Low Back Rehabilitation






  • Chapter Objectives



  • Explain the need for classification methods designed to direct the treatment of patients with low back pain.



  • Recognize red flags indicating the potential for a serious underlying condition.



  • Explain the importance of yellow flags to the management of patients with low back pain.



  • Determine the stage of a patient with low back pain.



  • Identify key signs and symptoms and determine the classification of the patient and the treatments associated with a patient classified to be in stage I.



  • Identify key impairments and the treatments designed to eliminate these impairments in patients determined to be in a stage II classification.


Low back pain (LBP) is a nearly universal experience in the adult population. Studies have documented the lifetime prevalence rate of LBP to be as high as 80%. Although most cases are self-limited and recover with little intervention, those who recover are prone to recurrences at a rate of up to 60%. The past few decades has witnessed numerous advances in the medical community’s understanding of the lumbar spine. The functional anatomy of the lumbar spine has been investigated in detail, the biomechanics of the lumbar motion segments has been studied, and new technology has allowed more precise diagnostic imaging of the spine. Despite these advances, the prevalence of LBP and its associated costs has been growing at an alarming rate in recent decades, which has led to the characterization of back pain as an epidemic.


LBP is also a prevalent and problematic condition in athletes. Up to 20% of all sports-related injuries are reported to involve the spine. Athletes in certain sports appear to be particularly susceptible to LBP. For example, high rates of LBP in athletes participating in the following sports have been reported: gymnastics, swimming, tennis, volleyball, and football, as well as others. Rehabilitation of individuals with LBP, including athletes, remains largely enigmatic. Numerous approaches to rehabilitation have been advocated, yet for any given individual with LBP, selection of a treatment method from among the many competing approaches has been said to take on the characteristics of a lottery, with the rehabilitation specialist often being left uncertain of the best course of action to undertake with any particular patient. This chapter presents a classification-based approach to the evaluation and treatment of patients with LBP. This approach seeks to classify patients with LBP on the basis of clusters of signs and symptoms. The patient’s classification is then matched to a treatment strategy believed to be most effective for that individual patient.




Evaluation and treatment: the importance of classification


Identifying the anatomic structure responsible for LBP is often difficult, and in up to 90% of patients, a precise diagnosis cannot be made on the basis of pathology. In this large group of patients a nominal diagnosis such as “lumbar strain” or “back pain” is typically made, and it has been considered a homogeneous entity. Although it is generally agreed that most of these patients should be treated conservatively, the search for effective conservative treatment measures has been elusive. It has been suggested that undiagnosed LBP is not actually a homogeneous entity but instead consists of subtypes or classifications of patients who can be identified on the basis of specific signs and symptoms noted during examination. The classification in turn directs the clinician to a specific treatment intervention. An effective classification system for LBP should improve the clinician’s decision making and may be necessary before the therapeutic benefit of specific conservative treatment interventions can be documented in research studies.


Delitto et al , have proposed a treatment-based classification system for use in the evaluation and treatment of individuals with LBP. This system uses information gathered from the physical examination and from patient self-reports to guide patient management. Three basic levels of decision making or classification are required: (1) the athlete must be screened for red flags and yellow flags to ascertain suitability for rehabilitation, (2) the acuity (or stage) of the low back condition must be determined, and finally (3) a treatment approach is selected.


Assessing for Red and Yellow Flags: First-Level Classification


Red Flags


Even though a specific pathoanatomic source cannot be identified in most individuals with LBP, the cause in most cases can be attributed to mechanical factors. In a much smaller percentage of patients, the cause may be something more serious such as a fracture, cauda equina syndrome, neoplastic condition, or inflammatory disease. Red flags are signs or symptoms that suggest a more serious underlying pathology and may necessitate referral for medical or surgical intervention.


Several findings from the patient’s history should alert the clinician to the potential for a serious underlying pathology. Spinal fractures can occur as a result of major trauma or falls. Compression fractures most commonly occur in postmenopausal women or in individuals with other bone-weakening conditions such as chronic corticosteroid use. Stress fractures are also not uncommon in athletes with persistent LBP. Stress fractures of the sacrum have been reported as a cause of LBP in athletes. The pars interarticularis of the vertebral arch is the most common site of stress fractures in the spine, particularly in athletes involved in sports activities that involve repeated extension and rotation movements. The term spondylolysis describes a bony defect in the pars interarticularis region. Rates of spondylolysis are particularly high in gymnasts, weight lifters, throwing athletes in track and field, divers, and rowers. , Spondylolysis may progress to spondylolisthesis, or forward slippage of one vertebra in relation to the vertebra below ( Fig. 17-1 ). Red flags that may indicate the presence of spondylolysis or spondylolisthesis include teenage athletes with LBP, participation in sports involving repetitive hyperextension of the spine, and pain with extension activities. If a spondylolytic lesion is suspected, referral for further diagnostic imaging should be considered. Early identification of these conditions may prevent a nonunion fracture or progression of the slippage. Treatment may involve bracing and limitation of activity. Rehabilitation typically focuses on stabilization exercises.




Figure 17-1


Grade 1 spondylolisthesis of the L4 vertebra in a 17-year-old football offensive lineman with low back pain.


LBP caused by a spinal neoplasm is rare and occurs in less than 1% of individuals with LBP. A missed or delayed diagnosis is possible if an awareness of red flags for the condition is lacking. Deyo and Diehl identified several red flags that should raise suspicion for spinal tumors, including older than 50 years of age, unexplained weight loss, and no relief with bed rest. The most significant red flag is a previous history of cancer. The most common cancers that may result in metastases to the spine involve the breast, lung, and prostate. LBP caused by infectious conditions such as osteomyelitis or septic discitis are also rare; red flags include fever, chills, a recent history of an infectious condition such as a urinary tract infection, or intravenous drug use. The medical history may also provide the first clues for detecting ankylosing spondylitis, a rheumatic inflammatory disorder more common in male individuals and characterized by fibrosis and ossification of ligaments and joint capsules. Most affected individuals are younger than 35 years of age when they first experience symptoms and will describe morning stiffness. The finding of relief with exercise and the need to get out of bed at night are also important in raising suspicion for ankylosing spondylitis. ,


Cauda equina syndrome occurs when a large midline disk herniation causes compression of the cauda equina nerve roots. The condition is rare, with estimates of it occurring in less than 0.01% of patients with LBP, but when present it represents a surgical emergency that requires immediate referral. Red flags for cauda equina syndrome are sensory deficits in the perineal (i.e., “saddle”) region, urinary retention, or loss of sphincter control. Box 17-1 provides a contrasting view of red flags that could potentially be a serious condition causing LBP.



Box 17-1


Fractures





  • Spinal fracture:




    • Major trauma such as a motor vehicle accident, a fall from a height, or a direct blow to the lumbar spine




  • Compression fracture:




    • Minor trauma or strenuous lifting in older or potentially osteoporotic individuals; prolonged corticosteroid use




  • Pars interarticularis stress fracture:




    • Persistent back pain in younger individuals involved in repetitive hyperextension activities




Cauda Equina Syndrome





  • Saddle anesthesia



  • Recent onset of bladder dysfunction, such as urinary retention, increased frequency, or overflow incontinence



  • Serious or progressive neurologic deficit in the lower extremity



Neoplastic Conditions





  • Older than 50 years of age



  • Previous history of cancer



  • Unexplained weight loss



  • No relief with bed rest



Ankylosing Spondylitis





  • Getting out of bed at night



  • Morning stiffness



  • Male gender



  • At onset, younger than 35 years of age



  • No relief when lying down



  • Relief with exercise and activity



Spinal Infection





  • Recent fever and chills



  • Recent bacterial infection, intravenous drug abuse, or immunosuppression (from steroids, organ transplantation, or human immunodeficiency virus infection)



Red Flags for Potentially Serious Conditions Causing Low Back Pain

Data from Bigos S., Bowyer, O., Braen, G., et al. (1994): Acute low back problems in adults. AHCPR Publication 95–0642. Rockville, MD, Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; and Deyo, R.A., and Diehl, A.K. (1988): Cancer as a cause of back pain: Frequency, clinical presentation, and diagnostic strategies. J. Gen. Intern. Med., 3:230–238.


Yellow Flags


LBP is a common experience, and most affected individuals are able to recover and resume normal activities within a few weeks. Research has shown that psychosocial variables are far more important than findings on physical examination for predicting which patients are at risk for not making a rapid recovery. , Yellow flags are findings that indicate an increased risk for prolonged pain and disability because of psychosocial factors. Research suggests that fear-avoidance beliefs may be the most important psychosocial yellow flag indicating increased risk for prolonged LBP. ,


The Fear-Avoidance Model was developed to help explain why some individuals with acute painful conditions progress to chronic pain whereas others are able to recover. The model proposes that pain perception has both a sensory component and an emotional reaction component. During normal conditions these two components have a proportional relationship. In some instances, however, the relationship between the sensory component and the emotional reaction component can become dissociated and result in pain experience or behavior, or both, that is out of proportion to the demonstrable pathology. The most important determinant of the relationship between the sensory and emotional components of pain perception is proposed to be an individual’s fear of pain and subsequent avoidance behavior. ,


The response of an individual to a painful experience may fall somewhere along a continuum between two extremes: avoidance and confrontation. Confrontation is seen as an adaptive response in which the individual resumes activities in a graded manner and eventually returns to a normal level of activity. Conversely, avoidance is viewed as a maladaptive response in which activities anticipated to cause pain are avoided. Avoidance may result in decreased activity levels, continued disability, and adverse psychologic consequences.




Fear-avoidance beliefs may be the most important psychosocial factor that increases the risk for prolonged disability caused by LBP. Patients with high levels of fear-avoidance beliefs need to be managed with an active rehabilitation approach that includes ample positive reinforcement when functional goals are achieved.


Clinical Pearl #1


The presence of an avoidance response to LBP has been associated with increased risk for prolonged disability and work loss. , , , Yellow flags indicating increased risk for prolonged disability caused by heightened fear-avoidance beliefs can be assessed by clinical evaluation or by questionnaire. Several attitudes and behaviors may represent yellow flags. Waddell et al developed the Fear-Avoidance Beliefs Questionnaire (FABQ) to quantify fear-avoidance beliefs in patients with LBP ( Fig. 17-2 ). The questionnaire is designed to assess the impact of fear-avoidance beliefs on two aspects of function: physical activity and work.




Figure 17-2


Fear-Avoidance Beliefs Questionnaire. The physical activity subscale is computed as the sum of questions 2 through 5. The work subscale is computed as the sum of questions 6, 7, 9 to 12, and 15.

(From Waddell, G., Newton, M., Henderson, I., et al. [1993]: A Fear-Avoidance Beliefs Questionnaire [FABQ] and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain, 52:157–168.)


When yellow flags are identified, the rehabilitation approach used with the patient may need to be modified. An emphasis on active rehabilitation and positive reinforcement of functional accomplishments is recommended for patients with increased fear-avoidance beliefs. Graded exercise programs that direct attention toward attaining certain functional goals and away from the symptom of pain have also been recommended. Finally, graduated exposure to specific activities that a patient fears as being potentially painful or difficult to perform may be helpful. Box 17-2 summarizes the attitudes and types of behavior that may be associated with yellow flags.



Box 17-2


Attitudes and Beliefs





  • Belief that pain is harmful or disabling and resulting in guarding and fear of movement



  • Belief that all pain must be abolished before returning to activity



  • Expectation of increased pain with activity or work, lack of ability to predict capabilities



  • Catastrophe focused, expecting the worst



  • Belief that pain is uncontrollable



  • Passive attitude to rehabilitation



Behavior





  • Use of extended rest



  • Reduced activity level with significant withdrawal from daily activities



  • Avoidance of normal activity and progressive substitution of lifestyle away from productive activity



  • Reports of extremely high pain intensity



  • Excessive reliance on aids (braces, crutches, and other aids)



  • Sleep quality reduced after the onset of back pain



  • High intake of alcohol or other substances with an increase since the onset of back pain



  • Smoking



Attitudes and Types of Behavior That May Represent Yellow Flags


Staging the Patient: Second-Level Classification


Determining the acuity of the patient’s LBP is an important consideration for rehabilitation. Acuity is not based strictly on the duration of symptoms but also includes the nature of the patient’s examination and the goals for rehabilitation. Patients who have difficulty performing basic daily activities such as sitting, standing, or walking are considered to be in stage I (i.e., acute). Patients in stage I tend to have increased levels of pain and disability, and the goals for rehabilitation are directed toward reducing the patient’s symptoms and permitting progression to stage II of treatment. Patients who are able to perform basic daily activities but experience difficulty with more demanding activities such as running, lifting, and sporting activities are considered to be in stage II. Patients in stage II will generally have less severe symptoms, but they tend to have had their symptoms for a longer duration, and the symptoms possibly limit their ability to work or engage in sports activities. The goals of rehabilitation for patients in stage II focus on reducing impairments in strength, flexibility, endurance, and neuromuscular control and returning to full participation in work or sports activities.


Determining the Best Treatment Approach: Third-Level Classification


When the patient has been screened for red and yellow flags and the stage of the condition has been judged, the next decision is determining which treatment approach is most likely to benefit the patient. Instead of focusing on a pathoanatomic diagnosis, the clinician should seek to classify the patient’s condition on the basis of clusters of signs and symptoms. The classification assignment should in turn assist in determination of the most appropriate treatment approach. The treatment-based classification system used in this chapter was originally described by Delitto et al in 1995 and has been updated and modified based on research developments since that time. , The system uses information gathered from the patient’s medical history and physical examination to place the patient into a classification, which in turn guides treatment of the patient. Four basic classifications are used for patients in stage I: manipulation/mobilization, specific exercise (flexion, extension, and lateral shift patterns), stabilization, and traction. Each of these classifications is associated with several key examination findings and a unique treatment approach. Components of the examination are assessed through patient self-report measures, neurologic evaluation, the patient’s medical history, and findings on physical examination. Table 17-1 summarizes the key examination findings and treatments for patients with a stage I classification.



Table 17-1

Key Examination Findings and Treatments for Stage I Classifications












































































Classification Key Examination Findings Treatments
Stabilization Frequent previous episodes of low back pain Trunk-strengthening stabilization exercises
Increasing frequency of episodes of low back pain
“Instability catch” or painful arcs during lumbar flexion/extension ROM
Hypermobility of the lumbar spine
Positive prone segmental instability test
Manipulation/mobilization No symptoms distal to the knee Manipulation or mobilization techniques targeted to the sacroiliac or lumbar region. ROM exercises
Recent onset of symptoms
Low levels of fear-avoidance beliefs
Hypomobility of the lumbar spine
Increased hip internal rotation (> 35°) or discrepancy in hip internal rotation ROM between the right and left hip
Specific Exercise
Extension pattern Symptoms distal to the knee Extension exercises
Signs and symptoms of nerve root compression Mobilization to promote extension
Symptoms centralize with lumbar extension
Symptoms peripheralize with lumbar flexion Avoidance of flexion activities
Flexion pattern Older age (> 55 years) Flexion exercises
Symptoms distal to the knee Mobilization to promote flexion
Signs and symptoms of nerve root compression and/or neurogenic claudication Deweighted ambulation
Symptoms peripheralize with lumbar extension Avoidance of extension activities
Symptoms centralize with lumbar flexion
Lateral shift pattern Visible frontal plane deviation of the shoulders relative to the pelvis Pelvic translocation exercises
Asymmetric side-bending active ROM Autotraction
Painful and restricted extension active ROM
Traction Signs and symptoms of nerve root compression Mechanical or autotraction
No movements centralize symptoms

ROM, Range of motion.


Self-Report Measures


Several self-report measures provide useful information for the classification process and may also serve as useful indicators of the effectiveness of treatment. Three self-report measures are recommended: a pain diagram and pain rating scale, the FABQ, and a disability measure.


Pain diagram and rating scale


A pain body diagram is used to determine the nature and distribution of the patient’s symptoms. The patient is asked to indicate the location and nature (e.g., aching, burning, numbness) of symptoms on the body diagram. If symptoms are noted to extend distal to the knee, a classification of manipulation/mobilization becomes less likely. The presence of symptoms distal to the knee or symptoms of numbness and tingling increases the likelihood of a specific exercise or traction classification. A pain diagram may also serve as an additional yellow flag screening tool. A nondermatomal or widespread distribution of symptoms may indicate that psychosocial factors are affecting the patient’s perception of pain. A pain rating scale asks the patient to rate the level of pain on a 0 to 10 scale, with 0 indicating no pain and 10 the worst imaginable pain. Ratings of pain may serve as a useful outcome measure to document treatment success or failure.


Fear-avoidance beliefs questionnaire


The FABQ is a helpful screening tool for yellow flags. It has both work and physical activity subscales (see Fig. 17-2 ). The work subscale of the FABQ may be particularly helpful for classifying patients. It contains seven items, each scored 0 to 6, with higher numbers indicating greater levels of fear-avoidance beliefs. Research has found that total scores greater than 34 should raise concern about prolonged disability. Total scores higher than 18 have been associated with a reduced likelihood of success with a manipulation treatment approach, and these patients may need a more active rehabilitation program.


Modified oswestry disability questionnaire


The two most commonly used self-report disability scales are the Modified Oswestry Disability Questionnaire and the Roland Morris Questionnaire. We have used the Oswestry questionnaire for the purposes of staging patients and assessing the outcomes of treatment. The Oswestry questionnaire has 10 sections: 1 section for pain severity and the other 9 representing various functional activities ( Fig. 17-3 ). The patient indicates the degree of limitation in that activity because of LBP. Each section contains six responses, scored from 0 to 5. Each section score is summed to obtain the final score. The final score is then multiplied by 2, and the degree of disability is expressed as a percentage. Higher scores on the Oswestry questionnaire indicate greater levels of perceived disability. The Oswestry score can assist in staging the patient. Generally, patients in stage I will have Oswestry scores at or greater than 30%, and patients in stage II will have scores lower than 30%.




Figure 17-3


The Modified Oswestry Disability Questionnaire.

(Reprinted with permission from Fritz, J.M., and Irrgang, J.J. [2001]: A comparison of a Modified Owestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys. Ther., 81:776–788.)


Neurologic Assessment


Neurologic evaluation is required for any patient who has symptoms that extend below the buttock. The neurologic examination consists of four components: (1) strength of key muscles for each lumbar and sacral myotome, (2) sensation within dermatomes of the lower quarter, (3) deep tendon reflexes of the lower quarter, and (4) signs of neural tension. Results of the neurologic examination will determine whether signs of nerve root compression are present and need to be monitored throughout treatment. Results of the neurologic assessment may also provide prognostic information. Individuals with positive findings on the neurologic examination may be more likely to experience long-term pain and disability.


Strength assessment


Evaluation of key muscles in each lumbar and sacral myotome is performed. Myotomal weakness may be indicative of lower motor neuron lesions, most commonly nerve root compression caused by intervertebral disk herniation. More generalized weakness may indicate more serious pathology or simply generalized disuse atrophy of the lower limb. The key muscles to be tested and corresponding myotomes are listed in Table 17-2 .



Table 17-2

Key Muscles to Be Tested and Corresponding Myotomes






















Muscles How to Test
Hip flexion (L1-L2) The hip is flexed to near end range and pressure is applied to the anterior aspect of the thigh into hip extension.
Knee extension (L3-L4) The knee is placed in a position slightly less than full extension. One hand stabilizes the patient’s thigh while the other applies pressure on the anterior aspect of the tibia into knee flexion.
Dorsiflexion (L4-L5) Dorsiflexion is best tested by having the patient walk on the heels. Non–weight-bearing assessment of dorsiflexion strength can be performed but may be less sensitive to subtle deficits in strength. For non–weight-bearing assessment, the foot is placed in full dorsiflexion with some inversion. One hand stabilizes the distal end of the tibia while the other hand applies pressure on the dorsum of the foot into plantar flexion with some eversion.
Great toe extension (L5) With the shoes off, the great toe is placed in extension. One hand stabilizes the foot while the other hand applies pressure on the dorsum of the distal phalanx of the great toe into flexion.
Ankle plantar flexion (S1-S2) Plantar flexion is best tested by having the patient walk on the toes. Non–weight-bearing assessment of plantar flexion strength can be performed but may be less sensitive to subtle deficits. For non–weight-bearing assessment, the foot is placed in full plantar flexion. One hand stabilizes the distal end of the tibia while the other applies pressure on the plantar aspect of the foot into plantar flexion. (With the knee flexed the soleus muscle is the primary plantar flexor.)


Sensory assessment


Evaluation for sensory loss is performed by lightly brushing the hand over key dermatomal areas. Any region of diminished or absent sensation should be tested further with the use of a pin to clearly map the area of sensory deficit. Box 17-3 contains the key areas used to assess specific dermatomes. Considerable overlap and individual variations in dermatomal patterns are known to exist. The results of sensory testing should be collaborated with the results of other components of the neurologic assessment to determine the presence and extent of nerve root compression.



Box 17-3





  • Inguinal area (L1)



  • Anterior aspect of the midthigh region (L2)



  • Distal anterior aspect of the thigh and medial part of the knee (L3)



  • Medial aspect of lower part of the leg and foot (L4)



  • Lateral aspect of the lower part of the leg and foot (L5)



  • Posterior of the calf (S1)



Key Areas Used to Assess Specific Dermatomes


Deep tendon reflex assessment


Diminished deep tendon reflexes may represent nerve root compression. Hyperactive reflexes can be another area of concern related to upper motor neuron disturbances (e.g., myelopathy). At the same time, hyperactive reflexes can be a normal variant. If encountered, the clinician should at least suspect a myelopathic process or upper motor neuron pathology. Confirming evidence for these conditions would be clonus or the presence of a Babinski response. If these findings exist, referral for further diagnostic work-up is probably required. Table 17-3 describes two lower extremity reflexes that are assessed.



Table 17-3

Lower Extremity Reflex Tests
















Reflex Test Integrity of Nerve Roots Technique
Patellar tendon reflex L3-L4 nerve roots The patient is seated with the knee flexed to approximately 90°. The patellar tendon is struck with the reflex hammer and reflexive knee extension is observed.
Achilles tendon reflex S1-S2 nerve roots The patient is seated and the ankle is supported at approximately neutral dorsiflexion. The ankle dorsiflexor muscles must be relaxed. The Achilles tendon is struck with the reflex hammer and reflexive plantar flexion is observed and felt with the supporting hand.


Neural tension tests


These tests are procedures designed to place tension on neural structures to assist in the diagnosis of nerve root compression that is typically caused by lumbar intervertebral disk herniation. Two different neural tension tests are used ( Fig. 17-4, A and B ).




Figure 17-4


A, Straight leg raise. The hip is passively flexed with the knee maintained in extension. The test is positive if the patient’s familiar leg symptoms are reproduced between 30° and 70° of hip flexion. B, Femoral nerve stretch. The knee and hip are passively flexed. The test is positive if the patient’s familiar anterior thigh symptoms are reproduced or intensified with these maneuvers.


Straight Leg Raise


A straight leg raise is used to place tension on the sciatic nerve to aid in diagnosis of the presence of nerve root compression of the lower lumbar nerve roots (L4-S1) (see Fig. 17-4, A ). The patient is prone and the lower extremity is raised by the clinician to the maximum tolerable level of hip flexion range of motion (ROM). The test must be performed passively and the patient’s knee maintained in full extension and the hip in neutral rotation. The opposite leg is kept in extension. For each test, the clinician notes any symptoms produced during the test and also the degree of hip flexion at which the symptoms are produced. A positive test result requires reproduction of the patient’s familiar leg symptoms between 30° and 70° of hip flexion. It is important to distinguish between reproduction of familiar symptoms and hamstring tightness.


Both the symptomatic and contralateral lower extremities are examined. A positive contralateral straight leg raise test result occurs when a straight leg raise of the asymptomatic lower extremity reproduces the symptoms in the symptomatic extremity. A positive contralateral straight leg raise test result is highly specific for lower lumbar disk herniation.


Femoral Nerve Stretch


Femoral nerve stretch is a neural tension test used to place tension on the femoral nerve to diagnose nerve root compression of the midlumbar nerve roots (L2-L4) (see Fig. 17-4, B ). The femoral nerve stretch is performed with the patient prone. The clinician first passively extends the patient’s hip and then passively flexes the knee. If the patient’s familiar anterior thigh symptoms are reproduced or intensified with these maneuvers, the test is considered positive. It is important to distinguish between reproduction of the patient’s familiar symptoms caused by tension on the femoral nerve and stretching of the rectus femoris muscle.




Stage I management


Manipulation/Mobilization Classification


Spinal manipulation is an intervention with at least some supporting evidence of its effectiveness. Several randomized trials have found spinal manipulation to be more effective than placebo or other interventions for patients with LBP. Manipulation/mobilization techniques may be directed at either the sacroiliac (SI) region or the lumbar spine. Many theoretic approaches to identifying patients likely to benefit from spinal manipulation have been proposed; however, little to no evidence support their use and reliability. These approaches are frequently based on pathoanatomic and biomechanical theories that use various examination procedures to identify a pathologic motion segment or a biomechanical dysfunction toward which a manipulative intervention is then directed.


An alternative to the traditional tests used to classify patients is the development of a clinical prediction rule. A clinical prediction rule is a tool designed to assist in the classification process and improve decision making for clinicians. Flynn et al developed a clinical prediction rule consisting of multiple factors from the medical history and physical examination to predict a priori which patients will most likely benefit from spinal manipulation. The results of this study identified a set of five criteria that accurately identified patients who would benefit from a manipulative intervention. The five criteria are listed in Box 17-4 . The presence of at least four of five of these findings was strongly predictive of a dramatic response to a manipulative intervention, and the presence of three findings was moderately predictive of success. Therefore, a classification of manipulation/mobilization should be strongly considered when at least three of these findings are present.



Box 17-4





  • Low Fear-Avoidance Beliefs Questionnaire work subscale score (< 19 points)



  • Short duration of current symptoms (< 16 days)



  • No symptoms extending distal to the knee



  • At least one hypomobile lumbar spine segment (judged from lumbar spring testing)



  • At least one hip with more than 35° of internal rotation ROM



  • No increasing frequency of low back pain episodes noted by the patient



  • No signs of nerve root compression



  • No peripheralization during lumbar active movement testing



Key Examination Findings Leading to a Classification of Manipulation/Mobilization *

* The five findings prefaced by bullets make up the clinical prediction rule.


From Flynn, T., Fritz, J., Whitman, J., et al. (2002): A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine, 27:2835–2843.


Examination for the Manipulation/Mobilization Classification


Patients who are most likely to respond to a manipulation/mobilization intervention are generally those with a more recent onset of symptoms and localization of the symptoms to the low back region, to the buttock, and possibly into the thigh. Patients with signs of nerve root compression (i.e., positive straight leg raise and strength tests, reflex, or sensory deficits) are likely to respond more favorably to an alternative treatment approach. Traditionally, classifying a patient for a manipulation/mobilization intervention has relied predominately on mobility assessments and special tests. Many of these diagnostic tests have been found to have poor reliability and questionable validity, , , and therefore clinicians should be cautious about basing classification decisions on any one of these findings in isolation. Confirmatory findings from the physical examination are outlined later in this chapter.


Further examination of the sacroiliac region


Tests of Bony Landmark Symmetry


The clinician assesses the symmetry of the pelvic landmarks, including the posterior superior iliac spines (PSISs), anterior superior iliac spines (ASISs), and the iliac crests with the patient standing. The iliac crests are evaluated from the posterior aspect of the patient with the clinician’s hands at the pelvic level. The clinician judges the symmetry of the heights of the iliac crests. A difference between the right and left sides can indicate a leg length discrepancy, iliac rotation, or both. Asymmetry of the iliac crests must be correlated with the positional findings of the PSISs and ASISs. PSIS levels are determined by placing the tips of the index fingers directly beneath the inferior aspect of the PSIS on each side and visually comparing the height. The same procedure is used in comparing ASIS heights.


After each of the landmarks has been palpated, the results are compiled to arrive at one of three possible determinations:




  • Long leg: symmetrically increased height of the ASIS, PSIS, and iliac crest on one side



  • Innominate rotation: asymmetric heights of the ASISs, PSISs, and iliac crests (e.g., low PSIS on the right, high iliac crest on the right, and high ASIS on the right)



  • Normal: even pelvic landmarks while standing



PSIS levels are palpated in a similar manner with the patient sitting. Palpation of the ASISs is difficult with the patient seated and is not performed. Interpretation of the position of the PSISs with the patient sitting is correlated with the results of palpation in the standing position. Asymmetry that was present while standing and remains while sitting may indicate dysfunction in the SI region. If the asymmetry is eliminated by sitting, a leg length discrepancy should be suspected.


The Standing and Seated Flexion Tests


The clinician places the tips of the index fingers directly beneath the PSISs on both sides. The fingers are directed against the inferior margin of the PSISs with maintenance of upward pressure. The patient is instructed to bend forward as far as possible while the clinician continues to monitor the position of the PSISs and observes for symmetry of cranial movement of these bony landmarks ( Fig. 17-5, A ). Normally, the superior movement of each PSIS should be equal. A positive finding occurs when the cranial excursion of one PSIS is judged to be greater than the other. The side that moves further in a cranial direction is presumed to be the hypomobile side that requires manipulation/mobilization.




Figure 17-5


A, Standing flexion test. The clinician palpates the posterior superior iliac spines (PSISs) while the patient flexes forward. The test is positive if one PSIS moves further in a cranial direction. B, Gillet test. The clinician palpates the PSIS while the patient flexes the hip and knee. The test is positive if the PSIS does not move in a caudal direction. C, Gaenslen test. The clinician flexes the knee and hip and then applies overpressure. The test is positive if the patient’s familiar symptoms are reproduced.


The seated flexion test is performed and interpreted in an identical manner, except that the patient is seated. The clinician palpates the PSISs on both sides and the patient is then asked to flex forward while the clinician continues to monitor the position of the PSISs. If one PSIS is found to move further in a cranial direction than the other, the test is considered to be positive. The side that moves further in a cranial direction is presumed to be the hypomobile side.


Gillet Test


With the patient standing, the clinician places one thumb under the PSIS on the side being tested. The other thumb is placed in the midline over the S2 spinous process. The patient is instructed to stand on one leg and flex the hip and knee on the side being testing while bringing the leg toward the chest. The clinician continues to palpate the PSIS on the tested side. The test is considered to be positive if the PSIS fails to move posterior and inferior with respect to the S2 spinous process (see Fig. 17-5, B ).


Gaenslen Test


The Gaenslen test is a provocation test for dysfunction of the SI region. The patient is supine with both legs extended. The leg being tested is passively brought into full hip and knee flexion while the opposite hip is maintained in an extended position. Overpressure is applied by the clinician to the flexed extremity (see Fig. 17-5, C ). A positive test result occurs when the patient’s familiar symptoms are reproduced in either SI region with the application of the overpressure.


Further examination of the lumbar region


Lumbar Active Motion Assessment: The Movement Diagram


Active ROM is performed with the patient standing. In performing these procedures, the clinician needs to determine the ROM present in each direction, as well as the behavior of the patient’s symptoms during and immediately after the movement in question. The patient is asked to perform the following movements:




  • Side bending to the right and left



  • Extension



  • Forward bending



Reliable methods of measurement with a single inclinometer have been described for quantification of forward bending and extension. For ease of recording the ROM present and the location of symptoms, we have developed a movement diagram and a shorthand system to denote the effect of movements on the patient’s symptoms and to record the pattern of motion restriction present ( Fig. 17-6 ).




Figure 17-6


Lumbar movement diagram.


For the classification of manipulation/mobilization, the focus of active movement testing is on identification of a noncapsular pattern of movement restriction that may indicate the need for manipulation or mobilization of the lumbar spine. Noncapsular patterns in the lumbar region were characterized by Cyriax as occurring when a gross limitation in side bending is present in only one direction. Noncapsular patterns may be further distinguished as either opening or closing restrictions. A closing restriction theoretically occurs when side bending is limited toward the side of pain and extension is also limited. The movement diagram of a left closing restriction is shown in Figure 17-7 . An opening restriction is proposed to occur when the restricted motions are side bending away from the painful side and flexion. The movement diagram of a left opening restriction is shown in Figure 17-8 .




Figure 17-7


Movement diagram depicting a left closing pattern. (See Figure 17-6 for definitions.)



Figure 17-8


Movement diagram depicting a left opening restriction. (See Figure 17-6 for definitions.)


Passive Segmental Motion Testing


Passive segmental motion tests include both provocation and tests of mobility of the lumbar motion segments. The patient lies prone and the clinician places the hypothenar eminence over the spinous process of the vertebra to be tested. The contact point of the hand is just distal to the pisiform. When the clinician’s hand is positioned appropriately, the wrist and elbow are extended and gentle but firm anteriorly directed pressure is applied to the spinous process. The force is applied not by pushing with the arms but by allowing the body weight to be lowered. The patient is instructed to report any change in symptoms during performance of the test. The clinician also judges the mobility as normal, hypomobile, or hypermobile. The presence of hypomobile lumbar motion segments is an indication for a manipulation/mobilization classification.


Treatment for the Manipulation/Mobilization Classification


Although it has not been studied extensively, a few studies have found greater benefit from manipulative techniques than from mobilization of the lumbosacral region. , Patients in whom spondylolisthesis, lumbar instability, or osteoporosis has been diagnosed or with any concern for a stress fracture should be approached with caution, and manipulative techniques are generally contraindicated in these individuals. Many different manipulation and mobilization techniques have been described, but currently no evidence has shown the superiority of one approach over another. Correct identification of a patient who actually needs manipulation/mobilization interventions is probably more important than the particular technique chosen by the clinician. Several manipulation/mobilization techniques are described in Figure 17-9, A to D . After these interventions are applied, the patient should be instructed in non–weight-bearing active ROM exercises. They may be performed in the supine or quadruped positions. In the supine position, the patient is instructed to actively tilt the pelvis anteriorly and posteriorly to create motion in the lumbar spine. In the quadruped position, the patient can be asked to rock backward over the heels and forward over the hands to create lumbar flexion and extension, respectively.


Apr 13, 2019 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Low Back Rehabilitation

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