LBP Treatment Approaches

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jbeneciuk -> LBP Treatment Approaches (June 24, 2005 5:30:00 PM)
Something popped into my head while reading a previous thread. It deals with how long do we stay with a given treatment approach before we decide to change the initial approach and attempt another one. Are there any guidelines that we use to determine that a given approach is not meeting our desired or expected outcomes? Are there time-frames we use to determine if change is needed? How many of us actually re-evaluate our patients (and how often) to determine if what we are doing is actually having an effect ? It would be interesting to see how and when is the time to go back into our "toolbox" and look at things from another perspective. *Lets just stick to LBP...I think reponses may lean toward commencing treatment based on the initial exam and altering treatment based on pt response to a given treatment. What I'm looking for is when do we try a totally different approach. I realize we have studies to help assist us in our treatment choices, however when do we determine that this given approach just isn't working and it is time to change ? JBeneciuk

PTupdate.com -> Re: LBP Treatment Approaches (June 24, 2005 5:43:00 PM)
Boy, that is a tough question. When someone comes in with 5-10 years of back pain, I don't expect rapid results. I start them on the first stages, and progress, and wait a few weeks before results seem to start. Acute pain is different, I expect results pretty quick, especially those with HNP/neural encroachment type problems. Much of it is gut feeling....those that are not getting better, yet seem to be skipping their home program or just doing thing to aggravate their problem don't get much of a program change. John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]

srcase -> Re: LBP Treatment Approaches (June 24, 2005 5:58:00 PM)
John, Can you expand on your treatment approach for an acute HNP? What kind of timeline are you looking at? I agree with you that much of it is intuition (or just unconscious reading of behavior). It is a multifactoral process, taking into account the patient's behaviors, symptom behaviors, impairments, and responses to treatment. I don't follow any particular protocol or formula, but in general, I usually give an approach a couple weeks (5 to 6 visits) and if no change, I take a different approach. The most difficult thing with LBP patients (as John alluded to above) is what are they doing at home to aggravate or help their condition? It's not like you can just put them in a cast and say, don't walk on it. So, I do a ton of education and movement retraining. Some patients are more receptive than others. At this point, I am actually trying to simplfy my approach to LBP, because I tend to throw everything at them, and never really know what actually worked and why, even though I have a pretty good idea. I hope this late night rambling made sense. Sarah

eam -> Re: LBP Treatment Approaches (June 24, 2005 6:11:00 PM)
Good question! I think it depends on the chronicity of the problem and how confident we are in our diagnosis. I think it varies amongst our patients, especially LBP, b/c there are so many other vocational factors to consider. The patient has to take on a certain level of responsibility as well re: the HEP. If someone comes to you BIW and does their HEP on the off days and someone else comes to with the same frequency and does absolutely nothing, everything else being equal, I "hopefully" believe that "motivated patient" will or should do better. If not, then re-think the approach, re-eval, re-QUESTION. If you truly believe in your approach, then ask more probing questions about activities, sleeping etc. I have a patient with a HNP, getting better-alleviated her origninal sx's , but suddenly developed sacral/coccyx pain. After more probing questioning, I find that she had changed her sleeping pattern approx. 1 month ago to s/l (sort of prone with pillow with a rotational posture). Actually, hurt my back getting into this position! I was thinking about changing something in my approach but after hearing her tell me about her sleeping posture, I decided not to and wait and see. I usually "re-eval" every time I see a patient, even if it is something very basic like a lumbar FB. I have gone on too long. Looking forward to other posts. Erica

jbeneciuk -> Re: LBP Treatment Approaches (June 24, 2005 6:31:00 PM)
John: You made a good point regarding intuition, which is what got me to this post, it seems as if we are very quick to mention the short-comings of approaches that revolve around a bio-mechanical approach, however this is the point I was trying to make...no matter how much we agree or disagree with instructors or philosophies we learn from, it is usually our "intuition" that leads us to our approach...some of us may be more biased toward the biomechanical approach, some may be more inclined to other approaches, yet it doesn't matter because we have the tools to change as necessary.. Sarah: I was thinking how most of the legit studies that we read are over a longer period of time (ex: 12 rx sessions, etc) isn't it odd how we tend to change so quick if we aren't getting the results we expect...I tend to do the same thing, then I will read a quality study that was done over a 5 week Rx program and I question myself ??...any thaughts ?? EAM: I tend to follow your "quick' re-eval at every session, prior to commencing Rx to see (and document) if there is any change, maybe its anal, to me its a habit.... **interested to hear from others...possibly those of us who are very adherent to one particular approach... JBeneciuk

nari -> Re: LBP Treatment Approaches (June 24, 2005 8:15:00 PM)
It's hard to answer this question, though it is a very useful one to consider. Every patient with LBP is different, so every treatment plan is different. History taking occupies most of the first session, so I have an idea of whom I am dealing with. Actual assessment sometimes takes only 5-10 minutes, after excluding red flags etc. I then decide on one thing - and one thing only for them to do. it might be EIL or EIS, or simply pelvic tilting, or something else. If it is acute (less than 1 month) improvement with pain education should be sufficient to discharge in a couple of weeks. If the patient is not receptive to pain ed, and is convinced his/her back is falling apart and discs are popping around - longer. The mainstay is pain ed. After that, it is up to them; and the movements program is almost always functional in nature, in order to activate a few inhibited areas. The failures come with those patients who are fixed on the idea that their pain is coming from their 'disc' or joint; and they hang onto the doctor who may have told them that the spine 'won't really get any better'. Quick evaluation is very useful, and often is verbal only, so I can see if they have understood the ed. and go over it again if necessary. LBP of many years is a slightly different approach and can take months, usually seeing the patient once a fortnight or so. I don't spend much time at all on ergonomic stuff but do advise on sitting and sleeping positions. Nari

Alex Brenner PT MPT OCS -> Re: LBP Treatment Approaches (June 25, 2005 2:44:00 AM)
For acute low back pain I really like to use the modified Oswestry. Why not let this score help you decide when to change an intervention. A clinically meaningful change in score is 6 points (or 12%) according to studies by Fritz and Delitto. I administer the questionairre on the initial visit and then after 3-4 interventions or whenever you follow up I administer it again. If there is a clinically meaningful change in score from the initial visit I typically continue with the intervention. If there is a worsening effect (although this is rare if we are manipulating this subgroup who meet the CPR) then I change or modify the intervention. You can use other outcome measures for various other NMS complaints too, not just back pain. I use them and I think they are very helpful.

KAK -> Re: LBP Treatment Approaches (June 25, 2005 3:37:00 AM)
I reassess every visit, with simple pain ratings (and frequency and location questions), and questions about functional improvements. Then every 3-4 visits I ask the big question, “Overall since beginning therapy are you worse, better or the same?” If they say better (what I’m hoping for), I ask for a percentage better. I am often pleasantly surprised by their response. I love to follow up with “How are you better?” - gleans all sorts of interesting info. I also use the modified Oswestry. I usually wait for 3 weeks (or at discharge it they are good to go before that) before having them fill it out again. Knowing when to change the treatment plan is a good and tough question. So many factors to consider- many already outlined. Often I have patients with significant insurance limitations. I don’t feel the luxury to wait 5 weeks and then reassess for improvement. I’m modifying my plan each visit based on their response. Sometimes that modification may be additional education about home program, compliance or exacerbating activities. In general, if the patient is on board, and I don’t see ANY improvement in 3 or so visits I change something I’m doing.

eam -> Re: LBP Treatment Approaches (June 25, 2005 4:37:00 AM)
Alex and KAK, You both bring up good points on outcome measures. They are so important and admittedly, I do not use them often enough and feel I should. Does anybody else use them? Are there any other ones that seem useful? Sometimes when a patient tells me, "no change" and with more questioning, they are actually functioning much better, I often wish that I had administered some measure at IE to document improvement. If you are seeing objective improvement but no subj.they are the same, it makes me question the approach. But when they actually are administered an outcome measure, they are better. I don't want to go off on a tangent to the original thread, I am just curious. Erica

Synergy -> Re: LBP Treatment Approaches (June 25, 2005 7:56:00 AM)
Currently, I only use the Modified Oswestry, NDI, and I think I may even have a Lysholm somewhere. I wish I had access to more outcome measures (for each joint/location) because I would use them. Often times, I see an improvement in overall function and a decreased score, but the patient may still have the same c/o pain. I guess improved, let's say, improved functional mobility, doesn't always equate to decreased pain.

Alex Brenner PT MPT OCS -> Re: LBP Treatment Approaches (June 25, 2005 9:36:00 AM)
There are times when I ask the patient if they are better and they will say no. I then show them their 20% decrease in Oswestry score and reassure them that they are showing signs of improvement even though they do not perceive them. Erica, I was presenting a case study at the European Physical Therapy conference a few months ago and I asked the audience how many were regularly using the Oswestry. Out of about 50 people only 2 raised their hands. It really surprised me.

wsherk -> Re: LBP Treatment Approaches (June 25, 2005 10:25:00 AM)
Have you noticed that people come back the second and third time, and they're improving and happy. Then about the fourth time, they say they're not improving and complain about this problem and that pain. I've learned to ask specific questions from the initial history "So you're still not sleeping through the night?" And they answer that they're sleeping very well now, no pain at night anymore. "What about that pain that was so severe in your calf, is it just as bad?" Oh, no, it's not there anymore, the whole leg is fine now. I think that they forget how bad they were in the beginning, and just start to focus on the remaining problem. And if you help them remember how much they've improved, their whole attitude changes, and you can go on from there.

Synergy -> Re: LBP Treatment Approaches (June 25, 2005 1:45:00 PM)
Alex, Your last post (the first 2 sentences) is exactly what happens most often with me as well. Sometimes, however, the patients will say "yeah...I can see that I've improved with [insert whatever], but what about [insert whatever]?" A lot of the time, they do improve with functional activities, but they may still report their pain as high. wsherk, I know exactly what you mean. To add, patients don't realize that new pains or aches increase when we increase/progress their programs. I imagine some therapists become absent minded and forget to inform the patient that he/she may notice some soreness during or after the new exercise. I think when they understand these simple truths they do know things are getting better and indeed their attitudes change. Just my 2 cents. :)

carleenej -> Re: LBP Treatment Approaches (June 25, 2005 5:56:00 PM)
I would like to reiterate Sarah C’s question to PTupdate on treatment approach for acute HNP/neural encroachment type problems--please elaborate Mr. Duffy. Thanks! ~Liz

USAPT -> Re: LBP Treatment Approaches (June 27, 2005 3:53:00 AM)
JBeneciuk, good thread. I question myself all the time, whether that's good or not, I don't know. I use the modified Oswestry at IE, ~4-6 sessions into it, and then at D/C. Sarah/Lizz, I can't speak for John, with an acute HNP I usually expect results before they leave the IE. A possible rx approach may be repeated backward bending, lateral shifts, and prone positioning (POE). And this of course depends on every person (age, MOI, uni/bilat, etc). Chris, I hear that all the time. I find re-iterating that they are going to have pain but it is going to differ in severity and frequency. The new 'pain' may very well be a response to normal re-education w/ ther-ex and that is normal. Unless it's severe 'new' pain, I'm not worried about an exaccerbation. Again, just my 2 cents:)

JLS_PT_OCS -> Re: LBP Treatment Approaches (June 27, 2005 4:35:00 AM)
OK, here I go again offering stuff... I have a bunch of outcome measures/ questionnaires I am willing to email people if they send me a PM. I have the OSW, the NDI, the FABQ, the FRI, etc. But after my DNF experiences and emailing files on and off for weeks, I can only offer it for 3 days. After that, you've got to ask someone else if they've got it... :) I need to get a website or something... J

JLS_PT_OCS -> Re: LBP Treatment Approaches (June 27, 2005 5:00:00 AM)
I think reeval depends on the patient. For the acute folks, I expect immediate improvement, within a week for the acute LBP people with manipulation. For the acute people who have some sort of leg symptoms that don't resolve with manip or that seem to be ?HNP, then I do some supine ham stretch/neuromob type stuff (can't go into detail yet, Shacklock's clinical neurodynamics is on it's way) as well as some extension positioning stuff a la McKenzie. If they don't centralize within 2-4 weeks, I'll redirect. The chronic LBP folks get more time, usually about 4-6 weeks of some approach before a change. I do manual therapy for those who don't move smoothly, and a local or global strength/stability approach depending on the person. I am developing a pain education class also, but I have a way to go before I'm ready to roll that joker out...still getting educated myself. For those with neuro signs and LE symptoms, I will usually combine a trial of traction and McKenzie type stuff for about 4-6 weeks as well before I decide it isn't happening one way or another and I change stuff up... J

USAPT -> Re: LBP Treatment Approaches (June 27, 2005 6:55:00 AM)
I only have 1 set of eyes in my clinic...mine. and it sometimes gets hard to see the forest. If it's not broke, don't fix it. I'll stay with a tech or ther-ex (progressing dynamics of it though)for a few weeks if it's working well. No need to change directions just b/c it has been "x" # of weeks or 'I should probably change this up". The chronic LBP pts of mine get a form-force closure type of program that I have had good success with. Is it valid/reliable...I don't know, but my pts leave w/ less pain and are functionally performing better during ADLs and at work. Jason, how about [URL=http://www.jsilverstudies.com...lol]www.jsilverstudies.com...lol[/URL]

Shill -> Re: LBP Treatment Approaches (June 27, 2005 8:10:00 AM)
Lots of good posts on this challenging issue. I make sure at first that the patient is doing things as asked. And that I asked my questions carefully. The patient must be doing as I have asked. All things, not just some occasional exercises or posture/bodymechanics changes. Sure it is difficult, but not impossible. The level of detail in the questions asked gives me a better idea of when I need to change my mind, and my approach. Location, intensity, frequency of pain, when it occurs, what they are doing at that time it occurs (position, activity, etc), what they do about the pain as it returns, (if exercises are helpful for consistent pain reduction, do they apply what they have learned, or just go on hurting?). Have they made the suggested changes to sleeping position, morning activities, etc, or are they just plowing through the routine with the daily pain and praying for relief? What are their barriers to recovery? Have we discovered all of these, and are they consistent? If all is being done well, and 4-6 weeks of no progress has occurred, I will consider changing. We have guidelines for # of visits per diagnosis,and even time frames for these visits, but quite honestly, I think these stink. Why? Take a look at all of the data on recurrence rate for LBP. 60-85% recurrence? Thats not too good. All of us can argue for going beyond the suggested visit number and treatment time durations (within reason), based on the recurrence rate. Which brings up the question, are we discharging care too soon, when there are still problems and pain, and therefore the healing is not complete? It is unrealistic and extreme that we should follow patients until complete resolution, but when you look at the recurrence data, something is amiss. Sorry for the ramble, Steve

JLS_PT_OCS -> Re: LBP Treatment Approaches (June 27, 2005 9:35:00 AM)
Steve has an interesting approach to compliance, but I have another one to mention to the group. I used to use adherence to my exercise program/instructions/ requests as an indicator of who would get better and who wouldn't. When I stepped back, it didn't seem to shake out that way. I now see noncompliance as a way to let me know some things: 1. Exercise prescribed did not relieve pain 2. Exercise prescribed did not seem appropriate 3. Improvement in ability to execute exercise prescribed not mentally connected to pain reduction 4. Patient unconvinced that I have the tools to help them All of which tell me a lot about where to go from here. For those few conditions with clearer practice guidelines (eccentric exercise for tendonopathy for example) I am more certain of the correctness of my prescription and am subsequently more demanding of compliance. But especially for spine patients, I find I am much less indignant now when they admit or I discover they are noncompliant with the program. It actually helps in my clinical decision scenario...I figure if the stuff I gave them was all that great, they would have stuck with it... :) J

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