy Techniques
Specific Exercise
  • Matched to patients impairments/directional
  • Centralization of symptoms is the goal
  • Repeated motions x 1 x 10 x 10 x 10
  • Disc - correct lateral shift first, then
    extension (prone lying (pillows if needed), POE,
    POE with over pressure, standing Extension, POE
    with rotation)
  • Stenosis SKTC, DKTC, seated flexion hands down
    legs, reaching forward, standing flexion
  • As symptoms resolve add controlled motion
  • Supine , standing, moving

  • Traction
  • Symptoms peripheralize with extension
  • a positive crossed (ie, contralateral)
    straight-leg raise test.
  • Signs of nerve root compression
  • 50-60 Body Weight prone or supine,
    Intermittent or static

When to refer
  • Clinicians should consider diagnostic
    classifications associated with serious medical
    conditions or psychosocial factors and initiate
    referral to the appropriate medical practitioner
  • (1) the patients clinical findings are
    suggestive of serious medical or psychological
  • (2) the reported activity limitations or
    impairments of body function and structure are
    not consistent with those presented in the
    diagnosis/classification section of these
  • (3) the patients symptoms are not resolving
    with interventions aimed at normalization of the
    patients impairments of body function. 3

My 2 Cents
  • Must assess before treatment of any kind and
    continue to reassess through the treatment --
  • Motion should not be initiated by the spine
    core strength initiate through the hips, stable
  • Use your manual skills to facilitate normal joint
    mechanics any time possible
  • Exercise should never hurt exercise to promote
    good motor patterns as well as strength
  • Patients/people are great at moving around pain
    and despite pain - dont encourage/facilitate
    abnormal movement patterns
  • Get your patients up and moving!!!!

  • Alon Rabin, DPT, PhD1, Anat Shashua, BPT, MS2,
    Koby Pizem, BPT3, Ruthy Dickstein, PT, DSc4, Gali
    Dar, PT, PhD4. A Clinical Prediction Rule to
    Identify Patients With Low Back Pain Who Are
    Likely to Experience Short-Term Success Following
    Lumbar Stabilization Exercises A Randomized
    Controlled Validation Study. J Orthop Sports Phys
    Ther. 2014 Jan 44(1)6-18
  • Beattie, Paul F PT, PhD, OCS, FAPTA. The lumbar
    Spine Physical therapy patient management
    utilizing current evidence. Current Concepts of
    Orthopedic Physical Therpy, 3rd Edition 2011.
  • Delitto A1, George SZ, Van Dillen LR, Whitman JM,
    Sowa G, Shekelle P, Denninger TR, Godges JJ. Low
    Back Pain J Orthop Sports Phys Ther. 2012
  • de Oliveira RF1, Liebano RE, Costa Lda C,
    Rissato LL, Costa LO. Immediate effects of
    region-specific and non-region-specific spinal
    manipulative therapy in patients with chronic low
    back pain a randomized controlled trial. Phys
    Ther. 2013 Jun93(6)748-56
  •  Flynn T1, Fritz J, Whitman J, Wainner R, Magel
    J, Rendeiro D, Butler B, Garber M, Allison S. A
    clinical prediction rule for classifying patients
    with low back pain who demonstrate short-term
    improvement with spinal manipulation. Spine
    (Phila Pa 1976). 2002 Dec 1527(24)2835-43.
  • Fritz, Cleland and Childs. Subgrouping Patients
    With Low Back Pain Evolution of a Classification
    Approach to Physical Therapy. Journal of
    orthopaedic and sports physical therapy June 2007
    Vol 37 (6) p 290-302.
  • Fritz JM1, Lindsay W, Matheson JW, Brennan GP,
    Hunter SJ, Moffit SD, Swalberg A, Rodriquez B. Is
    there a subgroup of patients with low back pain
    likely to benefit from mechanical traction?
    Results of a randomized clinical trial and
    subgrouping analysis. Spine (Phila Pa 1976). 2007
    Dec 1532(26)E793-800
  • Hebert J, Koppenhaver S, Fritz J, Parent E.
    Clinical prediction for success of interventions
    for managing low back pain. Clin Sports Med. 2008

  1. Hicks GE1, Fritz JM, Delitto A, McGill SM.
    Preliminary development of a clinical prediction
    rule for determining which patients with low back
    pain will respond to a stabilization exercise
    program. Arch Phys Med Rehabil. 2005 Sep
  2. Robert A Laird1,5, Jayce Gilbert2, Peter Kent3,4
    and Jennifer L Keating1. Comparing lumbo-pelvic
    kinematics in people with and without back pain
    a systematic review and meta-analysis. BMC
    Musculoskeletal Disorders 2014, 15229
  3. Simon Dagenais, DC, PhDa,b et al. NASS
    Contemporary Concepts in Spine Care Spinal
    manipulation therapy for acute low back pain. The
    Spine Journal 10 (2010) 918940
  4. Stanton, Tasha R, Julie M. Fritz, et al.
    Evalaution of a Treatment Based Claissifcation
    algorithm for low back pain a cross-sectional
    study. PHYS THER. 2011 91496-509.
  5. Stanton, Tasha et al. What Characterizes People
    Who Have an Unclear Classification Using a
    Treatment-Based Classification Algorithm for Low
    Back Pain? A Cross-Sectional Study. PHYS THER.
    2013 93345-355.
  6. Leonardo O.P. Costa et al. Motor Control Exercise
    for Chronic Low Back Pain A Randomized
    Placebo-Controlled Trial PHYS THER. 2009
  7. Day Joseph M and Nitz Arthur J. The Effect of
    Muscle Energy Techniques on Disability and Pain
    Scores in Individuals With Low Back Pain Journal
    of Sport Rehabilitation, 2012, 194-198
  8. Gary Fryer. Muscle energy technique An
    evidence-informed approach. International Journal
    of Osteopathic Medicine 14 (2011) 3e9
  9. Cook Chad E., et al. Effectiveness of Physical
    Therapy administered spinal manipulation
    for the treatment of low back pain A
    systematic review of the literature. The
    International Journal of Sports Physical Therapy
    Vol 7, Number 6 December 2012 P 647-662.
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