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What do you do for patients with acute LBP
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What do you do for patients with acute LBP - March 25, 2004 5:30:00 PM
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Bill Egan
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Joined: April 22, 2001
From: Newton, MA
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Group,
Manipulation is not the only PT intervention for acute LBP, but it has more evidence to support its use than many other interventions. I'm currently taking an on-line class for my tDPT and we were asked to post what management interventions we use for patients with acute LBP. I'd be interested to hear what clinicians in this group typically do, because most seem against manipulation. Please do not feel I am out to criticize anyone, I am more curious than anything else. For a survey of therapists in Canada, check out this article.
Li & Bombardier. Physical therapy management of low back pain: An exploratory survey of therapists approaches. PT Journal. 2001;81(4):1018-1028.
Bill
[This message has been edited by Bill Egan (edited March 25, 2004).]
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Re: What do you do for patients with acute LBP - March 26, 2004 2:17:00 PM
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Jeep
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From: USA
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It depends- What is the diagnosis?
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Re: What do you do for patients with acute LBP - March 26, 2004 3:34:00 PM
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p.glynn
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From: billerica
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I use both mobs and manipulations and find them beneficial when properly chosen and executed. Despite the lack of evidence regarding many of our special tests I feel when they're clustered together they provide a guide for our interventions, hence manips can't be blindly chosen and executed. Exercise, traction and thermal modalities are also used. All of the above demonstrate conflicting evidence as to there benefit however without them we are left with the proven treatments of advice to stay active and behavior modification. Obviously more research is needed.
Paul
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Re: What do you do for patients with acute LBP - March 27, 2004 2:55:00 AM
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chiroortho
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Two theoretical questions regarding manipulative therapy and EBM/best practice guidelines:
1) Do you have a ethical and moral obligation to stop using manipulation until there is "enough" research proving its safety and efficacy?
2) How much research is "enough"?
Look forward to your thoughts.
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ChiroOrtho
[This message has been edited by chiroortho (edited March 27, 2004).]
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Re: What do you do for patients with acute LBP - March 27, 2004 2:58:00 AM
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chiroortho
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Bill,
I realized that my above post was not on point regarding your initial question, so I will start a new thread for my questions.
My apologies.
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ChiroOrtho
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Re: What do you do for patients with acute LBP - March 28, 2004 11:32:00 AM
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j
Posts: 74
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From: wi
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I was asked in a different thread what my hesitation was with performing manipulation as I have admitted that research is suggestive of the efficacy of spinal manipulation. I stated I would answer the question here as it fits the topic heading better.
The main reason (I've said this before) is that it does not fit well into my belief system. I recognize the possibility that my beliefs may be wrong which is why I love rehabedge.com. It allows discussion of emotionally laden topics without having to argue with co-workers.
My interpretation of the literature (national guidelines, RCT's) I've read state spinal manipulation has evidence to support its use, especially in subpopulations of acute low back pain. At the same time there does not seem to be concensus that it the preferred or more effective intervention for acute low back pain. It would seem spinal manipulation is equivalent to exercise but not necessarily better (or vice versa). Here's a recent reference supporting this contention:
Assendelft WJJ, Morton SC, Yu Emily I, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
If faced with two different treatments, both equally effective, (of course there are more than 2 ways to treat low back pain) one will likely choose the technique that match the biologic rationale for the person's low back pain.
The belief system underpinning spinal manipulation, as I understand it, is that somehow the facet joints experience some sort of joint sprain resulting in hypomobility and/or malalignment and that this is painful. A spinal manipulation is purported to correct the condition by choosing a technique that will free the facet joint from its stuck or hypomobile state and this will be pain relieving. Feel free to correct my understanding of the biologic rationale for spinal manipulation. I can generally understand the kinematics of the treatment intervention, it makes intuitive sense. But it doesn't seem to be true.
While spinal manipulation is helpful for a subset of people with acute low back pain the biologic rationale explaining how these people got better is missing in action (not that people haven't tried). This is a problem because the physical exam is based on the biological rationale being true. My reasonable fear is that we are confusing a causal association with a non-causal association. I believe that people with low back pain are getting better with the treatment intervention rather than because of the intervention. This would explain why manipulation and exercise demonstrate equivicol efficacy according to research.
Thats a start. I'm sure more dialouge will follow.
Thanks, jon
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Re: What do you do for patients with acute LBP - March 28, 2004 5:46:00 PM
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j
Posts: 74
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From: wi
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While I'm on the topic of beliefs, check out this interesting study:
Daykin, Anne R. PhD, MCSP*; Richardson, Barbara PhD, MCSP
Physiotherapists’ Pain Beliefs and Their Influence on the Management of Patients With Chronic Low Back Pain
Volume 29(7) 1 April 2004 pp 783-795
thanks, jon
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Re: What do you do for patients with acute LBP - March 29, 2004 2:01:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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[QUOTE]Originally posted by j:
It would seem spinal manipulation is equivalent to exercise but not necessarily better (or vice versa).[/QUOTE]
Jon,
What I like about performing manipulation is that you can perform it on the same day as the evaluation. The technique takes about 30 seconds to perform and in 30 seconds you have the potential to take the patient from an Oswestry score of 40% to a score of 20% (Flynn et. al). Exercise may do the same thing, but most likely not in 30 seconds. The patient with acute low back pain wants to feel better now, not 2-3 weeks from now. Why not peform the manipulation after the initial exam, get them feeling better immediately, and then prescribe some therapeutic exercises that fits with your findings on phyiscal exam, i.e. lumbar stabilization, mobility exercises, extension etc. etc.. These are my thoughts and obviously there are a lot on this forum that disagree with them.
ArmyPT, OCS
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Re: What do you do for patients with acute LBP - March 29, 2004 2:39:00 AM
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j
Posts: 74
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From: wi
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This seems to be the same logic MD's used when prescribing antibiotics for colds.
jon
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Re: What do you do for patients with acute LBP - March 29, 2004 2:53:00 AM
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j
Posts: 74
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From: wi
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Be careful not to overstate your case also. Flynn reported successful response to manipulation is defined by a 50% reduction in oswestry score in less than 5 days. This is not the same as 30 sec.
Other considerations for non use is that 55% (that is number I've seen) of people manipulated will experience local discomfort, headache, tiredness or radiating discomfort. I don't get this adverse (albeit short lived) reaction in most of my patients.
Lastly, the reason I hesitate to manipulate is that I cannot honestly tell my patient what is wrong with them that I need to manipulate them. I can tell them that movements that they can do on their own will help. This is supported in the literature at least to the extent of manipulation and I feel more comfortable with the explaination.
jon
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Re: What do you do for patients with acute LBP - March 29, 2004 4:07:00 AM
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Alex Brenner PT MPT OCS
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Jon,
When I decide clinically to manipulate a lumbar spine (and I dont manipulate every spine that comes through the door) I usually explain to the patient and reassure them that the back pain that they are experiencing is not serious in nature and that they do not have signs or symptoms of serious spinal pathology (I know this based on a good physical exam and history). I go on to explain to the patient that recent research/literature tells us that there is a good/safe manual technique that can be performed that has a good chance at making their pain much less. I then explain to them exactly what I am going to do and I explain that during the technique they may feel or experience a "pop" in their back but this is normal and is not necessarily the desired effect (meaning that we are not trying to get a pop and that the pop does not mean that the technique did not work). I then ask the patient if they have any questions about the procedure. In as long as I have been performing this technique I have NEVER had someone tell me that they did not want me to try it. I then perform the gentle technique and then recheck motions/joint movement or actions that caused pain on the initial part of the physical exam (for example bending forward, or maybe extending, sidebending, etc.) Most the time the technique corrects the pain associated with the certain movement. I then prescribe exercises appropriate for the patient. How is this like prescribing antibiotics? What do you mean?
PS Jon, I respect your comments and your beliefs and in no way am I trying to convince you to change the way you practice. It is just mind boggling to me how many civilian therapists there are against manipulation or who are not willing to try something proven to be effective for low back pain.
Army
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Re: What do you do for patients with acute LBP - March 29, 2004 11:58:00 AM
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Ron
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Army is on the right track.
My Cyriax training provides me with an excellent way (articular signs) to distiguish those LBP patients that are suitable for man/manip RX. I would dare say, as would my fellow Cyriaxians that most patients with acute onset are manipulation candidates.
Remember however that all effective treatments have indications and contraindications.
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Re: What do you do for patients with acute LBP - March 29, 2004 12:13:00 PM
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j
Posts: 74
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From: wi
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Analogies are often problematic. They are intended to describe similarities between unlike things. Of course one can draw false analogies. Regardless of how good an analogy is there will likely be elements that are still dissimilar when carefully inspected. But my intent was this:
A patient comes to a doctor with complaints that are ubiquitous; coughing, sneezing, etc.
A patient comes to a PT with complaints that are ubiquitous; low back pain of short duration, difficulty moving one way or another, etc.
The MD, after ruling out more serious pathology realizes this patient is likely to get better over time with little intervention, just basic common sense.
The PT, after ruling out more serious pathology realizes this patient is likely to get better over time with little intervention, just basic common sense.
But the MD's patient is tired of their symptoms and wants to get rid of them now. The MD offers a treatment that is of low risk to the patient and the patient feels better as they recieved care for their problem. The patient likely feels better leaving the office with the knowledge that there really was something wrong with them that needed to be fixed and is feeling better within 5 days.
But the PT's patient is tired of their symptoms and wants to get rid of them now. The PT offers a treatment that is of low risk to the patient and the patient feels better as they recieved care for their problem. The patient likely feels better leaving the office with the knowledge that there really was something wrong with them that needed to be fixed and is feeling better within 5 days.
End of analogy
The MD's were aware of the biologic rationale (research confirmed) for use of antibiotics but ignored it in favor of making the patient feel better.
Eventually they had to launch a campaign to convince the public that they don't need antibiotics as the biological rationale for the use of antibiotics did not make sense. Of course antibiotic resistant organisms were the driving force behind the campaign.
On the contrary while there is a biologic rationale purported for the use of manipulation it has not been supported by research findings. However, the unsupported rationale is frequently conveyed to patients. It sounds like you don't convey this rationale so this is a non-issue for you. But it is a problem in my opinion.
That many PT's don't perform manipulation shouldn't be a suprise. It was not taught in PT school (perhaps it is now). In fact, manipulation was often poo-pooed as it was the technique of chiroprators. Mobilizations were popular however. Interestingly, mobilization uses the same biologic rationale and testing procedures as manipulation if I'm not mistaken.
I don't mind your directness. As I've written before, I enjoy it. We are both trying to understand all positions on the issue. This type of conversation is difficult with co-workers. If we never agree, and that is not my intent either, we can go on our merry way and likely never have to share a patient.
thanks, jon
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Re: What do you do for patients with acute LBP - March 29, 2004 2:55:00 PM
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Bill Egan
Posts: 52
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From: Newton, MA
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John,
I think we have debated manipulation enough with the other thread. I think it would be interesting to know what interventions you utilize for patients with acute LBP.
As far as diagnosis, I would say acute, mechanical LBP without signs of nerve root irritation or any known pathology (ie fracture, tumor). Beyond this, I would argue that in this population we can't make an accurate pathomechanical diagnosis even with imaging studies available.
Bill
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Re: What do you do for patients with acute LBP - March 30, 2004 3:46:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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On a first visit with acute LBP I simply try to do something, either manually, mechanically, or modality-wise that will relieve their pain, instill their confidence in me, and guarantee they will return with improvement, so I can then address the situation better.
A manipulation does not always mean instant relief of pain. We have all treated patients who went to either a chiro, DO, or another PT and were manipulated on visit one, became quite sore, and never went back.
Is this what I want for my business? No. I don't want them going back to their physician, insurance company, friends and family stating how they came to me with pain and were made worse.
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: What do you do for patients with acute LBP - March 30, 2004 6:04:00 AM
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j
Posts: 74
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From: wi
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Bill, I agree a pathomechanincal diagnosis is unlikely in this population. One thing we do know is that nociceptors have been activated by those things which activate nociceptors.
Based on my review of the literature I have identified some specific constraints that the PT solution for acute low back pain must obey. I say must obey because the contrary points have been shown to have poorer outcomes.
1. Movement is good.
2. The movement one does should make the patient feel good, by directly reducing their pain (this would include centralization of symptoms in those where this is an issue).
3. Being under a plan of care is good.
Thats it. Not too many constraints which probably explains why so many variations of treatment for low back pain exsist. So my approach is to help the patient figure out which movements are pain relieving. The patient could figure this out on their own but are reasonably afraid. Thus they can use the guidance of an appropriately educated person. I could choose spinal manipulation but don't for reasons already explained. The biologic rationale for movement? I'm sure this could lead to its own thread. I feel that movement (especially active) produces effects at most key areas that are often thought to be the sources of pain including the nociceptors themselves.
My point often gets lost so I will reiterate it again. If a specific treatment approach truly leads to pain relief for a patient, it is unlikely one would argue that the approach was wrong. It is the reasoning behind the approach that could be wrong. People suprisingly often do the right thing for the wrong reason. The problem is that this leads to systems of treatment that build on false constraints, like stored memories in tissues or malalignment of bones.
PTupdate indirectly brought up the argument in favor of placebo (I'm painting modalities here with a broad brush, suggesting that they are placebo in nature). I struggle with the use of placebo; it surely has benefits. But I keep coming back to whether we are doing our profession a favor by becoming fluent in the use of placebo. This too may be a topic for another thread and I'm sure this has been covered in years prior.
thanks, jon
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Re: What do you do for patients with acute LBP - March 30, 2004 7:43:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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Jon,
Again, excellent points.
Maybe it's just me, but I don't know why so many who are aware of the origins of pain (mechanical deformation and/or chemical irritation) remain so confused about what the best solution to the problem might be. Chemical problems aside, mechanical deformation can ONLY be reduced via movement. This is true whether or not the pain is acute or whether or not it's felt in the back.
More to the point: Should we make the patient move or should we allow them to move themselves? Willfully or without volition? With effort or without?
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Re: What do you do for patients with acute LBP - March 30, 2004 10:18:00 AM
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Ron
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Barrett
I would not disagree, however
I would clarify MOVEMENT.
An acute onset of pain in the LB would require a movement different than a slow onset. Back pain with neuro signs reqires movement different than back pain without.
IMHO certian movements can only be accomplished with help. A thoracic disc lesion is a good example. Self reduction is seldom successfull. On the other hand patients can be taught self reduction exercises (movements) and postures with good results
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Re: What do you do for patients with acute LBP - March 30, 2004 11:03:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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Ron,
You're right, not all movements will have the same effect. However, I don't think it's the speed of onset that indicates which sort of movement will be the best choice for correction but rather which tissue(s) need to be moved for relief. For connective tissue problems (rare, in my opinion), passive movement is probably best, as you suggest.
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