CPR for Lumbar Stabilisation: Difference between revisions

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'''Original Editor '''- [[User:Timothy Richardson|Timothy Richardson]]  
'''Original Editor '''- [[User:Lucy Bussard|Lucy Bussard]] and [[User:Kurt Kimmons|Kurt Kimmons]]  


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;  
'''Lead Editors''' &nbsp;  
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== Purpose<br>  ==
== <br>Indication<br>  ==


Hicks et al's <ref name="Hicks" /> lumbar stabilization rule contains two groups: a “Success” group and an “Improvement” group. The two groups are different in the magnitude of the change in their outcome score and in the variables used to predict group assignment.<ref name="Hicks">Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005 Sep;86(9):1753-62.</ref>  
Patients presenting with low back pain are&nbsp;generally a heterogeneous population, and because in 85% of cases no specific diagnosis can be made for low back pain, a treatment based classification system is useful for physical therapists in developing rehabilitation programs for patients unspecified with low back pain. In this type of system, patients are categorized according to general presentation, findings from a physical examination,&nbsp;impairments, and functional limitations, and are grouped into one of several treatment classifications. In order to assist with this classification, clinical prediction rules are a set of criteria that a patient should meet in order to be placed into a specific treatment group. The clinical&nbsp;prediction rule for the spinal stabilization treatment&nbsp;category is below, and generally includes a&nbsp;younger age, instability,&nbsp;and&nbsp;greater overall&nbsp;mobility.&nbsp;<ref>Fritz JM, Cleland JA, Childs JD. (2007) Subgrouping Patients with Low Back Pain: Evolution of a Classification Approach to Physical Therapy. Journal of Orthopaedic &amp;amp;amp;amp;amp;amp;amp;amp; Sports Physical Therapy, 37 (6), 290-302</ref>  


The Success group changed by better than 50% on the Oswestry Disablement Scale (ODI). The Improvement group changed from 6% to 49% on the ODI. Any change less than 6% was considered a treatment failure and alternative treatments were suggested.<ref name="Hicks" />
== Clinical Prediction Rule  ==


== Clinical Prediction Rule Components<ref name="Hicks" /><br>  ==
The presence of 3 or more of the following factors increase the probability of dramatic success for patients in&nbsp;the spinal stabilization&nbsp;category from 33% to 67%:


Use this template to test your patient for inclusion in the Success stabilization group.
*Younger Age (&lt;40 years old)
*Increased Flexibility (Average SLR &gt; 91<sup>o</sup>)
*Aberrant Motions or&nbsp;Instability Catch during Lumbar&nbsp;Flexion/Extension ROM
*(+) [[Prone Instability Test|Prone Instability Test]]


{| width="80%" cellspacing="1" cellpadding="1" border="1" align="center"
<br>  
|-
 
| Yes
The presence of 2 or more of the following increases the probability of some improvement with the spinal stabilization treatment method from 72% to 94%:&nbsp;:
| No
| Success Rule predictor variables
|-
| <br>  
| <br>
| Age less than 40 years old
|-
| <br>
| <br>
| SLR greater than 91 degrees
|-
| <br>
| <br>
| Aberrant motion present
|-
| <br>
| <br>
| Positive prone instability test
|}


Use this template to test your patient for inclusion in the Improvement stabilization group.
*(+) [[Prone Instability Test|Prone Instability Test]]
*Aberrant Motions during Lumbar Flexion/Extension ROM
*Hypermobility
*FABQ-PA&nbsp;<u>&lt;</u> 8


{| width="80%" cellspacing="1" cellpadding="1" border="1" align="center"
<ref>Hicks GE, Fritz JM, Delitto A, McGill SM. (2005) Preliminary Development of a Clinical Prediction Rule for Determining Which Patients with Low Back Pain Will Respond to a Stabilization Exercise Program. Archives of Physical Medicine and Rehabilitation, 86 (9), 1753-1762.</ref><br>  
|-
| Yes
| No
| Improvement Rule predictor variables
|-
| <br>  
| <br>
| FABQ physical activity scale greater than 9 points
|-
| <br>
| <br>
| Aberrant movements absent
|-
| <br>
| <br>
| No lumbar hypermobility with prone spring testing
|-
| <br>  
| <br>  
| Negative prone instability test
|}


==== Decision Rule ====
== Description ==


The decision rules can be considered separately.  
Optimal spinal stabilization can be achieved by strengthening the deep back and abdominal muscles. These include the transverse abdominus, quadratus lumborum, oblique abdominals, multifidus, and erector spinae. Exercises targeting&nbsp;these specific muscles should be done in a progression, usually beginning with the transverse abdominus which provides the patient with initial stabilization that is helpful during subsequent exercises and daily activities.  


{| width="80%" cellspacing="1" cellpadding="1" border="1" align="center"
<br>
|+ Success Rule
|-
| Number of variables present
| Likelihood ratio
| Probability shift
| Group assignment
|-
| &gt;1
| 1.3
| No shift
| Group assignment unlikely
|-
| &gt; 2
| 1.9
| Negligible shift
| Group assignment unlikely
|-
| &gt;3
| 4.0
| 34% upward shift
| 67% chance the patient is in the success group
|}


The “Improvement Rule” defines the amount or improvement each group achieved. The Success Group had better than a 50% improvement in the Oswestry while the Improvement Group had between 6 and 49% improvement in the Oswestry.<br>
Below are methods for activating the transverse abdominus and multifidus muscles, two major spinal stabilizers.&nbsp;These exercises should be incorporated initially in the spinal stabilization program for patients with low back pain. Once the patient is able to activate these muscles, more stabilizing exercises should be introduced the patient should be progressively challenged with more difficult exercises, targeting the muscles listed above.  


<br>  
<br>  


{| width="80%" cellspacing="1" cellpadding="1" border="1" align="center"
{| width="100%" cellspacing="1" cellpadding="1" align="center" class="FCK__ShowTableBorders"
|+ Improvement Rule
|-
|-
| Number of variables present
|  
| Positive likelihood ratio
{{#ev:youtube|aqwx6uCwhUQ|300}}
| Negative likelihood ratio
 
| Probability shift
| {{#ev:youtube|fUU0pGZ0v_U|300}}
| Group assignment
|-
| One or more
| 1.1
| 0.20
| no shift / -50%
| Group assignment unlikely
|-
|-
| Two or more
| <ref>online video, http://www.youtube.com/watch?v=aqwx6uCwhUQ, last accessed 6/2/09</ref><br>
| 6.3
| <ref>online video, http://www.youtube.com/watch?v=fkt1TOn1UfI, last accessed 6/2/09</ref><br>
| 0.18
| no shift / -50%
| 94% likely to be in the improvement group
|-
| Three or more
| 18.8
| 0.43
| +22% / - 50%
| 97% likely to be in the improvement group
|-
| Four
| 6.0
| 0.84
| +27% / negligible
| 94% likely to be in the improvement group
|}
|}


==== Prevalence of the group  ====
<br><br>The following videos are examples&nbsp;demonstrating progressions of spinal stabilization exercises&nbsp;that can be used for patients requiring this technique. They can and should be modified according to specific patient needs, preferences, or functional demands. The physical therapist should remember to consistently stress the importance of maintaining a neutral spine when performing these exercises.


Three sub-groups exhibited different responses to lumbar stabilization training.
<br>


{| width="80%" cellspacing="1" cellpadding="1" border="1" align="center"
{| width="100%" cellspacing="1" cellpadding="1" align="center" class="FCK__ShowTableBorders"
|-
| Number of subjects
| Prevalence
| Sub-group
| Oswestry change score at 8 weeks
|-
| 18/54
| 33%
| Success group
| &gt;50%
|-
| 21/54
| 39%
| Improvement group
| 6 – 49%
|-
|-
| 15/54
|  
| 28%
{{#ev:youtube|zJ63XJQbp7k|300}}  
| Failure group
| &gt;6%
|}
 
<br>
 
== Test Description<ref name="Hicks" />  ==
 
Historical and self-report findings are the following:&nbsp;
 
*Age less than 40 years old
*Fear Avoidance Beliefs Questionnaire physical activity scale greater than nine


Physical exam findings are described as follows:  
| {{#ev:youtube|bsJ7smHAyJk|300}}
 
*SLR greater than 90 degrees: The patient is supine. An inclinometer or a goniometer may be used. The inclinometer is calibrated placed on the tibial tubercle with the patient’s leg resting on the table. The stationary arm of the goniometer is placed alongside the patient’s trunk with the axis centered over the greater trochanter. The therapist raises the leg passively with the knee fully extended.
*Aberrant motion present with trunk forward bending: In standing, the patient is asked to bend forward while keeping the knees straight. Total spine flexion is encouraged although touching the toes is not emphasized. The patient is encouraged to relax in the fully flexed position for 2-5 seconds. Then, the patient is asked to straighten up. A positive test is an “instability catch”, painful arc of motion, thigh climbing (Gowers’ sign)or a reversal of the lumbo-pelvic motion.
*Positive prone instability test, Part 1: The patient lies on the exam table with the trunk, head and arms while the feet are on the floor. The therapist applies posterior-to-anterior pressure (P/A) to the spinous processes of the lumbar spine. Any painful provocation is recorded. Part 2: The therapist then asks the patient to raise one leg up off of the floor and P/A pressure is again applied to the spine. A reduction in pain while the leg is raised is a positive test.
 
{| width="100%" cellspacing="1" cellpadding="1" border="0"
|-
|-
| [[Image:DSC01195.JPG|left|300px|Test Position 1]]
| <ref>online video, http://www.youtube.com/watch?v=zJ63XJQbp7k, last accessed 6/2/09</ref><br>
| [[Image:DSC01197.JPG|center|300px|Test Position 2]]
| <ref>online video, http://www.youtube.com/watch?v=bsJ7smHAyJk, last accessed 6/2/09</ref><br>
|}
|}


*No lumbar hypermobility with spring testing: In prone, P/A pressure is applied to the lumbar spinous processes with the therapist’s thenar eminence. Segmental spinal mobility at each level is judged hypomobile (stiff), normal or hypermobile (lax).<br>
== <br>Key Evidence  ==


== Evidence<br> ==
Preliminary Development of a Clinical Prediction Rule for Determining Which Patients with Low Back Pain Will Respond to a Stabilization Exercise Program. Gregory Hicks, Julie Fritz, Anthony Delitto, Stuart McGill. ([http://www.archives-pmr.org/article/S0003-9993(05)00360-6/abstract Link to Abstract])<br>  


Hicks et al's rule is a Level 4 derivation rule.  
A&nbsp;2003 study done by Fritz et al compared the treatment based classification (TBC) approach and current clinical practice guidelines (CPG)&nbsp;for treatment of patients with low back pain. The TBC system involved classifying patients into categories and matching the treatment to the category. The clinical practice guidelines&nbsp;included&nbsp;low stress aerobic exercise, general muscle re-conditioning, and advice to remain active.&nbsp;The change was evaluated using the initial and four week [[Oswestry Disability Index|Oswestry Disability Index]] score. Although both groups showed some improvement, the study found a 22% greater&nbsp;improvement for patients whose treatment was matched on the TBC as compared to those who were provided treatment based on the CPG. <ref>Fritz JM, Delitto A, Erhard DC. (2003) Comparison of Classification-Based Physical Therapy with Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain. SPINE. 28 (13) 1363-1372. </ref>


Hicks et l examined 54 people with non-radicular lower back pain in three outpatient clinics in Pennsylvania and Mississippi over eight weeks using a prospective, single-arm study design. This study design is capable of deriving ''prognostic factors'' but not ''treatment effect modifiers''.
== Resources  ==


Prognostic factors are patient characteristics that estimate a patients' likely outcome irrespective of the chosen management.<ref name="Hill">Hill JC, Fritz JM. Psychosocial Influences on Low Back Pain, Disability and Response to Treatment. Phys Ther. 2011;91(5):pp.712-721.</ref>
add appropriate resources here, including text links or content demonstrating the intervention or technique


Treatment effect modifiers are factors measured at baseline that influence the relationship between a specific intervention and an outcome.<ref name="Hill" />
== Case Studies  ==


The research subjects were an average of 42.4 years old, had an average NPRS (pain) score of 4.5 and average FABQ physical activities score of 14.6. Baseline Oswestry Disability Index (ODI) score was 30 points.  
add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
 
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Change in the ODI score was calculated with this formula: Change score=[(baseline ODI score – 8 week ODI score)/(baseline ODI score)] x 100
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
 
Any three variables present for the Improvement group predicted group assignment better than any other combination (97%). Four positive test variables for the Improvement group did not improve the accuracy of the rule for physical therapist decision making (94%).


Hicks et al checked 26 physical examination variables, six self-report variables and eight demographic/historical variables for association with either success or failure. The association accepted a liberal error rate of 10% to avoid filtering potentially useful predictor variables. Four test variables for success and nine test variables for failure were then entered into a second filter, the logistic regression equation, which resulted in the tests above.<br>
<rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1T1hTO9Bp3L2Oq09cI0t_DwCjnYLg7n6IiWCH0GC4U8Gd4BkH|charset=UTF-8|short|max=10</rss>  
 
== Validity  ==
 
There is much debate with regards to their validity and clinical applicability and taking in to consideration results from contemporary research, we should caution clinicians in using them<ref name="Patel">Patel S, Friede T, Froud R, Evans DW, Underwood M. Systematic review of randomised controlled trials of clinical prediction rules for physical therapy in low back pain. Spine (Phila Pa 1976). 2012 Dec 11.</ref><ref name="Haskins">Haskins R, Rivett DA, Osmotherly PG. Clinical prediction rules in the physiotherapy management of low back pain: a systematic review. Man Ther. 2012 Feb;17(1):9-21</ref><ref name="Stanton">Stanton TR, Hancock MJ, Maher CG, Koes BW. Critical appraisal of clinical prediction rules that aim to optimize treatment selection for musculoskeletal conditions. Phys Ther. 2010 Jun;90(6):843-54.</ref>.&nbsp;The results from the available data do not support the use of clinical prediction rules in the management of non-specific low back pain<ref name="Patel" />. &nbsp;The current body of evidence does not enable confident direct clinical application of any of the identified CPRs<ref name="Haskins" />. &nbsp;There is, at present, little evidence that CPRs can be used to predict effects of treatment for musculoskeletal conditions. The principal problem is that most studies use designs that cannot differentiate between predictors of response to treatment and general predictors of outcome<ref name="Stanton" />. &nbsp;Currently only 1 CPR, the one classifying patients in a group likely to benefit from spinal manipulation, is at the validation stage of development within an RCT designed to predict response to treatment<ref name="Childs">Childs J, Fritz J, Flynn T, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004;141:920–928</ref><ref name="Cleland">Cleland JA, Fritz JM, Whitman JM, et al. The use of a lumbar spine manipulation technique by physical therapists in patients who satisfy a clinical prediction rule: a case series. J Orthop Sports Phys Ther. 2006;36:209–214.</ref><ref>Flynn T, Fritz J, Whitman J,et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine (Phila Pa 1976). 2002;27:2835–2843</ref><ref>Hancock MJ, Maher CG, Latimer J, et al. Independent evaluation of a clinical prediction rule for spinal manipulative therapy: a randomised controlled trial. Eur Spine J. 2008;17:936–943.</ref>. &nbsp;All other CPRs are still at a derivation level. Validation of these rules is imperative to allow clinical application.
 
Read more about the validity and applicability of CPRs on the main [[Clinical Prediction Rules|Clinical Prediction Rules]] page
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox">
<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=10__S9PoH30EANjg3zSnJAKTnEZ5qLChHaaC8VF6Liifbs3k1S|charset=UTF-8|short|max=10</rss>  
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== References  ==
== References  ==
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&nbsp; [[//www.pinterest.com/pin/create/extension/|//www.pinterest.com/pin/create/extension/]]
[[Category:MCG_Student_Project]] [[Category:Lumbar]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]
 
[[Category:Articles]] [[Category:Clinical_Prediction_Rules]] [[Category:Lumbar_Examination]] [[//www.pinterest.com/pin/create/extension/|//www.pinterest.com/pin/create/extension/]]

Revision as of 02:24, 10 July 2015

Original Editor - Lucy Bussard and Kurt Kimmons

Lead Editors  


Indication
[edit | edit source]

Patients presenting with low back pain are generally a heterogeneous population, and because in 85% of cases no specific diagnosis can be made for low back pain, a treatment based classification system is useful for physical therapists in developing rehabilitation programs for patients unspecified with low back pain. In this type of system, patients are categorized according to general presentation, findings from a physical examination, impairments, and functional limitations, and are grouped into one of several treatment classifications. In order to assist with this classification, clinical prediction rules are a set of criteria that a patient should meet in order to be placed into a specific treatment group. The clinical prediction rule for the spinal stabilization treatment category is below, and generally includes a younger age, instability, and greater overall mobility. [1]

Clinical Prediction Rule[edit | edit source]

The presence of 3 or more of the following factors increase the probability of dramatic success for patients in the spinal stabilization category from 33% to 67%:

  • Younger Age (<40 years old)
  • Increased Flexibility (Average SLR > 91o)
  • Aberrant Motions or Instability Catch during Lumbar Flexion/Extension ROM
  • (+) Prone Instability Test


The presence of 2 or more of the following increases the probability of some improvement with the spinal stabilization treatment method from 72% to 94%: :

[2]

Description[edit | edit source]

Optimal spinal stabilization can be achieved by strengthening the deep back and abdominal muscles. These include the transverse abdominus, quadratus lumborum, oblique abdominals, multifidus, and erector spinae. Exercises targeting these specific muscles should be done in a progression, usually beginning with the transverse abdominus which provides the patient with initial stabilization that is helpful during subsequent exercises and daily activities.


Below are methods for activating the transverse abdominus and multifidus muscles, two major spinal stabilizers. These exercises should be incorporated initially in the spinal stabilization program for patients with low back pain. Once the patient is able to activate these muscles, more stabilizing exercises should be introduced the patient should be progressively challenged with more difficult exercises, targeting the muscles listed above.


[3]
 [4]



The following videos are examples demonstrating progressions of spinal stabilization exercises that can be used for patients requiring this technique. They can and should be modified according to specific patient needs, preferences, or functional demands. The physical therapist should remember to consistently stress the importance of maintaining a neutral spine when performing these exercises.


[5]
 [6]


Key Evidence[edit | edit source]

Preliminary Development of a Clinical Prediction Rule for Determining Which Patients with Low Back Pain Will Respond to a Stabilization Exercise Program. Gregory Hicks, Julie Fritz, Anthony Delitto, Stuart McGill. (Link to Abstract)

A 2003 study done by Fritz et al compared the treatment based classification (TBC) approach and current clinical practice guidelines (CPG) for treatment of patients with low back pain. The TBC system involved classifying patients into categories and matching the treatment to the category. The clinical practice guidelines included low stress aerobic exercise, general muscle re-conditioning, and advice to remain active. The change was evaluated using the initial and four week Oswestry Disability Index score. Although both groups showed some improvement, the study found a 22% greater improvement for patients whose treatment was matched on the TBC as compared to those who were provided treatment based on the CPG. [7]

Resources[edit | edit source]

add appropriate resources here, including text links or content demonstrating the intervention or technique

Case Studies[edit | edit source]

add links to case studies here (case studies should be added on new pages using the case study template)

Recent Related Research (from Pubmed)[edit | edit source]

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1T1hTO9Bp3L2Oq09cI0t_DwCjnYLg7n6IiWCH0GC4U8Gd4BkH|charset=UTF-8|short|max=10: Error parsing XML for RSS

References[edit | edit source]

  1. ↑ Fritz JM, Cleland JA, Childs JD. (2007) Subgrouping Patients with Low Back Pain: Evolution of a Classification Approach to Physical Therapy. Journal of Orthopaedic &amp;amp;amp;amp;amp;amp;amp; Sports Physical Therapy, 37 (6), 290-302
  2. ↑ Hicks GE, Fritz JM, Delitto A, McGill SM. (2005) Preliminary Development of a Clinical Prediction Rule for Determining Which Patients with Low Back Pain Will Respond to a Stabilization Exercise Program. Archives of Physical Medicine and Rehabilitation, 86 (9), 1753-1762.
  3. ↑ online video, http://www.youtube.com/watch?v=aqwx6uCwhUQ, last accessed 6/2/09
  4. ↑ online video, http://www.youtube.com/watch?v=fkt1TOn1UfI, last accessed 6/2/09
  5. ↑ online video, http://www.youtube.com/watch?v=zJ63XJQbp7k, last accessed 6/2/09
  6. ↑ online video, http://www.youtube.com/watch?v=bsJ7smHAyJk, last accessed 6/2/09
  7. ↑ Fritz JM, Delitto A, Erhard DC. (2003) Comparison of Classification-Based Physical Therapy with Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain. SPINE. 28 (13) 1363-1372.
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