Conservative Therapy for Back Pain The Family Doctor and the PhysiotherapistFacilitators: Dr. Ranald Donaldson, BSc, MSc, MD Dr. Peter Huijbregts, PT, MSc, MHSc, DPT

Adult Case: Back PainTom is a 45 year old who presents complaining of back pain to his family doctor, Dr Grey. He moved some heavy boxes four weeks prior, and since has had a low grade, but bothersome muscle spasm of the low mid back with some radiation to the right buttock. He has had similar symptoms previously, but they have never persisted this long.

Adult Case: Back PainOur patient Tom is a manager in the electronics department at a big retail store. He is married and has two young teenaged daughters. He last saw his family doctor two years prior at his wifes urging. At that time his diabetes screen had been borderline, and he had been counselled about dietary management. He had not succeeded in making any significant lifestyle changes. He skips breakfast, takes lunch at the food court, drinks three cans of coke over the day, and usually prepares himself a large pasta dish for dinner. His exercise consists of participation in his weekly old-timers hockey game, which runs through the fall and winter. Over the last two years he has in fact gained 2 kg, such that he is now weights 120 kg.

Let us first get a misconception out of the way

LBP Myths80-90% of people with LBP get better in about 6 weeks irrespective of administration or type of treatment"Waddell G. A new clinical model for the treatment of lowback 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 yearCroft PR, et al. Outcome of low back pain in general practice: a prospective study. BMJ 1998;316:13561359)

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 4478%) Recurrent sick-listing 33% (range 2637%)Hestbaek L, et al. Low back pain: what is the longterm course? Eur Spine J 2003;12:149-165

LBP is not a self-limiting problem but a problem characterized by exacerbations and remissions, which becomes chronic in about 10% of the populationHestbaek L, The Natural Course of Low Back Pain and Early Identification of High-Risk Populations. PhD Thesis. Odense, Denmark: University of Southern Denmark, 2003.

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 conditionMurphy PL, Courtney TK. Low back pain disability: Relative costs by antecedent and industry group. Am J Ind Med 2000;37:558-571.

Role of the physician Differential

diagnosis Medical-surgical management Referral to other providers for comanagement

Role of the physical therapistMedical

screening based on systems approach and appropriate referral for medical-surgical (co) managementEvaluation

and management of patients with mechanical LBPPotential

role in the co-management of patients with LBP due to trauma, metabolic, infectious, inflammatory, and neoplastic disease

Types of Low Back Pain

Simple or mechanical back pain Back pain with neurological involvement Back pain with suspected serious spinal pathology: Red Flags But also: Back pain with indicators of poor prognosis or Yellow Flags

Patho-anatomical diagnosis

Traditional medical, structure-based model Assumes a direct correlation between underlying pathology and signs and symptoms Note: Unable to provide up to 85% of patients with low-back pain a specific diagnosis: Simple or mechanical low back pain

Mechanical Low Back Pain with or without Neurological Involvement

Zygapophyseal joint pain syndrome Diskogenic pain Lumbar radiculopathy Spinal stenosis Sacroiliac joint syndrome Lumbar instability Muscle/ligamentous sprain or strain Myofascial pain syndrome

Zygapophyseal Joint Pain Syndrome

Restricted motion lumbar spine with low back or buttock pain Pattern of motion loss indicating opening or closing restriction zygapophyseal joint: Decreased extension, sidebending, and rotation

Diskogenic Pain

Report of centralization or peripheralization of symptoms during repetitive movements or during prolonged periods in certain positions Difficulty with curve reversal: Rising after sitting or straightening up in morning out of bed

Lumbar radiculopathy

Lower extremity pain or paraesthesiae greater than low back pain Radicular deficit noted: Decreased strength or sensation

Spinal Stenosis

Pain in lower extremities that is exacerbated by an extension posture (standing and walking) and relieved by a flexion posture (sitting, semi-Fowler, sidelying, leaning on shopping cart)

Sacroiliac Joint Syndrome

Predominant unilateral pain just inferior to PSIS Also pain low back, posterolateral buttock, posterior thigh to knee, and groin Worse with load transfer through affected side 13% (95% CI: 9-26%) of patients with persistent low back pain have the origin of pain confirmed as the SIJ

Lumbar Instability

Recurrent locking, catching, giving way of the low back during active motion Difficulty with sustained postures

Muscle and Ligament Sprain or Strain

Pain aggravated with stretch of ligaments or muscles Pain increased with muscular contraction

Myofascial Pain Syndrome

Myofascial trigger points Central sensitization Peripheral neuropathy Chronic pain states

History

Inventory of current complaint Screening for yellow and red flags History of current complaint Medical history Social history

Inventory of Current Complaint

Location of pain Intermittent, constant, episodic Aggravating and easing factors Effect of coughing, sneezing, and straining Range of motion impairments (also locking and crepitus) Sensory abnormalities Motor deficits Inflammatory symptoms: redness, swelling, increased temperature Cauda equina syndrome

Zygapophyseal Joint Pain Syndrome

Lumbar Radiculopathy

Myofascial Pain Syndrome

Myofascial Pain Syndrome

Myofascial Pain Syndrome

Visceral Referral: Angiotomes

Visceral Referral: Organs

Mechanical versus Non-Mechanical

Constant versus intermittent Episodic Aggravating and easing factors Coughing, sneezing, and straining Inflammatory symptoms

Lumbar Spinal Stenosis

Do you have no pain when sitting +LR = 6.6; -LR = 0.58 Are you symptoms improved while seated +LR = 3.3; - LR = 0.58 Age > 65 +LR = 2.5; - LR = 0.33 Do you have severe lower extremity pain +LR = 2.0; - LR = 0.52

Lumbar Spinal Stenosis

Are you able to walk better when holding onto a shopping cart +LR = 1.9; - LR = 0.55 Do you have pain below the knees +LR = 1.5; -LR = 0.70 Do you have pain below the buttock? +LR = 1.3; - LR = 0.35

Katz JN, et al. Degenerative lumbar spinal stenosis: Diagnostic value of history and physical examination. Arthritis Rheum 1995;38:12361241.

Screening for Yellow and Red Flags

Non-mechanical low back pain General health: Night pain, unexplained weight loss, etc. Indicators of poor prognosis

Cauda Equina Syndrome

Urinary retention: sensitivity 90%, specificity 95% Fecal incontinence Saddle area anesthesia: sensitivity 75% Sexual dysfunction Unilateral or bilateral sciatica, sensory, or motor deficits: > 80% sensitivity

Deyo R, et al. What can the history and physical examination tell us about low back pain? JAMA 1992;268:760-765.

Back Pain and PathologyVisceral disease: Retroperitoneal and pelvic region or the gastrointestinal system Vascular disease: Abdominal aortic aneurysm Hematological disease: Hemoglobinopathies and myelofibrosis Trauma: Fracture, fatigue fracture, insufficiency fracture

Metabolic and endocrine disease: Osteoporosis, osteomalacia, Paget disease, and diabetes (diabetic radiculopathy) Infectious disease: Diskitis and osteomyelitis Inflammatory disease: Spondylarthropathies Neoplastic disease: Osteoid osteoma, multiple myeloma, metastasesHuijbregts 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.

Yellow Flags: DepressionRandom population-based surveyMultivariate

analysis excluded confounding variables.Independent

relationship between depressive symptoms and onset of neck or back pain episode.Comparing Adjusted

lowest quartile of depression scores to highest quartile. 3.97 risk ratio most depressed

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.

Depression Screening

During the past month have you often been bothered by feeling down, depressed, or hopeless? During the last month have you often been bothered by little interest or pleasure in doing things? Sensitivity 97%; specificity 67%

Arroll B, et al. Screening for depression in primary care with verbally asked questions: A cross sectional study. BMJ 2003;327:144-1146.

Yellow Flags: Fear AvoidanceProspective interventional case series design36

patients with chronic LBP.

Fear

avoidance beliefs questionnaire physical activity subscale.Comparing

29 to FABQ-PA

Increased

probability of negative outcome in high-score group: Likelihood ratio 3.78Al-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 workrelated 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 1.98Fransen 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?

Dionne CE, et al. A clinical return-to-work rule for patients with back pain. CMAJ 2005;172:1559-1567.

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

History of Current Complaint

Timeline Mechanism of injury Management of complaint and effect of various management strategies Diagnostic tests done

Medical History

Previous medical history Family history Medication use Imaging and lab test findings

Social History

Occupation Leisure time activities Environment/social role

Open versus Closed Questions?

Anything else I forgot to ask that might be relevant or related to your current complaint? Limit open question but give the patient a chance to have his or her say

Physical Examination

Observation Active range of motion testing Neuroconductive testing including straightleg raise Special tests

Active Range of Motion Testing

Cardinal plane motions: Flexion, extension, rotation, sidebending Combined motions: Flexion and extension with ipsilateral sidebending/rotation Repeated motion testing: McKenzie or Mechanical Diagnosis and Therapy

Neuroconductive Examination: Patellar DTR

Sensitivity of 12% and a specificity of 65% in the diagnosis of L4 nerve root compression Sensitivity and specificity were 100% and 65%, respectively, for L3 nerve root compression Sensitivity and specificity were 14% and 65% for L5 nerve root compression

Knuttson B. Comparative value of electromyographic, myelographic, and clinical-neurological examinations in diagnosis of lumbar root compression syndrome. Acta Orthop Scand 1961;(Suppl 49):19-49.

Neuroconductive Examination: Achilles DTR

Sensitivity of 87% and specificity of 89% in the diagnosis of L5-S1 disk herniation Sensitivity of 12% and specificity of 89% for the diagnosis of L4-L5 disk herniation.

Kerr RSC, Cadoux-Hudson TA, Adams CBT. The value of accurate clinical assessment in the surgical management of the lumbar disc protrusion. J Neurol Neurosurg Psychiatry 1988;51:169-173.

Neuroconductive Examination: Myotomal Strength (Kerr et al, 1988)

Hip extension weakness for the diagnosis of L4L5 and L5-S1 disc protrusion: sensitivity was 12% and 9% and specificity 96 and 89%, respectively. Ankle dorsiflexion weakness had a sensitivity of 33%, 66%, and 49% for L3-L4, L4-L5, and L5-S1 disc protrusion, respectively; specificity values were 89% for all levels Ankle plantar-flexion weakness had 0%, 0%, and 28% sensitivity for the diagnosis of L3-L4, L4-L5, and L5-S1 disc protrusion, respectively; specificity values were 100% for all levels

Neurodynamic Examination: Dermatomal Light TouchL4 (L3-L4 disc herniation) L5 (L3-L4 disc herniation) S1 (L3-L4 disc herniation) L4 (L4-L5 disc herniation) L5 (L4-L5 disc herniation) S1 (L4-L5 disc herniation) L4 (L5-S1 disc herniation) L5 (L5-S1 disc herniation) S1 (L5-S1 disc herniation) Sensitivity 0.50 0.50 0.0 0.59 0.50 0.23 0.16 0.42 0.74 Specificity 0.875 1.0 0.875 0.875 1.0 0.875 0.875 1.0 0.875 + LR 4 NA 0 4.7 NA 1.8 1.3 NA 5.9 -LR 0.6 NA 0 0.5 NA 0.9 0.96 NA 0.3

Straight Leg Raise

Positive test for presence of disk herniation: reproduction of back or leg pain at less than 40 degrees Sensitivity 91%; specificity 26% Crossed straight leg raise Positive if reproduction of pain in involved leg Sensitivity 29%; specificity 88%

Additional Tests

Prone knee bend test Slump test

Special Tests

Hip passive range of motion Sacroiliac tests Segmental tests: accessory motion, physiological motion, stability

Hip OsteoarthritisTest cluster 1

Hip pain Hip IR rotation ROM < 15 degrees Hip flexion ROM < 115 degrees

Hip OsteoarthritisTest cluster 2 (if hip IR ROM > 15 degrees)

Painful hip with IR >50 years of age Morning stiffness