Incidence. Overview 6/6/2011. Incidence. June 16, Garth Savidge, PT, DPT, OCS

Transcription

1 June 16, 2011 Garth Savidge, PT, DPT, OCS Overview Incidence Staging Stage 1: Treatment Based Classification Stage 2: Impairment Based (Strength and Flexibility) Stage 3: Sport Specific/Return to Sport Incidence Cross Country Skiers: 65% (Bahr et al. Spine 2004) Rowers 25%-35% (Bahr et al. Spine 2004, Hosea et al BJSM 2011, Teitz et al. AJSM 2002) Australian Rules Football 60% (Hoskins et al. BMC Musculoskel disorders 2009, 2010) Olympic Athletes: 58% (Ong et al BJSM 2003) Golf: 33% (Vad et al AJSM 2004) 1

2 Identify Red Flags May require Further Medical Work up or Management Fracture Cauda Equina Syndrome Viscerogenic Etiology Cancer Ankylosing Spondylitis Identify Yellow Flags Cognitive behavioral therapy Mental health practitioner Alternative fear avoidance approach George et al. JOSPT 2008 George et al. Spine 2003 High Fear Avoidance Depression Anxiety Pain Catastrophising Staging: Delitto et al. Physical Therapy 1995 Stage 1: Stage 2: Stage 3: High Disability Moderate Disability Low Disability (ODI >20) (ODI 10-20) (ODI <10) Limited ADL: Sit, stand dressing Limited BADL: Household chores etc Limited Sport Participation Treatment Based Classification Impairment Based Treatment Sport Specific, agility, plyometrics 2

3 Goals: Decrease Pain Restore ROM Improve Comparable Sign AROM Functional Movement Special Tests Stretch Goals: Decrease Pain Restore ROM Improve Comparable Sign Treatment Based Classification for Low Back Pain Originally Proposed by Delitto et al Modified by Fritz et al Patients classified into subgroups likely to respond to a particular treatment Enhances clinical outcomes Manipulation/ Mobilization Stabilization Specific Exercise Goals: Decrease Pain Restore ROM Improve Comparable Sign Manipulation/ Mobilization Stabilization Specific Exercise <166 days SLR>90 Leg L Pain Centralizes No symptoms + prone Neurological with below knee instability Signs movements in Low fear + aberrant +Crossed SLR 1 direction avoidance movements Peripheralizes or Hip IR>35 Age <40 with extension Peripheralize Hypomobility Hypermobility in opposite Fritz et al. Spine 2007 direction Fritz et al. Spine

4 Manipulation /Mobilization Flynn et al. Spine 2002 <16 days No symptoms below knee Low fear avoidance Hip IR>35 Hypomobility 4/5 findings 95% chance of improvement Decreased disability by 57% (Clealand et al JOSPT 2006) Manipulation /Mobilization Supine or Sidelying Lumbar Manipulation Technique (Clealand et al. JOSPT 2006) Supine Pic Sidelying Pic Manipulation /Mobilization Additional Considerations: Acute Sports related injuries Athletes often have low fear avoidance (Elfving et al. Physiother Res. Int. 2007) Other Applications: Influence on Muscle Activity Transversus Abdominus (Gill et al. Manulal Therapy 2006) Multifidus (Brennen et al. JOSPT 2007) Low Risk (Oliphant J of Manip Therapy, 2004) 4

5 Stabilization Hicks et al. Arch Phys Med Rehab 2005 SLR>90 + prone instability + aberrant movements Age <40 Hypermobility 3 or more 67% chance of success Stabilization Hicks et al. Arch Phys Med Rehab 2005 Transversus Abdominus: Abdominal Bracing With Heel Slides With Leg Lifts Wih Bridging With Standing With Standing Row With Walking Pics Stabilization Hicks et al. Arch Phys Med Rehab 2005 Erector Spinae/Multifidus: Quadruped: Alternating Arm Lift Alternating Leg Lift Alternating Arm/Leg Lift Pics 5

6 Stabilization Hicks et al. Arch Phys Med Rehab 2005 Quadratus Lumborum/Oblique Abdominals: Side Support: Knees Flexed Knees Extended Pics Specific Exercise Browder et al. Physical Therapy 2007 Long et al. Spine 2004 Centralizes with movements in 1 direction or Peripheralize in opposite direction Greater reduction in disability Greater Reduction in back and leg pain Reduced medication use Specific Exercise Browder et al. Physical Therapy 2007 Long et al. Spine 2004 EXTENSION Preference: More common Associated with Disc Pathology Sustained positions and repeated movements Prone Extension Standing extension 6

7 Specific Exercise Browder et al. Physical Therapy 2007 Long et al. Spine 2004 FLEXION Preference: Less common Associated with spinal stenosis Knee to chest Seated Flexion Specific Exercise Browder et al. Physical Therapy 2007 Long et al. Spine 2004 LATERAL SHIFT Preference: Less common Associated with disc pathology Sustained and repeated motion Lateral shift Flexion pics StageOne Fritz et al. Spine 2007 Leg Pain Neurological Signs +Crossed SLR Peripheralizes with extension Reduced Disability Reduced Fear Avoidance Beliefs Only Short Term benfit No difference at 6 weeks 7

8 Fritz et al. Spine 2007 Prone Position 10 minutes 40-60% Body Weight 4x/week StageOne Cai et al. Eur Spine J Noninvolvement of manual work Low fear avoidance No Neurological deficits Age >30 All 4 variables: 69% Chance of Success With Cai et al. Eur Spine J S i P iti Supine Position 15 minutes 30-40% Body Weight 3x/week 8

9 (Stanton et al. JOSPT 2011) Treatment Based Classification for Low Back Pain 250 Patients Studied 50% Met criteria for one subgroup 25% Met criteria for more than one 25% did not meet criteria for any subgroup Manipulation/ Mobilization Stabilization Specific Exercise Moderate Disability Score (ODI ) Limited ability to do BADL (Household chores, vacuuming etc) Goals: Restore Function Improve Muscle Length Improve Strength/Stability Improve Joint Mobility Improve ROM Decision Making Functional Assessment Pain/Abnormal Movement Identify Impairments Test/Retest Interventions Strength Muscle Length Joint Mobility Motor control ROM Strengthening Stretching Manual Therapy Neuromuscular Re-education ROM Exercises 9

10 Flexibility: Hamstrings, Hip Flexors, ITB, Quads, Piriformis etc Hip Range of Motion: Athletes with LBP tend to have reduced hip ROM than those without LBP. No causative evidence Different patterns of Hip ROM in LBP compared to control (Ellison et al. Physical Therapy 1990) Decreased overall ROM in Hips and presence of asymmetry in those with LBP participating in rotation related sports (Van Dillen et all Physical Therapy Sport 2008) Decreased Hip IR in lead leg in amateur golfers with LBP (Murray et al. Physical Therapy and Sport 2009, Vad et al AJSM 2004) Hip Mobility: Manual Therapy to Restore Hip ROM improved ODI, pain (Burns et al Physiother Theory Practice 2010) 10

11 Hip Strength: Subjects with NSLBP have significantly less hip strength compared to control After 3 week HABD strength program had improved strength and 48% reduction in pain. (Kendal et al. J Sports Rehab 2010) Female athletes found to have asymmetries in hip strength in those with LBP (Nadler et al Clinial J of Sports Med 2000) Percent difference in side to side hip strength predicted risk for LBP in female athletes (Nadler et al. AMJPMR 2001) Hip Strengthening improved ODI, pain (Burns et al Physiother Theory Practice 2010) Hip Strength: Clam Hip Single Abduction Shell Leg Bridge Mini Lunges Squats Stability/Motor Control 11

12 Frequency: 4 days/week training program Improved Strength and QoL Reduced Pain and disability (Kell et al. J of Strength and Cond. Res 2011) How do you know when they re ready to return to Sport? Stage 3 Lowest Disability Score (ODI < 10) Limited Sport Participation Risk Assessment and Injury Prediction/Prevention Agility, Plyometric drills Functional Movement Screen 12

13 Stage 3 Plyometric Training Double Leg Single leg Jump/Hop (Multi direction) Broad Jump/Box Jump Agility Training Shuttle Run Shuffle Run Cross Over (Karaoke) Box Drills/Ladder Work Etc Stage 3 Functional Movement Screen (Cook et al.) 9 Functional tests: Score: 1-3 on ability to perform without pain or compensation Score <14 predictive of Injury in Professional Football (Kiesel et al. NAJSPT 2007) Has been used to assess readiness and injury risk in Firefighters and Military (Peate et al. J Occ Med and Tox 2007, Goss et al. J Spec Ops Med 2009) Return to Sport Return to play in Professional athletes: 82% Baseball most success, Football least success (Hsu et al. Spine J. 2011) Return to play in recreational/amature athletes: 79-86% (Iwamoto et al AJPMR 2006, Iwamoto et al Scand J of Med Sci Sports 2004) ) 13

14 Summary : Treatment Based Classification Manipulation Stabilization Directional Preference Enhanced Outcomes Summary : Impairment Based Treatment Functional Assessment and Biomechanical Approach Hip ROM/Strength Summary Stage Three: Risk Assessment Injury Prediction/Prevention Sport Specific Training Return to Sport 14

15 References Bahr, R., Andersen, S. O., Loken, S., Fossan, B., Hansen, T., & Holme, I. (2004). Low back pain among endurance athletes with and without specific back loading--a cross-sectional survey of cross-country skiers, rowers, orienteerers, and nonathletic controls. Spine, 29(4), Brenner, A. K., Gill, N. W., Buscema, C. J., & Kiesel, K. (2007). Improved activation of lumbar multifidus following spinal manipulation: A case report applying rehabilitative ultrasound imaging. The Journal of Orthopaedic and Sports Physical Therapy, 37(10), Browder, D. A., Childs, J. D., Cleland, J. A., & Fritz, J. M. (2007). Effectiveness of an extension-oriented treatment approach in a subgroup of subjects with low back pain: A randomized clinical trial. Physical Therapy, 87(12), ; discussion Burns, S. A., Mintken, P. E., & Austin, G. P. (2010). Clinical decision making in a patient with secondary hip-spine syndrome. Physiotherapy Theory and Practice, Cai, C., Pua, Y. H., & Lim, K. C. (2009). A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with mechanical lumbar traction. European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 18(4), Cleland, J. A., Fritz, J. M., Whitman, J. M., Childs, J. D., & Palmer, J. A. (2006). The use of a lumbar spine manipulation technique by physical therapists in patients who satisfy a clinical prediction rule: A case series. The Journal of Orthopaedic and Sports Physical Therapy, 36(4), Delitto, A., Erhard, R. E., & Bowling, R. W. (1995). A treatment-based classification approach to low back syndrome: Identifying and staging patients for conservative treatment. Physical Therapy, 75(6), ; discussion Elfving, B., Andersson, T., & Grooten, W. J. (2007). Low levels of physical activity in back pain patients are associated with high levels of fearavoidance beliefs and pain catastrophizing. Physiotherapy Research International : The Journal for Researchers and Clinicians in Physical Therapy, 12(1), Ellison, J. B., Rose, S. J., & Sahrmann, S. A. (1990). Patterns of hip rotation range of motion: A comparison between healthy subjects and patients with low back pain. Physical Therapy, 70(9), References Flynn, T., Fritz, J., Whitman, J., Wainner, R., Magel, J., Rendeiro, D., et al. (2002). A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine, 27(24), Fritz, J. M., Cleland, J. A., & Childs, J. D. (2007). Subgrouping patients with low back pain: Evolution of a classification approach to physical therapy. The Journal of Orthopaedic and Sports Physical Therapy, 37(6), Fritz, J. M., & George, S. (2000). The use of a classification approach to identify subgroups of patients with acute low back pain. interrater reliability and short-term treatment outcomes. Spine, 25(1), Fritz, J. M., Lindsay, W., Matheson, J. W., Brennan, G. P., Hunter, S. J., Moffit, S. D., et al. (2007). Is there a subgroup of patients with low back pain likely to benefit from mechanical traction? results of a randomized clinical trial and subgrouping analysis. Spine, 32(26), E George, S. Z., Fritz, J. M., Bialosky, J. E., & Donald, D. A. (2003). The effect of a fear-avoidance-based physical therapy intervention for patients with acute low back pain: Results of a randomized clinical trial. Spine, 28(23), George, S. Z., Fritz, J. M., & Childs, J. D. (2008). Investigation of elevated fear-avoidance beliefs for patients with low back pain: A secondary analysis involving patients enrolled in physical therapy clinical trials. The Journal of Orthopaedic and Sports Physical Therapy, 38(2), Gill, N. W., Teyhen, D. S., & Lee, I. E. (2007). Improved contraction of the transversus abdominis immediately following spinal manipulation: A case study using real-time ultrasound imaging. Manual Therapy, 12(3), Goss, D. L., Christopher, G. E., Faulk, R. T., & Moore, J. (2009). Functional training program bridges rehabilitation and return to duty. Journal of Special Operations Medicine : A Peer Reviewed Journal for SOF Medical Professionals, 9(2), Hicks, G. E., Fritz, J. M., Delitto, A., & McGill, S. M. (2005). Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Archives of Physical Medicine and Rehabilitation, 86(9), Hosea, T., Hannafin, J., Bran, J., O'Hara, D., & Seuffert, P. (2011). Aetiology of low back pain in young athletes: Role of sport type. British Journal of Sports Medicine, 45(4), 352. References Hoskins, W., Pollard, H., Daff, C., Odell, A., Garbutt, P., McHardy, A., et al. (2009). Low back pain status in elite and semi-elite australian football codes: A cross-sectional survey of football (soccer), australian rules, rugby league, rugby union and non-athletic controls. BMC Musculoskeletal Disorders, 10, 38. Hoskins, W., Pollard, H., Daff, C., Odell, A., Garbutt, P., McHardy, A., et al. (2010). Low back pain in junior australian rules football: A crosssectional survey of elite juniors, non-elite juniors and non-football playing controls. BMC Musculoskeletal Disorders, 11, 241. Hsu, W. K., McCarthy, K. J., Savage, J. W., Roberts, D. W., Roc, G. C., Micev, A. J., et al. (2011). The professional athlete spine initiative: Outcomes after lumbar disc herniation in 342 elite professional athletes. The Spine Journal : Official Journal of the North American Spine Society, 11(3), doi: /j.spinee Iwamoto, J., Takeda, T., Sato, Y., & Wakano, K. (2006). Short-termterm outcome of conservative treatment in athletes with symptomatic lumbar disc herniation. American Journal of Physical Medicine & Rehabilitation / Association of Academic Physiatrists, 85(8), ; quiz Iwamoto, J., Takeda, T., & Wakano, K. (2004). Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment. Scandinavian Journal of Medicine & Science in Sports, 14(6), Kell, R. T., Risi, A. D., & Barden, J. M. (2011). The response of persons with chronic nonspecific low back pain to three different volumes of periodized musculoskeletal rehabilitation. Journal of Strength and Conditioning Research / National Strength & Conditioning Association, 25(4), Kendall, K. D., Schmidt, C., & Ferber, R. (2010). The relationship between hip-abductor strength and the magnitude of pelvic drop in patients with low back pain. Journal of Sport Rehabilitation, 19(4), Kiesel, K., Plisky, P. J., & Voight, M. L. (2007). Can serious injury in professional football be predicted by a preseason functional movement screen? North American Journal of Sports Physical Therapy : NAJSPT, 2(3), Long, A., Donelson, R., & Fung, T. (2004). Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine, 29(23), Murray, E., Birley, E., Twycross-Lewis, R., & Morrissey, D. (2009). The relationship between hip rotation range of movement and low back pain prevalence in amateur golfers: An observational study. Physical Therapy in Sport : Official Journal of the Association of Chartered Physiotherapists in Sports Medicine, 10(4),

16 References Nadler, S. F., Malanga, G. A., DePrince, M., Stitik, T. P., & Feinberg, J. H. (2000). The relationship between lower extremity injury, low back pain, and hip muscle strength in male and female collegiate athletes. Clinical Journal of Sport Medicine : Official Journal of the Canadian Academy of Sport Medicine, 10(2), Nadler, S. F., Malanga, G. A., Feinberg, J. H., Prybicien, M., Stitik, T. P., & DePrince, M. (2001). Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: A prospective study. American Journal of Physical Medicine & Rehabilitation / Association of Academic Physiatrists, 80(8), Oliphant, D. (2004). Safety of spinal manipulation in the treatment of lumbar disk herniations: A systematic review and risk assessment. Journal of Manipulative and Physiological Therapeutics, 27(3), Ong, A., Anderson, J., & Roche, J. (2003). A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the sydney 2000 olympic games. British Journal of Sports Medicine, 37(3), Peate, W. F., Bates, G., Lunda, K., Francis, S., & Bellamy, K. (2007). Core strength: A new model for injury prediction and prevention. Journal of Occupational Medicine and Toxicology (London, England), 2, 3. Stanton, T. R., Fritz, J. M., Hancock, M. J., Latimer, J., Maher, C. G., Wand, B. M., et al. (2011). Evaluation of a treatment-based classification algorithm for low back pain: A cross-sectional study. Physical Therapy, 91(4), Teitz, C. C., O'Kane, J., Lind, B. K., & Hannafin, J. A. (2002). Back pain in intercollegiate rowers. The American Journal of Sports Medicine, 30(5), Vad, V. B., Bhat, A. L., Basrai, D., Gebeh, A., Aspergren, D. D., & Andrews, J. R. (2004). Low back pain in professional golfers: The role of associated hip and low back range-of-motion deficits. The American Journal of Sports Medicine, 32(2), Van Dillen, L. R., Bloom, N. J., Gombatto, S. P., & Susco, T. M. (2008). Hip rotation range of motion in people with and without low back pain who participate in rotation-related sports. Physical Therapy in Sport : Official Journal of the Association of Chartered Physiotherapists in Sports Medicine, 9(2),