Chronic LBP Flashcards
Chronic LBP
What timeline makes it “Chronic”
Pain is there >/= 12wks
Inc’ing incidents of LBP related to 3 things
- Smoking
- Obesity
- Sedentary Occupations
Chronic LBP
Early Tx
Phys Ex
Pharmacologic tx
Edu. and self-mgmt
Recommencement of norm acts→ GOAL FROM THE BEGINNING
EVAL of Chronic LBP
Keep in mind….
Still try to Subgroup!!!!
*most will fit somewhere
Eval of Chronic LBP
Components
- 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 !!!
Some psychosocial factors w/ Chronic LBP
- 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
In Chronic LBP, PT Ex. approach remains a first-line tx and should routinely be used
Shipton, 2018
***********
Tx Guidelines for Tx of Chronic Non-specific LBP
*According to 4 specific journals
- ACOEM
- JOSPT***
- American College of Physicians
- American Pain Society
**All have something to say about this!!!
ACOEM’s Guidelines for CNSLBP
CNSLBP= Chronic Non-Specific Low Back Pain
- 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!!!
APTA’S ORTHO SECTION GUIDELINES FOR CNSLBP
- 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
Literature Review of Guidelines for CLBP
Shipton, 2018
- 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
Literature Review for Passive Modalities for CLBP
Shipton, 2018
- 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!!!
Literature Review for Mobilization/Manipulation and CLBP
- 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
Literature Review of Mvmt Control Exercises for CLBP
*focused on Quality of mvmt
Shipton, 2018
- LOW to MOD effect on disability
-
SIG DEC in pain intensity @ end of tx, BUT NOT @ 12 MONTHS
- Bc must be a HABIT!!!
Literature Review of McKenzie (MDT) in CLBP
Shipton, 2018
- High quality evidence MDT Superior to other rehab intervents in DEC’ing BOTH pain and disability***
Literature Review Back Schools
OLLDDDD SCHOOOOL TECHNIQUE
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**
1 Component w/ Chronic Pain
Pt. Education!!!!!
Tx and Fear-Avoidance Beliefs
- 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
Cognitive Tx Approaches w/ CNSLBP
-
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
Mindfulness/Relaxation w/ CNSLBP
- 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
Communication/Coordination for CNSLBP
- 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
Referral to Behavioral Health
- 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
In General,
Pts w/ Chronic LBP
- Still subgroup and match w/ exercises*
- Stay away from passive tx*
- Get them MOVING!!!*
- EDUCATION!!! → #1 component
