1. Dave Snyder, PT, OCS October 20 th, 2011

2. Popular Questions….. What can I do to help my patients with back pain get better faster? Is there an exercise sheet I can give out that will get my patients with back pain better? What role does physical therapy play in managing low back pain?

3. Low Back Pain Up to 90% of patients with LBP cannot be given a precise pathoanatomical diagnosis Common diagnosis’s include lumbar strain, lumbago, or back pain In the older literature, LBP was viewed as a homogeneous group, leading to no conclusive results of any specific interventions Albenhaim, et., al. Spine, 1995, 20:791-795

4. Low Back Pain Nonspecific LBP is not a homogeneous entity Current literature suggests the need to subdivide LBP into smaller sub groups in order to design more precise and effective treatment plans Kent, Spine, 2004;29:1022-1031

5. If you send a patient w/ LBP to PT… First we complete a thorough evaluation. With the data collected we attempt to categorize the patient into one of 6 treatment categories¹ Manipulation, Stabilization Specific Exercise Extension, Flexion, or Lateral shift Traction As the patient proceeds through the rehab process, based on their presentation, the patient may change categories ¹ Dellito, et al. Physical Therapy; 75:470-484

6. So what does this mean for my practice? In order to offer an intervention during your visit, you need to take a few moments to identify what your patients actual impairments are This requires a little extra time to be spent on the subjective and objective portion of your routine exam in order to appropriately classify your patient into a treatment group If you skip this step, your intervention has a high likelihood of failing and may even hurt the patients condition

7. First, lets review the basics… CONTINUE TO: Follow normal practice guidelines and procedures to arrive at a medical diagnosis Order appropriate diagnostics per your standard procedures Offer pharmacological interventions per your practice guidelines Refer appropriate patients to Ortho Spine, Physiatry, and Physical Therapy

8. Before you can offer a movement intervention…… Subjective Try to identify mechanism of injury

9. Also, try to… Identify a pain generator Identify a position of comfort Identify aggravating and easing factors

10. Other good questions to ask Has this happened before? What did you do to feel better? Have you been to therapy before for this same problem? Did it work? Are you still doing the exercises?

11. Subjective Continued… Try to categorize patient as Acute vs. Chronic Interventions and goals of these interventions are different based off of this classification

12. Acute/Sub Acute LBP Difficulty performing basic ADLs Increased levels of self reported pain and disability Recent onset with a recallable mechanism of injury Recent flair up of chronic condition

13. Chronic LBP Can perform basic ADL’s Have lower levels of pain and disability Has pain with more demanding activities

14. Subjective Continued… Is the patient fearful of movement? Does the patient seem to go out of their way to avoid pain because of this fear?

15. If Fear Avoidance is present.. Consider instituting a cognitive behavioral approach to managing the patients care when it is deemed appropriate¹ ¹George, Et. Al. Spine 2003; 28: 2551-2560

16. What does that mean?? Establish the need for exercise to be part of the solution to the patients condition Establish clear exercise goals that are agreed upon by the patient and the team delivering the care

17. At this point, what do we know? Mechanism of Injury Position of comfort Identified possible pain generator Acute vs. Chronic Fear avoidance behavior identified

18. Objective Exam: Continue to perform appropriate objective measures to arrive at your medical diagnosis In addition, each of the following suggestions will help you to identify impairments that you can offer quick and easy interventions that are highly effective.

19. Consider your patients posture

20. Why is posture so important?

21. What can we learn from posture?

22. Start with minimal corrections…

23. Neutral Spine Instruction

24. Posture with ADLs

25. Posture with ADL’s continued

26. Posture with ADL’s continued: log roll supine to sit

27. Modalities: Ice vs. Heat…. Ice when movement leads to pain Cool off the fire! Heat when pain limits movement Warm up the motor! TARGET THIS INTERVENTION TO THE SUSPECTED PAIN GENERATOR

28. Should I try to teach the patient specific stretching or strengthening?

29. Specific Exercise Instruction Requires: Specific impairments measured in conjunction with faulty movement patterns identified that allows one to make a logical conclusion as to why the patient presents with their particular subjective complaints Short Hamstrings with posterior pelvic tilt and long /weak erector spinae muscles leading to excessive compressive forces at L4/L5 disc leading to discogenic pain limiting patients ability to perform ADL’s.

30. OK…then what should I do? #1 Priority is to diagnose the problem as accurately as possible with the information you have, within the time frame you have to figure out the problem Rule out red flags if present Follow the suggestions outlined in today's talk Consider recommending pain free general exercise to your patient. Cardiovascular endurance type activity Pain free during and after activity Something that the patient would enjoy to do regularly

31. Who needs a PT referral? Mechanical connection to pain Never had PT before for this problem Had PT before, it helped, but now the condition has changed and the patient would benefit from a second look by a PT Impairments identified that correlate to condition and are potentially correctable with specific exercise or other therapeutic intervention Patient interested in learning exercises to help improve their condition

32. What will we do with your referral Prioritize the patients diagnosis and schedule accordingly Complete a full evaluation (1 hr) and develop a unique rehabilitation program to address the impairments found in the evaluation, and set clear goals for the treatment. Once goals are met, discharge the patient with an independent self management program

33. QUESTIONS?????