This text-based course is a transcript of the live seminar, “Updates on Treatment of MechanicalLow Back Pain,” by Guillermo Cutrone, PT, DSc, OCS, Cert. MDT, FAAOMPT.
>> Bill Cutrone: You can tell, based on my bio, that low back pain is my passion. I also treat these patients in the clinic, teach on the subject and focus my research on this particular topic. The focus of this presentation is on certain aspects of the classification of low back pain. Low back pain (LBP) is very complex and very difficult to cover in a one-hour presentation. I would like to guide your attention to certain aspects of the Treatment Based Classification and certain common points that it has with the McKenzie Classification and Approach. The objectives for today are to:· Recognize the importance and limitations of classifying patients into subgroups based on clinical presentations (TBC – Stage 1)· Identify chances of success when applying specific interventions based on clinical prediction rules (CPR)· Recognize different interpretations of common clinical presentations (i.e. directional preference and centralization) Prevalence of LBPBefore we begin, let us talk about some of the important aspects of low back pain starting with prevalence. Low back pain is considered to be epidemic. One-year incidence of first episode of low back pain ranges between 6.3% and 15.3%. It is highly recurrent and is the leading cause of activity limitation and work absences. You can imagine the amount of dollars that are being invested or wasted on the treatment of low back pain. Certain factors are related to a higher prevalence of low back pain. These factors include age (until 60 to 65 years of age), female gender, lower education levels, and occupations with higher physical demands. In the lower education levels, there is higher prevalence of LBP with longer episode duration and worse outcomes. In occupations with higher physical demand, there is similar prevalence between working and non-working groups. In the most recent clinical practice guidelines published in the JOSPT in April 2012 (Delitto et al.), they identified that the “Current evidence does not support a definitive cause for initial episodes of LBP. Risk factors are multifactorial, population specific, and only weakly associated with the development of low back pain.” This is something that creates a little more uncertainty in this topic. What can we do to prevent the onset of low back pain? Apparently we do not have anything to grasp on to for that. Do you treat all patients the same way? Do they present with similar clinical characteristics? No. The patients you see in the clinic present with a wide variety of clinical presentations. However in randomized clinical trials when they are looking at efficiency of a specific intervention, they have been treating this group in the literature as a homogeneous one, and actually it is an extremely heterogeneous group. Some, for a long time, have been using a medical model where patients are classified based on a patho-anatomical source of symptoms. You have probably heard of facet joint syndrome or sacroiliac joint syndrome, or discogenic problems. However, relevant spine pathology in patients with low back pain is identified in less than 10% of cases. Part of the problems is that any innervated structure in the lumbar spine can cause symptoms of low back pain and referred pain into the extremity or extremities. With that said, I try to stay away from sharing, even with my patients, the information that crosses my mind. I do not forget the biomechanical model when I am assessing and treating my patients; however, it is nothing but a theoretical model. Pain provocation tests and assessment based on patient response to intervention is the trend in low back pain right now. What are we studying if only 10% of patients can be diagnosed based on radiological findings or specific tests, and trying to assign a specific pathology? For 90% of our patients, we do not know where the pain is coming from. For this problem, we have to remember that it is highly prevalent, highly recurrent, and is highly unspecific. I would like to place the emphasis on the highly recurrent aspect. For a long time, we believed that low back pain was actually something that will happen, go away within 90 days and probably never come back. Reality is, as certain studies show, that what did not come back were the patients to the same clinician. They continue with recurrence of low back pain, seeking medical intervention somewhere else. Physical Therapy Diagnosis/Classifications of Patients with LBPAs I mentioned, those clinical practice guidelines were published in JOSPT in April 2012 (Delitto et al.), and I had committed to this presentation without knowing this was in the works. I got really excited when I saw these clinical practice guidelines for patients with low back pain. I highly recommend that you read it, but I warn you, it is 58 pages in length. You will learn a lot from it, and I incorporated a lot of that information into today’s presentation. Background: What Do We Use to Diagnosis or Classify Patients?We are going to look at patients with unspecific low back pain (without symptoms or signs of serious medical or psychological conditions) associated with clinical findings of mobility impairment in the thoracic, lumbar or sacroiliac joints; referred or radiating pain into the lower extremity; and generalized pain. The generalized pain is something that requires a whole new chapter or different chapter to be addressed. We will be looking more specifically to patients with mobility impairments without radiating pain into the lower extremity. We will be looking at patients who may present with referred pain into the buttocks, into the lower extremity above the knee, but not radicular in this presentation. The ICD codes can cover some of the physical therapy diagnoses that we use in the clinic. If you pay attention to this list below, it is mainly related to symptoms. ICD Categories:· Low Back Pain· Lumbago· Lumbosacral segmental/somatic dysfunction· Low back strain· Spinal instabilities· Flat back syndrome· Lumbago due to displacement of intervertebral disc· ...
This text-based course is a transcript of the live seminar, “Updates on Treatment of MechanicalLow Back Pain,” by Guillermo Cutrone, PT, DSc, OCS, Cert. MDT, FAAOMPT.
>> Bill Cutrone: You can tell, based on my bio, that low back pain is my passion. I also treat these patients in the clinic, teach on the subject and focus my research on this particular topic. The focus of this presentation is on certain aspects of the classification of low back pain. Low back pain (LBP) is very complex and very difficult to cover in a one-hour presentation. I would like to guide your attention to certain aspects of the Treatment Based Classification and certain common points that it has with the McKenzie Classification and Approach. The objectives for today are to:· Recognize the importance and limitations of classifying patients into subgroups based on clinical presentations (TBC – Stage 1)· Identify chances of success when applying specific interventions based on clinical prediction rules (CPR)· Recognize different interpretations of common clinical presentations (i.e. directional preference and centralization) Prevalence of LBPBefore we begin, let us talk about some of the important aspects of low back pain starting with prevalence. Low back pain is considered to be epidemic. One-year incidence of first episode of low back pain ranges between 6.3% and 15.3%. It is highly recurrent and is the leading cause of activity limitation and work absences. You can imagine the amount of dollars that are being invested or wasted on the treatment of low back pain. Certain factors are related to a higher prevalence of low back pain. These factors include age (until 60 to 65 years of age), female gender, lower education levels, and occupations with higher physical demands. In the lower education levels, there is higher prevalence of LBP with longer episode duration and worse outcomes. In occupations with higher physical demand, there is similar prevalence between working and non-working groups. In the most recent clinical practice guidelines published in the JOSPT in April 2012 (Delitto et al.), they identified that the “Current evidence does not support a definitive cause for initial episodes of LBP. Risk factors are multifactorial, population specific, and only weakly associated with the development of low back pain.” This is something that creates a little more uncertainty in this topic. What can we do to prevent the onset of low back pain? Apparently we do not have anything to grasp on to for that. Do you treat all patients the same way? Do they present with similar clinical characteristics? No. The patients you see in the clinic present with a wide variety of clinical presentations. However in randomized clinical trials when they are looking at efficiency of a specific intervention, they have been treating this group in the literature as a homogeneous one, and actually it is an extremely heterogeneous group. Some, for a long time, have been using a medical model where patients are classified based on a patho-anatomical source of symptoms. You have probably heard of facet joint syndrome or sacroiliac joint syndrome, or discogenic problems. However, relevant spine pathology in patients with low back pain is identified in less than 10% of cases. Part of the problems is that any innervated structure in the lumbar spine can cause symptoms of low back pain and referred pain into the extremity or extremities. With that said, I try to stay away from sharing, even with my patients, the information that crosses my mind. I do not forget the biomechanical model when I am assessing and treating my patients; however, it is nothing but a theoretical model. Pain provocation tests and assessment based on patient response to intervention is the trend in low back pain right now. What are we studying if only 10% of patients can be diagnosed based on radiological findings or specific tests, and trying to assign a specific pathology? For 90% of our patients, we do not know where the pain is coming from. For this problem, we have to remember that it is highly prevalent, highly recurrent, and is highly unspecific. I would like to place the emphasis on the highly recurrent aspect. For a long time, we believed that low back pain was actually something that will happen, go away within 90 days and probably never come back. Reality is, as certain studies show, that what did not come back were the patients to the same clinician. They continue with recurrence of low back pain, seeking medical intervention somewhere else. Physical Therapy Diagnosis/Classifications of Patients with LBPAs I mentioned, those clinical practice guidelines were published in JOSPT in April 2012 (Delitto et al.), and I had committed to this presentation without knowing this was in the works. I got really excited when I saw these clinical practice guidelines for patients with low back pain. I highly recommend that you read it, but I warn you, it is 58 pages in length. You will learn a lot from it, and I incorporated a lot of that information into today’s presentation. Background: What Do We Use to Diagnosis or Classify Patients?We are going to look at patients with unspecific low back pain (without symptoms or signs of serious medical or psychological conditions) associated with clinical findings of mobility impairment in the thoracic, lumbar or sacroiliac joints; referred or radiating pain into the lower extremity; and generalized pain. The generalized pain is something that requires a whole new chapter or different chapter to be addressed. We will be looking more specifically to patients with mobility impairments without radiating pain into the lower extremity. We will be looking at patients who may present with referred pain into the buttocks, into the lower extremity above the knee, but not radicular in this presentation. The ICD codes can cover some of the physical therapy diagnoses that we use in the clinic. If you pay attention to this list below, it is mainly related to symptoms. ICD Categories:· Low Back Pain· Lumbago· Lumbosacral segmental/somatic dysfunction· Low back strain· Spinal instabilities· Flat back syndrome· Lumbago due to displacement of intervertebral disc· ...
Updates on Mechanical Low Back Pain [Video Course]
