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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE August 2020 The Impact of LBP Recurrences A Call to Reconsider Clinical Decision Making? T Da Silva, K Mills, et al. What Is The Personal Impact Of Recurrence Of Low Back Pain? Sub analysis Of An Inception Cohort Study. JOSPT, June 2020: 50 (6): 294-300. by Allison Pulvino, PT, MSPT, CMP, FAFS The full text review is available via the Read More link below. We've begun using this summary of our article overview as a quick read version In an effort to honor your time demands. SUMMARY: There was a significant number of participants (68%) that had recurrences of their LBP after 1-2 wk. reduction to <1/10 for 1-2 weeks following formal care. Over 70% of those with exacerbation's had at least moderate level impact or needed formal care again, despite the authors concluding there was generally low impact overall from “non-specific” (this was poorly defined re diagnostic criteria etc.) LBP recurrences. While the authors don’t adequately specify what the treatments were exactly, the recurrence rate and impact on symptoms and function suggest several possible reasons that would affect how “non-specific” LBP presently is treated. The extent and impact of recurrences may indicate that the treatments prescribed and done in this case were potentially incomplete and/or ineffective since 68% experienced episodes again. We propose discharge criteria for LBP should include having done biomechanical scan and treatment of key contributing areas via corrective exercises at least, in order to minimize risk of recurrence vs symptom reduction modalities and exercises only. Also, counselling patients on gradual transition back to prior and goal based activities is key along with compliance with continuing their HEP until fully returned to all prior ADL, work, recreational, fitness, social, and athletic function. Background: Currently, it is known that recurrence of LBP is common but it is unclear what the ongoing pain issues may be or the limitations on physical function are for individuals who experience recurrences of low back pain. This study aimed to examine the impact of LBP over 1 year after recovery of a recent LBP episode, differences in impact between those with and without recurrences, and compare the impact considering three different definitions of a “recurrence”. Method: This is a preplanned sub analysis using data from a cohort study. There were 250 participants in this study that were 18 yrs. or older, and had recently completed care from a physical therapist or chiropractor in the last month from an episode of nonspecific low back pain. A patient-reported impact score outcome measure (pain intensity, pain interference with activity, and functional status) was used to assess the prior 3 months at 3, 6, 9, and 12 months. A recurrence was defined as an episode of LBP > 24 hrs. and >2/10 intensity, a recurrence of activity-limiting low back pain, or third – a recurrence of low back pain resulting in subject/patient seeking health care. Results: Of the 250 participants in this study 68% reported a recurrence of low back pain in the 12 month period, of which 14.0% reported a LBP recurrence of symptoms, 14.4% an episode of moderate activity limitation, and 39.6% needing to seek health care. The authors then conclude that these findings are not significant and patients should be reassured that many occurrences will have little impact on them in the future. This statement is not supported by the findings. Peak Performance Perspective: Assessing and treating low back pain is commonplace for many medical providers. There are various etiologies of low back pain, and most of us can agree it is not a “one size fits all” in the way of treatment. This study addresses the important topic of the “impact” LBP has on patients after recovery and from subsequent recurrences. It speaks to the efficacy of prior care and treatment decision making, patient compliance, and how we counsel patients about their LBP and expectations both surrounding recovery but also when a recurrence does occur. And when recurrences of pain happen, we first have to wonder why. While this study’s abstract states that the average impact due to recurrence of low back pain was low, this is not really what the results are showing. First, the authors used “median” rather than “means” in their analysis but neglected to explain why. They show that at least 68% of participants experienced recurrences of low back pain, with 80% of those (or 50% of the study’s participants) having experienced recurrences reporting moderate or greater activity limitation or needing formal healthcare again. Also, the Impact Score range appears small at first glance - with those with no recurrences having 11.1 points and 15.2 points for those with recurrences. Further review shows that recurrence groups ranged from 12.7 points for LBP recurrence episode, 15.5 points when moderate activity restriction recurrence, and up to 16.9 points for those needing to obtain further healthcare - therefore a majority of those having recurrences actually were showing impact scores in proximity to the 19 point Impact Score participants scored during the original LBP episode. The authors didn’t include the number of individuals that experienced minimal limitations, and there was no specifics provided as to what the affected activities were. This is a significant weakness of the study. One person’s minimal limitation could be another’s severe – this is contextual to their personal level of normal activity. As an example, one person doesn’t feel lifting 25 pounds is a necessary task to return to, but a young parent who has to repeatedly lift a 25 pound child all day has to have that ability. Another weakness of this study was that after the first two recurrences are reported by a participant, no further recurrences would be included or recorded. This could be significantly affect the real number of recurrences, and could affect the conclusion the authors tried to make altogether. Da Silva, et al. mention only nonspecific low back pain was the inclusion criteria, but gave a vague description and examples. There are many other structures and tissues that can cause LBP, including SI joint dysfunction, facet compression/dysfunction, and movement restrictions including flexion or extension sensitivities that tell re not specifically diagnosed by radiographic abnormalities or asymmetries by referring physicians. Since the authors only indicate radiographic based diagnoses as examples of exclusionary (specific) diagnoses, it remains unknown what commonly seen movement based diagnoses were included here or findings be applied to. Without imaging, there can be no medical diagnosis, which is true, but even with movement and tissue sensitivity screening; flexion and extension sensitivities can arise, leading towards obtaining a functional diagnosis. The high number of recurrences should make us wonder why these individuals were discharged from care, and what criteria did they meet. Were they just pain free for a few days or were they actually assessed to be functional and able to return to their favorite activity or sport or full time manual labor job? This detail would likely help give us more understanding into the care they may have or have not received. Feeling great for a few days over the weekend while sedentary doesn’t usually translate into going back to work and lifting 30 pound boxes or carrying 50 pound pieces of machinery over the course of eight or more hours. Many times patients ask us if “this could be the last day” when they walk into the clinic because they haven’t had any back pain in 5 days and they can finally get in and out of their car pain free. Being pain-free with basic ADLs, while excellent and a sign of meaningful progress, doesn’t mean they are ready to lift a heavy box off the ground or run a 5K race the next week. The few movements and activities they did over the weekend weren’t hard enough, and didn’t load their bodies and tissues in the way that is similar to the eventual ADL, work, or recreational task they still haven’t gotten back to. Participants in this DaSilva et al study needed only rate their symptoms at 0-1 out of 10 for 7 consecutive days but there is no functional scale reported here and certainly no mention of the PT or Chiropractor using any standardized means of assessing functionality or kinetic chain factors prior to discharge. The bypassing of key details like this does an injustice to how both PT’s and physicians view what should be high level care of patients with LBP. Care that focuses only local symptom reduction and generic stretching and strengthening may be easy to implement and produces seemingly good short term results in terms of pain relief and low level activity return, however, with many of the “failed prior care” cases we see it becomes evident more thorough vetting of underlying kinetic chain factors are often neglected and later become a mainstay in why we see many patients succeed. Many times individuals will go to a healthcare facility because it’s convenient and close to home or work, and often this is a driving factor in physician referral decisions as well. While for many patients simple, traditional PT care may suffice, this study demonstrates that LBP recurrences are far too high and that substantial limitations do happen with these recurrences. Properly screening the kinetic chain for limitations that would overload tissues in the lower back takes added time and skill. Too often patients come in and tell us they were asked to move their trunk in several directions and then given a canned sheet of “low back” exercises. Missing that patient’s stiff ankle or maybe a hip, especially when their ADL requires twisting into that side to reach 20 times a day could cause a strain as the low back compensates for the hip that has reached its ROM limits (but that wasn’t discovered because it was just a “low back pain” issue). Or maybe walking any distance feels fine, but any standing still sends pain into one side of the back because the leg length discrepancy is causing a unilateral pelvic rotation, and nobody saw that because it was just a “back” ache and the original five or six traditional physical therapy exercises made the pain go away for a couple of days. It takes a whole body system assessment to see what joint, and in what plane of movement and with what stress does that person experience his or her pain. It takes time and it takes individualized focused care and problem solving. And it also takes proper patient education from the PT for the patient to stick with their program long term, as that is the only way they have a greater chance of preventing the dreaded recurrence, which according to this article occurs all too often. That leads into our patient example. When multiple PT attempts did nothing for her pain, Amy looked into other options including spinal injections and a nerve ablation to help get through her day. She was a triathlete and even an Ironman competitor at one of the highest levels, but when her lower back pain became unable to be managed, she finally came into our clinic for what she said was her last hope for a pain free life. Peak Patient Experience Amy Said: "Now I am totally pain free and stiffness free!" Pt reported feeling pain free with all ADLs, work tasks, all transfers, and able to return to pain free running 3-3.5miles up to 3x/week. History: 45 year old female with a 3+ year history of lower back and SI joint pain, with a previous L5-S1 disc herniation a few years prior. Prior PT at one other facility for multiple months without relief of sx’s, as well as multiple L facet injections and a nerve ablation without success. Previous Ironman and elite triathlon competitor with now an inability to perform almost all ADLs without pain limiting her. Subjective: “Peak Performance is my last resort at trying to get better! I have to take a muscle relaxer in order to even sleep, and I can barely move and get in and out of the car.” 8/10 max sx's, with a constant 2/10 even at rest. Sx's exacerbated by any transfers, forward reaching, or squatting, ADL or fitness. She was unable to run or to don/doff shoes and socks without intense pain. Objective: * = pain Initial DC Eval Spinal Flexion 25% * 100% Spinal Extension 25% * 90% Spinal Rotation L 380, R 400 L 450, R 470 Hip Extension L 200, R 150 L 230, R 210 Prone hip ER L 270, R 240 L 350, R 310 Active Knee Extension Hamstring L -600, R -500 L -290, R -280 Slump test (+) B ** (-) B Leg length discrepancy R greater troch higher Neutral w/ lift Max pain 8/10 mild--1-2/10 Treatment: Manual therapy: Functional wb hip extension and ER mobilization, thoracic spine SB and extension mobilization, deep tissue release to hip flexors and hip rotators, SI joint muscle energy corrections for sacrum/ischium/ilia and Modalities: Class IV laser treatment-10 sessions with 25 watt intensity; L heel lift provided to correct leg length discrepancy Exercise: Stretching: 3-plane dynamic hip ext, thoracic spine ROM and self-mobilization, prolonged hip ER/hamstring/hip flexor stretching, McKenzie prone spinal extension stretching Strength: Standing eccentric extension drills of anterior chain with weights-overhead pressing and posterior tipping through hip flexor loading, thoracic spine and scapular strength drills, proper lunge mechanics tubing resistance lunges for proper hip hinge mechanics , dynamic plank drill for frontal and sagittal stability, frontal plane strength drills with opposite and same side load, hip ER resistance tubing stepping drills

View this email in your browser Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE August 2018 New insights into hip rotation and chronic back pain: When back pain isn't coming from the back CURRENT EVIDENCE Hoffman, S. Johnson, M. Zou, D. Van Dillen, L. Sex Differences in Lumbopelvic Movement Patterns During Hip Medial Rotation in People with Chronic Low Back Pain. Arch Phys Med Rehabil. 2011; 92: 1053-1059. by Allison Pulvino, PT, MSPT, CMP, CAFS Background: There have been numerous links between back pain and hip motion, but not many comparing the differences between the sexes with medial hip rotation and the possibility of low back pain. This study attempts to assess how medial hip rotation in males and females may differ with mobility as well as pain levels. Method: 62 subjects were selected from a larger randomized controlled clinical trial, and an equal numbers of males and females (n=31) were utilized. Subjects were required to have low back pain for a minimum of 12 months. Active hip medial rotation in prone was measured using a 6-camera, 3-dimensional motion capture system to collect and process kinematic data. The measurements were assessing hip and pelvic motions, with angular displacements calculated between the initial and final position of the pelvic and lower leg segments. Results: Men demonstrated significantly more total lumbopelvic rotation motion than women, as well as having decreased hip medial rotation before the start of the lumbopelvic rotation. Also, men were found to have less total hip medial rotation than women. A much greater proportion of men reported increased symptoms (60%) than women (34.5%) on one or both sides during active medial hip rotation. Hoffman et al do conclude that men and women average varying levels of medial hip rotation, and affects can be seen proximal to the assessed hip. Although this study does have limitations, it can lead to special considerations of appropriate lumbar and hip treatment interventions for males versus females due to the level of lumbopelvic mobility as it relates to lack of hip mobility. THE PEAK PERFORMANCE PERSPECTIVE So many people report being frustrated with back pain that just never seems to go away with stretching the sore structures, and/or performing the classic “core strength” exercises that they may have been taught. But what many still don’t know is that their back pain may not be coming from their actual spine limitations, but other adjacent or even distant regions of the body. Our hips, being able to move in three planes separately along with all the combined motions possible, provide the mobility necessary for ADL or sports/recreation tasks, but it is well known that current cultural habits include prolonged sitting or standing for the better part of the day, which mutually contributes to certain directions begin to develop other ROM deficits over time. Hoffman et al are wise to explore the relationship of hip internal rotation with chronic LBP and also any gender-based differences that might exist. It’s increasingly accepted that kinetic chain deficits are a contributing factor to the onset of low back pain. The activities we enjoy that involve bringing our hips past ranges that we have not been accustomed to with normal ADL (for example, kicking a soccer ball or swinging a golf club) can produce compensatory movements and eventually strain at the low back. Too often low back pain is treated locally and appreciation for underlying kinetic chain deficits is ignored. Men and women are now more than ever performing many of the same recreational activities such as weightlifting, rock climbing, golf, lacrosse, etc. This study sheds some light on the subject of why males may report more limitations with certain activities than females. Males had less hip IR than females and lumbopelvic compensatory motion. While Hoffman et al did not measure hip IR in a WB functional position, this motion limitation would be expected to potentially impact functional tasks. For example, from the proximal to distal (or “top-down” directed motion) aspect we can stress our hips with spinal/pelvic movements over the femur. If you are standing still and a sudden loid noise causes you to turn to the left to look and you lack adequate left hip IR, then the lumbar segments would likely experience excessive left rotational stress, potentially leading to back strain. Similar examples would be a right-handed thrower during release and follow-through phases or a mother reaching into the passenger side back seat to lift a child from her car seat. More classic distal on proximal (or “bottom up” directed motion) examples of similar kinetic chain examples would be when changing position and by stepping over something or cutting during athletics like soccer or football. Limited hip IR, as found by Hoffman, et al, causing earlier and larger lumbopelvic motion could then bring stresses more proximal to the spine. Some important limitations exist in this Hoffman, et al study. They studied only NWB internal rotation AROM done distal on proximal style. It must be remembered that we move differently actively versus passively, NWB vs WB, and directionally when proximal over distal. These are functional biomechanics differences that relate to normal human movements and demands that this study did not specifically examine. Motor control and tissue tensions will differ in WB and NWB environments. Concentric muscle actions (studied by Hoffman et al) may result in different forces and influences than when required to perform eccentrically, as is often the case with functional movements against gravity. Finally, this study did not examine cause-effect relationships, so care must be taken to avoid assuming the hip IR loss was contributing to the LBP since it also could have developed afterwards and be the result of and not a cause of the LBP. This is where a very thorough three-dimensional movement assessment is necessary to actually pinpoint one, two or even more structures that may be limiting this person’s eventual goal of swinging that golf club, or playing in a full tennis match without low back pain limiting this favorite activity. THE PEAK PERFORMANCE EXPERIENCE Richard stated recently: “I was able to golf three out of the last four days without any back pain, and only feeling stiffness in my back with prolonged sitting now for work. Golfing has been going much better! HX: Patient is 52 y/o male and reported having back pain after golf one day and when he woke up the next morning he felt “locked up.” He had right-sided lower back pain and right great toe numbness. His main goal was to be able to golf without pain as that’s what he loves in the summer. Patient Initial Subjective: Patient’s lower R side back pain can get up to 8/10 and was 5/10 at initial exam. The pain was much worse in the morning and felt somewhat better as the day would progress. Pain with golfing, any distance driving, sitting more than ten minutes, and standing more than ten minutes. His right side of his back feels constantly sore. ODI score was 38%. Objective Data: Patient demonstrates R thoracic convexity with forward flexion, R ischial tuberosity higher than L, decreased medial arches B feet, positive Thomas and Ely’s test B with negative Slump and SLR B. Tenderness reported R psoas, R iliacus and proximal ITB and QL. See table below. Treatment: Manual therapy: Muscle energy technique for SI jt correction prn, B anterior hip capsular mobilizations, R iliacus/TFL/ITB myofascial release, thoracic P-A mobilizations. Hip mobility: Functional dynamic multiplanar stretches/mobility drills for psoas, IR, ER done in WB. Thoracic and lumbar mobility: Elevated hip isolated thoracic R/L rotation with shoulder pullback, seated thoracic extensions over chair back prn daily with feet elevated, prone on elbows, prone press-ups, side-lying rotation with hip flexion, isolated R rotation for backswing loading R hip, isolated L rotation for follow-through loading L hip. Neural: Supine and seated sciatic nerve glides TID as able. Strength: Calf strength-Seated to standing progression single leg calf raises to allow for proper push-off at terminal stance. Trunk stability: Birddogs, incline planks with lateral taps, incline planks with alternating hip extension for sagittal control. Hip stability dynamic control: Hip IR and also extension stimulus via reaching and tubing resistance and balancing Golf swing progression: Half to full swing progression practicing loading each hip separately for each backswing and then follow through. Full swing performed only after single leg load with acceptable triplanar hip motion + trunk rotation noted You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Allison Pulvino, PT, MSPT, CMP, CAFS Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place.  COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com This email was sent to << Test Email Address >> why did I get this? unsubscribe from this list update subscription preferences Peak Performance Physical Therapy · 161 East Commercial Street · East Rochester, NY 14445 · USA