Chronic LBP

Question 1

Chronic LBP

What timeline makes it “Chronic”

Answer 1

Pain is there >/= 12wks

Question 2

Inc’ing incidents of LBP related to 3 things

Answer 2

1. Smoking
2. Obesity
3. Sedentary Occupations

Question 3

Chronic LBP

Early Tx

Answer 3

Phys Ex

Pharmacologic tx

Edu. and self-mgmt

Recommencement of norm acts→ GOAL FROM THE BEGINNING

Question 4

EVAL of Chronic LBP

Keep in mind….

Answer 4

Still try to Subgroup!!!!

*most will fit somewhere

Question 5

Eval of Chronic LBP

Components

Answer 5

• Hx injury/pain
• Full Eval
• Screen for red flags to exclude serious patho
  
  • Dx tests if suspected
• Screen for pyschosocial risk factors→ yellow flags
  
  • this predicts poorer outcomes
• Guidelines suggest caution use of imaging, meds, sx
  
  • bc this may NOT correlate w/ clinical sx’s !!!

Question 6

Some psychosocial factors w/ Chronic LBP

Answer 6

• self-efficacy
• catastrophizing→ making it way worse than actually is
• Fear of mvmt
• Pain→ subjective!→ NOT a reason not to do something
• Disability outcomes (ODI)→ usually really high

Question 7

In Chronic LBP, PT Ex. approach remains a first-line tx and should routinely be used

Answer 7

Shipton, 2018

***********

Question 8

Tx Guidelines for Tx of Chronic Non-specific LBP

*According to 4 specific journals

Answer 8

1. ACOEM
2. JOSPT***
3. American College of Physicians
4. American Pain Society

**All have something to say about this!!!

Question 9

ACOEM’s Guidelines for CNSLBP

CNSLBP= Chronic Non-Specific Low Back Pain

Answer 9

• Aerobic Ex. strongly reco’d→ just get them moving!!
  
  • 4x/week @ 60% MHR
• Directional Ex→ reco’d, no strong ev.
• Strengthy & Stab.→ some evidence for core
• Stretching/Flex. Ex.
  
  • use directional pref.
  • specific stretching for tightness
    
    • GEN. Stretching NOT recommended, BE SPECIFIC!!!

Question 10

APTA’S ORTHO SECTION GUIDELINES FOR CNSLBP

Answer 10

• Consider thrust/non-thrust manual intervents
• LOW intensity, proloooonged aerobic ex.→ common across board***
• Trunk coord., strength, endurance
• Rep’d mvmts to promote centralization
• LE nerve glides if distal sx’s
• Pt Education/counseling→ coping, resumption norm acts, address fear avoidance/depression

Question 11

Literature Review of Guidelines for CLBP

Shipton, 2018

Answer 11

• Simple mgmt begins w/ guidance & reassurance on self-mgmt, guidance to STAY ACTIVE, AVOID bed rest, possible referral for group or indiv. exercise program
• Chronic LBP >12 wks
  
  • Graded act.
  • programs w/ focus on functional improvement= PRIORITY!!!
• Inconsistencies w/ what type of program (yoga, tai chi, McKenzie, aquatic and they way delivered (group vs. indiv.)
  
  • MAY depend largely on pt prefs and experience of treating therapist

Question 12

Literature Review for Passive Modalities for CLBP

Shipton, 2018

Answer 12

• TENS, US, Traction, Back Supports
• Largely found to be ineffective in CLBP ****
• Not typ recommended in this pop.
• CLBP w/out serious patho GREATER BENEFIT FROM:
  
  • Exercise***
  • Yoga
  • Progressive relaxation→ ex. diaphragmatic breathing
  • Massage
  • Man. Therapy
    
    • Good, BUT NEED active mvmt!!!

Question 13

Literature Review for Mobilization/Manipulation and CLBP

Answer 13

• Examined treating CLBP w/ mob/manip
• mob compared w/ other active intervents showed GREATER DEC in pain, BUT not disability
• Manip MAY dec disability
• BOTH are safe tx options

Question 14

Literature Review of Mvmt Control Exercises for CLBP

*focused on Quality of mvmt

Shipton, 2018

Answer 14

• LOW to MOD effect on disability
• SIG DEC in pain intensity @ end of tx, BUT NOT @ 12 MONTHS
  
  • Bc must be a HABIT!!!

Question 15

Literature Review of McKenzie (MDT) in CLBP

Shipton, 2018

Answer 15

• High quality evidence MDT Superior to other rehab intervents in DEC’ing BOTH pain and disability***

Question 16

Literature Review Back Schools

OLLDDDD SCHOOOOL TECHNIQUE

Answer 16

No better than exercise

Passive therapy shown to be more effective than back school

Most important w/ CLBP pts→ Diminish fear-avoidance thru reassurance about mvmt and returning to PLOF**

Question 17

1 Component w/ Chronic Pain

Answer 17

Pt. Education!!!!!

Question 18

Tx and Fear-Avoidance Beliefs

Answer 18

• Pt education→ #1 component w/ chronic pain
• Graded exposure
  
  • Gradual and progressive exposure to the mvmt/activity the pt fears
  • MOST effective in pops. w/ LOW to MOD catastrophizing scores, not high
• Graded exercise/activity
  
  • Use quotas agreed upon by pt and PT
  • Pt keeps a log

Question 19

Cognitive Tx Approaches w/ CNSLBP

Answer 19

• Graded Motor Imagery
  
  • R/L Discrimination→ pt will eventually avoid chronic pain side
  • Mirror tx
  • SOME evidence for use in acute injuries
• Cog. Functional Therapy (CFT)
  
  • focus to re-conceptualize pain→ not using pain as limiting factor
  • Functional retraining of feared and maladaptive postures
    
    • uses videos/mirrors for feedback
  • Daily practice of functional mvmts in everyday tasks***
  • Phys Act. training GOAL of 3-5d/week, 20-40mins

Question 20

Mindfulness/Relaxation w/ CNSLBP

Answer 20

• Shown to be helpful in Fear Avoidance Behaviors (FAB)
• MAY dec use of pain meds
• Teach pt tech’s and set aside time for practice
• *Have pt carry out regularly

Question 21

Communication/Coordination for CNSLBP

Answer 21

• Make sure you keep everyone involved in the pts care informed
• Watch terms you use w/ pts
  
  • avoid terms like “degenerative”
• Make sure you are providing SAME INFO as other care providers→ otherwise can INC pts anxiety/fear

Question 22

Referral to Behavioral Health

Answer 22

• If pt referred by physician→ communicate w/ them!!!
• Consider if sig. h/o psychological probs, anxiety, depression
• Consider for pts w/ high score on Pain Catastrophizing scale, psychosocial barriers to recover and poor adherence

Question 23

In General,

Pts w/ Chronic LBP

Answer 23

• Still subgroup and match w/ exercises*
• Stay away from passive tx*
• Get them MOVING!!!*
• EDUCATION!!! → #1 component