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LBP exercises
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LBP exercises - December 31, 2006 4:45:00 AM
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rwillcott
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I am curious to know others thoughts on the type of exercises that they prescribe for LBP patients. More specifically the type of strengthening/endurance exercises.
If you were to go by the recent Australian findings of Hides et al then every patient should recieve TrA and multiidus retraining. However, recent published CPR's of stabilization training indicate that not all patients require stability exercises.
Also, there is a recent follow-up to the Childs et al study for CPR's for manipulation for acute LBP. Those that met the CPR's for manipulation were 8 times less likely to experience worsening of disability than those that were not manipulated. I beleive the only exercise the manipulation group performed was the hand-heel rock exercise.
I would like to know others thoughts on how they choose exercises for LBP patients.
Rob
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Re: LBP exercises - December 31, 2006 6:44:00 AM
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UTDC
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[QUOTE]Also, there is a recent follow-up to the Childs et al study for CPR's for manipulation for acute LBP. Those that met the CPR's for manipulation were 8 times less likely to experience worsening of disability than those that were not manipulated. I beleive the only exercise the manipulation group performed was the hand-heel rock exercise. [/QUOTE]Rob,
What study are you referring to here?
Thanks
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Re: LBP exercises - December 31, 2006 7:28:00 AM
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jma
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The study that this information comes from is the following:
" Man Ther. 2006 Nov;11(4):316-20. Epub 2006 Jul 12.
A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain.Childs JD, Flynn TW, Fritz JM.
US Army-Baylor University Doctoral Program in Physical Therapy, 3151 Scott Rd., Rm 2307, Fort Sam Houston, TX 78234, USA.
The purpose of this study was to determine if patients who do not receive manipulation for their low back pain (LBP) are at an increased risk for worsening disability compared to patients receiving an exercise intervention without manipulation. One hundred and thirty-one consecutive patients with LBP were randomly assigned to receive manipulation and an exercise intervention (n = 70) or an exercise intervention without manipulation (n = 61). Patients were classified as to whether they had experienced a worsening in disability upon follow-up. Relative risk and number needed to treat (NNT) statistics and associated 95% confidence intervals (CI) were calculated. Patients who completed the exercise intervention without manipulation were eight (95% CI: 1.1, 63.5) times more likely to experience a worsening in disability than patients who received manipulation. The NNT with manipulation to prevent one additional patient from experiencing a worsening in disability was 9.9 (95% CI: 4.9, 65.3) and 4 weeks with manipulation was 11.6 (95% CI: 5.2, 219.2). The results of this study offer an additional perspective for considering the risks and benefits of spinal manipulation and help to inform the integration of current evidence for spinal manipulation into healthcare policy.
PMID: 16839800 [PubMed - in process]"
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Re: LBP exercises - December 31, 2006 8:31:00 AM
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PTupdate.com
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Great question Rob, and there will probably be a million different answers here...all of them different, but probably each works for that clinician for various reasons.
I personally address the low back like I do with all other joints in the body...make a problem list, worst at the top, regarding what crosses that joint and is tight, what is weak, and what is not mechanically moving as it should. I then start working on those deficits that are worst, and progress from there (if I need to).
For back endurance, some clients recieve the Biering-Sorensen test, and I also use it as a treatment as well. Checking healthy males, I found that a 2-3 minute hold can be done, although with some muscular discomfort. Those with back pain usually do poor, and not due to back pain.
I also use the Nautlius back extensor strengthening machine, backing the thought process with the many studies produced by Vert Mooney. Patients love that thing, and many attribute its addition to their program with a speeding up effect.
Many will argue regarding strengthening, especially TrA and multifidus....but how do we really know, in the average clinic, that weakness to these groups is NOT one of the underlying causes of mechanical failure, and thus pain in that patient? Are the exercises to address these areas so time consuming that we somehow traumatized this patients life by not adding them in?
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: LBP exercises - December 31, 2006 10:28:00 AM
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steve
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Just for clarification, all of the patients in the Manipulation cpr study who received manipulation were treated 5 times: 2 sessions of manipulation and a home exercise for ROM and three follow-up sessions with spinal stabilization exercises. The exercise only group performed "stretching and strengthening exercises"
Steve
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Re: LBP exercises - December 31, 2006 11:45:00 AM
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mcap56
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I have quite a few questions about the study and will try to take a look at it next year :) . Off the top of my head, any time you see a RR or an OR of 8, you are dealing with some unexplored confouding or some type of other issue. One is suspicious anytime you see a number that high.
Marc
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Re: LBP exercises - January 1, 2007 4:04:00 AM
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rwillcott
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steve:
What were the spinal stabilization exercises prescribed to the manipulation group? Was it specific TrA and multifidus or general bridging type exercises?
Rob
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Re: LBP exercises - January 1, 2007 5:54:00 AM
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steve
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Off the top of my head, it was general stabilization exercises and included bridging, 4 point with leg extensions, wall squat with TA recruitment and a couple of others - I have them somewhere in the clinic if you really want the specifics. According to John, they included the spinal stabilization exercises based on the work by Jull and Hides.
The data used in the JMA posted study is all from the original validation for the clinical prediction rule study published in Annals of Internal medicine and is available for free download at:
http://www.annals.org/cgi/reprint/141/12/920.pdf
Marc, the reason for the high odds ratio is that the researchers are not looking at a single variable but rather multiple factors to help determine who would benefit from manipulation. The actual odds ratio fur successful outcome in the original study for those positive on the rule was 60.
Steve
Steve
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Re: LBP exercises - January 1, 2007 7:42:00 AM
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mcap56
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Hi Steve:
Happy New Year all. I just had a look at the study and I think it provides a nice case study on how statistics can be misleading. The relative risk was probably not the most appropriate measure in this case. Any time you see something that high - throw your red flag out. It probably isn't.
A look at the actual numbers in the trial, presents a far different picture than the relative risk. Itis true that you get a relative risk of 8 and 4 at 1 and 4 weeks respectively but look at the cells in their 2x2 contingency tables. LOW COUNTS!!!! NOT STABLE!!!
When you think that someone is "8x" more likely to have a worsening - the difference sounds severe. But is that supported by the actual numbers?
WEEK 1
Manip - Worsened - 1 (1%) Not worsened 69 (99%)
ex - Worsened - 7 (11%) Not worsened 54 (89%)
Week 4
Manip - Worse - 2 (3%) Not worse 68 (97%)
Ex - Worse - 7 (11%) Not worse 54 (89%)
Look at those numbers with a clinical - not a statistical eye. What you have is two groups where the vast majority don't get worse with slightly more getting worse in the non manip group (my guess is that this would stabilize over time). Add to this no data on both groups at the start and very little data on the 8 vs. 2 dropouts and we are left with picture that is incomplete at best, misleading at worst.
I will have a look at the clinical prediction rule study but my suspicion is that the patients identified by the rule would be likely to benefit from manipulation but also be those who are more likely to do well under any circumstance.
I don't mean to be harsh but in the drive to promote manipulation, I often see the benefits vastly overstated. When results don't show what they want, they just attack it from a different angle all with the intent to prove substantial benefit. That's not how research should be done.
mcap
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Re: LBP exercises - January 1, 2007 8:40:00 AM
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UTDC
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[QUOTE]I will have a look at the clinical prediction rule study but my suspicion is that the patients identified by the rule would be likely to benefit from manipulation but also be those who are more likely to do well under any circumstance.[/QUOTE]mcap,
You make some good points. Regarding the Childs validation study, there were significant differences between the two groups who received spinal manipulation, both of which were positive on the CPR. While it is a common criticism of this line of research to say that these patients get better no matter the treatment, I believe the authors do a good job at refuting this.
[QUOTE]I often see the benefits vastly overstated. When results don't show what they want, they just attack it from a different angle all with the intent to prove substantial benefit. That's not how research should be done.[/QUOTE]Wow, that's quite an accusation.
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Re: LBP exercises - January 1, 2007 8:47:00 AM
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mcap56
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I will have a look at the study....perhaps I am wrong.
mcap
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Re: LBP exercises - January 1, 2007 9:07:00 AM
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UTDC
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Figure 3 in the Childs validation is a good representation of the disability outcome.
Regarding the discussion of RRR above, I was under the impression that NNT represents a more accurate depiction of the benefit of a therapy.
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Re: LBP exercises - January 1, 2007 9:51:00 AM
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steve
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mcap,
If I do look at this with a clinical eye, I would have to look at the original study where the entire point was to figure out what characteristics are associated with individuals who benefit from manipulation. They had excellent results that didnt need to use "A different angle". This has been replicated in various forms of research (The original Flynn study to determine the CPR and Josh Cleland's consecutive case series published last year). Also consider that this is a secondary analysis of the data and was published to suggest to those that believe manipulation has a high risk associated with it that they are incorrect and that not doing performing manipulation does have consequences. Manipulation is under utilized by the physiotherapy community based on the research by Bombardier and Li who identfied 5% of clinicians who would use manipulation to treat a patient with acute low back pain that is non radicular in nature.
I would also consider (Not having the2006 manual therapy article in front of me) that you quoted the entire group that recieved manipulation or exercise without considering the subgroups that were positive on the rule as those would be the patients that I would clinically manipulate. One of the biggest problems to date in low back research is this failure to classify patients into sub groups and lessening the demonstrated effect of a given intervention (Ie. exercise and manipulation).
Remember this is only part of the arguement, this research only examines those that worsened and doesn't consider those who improved - this was what the original study looked at. I would suggest that this information needs to be considered in conjunction with the original where those who benefitted from manipulation were considered.
Steve
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Re: LBP exercises - January 1, 2007 11:22:00 AM
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mcap56
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Hi Steve and UTDC:
You raise good points and I will have a look at the CPR article in the next few weeks (it's a busy time for me).
As for number needed to treat - I agree that it is a good meaure and a nice alternative to null hypthesis significance testing. However, it is still based on the proportions, which in this case, are based on low cell counts. Same problem. And although there is not generally accepted standard for what constitutes a "good" NNT, 10 is fairly high unless you are talking about mortality. NNTs of less than or equal to three are considered to be good - this is taken from an artle in the PTJ on NNT.
Put another way - you would have to treat 10 patients with manip in order to prevent one from suffering a worsening on the Oswestry. And, keep in mind, these "worsenings" may not have been much more than 6 pts. How effective does that seem?
As for the CPR, perhaps you are correct. But, I will have to look into the study first before I comment.
I am just concerned, that in an era where computer processing power doubles every 18 months or so (not sure if Moore's law still applies), where technology is exploding, where the internet has revolutionized entire industries - PTs are looking backwards and trying to validate and support practices that have been around for decades. What are we doing that is new/revolutionary?
I am not against manip at all. But it does seem to dominate the ortho programming these days. The leaders of this movement are intellignet, dynamic, well spoken, fantastic clinicians and well read. Who is going to question what they say? So far, I don't see anyone and there are issues that need to be raised.
Respectfully,
Marc
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Re: LBP exercises - January 1, 2007 12:20:00 PM
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steve
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Marc,
I think your last paragraph is on the money and I have always questioned what we do. Just because we have done it for decades doesnt mean it works or that we are performing at our best. The idea behind this research is to improve our ability to select which intervention should be used for individual patients and thus improve our outcomes for patients based on high quality research. If you look at what this group of researchers is doing, you will find that they also advocate specific treatments (Ie. exercise, cognitive behavioural treatment) and are not a one trick "Manip only" group; I find this refreshing and superior to a guru tellong me how fantastic their results are using complex biologically pieced together theories and overly complex treatments that have not been tested clinically.
Keep questioning, from my personal experiences both John Childs and Tim Flynn both encourage and appreciate its importance in helping our profession grow and excel.
Im interested to hear your thoughts after reading the original article.
Steve
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Re: LBP exercises - January 1, 2007 12:23:00 PM
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rwillcott
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Thanks for the critique of the research. I am more concerned with what exercises people choose and why for LBP patients. Maybe if I explain approach it will help others explain their rationale.
If I have a patient who meets the CPR's for an "instability" I will go directly into TrA and MF exercises with the use of the pressure cuff. If it is a more chronic patient I tend to stick to more general exercises such bridging and four point etc.
I will also use the McKenzie approach with some patients that have a directional preference. Once they centralize I tend to use basic bridging type exercises and functional activities etc.
I have talked with other PT's that use TrA and MF exercises with all patients. I find that these exercises are very difficult for some patients. I find they tend to become frustrated easily as well. Plus I don't have a real time ultrasound in the clinic and often wonder if they are actually recruiting the proper muscles.
Rob
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Re: LBP exercises - January 1, 2007 1:07:00 PM
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mcap56
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Points well taken Rob and Steve....I will have a look soon. I am glad to hear that a more global approach is advocated. It just doesn't seem that way sometimes.
Do you use the U. Pitt classification system or something different??
Marc
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Re: LBP exercises - January 1, 2007 1:19:00 PM
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steve
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Rob,
I agree that transvers abdominis and multifidus can be confusing for patients and add to that that there is no solid evidence that we can correctly palpate for a proper contraction and no evidence that this in fact leads to a better outcome I tend not to focus too much on recruitment patterns - if they get it, great, if they dont I move on. Even in the CPR for spinal stabilization, fear avoidance beliefs were found to be correlated with good outcomes, suggesting that the exercises in some instances serve as desensitization to those that are kinesiophobic.
With respect to patients with chronic low back pain I tend to use functionally based exercise in conjunction with pain education particularly when they present with high fear avoidance beliefs. I also find that a significant portion of this population is clinically depressed and that this needs to be addressed before they will benefit from rehab.
Marc, for most of my low back pain patients I use a treatment based classification system for the most part as it has the best evidence to support its use.
Steve
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Re: LBP exercises - January 2, 2007 7:28:00 AM
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ysumpt2006
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Koumantakis et al--March 05 I believe compared multifidus/transverse ab with general abdominal and erector exercises and found no difference in the groups when compared over a 10 or 12 week span (can't remember the exact length of treatment.
Here is the pubmed link:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15733046&query_hl=2&itool=pubmed_docsum
and text:
Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain.Koumantakis GA, Watson PJ, Oldham JA.
School of Physical Therapy, Drosopoulou 6, Kypseli, Athens 112 57, Greece. gak4@otenet.gr
BACKGROUND AND PURPOSE: The purpose of this randomized controlled trial was to examine the usefulness of the addition of specific stabilization exercises to a general back and abdominal muscle exercise approach for patients with subacute or chronic nonspecific back pain by comparing a specific muscle stabilization-enhanced general exercise approach with a general exercise-only approach. SUBJECTS: Fifty-five patients with recurrent, nonspecific back pain (stabilization-enhanced exercise group: n=29, general exercise-only group: n=26) and no clinical signs suggesting spinal instability were recruited. METHODS: Both groups received an 8-week exercise intervention and written advice (The Back Book). Outcome was based on self-reported pain (Short-Form McGill Pain Questionnaire), disability (Roland-Morris Disability Questionnaire), and cognitive status (Pain Self-Efficacy Questionnaire, Tampa Scale of Kinesiophobia, Pain Locus of Control Scale) measured immediately before and after intervention and 3 months after the end of the intervention period. RESULTS: Outcome measures for both groups improved. Furthermore, self-reported disability improved more in the general exercise-only group immediately after intervention but not at the 3-month follow-up. There were generally no differences between the 2 exercise approaches for any of the other outcomes. DISCUSSION AND CONCLUSION: A general exercise program reduced disability in the short term to a greater extent than a stabilization-enhanced exercise approach in patients with recurrent nonspecific low back pain. Stabilization exercises do not appear to provide additional benefit to patients with subacute or chronic low back pain who have no clinical signs suggesting the presence of spinal instability.
PMID: 15733046 [PubMed - indexed for MEDLINE]
_____________________________
Ken Shearer, PT
Certified Strength and Conditioning Specialist
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Re: LBP exercises - January 2, 2007 12:54:00 PM
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SJBird55
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I think there has been some awesome research in the last 2-3 years that significantly assists in both classifying and treating patients. You guys are all talking statistical numbers and debating over the statistics. Going round and round with opinions is exhausting. No research is ever going to be perfect.. every study is going to have flaws. The studies revolving around the stability exercise programs, directional preference and the clinical prediction rules really do make clinical sense and common sense.
I decided in 2000 that I had to know my outcomes and my clinical performance. It took me a year to figure out exactly how I wanted to measure my performance, but I came up with a game plan. When I completed gathering my original data and analyzed it in 2004, I was very, very disappointed in my outcome numbers for patients with low back pain without radiculopathy. If I remember correctly, patients were attending with 43-45% disability on the Oswestry and improving to 24% disability in 12 visits (average numbers). Statistically, those numbers to have decent effect sizes. Clinically, I didn't like learning that patients were discharged with that high of an amount of disability. (And, if you asked me before I found out my numbers, I would have mentally guessed lower than 24% disability.) So, I decided that I needed to learn manipulation (that was one new thing that had definite clinical relevance and predictability with the appropriate patients). After looking at my outcomes in 2004, I made a goal that I wanted number of visits to decrease and I wanted a discharge disability of 10%. I've focused the last 2 years on classifying patients better and matching treatments with their classification. I also did attend a manipulation course with Childs, Bennett and Wainner. I didn't just sit in that course and agree - believe me, I discussed my concerns with some items that were presented and there was a discussion. And it wasn't a discussion where comments/questions are blowed off and waved away. There was an actual discussion with the researchers. 2006 is over and I'm looking at a new set of data now. I'm really, really happy with my clinical decision-making. Patients are beginning therapy with a 40-43% disability and being discharged in 7 visits with 12% disability on average.
I will admit, that I was a bit doubtful about putting thought into classifying and following clinical prediction rules (because we get a ton of information from patients and what about all those varous "special tests?") But... in a way, simplifying stuff (for lack of a better word) did lead to more effective and more efficient care. I think the "noise" of all the information we collect has a negative impact on our clinical decision-making. This is supported by Goldman's algorithm for treating chest pain. Cook County Hospital put the algorithm to use and that algorithm improved accurately treating serious patients from 75-89% of the time to a 95% of the time. It also saved time and resources.
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