Low Back Pain

Physical Therapy

PROBLEM

Eighty percent of the adult population is affected by low back pain (LBP) at some point in life and 1 out of 2 adults will experience LBP each year.^1-3 In the United States, LBP is the second leading cause for medical consultation and fifty billion dollars are spent annually for its medical coverage.¹ LBP is defined as pain below the scapulae and above the buttocks with or without radiation into the extremeties.⁴ Despite the advances in surgical intervention for LBP, the economic burden is largely unchanged.⁵ Chronic low back pain (CLBP) has been categorized as pain lasting for 3 months or longer.⁶ Whereas acute and subacute LBP pain lasts less than 1 month and 2-3 months respectively.^{6, 7} Studies are evolving with respect how psychology plays a role in recovery from LBP.

There is a general consensus that people who have psychological distress and an exaggerated sense of low back pain-related disability can be at risk for prolong recovery.^8-10 Fear can be a factor that can lead to avoidance of activities that were a normal aspect of life prior to onset of back-related symptoms. The longer one associates fear of engaging in an activity with re-injury or exacerbation of an injury, the more difficult it becomes to tackle that activity again and the greater likelihood for it to lead to chronic disability.¹¹ The problem is that even with the evidence supporting the use of treatment-based classifications for treatment of LBP, if one has high fear-avoidance behaviors then they are less likely to return to function and more likely to exhibit chronic pain patterns.^8-12

Relevance and Significance

Degenerative changes depicted by diagnostic imaging such as magnetic resonance imaging (MRI), myelogram and computer-assisted tomography (CAT) do not correlate with symptoms associated with LBP.^{5, 6} Thus making it more challenging to determine the cause of pain as well as to determine the appropriate treatment.⁵ However the evidence supports a shift from the biomedical model (pathology-based approach) to a treatment-based classification approach and biopsychosocial model to treatment of LBP.^{5, 13, 17, 18} This involves not focusing on the mechanical or anatomical structures, but emphasizing clustering of signs and symptoms, use of clinical prediction rules, the use of treatment-based classification and coping strategies. Randomized trial, systematic reviews and clinical practice guidelines have not supported the efficacy of the use of modalities such as ultrasound and electrical stimulation for the treatment of LBP.⁵ The Fear and Avoidance Model (FAM) suggest that factors such as anxiety, pain-related fear and pain catastrophizing influence one perception of pain.^{8, 11, 13} It also suggest that those who present with high levels of fear have a greater tendency to develop disability related to LBP.⁸

Best evidence supports a treatment-based classification approach that does not put emphasis on anatomical lesion.⁶ Recent evidence suggests the use of the classification or sub-grouping approach can enhance intervention effects when identical treatment is provided to all.⁶ One treatment classification approach uses information regarding ones history and physical examination to place subjects into 1 of 4 groups: specific exercise groups (directional preference exercises), stabilization, mobilization, and traction.⁶ Fritz found that patient who were appropriately matched with the correct subgroup had better outcomes.⁶

The subgroup of patients who respond to repeated endrange movement was initially proposed by Robin McKenzie several decades ago.¹⁷ Repeated exercise in a direction of preference (flexion, extension or lateral shift) or that causes centralization of pain is suggested to be an appropriate intervention.^{5, 6, 17, 19} Direction of preference is defined by reduction in pain and improvements in range of motion (ROM) with movement in one direction and increased symptoms with movement in the opposite direction.¹⁷ Centralization has been defined as movement of symptoms from a distal to a proximal location or closer to the midline of the spine.¹⁷ According to Clinical Practice Guidelines published in 2012 edition of the Journal of Orthopaedic & Sports Physical Therapy (JOSPT), clinicians should use repeated exercises in a direction of preference to treat acute, subacute and chronic LBP.⁶ This recommendation is supported by strong evidence.⁶ Centralization was associated with good outcomes and the lack of centralization was associated with poor outcomes.⁶ Short-term results demonstrated improvements in outcome measures. However long-term results favor remaining active over the use of directional preference or McKenzie exercises.^{6, 17}

Have you experience good results from physical therapy for your low back pain? What did you find most helpful from this blog? What was something good you learn from your physical therapist about managing your low back pain?

Reference List

1. Descarreaux M, Normand M, Laurencelle L, Dugas C. Evaluation of a specific home exercise program for low back pain. Journal of Manipulative Physiological Therapuetics. 2002;25:497-503.
2. Wheeler A. Diagnosis and Management of Low Back Pain. American Family Physician. 1995;52(5):333-341.
3. Miller E, Schenk R, Karnes J, Rousselle J. A comparison of the McKenzie approach to a specific spine stabilization program for chronic low back pain. The Journal of Manual and Manipulative Therapy. 2005;13(2):103-112.
4. Slade S, Keating J. Trunk Strengthening-Exercises for Chronic Low Back Pain: A Systematic review. Journal of Manipulative Physiol ther. 2006;29:63-173.
5. Hebert J, Koppenhaver S, Fritz J, Parent E. Clinical Predition of Success of Intervention for Managing Low Back Pain. Clinical Sports Medicine. 2008;27:463-479.
6. Delitto A, George SZ, Dillon LV, et al. Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. . April 2012;42(4):A1-A57.
7. Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med. May 3 2005;142(9):765-775.
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9. Nicholas MK, George SZ. Psychologically informed interventions for low back pain: an update for physical therapists. Phys Ther. May;91(5):765-776.
10. Rundell SD, Davenport TE. Patient education based on principles of cognitive behavioral therapy for a patient with persistent low back pain: a case report. J Orthop Sports Phys Ther. Aug;40(8):494-501.
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12. Kernan T, Rainville J. Observed outcomes associated with a quota-based exercise approach on measures of kinesiophobia in patients with chronic low back pain. J Orthop Sports Phys Ther. Nov 2007;37(11):679-687.
13. George SZ, Zeppieri G. Physical therapy utilization of graded exposure for patients with low back pain. J Orthop Sports Phys Ther. Jul 2009;39(7):496-505.
14. Calley DQ, Jackson S, Collins H, George SZ. Identifying patient fear-avoidance beliefs by physical therapists managing patients with low back pain. J Orthop Sports Phys Ther. Dec;40(12):774-783.
15. Surkitt LD, Ford JJ, Hahne AJ, Pizzari T, McMeeken JM. Efficacy of directional preference management for low back pain: a systematic review. Phys Ther. May;92(5):652-665.
16. George SZ, Valencia C, Zeppieri G, Jr., Robinson ME. Development of a self-report measure of fearful activities for patients with low back pain: the fear of daily activities questionnaire. Phys Ther. Sep 2009;89(9):969-979.
17. Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. Jun 2007;37(6):290-302.
18. Hicks G, Fritz J, Delitto A, McGill S. Preliminary Develpment of Clinical Prediction Rule for Determining Which Patients With Low Back Pain Will Respond to a Stabilizaiton Exercise Program. Ach Phys Med Rehabil. September 2005(86):1753-1762.