ADVANCES IN DIAGNOSIS, PROGNOSIS, AND MANAGEMENT OF LOW BACK PAIN Presented by Peter Huijbregts, PT
Physiotherapy Orthopaedic Forum Tuesday, May 8th, 2007 Victoria Victoria General General Hospital 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 Assistant Professor, USAHS Editor-in-Chief, JMMT Consulting Editor, Jones & Bartlett Educational Consultant, Dynamic Physical Therapy
About this prese presentatio ntation: n:
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
Lifetime prevalence: 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-surgeo surgeons ns 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 Preva Prevalenc lencee of low back Prevalence pain in adults adults:: A method methodologica ologicall review of the literature. literature. Phys methodological 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 Stratfor d PW. The prevalence prevalence of low back pain Stratford 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 (Source: physical therapists in the United Kingdom recognize psychosocial factors facto rs in patie patients nts patien ts with acute low back pain? Spine 2005;30:1316 -1322)
Common-sense summary:
LBP is a big health health care and societal societal problem. problem. However, 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 lo w 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 intervi ewed reported no complai complaints. nts. 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 4478%)
Recurrent sick -listing 33% (range 26-37%) Recurrent
(Source: Hestbaek L, et al. Low back pain: what is the long -term course? Eur Spine J 2003;12:149165.)
Common-sense summary: The natural 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 involv Surgeries involving ing 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 does not 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 (19881990):
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.)
But the 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 Arch Intern Med 2005;165:22522256.)
Common-sense summary:
Practice variation based on geographical region does not seem to indicate researchbased consensus on management…?
LBP Myth #4
“Randomized controlled trials, studies into diagnostic accuracy, systemic reviews, and metaanalysis 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 eview w w w ithin ithin the f ramework ramework of the Cochrane Collaboration Back Review Group. Spine 2000;25:27842796)
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 b ased on classification using the patient response method: A systematic r eview of the literature. JJ Manual Manipulative Ther 2005;13:152 -162.)
Meta-analysis on exercise for nonspecific specifi c LBP: specific
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 (Source: therapy for non-specific low back pain. Ann 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-analysi analysiss manipul manipulation ation versus other therapi therapies: es: No evidence that manipulation is superior to other standard treatments for patients with acute and chronic LBP. (Source: Assendelft Assendelft WJJ, WJJ, et al. Spinal manipulative therapy for low back pain. Ann Ann Intern Med 2003;138:871 -881.)
Systematic review 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 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 Efficacy of spinal spinal manipulation manipulation and mobilization mobili zation for low back pain and neck pain: A systematic systematic revie revie w and best evidence synthesis. Spine 2004;4:335-356.)
Common-sense summary:
Inconclusive, Inconclusiv e, inconsi inconsistent stent,, and even inconsistent, contradictory summary statements from systematic reviews and metaanalysis 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 exacerbatio exacer bations ns and remi remissio ssions, ns, 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 Am J Ind Med Med 2000;37:558 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 pathophysio patho physiologic logic and authori authority tyauthority based rationale is not working to solve the LBP problem…
LBP Fact #5:
Systematic reviews and meta-analysis of controlled clinical trials using heterogenous popu population lationss 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: Retroperitoneal itoneall and pelvic Visceral disease: Retroper Retroperitonea Retroperitoneal region or the gastrointestinal system. Vascular disease: Abdominal Abdominal aortic aneurysm. Haematological disease: Haemoglobinopathies and myelofibrosis. Trauma: Fracture, fatigue fracture, insufficiency fracture.
Metabolic and endocrine disease: Osteoporosis, osteomalacia, Paget’s disease, and diabet diabetes es (diabeti (diabeticc radicul radiculopathy). opathy).
Infectious disease: Diskitis and osteomyelitis.
Inflammatory disease: Spondylarthropathies.
Neoplastic disease: Osteoid osteoma, multiple myeloma, metasta metastases. ses.
(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 mechanical patients with mechan mechaniical cal 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 onse t of an episode of troublesome neck and low back pain. Pain 2004;107:134 2004;107:134--139.)
Prospective interventional case series design: Prospective
36 patients with chronic LBP.
Fear avoida avoidance nce beliefs questionnaire – – physical activity subscal subscale. e.
Comparing FABQ-PA >29 to FABQ-PA Comparing <20.
Increased probability of negative outcome in high-score group: Likelihood ratio 3.78
(Source: AlAl-Obaidi SM, et al. The relationship of anticipated pain and fear avoidance beliefs to outcome in patients with chronic low back p ain who are receiving workers’ compensation. Spine 2005;30:1051 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. Unavailabil ilability ity of duties: OR 1.66. Unava Unavailability of light duties: Lifting >75% of the day: OR 1.98. (Source: Fransen M, el al. Risk factors associated associated with the transition transition 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?” legs?” “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 “Late “Latellyy 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: (Sourc e: 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 manage Outpatient management ment (psychol (psychologist ogist and physical therapist) successfully affected pain beliefs, self -efficacy efficacy, psychological ogical distress. efficacy,, and psychol
Decreased avoidance nce beliefs and Decreased fear-avoida 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 programme:: A pilot study. Physiother 2006;92:43 2006;92:43--49. Woby Woby SR, Woby SR, et al. Are changes in fear avoidance beliefs, catastrophing , and appraisals of control, predictive of changes in chronic lo w lo w back pain and disability. Eur Eur J JJ 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 accordingly for optimal optimal outcome. outcome.
University of Pittsburgh diagnostic classification system: Attempts Attempts to provide subclassification of the heterogenous group of patients 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 2006;31:77--82.)
STABILIZATION CATEGORY:
Average 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 Three or more prior episodes. Age 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 (extensi onn categor category). y). (extensio 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 reliabil ity 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 hypomobi le segment segments. s. One or both hips have >35° of internal rotation in prone position. position.
Patients with 4 of 5 criteria clinical prediction rule met and who 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. Pragm (Source: Pragmatic atic application application of a clini clinical cal predictio ediction n rule in ediction 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 movemen Aberrant movementt 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 resp ond to a stabilization exercise program. Arch Arch Phys Med Rehabil 2005;86:1753-1762.)
Common-sense summary: A 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 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 months, mont hs, significant significant between-group differences in At 5 and 12 months, favour of manipulation/stabilization group for patient report of pain and disability (Source: Niemisto L, et al. A randomized trial of combined manipulation, stabiliz ing exercises, and physician consultation compared to physician consultation al one for chronic low back pain. 2003;28:2185--2191). Spine 2003;28:2185
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
Signifi Significant cant Signific ant between-group difference in favour of surgery group on decrease in ODI score (betweengroup difference 4.1 points)
No significant between-group differences on any other outcome measures, including shuttle walking test, SF-36 general health status questionnaire, returnto- work status, or psychological assessment
19 intra-operative complications and 11 re-surgeries
No complications in the rehabilitation program
(Source: (Source: Fairbank J, J, et al. Randomised controlled trial to compare surgical stabilization of the lumbar spine with an intensive rehabilitation programme for pati ents 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 At the 6-month follow -up patients, who had received manipulation had significantly lower health healt h care utili utilizatio zation, n, medic medication ation use, and time utilization, off work due to LBP than those receiving exercise only
(Source: Childs JD, et al. A clinical prediction rule to identif y patients with low back pain most likely to benefit from spinal manipulation: A validation study. Ann 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 pati ents with occupational low back pain? A case -control study. Spine J 2006;6:289-295).
Cost-effecti effectivene veness ss analy analysis sis of the stud study y effectiveness 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: RiveroRivero- Arias Arias O, et al. Surgical stabilization of the lumbar spine compared with a programme of intensive rehabilitation programme for the manageme nt 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 A treatment-based classification classificatio classification n 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 nonspecific 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 informatio n. 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 appropriate ate Screening for risk factors and appropri 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
