Merging stratification approaches in physical therapy management of a case of subacute low back pain
This report outlines the application of an amalgamation of two systems of stratification for patients with Low Back Pain (LBP) applied to a case of subacute back pain with a history of recurrence. The STarT Back Screening Tool (SBST) was used to assist with stratifying the patient along the lines of prognosis and to interventional resource allocation. She was found to fall within the Moderate risk stratification group who would benefit from specific Physiotherapy intervention. The Treatment Based Classification (TBC) was used to guide further stratification along the lines of best matched treatment to clinical findings. After three weeks of matched, evidence based intervention, the patient has demonstrated a clear positive response with the abolition of pain and reduction in her self rated disability, using the Oswestry Disability Index (ODI) and has been reclassified by the SBST as Low risk. This case represents the potential utility of this amalgamated approach.
This patient is a 37 year old registered nurse who is known to be Asthmatic but well controlled, and has a history of migraines and uterine fibroids with painful menses. She is an avid exerciser and is a member of a cross-fit exercise group that meets and exercises four times weekly. She gives a 2 year history of recurring episodes of LBP aggravated usually by increased work loads during her shift and which generally responds well to her exercise routine and settles within 2-3 days. About 7 weeks prior to her evaluation, she developed back pains after an unusually challenging work shift but noted on that occasion that she now had intermittent pains in the anterior of her left thigh. She was concerned about the new symptoms and sought medical attention at the staff clinic and had an MRI done which revealed a small central disc herniation at the L5 S1 level with no other bony or soft tissue anomaly. She was prescribed Norgesic with minimal relief and at her physician follow-up was referred to PT with a diagnosis of Mild L5 S1 Disc Prolapse.
She gave no history of trauma, or other symptoms or signs of serious spinal pathology including bowel or bladder disturbance, unexplained weight loss, saddle anaesthesia or widespread neurological symptoms. Her chief complaint was of intermittent central back pain, which was cramping in nature and rated at 4/10 on the Numerical Rating Scale (NRS) with occasional radiation into the mid-anterior aspect of the left thigh.
Pain is aggravated by static forward flexed postures such as during patient dressings and pains are reduced by raising the arms overhead and leaning backwards. She noted that sitting is more comfortable than standing. Her symptoms had generally decreased in frequency and intensity from onset but appeared to have plateaued at current levels. Despite her discomfort she had not stopped from work but was uncertain about resuming her exercise routine. Her self-rated disability, using the Oswestry Disability Index (ODI) was 6% and the patient reported her principal objective was to eliminate her current pains so she can resume her cross-fit workouts with her group. The STarT Back Screening Tool scored at a 4 (medium risk) with 3 points coming from the subscore (Question 5 -9).
- Impaired back extensor muscular endurance (could not clear the sternum off the plinth and hold for more than 20 seconds).
- Abdominal endurance tests were normal.
- Nil temporal or spatial gait deviations noted
- Full painfree ROM in flexion, extension, sideflexion and rotation.
- Aberrant movement on return from flexion, which was associated with pain.
- Repeated movements did not increase or decrease symptoms
- Nil impairment in motor control of the lumbar spine musculature during sit to stand transitions or ascending/descending stairs. However there was abnormal timing of the activation of the paravertebral muscles on return from flexion. bending
- Hypermobile L3 on PAIVM with reflex muscle spasm in the left sided paravertebral muscles at that level.
- Tenderness over the L3 and L4 spinous processes
- Normal reflexes
- Intact sensation
- Normal myotomal muscle power in lower limbs and trunk
- - ve SLR
- -ve SLUMP
- -ve Femoral Nerve Traction
- +ve Prone Instability test
The patient presents with subacute back pain with motor control impairments in the lumbar spine, within an overall background of recurrence. It can be reasoned that the disc protrusion identified on MRI likely represents the end result of the patient’s work habits, but given the lack of provocation signs with the dural mobility tests (Slump/SLR) and the disparate location of the extremity symptoms (L2/3 dermatome versus L5 S1) it seemed unlikely to be the cause of the patients symptoms. A more likely aetiologic factor is the tender, hypermobile vertebral segment at L3. The SBST also identified a yellow flag in the form of fear –driven pain beliefs. This also needed to be addressed to limit the risk of future disability.
- Patient education. She was educated on the fact that a protruded disc on MRI does not constitute proof of cause with LBP and that the prognosis was good highlighting the positive elements of her case including her premorbid exercise habits, and the fact that she remained at work through the episode.
- Back care advice: given the nature of her work and the MRI confirmation of a disc protrusion, the patient was also taken through a 1 on 1 session of biomechanical strategies to reduce the rate of progression of the lumbar disc degeneration, including the safe execution of exercises in her cross-fit program and ADLs.
- Progressive core muscle activation with emphasis on correct form.
- Staged reactivation: As part of the strategy to combat her fear of pain, a deliberate attempt is made to equip the patient to succeed on attempts to master new skills. Once she had progressed to the point where she was activating her spinal stabilizers effectively, we incorporated that activation into various postures and then movement including standing, reaching and walking.
- She has completed 3 treatments in as many weeks
Over the course of three weeks (3 visits) the patient’s pain has completely abolished with a commensurate reduction in her ODI score, currently at 2%. On re-pass of the SBST the patient’s overall score had declined to a 1, moving her into the low risk category. The next step in her rehabilitation is to translate her stabilization strategies into more dynamic functional tasks such as brisk walking. This is part of staged approach to returning to running and other exercises over the next 3-5 weeks.
Hancock (2015) alluded to the value of merging aspects of the various stratified care models in an effort to increase clinical utility. He proposed a hybrid model merging the STarT Back and Treatment Based Classification systems. This hybrid approach was applied to this case with the patient being stratified to the Medium risk category initially. The matched treatment approach to such a categorization involves Physiotherapy interventions based on clinical findings. The clinical findings satisfied 4 of 7 named criteria for the ‘Stabilization’ treatment sub-group of the TBC and consequently the patient’s management included exercises to activate the spinal stabilizers, including the Tranversus Abdominis and Multifidi muscles. Smith, Littlewood and May (2015) concluded from their systematic review, that specific core stabilization exercises as prescribed in this case, offer no distinct advantage over general conditioning exercises. However in their review the authors did not specifically examine stabilization exercises when prescribed after sub-grouping patients.
While the patient’s rehabilitation is currently on-going, initial response to three weeks of stratified care demonstrate elimination of pain with reduced disability, measured with the Oswestry Disability Index and an improvement in the patient’s overall risk stratification on the SBST.
It has been noted that the TBC is the only model that demonstrates no significant difference in intertester reliability between novice and experienced clinicians. Additionally, its ease of implementation relative to the significant training and time investment of other stratification models, such as the MDI gives it notable advantages in clinics where Physiotherapists of varying experience manage LBP patients. The merger of the SBST and the TBC also allows for consideration of the role of cognitive behavioural approaches to managing patients with yellow flags and chronic LBP, which the TBC does not explicitly address on its own. As such this hybrid approach offers clinicians an evidence based and pragmatic approach to stratification of patients and allocation of existing physiotherapy resources in patients with LBP.
- Hancock, M. (2015). What is still known? Which approach should I use next week? Lecture presented for the World Confederation for Physical Therapy congress,Suntec City, Singapore.
- Keele University (2015, November 5). Matched treatments. Retrieved from https://www.keele.ac.uk/sbst/matchedtreatments/
- Smith, B.E., Littlewood, C., & May S. (2015). An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskeletal Disorders (15):416.
- Karayannis, N., Jull, G., & Hodges, P. (2012). Physiotherapy movement based classification approaches to low back pain: comparison of subgroups through review and developer/expert survey. BMC Musculoskeletal Disorders 13(24). Retrieved fromfckLRhttp://link.springer.com/article/10.1186/1471-2474-13-24/fulltext.html
- O’Sullivan, P., Dankaerts, K., O’Sullivan, K., & Fersum, K. (2015). Multidimensional approach for the targeted management of low back pain. In G. Jull, A. Moore, D. Falla, J. Lewis, C. McCarthy & M. Sterling (Eds.), Grieves modern musculoskeletal physiotherapy (4th ed.), (pp 465 – 470). London: Elsevier.