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acute low back pain
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acute low back pain - July 8, 2004 6:04:00 AM
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FLAOrthoPT
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someone comes in 1 day after "their back went out." No radicular s+s, definitely lumbar and not SI, no myotome or dermatome patterns...palpation is limited secondary patient apprehension and guarding, at this point just about every test is positive secondary to the acute nature...so my question is, what do YOU typically do for this patient day 1? Is it a modality party, or a gentle mob time, MFR, neural glides, positional distraction, etc? Just curious what you all do?
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Re: acute low back pain - July 8, 2004 6:52:00 AM
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PTupdate.com
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For me, I focus on modalities to relieve pain and simple position, both for pain relief and to give some confidence. Often just some IFES and ice, perhaps some prone-on-elbows or knee to chest will relieve pain and restore some mobility.
I find that being too aggressive may just agitate the patient, and you will lose them. Often a problem I see with other PT's that just try something too quick. Give the patient some pain relief, earn their trust, and then you can do what they need as the next step.
After all, most of these people will get better on their own anyway. We are only speeding up the process a little and getting all the credit!
John Duffy, PT OCS
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Re: acute low back pain - July 8, 2004 7:06:00 AM
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Dr.Wagner
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I think the ultimate answer is pain control and slow progressive guided mobility exercises and relative rest. Manipulation, traction, and complete rest all have been shown to be fruitless in the acute setting.
This is a case where the "simpler the better"
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Re: acute low back pain - July 8, 2004 7:23:00 AM
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chiroortho
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Am I opening a can of worms here by offering up the suggestion of a good quality LSO?
Can't tell you how many times we've addressed acute LBP in part by fitting with a semirigid LSO. Instant improvement from 10 to 5.
Interferential, ice, pulsed US. Maybe all the studies show that they're useless, but my patients suffering from acute LBP beg to differ. I suppose it might be my powerful charisma, but I doubt it.
Greg
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Re: acute low back pain - July 8, 2004 7:43:00 AM
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steve
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Just my two cents but when I see these people, education and reassurance is probably the biggest component of my treatment. I explain the process of what they are going through, how it will likely resolve quickly, educate them on relieving/exacerbating postures and the importance of maintaining activity within tolerance. Sure I might do some very gentle manual techniques and a gentle stretch but probably the reassurance that I've seen this before and that it does get better makes people feel better.
Steve
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Re: acute low back pain - July 8, 2004 8:25:00 AM
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Alex Brenner PT MPT OCS
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I would manipulate his spine and then have him do some impairment based exercises to maintain motion. We have had this debate on this forum before. With what you have told me so far he already has 2 out of the 5 clinical predictors for successful outcome to manipulation (Flynn et. al 2003). Manipulate him.
Army
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 8, 2004 8:29:00 AM
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Alex Brenner PT MPT OCS
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Dr. Wagner wrote: [QUOTE]Manipulation, traction, and complete rest all have been shown to be fruitless in the acute setting.[/QUOTE]I disagree. I think there is a lot of evidence to support manipulation for acute low back pain. In fact, manipulation has more supportive literature than any other treatment that all of you have listed.
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Re: acute low back pain - July 8, 2004 8:39:00 AM
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Bournephysio
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I agree with most of the above posts. Education ++ with modalities, light movement and activity maybe TA retraining. If I can find a painfree plane, I'll manip. There is a subset of these patients who act like a meniscoid entrapment. Everything is painful but extension looks completely blocked at one facet. These patients respond remarkably to manipulation (flex and gap). One treatment is almost enough.
Doug
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Re: acute low back pain - July 8, 2004 10:14:00 AM
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mcap56
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What's wrong with this approach?
Education and reassure. Explain the nature of the problem to the patient.
Instruct the patient in home heat application and advise him to consider thermacare hot packs (OTC - and there is research behind them).
Instruct the patient to come back in three weeks or so for some exercises and education that may help to prevent the next episode.
Instruct them to come back sooner if it gets worse or if there is a problem.
I guess the question is??? Why do we have to TREAT this patient so much?
mcap
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Re: acute low back pain - July 8, 2004 10:32:00 AM
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Bournephysio
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mcap: nothing wrong with that but some modalities can provide enough relief to prevent flare up from assessment. Manipulation can be very effective even if only temporary. I believe that "success" in Army's study was at least a 50% reduction in pain. Thats too good to pass up especially since a manip takes so little time to perform.
Doug
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Re: acute low back pain - July 8, 2004 10:41:00 AM
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Dr.Wagner
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Coming from a DO (me), there is no compelling evidence supporting manipulation over "advice to stay active" NSAIDS and good ole advice/education in the ACUTE stage (first 24-72 hrs).
Coming from Issue 10 of Clinical Evidence, Dec 2003 manipulation in the acute setting was NOT shown to be more beneficial than the above and is listed as "unknown effectiveness".
While I am very proficient in manipulation of the spine, I have never seen it work better than NSAIDS or ice/heat, early guided movement in the acute stage of spasm. I use manipulation in the SUBACUTE stage or reactivation of chronic injury NOT in the ACUTE stage (first 24-72 hours or so).
"nagging" discomfort that is clearly non traumatic, non radicular, and not identified with overt spasm can be treated with great success.
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Re: acute low back pain - July 8, 2004 11:54:00 AM
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chiroortho
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I'd have to pitch in that when the patient is bent over w/acute LBP, I almost never even attempt manipulation. You guys would know more about 'mobs' than me, but manipulation's a crapshoot in the really acute patient.
When I was a new guy, and knew everything, I'd manipulate away. 50% got immediate relief and thought I was Albert Schweitzer, and 50% probably wanted to punch me in the nose.
If I had waited a few days for things to quiet down a bit, utilizing the approach that I've outlined above, my success rate went up dramatically, especially with the patients that wanted to punch me in the nose.
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Re: acute low back pain - July 8, 2004 6:14:00 PM
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rodgere
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I wish we could continue a discusion on details of your specific manipulations
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Re: acute low back pain - July 8, 2004 6:27:00 PM
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PTupdate.com
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I have to agree with Greg, in that I dont' want 50% wanting to hit me....not good for business, and this is also a business.
mcap, I am not sure I would suggest the use of heat in the acute phase, especially if there is torn tissue and an active acute inflammatory response occurring. While we could send them home with these instructions, there are things we can do to make them feel better, perhaps even permanently, and I see nothing wrong with this.
After all, we could all walk into a restaurant and be told by the waiter to just go home and microwave a frozen meal. It would satisfy our hunger, but perhaps not was satisfying as the good restaurant meal. This does not happen, because restaurants are in the service industry , and so are we. People pay for their insurance, and they want a product. I don't mind delivering this product in a way that benefits them, and satisfies them.
John Duffy, PT OCS
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Re: acute low back pain - July 8, 2004 6:33:00 PM
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Diane
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Steve wrote:
[QUOTE] Just my two cents but when I see these people, education and reassurance is probably the biggest component of my treatment. I explain the process of what they are going through, how it will likely resolve quickly, educate them on relieving/exacerbating postures and the importance of maintaining activity within tolerance. Sure I might do some very gentle manual techniques and a gentle stretch but probably the reassurance that I've seen this before and that it does get better makes people feel better.[/QUOTE]Ditto that Steve. Reassurance, reassurance..education.. more reassurance. The 'very gentle technique' I use is muscle energy. One visit is usually all they need. (Although they may come back a few weeks or months later to see if there's anything that can be done with all the "chronic" stuff they may have been putting up with for years.)
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Re: acute low back pain - July 8, 2004 9:26:00 PM
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Bournephysio
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I completely disagree that manipulating a patient with acute lbp is a crapshoot. In the subset I mentioned, the "meniscoid entrapment," flexion mobs are painfree. The response in these patients is very predictable.
In other patients if you can find a direction to manip in without pain (and you aren't manipulating into an instability) you will not get an adverse reaction. If you can't find a painfree direction you can still manip a joint above or below or si if indicated. I have only had a handful of patients who have flared up from a manip (I can actually only remember 2). That is one advantage of the PT way of learning manips, you learn what to manip long before you learn how to manip. Chiroortho, you are very correct that if you wait with some patients you can get very good results. I find that the proper time to manip a joint can usually be determined from their response to pivms.
Wags, you really need to take a course on how to critically appraise literature. There is not a large body of compelling evidence for manipulation period. It is not limited to just acute, subacute or chronic. Absence of evidence is not necessarily evidence of absence. Research will continue to be all over the map until proper inclusion/exclusion criteria are developed. Thats what I like about Flynn's work. There are starting to figure this out. By the way, I couldn't care less if you are a do, md, pt or ditchdigger, your posts get judged on what you say, not who you say you are.
Doug
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Re: acute low back pain - July 8, 2004 9:29:00 PM
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Alex Brenner PT MPT OCS
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MCAP,
In my opinion, what is wrong with your approach is that there is no current evidence to suggest that it may be helpful. Come back in 3 weeks? By that time the guy may progress to a chronic low back pain patient. Then you are going to have problems treating him! There is so much evidence to support treatments NOW in the acute phase. Anyone could tell a patient that the low back pain will get better with time and to come back in 3 weeks. I am sure the referring provider did not send you this acute patient so that you will tell him to come back later. And if the patient was a direct access self referral, he did not walk into your clinic to be told to come back in 3 weeks. The patient will probably leave your clinic and tell everyone "that guy didn't do anything to help my pain." You are seeing the acute low back pain patient because they want relief NOW. MCAP, you have all these skills at your disposal why not use them. TREAT the patient, dont send him home with hot packs. Maybe I am taking this evidence thing too far but that is the way I was taught to practice in school. Also, I agree with John in that I would probably not apply heat to a day 1 acute low back pain.
I would like to say also, that I do not manipulate every acute back pain that walks through the door. I make my decision based on a thorough physical exam. But I can tell you, manipulation is the first treatment option that crosses my mind. If the guy is in so much pain that I can't even place him into position, then I will not try to force the manipulation. But I will try it again in 1-2 days.
Outcomes: Are any of you using outcome measures to see if your interventions are making a difference? I challenge all of you to start using the Oswestry questionnaire to measure the outcomes of your intervention on acute low back pain. Administer the Oswestry on day one, score it, conduct your intervention then on follow up and adminster the Oswestry again. Compare the two scores, if you have a 6 point decrease (12%) this is considered a clinically significant change (Fritz et. al. 2003).
Manipulation has been shown to obtain a 50% reduction in oswestry in acute low back pain (Flynn et. al.). That is for example, a patient comes in with acute low back pain, scores a 38% on the Oswestry, you manipulate him, he comes back in 2 days and his Oswestry is 18%. I challenge any intervention listed above to obtain these types of results so quickly.
In addition to manipulation, I also provide reassurance, education, exercises and I follow up no more than 1-2 days after the initial visit.
Army
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 8, 2004 9:34:00 PM
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Alex Brenner PT MPT OCS
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Dr. Wagner,
You probably don't read much physical therapy research anymore since you are an ED physician but I can tell you that there is overwhelming current evidence (good critiqued peer reviewed research) to support manipulation as an effective intervention for acute spine pain. If you are still an APTA member, go to the APTA's hooked on evidence website and type in acute low back pain. An overwhelming majority of "hits" for treatment interventions will be manipulation. I wouldn't base your manipulation beliefs on just one article and I don't either. Just my thoughts.
Army
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 8, 2004 9:47:00 PM
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Alex Brenner PT MPT OCS
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Chiroortho wrote:
[QUOTE]I'd have to pitch in that when the patient is bent over w/acute LBP, I almost never even attempt manipulation. You guys would know more about 'mobs' than me, but manipulation's a crapshoot in the really acute patient.
When I was a new guy, and knew everything, I'd manipulate away. 50% got immediate relief and thought I was Albert Schweitzer, and 50% probably wanted to punch me in the nose.
If I had waited a few days for things to quiet down a bit, utilizing the approach that I've outlined above, my success rate went up dramatically, especially with the patients that wanted to punch me in the nose.[/QUOTE]Greg, I totally agree with you. As a new guy you were getting 50% of your patients complete relief with manipulation. That is great! Again, I would like to say that I practice like Greg describes above. I do not force the manipulation. If the patient is in terrible terrible pain then I may wait 1-2 days and then try to manipulate it.
Greg, I would probably not put a patient in a LOS because I would think that this would promote immobilization almost like bed rest which we know is not a good thing. I usually like to get the patient moving with some mobility exercises. If I did use a LOS, I would be sure to have the patient come out of it several times a day to conduct therapeutic exercises.
To all:
Sorry about all my posts, but low back pain has my strongest interests in physical therapy.
Army
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Alex Brenner, PT, MPT, OCS
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