Evidence-Based Management
of the Acute Lumbar Spine
Our Goal
• Early identification of the acute spine
– Based on current, high quality research
• Timely referral
– To an orthopedic manual therapist
• Maximize optimal outcomes
– Reduce risk of overall disability
– Reduce burden on health care system
Lumbar Red Flags
Spinal Manipulation
Clinical Prediction Rule
• Flynn et al. Spine 2002
–
–
–
–
–
Symptoms < 16 days
FABQ < 19
No symptoms distal to knee
Hip IR > 35o
Lumbar hypomobility
• 4 or 5 had +LR 24.4 which
equals 95% chance of
successful outcome
A Clinical
Prediction Rule
to Identify
Patients with
Low Back Pain
Most Likely to
Benefit from
Spinal
Manipulation: A
Validation Study
Treatment Groups
• Childs et al. Ann Intern Med
2004
• Manipulation
– First 2 sessions
• Manipulation
• AROM exercises
– Final 3 sessions
• Stabilization exercises
• Hypothesis
– Subjects in manipulation group
who fit CPR will have the best
outcomes
Results
Subjects who were positive on the rule and treated with manipulation had
greater improvements in pain and disability at 1 week, 4 weeks, and 6
months
Validation of Rule
4 or more present:
45%
Symptoms < 16 days
FABQ < 19
No symptoms distal to knee
Hip IR > 35o
Lumbar hypomobility
92%
The “2 Factor Rule”
45%
• Recent onset (< 16 d)
• No sx distal to knee
91%
Translation to Clinical Practice
• Patients with +CPR and
received manipulation,
the number needed to
treat (NNT) for successful
outcome:
– One week: 1.3
– Four weeks: 1.9
• Lower NNT the more
powerful the treatment
effect
– An NNT < 2 is quite
powerful
• Antibiotic cocktail to
eradicate bacteria
– NNT = 1.1
• Lipitor to prevent 1 heart
attack
– NNT = 16-23
• Crestor to prevent
progression of plague
build up
– NNT = 7
Conclusion
• High quality research indicates patient with acute low
back pain have a high probability of dramatic success
following 2 physical therapy sessions
• Optimal outcomes are dependent on:
– Identifying patients likely to benefit from manual therapy
– Early referral to an evidence-based orthopedic manual therapist
• At Kinetic Physical Therapy, we utilize state-of-the-art
care by incorporating evidence-based manual therapy,
exercise, and the application of a biopsychosocial model
in managing cervical and lumbar disorders
Supporting Article Summaries
• Flynn et al. Spine2002
The objective of this study is to develop a clinical prediction rule (CPR) for
identifying patients with low back pain who improve with spinal
manipulation. A clinical prediction rule with five variables was identified. The
presence of four of five of these variables increased the probability of
success with manipulation from 45% to 95%. Overall, it appears patients
with low back pain likely to respond to manipulation can be accurately
identified.
• Childs et al. Annals of Int Med 2005
The objective of this study was to validate a previous clinical prediction rule
(Flynn et al. 2002) for identifying patients with low back pain who improve
with spinal manipulation. Patients were randomly assigned to receive
manipulation plus exercise or exercise alone by a physical therapist for four
weeks. A patient who was positive on the clinical prediction rule and
received a manipulation has a 92% chance of a successful outcome with
an associated number needed to treat of 1.9 at four weeks.