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Low Back Pain With Mobility Deficit

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Introduction

Low back pain with mobility deficit is a specific classification of low back pain (LBP) that primarily involves pain accompanied by a reduction in the range of motion (ROM) in the lower back. This condition is commonly seen in patients who exhibit stiffness and restricted spinal movement, particularly during bending or twisting motions.[1]

Low Back Pain

Key Features:

  • Localised Low Back Pain: Pain is often centered in the lumbar region with minimal radiation to the legs.
  • Movement Limitation: The patient may experience difficulty performing movements like bending forward (flexion), arching backward (extension), or side bending.
  • Stiffness: A hallmark symptom of this condition is the sensation of stiffness, especially after periods of inactivity (e.g., sitting for extended periods or in the morning).
  • Segmental Mobility Deficits: Reduced movement in specific segments of the lumbar spine, which may lead to abnormal movement patterns or compensations.[2]
Poor Posture

Etiology

  • Degenerative Changes: Conditions like osteoarthritis, degenerative disc disease, or spondylosis can limit spinal mobility.
  • Muscle Strain or Ligament Sprain: Acute injuries to muscles or ligaments can lead to inflammation and restricted movement.
  • Poor Posture: Long periods of poor posture (e.g., slouching, improper sitting) can cause stiffness and lead to a mobility deficit.
  • Joint Hypomobility: Restrictions in spinal joints due to adhesions, scar tissue, or mechanical blockages can also contribute to reduced mobility.[3][4]

Factors

  • Low back pain (LBP) is a major medical and economic issue worldwide.[5]
  • The severity of LBP increases with advancing age and is a significant contributor to mobility disability.[6]
  • LBP is associated with substantial economic costs, including healthcare expenses and lost productivity
  • Obese individuals with LBP experience higher levels of disability compared to their non-obese counterparts.
  • Obesity is linked to increased pain severity and worse functional capacity in those with LBP.[7]
  • The causes of LBP are complex and multifactorial, involving both biological and psychosocial components.
  • Psychosocial factors play a significant role in the chronicity of LBP.[8]
  • There is a notable relationship between reduced hip mobility and LBP. Both passive and active range of motion (ROM) can be diminished.
  • Loss of hip mobility contributes to the overall functional limitations and pain associated with LBP.[9]
  • Approximately 85-90% of LBP cases are classified as non-specific, meaning there is no identifiable pathological cause.
  • The loss of mobility and functional capacity resulting from NSLBP is a serious public health concern, as it predicts chronic disability.[10]
  • LBP is the leading cause of activity limitation and work absence globally.
  • The condition is associated with a significant economic burden due to reduced workforce participation and productivity[11].

Characteristics-Clinical Presentation

According to the ICF (International Classification of Functioning, Disability and Health), codes of low back pain with (sub)acute low back pain with mobility deficits leads to the following problems on body functions, body structure, and activities and participation[12][13]

Condition Body Functions Body Structures Activities and Participation
Acute Low Back Pain with Mobility Deficits Pain in back, Pain in body part (buttock, groin, thigh), Mobility of several joints, Mobility of joint functions (vertebral segment) Thoracic vertebral column, Lumbar vertebral column, Joints of pelvic region Bending
Sub-acute Low Back Pain with Mobility Deficits Pain in back, Pain in body part (buttock, groin, thigh), Mobility of several joints, Mobility of joint functions (vertebral segment) Thoracic vertebral column, Lumbar vertebral column, Joints of pelvic region, Muscles of pelvic region, Hip joint, Muscles of thigh, Ligaments and fascia of thigh Bending

Differential Diagnosis

Tabel as follows[13] [9]

Characteristic Acute Sub-acute Chronic Recurrent
Duration < 1 month 1-6 months > 6 months < 6 months
Pain Location Low back, buttock, thigh Unilateral low back, thigh Variable Variable
Symptoms Restricted ROM, segmental mobility, pain with provocation Similar to acute, but longer duration Persistent pain, often with other symptoms Intermittent pain episodes
Mobility Deficits Present Present May or may not be present May or may not be present
Condition Symptoms Physical Exam Findings Special Tests
Lumbar Facet Joint Dysfunction Localised pain, worse with extension/rotation; increased with prolonged sitting or standing Pain on palpation of facet joints, limited ROM, especially extension Quadrant test
Lumbar Spondylosis (Degenerative Disc Disease) Gradual onset of pain and stiffness, worsens with activity; morning stiffness improves with movement Decreased lumbar ROM (extension), palpable tenderness along the spine N/A
Lumbar Disc Herniation (without Radiculopathy) Central low back pain, aggravated by flexion; pain worse with sitting and bending Limited flexion ROM, possible muscle spasms Slump test, Straight Leg Raise (SLR)
Sacroiliac Joint Dysfunction Pain localised to sacrum, radiating to buttocks/thighs; worsened by transitional movements Positive sacroiliac joint stress tests, limited pelvic mobility FABER, Compression, Distraction
Ankylosing Spondylitis (AS) Chronic back pain and stiffness, worse in the morning or after inactivity; improves with movement Limited ROM in all planes, pain on sacroiliac palpation, positive Schober’s test Schober’s test
Lumbar Spinal Stenosis Pain with walking or standing, relieved by sitting/flexion; possible neurogenic claudication Limited lumbar extension, relief with forward flexion N/A
Myofascial Pain Syndrome Deep muscle pain, often localized to trigger points; worsened with movement Palpable tight bands/trigger points, limited ROM due to muscle tightness N/A
Lumbar Sprain/Strain Acute onset after a specific movement or injury; worsens with movement Tenderness on palpation of affected muscles, limited ROM due to guarding N/A
Osteoarthritis Stiffness and pain, worse with activity; crepitus/grinding sensation Decreased lumbar ROM, bony enlargements, joint tenderness N/A
Piriformis Syndrome Pain in the buttocks, radiating to lower back or leg; worsens with sitting or climbing stairs Tenderness over piriformis muscle, limited hip ROM FAIR test
Spinal Tumor or Infection Severe, non-mechanical pain; night pain, fever, weight loss Significant tenderness over vertebrae, limited ROM, possible neurological signs MRI/CT, X-rays for bony changes

Outcome Measures

ODIs may be more useful than VAS scores in the clinical setting when considering functional movement parameters[16].

MRI image

Examination

There are three important lumbar examination components to examine a patient with low back pain and lumbar mobility deficit:

Subjective Assesment:

  • visualise possible deviations or abnormal structures in the spine of the patient by using radiography, for example: Magnetic Resonance Imaging (MRI) and Computed Topography (CT) scans:
    There is no imaging indicated if “reduced lumbar spinal movement with low back pain” is described as an acute symptom which lasts 1 month or less and with the absence of red flag signs[12]. It’s important to know that these investigations do not identify the specific causes of pain (low sensitivity and specificity), but this research is mostly used with serious conditions.
  • detailed and specific history of the patient. Based on this history we get an overview of possible clues to find the cause of low back pain.
  • physical examination. This consists of a series of tests which helps to find the causes of pain with which the patient struggles.[17]

Objective assessments of the lumbar motion can be achieved by a variety of methods:

  • Examination of the regional motion using an inclinometer ROM
  • Finger-to-floor distance
  • Schober-index[18]However, not a valid tool

However, associations between these ROM measures and the patient rated measures are low[19]

Physical Impairment Measures Examination Test

  • Lumbar Range of Motion (ROM) - Quadrant Test:[20]
    • Focus: Movement control impairments in the sagittal plane (flexion and extension).
    • Clinical Insight: Research by Bauer et al. highlights that increased LBP intensity correlates with variability in lumbar movement patterns.
    • Recommendation: Examination of lumbar flexion and extension should be performed for patients with LBP to assess movement control impairments.
  • Lumbar Spine Segmental Mobility Assessment:
    • Technique: Posterior-to-anterior (PA) gentle pressure applied to spinous processes with the hypothenar eminence.
    • Grading: Lumbar segments are graded as normal, hypomobile, or hypermobile.
      • Hypomobility: If any level shows reduced mobility, the patient is categorised as having hypomobility.
      • Hypermobile: A segment that shows excessive movement.
    • Interpretation: This assessment should be interpreted alongside other clinical findings..[21] [22]
  • Pain Provocation with Segmental Mobility Testing

  • Judgments of Centralisation during Movement Testing
  • Prone Instability Test: Judgments of the presence of aberrant movement: Measured by painful arc with flexion or return from flexion. If patient complains of pain when returning to standing from flexion or feels a catch, this is a positive test.
  • SLR
    Straight Leg Raise
  • Slump Test
  • Trunk Muscle Power and Endurance: Check Trunk Flexors, Extensors, Lateral Abdominals, Transversus Abdominis, Hip Abductors, and Hip Extensors for strength looking for any muscle imbalances.
  • .[23] Passive Hip Internal/External Rotation, Flexion, and Extension:
    • Assessment: Evaluates hip joint mobility, which can affect lumbar spine mechanics.
    • Insight: Research by Consmüller et al. shows that devices like the Epionics SPINE may provide objective, reliable assessments of lumbar and thoraco-lumbar movement and spinal shape, contributing to LBP evaluations.
Medical Management

Medical Management

medical treatment is the prescription of certain drugs, such as:[24]

  • Analgesics,
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Muscle relaxants
    These drugs can ensure that patients stay active without feeling pain, so that they can function in their daily live.[24] [17]
Lumbar Stretches

Physical Therapy Management

  • Manual therapy procedure (thrust or non-thrust) to diminish pain and improve segmental spinal or lumbopelvic motion
  • Therapeutic exercise to improve or maintain spinal mobility
  • Patient education that encourages the patient to return to or pursue an active lifestyle[9][10][21][13]
  • Stretching program using the Global Postural Reeducation (GPR) method showed effective at improving pain, function, some quality of life aspects (emotional, limitations in physical functioning, vitality and mental health) and had no effect on depressive symptoms in patients with chronic low back pain[25].[26]
  • Low-Impact Aerobic Exercise: Activities like walking, cycling, or swimming can enhance overall fitness and contribute to better back health.
  • As mobility and pain improve, incorporate more functional, task-specific movements
  • If the patient's symptoms persist or worsen despite conservative care, referral to a specialist (e.g., orthopedic surgeon or pain specialist) for further investigation might be required.

References

  1. ↑ Jakaria GM, Kuan CS. Muscle Strength, Lumbar Curve, Fear of Movement and Functional Disability among Patients with Lumbar Disc Herniation: A Review. Open Journal of Therapy and Rehabilitation. 2024 Jan 3;12(1):28-51.
  2. ↑ Hicks GE, George SZ, Pugliese JM, Coyle PC, Sions JM, Piva S, Simon CB, Kakyomya J, Patterson CG. Hip-focused physical therapy versus spine-focused physical therapy for older adults with chronic low back pain at risk for mobility decline (MASH): a multicentre, single-masked, randomised controlled trial. The Lancet Rheumatology. 2024 Jan 1;6(1):e10-20.
  3. ↑ Oertel J, Sharif S, Zygourakis C, Sippl C. Acute low back pain: Epidemiology, etiology, and prevention: WFNS spine committee recommendations. World Neurosurgery: X. 2024 Mar 1:100313.
  4. ↑ Oertel J, Sharif S, Zygourakis C, Sippl C. Acute low back pain: Epidemiology, etiology, and prevention: WFNS spine committee recommendations. World Neurosurgery: X. 2024 Mar 1:100313.
  5. ↑ Chapman JR, Norvell DC, Hermsmeyer JT, Bransford RJ, DeVine J, McGirt MJ, Lee MJ. Evaluating common outcomes for measuring treatment success for chronic low back pain. Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S54-68
  6. ↑ Macfarlane GJ, Beasley M, Jones EA, Prescott GJ, Docking R, Keeley P, McBeth J, Jones GT; MUSICIAN Study Team. The prevalence and management of low back pain across adulthood: results from a population-based cross-sectional study. Pain. 2012 Jan;153(1):27-32
  7. ↑ Fanuele JC, Abdu WA, Hanscom B, Weinstein JN. Association between obesity and functional status in patients with spine disease. Spine (Phila Pa 1976). 2002 Feb 1; 27(3):306-12.
  8. ↑ Laird RA, Kent P, Keating JL. Modifying patterns of movement in people with low back pain -does it help? A systematic review. 2012 Sep 7;13:169. doi: 10.1186/1471-2474-13-169.
  9. ↑ 9.0 9.1 9.2 Sarah Winter et al. Effectiveness of targeted home-based hip exercises in individuals with non-specific chronic or recurrent low back pain with reduced hip mobility. Journal of back and musculoskeletal rehabilitation, 2015
  10. ↑ 10.0 10.1 Kent PM, Keating JL. The epidemiology of low back pain in primary care. Chiropr Osteopat. 2005 Jul 26;13:13
  11. ↑ Nocera J, Buford TW, Manini TM, Naugle K, Leeuwenburgh C, Pahor M, Perri MG, Anton SD. The impact of behavioral intervention on obesity mediated declines in mobility function: implications for longevity. Journal of aging research. 2011;2011.
  12. ↑ 12.0 12.1 Anthony D., Steven G., Linda V.D. et al. 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. Journal of Orthopaedics & Sports Physical Therapy. 2012;42 (4)
  13. ↑ 13.0 13.1 13.2 Delitto A, George S.Z. et al, 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. J Orhtop Sports Phys Ther. 2012;42(4):A1-A57
  14. ↑ Caporaso F, Pulkovski N, Sprott H, Mannion AF. How well do observed functional limitations explain the variance in Roland Morris scores in patients with chronic non)specific low back pain undergoing physiotherapy?. Eur Spine J. 2012 May;21 Suppl 2:S187-95
  15. ↑ Cherkin DC, Sherman KJ, Balderson BH. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. JAMA. 2016 Mar 22-29;315(12):1240-9.
  16. ↑ Ruiz FK. Bohl DD. Webb ML. Russo GS. MD. Grauer JN. Oswestry Disability Index is a better indicator of lumbar motion than the Visual Analogue Scale. The Spine Journal 14 (2014) 1860–1865
  17. ↑ 17.0 17.1 David G.B., Andrei C. Diagnosis and Treatment of acute low back pain. Fast Facts: Low Back Pain. Health Press. 2012
  18. ↑ Taheri N, Becker L, Reitmaier S, Muellner M, Schömig F, Pumberger M, Schmidt H. Schober test is not a valid assessment tool for lumbar mobility. Scientific Reports. 2024 Mar 5;14(1):5451.
  19. ↑ Mieritz PM. Bronfort G. Hartvigsen J. Regional Lumbar Motion and Patient REGIONAL LUMBAR MOTION AND PATIENT-RATED OUTCOMES: A SECONDARY ANALYSIS OF DATA FROM A RANDOMIZED CLINICAL TRIAL. Journal of Manipulative and Physiological Therapeutics (2014) Volume 37, Number 9
  20. ↑ Bauer CM, Rast FM, Ernst MJ. et al. Pain intensity attenuates movement control of the lumbar spine in low back pain, M.J Electromyogr Kinesiol. 2015 Dec;25(6):919-27.[7]
  21. ↑ 21.0 21.1 Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. Arch Phys Med Rehabil. 2005 Sep;86(9):1745-52
  22. ↑ Kulig K, Powers CM, Landel RF, Chen H, Fredericson M, Guillet M, Butts K. Segmental lumbar mobility in individuals with low back pain: in vivo assessment during manual and self-imposed motion using dynamic MRI. BMC Musculoskelet Disord. 2007 Jan 29;8:8.
  23. ↑ Consmüller T, Rohlmann A, Weinland D, Druschel C, Duda GN, Taylor WR. Comparative evaluation of a novel measurement tool to assess lumbar spine posture and range of motion. Eur Spine J. 2012 Nov;21(11):2170-80
  24. ↑ 24.0 24.1 Casazza B.A. Diagnosis and Treatment of Acute Low Back Pain. American Family Physician.2012;85(4):343-50
  25. ↑ Lawand P. Lombardi IJ. Jones A. Sardim C. Ribeiro LH. Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: A randomized controlled trial. Joint Bone Spine 82 (2015) 272–277
  26. ↑ Bonetti F, Curti S, Mattioli S et Al. Effectiveness of a 'Global Postural Reeducation' program for persistent low back pain: a non-randomized controlled trial. BMC Musculoskelet Disord. 2010 Dec 16;11:285.
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