Treatment of a Patient with Chronic Low Back Pain By: Morgan McMahill

Overview Patient information Intervention Question Examine intervention evidence Application of evidence to patient Patient outcomes

The Patient 53 yo WM Low back pain & lumbar radiculopathy ~3 years L5 laminectomy & fusion on 5/18/16 Presented to physical therapy on 7/5/16

Subjective CC: right sided LBP; sharp pain in R buttock; stiffness Pain: 3-5/10 Aggravating factors: Worse in the mornings Laying  sitting/standing Relieving factors: Walking Advil N/T: stated some numbness in his foot that was present prior to surgery but has since decreased Social: Worked in an industrial plant; disability

Examination Findings AROM Lumbar flex: limited hand to shin (25%) Lumbar ext, SB, rot: WNL Hip flex (w/knee bent): WNL (B) SLR: limited to <90 (B) Special Tests: SLR (-) Denied TTP

ICF Model Impairments R low back and buttock p! Decreased lumbar flexion ROM Tight HS Stiffness in back Weak core Activity Limitations Transfers Rolling Tying shoes Yardwork Sleeping through night Participation Restrictions Unable to work Unable to play sports Unable to go to gym Environmental Factors Supportive family Easy access to therapy Personal Factors Motivation Body awareness Open mind Diagnosis LBP post lumbar laminectomy/spinal fusion

Goals Patient goals: Have no pain in his back while doing activities around the house/yard Have no stiffness in his back when he wakes up in the morning PT goals: Exhibit proper posture and body mechanics during ADLs Independent with HEP 0/10 pain in lumbar spine Ability to change body positions without pain

PT Treatment Therapeutic exercise & activities: Core stabilization Lumbar stretching LE strengthening Manual: STM & MFR to R lumbar PS and QL Modalities: Electrical stimulation w/moist heat 7/22/16 – Trigger point dry needling performed in S/L for right low back tightness; R QL, R IP HV w/CP

Is dry needling an effective adjunct to treatment to decrease pain for a middle- aged male with chronic low back pain?

Acupuncture and dry needling in the management of myofascial trigger point pain: A systematic review and meta-analysis of randomised control trials (Tough et al., 2009) Objective: Examine whether or not direct dry needling of myofascial trigger points (MTrP) that have been identified clinically is effective at reducing pain for patients with a diagnosis of MTrP pain. Effect of dry needling in the absence of any other potentially active treatment

Literature search (Pubmed, EMBASE, AMED, MEDLINE, Cochrane, PEDro, SCI-EXPANDED) IncludedExcluded - RCT’s - Intervention of direct insertion of a dry needle into the MTrPs after locating the patient’s area of tenderness - ‘Active tx’ involved inserting needles: o Superficially over the site of a MTrP o Into traditional acupuncture points o Into pre-specified MTrP locations (identified clinically) - Control tx was considered ‘active tx’: o Oral medication o An injected substance o Traditional meridian acupuncture needling Methods

Study Characteristics

4/7 adopted ‘sparrow pecking’ technique 5/7 offered three or more treatments, given once a week 2/7 used a co-intervention in both control and treatment groups Exercise rehab program & HEP 7/7 used VAS to measure short-term outcome of pain Study Designs

Evidence from one study suggests that direct MTrP needling was effective in reducing pain compared with no intervention Two studies provided contradictory results when comparing needling MTrPs directly versus needling elsewhere in muscle Four studies failed to show that needling directly into MTrPs is superior to various non-penetrating sham interventions The meta-analysis performed of 4 studies did not attain statistically significant, but the authors stated that the overall direction could be compatible with a treatment effect of dry needling on myofascial trigger point pain Hard to draw meaningful conclusions due to low internal validity and other limitations in design of the original studies Results

Study: MTrPs may not have been the sole cause of pain Small sample sizes Varied treatment interventions Overall heterogeneity of the studies My Patient: Only two chronic low back pain studies included Wide age ranges Limitations

Effects of trigger point acupuncture on chronic low back pain in elderly patients – a sham-controlled randomised trial (Itoh et al., 2006) Objective: To evaluate the effects of trigger point acupuncture on pain and quality of life in chronic low back pain patients compared with sham acupuncture

26 outpatients (17 women, 9 men) years Patient and assessor-blinded, randomized, sham controlled, crossover clinical trial Intervention: Groups A & B Trigger point (TrP) acupuncture vs. sham acupuncture 3 week washout/observation period after each treatment Outcome Measures: VAS & Roland Morris Questionnaire Methods

Given at the site of the TrP Presence of a tender taut band Patient recognition of pain Local twitch response (only accessible muscles) TrP acupuncture Needles inserted into skin over TrP ‘Sparrow pecking’ technique After LTR, needle was retained for 10min Sham acupuncture Tips of needles cut off and ends smoothed Pretended to insert needle and use ‘sparrow pecking’ Simulation of needle extraction after 10 min Interventions

A: TrP Acupuncture B: Sham A: Sham B: TrP Acupuncture Trial Design

Sig. diff. between groups A and B at weeks 2 & 3 (P<0.001) Group B No significant changes in VAS during the first phase (sham) Significant differences found between week 6 and weeks 7, 8, & 9 (P=0.049, 0.039, and <0.01, respectively) Results

Significant difference between groups at week 3 (P<0.01) Group A Change from baseline was significant (P<0.01) Group B Significant difference between weeks 6 and 9 (P<0.01) Results (continued):

Study: Small sample size Patient drop-out Carry over of TrP acupuncture in Group A? Significant difference between groups in the first phase but not second phase My Patient: Age of study subjects Acupuncture vs. dry needling? Limitations

Is dry needling an effective adjunct to treatment to decrease pain for a middle- aged male with chronic low back pain? Maybe

Application to my Patient Chronic low back pain Receiving dry needling 3x/week (vs. 1x/week) Subjective pain reports primary method of measurement Itoh et al. found that subjective pain scores decreased after TrP acupuncture Effects of TrP acupuncture were not sustained during the 3 week washout period Identified trigger points through palpation & patient pain recognition

Outcomes Patient attended therapy 19 times over 6 weeks Received dry needling 9 visits (3x/week) Pain: 0-1/10 Functional status: Able to sleep through the night Do yardwork for 1 hr without pain Back not as stiff Patient felt he benefited from dry needling ”My back feels looser after getting the dry needling” Prognosis  GOOD

References Itoh, K., Y. Katsumi, S. Hirota, and H. Kitakoji. "Effects of Trigger Point Acupuncture on Chronic Low Back Pain in Elderly Patients - a Sham- controlled Randomised Trial." Acupuncture in Medicine 24.1 (2006): Web. Tough, Elizabeth A., Adrian R. White, T. Michael Cummings, Suzanne H. Richards, and John L. Campbell. "Acupuncture and Dry Needling in the Management of Myofascial Trigger Point Pain: A Systematic Review and Meta-analysis of Randomised Controlled Trials." European Journal of Pain 13.1 (2009): Web.

Questions