ADVANCES IN DIAGNOSIS, PROGNOSIS,

AND MANAGEMENT OF
LOW BACK PAIN
Presented by
Peter Huijbregts, PT

Physiotherapy Orthopaedic Forum

Tuesday, May 8th, 2007
Victoria General Hospital
 About your Presenter:

 B.Sc. Physiotherapy, 1990

 M.Sc. Manual Therapy, 1994
 M.H.Sc. Physical Therapy, 1997
 Doctor of Physical Therapy, 2001
 Fellow in AAOMPT and CAMT
 Board-certified in Orthopaedic PT
 Current Positions:

 Consultant, Shelbourne Physiotherapy Clinic

 Assistant Professor, USAHS
 Editor-in-Chief, JMMT
 Consulting Editor, Jones & Bartlett
 Educational Consultant, Dynamic Physical
Therapy
 About this presentation:

 Presentation for general practitioners on state-

of-the-art physical therapy diagnosis, prognosis,
and management
 US physicians
 Parallel to Canadian situation?
A patient complains of
low back pain…
So now what do we do?
 Topics:
 Epidemiology

 LBP Myths

 LBP Facts

 Clinical Implications

 Other Research
1. Epidemiology
 Lifetimeprevalence: 80% of all people will
experience LBP at some point in their lives
(Source: Waddell G. A new clinical model for the treatment of
low-back pain. Spine 1987;12:632-643)
Back symptoms are the most
frequently cited reason for consulting
orthopaedic and neuro-surgeons and
represent the second most common
reason to visit a physician

(Source: Taylor VM, et al. Low back pain hospitalization. Spine

1994;19:1207-1213)
Point prevalence for LBP in North
American adults is estimated at
5.6%: 10 million of 178 million US
adults experience LBP at any given
day

(Source: Loney PL, Stratford PW. The Prevalence of low back

pain in adults: A methodological review of the literature. Phys
Ther 1999;79:384-396)
 One-year prevalence of LBP in North
American adults: 32+/-23%: Up to 97.9
million of 178 million US adults experience
LBP in the course of a year

(Source: Loney PL, Stratford PW. The prevalence of low back pain
in adults: A methodological review of the literature. Phys Ther
1999;79:384-396)
What is the yearly cost to
society of LBP?
Greater than 10 billion
pounds in the UK
Greater than 170
billion dollars in the US
(Source: Bishop A, Foster NE. Do
physical therapists in the United
Kingdom recognize psychosocial
factors in patients with acute low back
pain? Spine 2005;30:1316-1322)
 Common-sense summary:
 LBP is a big health care and societal problem. However, don’t
we all know the following statements to be true?
 Most people get better no matter what we do.

 The situation is definitely improving.

 The health care community knows how to deal

with the problem.
 Evidence-based practice will provide the
definitive answer.
The question is:

Are these commonly heard

statements fact or fiction?
2. Low Back Pain Myths
 LBP Myth #1
 “80-90% of people with LBP get
better in about 6 weeks irrespective of
administration or type of treatment"

(Source: 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.
(Source: 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%)

(Source: Hestbaek L, et al. Low back pain: what is

the long-term course? Eur Spine J 2003;12:149-
165.)
 Common-sense summary:
 Thenatural history of LBP is not as
benign as we might think!
 LBP Myth #2
 “There is no LBP epidemic: The situation is
improving”
National Hospital Discharge Survey
data (1979-1990):
Increase in low back surgery from
147,500 to 279,000.
Increase from 102 to 158 low back
surgeries per 100,000 adults (adjusted
for population growth)
Non-fusion surgery increased by
47%.
Surgeries involving fusion increased
with 100%.
(Source: Taylor VM, et al. Low back pain
hospitalization. Spine 1994;19:1207-1213.)
Estimated yearly cost to society
for LBP in the US:
1994: greater than 50 billion
dollars.
2005: greater than 170 billion
dollars.
(Sources: Taylor VM, et al. Low back pain
hospitalization. Spine 1994;19:1207-1213.
Bishop A, Foster NE. Do physical therapists
in the United Kingdom recognize
psychosocial factors in patients with acute
low back pain. Spine 2005;30:1316-1322.)
 Common-sense summary:
 It doesnot look like that pesky – and very
costly – LBP problem is being solved!
 LBP Myth #3
 “The health care community knows how to
fix the LBP problem”.
Annual LBP surgery rates in the US (1988-
1990):
113 per 100,000 in the Western US.

131 per 100,000 in the Northeastern US.

157 per 100,000 in the Midwest.

171 per 100,000 in the South

Yet, reported LBP prevalence in these 4 areas was

nearly identical.
Conclusion:
The indications used for surgical
management of LBP are far from uniform!
(Source: Taylor VM, et al. Low back pain
hospitalization. Spine 1994;19:1207-1213.)
 Butthe situation must have improved
since then?

 22 Orthopedic and 8 Neurosurgeons of varying

regions and backgrounds were asked about surgical
indication, approach, and use of fusion and
instrumentation for 5 simulated cases.
 Significant variation between surgeons on all
variables in 4 of 5 cases presented.
 Conclusion: It does not look like the situation has
become any better…?
(Source: Irwin ZN, et al. Variation in surgical decision making
for degenerative spinal disorders. Part I: Lumbar spine. Spine
2005;30:2208-2213.)
Telephone survey nationally
representative sample of 5,490
primary care doctors:
Clinical vignette: 35 y/o man with
foot drop.
Decision to recommend MRI was
based on whether the physician lived
in a high- or low-spending region of
the country.
(Source: Sirovich BE, et al. Variations in the
tendency or primary care physicians to
intervene. Arch Intern Med 2005;165:2252-
2256.)
 Common-sense summary:
 Practice
variation based on geographical
region does not seem to indicate research-
based consensus on management…?
 LBP Myth #4
 “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?
Advice to stay
active?
Manipulation?
 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.
(Source: 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.
(Source: 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:
Slightly effective at improving pain and
function in chronic LBP.
Graded activity decreases sick-leave in
subacute LBP.
As effective as no treatment in acute LBP.

(Source: 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.

(Source: 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.
(Source: Assendelft WJJ, et al. Spinal
manipulative therapy for low back pain. Ann
Intern Med 2003;138:871-881.)
Systematicreview 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.
(Source: 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…
3. LBP Facts
 LBP Fact #1:

LBP is not a self-limiting problem

but a problem characterized by
exacerbations and remissions, which
becomes chronic in about 10% of the
population.

(Source: 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.)
LBP Fact #2:

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.
(Source: Murphy PL, Courtney TK. Low back pain disability:
Relative costs by antecedent and industry group. Am J Ind Med
2000;37:558-571.)
LBP Fact #3:

Treatment costs for LBP

are rising by at least 7% per
year.
(Source: Bishop A, Foster NE. Do physical therapists
in the United Kingdom recognize psychosocial factors
in patients with acute low back pain. Spine
2005;30:1316-1322.)
 LBP Fact #4:

Our current approach to

evaluation and management
based on a mainly
pathophysiologic and authority-
based rationale is not working to
solve the LBP problem…
LBP Fact #5:

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!
4. Clinical Implications
 Clinical Implication #1
 First determine if the patient belongs in your
office!
 LBP can be a symptoms of:
 Visceral disease: Retroperitoneal and pelvic
region or the gastrointestinal system.
 Vascular disease: Abdominal aortic
aneurysm.
 Haematological disease:
Haemoglobinopathies and myelofibrosis.
 Trauma: Fracture, fatigue fracture,
insufficiency fracture.
Metabolic and endocrine disease:
Osteoporosis, osteomalacia, Paget’s disease,
and diabetes (diabetic radiculopathy).
Infectious disease: Diskitis and
osteomyelitis.
Inflammatory disease:
Spondylarthropathies.
Neoplastic disease: Osteoid osteoma,
multiple myeloma, metastases.

(Source: 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.)
Role of the physician:

 Differential diagnosis.
 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.
 Common-sense summary:
 Make sure you are the appropriate
person to see this particular patient
with LBP.
 Clinical Implication #2
 Determine the presence of risk
factors for chronic LBP and
disability.
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
(Source: 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.)
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
(Source: 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.
(Source: 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?”

(Source: Dionne CE, et al. A clinical return-to-work rule for patients

with back pain. CMAJ 2005;172:1559-1567.)
 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.
(Sources: Sowden, et al. Can four psychosocial risk factors for chronic pain and
disability (Yellow Flags) be modified by a pain management programme: A pilot
study. Physiother 2006;92:43-49. Woby SR, et al. Are changes in fear avoidance beliefs,
catastrophing, and appraisals of control, predictive of changes in chronic low back
pain and disability. Eur J Pain 2004;8:201-210)
 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.
 Clinical Implication #3:
 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.
(Source: 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.)
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.
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.

(Source: Source: 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.
(Source: 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.

(Source: 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:

Positive response 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.

If 3 of 4 criteria clinical prediction
rule were met the positive likelihood
ratio for success with stabilization
was 4.0.
(Source: 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.
Additional evidence for the use of
stabilization exercises:
 204 patients with chronic LBP (> 3 months); ODI ≥ 16%
 All patients were provided with examination, education, and
instruction by physician
 Random assignment to only physician consultation or
consultation in combination with 4 sessions of manipulation and
stabilization exercises
 At 5 and 12 months, significant between-group differences in
favour of manipulation/stabilization group for patient report of
pain and disability

(Source: Niemisto L, et al. A randomized trial of combined manipulation, stabilizing exercises,

and physician consultation compared to physician consultation alone for chronic low back pain.
Spine 2003;28:2185-2191).
 349 patients with LBP randomized to either
surgical stabilization (fusion surgery) or intensive
rehabilitation
 Rehabilitation included stretching,
strengthening, cardiovascular endurance
training, and spinal stabilization exercises for on
average 75 hours (range 60-110)
 284 (81%) patients provided follow-up data at
24 months
Significant between-group difference in favour of
surgery group on decrease in ODI score (between-
group difference 4.1 points)
No significant between-group differences on any
other outcome measures, including shuttle walking
test, SF-36 general health status questionnaire, return-
to-work status, or psychological assessment
19 intra-operative complications and 11 re-surgeries

No complications in the rehabilitation program

(Source: Fairbank J, et al. Randomised controlled trial to compare surgical stabilization of the
lumbar spine with an intensive rehabilitation programme for patients with chronic low back
pain: The MRC spine stabilisation trial. BMJ 2005;330:1233-1241).
 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
(Source: 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

(Source: 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).
Cost-effectiveness analysis of the study
comparing surgical stabilization to intensive
rehabilitation
Mean total cost surgery group patient
£7,830
Mean total cost rehabilitation group patient
£4,526
Significant
between-group difference
£3,304 (95% CI: £2,317-£4,291)

(Source: Rivero-Arias O, et al. Surgical stabilization of the lumbar spine compared with a
programme of intensive rehabilitation programme for the management of patients with
chronic low back pain: Cost utility analysis based on a randomised controlled trial. BMJ
2005;330:1239-1241).
 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
5. Other Research:
So, research into LBP can provide clinically relevant information. Is there
any other such research being done?
 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
 Diagnosis of mechanical LBP aims to classify the
patient into a treatment-based diagnostic category
with clear implications for management