PhysiotherapyandtheManagementofLowBackPainCameronBullussAdvancedPhysiotherapy
MusculoskeletalInjury• Resultsin:• Pain• Inflammation• Autonomicchanges• Psychologicaleffects• Lossofmovement,function,• LossofFitness
• Strength,endurance,power,cardiovascularfitness
• Lossofproprioception
ContemporaryPhysiotherapyModel• Diagnosis• Goalsetting• PainManagementandeducation• PsychosocialManagement• RestorationofMovement,motorcontrolandstrength• PreventionofRe-injury• Ergonomicsandbiomechanics• Fitnessandfunctionaltesting
NecessaryPhysiotherapySkills• Historytakingincludingunderstandingofdisabilityscales• PhysicalAssessment• Anatomy,Functionalanatomyandbiomechanics• Manipulation,massageandothermodalitiessuchasneedling• Psychology• GoalSettingandcommunication• Strengthandconditioning• Functionaltesting• Literaturecriticalanalysis
EffectivePhysiotherapyRequires
• Sufficienttimespentwithpatients• Onetoonemanagement• Useofappropriateequipment
LowBackPain• Highprevalence• OnestudyinUKindicateda1monthprevalenceof37%• Approximately30%ofourwork(80newcasespermonth)
PossibleMusculoskeletalCausesofLumbopelvic Pain
Intervertebral Disc 25- 39%
SacroiliacJoint 15- 40%
Nerve Root 6– 13%
Facet Joint 2– 10%
Muscle/Ligaments Unknown
LowBackPain• Acutevs Chronic
AcuteLowBackPain• Rarelyhaveadefinitediagnosis• Optimalmodelnotestablished• ?Limitedliteraturethatactuallyexamineswhathappensintherealworld
• Asub-groupofpatientswhowereallystruggletomanageadequately
AcuteLowBackPain• Common• Themajorityimprovesignificantlyover3months• Ongoinglowlevelsymptomsarecommon• 44– 90%recurrence• 6%significantlongtermissues
StagesofTreatment• Acute• FunctionalRecovery• Prevention
• AnkleSprainExample
AcuteLowBackPain– PhysioManagement• AcutePhase– Painrelief,protection,education• Bracing,Taping,toprotectinjuredstructuresandforpainrelief
• Demonstration
• Advice/GoalSetting/Education(backbook)• EncouragedtoseeGPforanalgesia• Reassurance• Needtostayactive– howactiveneedstobespecified
• Correctiveexercises• Demonstrationofflexionextensionin4pt kneeling
• (Modalitiesforpainrelief–massage,needling,TENS,Ultrasound)• Ergonomics
• DemonstrationofCorrectSittingvs IncorrectSitting
Ergonomics
ChangesinDiscPressure(Nachemson)
AcuteLowBackPain– PhysioManagementContinued• FunctionalRecoveryPhase• ExercisesandMobilisationtorestorerangeofmotion
• Demonstration
• Exercisestorestoremusclefunction• Gradedexposuretopre-injuryactivity• AdviceandEducation• Ergonomics/Manualhandlingretraining
• DEMONSTRATION• Whatisoptimalbackpositionforlifting
AcuteLowBackPain– PhysioManagement• Prevention• Progressionofexercises• Manualhandlingtraining• Overallbodystrengthening
AcuteLowBackPain-Evidence• Basically2viewpoints• Assess/advisedtostayactive/Physio• Assess/advisedtostayactive/waitandsee
AcuteLowBackPainEvidence• Wand(2004)• Compared2models
• Assess/advise/treatvs.Assess/Advise/Wait• Intervention– Biopsychosocial education,manualtherapyandexercise
• Studyoutcomes– Pain,functionaldisability,mood,generalhealth,qualityoflife
• assess/advise/treatgroupdidbetteronallmeasuresat6weeksandmostmeasuresat12months
AcuteLowBackPainEvidence• Hides(1996,2001)• Foundthatmuscularrecover(Multifidus)wasnotautomaticafterresolutionofNSLBP
• Hypothesisedthatthebackisvulnerabletore-injuryduetolossofmusclefunction
• Retrainingofthemuscle- 12Monthrecurrenceratesc.f.controls30%vs.84%
Summary• Physios needtousethemodernmodeltobeeffective• Manipulation/mobilisation/needlinghavesomesoftevidencetosupportthemandintheclinichelpsomepatients
• Theyhaveverylimitedvaluepast6weekswheretheapproachneedstobefocusedonexercise,biomechanicsandergonomics
• Futureresearchneedstolookfurtheratthismulti-modalapproach
• Furtherprogressmaybepossiblewithsub-categorisation oflowbackpainintosub-categories
• Furtherresearchneededintothenon-responders
TimingofReferrals• EarlyReferral• Earlierpainrelief• Reducedsecondarychangessuchaslossofmusclefunction• RemovalofDriverssuchaspoorposture,fearavoidance
ChronicLowBackPain• Someevidencefor• Manualtreatment• Exercise• Education
• ButGoodevidenceforacombinationofthese
ChronicLowBackPain• ManualTherapy• TargetedEducation• SpecificMuscleStrengthening
• EffectiveinImprovingpainanddisability[MoseleyL(2002):Combinedphysiotherapyandeducationisefficaciousforchroniclowbackpain.AustralianJournalofPhysiotherapy48:297-302]
Eraring Study• 8ParticipantswithChronicLowBackPain• 16weekinterventionofsupervisedexerciseandhomeexercises
• VAS24%lower• DisabilityScores19%lower