Regional Interdependence in Low Back Pain: Interventions

Original Editors - Brandan Lym, Mitchell Blythe, Cory Horstman, Nathan Domino, and Dana Schmidt part of the Des Moines University Student Project    

 Regional Interdependence

• Regional interdependence is the concept that a musculoskeletal treatment targeting a specific area of the body could have effects in another, seemingly unrelated, part of the body.
• Examples of Regional Interdependence:

          -  Elbow

          -  Shoulder

Lumbar Examination

Screen patient for red flags

Condition	Red Flags
Back-related tumor	Constant pain not affected by position or activity; worse with weight bearing, worse at night Age over 50 History of cancer Failure of conservative intervention (failure to improve within 30 days) Unexplained weight loss
Cauda equina syndrome	Urine retention Fecal incontinence Saddle anesthesia Sensory or motor deficits in the feet (L4, L5, S1 areas)
Back-related infection	Recent infection (eg, urinary tract or skin), intravenous drug user/abuser Concurrent immunosuppressive disorder Deep constant pain, increases with weight bearing Fever, malaise, and swelling Spine rigidity; accessory mobility may be limited Fever: tuberculosis osteomyelitis Fever: pyogenic osteomyelitis Fever: spinal epidural abscess
Spinal compression fracture	History of major trauma, such as vehicular accident, fall from a height, or direct blow to the spine Age over 50 Age over 75 Prolonged use of corticosteroids Point tenderness over site of fracture Increased pain with weight bearing
Abdominal aneurysm	Back, abdominal, or groin pain Presence of peripheral vascular disease or coronary artery disease and associated risk factors (age over 50, smoker, hypertension, diabetes mellitus) Smoking history Family history Age over 70 Non-Caucasian Female Symptoms not related to movement stresses associated with somatic low back pain Abdominal girth <100 cm Presence of a bruit in the central epigastric area upon auscultation Palpation of abnormal aortic pulse Aortic pulse 4 cm or greater Aortic pulse 5 cm or greater

Physical Impairment Measures

• Evaluate Thoraco-Lumbar Active and Passive ROM

          -  Quadrant Test

• Segmental Mobility
• Pain Provocation with Segmental Mobility Testing
• Judgments of Centralization during Movement Testing
  

          - Look for a centralization of pain with repeated motion in a specific direction.

• Prone Instability Test
• Judgments of the presence of aberrant movement
  

• Straight Leg Raise
• Slump Test
• Trunk Muscle Power and Endurance
  

• Passive Hip Internal Rotation, External Rotation, Flexion, and Extension
• Mental Impairment Measures

          -  Depression

          -  Yellow Flags

          -  Fear Avoidance Beliefs Questionnaire

Also consider Hip Examination

• Active and Passive ROM
• Joint Mobility
• Strength

Interventions

In the articles reviewed, the following interventions were found to be beneficial in the treatment of low back pain. 

Thoracic Spine

Manipulation

• Supine Thoracic Posterior to Anterior HVLA Manipulation
  

   

Hip

Manipulation

• Supine Long Axis Distraction HVLA Manipulation

  

Mobilizations

• Supine Hip Caudal Glide Mobilization

  

• Prone Hip Posterior to Anterior Mobilization

  

• Hip Posterior to Anterior Mobilization with Flexion, Abduction, and External Rotation

• Hip Anterior to Posterior Mobilization with Flexion, Adduction, and Internal Rotation      

   - Hip Mobilization Physiopedia Page

  

Therapeutic Exercise

•  Strengthening

          - Hip Abduction with slight extension and internal rotation

  

•  Flexibility
  

          - Supine Iliopsoas Stretch

  

          - Prone Rectus Femoris Stretch

  

          

Outcomes

Articles	Level of Evidence	Improved Oswestry Disability Index Score	Improved Fear Avoidance Behavioral Questionairre Score	Improved Global Rating of Change Score	Improved Modified Spinal Stenosis Scale Score	Improved Pain Pressure Threshold	Decreased Pain	Improved Function
Burns et al.	4	X	X	X				X
Cibulka	4	X					X	X
Oliviera et al.	2					X	X
Whitman et al. 2003	4	X		X	X			X
Whitman et al. 2006	2	X		X	X		X	X
Lejkowski & Poulsen	4						X	X

          - An "X" denotes improvement in each specific category regardless of statistical significance. 

 Clinical Implications

• Utilizing manual therapy interventions targeted at the hip and thoracic spine along with therapeutic exercise has been shown to provide improved outcomes for patients with low back pain. Clinicians should consider these interventions along with treatments focused on the low back to treat the entire patient and achieve improved results. Additional information can be found in the references listed below.