Vous êtes sur la page 1sur 114

Conservative Therapy for Back Pain –

The Family Doctor and the


Physiotherapist

Facilitators:

Dr. Ranald Donaldson, BSc, MSc, MD


Dr. Peter Huijbregts, PT, MSc, MHSc, DPT
Adult Case: Back Pain
Tom is a 45 year old who presents complaining of
back pain to his family doctor, Dr Grey. He
moved some heavy boxes four weeks prior, and
since has had a low grade, but bothersome
“muscle spasm” of the low mid back with some
radiation to the right buttock. He has had similar
symptoms previously, but they have never
persisted this long.
Adult Case: Back Pain
Our patient Tom is a manager in the electronics department at a big
retail store. He is married and has two young teenaged daughters.
He last saw his family doctor two years prior at his wife’s urging. At
that time his diabetes screen had been borderline, and he had been
counselled about dietary management. He had not succeeded in
making any significant lifestyle changes. He skips breakfast, takes
lunch at the food court, drinks three cans of coke over the day, and
usually prepares himself a large pasta dish for dinner. His exercise
consists of participation in his weekly old-timers hockey game,
which runs through the fall and winter. Over the last two years he
has in fact gained 2 kg, such that he is now weights 120 kg.
Let us first get a
misconception out of the
way…
LBP Myths

“80-90% of people with LBP get better


in about 6 weeks irrespective of
administration or type of treatment"

Waddell G. A new clinical model for the treatment of low-


back pain. Spine 1987;12:632-643.
PRIMARY CARE PHYSICIAN STUDY
Follow up within 1-2 weeks - 2%
reported no pain or disability
At 3-months follow up – 21% reported
no pain or disability
At 12-months – only 25% of those
interviewed reported no complaints
So 75% of those interviewed still
had continuing LBP and disability
at 1 year
Croft PR, et al. Outcome of low back pain in general
practice: a prospective study. BMJ 1998;316:1356-
1359)
SYSTEMATIC REVIEW
62% of patients (range 42-75%) still
experience LBP at 12 months
16% (range 3-40%) of patients still
sick-listed at 6 months
Recurrence of LBP in 60% (range 44-
78%)
Recurrent sick-listing 33% (range 26-
37%)
Hestbaek L, et al. Low back pain: what is the long-
term course? Eur Spine J 2003;12:149-165
LBP is not a self-limiting problem
but a problem characterized by
exacerbations and remissions,
which becomes chronic in about
10% of the population

Hestbaek L, The Natural Course of Low Back Pain and Early Identification
of High-Risk Populations. PhD Thesis. Odense, Denmark: University of
Southern Denmark, 2003.
The 10% of patients with LBP
who go on to have chronic
LBP and disability are
responsible for 80% of the
costs associated with this
condition

Murphy PL, Courtney TK. Low back pain disability:


Relative costs by antecedent and industry group. Am J
Ind Med 2000;37:558-571.
Role of the physician

 Differentialdiagnosis
 Medical-surgical management

 Referral to other providers for co-


management
Role of the physical
therapist
Medical screening based on systems
approach and appropriate referral for
medical-surgical (co) management
Evaluation and management of
patients with mechanical LBP
Potential role in the co-management
of patients with LBP due to trauma,
metabolic, infectious, inflammatory, and
neoplastic disease
Types of Low Back Pain

 Simple or mechanical back pain


 Back pain with neurological involvement
 Back pain with suspected serious spinal
pathology: Red Flags
 But also: Back pain with indicators of
poor prognosis or Yellow Flags
Patho-anatomical diagnosis
 Traditional medical, structure-based model
 Assumes a direct correlation between
underlying pathology and signs and
symptoms
 Note: Unable to provide up to 85% of
patients with low-back pain a specific
diagnosis: Simple or mechanical low back
pain
Mechanical Low Back Pain with or
without Neurological Involvement

 Zygapophyseal joint pain syndrome


 Diskogenic pain
 Lumbar radiculopathy
 Spinal stenosis
 Sacroiliac joint syndrome
 Lumbar instability
 Muscle/ligamentous sprain or strain
 Myofascial pain syndrome
Zygapophyseal Joint Pain Syndrome

 Restricted motion lumbar spine with low


back or buttock pain
 Pattern of motion loss indicating opening
or closing restriction zygapophyseal joint:
Decreased extension, sidebending, and
rotation
Diskogenic Pain
 Report of centralization or
peripheralization of symptoms during
repetitive movements or during prolonged
periods in certain positions
 Difficulty with curve reversal: Rising after
sitting or straightening up in morning out of
bed
Lumbar radiculopathy

 Lower extremity pain or paraesthesiae


greater than low back pain
 Radicular deficit noted: Decreased
strength or sensation
Spinal Stenosis
 Pain in lower extremities that is
exacerbated by an extension posture
(standing and walking) and relieved by a
flexion posture (sitting, semi-Fowler,
sidelying, leaning on shopping cart)
Sacroiliac Joint Syndrome

 Predominant unilateral pain just inferior to PSIS


 Also pain low back, posterolateral buttock,
posterior thigh to knee, and groin
 Worse with load transfer through affected side
 13% (95% CI: 9-26%) of patients with persistent
low back pain have the origin of pain confirmed
as the SIJ
Lumbar Instability

 Recurrent locking, catching, giving way of


the low back during active motion
 Difficulty with sustained postures
Muscle and Ligament Sprain
or Strain

 Pain aggravated with stretch of ligaments


or muscles
 Pain increased with muscular contraction
Myofascial Pain Syndrome

 Myofascial trigger points


 Central sensitization
 Peripheral neuropathy
 Chronic pain states
History

 Inventory of current complaint


 Screening for yellow and red flags
 History of current complaint
 Medical history
 Social history
Inventory of Current Complaint

 Location of pain
 Intermittent, constant, episodic
 Aggravating and easing factors
 Effect of coughing, sneezing, and straining
 Range of motion impairments (also locking and
crepitus)
 Sensory abnormalities
 Motor deficits
 Inflammatory symptoms: redness, swelling,
increased temperature
 Cauda equina syndrome
Zygapophyseal Joint Pain Syndrome
Lumbar Radiculopathy
Myofascial Pain Syndrome
Myofascial Pain Syndrome
Myofascial Pain Syndrome
Visceral Referral: Angiotomes
Visceral Referral: Organs
Mechanical versus Non-Mechanical

 Constant versus intermittent


 Episodic
 Aggravating and easing factors
 Coughing, sneezing, and straining
 Inflammatory symptoms
Lumbar Spinal Stenosis
 Do you have no pain when sitting
 +LR = 6.6; -LR = 0.58
 Are you symptoms improved while seated
 +LR = 3.3; - LR = 0.58
 Age > 65
 +LR = 2.5; - LR = 0.33
 Do you have severe lower extremity pain
 +LR = 2.0; - LR = 0.52
Lumbar Spinal Stenosis
 Are you able to walk better when holding onto a
shopping cart
 +LR = 1.9; - LR = 0.55
 Do you have pain below the knees
 +LR = 1.5; -LR = 0.70
 Do you have pain below the buttock?
 +LR = 1.3; - LR = 0.35
Katz JN, et al. Degenerative lumbar spinal stenosis: Diagnostic value of
history and physical examination. Arthritis Rheum 1995;38:1236-
1241.
Screening for Yellow and Red
Flags

 Non-mechanical low back pain


 General health: Night pain, unexplained
weight loss, etc.
 Indicators of poor prognosis
Cauda Equina Syndrome
 Urinary retention: sensitivity 90%, specificity
95%
 Fecal incontinence
 Saddle area anesthesia: sensitivity 75%
 Sexual dysfunction
 Unilateral or bilateral sciatica, sensory, or motor
deficits: > 80% sensitivity

Deyo R, et al. What can the history and physical examination tell us
about low back pain? JAMA 1992;268:760-765.
Back Pain and Pathology
Visceral disease:
Retroperitoneal and pelvic region or the
gastrointestinal system
Vascular disease:
Abdominal aortic aneurysm
Hematological disease:
Hemoglobinopathies and myelofibrosis
Trauma:
Fracture, fatigue fracture, insufficiency
fracture
Metabolic and endocrine disease:
Osteoporosis, osteomalacia, Paget
disease, and diabetes (diabetic
radiculopathy)
Infectious disease:
Diskitis and osteomyelitis
Inflammatory disease:
Spondylarthropathies
Neoplastic disease:
Osteoid osteoma, multiple myeloma,
metastases
Huijbregts PA. HSC 11.2.4. Lumbopelvic region: Aging, disease,
examination, diagnosis, and treatment. In: Wadsworth C. HSC 11.2.
Current Concepts of Orthopaedic Physical Therapy. LaCrosse, WI:
Orthopaedic Section APTA, 2001.
Yellow Flags: Depression
Random population-based survey
Multivariate
analysis excluded
confounding variables.
Independent relationship between
depressive symptoms and onset of
neck or back pain episode.
Comparing lowest quartile of
depression scores to highest quartile.
Adjusted risk ratio most depressed
3.97
Carroll LJ, et al. Depression as a risk factor for onset of an episode
of troublesome neck and low back pain. Pain 2004;107:134-139.
Depression Screening
 During the past month have you often been
bothered by feeling down, depressed, or
hopeless?
 During the last month have you often been
bothered by little interest or pleasure in doing
things?
 Sensitivity 97%; specificity 67%

Arroll B, et al. Screening for depression in primary care with verbally


asked questions: A cross sectional study. BMJ 2003;327:144-1146.
Yellow Flags: Fear Avoidance
Prospective interventional case series
design
36 patients with chronic LBP.
Fear avoidance beliefs questionnaire –
physical activity subscale.
Comparing FABQ-PA >29 to FABQ-PA
<20.
Increased probability of negative
outcome in high-score group: Likelihood
ratio 3.78
Al-Obaidi SM, et al. The relationship of anticipated pain and fear
avoidance beliefs to outcome in patients with chronic low back pain who
are receiving workers’ compensation. Spine 2005;30:1051-1057.
Prospective cohort study on risk factors in chronic work-
related LBP
 Multiple regression analysis - 854 patients

 Severe leg pain (7-10 pain rating): odds ratio (OR) 1.92

 Body mass index >30: OR 1.68

 Oswestry Disability Index (ODI) score 21-40: OR 3.1

 ODI score 41-59: OR 3.98

 ODI score >60: OR 3.43

 General Health Questionnaire (GHQ-28) score >6: OR 1.87

 Unavailability of light duties: OR 1.66

 Lifting >75% of the day: OR 1.98

Fransen M, el al. Risk factors associated with the transition from acute to
chronic occupational back pain. Spine 2002;27:92-98.
Prospective cohort study to determine clinical
prediction rule for return-to-work status at 2 years
for 1,007 patients with LBP

 >50% successful return-to-work (RTW) by 12 weeks.


 Seven relevant questions to predict RTW.
 “Do you think you will be back to your normal work in 3
months?”
 “Does your pain radiate into your arms or legs?”
 “Have you ever had back surgery?”
 “On a scale of 0-10, how do you rate your pain?”
 “Lately because of your back pain, do you change position
often?”
 “Lately because of your back pain, are you more irritable?”
 “Does your back pain affect your sleep?”

Dionne CE, et al. A clinical return-to-work rule for patients with


back pain. CMAJ 2005;172:1559-1567.
Common-sense summary

 Include a screen for depression and the


Oswestry Disability Index and Fear
Avoidance Beliefs Questionnaire in your
initial evaluation of a patient with LBP
 Implement appropriate intervention if risk
factors for chronic LBP are present
History of Current Complaint

 Timeline
 Mechanism of injury
 Management of complaint and effect of
various management strategies
 Diagnostic tests done…
Medical History
 Previous medical history
 Family history
 Medication use
 Imaging and lab test findings
Social History

 Occupation
 Leisure time activities
 Environment/social role
Open versus Closed Questions?
 Anything else I forgot to ask that might be
relevant or related to your current
complaint?
 Limit open question but give the patient a
chance to have his or her say…
Physical Examination
 Observation
 Active range of motion testing
 Neuroconductive testing including straight-
leg raise
 Special tests
Active Range of Motion
Testing

 Cardinal plane motions: Flexion,


extension, rotation, sidebending
 Combined motions: Flexion and extension
with ipsilateral sidebending/rotation
 Repeated motion testing: McKenzie or
Mechanical Diagnosis and Therapy
Neuroconductive Examination:
Patellar DTR
 Sensitivity of 12% and a specificity of 65% in the
diagnosis of L4 nerve root compression
 Sensitivity and specificity were 100% and 65%,
respectively, for L3 nerve root compression
 Sensitivity and specificity were 14% and 65% for
L5 nerve root compression

Knuttson B. Comparative value of electromyographic, myelographic,


and clinical-neurological examinations in diagnosis of lumbar root
compression syndrome. Acta Orthop Scand 1961;(Suppl 49):19-49.
Neuroconductive Examination:
Achilles DTR
 Sensitivity of 87% and specificity of 89% in
the diagnosis of L5-S1 disk herniation
 Sensitivity of 12% and specificity of 89%
for the diagnosis of L4-L5 disk herniation.

Kerr RSC, Cadoux-Hudson TA, Adams CBT. The value of


accurate clinical assessment in the surgical
management of the lumbar disc protrusion. J Neurol
Neurosurg Psychiatry 1988;51:169-173.
Neuroconductive Examination:
Myotomal Strength (Kerr et al, 1988)
 Hip extension weakness for the diagnosis of L4-
L5 and L5-S1 disc protrusion: sensitivity was
12% and 9% and specificity 96 and 89%,
respectively.
 Ankle dorsiflexion weakness had a sensitivity of
33%, 66%, and 49% for L3-L4, L4-L5, and L5-S1
disc protrusion, respectively; specificity values
were 89% for all levels
 Ankle plantar-flexion weakness had 0%, 0%,
and 28% sensitivity for the diagnosis of L3-L4,
L4-L5, and L5-S1 disc protrusion, respectively;
specificity values were 100% for all levels
Neurodynamic Examination:
Dermatomal Light Touch

Sensitivity Specificity + LR -LR


L4 (L3-L4 disc herniation) 0.50 0.875 4 0.6
L5 (L3-L4 disc herniation) 0.50 1.0 NA NA
S1 (L3-L4 disc herniation) 0.0 0.875 0 0
L4 (L4-L5 disc herniation) 0.59 0.875 4.7 0.5
L5 (L4-L5 disc herniation) 0.50 1.0 NA NA
S1 (L4-L5 disc herniation) 0.23 0.875 1.8 0.9
L4 (L5-S1 disc herniation) 0.16 0.875 1.3 0.96
L5 (L5-S1 disc herniation) 0.42 1.0 NA NA
S1 (L5-S1 disc herniation) 0.74 0.875 5.9 0.3
Straight Leg Raise
 Positive test for presence of disk
herniation: reproduction of back or leg pain
at less than 40 degrees
 Sensitivity 91%; specificity 26%
 Crossed straight leg raise
 Positive if reproduction of pain in involved
leg
 Sensitivity 29%; specificity 88%
Additional Tests

 Prone knee bend test


 Slump test
Special Tests
 Hip passive range of motion
 Sacroiliac tests
 Segmental tests: accessory motion,
physiological motion, stability
Hip Osteoarthritis

Test cluster 1

 Hip pain
 Hip IR rotation ROM < 15 degrees
 Hip flexion ROM < 115 degrees
Hip Osteoarthritis

Test cluster 2 (if hip IR ROM > 15


degrees)

 Painful hip with IR


 >50 years of age
 Morning stiffness <60 minutes
Hip Osteoarthritis
 All 3 components of either test cluster
present: + LR = 3.4
 If all three are not met: - LR = 0.19

Altman R, et al. The American College of Rheumatology


Criteria for the classification and reporting of
osteoarthritis of the hip. Arthritis Rheum 1991;34:505-
514.
Sacroiliac Joint Tests
 Compression
 Distraction
 Torsion (Gaenslen)
 Thigh thrust
 Sacral thrust
Sacroiliac Joint Tests
 Three or more positive pain provocation SIJ tests have
sensitivity of 91% and specificity 78%, respectively.
 Specificity of three or more positive tests increases to
87% in patients whose symptoms cannot be made to
move towards the spinal midline, i.e., centralize.
 In chronic back pain populations, patients who have
three or more positive provocation SIJ tests and whose
symptoms cannot be made to centralize have a
probability of having SIJ pain of 77%, and in pregnant
populations with back pain, a probability of 89%.

Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac


joint. J Manual Manipulative Ther 2008;16:142-152.
Active Straight Leg Raise Test
 Test of load transfer
 Supine 5-10 degree active straight leg
raise
 Near-perfect association with radiological
instability sacroiliac joint

Mens JMA, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ. The active
straight leg raise test and mobility of the pelvic joints. Eur Spine J
1999;8:468-473.
Segmental tests
 Motion and provocation tests
 Accessory motion tests: prone posterior-
to-anterior pressure
 Physiological motion tests: Flexion,
extension, sidebending, rotation
 Stability: Translational mobility
Accessory Motion Tests
Physiological Motion Tests
Segmental Motion Tests
 Combination of accessory and physiological
manual tests
 Compared to lumbar spinal block
 Prospective study component
 Segmental dysfunction based on both mobility
and pain findings
 Sensitivity 95%
 Specificity 100%
1Phillips DR, Twomey LT. A comparison of manual diagnosis with a
diagnosis established by a uni-level lumbar spinal block procedure.
Man Ther 1996;2:82-87.
Palpation
 Diagnosis myofascial trigger points
 Essential criteria include:
 Taut band palpable (where muscle is
accessible)
 Exquisite spot tenderness of a nodule in a taut
band
 Patient recognition of current pain complaint by
pressure on the tender nodule (identifies an
active trigger point)
 Painful limit to full stretch range of motion
Palpation
 Confirmatory observations are:
 Visual or tactile identification of a local twitch
response
 Imaging of an local twitch response induced by
needle penetration of tender nodule
 Pain or altered sensation (in the distribution
expected from a trigger point in that muscle) on
compression of tender nodule
 Electromyographic demonstration of
spontaneous electrical activity characteristic of
active loci in the tender nodule of a taut band
Simons DG, Travell JG, Simons LS. Travell and Simons' Myofascial Pain and
Dysfunction: The Trigger Point Manual. 2nd ed. Vol. 1. Baltimore, MD:
Williams & Wilkins, 1999.
Imaging and Lab Tests
 Imaging not required when red flags are absent
 High number of false positives of CT and MRI
 Imaging needs to be interpreted in light of
findings of clinical examination
 Lab tests?
Management
 Medical management
 Surgical management
 Other specialist referral
 Physiotherapy: Evaluation and diagnosis,
education, exercise, manual therapy and
massage, modalities, acupuncture and dry
needling, orthotics/bracing/taping,
ergonomic advice and adaptations
 Other
LBP Myths
“Randomized controlled trials, studies into
diagnostic accuracy, systemic reviews,
and meta-analysis with provide the answer
to all our diagnostic and management
dilemmas!”
Anybody for exercise?
 Systematic review on the use of exercise therapy for
acute and chronic LBP:
 No indication that specific exercises are effective for
treatment of acute LBP.
 Conflicting evidence on the effectiveness of exercise
therapy compared with inactive treatments for chronic
LBP.
 Exercise therapy was more effective than usual care
by the general practitioner and just as effective as
conventional PT for chronic LBP.

Van Tulder M, et al. Exercise Therapy for Low Back Pain: A


systematic review within the framework of the Cochrane
Collaboration Back Review Group. Spine 2000;25:2784-2796
Systematic review on the use of exercise
therapy for acute and chronic LBP:

 Reviewed only articles that used a


diagnostic classification method with
implications for treatment
 Only 5/82 studies met inclusion criteria
 Exercise better than pragmatic control
interventions in 4/5 studies
Cook C, et al. Physical therapy exercise intervention based on
classification using the patient response method: A systematic
review of the literature. J Manual Manipulative Ther
2005;13:152-162.
Meta-analysis on exercise for
non-specific LBP
Slightlyeffective at improving pain
and function in chronic LBP
Graded activity decreases sick-leave
in subacute LBP
As effective as no treatment in acute
LBP
Hayden JA, et al. Meta-analysis: Exercise therapy for
non-specific low back pain. Ann Intern Med
2005;142:765-775.
Advice to stay active?
Systematic review on advice to stay
active as a single treatment:
 Little beneficial effects for patients with LBP.
 Little or no effect for patients with sciatica.

 Better than advice to have bed rest.

Hagen KB, et al. The Cochrane Review of advice to stay active as


a single treatment for low back pain and sciatica. Spine
2002;27:1736-1741.
Manipulation?
Meta-analysis manipulation versus
other therapies:

No evidence that manipulation is


superior to other standard treatments
for patients with acute and chronic
LBP.
Assendelft WJJ, et al. Spinal manipulative therapy for low back
pain. Ann Intern Med 2003;138:871-881.
Systematic review of spinal
mobilization and manipulation for
LBP and neck pain:
Moderate evidence favoring manipulation
over mobilization for acute LBP.
Moderate evidence that manipulation and
mobilization are more effective than
general practitioner care and placebo for
chronic LBP.
Manipulation and mobilization is a viable
treatment option for patients with LBP.
Bronfort G, et al. Efficacy of spinal manipulation and
mobilization for low back pain and neck pain: A systematic
review and best evidence synthesis. Spine 2004;4:335-356.
Common-sense summary

Inconclusive, inconsistent, and


even contradictory summary
statements from systematic
reviews and meta-analysis are
not much help for the clinician…
Systematic reviews and meta-
analysis of controlled clinical trials
using heterogenous populations or
people with LBP based on time-
delineated or structure-based
classification systems will not provide
information useful for management of
LBP
However, pragmatic trials with
homogenous populations based on
a treatment-based classification
system are much more likely to
produce clinically relevant
information!
Clinical Implication
Classify patients using a
TREATMENT-BASED diagnostic
classification model and treat
accordingly for optimal outcome
University of Pittsburgh Diagnostic
Classification System
 Attempts to provide subclassification of the heterogenous
group of patients with non-specific LBP into 4 homogenous
subgroups based on physical therapy treatment response.
 Initially based on expert consensus.
 Four different treatment-based diagnostic categories:
stabilization, manipulation, specific exercise, and traction.
 Established interrater reliability classification decisions:
Kappa=0.60.
 Interrater reliability irrespective of therapist level of
experience.
Fritz JM, et al. An examination of the reliability of a classification
classification algorithm for subgrouping
patients with low back pain. Spine 2006;31:77-
2006;31:77-82.
STABILIZATION CATEGORY:

 Average SLR PROM >91°.


 Positive prone instability test.
 Positive aberrant movements: painful arc, catch,
climbing thighs.
 Hypermobility with prone spring testing.
 Increasing LBP episode frequency.
 Three or more prior episodes.
 Age <40 years.

TREATMENT: Trunk strengthening and stabilization


exercises.
STABILIZATION CATEGORY:

 Variables associated with failure of a stabilization


approach were (Hicks et al, 2005):

 Negative prone instability test


 Absence of aberrant motions
 Absence of hypermobility on lumbar spring testing
 Fear Avoidance Beliefs Questionnaire Physical Activity
(FABQ-PA) subscale score of < 9

 Two or more of these variables present carried a


negative LR of 0.18 (95% CI: 0.08-0.38)
MANIPULATION CATEGORY:

Recent onset of symptoms, i.e. <16 days.


Hypomobility on prone spring testing.
No symptoms distal of the knee.
Low FABQ score (<19)

TREATMENT: Manual therapy and end or range


motion exercises.
SPECIFIC EXERCISE CATEGORY:

 Preference for sitting (flexion category) or


walking (extension category).
 Centralization of symptoms with repeated
movement testing.
 Peripheralization of symptoms with repeated
movement testing in opposite direction.

TREATMENT: Repeated end of range


exercises.
TRACTION CATEGORY:

Radicular symptoms.
Symptoms did not improve with any movement
tests.
Symptoms worsened with most movement tests.

TREATMENT: Traction and repeated end of


range exercises.

Fritz JM, et al. An examination of the reliability of a classification algorithm for


subgrouping patients with low back pain. Spine 2006;31:77-82.
Five-factor clinical prediction rule
manipulation and LBP:

 Positive response defined as a >50%


improvement in ODI score in one to two
treatments.
 Duration of current episode <16 days.
 No symptoms distal to the knee.
 FABQ work subscale score <19.
 Prone hypomobility testing indicates one or
more hypomobile segments.
 One or both hips have >35° of internal rotation in
prone position.
Patients with 4 of 5 criteria
clinical prediction rule met and
who received manipulation has an
odds ratio for successful outcome
of 60.8.
Childs JD, et al. A clinical prediction rule to
identify patients with low back pain most likely to
benefit from spinal manipulation. A validation
study. Ann Intern Med 2004;141:920-928.
Two-factor clinical prediction
rule manipulation and LBP:

 Duration of current symptoms <16 days.


 No symptoms distal to the knee.
 Positive likelihood ratio for 50% decrease in
ODI if positive on the two-factor rule and
treated with manipulation: 7.2.

Fritz JM, et al. Pragmatic application of a clinical prediction rule in


primary care to identify patients with low back pain with a good
prognosis following brief spinal manipulation intervention. BMC
Family Practice 2005;6:29.
Four-factor clinical prediction
rule stabilization and LBP:

Positiveresponse defined as a >50%


improvement in ODI score after twice a week
treatment for 8 weeks.
Age >40 years.
Average SLR >91°.
Aberrant movement present.
Positive prone instability test.
If3 of 4 criteria clinical
prediction rule were met the
positive likelihood ratio for
success with stabilization was
4.0.
Hicks JM, et al. 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.
Common-Sense Summary
 A treatment-based classification for
patients with non-specific LBP has the
potential of producing an optimal
diagnosis-intervention combination.
 Preliminary research indicates the ability
to reliably and with prognostic validity
classify patients with non-specific LBP
How about cost?

 Manipulation clinical prediction rule


validation study
 At the 6-month follow-up patients, who had
received manipulation had significantly
lower health care utilization, medication
use, and time off work due to LBP than
those receiving exercise only
Childs JD, et al. A clinical prediction rule to identify patients
with low back pain most likely to benefit from spinal
manipulation: A validation study. Ann Intern Med
2004;141:920-928.
UK BEAM trial comparing physician
management to manipulation or
manipulation and exercise for non-
specific LBP
Economic analysis
Manipulation or manipulation
combined with exercise was most the
cost-effective approach to the
management of patients with LBP

UK BEAM Trial Team. United Kingdom back pain


exercise and manipulation (UK BEAM) randomized trial:
Cost effectiveness of physical treatments for back pain
in primary care. BMJ 2004;329:1381.
 Patients with occupational LBP that fit the two-
factor clinical prediction rule
 Receiving thrust and non-thrust techniques
resulted in greater reductions in disability and
pain than not receiving these interventions
 However, physical therapy treatment cost,
number of therapy sessions, and duration of stay
in therapy were significantly smaller in the thrust
as compared to the non-thrust group

Fritz JM, Brennan GP, Leaman H. Does the evidence for spinal manipulation
translate into better outcomes in routine clinical care for patients with occupational
low back pain? A case-control study. Spine J 2006;6:289-295.
Common-Sense Summary

A treatment-based classification for


patients with non-specific LBP has
the potential of producing an optimal
diagnosis-intervention combination
Preliminary research indicates the
ability to reliably and with
prognostic validity classify patients
with non-specific LBP
 Treatment-based classification
and intervention seem to provide
for superior outcome with regard
to pain, function, and health care
cost
Mechanism-Based versus
Treatment-Based
 The mechanism-based classification system is
based on the premise that impairments identified
during examination are the cause of
musculoskeletal pain and dysfunction
 In the treatment-based system, a cluster of signs
and symptoms from the patient history and
physical examination is used to classify patients
into subgroups with specific implications for
management
Adult Case: Back Pain
With ibuprofen and physiotherapy there is no
significant improvement. In fact, at four weeks
the pain is suddenly ten fold worse and shooting
down the right leg. It is always present. He
cannot walk or sit comfortably, his sleep is
disturbed. He calls in sick to work. He is
essentially immobile, and certainly not
performing the physiotherapy exercises. He
tries T3’s, and quickly is taking more than is
recommended. Soon he obtains a prescription
from hydromorphone from Dr Grey.
Can fear-avoidance beliefs be
altered and how does this
affect LBP and disability?
Cognitive-behavioral programs.
Outpatient pain management
(psychologist and physical therapist)
successfully affected pain beliefs, self-
efficacy, and psychological distress.
Decreased fear-avoidance beliefs and
perceptions of control over pain explained
71% of the variance of reductions in
disability.
Sowden,
Sowden, et al. Can four psychosocial risk factors for chronic pain and disability
(Yellow Flags) be modified by a pain management programme:
programme: A pilot study.
Physiother 2006;92:43-
2006;92:43-49.
Woby SR, et al. Are changes in fear avoidance beliefs, catastrophing,
catastrophing, and appraisals
of control, predictive of changes in chronic low back pain and disability.
disability. Eur J Pain
2004;8:201-
2004;8:201-210.
TAKE-HOME MESSAGE

 Differential diagnosis by the physician


and medical screening by the physical
therapist is aimed at identifying those
patients with non-mechanical LBP that
require medical-surgical management
 Screening for risk factors and
appropriate intervention may decrease
the transition from acute to chronic LBP
and disability
TAKE-HOME MESSAGE
 Diagnosis of mechanical LBP aims to
classify the patient into a treatment-based
diagnostic category with clear implications
for management
 Mechanism-based treatment is used when
guidance based on treatment-based
research is lacking
TAKE-HOME MESSAGE
 Remember the three pillars of evidence-
based medicine
 1. Best available evidence
 2. Clinician expertise
 3. Patient preference

Vous aimerez peut-être aussi