Ron Schenk PT, PhD 1

Transcription

1 Ron Schenk PT, PhD 1

2 Objectives Describe the anatomy of the neck (cervical spine) and low back (lumbar spine) Describe the risk factors associated with neck and low back injury Describe physical therapy approaches to neck and low back pain Analyze which treatment approaches are most appropriate based on the literature and evidence of the patient 2

3 Agency for Health Care Policy and Research; Systematic Reviews & Metaanalyses of RCTs United States, 1994 Manipulation can be helpful for patients with acute low back problems without radiculopathy when used within the first month of symptoms (Strength of Evidence = B). This was the first clinical practice guideline to recommend the use of manipulation in the care of acute LBP. Spinal manipulation is a safe, effective, and recommended intervention in the management of LBP. Spinal manipulation received the highest level of evidence of any intervention in the 1994 Agency for Health Care Policy and Research (AHCPR) Guidelines Final recommendations included stay active approach, education, and general exercise.

4 Talking Points No particular physical therapy approach has been found to be most effective in the management of neck and low back pain Certain approaches have more attractiveness based on their theoretical model The reason no approach has been found to be most reliable is because all spine pain is not the same. 4

5 Physical Therapy Examination and Treatment Approaches Exercise based approaches Janda, Australian, McKenzie, Sahrmann Manual therapy based approaches Cyriax, Maitland, McKenzie, Nordic, Osteopathic Functional approaches Gray, Cook Physical agents (modalities)

6 Patient response methods Maitland patient response to passive Movement System Balance (Sahrmann) patient response to active limb movements MDT (McKenzie) patient response to repeated end range movements

7 Patient response methods require dedicated communication between clinician and patient for clinical decisions, without necessarily requiring a pathology based diagnosis. Cook C, Ramey K, Hegedus E. Physical therapy exercise intervention based on classification using the patient response method: a systematic review of the literature. J Man Manip Ther. 2005;13(3):

8 Is neck and back pain the result of muscle (strain) injury?

9 Neck (Cervical Spine) Anatomy

10 Neck anatomy

11 Neck Musculature Erector Spinae Iliocostalis Longissimus Spinalis Transversospinalis Cervicis Capitis Interspinales Intertransversarii Splenius

12 Neck Musculature Anterior and Lateral Neck Rectus Capitis Anterior Rectus Capitis Lateralis Longus Capitus Longus Colli (Cervicis) Scalenii Sternocleidomastoid Lower Spine Posterior Postural Muscles Upper, Middle, and Lower Trapezius Levator Scapulae Rhomboids Serratus Anterior

13 Upper neck from behind

14 Neck anatomy

15

16 Low Back Anatomy

17 Predisposing Factors: Poor posture Spine at end range flexion Increases discal pressure Stretching of passive structures

18 Frequency of flexion

19 Frequency of flexion + = Loss of extension Poor posture

20 Assessment process: History taking

21 Posture Syndrome Symptoms produced with sustained end range loading

22 Posture Syndrome Local Intermittent No movement loss

23 Effects of postural correction

24 No Effect

25 Flexion

26 Extension

27 Centralization

28 Directional Preference The phenomenon of preference for postures, movement, exercise in one direction.

29 Predicting Success with Manipulation 45% 4 or more present: Recent onset (<16 days) Low FABQ (<19) No symptoms below knee Lumbar stiffness Good hip IR (>35 0 ) 95% Pre-test Probability of Dramatic Success with Manipulation +LR=24.3 Post-test Probability of Dramatic Success with Manipulation

30 Spinal Manipulation CPR Symptoms < 16 days History FABQWK < 19 No symptoms distal to the knee Physical Exam Hip IR > 35 degrees Lumbar hypomobility Flynn et al, Spine,

31 Not just about extension!

32 Alternative: Management without classification Treatment P Treatment X Treatment A Treatment D Treatment R

33 Repeated end range testing can be used to evaluate and treat musculoskeletal conditions

34 Matched Treatment Treatment that is matched to classification has been shown to be more effective: better outcomes decreased disability, improved return to work. 1 4

35 Specific subgroup Specific treatment Specific subgroup Specific treatment

36 Neck injury prevention

37 Low back injury prevention

38 Balance...during a typical day flexion extension