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Council of Health Insurance Council of Health Insurance Low Back Pain - Physical Therapy Clinical Practice Guideline Tool and Recommendations الجمعيه السعوديه لطب الاسره والملاحظات Saudi Society of Family and Community Medicine - Acute back pain is defined as back pain lasting less than 4 weeks. Subacute back pain last 4 to 12 weeks. •Chronic back pain last more than 12 weeks. Red flags Box 1 Qauda equina syndrome: Saddle anaesthesia or parasthesia, perianal/perineal sensory loss, positive straight leg raise testing, multiple motor deficits, bowel/bladder dysfunction, fecal/urinary incontinence, severe(paralysis rather than paresis) or bilateral neurological compromise. Spinal fracture: Recent violent trauma(fall from big height, car accident), minor trauma in patient with osteoporosis, older age structural bone deformity, prolonged corticosteroids use, severe central back pain relieved by lying down. Infection or cancer: Age above 50 and below 20, constitutional symptoms(fever, weight loss, chills, malaise), history of cancer, pain on the thorac cispine, recent bacterial infection(e.g. Urinary tract or respiratory tact), immune depression(e.g. HIV, chemotherapy or IV drug users, prolonged use of corticosteroids, recent puncture wound or surgery, diabetes, spinal tenderness to percussion, recent or fast developing spinal deformity(e.g. scoliosis), non-mechanical(not better with lying down) or progressive pain, failure to improve with treatment in 4-6 weeks, unremitting night time pain. Abdominal aortic aneurysm: Age above 60, history of cardiovascular disease(e.g. MI or stroke), pulsating mass on the abdomen, leg pain, thoracic pain, absent of aggravating features. Spondylo-arthritis: Age lower than 45, morning stiffness improve with exercise, alternating buttock pain, significant and persistent lumbar flexion restriction(positive Schobers test), awakening because of back pain during second part of night, oligo-arthritis or poly-arthritis, skin rash, diarrhea, hypersensitivity to NSAID. GI or genitourinary: Abdominal or flank pain/tenderness, rebound tenderness, costo-vertebral angle tenderness, reduced urine stream, reduced stool caliper, dysuria, abnormal urine or stool coloration/smell, diarrhea, constipation, anuria, oliguria, polyuria, abnormal menses, dyspareunia, painful erection. Patient present with chronic low back pain Conduct Full Back Assessment History taking, physical and neurological exam, evaluation of red flags Box 1 Confirm the diagnosis of chronic low back pain which should include spine x-ray •Presence of red flags or significant concern for serious pathology? Box 1 •Or presence of spinal pathology other than: ➢Degenerative Disc Disease ➢Spondylolisthesis ➢Sciatica/Radiculopathy or Facet Arthrosis Patient had physical therapy done in the last 3 months? OR Patient with mild pain and no functional limitation Yes - Patients should be encouraged to increase their overall activity level. Minimum of 30 minutes of daily recreational activity is recommended - Provide patient with pamphlet that contain different type of exercises that has quality evidence of efficacy. No -Physical therapy referral -Ask the patient to fill Osw estry questionnaire (as baseline) Yes Proceed with appropriate laboratory testing, imaging And/ or Consultation with appropriate health care provider Start patient on physical therapy (6 sessions) Exercise - Manual therapy: in case of impaired joint functionality, consider: joint mobilization or manipulation and/or thermal therapy (limited duration) to reduce the pain. - Spinal Exercise : focusing on strengthening and stabilizing the core muscle • Motor control exercise • Progressive Endurance Exercise and Fitness Activities Optional adjunct measures - Thermotherapy • Therapeutic US • Electrical stimulation - Taping (Note: the above measures can only be used for short period of time, and to achieve the best benefit, they should be combined with other exercises that have quality evidence of efficacy) Reassess the patient symptoms by Physiotherapist Oswestry questionnaire form: https://www.rehab.msu.edu/ files / docs/Oswestry_Low_Back_Disability.pdf Important points • The exercise program must be designed based on the physical therapy assessment and to fit the patient's needs or goals. • Develop a goal setting care plan based on need, evidence for effectiveness and patient preferences. - Avoid recommendations that encourage the patient to remain passive and recommend a physically active lifestyle. • Prescribe a graded activities program. • Educate individual on disease etiology, risk factors, persistent pain and prognosis • Symptom severity should guide appropriate management. • Encourage individual to take an active role in the management of their condition • Establish treatment goals and monitor periodically to maximize adherence and behavioral changes Therapeutic process level of evidence - Aerobic exercise: Aerobic exercise most commonly a progressive walking program targeting either time or distance, are strongly recommended for chronic LBP (A). - Strengthening exercise: Strengthening exercises are Recommended (C), High Confidence for nearly all LBP patients other than those with acute LBP. - Aquatic exercise: Aquatic therapy is Recommended, Evidence (C) for selective patient chronic LBP (eg, extreme obesity, significant degenerative joint disease, etc). - Spinal manipulation: Spinal manipulation is one of many non-pharmacologic therapies to initially offer patients with chronic low back pain (ACP Strong recommendation, Low-quality evidence) - Motor control exercise coordination/stabilization and motor control exercises may moderately reduce pain in adults with chronic low back pain (DynaMed Level2) References • Physicians of Ontario Collaborating for Knowledge Exchange and Transfer (POCKET), Institute for Work & Health. POCKET Card for Red & Yellow Flags [Internet]. 2006. • Toward Optimized Practice. Guideline for the evidence-informed primary care management of low back pain. Edmonton, AB: Toward Optimized Practice; 2011. Appendix A: Red and Yellow Flags. • Busse J, Alexander PE, Abdul-Razzak A, Riva JJ, Alabousi M, Dufton J, et al. Appropriateness of spinal imaging use in Canada [Internet]. 2013 Apr 25. • University Health Network, Health Quality Ontario, Ministry of Health and Long-Term Care. Low back pain imaging pathway. Developed as part of the Diagnostic Imaging Appropriateness (DI-APP) Tods in Primary Care. 2015.