Download Recognition of Back Injuries in the Non Athletic Population

Ryan Perry
PT, DPT, OCS, CSCS, MTC, FAAOMPT
NovaCare Rehabilitation - Chicago
March 12th, 2010

Incidence
◦ Prevalence of LBP among former elite athletes of all
sports was 29%, compared with 44% among nonathletes.
 Bono, 2004
◦ Higher rates of spondylolysis, spondylolisthesis and
disc degeneration have been reported in athletes
than in the general population.
 Ong et al, 2003
Fritz, 2010
 Adolescents with LBP as a result of sports
participation tended to have lower baseline
disability scores and to experience less
improvement in disability than nonparticipants
◦ Also attended more PT sessions over a longer
period of time
Fritz, 2010


Patients who were sports participants were
more likely to undergo an MRI before referral
Overall pattern of outcomes in this sample of
adolescents was similar to reports of
outcomes from adults with LBP

Athlete
◦ Typically in better shape
than non-athlete
◦ Very motivated to
exercise
◦ Understands the
difference between pain
from DOMS and true pain
◦ Can be demanding

Non-Athlete
◦ Lower physical
expectations at discharge
◦ Less diagnostic imaging
before onset of PT
◦ Subjected to decreased
load and strain
Common Diagnoses
 Lumbar sprain/strain
 Discogenic pain
 Instability
 Facet syndrome
 Scoliosis
 Stenosis
 Arthritis
 Fracture
 Other Miscellaneous
 Non-musculoskeletal (3% of LBP- Deyo,2001)
Primary areas of CA that can cause metastatic spine CA



Breast
Lung
Thyroid
◦ with



•
Kidney
Prostate
The spine is the most common site of
bone metastasis
Tumor-related pain is predominantly nocturnal or
early morning pain and generally improves with
activity during the day





Malignancy
Infection
Inflammatory
spondyloarthropathy
(ankylosing spondylitis,
psoriatic spondylitis, Reiter's
syndrome, inflammatory bowel
disease)
Osteochondrosis
Paget's disease of bone




Pelvic disease (prostatitis, endometriosis,
pelvic inflammatory disease)
Renal disease (kidney stones, pyelonephritis,
perinephric abscess)
Aortic aneurysm
Gastrointestinal disease (pancreatitis,
cholecystitis, penetrating ulcer)
Described by Waddell, and these usually suggest
delayed recovery and need for multi-disciplinary
approach
 Pain at the tip of the tailbone
 Whole-leg pain in global distribution
 Whole-leg numbness in a global distribution
 Sudden give-way weakness of the leg
 Absence of even brief periods of relative pain relief
 Failure or intolerance of numerous treatments
 Numerous urgent care visits or hospitalizations for
back pain
◦ Waddell G, Bircher M, Finlayson D, Main CJ: Symptoms and
signs: Physical disease or illness behaviour? BMJ (Clin Res
Ed) 1984:289:739-741.





Most commonly diagnosed lumbar pathology
Strain
◦ Occurs by disruption of muscle fibers or the
musculotendinous junction
Sprain
◦ Stretching or tearing of spinal ligaments
Will have localized isolated tenderness of the
lumbosacral spine
Patient will not have signs of red flags for non-spinal
conditions or cauda equina nor tension signs associated
with nerve root irritation
 Graw & Wiesel, 2008





Typically seen between in 4th & 5th decade of
life
Pain often in the lower extremity
Pain usually worse with sitting or bending
Neural tension signs
Many false positives with MRI

Not all disc problems that present on MRI
cause pain
◦ Make sure you correlate the clinical exam with the
MRI

Jensen et al, 1994
◦ Thirty-six percent of the 98 asymptomatic subjects
had normal disks at all levels.
◦ Thus, 64% had at least a disk bulge at least at one
level in the lumbar spine






Usually present in
patients >60 y/o
Pain worse with walking
Pain relieved with sitting
Typically have decreased
extension ROM
Pain often primarily in LEs
Use Bicycle test of van
Gelderen to differentiate
between vascular disease

Characterized by stiffness

Patients usually >50 y/o

Typically worse in the morning

Amount of ROM proportional to disc height

Spondylolysis: A defect in the continuity
of the pars interarticularis of the
vertebrae
◦ Seen in ~5% of the population
◦ Controversial whether the incidence is higher in
the athletic or non-athletic population
 Athletes tested more frequently for this
 Some studies show a lower rate of this abnormality in
athletes compared to non-athletes
 Moller & Hedlund, 2000

Slippage of one vertebrae on its
adjacent segment
◦ Thought to be a further
progression of bilateral
spondylosis

Over 5 years of follow-up,
younf athletes demonstrated a
38% rate of slippage, which was
not significantly different than
the general population
◦ Bono, 2004

Clinical findings:
◦ Radiographic evidence of spondylolysis and
slippage with flexion-extension X-rays
◦ Localized LBP with or without radiating LE pain
and/or neurological findings
◦ Positive Stork sign (one-legged extension)
◦ Graded I-V
 Grades I-II usually successful with conservative care
 Grade V (spondyloptosis): Surgical

LBP in the presence of non-specific
abnormalities on imaging studies
◦ Graw & Wiesel, 2008
1.
2.
3.
4.
The structure should have a nerve supply
The structure should be capable of
causing pain similar to that seen
clinically
These structures should be susceptible
to diseases or injuries that are known
to be painful
The structure should have been shown
to be a source of pain in patients using
diagnostic techniques of known
reliability and validity.
Bogduk 1997

Do we really have an accurate
pathoanatomical diagnosis?
◦ Unlike younger patients, only 15% of mature
patients can be given a precise diagnosis
 Deyo 2001
◦ No firm evidence exists for the presence or absence
of a causal relationship between radiographic
findings and nonspecific LBP
 van Tulder, 1997
◦ Identifying relevant pathology in patients with LBP
has proved elusive and is identified in <10% of
cases
 Abenhaim et al, 1995

Despite the fact that >1000 RCTs have
investigated the effectiveness of conservative
and surgical interventions for the
management of LBP have been reported in
the literature, evidence remains contradictory
and inconclusive for many interventions
◦ Hayden et al, 2005 & Koes et al, 2006; both in Fritz,
et al 2007

Cannot treat LBP with only one approach, as
not one single approach has shown to be
effective

Subgrouping
◦ The subgrouping hypotheses proposed are
intended for patients who may or may not be
involved in athletic activities with acute LBP or an
acute exacerbation of LBP causing substantial pain
and limitations in daily activities.
◦ After screening patients for any signs of serious
pathology, information collected during the history
and physical examination is used to place a patient
into a subgroup.
Hebert et al, 2008 & Delitto et al, 1995

Subgrouping
◦ Four subgroups were established by Delitto et al in
1995




Manipulation
Stabilization
Specific Exercise
Traction
◦ Subgroups classification criteria and intervention
procedures updated in 2007 by Fritz et al.
◦ Clinical prediction rule (CPR) developed & validated
by Flynn & Childs, respectively.
 Goal of the CPR for the manipulation classification is to
identify patients with LBP who are likely to respond to
manipulation with rapid and sustained movement
 Improvement defined as a 50% or greater reduction in
self-reported disability over 2 treatment sessions
 Intervention: Manipulation of the lumbopelvic region
and AROM exercises


CPR included 5 factors
◦ Current symptom duration of less than 16 days
◦ Score <19 on the work subscale of the Fear-Avoidance
Beliefs Questionnaire (FABQ)
◦ Hypomobility of the lumbar spine as assessed with
posterior-to-anterior pressure
◦ Hip IR of at least 1 hip greater than 35°
◦ Symptoms not extending distal to the knee.
When 4 of these 5 factors were present, patients were
highly likely to improve, while the presence of 2 or fewer
factors was almost always associated with a failure to
improve.


4 or greater: +LR = 24
2 or less:
- LR = 0.09
* Flynn et al, 2002
Clinical Prediction Rule (Hicks, 2005)

If the patient has three of the following four
criteria, then he/she will be four times more
likely to be successful with a stabilization
program in physical therapy
◦
◦
◦
◦
Age <40 years old
Straight leg raise >90 degrees
Aberrant movement present during ROM testing
Positive prone instability test
Stabilization Interventions (Fritz et al, 2007)
 Isolated contractions of the deep multifidus
and transverse abdominis
 Strengthening of large spinal stabilizing
muscles (erector spinae, obliques, etc)
Long-term effects (Hides 2001)


Studied recurrence rate of LBP after acute,
first-time episode of LBP
Subjects allocated to two groups
◦ Control: General advice plus use of medications
◦ Experimental: Specific exercise targeting the
lumbar multifidus and transverse abdominis
Long-term effects (Hides 2001)
Results
◦ The recurrence rate at one-year of follow-up was
84% in the control group and 30% in the
experimental group (p<0.001)
◦ Results were similar at the three-year follow-up


Classification approach
was updated for patients
who are post-partum
Updated classification
criteria
◦ Positive posterior pelvic
pain provocation (P4), AND
SLR and modified
Trendelenburg tests
◦ Pain provocation with
palpation of the long dorsal
SI ligament or pubic
symphysis

Fritz, 2007

Patients that typically respond are the
following
◦ If the patient has reduction of symptoms with >2
repetitions in the same direction OR
◦ If the patient has centralization of symptoms in
one direction and peripheralization of symptoms
in the opposite direction

Directional preference can be extension,
flexion, or lateral shift


Repeated ROM performed initially, followed
by strengthening exercises toward the
directional preference
McKenzie program is the most common
form of directional preference therapy
◦ McKenzie program is not always extension

Performed when the following criteria are
present:
◦ Signs and symptoms of nerve root compression
◦ No movements centralize symptoms

Typical treatment: Mechanical traction
or autotraction
Fritz et al, 2007

Fritz et al (Spine, 2007) found that the
presence of symptoms below the buttock and
signs of nerve root compression were not
specific enough to identify this subgroup
◦ Two additional factors were found to identify patients
likely to respond favorably to traction
 Peripheralization with extension movement
 Positive crossed SLR (aka Well SLR)

When patients with symptoms below the
buttock and signs of nerve root compression
had either of these findings received traction
plus an extension-specific exercise program,
they showed greater short-term reductions in
disability than patients who received only the
extension exercise program (Fritz, 2007)

Cai et al, 2009
◦ A clinical prediction rule with four variables was
identified.




Non-involvement of manual work
Low level fear-avoidance beliefs
No neurological deficit
Age above 30 years
◦ The presence of all four variables (+LR = 9.36)
increased the probability of response rate with
mechanical lumbar traction from 19.4 to 69.2%.

Fear avoidance simply
refers to avoidance of
movements or physical
activities because of the
patients’ fears that pain
will make them worse

Studies suggest that questionnaires based on
the fear-avoidance model accurately identify
poor prognosis for patients with LBP
◦ Al-Obaidi et al, 2005

Interventions aimed at confronting these
beliefs and graded exercise have been
effective at reducing pain
◦ George et al, 2003
Fear-Avoidance Beliefs Questionaire (FABQ)
 http://www.kmcnetwork.org/ksmc/menu/FABQ.pdf
 Waddell et al, 1993
 These results confirm the importance of fearavoidance beliefs and demonstrate that specific fearavoidance beliefs about work are strongly related to
work loss due to low back pain
Grotle, Spine, 2006


In the acute sample, fear-avoidance beliefs
for work predicted pain and disability at 12
months.
In the chronic sample, fear-avoidance beliefs
for physical activity predicted disability at 12
months, but not pain.


The FABQ is a self report questionnaire with 16
items each scored from 0 to 6 with higher numbers
indicating increased levels of fear avoidance
beliefs.
The questionnaire contains two subscales
◦ A 4 item activity subscale
◦ A 7 item work subscale

The work subscale is associated with current and
future disability and work loss in patients with
acute and chronic LBP.
* Waddell, 1993

The work subscale has been identified as a
strong predictor of work status.
◦ Scores of 30 or less are associated with a greater
likelihood of return to work whereas of 34 or more
are associated with less likelihood of return to work
or increased risk of prolonged work restrictions.
◦ Thus, a score of 34 or more on the work subscale
of the FABQ should be a “Yellow Flag” for therapists
and case managers working with out of work
workers with low back pain.
 Fritz & George, 2002
Croft et al, 1998
 The results are consistent with the
interpretation that 90% of patients with low
back pain in primary care will have stopped
consulting with symptoms within three
months.
 However most will still be experiencing low
back pain and related disability one year after
consultation.
◦ Only 25% will be completely recovered at this time
in terms of both pain and disability


10% of LBP patients account for 90% of
healthcare and disability costs
Identification of individuals at risk is the first
step in preventing chronic instability due to
non-specific LBP
◦ Iles et al, 2009


Recovery expectations when measured using
a specific, time-based measure within the
first 3 weeks of non-specific LBP is a strong
predictor of people at risk of poor outcome
Iles et al, 2009

Patients with lower than average initial pain
intensity, shorter duration of symptoms and
fewer previous episodes were 3.5 more likely
to be recovered at any time point than
patients without these characteristics
◦ These were described as the following:
 Baseline pain </= to 7/10
 Duration of current episode </= 5 days
 One or zero previous episodes of pain
 Hancock et al, 2009