Lumbar Spine Management. Jason Zafereo, PT, OCS, FAAOMPT

Transcription

1 Lumbar Spine Management Jason Zafereo, PT, OCS, FAAOMPT Clinical i l Orthopedic Rehabilitation ti Education Are we being billed for this? 1

2 Objectives 2 Discuss the components of the ICF classification scheme Describe the treatment interventions used for the primary management of: Pain Stiffness Weakness Describe treatment considerations for rehabilitation after disc or fusion surgery

3 3 TREATMENT BY CLASSIFICATION

4 Old Classification Categories 4 Treatment-based classification (TBC) system (Delitto et al 1995) Pain-dominant treatment Specific Exercise Traction Impairment-dominant treatment Mobilization Stabilization

5 New Classification Categories ICF-based system (Delitto et al, JOSPT 2012) Pain-dominant treatment Acute LBP with referred LE pain Acute - Chronic LBP with radiating LE pain Impairment-dominant treatment Acute - Chronic LBP with mobility deficits Acute - Chronic LBP with movement impairments Acute LBP with related cognitive or affective tendencies Chronic LBP with related generalized pain 5

6 Acute LBP with Referred LE Pain 6 Often worsens with flexion Preference for lateral shift and sitting Visible frontal plane deviation of shoulders to Centralization with specific pelvis postures/rom Preference for extension Limited lumbar extension Symptoms distal to the mobility buttock Lateral trunk shift possible Symptoms centralize with lumbar extension Findings of Symptoms peripheralize subacute/chronic LBP with with lumbar flexion movement impairments Preference for traction Delitto et al, JOSPT 2012 No movements centralize symptoms Fritz et al 2007

7 Acute-Chronic LBP with Radiating Pain LE paresthesias, numbness, weakness, DTR changes possible Concordant sx with initial to mid range (acute), mid to end range (subacute), or sustained mvts/ nerve tension tests Delitto et al, JOSPT 2012 Preference for flexion Age > 50 Imaging evidence of lumbar spinal stenosis Preference for traction Signs and symptoms of nerve root compression Fritz et al

8 Acute-Chronic LBP with Mobility Deficits 8 Restricted ROM/segmental mobility of at least one of the following regions: Thoracic Lumbar Lumbopelvic Hip Concordant sx with LS PA (acute) or end range movements (subacute) Delitto et al, JOSPT 2012 Manipulation CPR Asymmetrical lateral flexion Positive Cibulka cluster Fritz et al 2007

9 Acute-Chronic LBP with Movement Impairments 9 Recurrent LBP, commonly referred Concordant sx with LS PA (acute-subacute), initial to mid range mvts (acute), mid to end range mvts (subacute), or sustained end range mvts (chronic) Hypermobile PA Stiff Thorax, Pelvis, Hips Weak Trunk, Hips Delitto et al, JOSPT 2012 Stabilization CPR Recurrent episodes with trivial onset History of lateral shift with alternating sides Prior use of manipulation for relief Trauma, pregnancy Relief with bracing Fritz et al 2007

10 Acute LBP with Related Cognitive or Affective Tendencies Chronic LBP with Related Generalized Pain 10 One or more of the following: High Fear-Avoidance or Anxiety FABQ-PA: Sum 2-5 Cutoff >14 FABQ-W: Sum 6-7, 9-12, 15 Cutoff >29 High Pain Catastrophizing Scale scores Rumination: 8-11 Magnification: 6-7,13 Helplessness:1-5,12 During the past month, have you often been bothered by feeling down, depressed, or hopeless? During the past month, have you often been bothered by little interest or pleasure in doing things? 2 no answers = -LR of 0.07 Delitto et al, JOSPT 2012

11 Classification Reliability and Utility 11 Reliability K =.60 when traction removed (paper assessment) Fritz et al 2006 K =.52 for all groups (individual assessment) Stanton et al, PT 2011 Utility Classification versus clinical practice guidelines or unmatched care Significant improvements in pain, disability, general health, satisfaction, and likelihood of returning to work in matched classification group (4 wks & 1yr) Fritz et al 2003; Brennan et al 2006

12 Prevalence Data 50% of patients meet criteria for one subgroup Of remaining 50%... 25% cannot be classified (myofascial pain?) 25% fit >1 classification 68% of these individuals fitting manipulation/specific exercise Stanton et al, PT 2011 (acute); Apeldoorn et al, Spine 2012 (chronic) c) 12

13 Beyond the old TBC 13 Classification often unclear in patients who are older, chronic, less affected by LBP (FABQ and ODI) Stanton t et al 2013 Treatment by old TBC criteria yielded equivocal outcomes to an individualized approach (Dutch LBP guidelines) (Apeldoorn et al 2012) and did not reveal a preference for matched care in the stabilization category (Henry et al 2014) in patients with CLBP New ICF guidelines represent the best attempt yet to provide considerations for directional preferences, regional interdependence, and chronic pain states

14 14 PAIN-DOMINANT TREATMENT

15 Pain-Dominant Treatment Contractile Myofascial pain syndrome Non-contractile Acute to subacute LBP with referred/radiating pain Lumbar spine stenosis Cauda equina syndrome Herniated disc HNP with radiculopathy Sciatica 15

16 Comprehensive Treatment for Pain 16 Tissue-Specific Rx Contractile Soft tissue mobilization Dry needling Submaximal isometrics Non-contractile Graded mobilization Graded spinal ROM (directional pref) Spinal traction Neural gliding/tensioning Generalized Rx Relative rest Education Modalities Short-term orthosis Exercise Relaxation/Breathing Cognitive behavioral therapy

17 Myofascial Pain Syndrome 17 Environmental/Emotional/Physical Ergonomics (short upper arms) Stress Hormone and Vitamin deficiencies Structural misalignment (legs and pelvis) Mechanical Underlying facilitated segment or thoracolumbar joint dysfunction SI joint dysfunction (Iliopsoas/Quadratus) Synergist/agonist strengthening

18 Support for Myofascial Pain Management 18 Non-specific low back pain (13 studies) Massage might be beneficial i for patients t with subacute and chronic non-specific low back pain, especially when combined with exercises and education. Furlan et al, Cochr Syst Rev 2008 Myofascial low back pain Support for multimodal treatment including massage, correction of muscle imbalance, and dry needling Malanga and Cruz, Phys Med Rehabil Clin N Am 2010 Furlan et al, Spine 2005 Currently no high quality evidence supporting the use of US for improved pain/qol Ebadi et al., 2014

19 Acute to Subacute LBP with Referred/Radiating Pain Management Disc Graded d ROM (Specific Exercise) Graded Axial distraction (Traction) Nerve Graded ROM Specific Exercise Neural gliding Painfree (Acute) Mid to end-range (Subacute) Graded Axial distraction 19

20 Specific Exercise Philosophy Achieve centralization of patient s referred pain Patient-directed approach consisting of McKenzie-based techniques Perform movements in opposite direction once movement no longer creates peripheralization 20

21 Specific Exercise - Extension Positioning Patient t prone lying or prone on elbows Useful when movement peripheralizes sx Typically acute Hold positions for minutes 21

22 Specific Exercise - Extension 22 ROM Passive movements Prone press up Standing back bends Perform in sets of 10 until sx centralization plateaus Perform as many timesasneeded during the day

23 Specific Exercise - Translocation Positioning Sidelying on the side describing the shift Pillows under thorax to encourage pelvic translocation Prone with pelvic translocation Standing lateral l shift correction Active ROM 23

24 Specific Exercise - Translocation Standing lateral shift correction Passive ROM with therapist Active-assist ROM on lat bar with manual correction Patients beginning with a translocation preference will typically favor extension at some point 24 Laslett, JMMT 2009

25 Specific Exercise - Flexion 25 Positioning Supine hook lying Supine 90/90 Seated forward bend Passive ROM Quadruped flexion Bilateral/unilateral knees to chest Active ROM Standing/Seated lumbar flexion Post pelvic tilts

26 Subacute Management of Referred/Radiating Pain Specific exercise Self treatment t t techniques should be exhausted before application of therapist-assisted assisted technique Therapist assistance provided via positioning, PA mobilization, overpressure, or soft tissue mobilization 26

27 Subacute Management of Referred/Radiating Pain 27 Extension therapist-assisted techniques Overpressure Stabilization of pelvis during prone press ups Extension mobilization PA over level l that t provides favorable response Followup with prone press ups Lateral compartment t Pelvic translocation away from pain side Maintain position during prone press ups

28 Subacute Management of Referred/Radiating Pain 28 Flexion therapistassisted techniques Soft tissue mobilization or overpressure while patient is in position of flexion Best applied in Quadruped Leaning over edge of table Sitting

29 Support for Directional Preference 29 Systemic review supports short term to intermediate benefits (Claire et al. Aust J Physiother 2004; Machado et al. Spine 2006; Surkitt et al. PT 2012) Moderate evidence DPM superior to multidirectional mid-range exercises, stretches, and advice in those with DP Conflicting evidence when DPM compared to manual therapy and strengthening Patients given exercises matched to their movement preference improved significantly in pain, med use, disability y( (Long et al, Spine 2004)

30 Support for Centralization 30 Patients centralizing with repeated movements SE and mobilization superior to stabilization for pain/disability at 1 week, disability at 4 weeks and 6 months Browder et al. JOSPT 2007 SE superior to manipulation for patient reports of success (2mos) and disability (2mos/12mos) Petersen et al 2011 Patient experiencing reduced pain levels ( 2/10) with mobilization and prone press ups demonstrated concurrent increase in disc water diffusion Beattie et al, 2010 Rates of centralization in other CPR categories Manipulation = 68% Stabilization = 80% Werneke et al, 2010

31 Spinal Traction Philosophy Achieve centralization of patient s referred pain Patient-directed Positional Maximum IVF opening with flexion, side bending contralateral, rotation ipsilateral Creighton JMMT 1993 Therapist-directed Manual Mechanical 31

32 Spinal Traction 32 Effective parameters in the literature 30-60% body weight Static or intermittent (3:1) duty cycle 12-15mins Supine or prone Cai et al 2009, Fritz et al 2007, Saunders 1993

33 Conflicting Support for Traction (General LBP) 33 Traction efficacy (pain and disability) not endorsed in systematic reviews for mixed samples of LBP Macario and Pergolizzi, Pain Pract 2006; Clark et al, Spine 2006 Physiological effects are supported Widens IVF/Stretch posterior spinal elements (Lehmann et al 1958) Creates negative intradiscal pressure (Ramos et al, J Neurosurg, 1994)

34 Support for Traction Population: Lumbar Radiculopathy Intervention: Lumbar extension exercises (6 weeks) versus lumbar extension protocol with traction (2 weeks) Significant improvements in disability and FABQ favoring traction group at two weeks Improved outcomes and sustained changes in subgroup at six weeks Positive crossed leg raise (<45deg) Lower extremity pain that peripheralized with extension Fritz et al

35 Subacute LBP with Radiating (Non- Peripheralizing) Pain Management Neural gliding Generalized PT program (aerobic exercise, global PRE, and PA mobilization) versus Generalized PT with Slump stretching (30secx5), 2x/week x 3 weeks Slump group improved disability, pain compared to control Cleland et al 2006 Nagrale et al

36 Acute to Subacute LBP with Referred/Radiating Pain Management 36 Contributing Impairments (Env.) Ergonomics Encourage positioning into specific exercise movement preference Weight bearing Wheeled walker: >250% increase in self reported walking distance in 71% of subjects Goldman et al, J Fam Pract 2008 Walking stick: no significant improvement in walking tolerance Comer et al, Arch Phys Med Rehabil 2010

37 Acute to Subacute LBP with Referred/Radiating Pain Management Contributing Impairments 37 Mechanical Mobilization of hypomobile segments above/below level Tightness opposite specific exercise movement preference Mobilization of nerve interface points Strengthening of hypotonic lumbopelvic muscles to address underlying instability Weakness into specific exercise movement preference

38 Support for Contributing ti Impairment Management 38 Population: Lumbar Spine Stenosis Intervention: Flexion-based program with progressive walking program versus manual therapy to hips and spine with PRE and unweighted treadmill ambulation (6 weeks) Significant ifi improvements in disability and pain at 6 weeks, 1 year, and 29 months in both groups Improved perceived recovery in manual therapy group (79% vs 41% at 6 weeks) Whitman et al Spine 2006

39 Support for Contributing ti Impairment Management Population: Subacute to chronic back-related LE pain (not stenosis) Intervention: ROM and stabilization exercise versus manual therapy (including thrust) with ROM and stabilization exercise (12 weeks) Significant improvements in disability, pain, medication usage, satisfaction, global improvement, and medication use at 12 weeks Maintained satisfaction, global improvement, and meds at 1 year Bronfort et al,

40 40 STIFFNESS-DOMINANT TREATMENT

41 Treatment Considerations Primary treatment for patients in Acute to Chronic LBP with Mobility Deficits category Classification for patients with undifferentiated pain May address a mixture of myofascial, joint, or neural limitations in motion Primary treatment for addressing motion loss in patients without a chief complaint of pain Reduced manual emphasis in Acute LBP with Related Cognitive or Affective Tendencies and Chronic LBP with Related Generalized Pain 41

42 Spinal Manipulative Therapy (SMT) Cochrane Reviews In general, SMT not superior to inert treatment, sham SMT, or other active treatments in acute or chronic heterogeneous LBP subjects Rubinstein et al 2013 (acute) Rubinstein et al 2011 (chronic) Thrust equal to non-thrust in CLBP (Cook et al 2013) and adults 55+ (Learman et al 2013) 42

43 Acute LBP with Mobility Deficits CPR for lumbar manipulation Duration of symptoms < 16 days * No symptoms distal to the knee * At least one hip with > 35 of IR Hypomobility with lumbar PAIVM testingti FABQ(W) < 19 4/5 criteria Posttest probability of success increased from 44% to 92% (+LR=13.2) Flynn et al, Spine 2002; Childs et al, Ann Intern Med CPR has been Validated!

44 In Patients Fitting the CPR Expect a good prognosis regarding ODI change, NPRS change, # visits, extent of recovery Cook et al, 2013 Thrust technique (lumbopelvic or lumbar rotation) does not matter Range of inferior to equal outcomes for nonthrust techniques Cleland et al, 2009; Learman et al, 2014 Equivocal outcomes between repeated end range movements and manipulation Schenk et al, 2012 End range may be what s most important! 44

45 Inability to Respond to Manipulation Longer duration of symptoms Symptoms in the buttocks or leg Absence of hypomobility/pain on mobility testing Less discrepancy in the left to right hip IR ROM Negative Gaenslen s sign Peripheralization with motion testing Fritz et al, PT

46 Chronic LBP with Mobility Deficits 46 Case series 8 patients t with chronic LBP and hip stiffness in at least 2 planes 3 visits it for hip mobilization and hip stretching 62.5% rated improvement as moderately better or higher on GROC 24.4% improvement on ODI Burns et al, JMMT 2011

47 Chronic LBP with Mobility Deficits RCT investigating non- region specific manipulation for CLBP Immediate pain reduction for T1-T5 manipulation comparable to L2-L5 manipulation De Oliveira et al., PT

48 48 PRIMARY INSTABILITY IMPAIRMENT

49 Treatment Considerations Primary treatment for patients in Acute to Chronic LBP with Movement Coordination Impairments category Classification for patients with undifferentiated pain Treatment primarily focused on contractile tissue neuromuscular re-education/strengthening at the site of pain Secondary treatment for patients in all other categories, especially Acute LBP with Referred LE Pain 49

50 Examples of Education for Joint Instability 50 Sleeping Pillow between the knees, under the lateral trunk, or anterior to trunk Medium mattress preferred to firm Sitting Kovacs et al, 2003 Foot support Lumbar support Arm support LS corsets Equivocal findings for management van Duijvenbode et al, 2008

51 Overview of Exercise Progression Strengthening of lumbar spine away from syndrome Avoids aggravation associated with loading into DSM Begin with isometrics of deep stabilizers, progress to superficial muscles Teach patient how to use lumbar region more Stretching of thoracic spine and hips spine into syndrome Motor control of lumbar spine into syndrome Ensures activation of weakest synergist(s) Teach patient how to use hip and thoracic regions more 51

52 Examples of Initial Treatment for Joint Instability Independent activation and tonic hold Pelvic floor TRA (extension syndrome) Lumbar multifidus isometrics (flexion syndrome) Glutes (rotation syndrome) 52

53 Examples of Progressive Treatment for Joint Instability 53 Integrated tonic hold Iliopsoas strengthening (flexion syndrome) Glut max and thoracic extensor strengthening (extension syndrome) Hip versus lateral trunk strengthening (rotation syndrome)

54 Recruitment of Abdominal Muscles 54 Drawing-in maneuver and Bird-dog (TRA) Posterior pelvic tilt and abdominal bracing (IO) Side plank and Abdominal crunch (Both) Urquhart et al, Man Ther 2005; Teyhen et al, JOSPT 2008 Hollowing during typical exercises increases TRA recruitment from 4-43% Bjerkefors et al, Manual Therapy 2010 Adding ankle DF to drawing-in led to greater gains in pain/function You et al, Clinical Rehabilitation, 2013

55 Recruitment of Gluteals over TFL 55 Clam Neutral (vertical) pelvis maximizes G med/max activation Gmed maximized i at 60deg hip flexion Sidestepping Unilateral bridge Quadruped hip extension with bent/straight knee Willcox & Burden, 2013; Selkowitz et al, 2013

56 Chronic LBP with Mobility Deficits A Meta Analysis and RCT 56 Motor control exercise was superior to general exercise, manual therapy, and minimal intervention for the reduction of pain and disability at variable time intervals, depending on the comparison condition First evidence suggesting widespread application of this procedure in heterogeneous samples of CLBP subjects (Bystrom et al, 2013) No added benefit to matching motor control deficit to exercise preference in CLBP using Sahrmann categories (Henry et al. 2014) Lack of evidence for matched stabilization treatment in ALBP or chronic widespread pain

57 Acute LBP with Mobility Deficits A Systematic and Cochrane Review 57 Evidence for general exercise programs Systematic Review: Acute LBP Equivocal results for exercise compared to other interventions in acute population (C) Lawrence et al, 2008 Cochrane Review Moderate quality evidence that post-treatment exercise program can prevent recurrence of low back pain Choi et al, 2010

58 Acute LBP with Mobility Deficits it Who Needs Motor Control Approach? CPR for lumbar stabilization Age < 41 years * Positive prone instability test Aberrant motion SLR > 91 3/4 criteria (LR+ = 4.0) Validation study failed to completely support CPR (underpowered?) Modified CPR of + PIT and aberrant movement may provide better predictive validity 58 Hicks et al, Arch Phys Med Rehabil 2005; Rabin et al, JOSPT, 2014

59 Motor Control Exercise in Radiographic Instability Population: Spondylolysis or spondylolisthesis Intervention: Stabilization program with TRA and multifidus focus versus treatment t t as directed d by PT (10 weeks) Significant improvements in disability and pain at 10 weeks and 30 months in stabilization group O Sullivan et al, Spine

60 Inability to Respond to Stabilization 60 Discrepancy in SLR ROM >10deg Apeldoorn et al, 2012 Negative prone instability test Hypomobility with PAIVM testing Aberrant motion absent FABQ(PA) score 9 2/4 criteria SN =.85; SP =.87 Hicks et al, Arch Phys Med Rehabil 2005

61 Summary of Recommendations: Acute-Chronic LBP with Movement Impairments 61 Education Supportive postures Ergonomic activities Temporary bracing (acute) Motor control exercise Begin with isolated contractions and holds Progress to isotonic open/closed chain loading Graded dosing: 2min total time under tension PRE Functional movements Gym-based activity Pilates Manual therapy to thoracic spine, ribs, sacrum, and hips Progression to work reintegration programs as needed Delitto et al, JOSPT 2012

62 Summary of Recommendations: Acute LBP with Related Cognitive or Affective Tendencies and Chronic LBP with Related Generalized Pain 62 Education De-emphasize pathology Emphasis on anatomical strength of spine Neuroscience of pain Overall favorable prognosis of LBP Strategies to limit fear and catastrophizing (CBT) Emphasis on increasing activity capacity, not just pain relief =4b8oB757DKc Fitness Low intensity, submaximal fitness and endurance activities for above mentioned categories Moderate to high intensity exercise for CLBP without generalized pain Exercise Graded stabilization Graded functional activity Delitto et al, JOSPT 2012

63 Graded d Functional Activities iti vs Stabilization 63 Graded functional activity versus motor control exercise No significant difference between groups at 2, 6, and 12 months Macedo et al, PT 2012 Graded stabilization program compared to general walking program 55% success (stab) versus 26% success (walk) at 12 and 36 months Rasmussen-Bar et al, Spine 2009

64 Lumbar Spine Instability Questionnaire 64 Give way or give out Self-manipulation Frequent pain in the day Back catches or locks Pain with sit to stand Pain with supine to sit Painful quick, unexpected, mild movements Need back support in chair Pain with sustained posture Worsening over time Temporary relief with corset Muscle spasms common Fearful of movement Trauma MOI in the past Long duration of problem Positive test is 9/15 Predictive of which CLBP patients respond best to motor control over graded exercise Macedo et al., 2014

65 Aquatic Therapy in CLBP 5x/w x 4w supervised 60min aquatic program to comparably dosed unsupervised land HEP Both groups improved; Statistical (not clinical) significant difference in ODI and QL scores Dundar et al, Spine x/w x 6w supervised 60min aquatic versus land program Both groups improved pain/function, no differences Sjogren, Physiother Res Int 1997 Systematic review supported benefits in CLBP and pregnancy Waller et al, Clin Rehabil

66 66 POST-SURGICAL MANAGEMENT

67 Overview 67 Pain/Pathology focus is patient dependent, usually limited Cryotherapy/TENS for post-surgical pain Impairment focus is key Stabilization Neural gliding Conditioning Spinal ROM Mobilization away from surgical site Cioppa-Mosca et al, 2006; Maxey and Magnusson 2013

68 Lumbar Fusion Types 68 Instrumented Posterolateral t l fusion Disc preserved Most common Multifidus partial denervation Anterior lumbar interbody fusion Disc resected Circumferential fusion Oblique partial denervation Cage fusion Disc resected Interbody fusion only

69 Lumbar Fusion Rehab Considerations 69 Outpatient therapy typically begins at 6-10 weeks post-opop Precautions No iliopsoas stretching until 8 weeks No lifting >10lbs or overhead until 12 weeks No lumbar standing ROM testing or iliopsoas MMT until ready for return to sport (typically 20 weeks) No US over healing fusion No end range extension for 6 months (cage)

70 Lumbar Disc Surgical Procedures 70 Disc replacement Anterior approach consistent t with cage fusion Lumbar discectomy Microscopic or open Lamina removal variable Multifidus partial denervation possible Minimally invasive percutaneous technique Chemonucleolysis Percutaneous discectomy

71 Lumbar Disc Rehab Considerations Outpatient therapy typically begins at 4-6 weeks post-opop Discectomy Precautions Limit lumbar flexion stress 71 No lumbar standing ROM or slump testing until 6 th week Running and return to sport between 8-12 weeks Replacement Precautions Limit lumbar extension stress No lumbar standing ROM or PAs until 6-8 weeks Return to sport weeks

72 Lumbar Surgery General Guidelines 72 Body mechanics Stabilization All positions Conditioning Bike, treadmill Stretching Hip and leg muscles Scar mobility Thoracic/Hip joints Neural mobilization Lumbar spine Strengthening (discectomy) Back extensors (Kulig et al 2009)

73 Support for Post-Operative PT 73 Cochrane Review: 14 trials, status post discectomy or microdiscectomy (Ostelo et al 2009) Moderate quality evidence Exercise more effective than no treatment at improving disability High intensity exercise more effective than low intensity exercise Low quality evidence + effects of exercise (regardless of intensity) on pain Negligible gg effects of neural gliding gshort-long term Home and supervised programs yield same short term results 8 week exercise program administered 2 weeks post- op discectomy (Hebert et al, 2015) No difference in general vs specific exercise programs on clinical outcomes or multifidus function at 10wks or 6mos