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How to Solve Non-Specific Chronic Low Back Pain: The ...€¦ · NON-SPECIFIC CHRONIC LOW BACK...
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COPYRIGHT© 2020 POSITIONAL RELEASE THERAPY INSTITUTE ® How to Solve Non-Specific Chronic Low Back Pain: The Wheelhouse Protocol SM
Transcript of How to Solve Non-Specific Chronic Low Back Pain: The ...€¦ · NON-SPECIFIC CHRONIC LOW BACK...
COPYRIGHT© 2020 POSITIONAL RELEASE THERAPY INSTITUTE®
How to Solve Non-Specific Chronic Low Back Pain: The Wheelhouse ProtocolSM
DISCLOSURE
The Positional Release Therapy Institute is a company that provides continuing education and certification in Positional Release Therapy. Online courses and instructional videos are also associated with the instruction provided by the Institute.
OBJECTIVES
After this session, participants will:
1. be able to identify 3 causative factors of chronic non-specific low back pain (LBP)
2. be able to identify the proposed primary condition causing chronic non-specific low back pain and;
3. be able to articulate how the The Wheelhouse ProtocolSM may be effective in the treatment of chronic non-specific LBP
NON-SPECIFIC CHRONIC LOW BACK PAIN?
• 90% of all low back pain cases- no known cause1
• Chronic LBP = > clinical, social, economic and public health burden2
• ~ $100-200 Billion3
• Worldwide greatest cause of disability4
• 61% of Opioid deaths linked to chronic pain5
• 59.3% in chronic pain group diagnosed with LBP
• Who is most affected?6
• 28.1% Adults reported LBP in last 3 months• Women (30.1%) more than men (26%)• Less educated (34.8%) and poor (37.8%) • Athletes (~30-50%)7
LBP RISK FACTORS8
Non-Modifiable
• Old Age
• Female
• Poverty
• Lower Education Level
Modifiable
• BMI (Obesity)
• Smoking
• Lower Health Status
• Physical Activity
• Repetitive Tasks (bending, lifting, twisting, etc…)
• Job Dissatisfaction
• Depression
Greatest Contributors = Mechanical Stress and age-related degeneration
WHAT ELSE?• Imaging-degenerative changes, disk abnormalities, spinal
anomalies ⌧ correlation to LBP Prediction9
• Psychosocial factors?9
• Negative beliefs pain is harmful/disabling
• Fear avoidance behaviors
• Poor or maladaptive coping strategies
• Passive treatment expectation
• Focus on pain
• High distress levels
• Depressive mood
• Resistance to change
• Low self-efficacy
• Family reinforcement of illness
• Social/financial problems
• Troubled childhood
WHY DO ATHLETES HAVE CHRONIC LBP?
Lets Take a Poll
A. Disc Bulge / Herniation
B. Sacroiliac Joint Dysfunction
C. Strains / Sprains
D. Spondys’
E. Psychosocial Factors
SACROILIAC JOINT DYSFUNCTION (SIJD)
• The SI Joint is a common source of LBP in the general population as well as athletes.10-14
• Asymmetrical (e.g., single stance phase) or repetitive loads (e.g., rowing) = risk12,14
• Athletes ~ 30%-80% non-specific LBP15,16
• SIJD = pain arising as result of altered kinematics11
• Is it even possible? I heard that the joint does not even move—well….
THE SACROILIAC JOINT
• Diarthrodial Joint10
• largest axial joint in the body
• Anterior 1/3 synovial, posterior ligamentous/fascial/muscular
• Provides load transfer15
• 2-7 degrees– clearly established now10,12,15
• Multiple axes15
• Left and Right Oblique
• Vertical and anteroposterior (AP)
• Vertical and sagittal
• Horizontal- #3
DYSFUNCTIONS OF THE SI JOINT
• Hypomobility or Hypermobility12
• Age impact
• Each can produce somatic dysfunction
• Innominate Shears (Superior / Inferior)
• Innominate Rotations (Anterior / Posterior)
• Innominate Flares (Out / In)
• Sacral Torsions (Flexion / Extension)
• Role of Closure12,17
• Form = chock stone fit
• Force = external compression
ANTERIOR INNOMINATE ROTATION
THE FALL OUT
THE FALLOUT CONTINUED
• Sacral Torsion
• The “Floating Boat”
• Subtalar Joint Dysfunction = Eversion
• Functional Scoliosis = Disc Compression and Neural / Tissue Tension
• Neural Shutdown / Inhibition (we need the hip!)
• Central Sensitization Syndrome
• Altered Biomechanics• Non-contact ACL mechanism?
• Altered tendon-muscle length / function
COMMON PAIN REFERRAL PATTERNS & ALIGNMENT
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COPYRIGHT© 2020 POSITIONAL RELEASE THERAPY INSTITUTE®
LEG LENGTH DISCREPANCY? –MAYBE
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COPYRIGHT© 2020 POSITIONAL RELEASE THERAPY INSTITUTE®
THE WHEELHOUSE PROTOCOLSM
• Evaluation
• History
• Causative Factors
• Postural Exam (TART)
• One-Minute Wheelhouse Screening©
• Special Tests (Combined)
• The Wheelhouse ProtocolSM
• PRT (Positional Release Therapy)
• Thermal Ultrasound
• Joint Mobilization (Maitland- II)
• Muscle Energy (MET)
• HVLA (The Speicher Whip©)
EVALUATION• Integrative & Summative Evaluation Approach Required
• Diagnosis based on multiple findings
• History*
• Primarily one-sided on involved side
• Pain Pattern
• Youth / Children vs. Adults
• TART Exam
• Observation
• Folds
• Contralateral Hyperextended leg
• Spinal & Pelvic Alignment
• Unilateral Femoral External Rotation (Supine)
• Special Tests for Motion
• Gillet (March) – Speicher Modification
• Long Sit Test (aka: Supine to Sit Test)
WHAT IS GOING ON HERE?
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WHY ARE THEY NOT LINING UP?
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SPECIAL TESTS FOR SI JOINT DYSFUNCTION
Motion
• Sensitivity, Reliability, Validity, Predictive Values LOW
• Assessed individually14,16-20
• 8-44%16
• Gillet only test found to have (+) association w/ LBP16
• Combined (3 or >) = (.82 - .94)15,21
• Which to combine? That is the grand question
• Most based on landmark assessment
• Gillet (Looking for ”fixation”)
• Looking for Fire-Hydrant Sign ©)
• Supine to Sit Test (Long-Sit)
• Place Fingers BELOW malleoli
Provocation• Similar findings as with SI Motion Tests Above
• FABER, FADIR, SLR
A CASE-SERIES DESIGN OF PATIENTS WITH
CHRONIC NON-SPECIFIC LOW BACK PAIN
Objective: To determine the effectiveness of the Wheelhouse ProtocolSM for treatment of chronic non-specific low-back pain in a general population.
Methods:
• Case-Series Design (Pre-Post Test)
• N= 10 (21-68 yrs)
• TX: 1x/wk for 3 wks with a 6 month Follow-Up
• Outcome Measures:
• DPA Scale (Disablement in the Physically Active Scale
• Oswestry Low Back Pain Disability Index
• Global Pain Rating
• Range of Motion (Trunk Flexion, Extension, SLR)
• Provocation Tests (FABER, FADIR, SLR)
• Special Tests (March, Long Sit)
• Pressure Sensitivity
DEMOGRAPHICSGender Race Age Months
w/LBP
Location of
LBP
M = 4, F = 6 Caucasian 21-68 3 - 600 R = 8, L = 2
Mean 43 86.50
Std. Dev 15.902 181.51
RESULTS SUMMARYOutcome Mean Std. Dev. Effect Size (d) Significance
DPA 15.1 13.601 ***1.292 *.007
Oswestery 6.3 5.716 ***1.555 *.007
Global Pain 5.8 2.044 ***3.862 *.000
AROM-SLR (R) 9.4 11.306 **.670 *.027
AROM-SLR (L) 5.8 7.239 .396 *.032
PROM-SLR (R) 3.1 11.742 .102 .425
PROM-SLR (L) 1.7 8.166 .056 .527
Trunk Flexion 9.8 22.809 .299 1.990
Trunk Ext. 11.6 11.147 **.737 *.009
* = <.05 Priori Significance Level** = Moderate Effect Size (.50>)*** = Large Effect Size (.80>)
DPA RESULTS
OSWESTERY RESULTS
GLOBAL PAIN RATING
DISCUSSION
• Chronic LBP next to OA is one of the biggest problems clinicians face and that plagues our patients1,4,9
• Chronic non-specific LBP may not be so non-specific
• Anterior Innominate Rotations (AIRs) may be a major player
• Assessment/DX is not difficult when using an integrated evaluation approach
• The Wheel House ProtocolSM shows early promise in treatment of chronic non-specific LBP
• Limitations
1. More patient cases needed, specifically at 6 mo.
2. Cross-sectional population sample needed
3. Potential researcher bias w/case-series design
4. Requires expertise in manual therapy / PRT
CLINICAL IMPLICATIONS
The Wheel House ProtocolSM may help to:
1. Reduce opiate use and opiate-related deaths
2. Reduce world-wide clinical, social, economic and public health burden
3. Reduce number of ankle related pathologies (e.g., ankle sprain)
4. Curb the ACL epidemic
5. Improve quality of life & Sport of patients with chronic LBP
6. Further the the AT profession’s mission
REFERENCES 1. Krismer M, Tulder M van. Low back pain (non-specific). Best Practice & Research
Clinical Rheumatology. 2007;21(1):77-91. doi:10.1016/j.berh.2006.08.004
2. Manchikanti L, Singh V, Pampati V, Smith HS, Hirsch JA. Analysis of growth of interventional techniques in managing chronic pain in the Medicare population: a 10-year evaluation from 1997 to 2006. Pain Physician. 2009;12(1):9-34.
3. Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169(3):251-258.
4. Friedly J, Standaert C, Chan L. Epidemiology of spine care: the back pain dilemma. Phys Med Rehabil Clin N Am. 2010;21(4):659- 677.
5. Mark Olfson, Melanie Wall, Shuai Wang, Stephen Crystal, Carlos Blanco. Service Use Preceding Opioid-Related Fatality. American Journal of Psychiatry, 2017; appi.ajp.2017.1 DOI: 10.1176/appi.ajp.2017.17070808
6. National Center for Health Statistics. Summary Health Statistics: National Health Interview Survey, 2014: Table A-5a. Available at http://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2014_SHS_Table_A-5.pdf. Last accessed July 22, 2016.
7. Trainor TJ, Trainor MA. Etiology of low back pain in athletes. Current sports medicine reports. 2004;3(1):41–46.
8. Rathmell JP. A 50-year-old man with chronic low back pain. JAMA. 2008;299(17):2066-2077.
9. Rose, M. Low back pain. (2016). Available at: www.net.ce. Net CE.
REFERENCES
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11. Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. 1996;21(22): 2594–2602.
12. Brolinson PG, Kozar AJ, Cibor G. Sacroiliac joint dysfunction in athletes. Current Sports Medicine Reports. 2003;2(1):47–56.
13. Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. The Lancet. 2012;379(9814):482–491.
14. Adhia DB, Milosavljevic S, Tumilty S, Bussey MD. Innominate movement patterns, rotation trends and range of motion in individuals with low back pain of sacroiliac joint origin. Manual Therapy. 2016;21:100-108. doi:10.1016/j.math.2015.06.004
15. Peebles R, Jonas CE. Sacroiliac Joint Dysfunction in the Athlete: Diagnosis and Management. Current sports medicine reports. 2017;16(5):336–342.
16. Cattley P, Winyard J, Trevaskis J, Eaton S. Validity and reliability of clinical tests for the sacroiliac joint: A review of literature. Australasian chiropractic & osteopathy. 2002;10(2):73.
17. Levangie PK. Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain. Physical Therapy. 1999;79(11):1043–1057.
REFERENCES
18. Potter NA, Rothstein JM. Intertester reliability for selected clinical tests of the sacroiliac joint. Physical therapy. 1985;65(11):1671–1675.
19. van der Wurff P. Clinical diagnostic tests for the sacroiliac joint: motion and palpation tests. Australian Journal of Physiotherapy. 2006;52(4):308.
20. Aufdemkampe G. Intraexaminer and interexaminer reliability of the Gillet test. Journal of Manipulative & Physiological Therapeutics. 1999;22(1):4–9.
21. Cibulka MT., Koldehoff RM. Clinical usefulness of a cluster of sacroiliac joint tests in patients with and without low back pain. J Orthop Sports Phys Ther. 1999; 29:83-92.
