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 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.

Treatment-Based Classification System for Lower Back Pain

According to the research by Alrwaily et al, 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 assessment.

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.

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.

Functional Optimization 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.

Examples of two approaches are outlined below:

1. Example of hierarchical exercise progression for patients matched to symptom modulation approach
   • 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
2. Example of hierarchical exercise progression for patients matched to movement control approach
   • 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
     • 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 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

Research shows that thrust manipulation targeting both stiff segments and painful segments is helpful for low back pain. 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.

Signs and symptoms approach  and asterisk sign details.

Be as specific as possible and make sure positive tests are reproducible and watch how they change over time.

Identifying recovery limiting factors and frame everything with a correct view of pain

Treatment

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.

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)

Lumbar traction is a common intervention performed.

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: 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: 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.
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: 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: 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.
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: 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: 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

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