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. 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"

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: symptom modulation, movement control and functional optimisation. These approaches each address different signs and symptoms you may find on assessment.

1. Symptom Modulation Approach

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. Movement Control Approach

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.

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 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).

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

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).

Active Range of Motion of the Lumbar Spine

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)
  • 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

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 principle 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 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.

Lumbar traction is one manual technique that is used widely by many clinicians. While there is mixed evidence for the use of lumbar traction, 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.

"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)

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."

"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."

More information on IASTM is available in these articles:

• Instrument Assisted Soft-Tissue Mobilization: A Commentary on Clinical Practice Guidelines for Rehabilitation Professionals
• The efficacy of instrument assisted soft tissue mobilization: a systematic review

Communication Ideas

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 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

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

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