Reconsidering the Prognosis of Low Back Pain

Takeaways:

  • Most cases of low-back pain resolve in four weeks, but up to 77% recur without treatment.

  • Three of four patients presenting to primary care with low-back pain are already in a recurring pain pattern.

  • If recovery is considered the cessation of serious back pain for a year, less than half of patients recover spontaneously.

 

In a review published recently by The Lancet, Dr. Chris Maher and colleagues state, “The simple portrayal of the course of low back pain needs reconsideration.”1 Dr. Maher refers to the view that most cases of acute, non-specific low back pain recover completely within four to six weeks. He qualifies this view as commonly held. Is this view oversimplified or a bad management guideline?

 

For older adults, data from a very large study suggests a new perspective.2 Researchers followed 5,239 adults, age 65+, after their first primary care visit for low back pain (LBP). At three months, only 42% (a minority) experienced a 30% or greater improvement in pain. At one year, 65% still experienced disability within 30% of baseline. Seventy-seven percent reported that their back pain had not resolved at 12 months.

 

For the general population, Dr. Maher and colleagues recommend a treatment protocol that differentiates acute LBP from persistent LBP (> two weeks). Among patients presenting to primary care with persistent low back pain, only 42% report recovery at 12 months.3 For patients with persistent low back pain, Dr. Maher and colleagues recommend immediate referral for treatments such as exercise therapy and manual therapy.

 

Research suggests a better prognosis for younger patients presenting with acute LBP, but only by using a narrow definition of recovery.4 When defining recovery as a singular report of no pain or disability, 72% of adults with acute LBP and presenting to primary care report recovery within 12 months. That still leaves an important percentage of patients without recovery. That definition of recovery excludes recurrence within 12 months. Among patients who report recovery from acute LBP after their primary care visit, one third experience recurrence.5 If one were to define recovery as a cessation of significant pain or disability and no recurrence within 12 months, only 48% of patients presenting with acute LBP would be considered recovered. Dr. Maher and colleagues state that these recovery patterns provide caution against overestimating the likelihood of spontaneous recovery.

 

Dr. Maher and colleagues suggest that some patients presenting with acute LBP should receive treatment beyond advice and analgesics on day one, and others should be given two weeks to allow for spontaneous recovery. They recommend using risk prediction methods such as the 10-item Orebro Musculoskeletal Pain Screening Questionnaire6 to determine which patients will have earlier access to treatment.

 

It is noteworthy that 76% of patients presenting to primary care with acute LBP report having a previous episode of LBP.7 Most LBP cases labeled as acute are from patients already in a recurring pain pattern. This would suggest that the majority of acute LBP patients would qualify for non-pharmacological treatments such as exercise therapy and manual therapies on day one. If we hypothesize that all patients age 65+ receive physical therapy referrals on day one and all patients with LBP lasting greater than two weeks get a physical therapy referral on day one, we define a situation where most patients presenting to primary care with non-specific LBP receive treatment. Using the most modern evidence in LBP prognosis, only the most healthy patients presenting with non-specific LBP (a minority of patients) would be eligible for wait-and-see.

 

Specialized Treatment for Enhanced Outcomes

Back to Action invests in training, equipment, and facilities well beyond the standard training of physical therapists. This includes aquatic therapy, hand therapy, vestibular rehab, myofascial release, Mulligan technique, Maitland technique and much more. The availability of specialty approaches gives us greater opportunity for faster and better outcomes for all your patients.

 

References

  1. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. The Lancet. 2016; 389 (10070): 736-747.
  2. Rundell S, Sherman K, Heagerty P, et al. The clinical course of pain and function in older adults with a new primary care visit for back pain. J Am Geriatr Soc. 2015; 63 (3): 524-30.
  3. Costa Lda C, Maher C, McAuley J, et al. Prognosis for patients with chronic low back pain: inception cohort study. BMJ. 2009; 339: b3829.
  4. Henschke N, Maher C, Refshauge K, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008; 337: a171.
  5. Stanton T, Henschke N, Maher C, et al. After an episode of acute low back pain, recurrence is unpredictable and not as common as previously thought. Spine. 2008: 33: 2923-28.
  6. Linton S, Nicholas M, MacDonald S. Development of a short form of the Orebro Musculoskeletal Pain Screening Questionnaire. Spine. 2011; 36: 1891-95.
  7. Henschke N, Maher C, Refshauge K, et al. Characteristics of patients with acute low back pain presenting to primary care in Australia. Clin J Pain. 2009; 25: 5-11.
  8. de Almeida AM, Demange MK, Sobrado MF, Rodrigues MB, Pedrinelli A, Hernandez AJ. Patellar tendon healing with platelet-rich plasma: a prospective randomized controlled trial. The American Journal of Sports Medicine. 2012 Jun; 40 (6): 1282-8.

 

The Sequelae of Rest

Elderly Patients Lose Muscle Mass at Three Times the Normal Rate

Takeaways:

  • Over the age of 70, bed rest is associated with a major new disability in one-third of cases.

  • Most elderly patients do not engage in the intensive exercise necessary for full recovery after periods of bed rest.

  • Prescribing physical therapy after periods of prolonged rest may protect against geriatric decline.

Bed rest serves as a time-honored recommendation for illness and some injuries, especially for flu and other infections. A normal muscle, at complete rest, in the absence of illness, loses up to 15% of its strength each week.1 During bed rest, the first muscles to become atrophied are the trunk and lower extremity muscles involved in gait and upright posture.2 Illness itself can also cause atrophy of the skeletal muscles, over and above the strength losses caused by rest. Your older patients prove particularly vulnerable to the negative sequela of rest. Among a test sample of healthy subjects age 67 and older, 10 days of bed rest resulted in more lean tissue loss than 28 days of bed rest caused in younger test subjects.3  For patients over the age of 70, bed rest is associated with a major, new disability in one-third of prolonged cases.4 Among elderly patients, when the negative effects of bed rest are not addressed assertively, injury or prolonged difficulties become more likely.  Refer these patients to Back to Action to restore their former ability.

Research has found that during periods of bed rest at home, elderly patients tend to spend more time than needed resting in bed or sitting.4 This stems largely from a lack of confidence and fear of self-injury inspired by the sudden loss of strength and fitness. After the injury has healed or illness has abated, many elderly patients still experience considerable risks associated with their period of rest. Rate of recovery from disuse weakness is slower than the rate of loss. With intensive exercise, the average patient takes 2.5 times longer than the period of rest to regain lost strength.5 Older patients may take even longer because age brings loss of myocellular plasticity which blunts the hypertrophic response.6,7 The fact of the matter is that most elderly patients do not engage in intensive exercise after periods of bed rest and are more likely to quietly decrease their daily activities and self-care. Fall injuries, medication errors, and other problems become more likely during the months following bed rest. Back to Action Physical Therapy can efficiently develop a safe exercise program that will help your older patients maximize their recovery.

The Doctors’ Choice for Physical Therapy

From San Antonio to the southern border of Texas, several hundred doctors refer patients specifically to Back to Action Physical Therapy. Doctors prefer our good outcomes, efficiency of care, fast response to referrals, availability of physical therapists for telephone consults, and mailed case summaries showing real-world results. When you have patients who could benefit from outpatient rehab . . .

 

Please offer Back to Action to your patients.

References

  1. Dittmer D, Teasell R. Complications of immobilization and bed rest – Part 1: musculoskeletal and cardiovascular complications. Can Fam Physician. 1993; 39: 1428-1437.
  2. Halar E, Bell K. Rehabilitation’s relationship to inactivity. In: Kottke F, Lehmann J, editors. Krusen’s Handbook of Physical Medicine and Rehabilitation. 4th ed. Philadelphia: WB Saunders Co, 1990: 1113-39.
  3. Kortebein P, Ferrando A, Lombeida J, et al. Effect of 10 days of bed rest on skeletal muscle in healthy older adults. JAMA. 2007; 297 (16): 1772-1774.
  4. Brown C, Redden D, Flood K, et al. The underrecognized epidemic of low mobility during hospitalization of older adults. Journal of the American Geriatrics Society. 2009; 57 (9): 1660-65.
  5. Muller E. Influence of training and inactivity on muscle strength. Arch Phys Med Rehabil. 1970; 51: 449-62.
  6. Slivka D, Faue U, Hollon C, et al. Single muscle fiber adaptations to resistance training in old (>80 year) men: Evidence for limited skeletal muscle plasticity. Am J Physio Regul Integr Comp Physiol. 2008; 295: R273-R280.
  7. Raue U, Slivka D, Minchev K, et al. Improvements in whole muscle and myocellular function are limited with high-intensity resistance training in octogenarian women. J Appl Physiol. 2009; 106: 1611-1617.

 

Rotator Cuff Tears

Which Patients Prove More Likely to Succeed with Conservative Treatment?

Takeaways

  • Most patients can avoid surgery with PT alone if the tear is of atraumatic onset, full thickness, or less than 50% thickness.

  • Most patients will end up in surgery (even after PT) if the tear is traumatic in origin or of greater than 50% thickness.

  • Research suggests pre-surgical physical therapy may improve the outcomes of rotator cuff repair surgery.

Rotator cuff tears are a common cause of shoulder pain and may occur without traumatic injury. The classic explanation for how a rotator cuff can tear without traumatic injury has been that the supraspinatus tendon impinges on the acromion,1 but more recently, authors have emphasized the role of intrinsic tendon degeneration.2-4 These types of tears are especially prevalent among patients age 60+, with prevalence estimates ranging from 20% to 30%.5 Both physical therapy and surgery have been considered among first-line treatments, but there has been little research on how to identify the patients most likely to benefit from physical therapy as a first-line treatment. Recently, Ian Lo, of the University of Calgary’s Department of Surgery, and fellow researchers published research to answer this need for information.6

 

They followed 76 patients with uncomplicated, partial-thickness rotator cuff tears. Patients received conservative treatment from doctors and physical therapy. Physical therapy programs included posterior capsular stretching, rotator cuff and parascapular muscle strengthening, and other treatments as individually indicated. Conservative physician treatment was individually determined but included pain medications, anti-inflammatories, and/or subacromial steroid injections. Ian Lo and colleagues considered conservative treatment a failure if patients elected surgery within 4.4 years and a success if patients did not elect surgery, although this definition of “failure” merits some examination.

 

Overall, conservative treatment resulted in improved clinical outcomes, but regression analysis did reveal characteristics that predicted success. These were dominant shoulder, tear thickness, and traumatic status. The most dramatic difference was in traumatic vs. atraumatic onset (16% and 84% success rates of conservative treatment respectively). Tears of less than 50% thickness had a 65% success rate. Success proved slightly more likely with non-dominant shoulders (51% vs 49%).

 

The success/failure dichotomy set up in this study is useful for easy examination of the outcomes, but we should be careful of overinterpreting the term “failure.” Kim et al. has previously found that delaying surgery for a course of conservative treatment in partial thickness tears improved functional results of surgery at six months.7 Even patients who elect surgery after conservative treatment likely benefit from the pre-surgical physical therapy.

 

The findings of the current study are consistent with a growing body of evidence showing that physical therapy can be considered a worthwhile first-line treatment.8-11 Orthopaedic surgeon J. Kukkonen found that for non-traumatic rotator cuff tears the results of physical therapy as first-line treatment were not inferior to the results of surgery.8 Similarly, the multi-center trial of Kuhn et al found a 90% success rate from physical therapy for chronic, atraumatic, full-thickness rotator cuff tears.9 The current body of research suggests that the majority of patients will be satisfied with the improvements achieved through conservative treatment alone when the tear is atraumatic and it is either full-thickness or less than 50% thickness. However, monitoring for tear progression may be indicated. For patients with traumatic rotator cuff tears and/or partial tears of greater than 50% thickness, surgery seems likely, but a pre-surgical course of physical therapy may improve the outcomes of surgical repair.

The Doctor’s Choice for Physical Therapy

The Physical Therapy Doctors Choose for Themselves

From San Antonio to the southern border of Texas, several hundred doctors refer patients specifically to Back to Action Physical Therapy. Doctors prefer our good outcomes, efficiency of care, fast response to referrals, availability of physical therapists for telephone consults, and mailed case summaries showing real-world results. When you have patients who could benefit from outpatient rehab . . .

Please offer Back to Action to your patients.

 

References

  1. Neer CS 2nd. Impingement lesions. Clin Orthop Relat Res. 1983; 173:70-77.
  2. Operatively treated traumatic versus non-traumatic rotator cuff ruptures: a registry study. Ups J Med Sci. 2013; 118: 29-34.
  3. Kim H, Dahiya N, Teefey S, et al. Location and initiation of degenerative rotator cuff tears: an analysis of three hundred and sticky shoulders. J Bone Joint Surg [Am]. 2010; 92-A: 1088-1096.
  4. Moosmayer S, Tariq R, Stiris M, Smith H. MRI of symptomatic and asymptomatic full-thickness cuff tears: a comparison of findings in 100 subjects. Acta Orthop. 2010; 81: 361-366.
  5. Fehringer E, Sun J, VanOveren L, et al. Full-thickness rotator cuff tear prevalence and correlation with function and co-morbidities in patients sixty-five years and older. J Shoulder Elbow Surg. 2008; 17: 881-885.
  6. Lo IK, Denkers MR, More KD, Nelson AA, Thornton GM, Boorman RS. Partial-thickness rotator cuff tears: clinical and imaging outcomes and prognostic factors of successful nonoperative treatment. Open Access Journal of Sports Medicine. 2018; 9: 191.
  7. Kim YS, Lee HJ, Kim JH, Noh DY. When should we repair partial-thickness rotator cuff tears? Outcome comparison between immediate surgical repair versus delayed repair af-ter 6-month period of nonsurgical treatment. The American Journal of Sports Medicine. 2018 Apr; 46 (5): 1091-6.
  8. Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, Äärimaa V. Treatment of nontraumatic rotator cuff tears: a randomized controlled trial with two years of clinical and imaging follow-up. JBJS. 2015 Nov 4; 97 (21): 1729-37.
  9. Kuhn JE, Dunn WR, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH, Carey JL, Holloway BG, Jones GL, Ma CB. Effectiveness of physical therapy in treating at-raumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. Journal of Shoulder and Elbow Surgery. 2013 Oct 1; 22 (10): 1371-9.
  10. Mathiasen R, Hogrefe C. Evaluation and management of rotator cuff tears: A primary care perspective. Current Reviews in Musculoskeletal Medicine. 2018 Mar 1; 11 (1): 72-6.
  11. Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, Wang A. Exercise rehabilitation in the non-operative management of rotator cuff tears: a review of the literature. International Journal of Sports Physical Therapy. 2016 Apr; 11 (2): 279.

 

 

Low Back Pain: Supervised Physical Therapy Superior to Home Exercise

Takeaways

  • Teaching patients self-care for low back pain does not save costs.

  • Teaching self-care to patients does not achieve clinically important outcomes.

  • Patients receiving supervised exercise plans prove 1.8 times more likely to achieve clinically significant improvement at 10 weeks.

  • Patients with supervised therapeutic exercise rate much higher in patient satisfaction.

Nonspecific low back pain (LBP) ranks as one of the most common and costly musculoskeletal disorders, and the expense of LBP continues to rise. The majority of costs related to LBP can be attributed to recurrence and chronicity. One often-recommended solution for this problem is the teaching of self-care in the medical setting.1-2 Advice as treatment for back pain persists despite the fact that a 2012 systematic review finds self-care alone unable to achieve clinically important results.3 Since the effects of self-care are clinically insignificant, is offering self-care without clinical supervision a lesser intervention than a referral to physical therapy? Recently, Physical Therapy and Rehabilitation published a randomized trial addressing this question.4

 

Researchers randomized 59 patients with chronic low back pain into a supervised group and a home exercise group. The home exercise group received consultation and training sessions at day one and two weeks later. In addition to advice on staying active and posture, they received personal and printed instructions in a fairly mainstream exercise therapy program. The program included stabilization exercises, cat-camel, spinal flexion / extension from quadruped position, curl-up exercises, “dead bug” exercises, the side-support exercise, etc. All participants received exercise logs. The supervised exercise group received the exact same treatment protocols, except they were scheduled for clinic appointments multiple times per week. At six-week follow-up, improvement in pain and physical function was significantly better among the patients receiving physical therapist supervision.

 

The researchers noted poor adherence rates to home exercise programs as demonstrated by the patients’ exercise logs. The home exercise patients showed 32% adherence compared to 36% in the supervised group. While neither adherence rate is sufficient, the supervised group had enough clinic visits to create the needed exercise frequency. A previous study confirms a correlation between degree of home exercise adherence and clinical outcomes,5 and the adherence rates in the present study are consistent with home exercise adherence rates observed previously.6 Researchers additionally hypothesize that supervision ensures correct performance of the exercises and the most efficient progression of difficulty.

 

The current study adds to the results of the recently published, first randomized trial on this subject.7 In that study, researchers randomized 300 patients to 16 different therapy practices. Similarly, those researchers found that patients receiving more supervision achieved a greater level of improvement. Statistically significant differences in favor of physical therapy persisted at the 52-week follow-up. For instance, at ten weeks, patients receiving physical therapy proved 1.8 times more likely to demonstrate clinically significant improvement in back pain ratings. On a one-to-four scale, median patient satisfaction in the physical therapy group was a four compared to a two in the advice group.

 

The current evidence suggests that offering good home exercise plans achieves lesser outcomes than referrals to physical therapy.

 

Back to Action Physical Therapits

Our Therapists Average 9 Years’ Tenure Each

Experience, consistency, effectiveness – those are the hallmarks of the rehab your patients will receive at Back to Action. In addition to ample professional experience before joining our team, BTA therapists average nine years tenure each with Back to Action. This speaks to the quality of our workplace and the consistency you can count on when referring patients to Back to Action.

Please offer Back to Action to your patients.

 

References:

  1. Maher C, Williams C. Managing low back pain in primary care. Aust Prescr. 2011; 34: 128-32.
  2. Dagenais S, Tricco A, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J. 2010; 10: 514-29.
  3. Oliveira V, Ferreira P, Maher C, et al. Effectiveness of self-management of low back pain: systematic review with meta-analysis. Arthritis Care & Research. 2012; 64 (11): 1739-1748.
  4. Ammar T. A randomized comparison of supervised clinical exercise versus a home exer-cise program in patients with chronic low back pain. Physical Therapy and Rehabilitation. 2017 Aug; 4( 1): 7.
  5. Jordan J, Holden M, Mason E, Foster N. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2010; CD005956.
  6. Holden M, Haywood K, Potia T, et al. Recommendations for exercise adherence measures in musculoskeletal settings: a systematic review and consensus meeting (protocol). Syst Rev. 2014; 3: 10.
  7. Ford J, Hahne A, Surkitt L, et al. Individualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial. Br J Sports Med. 2016; 50: 237-245.
Articles in the Physician Article category are not intended for public consumption. They are news bulletins for clinicians licensed to refer to physical therapy. In reviewing this data, you agree that this is not medical advice and that medical advice should only be heeded after a proper assessment from a licensed healthcare professional.

Rest & Protect or Stay Active? Conditions of the Elbow, Wrist and Hand.

What’s the Evidence-Based Recommendation?

Takeaways

  • Patients advised to stay active prove 40% more likely to have complete recovery.

  • Back to Action offers hand therapy and many other specialty treatments.

Upper limb pain is common, disabling, and – without treatment – prone to recurrence. Each year, up to one half of adults report upper limb pain lasting a day or longer, and roughly a third of them seek health care.1 Transient disability frequently results in lost work days.2 Those seeking health care often receive advice to rest the involved joint so it can heal, and this is concordant with guidelines.3 However, resting distal arm pain is not well supported in the literature.

It seems to be based on a concept that distal arm pain is an injury that needs to heal, and that rest and protection will result in the most efficient healing. To the contrary, research suggests that most distal arm pain presented in primary care is not an injury such as a fall injury.4 Much like back pain,5 many of the conditions we have previously described as injuries or inflammatory conditions are more akin to failed healing responses, cumulative microtrauma, and deconditioning syndromes – without an important inflammatory component. More than twenty years ago, the first systematic review on the subject concluded that advice for bed rest was counterproductive in back pain.6 Have we been ignoring upper limb pain in this consideration? Is the long-standing practice of advice to rest productive or counterproductive?

This past May, Gareth Jones and colleagues addressed this question in a multi-site, randomized trial.7 They followed 538 patients referred to outpatient physical therapy for distal arm pain – mostly lateral epicondylitis, tenosynovitis, and thumb osteoarthritis. At baseline, patients averaged one month of pain. Researchers randomized patients between a group advised to stay active and a group advised to rest the injury according to established practice. Patients advised to stay active proved 40% more likely to achieve full recovery at 26 weeks. Advice to rest these distal arm pain conditions was associated with poorer outcomes.

Patients in the stay-active group received advice to stay active to recover quickly. Patients were told that distal arm pain is common, lasting damage is rare, and that recovery can be expected. They were advised that early return to work with gradually increasing activity was helpful. The advice-to-rest group received advice to rest the involved joint and avoid activities that might further aggravate the symptoms.

It appears that, even with physical therapy, in cases of chronic distal arm pain such as epicondylalgia, advice to stay active may improve outcomes. When your patients present with distal arm pain, remember Back to Action Physical Therapy. Our physical therapy expertise includes hand therapy so you can count on us for all your therapy referrals.

 


Specialized Treatment for Enhanced Outcomes

Aquatic therapy in Harlingen TX

Back to Action invests in training, equipment, and facilities well beyond the standard training of physical therapists. This includes aquatic therapy, hand therapy, vestibular rehab, myofascial release, Mulligan technique, Maitland technique and much more. The availability of specialty approaches gives us greater opportunity for faster and better outcomes for all your patients.


References:

  1. Palmer KT, Calnan M, Wainwright D, et al. Upper limb pain in primary care: health beliefs, somatic distress, consulting and patient sat-isfaction. Family Practice. 2006 Oct 11; 23(6): 609-17.
  2. Buckley P. Work-related Musculoskeletal Disorder (WRMSDs) statistics. Health and Safety Executive, Great Britain. 2016:1-20.
  3. Informed Health. How can tenosynovitis be treated? Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG). 2018 Jul 26.
  4. Khan K, Cook J, Kannus P, et al. Time to abandon the ‘tendinitis’ myth. BMJ. 2002; 324: 626-7.
  5. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. The Lancet. 2018 Jun 9;391(10137):2356-67.
  6. Waddell G, Feder G, Lewis M. Systematic reviews of bed rest and advice to stay active for acute low back pain. Br J Gen Pract. 1997 Oct 1;47(423):647-52.
  7. Jones GT, Macfarlane GJ, Walker-Bone K, et al. Maintained physical activity and physiother-apy in the management of distal arm pain: a randomised controlled trial. RMD Open. 2019 Mar 1;5(1):e000810.
Articles in the Physician Article category are not intended for public consumption. They are news bulletins for clinicians licensed to refer to physical therapy. In reviewing this data, you agree that this is not medical advice and that medical advice should only be heeded after a proper assessment from a licensed healthcare professional.

©BMA 2020