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.

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References

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• 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.
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  T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M,
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  J, Holmes G, Agans R, Jackman A, Darter J, Wallace A, Castel L, Kalsbeek W,
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• 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):
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Author- Kris Heintzelman PT, DPT, OCS.