Lumbar interventions

what are the groupings of interventions listed in the CPG?

• acute or chronic LBP

• LBP with leg pain

• LBP in older adults

• post-op LBP 

what are interventions for LBP with mobility deficits?

• manual therapy of the spine, pelvis, and hip

• exercise:

  • mobility focused of the spine and hip

  • motor control + strength and endurance

• patient education toward activity

what are ACUTE LBP with mobility deficits interventions? (2021 CPG update)

• thrust or non thrust joint mobilizations

• soft tissue mobilization

• massage 

• general exercise training 

• active education and advice to pursue an active lifestyle

• education on the favorable natural history of acute LBP and self-management techniques

LBP with movement coordination impairments interventions

• exercise:

  • motor control in midranges

  • strength and endurance

• temporary external support

• manual therapy of spine, pelvis, hip, and ribs

• self care

• return to work/community

ACUTE LBP with movement coordination impairments interventions (2021 CPG update)

• specific trunk activation training

• trunk muscle strengthening and endurance exercises

• thrust or non thrust joint mobs

• soft tissue mobs

• massage

• active education and advice to pursue active lifestyle

• education on the favorable natural history of acute LBP and self-management techniques 

CHRONIC LBP with movement coordination impairments interventions (2021 CPG update)

• specific trunk activation and movement control training

• trunk muscle strengthening and endurance exercises

• thrust or non thrust joint mobs

• soft tissue mobs

• massage

• active education and advice to pursue active lifestyle

LBP with related referred LE pain interventions

• centralization and improved extension

  • traction, manual therapy, therex

• patient education to maintain centralization

• interventions with movement coordination impairments

ACUTE LBP with related referred LE pain interventions (CPG 2021 update)

• mechanical diagnosis and therapy interventions

• progress to acute LBP with movement coordination impairments intervention strategies 

LBP with radiating pain interventions

• patient education to reduce stress on involved nerve root

• manual/mechanical traction

• manual therapy to segments adjacent to nerve root or nerve roots with mobility deficits

• neural mobilization

• manual therapy and therex for lower quarter neural mobility

• pain management strategies

ACUTE LBP with radiating pain interventions (2021 CPG update)

• general exercise training and neural tissue mobs

• thrust or non thrust joint mobs

• soft tissue mobs

• massage

• education on the favorable natural history of acute LBP and self management techniques

CHRONIC LBP with radiating pain interventions (2021 CPG update)

• general exercise training and neural tissue mobilization exercises

• thrust or non thrust joint mobs

• soft tissue mobs

• massage

• active education to pursue an active lifestyle

LBP with related cognitive or affective tendencies interventions

education and counseling

ACUTE LBP with related cognitive or affective tendencies interventions (2021 CPG update)

• prognostic risk stratification to prioritize interventions to address biopsychosocial contributors to pain

• pain neuroscience education

• general exercise training, aerobic exercises, and active education and advice

LBP with related generalized pain interventions

• education and counseling

• exercise

• low intensity and prolonged 

CHRONIC LBP with related generalized pain interventions (2021 CPG update)

• prognostic risk stratification to prioritize interventions to address biopsychosocial contributors to pain

• pain neuroscience education

• general exercise training, aerobic exercises, and active education and advice

• cognitive functional therapy to address multiple components associated with LBP

PT LBP purview interventions include

• exercise

• passive mechanical treatments

• modalities and other physical agents

• patient education

• alternative medicine

physician LBP interventions purview includes

• meds

• epidural steroid injection

• chronic pain:

  • implanted nerve stimulators

  • radiofrequency neruotomy

what are general thoughts on MDs prescribing medications for LBP?

• consider that the MD feels like they “have to do something” for the patient to validate their visit so they often include recommendations for OTC analgesics/NSAIDs or prescription meds

• part of an overall approach of benign neglect or watchful waiting 

• reality is that they are just appeasing the patient while the natural history evolves because most episodes of LBP resolve spontaneously in 6 weeks 

what are the actions/effects of muscle relaxants?

• primary action on the CNS rather than on direct muscle

• reduce excitation of neuronal pathways / overall inhibitory effect 

what are general thoughts on muscle relaxants?

• often given to enhance sleep quality toward natural resolution

• no real direct effect on etiology

• most clinical trials of low quality and completed long ago 

among the most common “muscle relaxants” used are which 5? how long is the prescription usually?

• flexeril (cyclobenzaprine)

• soma (carisoprodol)

• skelexin (metaxalone)

• robaxin (methocarbamol)

• parafon forte (chlorozoxazone)

usually 1-2 week prescription

what are general thoughts on narcotics for LBP? what are examples of narcotics?

• once more often used in acute MSK pain but now much more conservatively prescribed

• if prescribed, usually very short duration and only if debilitating pain

opioids (oxycodone or hydrocodone)

what is the function/effect of anti-depressants? what are examples of anti-depressants for LBP?

• discovered by accident to decrease CHRONIC MSK pain

• effect on neurotransmitters and may have sedative effect

• used as a “pain med” vs to treat depression (may be an important distinction for patient perception)

cymbalta (duloxetine) and elavil (amitriptyline)

what are general thoughts on steroids for LBP? what is an example of a steroid for LBP?

• sometimes known as a “DosePak” in acute debilitating pain

• more specifically targeting an inflammatory event

• large doses initially for greater immediate effect with tapering off on subsequent days 

medrol (methylprednisolone)

what are modalities that can be used for LBP intervention? what does the evidence say about its benefit?

• ESTIM/TENS

• US

• laser

• diathermy

• iontophoresis

minimal evidence of benefit 

when selecting exercises, you should consider category-related objectives for exercise such as?

• self-mobilization of spine

• motor control exercise of spine

• targeted complementary exercise

• general conditioning 

what are general thoughts on self-mobilization exercises of the spine?

• used to address mobility deficits

• consistent with manual exam and treatment results, if specific directional and segmental loss is evident

• directional preference oriented

what are general thoughts on motor control exercise of the spine?

• sometimes labeled as “stabilization” “core exercises” etc

• focus on motor control, then strengthening/conditioning layered over the motor control

• do not leap over motor control quality, which is essential to establish

• once thought to be the answer for LBP but now it is recognized as valuable but not a “panacea”

what are general thoughts on targeted complementary exercise?

• it addresses other potentially contributory findings/factors such as:

  • short hip flexors in patients with flexion directional preference

  • other LE strength/motor control deficit possibly influencing LBP (like glute strength deficits)

  • numerous possibilities

  • dependent of throroughness of scan and general assessment

  • may have direct functional implications or address specific functional deficits

what are general thoughts on general conditioning exercises?

• targets overall fitness, wellness, and pain management

• may consider details of patient presentation such as:

  • patients with lumbar stenosis on a recumbent bike for sx relief

  • may need to consider comorbidities (like hip or knee OA, cardiac disease, control of DM)

  • may require extensive individual problem-solving

what are 2 additional psychosocial effects of exercise?

• reduction of kinesiophobia

• change in pain interpretation/processing

what does evidence say about the effects of pilates on low back pain?

• a clinical trial used pilates to address catastrophization and kinesiophobia

• saw modest gains in pain and physical function

• causal analysis: gain was partially attributable to the exercises

• key issue is finding clinical trials with comparable interventions because you don’t know if one thing really helped over another

what is the general consensus of apps and video exercise instruction compared to face-to-face exercise?

face to face exercise instruction and follow up with better satisfaction and adherence than app with videos only

what are general thoughts on hip exercises for low back pain?

• patients with chronic low back pain tend to have hip musculature weakness

• functional tests like Trendelenburg and step down are not as revealing as manual dynamometry

• deficits around the hips are a major contributor to LBP especially in older adults

• interventions directed at the hips are often beneficial

what are general thoughts on breathing and core exercises for low back pain?

• diaphragm is important for respiratory and postural function and tends to contract with transversus abominus

• has an effect on intra-abdominal pressure

• treatment should include normal breathing patterns

• diaphragmatic breathing w/ motor control exercises are recommended especially in chronic pain syndromes

• core training with breathing exercises more effective in alleviating chronic non-specific low back pain symptoms

can aquatic exercise be helpful in low back pain?

in RCT, aquatic exercise observed to contribute to MRI measured greater paraspinal muscle volume and other patient reported outcome measures in patients with chronic low back pain

what are general thoughts on positional distraction for low back pain?

• in a RCT of 100 patients with radiating pain, adding positional distraction improved outcomes over exercise alone

• proposed to have a decompression effect on impinged nerve roots in patients with unilateral lumbar disc radiculopathy in one study, where they used CT to measure greater dimension of IV foramen, and the patients had improved SLR up to 48 hours, but there were no other outcome measures or data over 48 hours and no data on incorporation into other interventions so its iffy

what are different kinds of mechanical treatments for low back pain?

• manual therapy

  • thrust manipulation

  • non thrust mobilization

  • soft tissue massage

  • myofascial release

  • strain-counterstrain

• mechanical traction

  • lumbar/pelvic traction

what is the general consensus on mechanical lumbar traction?

• used largely by convention

• evidence for lumbar traction is scant

• if overall evidence is limited, details are even less known (prone vs supine 90/90, dosage parameters, etc)

• best considered last resort for otherwise irreducible peripheral symptoms 

• should NOT be the default mechanical treatment

• traction groups generally w/ greater improvement in pain and function but differences are small and only short-term

what are general thoughts on inversion tables for mechanical treatment of low back pain?

• caution with solo use

• increases intra-ocular pressure

• dynamics of intra-cranial blood pressure

• not for those with vestibular disorders

• anxiety issues complicate

what are general thoughts on home mechanical lumbar traction

• no evidence of value, only individual experience

• very costly (450$-600$)

• some patients may consider it unwieldy/awkward and set up may not be perceived as easy by some

what are issues with the evidence behind mechanical traction?

• no distinct definition of what qualifies as traction (decompression vs traction)

• study design issues (single arm trials, co-interventions, inability to isolate treatment effect)

what are the mechanical effects of traction?

• increased disc height (perhaps in younger more posterior portion than anterior)

• changes of disc shape, separation of herniation and nerve root and widening of the z joints

• increased water diffusion of disc, especially middle aged adults

what are considerations for traction?

• only last resort for irreducible peripheral sx of lumbar origin

• distress relieved by manual treatment

• potential for promoting dependency

• should be accompanied by active interventions ASAP

• typically, only an early course of care application

• may be used to precede manual treatment or extension exercise to promote response within session (only anecdotal reports)

• patients with tendency toward claustrophobia may not tolerate

what interventions have the strongest evidence for LBP?

• advice and education (including individualized)

• remaining active

• exercise

• psychological therapies for specific subgroups (persistent pain, high psychosocial risk, etc)

• return to work programs 

what interventions have moderate evidence for LBP

manual therapy in combination with other treatments

what interventions have the strongest evidence against using for LBP?

• bed rest

• anti-depressants (for routine use, it is okay for chronic or concurrent depression)

• anti-convulsants

• muscle relaxants

• traction

• modalities

• external supports

what are thoughts on early PT intervention for LBP?

early PT can have greater improvements and more likely to self-report treatment success at 1 year

what is the general consensus on manual therapy for LBP?

• LBP is the most studied area of manual therapy

• literature is complex and many clinical trials have study design issues (co-interventions, no long-term follow up, no blinding, difficulty with isolating treatment effect)

• manual therapy of benefit overall

• more manual therapy does not equal better outcomes

• manual therapy + exercise have greater effect than either alone

• effect of manual therapy more limited in patients with chronic low back pain (selective use)

• allows for better motor control and muscle recruitment

• differences in thrust vs non thrust unclear

what are the theoretical effects of manual therapy?

• interruption in abnormal afferent input

• change in central processing of peripheral information

• may change perception of pain

• negative inhibitory/excitatory signals reduced/removed

• potential for improved motor recruitment

2 key mechanisms implied on the effects of manual therapy?

• decreased temporal summation

• increased descending inhibition 

what are general thoughts on specificity in LBP manual therapy?

• specificity is more important in the c spine, not as critical for LBP

• some patients benefit from specific treatment, but many simply need to move, so specificity may not be critical but we don’t know prospectively 

should you perform manual therapy before or after exercise?

before exercise is most effective

what is the general consensus on the association between manual therapy and risk of escalated care of the spine, including opioid prescriptions, spinal injections, meds, imaging, and specialty care visits?

• low and moderate use of manual treatment had 55% and 42% risk reduction of escalated spine care later

• passive PT interventions (estim, heat/cold, US, traction) had elevated risk for escalated care 1 year later

• manual treatment associated with favorable downstream health care outcomes

• need to be very judicious with passive interventions (including DN)

is there a difference between mobilization and manipulation in chronic LBP?

both mobilization and manipulation provide similar immediate benefits for patients with chronic LBP and the choice between the techniques should be based on therapists clinical reasoning and individualized risk stratification

true/false: manual therapy is observed to change neural network activity in the brain associated with an analgesic effect

true, neural changes may involve opioid neurotransmission

what are general thoughts on neural mobilization in LBP?

• neural mobilization can reduce pain intensity and may be especially valuable in persistent symptoms

• neural mobilizations and exercises may be better than exercise only 

what are general thoughts on dry needling for LBP?

• evidence is limited

• mixed outcomes across multiple studies, some have reduced pain and better outcomes and others have minimal differences

• low level support and questionable study designs

what is the general consensus on pain neuroscience education?

• evidence is limited

• suggestions of benefit

• magnitude of effect is variable across individuals and may be dependent on belief systems

• context of PNE and its fit with other interventions are important

• don’t abandon individual problem solving

what are general thoughts on telerehab for LBP?

• potentially of value with exercise progression and monitoring especially in chronic LBP

• suggest benefits for mental health dimensions of quality of life, walking ability, and exercise adherence

• remote therapy could be introduced in clinical practice to improve patient outcomes and resource utilization

PT interventions with greatest magnitude of effect for LBP?

• manual therapy

• exercise (matching patient need critical)

• therapeutic alliance

PT interventions with complementary smaller effects of values unclear for LBP?

• traction

• dry needling

• PNE

• external support like bracing (patient specific)

what are negative predictors of responses to treatment for LBP?

• number of painful sites

• negative expectations of outcomes

what are positive predictors of responses to treatment for LBP?

clinican’s good prognosis

PT interventions of little to no benefit for LBP

modalities, rest/inactivity

does external support like bracing have a lot of evidence behind it for treating LBP?

there is not a lot of evidence favoring it, but SI belts for SI joint pain has a decent amount of evidence for it

what is the STarT back tool?

a risk stratification tool intended to identify those at elevated risk of long standing problems

what is shear wave elastography?

a type of US that measures stiffness of tissue

when is positional distraction usually used?

• can be used in a HEP

• sometimes with radiating pain but probably more so older adults with a flexion preference who are not capable of a full blown flexion program

• key is the symptoms have to be unilateral

what is a risk for doing modified reversed contralateral axial rotation?

it can put your patient at risk for falling and having an injury

what is often the last thing to come back in patients with radiating pain?

sensation

what is a common misconception of LBP and hamstring length?

• some people say you probably have back pain because the hamstrings are short but its probably the other way around

• if efferent output from the lumbar spine is changed it leads to hamstring tightness 

• problem is not the hamstring length but efferent output to the hamstrings

if a patient presents like they have a piriformis syndrome, is it more likely to be the piriformis or the back?

it is more likely an L5/S1 issue