how to solve non-specific chronic low back pain: the ...€¦ · non-specific chronic low back...
TRANSCRIPT
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COPYRIGHT© 2020 POSITIONAL RELEASE THERAPY INSTITUTE®
How to Solve Non-Specific Chronic Low Back Pain: The Wheelhouse ProtocolSM
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DISCLOSURE
The Positional Release Therapy Institute is a company that provides continuing education and certification in Positional Release Therapy. Online courses and instructional videos are also associated with the instruction provided by the Institute.
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OBJECTIVES
After this session, participants will:
1. be able to identify 3 causative factors of chronic non-specific low back pain (LBP)
2. be able to identify the proposed primary condition causing chronic non-specific low back pain and;
3. be able to articulate how the The Wheelhouse ProtocolSM may be effective in the treatment of chronic non-specific LBP
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NON-SPECIFIC CHRONIC LOW BACK PAIN?
• 90% of all low back pain cases- no known cause1
• Chronic LBP = > clinical, social, economic and public health burden2
• ~ $100-200 Billion3
• Worldwide greatest cause of disability4
• 61% of Opioid deaths linked to chronic pain5
• 59.3% in chronic pain group diagnosed with LBP
• Who is most affected?6
• 28.1% Adults reported LBP in last 3 months• Women (30.1%) more than men (26%)• Less educated (34.8%) and poor (37.8%) • Athletes (~30-50%)7
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LBP RISK FACTORS8
Non-Modifiable
• Old Age
• Female
• Poverty
• Lower Education Level
Modifiable
• BMI (Obesity)
• Smoking
• Lower Health Status
• Physical Activity
• Repetitive Tasks (bending, lifting, twisting, etc…)
• Job Dissatisfaction
• Depression
Greatest Contributors = Mechanical Stress and age-related degeneration
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WHAT ELSE?• Imaging-degenerative changes, disk abnormalities, spinal
anomalies ⌧ correlation to LBP Prediction9
• Psychosocial factors?9
• Negative beliefs pain is harmful/disabling
• Fear avoidance behaviors
• Poor or maladaptive coping strategies
• Passive treatment expectation
• Focus on pain
• High distress levels
• Depressive mood
• Resistance to change
• Low self-efficacy
• Family reinforcement of illness
• Social/financial problems
• Troubled childhood
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WHY DO ATHLETES HAVE CHRONIC LBP?
Lets Take a Poll
A. Disc Bulge / Herniation
B. Sacroiliac Joint Dysfunction
C. Strains / Sprains
D. Spondys’
E. Psychosocial Factors
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SACROILIAC JOINT DYSFUNCTION (SIJD)
• The SI Joint is a common source of LBP in the general population as well as athletes.10-14
• Asymmetrical (e.g., single stance phase) or repetitive loads (e.g., rowing) = risk12,14
• Athletes ~ 30%-80% non-specific LBP15,16
• SIJD = pain arising as result of altered kinematics11
• Is it even possible? I heard that the joint does not even move—well….
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THE SACROILIAC JOINT
• Diarthrodial Joint10
• largest axial joint in the body
• Anterior 1/3 synovial, posterior ligamentous/fascial/muscular
• Provides load transfer15
• 2-7 degrees– clearly established now10,12,15
• Multiple axes15
• Left and Right Oblique
• Vertical and anteroposterior (AP)
• Vertical and sagittal
• Horizontal- #3
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DYSFUNCTIONS OF THE SI JOINT
• Hypomobility or Hypermobility12
• Age impact
• Each can produce somatic dysfunction
• Innominate Shears (Superior / Inferior)
• Innominate Rotations (Anterior / Posterior)
• Innominate Flares (Out / In)
• Sacral Torsions (Flexion / Extension)
• Role of Closure12,17
• Form = chock stone fit
• Force = external compression
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ANTERIOR INNOMINATE ROTATION
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THE FALL OUT
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THE FALLOUT CONTINUED
• Sacral Torsion
• The “Floating Boat”
• Subtalar Joint Dysfunction = Eversion
• Functional Scoliosis = Disc Compression and Neural / Tissue Tension
• Neural Shutdown / Inhibition (we need the hip!)
• Central Sensitization Syndrome
• Altered Biomechanics• Non-contact ACL mechanism?
• Altered tendon-muscle length / function
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COMMON PAIN REFERRAL PATTERNS & ALIGNMENT
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LEG LENGTH DISCREPANCY? –MAYBE
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COPYRIGHT© 2020 POSITIONAL RELEASE THERAPY INSTITUTE®
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THE WHEELHOUSE PROTOCOLSM
• Evaluation
• History
• Causative Factors
• Postural Exam (TART)
• One-Minute Wheelhouse Screening©
• Special Tests (Combined)
• The Wheelhouse ProtocolSM
• PRT (Positional Release Therapy)
• Thermal Ultrasound
• Joint Mobilization (Maitland- II)
• Muscle Energy (MET)
• HVLA (The Speicher Whip©)
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EVALUATION• Integrative & Summative Evaluation Approach Required
• Diagnosis based on multiple findings
• History*
• Primarily one-sided on involved side
• Pain Pattern
• Youth / Children vs. Adults
• TART Exam
• Observation
• Folds
• Contralateral Hyperextended leg
• Spinal & Pelvic Alignment
• Unilateral Femoral External Rotation (Supine)
• Special Tests for Motion
• Gillet (March) – Speicher Modification
• Long Sit Test (aka: Supine to Sit Test)
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WHAT IS GOING ON HERE?
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WHY ARE THEY NOT LINING UP?
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SPECIAL TESTS FOR SI JOINT DYSFUNCTION
Motion
• Sensitivity, Reliability, Validity, Predictive Values LOW
• Assessed individually14,16-20
• 8-44%16
• Gillet only test found to have (+) association w/ LBP16
• Combined (3 or >) = (.82 - .94)15,21
• Which to combine? That is the grand question
• Most based on landmark assessment
• Gillet (Looking for ”fixation”)
• Looking for Fire-Hydrant Sign ©)
• Supine to Sit Test (Long-Sit)
• Place Fingers BELOW malleoli
Provocation• Similar findings as with SI Motion Tests Above
• FABER, FADIR, SLR
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A CASE-SERIES DESIGN OF PATIENTS WITH
CHRONIC NON-SPECIFIC LOW BACK PAIN
Objective: To determine the effectiveness of the Wheelhouse ProtocolSM for treatment of chronic non-specific low-back pain in a general population.
Methods:
• Case-Series Design (Pre-Post Test)
• N= 10 (21-68 yrs)
• TX: 1x/wk for 3 wks with a 6 month Follow-Up
• Outcome Measures:
• DPA Scale (Disablement in the Physically Active Scale
• Oswestry Low Back Pain Disability Index
• Global Pain Rating
• Range of Motion (Trunk Flexion, Extension, SLR)
• Provocation Tests (FABER, FADIR, SLR)
• Special Tests (March, Long Sit)
• Pressure Sensitivity
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DEMOGRAPHICSGender Race Age Months
w/LBP
Location of
LBP
M = 4, F = 6 Caucasian 21-68 3 - 600 R = 8, L = 2
Mean 43 86.50
Std. Dev 15.902 181.51
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RESULTS SUMMARYOutcome Mean Std. Dev. Effect Size (d) Significance
DPA 15.1 13.601 ***1.292 *.007
Oswestery 6.3 5.716 ***1.555 *.007
Global Pain 5.8 2.044 ***3.862 *.000
AROM-SLR (R) 9.4 11.306 **.670 *.027
AROM-SLR (L) 5.8 7.239 .396 *.032
PROM-SLR (R) 3.1 11.742 .102 .425
PROM-SLR (L) 1.7 8.166 .056 .527
Trunk Flexion 9.8 22.809 .299 1.990
Trunk Ext. 11.6 11.147 **.737 *.009
* = <.05 Priori Significance Level** = Moderate Effect Size (.50>)*** = Large Effect Size (.80>)
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DPA RESULTS
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OSWESTERY RESULTS
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GLOBAL PAIN RATING
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DISCUSSION
• Chronic LBP next to OA is one of the biggest problems clinicians face and that plagues our patients1,4,9
• Chronic non-specific LBP may not be so non-specific
• Anterior Innominate Rotations (AIRs) may be a major player
• Assessment/DX is not difficult when using an integrated evaluation approach
• The Wheel House ProtocolSM shows early promise in treatment of chronic non-specific LBP
• Limitations
1. More patient cases needed, specifically at 6 mo.
2. Cross-sectional population sample needed
3. Potential researcher bias w/case-series design
4. Requires expertise in manual therapy / PRT
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CLINICAL IMPLICATIONS
The Wheel House ProtocolSM may help to:
1. Reduce opiate use and opiate-related deaths
2. Reduce world-wide clinical, social, economic and public health burden
3. Reduce number of ankle related pathologies (e.g., ankle sprain)
4. Curb the ACL epidemic
5. Improve quality of life & Sport of patients with chronic LBP
6. Further the the AT profession’s mission
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17. Levangie PK. Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain. Physical Therapy. 1999;79(11):1043–1057.
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21. Cibulka MT., Koldehoff RM. Clinical usefulness of a cluster of sacroiliac joint tests in patients with and without low back pain. J Orthop Sports Phys Ther. 1999; 29:83-92.