With Low Back Pain Sara Patterson SPT Clinical Instructor Kelly Fosberg PT DPT Objectives Learn about the effectiveness of two different interventions used for your patients with low back pain ID: 800085
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Slide1
Interventions in Treating Patients With Low Back Pain
Sara Patterson, SPT
Clinical Instructor: Kelly
Fosberg
, PT, DPT
Slide2Objectives
Learn about the effectiveness of two different interventions used for your patients with low back pain
Integrate these interventions into individualized care for your patients with low back pain
Learn about the value PTs can provide when treating patients with low back pain
Slide3Meet S.E.
58 year old female
Work: Inspects products
Chief Complaint: L. LE Throbbing pain
June, 2016
July, 2016
March, 2016
Slide4Meet S.E.
Tests and Measures:
P-A Spring Testing
:
Mild
Hypomobility
Pain L4-S1
Active Lumbar Ext.: Mild pain; 150
Active Lumbar Flex:
Sharp pain; 450SLR
:
0-35
0
caused pain (ipsilateral)
Standing Lumbar Quadrant Ext. with Overpressure
:
+
ive
Myotomes
:
L. Knee Extension, L. ankle plantarflexion - 4/5
Slump Test
:
+
ive
Slide5S.E.’s SINSS StatementSeverity
–
Throbbing Pain
Irritability
– Lumbar Flex. Hurts! (only can sit for ~15 min
.)
Nature – Nerve/radiculopathyStage – Chronic with subacute symptomsStability – Improving; pt. states due to injections
Slide6ICF Model
Health Condition
:
Radiculopathy
, lumbosacral region
Body Structure and Function:
Hypomobility
Pain w/ Flex.
Pain w/ Ext.
Strength
Participation
:
Abilities:
- Sleep
Restrictions:
- Work
- Family
- Driving
Activity
:Abilities: - StandingLimitations: - Sitting
Environmental Factors+: Insurance Family- : Stress of Work
Personal Factors+ : Motivated- : Stress
Slide7Study Design:
Cross Sectional, Observational Study
Test, Retest
Objective:
To investigate prevalence and reliability of placement into a intervention from translating the use of subgroups to a classification algorithm
(Physical Therapy, 2011)
Slide8(Physical Therapy, 2011)
Slide9PICO Question
P: In a 58
y.o
. woman with chronic low back
pain and
L. posterolateral leg symptoms
I: would traction be more effectiveC: than manipulation
O: in reducing pain?
Slide10(Cochrane Database of Systematic Reviews, 2013)
Selection Criteria:
RCT’s involving traction to treat acute, subacute, or chronic non-specific LBP w/ or w/0 sciatica (32 RCTs were included)
Outcome Measurements:
Pain Intensity
Functional Status
Global Improvement
Return to Work
Results:
Low to moderate quality evidence - no impact on pain intensity, functional status, or global improvement
Low to moderate
quality evidence
-
makes little or no difference when comparing sham, placebo, or no treatment
Very low to moderate
quality evidence - makes little or no difference when comparing physiotherapy and traction or other treatments
Limitations:
Amount of high quality studies
Studies distinguishing between people with different symptom patterns
*23/32 studies included mostly people with LBP and sciatica pain
8 studies were a mix of with and without sciatic1 study had no sciatica painQuality of Review: Good2
Slide11(Annals of Internal Medicine, 2014)
Objective: To compare spinal manipulative therapy (SMT) plus home exercise and advice (HEA) vs. HEA alone while studying the reduction in pain, short term and long term
Limitations:
Patients and providers were not blinded
Study size
Back pain potentially gets better over time
Study Design:
192 patients (191 at 12
wks
, 179 at 52
wks
)
96 patients assigned to each group
Patients were 21
y.o
. or older and have had BRLP for at least 4
wks
Outcomes:
Leg Pain
Low Back Pain
Global ImprovementMedication UseSatisfaction
Slide12(Annals of Internal Medicine, 2014)
Quality of Study: Fair
2
*Effect size for leg pain at 12
wks
was considered medium (0.6)
Slide13Did I answer my PICO question . . . .
No . . .
Why?
The research I found does not compare traction and manipulation
Clinical prediction rule for utilization of manipulation as an intervention for patients with LBP suggests less likelihood of success for patients with symptoms distal to the knee
Slide14Costs to the Healthcare System
61% of Americans experience back pain but 37% don’t seek professional help for pain
relief.
4
More than 1/3 of adults say that their low back pain has affected their ability to participate in daily living tasks, exercise, and
sleep.
4Overall U.S. healthcare expenditure for low back pain in 1998 was estimated at $90 billion dollars2Costs of low back pain have risen so high, total healthcare expenditure could not be observed
2Patients with chronic low back pain account for the bulk of these costs2
Slide15PT’s Role
PT first vs. Imaging – Initial referral for PT costs on average $504 (3.8 visits) vs. an MRI which costs $1,306.
Avg. subsequent costs were 72% lower for patients who started with PT.
3
Effectiveness of PT – 471 patients
5Active PT (n=132) – high percentage of active exerciseNon-adherent care (n=339) – Involving greater than 25% passive treatments like hot/cold, ultrasound, E-stimRate of additional healthcare utilization was 65.8% compared with 55.3% for active care
Slide16Remember the 3 legged stool
There is not one intervention for each diagnosis
If something is not working, try something different
Listen to your patients and figure out their goals to ultimately give them the best treatment
Practicing at the top of Your License!
Slide17References
Bronfort
,
Gert
, Maria A.
Hondras
, Craig A. Schulz, Roni L. Evans, Cynthia R. Long, and Richard Grimm. "Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation." Annals of internal medicine 161, no. 6 (2014): 381-391.Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt E. Noninvasive Treatments for Low Back Pain. Comparative Effectiveness Review No. 169. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I.) AHRQ Publication No. 16-EHC004EF. Rockville, MD: Agency for Healthcare Research and Quality; February 2016. www.
effectivehealthcare.ahrq.gov/reports/final.cfmFritz, Julie M., Gerard P. Brennan, and Stephen J. Hunter. "Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: associations with future health care utilization and charges."
Health services research 50, no. 6 (2015): 1927-1940.Most
americans live with low back pain – and don’t seek treatment. American Physical Therapy Association. April 4th, 2012. http://www.apta.org/Media/Releases/Consumer/2012/4/4/
“PTs offer low-cost solutions to acute low back pain.” American Physical Therapy Association.
August 12, 2008. http://www.apta.org/Media/Releases/Consumer/2008/8/12/
Stanton
, Tasha R., Julie M. Fritz, Mark J. Hancock, Jane Latimer, Christopher G. Maher, Benedict M. Wand, and Eric C. Parent. "Evaluation of a treatment-based classification algorithm for low back pain: a cross-sectional study."
Physical therapy
91, no. 4 (2011): 496-509.
Wegner
, Inge, Indah S.
Widyahening
, Maurits W. van Tulder, Stefan EI Blomberg, Henrica CW de Vet, Gert Brønfort, Lex M.
Bouter, and Geert J. van der Heijden. "Traction for low‐back pain with or without sciatica." The Cochrane Library (2013).
Slide18Any Questions?
Slide19