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Low back pain treatment groups based on non-pathoanatomic model

Low back pain treatment groups based on non-pathoanatomic model
June 12, 2019TherexCliniciansEducational VideosPatients

Prevalence of low back pain is estimated up to 80% of the population will experience some form of low back pain in their lives

Most will have complete resolution not requiring intervention

Between 10% and 30% will have chronic symptoms (greater than 3 months)

Up to 5% of people with low back pain will become disabled

Largest predictor of low back pain is presence of a previous episode

Using non-anatomic model for diagnosis in non-specific low back pain

  • Using
    mechanical evaluation rather than trying to find specific anatomical culprit can
    be more effective in diagnosis
  • Treatment
    based on separating patients into syndromes or treatment groups
  • Judge
    whether treatment is effective based on a change in the comparable sign

Extension-based exercise

  • Symptoms
    worsen or peripheralize with prolonged or repeated flexion
  • Symptoms
    improve or centralize with prolonged or repeated extension
  • Treatment includes end-range
    extension, education on avoidance of flexion. Patients may benefit from
    mobilization

Flexion-based exercise

  • Usually
    older age (>50 years)
  • Symptoms
    worsen with prolonged or repeated extension
  • Symptoms
    improve with prolonged or repeated flexion
  • Imaging
    evidence of lumbar spinal stenosis
  • Treatment includes exercise to
    address flexibility, strength. Patients may benefit from mobilization, body
    weight supported ambulation

Lateral shift

  • Both
    flexion and extension worsen symptoms
  • Side
    glide motion relieves or centralizes symptoms
  • Patient
    may have visible frontal plane deformity (lateral deviation of shoulder girdle
    relative to pelvis in standing)
  • Treatment includes correction of
    lateral shift deformity, end-range side glide

Manipulation

  • Onset
    of symptoms < 16 days ago
  • Fear
    Avoidance Belief Questionnaire Work Subscale score < 19
  • No
    symptoms distal to the knee
  • One
    or more hypomobile segments in lumbar spine
  • Hip
    internal rotation range of motion > 35° at least one side
  • Treatment includes manipulation of
    lumbar spine, active range of motion exercise

Stabilization exercise

  • Usually
    younger age (<40 years)
  • Greater
    flexibility
  • Instability
    catch reported on motion testing in sagittal plane
  • Positive
    prone instability test
  • Treatment includes progression from
    individual activation of deep stabilizing muscles to co-contraction of flexors
    and extensors, static to dynamic movements, unloaded to loaded exercise

Traction

  • Symptoms
    of nerve root compression
  • No
    movement decreases or centralizes symptoms
  • Treatment focuses on auto traction or
    mechanical traction recommended in prone position

Therex Portal lists exercises to treat low back pain into treatment groups based on 1) Directional Preference 2) Mobility Deficit and 3) Movement Coordination Deficit. Here is an example of flexion-based exercise and an extension-based exercise.

Extension Based Exercise

Flexion Based Exercise

Sign up to Therex Portal to learn more and treat your
patients effectively. 

Register to our free trial at – https://therexportal.org/signup?type=trail

References

  • Beattie P, Nelson R, Michener L, Cammarata J, Donley
    J. Outcomes after a prone lumbar traction protocol for patients with activity-limiting
    low back pain: A prospective case series study. Arch Phys Med Rehabil. 2008;89(2):269-74.
  • Brennan G, Fritz
    J, Hunter S, Thackeray A, Delitto A, Erhard R. Identifying subgroups of
    patients with acute/subacute “nonspecific” low back pain: Results of a
    randomized clinical trial. Spine.
    2006;31(6):623-31.

  • Childs
    J, Fritz J, Flynn T, Irrgang J, Johnson K, Maikowski G, Delitto A. A clinical
    prediction rule to identify patients with low back pain most likely to benefit
    from spinal manipulation: A validation study. Ann Intern Med. 2004;141(12):920-8.
  • Flynn
    T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M,
    Allison S. A clinical prediction rule for classifying patients
    with low back pain who demonstrate short-term improvement with spinal
    manipulation. Spine.
    2002;27(24):2835-43.
  • Freburger
    J, Holmes G, Agans R, Jackman A, Darter J, Wallace A, Castel L, Kalsbeek W,
    Carey T. The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169(3):251-8.
  • Fritz J, Brennan
    G, Clifford S, Hunter S, Thackeray A. An examination of the reliability of a
    classification algorithm for subgrouping patients with low back pain. Spine. 2006;31(1):77-82.
  • Fritz J, Cleland J, Childs J.Subgrouping patients with low back pain: evolution of a
    classification approach to physical therapy. J Orthop Sports Phys Ther. 2007;37(6):290-302.
  • Johannes C, Le T, Zhou X, Johnston J, Dworkin R. The
    prevalence of chronic pain in United States adults: Results of an
    internet-based survey. J Pain. 2010;11:1230-9.
  • Long A, Donelson
    R, Fung T. Does it matter which exercise? A randomized control trial of
    exercise for low back pain. Spine. 2004;29(23):
    2593-602.
  • McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis & Therapy. 2nd
    ed. Waikanae, NZ: Spinal Publications New Zealand Ltd; 2003.
  • Tygiel P, Smith
    B, Robertson E, Shropshire M, Thorsen T. Misguided
    Guidelines for Low Back Pain Interventions. J
    Man Manip Ther
    . 2008;16(3):182–184.

Author- Kris Heintzelman PT, DPT, OCS.


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