EXERCISE AND LBP

A/Prof Kathryn Refshauge

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Low back pain

15%85%

no specificpathologyspecific

pathology NSLBP(mechanical)

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“Mechanical” NSLBP

• pain is worsened with movement

• pain is improved with rest

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Triage

• Is the LBP due to serious pathology?

• Duration of the LBP?

• What treatment is indicated for the LBP?

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Hypotheses generated about:

• diagnosis

• physical examination

• treatment

• prevention

• contra-indications/precautions

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Need knowledge about:

• causes of LBP

• pathology

• tests (odds ratio, sensitivity and specificity)

• treatment effects and efficacy

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Serious spinal pathology

• Cancer• Infection eg osteomyelitis• Cauda equina syndrome• Cord compression• Fracture (osteoporotic)• Inflammatory diseases/arthritides• Abdominal or cardio-thoracic pathology

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Typical Non-typicalPresentation Presentation

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Eliminate serious pathology

(red flags)• unexplained weight loss• night pain• poor general health/systemic symptoms• fever• previous history of cancer• no relief with bedrest• failure to improve with therapy

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Red flags (cont’d)

• history of trauma

• steroid use (osteoporosis)

• very severe pain/muscle spasm

• bowel/bladder frequency (cauda equina syndrome)

• widespread neurological symptoms

• non-mechanical behaviour of symptoms

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Red Flags (cont’d)

• Age > 50 years

• Constant progressive non-mechanical pain

• Thoracic pain

• Persisting severe restriction of lumbar flexion

• Pain that worsens in supine

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Cancer (Deyo 1988)

Sensitivity Specificity

Age > 50 0.77 0.71

Unexplained weight loss (>5kg in 6/12)

0.15 0.94

Previous history of cancer

0.31 0.98

Not improving with medical care (1/12)

0.31 0.90

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Cancer (cont’d)

Sensitivity Specificity

No relief with bed rest

1.00 0.46

Insidious onset 0.61 0.42

Duration > 1/12 0.50 0.81

Recent back injury 0.00 0.82

Thoracic pain 0.17 0.84

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Compression fracture

Sensitivity Specificity

Age > 50 years 0.84 0.61

Age > 70 years 0.22 0.96

Trauma 0.30 0.85

Corticosteroid use 0.06 0.995

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Decisions

seriousnesss

probability

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• If suspect pathology, refer patient to appropriate health professional

• If NSLBP, use knowledge (evidence-based practice)

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Yellow flags

• Previous history of LBP

• Radiating leg pain, NR involvement

• Poor fitness

• Poor extensor endurance

• Poor general health

• Psychological distress (fear avoidance behaviour, depressed)

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Yellow flags (con’td)

• Much time lost from work

• Disproportionate illness behaviour

• Low job satisfaction

• Personal problems (alcohol, marital, financial)

• Adversarial medico-legal proceedings

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6 weeks 3 months

acute sub-acute chronic

Time

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acute sub-acute chronic

most recoverwithout

intervention

some recover very fewrecover

psychosocial domainfear of activity

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acute sub-acute chronic

Rx:

spinal manualtherapy

McKenzie exercises

spinal manualtherapy

exercises

exercisecognitive

behaviouraltherapy

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Routine Tests:

   observation   active movements   tension tests ***   palpationAs applicable:   stress active movements   neurological examination   muscle performance   passive tests

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Biering-Sorensen test

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Active treatment

• acute NSLBP:

- McKenzie exercises

- specific stabilisation

exercises

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multifidus

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Active treatment

• sub-acute NSLBP

- specific stabilisation

exercises

- McKenzie exercises

- general exercises

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Active treatment

• chronic NSLBP

- general exercises

use principles of cognitive-behavioural therapy

(CBT)

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Exercise:

• chronic NSLBPexercise: supervised

gradedwhole body

CBT: quotasgoal settingpacingreinforcement

(+ job application/CV)

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General aims

• Improve physical function

• Increase confidence in normal movement

• Teach patients how to cope with present and future episodes

• Reduce reliance on health professionals

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Specific aims

• Strengthen main muscle groups

• Stretch main muscle groups

• Increase CV fitness with low impact aerobic exercises

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The program

• Warm-up and stretching

• Individual exercises

• Warm-down

• Tip for the day

• Relaxation session

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Treatment

• treatments that are harmful:

bedrest

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Treatment

• Treatments that are ineffective:

back school

TENS

laser

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Treatment

• Treatments with unknown effect:

massage

ice

heat

short wave diathermy

ultrasound

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Conclusion

Need broad and deep knowledge base to recognise:

• Contraindications and pathology

• Stage of LBP

• Effective exercise programs

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Conclusions

• knowledge of clinical trials to determine the most effective treatment.

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