Treatment Principles for the Lumbar Spine: Difference between revisions

No edit summary
No edit summary
 
(11 intermediate revisions by 2 users not shown)
Line 2: Line 2:


== Introduction ==
== Introduction ==
Treating the lumbar spine can be a complex scenario. It is difficult to know when to apply all the techniques you have been taught and how to adapt your plan if the outcome is not as predicted.
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. When structuring an assessment and treatment, the following principles can be helpful:
 
* 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 factors and consider how you talk about [[Pain-Modulation|pain]] - "words are very powerful"<ref name=":3">Rainey, N. Treatment of the Lumbar Spine Course. Physiopedia Plus. 2023</ref>


== Treatment-Based Classification System for Lower Back Pain ==
== Treatment-Based Classification System for Lower Back Pain ==
According to the research by Alrwaily et al<ref name=":0" />, there are three simple approaches when treating lower back pain: A Symptom Modulation Approach, a Movement Control Approach and a Functional Optimization Approach. These approaches are very interesting as they address different signs and symptoms commonly found on [[Lumbar Assessment|assessment]].
Alrwaily et al.<ref name=":0">Alrwaily M, Timko M, Schneider M, Stevans J, Bise C, Hariharan K, Delitto A. [https://academic.oup.com/ptj/article/96/7/1057/2864925 Treatment-based classification system for low back pain: revision and update.] Physical therapy. 2016 Jul 1;96(7):1057-66.</ref> describe three approaches to determining the most appropriate ''rehabilitation approach'' for low back pain: symptom modulation, movement control and functional optimisation. These approaches each address different signs and symptoms you may find on [[Lumbar Assessment|assessment]].


===== Symptom Modulation Approach =====
===== 1. Symptom Modulation Approach =====
A symptom modulation approach is matched to patients with recent—new or recurrent—LBP episode that is currently causing significant symptomatic features (Table). Because their clinical status is volatile, these patients tend to avoid certain postures; active range of motion is limited and painful. The neurological examination can reveal increased sensitivity. These patients need interventions that modulate their symptoms. In this group, patients are treated mainly with manual therapy, directional preference exercises, traction, or immobilization.
A symptom modulation approach is for patients with recent low back pain. This pain can be new or recurrent, and the episode of low back pain results in "significant symptomatic features" for the individual. Therefore, 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.<ref name=":0" />


===== Movement Control Approach =====
===== 2. Movement Control Approach =====
A movement control approach is matched to patients who have low-to-moderate levels of pain and disability that interfere with their activities of daily living (Table). The patient's status tends to be stable; that is, the patient describes a low baseline level of pain that increases by doing certain daily activities; however, the pain returns to its low-level baseline as soon as the patient ceases the activity. Other patients may describe recurrent attacks of LBP that are aggravated with sudden or unexpected movement, but currently they are asymptomatic or in remission. The patient's active spinal movements are typically full but may be accompanied by aberrant movements. The physical examination can reveal findings of impaired flexibility, muscle activation, and motor control. These patients need interventions to improve the quality of their movement system. For this group, the treatment in the 2007 TBC system mainly relied on stabilization exercises.16,35 In this updated 2015 TBC, however, we believe that stabilization exercises must be better defined, and other treatments need to be explored.
A [[Movement Control Tests For Lumbar Spine|movement control]] approach is for patients with low-to-moderate pain and disability, but who note difficulty performing activities of daily living. In these individuals, pain usually returns to baseline once an aggravating movement has ended. Other patients may be asymptomatic, but report repeated episodes of back pain that are often associated with a sudden movement. These patients usually have 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.<ref name=":0" />


===== Functional Optimization Approach =====
===== 3. Functional Optimisation Approach =====
A functional optimization intervention is for patients who are relatively asymptomatic; they can perform activities of daily living but need to return to higher levels of physical activities (eg, sport, job). The patient's status is well controlled (Table); that is, the pain is aggravated only by movement system fatigue. These patients may not have flexibility or control deficits, but they have impairments in movement system endurance, strength, and power that do not meet their physical demands.36 These patients need interventions that maximize their physical performance for higher levels of physical activities. For this group, the treatment should optimize the patient's performance within the context of a job or sport.
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 returning to sport or specific job requirements. 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).<ref name=":0" />


Examples of two approaches are outlined below:
If you would like to learn more on these approaches, the article by Alrwaily et al.<ref name=":0" /> is available here: [https://academic.oup.com/ptj/article/96/7/1057/2864925?login=false Treatment-Based Classification System for Low Back Pain: Revision and Update].
 
#'''Example of hierarchical exercise progression for patients matched to symptom modulation approach<ref name=":0">Alrwaily M, Timko M, Schneider M, Stevans J, Bise C, Hariharan K, Delitto A. [https://academic.oup.com/ptj/article/96/7/1057/2864925 Treatment-based classification system for low back pain: revision and update.] Physical therapy. 2016 Jul 1;96(7):1057-66.</ref>'''
#* Is the patient irritable or inflamed?
#** Yes, address inflammation by active rest
#** Active rest means limiting the patient's movement until the inflammation subsides
#* Does the patient peripheralise with extension and flexion, or have positive crossed SLR test?
#** Yes, prescribe traction
#**[[Lumbar Traction]]
#* Does the patient peripheralise with extension and flexion?
#** Yes, prescribe specific exercises that centralise the symptoms
#* Does the patient stop to centralize and have no symptoms distal to the knee?
#** Yes, prescribe manipulation
#**[[Manipulation of the Lumbar Spine]]
#'''Example of hierarchical exercise progression for patients matched to movement control approach<ref name=":0" />'''
#* Is there a sensitised neurological structure?
#** Yes, address the sensitised neurological structure
#** Neural
#* Is there a joint mobility or muscle flexibility impairment?
#** Yes, prescribe flexibility exercises or joint mobilisation
#**[[Flexibility]]
#**[[Maitland's Mobilisations|Maitlands' Mobilisation]]
#**[[Mulligan Manual Therapy]]
#**[[McKenzie Method]]
#* Is there a motor control impairment?
#** Yes, prescribe motor control exercises
#**[[Movement Control Tests For Lumbar Spine]]
#* Is there a muscle endurance impairment?
#** Yes, prescribe
#**[[Endurance Exercise|Endurance Exercises]]
 
=== Considerations Related to the Rehabilitation Approaches ===
The 3 rehabilitation approaches are mutually exclusive; however, patients can always be reclassified to receive a different rehabilitation approach as their clinical status changes (Fig. 1). For example, a patient who initially receives a movement control approach due to moderate levels of pain and disability can be reclassified to receive a functional optimization approach if his or her status improves to low pain and disability status, or the patient can be reclassified to receive a symptoms modulation approach if his or her status suddenly worsens. Alternatively, a patient can be discharged at any point when rehabilitation goals are attained.
 
It should be noted that, within each of the 3 rehabilitation approaches, a patient might fit the criteria of 2 or more treatment options, which requires prioritization of treatment. For example, in the symptom modulation approach, a patient may satisfy the criteria for manipulation and extension exercises as shown by Stanton et al.18 In that case, extension exercises take priority over manipulation. Extension exercises should be the treatment of choice until the patient's status plateaus. At that moment, manipulation may ensue (Fig. 4). Similarly, in the movement control approach, a patient may have motor control impairment and reduced muscle performance. In that case, motor control deficit takes priority over the muscle reduced performance. When the control deficit is corrected, muscle performance training can ensue (Fig. 5). This method of prioritization process is largely based on common clinical sense, warrants further research, and will be described in future articles.


== Treatment ==
== Treatment ==
Research shows that thrust manipulation targeting both stiff segments and painful segments is helpful for low back pain.<ref name=":1" /> Physiotherapists anecdotally apply this concept to non-thrust manipulation since most manual therapy techniques have similar mechanisms. 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 signs can be the stiffness or painfulness of the segment feels with a technique either to the patient or to the therapist.<ref name=":1">Nim CG, Kawchuk GN, Schiøttz-Christensen B, O’Neill S. [https://www.nature.com/articles/s41598-020-71557-y The effect on clinical outcomes when targeting spinal manipulation at stiffness or pain sensitivity: a randomized trial.] Scientific Reports. 2020 Sep 3;10(1):14615.</ref>
There are many different treatment approaches for low back pain, and all can have favourable outcomes. Some examples are: the [[Maitland's Mobilisations|Maitland approach]], [[McKenzie Method|Mechanical Diagnosis and Therapy]] (also commonly known as the McKenzie approach), [[Behavioural Approaches to Pain Management|Cognitive Functional Therapy]]<ref>Castro J, Correia L, de Sousa Donato B, Arruda B, Agulhari F, Pellegrini MJ, Belache FT, de Souza CP, Fernandez J, Nogueira LA, Reis FJ. [https://journals.lww.com/pain/Abstract/2022/12000/Cognitive_functional_therapy_compared_with_core.17.aspx Cognitive functional therapy compared with core exercise and manual therapy in patients with chronic low back pain: randomised controlled trial.] Pain. 2022 Dec 1;163(12):2430-7.</ref> (Peter O’Sullivan<ref>O’Sullivan PB, Caneiro JP, O’Keeffe M, Smith A, Dankaerts W, Fersum K, O’Sullivan K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6037069/ Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain.] Physical therapy. 2018 May 1;98(5):408-23.</ref>), and [[Classification Of Low Back Pain Using Shirley Sahrmann’s Movement System Impairments, An Overview Of The Concept|Movement Impairment Syndromes]]<ref>Sahrmann S, Azevedo DC, Van Dillen L. [https://www.sciencedirect.com/science/article/abs/pii/S1413355517303660 Diagnosis and treatment of movement system impairment syndromes.] Brazilian journal of physical therapy. 2017 Nov 1;21(6):391-9.</ref><ref>Sahrmann S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8720255/ Doctors of the movement system–identity by choice or therapists providing treatment–identity by default.] International Journal of Sports Physical Therapy. 2022;17(1):1.</ref> (Shirley Sahrmann).
 
{{#ev:youtube|jhqPp9JGq9s}}


===== Signs and symptoms approach  and asterisk sign details. =====
=== Active Range of Motion of the Lumbar Spine ===
Be as specific as possible and make sure positive tests are reproducible and watch how they change over time.  
For individuals with low back pain, assessing active range of motion can give you a lot of clues about possible impairments and treatment options. Look for the following.


Identifying recovery limiting factors and frame everything with a correct view of pain
* Movement patterns
** Does the patient move to the side when moving into lumbar flexion? This could indicate scoliosis or that they are trying to avoid pain in certain positions
*[https://jnnp.bmj.com/content/68/2/149 Gowers' sign] (i.e. climbing up the legs while returning to standing from a flexed position<ref>Shrestha S, Munakomi S. Gower Sign. [Updated 2022 Feb 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK540973/</ref>)
** If a patient uses their hands to return to neutral after performing lumbar flexion, it can indicate weakness
* Always look at where the movement is coming from, and check repeated movements
For more information on using repeated movements as an intervention, please see the Management Section in [[McKenzie Method]].


===== Treatment =====
=== Potential Treatment Options ===
Patients with chronic low back pain should perform intense aerobic exercise for greater than 30 minutes 3 times each week. Chatzitheodorou 2007


Chatzitheodorou, Dimitris, et al. "A pilot study of the effects of high-intensity aerobic exercise versus passive interventions on pain, disability, psychological strain, and serum cortisol concentrations in people with chronic low back pain." Physical therapy 87.3 (2007): 304-312.
===== Aerobic Exercise =====
According to Chatzitheodorou et al.,<ref name=":2">Chatzitheodorou D, Kabitsis C, Malliou P, Mougios V. [https://academic.oup.com/ptj/article/87/3/304/2742120 A pilot study of the effects of high-intensity aerobic exercise versus passive interventions on pain, disability, psychological strain, and serum cortisol concentrations in people with chronic low back pain.] Physical therapy. 2007 Mar 1;87(3):304-12.</ref> patients with chronic low back pain should be encouraged to perform aerobic exercise for 30+ minutes 3 times per week.<ref name=":2" />


Back to classification. All schools of thought are trying to be as specific as possible- Maitland approach, Mechanical Diagnosis and Therapy (McKenzie), CFT (O’Sullivan), Movement Impairment Syndromes (Sahrmann)
===== Manual Therapy =====
Research shows that thrust manipulation which targets both stiff and painful segments is helpful for low back pain.<ref name=":1" /> Since all manual therapy has similar mechanisms, this principle can be used for non-thrust manipulation as well.<ref name=":3" /> 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 the patient has 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.<ref name=":1">Nim CG, Kawchuk GN, Schiøttz-Christensen B, O’Neill S. [https://www.nature.com/articles/s41598-020-71557-y The effect on clinical outcomes when targeting spinal manipulation at stiffness or pain sensitivity: a randomized trial.] Scientific Reports. 2020 Sep 3;10(1):14615.</ref>


Lumbar traction is a common intervention performed.  
{{#ev:youtube|jhqPp9JGq9s}}Lumbar traction is one manual technique that is used widely by many clinicians. While there is mixed evidence for the use of lumbar traction,<ref>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.</ref><ref>National Institute for Health and Care Excellence (Great Britain). 2[https://pubmed.ncbi.nlm.nih.gov/27929617/ 018 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.</ref><ref>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.</ref><ref>Thackeray A, Fritz JM, Childs JD, Brennan GP. [https://www.jospt.org/doi/full/10.2519/jospt.2016.6238 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.</ref><ref>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.</ref><ref>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.</ref> Nick Rainey notes that, in clinical settings, it can sometimes be helpful as a treatment for low back pain and lumbar radicular pain. But it's important to remember that it isn’t "magical" by itself.<ref name=":3" /> <blockquote>"My experience shows that people can have less pain with extension after manual traction. I often do this by having them do an extension exercise and then providing manual sacral traction... These techniques likely wouldn’t show any difference if the patient just did the extension exercises for 6 weeks on their own. However, they are more likely to do the exercises in a non-research based setting if they are more comfortable." - Nick Rainey</blockquote>


===== Lumbar Traction Literature: =====
===== Instrument Assisted Soft Tissue Mobilisation (IASTM) =====
[[Instrument Assisted Soft Tissue Mobilization|IASTM]] is commonly used to treat myofascial restriction. There are a range of IASTM instruments available, which are designed to "provide a mobilizing effect to soft tissue [...] to decrease pain and improve range of motion (ROM) and function."<ref name=":4" /><blockquote>"As a standalone technique, is this [IASTM] going to be very effective? No. But as a whole, this can help me with my other techniques, they feel a lot better. And it helps them be more active."<ref name=":3" /></blockquote>More information on IASTM is available in these articles:


# 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.<ref>Schimmel JJ, De Kleuver M, Horsting PP, Spruit M, Jacobs WC, Van Limbeek J. [https://link.springer.com/article/10.1007/s00586-009-1044-3 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.</ref>
* [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6670063/ Instrument Assisted Soft-Tissue Mobilization: A Commentary on Clinical Practice Guidelines for Rehabilitation Professionals]<ref>Cheatham SW, Baker R, Kreiswirth E. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6670063/ INSTRUMENT ASSISTED SOFT-TISSUE MOBILIZATION: A COMMENTARY ON CLINICAL PRACTICE GUIDELINES FOR REHABILITATION PROFESSIONALS]. Int J Sports Phys Ther. 2019 Jul;14(4):670-82.</ref>
#* '''<u>Summary:</u>''' 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.
* [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5039777/ The efficacy of instrument assisted soft tissue mobilization: a systematic review]<ref name=":4">Cheatham SW, Lee M, Cain M, Baker R. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5039777/ The efficacy of instrument assisted soft tissue mobilization: a systematic review]. J Can Chiropr Assoc. 2016 Sep;60(3):200-211. </ref>
# 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.<ref>National Institute for Health and Care Excellence (Great Britain). [https://pubmed.ncbi.nlm.nih.gov/27929617/ 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.</ref>
#* '''<u>Summary:</u>''' 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 (RFA) to offer I question. I put a few of the common things we encounter that I thought would be of interest below.
# 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.<ref>Gudavalli MR, Cambron JA, McGregor M, Jedlicka J, Keenum M, Ghanayem AJ, Patwardhan AG. [https://link.springer.com/article/10.1007/s00586-005-0021-8 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.</ref>
#* '''<u>Summary:</u>''' 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.
# 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.<ref>Thackeray A, Fritz JM, Childs JD, Brennan GP. [https://www.jospt.org/doi/full/10.2519/jospt.2016.6238 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.</ref>
#* '''<u>Summary:</u>''' 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 MDT model that included lateral shift correction if needed. The traction group did have 13% go on to surgery compared to 20% in the EOTA group. This is despite the fact that more people in the traction group viewed surgery initially as favorable. A similar finding occurred with crossover. Four people crossed over from EOTA to the traction group compared to only 1 the other way even though more people in the EOTA viewed traction favorably than in the traction group.
# 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.<ref>Ozturk B, Gunduz OH, Ozoran K, Bostanoglu S. [https://link.springer.com/article/10.1007/s00296-005-0035-x Effect of continuous lumbar traction on the size of herniated disc material in lumbar disc herniation.] Rheumatology international. 2006 May;26:622-6.</ref>
#* '''<u>Summary:</u>''' There is at least some specific effect for decreasing herniated disc material.
# 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.<ref>Cai C, Pua YH, Lim KC. [https://link.springer.com/article/10.1007/s00586-009-0909-9 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.</ref>
#* <u>'''Summary:'''</u> 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.


== Summary ==
== Communication Ideas ==
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”<ref>Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. [https://www.annfammed.org/content/11/6/527.short The enduring impact of what clinicians say to people with low back pain.] The Annals of Family Medicine. 2013 Nov 1;11(6):527-34.</ref> 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?
When treating individuals with low back pain, it is essential to communicate your assessment findings effectively. If a patient has an emergency red flag, then helping them understand the gravity of it is essential, so they can take the proper emergency steps.  


You’ll still have times when you’re unsure of what’s best. Here’s a summary:
However, the majority of people with low back pain, even those with specific low back pain, do not present with an emergency red flag symptom, so we have to consider carefully how we communicate with our patients. We know from Ben Darlow’s<ref>Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. [https://www.annfammed.org/content/11/6/527.short The enduring impact of what clinicians say to people with low back pain.] The Annals of Family Medicine. 2013 Nov 1;11(6):527-34.</ref> 2003 work "[t]he enduring impact of what clinicians say to people with low back pain” - i.e. that what we as clinicians say plays a huge role in what patients believe about back pain. In the article, [https://journals.lww.com/spinejournal/Abstract/2015/06010/Easy_to_Harm,_Hard_to_Heal__Patient_Views_About.21.aspx Easy to Harm Hard to Heal], there are many statements from patients on their beliefs about their back.<blockquote>Therefore, when thinking about treating persons with back pain, consider the following: "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?" - Nick Rainey<ref name=":3" /></blockquote>You’ll still have times when you’re unsure of what’s best, but consider the following:<ref name=":3" />


# Work to help them not worry about what is occurring.
# Work to help them not worry about what is occurring
# Address lifestyle issues- sleep, nutrition are big ones
# Address lifestyle issues - sleep and nutrition are big ones
# Try manual therapy
# Try manual therapy
# Repeated motions help a lot of people
# Repeated motions help a lot of people
# Low back and core specific exercises
# Try low back and core specific exercises
# Lower extremity strength exercises such as lunges and dead lifts
# Lower extremity strength exercises such as lunges and dead lifts can be helpful
# Aerobic training  
# Incorporate aerobic training


== References ==
== References ==

Latest revision as of 10:48, 9 March 2023

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

Introduction[edit | edit source]

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. When structuring an assessment and treatment, the following principles can be helpful:

  • 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 factors and consider how you talk about pain - "words are very powerful"[1]

Treatment-Based Classification System for Lower Back Pain[edit | edit source]

Alrwaily et al.[2] describe three approaches to determining the most appropriate rehabilitation approach for low back pain: symptom modulation, movement control and functional optimisation. These approaches each address different signs and symptoms you may find on assessment.

1. Symptom Modulation Approach[edit | edit source]

A symptom modulation approach is for patients with recent low back pain. This pain can be new or recurrent, and the episode of low back pain results in "significant symptomatic features" for the individual. Therefore, 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]

2. Movement Control Approach[edit | edit source]

A movement control approach is for patients with low-to-moderate pain and disability, but who note difficulty performing activities of daily living. In these individuals, pain usually returns to baseline once an aggravating movement has ended. Other patients may be asymptomatic, but report repeated episodes of back pain that are often associated with a sudden movement. These patients usually have 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.[2]

3. Functional Optimisation Approach[edit | edit source]

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 returning to sport or specific job requirements. 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).[2]

If you would like to learn more on these approaches, the article by Alrwaily et al.[2] is available here: Treatment-Based Classification System for Low Back Pain: Revision and Update.

Treatment[edit | edit source]

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[3] (Peter O’Sullivan[4]), and Movement Impairment Syndromes[5][6] (Shirley Sahrmann).

Active Range of Motion of the Lumbar Spine[edit | edit source]

For individuals with low back pain, assessing active range of motion can give you a lot of clues about possible impairments and treatment options. Look for the following.

  • Movement patterns
    • Does the patient move to the side when moving into lumbar flexion? 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[7])
    • If a patient uses their hands to return to neutral after performing lumbar flexion, it can indicate weakness
  • Always look at where the movement is coming from, and check repeated movements

For more information on using repeated movements as an intervention, please see the Management Section in McKenzie Method.

Potential Treatment Options[edit | edit source]

Aerobic Exercise[edit | edit source]

According to Chatzitheodorou et al.,[8] patients with chronic low back pain should be encouraged to perform aerobic exercise for 30+ minutes 3 times per week.[8]

Manual Therapy[edit | edit source]

Research shows that thrust manipulation which targets both stiff and painful segments is helpful for low back pain.[9] Since all manual therapy has similar mechanisms, this principle can be used for non-thrust manipulation as well.[1] 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 the patient has 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.[9]

Lumbar traction is one manual technique that is used widely by many clinicians. While there is mixed evidence for the use of lumbar traction,[10][11][12][13][14][15] Nick Rainey notes that, in clinical settings, it can sometimes be helpful as a treatment for low back pain and lumbar radicular pain. But it's important to remember that it isn’t "magical" by itself.[1]

"My experience shows that people can have less pain with extension after manual traction. I often do this by having them do an extension exercise and then providing manual sacral traction... These techniques likely wouldn’t show any difference if the patient just did the extension exercises for 6 weeks on their own. However, they are more likely to do the exercises in a non-research based setting if they are more comfortable." - Nick Rainey

Instrument Assisted Soft Tissue Mobilisation (IASTM)[edit | edit source]

IASTM is commonly used to treat myofascial restriction. There are a range of IASTM instruments available, which are designed to "provide a mobilizing effect to soft tissue [...] to decrease pain and improve range of motion (ROM) and function."[16]

"As a standalone technique, is this [IASTM] going to be very effective? No. But as a whole, this can help me with my other techniques, they feel a lot better. And it helps them be more active."[1]

More information on IASTM is available in these articles:

Communication Ideas[edit | edit source]

When treating individuals with low back pain, it is essential to communicate your assessment findings effectively. If a 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, the majority of people with low back pain, even those with specific low back pain, do not present with an emergency red flag symptom, so we have to consider carefully how we communicate with our patients. We know from Ben Darlow’s[18] 2003 work "[t]he enduring impact of what clinicians say to people with low back pain” - i.e. that what we as clinicians say plays a huge role in what patients believe about back pain. In the article, Easy to Harm Hard to Heal, there are many statements from patients on their beliefs about their back.

Therefore, when thinking about treating persons with back pain, consider the following: "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?" - Nick Rainey[1]

You’ll still have times when you’re unsure of what’s best, but consider the following:[1]

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

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Rainey, N. Treatment of the Lumbar Spine Course. Physiopedia Plus. 2023
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Alrwaily M, Timko M, Schneider M, Stevans J, Bise C, Hariharan K, Delitto A. Treatment-based classification system for low back pain: revision and update. Physical therapy. 2016 Jul 1;96(7):1057-66.
  3. ↑ Castro J, Correia L, de Sousa Donato B, Arruda B, Agulhari F, Pellegrini MJ, Belache FT, de Souza CP, Fernandez J, Nogueira LA, Reis FJ. Cognitive functional therapy compared with core exercise and manual therapy in patients with chronic low back pain: randomised controlled trial. Pain. 2022 Dec 1;163(12):2430-7.
  4. ↑ O’Sullivan PB, Caneiro JP, O’Keeffe M, Smith A, Dankaerts W, Fersum K, O’Sullivan K. Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Physical therapy. 2018 May 1;98(5):408-23.
  5. ↑ Sahrmann S, Azevedo DC, Van Dillen L. Diagnosis and treatment of movement system impairment syndromes. Brazilian journal of physical therapy. 2017 Nov 1;21(6):391-9.
  6. ↑ Sahrmann S. Doctors of the movement system–identity by choice or therapists providing treatment–identity by default. International Journal of Sports Physical Therapy. 2022;17(1):1.
  7. ↑ Shrestha S, Munakomi S. Gower Sign. [Updated 2022 Feb 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK540973/
  8. ↑ 8.0 8.1 Chatzitheodorou D, Kabitsis C, Malliou P, Mougios V. A pilot study of the effects of high-intensity aerobic exercise versus passive interventions on pain, disability, psychological strain, and serum cortisol concentrations in people with chronic low back pain. Physical therapy. 2007 Mar 1;87(3):304-12.
  9. ↑ 9.0 9.1 Nim CG, Kawchuk GN, Schiøttz-Christensen B, O’Neill S. The effect on clinical outcomes when targeting spinal manipulation at stiffness or pain sensitivity: a randomized trial. Scientific Reports. 2020 Sep 3;10(1):14615.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ 16.0 16.1 Cheatham SW, Lee M, Cain M, Baker R. The efficacy of instrument assisted soft tissue mobilization: a systematic review. J Can Chiropr Assoc. 2016 Sep;60(3):200-211.
  17. ↑ Cheatham SW, Baker R, Kreiswirth E. INSTRUMENT ASSISTED SOFT-TISSUE MOBILIZATION: A COMMENTARY ON CLINICAL PRACTICE GUIDELINES FOR REHABILITATION PROFESSIONALS. Int J Sports Phys Ther. 2019 Jul;14(4):670-82.
  18. ↑ Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. The Annals of Family Medicine. 2013 Nov 1;11(6):527-34.
Retrieved from "https://www.physio-pedia.com/index.php?title=Treatment_Principles_for_the_Lumbar_Spine&oldid=328209"