Non-Invasive and Minimally Invasive Management of Low Back Disorders.

OBJECTIVE: This abbreviated version of the American College of Occupational and Environmental Medicine's (ACOEM) Low Back Disorders Guideline reviews the evidence and recommendations developed for non-invasive and minimally invasive management of low back disorders. METHODS: Systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking. A total of 70 high-quality and 564 moderate-quality trials were identified for non-invasive low back disorders. Detailed algorithms were developed. RESULTS: Guidance has been developed for the management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 121 specific recommendations. CONCLUSION: Quality evidence should guide treatment for all phases of managing low back disorders.

Convergence and Divergence of Exercise-Based Approaches That Incorporate Motor Control for the Management of Low Back Pain.

SYNOPSIS: Many approaches for low back pain (LBP) management focus on modifying motor control, which refers to motor, sensory, and central processes for control of posture and movement. A common assumption across approaches is that the way an individual loads the spine by typical postures, movements, and muscle activation strategies contributes to LBP symptom onset, persistence, and recovery. However, there are also divergent features from one approach to another. This commentary presents key principles of 4 clinical physical therapy approaches, including how each incorporates motor control in LBP management, the convergence and divergence of these approaches, and how they interface with medical LBP management. The approaches considered are movement system impairment syndromes of the lumbar spine, Mechanical Diagnosis and Therapy, motor control training, and the integrated systems model. These were selected to represent the diversity of applications, including approaches using motor control as a central or an adjunct feature, and approaches that are evidence based or evidence informed. This identification of areas of convergence and divergence of approaches is designed to clarify the key aspects of each approach and thereby serve as a guide for the clinician and to provide a platform for considering a hybrid approach tailored to the individual patient. J Orthop Sports Phys Ther 2019;49(6):437-452. Epub 15 May 2019. doi:10.2519/jospt.2019.8451.

The cost impact of a quality-assured mechanical assessment in primary low back pain care.

Objectives: The escalating cost of low back pain (LBP) care has not improved outcomes. Our purpose: to compare costs between LBP care guided by a quality-assured mechanical assessment (MC) and usual community care (CC).Study Design: Administrative claims data analysis.Methods: Employees and dependents of a large self-insured manufacturer seeking care for LBP in 2013 chose between the company's primary care clinic (where MC was delivered) and community care.The claims of 5,036 were analyzed for one year following subjects' initial evaluation excluding only those with diagnostic codes for fractures, dislocations, or infections. MC included an advanced form of Mechanical Diagnosis & Therapy (MDT). CC varied based on each subjects' selection of providers. Primary outcome measure: one-year cost of each subject's care. Secondary: number of MRIs, spinal injections, and lumbar surgeries undertaken. The payer's proprietary risk-adjustment algorithm was utilized.Results: After risk adjustment, the average cost per MC subject was 51.48% lower than the CC average cost (p < .0279). The utilization of MRIs, injections, and surgeries was lower with MC by 49.75%, 39.44%, 78.38% with relative risks of 1.99, 1.64, and 4.73, respectively.Conclusions: This 51.5% cost-savings reflects the substantial reduction in downstream care-seeking with MC, including lower utilization of MRIs, injections, surgeries, and downstream care after six months from the initial visit. It is well documented that the MDT clinical examination typically elicit patterns of pain response that in turn identify how most can rapidly recover with self-care with no need for other intervention.Level of Evidence: 1b.

Diagnostic Tests for Low Back Disorders.

OBJECTIVE: The aim of this study was to summarize evidence-based diagnostic guidelines for low back disorders. METHODS: A comprehensive literature review was conducted. A total of 101 articles of high or moderate quality addressing low back disorders diagnostic evaluation met the inclusion criteria. Evidence-based recommendations were developed and graded from (A) to (C) in favor and against the specific diagnostic test, with (A) level having the highest quality body of literature. Expert consensus was employed for insufficient evidence (I) to develop consensus guidance. RESULTS: Recommendations are given for these diagnostic tests: functional capacity evaluations, roentgenograms (x-rays), magnetic resonance imaging (MRI), computerized tomography, myelography, bone scans, single proton emission computed tomography, electromyography, surface electromyography, ultrasound, thermography, fluoroscopy, videofluoroscopy, lumbar discography, MRI discography, and myeloscopy. CONCLUSION: Diagnostic testing is not indicated for the majority of patients with low back pain.

Effectiveness of Directional Preference to Guide Management of Low Back Pain in Canadian Armed Forces Members: A Pragmatic Study.

INTRODUCTION: Low-back pain (LBP) is a leading cause for disability in military personnel. Consequently, effective management strategies are required to maintaining operational capabilities. Physical therapy clinical practice guidelines recommend the use of directional preference (DP) to guide management. The effectiveness of this approach has not been tested in military personnel using a pragmatic study design. Pragmatic studies are ideal to inform clinicians and policymakers about the usefulness of proven interventions in real-life clinical conditions. The purpose of this study was therefore to determine, in clinical practice, the effectiveness of a management approach guided by DP vs. usual care (UC) physical therapy in Canadian Armed Forces (CAF) members with LBP. MATERIAL AND METHODS: A pragmatic study was conducted among 44 consecutive CAF members with LBP who received management guided by DP (n = 22) or UC (n = 22). Outcomes were pain intensity (primary outcome), pain location and frequency, perceived disability, medication use, perceived global effect (pain, function, overall status), work loss, and health care utilization. The effectiveness of the intervention was assessed at 1-month and 3-months follow-up. RESULTS: Statistically significant differences favoring the DP group were observed for pain intensity (Δ 1 month: 1.9/10; 95% confidence interval [CI]; 0.97-2.89; Δ 3 months: 1.3/10; 95% CI: 0.35-2.31), pain location at 1 month (54.5% vs. 19.0%; p = 0.02) and 3 months (68.2% vs. 38.1%; p = 0.01), disability (Δ 1 month: 4.3/24; 95% CI: 2.12-6.38; Δ 3 months: 3.5/24; 95% CI; 1.59-5.33), perceived global effect at 1 month (pain: 86.4% vs. 57.1%; function: 81.8% vs. 47.6%; overall status: 86.4% vs. 57.1%) and 3 months (pain: 95.5% vs. 71.1%; overall status: 95.5% vs. 66.7%) with p values < 0.05, and improvement in work status at 3 months (54.5% vs. 23.8%; p = 0.04). CONCLUSION: DP-guided management appears more effective than UC physical therapy to reduce pain and improve function in CAF members with LBP. Rapid improvements and the patient's ability to self-manage may prove especially advantageous in deployed settings. Our findings are particularly useful to inform military policymakers and clinicians on optimal management for CAF members.

Influence of directional preference on two clinical dichotomies: acute versus chronic pain and axial low back pain versus sciatica.

OBJECTIVE: To determine whether outcomes from treatment determined by subjects' directional preference (ie, reduction in back and/or leg pain, by performing a single direction of repeated end-range lumbar movement) would vary based on pain duration, location, or neurologic status. DESIGN: A secondary analysis of data from a multicenter randomized clinical trial. SETTING: Eleven physical therapy departments or clinics in 5 countries, with referrals for both acute and chronic low back pain. SUBJECTS: Seventy-one of 80 subjects with acute to chronic low back pain, and with and without radicular leg pain, and with or without mild neurologic deficit, were found at baseline to have a directional preference and were then treated with directional exercises that matched their directional preference. METHODS: All of the subjects were treated for 2 weeks with directional exercises and compatible posture modifications. Independent variables were pain duration, pain location, and neurologic status. MAIN OUTCOME MEASUREMENTS: Primary measures were back and leg pain intensity and function (Roland Morris Disability Questionnare). Secondary measures were activity interference, medication use, depression (Beck Depression Inventory), and a self-report of improvement. RESULTS: The subjects significantly improved their back and leg pain intensity, disability, and all secondary outcome measures, but pain duration, location, and neurologic status classification did not predict treatment responsiveness. Across all pain duration categories, 91%-100% either improved or resolved completely. There also was significant improvement across all pain location and neurologic status categories, with no significant differences across the outcome variables. CONCLUSIONS: In subjects found to have a directional preference who then treated themselves with matching directional exercises, neither pain duration nor pain location and neurologic status predicted their uniformly good-to-excellent outcomes.

Is it time to rethink the typical course of low back pain?

OBJECTIVE: To determine the frequency and the characteristics of low back pain (LBP) recurrences. The research questions were as follows: (1) Are LBP recurrences common? (2) Do episodes worsen with multiple recurrences? (3) Does pain change location in any recognizable pattern during an episode? DESIGN: Single-page self-administered questionnaire. SETTING: Thirty clinical practices (primary care, physical therapy, chiropractic, and surgical spine) in North America and Europe. PATIENTS: A convenience sample of 589 respondents with LBP. There were no exclusions based on type of LBP, history of onset, or comorbidities. METHODS: The survey was distributed during patients' assessment or initial treatment at their respective clinics. The survey queried the following: (1) the severity of original versus most recent episodes based on the following: pain intensity, interference with leisure and work activities, duration of episodes, and most distal extent of pain; and (2) changes in pain location within episodes. RESULTS: In response to research question 1, a previous episode was reported by 73%; of those, 66.1% reported their first episode lasted ≤3 months, 54% reported ≥10 episodes, and 19.4% reported >50 episodes. In response to research question 2, of those with recurrences, 61.1% reported that at least one of the survey domains was worse in recent episodes (P < .01) and only 36.9% reported that they were better; 20.5% were worse in all domains, whereas 8.6% were better or the same. In response to research question 3, the pain location changed during the episode in 75.6%; of these, 63.2% reported that their pain first spread distally before retreating proximally during recovery; there was a strong trend toward those reporting worsening episodes also reporting proximal-to-distal-to-proximal changes in pain location during their episodes (r = 0.132, P < .06). CONCLUSION: Recurrent LBP episodes were common and numerous. Recurrences often worsened over time. It seems inappropriate to characterize the typical course of LBP as benign and favorable.

Mechanical diagnosis and therapy for radiculopathy.

Despite its classic clinical presentation, and even when confirmed by compatible imaging findings of a herniated disc, the radiculopathy diagnosis provides only limited assistance for making decisions about treatment. The 2003 Medicare data revealed an eightfold variation in the rates of lumbar laminectomy and discectomy across geographic regions. In an effort to address this uncertainty in care, this article describes the management paradigm known as Mechanical Diagnosis and Therapy and its usefulness in decision-making for patients with lumbar radiculopathies, and reviews the relevant literature.

Is your client's back pain "rapidly reversible"? Improving low back care at its foundation.

PURPOSE/OBJECTIVES: To convey a valuable and greatly misunderstood paradigm for evaluating and treating low back pain (LBP) and its extensive scientific evidence. PRIMARY PRACTICE SETTING(S): Low back pain is a highly prevalent and very expensive health dilemma. But by using a paradigm called Mechanical Diagnosis and Therapy (a.k.a. McKenzie methods), it is now possible to identify a very large LBP subgroup whose pain is rapidly reversible, meaning that it can often be eliminated quickly, with return to full function using a single, patient-specific direction of simple, yet precise, end-range low back exercises and some posture modifications. This interesting subgroup includes patients with both acute and chronic LBP as well as both LBP-only and sciatica with neural deficits. FINDINGS/CONCLUSIONS: This special form of clinical assessment can detect which patients are in this large, rapidly reversible subgroup and which ones are not. Of the numerous studies targeting Mechanical Diagnosis and Therapy (MDT), three have focused on patients whose persisting pain had led to recommendations of disc surgery where 50% were then found to still have a rapidly reversible disc problem with high rates of nonsurgical rapid recovery. If patients are never assessed in this way, this reversibility remains undiscovered and these patients commonly undergo potentially unnecessary surgery. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Armed with knowledge of this subgroup, how to identify it, the considerable supportive scientific evidence and strongly beneficial implications of utilizing this MDT paradigm, case managers are positioned to have an immensely positive impact on the care of LBP. Tremendous cost savings and greatly improved clinical outcomes are available by utilizing this form of evidence-based MDT care.

Evidence-informed management of chronic low back pain with the McKenzie method.

The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Can a patient educational book change behavior and reduce pain in chronic low back pain patients?

BACKGROUND CONTEXT: This study was prompted by 1) the almost universal use of patient education as an initial or at least an ancillary step in the treatment of patients presenting with low back pain, 2) the relative dearth of studies evaluating the effectiveness of patient education and 3) the complete lack of support in the few existing studies for the efficacy of education in improving patients' long-term health status. PURPOSE: A feasibility study to evaluate the efficacy of an individualized biomechanical treatment educational booklet to effect improvement in health status. STUDY DESIGN: A prospective, longitudinal cohort study. PATIENT SAMPLE: Sixty-two subjects (35 female, 27 male), average age 42.4 years, reported a mean duration of back pain before inclusion of 10.4 years. However, because of attrition, only 48 subjects had complete data across the 18-month follow-up period. OUTCOME MEASURES: Outcome measures included pain status, number of back pain episodes, subject compliance with self-care behaviors, knowledge and opinion of booklet content. METHODS: Volunteers with chronic low back pain were provided a copy of an individualized biomechanical treatment educational book and told they would undergo a written survey of its content 1 week after reading the book. Subjects' health status at 9 and 18 months was evaluated using a structured telephone interview. RESULTS: One week after the 62 subjects, with an average of 10.4 years of symptoms and extensive use of the medical system, finished reading the index book, 51.62% reported noticeable improvement in their pain, their content comprehension was good and opinions about the text were generally positive. At 9-month follow-up, there was statistically significant and clinically relevant improvement in reported pain magnitude (p< .03), number of episodes (p< .0001) and perceived benefit (p< .04). At 18-month follow-up, these gains held or demonstrated even further improvement. CONCLUSION: This study's results suggest that the Treat Your Own Back book may have considerable efficacy in helping readers decrease their own low back pain and reduce the frequency of, or even eliminate, their recurrent episodes. These findings also justify conducting a randomized controlled clinical trial to assess this book's efficacy in improving health status in subjects with low back pain with the study design including internal controls to minimize bias issues and a wider range of outcomes, including measures of pain, function, disability, patient satisfaction, utilization of health care services and psychosocial measures.

The role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs.

BACKGROUND CONTEXT: The selection of appropriate patients for lumbar disc surgery is a challenging task involving a highly variable, multifactorial decision process complicated by a lack of reliable, validated clinical signs and imaging findings. Recently, multiple studies have demonstrated the reliability and diagnostic utility of a standardized form of spinal assessment using repeated end-range test movements while monitoring patterns of pain response (McKenzie assessment). PURPOSE: It is the aim of this article to evaluate the utility of this assessment system and its literature support in the selection of candidates for surgery for disc-related pain. STUDY DESIGN AND METHODS: A literature review. RESULTS: Most patients under consideration for lumbar disc surgery, when examined using this form of dynamic mechanical spinal evaluation, based on patients' patterns of pain response to standardized repeated end-range lumbar test movements and positions, fall into one of three subgroups: 1) a reversible condition, 2) an irreversible condition or 3) an unaffected condition. Reversible conditions in acute to chronic low back and/or leg pain are recoverable, often rapidly so, using nonoperative self-care dictated by the patient's assessment findings. The elicitation of pain "centralization," an improvement (favorable change) in pain location in response to repetitive end-range testing, typically occurring with only one direction of test movement(s), predicts a high likelihood of successful response to conservative care, even in the presence of neurologic deficits. Irreversible conditions are characterized by symptom aggravation by all directions of testing, including the absence of the centralization response, predicting a poor response to nonsurgical care. In those whose pain is unaffected with similar testing, evidence indicates the pain is likely nondiscogenic. A dynamic disc model has been described as a possible model for these varying pain responses. Insight into annular integrity of symptomatic discs is also provided using this repeated end-range/pain response (McKenzie) assessment. CONCLUSIONS: As described, the literature supports the use of a repeated end-range/pain response assessment (dynamic mechanical evaluation) in obtaining diagnostic and therapeutic information in patients with low back and leg pain. This may contribute to improving the selection process of surgical patients.