1 / 48

Recognition of Back Injuries in the Non Athlete

Recognition of Back Injuries in the Non Athlete. Ryan Perry PT, DPT, OCS, CSCS, MTC, FAAOMPT NovaCare Rehabilitation - Chicago March 12 th , 2010. Athlete vs Non-Athlete. Incidence Prevalence of LBP among former elite athletes of all sports was 29%, compared with 44% among non-athletes.

alyson
Download Presentation

Recognition of Back Injuries in the Non Athlete

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Recognition of Back Injuries in the Non Athlete Ryan Perry PT, DPT, OCS, CSCS, MTC, FAAOMPT NovaCare Rehabilitation - Chicago March 12th, 2010

  2. Athlete vs Non-Athlete • Incidence • Prevalence of LBP among former elite athletes of all sports was 29%, compared with 44% among non-athletes. • Bono, 2004 • Higher rates of spondylolysis, spondylolisthesis and disc degeneration have been reported in athletes than in the general population. • Ong et al, 2003

  3. Athlete vs Non-Athlete Fritz, 2010 • Adolescents with LBP as a result of sports participation tended to have lower baseline disability scores and to experience less improvement in disability than non-participants • Also attended more PT sessions over a longer period of time

  4. Athlete vs Non-Athlete Fritz, 2010 • Patients who were sports participants were more likely to undergo an MRI before referral • Overall pattern of outcomes in this sample of adolescents was similar to reports of outcomes from adults with LBP

  5. Easier or Harder to Treat? • Athlete • Typically in better shape than non-athlete • Very motivated to exercise • Understands the difference between pain from DOMS and true pain • Can be demanding • Non-Athlete • Lower physical expectations at discharge • Less diagnostic imaging before onset of PT • Subjected to decreased load and strain

  6. Recognition of Back Injuries Common Diagnoses • Lumbar sprain/strain • Discogenic pain • Instability • Facet syndrome • Scoliosis • Stenosis • Arthritis • Fracture • Other Miscellaneous • Non-musculoskeletal (3% of LBP- Deyo,2001)

  7. Cancer & LBP Primary areas of CA that can cause metastatic spine CA • Breast • Lung • Thyroid • with • Kidney • Prostate • The spine is the most common site of bone metastasis • Tumor-related pain is predominantly nocturnal or early morning pain and generally improves with activity during the day

  8. Non-mechanical Causes • Malignancy • Infection • Inflammatory spondyloarthropathy (ankylosing spondylitis, psoriatic spondylitis, Reiter's syndrome, inflammatory bowel disease) • Osteochondrosis • Paget's disease of bone

  9. Referred Pain • Pelvic disease (prostatitis, endometriosis, pelvic inflammatory disease) • Renal disease (kidney stones, pyelonephritis, perinephric abscess) • Aortic aneurysm • Gastrointestinal disease (pancreatitis, cholecystitis, penetrating ulcer)

  10. Nonorganic Signs of LBP Described by Waddell, and these usually suggest delayed recovery and need for multi-disciplinary approach • Pain at the tip of the tailbone • Whole-leg pain in global distribution • Whole-leg numbness in a global distribution • Sudden give-way weakness of the leg • Absence of even brief periods of relative pain relief • Failure or intolerance of numerous treatments • Numerous urgent care visits or hospitalizations for back pain • Waddell G, Bircher M, Finlayson D, Main CJ: Symptoms and signs: Physical disease or illness behaviour? BMJ (Clin Res Ed) 1984:289:739-741.

  11. Lumbar sprain/strain • Most commonly diagnosed lumbar pathology • Strain • Occurs by disruption of muscle fibers or the musculotendinous junction • Sprain • Stretching or tearing of spinal ligaments • Will have localized isolated tenderness of the lumbosacral spine • Patient will not have signs of red flags for non-spinal conditions or cauda equina nor tension signs associated with nerve root irritation • Graw & Wiesel, 2008

  12. Typically seen between in 4th & 5th decade of life Pain often in the lower extremity Pain usually worse with sitting or bending Neural tension signs Many false positives with MRI Discogenic Pain

  13. Discogenic Pain • Not all disc problems that present on MRI cause pain • Make sure you correlate the clinical exam with the MRI • Jensen et al, 1994 • Thirty-six percent of the 98 asymptomatic subjects hadnormal disks at all levels. • Thus, 64% had at least a disk bulge at least at one level in the lumbar spine

  14. Usually present in patients >60 y/o Pain worse with walking Pain relieved with sitting Typically have decreased extension ROM Pain often primarily in LEs Use Bicycle test of van Gelderen to differentiate between vascular disease Spinal Stenosis

  15. Characterized by stiffness Patients usually >50 y/o Typically worse in the morning Amount of ROM proportional to disc height Arthritis

  16. Spondylolysis • Spondylolysis: A defect in the continuity of the pars interarticularis of the vertebrae • Seen in ~5% of the population • Controversial whether the incidence is higher in the athletic or non-athletic population • Athletes tested more frequently for this • Some studies show a lower rate of this abnormality in athletes compared to non-athletes • Moller & Hedlund, 2000

  17. Spondylolisthesis • Slippage of one vertebrae on its adjacent segment • Thought to be a further progression of bilateral spondylosis • Over 5 years of follow-up, younf athletes demonstrated a 38% rate of slippage, which was not significantly different than the general population • Bono, 2004

  18. Spondylolisthesis • Clinical findings: • Radiographic evidence of spondylolysis and slippage with flexion-extension X-rays • Localized LBP with or without radiating LE pain and/or neurological findings • Positive Stork sign (one-legged extension) • Graded I-V • Grades I-II usually successful with conservative care • Grade V (spondyloptosis): Surgical

  19. Non-specific LBP • LBP in the presence of non-specific abnormalities on imaging studies • Graw & Wiesel, 2008

  20. Philosophical Persceptive • The structure should have a nerve supply • The structure should be capable of causing pain similar to that seen clinically • These structures should be susceptible to diseases or injuries that are known to be painful • The structure should have been shown to be a source of pain in patients using diagnostic techniques of known reliability and validity. Bogduk 1997

  21. Diagnosis • Do we really have an accurate pathoanatomical diagnosis? • Unlike younger patients, only 15% of mature patients can be given a precise diagnosis • Deyo 2001 • No firm evidence exists for the presence or absence of a causal relationship between radiographic findings and nonspecific LBP • van Tulder, 1997 • Identifying relevant pathology in patients with LBP has proved elusive and is identified in <10% of cases • Abenhaim et al, 1995

  22. Need for Change • Despite the fact that >1000 RCTs have investigated the effectiveness of conservative and surgical interventions for the management of LBP have been reported in the literature, evidence remains contradictory and inconclusive for many interventions • Hayden et al, 2005 & Koes et al, 2006; both in Fritz, et al 2007 • Cannot treat LBP with only one approach, as not one single approach has shown to be effective

  23. Classification Model • Subgrouping • The subgrouping hypotheses proposed are intended for patients who may or may not be involved in athletic activities with acute LBP or an acute exacerbation of LBP causing substantial pain and limitations in daily activities. • After screening patients for any signs of serious pathology, information collected during the history and physical examination is used to place a patient into a subgroup. Hebert et al, 2008 & Delitto et al, 1995

  24. Classification Model • Subgrouping • Four subgroups were established by Delitto et al in 1995 • Manipulation • Stabilization • Specific Exercise • Traction • Subgroups classification criteria and intervention procedures updated in 2007 by Fritz et al.

  25. Classification Model: Manipulation • Clinical prediction rule (CPR) developed & validated by Flynn & Childs, respectively. • Goal of the CPR for the manipulation classification is to identify patients with LBP who are likely to respond to manipulation with rapid and sustained movement • Improvement defined as a 50% or greater reduction in self-reported disability over 2 treatment sessions • Intervention: Manipulation of the lumbopelvic region and AROM exercises

  26. Classification Model: Manipulation • CPR included 5 factors • Current symptom duration of less than 16 days • Score <19 on the work subscale of the Fear-Avoidance Beliefs Questionnaire (FABQ) • Hypomobility of the lumbar spine as assessed with posterior-to-anterior pressure • Hip IR of at least 1 hip greater than 35° • Symptoms not extending distal to the knee. • When 4 of these 5 factors were present, patients were highly likely to improve, while the presence of 2 or fewer factors was almost always associated with a failure to improve. • 4 or greater: +LR = 24 • 2 or less: - LR = 0.09 * Flynn et al, 2002

  27. Classification Model: Stabilization Clinical Prediction Rule (Hicks, 2005) • If the patient has three of the following four criteria, then he/she will be four times more likely to be successful with a stabilization program in physical therapy • Age <40 years old • Straight leg raise >90 degrees • Aberrant movement present during ROM testing • Positive prone instability test

  28. Classification Model: Stabilization Stabilization Interventions (Fritz et al, 2007) • Isolated contractions of the deep multifidus and transverse abdominis • Strengthening of large spinal stabilizing muscles (erector spinae, obliques, etc)

  29. Classification Model: Stabilization Long-term effects (Hides 2001) • Studied recurrence rate of LBP after acute, first-time episode of LBP • Subjects allocated to two groups • Control: General advice plus use of medications • Experimental: Specific exercise targeting the lumbar multifidus and transverse abdominis

  30. Classification Model: Stabilization Long-term effects (Hides 2001) Results • The recurrence rate at one-year of follow-up was 84% in the control group and 30% in the experimental group (p<0.001) • Results were similar at the three-year follow-up

  31. Classification Model: Stabilization • Classification approach was updated for patients who are post-partum • Updated classification criteria • Positive posterior pelvic pain provocation (P4), AND SLR and modified Trendelenburg tests • Pain provocation with palpation of the long dorsal SI ligament or pubic symphysis • Fritz, 2007

  32. Classification Model:Specific Exercise/Directional Preference • Patients that typically respond are the following • If the patient has reduction of symptoms with >2 repetitions in the same direction OR • If the patient has centralization of symptoms in one direction and peripheralization of symptoms in the opposite direction • Directional preference can be extension, flexion, or lateral shift

  33. Classification Model:Specific Exercise/Directional Preference • Repeated ROM performed initially, followed by strengthening exercises toward the directional preference • McKenzie program is the most common form of directional preference therapy • McKenzie program is not always extension

  34. Classification Model: Traction • Performed when the following criteria are present: • Signs and symptoms of nerve root compression • No movements centralize symptoms • Typical treatment: Mechanical traction or autotraction Fritz et al, 2007

  35. Classification Model: Traction • Fritz et al (Spine, 2007) found that the presence of symptoms below the buttock and signs of nerve root compression were not specific enough to identify this subgroup • Two additional factors were found to identify patients likely to respond favorably to traction • Peripheralization with extension movement • Positive crossed SLR (aka Well SLR)

  36. Classification Model: Traction • When patients with symptoms below the buttock and signs of nerve root compression had either of these findings received traction plus an extension-specific exercise program, they showed greater short-term reductions in disability than patients who received only the extension exercise program (Fritz, 2007)

  37. Classification Model: Traction • Cai et al, 2009 • A clinical prediction rule with four variables was identified. • Non-involvement of manual work • Low level fear-avoidance beliefs • No neurological deficit • Age above 30 years • The presence of all four variables (+LR = 9.36) increased the probability of response rate with mechanical lumbar traction from 19.4 to 69.2%.

  38. Fear-Avoidance Beliefs • Fear avoidance simply refers to avoidance of movements or physical activities because of the patients’ fears that pain will make them worse

  39. Fear-Avoidance Beliefs • Studies suggest that questionnaires based on the fear-avoidance model accurately identify poor prognosis for patients with LBP • Al-Obaidi et al, 2005 • Interventions aimed at confronting these beliefs and graded exercise have been effective at reducing pain • George et al, 2003

  40. Fear-Avoidance Beliefs Fear-Avoidance Beliefs Questionaire (FABQ) • http://www.kmcnetwork.org/ksmc/menu/FABQ.pdf • Waddell et al, 1993 • These results confirm the importance of fear-avoidance beliefs and demonstrate that specific fear-avoidance beliefs about work are strongly related to work loss due to low back pain

  41. Fear-Avoidance Beliefs Grotle, Spine, 2006 • In the acute sample, fear-avoidance beliefs for work predicted pain and disability at 12 months. • In the chronic sample, fear-avoidance beliefs for physical activity predicted disability at 12 months, but not pain.

  42. Fear-Avoidance Beliefs • The FABQ is a self report questionnaire with 16 items each scored from 0 to 6 with higher numbers indicating increased levels of fear avoidance beliefs. • The questionnaire contains two subscales • A 4 item activity subscale • A 7 item work subscale • The work subscale is associated with current and future disability and work loss in patients with acute and chronic LBP. * Waddell, 1993

  43. Fear-Avoidance Beliefs • The work subscale has been identified as a strong predictor of work status. • Scores of 30 or less are associated with a greater likelihood of return to work whereas of 34 or more are associated with less likelihood of return to work or increased risk of prolonged work restrictions. • Thus, a score of 34 or more on the work subscale of the FABQ should be a “Yellow Flag” for therapists and case managers working with out of work workers with low back pain. • Fritz & George, 2002

  44. Return to Activity/Prognosis Croft et al, 1998 • The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months. • However most will still be experiencing low back pain and related disability one year after consultation. • Only 25% will be completely recovered at this time in terms of both pain and disability

  45. Return to Activity / Prognosis • 10% of LBP patients account for 90% of healthcare and disability costs • Identification of individuals at risk is the first step in preventing chronic instability due to non-specific LBP • Iles et al, 2009

  46. Return to Activity / Prognosis • Recovery expectations when measured using a specific, time-based measure within the first 3 weeks of non-specific LBP is a strong predictor of people at risk of poor outcome • Iles et al, 2009

  47. Return to Activity / Prognosis • Patients with lower than average initial pain intensity, shorter duration of symptoms and fewer previous episodes were 3.5 more likely to be recovered at any time point than patients without these characteristics • These were described as the following: • Baseline pain </= to 7/10 • Duration of current episode </= 5 days • One or zero previous episodes of pain • Hancock et al, 2009

More Related