PHYSIOTHERAPY CARE PROTOCOL – LOW BACK PAIN

CONTENTS

1. Definition 2

2. Overview 3

3. Diagnostic Triage 5

4. Assessment 7

5. Goals of Treatment 10

6. Intervention:

Acute Low Back Pain 11

Chronic Low Back Pain 13

7. Specific Conditions 15

8. Algorithm 16

9. References 18

10. Glossary
19

Appendix 1
Patient Education 21

Appendix 2
Oswestry Low Back Pain Disability 22
Questionnaire
Appendix 3
Use And Interpretation Of The Revised Oswestry 24
Low Back Pain Disability Questionnaire

Appendix 4
Hospital Anxiety and Depression Scale (HADS) 27

13. Appendix 5 29
Table Of Evidence : Acute And Subacute Low Back
Pain
Further Reading 33

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1. Definition

Low back pain is pain, muscle tension, or stiffness localised below the
costal margin and above the inferior gluteal folds, with or without leg pain
(sciatica).
Non-specific low back pain is low back pain not attributed to a recognisable
pathology, such as infection, tumour, osteoporosis, rheumatoid arthritis,
fracture, or inflammation (Van Tulder MW, Koes BW, 2002)

Low back pain may be classified as:

Acute low back pain

Activity intolerance due to lower back pain or back-related leg symptoms of
less than 3 months

Chronic low back pain

Activity intolerance due to lower back pain or back and leg symptoms lasting
more than 3 months

Recurrent low back pain

Episodes of acute low back pain problems lasting less than 3 months.
Patient has history pf previous episodes of low back pain.

The above definition will be used for the purposes of this protocol.

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2. OVERVIEW

Incidence

Low back pain affects 60%-80% of adults of some point of their lives with
10%-50% receiving physiotherapy of various types (Foster et al, 1999). It
was reported that the incidence of recurrent low back pain is about 50% in
the foillowing 12 months (Moffet et al, 1999). Low back pain is not only a
major medical problem but also a socio-economic problem. Low back pain
has significant impact on functional ability and it restricts occupational
activities (Van Tulder et al, 1999)

Low back pain is one of the most frequent reasons for visiting a
physiotherapist (Kerssens et al, 1999). Of all the referrals to an outpatient
physiotherapy department, it has been found that 60% of these are patients
with low back pain (Callaghan, 1994)

Low back pain is also one of the most common problem managed by the
physiotherapists in Malaysia, and 25% of all referral to the outpatient
physiotherapy department, Kuala Lumpur Hospital are patients with low
back pain (based on statistics).

Although acute low back pain is self-limiting and transient, the prognosis is
generally thought to be good. However in some, it progresses into a chronic
disorder. Reported recurrence rates are about 50% in the following 12
months (Moffet et al. 1999)

Causes

The causes of back pain can be very complex, as there are many
structures in the low back that can cause pain:
• the peripheral nerve roots
• the smaller nerves that innervate the spine

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• the muscles of the spine

• the bones, ligaments and joints
• the intervertebral discs

It is important to note that many types of low back pain have no known
anatomical cause. However the pain is real and has to be treated.
Usually, low back pain can be linked to a general cause e.g. muscle strain
or a specific and diagnosable condition e.g. degenerated disc (www.spine-
health.com)

Signs and symptoms

Acute low back pain usually occurs in persons without a history of chronic
discomfort and is typically related to preceding events or incidents
(www.merck.com).

Chronic pain may be associated with tender points which may be localised
or diffuse.
Pain may:
• arise from deeper lying tissues (e.g. as in spondylosis)
• be radicular (e.g. sciatica)
• be referred ( resulting from other structures that share the same
spinal segments distribution as site of pain)
Limited back mobility that is caused by pain, tightness and tenderness of the
para vertebral muscles or restriction of other vertebral related structures are
common. (www.merck.com)

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3. DIAGNOSTIC TRIAGE

Diagnostic triage is the differential diagnosis between:

• Simple backache (non-specific low back pain)
• Nerve root pain
• Possible serious spinal pathology

1. Simple Backache (Non specific low back pain)

• Presentation 20 – 55 years
• Symptoms at lumbosacral regions, buttock and thighs
• “Mechanical” pain (depends on physical activity and with time)
• General health - well
• Prognosis good
• 90% recover from acute attack within 6 weeks

2. Nerve Root Pain

• Unilateral leg pain worse than low back pain
• Pain radiates to foot or toes
• Numbness and paraesthesia in same dermatome
• Nerve irritation signs (reduced SLR and which reproduces leg
pain)
• Localised neurological signs (Motor, sensory or reflex change
if there is nerve root pain)
• Prognosis reasonable
• 50% recover from acute attack within 6 weeks

3. Red flags for possible serious spinal pathology

• Presentation under age 20 or onset over 55
• Non-mechanical pain (constant, progressive)
• Possible fractures - Major trauma, e.g. fall from a height, RTA
- Minor trauma if older or potentially
osteoporotic )

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• Possible tumour (Age < 20; Past medical history of

carcinoma, systemic steroids, Drug abuse, HIV; Constitutional
symptoms e.g. fever, chill, weight loss)
• Possible infections (Risk factors for spinal infections; recent
bacterial infection; IVDU or immunosuppressant; Pain worse in
supine position or severe night time pain)
• Thoracic pain (if pain is severe and localised – to rule out
other pathology especially TB spine)
• Persisting severe restriction of lumbar flexion
• Widespread neurological symptoms or signs
• Structural spinal deformity e.g. structural scolisis.

4. Cauda Equina Syndrome: (To refer to the doctor

immediately)
• Loss of anal sphincter tone or faecal incontinence
• Difficulty with micturation
• Saddle anaesthesia (around the anus, perineum or genitals)
• Gait disturbance or major motor weakness (quadriceps, ankle
plantar
Flexors, evertors & dorsiflexors) in the legs (widespread or
progressive)

5. Inflammatory disorders (Ankylosing spondylitis and related

disorders)
• Gradual onset before age 40
• Marked morning stiffness
• Persisting limitation of spinal movements in all directions
• Peripheral joint involvement
• Iritis, skin rashes (psoriasis), colitis, urethral discharge
• Family history of the condition

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4. ASSESSMENT OF LOW BACK PAIN

Carry out assessment using assessment form Physio/AX.6/200,
Kementerian Kesihatan Malaysia.

A. KEY POINTS OF ASSESSMENT

• Identify the patient’s needs and expectations and his
complaints.
• What are the consequences of the complaints for daily life
• What are the expectations of the patient and maybe his
underlying fears
• Identify the onset of the complaints, taking details of:
- The situation before the start of complaints
(levels of activity and participation).
- The development and course of the complaints
• Evaluate the course of the condition over time, taking details
of the present: severity and nature of complaints (impairments,
disabilities and participation problems)
• Previous diagnostic procedures and treatment interventions
and their results
• Determine coping strategy, taking details of:
- The significance the patient attaches to his
complaints
- The patient’s degree of control over his
complaints
• note additional information on co-morbid conditions
• current treatment: medication, other treatment or advice, and
medical aids
• work-related factors that affects patient complaint.

B. SUBJECTIVE ASSESSMENT
• Chronology of complains
• Specific reasons for attending
• Changes in signs and symptoms over time
• How does the patient cope with the problem

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• Present status of problem

• Pain
- Intensity of pain using Visual Analog Scale (VAS)
- Type of pain:
Cramping dull aching -Muscle
Sharp and shooting -Nerve root
Sharp, bright, lightning-like -Nerve
Burning pressure-like, stinging -Sympathetic nerve
Deep, nagging dull -Bone
Sharp, severe, intolerable -Fracture
Throbbing, diffuse -Vascular
- Area of pain, noted in the body chart
- Aggravating, easing and 24 hour behaviour are noted

C. OBJECTIVE ASSESSMENT

• Observation
- Posture
- Spinal curve (Thoracic kyphosis, lumbar lordosis and
Scoliosis)
- Leg length discrepancies
- Muscle bulk (muscle wasting especially of gluteus
maximus, gastroc and erector spinae)

• Palpation
- Temperature, sweating (increase and decrease)
- Muscle spasm
- Bony anomalies
- Soft tissue thickening, tightness, swelling (either
paravertebrallyinvolving the
interspinous space)
- Tenderness

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• Physical examination
- Mobility (Range of Spine Movement)
- Strength
- Flexibility (esp. Hamstrings, Illiopsoas)

• Movement Analysis
- Quality of Spinal Movement (Normal, abnormal and areas of
stiffness)
- Gait pattern

• Neurological Examination (To be done if symptoms extend

below knee joint)
- Reflexes: Sensory and Motor

• Neural Tension Test

- SLR
- PKB
- Slump

Levels of impairment and disabilities *

- Functional abilities (use Oswestry low back pain
questionnaire)

• Assess psychosocial problems for Yellow Flag

(If necessary, use Hospital anxiety and Depression Scale
(HADS)

NB. This assessment is to be done if there is no

improvement within the 6 weeks.

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D. ANALYSIS
• Level of impairment / disability and factors affecting it.
• Level of functional ability

* Refer glossary

5. GOALS OF TREATMENT

1. Patient education (Refer appendix: Process in Patient

education)
2. Increase patient’s confidence to cope adequately
3. Encourage continuation of normal activities
4. Gradual increase in activity level, exercise participation &
incorporating realistic limitations of the recovery process
• To advice on the consequences of increasing activity
excessively
- Giving guidance on gradual return to normal activities

6. INTERVENTION

A. ACUTE LOW BACK PAIN (<3 MONTHS OF ACTIVITY

INTOLERANCE WITH NO RED FLAGS)

1. Assurance and explanation

• Provide assurance that recovery is expected
• Information and patient education on low back pain
(Refer to appendix: Process in patient education)
• Advice to stay active

2. Activity alteration/modification to avoid back irritation

• Bed rest more than 2 days should be discouraged.
o Teach and encourage to continue current activity and to build
up to full level of activity and participation (not guide by pain
level)

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• Discuss, demonstrate and practice daily functional, work

activities especially those involving heavy lifting, bending and
twisting.

Key Points to include:

• Sleeping position: Instruct the patient to try sleeping on his/her
back with a pillow under the knees or sleep on their side with
knee bent and a pillow between the knees

• Sitting/Standing/walking:
- Wear comfortable low-heeled shoes.
- Use a chair with good lower back support that may recline
slightly. If the patient must sit for long periods of time, try
resting their feet flat on the floor or on a low stool, whichever
is more comfortable.
- If the patient must stand for long periods of time, try resting
one foot on a low stool. Make sure the work surface is that of
comfortable height

• Bending/Lifting/Twisting/Reaching:
- Protect the back by using good posture, body mechanics
and lifting techniques. For example, tighten the abdominal
muscles and bend the knees while lifting. Avoid reaching,
turning and twisting while lifting.
- Keep any lifted object close to the navel of the body

• The physiotherapist should make clear to patients and

employers that:
- Even moderately heavy unassisted lifting may aggravate
back symptom
- Any restrictions are intended to allow for spontaneous
recovery or time to build activity tolerance through
exercises

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3. Pain management (i.e. TENS, Hot pack, ice pack)

4. Low stress aerobic exercises

Until the patient returns to normal activity, aerobic (endurance)
conditioning exercise such as walking, stationary biking, swimming,
and even light jogging may be recommended to help avoid
debilitation from inactivity. An incremental, gradually increasing
regimen of aerobic exercise (up to 20 to 30 minutes daily) can
usually be started within the first 2 weeks of symptoms.

5. Graded exercise programme

Gentle mobilising, stretching & strengthening.

6. Mc kenzies’s exercises
According to the classification: - derangement, dysfunction or
postural.

7. Spinal manipulation
Should only be done by a trained manipulative therapist.

8. Lumbar stabilization exercises

Refer to Low Back Pain - Supplement

N.B. Lumbar Corset of Brace

There is no evidence to support the effectiveness of using
lumbar corset or brace for low back pain. It was shown that
by using the device it will lead to muscle deconditioning,
restrict or cause stiffness in movement and give false
security to patient.

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B. CHRONIC LOW BACK PAIN (>3 MONTHS OF ACTIVITY

INTOLERANCE WITH NO RED FLAGS)

1. Exercise therapy is useful in patient with chronic low back pain. The
use of varied exercise programs that meets the patient’s needs and
preferences is recommended. This will include:
• Mobilising
• Stretching,
• Strengthening,
• Endurance, and coordination Improvements

2. Hydrotherapy - Exercises therapy also can be carried out in water.

3. Behavioral approach to therapy focuses on preventing further

disability.
Two approaches are used:
• Time Contigent

• Active participation

Time Contigent Approach

Activities are increased step by step and do not depend on the
level of pain. Time rather than pain determine degree of activities.
e.g. Patient stop a certain activities or exercises because an amount
of time has been reach and not because of pain. The aim is to teach
patient to function despite the present of pain. A baseline level of
activities is found that is, a level of activities that does not cause
increase stress.

Active Participation
Patient cooperates actively in treatment and feels responsible
for the result. The objective is to promote patient’s control over his
own movement behavior.

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C. SPECIFIC CONDITIONS
1. Spinal stenosis:
Has been defined as narrowing of the spinal canal, nerve roots canal
or intervertebral foramina. It may be local, segmental or generalised
and can be caused by bony or soft tissue narrowing.
(Arnoldi et al, 1976)
The intervention of the spinal stenosis includes a programme of
exercises designed to widen the spinal canal and take the pressure of
the spinal nerve:-
1. position to ease the symptom;
-Sitting down
-Curling up to sleep
-Lying back with with their knee bend supported
2. exercises to be taught
-Strengthening exercises focusing on improving
the strength and control of the back and
abdominal muscle.
- Aerobic exercises to improve cardio-respiratory
function and increase endurance in the spinal
muscle
3. activities to regain back movement and function

2. Spondilolisthesis:
Is a forward slip of a vertebral body on the one below, common site is
L5S1.
The goals of the interventions are:
- to improve strength of the abdominal muscle
- increase flexibility by stretching of the
lower back and hamstrings muscle.
The rehabilitation programme that to is be emphasized are activities
and exercises which reduces extension stress
3. Prolapsed intervertebral disc
Follow McKenzie ‘s management

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7. Algorithm :
Algorithm 1: Initial Management of Low Back Pain
REFERRAL PID

Non Specific low back pain Specific Low back pain Spondylolisthesis
(< 3 months of activity intolerance due to (need special
low back pain and/ or back related leg consideration)
symptoms) Stenosis

Perform focused history and Others

physical examination
Table of – Red Flags
(including neurologic screening)
• Possible Fracture
Major Trauma – MVA, fall
Minor Trauma – Strenuous lifting in
YES older or potentially osteoporotic
ANY Refer to
RED patient
GP/Medical
FLAG ? • Possible Tumor or Infection
consultant Age over 50 or under 20
No History of Cancer
Recent fever, chills, unexplained
Promote assurance the recovery is expected weight loss.
Patient education about low back pain Risk factors for spinal infection:
Counselling, advice and home treatment Recent bacterial infection (UTI, IV
If necessary, TENS, Hot pack/Ice pack drug abuse, Immune suppression)
• Possible Cauda Equina Syndrome
Saddle anaesthesia
YES Recent onset of bladder dysfunction
Severe or progressive neurological
Improves Return to normal deficit in lower extremity
? activity/discharge • Radiculopathy
Severe unremitting pain or
weakness in myotomal distribution
No
`
• Recommend activity alteration/modification to
avoid back irritations
• Encourage to continue or return to normal activities
as soon as possible including work
• Encourage low stress aerobic exercise
• Graded muscle conditioning exercise programme
• Mckenzie’s or Spinal manipulation
• Lumbar stabilization exercises

Improve YES
Symptoms improved Return to normal
Within 6 activity/discharge
/Recovered
weeks ?

No

Assess for Yellow Flag GO TO ALGORITHM 2

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Algorithm 2 Further Management of Low Back Pain

ANY YES Consider referral to

YELLOW multidisciplinary
FLAG? assessment and care
if available

Psychosocial yellow Flags

Clinical assessment of yellow Flags may
identify the risk of long-term disability,
NO distress and work loss due to:
• Attitudes and beliefs about back
pain
• Emotions
• Explain, reassure and encourage continuation of normal • Behaviours
activities and return to work • Family
• Consider continuation of appropriate effective treatment • Compensation issues
• Cognitive therapy • Work
• Diagnostic and treatment issues

Reassess next 2 week

YES Symptoms improved Return to normal

/Recovered activity/discharge
Improve
?

No

Indication for Further Management:

• Unsatisfactory restoration of activities
• Failure to return to work
• Unsatisfactory response to treatment

Note: Patient who come with low back pain more than 3 month but first time referral for
Physiotherapy management, manage as an acute care and follow algorithm 1

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8. References

GE Bekkering, Hendriks, Blokoes, RAB Oostendorp, Ostelo, TMC

Thomassen and MW Van Tulder (2003)

National Practice Guidelines For Physical Thearpy in Patients with

Low Back pain

Phildephia Panel Evidence Based Clinical Practice Guidelines On

Selected Rehabilitation Interventions For Low Back Pain (2001)
Clinical Practice Guidelines: Acute Low Back Problems in
Adults:Assessment and Treatment (AHCPR Publication No. 95-
0643,1994)

Clinical Guideline On Management Of Low Back Pain, New Zealand

Guidelines Group (1998)

Evidence Based Table : Appendix 4

http:// www.spine-health.com

Van Tulder MW, Koes BW, 2002. Low Back Pain. American
Family Physcian. March

http://www.merck.com/pubs/mmanual/section5/chapter59/59b.htm

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9. Glossary

1. Impairment
Problem with the function or structure or part of the body,
difficulties an individual have in executing activities such as range
of movement during straight leg raised.
This includes decreased strength in back extensors, decreased
lumbar spine mobility or physical fitness.

2. Disability
Inability to perform an activity in the manner or to the extend
considered normal to that person such as problem in maintaining
sitting position, picking object from the floor and standing up from
lying position.

3. Coping
Is defined as a the cognitive and behavioral efforts made by
individual to control, reduce and tolerate the external and
internal stress due to the condition.

4. Yellow Flags
Yellow flag or psychosocial factors are considered important
because they are often associated with less successful
outcomes and when present can be more important than
physical symptoms and signs. Beliefs and behaviours on the
part of the patient are significant in this
In case records, a useful way to record the assessment for
psychosocial factors is under the heading ‘likelihood of
chronicity’ (i.e. likely, unlikely or impossible to tell, an why). This
assessment is very much in the context of a first visit. It does
not necessarily imply treatment at this stage, and the impression
gained may be confirmed (or otherwise) at subsequent visits.
Psychosocial factors should be recognised in order to try to
ensure that they do not prejudice recovery .

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APPENDIX 1

Patient education:
Patient education plan should start with an analysis of the patient’s need for
information, identified during history taking. Questions to be considered
asking are:

What does the patient know about the disorder and its treatment?

How is the patient coping?

Does the patient know how to influence the complaints?

What do the patient and the patient’s partner expect from treatment?

Patient education process should include four tasks.

Informing: providing the patients with facts about the disorder, its
treatment and patient care.

Instructing: providing concrete guidelines that the patient must
follow in order to influence the treatment process.

Educating: detailed explanations of the disorder and it’s treatment
from which the patient learns about the background to
the disorder and its consequences and learn to keep
the disorder under control.

Guiding: providing emotional support so that the disorder and its
consequences can be accepted and emotionally
processed by the patient.

APPENDIX 2
Oswestry Low Back Pain Disability Questionnaire

Please Read: This questionnaire is designed to enable us to understand how much

your low back has affected your ability to manage everyday activities. Please
answer each Section by circling the ONE CHOICE that most applies to you. We
realize that you may feel that more than one statement may relate to you, but
please just circle the one choice, which closely describes your problem right
now.

SECTION 1--Pain Intensity

A. The pain comes and goes and is very mild.
B. The pain is mild and does not vary much.
C. The pain comes and goes and is moderate.
D. The pain is moderate and does not vary much.
E. The pain is severe but comes and goes.
F. The pain is severe and does not vary much.

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SECTION 2--Personal Care

A. I would not have to change my way of washing or dressing in order to avoid
pain.
B. I do not normally change my way of washing or dressing even though it causes
some pain.
C. Washing and dressing increase the pain, but I manage not to change my way of
doing it.
D. Washing and dressing increase the pain and I it necessary to change my way of
doing it.
E. Because of the pain, I am unable to do any washing and dressing without help.
F. Because of the pain, I am unable to do any washing or dressing without help.

SECTION 3--Lifting
A. I can lift heavy weights without extra pain.
B. I can lift heavy weights, but it causes extra pain.
C. Pain prevents me from lifting heavy weights off the floor.
D. Pain prevents me from lifting heavy weights off the floor, but I can manage if
they are conveniently positioned, e.g. on the table.
E. Pain prevents me from lifting heavy weights, but I can manage light ton medium
weights if they are conveniently positioned.
F. I can only lift very lightweights, at the most.

SECTION 4 --Walking
A. Pain does not prevent me from walking any distance.
B. I have some pain with walking but it does not increase with distance.
C. Pain prevents me from walking more than one mile.
D. Pain prevents me from walking more than 1/2 mile.
E. I can only walk while using a cane or on crutches.
F. I am in bed most of the time and have to crawl to the toilet.

SECTION 5--Sitting
A. 1 can sit in any chair as long as I like without pain.
B. I can only sit in my favorite chair as long as I like.
C. Pain prevents me from sitting more than one hour.
D. Pain prevents me from sitting more than 1/2 hour.
E. Pain prevents me from sitting more than ten minutes.
F. Pain pevents me from sitting at all.

SECTION 6 -- Standing
A I can stand as long as I want without pain
B. I have some pain while standing, but it does not increase with time.
C. I cannot stand for longer than one hour without increasing pain.
D. I cannot stand for longer than 1/2 hour without increasing pain.
E. I can't stand for more than 10 minutes without increasing pain.
F. I avoid standing because it increases pain right away.

SECTION 7--Sleeping
A. I get no pain in bed.
B. I get pain in bed, but it does not prevent me from sleeping.
C. Because of pain, my normal night's sleep is reduced by less than one-quarter.
D. Because of pain, my normal night's sleep is reduced by less than one-half.
E. Because of pain, my normal night's sleep is reduced by less than three-
quarters.
F. Pain prevents me from sleeping at all.

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SECTION 8--Social Life

A. My social life is normal and gives me no pain.
B. My social life is normal, but increases the degree of my pain.
C. Pain has no significant effect on my social life apart from limiting my more
energetic interests, e.g., dancing, etc.
D. Pain has restricted my social life and I do not go out very often.
E. Pain has restricted my social, life to my home.
F. Pain prevents me from social, life at all.

SECTION 9--Traveling
A. I get no pain while traveling.
B. I get some pain while traveling, but none of my usual forms of travel make it any
worse.
C. I get extra pain while traveling, but it does not compel me to seek alternative
forms of travel.
D. I get extra pain while traveling which compels me to seek alternative forms of
travel.
E. Pain restricts all forms off travel.
F. Pain prevents all forms of travel except that done lying down.

SECTION 10--Changing Degree of Pain

A. My pain is rapidly getting better.
B. My pain fluctuates, but overall is definitely getting better.
C. My pain seems to be getting better, but improvement is slow at present.
D. My pain is neither getting better nor worse.
E. My pain is gradually worsening.
F. My pain is rapidly worsening.

APPENDIX 3

USE AND INTERPRETATION OF THE REVISED OSWESTERY LOW

BACK PAIN DISABILITY QUESTIONNAIRE
Physiotherapists in HKL who are experienced in the management of spinal pain
agreed by consensus that the following statements in the 10 sections can be
considered as a high level of functional ability
Date:
Scale : 0 - 5 from mild to severe
Section 1 - Pain intensity
The pain come and goes and this is very mild
The pain is mild and does not vary much
The pain comes and goes and is moderate 2
The pain is moderate and does not vary much
The pain comes and goes and is severe
The pain is severe and does not vary much

Section 2 - Personal care

I can look after myself normally without causing extra pain
I can look after myself normally but it causes extra pain 1
It is painful to look after myself and I am slow and careful
I need some help but manage most of my personal care
I need help everyday in most aspects of self care
I do not get dressed, wash with difficulty and stay in bed

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Section 3 - Lifting
I can lift heavy weights without extra pain
I can lift heavy weights but it gives extra pain 1
Pain prevents me from lifting heavy weights off the floor,
but I can manage if they are placed conveniently e.g. on table
Pain prevents me from lifting heavy weights but I can manage
light to medium weights if they are conveniently placed
I can lift very light weights
I cannot lift or carry anything at all

Section 4 - Walking
Pain does not prevent me walking any distance
Pain prevents me walking more than 1 mile 1
Pain prevents me walking more than 1/2 mile
Pain prevents me walking more than 1/4 mile
I can only walk using a stick or crutches
I am in bed most of the time and have to crawl to the toilet

Section 5 - Sitting
I can sit in any chair as long as I like
I can only sit in my favourite chair as long as I like
Pain prevents me from sitting more than 1 hour 2
Pain prevents me from sitting more than 1/2 hour
Pain prevents me sitting more than 10 mins
Pain prevents me from sitting at all

Section 6 - Standing
I can stand as long as I want without extra pain
I can stand as long as I want but it gives extra pain
Pain prevents me from standing for more than 1 hour 2
Pain prevents me from standing for more than 30mins
Pain prevents me from standing for more than 10mins
Pain prevents me from standing at all

Section 7 - Sleeping
Pain does not prevent me from sleeping well
I can sleep well only by using tablets 1
Even when I take tablets I have less than 6 hours of sleep
Even when I take tablets I have less than 4 hours of sleep
Even when I take tablets I have less than 2 hours of sleep
Pain prevents me from sleeping

Section 8 - Social Life

My social life is normal and gives no extra pain
My social life is normal but increases the degree of pain
Pain has no significant effect on my social life apart from 2
limiting my energetic interests e.g. dancing etc
Pain has restricted my social life and I do not go out as often
Pain has restricted my social life to my home
I have no social life because of my pain

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Section 9 - Travelling
I can travel anywhere without extra pain
I can travel anywhere but it gives me extra pain 1
Pain is bad but I manage journeys over 2 hours
Pain restricts mw to journeys of less than 1 hour
Pain restricts me to short necessary journeys under 30mins
Pain prevents me from travelling except to the doctor or hospital

Section 10 - Changing degree of pain

My pain rapidly better
My pain fluctuates but overall is definitely getting better 1
My pain seems to be getting better but improvement is
slow at present
My pain is neither getting better nor worse
My pain is gradually worsening
My pain is rapidly worsening

Total score: 14 / 50

Therefore we can take it that a score of 14 and less would indicate a high level of
functional ability.

Scoring the Oswestry Low Back Pain Disability

Questionnaire
All 10 sections have 6 statements, each of which describes an increasing degree of
severity.
The patient is instructed to check one statement for each section. The first statement
in each section describes little or no pain or functional limitation and is scored as no
points (0) while the sixth statement describes extreme pain or functional limitation
and is scored as 5 points.
The total is calculated by adding the number of points, with the highest possible
score being 50.
This score is multiplied by 2 to give a percentage.
Thus the higher the percentage score, the higher the patient's perceived disability
related to LBP.
(Reference:'The role of functional status questionnaires for low back pain',
Australian Physiotherapy.
Vol.43, No 1, 1997.)

Based on the above:

Total score is 50 and
Score of 14/50 and below is considered functionally fit.
This is based on the level of independence and degree of functional ability in each
section.

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APPENDIX 4

Hospital Anxiety and Depression Scale (HADS)

Instructions: Physiotherapists are aware that emotions play an important
part in most illnesses. If your physiotherapist knows about these feelings he
or she will be able to help you more. This questionnaire is designed to help
your physiotherapist know how you feel. Read each item and place a firm
tick in the box opposite the reply, which comes closest to how you have
been feeling in the past week. Don’t take too long over your replies: your
immediate reaction to each item will probably be more accurate than a long
thought out response.

I feel tense or ‘wound up’: A I feel as if I am slowed D

down:
Most of the time 3 Nearly all of the time 3
A lot of the time 2 Very often 2
Time to time, occasionally 1 Sometimes 1
Not at all 0 Not at all 0
I still enjoy the things I used D I get a sort of frightened A
to enjoy: feeling like ‘butterflies in
the stomach’:
Definitely as much 0 Not at all 0
Not quite so much 1 Occasionally 1
Only a little 2 Quite often 2
Not at all 3 Very often 3
I get a sort of frightened A I have lost interest in my D
feeling like something awful appearance:
is about to happen:
Very definitely and quite badly 3 Definitely 3
Yes, but not too badly 2 I don’t take as much care as 2
I should
A little, but it doesn’t worry me 1 I may not take quite as much 1
care
Not at all 0 I take just as much care as 0
ever
I can laugh and see the D I feel restless as if I have A
funny side of things: to be on the move:
As much as I always could 0 Very much indeed 3
Not quite so much now 1 Quite a lot 2
Definitely not so much now 2 Not very much 1
Not al all 3 Not at all 0

Worrying thoughts go A I look forward with D

through my mind: enjoyment to things:
A great deal of the time 3 A much as I ever did 0

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A lot of the time 2 Rather less than I used to 1

From time to time but not too 1 Definitely less than I used to 3
often
Only occasionally 0 Hardly at all 2
I feel cheerful: D I get sudden feelings of A
panic:
Not at all 3 Very often indeed 3
Not often 2 Quite often 2
Sometimes 1 Not very often 1
Most of the time 0 Not at all 0
I can sit at ease and feel A I can enjoy a good book or D
relaxed: radio or TV programme:
Definitely 0 Often 0
Usually 1 Sometimes 1
Not often 2 Not often 2
Not at all 3 Very seldom 3

Questions relating to anxiety are indicated by an 'A' while those relating to

depression are shown by a 'D'. Scores of 0-7 in respective subscales are
considered normal, with 8-10 borderline and 11 or over indicate
psychosocial problem.

APPENDIX 5

TABLE OF EVIDENCE: ACUTE & SUBACUTE LOW BACK PAIN

Study Methods & outcome measures (om ) Results & Conclusion

Effective Systematic reviews of RCTs No evidence that early activity had any
Health 8 RCTs , n =1784 harmful effects or led to more recurrence.

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Care, 2000. Advice to stay active vs. single or Advice to stay active showed positive results
Bulletin combination therapy e.g. back school in all 8 RCTs.
& bed rest.
om – pain intensity ,patient
satisfaction ,time off work ,
healthcare use for back pain in the
next year

Effective Systematic reviews of RCTs Manipulation more effective than exercise (2

Health 8 RCTs , n = 1149 RCTs) ; No significant differences between
Care, 2000. Exercise therapy vs conservative exercise and other inactive treatments (4
Bulletin treatment e.g. standard treatment by RCTs) & 1 RCT - better outcome with the
GP, manipulation, back schools, bed control group.
rest, placebo electrotherapeutic Exercise therapy ineffective in the treatment of
modalities & NSAIDS acute low backache.
om – pain intensity, day off work,
return to work status , functional
status overall recovery.

Effective Systematic reviews of RCTs Both RCTs had no clear evidence to positive
Health 2 RCTs (poor quality) examining results.
Care, 2000. effectiveness of multidisciplinary Multidisciplinary program ineffective in the
Bulletin rehabilitation in a sub acute, treatment of acute low backache.
including work place visits.
om – return to work(days off work,
return to work status)

Effective Systematic reviews of RCTs No difference and worst outcomes with bed
Health 9 RCTs , n = 1435 rest in all RCTs .2 RCTs also showed no
Care, 2000. Bed rest vs. exercise therapy, significant difference on the no. of days of rest.
Bulletin physiotherapy, manipulation & Bed rest ineffective in the treatment of acute
NSAIDS low backache.
Om – pain, functional status, recovery
& days off work.

Effective Systematic reviews of RCTs 5 RCTs had positive results with manipulation
Health 36 RCTs - assessed efficacy of & 4 RCTs showed negative effects & 3 RCTs
Care, 2000. various spinal manipulation showed positive results in sub groups
Bulletin 12 RCTs , n = 899 -spinal All 5 RCTS showed contradictory results on
manipulation vs other treatment e.g. pain reduction
exercise , massage ,back school Very low risk if manipulation carried out by
analgesics ,SWD,& NSAIDS competent people.
5 RCTs ,n = 383 –spinal manipulation Manipulation therapy has unclear evidence
vs placebo treatment for effectiveness in the treatment of acute low
om – pain ,activity levels & patient backache.
satisfaction .

Effective Systematic reviews of RCTs Inconclusive evidence that traction is effective.

Health 17 RCTs assessing effectiveness of 1 RCT showed more overall improvements
Care, 2000. traction after 1 to 3 weeks & 1 RCT showed no
Bulletin 2 RCTs ( poor quality) , n = 225 difference with traction.
Traction vs. corset & Infra red ray. Traction ineffective in the treatment of acute
low back pain .

Effective Systematic reviews of RCTs 1 RCT showed no difference in the outcome &
Health 2 RCTs , n = 98 1 RCT reported improved outcome with
Care, 2000. TENS vs. rehabilitation program (1 TENS at 6 weeks
Bulletin RCT ) , paracetamol ( RCT ) TENS – no significant evidence for
om – pain , functional status and effectiveness in the treatment of acute low
mobility back pain

Cohen et al Systematic reviews of literature on Only short term relieve in pain and initial

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 PHYSIOTHERAPY CARE PROTOCOL – LOW BACK PAIN
, 1994 group education decrease in sick leave. At 1 year no difference
( which including work side visits ) in the outcome measures.
2 studies with acute cases Patient education has unclear effectiveness in
om- pain , sick leave the management of low back pain .

Van Tulder Systematic reviews of RCTs 1 RCT (low quality) reported better outcomes
et al ,2001 8 RCTs , n = 1149 (2 high quality ,6 with exercise, 2 RCTs reported positive results
(Cochrane low quality ) with manipulation & the other 5 RCTs showed
Database ) Exercise therapy vs. usual care by a no significant difference with exercise & other
primary care physician ,manual active treatments.
therapy ,back school & NSAIDs Exercise therapy ineffective in the treatment of
om – pain ,return to work , functional acute low back pain.
status & overall improvements

Van Tulder Systematic reviews of RCTs Better outcomes with exercise (1 RCT ) & No
et al ,2001 1RCT -Back school vs. McKenzie difference (1 RCT )
(Cochrane exercise (high quality) Back school ineffective in the treatment of
Database) 1 RCT -Back school vs physical acute low back pain .
therapy (low quality)
om – short & long term outcomes
Underwood RCT , n = 75 No significant difference in both the groups
& Morgan Back class, teaching extension but less chronic disability in the Back class
,1998 exercises vs conventional at 1 year.
management.
Om – Oswestry disability score &
VAS
Faas ,1996 Criteria based review
On acute back pain, 4 RCTs , n= 772 1 RCT had better results with extension
Exercise therapy vs no therapy exercise but overall there was no difference in
Extension exercise vs flex exercise either type of exercise.
and mini back school
Om – pain , disability , sick leave ,
recurrences
Moffet et al RCT , n = 187 – Greater improvements in function seen at 6 &
,1999 exercise program vs standard care 12 months .The quality of life and the costs at
from GP 12 months not statically different.
om – Roland back pain disability Moderate evidence that Exercise program
questionnaire(functional limitations ), effective in the treatment of sub acute low
Aberdeen back pain scale (clinical back pain.
status), Euro QoL health index and
Fear Avoidance Beliefs Questionnaire
(quality of life ),use of health services
& costs.

Study Methods & outcome measures (om ) Results & Conclusion

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Effective Systematic reviews of RCTs Evidence of moderate positive effects in all
Health 20RCTs , n =? RCTs with behavioural therapy .
Care, 2000. Behavioural therapies (cognitive,
Bulletin operant & respondent )vs no
treatment (from waiting list )
om – pain intensity ,general
functional status & behavioural
outcomes .

Effective Systematic reviews of RCTs Multidisciplinary treatment showed strong

Health 10 RCTs , n = 1691 evidence of effectiveness ( up to one year post
Care, 2000. Multidisciplinary treatment treatment ).
Bulletin programmes (intensive physical &
psychosocial programmes –
education, active exercises,
behavioural treatment, relaxation
exercises & work place visits) vs
conservative treatment e.g. standard
treatment by GP, manipulation, back
schools, bed rest, placebo
electrotherapeutic modalities &
NSAIDS
om – functional status , coping
strategies of symptoms , pain
intensity, day off work, return to
work status

Effective Systematic reviews of RCTs 3 RCTs with exs vs conventional

Health 12 RCTs , n=1692. physiotherapy found no difference in
Care, 2000. Exercises, all type -specific back effectiveness. 3 RCTs vs with exs vs GP care
Bulletin exercises, abdominals, flexion, showed better outcomes with exs.
extension, static, dynamic, 6 RCTs with exs vs inactive treatment ( hot
strengthening, stretching, aerobic) pack , rest & placebo ) showed conflicting
with additional treatment e.g. SWD results .
or US vs standard conservative
treatment (treatment by GP, Exercise therapy effective in the treatment of
conventional physiotherapy, back chronic low backache.
school, behavioural treatment)
om – return to normal activities &
work (days off work, return to work
status) , sick leave , functional status ,
pain intensity

Effective Systematic reviews of RCTs 11 RCTs –Back schools effective in 6 months

Health 11 RCTs , n = 1286 but no difference at 1 year.
Care, 2000. 5 RCTs , n = 425 (in occupational 5 RCTs – Back schools effective.
Bulletin settings )
Back school (education, skiil & exs Back schools effective in the treatment of
programmes) vs. exercise therapy, chronic low backache.
physiotherapy, manipulation &
NSAIDS, no treatment, placebo
Om – pain, functional status & sick
leave

Effective Systematic reviews of RCTs All RCTs had contradictory results.

Health 12 RCTs , n= 1059
Care, 2000. Spinal manipulation vs placebo, Manipulation therapy has unclear evidence
Bulletin conservative treatments (GP care, exs for effectiveness in the treatment of chronic
, back school , US ) low backache.
om – pain ,functional status & overall
improvement .

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Effective Systematic reviews of RCTs Both RCTs had no difference in outcomes.
Health 2 RCTs , n=176
Care, 2000. Traction vs placebo traction Traction ineffective in the treatment of
Bulletin 2 RCTs ( poor quality) , n = 225 chronic low back pain .
Traction vs. corset & Infra red ray.
Effective Systematic reviews of RCTs All RCTs showed no difference , slight
Health 4 RCTs , n = 253 improvement & short term improvement in
Care, 2000. Effectiveness TENS the outcomes
Bulletin om – pain , functional status and TENS – no significant evidence for
mobility effectiveness in the treatment of chronic low
back pain

Effective Systematic reviews of RCTs Lumbar supports & corsets have unclear
Health 1 RCTs , n= 19 effectiveness in the management of chronic
Care, 2000. Lumbar supports & corsets low back pain.
Bulletin om- global improvement

11. Further Reading

1. Musculoskeletal Physiotherapy – Clinical Science and Practice

Kathryn M. Refshauge and Elizabeth M. Gass
Butterworth-Heinemann Ltd. 1995

2. Physical Therapy Of The Low Back

Lance T. Twomey and James R. Taylor
Churchill Livingstone. 2000

3. Manage Your pain

Dr. Michael Nicholas, Dr. Allan Molloy, Lois Tonkin and Lee Beeston
ABC Books. Reprinted 2002

4. Vertebral Manipulation
GD Maitland
Butterworth-Heinemann Ltd.1986

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