9/19/2016
LETS WORK TOGETHER TO ENSURE
THE BEST OUTCOME FOR PATIENTS
WITH BACK PAIN
David J Pleva, PT, MA, Dip.MDT
DISCLOSURES
Outpatient Clinic Manager for Community Physical Therapy & Assoc,
Ltd
McKenzie Faculty, USA
Ergonomics consultant for Pelton-Crane
Consultant to the American Dental Association
WHAT IS PHYSICAL THERAPY?
therapy for the preservation, enhancement, or restoration of movement
and physical function impaired or threatened by disability, injury, or disease that
utilizes therapeutic exercise, physical modalities (as massage and electrotherapy),
assistive devices, and patient education and training—called also physiotherapy
Merriam-Webster Dictionary
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WHAT IS A PHYSICAL THERAPIST?
Physical therapists (PTs) are highly-educated, licensed health care professionals
who can help patients reduce pain and improve or restore mobility - in many cases
without expensive surgery and often reducing the need for long-term use of
prescription medications and their side effects.
APTA 11/24/15
What is a Physical Therapist Assistant?
What is a Physical Therapy Aid/Tech?
WHO IS APPROPRIATE FOR PT?
Musculoskeletal disorders
Neurological disorders
Lymphedema
Cardio-Pulmonary
Vestibular/Balance
Pediatrics
Wound Management
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MUSCULOSKELETAL (BACK PAIN)
Acute/Subacute/Chronic
Nerve root problems
Mechanical back pain
Mostly aged 20-55
Lumbosacral region, buttocks and thighs
“Mechanical” in nature
Patient is generally well
Contraindications for
MDT
Serious spinal pathology
Contraindications for
MDT
•
•
•
•
•
Cauda equina
Cancer
Cord compression
Infections
Widespread
neurological deficit
• Progressive
neurological deficit
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PREVALENCE OF BACK PAIN
Affects 50-80% of adult population
40% have back pain in any one year
Croft 1997: simple LBP after 1 yr, many patients still had pain.
90% were not getting treatment secondary to dissatisfaction
with treatment.
NATURAL HISTORY OF BACK PAIN
Considerable variability in natural history
Recurrence, episodes, and persistent symptoms are common
Acute and chronic definitions are insufficient to describe reality
of back pain
Generic diagnosis of LBP: patients resolve 50% faster than with
a specific diagnosis.
IMPLICATIONS OF BACK PAIN
One of most common causes of disability
Total costs of back pain are larger than for any other disease
25-40% of those with back pain seek healthcare
Back pain accounts for 3-5% of primary care physician consults
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IMPLICATIONS OF LBP CONTINUED
1/4 population in Sweden over 30 on disability
Countries going broke secondary to medical
costs
Luo 2004: Healthcare expenditures in 1998 in
US: $90.7 billion
In 2012, $253 billion (United States Bone and
Joint Decade: The Burden of Musculoskeletal
Diseases in the United States website 2014)
In 2002: Fusions > THA + TKA
RISK FACTORS
1) Individual and lifestyle
History of back pain
2) Physical or biomechanical
Heavy or frequent lifting
Whole body vibration
Prolonged or frequent bending and twisting
Postural stresses
3) Psychosocial
Poor Prognostic Factors
Psychosocial factors
Occupational factors
Leg symptoms
Previous episodes
Lack of centralization
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GUIDELINES
Patient needs reassurance of (+) outcome
Expensive imaging only with consideration of surgery
Screen for red flags
Meds as needed
Advise patient to stay active
RTW FACTORS
1) Relationship with boss
2) Job satisfaction
WHEN TO REFER TO PT?
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MODALITIES
NSAIDs
Short-term relief in acute back pain
Not clearly better than simple analgesics
Not proven to help chronic back pain
Some evidence for:
Behavioral
therapy
Education
Exercise
Manipulation
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WHAT EXERCISE IS APPROPRIATE?
Flexion
Anterior sagittal
rotation
&
anterior translation
Extension
Posterior sagittal
rotation
&
posterior translation
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DOES IT MATTER?
312 acute, subacute and chronic
LBP only and sciatica
Underwent MDT evaluation
Randomized
Matching Directional Preference
Opposite Directional Preference
Non Directional Exercises
RESULTS
74% directional preference found (230 subjects)
1/3 of opposite and non-directional group withdrew within 2 weeks because of no
improvement or worsening
No directional preference group withdrew
Significant improvements occurred in matched subjects compared with the other
2 groups in every outcome
The matched group had statistically significantly greater improvement
than the other two groups in all 5 areas:
Satisfaction with care
RTW
Home/Recreational activities
Perceived need for further RX
Self-rated improvement
In addition, had a 3 fold decrease in the use of medication
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Opposite group faired the poorest on all satisfaction parameters
15-17% of both the opposite and non-specific group reported worsening of their
condition
Long A: Does it Matter Which Exercise?
A Randomized Control Trial of Exercise for Low Back Pain
Spine Volume 29, Number 23, pp. 2593-2602
MECHANICAL DIAGNOSIS AND TREATMENT
(MDT)
System of Evaluation
Not a set/group of exercise
Repeated end-range movements
Classification made, not a diagnosis
Suspected tissue of origin unimportant
Strong prognosticator
Exclusionary system
Red/yellow/green flags
Self-treatment and independence emphasized
3 major syndromes
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Focus on Centralization
&
Directional Preference
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CENTRALIZATION
Process by which distal pain
is progressively abolished in a
distal to proximal direction. This
is in response to specific
repeated movement and/or
sustained positions
ROLE OF IMAGING IN PT
Safety precaution
Does not guide treatment
MRI
MRI is so sensitive it has lost specificity: cannot differentiate
painful from non-painful herniations.
Since MRI:
Surgery rate increased
Disability cost increased
Cost increased
Failed surgery increased
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COMMUNICATION
Initial/DC
Re-evaluation prior to follow-up appointment
Change in patient status
Collaborative
Questions
mckenzieinstituteusa.org
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9/19/2016
Thank You
David J Pleva, PT, MA, Dip.MDT
630-282-5588
[email protected]
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