Paint by number

I recently finished my transitional Doctorate of Physical Therapy degree.  There was long hours involved and lucky for you, I saved all (well…maybe most) of my work.  Here is an oldie, but a goodie (voice of Kasey Kasem)

 

A Critical Appraisal of Clinical Practice Guidelines for Low Back Pain (LBP)

 

P: For patients with back and/or leg pain

I: what is the level of evidence regarding varying interventions, outcome measures, risk factors, and assessment processes

C: throughout the profession of physical therapy

O: that can be used in the course of care of individual patients

 

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

 

Search:

Ovidsp with title terms “low back pain” and “guidelines” with keyword of “physical therapy”. The results were limited to articles published in the previous two years.   Seven citations were found.

 

Date of Search: March 1, 2014

 

Citation:

Delitto A, George S, Van Dillen L, et al. Low Back Pain: Clinical Practice Guidelines Linded to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. JOSPT 2012;42(4):A1-A57.

 

Summary:

 

The purpose of this guideline is to provide physical therapists with information, based on strength of the current evidence, regarding risk factors, clinical course, diagnosis/classification, differential diagnosis, examination, and interventions in the treatment of low back pain, with or without leg symptoms.

 

Content experts, appointed by the Orthpaedic Section of the American Physical Therapy Association (APTA), researched the above information. The authors independently searched the following databases: MEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews to initially acquire the content matter. The articles were limited to articles published prior to 2011 and the authors searched the reference list of each article in order to prevent the omission of a relevant article. The articles were leveled according to the criteria from the Centre for Evidence-based Medicine and were then were issued a grade of recommendation as previously described in the research.

 

The authors provided a comprehensive list of both International Statistical Classification of Diseases and Related Health Problems (ICD) Codes 10 and International Classification of Functioning, Disability and Health (ICF) codes.

 

The authors determined that based on lesser quality studies that data does not support a cause of LBP and risk factors are weakly associated with LBP.

 

Based on lesser quality studies, the data supports performing interventions that reduce the likelihood of transitioning from acute to chronic LBP and reducing the likelihood of recurrences.

 

Based on evidence from high quality studies, it is recommended to sub-classify patients based on signs and symptoms, such as the Treatment Based Classification System. Based on moderate evidence, the following signs and symptoms are useful in classifying patients based on the ICF and ICD-10: mobility impairment in the thoracic, lumbar or sacroiliac regions, referred or radiating pain into a lower extremity and generalize pain.

 

Based on evidence from high quality studies through expert opinion, it is recommended based on moderate evidence to consider performing a differential diagnosis to when serious medical conditions are suspected.

 

Based on high quality studies, there is strong evidence to recommend utilizing the Oswestry Disability Index (ODI or the Roland and Morris Disability Questionnaire (RMDQ) in order to monitor change pre-post intervention.

 

Based solely on case control studies, it is recommended based on opinion that clinicians should assess activity participation limitations.

 

Based on multiple high quality studies and few case studies, the authors provide strong evidence for recommending manipulative therapy in the treatment of LBP. These recommendations are only provided for patients with symptoms above the knee.

 

Based on high quality studies, the authors recommend performing trunk coordination, strengthening and endurance exercises to reduce pain and disability with patients ranging from subacute to chronic and also patients status post microdiscectomy. This recommendation is based on strong evidence.

 

Based on both high quality studies and case control studies, the authors recommend utilizing repeated movements or procedures, in a specific direction, to promote centralization. This is based on strong evidence.

 

Based on lesser quality evidence and case controlled studies, the authors recommend flexion exercises, combined with other interventions, for reducing pain in older patients with chronic symptoms. This is based on weak evidence.

 

Based on lesser quality studies and case series, the authors recommend lower quarter nerve mobilization procedures to reduce pain in patients with subacute and chronic LBP, with lower extremity symptoms. This is based on weak evidence.

 

Based on research ranging from high quality studies to expert opinion, it is recommended that clinicians avoid educational techniques based on pathoanatomy and extended bed rest. Recommended advice is centered on the inherent strength of the spine, the neuroscience explaining pain, the overall favorable prognosis of LBP, the use of active (as compared to passive) coping mechanisms, and early return to activity. This is based on strong evidence.

 

Conclusion:

Based on the Clinical Practice Guidelines above, the following is recommended based on strong evidence: utilizing an outcome measure such as the ODI or RMDQ, manual therapy, trunk coordination, strengthening and endurance exercises, promoting centralization, and performing patient education.

If you have back and want to be seen by a therapist that reads research for fun, come see me at 

FUNCTIONAL THERAPY AND REHABILITATION

now a part of the Goodlife family

903 N 129th Infantry Dr. 

suite 500

Joliet IL

8154832440 

 

 

Author: Dr. Vince Gutierrez, PT, cert. MDT

After having dedicated 8 years to growing my knowledge regarding the profession of physical therapy, it seems only fitting that I join the social media world in order to spread a little of the knowledge that I have gained over the years. This by no means is meant to act in place of a one-one medical consultation, but only to supplement your baseline knowledge in which to choose a practitioner for your problem. Having completed a Master of Physical Therapy degree, the MDT (Mechanical Diagnosis and Therapy) certification and currently finishing a post-graduate doctorate degree, I have spent the previous 12 years in some sort of post-baccalalaureate study. Hopefully the reader finds the information insightful and uses the information in order to make more informed healthcare decisions. MISSION STATEMENT: My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations. I choose to be a leader of example, and not words, all the while reducing negativity in my life. I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment. I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

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