AIM OF THE GUIDELINE
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF).320


The purposes of these clinical guidelines are to: 


Describe evidence-based physical therapy practice including diagnosis, prognosis, intervention, and assessment of outcome for musculoskeletal disorders commonly managed by orthopaedic physical therapists


Classify and define common musculoskeletal conditions using the World Health Organization’s terminology related to impairments of body function and body structure, activity limitations, and participation restrictions


Identify interventions supported by current best evidence to address impairments of body function and structure, activity limitations, and participation restrictions associated with common musculoskeletal conditions


Identify appropriate outcome measures to assess changes resulting from physical therapy interventions in body function and structure as well as in activity and participation of the individual


Provide a description to policy makers, using internationally accepted terminology, of the practice of orthopaedic physical therapists


Provide information for payers and claims reviewers regarding the practice of orthopaedic physical therapy for common musculoskeletal conditions


Create a reference publication for orthopaedic physical therapy clinicians, academic instructors, clinical instructors, students, interns, residents, and fellows regarding the best current practice of orthopaedic physical therapy





STATEMENT OF INTENT
This guideline is not intended to be construed or to serve as a standard of medical care. Standards of care are determined on the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and patterns of care evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome in every patient, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made in light of the clinical data presented by the patient, the diagnostic and treatment options available, and the patient’s values, expectations, and preferences. However, we suggest that significant departures from accepted guidelines should be documented in the patient’s medical records at the time the relevant clinical decision is made.

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Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association

Pain and motor control of the lumbopelvic region: effect and possible mechanisms

Chronic pain is a significant and costly problem in the United States as well as throughout the industrialized world. Unfortunately, there have been concerns about the effectiveness of traditional medical interventions, suggesting the need for alternative chronic pain treatment strategies. However, the introduction of the biopsychosocial model of pain during the past decade stimulated the development of more therapeutically effective and cost-effective interdisciplinary chronic pain management programs. In the present article we briefly review the history of pain management, discuss the major components of a "true" interdisciplinary pain management program, focus on the evidence-based outcomes that have documented the effectiveness of such interdisciplinary pain management programs, and note the barriers that have blocked the wider use of such programs. Finally, we discuss future directions in interdisciplinary pain management.

/pdf/interdisciplinary-chronic-pain-management-2pu6rgjj1i.pdf

Interdisciplinary chronic pain management

Study Design. Cross-sectional study. Objective. The present study compared activity of deep and superficial cervical flexor muscles and craniocervical flexion range of motion during a test of craniocervical flexion between 10 patients with chronic neck pain and 10 controls. Summary of Background Data. Individuals with chronic neck pain exhibit reduced performance on a test of craniocervical flexion, and training of this maneuver is effective in management of neck complaints. Although this test is hypothesized to reflect dysfunction of the deep cervical flexor muscles, this has not been tested. Methods. Deep cervical flexor electromyographic activity was recorded with custom electrodes inserted via the nose and fixed by suction to the posterior mucosa of the oropharynx. Surface electrodes were placed over the superficial neck muscles ( sternocleidomastoid and anterior scalene). Root mean square electromyographic amplitude and craniocervical flexion range of motion was measured during five incremental levels of craniocervical flexion in supine. Results. There was a strong linear relation between the electromyographic amplitude of the deep cervical flexor muscles and the incremental stages of the craniocervical flexion test for control and individuals with neck pain ( P = 0.002). However, the amplitude of deep cervical flexor electromyographic activity was less for the group with neck pain than controls, and this difference was significant for the higher increments of the task ( P < 0.05). Although not significant, there was a strong trend for greater sternocleidomastoid and anterior scalene electromyographic activity for the group with neck pain. Conclusions. These data confirm that reduced performance of the craniocervical flexion test is associated with dysfunction of the deep cervical flexor muscles and support the validity of this test for patients with neck pain.

Patients With Neck Pain Demonstrate Reduced Electromyographic Activity of the Deep Cervical Flexor Muscles During Performance of the Craniocervical Flexion Test

Evidence-Based Scientific Data Documenting the Treatment and Cost-Effectiveness of Comprehensive Pain Programs for Chronic Nonmalignant Pain

https://www.archives-pmr.org/article/S0003-9993(96)90224-5/pdf

Lumbar trunk muscle endurance testing: An inexpensive alternative to a machine for evaluation

At a certain position of trunk flexion, there is a sudden onset of electrical silence in back muscles. This is called "flexion-relaxation (F-R) phenomenon." The goals of this study were (1) to evaluate the relationship between flexion angle and activity of back muscles during flexion movement and (2) to determine what the difference is between healthy subjects and patients with chronic low back pain (CLBP). Twenty-five healthy subjects (13 males and 12 females; average age, 28.3 yr) and 20 patients with CLBP (12 males and 8 females; average age, 34.1 yr) volunteered for this study. The subjects were asked to flex forward maximally from the erect position and to maintain full flexion, followed by returning to the initial upright position. Flexion angle of trunk and hip was measured during the examination. Electromyographic activity of erector spinae was also monitored simultaneously. F-R phenomenon was observed in all healthy subjects before reaching the maximum flexion. Electrical silence continued even after extending the trunk began. In contrast, no patients with CLBP demonstrated F-R phenomenon. A significant difference in muscular activities of erector spinae between the groups was obtained when returning to the erect position from the maximum flexion. Moreover, time lag between trunk and hip movement was much greater in patients than in healthy subjects. This study demonstrated that neuromuscular coordination between trunk and hip could be abnormal in patients with CLBP.

Flexion-relaxation phenomenon in the back muscles. A comparative study between healthy subjects and patients with chronic low back pain

https://www.archives-pmr.org/article/S0003-9993(95)80628-8/pdf

Concentric and eccentric strength of trunk muscles: influence of test postures on strength and characteristics of patients with chronic low-back pain.

Study Design A prospective cohort study Objectives To introduce a novel back school for the treatment of patients with chronic low back pain (CLBP), and to report its clinical results Summary of Background Data Although back school is one of the treatment methods for patients with CLBP, its efficacy and appropriate style remain controversial No studies have been published regarding the combined program of back school with a multidisciplinary team approach Methods A total of 182 patients with CLBP (74 men and 108 women; average age, 438 years) participated in this study All patients were enrolled in the back school using a multidisciplinary team approach featuring quantitative functional evaluation and therapeutic exercises The following outcome measures were evaluated at the baseline, and 6 and 12 months after the enrollment: the level of pain evaluated with a Visual Analog Scale (VAS) flexibility of trunk and hamstrings (finger-floor distance, straight leg raising), trunk muscle strength and endurance, frequency of therapeutic exercises, and self-reported patient satisfaction Results An averaged VAS score was 62 before enrollment in the program and 28 at follow-up The pain improved in 141 patients (808%), did not change in 27 (154%), and was aggravated in 7 (38%) There was statistically significant improvement of finger-floor distance, trunk muscle strength, and endurance in the patients whose pain was relieved after enrollment in the program (P < 005) The compliance with the exercise program was significantly correlated with the clinical results (P < 005) Conclusions We developed a novel back school using a multidisciplinary team approach, featuring quantitative functional evaluation and therapeutic exercises The current study demonstrated that our program could provide a satisfactory result for the treatment of patients with CLBP The quantitative functional evaluation was a worthwhile outcome measure when evaluating the efficacy of the treatment program Teaching body mechanics and performing the therapeutic exercises through the multidisciplinary team approach are essential to managing CLBP in a general setting

A novel back school using a multidisciplinary team approach featuring quantitative functional evaluation and therapeutic exercises for patients with chronic low back pain: the Japanese experience in the general setting.

https://www.archives-pmr.org/article/S0003-9993(95)80605-9/pdf

Thomas E. Strax

Papers

Lumbar trunk muscle endurance testing: An inexpensive alternative to a machine for evaluation

Flexion-relaxation phenomenon in the back muscles. A comparative study between healthy subjects and patients with chronic low back pain

Concentric and eccentric strength of trunk muscles: influence of test postures on strength and characteristics of patients with chronic low-back pain.

A novel back school using a multidisciplinary team approach featuring quantitative functional evaluation and therapeutic exercises for patients with chronic low back pain: the Japanese experience in the general setting.

Electromyographic analysis of four techniques for isometric trunk muscle exercises