This document discusses evidence-based therapies for low back pain. It finds that staying active and exercise programs are effective in reducing pain and sick leave. Bed rest for more than 2 days and lumbar supports have insufficient evidence of effectiveness. Physical therapies including spinal mobilization and structured exercise programs are effective when combined with early active movement. Chiropractic and acupuncture may provide short-term pain relief but no significant difference compared to other interventions.

1.
WHAT
ARE
THE
BEST
THERAPIES
?
BACK
PAIN

2. Low
Back
Pain
Episodes

3. Low
Back
Pain
Episodes
Acute
<3
months

4. Low
Back
Pain
Episodes
Sub
Acute
>5
weeks
<3
months

5. Low
Back
Pain
Episodes
Chronic
>3
months

6. LBP
affects
70%
Adult
PopulaKon
• Episodes
>2
wks
have
cumulaKve
lifeKme
prevalence
in
14%
cases
• Cause
Nonspecific
in
95%
• Australia
:
most
frequently
seen
m/s
condiKon
in
General
PracKce

7. NHMRC
Evidence
Based
Management
Advice
to
Stay
AcKve
Reduces
Sick
Leave

8. NHMRC
Evidence
Based
Management
Massage
• No
controlled
studies
in
LBP
• Might
be
beneficial
+
exercises
+
educaKon
• Cochrane
2012
:

9. NHMRC
Evidence
Based
Management
Lumbar
Supports
• No
controlled
studies,
insufficient
evidence
are
effecKve

10. NHMRC
Evidence
Based
Management
Bed
Rest
• Insufficient
Evidence
• >2
days
increases
sick
leave
• Evidence
that
prolonged
bed
rest
is
harmful

11. NHMRC
Evidence
Based
Management
Spinal
ManipulaKon
• ConflicKng
evidence
v’s
placebo
first
2-­‐4wks

12. NHMRC
Evidence
Based
Management
Acupuncture
• Insufficient
evidence
v’s
injecKon
therapy

13. NHMRC
Evidence
Based
Management
Back
Exercises
• Similar
pain
+
funcKon
outcomes
to
usual
care
• Reduces
pain
+
sick
leave
• Paravert.
Muscle
ex’s
• CoordinaKon/Stability
+
Strength/Resistance
• Complements
principle
of
acKvity

14. Evidence
Based
Management
Physical
Therapies
Structured
Exercise
Programs
+
Spinal
MobilisaKon
effecKve
Alongside
early
acKve
movement

15.
Evidence
Based
Management
ChiropracKc
Short
term
slightly
improve
pain
and
disability
(Cochrane
report)
No
clinical
meaningful
difference
v’s
other
intervenKons

16. NHMRC
Evidence
Based
Management
Homeopathy
Curing
“like
with
like”
PotenKsing
NHMRC
:
“Groundless”

17. NHMRC
Evidence
Based
Management
Review
of
Scope
of
Private
Health
Insurance
Rebate
!7
Therapies
being
reviewed
Released
1
April
2015

18. NHMRC
Evidence
Based
Management
Provide
InformaKon

19. NHMRC
Evidence
Based
Management
Provide
InformaKon
Provide
Assurance

20. NHMRC
Evidence
Based
Management
Provide
InformaKon
Provide
Assurance
Advice
to
Remain
AcKve

21. NHMRC
Evidence
Based
Management
Provide
InformaKon
Provide
Assurance
Advice
to
Remain
AcKve
Other
Pain
Management
OpKons

22. NHMRC
Evidence
Based
Management
Acute
LBP
Management
Aims
IdenKfy
Serious
Causes
(<5%)
Self
Management
Maximize
FuncKon
Minimise
Disability

23. REHABILITATION
AFTER
BACK
PAIN
EPISODE
• MODIFY
ACTIVITIES
• CORRECT
BIOMECHANICAL
ABNORMALITIES
• POSTURAL
ASSESSMENT
OF
FUNCTIONAL
POSITIONS
• LIFTING
MECHANICS
• CORE
STABILITY
:
LOCAL
THEN
GLOBAL
• ASSESS
/
STRETCH
TIGHTNESS
• EDUCATION
• HOME
EXERCISE
REGIME

24. RehR
REFERRAL
PRESCRIPTIONS
Acute
Back
Pain
Local
modaliKes
for
pain/spasm
Encourage
non-­‐aggravaKng
movement
and
exercise
Educate
/
encourage
neutral
spine
Manual
therapy
techniques
Home
exercise
Back
Care
advice

25. RehR
REFERRAL
PRESCRIPTIONS
SUB-­‐ACUTE
BACK
PAIN
Local
modaliKes
for
pain/spasm/hypo
mobility
Restore
range
with
manual
therapy
and
exercise
Core
stability
regime
and
upgrade
Review
postures/biomechanics
Home
exercise
/
Cardio
fitness

26. FUNCTIONAL
STABILITY
NEED
TO
UTILISE
BOTH
MUSCLE
FORCES
AND
PASSIVE
STRUCTURES
TO
DYNAMICALLY
STABILISE
THE
SPINE
FUNCTIONALLY
ANY
DEFICITS
ASSESSED
NEED
TO
BE
ADDRESSED
IN
A
REHAB.
PLAN

27. CORE
STABILITY
• MUSCULAR
CONTROL
TO
MAINTAIN
FUNCTIONAL
STABILITY
• MUSCULAR
CORSET
• STABILITY
INVOLVES
PASSIVE
AND
ACTIVE
STIFFNESS
• INSTABILITY
WHEN
EITHER
COMPONENT
DISTURBED

28. CORE
STABILITY
• GLOBAL
:
DYNAMIC
/
PHASIC
MUSCLES
=
ACTIVE
TRUNK
MOVEMENT
• RECTUS
ABDOMINIS
• EXTERNAL
OBLIQUES
• ILIOCOSTALIS
(THORACIC
PART)
• LATISSIMUS
DORSI
• LINK
PELVIS
TO
THORACIC
CAGE

29. CORE
STABILITY
• LOCAL
:
POSTURAL
/
TONIC
=
INTERSEGMENTAL
STABILITY
• TRANSVERSUS
ABDOMINIS
• MULTIFIDIS
• PSOAS
MAJOR
• QUADRATUS
LUMBORUM
• DIAPHRAGM
• ILIOCOSTALIS
(
LUMBAR
SEGMENT)
• INTERNAL
OBLIQUE

30. STABILITY
TEACHING/
RETRAINING
• EDUCATION
:
ANATOMY
AND
FUNCTION
• ISOLATE
DEEP
LAYER
T.A
• MOTOR
RELEARNING
• TRAIN
STABILISERS
IN
ISOLATION
• ADD
FUNCTIONAL
MOVEMENTS
WITH
STABILITY
• PAINFREE
• NEUTRAL
SPINE
INITIALLY
• FEEDBACK
:
TACTILE
,
PBU,
ULTRASOUND

31. STABILISATION
EXERCISES
• INITIATE
PELVIC
FLOOR
HELPS
ISOLATE
T.A.
• PALPATE
1CM
IN
1CM
DOWN
A.S.I.S.
• FEEL
TENSION,
NOT
BULGE
• CONTROLLED
BREATHING
• SUPINE
/
4
POINT
KNEEL
/
STANDING
/
SITTING
• PROGRESS
UPGRADED
POSITIONS/EXERCISES

32. CONDITIONING
• GENERAL
AEROBIC
FITNESS
• POSTURAL
CORRECTION
• 20-­‐30
MINUTE
PERIODS
• WEIGHT
LOSS
• POSITIVE
RATHER
THAN
PURELY
CLINICAL
SETTING
NORMALISE
SETTING
:
TAI
CHI,
PILATES,
YOGA,
GYM
CLASSES,
SWIM
FOCUS
ON
SELF
MANAGEMENT

33. MULTIMODAL
ROLE
• UNDERSTANDING
• RELATIONSHIP
• EARLY
ACTIVITY
• EARLY
EXERCISE
• EARLY
MOBILITY
• SHIFT
ONUS
OF
RESPONSIBILITY
• SELF
MANAGEMENT