Practice Patterns of Physical

Therapist Interns Managing Low

Back
►Christopher Beaudoin, SPT Pain
Heather Berube, SPT
►Mutya Castilla, SPT Nathan Edwards, SPT
►Mariah Marsh, SPT Jennifer Williams, SPT
►Research Advisor: Tim Flynn, PT, PhD
 Is this
important…

Deyo et al 2009
Fritz et al, JOSPT 2007
Spinal manipulation is an effective and lower


cost treatment for patients with LBP.

Brennan et al , Spine, 2006

Ø However, manipulation is underutilized by
physical therapists when compared to other
common interventions which lack the same
level of evidence.
 Medical Model of
Disease
Signs/symptoms
analyzed

Pathology is
determined

Treatment corrects
pathology

Signs/symptoms
disappear
 Implications of the Medical
Model
► Signs and symptoms
are directly
proportional to the
underlying pathology
► Identifying the
underlying pathology is
critical for guiding
treatment
► Signs and symptoms
should disappear when
pathology is corrected
 Shortcomings of
the Medical Model

► Only 15% of LBP can be given a

specific pathoanatomical diagnosis
► The remaining - grouped as a
homogenous entity (low back
sprain/strain, lumbago, mechanical low
back pain, etc.)
 Shortcomings of the Medical
Model
► “Treatment of back pain
according to the disease
model has failed because
there is a fundamental
flaw to the approach. The
disease model views back
pain and disability only in
terms of spines and
physical disease. It does
not allow for the complex
human responses to pain
and disability.”
(Waddell,
1998)
 Classification

“The objectives of a
physical therapy
diagnosis are focused on
classifying movement
dysfunction rather than
disease and are directed
primarily to planning
and predicting outcome
of treatment.”
(Rose, 1989)
 Classification

Classification systems must specifically

direct treatment and improve
outcomes.
“It is rare to find anyone with a clear idea of
what form of physiotherapy is indicated for
which type of back pain… The situation takes
on the characteristics of a lottery… with
treatment left to the whim of the therapist, it is
not surprising that the results are often poor.”
 Treatment-Based Classification System

“This examination approach leads to a

classification that is detailed with regard to
the precise type of treatment to be
prescribed, and not relegated to nonspecific
terminology where any number of
conservative strategies can be used for one
classification.”
(Delitto et al, Phys Ther, 1995)
 LBP Treatment
Manipula Specific Stabiliza Traction
tion Exercise tion

No sxs below  Centralization  Prone  Neurological

knee phenomenon instability Signs
Recent with test  Leg
symptoms movement  Aberrant Symptoms
Hypomobility exam motions  Peripheraliza
Low Fear-  Hypermobili tion with
Avoidance ty movement
More hip IR  Younger age testing
 Crossed

Activities to Stabilization Mechanical or

Manipulation &
Promote exercises Autotraction
exercise
Centralization
Methods
Methods
 Did Function & Disability
Improve?

P<0.000
1

MCID ~ 6 Average Number of Visits = 7

points
 How were patients initially
classified?
22 Graded Mobilization
11.8
18.4
Manipulation
9.9
Stabilization

Flexion DP

Extension DP

52.6 Traction
How often were patients correctly
classified?

62%
Did correct classification and the
matched treatment improve

p=0.4
4

N N
=62 =12
Was there a difference in the
group most frequently
treated with an unmatched
 Discussion
► Patients
experienced a 32%
improvement in Oswestry Disability
Index
Regis interns were implementing a


standardized evidence-based decision

making process for patients with LBP
100% of time

► Datasuggests that patients’ fear of
movement may be changed with
physical therapy
Grade V (thrust) manipulation is not
allowed in Washington
Clinical instructor dictated the plan of

care
A perceived disconnect between CI

experience based decision making and

current best practice.
 Limitations
► LBP treatment-based classification
systems were developed with patients
with acute symptoms from 18-59 yrs
► Non-randomized
► Small number of patients with
complete follow up data that were
incorrectly classified and/or received
unmatched treatment
► Low statistical power
 Future Research
► Educational modules for students and
clinical instructors to change clinician
behaviors
§ To improve initial classification for
patients with LBP
§ To improve treatment of patients with LBP
► FABQ (research in progress)
 Conclusion
► Patients’ level of disability improved
with physical therapy intervention for
low back pain.
► It may be possible to change patients’
fear-avoidance beliefs through
physical therapy treatment.
 Dr. Tim Flynn

KEEP ON ROCKIN IN THE FREE

WORLD
Questions?