Treatment Protocol Lbp Manguzi

7/30/2019 Treatment Protocol Lbp Manguzi

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TREATMENT PROTOCOL LOWER BACK PAINBased on international guidelines for the management thereof

Supporting Literature;o EU physiotherapy guidelines for lower back pain

o Australian Guidelines on Yellow Flagso Cognitive Behavioural Guidelines for Physio and Occupational Therapists

Triage:1. the acute back2. sub-acute back3. chronic back4. red and yellow flags

1. The Acute Back:80% of any population will experience LBP during their lives. Most episodes are short lived and

self-resolving. 20% of the above will become chronic back pain, which is classified as back painlasting longer than 3 months.

Of major importance is the identification of red and yellow flags on initial and follow upassessments by the therapist. The presence thereof will greatly influence the choice ofmanagement and treatment techniques applied.

Initial assessment of the acute back may be restricted if the nature of pain is such that it is easilyexacerbated (high SIN). A thorough subjective must be done, and questions including red andyellow flags, as well as onset, previous history, mechanism of injury and type/location of painshould be asked.

Emphasis is placed on reduction in pain through advice and gentle movement and referral torelevant sections should any flags be identified. It is important that the client is educated on thefollowing:

- back pain is usually self limiting and will recover with appropriate management- bedrest and inactivity should be discouraged- no more than 2 days maximum!- as this is

likely to lead to poor functional outcome due to small intervertebral muscle degenerationand psychological fear avoidance.

- Early return to original activities- with adaptations- is required. (although in our case, ashort break from heavy work such as ploughing and lifting 25L water is a good idea)

Subtypes: a. traumaticb. insidious with uni-directional movement limitationc. insidious and non-specific

a. TraumaticThese can usually be classified into disc injury and multiple facet joint involvement.Distinguishing between the two can be challenging (see following notes). Beware of releasingtoo much soft tissue restriction in one session- it can exacerbate symptoms. Mobilization can


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be done- try to start on contralateral side: you need to mobilize into the maximum gradepossible (usually a grade 3) for effect. Grade 1 and 2 on the affected side is not usually worthit.

The client can be taught self traction (knees on a chair), sleeping positions, gentle knee rolling

and pelvic tilts. Encourage log rolling and get the client to demonstrate certain functionalmovements (dressing, washing, moving in and out of one position to another) and correct themin each. Try an avoid issuing back braces as much as possible, and ESPECIALLY if there areany signs of yellow flags.

Screen for flags, refer to Yvonne if yellow flags present.

Mobilize.

b. insidious with uni-directional movement limitationIt is rare to find a restriction in one direction only- usually there is a predominant restriction with

secondary restrictions in other directions. Usually facet involvement is the cause. Use thefollowing method to determine which structures are gapped/compressed andstretched/shortened so that you can chose the best mobilization for the restriction:

anterior

left right

Posterior

The trick is to start in the position furthest away from the most painful position. For instance, ifextension/lat flex left is the worst, start the person in flex/lat flex right, slowly moving the persontowards their most painful position with each treatment. If the person is not very irritable, youcan start in a more aggravating position. If very irritable, start in the position furthest away. Ifthe problem is a stiff facet joint, I would mobilize on it. If the problem is a nerve rootsensitization, I would mobilize on the contralateral side. Remember what plane the facets lie atin Cx (45) vs Tx (60) vs Lx (90)- if you are doing a unilateral pa, are you compressing whatshould be gapped? If you choose rotations, few clients relax for it to be effective- rather put intocrook lie supine (with a towel under buttocks if you want to target lower lumber) and do activerotations, or prone and rotate by stabilizing the Sx and rotating the hemipelvis posteriorly.

The most important consideration is:Why does this person have a movement limitation?Usually you will find a considerable amount of asymmetry in their posture which can explainthe movement deficit. You will need to address this otherwise it is pointless mobilizing them.Make sure you lift ladies skirts- many an old polio case has been mistaken for a simple pelvicrotation! Think globally, and get them to move through various postures- you will be able topick up rotations/stuck SIJs/poor unilateral hip stabilities/tight lateral structures/poor segmentalcontrol by just observing.


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Start in closed kinetic chain as soon as possible, and work globally (pilates doesnt work here,and the link between the HEP and the ADL doesnt happen). Use your Bobath principles- theyare useful and activity related- and sling concepts.

Again, always screen for red and yellow flags.

Correct asymmetry

c. insidious and non-specificUsually these are your instabilities and/or your yellow flags. These are the ladies with noconsideration for their spine whatsoever- usually found to hinge badly around L3/4 (uni-segmental instability), with consequent stiffness above and below these segments anddegeneration as a result (anterior sway or lordotics). Briefly mobilize the segments above andbelow if you want, but these people need to learn how to maintain a neutral spine, and thenhow to maintain a neutral spine during lower and upper limb activity. Easier said than done,

and much visual feedback using cellphone cameras, the spine model and biofeedback can bedone. You need to link it to ADL positions as soon as possible. Occasionally we have multi-level instabilities- treat similarly, but without mobilization. Screen for red and yellow flags.

Stabilize.

2. The Sub-acute Back:This is usually the time they eventually get to rehab- it is getting better though! Strict screeningfor flags- we still have to catch them and refer! The same categories can be applied as above,but patients will usually be of lower SIN and thus a more aggressive treatment can be done.Again, check GLOBALLY for reasons for lower back pain- you will find them throughobservation! Emphasis must be placed on HEP and activities, with kinetic handling per activity.Self management of pain is essential.

3 & 4. The chronic back and yellow flags:I have grouped these because there are very few patients with chronic back pain and aphysiological reason only. Much can be achieved in mobility through correct exercises andactivities rather than OMT, and it is easier to grade, steers away from passive treatment andpromotes self management. Please note- just because there are yellow flags does NOT meanyou do not investigate and treat the underlying pathology!!!!!! Chronic backs need just as muchobservation, otherwise the exercises given will not be specific and will not support the activitygoals set by the patient.

If yellow flags present, refer to Yvonne immediately (see screening tool). The earlier youaddress these, the better the functional outcome and the less likely they are to become achronic back. The basis for addressing yellow flags is the following:- check for anxiety, depression, fear avoidance (of movement- usually in traumatic backs

rather than insidious onset), inappropriate pain beliefs, poor social support from family and


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or partner, DG/RAF seeking focus, poor incentive to continue/return to work (ie, ADLtasks) and catastrophizing

- education that some pain during activities is not bad, and that activities must be resumedearly, even if the pain has not disappeared entirely. Move away from the broken machineexplanation- it sometimes becomes a crutch

- avoid assistive devices such as braces and educate on medicating wisely (dont overdo)- preferably try to find out the root cause of the distress with the patient. Decide together onfunctional goals (activities) that should be achieved in a specific timeframe, regardless ofpain- these should take the physical and emotional barriers into account. Stick to thesegoals. Goals should be specific, measurable, activity based, realistic (achievable) andhave a time frame attached.

- Do not ask about pain- rather concentrate on function- Very important is that the person learns pacing. It is important that they do not experience

flare-ups which will result in periods of inactivity and thus deconditioning and an inability toreach goals. The general rule is- find your maximum tolerance for one activity or position,then try to maintain daily participation of 50-80% of this maximum tolerance. Slowly

increase this amount.- If the person is literate, they can be asked to keep a diary.- Steer away from passive treatments (like massage, electrotherapy and OMT) and keep

patient involvement in treatment (exercises as well as goal setting) at a maximum. Teachrelaxation and self management (hot packs, positioning) techniques.

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Treatment Protocol Lbp Manguzi