Lumbar Examination & Treatment: Practical Tips for Clinicians

1. Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID: 32694-30782

2. Tips for the Busy Clinician: Lumbar Exam & Treatment Leah Tobey, PT, DPT, cert. DN Physical Therapist AGEC Clinical Coordinator University of Arkansas for Medical Sciences

3. Objectives • Review A&P of lumbar spine • Identify elements which compose 5 minute exam for PCP • Recognize statistics associated with “normal” age-related spine changes • Discuss evidence-based treatment for LBP • Psychology meets Physiotherapy-words matter • Several tips from PTs

4. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations

5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464797/

6. Patient with DDD • A complex degenerative process due to age-related changes in molecular composition of the disc • Intervertebral disc is a hydrostatic, load-bearing structure between the vertebral bodies • Nucleus pulposus + annular fibers • Aging reduces the water content of the intervertebral disc & fissures form in the nucleus pulposus (NP) FYI: A healthy disc has an abundance of proteoglycans (proteins in connective tissues) to allow for absorption of H2O

7. Cellular & Biomechanical Change • Uneven stress distribution through the annulus • Spinal degeneration thoughts: • Small tears in the annulus fissures formed extend into the NP loss of proteoglycans & water loss of disc height disc collapses shortened space between 2 vertebral bodies vertebral sclerosis + osteophytes • MRIs do not provide all pieces to the puzzle • Static testing doesn’t show us the puzzle piece of how back pain manifests in weight-bearing positions (standing).

8. Encourage patient ownership of changes to be made

9. Multidisciplinary treatment model Physiotherapy meets Psychology • Patient education: Our words matter • Avoid “bone on bone” or “never bend over again” • Physical: PT, chiropractor, personal trainer • Educational: body mechanics handout? • Psychological • Work-related • All are thought to be more effective vs monotherapies. • It is important to educate patients on how to alleviate disc loads, reduce and remove any aggravating factors/activities in order to reduce LBP.

10. 5 minute Examination • Inspection & Observation in Standing • Asymmetry, redness, kyphosis, lordosis, scoliosis • Palpate for areas of tenderness • SPs, Paraspinous Mm, Sacroiliac joint • ROM: looking for pain & limitation • Flex, Extend, (Side-bend, Rotate) • Strength testing • L4: heel walking; Anterior Tib • L5: resisted great toe ext • S1: toe walking; Gastroc • Neuro testing • DTRs, SLR, ankle clonus

11. History • The patient’s detailed subjective history will guide your examination, further testing (SLR, clonus) etc. • Try to determine flexion or extension bias • can be disguised by hip or SIJ pain/dysfunction  Differentiate

13. How to join Poll everywhere questions • Open a new text • Text To: 22333 • In the message line, type LEAHTOBEY999 (not case sensitive)

15. Facts • LBP is the single most common cause for disability in individuals aged 45 years or younger • Economic losses resulting from LBP estimated to exceed $100 billion/yr due to reduced productivity • Radiographic evidence often shows lumbar DDD seen in asymptomatic patients • Traditional treatment options for DDD remain suboptimal • Novel tx ideas with theoretical potential: stem cells, growth factors & gene therapies may slow or even reverse disc degeneration (Taher, et al. “Lumbar Degenerative Disc Disease: Current & Future Concepts of Diagnosis & Management.”)

16. Physical Therapy • From exam, you decide to refer your patient to PT…

17. Patient Education • Pt needs to understand: • Her/his common causes of back pain • Action planning & problem solving techniques • Topics frequently discussed in PT: • Anatomy of the spine • Pain mechanisms • Exercises for managing back pain

18. Alternate changes to reduce pain • Repair occurs through nutrition from repetitive motion. This is the same concept used with Continuous Passive Motion machines in cartilage repairs of the knee.  Movement aids in lubrication and bringing natural nutrients to the disc • Repetitive motion may reduce the acidity and centralize symptoms • Changes to the disc result in a lower PH surrounding the disc 

19. PT Tips • Lessen your load(ing): • Avoid sleeping on soft mattresses • Avoid prolonged sitting • *Correlation studies associate these with higher LBP rates • Sedentary behaviors Stand & walk each hour • Research suggests trunk strengthening and endurance exercise can help treat & prevent some cases of LBP

20. Sitting is the new smoking

22. What core? • PT Tip: Not all patients benefit from core strengthening • Pt planks for 2 min may still have back pain… • Recent studies are showing core strengthening is no better than general exercise for LBP • CirculationIncreased Mobility?

23. Research: Evidence-based practice

24. Results: Significantly lower chronic LBP with intervention groups using exercise compared to a control group or other treatment group

25. More Patient Education • The importance of maintaining physical activities • Importance of resuming daily activities • Use of medicines for controlling back pain • Rx or OTC • Physical methods of pain control • Ice, TENS, heat • Mind-body techniques for pain control • Imagery • Meditation • Use of proper posture and body mechanics • goal example: Pt to demonstrate correct hip hinge with squat while lifting 10# without increased pain

26. Educational topics continued • Stretching exercises • Strengthening exercises • The importance of aerobic exercise • Handling emotional & interpersonal effects of back pain • Managing sleep difficulties • Managing flare-ups of back pain

27. The Why is important… Understanding diagnosis Unable to recall conditions or limitations, course of action, etc. Poor health literacy ~37% adult Arkansas heave low health literacy (AR Dept of Health) Inactivity Higher mortality risk Lower QOL scores Higher pain ratings Sedentary lifestyle Poor eating habits • Knowledgeis power • Moderate level of activity • Lower mortality risk • High QOL scores • Lower pain ratings • Active lifestyle • Mindful nutrition • Self-pacing

28. Health literacy • Educational pamphlets on pain management • IOA grant booklet • Available for purchase as a starter • lrtobey@uams.edu • Educational handouts on common ways to manage pain • Diagnosis specific • This helps you as a clinician document educational efforts toward health literacy • Patients can keep a journal • Sleep journal • Pain journal • Improves self-awareness & management • General exercise suggestions • 30’/day (10’ min increments) • 150 minutes of moderate exercise/wk

29. Conclusion • Encourage patients to take an active role in protecting their well-being & happiness, in particular during periods of stress or pain. (Oxford living dictionary)

30. In closing… • Use evidenced-based, clinical judgement to make an informed treatment decisions when treating your patients with LBP. • Education is key to alleviating disc loads, and removing the aggravating factors that resulted in LBP in the first place. • Examples: • Sitting posture at work • Frequent rest breaks from constant sitting • Body mechanics • Lifting corrections • Encourage general exercise program • Walking 10 mins/day, incrementally increase to 30 mins as pain allows

31. References • The American Physical Therapy Association, www.apta.org • Taher, et al. Lumbar degenerative disc disease: current and future concepts of diagnosis and management. AdvOrthop. 2012;2012:970752. doi: 10.1155/2012/970752. Epub 2012 Apr 2. • National Institute of neurological disorders and stroke, Low Back Pain Fact Sheet • American Chronic Pain Association (ACPA); http://www.theacpa.org • Patient education: low back pain in adults, beyond the basics; March 21 2018 update • Castillo, E., Lieberman D., Lower back pain. Evolution, Medicine, and Public Health, Vol 2015, Issue 1, 2015, Pg 2-3. https://doi.org/10/1093/emph/eou034 • Kamper et al Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta analysis. BMJ 2015. Doi: https://doi.org/10.1136/bmj.h444

32. Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076 Event ID: 32694-30782