Outpatient care for low back pain in a medically complex patient : a clinical presentation

1. Outpatient care for low back pain in a medically complex patient: aclinical presentation AJ Cushman, SPT 2016

2. Purpose Purpose Begin a discussion proposing potential strategies for treating chronic low back pain when unique complications are present.

3. Demographics – Marty Marine • 57 yo male. • Lives his wife. • Former military. • Non-working. • Complicated medical history since 1984 • Permanent disability since 1991.

4. Current Patient History • Chronic LBP with L4-5 spondylolisthesis • Since 1984, over a dozen bowel resections due to severe Crohn’sDisease, most pertinent for: • Dec 2012: Abdomen was left open for 14 months • Feb 2014: Surgical mesh placed instead of completely closing abdomen • Aortic valve replacement 2002 • Chronically anticoagulated with Warfarin • Unclear follow up surgeries • Osteopenia • Osteoarthritis

5. Subjective CC: LBP and significant abdominal weakness due to multiple sx and skin/mesh grafts Recent MOI: In Dec 2014 he helped lift a neighbor with an acute exacerbation of pain. Pain Level • Current: 4/10 • Best: 3/10 • Worst: 7/10 Nature: Constant aching, but worse with activity Location: Midline lumbosacral area. Denies radicular symptoms Functional Status • Difficulty/pain with lifting, standing, ADLs

6. Patient Goals • Improve core strength • Minimize LBP

7. Objective Exam: Observation • Posture • Increased posterior shift of thoracic spine w/ mild anterior pelvic tilt • Integument • 12cm x 18cm abdominal graft site in midline abdomen with decreased tissue tension • Central line port in L chest (receives TPN 3x/week) • Colostomy (permanent)

9. Objective Exam: Tests and Measures • Lumbar AROM • Extension: 15 degrees • Flexion: 50 degrees • L Rotation: 10 degrees • R Rotation: 15 degrees • L Side Bend: 10 degrees • R Side Bend: 15 degrees • MMT • LE R/L: 5-/5 • Thoracolumbar Planes R/L: 3+/5(**S/S) • Dermatomal Sensation: Intact and equal bilaterally

10. ICF Spine: Lumbago & Abdominal Pain Pain Abdominal weakness Impaired spinal stabilization Decreased lumbar ROM Decreased skin integrity Unable to participate in communities activities and social outings with wife Lifting Standing ADLs Insurance limitations Multiple physicians Family support Crohn’s Disease/PMH Psychology of disability Motivation

11. Plan of Care • “Good” candidate for therapy • Frequency: 2x/week • Duration: 3 weeks • 6 visits total

12. Goals. Pt will… STG (2 weeks) • Report decrease in pain at worst to 5/10. • Report independence with self care/HEP. • Demonstrate ROM improvements to lumbar spine: • L/R Rotation: 15 degrees LTG (4 weeks) • Report decrease in pain at worst to 4/10. • Able to perform functional lifting with improved core control/posture and decreased LBP • Be able to stand longer periods with decreased severity of LBP and improved posture • Demonstrate ROM improvements to lumbar spine: • L/R Rotation and Side Bend: 20 degrees

13. Treatments • Gentle spine ROM : LTRs (pain-free) • Spinal stabilization progression • Supine, quadruped, sitting, standing • External support garment and hands for additional support • Pt education = CONSTANT • Deep core stabilization philosophy • Breathing cues • Effect of valsalva maneuver (VM)  intraabdominal pressure (IAP) + graft tension • Positional tolerance

14. Outcomes • Improved: • Pain severity • Ability to isolate TrA • Core control during functional tasks • Lumbar ROM (modest) • Still requires cueing for proper breathing • Instructed to: • Follow up with MD regarding issues • Avoid pos/ex that increase “pressure” sensation • Discharge secondary to: insurance visit limitations

15. In a middle-aged male with significant mechanical core compromise secondary to multiple abdominal surgeries, is core strengthening an effective treatment strategy to address his low back pain?

17. Effects of exercise on diastasis of the rectus abdominismuscle (DRAM) in the antenatal and postnatal periods: a systematic review D.R. Benjamin, A.T.M. van de Water b, C.L. PeirisPhysiotherapy, 2014

18. From bowel resections to women’s health • Diastasis (DRAM) = Inter-rectus distance >2 cm • Very common during and after pregnancy: • 66-100% report in 3rd trimester • >50% remain postpartum • Greatest recovery up to 8 weeks after delivery • Acknowledgedrisks of increased inter-recti distance • Altered trunk mechanics • Change posture • Impaired pelvic/spinal stability = Vulnerable to injury!! • Surgical reduction of DRAM shown to reduce back pain.

19. Purpose Determine if non-surgical intervention can prevent/reduce DRAM for similar results.

20. Methods/Study Selection • 1682 screened 20 relevant 12 excluded: • No intervention being investigated • No DRAM outcomes reported • 8 studies included • 4 studies examined antenatal interventions to reduce risk of DRAM • 4 studies examined postnatal interventions to reduce DRAM width/aid recovery

21. Of these 4 studies

22. Outcomes/Conclusion • Zappile-Lucis2009 reported significant improvements in: • Back pain • SF36 measure • Primary finding • All studies showed significant reduction in DRAM width with exercise • Rationale: Improved abdominal strength/control improves integrity of linea alba by reducing stress • Secondary • Improved TA activation and endurance (Sheppard 1996) • Corset helped reduce low back pain (Thornton et al. 1993) HOWEVER, Due to poor quality of the included studies, current evidence suggests that non-specific exercise may or may nothelp reduce DRAM during postnatal periods.

23. Strengths Weaknesses • Comprehensive search • Reduced selection bias • Robust extraction/analysis • Similar deficit • Orientation of damage • Core strengthening • Use of external support • Poor quality of literature • Low power • Variable interventions, definitions/measurement methods of DRAM • Pregnancy vs surgery • Tissue stretched vs tissue broken • Timeline Relevance to my patient

24. The Importance of a Normal Breathing Pattern for an Effective Abdominal-Hollowing (AH) Maneuver in Healthy People: An Experimental Study Sung-min Ha, Oh-yun Kwon, Su-jung Kim, and Sung-daeChoung Journal of Sports Rehabilitation, 2014

25. Purpose Compare abdominal mm thickness according to breathing pattern during AH maneuver and investigate preferential contraction ratio (PCR) of TrA during each pattern.

26. Methods 16 subjects (8 M, 8 F) with mean age 21.5 years Exclusion for neuro, msk, cardiopulm, disease and persistent pain Real-time US Scanner Pressure Biofeedback Unit (@ 40 mmHg) Respiratory Monitor Unit

27. Procedure All participants performed AH under both breathing patterns • Normal breathing: emphasize abdominal/lateral costal expansion • Abnormal breathing: emphasize superior thoracic expansion AH maneuver: • “Gently hollow your abdomen while breathing out, so as to keep the pressure (40 mmHg) as stable as possible.” (Draw your belly-button towards your spine) • Contraction held 5” • 1’ rest b/t trials • 3 trials for each breathing pattern • 5’ rest b/t breathing patterns • Measured muscle thickness at both relaxed and contracted states

28. Measurements and Calculations • 3 mm thickness ratios: • TrA • EO + IO • TrA PCR • PCR = preferential contraction ratio • Proportion of TrA mm thickness relative to EO and IO during relaxed/contracted states • Higher values = more TrA!

29. Results NORMAL ABNORMAL

30. Effect of Normal Breathing Pattern onTrA mm Thickness/PCR

31. Conclusion and My Patient Normal breathing is important for an effective AH maneuver Limitations • No long term training? • No measurement of diaphragm activity/rib cage motion • Are these effects the same in different positions? • Not widely generalizable How this information could help my patient • Understand detriment of inadequate breathing • Specific strategy • Help prevent VM…and secondary effects

32. Unknown. Need more info. In a middle-aged male with severe mechanical core compromise secondary to multiple abdominal surgeries, is core strengthening an effective treatment strategy to address his low back pain?

34. References Sung-min Ha et al. “The Importance of a Normal Breathing Pattern for an Effective Abdominal-Hollowing Maneuver in Healthy People: An Experimental Study.” Journal of Sports Rehabilitation 2014; 23: 12-17. Benjamin, D.R. et al. “Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review.” Physiotherapy 2014; 100: 1-8. Cobb, S. William et al. “Normal Intraabdominal Pressure in Healthy Adults.” Journal of Surgical Research 2005; 129:231-235. Hackett, Daniel A. “The Valsalva Maneuver: Its Effect on Intra-abdominal Pressure and Safety Issues During Resistance Exercise.” Discipline of Exercise and Sports Science, University of Sydney, Sydney, Australia 2013; 8: 2338-45. Liebenson, Craig. “The role of the transverse abdominus in promoting spinal stability.” Journal of Bodywork and Movement Therapies 2000; 4 (2): 109-112. Miyamoto, Kei et al. “Effects of abdominal belts on intra-abdominal pressure, intra- muscular pressure in the erector spinae muscles and myoelectricalactivities of trunk muscles.” Clinical Biomechanics 1999; 14: 79-87. Monfort-Pañego, Manuel et al. “Electromyographic studies in abdominal exercise: A literature synthesis.” Journal of Manipulative and Physiological Therapeutics 2009; 32 (3).

35. ?????????? Bring ‘em on Questions?