CPR for Lumbar Stabilisation

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Indication

Because patients presenting with low back pain are a heterogeneous population, and because in 85% of cases no specific diagnosis can be made for low back pain, a treatment based classification system is useful for physical therapists in developing rehabilitation programs for patients unspecified with low back pain. In this type of system, patients are categorized according to general presentation, findings from a physical examination, impairments, and functional limitations, and are grouped into one of several treatment classifications. In order to assist with this classification, clinical prediction rules are a set of criteria that a patient should meet in order to be placed into a specific treatment group.

Clinical Prediction Rule

• Younger Age (<40 years old)
• Increased Flexibility (Average SLR > 91^o)
• Aberrant Motions or Instability Catch during Lumbar Flexion/Extension ROM
• Hypermobility of the Lumbar Spine
• (+) Prone Instability Test

Description

Optimal spinal stabilzation can be achieved by strengthening the deep back and abdominal muscles. These include the transverse abdominus, quadratus lumborum, oblique abdominals, multifidus, and erector spinae. Exercises targeting these specific muscles should be done in a progression, usually beginning with the transverse abdominus to provide the patient with initial stabilization that can be used during subsequent exercises and daily activities.

Below are methods for activating the transverse abdominus and multifidus muscles, two major spinal stabilizers.

 

 

These exercises should be incorporated initially in the spinal stabilization program for patients with low back pain. Once the patient is able to activate these muscles, more stabilizing exercises should be introduced the patient should be progressively challenged with more difficult exercises, targeting the muscles listed above.

The following videos are examples demonstrating progressions of spinal stabilization exercises that can be used for patients requiring this technique. They can and should be modified according to specific patient needs, preferences, or functional demands. The physical therapist should remember to consistently stress the importance of maintaining a neutral spine when performing these exercises.

 

Key Evidence

A 2003 study done by Fritz et al compared the treatment based classification (TBC) approach and current clinical practice guidelines (CPG) for treatment of patients with low back pain. The TBC system involved classifying patients into categories and matching the treatment to the category. The clinical practice guidelines included low stress aerobic exercise, general muscle re-conditioning, and advice to remain active. The change was evaluated using the initial and four week Oswestry score. Although both groups showed some improvement, the study found a 22% greater improvement for patients whose treatment was matched on the TBC as compared to those who were provided treatment based on the CPG.

Fritz JM, Delitto A, Erhard DC. (2003) Comparison of Classification-Based Physical Therapy with Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain. SPINE. 28 (13) 1363-1372.

Hicks GE, Fritz JM, Delitto A, McGill SM. (2005) Preliminary Development of a Clinical Prediction Rule for Determining Which Patients with Low Back Pain Will Respond to a Stabilization Exercise Program. Archives of Physical Medicine and Rehabilitation, 86 (9), 1753-1762.

Ultrasound- Strong Internal Oblique if Transverse Abdominus not working very much or weak.

Resources

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Case Studies

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References

Fritz JM, Cleland JA, Childs JD. (2007) Subgrouping Patients with Low Back Pain: Evolution of a Classification Approach to Physical Therapy. Journal of Orthopaedic & Sports Physical Therapy, 37 (6), 290-302.

Hicks GE, Fritz JM, Delitto A, McGill SM. (2005) Preliminary Development of a Clinical Prediction Rule for Determining Which Patients with Low Back Pain Will Respond to a Stabilization Exercise Program. Archives of Physical Medicine and Rehabilitation, 86 (9), 1753-1762.