When would you refer?

fozzy40 said:

I was reading this article by Childs today and had a question.
Low Back Pain: Do the Right Thing and Do It Now

There is obviously a huge push for quicker access to care when it comes to back pain. My question is if physical therapists were the first line provider for low back pain, when would you refer for a medical work up? What would be your trigger? Uncontrolled pain? How many sessions/weeks of therapy?

Click to expand...

Fozzy,

The short answer here is when the subjective and physical exam indicated that it was necessary. But, I'm assuming that you want some more specifics. Not much time to get into that today, but I'll start off the conversation by saying that if if a patient has any of the typical "red flags" (unrelenting pain, particularly at night, rapid weight loss/gain, saddle anesthesia, significant changes in bowel/bladder since the onset of LBP), etc., I would likely refer for medical work-up.

Fozzy,

Besides "red flags," I look at ODI and FABQ, pain description, pain referral, intensity, duration, and neurological signs. If ODI and FABQ are high, pain is described as "sore, dull, achy, stabbing, pins and needles," is 10/10 but the patient drove to the clinic and walked in, I'm quick to refer out to a pain specialist or psychiatrist. As a PT, I want to get my hands on the patient, make them move, and get them moving themselves.
A thorough physical exam and constant re-assessment is necessary. I look for fatigueable weakness and S & S of lumbar radiculopathy. If the physician doesn't already know, I'll call with an update. Un-changing pain despite best practice means I missed something or the patient is full of it. If the pain is CONSTANT and interferes with bADLs, I'm talking to the physician.
It's funny; in Australia, PTs ARE the first-line providers for low back pain and anything else musculoskeletal but here in the States, PTs often come after NSAIDS and muscle relaxers. People get laughed out of physician offices for going there for acute LBP....

Fozzy40,

Not to cop-out, but in my experience, it's both subjective and objective. There are those patients who come and it's like talking to a brick wall when it comes to education, activity modification, and treatment plan. Often, those are the patients who want the quick fix and not to actually have to do something to help themselves. They won't respond to PT.
Anyway, to answer your direct question, I have a good idea after 1-2 treatment sessions. Did they respond favorably to the last tx session? Did they meet a CPR? Are they able to recall the HEP? Are they active? What is the patient's attitude on pain? Do they do as I ask them?
I'll aim for 2x/week x 2 weeks. If no change, I'm chatting with referring physician.

I consider differential diagnoses the best I can... Patient's generally confuse LBP, pelvic/SIJ, and hip pain. So if a patient self refers for LBP, it's not even given that the pain is in the lumbar area.

If the painful condition is traumatic/known MOI or described in another way, without severe unrelenting pain, MSK with or without PNS symptoms (based on eval), and likely to be amenable to PT, no referral.

If it is atraumatic acute LBP without other possible causes, pain in a kidney stone referral pattern, issues with bowel/bladder/woman's reproductive, S/S of fracture, undescribable pain in other areas of the body, appearing non MSK or not within the scope of PT practice, based on the evaluation. Then referral.

fozzy40 said:

So how many weeks or sessions does it take you before you seek another opinion for help? I know that every patient is different but can you give a rough guess?

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Fozzy,

It sounds as though the question you most want to be answered, out of all of the questions you asked in your initial post, is what the approximate number of sessions it takes a PT to refer their patient with LBP to a provider of another discipline for consideration of additional medical management. Am I understanding you correctly?

If that's the case, it usually one to two visits. And if it's two, it's usually because I have to convince the patient that they would be better off seeing another provider. For example, I saw a patient for an initial visit last week with EHL weakness, plantar flexor weakness, radicular pain into his leg and decreased reflex for his peroneals. He was in significant pain and did not have directional preference during his exam. In fact, all active AROM increased his pain and peripheralized his symptoms. He had seen his PCP two weeks earlier who had given him a Medrol pack which improved his symptoms somewhat. I tried to send him to an MD for an ESI right away, as without directional preference his prognosis from improvement from PT isn't great. He didn't want to go. Saw him again four days later and he was willing to give it a try, after I explained the process to him (he is afraid of needles).

I think an important question is who do we refer these patients to? The patient above is one of the few patients I would be comfortable sending to an ortho/neuro surgical consult, as he is part of the sub-group of patients who seem to well with surgical intervention, at least according to the SPORT Trial (young male with intense leg pain). But, usually, there's no way in hell I'm sending them to a surgeon unless I'm seeing progressive motor loss, or their symptoms fall into the "red flag" category.

fozzy40 said:

JessPT,

Basically yes...I guess "what's your number" for when you don't think that your treatment is working. For me, I feel like I will know in about 1-3 visits if the patient is going to respond. I have called therapists for some of my current patients who aren't responding to current treatments. Sometimes they ask for more therapy visits to hit their goals. However, it's hard to convince me that more therapy is visits are going to help if it hasn't after 2-3 weeks. I usually think that it's time to re-evaluate. I have talked with therapists ans asked them as well "what's your number." I get a variety of responses so I'm trying to get a sense from you guys as well.

Thanks for your responses!

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As a therapist you have a good idea of where things are going after 4-6 visits (2 weeks). I generally look for a comparable sign (i.e pain with sit-->stand or pain with walking or pain with a golf swing). You have the patient perform the comparable sign and assess pain and ROM. Perform the manual therapy techniques (i.e. soft tissue work, joint work or nerve glides) and then have the patient perform the same movement. If things improve (and you can recreate their pain with manuals) than it is likely you have found a pain producing structure and CAN treat it with skilled PT. That answers your initial question. If NOTHING I do effects the comp. sign, I generally would like a more skilled clinician to take a look, then refer if necessary (Keep in mind a more experienced clinician may just refer). That is the quick and dirty, but that is only part of PT.

The other huge factor is core stability. It can take up to 12 weeks for someone to get through a GOOD core stabilization program. Sometimes you can decrease the pain with your manuals, but what gets the change to happen is improved neuromuscular control and endurance of core musculature (Quadratus, TA, Rectus, Multifidi and obliques). That is why low back pain treatment can take forever. Maybe the goals aren't being met in 2-3 weeks, not because PT isn't working, but because the patient has yet to transfer the core stabilization to their dynamic activity.

Also Fozzy you talk about managing pain so that someone can partake in PT. We are trained to take patients as they are. I always appreciate the help if the patient is just too flared up, but sometimes having the patient flared up helps us from a diagnostic standpoint. It may be easier to identify pain producing structures if the patient is not on medication.

I generally follow a progression developed by McGill. The first step is volitional transverse abdominis bracing maneuver (TA, int. oblique and ext. oblique contracting together). Couple that with lower extremity movement in supine of increasing difficulty as the patient progresses in their ability to perform these movements. Eventually you can have them standing performing this contraction with dynamic movements. Also, there is a plank progression and side plank progression to activate QL and multifidi. Once the pateint makes it through the progression and starts performing dynamic activity with minimal aberrent motion in the trunk I believe they are ready to be D/C. This is usually coupled with decreased pain with golf, work outs, boxing etc.

The selling point is that you can decrease their pain with manuals. That is where the trust is built. Then you explain that controling this aberrent motion will decrease the pressure on a nerve and eventually lead to decreased pain (if it is a nerve dysfunction). I wish there was a great objective measure for core stability, but it is such a multi factorial construct you have to use your clinical judgement. At the same time McGill is great and his exercise is very well researched.

dg1984 said:

I generally follow a progression developed by McGill. The first step is volitional transverse abdominis bracing maneuver (TA, int. oblique and ext. oblique contracting together). Couple that with lower extremity movement in supine of increasing difficulty as the patient progresses in their ability to perform these movements. Eventually you can have them standing performing this contraction with dynamic movements. Also, there is a plank progression and side plank progression to activate QL and multifidi. Once the pateint makes it through the progression and starts performing dynamic activity with minimal aberrent motion in the trunk I believe they are ready to be D/C. This is usually coupled with decreased pain with golf, work outs, boxing etc.

The selling point is that you can decrease their pain with manuals. That is where the trust is built. Then you explain that controling this aberrent motion will decrease the pressure on a nerve and eventually lead to decreased pain (if it is a nerve dysfunction). I wish there was a great objective measure for core stability, but it is such a multi factorial construct you have to use your clinical judgement. At the same time McGill is great and his exercise is very well researched.

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The last several posts have just highlighted the problems with the core stabilization paradigm It's a concept with fairly poor face validity, a questionable theory behind it, and few if any compelling outcomes studies. Take a quick look at this blog entry by Neil O'Connell. I think it sums up the problems with core stability nicely.

http://bodyinmind.org/more-fragility-in-core-stability/

I enjoyed reading Neil's post, it had a lot of good points. However, with that explanation what other valid treatment plans can be used to decrease the phenomenon of LBP in addition to being effective? It seems to be that no modality or treatment plan can ultimately cure or mitigate the pain created from the spine or cortical process. From my personal experience I have had pt's resolve thier LBP, but by any means do I justify that it was soley from 1 aspect of treatment (lumbar stability). There seems to be a variety of treatments that may be combined in dealing with this dilemma. So is there any HOPE?

fozzy40 said:

I see what you are saying but I've sent patients with severe pain to PT and have had two responses a majority of the time:
1) The PT saying pain is too severe and they can't progress them in their program
2) Patients say its not working for pain and that sometimes its worse.

If I can minimize the pain I find that it's helpful for everybody

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I don't get the bold above. Why "progress" them "through a program" when the program is obviously not benefitting the patient?

PT can't help everybody. And those patients with persistent pain that is severe, have a very high ODI, are difficult for anyone to treat, PTs, MD/DOs, chiros, you name it.

1. Go back to Netter and Grey's. If you sense that aberrent spinal motion is a problem THINK. You can't change the bony or ligamentous structures with your treatment. You can't change any residual motion control provided by the disc. As a PT you have to work within your scope and control the muscles I mentioned above (TA, int oblique, ext, oblique, multifidi, QL and selective rectus)

2. You need to at least brush through this book. It is far more substantial than a blog entry that took about 3 minutes to write (as did this post haha)

http://www.amazon.com/Low-Back-Disorders-Second-Edition/dp/0736066926#productPromotions

3. I agree there are flaws, but what else would you work on with a low back patient. There is also some solid literature for the concept of graded exposure and graded exercise to help patients with chronic low back pain. These concepts use components of core stabilization.

dg1984 said:

1. Go back to Netter and Grey's. If you sense that aberrent spinal motion is a problem THINK. You can't change the bony or ligamentous structures with your treatment. You can't change any residual motion control provided by the disc. As a PT you have to work within your scope and control the muscles I mentioned above (TA, int oblique, ext, oblique, multifidi, QL and selective rectus)

2. You need to at least brush through this book. It is far more substantial than a blog entry that took about 3 minutes to write (as did this post haha)

http://www.amazon.com/Low-Back-Disorders-Second-Edition/dp/0736066926#productPromotions

3. I agree there are flaws, but what else would you work on with a low back patient. There is also some solid literature for the concept of graded exposure and graded exercise to help patients with chronic low back pain. These concepts use components of core stabilization.

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I have his book too, big deal. He's not even a PT, and therefore does not even have experience treating patient's with physical thearpy for LBP. Where McGill and your reasoning falls short is the lack of outcome based train of thought. Stabilization exercises do not necessarily stabilize anything, and if they did does that even coorelate to symptomatic improvement? (You know, what the patient actually cares about?).

For me in LBP I typicall use a few approaches: 1) joint mobility/ROM exercise of lumbopelvic (biasing to a directional preference if there is one). 2) manipulation if indicated. 3) LE neurodynamics (if there is paresthesia or radiculopathy). 4) pt education.

I find a good program for each patient the best that I can, and usually stick to it. As opposed to "progressing." I don't comprehend everyone's reasoning when it comes to desire to progress everything in PT. Some patient's need a progression, some not so much. Some just need a good program to stick to. In medicine, do patient's receiving Rx for HTN get progressed if the treatment is working, i.e. nearly complete change of the POC?

fozzy40 said:

I.E. the pain is bad enough that it's hard to evaluate and/or get past visit 2-3 because of the symptoms.

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These are tough patients for anybody to help.

Fozzy, how do you typically manage these type of patients medically. You earlier referenced getting their pain under control. How is this typically done, and are you able to achieve this often for the type of patient that we are talking about in this thread?

dg1984 said:

1. Go back to Netter and Grey's. If you sense that aberrent spinal motion is a problem THINK. You can't change the bony or ligamentous structures with your treatment. You can't change any residual motion control provided by the disc. As a PT you have to work within your scope and control the muscles I mentioned above (TA, int oblique, ext, oblique, multifidi, QL and selective rectus)

2. You need to at least brush through this book. It is far more substantial than a blog entry that took about 3 minutes to write (as did this post haha)

http://www.amazon.com/Low-Back-Disorders-Second-Edition/dp/0736066926#productPromotions

3. I agree there are flaws, but what else would you work on with a low back patient. There is also some solid literature for the concept of graded exposure and graded exercise to help patients with chronic low back pain. These concepts use components of core stabilization.

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1. And how is it you control those muscles?

In individuals without history of LBP many of the muscles you mention work in a feed forward mechanism, essentially unconsciously. Core stabilization asks an individual to use these muscles in a way that has little to do with how the act in a healthy, non-symptomatic person.

2. Neil has done just a little more than write a 3 minute blog. His analysis of the current sad state of affairs regarding rehabilitation and medical management of patients with persistent pain is spot on. Here is a list of his publications: http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term="O'Connell+NE"[Author]+NOT+%22cattle%22[Text+Word]+NOT+%22protein%22[Text+Word]

And here is a site where you can access research from the Bidy In Mind team, some of which Mr. O'Connell worked on:
http://bodyinmind.org/resources/journal-articles/

3. I find this statement disturbing. This is a very poor argument for the spinal stabilization treatment paradigm, and it is one that our profession uses far too often. I would opt for treatments that, first and foremost have a good supporting theory (I think spinal stabilization fails this test), then have some documented data that indicate efficacy beyond that of placebo (stabilization is rapidly failing this test too, but most PTs are digging in their heels rather than admit we have been wrong since 1996.).

Fiveoboy11 said:

I have his book too, big deal. He's not even a PT, and therefore does not even have experience treating patient's with physical thearpy for LBP. Where McGill and your reasoning falls short is the lack of outcome based train of thought. Stabilization exercises do not necessarily stabilize anything, and if they did does that even coorelate to symptomatic improvement? (You know, what the patient actually cares about?).

For me in LBP I typicall use a few approaches: 1) joint mobility/ROM exercise of lumbopelvic (biasing to a directional preference if there is one). 2) manipulation if indicated. 3) LE neurodynamics (if there is paresthesia or radiculopathy). 4) pt education.

I find a good program for each patient the best that I can, and usually stick to it. As opposed to "progressing." I don't comprehend everyone's reasoning when it comes to desire to progress everything in PT. Some patient's need a progression, some not so much. Some just need a good program to stick to. In medicine, do patient's receiving Rx for HTN get progressed if the treatment is working, i.e. nearly complete change of the POC?

Click to expand...

Fiveoboy11 said:

I have his book too, big deal. He's not even a PT, and therefore does not even have experience treating patient's with physical thearpy for LBP. Where McGill and your reasoning falls short is the lack of outcome based train of thought. Stabilization exercises do not necessarily stabilize anything, and if they did does that even coorelate to symptomatic improvement? (You know, what the patient actually cares about?).

For me in LBP I typicall use a few approaches: 1) joint mobility/ROM exercise of lumbopelvic (biasing to a directional preference if there is one). 2) manipulation if indicated. 3) LE neurodynamics (if there is paresthesia or radiculopathy). 4) pt education.

I find a good program for each patient the best that I can, and usually stick to it. As opposed to "progressing." I don't comprehend everyone's reasoning when it comes to desire to progress everything in PT. Some patient's need a progression, some not so much. Some just need a good program to stick to. In medicine, do patient's receiving Rx for HTN get progressed if the treatment is working, i.e. nearly complete change of the POC?

Click to expand...

If performing marches with TAC bracing becomes to easy would you not progress to TAC with a bridge?

If the patient has been performing modified side planks for two weeks, and can perform the exercise with a 30 second hold and proper form with no increased motion would you not progress to a side plank?

Now, if it takes you 5 weeks to teach someone low level exercises. I would agree. I would rather have someone perform the exercises right than just do a bunch of things to do them.

jesspt said:

1. And how is it you control those muscles?

In individuals without history of LBP many of the muscles you mention work in a feed forward mechanism, essentially unconsciously. Core stabilization asks an individual to use these muscles in a way that has little to do with how the act in a healthy, non-symptomatic person.

2. Neil has done just a little more than write a 3 minute blog. His analysis of the current sad state of affairs regarding rehabilitation and medical management of patients with persistent pain is spot on. Here is a list of his publications: http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=DetailsSearch&Term="O'Connell+NE"[Author]+NOT+%22cattle%22[Text+Word]+NOT+%22protein%22[Text+Word]

And here is a site where you can access research from the Bidy In Mind team, some of which Mr. O'Connell worked on:
http://bodyinmind.org/resources/journal-articles/

3. I find this statement disturbing. This is a very poor argument for the spinal stabilization treatment paradigm, and it is one that our profession uses far too often. I would opt for treatments that, first and foremost have a good supporting theory (I think spinal stabilization fails this test), then have some documented data that indicate efficacy beyond that of placebo (stabilization is rapidly failing this test too, but most PTs are digging in their heels rather than admit we have been wrong since 1996.).

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Then give me a better answer of what to do.

Preliminary Development of a Clinical Prediction Rule for

Determining Which Patients With Low Back Pain Will

Respond to a Stabilization Exercise Program



Gregory E. Hicks, PhD, PT, Julie M. Fritz, PhD, PT, ATC, Anthony Delitto, PhD, PT, Stuart M. McGill, PhD


This isn't GREAT evidence, but it is a good starting point. I am having trouble understanding what you would suggest we do if core stabilization is just not doing anything. Greg Hicks is a PT with both great clinical and research experience. You could learn a lot from reading his research.

dg1984 said:

If performing marches with TAC bracing becomes to easy would you not progress to TAC with a bridge?

If the patient has been performing modified side planks for two weeks, and can perform the exercise with a 30 second hold and proper form with no increased motion would you not progress to a side plank?

Now, if it takes you 5 weeks to teach someone low level exercises. I would agree. I would rather have someone perform the exercises right than just do a bunch of things to do them.

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I don't necessarily care about how easy something has become. What I do care about is whether the exercise program is provocative, relieving or neutral. Especially as time goes on. An exercise could be easy as can be, but at the same time be perfect for a particular patient to alleviate the problem they have. It doesn't have to be challenging or hard to be the right plan.

I don't really do side planks, or modified side planks.

Fiveoboy11 said:

I don't necessarily care about how easy something has become. What I do care about is whether the exercise program is provocative, relieving or neutral. Especially as time goes on. An exercise could be easy as can be, but at the same time be perfect for a particular patient to alleviate the problem they have. It doesn't have to be challenging or hard to be the right plan.

I don't really do side planks, or modified side planks.

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I do not disagree with your statement regarding exercise. In the spirit of this discussion I will offer what I do with side planks.

side plank progression

1. Pt is sidelying with adequate head support (May require two or three pillows). Pt lifts both legs ONLY 2-3 inches off the table. This will turn on TA, int oblique, ext oblique and QL. The activation is automatic, well-studied and important. In my experience QL has to be activated. I love this exercise so much because it generally doesn't provoke pain, it ensures spine neutral and starts low level activation WITHOUT much thought on the pt's part. Also, have the patient feel just inside the ASIS to feel the contraction. I MAY NEVER GO BEYOND THIS MOVE, just increase hold times and or reps.

2. Side plank on knees (Generally higher level athletes)

3. Side planks

4. Side planks with pt's elbow on BOSU ball.

You should be activating QL. When you work with boxers, runners or laxers you have to progress them from low level ther ex because their demand rises with the intensity of their activity. A 67 year old medicare patient usually doesn't make it past step one.

dg1984 said:

I do not disagree with your statement regarding exercise. In the spirit of this discussion I will offer what I do with side planks.

side plank progression

1. Pt is sidelying with adequate head support (May require two or three pillows). Pt lifts both legs ONLY 2-3 inches off the table. This will turn on TA, int oblique, ext oblique and QL. The activation is automatic, well-studied and important. In my experience QL has to be activated. I love this exercise so much because it generally doesn't provoke pain, it ensures spine neutral and starts low level activation WITHOUT much thought on the pt's part. Also, have the patient feel just inside the ASIS to feel the contraction. I MAY NEVER GO BEYOND THIS MOVE, just increase hold times and or reps.

2. Side plank on knees (Generally higher level athletes)

3. Side planks

4. Side planks with pt's elbow on BOSU ball.

You should be activating QL. When you work with boxers, runners or laxers you have to progress them from low level ther ex because their demand rises with the intensity of their activity. A 67 year old medicare patient usually doesn't make it past step one.

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to me that is personal training, not PT

The whole basis for stability training is troublesome to me. The concept is to keep the trunk rigid while you move something else, or support the trunk off a surface while keeping it rigid. Why not tell a patient to get a back brace and lay in bed all day long. That'll keep it stable too. Who gives a squat about that. What about pain, function, and QOL?

Some times I actually would be in favor of a stabilization program would be in a hypermobile patient with aberrant motion of the spine during AROM, and spondylolisthesis.

Otherwise I think the stability rationale heads off on the wrong path. For example, in a patient who is "out," would you put them back "in" followed by "stabilization" exercises and encourage them to avoid ROM, so they don't go back "out"?

Fiveoboy11 said:

to me that is personal training, not PT

The whole basis for stability training is troublesome to me. The concept is to keep the trunk rigid while you move something else, or support the trunk off a surface while keeping it rigid. Why not tell a patient to get a back brace and lay in bed all day long. That'll keep it stable too. Who gives a squat about that. What about pain, function, and QOL?

Some times I actually would be in favor of a stabilization program would be in a hypermobile patient with aberrant motion of the spine during AROM, and spondylolisthesis.

Otherwise I think the stability rationale heads off on the wrong path. For example, in a patient who is "out," would you put them back "in" followed by "stabilization" exercises and encourage them to avoid ROM, so they don't go back "out"?

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I am going to take the high road and not address the personal training comment.

Actually putting someone in a back brace would be the complete antithesis of what I am talking about. A lot of people I perform this type of training with are generally people with 1 or more hypermobile segments as your said. Can you not perform this exercise progression and administer an OSW? Actually just did that about 3 days ago. Am I not allowed to check a comparable sign, administer an FABQ or assess return to work because I have administered a core stability program? This is a part of your program, of course you will assess AND care about QOL and function.

To address the final point you made about someone being "out". I don't believe in that language. I don't think people are out and you magically put them back in. Talk about a house of cards collapsing on itself if you want to go through the lit on that one. The only thing a mobilization or manipulation has ever been "proven" to do is overcome a range restriction. (hypomobilie segment, mob or manip, re-assess). Then you have to ask yourself what caused the hypomobilie segment or hypermobile segment. Think of someone who gets a one level fusion (almost presents as a functional hypomobility). The segments above and below tend to become more mobile. No? So wouldn't you want to control motion at other segments? I am getting outside of the literature a little and into the domain of common sense.

As a PT it can be very taxing and take up a lot of time to teach a good core stability program. A lot get LAZY, and give up. Show me something better and I will change my ways.

fozzy40 said:

It's not hopeless but more of a challenge! We are all right to some degree but I think we can agree that there are a lot of ways to treat this problem. I will also say that anyone would be foolish to claim they have the silver bullet for back pain.

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I'll take that as a YES to my answer, there is Hope! Having an open mind and little optimism most likely will not lead to a solution, however, it will provide options.

fozzy40 said:

It's definitely a tough problem. There are several ways to approach back pain. However, which one is "the best?" That's the holy grail!

I work in a community setting and have about 10-15 therapists that I refer to for various things like low back pain. Each one has a different bias and approach based on where they trained, where they currently work, and their clinical experience. Despite the wide variety of approaches, they all seem to get patients better. How can that be?

Back pain typically gets better. I believe that natural history plays a HUGE role in this picture. One could essentially do nothing and just ride out the acute phase and the chances are that it will get better on it's own. I think what we do (health care providers) in terms of back pain is give people options of managing the symptoms until natural history takes over. Generally speaking, I think a focused therapeutic exercise program no matter what your bias is (McKenzie, DeLitto, Sullivan, Sahrmann) will likely work 90% of the time. Those "10 percenters" are a very different cohort and may require a very specific program (i.e. core stabilization etc.) before they get better.

It's not hopeless but more of a challenge! We are all right to some degree but I think we can agree that there are a lot of ways to treat this problem. I will also say that anyone would be foolish to claim they have the silver bullet for back pain.

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Very well said. You can argue forever, but at the end of the day we all have our bias and we all get good results. I think that one on one time between therapist and patient is a huge key. Whether it is directional bias, manual therapy, nerve glides, or core stabilization training, I really think the patient benefits from increased 1 on 1 time. I rely on all of these to treat a patient and I am lucky to work for a clinic that allows me to have 1/2 hour with each patient and a full hour for evals. That helps a lot.

fozzy40 said:

Cool article:

Akuthota, V., A. Ferreiro, T. Moore, and M. Fredericson. “Core Stability Exercise Principles.” Current Sports Medicine Reports 7, no. 1 (2008): 39.

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Interesting. This is what I was taught during PT school and exactly what I was explaining before. The only difference is I would never have someone in a rehab setting perform a weighted rotation. Instead you can hold the weight in front of you (using a free motion machine) and resist rotation. This keeps a neutral spine and will not aggrivate low back symptoms.

dg1984 said:

Interesting. This is what I was taught during PT school and exactly what I was explaining before. The only difference is I would never have someone in a rehab setting perform a weighted rotation. Instead you can hold the weight in front of you (using a free motion machine) and resist rotation. This keeps a neutral spine and will not aggrivate low back symptoms.

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Also, the prone instability test does have some good data behind it in terms of determining those who could benefit from a core stability program. There is some new work that may be presented that refutes the validity of the test; however, they perform the prone instability test with the patient BELTED down (Effectively taking core stabilization out of the picture). This is not how the test has been described in the literature.

dg1984 said:

Preliminary Development of a Clinical Prediction Rule for

Determining Which Patients With Low Back Pain Will

Respond to a Stabilization Exercise Program



Gregory E. Hicks, PhD, PT, Julie M. Fritz, PhD, PT, ATC, Anthony Delitto, PhD, PT, Stuart M. McGill, PhD


This isn't GREAT evidence, but it is a good starting point. I am having trouble understanding what you would suggest we do if core stabilization is just not doing anything. Greg Hicks is a PT with both great clinical and research experience. You could learn a lot from reading his research.

Click to expand...

An uncontrolled CPR development study, that had to have the criteria for a succesful outcome modified due to so few paticipants meeting that level of functional improvement, and that actually does a btter job of determining who wo'nt benefit from lumbar stabilization - not sure that this is overly helpful.

You asked what I would suggest we do if stabilization exercises don't seem to be doing anything. I guess I would suggest that we don't fill our patients' heads full of information that is unlikely to be true (i.e. better contraction of certain muscles will improve back pain) and avoid basing our primary treatment intervention ( a "weak" core) on something we cannot reliably measure ("core" strength or poor TrA-multifidus timing).

dg1984 said:

I am going to take the high road and not address the personal training comment.

Actually putting someone in a back brace would be the complete antithesis of what I am talking about. A lot of people I perform this type of training with are generally people with 1 or more hypermobile segments as your said. Can you not perform this exercise progression and administer an OSW? Actually just did that about 3 days ago. Am I not allowed to check a comparable sign, administer an FABQ or assess return to work because I have administered a core stability program? This is a part of your program, of course you will assess AND care about QOL and function.

To address the final point you made about someone being "out". I don't believe in that language. I don't think people are out and you magically put them back in. Talk about a house of cards collapsing on itself if you want to go through the lit on that one. The only thing a mobilization or manipulation has ever been "proven" to do is overcome a range restriction. (hypomobilie segment, mob or manip, re-assess). Then you have to ask yourself what caused the hypomobilie segment or hypermobile segment. Think of someone who gets a one level fusion (almost presents as a functional hypomobility). The segments above and below tend to become more mobile. No? So wouldn't you want to control motion at other segments? I am getting outside of the literature a little and into the domain of common sense.

As a PT it can be very taxing and take up a lot of time to teach a good core stability program. A lot get LAZY, and give up. Show me something better and I will change my ways.

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What?

fozzy40 said:

It's definitely a tough problem. There are several ways to approach back pain. However, which one is "the best?" That's the holy grail!

I work in a community setting and have about 10-15 therapists that I refer to for various things like low back pain. Each one has a different bias and approach based on where they trained, where they currently work, and their clinical experience. Despite the wide variety of approaches, they all seem to get patients better. How can that be?

Back pain typically gets better. I believe that natural history plays a HUGE role in this picture. One could essentially do nothing and just ride out the acute phase and the chances are that it will get better on it's own. I think what we do (health care providers) in terms of back pain is give people options of managing the symptoms until natural history takes over. Generally speaking, I think a focused therapeutic exercise program no matter what your bias is (McKenzie, DeLitto, Sullivan, Sahrmann) will likely work 90% of the time. Those "10 percenters" are a very different cohort and may require a very specific program (i.e. core stabilization etc.) before they get better.

It's not hopeless but more of a challenge! We are all right to some degree but I think we can agree that there are a lot of ways to treat this problem. I will also say that anyone would be foolish to claim they have the silver bullet for back pain.

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So Fozzy, are these 10%-ersthe patients who caused yo to begin this thread?

A nice outline of the lumbar stabilization exercise CPR:

http://www.ispinstitute.com/adminv2...22-Stabilization_Clinical_Prediction_Rule.pdf

fozzy40 said:

Back pain typically gets better. I believe that natural history plays a HUGE role in this picture. One could essentially do nothing and just ride out the acute phase and the chances are that it will get better on it's own. I think what we do (health care providers) in terms of back pain is give people options of managing the symptoms until natural history takes over. Generally speaking, I think a focused therapeutic exercise program no matter what your bias is (McKenzie, DeLitto, Sullivan, Sahrmann) will likely work 90% of the time. Those "10 percenters" are a very different cohort and may require a very specific program (i.e. core stabilization etc.) before they get better.

It's not hopeless but more of a challenge! We are all right to some degree but I think we can agree that there are a lot of ways to treat this problem. I will also say that anyone would be foolish to claim they have the silver bullet for back pain.

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When it comes to LBP, we need to define "better". In many cases, better doesn't mean gone for good or gone completely. Residual pain and episodic recurrences are probably more the norm, suggesting that natural history isn't what we used to think it was and blurring the line between acute/chronic.

http://www.ncbi.nlm.nih.gov/pubmed/12709853

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC169642/?tool=pubmed

jesspt said:

An uncontrolled CPR development study, that had to have the criteria for a succesful outcome modified due to so few paticipants meeting that level of functional improvement, and that actually does a btter job of determining who wo'nt benefit from lumbar stabilization - not sure that this is overly helpful.

You asked what I would suggest we do if stabilization exercises don't seem to be doing anything. I guess I would suggest that we don't fill our patients' heads full of information that is unlikely to be true (i.e. better contraction of certain muscles will improve back pain) and avoid basing our primary treatment intervention ( a "weak" core) on something we cannot reliably measure ("core" strength or poor TrA-multifidus timing).

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Good point on the research. I said it wasn't great, but not a bad start. Isn't it important to determine who won't benefit from core stability? Doesn't that get at the question we are asking? I honestly thought you would love this article for those reasons.

I never tell patients that they can cure back pain with a core stability program. Only that it is a part of what COULD help their pain with dynamic activity. I would hardly describe it as the basis of my treatment. I perform 30 minutes of manuals (nerve glides, directional preference, which also finds its way into some core stability ther ex, jt mobs, manips and soft tissue mobilization) as needed. I will then have the patient perform core stability training if they either A. present with 1 or more hypermobile segments B. Have a positive prone instability test or C. Look like garbage with a dynamic task (aberrent motion with lateral stepdown, modified plank, modified side plank, lunge etc.).

In PT do we not fix weakness?

If you have a an ACL patient with weak dorsiflexion (maybe it was that way before the surgery) would you not address it? I doubt you could find ANY research on that, let alone an RCT, but to not address a muscular weakness in the area of dysfunction is sloppy PT.

And I will address the low blow personal training comment from earlier (not from you but from another). If you are treating a division 1 soccer player with low back pain and you do not challenge them from a core stability standpoint (especially if they need it) they will think you are a joke. Regardless of how good you think you may be. People at those levels must be taxed in the late stages of rehab and if you do not bridge the gap between physical therapy and their own workouts, you will look foolish.

JessPT,

What is your answer to my question? What do you do? What types of treatments do you perform instead of core stability? I am all ears.

jesspt said:

A nice outline of the lumbar stabilization exercise CPR:

http://www.ispinstitute.com/adminv2...22-Stabilization_Clinical_Prediction_Rule.pdf

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Great rundown.