Ryan Perry
PT, DPT, OCS, CSCS, MTC, FAAOMPT
NovaCare Rehabilitation - Chicago
March 12th, 2010
 Incidence
◦ Prevalence of LBP among former elite athletes of all
sports was 29%, compared with 44% among non-
athletes.
...
Fritz, 2010
 Adolescents with LBP as a result of sports
participation tended to have lower baseline
disability scores and...
Fritz, 2010
 Patients who were sports participants were
more likely to undergo an MRI before referral
 Overall pattern o...
 Athlete
◦ Typically in better shape
than non-athlete
◦ Very motivated to
exercise
◦ Understands the
difference between p...
Common Diagnoses
 Lumbar sprain/strain
 Discogenic pain
 Instability
 Facet syndrome
 Scoliosis
 Stenosis
 Arthriti...
Primary areas of CA that can cause metastatic spine CA
 Breast
 Lung
 Thyroid
◦ with
 Kidney
 Prostate
 The spine is...
 Malignancy
 Infection
 Inflammatory
spondyloarthropathy
(ankylosing spondylitis,
psoriatic spondylitis, Reiter's
syndr...
 Pelvic disease (prostatitis, endometriosis,
pelvic inflammatory disease)
 Renal disease (kidney stones, pyelonephritis,...
Described by Waddell, and these usually suggest
delayed recovery and need for multi-disciplinary
approach
 Pain at the ti...
 Most commonly diagnosed lumbar pathology
 Strain
◦ Occurs by disruption of muscle fibers or the
musculotendinous juncti...
 Typically seen between in 4th & 5th decade of
life
 Pain often in the lower extremity
 Pain usually worse with sitting...
 Not all disc problems that present on MRI
cause pain
◦ Make sure you correlate the clinical exam with the
MRI
 Jensen e...
 Usually present in
patients >60 y/o
 Pain worse with walking
 Pain relieved with sitting
 Typically have decreased
ex...
 Characterized by stiffness
 Patients usually >50 y/o
 Typically worse in the morning
 Amount of ROM proportional to d...
 Spondylolysis: A defect in the continuity
of the pars interarticularis of the
vertebrae
◦ Seen in ~5% of the population
...
 Slippage of one vertebrae on its
adjacent segment
◦ Thought to be a further
progression of bilateral
spondylosis
 Over ...
 Clinical findings:
◦ Radiographic evidence of spondylolysis and
slippage with flexion-extension X-rays
◦ Localized LBP w...
 LBP in the presence of non-specific
abnormalities on imaging studies
◦ Graw & Wiesel, 2008
1. The structure should have a nerve supply
2. The structure should be capable of
causing pain similar to that seen
clinic...
 Do we really have an accurate
pathoanatomical diagnosis?
◦ Unlike younger patients, only 15% of mature
patients can be g...
 Despite the fact that >1000 RCTs have
investigated the effectiveness of conservative
and surgical interventions for the
...
 Subgrouping
◦ The subgrouping hypotheses proposed are
intended for patients who may or may not be
involved in athletic a...
 Subgrouping
◦ Four subgroups were established by Delitto et al in
1995
 Manipulation
 Stabilization
 Specific Exercis...
◦ Clinical prediction rule (CPR) developed & validated
by Flynn & Childs, respectively.
 Goal of the CPR for the manipula...
 CPR included 5 factors
◦ Current symptom duration of less than 16 days
◦ Score <19 on the work subscale of the Fear-Avoi...
Clinical Prediction Rule (Hicks, 2005)
 If the patient has three of the following four
criteria, then he/she will be four...
Stabilization Interventions (Fritz et al, 2007)
 Isolated contractions of the deep multifidus
and transverse abdominis
 ...
Long-term effects (Hides 2001)
 Studied recurrence rate of LBP after acute,
first-time episode of LBP
 Subjects allocate...
Long-term effects (Hides 2001)
Results
◦ The recurrence rate at one-year of follow-up was
84% in the control group and 30%...
 Classification approach
was updated for patients
who are post-partum
 Updated classification
criteria
◦ Positive poster...
 Patients that typically respond are the
following
◦ If the patient has reduction of symptoms with >2
repetitions in the ...
 Repeated ROM performed initially, followed
by strengthening exercises toward the
directional preference
 McKenzie progr...
 Performed when the following criteria are
present:
◦ Signs and symptoms of nerve root compression
◦ No movements central...
 Fritz et al (Spine, 2007) found that the
presence of symptoms below the buttock and
signs of nerve root compression were...
 When patients with symptoms below the
buttock and signs of nerve root compression
had either of these findings received ...
 Cai et al, 2009
◦ A clinical prediction rule with four variables was
identified.
 Non-involvement of manual work
 Low ...
 Fear avoidance simply
refers to avoidance of
movements or physical
activities because of the
patients’ fears that pain
w...
 Studies suggest that questionnaires based on
the fear-avoidance model accurately identify
poor prognosis for patients wi...
Fear-Avoidance Beliefs Questionaire (FABQ)
 http://www.kmcnetwork.org/ksmc/menu/FABQ.pdf
 Waddell et al, 1993
 These re...
Grotle, Spine, 2006
 In the acute sample, fear-avoidance beliefs
for work predicted pain and disability at 12
months.
 I...
 The FABQ is a self report questionnaire with 16
items each scored from 0 to 6 with higher numbers
indicating increased l...
 The work subscale has been identified as a
strong predictor of work status.
◦ Scores of 30 or less are associated with a...
Croft et al, 1998
 The results are consistent with the
interpretation that 90% of patients with low
back pain in primary ...
 10% of LBP patients account for 90% of
healthcare and disability costs
 Identification of individuals at risk is the fi...
 Recovery expectations when measured using
a specific, time-based measure within the
first 3 weeks of non-specific LBP is...
 Patients with lower than average initial pain
intensity, shorter duration of symptoms and
fewer previous episodes were 3...
Recognition of Back Injuries in the Non Athletic Population
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Recognition of Back Injuries in the Non Athletic Population

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Recognition of Back Injuries in the Non Athletic Population

  1. 1. Ryan Perry PT, DPT, OCS, CSCS, MTC, FAAOMPT NovaCare Rehabilitation - Chicago March 12th, 2010
  2. 2.  Incidence ◦ Prevalence of LBP among former elite athletes of all sports was 29%, compared with 44% among non- athletes.  Bono, 2004 ◦ Higher rates of spondylolysis, spondylolisthesis and disc degeneration have been reported in athletes than in the general population.  Ong et al, 2003
  3. 3. Fritz, 2010  Adolescents with LBP as a result of sports participation tended to have lower baseline disability scores and to experience less improvement in disability than non- participants ◦ Also attended more PT sessions over a longer period of time
  4. 4. Fritz, 2010  Patients who were sports participants were more likely to undergo an MRI before referral  Overall pattern of outcomes in this sample of adolescents was similar to reports of outcomes from adults with LBP
  5. 5.  Athlete ◦ Typically in better shape than non-athlete ◦ Very motivated to exercise ◦ Understands the difference between pain from DOMS and true pain ◦ Can be demanding  Non-Athlete ◦ Lower physical expectations at discharge ◦ Less diagnostic imaging before onset of PT ◦ Subjected to decreased load and strain
  6. 6. Common Diagnoses  Lumbar sprain/strain  Discogenic pain  Instability  Facet syndrome  Scoliosis  Stenosis  Arthritis  Fracture  Other Miscellaneous  Non-musculoskeletal (3% of LBP- Deyo,2001)
  7. 7. Primary areas of CA that can cause metastatic spine CA  Breast  Lung  Thyroid ◦ with  Kidney  Prostate  The spine is the most common site of bone metastasis • Tumor-related pain is predominantly nocturnal or early morning pain and generally improves with activity during the day
  8. 8.  Malignancy  Infection  Inflammatory spondyloarthropathy (ankylosing spondylitis, psoriatic spondylitis, Reiter's syndrome, inflammatory bowel disease)  Osteochondrosis  Paget's disease of bone
  9. 9.  Pelvic disease (prostatitis, endometriosis, pelvic inflammatory disease)  Renal disease (kidney stones, pyelonephritis, perinephric abscess)  Aortic aneurysm  Gastrointestinal disease (pancreatitis, cholecystitis, penetrating ulcer)
  10. 10. Described by Waddell, and these usually suggest delayed recovery and need for multi-disciplinary approach  Pain at the tip of the tailbone  Whole-leg pain in global distribution  Whole-leg numbness in a global distribution  Sudden give-way weakness of the leg  Absence of even brief periods of relative pain relief  Failure or intolerance of numerous treatments  Numerous urgent care visits or hospitalizations for back pain ◦ Waddell G, Bircher M, Finlayson D, Main CJ: Symptoms and signs: Physical disease or illness behaviour? BMJ (Clin Res Ed) 1984:289:739-741.
  11. 11.  Most commonly diagnosed lumbar pathology  Strain ◦ Occurs by disruption of muscle fibers or the musculotendinous junction  Sprain ◦ Stretching or tearing of spinal ligaments  Will have localized isolated tenderness of the lumbosacral spine  Patient will not have signs of red flags for non-spinal conditions or cauda equina nor tension signs associated with nerve root irritation  Graw & Wiesel, 2008
  12. 12.  Typically seen between in 4th & 5th decade of life  Pain often in the lower extremity  Pain usually worse with sitting or bending  Neural tension signs  Many false positives with MRI
  13. 13.  Not all disc problems that present on MRI cause pain ◦ Make sure you correlate the clinical exam with the MRI  Jensen et al, 1994 ◦ Thirty-six percent of the 98 asymptomatic subjects had normal disks at all levels. ◦ Thus, 64% had at least a disk bulge at least at one level in the lumbar spine
  14. 14.  Usually present in patients >60 y/o  Pain worse with walking  Pain relieved with sitting  Typically have decreased extension ROM  Pain often primarily in LEs  Use Bicycle test of van Gelderen to differentiate between vascular disease
  15. 15.  Characterized by stiffness  Patients usually >50 y/o  Typically worse in the morning  Amount of ROM proportional to disc height
  16. 16.  Spondylolysis: A defect in the continuity of the pars interarticularis of the vertebrae ◦ Seen in ~5% of the population ◦ Controversial whether the incidence is higher in the athletic or non-athletic population  Athletes tested more frequently for this  Some studies show a lower rate of this abnormality in athletes compared to non-athletes  Moller & Hedlund, 2000
  17. 17.  Slippage of one vertebrae on its adjacent segment ◦ Thought to be a further progression of bilateral spondylosis  Over 5 years of follow-up, younf athletes demonstrated a 38% rate of slippage, which was not significantly different than the general population ◦ Bono, 2004
  18. 18.  Clinical findings: ◦ Radiographic evidence of spondylolysis and slippage with flexion-extension X-rays ◦ Localized LBP with or without radiating LE pain and/or neurological findings ◦ Positive Stork sign (one-legged extension) ◦ Graded I-V  Grades I-II usually successful with conservative care  Grade V (spondyloptosis): Surgical
  19. 19.  LBP in the presence of non-specific abnormalities on imaging studies ◦ Graw & Wiesel, 2008
  20. 20. 1. The structure should have a nerve supply 2. The structure should be capable of causing pain similar to that seen clinically 3. These structures should be susceptible to diseases or injuries that are known to be painful 4. The structure should have been shown to be a source of pain in patients using diagnostic techniques of known reliability and validity. Bogduk 1997
  21. 21.  Do we really have an accurate pathoanatomical diagnosis? ◦ Unlike younger patients, only 15% of mature patients can be given a precise diagnosis  Deyo 2001 ◦ No firm evidence exists for the presence or absence of a causal relationship between radiographic findings and nonspecific LBP  van Tulder, 1997 ◦ Identifying relevant pathology in patients with LBP has proved elusive and is identified in <10% of cases  Abenhaim et al, 1995
  22. 22.  Despite the fact that >1000 RCTs have investigated the effectiveness of conservative and surgical interventions for the management of LBP have been reported in the literature, evidence remains contradictory and inconclusive for many interventions ◦ Hayden et al, 2005 & Koes et al, 2006; both in Fritz, et al 2007  Cannot treat LBP with only one approach, as not one single approach has shown to be effective
  23. 23.  Subgrouping ◦ The subgrouping hypotheses proposed are intended for patients who may or may not be involved in athletic activities with acute LBP or an acute exacerbation of LBP causing substantial pain and limitations in daily activities. ◦ After screening patients for any signs of serious pathology, information collected during the history and physical examination is used to place a patient into a subgroup. Hebert et al, 2008 & Delitto et al, 1995
  24. 24.  Subgrouping ◦ Four subgroups were established by Delitto et al in 1995  Manipulation  Stabilization  Specific Exercise  Traction ◦ Subgroups classification criteria and intervention procedures updated in 2007 by Fritz et al.
  25. 25. ◦ Clinical prediction rule (CPR) developed & validated by Flynn & Childs, respectively.  Goal of the CPR for the manipulation classification is to identify patients with LBP who are likely to respond to manipulation with rapid and sustained movement  Improvement defined as a 50% or greater reduction in self-reported disability over 2 treatment sessions  Intervention: Manipulation of the lumbopelvic region and AROM exercises
  26. 26.  CPR included 5 factors ◦ Current symptom duration of less than 16 days ◦ Score <19 on the work subscale of the Fear-Avoidance Beliefs Questionnaire (FABQ) ◦ Hypomobility of the lumbar spine as assessed with posterior-to-anterior pressure ◦ Hip IR of at least 1 hip greater than 35° ◦ Symptoms not extending distal to the knee.  When 4 of these 5 factors were present, patients were highly likely to improve, while the presence of 2 or fewer factors was almost always associated with a failure to improve.  4 or greater: +LR = 24  2 or less: - LR = 0.09 * Flynn et al, 2002
  27. 27. Clinical Prediction Rule (Hicks, 2005)  If the patient has three of the following four criteria, then he/she will be four times more likely to be successful with a stabilization program in physical therapy ◦ Age <40 years old ◦ Straight leg raise >90 degrees ◦ Aberrant movement present during ROM testing ◦ Positive prone instability test
  28. 28. Stabilization Interventions (Fritz et al, 2007)  Isolated contractions of the deep multifidus and transverse abdominis  Strengthening of large spinal stabilizing muscles (erector spinae, obliques, etc)
  29. 29. Long-term effects (Hides 2001)  Studied recurrence rate of LBP after acute, first-time episode of LBP  Subjects allocated to two groups ◦ Control: General advice plus use of medications ◦ Experimental: Specific exercise targeting the lumbar multifidus and transverse abdominis
  30. 30. Long-term effects (Hides 2001) Results ◦ The recurrence rate at one-year of follow-up was 84% in the control group and 30% in the experimental group (p<0.001) ◦ Results were similar at the three-year follow-up
  31. 31.  Classification approach was updated for patients who are post-partum  Updated classification criteria ◦ Positive posterior pelvic pain provocation (P4), AND SLR and modified Trendelenburg tests ◦ Pain provocation with palpation of the long dorsal SI ligament or pubic symphysis  Fritz, 2007
  32. 32.  Patients that typically respond are the following ◦ If the patient has reduction of symptoms with >2 repetitions in the same direction OR ◦ If the patient has centralization of symptoms in one direction and peripheralization of symptoms in the opposite direction  Directional preference can be extension, flexion, or lateral shift
  33. 33.  Repeated ROM performed initially, followed by strengthening exercises toward the directional preference  McKenzie program is the most common form of directional preference therapy ◦ McKenzie program is not always extension
  34. 34.  Performed when the following criteria are present: ◦ Signs and symptoms of nerve root compression ◦ No movements centralize symptoms  Typical treatment: Mechanical traction or autotraction Fritz et al, 2007
  35. 35.  Fritz et al (Spine, 2007) found that the presence of symptoms below the buttock and signs of nerve root compression were not specific enough to identify this subgroup ◦ Two additional factors were found to identify patients likely to respond favorably to traction  Peripheralization with extension movement  Positive crossed SLR (aka Well SLR)
  36. 36.  When patients with symptoms below the buttock and signs of nerve root compression had either of these findings received traction plus an extension-specific exercise program, they showed greater short-term reductions in disability than patients who received only the extension exercise program (Fritz, 2007)
  37. 37.  Cai et al, 2009 ◦ A clinical prediction rule with four variables was identified.  Non-involvement of manual work  Low level fear-avoidance beliefs  No neurological deficit  Age above 30 years ◦ The presence of all four variables (+LR = 9.36) increased the probability of response rate with mechanical lumbar traction from 19.4 to 69.2%.
  38. 38.  Fear avoidance simply refers to avoidance of movements or physical activities because of the patients’ fears that pain will make them worse
  39. 39.  Studies suggest that questionnaires based on the fear-avoidance model accurately identify poor prognosis for patients with LBP ◦ Al-Obaidi et al, 2005  Interventions aimed at confronting these beliefs and graded exercise have been effective at reducing pain ◦ George et al, 2003
  40. 40. Fear-Avoidance Beliefs Questionaire (FABQ)  http://www.kmcnetwork.org/ksmc/menu/FABQ.pdf  Waddell et al, 1993  These results confirm the importance of fear- avoidance beliefs and demonstrate that specific fear- avoidance beliefs about work are strongly related to work loss due to low back pain
  41. 41. Grotle, Spine, 2006  In the acute sample, fear-avoidance beliefs for work predicted pain and disability at 12 months.  In the chronic sample, fear-avoidance beliefs for physical activity predicted disability at 12 months, but not pain.
  42. 42.  The FABQ is a self report questionnaire with 16 items each scored from 0 to 6 with higher numbers indicating increased levels of fear avoidance beliefs.  The questionnaire contains two subscales ◦ A 4 item activity subscale ◦ A 7 item work subscale  The work subscale is associated with current and future disability and work loss in patients with acute and chronic LBP. * Waddell, 1993
  43. 43.  The work subscale has been identified as a strong predictor of work status. ◦ Scores of 30 or less are associated with a greater likelihood of return to work whereas of 34 or more are associated with less likelihood of return to work or increased risk of prolonged work restrictions. ◦ Thus, a score of 34 or more on the work subscale of the FABQ should be a “Yellow Flag” for therapists and case managers working with out of work workers with low back pain.  Fritz & George, 2002
  44. 44. Croft et al, 1998  The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months.  However most will still be experiencing low back pain and related disability one year after consultation. ◦ Only 25% will be completely recovered at this time in terms of both pain and disability
  45. 45.  10% of LBP patients account for 90% of healthcare and disability costs  Identification of individuals at risk is the first step in preventing chronic instability due to non-specific LBP ◦ Iles et al, 2009
  46. 46.  Recovery expectations when measured using a specific, time-based measure within the first 3 weeks of non-specific LBP is a strong predictor of people at risk of poor outcome  Iles et al, 2009
  47. 47.  Patients with lower than average initial pain intensity, shorter duration of symptoms and fewer previous episodes were 3.5 more likely to be recovered at any time point than patients without these characteristics ◦ These were described as the following:  Baseline pain </= to 7/10  Duration of current episode </= 5 days  One or zero previous episodes of pain  Hancock et al, 2009

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