A Classification Approach for patients with Low Back Pain has been used as a guide to sub-group patients based on their clinical signs and symptoms. In 2012, Low Back Pain Clinical Practice Guidelines were published.
Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association
- Describes evidence-based physical therapy practice, including diagnosis, prognosis, intervention, and assessment of outcome, for musculoskeletal disorders
- Identifes interventions supported by current best evidence to address impairments of body function and structure, activity limitations, and participation restrictions
- Identifies appropriate outcome measures
- Overall, the purpose of these Low back Pain Guidelines is to describe literature and make recommendations for:
- Treatment for associated subgroups of low back pain
- Treatments that have supported evidence
- Classifies patients into groups based on clinical characteristics and matching these patient subgroups to management strategies likely to benefit them will improve the outcome of physical therapy interventions
- Evolution of Treatment Based Classification: Fritz, Cleland, Childs
- 3 distinct differences from the Treatment Based Classification Approach to Low Back Pain
- Categories incorporate International Classification of Functioning, Disability, and Health (IFC) impairments of body functions terminology
- Addition of the low back pain with “related cognitive or affective tendencies” and “generalized pain”
- Addition of the patients acuity level
- Low Back Pain Clinical Practice Guidelines is divided into 6 categories, upon which this page will focus on Low back pain with mobility deficits
The lumbar spine has several distinguishing characteristics:
- The lower the vertebra is in the spinal column, the more weight it must bear. The five vertebrae of the lumbar spine (L1-L5) are the biggest unfused vertebrae in the spinal column, enabling them to support the weight of the entire torso.
- The lumbar spine's lowest two spinal segments, L4-L5 and L5-S1, which include the vertebrae and discs, bear the most weight and are therefore the most prone to degradation and injury.
- The lumbar spine meets the sacrum at the lumbosacral joint (L5-S1). This joint allows for considerable rotation, so that the pelvis and hips may swing when walking and running.
The sacroiliac joint (SI-joint) connects the sacrum (triangular bone at the bottom of the spine) with the pelvis (iliac bone that is part of the hip joint) on each side of the lower spine. It transmits all the forces of the upper body to the pelvis and legs. There is not a lot of motion in the joint and it is very strong and stable.
ETIOLOGY:
Low back pain (LBP) has a major medical and economic impact in the world. The impact of severe LBP increases with advancing age and is a strong contributor to mobility disability. Obese persons with LBP have increased disability, higher pain severity and worse functional capacity than non-obese counterparts. The causes of LBP appear to be complex and multifactorial, with both biological and psychosocial components associated with chronicity. There is a significant relationship between reduced hip mobility and low back pain as the reduction in of both passive and active movement (ROM) has been demonstrated in general . Several researchers described low back pain as the leading cause of activity, limitation and work absence throughout much of the world and is associated with an enormous economic burden. In spite of the large number of potentially pain generating structures and pathological conditions that can give rise to LBP in most cases approximately eighty-five to ninety percent have no identifiable cause which are defined as non-specific low back pain. The loss of mobility and functional capacity resulting from back pain are serious threats to public health as they are predictive of chronic disability.
CLINICAL FEATURES:
For acute low back pain with mobility deficits, the distinguishing movement/pain characteristic is that the patient demonstrates restricted spinal range of motion and segmental mobility, and that the patient’s low back and low back–related lower extremity symptoms are reproduced with provocation of the involved segments, with intervention strategies focused on reducing pain and improving mobility of the involved spinal segments.
For subacute low back pain with mobility deficits the distinguishing movement/pain characteristic is pain that occurs with mid- to end-ranges of active or passive motions, with intervention strategies focused on movements that in¬crease movement tolerances in the mid- to end-ranges of motions.
Acute low back pain: According to the ICF (International Classification of Functioning, Disability and Health), codes of low back pain with (sub)acute low back pain with mobility deficits leads to the following problems on body functions, body structure, and activities and participation
- Acute low back, buttock, or thigh pain (duration of 1 month or less)
- Restricted lumbar range of motion and segmental mobility
- Low back and low back–related lower extremity symptoms reproduced with provocation of the involved lower thoracic, lumbar, or sacroiliac segments.
- Sub-acute, unilateral, low back, buttock, or thigh pain
- Symptoms reproduced with end-range spinal motions and provocation of the involved lower thoracic, lumbar, or sacroiliac segments
- Presence of thoracic, lumbar, pelvic girdle, or hip active, segmental, or accessory mobility deficits.
Objective assessments of lumbar motion can be achieved by a variety of methods:
- Examination of regional motion using an inclinometer ROM,
- Finger-to-floor distance
- Schober Index
- Visualize possible deviations or abnormal structures in the spine of the patient by using radiography, for example: MRI and CT scans.
Imaging and Examinations:
There are three important examination-components to examine a patient with low back pain and lumbar mobility deficit. The first one is to visualize possible deviations or abnormal structures in the spine of the patient by using radiography, for example: MRI and CT scans.
There is no imaging indicated if “reduced lumbar spinal movement with low back pain” is described as an acute symptom which lasts 1 month or less and with the absence of red flag signs.It’s important to know that these investigations do not identify the specific causes of pain (low sensitivity and specificity), but this research is mostly used with serious conditions. The second one is to take a detailed and specific history of the patient. Based on this history we get an overview of possible clues to find the cause of low back pain. And at least there is the last component, the physical examination. This consists of a series of tests which helps to find the causes of pain with which the patient struggles.
Objective assesments of the lumbar motion can be achieved by a variety of methods
- Examination of the regional motion using an inclinometer ROM
- Finger-to-floor distance
- Schober-index
Physical examinations:
Lumar ROM test: People with low back pain frequently show movement control impairments of the lumbar spine in the sagittal plane: flexion and extension. The research of C.M. Bauer et Al. noted also a linear effect of Low Back Pain intensity on variability of lumbar movement patterns. It’s therefore we recommend therapists to examine those specific movements in the sagittal plane.
Lumbar mobility examination: In an article of J.M. Fritz et Al. the mobility of each spinal segment of the lumbar spine was graded as normal, hypomobile, or hypermobile by using PA-techniques (posterior to anterior gentle pressure on the processus spinosus with the hypothenar eminence). Thereafter the patient was categorized in either the presence of hypomobility or the presence of hypermobility. If hypomobility was judged to be present at any level of a subject’s lumbar spine, the subject was categorized as having hypomobility. This examination technique should be interpreted with other information have obtained.
SLR test:
Slump test:
Trunk muscle power and endurance test: Check Trunk Flexors, Extensors, Lateral Abdominals, Transversus Abdominis, Hip Abductors, and Hip Extensors for strength looking for any muscle imbalances.
MANAGEMENT:
Medical management:
- The patients with low back pain need to be stimulated and motivated to remain active and keep doing ADL, instead of resting in bed which has many disadvantages: joint stiffness, muscle wasting, loss of bone mineral density, pressure ulcers, and venous thrombo-embolism.
- To develop coping-strategies through education
- To avoid movements such as: twisting and bending
Another medical treatment is the prescription of certain drugs, such as:
- Analgesics, the research of JM. Williams et Al. shows us that reducing pain by analgesics does not alter the lumbar range of motion in chronic patients with low back pain.
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Muscle relaxants
1. Aim and strategy of therapy in this case:
1.1 Manual therapy procedure (thrust or non-thrust) to diminish pain and improve segmental spinal or lumbopelvic motion
1.2 Therapeutic exercise to improve or maintain spinal mobility
1.3 Patient education that encourages the patient to return to or pursue an active lifestyle
2. Example of full therapy:
- Joint mobilizations or manipulations on thoracic spine like the Supine Thoracic Thrust Manipulation. For more information on Manual Therapy.
2.2 Therapeutic Exercises:
- Core Stabilization including engaging the transverse abdominus and multifidus. Biofeedback may be useful.
- Anterior and posterior pelvic tilts
- Bridges
- Quadruped for cat/camel stretching
2.3 Patient Education:
- Posture
- Home Exercise Program
Multi-directional hip stretching home exercise program
Frequency; 5 times a week
Duration; each stretch is to be held for 30 seconds
Repeat; 3 times
All stretches most be done on both sides
- Crook lying
- Lunge
- Sitting – Hip medial rotation, flexion and abduction stretch
- Standing – Groin stretch
- Sitting – Groin stretch
- Prone hip medial rotation – Leg fall out stretch
- Prone hip lateral rotation – Leg fall in stretch
2.2. 3 Strengthening home exercise programme
Frequency; 5 times a week
All stretches most be done on both sides
Weeks 1 & 2
- Clams
- Prone hip external rotation with theraband
- Side-lying hip abduction
- Quadruped hip extension
- Single leg stand
- Prone hip medial rotation – Leg fall out stretch
- Prone hip lateral rotation – Leg fall in stretch
Weeks 3 & 4
- Quadruped hip extension
- Single leg bridge
- Single leg squats
- Lateral step exercise
- Standing hip rotation exercise
- Prone hip medial rotation – Leg fall out stretch
- Prone hip lateral rotation – Leg fall in stretch
Weeks 5 & 6
- Single leg squats
- Single leg bridge
- Lateral step exercise
- Standing hip rotation exercise with theraband
- Prone hip medial rotation – Leg fall out stretch
- Prone hip lateral rotation – Leg fall in stretch
Stretching program using the Global Postural Reeductaion method showed effective at improving pain, function, some quality of life aspects (emotional, limitations in physical functioning, vitality and mental health) and had no effect on depressive symptoms in patients with chronic low back pain.
The GPR is a therapy which is based on the muscle chains of the muscular system wherein a shortening can occur.
Reasons:
- constitutional factors
- Behavioral factors
- Psychological factors
The main goal of this therapy is to stretch the shortened muscles using the creep of viscoelastic tissue and to improve contraction of the antagonist muscles, which leads thus to avoiding postural asymmetry.
Method:
A. Lying on back with the legs extended.
B. Lying on back with the legs flexed.
C. Standing with the body leaning forward’.
D. Sitting with legs extended.
E. Standing in the center
Physiotheray Practice Guidelines can be used by physiotherapists in examination, differential diagnosis, and intervention planning for patients with low back pain. These evidence-based guidelines can be applied to patients with acute and sub-acute low back pain. This page has summarized the guidelines for patients in the categories of Acute and Sub-acute Low Back Pain with Mobility Deficits and knowledge about the problems.
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