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Low back pain ii

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  • Transcript

    • 1. LOW BACK PAINA pragmatic approach for real world application
    • 2. Michael Stare, DPT, CSCS, FAAOMPT, CNSU of Illinois: biomechanics/kinesiology, certifiedpersonal trainer.Boston U: Masters in Physical therapyDoctorate in PT at MGHFellowship in Orthopedics manual therapy, research onLow back painBoard certified nutritionist, American College ofNutrition.
    • 3. Epidemiology2nd most common reason to see MD behindrespiratory compliants.Many cases resolve over time, up to 84% willreoccur
    • 4. Cost86% with a duration of < 1 month account for 11% ofcost<5% with duration of >1 year account for 65% of thecosts
    • 5. Why do we stuggle to solve LPB?Lack of understanding the cause.Focus on treating the symptoms, instead of the cause.Limited emphasis on patient education and instruction.Feeding into patient’s desire to be a passive recipient ofcare.
    • 6. Causes: Where is pain coming from?The brain! “pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage” -IASP “Pain is the individual response to threat to the body tissue, real or perceived” -Moseley
    • 7. Causes: What is pain?Response to damaged anatomy: mechanical or chemicalProduct of altered peripheral nervous systemProduct of altered central nervous system
    • 8. Peripheral Nervous System=PainHypersensitivity of the PNS can occur in response tochronic mechanical or chemical irritation“irritability threshold” decreasesSolution=desensitize through touch, movement, gradedexposures.
    • 9. Altered Central Nervous System=PainBrain centers for processing pain can be altered inresponse to chronic pain.Solutions: education
    • 10. What movement is the spine equipped for? Cervical: rotation Thoracic: Sidebending Lumbar: flexion/extension
    • 11. What Mechanical forces Cause Damage?CompressionTorsionShearVibrationTension
    • 12. CompressionVertebral endplate is the first to buckleOnly an unhealthy annular matrix will herniateCompression is from both sudden impact but mostlyfrom repeated or prolonged compression.The position of the spine and the speed of movementdictates the spines tolerance to compression (Adams1994)
    • 13. TorsionDamages the annular rings, causing fissures (Farfan1984)Maximal tolerance for elongation of the annular fibersis 4% (3 degrees of rotation)Lumbar spine can only tolerate 15 degrees of totalrotation before sustaining damage.The facets will forcefully impact exposing them and theposterior arch to damageThis is why we educate to get more rotation from thehips
    • 14. ShearIncrease in flexion, extensors are unable to resist shearloads in flexion (McGill et al 2000)As a result of spondylolisthesisCauses damage to the discIf you have an unstable spine: reduce flexion orextension shearing
    • 15. Enemies of the spineProlonged sittingRepeated<sustained bending (McGill,Callahan,Gordon, Little et al 2005)Repeated twisting (McGill)Sit-ups, crunches, oblique twists, hyperextensions(McGill 2006)Golfing or any bending/twisting first thing in themorning or after prolonged sitting (McGill, Adams1987, Snook, et al 1998)
    • 16. Common Enemies of the SpineLow back stretches: deadens neural response andreplicates mechanism of injury (Kokkonen 98,Solomonow 00, McGill 06)Most hamstring stretches (McGill 2006)Lifting with a flexed spine (Gunning 01, 43% higherload on disc)Spine power (Adams et al 1994)- more power from thehipsFear/Avoidance
    • 17. A Common Low Back Pain Story
    • 18. A Common Low Back Pain StoryLots of sit ups, prolonged sitting, flexed spine lifting,occasional heavy compression, etc.
    • 19. A Common Low Back Pain StoryLots of sit ups, prolonged sitting, flexed spine lifting,occasional heavy compression, etc.Ligament laxity
    • 20. A Common Low Back Pain StoryLots of sit ups, prolonged sitting, flexed spine lifting,occasional heavy compression, etc.Ligament laxityMicrofractures of the vertebral endplates
    • 21. A Common Low Back Pain StoryLots of sit ups, prolonged sitting, flexed spine lifting,occasional heavy compression, etc.Ligament laxityMicrofractures of the vertebral endplatesMicrofractures of the annulus
    • 22. A Common Low Back Pain StoryLots of sit ups, prolonged sitting, flexed spine lifting,occasional heavy compression, etc.Ligament laxityMicrofractures of the vertebral endplatesMicrofractures of the annulusSporadic episodes of low back pain
    • 23. A Common Low Back Pain StoryLots of sit ups, prolonged sitting, flexed spine lifting,occasional heavy compression, etc.Ligament laxityMicrofractures of the vertebral endplatesMicrofractures of the annulusSporadic episodes of low back painMicrofractures and fissures continue, and more sitting,flexed spine lifting
    • 24. A common low back pain story
    • 25. A common low back pain story To relieve pain more stretching, add in decreased hip,ankle and mid back mobility, and decreased legstrength
    • 26. A common low back pain story To relieve pain more stretching, add in decreased hip,ankle and mid back mobility, and decreased legstrengthLigaments become more lax and...
    • 27. A common low back pain story To relieve pain more stretching, add in decreased hip,ankle and mid back mobility, and decreased legstrengthLigaments become more lax and...Symptoms occur more frequent, and more severe
    • 28. A common low back pain story To relieve pain more stretching, add in decreased hip,ankle and mid back mobility, and decreased legstrengthLigaments become more lax and...Symptoms occur more frequent, and more severeBlood resulting from microfractures penetrates viaannular fissures, interacting with nucleus alteringchemical composition and integrity of nucleus andability to load.
    • 29. A common low back pain story
    • 30. A common low back pain storyCascade of degredation is set in place
    • 31. A common low back pain storyCascade of degredation is set in placeOther factors may contribute: nutrition, infection,genetics, age
    • 32. A common low back pain storyCascade of degredation is set in placeOther factors may contribute: nutrition, infection,genetics, ageAltered motor control of the spinal stabilizers inresponse to improper training and episodes of pain.
    • 33. A common low back pain storyCascade of degredation is set in placeOther factors may contribute: nutrition, infection,genetics, ageAltered motor control of the spinal stabilizers inresponse to improper training and episodes of pain.Load bearing capacity of disc decreases, stress shifts tofacets, facet get irritated, intermittent swelling irritatesnerves, instability perpetrates disc and facet irritationand the cycle goes on...
    • 34. A common low back pain story
    • 35. A common low back pain storyVery benign incidents trigger back issues (picking up apen).
    • 36. A common low back pain storyVery benign incidents trigger back issues (picking up apen).MRI and muscle relaxers and various treatments areoffered: findings inconclusive, treatments variable
    • 37. A common low back pain storyVery benign incidents trigger back issues (picking up apen).MRI and muscle relaxers and various treatments areoffered: findings inconclusive, treatments variableCause still not found
    • 38. A common low back pain storyVery benign incidents trigger back issues (picking up apen).MRI and muscle relaxers and various treatments areoffered: findings inconclusive, treatments variableCause still not foundCompensatory arthritic changes occur to restorestability
    • 39. A common low back pain storyVery benign incidents trigger back issues (picking up apen).MRI and muscle relaxers and various treatments areoffered: findings inconclusive, treatments variableCause still not foundCompensatory arthritic changes occur to restorestabilityLess space for the nerve- stenosis
    • 40. A common low back pain storyVery benign incidents trigger back issues (picking up apen).MRI and muscle relaxers and various treatments areoffered: findings inconclusive, treatments variableCause still not foundCompensatory arthritic changes occur to restorestabilityLess space for the nerve- stenosisDisc hardens: less effective, but less vulnerable
    • 41. HistoryRed flagsOnsetMechanismPreciptating activityAlleviationPrior treatmentImagingPrior historyWhat do you think is going on?
    • 42. PT- ExaminationHistoryWhere pain coming from?What stresses are the tissue sensitive to? compression, position sensitive....What are the impairments that make them susceptible to LBP?Posture: Are they listing, trying to unload the spine? Position of pelvis.Function: squat, lunge, transfers, work, sport specific, ADLsAROMNeuro-examJoint mobility: prone extension test, prone instability test
    • 43. PT examinationPalpationMotor control: assessing lumbopelvic proprioceptionMuscle performance: endurance significantly correlated with decreased incidenceof LBP (prone plank, lateral plank), testing length.Oswestry disability questionnaireFear avoidance questionaireWaddel’s signs
    • 44. TreatmentBased on thorough assessmentThorough educationErgonomic and ADL modificationAddress acute symptomsAddress key impairmentsGive them a HEP they understand
    • 45. TreatmentClassifications: systematic arrangement of patients intotreatment groups they are likely to benefit from basedon characteristics Manipulation, stabilization, specific exercise: extension,flexion, lateral shift, or Traction.
    • 46. Support for traction based classificationFritz et al, spine 2003: Patients treated based on TBCimproved functionally more than those based oncurrent practice guidelinesBrennan et al, Spine, 2006: Patients randomly assignedto one of the TBC’s ended up doing better than ifassigned to the classification they would actually be in.
    • 47. Manual Intermittent TractionProne, supine, hook lying, 90/90, standingBelt or harness (Morgan pelvic harness)Intermittent pressure <10sec prevents ligamentouscreepIntermittent pressure allows for graded forcesIntermittent pressure improves diffusion of nutrients
    • 48. Ergonomic and ADL modificationProlonged sitting: manual traction (10 sets of 10seconds) seated, standing at table, hanging from lat pulldown or towel over door, hooklying in doorway.Reaching and lifting: hip hinge, golfers liftForward bending compensationsSumo squat
    • 49. ExercisesPlanksDeloaded lunges: reduces intradiscal pressureInverted rows: activates mostly mid back, least stresson lumbarLat pull downs: with hip not back extensionPull throughsTerminal hip extensions (esp. w/ geriatric patients)Hip flexor and hamstring stretching
    • 50. The art of educationInstability scenario: wrist analogyPosition sensitivity scenario: punching with a bentwristLoad sensitivity scenario: How do we manage a brokenfoot?Movement apprehension scenario: movement providesnutrition, prevents “the guards” from getting lazy andteaches the brain that the threat is under control.
    • 51. Art of educationOver doing it scenario: back budgetStrong invincible scenario: how strong do you need tobe to throw a punch with a bent wrist?Explaining motor control: doesn’t matter how brightthe light bulb is if you can’t find the switch.
    • 52. Art of educationOut of pain/out of mind scenario: Most issues willreturn if we don’t address the cause. Damage mayoccur before pain occurs like tooth decay. Deficits associated with low back pain linger for years even without symptoms (McGill 2003).
    • 53. The impact of education on pain Randomized controlled trials have demonstrated that 1 to 1 patient education will: Change beliefs and attitudes about pain Improve performance Increase pain thresholds (Moseley 2002, Hodges, Nicholas 2004)
    • 54. Summary- Causes of LBPMulti-factorialLBP is not simply a pathoanatomical issue, but rather abiopsychosocial issue.The brain is the source of painSolutions must take into consideration the causeEducation is the Key