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Old 05-03-2009, 07:22 AM   #1
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Default Acute Low back pain

Hello.

I see a lot of acute LBP patients in my clinic. Over the years I have attended different courses (Maitland, Kaltenborn, Cyriax, McKenzie, etc.etc.) and met a lot of interresting people in the field of physio- and manual therapy.
A lot of these "authorities" have different take on the classic acute LBP without radiating pain; ranging from psoas spasm, different disc lesjons, facets syndrome etc.

What is the people at this forums take on the acute LBP?
What is (in most cases) "the source of" pain?
How come people can get so disabled by their acute LBP?
In your experience; what is "the best treatment" for acute LBP?

I dont know if you have been through this discussion before. If so, please guide me to it .

Regards Jan K.
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Old 05-03-2009, 09:10 AM   #2
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Risk factors for long term disability are typically psychosocial... the 'yellow flags'...
There may be no specific nociceptive source for ALBP.
Most ALBP gets better quickly by itself with good analgesia and gradual return to normal activity.
This is the New Zealand guide to the management of ALBP - nothing much has changed really even though it's been around for a while...
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Old 05-03-2009, 11:22 AM   #3
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Jan,

I see a lot of acute low back pain aswell, and have spent some time trying to figure out why the presentations can be so vastly different. I mean, they all present with some unique signs and symptoms, coping strategies, cognitive factors etc.

First I try to reason the origin of pain, either mechanical or chemical, or both.
Based on signs and symptoms during the eval, I think it is possible to make a case for the peripheral nociceptive driver in most patients, be it either mechanosensitive nervous tissue or nociceptors related to facet joint meniscoid / ligaments / capsule or the disc.

Having said that, I am well aware of the limitations of trying to identify a "specific source", and signs and symptoms directs my interventions more than "the source".

Generally I manipulate, if I can find a painfree and comfortable position / set up. Otherwise I go with muscle energy, or a combination.
As evidence has shown us, I don't try to identify a specific "dysfunction / impairment", other than possibly a "closing" or "opening" pattern.

I often combine with directional preference if indicated.

Education, advice and home excercise on top of that.
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Old 05-03-2009, 11:43 AM   #4
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Perhaps the Five Questions thread will help you understand how a number of us think.

When I hear "acute" I always wonder whether the word is being used to mean "recent" or severe" - perhaps you mean both. In any case, since all pain is neurogenic, origin is far more useful a concept than source which, to me, is always confusing and too often a product of pure speculation.

Melzack's neuromatrix model should always be considered when thinking about such things. There you'll find how many contributions to pain and its resolving there may be, a number of which are at your disposal to affect.

Finally, there is no "best treatment" for disabling low back pain. There's only what the therapist truly understands and how they impart that understanding through methods that can be defended and altered as circumstances dictate. What the patient needs is a therapist with deep understanding, not a fancy technique.
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Old 05-03-2009, 07:00 PM   #5
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I don't see a great deal of use in classifying things as "acute", even on top of Barrett's well-stated concerns above.

I generally use the classification approach to spinal pain, and I would agree that any technique is far less important than the understanding the therapist brings.

I think there is evidence out there that contradicts Bronnie's point about it spontaneously resolving - and in fact some evidence suggests people just stop seeking care for it since the care (especially primary care) doesn't help. There is an ocean of mechanical neurogenic pain out there - found even in those whose job it is to care for it in other people, like physical therapists.

There's no best treatment. There are varying interventions with varying strength of evidence that have shown they are sufficient in many cases in helping to improve these problems, but we're far from any one best treatment. The evidence out there now suggests that we can help to improve our odds by matching the correct treatment to the correct patient presentation.
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Old 05-03-2009, 07:04 PM   #6
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Thank you, Barrett.

I will use the evening reading the "five question" thread.

Jan K.
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Old 05-03-2009, 07:13 PM   #7
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Hei Anders.

What do you mean by "directional preference"?

Jan K.
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Old 05-03-2009, 07:31 PM   #8
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Quote:
Originally Posted by Jason Silvernail View Post
I think there is evidence out there that contradicts Bronnie's point about it spontaneously resolving - and in fact some evidence suggests people just stop seeking care for it since the care (especially primary care) doesn't help. There is an ocean of mechanical neurogenic pain out there - found even in those whose job it is to care for it in other people, like physical therapists.

There's no best treatment. There are varying interventions with varying strength of evidence that have shown they are sufficient in many cases in helping to improve these problems, but we're far from any one best treatment. The evidence out there now suggests that we can help to improve our odds by matching the correct treatment to the correct patient presentation.
I'm not suggesting the pain completely resolves - there is conflicting evidence that suggests ALBP 'grumbles' periodically over the next 3 - 6 or more months, although another recent study suggests that this isn't the case.

I'm not sure of the 'mechanical neurogenic pain' construct, not so much that it may not be present, but more that it doesn't seem to matter what we call it, restoration of normal movement seems to promote better function. If we can achieve this through adequate analgesia and 'reassurance' to move more normally, then we're well on the way to reducing the long term disability from it.

It doesn't seem to be the pain that is the problem in ALBP - it's the disability arising from pain that is. The prevalence of ALBP or CLBP around the world remains roughly the same whether industrialised or developing country, what does differ is the amount of disability. I wonder whether we need to be much more open to thinking about ALBP and CLBP as similar to headache - present a lot of the time, related to lifestyle things, not requiring much more than a bit of attention to taking care of oneself and not requiring 'treatment'.

I can't access references at present, but will provide some to support this contention!!
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Old 05-03-2009, 07:51 PM   #9
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Quote:
Originally Posted by aplikator View Post
Hei Anders.

What do you mean by "directional preference"?

Jan K.
Repeated movement testing, i.e. McKenzie, looking for repeated movements that lead to less pain, improved range of motion, or centralisation. I avoid the "pushing the disc back in" explanation though.
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