PT Classroom - Evidence Based Management of Low Back Pain ׀ by Larry Sandberg, PT

 

Larry Sandberg, PT, received his physical therapy degree from Marquette University. He has over 30 years of experience in orthopedic and sports physical therapy. He has a special area of interest in kinetic chain mechanics of the spine/extremities as it relates to manual therapy and functional exercise. He presently serves as a clinical coordinator at the KMCC campus at United Hospital System.



 Evidence Based Management of Low Back Pain

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Low back pain (LBP) is one of the most difficult challenges faced by physical therapists. To further compound this problem, research studies reveal that 90% of patients with LBP cannot be given a precise pathoanatomical diagnosis (1). Often times, patients are given a nominal diagnosis of lumbar strain, lumbago, back pain (1). Furthermore, many patients frequently present with a recurrent exacerbation of symptoms, but will have had a history of LBP thereby complicating the traditional definitions of acute and chronic pain (2).


In an effort to assist physical therapists in their evaluation and treatment for LBP, Delitto and colleagues proposed a treatment-based classification system (3). The development of this system is an ongoing process as more research studies have shown this to produce better clinical outcomes than the traditional non-classification approaches of back pain (3).

Utilizing this approach, physical therapists seek to classify patients back pain based on their signs and symptoms rather than focusing on a specific diagnosis. This will enable therapists to better determine which type of treatment approach would be most effective (4). It is important to remember that during the course of a physical therapy evaluation, the potential for serious medical conditions or psychosocial factors that can cause back pain must be ruled out prior to classifying a patient’s back pain (4).

Once this has been done, a patient’s signs and symptoms tends to fall in one or more of the following classifications in order to determine the best course of treatment (3, 5, 6):
1) Manipulation/Manual Therapy
2) Stabilization
3) Specific Exercise

Manipulation/Manual Therapy Classification (5)
Patients who are < 60 years old that demonstrate 4 out of the 5 below noted clinical criteria increase the likelihood of achieving a 50% functional improvement by 92% utilizing a manual therapy approach.

• Symptoms < 16 days
• No pain below the knee
• Lumbar hypomobility with PA assessment
Fear Avoidance Belief Questionnaire (FABQ) work subset score <19
• At least one hip ROM with IR of 35

The evidence from studies are also suggesting that the choice of manual therapy technique performed may not be as important as previously thought compared to proper identification of the patient type for a positive functional outcome (6).

Stabilization Classification (7)
Patients meeting 3 out of 4 below noted clinical criteria increase the likelihood of achieving a 50% functional improvement.

• Age < 40 years
• Average SLRing > 90
• Aberrant motion noted with lumbar flexion
• Positive prone instability test

Stabilization programs typically focus on strengthening the erector spinae, multifidus, transverse abdominals and oblique musculature (4,7).

Furthermore, recent studies have shown there is little difference in the clinical outcomes after an 8 and 20 week follow up when comparing stabilization programs that focus on trying to isolate these muscle groups vs a general functional approach (8).

Specific Exercise Classification (4, 8)
Patients who would benefit from a specific exercise approach will demonstrate one of the following:
• Centralization of pain symptoms with 2 or more movements in same
direction
• Centralization of pain with a movement in one direction and
peripheralization of symptoms with an opposite movement.

Specific exercises will often involve extension, flexion or lateral shift correction approach (4). Studies have shown substantially greater reductions in functional disability after a 2 week follow up when a specific exercise regime that matched patient preference of movement was used compared to a non-specific approach (9).

In situations when therapists are unable to centralize pain symptoms with a specific directional movement, lumbar traction has been utilized as an adjunct with treatment (10). While there is a subgroup of patients that do appear to benefit from lumbar traction, these patients have not yet been identified in studies (10). For the most part, research evidence doesn’t support the use of lumbar traction and is generally not recommended in clinical practice guidelines (11).

Conclusion
Low back pain will continue to make up a large portion of an orthopedic physical therapy practice. The evidence from research is beginning to recognize there are subgroups of patients with LBP and that integrating a classification based treatment approach can improve functional outcomes (4).

 

Last revised: May 1, 2009
by Larry Sandberg, PT


References:
1. Abenhaim L, Rossignol M. The Prognostic Consequences in Making of Initial Medical Diagnosis of work related back injuries. Spine 1995;20:791-795
2. Von Korff M,Saunders K. The course of back pain in primary care. Spine 1996;21:2833-2839
3. Delitto A, Erhard RE. A treatment based classification approach to low back syndrome; Identifying and staging patients for conservative management. PhyTher.1995;75:470-489
4. Wilmarth Mary Ann, The Lumbar Spine: Physical Therapy Patient Management Utilizing Current Evidence, Current Concepts of Orthopedic Physical Therapy- APTA Independent Study Course, 2006
5. Flynn T, Fritz J, Whitman J et al, A clinical prediction rule for classifying patients with low back pain who demonstrate short term improvement with spinal manipulation. Spine 2002:27:2835-2843
6. Chiradejnant A, Maher CG,Latimer J, Stepovitch N. Efficacy of therapist selected verses randomly selected mobilization techniques of low back pain: a randomized controlled trial. Aust J Physiotherapy. 003;49:233-241
7. Hicks GE, 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 2005:86:1753-1762
8. McKenzie RA The Lumbar Spine; Mechanical Diagnosis and Therapy, Waikanae, NZ Spinal Publications Limited 1989
9. Koumantakis GA, Watson PJ, Oldman JA. Trunk muscle stabilization training plus general exercise verses general exercise only: randomized controlled trial of patients with recurrent low back pain. Phy Ther. 2005:85:209-225.
10. Harte AA, Gracey JH, Baxter GD. Current use of lumbar traction in the management of low back pain: results of a survey of physiotherapists in the United Kingdom. Arch Phys Med Rehabil. 2005:86; 1164-1169
11. VanTulder MV, Koes BW, Bouter LM. Conservative treatment of acute and chronic non specific low back pain. A systemic review of randomized controlled trials of the most common interventions. Spine 1991:22:2128-2156

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