Outpatient Rehabilitation for a Patient with Low Back Pain

OUTPATIENT REHABILITATION FOR A PATIENT WITH LOW BACK PAIN

A Doctoral Project A Comprehensive Case Analysis

Presented to the faculty of the Department of Physical Therapy

California State University, Sacramento

Submitted in partial satisfaction of the requirements for the degree of

DOCTOR OF PHYSICAL THERAPY

Nan Qiu

SUMMER 2017

Nan Qiu

OUTPATIENT REHABILITATION FOR A PATIENT WITH LOW BACK PAIN

A Doctoral Project

Nan Qiu

Approved by:

______, Committee Chair Lois Boulgarides, PT, DPT, MS

______, First Reader Edward Barakatt, PT, PhD

______, Second Reader Bill Garcia, PT, DPT, FAAOMPT

______Date

iii

Student: Nan Qiu

I certify that this student has met the requirements for format contained in the University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the project.

______, Department Chair ______Michael McKeough, PT, EdD Date

Department of Physical Therapy

Abstract

OUTPATIENT REHABILITATION FOR A PATIENT WITH LOW BACK PAIN

Nan Qiu

A 21-year-old female college student and receptionist with a 3-week history of left posterior LBP and left lateral buttock pain was seen for physical therapy treatment for 7 weekly sessions at a physical therapy outpatient pro-bono clinic. The signs and symptoms were mild to moderately irritable and musculoskeletal in nature. Treatment was provided by a student physical therapist under the supervision of a licensed physical therapist.

The patient was evaluated at the initial encounter with a subjective and objective examination. The Oswestry Disability Index was given as an outcome measure assessing functional disability due to low back pain, and a plan of care was established. The main goals for the patient were to improve range of motion, decrease pain, increase lumbosacral stability, decrease functional disability, and to improve the patient’s function as a full-time student and part-time office assistant. The main interventions used were lumbar spine stabilization exercises, lumbar joint

mobilization, postural awareness, pain management, ergonomic training, stretching exercises, and patient education.

The patient made clinically meaningful changes in pain severity, range of motion, lumbosacral stability, and functional disability outcome measure. The patient was able to return to being a student and a receptionist, and was discharged from physical therapy with a home exercise program.

______, Committee Chair Lois Boulgarides, PT, DPT

______Date

ACKNOWLEDGEMENTS

I acknowledge the CSUS Physical Therapy pro-bono clinic and Lois Boulgarides, PT,

DPT for allowing me to treat and work with an orthopedic rehabilitation patient for my case study.

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TABLE OF CONTENTS

Page

Acknowledgements ...... vii

List of Tables...... ix

Chapter

1. GENERAL BACKGROUND ...... 1

2. CASE BACKGROUND DATA ...... 3

3. EXAMINATION – TESTS AND MEASURES ...... 7

4. EVALUATION ...... 14

5. PLAN OF CARE – GOALS AND INTERVENTIONS ...... 16

6. OUTCOMES ...... 25

7. DISCUSSION ...... 29

References ...... 31

viii

LIST OF TABLES Tables Page

1. Medication Table………………… ...... ……………………………….6

2. Examination Table……………………………….… ...………………………12

3. Evaluation and Plan of Care… ...………….…………………………………. 16

4. Outcomes……………………………….……… ....………………………….25

ix 1

Chapter 1

General Background

Low back pain (LBP) is the fifth most common reason for physician visits and is the most common disorder seen by physical therapists (PT) in the United States.1-3

In addition, LBP is the primary cause of work absences and activity limitations throughout the world. The economic burden of LBP on society is high and increasing in the US with an estimated annual cost of $100 billion.2,3 Sixty to 90% of the general population is at risk of developing LBP in their lifetime.1 Of those who develop acute

LBP, 30% develop chronic LBP.4 The one year incidence of individuals experiencing a first episode of LBP ranges from 6.3% to 15.4% .2 The one year prevalence of LBP in the general population is reported to be as high as 82.5%.2,5,6

Any innervated structures in the lumbar spine (LS), such as peripheral nerves, ligaments, muscles, annulus fibrosis, zygapophyseal joints, thoracolumbar fascia and vertebrae, can be the source of pain and symptoms in the lower back and referred pain in the lower extremities.2-4 Evidence shows that determining the cause of LBP is challenging due to the rate of false-positive results on imaging studies.2-4 Even when abnormal findings are present on imaging, forming a direct cause and effect between the pathological finding and the patient presentation may not be supported.2-4

Many risk factors are only weakly related to development of LBP. Possible non-modifiable risk factors for LBP include the following: gender, age, and genetic factors.5,6 Advancing age is associated with an increased prevalence of LBP with higher incidence occurring after 30 years of age. 5,6 Genetics have also, been

2 connected to disc degeneration, and women have a higher prevalence of LBP as compared to men.5,6 Modifiable factors that can significantly increase the risk for LBP include the presence of comorbidities such as cardiovascular hypertension, smoking, obesity; low educational status; strength; body build; flexibility; psychosocial characteristics; and an occupation that has high physical demand. 5,6 Psychosocial factors such as depression, anxiety, stress, and fear avoidance are risk factors for

LBP.5,6

There are numerous prognostic factors that are commonly related to poor outcomes. These factors include the following: longer duration of LBP, previous episodes of LBP, higher level of initial disability, pain that is exacerbated when supine or standing, radiating symptoms into the lower extremities, and an onset that is gradual as opposed to sudden.3,6

Chapter 2

Case Background Data

Examination – History

The patient was a 21-year-old female referred to physical therapy with a medical diagnosis of left LBP and left posterior and lateral hip pain. The pain had started 3 weeks before treatment after she had vigorously climbed 2 flights of stairs to get back home after her regular 1 mile run at the gym. The patient indicated that she had felt a sharp pain in her lower lumbar spine (LS) 20 minutes after the incident occurred. The pain was severe enough to make her take the rest of the day off, and she immediately lay prone on her bed to ease the pain. The patient went to see a medical doctor 2 days after her injury and received ibuprofen to relieve her pain. The patient reported immediate improvement of her symptoms after the medication. At the time of her initial evaluation, the patient reported her symptoms were improving. She had managed her symptoms by avoiding or modifying activities that provoked her pain, such as running, prolonged sitting, and moving from sit to stand, stand to sit, and supine to sit. At the time of evaluation, the area of pain was located at her left lower lumbar spine extending into her left gluteal and left lateral buttock region. The symptoms were described as intermittent, variable, deep, and dull pain that ranged from 0-8/10 on a numeric pain rating scale (NPRS). The patient reported that sitting longer than 30 minutes increased her back and hip pain to 5/10 which then eased after

5 to 10 minutes after walking. Getting in and out of the car after driving for 1.5 hours

4 increased her pain to 5/10 which then eased to 2/10 after 5 to10 minutes of walking or lying prone.

The patient reported a previous injury to her right LS during an overhead serve at a tennis practice when she was a junior in high school. That injury was managed by muscle relaxants, the patient had not felt the pain for many years, and she did not feel that the current condition was related to her previous right LBP. The patient did not use any supportive equipment during the course of the current injury.

The patient was a college student living alone in an upstairs apartment. Prior to injury, the patient was participating in gym actives such as running and kickboxing three times per week. The patient’s chief complaint was her limited ability to sit for prolonged periods during work and school. Her goals were to improve postural ergonomics, be able to sit 5 to 6 hours a day without pain, and to increase core strength to live life comfortably and prevent future injures.

Systems Review

All systems (cardiopulmonary, neuromuscular, integumentary, cognitive, and musculoskeletal) were screened during the subjective and objective exams. The cardiopulmonary system was not impaired based on a blood pressure of 119/72 mmHg, an oxygen saturation of 99%, a respiratory rate of 12 breaths per minute and a normal heart rate of 78 beats per minutes (bpm). Based on observation, the patient’s integumentary system, communication and cognition were not impaired; she was oriented, alert and fully proficient with both spoken and written communication.

Based on examination, the patient’s neuromuscular system was not impaired; motor

5 function and gross coordination were normal. The musculoskeletal system was impaired by the LBP (see details in Table 2). All other systems were within normal limits. The patient denied taking any medications at the time of the physical therapy initial evaluation.

Examination - Medications

Table 1

Medications Table7

MEDICATION DOSAGE REASON SIDE EFFECTS Ibuprofen 200mg orally every 4-6 hours Pain control Diarrhea, dizziness, as needed bloating, constipation, tinnitus, rash, headache, Not taking throughout the nervousness, vomiting, mild course of care. heartburn, difficulty breathing or swallowing fatigue, and loss of appetite.

Chapter 3

Examination – Tests and Measures

The patient’s impairments were categorized according to the International

Classification of Functioning, Disability and Health (ICF) Model.8 The following tests were at the body structure and function level: the double inclinometer and tape measure methods were used to measure spinal active range of motion (AROM); the

NPRS was used to measure pain severity; manual muscle testing (MMT) was used to measure strength in the trunk and lower extremities; a trunk flexion endurance test at

60°, and Biering-Sorensen test were used to evaluate muscle endurance; a straight leg raise was used to measure hamstring length; and LS segmental mobility was measured by the passive lumbar extension test (PLET), prone instability test (PIT) and aberrant movement. The Oswestry Disability Index (ODI) and patient report were used to identify activity limitations. Measures of participation restrictions and fear of activity included the Fear-Avoidance Beliefs Questionnaire (FABQ) and patient report.

The double inclinometer test is used to assess LS extension ROM. Two inclinometers are placed at T12 and at S1, the patient moves into extension, and the difference between the angle values of the two inclinometers is the measurement of LS

9,10 extension. The minimal detectable change with a 90% confidence level (MDC90) of double inclinometer testing ranges from 4° to 9° which indicates that a minimum of 9° change after an intervention is required to show true change that is not due to measurement error.10

The fingertip to floor tape-measure method was used to assess AROM of thoracolumbar flexion by measuring the distance between the patient’s middle

11,12 fingertip to the floor in standing flexion. For thoracolumbar flexion the MDC95 is

2.5 cm, which indicates a minimum of 2.5 cm of change is required to show true change. 11,12

The NPRS assesses a patient’s pain level by using an 11-point scale ranging

13 from 0-10. With an MDC95 of 2.0 points for patients with LBP, a minimum change of 2.0 points is required to be 95% confident that a true change in pain level has occurred. 13 The minimal clinically important difference (MCID) for patients with

LBP is 2.2 points at 4 weeks of treatment indicating that a change of at least 2.2 points is required to be clinically meaningful to the patient. 13 Meaningful NPRS goals should meet or exceed 3 points. 13

The MMT is a standardized assessment tool used to measure muscle strength with a grading scale of 0 to 5. The test has good to excellent interrater reliability with a percent agreement of 82-97% and test-retest reliability percent agreement of 96-

98%.14 The MDC and MCID are not yet established, however, a systematic review by

Cuthbert et al indicated that a MMT grade must change by more than one full grade in order to be confident that a true change has occurred.14

The Biering-Sorensen test is used to evaluate the isometric endurance of the trunk extensor muscles by measuring the time, in seconds (s), that the upper body is held in a horizontal position.15-17 The normative data for a 20 year old female with current LBP is 177 s and for a healthy female is 189-197 s.17,19 For a patient with LBP,

the MDC95 is 43.2 s, so a change in time of greater than 43.2 s gives 95% confidence that an actual change in LS extensor endurance has occurred. 15 Currently, an MCID has not been established for the Biering-Sorensen test.

The isometric trunk flexion test was used to evaluate the endurance of the abdominal muscles. The test is performed with the patient in a hook lying position with both knees bent at 90° and the trunk inclined at a 60° angle.18,20 The patient is then instructed to maintain an isometric contraction in the inclined position for as long as possible. This test has excellent test-retest reliability with an ICC of 0.96 (95% CI of 0.92-0.99). The SEM for a female office worker’s abdominal endurance is 2.67s, and the MDC95 calculated from the SEM, is 7.4 s. A minimum increase of 7.4 s is required to judge that a true change has occurred that is not due to measurement error.

Currently the MCID has not been established. The normative data for a 20-year-old female with current LBP is 134 s.18,20

The SLR test is commonly used to assess lumbar radiculopathy, neural tissue mechanosensitivity, and hamstring length.24,25 The patient is placed in supine and the angle between the thigh and pelvis is measured while maintaining a fully extended

26 knee. As a measure of hamstring length, the SLR has an MDC95 between 6° - 7°. So a minimum increase of 7° is required to be 95% confident that an actual change in hamstring length has occurred that is not due to measurement error.26 The MCID has not been established.24

The PLE test is used to diagnose the existence of lumbar instability. 28 While the patient lies prone, the tester passively lifts the patient’s legs into extension.

Reproduction of symptoms and pain suggests lumbar instability in patients with

LBP.28 A LR+ of 8.78, and a LR- of 0.17 indicate that a positive test result will lead to a moderate positive shift in the post-test probability that the patient has instability, and a negative test leads to a moderate decrease in post-test probability of having LS instability.28

The ODI is a validated self-report questionnaire used to assess a patient’s activity limitations. This outcome measure contains 10 items with 6 statements scored at 0 to 5 (0 indicates no disability and 5 represents severe disability). The MCID95 and

29 MDC95 are 6.44 points (12.88 %) and 5.87 points (11.74%), respectively , indicating there must be at least a 6.44 point change after an intervention to show a clinically meaningful change has occurred.29

The FABQ is a 16 item questionnaire used as a prognostic measure to investigate fear-avoidance beliefs among LBP patients, with higher scores indicating higher levels of fear-avoidance beliefs about work and physical activity that may contribute to their low back pain.30 The FABQ is also useful to identify patients in the acute phase who are at risk for long term disability.30 The survey consists of 2 sections: a 7 item work scale (FABQW) with scores ranging from 0-42, and a 4-item physical activity scale (FABQPA) with scores ranging from 0-24.30 The LR+ is 2.35 and the LR- is 0.30 for a FABQW cutoff score of greater than 20 to predict ODI

(disability) scores at 6 month. 30 A LR+ of 2.35 represents a small increase in the probability that a patient with a score greater than 20 is not likely to experience significant improvement in 6 months and that patient will possibly have a higher level

11 of disability. 30 The LR- value of 0.30 represents a small decrease in the probability that a patient who does not score greater than 20 will have a higher level of disability in 6 month. 30

In a CPR proposed by Hicks et al, the presence of three of four indicators (age under 40-years, presence of aberrant movements, average SLR of more than 91 degrees, and a positive prone instability test) is significantly associated with a successful result when stabilization treatment is given.31 The CPR has a LR+ of 4.0

(95% CI: 1.6-10) and a LR- of 0.52 (95% CI: 0.30-0.88). Rabin et al proposed a modified CPR (mCPR) including only the positive prone instability test and presence of aberrant movement as factors predictive of a positive outcome following stabilization treatment. Further studies are needed to validate both the CPR and the mCPR.

Table 2

Examination Table

BODY FUNCTION OR STRUCTURE Measurement Test/Measure Used Test/Measure Results Category Active range Thoracolumbar flexion (middle Thoracolumbar flexion = 19 in of motion finger tip to floor) (48.26cm) with 5-6/10 pain Lumbar extension (double Lumbar extension 0-5° with 6/10 pain inclinometer) Pain Numeric pain Rating Scale (NPRS) Worst: 8/10 Best: 0/10 Average: 5/10 Strength Trunk flexion (upper abdominals) Upper abdominals: 4/5 with 3/10 pain Trunk flexion (lower abdominals) Lower abdominals: 3/5 with 4/10 pain Abdominal oblique Abdominal oblique: Right (R) and Left (L)= 4/5 with 3/10 pain Trunk extensor Hip extension, prone (Gluteus Trunk extensor: 4/5 with 4/10 pain Maximus) Hip extension: L= 4/5 with Hip abduction, side-lying (Gluteus compensation of anterior pelvic tilt. Medius) Pain 2/10 pain R=5/5

Hip abduction: L= 5/5 with 2/10 pain. R=5/5 no pain

Endurance Trunk flexion endurance test at 60° Trunk flexion:30s with 3/10 pain Trunk extensor (Biering-Sorensen Trunk extension: 32s with 3/10 pain Test)

Muscle SLR test L= 10° hip flexion PROM with 6/10 Length/ pain at both L lower back and L Neural buttock region. R=80° PROM with no Tension pain.

Lumbar spine Prone Instability test Positive instability Passive lumbar extension test Positive Observation of Aberrant Movement Positive

Fear of FABQW 22/42 occupational re-injury FUNCTIONAL ACTIVITY Measurement Test/Measure Used Test/Measure Results Category Running Patient report: Treadmill run 8/10 pain at more than ¼ mile.

Transitional Patient report: Transfer out of car 5/10 pain after 1.5hours of driving. movement (sit to stand from car) Sitting Patient report: Sitting tolerance Pain = 5/10 after sitting >30min Standing Patient report: Standing tolerance Pain = 3/10 – 6/10 after 1 hour Functional ODI 16/50 (32% disabled) disability PARTICIPATION RESTRICTIONS Measurement Test/Measure Used Test/Measure Results Category Social life Patient report: Social outings Limited participation due to back pain Gym activities Patient report: Gym participation Unable to patriciate due to low back (cardio training, kickboxing) pain FABQW= Fear-Avoidance Belief Questionnaire Work subscale; MDC= minimal detectable change; MCID=minimal clinically important difference; NPRS=Numerical Pain Rating Scale; ODI=Oswestry Disability Index; SLR=straight leg raise test; LE=lower extremity; AROM=active range of motion; PROM= passive range of motion R=Right; L=Left; s= seconds; x= times; HS= hamstring; MMT= manual muscle test; min=minute; in= inches; cm= centimeter

Chapter 4

Evaluation

Evaluation Summary

The patient was a 21-year-old female student and receptionist with a 3 week

history of left posterior LBP and left lateral buttock pain. The signs and symptoms were

mild to moderately irritable and musculoskeletal in nature. The patient was found to have

the following impairments at the body structure and function level: pain, decreased

AROM, decreased strength, decreased endurance, decreased muscle flexibility, and poor

body mechanics which limited her running, walking and sitting ability at the activity level. She was also limited in her ability to participate in social outings, and her normal recreational exercise routines.

Diagnostic Impression

The patient presented with signs and symptoms consistent with the physician’s diagnosis of left posterior LBP and left lateral upper hip pain. In addition, findings in both subjective and objective exams confirmed that the patient fit the lumbar treatment based classification for patients who respond well to stabilization exercises. The patient’s indicators for the stabilization category of the treatment based classification included: young age, previous history of LBP, presence of aberrant movements, and positive on the prone instability test. The patient’s body structure and function impairments in pain, decreased ROM, strength, endurance, muscle flexibility, and poor body mechanics contributed to the activity limitations in prolonged sitting, walking, running, and

transitional movements. Her limitations in recreational exercise and social participation

were due to her impairments and activity limitations.

Prognostic Statement

The patient’s positive prognostic indicators included young age, short duration of

symptoms, high level of education, and no adverse behavioral factors.32 The patient also

demonstrated good body awareness and a motivated mindset to reach goals. Some

negative prognostic indicators included female gender, decreased strength, decreased

muscle flexibility, and previous episodes of LBP. Even given negative factors, the

patient’s positive factors suggested excellent rehabilitation potential. Good potential was

strengthened by the fact that the patient also fit into a clinical prediction rule (CPR) identifying those who benefit from stabilization exercise, with three of four factors associated with successful stabilization treatment. Because of the strong prognostic factors, the patient was expected to make clinically meaningful improvements in AROM, pain, strength, endurance, muscle flexibility, functional disability, and ability to participate in her work and social life without limitations.

G-Codes

Current with modifier: G8990CI based on the ODI

Goal with modifier: G8991CH based on the ODI

Discharge Plan

The patient was expected to be discharged with a self-care home exercise

program.

Chapter 5

Plan of Care-Goals and Interventions

Table 3

Evaluation and Plan of Care

PLAN OF CARE Short Term Long Term Goals Planned Interventions Goals (9 weeks) Interventions are Direct or Procedural (4 weeks) unless they are marked: PROBLEM (C) = Coordination of care intervention (E) = Educational intervention BODY FUNCTION OR STRUCTURE IMPAIRMENTS Decreased AROM • Increase • Increase • HEP: Thoracolumbar thoracolumbar F o Prone press up (10s hold, 1set 10 Thoracolumbar F 48.26cm to 28cm to 24cm or reps per day 3-5x per week) flexion (MDC95 = 28cm (fingertip less o Cat/ camel (4 sets of 30 reps per 2.5 cm) to floor) day 3-5x per week), • Increase lumbar o Bilateral knee to chest stretch in Lumbar extension • Increase lumbar extension AROM supine (30s hold 3x per day 3-5x (MDC90= 4°-9°) extension from 14° to per week), AROM from 5° minimum 23° o Hamstring stretch with towel to 14° around the thigh in supine or sitting position (3 sets 30s hold 3x per day), o Quadriceps and iliopsoas stretch in either lunge position or sidelying position (3 sets of 30s hold 3x per day) • PNF hold-relax hamstring stretch in SLR position (10s static stretch followed by 10s isometric contraction, 2 sets of 5reps) • CPT and left UPA mobilization at L4-L5, 3sets of 40s bouts Pain • Decrease worst • Decrease worst • Diaphragmatic breathing and pain from 8/10 pain from 5/10 to relaxation practice in supine progress (MCID= 2.2/10) to 5/10 2/10 to sitting. • Posture instruction with pillow/ towel • Decrease pain • Decrease pain roll for lumbar support during sitting, with with supine, sideling. (E) thoracolumbar thoracolumbar • Side-lying physiological flexion and flexion and intervertebral rotation mobilization extension from extension from (PPIVM’s) grade III- with 3sets of 6/10 to 3/10 3/10 to 0/10 40s bout.

• CPA and L UPA at L4-L5 grade III- to IV- 3 bout of 30s progress to 3 bouts of 30s of grade III-IV (Initiated at treatment 4). • Soft tissue massage around L erector spinae, multifidus, quadratus lumborum. • HEP: Side-lying trunk rotation 10s hold 10 reps on each side 2x a day • HEP: Pelvic rotation exercises in clockwise motion, performed in sitting on a chair or Swiss ball, 2 sets of 10reps perform 3-4x a week. Progress by increase duration. • (E) Set reminders on phone for posture check at least every 30min.

Decreased strength • Increased upper • Increased upper All exercises performed both in clinic oblique strength oblique strength and as HEP 4/5 with 3/10 measured by Transverse abdominus: pain to 4/5 with MMT from 4/5 o Abdominal bracing in supine (3 no pain. with no pain to sets of 10 reps with 10s hold, 5/5 with no pain. daily. • Increase lower . Progression: oblique muscle • Increase lower 1. Bracing with heel slides (3 strength from oblique muscle sets of 10 reps per day with 3/5 with 4/10 strength 5s hold, daily). pain to 4/5 with measured by 2. Bracing with leg lifts (3 sets no pain. MMT from 4/5 of 10 reps per day with 5s with no pain to hold, daily). • Increase Trunk 5/5 with no pain. 3. Bracing with bridging extensor progress to single leg strength from • Increase Trunk bridging (3 sets of 10 reps 4/5 with 4/10 extensors with 10s hold, daily). pain to 4/5 with strength 4. Bracing in standing and no pain. measured by progress to bracing in MMT from 4/5 walking (3 sets of 10 reps • Increase L with no pain to with 10s hold, daily). gluteus 5/5 with no pain. Erector spinae/multifidus : maximums o Quadruped arm raises with strength from • Increase L bracing (3 sets of 10 reps each 4/5 on the MMT gluteus side with 10s hold, daily. with 2/10 pain maximums . Progression: and pelvic tilt strength from 4/5 1. Quadruped leg lifts with substitution to on the MMT bracing ((3 sets of 10 reps 4/5 with no pain with no pain and each side with 10s hold, and no no compensation daily). compensation. to 5/5 with no 2. Quadruped alternate arm and pain. leg lifts with bracing (3 sets • Increase L of 10 reps each side with 10s gluteus medius hold, daily).

strength Increase strength/ endurance of measured by • Maintain L oblique abdominals and quadratus MMT from 5/5 gluteus medius lumborum: with 2/10 pain strength at 5/5 on o Side plank with bilateral knees to 5/5 with no the MMT with bent (3sets of 10 reps each side pain no pain with 10s hold, daily). . Progression: o Side plank with bilateral knees extended (3sets of 10 reps each side with 10s hold, daily).

Additional exercise progression included: • Prone superman with bilateral arm flexion overhead (3 sets of 10 reps with 10s hold perform minimum 4x per week, progress by increased reps to 2sets of 20 and increase intensity by extending hold time from 10s to 15s. o Prone dart exercises with extension of bilateral arms, neck, trunk, and bilateral legs all at the same time. (3 sets of 10 reps with 10s hold perform minimum 4x per week, progress by increases reps to 2sets of 20 and increase intensity by extending hold time from 10s to 15s. Gluteus maximus and gluteus medius: o Sidelying hip abduction (2 sets of 10 reps each side with 5 sec hold) o Supine bridging with bracing, progress to single leg bridging (3 sets of 10 reps with 10s hold, daily) o Kickboxing class (focus on squats to increase glute max strength) 2-3 time per week. Decreased • Increase trunk • Increase trunk • See exercises for strength section in endurance flexion flexion table 3 for planned interventions. endurance from endurance from Endurance was addressed by Trunk flexion 30s with 3/10 90 s to 134s performing the same strengthening endurance (MDC95= pain to 90 s with exercises with increased duration of 7.4s) no pain • Increase Trunk hold time and repetition. (Progression (Age norm=134s.) • Increase Trunk extensor from 1 set of 10 reps with 5s hold to extensor endurance 3 sets of 10 reps each side with 10s Trunk extensor endurance measured by hold to 2 sets of 20 with 10s hold). endurance (MDC= measured by Biering-Sorense >43.2sec) Biering-Sorense

(Age norm=189- from 32s to from 53.6s to 197s) 53.6s (a increase 75.2s of 21.6s) with no pain • Decreased L • Increase L HS • Increase L HS • HEP: self-hamstring stretches with hamstring length length from 10° length from 60° towel behind thigh in supine or with 6/10 pain with 3/10 pain to sitting (3 sets 30s hold 2x per day, (MDC=7° Age to 60°with 3/10 80° with no pain daily), norm=78.2°) pain • PNF hold-relax hamstring stretch in SLR position (10s static stretch followed by 10s isometric contraction, 2 sets of 5reps) Increased fear of • Decrease • Decrease • (E) Patient was educated on pain due to work FABQW from FABQW from improving correct posture, body and school 22/42 to 15/42. 15/42 to 10/42 mechanics, and incorporated core stabilization techniques (abdominal bracing) into daily activities during work and school. • (E) Educated the patient about importance of abdominal bracing in different positions. • (E) Education on increased awareness to avoid aggravating movement to prevent reoccurrence of LBP. • (E) Ergonomic education where the patient took pictures of work, car, and school environment. SPT and patient consulted on changes for better posture/ body mechanics. ACTIVITY LIMITATIONS Limited sitting • Able to sit • Able to sit • (E) Use of lumbar support and towel tolerance 30min with 5/10 without changing (under ischial tuberosity and upper pain to 45min position from 45 thigh) to increase body awareness of with 3/10 pain. with 3/10 pain to lumbar neutral and correct posture Measured by 1hr with no pain. during sitting for prolonged periods patient report Measured by of time. Patient advised to take patient report. frequent walk breaks and to sit near • NPRS MCID= an exit during school for easy 2.2/10 walking accessibility. Impaired Running • No expectation • Ability to run 1/2 • Lumbar stabilization exercises both Tolerance for changes to mile at speed= performed in clinic and included as occur. 5.0MPH with HEP (refer to strength/ endurance pain no greater section). than 2/10 on the • (E) Patient education on proper body NPRS. mechanics during running, and proper progression to return to

running, including increasing running distance and duration. • Stretching exercises of rectus femoris, iliopsoas, hamstring, and TFL was performed both in clinic and included as HEP (3 sets, 30sec hold each, 2x per day) Impaired tolerance • Decrease pain • Decrease pain • Lumbar stabilization exercises both to transitional from 5/10 pain from 3/10 pain to performed in clinic and included as movement to 3/10 pain 0/10 with getting HEP (refer to in strength/ endurance with getting in in and out of the section). and out of the car after 1.5 hrs • (E) Patient education on the proper car after 1.5 hrs of driving based driving ergonomics and proper usage of driving based on patient’s of towel roll under ischial tuberosity on patient’s report. and upper thigh to encourage neutral report. lumbar spine. • (E) Advice on taking walk breaks at least every 30min during long driving trips.

Functional disability • Decrease ODI • Decrease ODI • Lumbar stabilization exercises both (MCID95= 6.44pts score from 32% score from 10% performed in clinic and included as or 12.88%) to 10%. to 0%. HEP • (E) Patient education on proper body mechanics and posture control during ADL such as walking, sitting and running. Pain prevention by taking frequent breaks during prolonged sitting. • Stretching exercise of rectus femoris, iliopsoas, hamstring, and TFL was performed both in clinic and included as HEP (3 sets, 30sec each, 2x per day) PARTICIPATION RESTRICTIONS Inability to • Participation in • Participation in • (E) Patient education on proper body participate in social social outings at social outings mechanics and posture control during outings and gym least 3x week with no ADL such as walking, sitting and activities. with <2/10 pain. restrictions or running. pain. • Lumbar stabilization exercises both • Participation in performed in clinic and included as gym activities at HEP (referred to in strength/ least 3x a week endurance section). with <2/10 pain • E) Patient education on improving and able to correct posture, body mechanics, and perform all incorporate core stabilization exercise techniques (abdominal bracing) into activities with daily activities during social outings/ good body gym activities. mechanics. • (E) Education on the importance of abdominal bracing in different positions.

• (E) Decrease fear and anxiety by promoting the patient’s awareness of how to avoid aggravating movement to prevent reoccurrence of LBP.

HEP= Home exercise program; FABQW= Fear-Avoidance Belief Questionnaire Work subscale; MDC= minimal detectable change; MCID=Minimal Clinically Important Difference; NPRS=Numerical Pain Rating Scale; ODI=Oswestry Disability Index; SLR=straight leg raise test; LE=lower extremeity; AROM=Active Range of Motion; R=Right; L=Left; s= seconds; x= times; TFL= tensor facia lata; HS= hamstring; reps= repetitions; pts= points

Plan of Care – Interventions

See Table 3 for details.

Overall Approach

The interventions used in this course of physical therapy were made based on the treatment-based classification (TBC). The TBC has four classification groups which include manipulation, stabilization, traction and specific exercise. This approach focused on improving impairments by placing the patient into the correct subgroup of patients likely to respond to a specific treatment method. This patient fit into the stabilization category as she presented with three of the four factors which included age under 40 years old, positive prone instability test, and aberrant movement. Stabilization exercises focus on the core musculature, including transversus abdominus, oblique abdominal erector spinae, multifidus, and gluteal muscles.

In addition to stabilization exercises, stretching exercises were included for the hamstrings based on the restrictions found on SLR testing. Stretching exercises for hip flexor muscle groups (rectus femoris, iliopsoas) were also included. Even though the patient tested negative for tight hip flexors on the Thomas Test, a trial of stretching of these hip flexor muscle groups caused immediate improvement in lumbar spine active range of motion with decreased pain.

Patient education was given throughout treatment sessions on biomechanical and anatomical considerations, body awareness, posture, activity adjustment, and functional activities.

During the fifth treatment, the patient’s pain level had not decreased from a

3/10 to 0/10 during flexion and extension movements. Since there is evidence suggesting that manual therapy (MT) with PA’s and UPA’s helps decrease pain for patients with acute and subacute LBP, PA’s and UPA’s were initiated with a test and retest approach as treatment for pain relief.33 After one session of MT, immediate reassessment demonstrated decreased pain level from 3/10 to 0/10 at the end ROM of flexion and extension, confirming that MT was effective to eliminate lingering pain with movement. In the subsequence sessions, the symptoms remained improved.

PICO question

For a 20-year-old female with subacute LBP presenting with aberrant movement and a positive prone instability test (P), are stabilization exercises more effective (I) than other treatment types such as mobilization/manipulation and stretching (C), when the expected result is to decrease disability, decrease pain, and restore functional mobility (O)?

A randomized controlled trial (Sackett level of evidence:1b, PEDro Score

9/10) evaluated outcomes for patients who have positive findings on the stabilization

CPR and use of stabilization exercises as a primary intervention compared to using other conventional therapy treatments.34 One hundred and five participants with LBP were classified by CPR status (either positive or negative) and randomized placement into one of the two treatment groups, a lumbar stabilization exercise group (LSE) and a ROM, flexibility exercise, and manual therapy group (MT). The ODI was used to measure LBP related disability. The average age of the participants ranged from 18 to

60 years of age, and the average ODI score was 24%. Both groups included 11 treatment sessions distributed over 8 weeks. 34

Patients with a positive CPR status who received LSE compared to those with a negative CPR status who received LSE experienced significantly less disability

(p=0.02). Patients with a positive CPR status treated with LSE experienced significantly greater functional improvement compared to those treated with MT

(p=0.03).34 Statistical significance was improved slightly when a modified CPR

(including only the prone instability test and aberrant movement) was used.34

Although the study lacked long term follow-up, had a 22.8% dropout rate, and had low power, it had a PEDro score of 9. The patient fit the subject demographics in the article for age, type of LBP and ODI score.

This articles support the use of lumbar spine stabilization exercises as the main treatment in the current case.

Chapter 6

Outcomes

Table 4

Outcomes

OUTCOMES BODY FUNCTION OR STRUCTURE IMPAIRMENTS Outcome Initial Follow-up (DC) Change Goal Measure Met? (Y/N) AROM • Thoracolumbar flexion • Thoracolumbar • Thoracolumbar flexion= - Y (fingertips to floor) = flexion =0 in (0 19 in (-48.26cm) 19in (48.26cm) with cm) no pain (MDC=2.5cm) 5-6/10 pain • Lumbar • Lumbar extension= +27 ° • Lumbar extension= 5° extension=32° no (MDC= 9°) with 6/10 pain pain

Pain • Worst: 8/10 • Pain free at all • Pain at worst = -8 pts Y (NPRS) • Best: 2/10 times with all • Pain at best = -2 pts • Average: 5/10 movements • Average pain = -5 pts • Pain with • Pain with thoracolumbar thoracolumbar flexion: flexion and extension = -6 5-6/10 pts (MCID= 2.2/10) • Pain with thoracolumbar extension: 6/10 Strength • Upper abdominals: 4/5 • Upper • Upper abdominals Y (MMT) with 3/10 pain abdominals: 5/5 increased 1 grade • Lower abdominals: with no pain • Lower abdominals: 3/5 with 4/10 pain • Lower increased 1 grade • Abdominal oblique: R abdominals: 5/5 • Abdominal oblique: R and and L= 4/5 with 3/10 with no pain L increased 1 grade pain • Abdominal • Trunk Extensor increased • Trunk Extensor: 4/5 oblique: R and 1 grade with 4/10 pain L= 5/5 with no • Hip extension: L • Hip extension: L= 4/5 pain increased 1 grade with substitution of • Trunk Extensor: • Hip abduction: L anterior pelvic tilt and 5/5 with no pain decreased pain by 2 point 2/10 pain. • Hip extension: on NPRS. • Hip abduction: L= 5/5 L= 5/5 with no • (MDC= increase by1full with 2/10 pain. pain grade) • Hip abduction: L= 5/5 with no pain

Endurance • Trunk flexion: 30s • Trunk flexion: • Trunk flexion increased: Y (Trunk with 3/10 pain 150s with no pain +120s flexion • Trunk extension: 32s • Trunk extension: • Trunk extension endurance with 3/10 pain 192s with no increased: +160s test, pain. • Trunk flexion endurance Biering- test MDC=7.6s (Age Sorensen) Norm=134s) • Biering-Sorensen test MDC= 43.2s (Age norm= 189s-197s) HS length • L HS length= 10° hip • L HS length= • L HS length changes: Y (SLR) flexion with 6/10 pain. 101° hip flexion +91° hip flexion PROM with no pain. • MDC=7° • Age norm= 78.2° Fear of • FABQW= 22/42 • FABQW= 5/42 • -17 pts (MCID=13pts) Y work leading to re-injury ACTIVITY LIMITATIONS Outcome Initial Follow-up (DC) Change Goal Measure Met ? (Y/N) Sitting • Sit 30 min increases • No pain with • Decreased pain by 5 pts Y Tolerance pain to 5/10 sitting for any based on NPRS duration (MCID=2.2 pts) Running • Running on treadmill • No pain and no • 1.5 mile increase in Y Tolerance >1/2 miles increases difficulty with running distance with no pain running on pain treadmill <2 milles, 30min. Transitional • 5/10 pain when getting • No pain and no • Decreased pain by 5 pts Y movement in and out of the car difficulty with based on NPRS tolerance after 1.5 hrs of transitional (MCID=2.2 pts) driving. movement after prolong driving. Functional • 16 point (32%) • 0 points (0%) no • -16 point (32% Y disability Moderate disability disability improvement) MCID= (ODI) 15points

PARTICIPATION RESTRICTIONS Outcome Initial Follow-up (DC) Change Goal Measure Met? (Y/N) Ability to • Limited participation • No limitation in • Increased ability to Y participate in social outings due social participate in gym in social to back pain participation , activities from 0 x per outings and • Unable to patriciate in and able to week to at least 3x per gym gym activities due to participate in weeks. activities gym activities

low back pain (cardio such as training, kickboxing) kickboxing and other cardio training at least 3x per week. HEP= Home exercise program; FABQW= Fear-Avoidance Belief Questionnaire Work subscale; MDC= minimal detectable change;MCID=Minimal Clinically Important Difference; NPRS=Numerical Pain Rating Scale; ODI=Oswestry Disability Index; SLR=straight leg raise test; LE=lower extremity; AROM=Active Range of Motion; PROM= Passive Range of Motion R=Right; L=Left; s= seconds; x= times; HS= hamstring; reps= repetitions; MMT= manual muscle test

Discharge Statement:

The patient attended outpatient physical therapy for treatment of LBP and associated hip pain a total of 7 treatments over a 9 week period. The patient received lumbar stabilization exercises, strengthening and ROM exercises, mobilization, stretching exercises, patient education, and a HEP. At her initial evaluation, she had substantial pain, decreased AROM, decreased strength, decreased endurance, decreased muscle flexibility, aberrant movement, and functional disability. These impairments contributed to her inability to fully perform her roles as a student and receptionist. The patient made meaningful progress during the course of treatment.

The patient reached body structure and function goals in pain, AROM, strength, endurance, and muscle length. She reached activity goals and was able to perform prolonged sitting, running, walking, and transitional movements with no pain.

Ultimately, the patient reached her participation goals and was able to perform two jobs and attend school with no restrictions. She was also able to attend the gym regularly, and participate in night time social outings more frequently with no LBP or fear of re-injury. The patient was discharged with a HEP and given specific instructions regarding continued gradual progression of stabilization, strengthening, and stretching exercises.

DC G-Code with modifier

• G8992 CH based on a score of 0 on the ODI outcome measure.

Chapter 7

Discussion

All impairment level goals were met throughout the course of treatment.

Improvements can be credited in part to the patient’s motivation to improve overall strength, endurance, flexibility and postural control. The patient’s full compliance to her HEP played an important part in her full recovery. Positive reassurance and motivational advice given from the student physical therapist probably enhanced the patient’s motivation. A majority of the patient’s impairments (AROM, strength, endurance, posture) responded well to the stabilization CPR guided treatment, but, persistent pain only resolved with additional MT and flexibility treatments. This patient case exemplifies the usefulness of a multimodal approach that is informed by the patient’s impairments and response to treatment in addition to the available evidence. When treating a similar patient in the future, I will implement similar exercises and include manual therapy at an earlier stage if it is indicated for pain management, rather than waiting until later in the episode of care.

Patient education on postural control and ergonomics provided her awareness of positions that would reproduce her pain. She learned to constantly remind herself to maintain a good posture during prolonged sitting and to take breaks during sitting and activities to prevent recurrent LBP. Muscle endurance and stabilization training during the course of treatment were helpful in terms of preventing excessive lordosis and keeping the spine in neutral. With better sitting posture and increased neuromuscular control and strength of core muscles, the patient was able to sit for

30 prolonged periods, run, and walk with no pain. At discharge, the patient had achieved full recovery and returned to work and school with no back pain.

The treatment approach was successful, and the patient responded favorably as predicted. Treatment for a patient with subacute LBP should incorporate a TBC approach, as well as other appropriate treatments taking into account all of the patient’s signs and symptoms.

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