Treating Back Pain A Physical Therapy Approach

1. Treating Back PainA Physical Therapy Approach PRESENTED BY: Paula P. Godes, PT, DPT Dewitt physical therapy December, 2009

2. OUTLINE Prevalence and Cost ACP Guidelines Ruling out Red Flags Classification Systems Interventions Core Stability Stability Exercise Progression Outcome Measures Our Approach Improving Efficacy References

3. PREVALENCE and COST • 90% of Americans will experience back pain in their life • Most common cause of pain and disability • Second only to respiratory problems for visits to PCM • Most acute cases are self-limiting: 4-6 weeks • 85% of patients who experience pain cannot be attributed to a specific disease or spinal abnormality • Strong association with pain and psychosocial risk factors • 60% of LBP suffers experience functional limitation or disability as a result of their pain • Pain and disability expenditures: 100 – 200 billion in health care costs and lost wages annually • LBP and economic cost unchanged in past decade, despite medical advances • Leading cause of disability in persons younger than 45 and 3rd leading cause of disability in persons > 45 years of age

4. ACP Guidelines for the Dx and Tx of LBP American Family Physician, Vol 77, Number 11, June 2008 • PCM exam to classify in one of three categories: • Nonspecific pain • Pain associated with radiculopathy or spinal stenosis • Pain from another specific spinal cause • Routine imaging not recommended for patients with nonspecific pain • Dx imaging performed in patients with severe or progressive neurologic deficits or serious underlying condition • S/S of radiculopathy or spinal stenosis: MRI (preferred) or CT if candidate for injection or surgery • Patients provided with evidence-based information on expected tx course, advised to remain active, provided info about self-care options. • NSAIDS recommended as first-line medication options • If not improving w/ self-care: recommend nonpharmacologic therapies

5. Management of Low Back Pain in Adults ACP Guidelines for the Dx and Tx of LBP TABLE 2Intervetions for the Management of Low Back Pain

6. The Role of Exercise in the Prevention and Management of Acute Low Back Pain Dugan, 2006 There is no proven benefit to prolonged bed rest (> 4 days) in acute LBP without radiculopathy Aerobic fitness may be mildly protective against low back injury and pain Aerobic exercises should be incorporated into the spine rehab program as early as possible Findings of reduced strength, endurance and flexibility are common in patients who have LBP. These findings may be consequences of acute deconditioning and a potential causative factor for dysfunction in the future There is a mild relationship between trunk muscle strength and LBP There is a mild relationship between decreased flexibility in the direction of repeated spinal motion and LBP The causes of LBP are multifactorial, even when a pain generator is identified

7. Red Flags of Back Pain Winters et al, 2006 HISTORY PHYSICAL EXAM Gradual onset Age <20 or > 50 years Thoracic back pain Pain > 6 weeks History of trauma Fever/chills/night sweats Unintentional weight loss Pain worse with recumbency Pain worse at night Unrelenting pain despite analgesics History of malignancy History of immunosuppression Recent procedure known to cause bacteremia History of intravenous drug use Fever Hypotension Extreme hypertension Pale, ashen appearance Pulsatile abdominal mass Pulse amplitude differentials Spinous process tenderness Focal neurologic signs Acute urinary retention

8. Classification Systems Riddle, 1998 • Bernard and Kirkaldy-Willis • Developer: Orthopedic surgery • Status Index • 23 categories based on pathophysiology and disease • Delitto and Colleagues • Developer: Physical Therapy • Clinical guideline index • Three levels of classification • McKenzie • Developer: Physical Therapy • Clinical guideline index • 13 categories • Postural Syndrome • 4 dysfunction syndromes • 7 derangement syndromes • Quebec Task Force • Developer: Medical and nonmedical disciplines • Mixed Index • 11 categories with 2 axes • The development of classification systems for low back pain stemmed from the realization that pathoanotomical causes are often unclear • The lack of cause makes it difficult to treat patients within a medical model where all disease must be explained in terms of derangement of underlying physical mechanisms • The classification systems presented today represent a paradigm shift away from the medical model • Classification: A process of organizing clinical data into named categories for the purpose of making decisions regarding treatment • Classification schemes are designed to reliably group patients into treatment-directing categories • Which tx work on which subgroups? • Clinical Prediction Rules (CPR) “predict” which treatment is most likely to benefit the patient

9. LBP Classification System Brennan et. al, 2006

10. LBP Classification System Brennan et. al, 2006 Outcomes are better for patients treated matched in the classification category The study was conducted to ensure that improved outcomes were secondary to treatment within the classification scheme and not due to superior treatment As patient met preset criteria, the therapists progressed both matched and unmatched patients into more advanced care

11. Interventions Self care - positioning Medication/NSAIDS STM Modalities General exercise Mobilization ** Stabilizing exercises ** Stretching Injections Surgery ** CPR developed

12. Intervention: Modalities Includes heat, ice, ultrasound, electrical stimulation May be effective for short term, acute intervention Limited use in outpatient setting Weak correlation for long-term results Promotes passive, rather than active intervention TENS for chronic pain may be tried – if effective, recommend PCM orders to reduce use of medication Traction – limited use – may be effective for radicular symptoms that do not localize w/ movement

13. Intervention: CPR for Mobilization Childs et al, 2004 4 of 5 positive for Rule

14. Intervention: CPR for Stability Exercises Hicks et al, 2003 • A CPR for stabilization was developed • Predictors of success: + PIT, avg SLR > 90 deg, age <40, aberrant motions – re: “Gower’s” sign upon return from FF • Numerous physical exam variables were conducted then treatment stabilization exercise was given • After completion of the program the authors evaluated which pretreatment variables precluded dramatic success with the stabilization protocols • 73% of the 54 subjects with LBP responded favorably to lumbar stab program (27% failed to respond)

15. Stability Exercises Outcomes Hicks et al, 2003 MODIFIED OSWESTRY

16. What is Core Stability? MUSCLES FUNCTION • Major core muscles: • Transversus abdominus • Multifidus • Pelvic floor muscles • Internal and external obliques • Rectus abdominus • Erector spinae • Diaphragm • Minor core muscles: • Latissimus dorsi • Gluteus maximus • Trapezius Contraction of the TA and other muscles reduces the vertical pressure on the intervertebral discs by as much as 40%. The transversus abdominis and the segmental stabilizers (multifidi) of the spine are designed to work in tandem The “core” stabilize the thorax and the pelvis during dynamic movement Control of whole-body equilibrium

17. Transversus Abdominus • Major muscle of the functional core of the human body • Creates rigid cylinder • Enhances stiffness of the lumbar-spine and lateral tension through attachment to transverse processes to assist rotational motion • Creates pressurized visceral cavity anterior to the spine • Creates forces against apex of lumbar-lordosis • Prevents spinal extension • Counteracts pull of psoas (flutter kicks, sit-ups) • Fibers run horizontally and attach via thoraco-lumbar fascia to transverse processes • Enhances stabilization of spine

18. Lumbar Multifidus Vertebra-to-vertebra Segmental innervation Provides segmental stiffness, support and control, intervertebral compression Control of anterior rotation and translation Strongest influence on lumbar segmental stability-as compared to erector spinae (Wilke et al – 1995) Type I fibers – ENDURANCE (increased pain w/ prolonged sitting, standing)

19. Training the Transverse Abdominus Pelvic Tilt: contraction of TA “belly button to spine” Biofeedback using ultrasound, inflation cuff maintaining 40 PSI

20. Using Ultrasound for Biofeedback

21. Progression • Phase I • Isolate transverse abdominus/multifidus • Avoid substitutions – assess via BP cuff/US • Phase II • Integrate local muscles into extremity antigravity movement (prone swimmer, dying bug) • Phase III • Develop global muscle activation with closed chain weight bearing activity (lunges, push-ups, plank, bridge)

22. Progression cont. Progress from stable to unstable Large simple movements to smaller, more complex One plane of movement to multiple/combined Short lever arm to longer No weights to weights Slow speed to fast Relate to functional tasks, sports, gym

23. Low Back Stretches Knee to chest Double knee to chest Lumbar rotation Lumbar rotation – leg extension – contralateral arm elevation

24. Stretches cont. Supine Hamstring – knee extended 90 deg – normal length Periformis stretch – pressing outward on crossed knee Deeper stretch – elevate arm on same side of extended leg Hip Flexor stretch – front knee at 90 degrees

25. ROM/Localizing/Strengthening Prone on elbows Prone Press-ups Pain free only Multifidus engagement – activate TA Extend leg 2-3 inches off surface Swimmers (Multifidus) – activate TA Extend opposite arm/leg

26. Strengthening - TA Plank – activate TA – elevate on forearms - toes 3-point Plank – raise one foot 2-point plank – elevate opposite arm/leg

27. Side plank – obliques, greatest activation of TA Side plank – Elevate leg Star Plank – extend top leg/arm

28. Bridge – activation of TA Pelvis level Bridge – unstable surface (Bosu) Bridge with SL extension Switch legs without lowering trunk or pelvis Increase difficulty with Bosu Response to perturbations

29. Want a challenge? Bridge on Bosu, single leg extension with hip abduction against resistance band

30. Progressing difficulty – Plank on Bosu, Dead Bug on foam roller, double leg lift/lower on foam roller, Tband “sword” on foam roller

31. STABILITY BALL Pelvic Rocks – activation of TA Side to side Anterior – Posterior Seated marching

32. Bridge on ball Crunches on ball – pelvis level Front resting plank on ball Plank on ball with arm extension

33. Outcome Measures Fairbank, 2000 • Oswestry Disability Index • “Gold Standard” of low back functional outcome tools • 25 years of clinical use • Scoring • The ODI score (index) is calculated as: • 0% to 20%: minimal disability: The patient can cope with most living activities. Usually no treatment is indicated apart from advice on lifting sitting and exercise. • 21%-40%: moderate disability: The patient experiences more pain and difficulty with sitting lifting and standing. Travel and social life are more difficult and they may be disabled from work. Personal care and sleeping are not grossly affected and the patient can usually be managed by conservative means. • 41%-60%: severe disability: Pain remains the main problem in this group but activities of daily living are affected. These patients require a detailed investigation. • 61%-80%: crippled: Back pain impinges on all aspects of the patient's life. Positive intervention is required. • 81%-100%: These patients are either bed-bound or exaggerating their symptoms

34. Our Approach • Referral received – Initial evaluation with Physical Therapist • Initial Oswestry exam • Subjective: Hx of pain, extent of limitation, current activity level, agg/ease of symptoms, past occurrences or interventions, medications, r/o red flags • Objective: ROM, GMMT, Neuro screen, special tests – classify to tx subgroup • Instruction: Stretches, basic Phase I core stability • Intervention: Mobilization if appropriate • Return to clinic for advanced exercises – in clinic for limited treatments/ mobes • Follow-up in 4-6 weeks – re-assess Oswestry • May consider additional clinic sessions or aquatic therapy to assist w/ progression of exercises and strength building • Consideration of advanced imaging and additional referral if not progressing after 3 mos.

35. Improving Efficacy • Introduction of a Back Class – focus on general exercise, posture, ergonomic education • Clinic treatments: Designed to promote independence and compliance – “lifestyle” change • Promote an understanding of multifactoral issues contributing to back pain: stress, inactivity, muscular imbalance and tightness, weakness • Goal is for patient to understand and manage through a variety of self-care options and exercise techniques • Goal is not for physical therapy to “fix” the pain • Understand there is a cognitive and behavioral contribution to back pain, as well as secondary gains that may prevent optimal outcomes

36. References Childs JD, Fritz JM, Flynn TW, et al. Validation of a clinical prediction rule to identify patients with low back pain likely to benefit from spinal manipulation. Ann Intern Med 2004;141:920–8 Cleland, J, Fritz, J, Whitman, J, Childs, J, Palmer, J. (2006) The use of a lumbar spine manipulation technique by physical therapists in patients who satisfy a clinical prediction rule: A case series. Journal of Orthopaedic and Sports Physical Therapy 36(4): 209- 214. Dugan, S (2006) The Role of Exercise in the Prevention and Management of Acute Low Back Pain. Clin Occup Environ Med 5(3) 615-632 Davidson M & Keating J (2001) A comparison of five low back disability questionnaires: reliability and responsiveness. Physical Therapy. 82:8-24. Fairbank JC. (2000)The Oswestry Disability Index. Spine 25(22):2940-2952 Feuerstein, M, Harrington, C, Lopez, M, Haufler, A. (2006) How do job stress and ergonomic factors impact clinic visits in acute low back pain? A prospective study. JOEM 48(6): 607 – 614. Fritz, J, Delitto, A, Erhard, R (2003) Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain. Spine (28)13: 1363-1372. Hammill, R, Beazell, J, Hart, J. (2008) Neuromuscular consequences of low back pain and core dysfunction. Clin Sports Med 27 (2008) 449-462. Hebert, J, Koppenhaver, S, Fritz, J, Parent, E (2008) Clinical prediction for success of interventions for managing low back pain. Clin Sports Med 27: 463-479.

37. References Cont. Hicks GE, Fritz JM, Delitto A, et al. (2003) The reliability of clinical examination measures used for patients with suspected lumbar segmental instability. Arch Phys Med Rehabil 84:1858–64. Hides, J, Jull, G, Richardson, C. (2001) Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine 26(11): 243 – 248. Horsley, L (2008) ACP Guidelines for the diagnosis and treatment of low back pain. American Family Physician. 77(11): 1607-1610. Last, A, Hulbert, K (2008) Chronic low back pain: Evaluation and management. American Family Physician 79(12): 1067-1074. Long, A, Donelson, R (2004) Does it Matter Which Exercise? Spine 29(23): 2593-2602 Riddle, D (1998) Classification and low back pain: A review of the literature and critical analysis of selected systems. Physical Therapy 78(7): 708-737. Shelerud, R. (2006) Epidemiology of Occupational Low Back Pain. Clin Occup Environ Med 5(3): 501-528. Wasiak, R, Kim, J, Pransky, G. (2007) The association between timing and duration of chiropractic care in work-related low back pain and work-disability outcomes. JOEM 49(10): 1124-1134. Winters, M, Kluetz, P, Zilberstein, J (2006) Back pain emergencies. Med Clin N Am 90: 505-523.