Recognition of Back Injuries in the Non

Athlete

Ryan PerryPT, DPT, OCS, CSCS, MTC, FAAOMPTNovaCare Rehabilitation - Chicago

March 12th, 2010

Incidence◦ Prevalence of LBP among former elite athletes of

all sports was 29%, compared with 44% among non-athletes. Bono, 2004

◦ Higher rates of spondylolysis, spondylolisthesis and disc degeneration have been reported in athletes than in the general population. Ong et al, 2003

Athlete vs Non-Athlete

Fritz, 2010 Adolescents with LBP as a result of sports

participation tended to have lower baseline disability scores and to experience less improvement in disability than non-participants◦ Also attended more PT sessions over a longer

period of time

Athlete vs Non-Athlete

Fritz, 2010

Patients who were sports participants were more likely to undergo an MRI before referral

Overall pattern of outcomes in this sample of adolescents was similar to reports of outcomes from adults with LBP

Athlete vs Non-Athlete

Easier or Harder to Treat? Athlete

◦ Typically in better shape than non-athlete

◦ Very motivated to exercise

◦ Understands the difference between pain from DOMS and true pain

◦ Can be demanding

Non-Athlete◦ Lower physical

expectations at discharge

◦ Less diagnostic imaging before onset of PT

◦ Subjected to decreased load and strain

Common Diagnoses Lumbar sprain/strain Discogenic pain Instability Facet syndrome Scoliosis Stenosis Arthritis Fracture Other Miscellaneous Non-musculoskeletal (3% of LBP- Deyo,2001)

Recognition of Back Injuries

Primary areas of CA that can cause metastatic spine CA

Breast Lung Thyroid

◦ with Kidney Prostate

The spine is the most common site of bone metastasis

• Tumor-related pain is predominantly nocturnal or early morning pain and generally improves with activity during the day

Cancer & LBP

Non-mechanical Causes Malignancy Infection Inflammatory

spondyloarthropathy (ankylosing spondylitis, psoriatic spondylitis, Reiter's syndrome, inflammatory bowel disease)

Osteochondrosis Paget's disease of bone

Referred Pain Pelvic disease (prostatitis, endometriosis,

pelvic inflammatory disease) Renal disease (kidney stones,

pyelonephritis, perinephric abscess) Aortic aneurysm Gastrointestinal disease (pancreatitis,

cholecystitis, penetrating ulcer)

Nonorganic Signs of LBP

Described by Waddell, and these usually suggest delayed recovery and need for multi-disciplinary approach

Pain at the tip of the tailbone Whole-leg pain in global distribution Whole-leg numbness in a global distribution Sudden give-way weakness of the leg Absence of even brief periods of relative pain relief Failure or intolerance of numerous treatments Numerous urgent care visits or hospitalizations for

back pain◦ Waddell G, Bircher M, Finlayson D, Main CJ: Symptoms and

signs: Physical disease or illness behaviour? BMJ (Clin Res Ed) 1984:289:739-741.

Most commonly diagnosed lumbar pathology Strain

◦ Occurs by disruption of muscle fibers or the musculotendinous junction

Sprain◦ Stretching or tearing of spinal ligaments

Will have localized isolated tenderness of the lumbosacral spine

Patient will not have signs of red flags for non-spinal conditions or cauda equina nor tension signs associated with nerve root irritation

Graw & Wiesel, 2008

Lumbar sprain/strain

Discogenic Pain Typically seen between in 4th & 5th decade of

life Pain often in the lower extremity Pain usually worse with sitting or bending Neural tension signs Many false positives with MRI

Not all disc problems that present on MRI cause pain◦ Make sure you correlate the clinical exam with the

MRI

Jensen et al, 1994◦ Thirty-six percent of the 98 asymptomatic

subjects had normal disks at all levels.◦ Thus, 64% had at least a disk bulge at least at

one level in the lumbar spine

Discogenic Pain

Spinal Stenosis

Usually present in patients >60 y/o

Pain worse with walking Pain relieved with sitting Typically have decreased

extension ROM Pain often primarily in

LEs Use Bicycle test of van

Gelderen to differentiate between vascular disease

Arthritis

Characterized by stiffness

Patients usually >50 y/o

Typically worse in the morning

Amount of ROM proportional to disc height

Spondylolysis

Spondylolysis: A defect in the continuity of the pars interarticularis of the vertebrae◦Seen in ~5% of the population◦Controversial whether the incidence is higher

in the athletic or non-athletic population Athletes tested more frequently for this Some studies show a lower rate of this abnormality

in athletes compared to non-athletes Moller & Hedlund, 2000

Spondylolisthesis Slippage of one vertebrae on

its adjacent segment◦ Thought to be a further

progression of bilateral spondylosis

Over 5 years of follow-up, younf athletes demonstrated a 38% rate of slippage, which was not significantly different than the general population◦ Bono, 2004

Spondylolisthesis Clinical findings:

◦ Radiographic evidence of spondylolysis and slippage with flexion-extension X-rays

◦ Localized LBP with or without radiating LE pain and/or neurological findings

◦ Positive Stork sign (one-legged extension)◦ Graded I-V

Grades I-II usually successful with conservative care Grade V (spondyloptosis): Surgical

Non-specific LBP LBP in the presence of non-specific

abnormalities on imaging studies ◦ Graw & Wiesel, 2008

1. The structure should have a nerve supply

2. The structure should be capable of causing pain similar to that seen clinically

3. These structures should be susceptible to diseases or injuries that are known to be painful

4. The structure should have been shown to be a source of pain in patients using diagnostic techniques of known reliability and validity.

Bogduk 1997

Philosophical Persceptive

Do we really have an accurate pathoanatomical diagnosis?◦ Unlike younger patients, only 15% of mature patients

can be given a precise diagnosis Deyo 2001

◦ No firm evidence exists for the presence or absence of a causal relationship between radiographic findings and nonspecific LBP van Tulder, 1997

◦ Identifying relevant pathology in patients with LBP has proved elusive and is identified in <10% of cases Abenhaim et al, 1995

Diagnosis

Despite the fact that >1000 RCTs have investigated the effectiveness of conservative and surgical interventions for the management of LBP have been reported in the literature, evidence remains contradictory and inconclusive for many interventions◦ Hayden et al, 2005 & Koes et al, 2006; both in Fritz,

et al 2007 Cannot treat LBP with only one approach, as

not one single approach has shown to be effective

Need for Change

Subgrouping◦ The subgrouping hypotheses proposed are

intended for patients who may or may not be involved in athletic activities with acute LBP or an acute exacerbation of LBP causing substantial pain and limitations in daily activities.

◦ After screening patients for any signs of serious pathology, information collected during the history and physical examination is used to place a patient into a subgroup.

Hebert et al, 2008 & Delitto et al, 1995

Classification Model

Subgrouping◦ Four subgroups were established by Delitto et al

in 1995 Manipulation Stabilization Specific Exercise Traction

◦ Subgroups classification criteria and intervention procedures updated in 2007 by Fritz et al.

Classification Model

◦ Clinical prediction rule (CPR) developed & validated by Flynn & Childs, respectively. Goal of the CPR for the manipulation classification is

to identify patients with LBP who are likely to respond to manipulation with rapid and sustained movement

Improvement defined as a 50% or greater reduction in self-reported disability over 2 treatment sessions

Intervention: Manipulation of the lumbopelvic region and AROM exercises

Classification Model:Manipulation

CPR included 5 factors◦ Current symptom duration of less than 16 days◦ Score <19 on the work subscale of the Fear-Avoidance

Beliefs Questionnaire (FABQ)◦ Hypomobility of the lumbar spine as assessed with

posterior-to-anterior pressure◦ Hip IR of at least 1 hip greater than 35°◦ Symptoms not extending distal to the knee.

When 4 of these 5 factors were present, patients were highly likely to improve, while the presence of 2 or fewer factors was almost always associated with a failure to improve. 4 or greater: +LR = 24 2 or less: - LR = 0.09 * Flynn et al, 2002

Classification Model:Manipulation

Clinical Prediction Rule (Hicks, 2005)

If the patient has three of the following four criteria, then he/she will be four times more likely to be successful with a stabilization program in physical therapy◦ Age <40 years old◦ Straight leg raise >90 degrees◦ Aberrant movement present during ROM testing◦ Positive prone instability test

Classification Model:Stabilization

Stabilization Interventions (Fritz et al, 2007) Isolated contractions of the deep multifidus

and transverse abdominis Strengthening of large spinal stabilizing

muscles (erector spinae, obliques, etc)

Classification Model:Stabilization

Long-term effects (Hides 2001)

Studied recurrence rate of LBP after acute, first-time episode of LBP

Subjects allocated to two groups◦ Control: General advice plus use of medications◦ Experimental: Specific exercise targeting the

lumbar multifidus and transverse abdominis

Classification Model:Stabilization

Long-term effects (Hides 2001)

Results ◦ The recurrence rate at one-year of follow-up

was 84% in the control group and 30% in the experimental group (p<0.001)

◦ Results were similar at the three-year follow-up

Classification Model:Stabilization

Classification approach was updated for patients who are post-partum

Updated classification criteria◦ Positive posterior pelvic pain

provocation (P4), AND SLR and modified Trendelenburg tests

◦ Pain provocation with palpation of the long dorsal SI ligament or pubic symphysis

Fritz, 2007

Classification Model:Stabilization

Patients that typically respond are the following ◦ If the patient has reduction of symptoms with

>2 repetitions in the same direction OR ◦ If the patient has centralization of symptoms in

one direction and peripheralization of symptoms in the opposite direction

Directional preference can be extension, flexion, or lateral shift

Classification Model:Specific Exercise/Directional Preference

Repeated ROM performed initially, followed by strengthening exercises toward the directional preference

McKenzie program is the most common form of directional preference therapy◦ McKenzie program is not always extension

Classification Model:Specific Exercise/Directional Preference

Performed when the following criteria are present:◦ Signs and symptoms of nerve root compression◦ No movements centralize symptoms

Typical treatment: Mechanical traction or autotraction

Fritz et al, 2007

Classification Model:Traction

Fritz et al (Spine, 2007) found that the presence of symptoms below the buttock and signs of nerve root compression were not specific enough to identify this subgroup

◦ Two additional factors were found to identify patients likely to respond favorably to traction Peripheralization with extension movement Positive crossed SLR (aka Well SLR)

Classification Model:Traction

When patients with symptoms below the buttock and signs of nerve root compression had either of these findings received traction plus an extension-specific exercise program, they showed greater short-term reductions in disability than patients who received only the extension exercise program (Fritz, 2007)

Classification Model:Traction

Cai et al, 2009◦ A clinical prediction rule with four variables was

identified. Non-involvement of manual work Low level fear-avoidance beliefs No neurological deficit Age above 30 years

◦ The presence of all four variables (+LR = 9.36) increased the probability of response rate with mechanical lumbar traction from 19.4 to 69.2%.

Classification Model:Traction

Fear avoidance simply refers to avoidance of movements or physical activities because of the patients’ fears that pain will make them worse

Fear-Avoidance Beliefs

Studies suggest that questionnaires based on the fear-avoidance model accurately identify poor prognosis for patients with LBP◦ Al-Obaidi et al, 2005

Interventions aimed at confronting these beliefs and graded exercise have been effective at reducing pain ◦ George et al, 2003

Fear-Avoidance Beliefs

Fear-Avoidance Beliefs Questionaire (FABQ) http://www.kmcnetwork.org/ksmc/menu/FABQ.pdf

Waddell et al, 1993

These results confirm the importance of fear-avoidance beliefs and demonstrate that specific fear-avoidance beliefs about work are strongly related to work loss due to low back pain

Fear-Avoidance Beliefs

Grotle, Spine, 2006

In the acute sample, fear-avoidance beliefs for work predicted pain and disability at 12 months.

In the chronic sample, fear-avoidance beliefs for physical activity predicted disability at 12 months, but not pain.

Fear-Avoidance Beliefs

Fear-Avoidance Beliefs The FABQ is a self report questionnaire with 16

items each scored from 0 to 6 with higher numbers indicating increased levels of fear avoidance beliefs.

The questionnaire contains two subscales◦ A 4 item activity subscale ◦ A 7 item work subscale

The work subscale is associated with current and future disability and work loss in patients with acute and chronic LBP.

* Waddell, 1993

Fear-Avoidance Beliefs The work subscale has been identified as a

strong predictor of work status.

◦ Scores of 30 or less are associated with a greater likelihood of return to work whereas of 34 or more are associated with less likelihood of return to work or increased risk of prolonged work restrictions.

◦ Thus, a score of 34 or more on the work subscale of the FABQ should be a “Yellow Flag” for therapists and case managers working with out of work workers with low back pain.

Fritz & George, 2002

Croft et al, 1998 The results are consistent with the

interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months.

However most will still be experiencing low back pain and related disability one year after consultation.◦ Only 25% will be completely recovered at this

time in terms of both pain and disability

Return to Activity/Prognosis

Return to Activity / Prognosis 10% of LBP patients account for 90% of

healthcare and disability costs

Identification of individuals at risk is the first step in preventing chronic instability due to non-specific LBP◦ Iles et al, 2009

Return to Activity / Prognosis Recovery expectations when measured

using a specific, time-based measure within the first 3 weeks of non-specific LBP is a strong predictor of people at risk of poor outcome

Iles et al, 2009

Return to Activity / Prognosis Patients with lower than average initial pain

intensity, shorter duration of symptoms and fewer previous episodes were 3.5 more likely to be recovered at any time point than patients without these characteristics◦ These were described as the following:

Baseline pain </= to 7/10 Duration of current episode </= 5 days One or zero previous episodes of pain

Hancock et al, 2009