Treatment Principles for the Lumbar Spine

Original Editor - Carin Hunter based on the course by Nick Rainey
Top Contributors - Carin Hunter and Jess Bell

Introduction

Treating the lumbar spine can be complex. It can be difficult to know when to apply the techniques you have been taught and how to adapt your plan if the outcome is not as predicted. It is important to be as specific as possible, make sure tests are reproducible and watch how results change over time.

Active Range of Motion of the Lumbar Spine

When evaluating a client, assessing active range of motion can give you a lot of clues about possible impairments. Look for the following.

• Movement patterns
  • Does the patient move to the side when performing flexion (i.e. appears crooked)? This could indicate scoliosis or that they are trying to avoid pain in certain positions
• Gowers' sign (i.e. climbing up the legs while returning to standing from a flexed position)
  • If a patient uses their hands to return to neutral after performing lumbar flexion, it can indicate weakness
• Check where the movement is coming from, and check repeated movements

Treatment-Based Classification System for Lower Back Pain

Alrwaily et al. describe three approaches to determining the most appropriate "rehabilitation approach" for low back pain: a symptom modulation approach, a movement control approach and a functional optimisation approach. These approaches each address the different signs and symptoms you may find on assessment.

The full text of this article is available here: Treatment-Based Classification System for Low Back Pain: Revision and Update

1. Symptom Modulation Approach

A symptom modulation approach is for patients with recent low back pain. The pain can be new or recurrent. This episode of low back pain results in "significant symptomatic features" for the individual, so interventions focus on alleviating symptoms. Patients often present with the following: avoiding specific postures, reduced / painful active range of motion, sensitivity on neurological testing. Common treatments are manual therapy, directional preference exercises, traction, or immobilisation.

2. Movement Control Approach

A movement control approach is for patients with low-to-moderate pain and disability. They also have difficulty performing activities of daily living. Pain usually returns to the baseline once an aggravating movement has ended. Other patients may report repeated episodes of back pain, often associated with a sudden movement, but they are currently asymptomatic / in remission. A patient usually has full active range of motion, but may have some deviations in their movement patterns. Patients often present with: impaired flexibility, muscle activation, and motor control. Treatment commonly focuses on stabilisation exercises.

3. Functional Optimisation Approach

A functional optimisation approach is for relatively asymptomatic patients who are able to complete their activities of daily living, but who want / need to achieve a higher level of physical activity. This is commonly associated with a sport or job. Pain for these individuals is aggravated by movement system fatigue. Patients will often present with reduced endurance of their movement system, strength, and power, rather than a decrease in flexibility or movement control. Interventions should focus on maximising physical performance to achieve the required high-level physical activities (i.e. relevant to the specific job or sport).

Treatment

There are many different treatment approaches for low back pain, and all can have favourable outcomes. Some examples are: the Maitland approach, Mechanical Diagnosis and Therapy (also commonly known as the McKenzie approach), Cognitive Functional Therapy (Peter O’Sullivan), and Movement Impairment Syndromes (Shirley Sahrmann).

Some basic principles of treatment are as follows:

• be as specific as possible in your assessment and treatment
• make sure that positive tests are reproducible and watch how results to these tests change over time
• always identify recovery limiting factor and consider how you talk about pain - "words are very powerful"

Aerobic Exercise

According to Chatzitheodorou et al., patients with chronic low back pain should be encouraged to perform aerobic exercise for 30+ minutes 3 times per week.

Manual Therapy

Research shows that thrust manipulation which targets both stiff and painful segments is helpful for low back pain. Since all manual therapy has similar mechanisms, this principles can be used for non-thrust manipulation as well. The video below on the lumbar accessory mobility testing details the examination of stiff and painful segments. These should be treated with the same techniques. Following treatment, the “asterisk signs” from the assessment should be retested to see if they have improved. An asterisk sign for manual techniques could be how stiff or painful the segment feels with this technique to the patient or how stiff it feels to the therapist.

Lumbar Traction Literature:

1. Schimmel JJ, De Kleuver M, Horsting PP, Spruit M, Jacobs WC, Van Limbeek J. No effect of traction in patients with low back pain: a single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy®. European spine journal. 2009 Dec;18:1843-50.
   • Summary from Nick Rainey: People with chronic low back pain and imaging findings of a disc issue have minimal benefit from a lot of traction when used as a sole intervention. They did not capture how the subjects felt the day of traction.
2. National Institute for Health and Care Excellence (Great Britain). 2018 Surveillance (exceptional Review) of Low Back Pain and Sciatica in Over 16s: Assessment and Management (NICE Guideline NG59). National Institute for Health and Care Excellence; 2018.
   • Summary from Nick Rainey: If you’re going to hang your hat on the NICE guidelines you can’t pick and choose. No one thing works so there are a lot of “do not offers”. Some of the things they recommend to offer I question. I put a few of the common things we encounter that I thought would be of interest below. This is for you to consider if you would recommend these options, and if you would, where would you send the patient.
     • Manual therapies
     • Exercise
     • Psychological therapy
     • Return-to-work programmes
     • Radiofrequency denervation
     • Epidurals
     • Surgery and prognostic factors
3. Gudavalli MR, Cambron JA, McGregor M, Jedlicka J, Keenum M, Ghanayem AJ, Patwardhan AG. A randomized clinical trial and subgroup analysis to compare flexion–distraction with active exercise for chronic low back pain. European Spine Journal. 2006 Jul;15:1070-82.
   • Summary from Nick Rainey: The exercise group looks like good treatment. There wasn’t an psychosocial info in either group. The flexion distraction technique was more helpful at 1 month, 3 months, 6 months, and 12 months and people were generally more satisfied with it. The flexion-distraction group didn’t do any prescribed exercise. Pain improved whereas other measures did not.
4. Thackeray A,Fritz JM,Childs JD,Brennan GP.The effectiveness of mechanical traction among subgroups of patients with low back pain and leg pain:a randomized trial.Journal of orthopaedic&sports physical therapy.2016 Mar;46(3):144-54.
   • Summary from Nick Rainey: Mechanical traction isn’t magical or extremely powerful. If it were then the results would have been stronger. Both groups received the same extension oriented treatment that fit a standard Mechanical Diagnosis and Therapy model that included lateral shift correction if needed. The traction group did have 13% go on to surgery compared to 20% in the Extension-Oriented Treatment Approach group. This is despite the fact that more people in the traction group viewed surgery initially as favourable. A similar finding occurred with crossover. Four people crossed over from Extension-Oriented Treatment Approach to the traction group compared to only 1 the other way even though more people in the Extension-Oriented Treatment Approach viewed traction favourably than in the traction group.
5. Ozturk B, Gunduz OH, Ozoran K, Bostanoglu S. Effect of continuous lumbar traction on the size of herniated disc material in lumbar disc herniation. Rheumatology international. 2006 May;26:622-6.
   • Summary from Nick Rainey: There is at least some specific effect for decreasing herniated disc material.
6. Cai C, Pua YH, Lim KC. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with mechanical lumbar traction. European spine journal. 2009 Apr;18:554-61.
   • Summary from Nick Rainey: This study really doesn’t tell us anything. People who are worse don’t do as well as people who aren’t as bad. The predicting factors found (non-involvement of manual work, low level fear-avoidance beliefs, no neurological deficit and age above 30 years) are positive predictor factors except maybe age above 30, but most of the participants hovered around this age.

Some treatment options with further reading

• Instrument-Assisted Soft Tissue Mobilisation
• Lumbar Traction
• Manipulation of the Lumbar Spine

• Flexibility
• Maitlands' Mobilisation
• Mulligan Manual Therapy
• McKenzie Method
• Movement Control Tests For Lumbar Spine
• Endurance Exercises

Summary

Regardless of your assessment of the person’s problem with back pain communicating it effectively is essential. If the patient has an emergency red flag then helping them understand the gravity of it is essential so they can take the proper emergency steps. However, people, even with specific low back pain do not have an emergency and most people have “non-specific” low back pain. In the article “Easy to Harm Hard to Heal” we read many statements that patients have made in regards to their beliefs about their back. We know from Ben Darlow’s earlier work in 2013, "The enduring impact of what clinicians say to people with low back pain”, that what we as clinicians say plays a huge role in what patients believe about back pain. Focus your attention starting at the section “Vulnerability of the back” on page 2 through “The prognosis of back pain” which ends on page 8. When you read, think about two things. First, how do I make sure I never make someone more fearful than they need to be? Second, how do I help correct these beliefs if my patient has them?

You’ll still have times when you’re unsure of what’s best. Here’s a summary:

1. Work to help them not worry about what is occurring.
2. Address lifestyle issues- sleep, nutrition are big ones
3. Try manual therapy
4. Repeated motions help a lot of people
5. Low back and core specific exercises
6. Lower extremity strength exercises such as lunges and dead lifts
7. Aerobic training