Updates into Therapeutic Exercise Programs for Patients with LBP. Maximizing Patient Motivation and Outcomes Alice M.

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1 Updates into Therapeutic Exercise Programs for Patients with LBP Maximizing Patient Motivation and Outcomes Alice M. Davis, PT, DPT

2 Objectives Review Statistics on LBP Discuss current research findings regarding therapeutic exercise and LBP Discuss why it matters to select specific exercise programs for patients with LBP Describe the benefits of Pilates based exercises in the management of LBP Demonstrate exercise interventions based on current best evidence

programs for patients with LBP Describe the benefits of Pilates based exercises in

3 Where are we today?

4 Ubiquitous Low Back Pain A leading cause of disability > 25 % of Adults in the U.S. experience at least one episode of LBP in a three month period of time. CDC, Estimated Direct Cost : 90 Billion dollars. The Spine Journal 8 (2008). 85% recurrence rate. NIH Guide Research on LBP. Exercise is a widely used modality to management LBP

Estimated Direct Cost : 90 Billion dollars. The Spine Journal 8 (2008).

6 Exercise therapy for treatment of non-specific low back pain Cochrane Database of Systematic Reviews 2005, Issue 3. 3 Author s s conclusions: Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with CLBP. In ALBP exercise therapy is no more effective than no treatment or conservative interventions.

3 Author s s conclusions: Exercise therapy appears to be slightly effective at

7 Interpretation Please?

8 Long-Term Effects of Specific Stabilizing Exercises for First-Episode Low Back Pain Hides JA et al. Spine. 2001;26(11):E RCT with 1 year and 3 year follow-up 39 patients with acute, first episode LBP Control Group (CG): Advice and Medication Specific exercise group(seg): MF & TrA 2x/week for 4 weeks

RCT with 1 year and 3 year follow-up 39 patients with acute, first episode

9 Outcome Measures McGill Pain Questionnaire Visual Analog Scale Roland Morris Disability Index Real Time Ultrasound

10 Results Immediately after and at a 10 week follow- up CG: CSA of the MF muscle recovery was not spontaneous upon remission of painful symptoms. SEG: MF muscle recovery was more rapid and more complete. Pain and disability for both groups were similar.

11 Results Recurrence Rate At One-Year follow-up CG: 84% SEG: 30% At Two-Three Three Year follow-up CG: 75% SEG: 35%

12 A Randomized, Controlled Trial of Manual Therapy and Specific Adjuvant Exercise for Chronic Low Back Pain Geisser ME, et al. Clin J Pain 2005 Study Objective: Determine the effectiveness of manual therapy(mt) with specific adjuvant exercise(sae) for treating chronic low back pain and disability Results revealed significant reductions in pain reports for patients receiving MT with SAE. However, no significant change in perceived disability occurred Suggested a multidisciplinary approach

exercise(sae) for treating chronic low back pain and disability Results revealed significant reductions in pain reports

13 Would it be better to Identify Subgroups of Patients?

14 Preliminary Development of a Clinical Prediction Rule for Determining Which Patient With Low Back Pain Will Respond to a Stabilization Exercise Program Hicks GE, et al Arch Phys Med Rehabil. 54 Patients with nonradicular LBP Treatment: Supervised therapy sessions twice a week for 8 weeks along with a daily home exercise program Exercise program details Results revealed identification of variables that aide in determining which patients will have successful outcomes with a stabilization program.

54 Patients with nonradicular LBP Treatment: Supervised therapy sessions twice a week for 8 weeks along with a daily home

15 Identifying Subgroups of Patients With Acute/Subacute Nonspecific Low Back Pain. Results of a Randomized Clinical trial. Bottom Line: Brennan GP, et al. Spine ;31(6): Nonspecific low back pain should not be viewed as a homogenous condition. Outcomes can be improved when sub grouping is used to guide treatment decision-making. making.

. 2006;31(6):623-631 631 Nonspecific low back pain should not be viewed as a homogenous

16 Comparison of Classification-based Physical Therapy with Therapy based on Clinical Practice Guidelines for Patients with Acute Low Back Pain. Fritz JM, et al. Spine. 2003;28(13): Purpose: Compared classification based PT with therapy based on clinical practice guidelines. Subjects: 78 with work related LBP < 3 weeks. Methods: Randomized into two groups Group 1: Classification-Based Group Group 2: Guideline-Based Group

2003;28(13):1363-1372 1372 Purpose: Compared classification based PT with therapy based on clinical practice

17 Outcomes Pain scale-11 item Modified Oswestry Medical Outcomes Survey Short Form SF-36 Fear Avoidance Beliefs Questionnaire (FABQ)

18 Results Modified Oswestry: Greater change in the Classification-group vs. Guideline-group SF-36: Greater improvement in Classification-group vs. Guideline-group Return to work more likely with the Classification-group One year follow-up : stable results Costs: vs

19 Does it Matter Which Exercise? A Randomized Control trial of Exercise for Low Back Pain Long A, et al. Spine.2004; 29 (23): Key Points Patient specific exercises based on directional preference showed significant and rapid decreased pain, reduced medication use and improved outcomes. Counterproductive exercises in patients with LBP may be one reason why the research supports clinical guidelines of remaining active and integrate self-care options vs. physical therapy.

rapid decreased pain, reduced medication use and improved outcomes.

20 Integration of Pilates Based Exercises for Treatment of LBP What is Pilates? A movement based form of exercise that incorporates core stabilization, strengthening and stretching.

21 Benefits of Pilates in the management of low back pain

23 Current research Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability: a randomized controlled trial.rydeard trial. R. JOSPT. 2006;38(7): Clinical bottom line: For a subgroup of patients with CLBP Pilates based exercises aimed at neuromuscular control is effective in improving pain and functional disability.

24 Common scientific foundations between therapeutic interventions and Pilates Muscle balance and strengthening Motor control Movement integration Balance and coordination Core stabilization Postural alignment Body awareness

25 Core Stabilization

26 Core Stabilization

27 Motivation

28 Motivation The stimulus, incentive, or inducement to act or react in a certain way. Multifactorial Fast Facts from NCHS on exercise 30% engage in regular physical activity 39% do not engage in any physical activity 50% adults who start an exercise program discontinue in six weeks

29 Stages of Adopting Healthy Behavior Stage 1: Pre-contemplation Stage 2: Contemplation Stage 3: Preparation Stage 4: Action! Stage 5: Maintenance Stage 6: Termination

30 Transtheoretical Model

PT and Physician Perspectives

PT and Physician Perspectives Specialists in evaluating and treating movement disorders Restore, maintain, and promote optimal physical function, as well as, optimal wellness and fitness and optimal quality