Transcript Low Back Pain in the Elderly

Chronic Low Back Pain
Gregory E. Hicks, PT, PhD
University of Delaware
Chronic LBP
• 80% will experience LBP at some point in
their life (van Tulder, 2001)
• 80-90% recover within 6 weeks (van Tulder,
1997)
• 5-15% will develop chronic LBP
Is There An Alternative Model?
Biopsychosocial model
Vicious Cycle of Pain
Pain
Experience
Pain
Catastrophizing
Disability, Disuse,
Depressions and Sick Leave
Kori et al, 1990
Vlaeyen et al, 1995
Elfving et al, 2007
Fear
Avoidance
Behaviors
Kinesiophobia
Outcomes for Assessment of
Therapeutic Effectiveness
• 5 Core Measures
– Back Specific Function
• Oswestry, Quebec
– General Health Status
• SF-36, EuroQOL
– Pain
• Visual Analog Scale, McGill Pain Questionnaire
– Work disability
• Days off work
– Patient satisfaction
• Patient Satisfaction Scale
Nonpharmacologic Therapies for
Acute and Chronic LBP:
A review of the evidence for an American Pain
Society/American College of Physicians Clinical
Practice Guidelines
Chou and Huffman, Ann Intern Med, 2007
Quality of Evidence
• Good
– Evidence from at least 2 high quality trials
• Fair
– Evidence from at least 1 high quality trial or
from 2 or more higher quality trials with
limitations
• Poor
– Evidence is limited due to insufficient power or
poor study design
Back Schools
• Educate LBP sufferers in exercises, ergonomic
techniques and the psychological aspects of low
back pain
– Main criticism-education is not put in the context of the
persons specific job duties
• Fair quality of evidence
– Inconsistent results from trials
• Small net benefit
• Results were best when done in occupational
setting or more intense programs based upon
original Swedish model.
Psychological Therapies
• Cognitive-Behavioral Therapy
• Biofeedback
– Use of auditory and visual signals reflecting
muscle tension or activity to inhibit or reduce
muscle activity
• Progressive Relaxation
– Deliberate tensing and relaxing of muscles to
facilitate the recognition and release of muscle
tension
Psychological Therapies
• Standard Cognitive-Behavioral Therapy
– Good quality of evidence
– Moderate net benefit
• Biofeedback
– Poor quality of evidence
– Unable to estimate effect
• Progressive Relaxation
– Poor quality of evidence
– Large impact on short term pain
Cognitive-behavioral
Interventions
• The intervention encompasses a 6-session
structured program where participants meet
in groups of 6 to 10 people, 6 times, once a
week for 2 hours.
• First session deals mainly with helping
participants feel comfortable and getting to
know one another and providing
information about the course
Multidisciplinary Therapy
• Combines and coordinates physical,
vocational, and behavioral components and
is provided by multiple health care
professionals with different clinical
backgrounds. Intensity and content varies
widely
Multidisciplinary Therapy
• Good quality of evidence
• Moderate net benefits gained
• More intense multidisciplinary
rehabilitation was more effective than less
intense programs
Functional Restoration
• AKA- work hardening or work conditioning
• Involves simulated or actual work tests in a
supervised environment in order to enhance
job performance skills and improve
strength, endurance, flexibility and
cardiovascular fitness in injured workers
Functional Restoration
• Fair quality of evidence
– 9 higher quality trials with conflicting reports
• Moderate net benefit gained
Modalities
• Includes all typical passive modalities
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Ultrasound
TENS
Interferential
Moist heat
Short wave diathermy
Laser
Modalities
• Poor quality of evidence
– 5 higher quality trials
• No benefit gained
Lumbar Supports
• Poor quality of evidence
– 1 higher quality trial
• No benefit in this population
Massage
• Fair quality of evidence
– 3 higher quality trial
• Moderate benefit gained
Traction
• Fair quality of evidence
– 3 higher quality trial
• Not effective (for continuous traction)
Spinal Manipulation
• Includes manipulation and mobilization
• Good quality of evidence
– 15 higher quality trials
• Moderate benefit gained
Exercise
• Includes supervised exercise programs or
formal home exercise programs, ranging in
focus from general aerobic fitness to muscle
strengthening and flexibility
Exercise
• Good quality of evidence
• Small to moderate benefits
– Varies due to variation in types and
combinations of exercise used
Systematic Review on Exercise
Liddle, Pain, 2004
• Strengthening for the lumbar extensors and abdominals
is key!
• Unclear about the benefit of flexibility training due to
study designs
– Flexibility is often included with other forms of exercise
• Supervision contributes to maintenance of exercise
benefits and appears to increase compliance
• Higher doses of exercise (>/=20 hours) are more
effective in improving outcomes
Comparison of general exercise,
motor control exercise and spinal
manipulative therapy for chronic low
back pain: A randomized trial
Ferreira et al., Pain, 2007
• 240 patients with CLBP randomized for 8wk intervention
• General exercise included strengthening, stretching and
aerobic exercises.
• Motor control exercise involved retraining specific trunk
muscles using ultrasound feedback.
• Spinal manipulative therapy included joint mobilization
and manipulation.