How to tell what will work for low back pain.

Posted in Guidelines for Treatment at 1:50 PM by Dr. Greathouse

Which LBP patients are more likely to respond favorably to physical medicine procedures?

This question has been asked by numerous scientists interested in back pain, in particular, at the University of Pittsburgh and the University of Utah.  In fact, they even went one step further; they asked who would do best with each of the following physical medicine procedures: Manipulation, Therapeutic Directional Movement Strategies (McKenzie a.k.a. Mechanical Diagnoses & Treatment) and Stabilization (physical therapy) Exercises.

Here’s what was found. We provide all four of these procedures.

Patients most likely to respond to manipulation.

  1. Recent onset of pain < 16 days.
  2. No pain distal to the knee.
  3. Low fear avoidance beliefs score.
  4. Segmental hypomobility.

(Fritz J., Whitman, Archives of Physical Medicine and Rehabilitation, 2005)

Ø     When three quarters of these criteria were present the chances of success with manipulation was 95%.

Ø     When the criteria was not met, the chances of success was 45%.

(Flynn T, Fritz J. et al. Spine, 2002)

Patients most likely to respond to Therapeutic Directional Movement Strategies.

Those who improve by decreasing or abolishing peripheral or local pain with specific test movements/static tests.  Conversely, contralateral movements most commonly exhibit the opposite effects, causing production or increase in focal or peripheral symptoms.

As opposed to a diagnosis, a provisional classification is given to each patient.  The principal management is by means mechanical therapy, with an emphasis on active vs. passive care, with specific directional movement application; also known as directional preference exercises. Important to note that this protocol does progress, as clinically indicated, to mobilization and ultimately to manipulative procedures, in a specific directional manner.

(Brennan GP, Fritz J. M. Spine 2006)

Patients most likely to respond to “McKenzie Method” are those who demonstrate a “directional preference”.

In a study by Long A, et al. of “evidence based” versus “directional preference” treatment, it was found that 95% of “directional preference” treated patients recovered versus 56% of “evidence based” treated patients recovered.

Patients most likely to respond to stabilization exercise.

Preliminary evidence suggests the following findings are relevant:

  1. Positive prone instability test.
  2. Aberrant motions present (instability catch, reversal of lumbo-pelvic rhythm.
  3. Average straight leg raise (SLR) > 91°.
  4. At least three prior episodes.

(Hicks GE, Fritz J. M., Delitto J., McGill SM, Archives of Physical Medicine and Rehabilitation, 2005)

Evidence from Australian (Hides, et al.) showed that Stabilization exercise might not help acute low back pain resolve faster, but that it will reduce recurrence rates.

(Hides J. A., Jull G. A., Richardson C. A. Spine 2001)

Additionally, does traction play a role in low back treatment?

Although there’s not much evidence supporting the efficacy of traction, there is some indication that traction may be of some benefit to individuals with low back pain/leg symptoms who do not qualify for provision classification to directional preference treatment and have a positive Well Leg Raise.

(Fritz J., Lindsay W. Spine, 2007)

A meaningful way to classify non-specific low back pain is of dire necessity!

It is with this in mind that the above research from scientific teams at the University of Pittsburgh & University of Utah has been pursuing a more rational basis for treatment decisions for non-specific low back pain and leg pain.

Ø     “Patients receiving matched treatments experienced greater short and long-term reductions in disability than those receiving unmatched treatments.”

Ø     “Nonspecific low back pain should not be viewed as a homogenous condition.  Outcomes can be improved when subgrouping is used to guide treatment decision making”

(Brennan GP, Fritz J. M. Spine 2006)

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