Dave Snyder, PT, OCSOctober 20th, 2011

Popular Questions…..What can I do to help my patients with back pain get better faster?

Is there an exercise sheet I can give out that will get my patients with back pain better?

What role does physical therapy play in managing low back pain?

Low Back PainUp to 90% of patients with LBP cannot be given a precise pathoanatomical diagnosis Common diagnosis’s include lumbar strain, lumbago, or back painIn the older literature, LBP was viewed as a homogeneous group, leading to no conclusive results of any specific interventionsAlbenhaim, et., al. Spine, 1995, 20:791-795

Low Back PainNonspecific LBP is not a

homogeneous entityCurrent literature suggests the need

to subdivide LBP into smaller sub groups in order to design more precise and effective treatment plans

Kent, Spine, 2004;29:1022-1031

If you send a patient w/ LBP to PT…First we complete a thorough evaluation.With the data collected we attempt to categorize

the patient into one of 6 treatment categories¹Manipulation,StabilizationSpecific Exercise Extension, Flexion, or Lateral

shift Traction

• As the patient proceeds through the rehab process, based on their presentation, the patient may change categories

¹ Dellito, et al. Physical Therapy; 75:470-484

So what does this mean for my practice?In order to offer an intervention during your visit,

you need to take a few moments to identify what your patients actual impairments are

This requires a little extra time to be spent on the subjective and objective portion of your routine exam in order to appropriately classify your patient into a treatment group

If you skip this step, your intervention has a high likelihood of failing and may even hurt the patients condition

First, lets review the basics…CONTINUE TO:Follow normal practice guidelines and procedures to arrive at a medical diagnosisOrder appropriate diagnostics per your standard proceduresOffer pharmacological interventions per your practice guidelinesRefer appropriate patients to Ortho Spine, Physiatry, and Physical Therapy

Before you can offer a movement intervention……Subjective

Try to identify mechanism of injury

Also, try to…Identify a pain generatorIdentify a position of

comfortIdentify aggravating and

easing factors

Other good questions to askHas this happened before? What did you do to feel better?Have you been to therapy before for this

same problem? Did it work? Are you still doing the exercises?

Subjective Continued…Try to categorize patient as Acute vs. Chronic

Interventions and goals of these interventions are different based off of this classification

Acute/Sub Acute LBPDifficulty performing

basic ADLsIncreased levels of self

reported pain and disability

Recent onset with a recallable mechanism of injury

Recent flair up of chronic condition

Chronic LBP

Can perform basic ADL’sHave lower levels of pain and

disabilityHas pain with more

demanding activities

Subjective Continued…Is the patient fearful of movement?Does the patient seem to go out of their way

to avoid pain because of this fear?

If Fear Avoidance is present..

Consider instituting a cognitive behavioral approach to managing the patients care when it is deemed appropriate¹

¹George, Et. Al. Spine 2003; 28: 2551-2560

What does that mean??Establish the need

for exercise to be part of the solution to the patients condition

Establish clear exercise goals that are agreed upon by the patient and the team delivering the care

At this point, what do we know?Mechanism of InjuryPosition of comfortIdentified possible pain

generatorAcute vs. ChronicFear avoidance behavior

identified

Objective Exam:Continue to perform appropriate

objective measures to arrive at your medical diagnosis

In addition, each of the following suggestions will help you to identify impairments that you can offer quick and easy interventions that are highly effective.

Consider your patients posture

Why is posture so important?

What can we learn from posture?

Start with minimal corrections…

Neutral Spine Instruction

Posture with ADLs

Posture with ADL’s continued

Posture with ADL’s continued:log roll supine to sit

Modalities: Ice vs. Heat….Ice when movement

leads to painCool off the fire!

Heat when pain limits movementWarm up the motor!

TARGET THIS INTERVENTION TO THE SUSPECTED PAIN GENERATOR

Should I try to teach the patient specific stretching or strengthening?

Specific Exercise Instruction Requires:Specific impairments measured in

conjunction with faulty movement patterns identified that allows one to make a logical conclusion as to why the patient presents with their particular subjective complaintsShort Hamstrings with posterior pelvic tilt and

long /weak erector spinae muscles leading to excessive compressive forces at L4/L5 disc leading to discogenic pain limiting patients ability to perform ADL’s.

OK…then what should I do?#1 Priority is to diagnose the problem as

accurately as possible with the information you have, within the time frame you have to figure out the problem

Rule out red flags if presentFollow the suggestions outlined in today's talkConsider recommending pain free general

exercise to your patient.Cardiovascular endurance type activityPain free during and after activitySomething that the patient would enjoy to do

regularly

Who needs a PT referral?Mechanical connection to painNever had PT before for this problemHad PT before, it helped, but now the condition

has changed and the patient would benefit from a second look by a PT

Impairments identified that correlate to condition and are potentially correctable with specific exercise or other therapeutic intervention

Patient interested in learning exercises to help improve their condition

What will we do with your referralPrioritize the patients diagnosis and schedule

accordinglyComplete a full evaluation (1 hr) and develop

a unique rehabilitation program to address the impairments found in the evaluation, and set clear goals for the treatment.

Once goals are met, discharge the patient with an independent self management program

QUESTIONS?????