Resources and Strategies

The Evidence-Informed Chiropractor

 

The Low Back - Dx and Tx

 

                                                    

 

Practical Questions
  • How do you know if your patient's radiating pain is radicular (nerve root)?
  • What is scleratogenous pain?
  • What is the true natural history of low back pain (LBP)?   
  • Is manipulative therapy safe and/or effective for radicular pain due to disk herniation?

  • What is the evidence for manipulation and exercise in the management of LBP?

  • At what point do I refer a patient with LBP?

    Natural History of Acute Low Back Pain

     

    Important Statistics


    • In the U.S. population, the 1 month prevalence for LBP is between 35% and 37%
    • 80% of individuals will have LBP in their lifetime
    • 14% will complain of pain lasting longer than 2 weeks

     

     

    90% of LBP will resolve within 1 month (or does it?)

     It depends on when and how long you measure a patient after their initial occurrence of low back pain.

    • Von Korff (1996) has shown that a significant amount of even acute LBP patients have persistent pain if followed for 1 to 2 years.

    • As much as 62% will have one or more relapses during one-year follow-up of an index episode and 40% still have LBP at 6 months (Phillips& Grant, 1991).

    • Initial relapses tend to occur at 6 to 7 week intervals with a decreasing number of cases suffering renewed pain each time.

    • While 95% of patients may have returned functionally to near pre-episode status within 6 months, 31% continue to suffer pain with activity

    Spinal Manipulative Therapy for Lumbar Disk Herniation-Related Radiculopathy

    On the heels of the North American Spine society (NASS) guidelines recommendation for spinal manipulation as an alterative for patients with disk-related radiculopathy, two new Swiss studies add weight to the evidence. The most recent study published in 2014, is an extension of a 2013 study which follows 148 patients through one year to determine effects on both acute and chronic patients.

    • Improvement was approximately 70% at 2 weeks, 80% at one month, and about 90% at 1 year follow-up
    • Although improvements for acute patients seem to stabilize at 3 months, for chronic patients higher percentages of “improvement” occurred at both 6 months (88.6%) and 1 year (89.2%)
    • The pain and disability scores continued to decrease substantially for both groups up to 3 months
    • Acute patients were 73% more likely to “improve” at 2 weeks.
    • At both 3 and 6 months, the only predictor of “improvement” was the baseline Oswestry Disability and pain scores score

    Abstract

    2014 JMPT Study on Manipulation and Lumbar Radiculopathy

     

    Spine Surgery and First Provider Seen

    In the Workers' Compensation system, spine injuries account for a significant amount of health care expenses. A unique study from the Washington State Department of Labor and Industries examines which factors influence the odds of having spine surgery following an occupational injury.

    • Costs for occupational back pain increased over 65% from 1996 through 2002. Spine surgeries accounted for approximately 21% of these costs
    • Although there are many studies that examine predicting chronicity following an acute episode of LBP, there are few that address prediction of lumbar spine surgery following occupational injury
    • Among workers with compensation for temporary total disability for occupational back injury, 9.2% underwent lumbar spine surgery within 3 years
    • Higher Roland-Morris Disability Questionnaire scores, greater injury severity, and first seeing a surgeon for the injury significantly increased the odds of having spine surgery
    • Participants younger than 35 years, females, Hispanics, and participants whose first visit for the injury was to a chiropractor had lower odds of surgery
    • No other factors in the employment-related, health behavior, or psychological domains were significant.
    • The odds of surgery were highest for workers with reflex, sensory, or motor abnormalities but odds were also high for workers with symptomatic radiculopathy without such abnormalities
    • 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor

    Abstract

    First Provider Seen Predicts Lumbar Spine Surgery in Workers - Spine 2012

    Early Predictors of Lumbar Spine Surgery

     

    More Workers' Comp Evidence

     • In a recent study workers' compensation injury patients were tracked for a one-year interval while recording symptom severity and work status.

     • While 50 percent experienced no work time loss within the first month after injury, 30 percent of them had work absence because of their injury at the end of one year.

     • Of those who had work absence within the first month (12%) and had returned, an additional 19% had absence later in the year.

     • Reports of return to work experience at one month that are in general use do not capture the chronic, episodic nature of back problems.

     • Many patients who appear to have improved and returned to stable employment continue to experience subsequent injury-related symptoms and work absences.

     • Assuming the typical case mix attended by an individual practitioner, the presence of symptoms and impairment beyond 12 weeks may be as high as between 31% to 40%, not the typical 10% often quoted.

     

    What makes up your patient population with low back pain?

     • Only 1% of patients with LBP have neurological deficits

     • 39% of patients will have pain due to disc disruption (internal or external)

     • 5% will have disc herniation

     • 15% to 40% (dependent on study) will have facet involvement

     • 4% will have a compression fracture

     • 3% will have a spondy

     • 1% will have a malignant neoplasm

     • 0.3% will have ankylosing spondylitis

     • 0.01% will have a spinal infection

    How good is the clinical examination at determining if there is disc-related nerve root involvement causing radicular pain?

    Localization of Disc Level Based on Signs & Symptoms

     L5-S1 disc rupture is 86% probable if three S1 signs are found:

     • pain projection to S1 area

     • pathologic Achilles reflex

     • sensory defect in S1 area

     • Pain projection into the S1 area is found with all lumbar disc lesions including high levels

    L4-L5 disc rupture is 87% probable with three L5 signs:

     • extensor hallucis (EH) weakness

     • pain projection into L5 area

     • sensory defect of L5

     • With concomitant S1 findings accuracy of pain projection into L5 and EH weakness were still accurate

     • EH weakness and sensory defect in L5 area were 100% reliable for fourth disc herniation

    McCombe PF, Fairbank JCT, Cockersole BC, et al. Reproducibility of physical signs in low back pain. Spine. 1989;14:908-918.

    Straight-Leg Raise (SLR)

     • The SLR in several studies has been found to be specific but NOT very sensitive for lumbar radiculopathies (i.e. a positive test result tends to rule-in but a negative does not rule-out)

     • This means that a patient with nerve root compression may not have a positive SLR or crossed SLR

     • One study evaluated response to SLR in patients prior to surgery and compared with results post-surgically to determine the value of a positive test related to the range of motion in which it occurs

     • Prior cadaveric studies indicated little dural tension until 30 degrees therefore positives below 30 degrees were interpreted as not indicative of disc herniation as a cause of LBP

     • In the more recent study, the SLR was positive in 42% of patients with disc herniation from 0-30 degrees

     • SLR positive in 26% of disc herniation patients from 30-60 degrees

    Kosteljanetz M, Bang F, Schmidt-Olsen S. The clinical significance of straight-leg raising (Lasegue's sign) in the diagnosis of prolapsed lumbar disc. Interobserver variation and correlation with surgical finding. Spine. Apr 1988;13(4):393-395.

    Lauder TD, Dillingham TR, Andary M, et al. Effect of history and exam in predicting electrodiagnostic outcome among patients with suspected lumbosacral radiculopathy. Am J Phys Med Rehabil. Jan-Feb 2000;79(1):60-68;

    Jonsson B, Stromqvist B. Spine, 20(1), 27-30, 1995

    Powered by Wild Apricot Membership Software