Dave Snyder, PT, OCS October 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 Pain

Up to 90% of patients with LBP cannot be

given a precise pathoanatomical diagnosis Common diagnosiss include lumbar strain, lumbago, or back pain In the older literature, LBP was viewed as a homogeneous group, leading to no conclusive results of any specific interventions
Albenhaim, et., al. Spine, 1995, 20:791-795

Low Back Pain

Nonspecific LBP is not a homogeneous

entity Current 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 categories

Manipulation, Stabilization Specific Exercise Extension, Flexion, or Lateral shift Traction

As the patient proceeds through the rehab process,

based on their presentation, the patient may change categories

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 diagnosis Order appropriate diagnostics per your standard procedures Offer pharmacological interventions per your practice guidelines Refer 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 generator Identify a position of comfort Identify aggravating and easing

factors

Other good questions to ask

Has 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 LBP

Difficulty performing basic

ADLs Increased 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 ADLs Have lower levels of pain and

disability Has 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 appropriate

George, 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 Injury
Position of comfort Identified possible pain

generator Acute vs. Chronic Fear 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 ADLs continued

Posture with ADLs continued: log roll supine to sit

Modalities: Ice vs. Heat.

Ice when movement

leads to pain
Cool off the fire!

Heat when pain limits

movement
Warm 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 complaints
Short 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 ADLs.

OKthen 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 present Follow the suggestions outlined in today's talk Consider recommending pain free general exercise to your patient.
Cardiovascular endurance type activity Pain free during and after activity Something that the patient would enjoy to do regularly

Who needs a PT referral?

Mechanical connection to pain
Never had PT before for this problem Had 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 referral

Prioritize the patients diagnosis and schedule

accordingly Complete 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?????