Physical therapists no longer use a "one-size fits all" approach to treating lower-back pain. The evolution in treatment follows the development of evidence-based prediction rules that help therapists match certain characteristics of back pain with specific treatment options.
"What people are after is the fastest way to get better," according to Anthony Delitto, chair of the University of Pittsburgh's department of physical therapy. "And that's where this evidence-based approach comes into play. If therapists use the prediction rules to choose treatments and everything aligns well, you can see a 50 percent improvement in pain in a couple of visits."
Delitto started pushing for the research needed to develop the prediction rules more than two decades ago. He and his colleagues began to notice that patients responded differently to treatments. Some patients had good results from manual manipulations, such as the high-velocity thrust procedures often performed by chiropractors. Other patients had good results from either McKenzie exercises or core-stabilization exercises.
"The challenge was to figure out what type of patient responded best to which treatment. So we began to study and document patients' treatment responses," says Delitto.
The result is a growing body of peer-reviewed medical literature that validates the treatment model. For instance, a 2004 study in the Annals of Internal Medicine published patients' response to a specific high-velocity manual therapy called a "Grade 5" thrust. This manipulation is used by therapists to adjust sections of the spine.
The study determined that patients who had certain characteristics of pain responded well to the procedure. For instance, people who'd been experiencing pain for less than 15 days, had no pain below the knee, and had a hypo-mobile or stiff spine benefited from the "Grade 5 " thrust.
"In the randomized trial, only the people who were positive to the prediction rule, meaning their pain matched the cluster of pain-characteristics (outlined above), got better as the result of the Grade 5 thrust," says Delitto.
The results of this study can guide therapists as they make treatment decisions. It helps them figure out which patients are good candidates for manual-manipulation therapies.
Physical therapist Jennifer Mahler-Gamboa of Body Dynamics in Arlington, Va., uses the published literature and the prediction rules to guide her treatment strategies. Recently she began treating Maureen Culhane, a schoolteacher who'd been experiencing excruciating back pain for four years.
"She came in for her initial evaluation with a 74 percent disability score. That's huge. That tells you something is not working," says Mahler-Gamboa. As part of an initial evaluation , Mahler-Gamboa performed vertical compression tests on her new patient and observed a quick buckling, which suggested hyper-mobility in the spine. Mahler-Gamboa's clinical observations helped her tailor some specific treatment recommendations.
"That's what helped me build the case of what I needed to do with this patient" says Mahler-Gamboa.
The evidence-based prediction rules suggest that patients with Culhane's characteristics of back pain respond well to core stabilization treatment. This treatment involves strengthening the muscle groups that support the spine such as the transverse abdominus. "It's all those deep muscles that you can't put your hands on," says Mahler-Gamboa.
Since many patients don't know how to locate these muscles, Mahler-Gamboa uses several techniques to teach them. For instance, one exercise involves placing an inflated blood-pressure cuff under the patient's lower back. The patient moves into a position that engages the transverse abdominals, and then attempts to hold the position without changing the reading on the blood-pressure cuff. It's a feedback system that enables patients to register whether they're deep abdominals are getting the workout they need.
"It's one of the fastest ways to get patients to be really aware of what it's supposed to feel like. It's very different from the kind of burning sensation you get from a bicep curl. It's much more subtle," says Mahler-Gamboa. It's also critical to stabilizing the core.
After six weeks of therapy, Culhane is reporting a significant improvement in her symptoms. " I came here only for an evaluation. Now, I'm asking how can this miracle be happening to me," says Culhane.
Therapists say this is not a miracle. It's a matter of matching a patient's back pain characteristics with the appropriate and specific treatments.