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Exercise Interventions for Chronic non-specific LBP

Excel Physical Therapy In-Service Presentation
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on 18 August 2013

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Transcript of Exercise Interventions for Chronic non-specific LBP

Classification
Choosing Exercise Interventions
APTA Orthopedic Section Clinical Practice
Guidelines
Range of Motion
Examination
ELEMENTS
information gathering to guide interventions
Pain Provocation
Trunk Muscle Power & Endurance
Diagnosis
Prevalence
for "Chronic & non-specific" Low Back Pain
by kristina pattison
Classic Phases
Presence of aberrant Movement
ACUTE
Greater than 12 weeks
CHRONIC
SUB-ACUTE
Between 2-3 months
Recurrent
Classic Phases challenged in the literature:

67% of patients with acute low back pain reported one or more episodes in the following year
APTA Clinical Practice Guidelines
2012
`
LOW BACK PAIN
Exercise therapy effective in decreasing pain in the chronic population & as effective as other conservative treatment or no treatment in acute population
Intervention
ELEMENTS
Trunk Coordination, Strengthening, and Endurance Exercises
Motor Control Exercises
General Exercise Vs. Stabilization
Preliminary Clinical Prediction Rule
Stabilization (motor control) Exercises
Individual
Risk Factors
Higher occupational physical demands
Lower Education Status
Women > Men
Increased Age







Psychosocial Factors
Fear Avoidance
Physical Distress
Depression
Lower Education Status associated with: "Sciatica"
Reoccurring Episodes of
Low Back Pain
24-33% of CASES
Enormous
Economic
Burden

Leading Cause of Activity limitation & work absence

Increased Reports of Incidents in the past 20 years
Increased Prevalence
Increased Duration
Worse Outcomes
judgements about phase must be based on tissue state as well as time since onset of symptoms
Risk for Recurrence
History of previous episodes
Excessive spine mobility
Excessive mobility in other joints
Risks for Developing Chronic Low Back Pain:
Symptoms below the knee
Psychological distress or depression
Fear of pain, movement, or reinjury
Low expectations for recovery
Pain of high intensity
Passive coping style
Attempts to identify effective interventions have been "largely unsuccessful with most interventions being found to be ineffective or having only marginal effect sizes."
HOWEVER:
Intervention studies often treat low back pain as a homogenous entity once red flags and nerve root compression are cleared
RECOGNIZABLE SUBGROUPS EXIST!!
"The best available evidence supports a classification approach that de-emphasizes the importance of identifying specific anatomical lesions after red flag screening is completed."
Interventions based on subgroup classifications show enhanced effect sizes over "one-size-fits-all approaches"
Classification improves intervention effect sizes
Impairment/Function Based Diagnosis
Low back pain with
mobility deficits
movement coordination impairments
related lower extremity pain
radiating pain
generalized pain
cognitive or affective tendencies
Level of Acuity: acute, sub-acute, chronic
Movement & Pain relations
active or passive movement related to pain

Exercise Intervention Strategies for Chronic Low Back Pain with Movement coordination impairments or radiating pain
focus on increase movement tolerances in the mid- to end-ranges of motions
Lumbar active range of motion
Flexion & Extension measured with inclinometers
Sidebending measured with inclinometers
Segmental Mobility Assessment
PA force over spinous or transverse process
hypomobile, hypermobile, normal
Segmental Mobility testing
Centralization with movement
pain or parasthesias perceived more proximal during a movement or sustained posture
Slump and SLR
Prone Instability Test
Useful as a component of a cluster of tests to predict response to motor control exercise
PA force over spinous process to determine painful segment
relief of pain with stabilization with legs lifted is positive
Painful arc with flexion or return from flexion
Instability catch
"Gower" sign
Reversed lumbopelvic rhythm
Flexors:
leg lowering: measure angle of legs to plinth
>50 degrees (males) or >60 degrees (females) indicates likelihood of having chronic LBP
Extensors
Prone raise of trunk off table 30 degrees
Measure time until patient can no longer hold
<31" (males) or <33" females are more likely to have LBP
Lateral Abdominals
side plank on elbows and knees: measured for time
Transverse Abdominus
Prone over biofeedback cuff to 70mmHg
"draw-in" maneuver for 10" without pelvic motion and breathing normally
measure maximum decrease in pressure
4-mm decrease established as normal; <2-mm associated with LBP
Fear-avoidance beliefs Questionnaire
predictive validity for disability and work loss in patients with LBP (>29 low return to work)
Pain Catastrophizing Scale
Assess exaggerated negative orientations toward actual or anticipated pain
Orebro Musculoskeletal Pain Screening Questionnaire
Predicts long-term pain, disability and sick leave
STarT (Subgroups for targeted treatment)
Discriminates for disability, catastrophizing, fear, comorbid pain, and time off work reference standards
Other Clinical Assessment Tools
Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;CD000335. http://dx.doi.org/10.1002/14651858.CD000335.pub2
Motor control used in isolation or with other interventions is effective at decreasing pain and disability related to nonspecific LBP
No recommendations for specific strategies for implementation
Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther. 2009;89:9-25. http://dx.doi.org/10.2522/ptj.20080103
The number of recurrences of low back pain was significantly reduced in patients continuing strength & endurance exercises with aerobic activity following discharge when compared with those who did not continue exercise programs
Choi BK, Verbeek JH, Tam WW, Jiang JY. Exercises for prevention of recurrences of low-back pain. Cochrane Database Syst Rev. 2010;CD006555. http://dx.doi.org/10.1002/14651858.CD006555.pub2
Exercise Therapy
In the treatment of low back pain lasting >8-weeks a program emphasizing stabilization exercises outperformed a graded exercise walking group with 55% of stabilization group meeting criteria for success vs. 26% in the walking-alone group
Rasmussen-Barr E, Ang B, Arvidsson I, Nilsson-Wikmar L. Graded exercise for recurrent low-back pain: a randomized, controlled trial with 6-, 12-, and 36-month follow-ups. Spine (Phila Pa 1976). 2009;34:221-228. http://dx.doi.org/10.1097/BRS.0b013e318191e7cb
Costa et al in a placebo-controlled RCT examined motor control exercises for chronic LBP using exercises directed to multifidus and TA or non-therapeutic modalities
Exercise therapy included
Stage 1: pt learning to contract muscles independently of trunk muscles; real-time ultrasound was used for biofeedback; exercised progressed until the patient could maintain 10 reps of 10-sec holds while breathing normally.
Stage 2: targeted coordination of trunk and limb movement while maintaining optimal trunk stability and improving posture & movement patterns.
Small but significant improvement in favor of motor control group for pt activity tolerance and global impression of recovery.

Costa LO, Maher CG, Latimer J, et al. Motor control exercise for chronic low back pain: a randomized placebo-controlled trial. Phys Ther. 2009;89:1275-1286. http://dx.doi.org/10.2522/ptj.20090218
A 12-week exercise and education program resulted in greater reduction in Oswestry scores and distance walked than education alone.

Kulig K, Beneck GJ, Selkowitz DM, et al. An intensive, progressive exer- cise program reduces disability and improves functional performance in patients after single-level lumbar microdiskectomy. Phys Ther. 2009;89:1145-1157. http://dx.doi.org/10.2522/ptj.20080052
Dynamic lumbar stabilization exercises under PT direction supervision shown to be superior post-lumbar microdiscectomy to general exercise program independently at home and to a no-exercise group at 3-months.

Yilmaz F, Yilmaz A, Merdol F, Parlar D, Sahin F, Kuran B. Efficacy of dynamic lumbar stabilization exercise in lumbar microdiscectomy. J Rehabil Med. 2003;35:163-167.
In subjects with radiologically confirmed spondyloslysis or spondylolisthesis, specific exercise promoting isolation and co-contraction of the deep abdominals and multifidus showed significant improvements in pain intensity and functional disability maintained at 30-month follow-up for when compared to a group receiving usual care consisting of aerobic exercise, rectus abdominis training, and modalities

O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radio- logic diagnosis of spondylolysis or spondylolisthesis. Spine (Phila Pa 1976). 1997;22:2959-2967.
Hicks et al developed a preliminary clinical prediction rule for the stabilization classification to assist clinicians in accurately identifying who will benefit from a stabilization-focused exercise program
A positive clinical prediction for stabilization was defined as greater than 3 of the following:
i. Age <40 y/o
ii. Positive prone instability test
iii. Presence of aberrant movements with motion testing
iv. Straight leg raise greater than 91 degrees

Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005;86:1753-1762. http://dx.doi.org/10.1016/j.apmr.2005.03.033
BOTTOM LINE:
“Clinicians should consider utilizing trunk coordination, strengthening, and endurance exercises to reduce low back pain and disability in patients with subacute and chronic LBP with movement coordination impairments and in patients post-lumbar microdiscectomy"
Pathoanatomical Features
a. “Any innervated structure in the lumbar spine can cause symptoms of low back and referred pain into the extremity or extremities”
i. Including: muscles, ligaments, dura mater, nerve roots, zygapohphyseal joints, annulus fibrosis, thoracolumbar fascia, vertebrae
ii. Herniated discs found in 20-76% of people with no sciatica
iii. 32% of asymptomatic subjects have “abnormal” spines (e.g. disc degeneration, disc bulge or protrusion, facet hypertrophy, nerve root compression) (Savage et al)
iv. Only 47% of subjects experiencing LBP had abnormalities identified by imaging (Savage et al)
v. Physical characteristics & psychological aspects of work are more powerful indicators than MRI-identifies disc abnormalities in predicting the need for LBP-related medical consultation (Boos et al in a 5-year longitudinal study of asymptomatic patients with herniated discs)
ICD-10 Codes (October 2014)

M99.0

M53.2

M40.3 M51.2

M54.1 M54.4

M54.5 G96.8 F45.4

M54.5 G96.8
Flexors:
leg lowering: measure angle of legs to plinth
>50 degrees (males) or >60 degrees (females) indicates likelihood of having chronic LBP
Extensors
Prone raise of trunk off table 30 degrees
Measure time until patient can no longer hold
<31" (males) or <33" females are more likely to have LBP
Lateral Abdominals
side plank on elbows and knees: measured for time
Transverse Abdominus
Prone over biofeedback cuff to 70mmHg
"draw-in" maneuver for 10" without pelvic motion and breathing normally
measure maximum decrease in pressure
4-mm decrease established as normal; <2-mm associated with LBP
Clinical main points:
Low back pain is prevalent and a significant economic burden
Physical and psychological factors are better indicators of return to work than imaging results indicating specific anatomical lesions
Use objective measures to determine LBP classification, acuity, & pain-related movement patterns
Sub-grouping based on impairment/function based-diagnosis improves intervention effect sizes
Exercise including motor control (stabilization) exercise helps reduce pain and improve function in patients with movement coordination impairments
Over 50% of the general population is affected by LBP
Over 75% of adults have experienced at least one episode of LBP

"Stabilization exercises"
"Although no formal definition of lumbar stabilization exercise exists, the approach is aimed at improving the neuromuscular control, strength, and endurance of the muscles that are central to maintaining the dynamic spinal and truck stability."
Muscles involved include: transverse abdominis & lumbar multifidi, but also, paraspinals, abdominal, diaphragmatic, and pelvic muscles
Standaert CJ, Weinstein SM, Rumpeltes J. Evidence informed management of chronic low back pain with lumbar stabilization exercises. Spine J 2008;8:114-20.
Lumbar dynamic Strengthening
Each position held 10" for 10 reps
Lumbar Stabilization Exercises
Each position held 10"
Aimed to strengthen the lumbar multifidus, Transverse abdominues, and internal obliques
Instructions: breathe in and out
gently & slowly draw in lower abdomen
below umbilicus without moving upper
stomach, back or pelvis, resulting in a
"hallowing"
Tactile feedback and verbal cues may be
used if necessary
In addition, a "bulging" of the multifidus
should be felt on either side of the
L4 and L5 vertebrae, directly over the
belly of the muscle
Moon, Hye Jin, et al. Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients with Chronic Low Back Pain. Ann Rehabil Med 2013;37(1):110-117. pISSN: 22234-0645.
Moon, Hye Jin, et al. Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients with Chronic Low Back Pain. Ann Rehabil Med 2013;37(1):110-117. pISSN: 22234-0645.
Lumbar Dynamic strengthening versus lumbar stabilization in patients with chronic non-specific Low Back Pain
Objective: Comparing the effects on isometric strength of the lumbar extensors, pain severity, and functional disability
Results: Lumbar extension strength at all angles improved significantly in both groups after 8 weeks with significantly greater improvements in the lumbar stabilization group at zero and 12 degrees of lumbar flexion.
Conclusion: Both groups strengthened the lumbar extensors and reduced LBP, but stabilization exercise was more effective in lumbar extensor strengthening and functional improvement.
Moon, Hye Jin, et al. Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients with Chronic Low Back Pain. Ann Rehabil Med 2013;37(1):110-117. pISSN: 22234-0645.
Motor control exercise aimed to improve control of TA, multifidus, and pelvic floor muscles with spinal manipulative therapy produced better short-term function and perceptions of effect than general exercise, but not better medium or long-term effects
Initially, subjects were taught to recruit muscles, with gradual progression of difficulty incorporated with more functional positions and coordinating trunk muscles during functional tasks
M.L. Ferreira et. al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial. Pain 2007;131:31-37.
Less than 1 month
QUESTIONS?
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