Units of measurement (continued) <strong>Low</strong> <strong>Back</strong> <strong>Pain</strong>: Clinical Practice Guidelines Subgroups for Targeted Treatment <strong>Back</strong> Screening Tool (continued) Subgroup scoring: High risk (psychosocial subscale scores �4) Medium risk (overall score >3; psychosocial subscale score
<strong>Low</strong> <strong>Back</strong> <strong>Pain</strong>: Clinical Practice Guidelines A variety of interventions have been described for the treatment of low back pain, and it is not the intention of these clinical practice guidelines to exhaustively review all interventions. Instead, these guidelines focus on randomized, controlled trials and/or systematic reviews that have tested these interventions in environments that would match physical therapy application. In keeping with the overall theme of these guidelines, we are focusing on the peer-reviewed literature and making recommendations related to (1) treatment matched to subgroup responder categories, (2) treatments that have evidence to prevent recurrence, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability. It is believed that early physical therapy intervention can help reduce the risk of conversion of patients with acute low back pain to patients with chronic symptoms. A study by Linton et al 200 demonstrated that early active physical therapy intervention for patients with the first episode of acute musculoskeletal pain significantly decreased the incidence of chronic pain. This study represented a cohort study comparing patients who received early versus delayed or no physical therapy intervention for occupational-related injury. At 12-month follow-up, the group that received early active physical therapy had significant reductions in amount of work time lost. Only 2% of patients who received early intervention went on to develop chronic symptoms, compared to 15% of the delayed treatment group. 200 These findings have been supported numerous times. 119,133,230,244,308 Recently, Gellhorn et al 120 demonstrated that those with early referral to physical therapy (less than 4 weeks), as compared to those referred after 3 months, were significantly less likely to receive lumbosacral injection (OR = 0.46; 95% CI: 0.44, 0.49) and frequent physician visits (OR = 0.47; 95% CI: 0.44, 0.50) in Medicare patients. The order of the interventions presented in this section is based upon categories and intervention strategies presented in the Recommended <strong>Low</strong> <strong>Back</strong> <strong>Pain</strong> Impairment/Functionbased Classification Criteria with Recommended Interventions table. MANUAL THERAPY Thrust and nonthrust mobilization/manipulation I is a common intervention utilized for acute, subacute, and chronic low back pain. Despite its popu- CLINICAL GUIDELINES Interventions larity, recent systematic reviews have demonstrated marginal treatment effects across heterogeneous groups of patients with low back pain. 10,11 Also, most trials have assessed the efficacy of mobilization/manipulation in isolation rather than in combination with active therapies. Recent research has demonstrated that spinal manipulative therapy is effective for subgroups of patients and as a component of a comprehensive treatment plan, rather than in isolation. Research has determined a subgroup of patients likely to have dramatic changes with application of thrust manipulation to the lumbar spine, advice to remain active, and mobility exercise. Flynn et al99 II conducted an initial derivation study of patients most likely to benefit from a general lumbopelvic thrust manipulation. Five variables were determined to be predictors of rapid treatment success, defined as a 50% or greater reduction in Oswestry Disability Index scores within 2 visits. These predictors included: • Duration of symptoms of less than 16 days • No symptoms distal to the knee • Lumbar hypomobility • At least 1 hip with greater than 35 o of internal rotation • FABQ-W score less than 19 The presence of 4 or more predictors increased the probability of success with thrust manipulation from 45% to 95%. This test-item cluster was validated by Childs et al, 51 I who demonstrated similar results with patients meeting 4 of the 5 predictors who received thrust manipulation (+LR = 13.2; 95% CI: 3.4, 52.1). Patients were randomized to receive either spinal manipulation or trunk strengthening exercises. Patients meeting the rule who received manipulation had greater reductions in disability than all other subjects. These results remained significant at 6-month follow-up. A pragmatic rule has also been published to predict dramatic improvement based on only 2 factors: • Duration less than 16 days • Not having symptoms distal to the knee If these 2 factors were present, patients had a moderate-tolarge shift in probability of a successful outcome following application of thrust manipulation (+LR = 7.2; 95% CI: 3.2, 16.1). 106 journal of orthopaedic & sports physical therapy | volume 42 | number 4 | april 2012 | a31
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