LBP Prevalence:

 Chronic back pain is becoming more common. In 1992, prevalence was estimated at 3.9%.
In 2006, it was at 10.2%.
 Individuals who have activity-limiting low back pain often experience recurring episodes
with estimates ranging from 24% to 33%. 
o So if you have a patient case on the OCS exam where an individual has had a history
of activity-limiting low back pain and has a recurrence, you shouldn’t necessarily
panic and send them to a spine surgeon. Remember: recurrences are normal. 
 Women tend to have a higher prevalence of back pain than men.
 And prevalence increases as we age up until 60-65 years old. After that, prevalence no
longer increases. This is a little counter-intuitive, because degeneration continues to get
worse after 65 years old, but pain does not.
 Lower education status is associated with increased prevalence of back pain, longer
duration, and worse outcome. So there are some socioeconomic factors that increase the
chance of developing low back pain.
 Occupational status affects prevalence, with higher physical demand being associated with
more low back pain than more sedentary jobs.

First, physical risk factors:

 There is some evidence that back pain is associated with operating heavy equipment.
 Cardiovascular risk factors (hypertension, smoking, obesity, being overweight) are
associated with sciatica.
 Degenerative changes on MRI, myelography, and CAT-scans are not strongly related to
low back pain symptoms. More on this later. But for now, remember: if you’re comparing
two patients, and one has a much worse sounding MRI, those imaging findings won’t
necessarily correspond to worse symptoms or a worse prognosis.
 “There is inconclusive evidence for a relationship between trunk muscle strength or mobility
of the lumbar spine and the risk of low back pain.” This is counterintuitive to us as PTs, so
keep that in mind.

Next, psychosocial factors.

“Psychosocial factors appear to play a larger prognostic role than physical factors in low back pain.”
So this is very important to know.
 There is some evidence to suggest that fear may play a role when pain has become
persistent.
 There is a growing consensus that distress/depression plays an important role at early stages,
and clinicians should focus on these factors.
 Third, expectations of recovery is a predictor of return to work. Patients with higher
expectations of recovery had fewer absences from work than those with lower expectations.
  Finally, active coping styles are associated with better outcomes.

The CPG also notes that higher pain intensity is associated with worse outcomes.
 Comorbidities appear to have no association with back pain prognosis.

Factors that increase the probability of developing recurrent or chronic low back pain.
Prognostic factors for development of recurrent pain include:
(1) history of previous episodes,
(2) excessive spine mobility, and
(3) excessive mobility in other joints

Prognostic factors for development of chronic pain include

(1) presence of symptoms below the knee,
(2) psychological distress or depression,
(3) fear of pain, movement, and reinjury or low expectations of recovery
(4) pain of high intensity
(5) a passive coping style

OUTCOMES:
Roland-Morris Disability Questionnaire
- 24 statements about back pain- a score of 24 indicates very high disability, and a score of zero is
very low.
- MCID: A change of 5 points or a 30% improvement
Oswestry Disability Index (or ODI)
- This test is scored as a percentage, with 100% representing complete disability, and 0%
representing no disability.
0-20% indicates minimal disability
21-40% indicates moderate disability
41-60% indicates severe disability
- MCID on the Oswestry is 10 percentage points.

Neurogenic Claudication vs. Intermittent/Vascular Claudication

1. Intermittent Claudication:
- symptoms brought on by exertion and decreased with rest / more exertion = more severe sx.
- sx. Usually start in the calves and move upward into the thighs
- problem is blood flow not nerve- spinal position shouldn’t have any effect on sx.
- ABI: <1 indicates possible presence of peripheral arterial disease, an ABI of <0.9 is considered
clearly abnormal, <0.8 indicates intermittent claudication may be present, and <.25 is limb-
threatening.

2. Nuerogenic Claudication
- worse with walking downhill, improved walking uphill
- pain decreased with spinal flexion
- pain may take a while to calm down
- symptoms usually start at the buttock and move distally
Treatment:
- lumbar stenosis with manual therapy, flexion exercises, and bodyweight supported treadmill
training.
- intermittent claudication from PVD with progressive treadmill walking to the point of moderate or
near-maximal pain, followed by rest, followed by more walking.

Lumbar Treatment- based on CPG evidence

 A-level recommendations for the following:

 manipulation for acute back pain
 stabilization for subacute or chronic back pain in individuals who fit the stabilization
classification or have had a microdiscectomy.
 Directional preference exercises for acute, sub-acute, or chronic back pain in
people who fit the directional preference classification.
 moderate to high intensity exercise for chronic back pain patients without
generalized pain, and low-intensity endurance exercise for chronic back pain
patients with generalized pain also get A-level recommendations.
 B-level recommendation
 patient education and counseling that avoids increasing the patient’s fear and
emphasizes the strength of the spine, pain science, good prognosis, active coping,
resuming activities even if pain is present, and return to functional goals—not just
decreasing pain.

C-level recommendations
 flexion-based exercises for spinal stenosis
- multimodal approach to lumbar stenosis including manual therapy and bodyweight
supported treadmill training does better than flexion exercises alone
 nerve mobilizations.