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Re: acute low back pain
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Re: acute low back pain - July 9, 2004 3:38:00 AM
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Sebastian Asselbergs
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I'm lucky: I usually get a phone call first, and my secretary knows well enough to get me. If the patient (or the spouse/partner/parent) is unable to get out of bed/car/chair and is bent over, I give them a phone consult and tell them NOT to come in yet because getting in the car, driving and getting out are not helpful actions at this time. Let alone getting up and down from the treatment table....Usually two to three days - lots of mild motion, good breathing, ice, check with the family doc's nurse/secretary if taking OTC NSAIDS is ok (Advil, Ibuprofen, Aleeve) and call me back every day.
Do I bill for that? I probably should....
Then there are many many other acute scenarios that do not lend themselves to a "routine" approach.....
Sebastian
Sebastian
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Mundi vult decipi
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Re: acute low back pain - July 9, 2004 5:30:00 AM
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mcap56
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Good, an interesting thread!!
ArmyPT:
I respect what you have to say. No one is saying this patient needs to be kicked out the door. I am also, well too aware of the need for action by referral sources and patients. I also know that manipulation has been judged to be effective for acute LBP.
You hit upon the real issue though - the transition to chronicity. Those are the patients we need to be concerned about. And, I would imagine, that the transformation has much more to do with attitude, psychosocial factors, fear avoidance, etc, and very little to do with whether the patient received manipulation. IN fact, there is no evidence that manipulation will prevent the transition to chronicity at all (Doug's point taken though).
Is it possible that when the next flare up happens the patient runs for another manipulation? Is it possible that manipulation reinforces medicalization of the patient and the idea that there is something more seriously wrong? Is it possible that manipulation in the acute stage will incresase chronicity over a longer peroid of time?
I know that none of the more expert/manual therapists that post regularly rely on manipulation alone and that you educate as much or more than anyone. But isn't at least worth considering the questions above.
Manipulation is being pushed by the orthopedic heirarchy in our profession. And, in every case, the evidence is declared as overwhelming. Well, as far as I can see (and admittedly, I don't review it each month), it isn't. When expert panels get together, their conclusions are far, far different.
mcap
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Re: acute low back pain - July 9, 2004 5:38:00 AM
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chiroortho
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Army we use 2 different types of LSOs, and we use them very infrequently. The first is the typical white elastic band with velcro. Our primary purpose for using this type of support is to remind the patient that they had acute back pain 2 days ago, so don't do anything stupid.
The second kind (I wish that I could recall the name) is semirigid but still allows for movement, a bit thinner, and has a handle connected to wires or strings that allows for a really comfortable fit. This is for the severe LBP patient to help him get comfortable enough to ambulate, get in/out of car, etc. We do not encourage prolonged use of either.
Interesting enough, I can't even tell you how many times I've had patients come in 6 weeks after an MVA still wearing their soft collar that was given to them in the ER. The first thing I do is tell them to take it off and make a planter out of it.
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Greg Priest, DC, DABCO
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Re: acute low back pain - July 9, 2004 8:39:00 AM
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Shill
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So, what do you suppose that we all might agree on?
Acute back pain = Acute tissue damage and onset of the "inflammatory cascade" (?) Do we agree that there has been some tissue injury, therefore all of those chemicals of inflammation are in the area, helping, yet irritating things? I dont think that there is anything we can do to directly change this, nor do I think we should. This is a necessary part of the healing process.
For those 3-7 days, the patient is going to hurt, and hurt a lot. Snap it, crack it, pop it, whip it good, whatever, the pain will be there until the chemical irritators are gone. I must admit, I dont manipulate, for the fact that I need to be able to rationalize that what I am doing is bringing about something helpful. Does the manipulation flush out the chemicals? I doubt it. It is argued that it doesnt matter what it does, as long as it helps, but the evidence available doesnt convince me yet. (although I will revist hooked on evidence and check these out Army)
So what would I do?
Educate, tell them what to avoid (moving in the direction of injury), how to move with less irritation of symptoms, positions of comfort, dressing without pain, etc, etc, and have them come back in a week. Now those nasty chemicals should be on their way out. Now we can get somewhere, and stave off chronicity.....Maybe.
Thats an evaluation, therapeutic activities for positional relief, and neuromuscular reeducation of posture and body mechanics. That fills up an hour nicely. I will give the patient the choice regarding modalities, etc. "these will feel nice for a moment, but by the time you get to your car, it is likely the effects will have worn off" would you like to try it anyway? Few take me up on it.
Greg
In regards to the LSO, I dont think it is a bad idea. The evidence isnt good because the studies looking at whether or not there is benefit are also not good. Most of these folks hurt themselves bending and or twisting. Strap on the corset and remind them that they should do no bending or twisting for a while. This means NONE, no slouching, etc. etc. Sure they will stiffen up a bit, but this is easy to fix.As an adjunct to a good repeated movements program, the LSO may prevent many of the worsening or perpetuating movements, if properly instructed.
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Steve Hill PT
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Re: acute low back pain - July 9, 2004 9:03:00 AM
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Bournephysio
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To figure out whether or not manipulation is supported or not in the literature you really need to go through it with a fine toothed comb. There are negative and positive studies so you need to try and determine if there are any reasons for the differences (different techniques, outcome measures, inclusion criteria, followup etc). While Flynn and Fritz look like they are filling a significant hole that hasn’t been looked at, I have not gone through all the evidence (maybe ArmyPT has). I don’t think that the relationship between manipulation and chronicity has even been looked at. Because of this we all have to fall back on clinical experience. Not a bad thing but we have to recognize its strengths and limitations.
I believe that there is clinical evidence that manipulation can lead to dependency issues. I have seen it in chiropractic patients and have seen the tendency in some of mine. In my experience these tend to be patients with unstable segments. The muscles clamp down on an unstable segment to stabilizing it either causing muscle pain or compressing the pain generating structure. The manipulation decreases the compression and the patient has instant relief. Without proper muscle reeducation it will “go out” again and need another manip. Repetitive manips probably increase the instability either directly or by decreasing the stability that the muscles provide. I think that this dependancy is preventable by educating patients, not manipulating clinically unstable segments and by limiting repeat manipulations. If done right it can be a powerful tool to prevent chronicity. “Your back feels great now. If you want to keep it that way you need to do this, this and this.”
As for hotpacks, I’m not overly concerned if an acute lbp patient wants to use one. The actual pathology is usually so deep that I doubt that the heat actually gets there.
“Then there are many many other acute scenarios that do not lend themselves to a "routine" approach.....”
This one sentence paragraph from Sebastian is key, every patient is different. The assessment and treatment of every patient is tailor made and can be very different even in very similar circumstances.
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Re: acute low back pain - July 9, 2004 9:09:00 AM
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Bournephysio
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Shill, I believe Wright presented some of his work on animal models and manipulation/mobilization at IFOMT. From what I remember the analgesia was neuro based. They injected the ankle with an inflammatory substance and mobilized the knee. I'll check on that.
If the pain relief they get keeps them from hiding in bed all day it is probably a good thing. If it gets them lifting weights with an injured back it is probably bad.
Doug
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Re: acute low back pain - July 9, 2004 9:23:00 AM
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mcap56
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Here is something they can do for themselves (they can pick it up OTC at the drug store) at far less cost than additional PT visits....
Abeln SB, Weingand KW, Erasala G, Hengehold D, Barnes PW, Steiner D. Overnight treatment with continuous low level topical heat therapy provides effective relief of low back pain. Journal of the American Pharmaceutical Association. 2000; 41(2):307. (abstract)
Objective: To determine the clinical efficacy and safety of the overnight use of continuous low-level heat wrap therapy in subjects with acute muscular low back pain. Setting: New York Design: Randomized, controlled, single-blind, parallel, clinical study. Participants: Seventy-six adult subjects with acute muscular low back pain of moderate or greater intensity completed the study. Subjects were stratified by gender and baseline pain intensity, then randomly assigned to one of four treatments: heated back wrap (n=33), oral placebo (n=34), oral ibuprofen; 400 mg (n=4) or unheated back wrap (n=5). Back wraps were worn for 8 hours per night on 3 consecutive nights. Oral treatments were administered once a night on 3 consecutive nights. Treatment response was assessed by subjective measures of pain relief, muscle stiffness, and objective trunk range of motion, Roland Morris disability, sleep onset difficulty and sleep quality. The skin quality was assessed as a measure of safety. Results: Heat therapy compared to placebo provided significant increases in mean 3 day morning pain relief (2.75 vs. 1.45; p = 0.00005) and trunk range of motion (20 vs. 17 cm ; p = 0.001) and decreases in muscle stiffness (36.3 vs. 47.9; p = 0.0008) and disability (15% vs. 24% ; p = 0.005). These therapeutic benefits were evident both during the 3 day treatment period as well as during the 2 day follow-up period. Conclusion: Continuous low-level heat therapy overnight was shown to be clinically effective for treating acute low back pain. In addition, heat therapy improved subjective sleep quality and reduced sleep onset difficulty. The effect of heat therapy on the skin during overnight use was minimal and comparable to daytime use.
Why not?
mcap
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Re: acute low back pain - July 9, 2004 11:05:00 AM
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USAPT
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I am on this site everyday and read most topics. I have to agree with Army PT'a clinical understanding and approach to treatment. I am not a big believer in modalities, except for ice when appropriate. To me, US and E-stim isn't PT.
I too have treated those acute LBP pts. and I give them an understanding of their primary and secondary dysfunctions, most of the time it is postural. I manipulate if necessary but most of the time on day one they are just looking for an educated answer for their dysfunction.
Army PT has a select group of pts. and they are not the "general public". They are for the most part young, healthy individuals and thus manipulation can be performed more frequently in acute stage.
To answer the question, if a pt. comes to me and states that they cannot or will not move, that's a red flag. There has to some position they can get into to that will either decrease or centralize their pain. If they walked into your clinic..isn't that moving? Why feed into the pain when a functional exercise can be performed instead.
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Jason, PT
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Re: acute low back pain - July 9, 2004 7:37:00 PM
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Dr.Wagner
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ArmyPT, I read the JAOA monthly as it is a small throw away journal...quite a bit of manipulation info there.
Please...list the overwhelmingly positive manipulation articles. I would love to read them and the methods utilized.
I am not being confrontational, but I was drilled with this business in medical school and I still am NOT convinced, nor are the Cochrane reviews nor the book I quoted.
I see no place for manipulation (HVLA) in the acute setting for the majority of the population and I CERTAINLY DO NOT BELIEVE IT HAS SHOWN TO BE MORE BENEFICIAL THAN RELATIVE REST, NSAIDS, ICE etc.
I would love to believe, but the evidence (unless amazing research has been done in 6 months) is simply lacking.
If there is new stuff...I will use it tomorrow.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: acute low back pain - July 9, 2004 8:28:00 PM
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Bournephysio
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A quick search using authors mentioned in this thread:
Phys Ther. 2004 Feb;84(2):173-90.
Factors related to the inability of individuals with low back pain to improve with a spinal manipulation.
Fritz JM, Whitman JM, Flynn TW, Wainner RS, Childs JD.
Department of Physical Therapy, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260, USA. jfritz@pitt.edu
BACKGROUND AND PURPOSE: Although spinal manipulation is one of the few interventions for low back pain supported by evidence, it appears to be underutilized by physical therapists, possibly due to therapists' concerns that a patient may not benefit from the intervention. The purpose of this study was to identify factors that are associated with an inability to benefit from manipulation. SUBJECTS: Seventy-five people with nonradicular low back pain (mean age=37.6 years, SD=10.6, range=19-59; mean duration of symptoms=41.7 days, SD=54.7, range=1-252) participated. METHODS: Subjects underwent a standardized examination that included history-taking; self-reports of pain, disability, and fear-avoidance beliefs; measurement of lumbar and hip range of motion; and use of various tests. All subjects received a spinal manipulation intervention for a maximum of 2 sessions. Subjects who did not show greater than 5 points of improvement on the modified Oswestry Low Back Pain Disability Questionnaire were considered to have shown no improvement with the manipulation. Baseline variables were tested for univariate relationship with the outcome of the manipulation. Variables showing a univariate relationship were entered into a logistic regression equation, and adjusted odds ratios were calculated. RESULTS: Twenty subjects (28%) did not improve with manipulation. Six variables were identified as being related to inability to improve with manipulation: longer symptom duration, having symptoms in the buttock or leg, absence of lumbar hypomobility, less hip rotation range of motion, less discrepancy in left-to-right hip medial rotation range of motion, and a negative Gaenslen sign. The resulting logistic regression model explained 63% of the variance in manipulation outcome. DISCUSSION AND CONCLUSION: The majority of subjects improved with manipulation. Baseline variables could be identified that were predictive of which subjects would not improve.
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Re: acute low back pain - July 9, 2004 8:49:00 PM
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nari
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Doug
Re the study -
where is the control group?
where is the comparison with 'traditional PT'?
I would bet that a sizeable proportion of folk with low back pain would get better no matter what is done. One study. a long time back, demonstrated that out of four groups with LBP:
one group received manipulation/s, a second did nothing but swallow meds and keep going, a third group went to traditional PT, and a fourth went on to surgery. At the end of 6 months, the surgery group had a slight advantage, at the end of 12 months the outcomes were the same.
The one thing probably all four missed out on was education...(I think it was a study in the late 80s - the pre-education days)
Nari
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Re: acute low back pain - July 9, 2004 10:59:00 PM
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Alex Brenner PT MPT OCS
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Below are the articles that I have read:
A clinical prediction rule for classifying patients with low back pain who demonstrate short term improvement with spinal manipulation. Flynn, Fritz, Whitman et al. Spine 2002 27(24): 2835-2843.
I guess this is the pentacle article that I go by and this is how I choose to examine and treat low back pain, especially acute low back pain. This article recently won the Rose award for research excellence.
Clinical decision making in the identification of patients likely to benefit from spinal manipulation: a traditional versus an evidence based approach. Childs, Fritz et al. J. Orthop Sports Phys Ther 2003; 33(5): 259-272.
A benefit of spinal manipulation as adjunctive therapy for acute low abck pain: a stratified controlled trial. Hadler NM et al. Spine 1987; 12(7): 702-706
The audible pop is not necessary for successful spinal high velocity thrust manipulation in individuals with low back pain Flynn, Fritz et al. Arch Phys Med Rehab 2003; 84(7): 1057-1060.
Manipulative therapy versus education programs in chronic low back pain.
Triano JJ, McGregor M, Hondras. Spine 1995; 20(8): 948-953.
Note: The above study was looking at chronic low back pain but interestingly they noticed that people with more acute low back pain responded better to manipulation. Hmmm, maybe we should look at manipulating people sooner.
Relative therapeutic efficacy of vertebral manipulation and conventional treatment in back pain management. Nwuga VC. Am J Phys Med 1982; 61(6): 273-278.
Studies that list positive results in their abstract but I have not entirely yet:
Conservative treatment in patients sick listed for acute low back pain: a prospective randomized study with 12 months follow up. Seferlis T, nemeth G, Carlsson. Eur Spine J 1998. 7(6) 461-470.
There is no other intervention for low back pain that has more evidence to support it.
Army
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 10, 2004 12:08:00 AM
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Alex Brenner PT MPT OCS
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MCAP Wrote: [QUOTE]Manipulation is being pushed by the orthopedic heirarchy in our profession. And, in every case, the evidence is declared as overwhelming. Well, as far as I can see (and admittedly, I don't review it each month), it isn't. When expert panels get together, their conclusions are far, far different.[/QUOTE]Mcap,
Manipulation is being suggested by orthopaedic hierarchy because it is EVIDENCED based. You mention in your above quote that there is no evidence to support manipulation. There is. Refer to my above post. If you believe that the above evidence is lacking then tell me what else are you looking for? What other proof do you need? Would you rather rely on your current treatment methods which are possibly unsubstantiated or would you rather perform interventions that have supporting scientific research?
It seems to me that in your previous post that you are pretty convinced about the ONE research study on the drug store hot pack being effective. What about the six well-accepted peer reviewed articles that I listed above that support manipulation???
Army
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 10, 2004 3:49:00 AM
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SJBird55
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Wainner and Childs have another article or two that will be published this fall. I can't remember what the focus of those articles will be though - I believe a continuation of their previous work. They are also trying to come up with a classification system for manipulation of the cervical spine. From listening to them present, I highly doubt that any patient would become dependent on either of them and their manipulations. (I look at it logically though when I state that - I just doubt that anyone can be dependent on 1-3 treatments of manipulation.) Whoever mentioned outcomes in the future from manipulations... Childs and Wainner have thought of that, but since they are military (air force) therapists, they may not be able to successfully do something like that because the military population is always on the move, so they would have a more difficult time capturing outcome scores 1 year or more out. Also, manipulation is only a part of the treatment plan. The manipulation reduces the pain significantly and substantially increases function.... which then allows for a transition into an exercise program. Manipulation and exercise were the key components. Manipulation alone and exercise alone did not provide the same outcomes (when looking at their research). The manipulation and exercise combination also pretty much maintained their positive outcomes for a defined period of time.
Every patient is different, yes, but Wainner and Childs (and whomever else they are working with) are finding success following their classification system when using manipulation. If the patient doesn't fit into the classification system, they don't manipulate the patient.
I do have to chuckle at us though. There are so many therapists that will jump on the bandwagon of a therapist who proports to have good outcomes with a particular technique or approach (all theoretical of course).... and then, when there are articles with good descriptions of what can be done, when it should be done and a clear definitition of the anticipated outcome within a clear timeframe, we balk at that information.
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Re: acute low back pain - July 10, 2004 6:53:00 AM
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Bournephysio
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Nari: the study is not an rct thus no control. They were trying to determine what factors led to manipulation not helping. They found that certain factors explained 63% of the variance. That is a high value for something so ill defined as low back pain. You are right that the time it took to do the study is a confounding factor. Not because people get better with time but because people who have been in pain for a shorter period of time will probably get better faster than those who have been in pain longer. There were only two treatments with this study which would limit this effect. In addition they were looking for a clinically significant difference before they were willing to say that the manipulation was successful. The follow up to these studies needs to be an rct to see if manipulation is successful using these criteria.
“I do have to chuckle at us though. There are so many therapists that will jump on the bandwagon of a therapist who proports to have good outcomes with a particular technique or approach (all theoretical of course).... and then, when there are articles with good descriptions of what can be done, when it should be done and a clear definitition of the anticipated outcome within a clear timeframe, we balk at that information.”
I was going to bring that up. Many people expect a lower level of evidence for things there pet treatments while expecting a much higher level of evidence for treatments they dislike. For instance Wagner is willing to except that manipulation can be benefiicial in a subacute stage based on very little information but wants rct evidence of manipulation vs everything before willing to accept it in the acute stage. It is very easy for us to grasp on to a few positive studies without looking closely at the negative studies. Despite the studies mentioned by Army, a recent Cochrane review concluded that “There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.” For this profession (and the treatment of our patients) to progress we need to try and remain as unbiased as possible when evaluating the literature.
When drug companies do rcts on medications they first know what the drug is to be used for and what an effective dose should be. Why do we as PTs think we should skip these first steps? Its the same with reliability studies. We look at reliability of isolated tests, outside of their context of a complete exam, without knowing the reliability we need.
SJ, I haven't seen Wainner and Childs work but it continues a growing trend I am seeing that the studies with the best results are combining exercise with manual therapy. There are a couple of articles from a group in the netherlands looking at neck pain, and there is an article on shoulder pain as well. I believe that Jull has done similar work in the neck. It really makes sense to me. Manipulation is not likely going to have a long lasting effect unless you can retrain the muscles to use the new range of motion and maintain stability in that range.
Doug
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Re: acute low back pain - July 10, 2004 9:05:00 AM
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Diane
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Hi Doug,
[QUOTE]Manipulation is not likely going to have a long lasting effect unless you can retrain the muscles to use the new range of motion and maintain stability in that range.[/QUOTE](Ditto that!)
Off track a little, I realize, (sorry folks) but I have a 'gotta know' question for Doug:
What is your opinion in that case of "muscle energy technique" (please forgive the bizarre name it ended up with) as a manual modality that appears to do both at the same time;
1. "manipulate" (defined by myself on the fly here as a practitioner-guided change in 'spinal' behavior, with reduction of noxious input to and/or from the brain) and;
2. reeducation of muscular components of the spine..
..all at the same time. (The patient is actively in the loop; the only "passive" input to the patient's body is to get them set up in the right position.)
Look forward to hearing any insights/opinions you may have on this.
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Re: acute low back pain - July 10, 2004 9:47:00 AM
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mcap56
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Army:
Dough hit upon the points I was trying to make. When expert panels (like cochrane) get together, they have decided that manipulation provides short term pain releif in the acute stage but nothing much more than other treatments. They find no support for chronic or subacute patients. Nor do they find any evidence that it shortens the duration of LBP.
I am not saying it doesn't work. But you have hand picked a few studies and drew a conclusion. That is not adequate. There in absolutely no overwhelming evidence in favor of manipulation. And yet, there are so many presenting the evidence as incontrovertible. The presenters at CSM declared that the debate was over. Manipulation works and it is supported by the evidence. End of discussion. I would be happier if these statements came from non - maniupulators. If it was presented to PTs like this has some support but we need further research, it would be a different story.
With a lot of PTs, when years of education and training are invested, when they see positive clinical outcomes, it is very hard to be objective. You see the same thing with all kinds of treatments. Some of the support for manipulation is there but not like it is being presented.
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Re: acute low back pain - July 10, 2004 10:32:00 AM
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SJBird55
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mcap, you aren't going to get "manipulation works and is supported by evidence" from non-manipulators. A non-manipulator isn't going to know because a non-manipulator doesn't manipulate. The manipulators aren't saying that manipulation works for everyone either... they have a classification system. They also aren't saying that manipulation alone is the key. They are very strong advocates of exercise included within the interventions provided.
What I think has happened is that manipulation has been engrained in our heads (some of us) to be dangerous or having a high risk of harmful effects. It has also been engrained in our heads that it takes a high level of skill to do a manipulation. I'll admit, when I was at a manipulation course, I was a bit anxious and I wasn't terribly comfortable attempting the techniques on various lab partners. It's a mental thing... it's really not that hard to do and I wouldn't find any of the positions patients were put in to be dangerous or extreme by any means... and the forces are not as extreme as I had anticipated. It doesn't take long to perform either... and after the technique all you have to do is whatever functional test you did that determined you would manipulate. The person is either better or isn't better. The patient is supposed to have a 50% improvement in complaints. It's actually pretty simple. I'm more of an advocate of exercise - but after seeing their outcome scores of exercise alone, manipulation alone and manipulation and exercise, I know I have to change my current, comfortable practice patterns. I can't say that I am completely sold on manipulation, but I've decided to face my fear barrier in regard to manipulation and start adding that particular intervention to appropriate patients and see what happens to my outcomes. I haven't heard anyone pro-manipulation every say that further research wasn't needed either.
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Re: acute low back pain - July 10, 2004 11:41:00 AM
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Bournephysio
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Great discussion everyone.
Diane: I'm really not aware of any evidence with respect to muscle energy so I can only go by clinical experience. I personally really like muscle energy techniques sometimes when I don't think I should be manipulating or mobilizing. Often in conjunction with manips or mobs. One thing I learned from Jim Meadows was to do muscle energy first to get rid of muscle tone then mob (it was a premanip course) to get at the conective tissue restrictions then do muscle reeducation. I have at this point forgotten how he did the muscle re-ed. I use which I guess in PNF terms would be called combination of contractions (mostly isometric but sometimes isotonic or eccentric contractions in different directions). It is interesting to see how long it takes some people to sense that you've changed the direction of pressure. Very little change in hand or patient position is needed to switch between the techniques. One thing with muscle energy is that the contraction is often in one direction. I think with re-education you need to get multiple directions. I have found that in many ways mobs/manips, muslce energy and acupuncture/ims work very similar and often work very well in conjunction with each other. Each provides slightly different input into the nms system.
Doug
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Re: acute low back pain - July 10, 2004 12:07:00 PM
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Diane
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Doug, thanks for your reply.
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