AHCPR Low Back Pain Guidelines

When the AHCPR Low Back Pain Guidelines were first released, some interpreted the lack of support for physical modalities (heat, cold, ultrasound, etc.) as a lack of support for physical therapy during the acute phase. Quite to the contrary, the AHCPR document clearly notes that "One very important goal of these guidelines is to prevent long-term back problems and disability by improving care provided during the acute phase" (Stanley Bigos, M.D. Chair of Guidelines Panel). The findings and recommendations included in the Clinical Practice Guidelines also describe a "paradigm shift away from focusing care exclusively on the pain and toward helping patients improve activity tolerance."
The following excerpts from the AHCPR Low Back Pain Guidelines are followed by some key areas where the expertise of the physical therapist in their role as movement specialist and patient educator can assist in managing acute low back problems and facilitate achieving the goals of "preventing long-term back problems and disability" and "helping patients improve activity tolerance."

Algorithm 2. Initial visit:

"Provide assurance; education about back problems." A critical element of adult education is finding the "the teachable moment", that window of opportunity when the patient is receptive to learning because he/she receives positive feedback (pain reduction) from minimizing stressful movements, postures and activities. A patient in the acute phase of low back pain is very receptive to learning techniques to decrease and manage their pain. Intervention at this stage helps to limit further aggravation of low back symptoms and reinforce the importance of strategies that can be used if pain recurs.
"Review activity limitations due to back problem." Patient education regarding activity limitations must be pertinent to the patient's lifestyle and mechanism of pain production. Instructing a patient not to bend, twist or reach and to lift loads "close to the level of the navel" (as recommended in the guidelines) have limited value if the patient doesn't understand how these activities impact the low back. If they don't understand the "why", they may perform other high risk activities without recognizing the potential for stressing the low back.

"Recommend activity alterations to avoid back irritation." It is rarely sufficient to tell a patient "don't sit too much" or "change positions frequently." Compliance with recommendations will be improved if patients understand the benefits of activity alteration. For example, if patients are taught that compressive forces and stress on the low back are greater when sitting than standing, changing positions makes sense.

"Encourage low stress aerobic exercise ." Patients who have never, or rarely, participated in low stress exercises usually have a great deal of anxiety about beginning a program without specific support and instruction for fear of increasing their symptoms. The Guidelines suggest walking, swimming and stationary biking. If these activities are to be successful in "helping patients improve activity tolerance", then patients need individualized guidelines for intensity and precautions regarding posture (e.g. hyperflexion while stationary biking can provoke symptoms).

Algorithm 2. Follow-up visits:

"Recommend activities to avoid debilitation and reduce risk of recurrence." Individuals are often unaware of daily activities that are contributing to stress on soft tissues and causing mechanical irritation. Identification of stressful activities and instruction in alternative methods is an important step in minimizing the recurrence of the low back pain.
"Support return to work or required daily activities." Instruction in gradual resumption of least stressful to most stressful activities minimizes set backs.

"Can begin muscle conditioning exercises after a few weeks." Patients need individualized instruction in appropriate exercises and proper exercise methods - improper performance can aggravate symptoms. (e.g.forward flexion with knees extended, straight leg sit ups, anterior vs. posterior pelvic tilts, etc.)

Algorithm 5. Further management of acute low back problem (greater than 4 weeks, less than 3 months duration)

"Establish safe exercise plan to build tolerance for intended activity." The individual needs of the patient (age, flexibility, comorbidities, etc.) must be taken into account in establishing a safe exercise plan. Flexibility, strengthening and conditioning components must be balanced according to the needs of the patient.

It is evident that the expertise of the physical therapist can provide an important link in the treatment intervention chain of events, especially if the goals are to prevent long-term back problems and disability and to help patients improve activity tolerance."

CTI Physical Therapy provides comprehensive programs ranging from prevention to treatment of low back pain problems. Call any of our offices for additional information about our programs.