9 Long A; The centralization phenomenon: its usefulness as a predictor of outcome in conservative treatment of chronic low back pain, a pilot study. Spine; 20(23): , 1995.A pilot study indicating that centralization is useful as an outcome predictor in chronic patients. There was a superior outcome comparing centralizers to non-centralizers in an interdisciplinary work-hardening programme.
10 Force Progression Patient generated Patient generated w/ self OP Patient generated w/ therapist OPMobilizationManipulation
20 Exercise Prescription Once a provisional mechanical diagnosis has been established and directional preference, the patient will continue on an independent basis until follow up.Typically bouts of 10 reps 4-5x /day is a minimum to produce changeDependent upon patients mechanical diagnosis, severity of problem, capabilities of the patient.
21 Long A, Donelson R, Fung T. Does it matter which exercise Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercises for low back pain. Spine; Dec 1;29(23): , 2004.Following a mechanical evaluation all patients who demonstrated directional preference (DP) (230/312, 74%) were randomized to receive exercise matched to DP (1), exercise opposite to DP (2) or evidence-based management (3). Over 30% of groups 2 and 3 withdrew because of failure to improve or worsening, compared to none in group 1. Over 90% of group 1 rated themselves better or resolved at 2 weeks, compared to just over 20% (group 2) and just over 40% (group 3). There were further significant differences between the groups in back and leg pain, functional disability, depression and QTF category.
22 Reevaluation/Treatment Progression Confirm, reject or modify the provisional mechanical diagnosisDetermine the need for progressions/regression of forceDetermine when it is appropriate and how to initiate recovery of function/reactivationDetermine any worsening or progression of the disorder which prompts the need to contact the referring medical physicianDetermine the need and timing for discharge planningDevelop the patient's self management and problem-solving skills essential for long-term, prophylactic benefit.
23 Discharge Planning and Prophylactic Concepts Provision of educationEncouragement of patients to ‘problem solve' their own difficulties should be part of treatment.Supervision of patients must, in the light of the epidemiology of back pain, involve the nurturing of self-management strategies.This should be done from day one and those strategies will need to be individualized according to the patient.
24 ReferencesDonelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine; 22(10): , 1997.Long A; The centralization phenomenon: its usefulness as a predictor of outcome in conservative treatment of chronic low back pain, a pilot study. Spine; 20(23): , 1995.Long A, Donelson R, Fung T; Does it matter which exercise? A randomized control trial of exercises for low back pain. Spine; Dec 1;29(23): , 2004.McKenzie Course notes A, B, C, D, EMcKenzie RA The lumbar spine: mechanical diagnosis and therapy. Spinal Publications, New Zealand.McKenzie RA The cervical and thoracic spine: mechanical diagnosis and therapy. Spinal Publications, New ZealandMcKenzieMDT.orgPetty NJ Neuromusculoskeletal examination and assessment: a handbook for therapist, 3rd ed. Elsevier Limited.Spitzer WO. Scientific approach to the assessment and management of activity-related spinal disorders: A mono-graph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine 1987;12(7 Suppl):1-59.