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